Wednesday, July 20, 2011

A Move to PLoS

It looks like I'm about to move from my cozy studio at this URL to a new community with some very nice neighbors.  Neighbors like Pulitzer-prize winning science writer Deborah Blum, former Scientific American editor in chief John Rennie, and The Panic Virus author Seth Mnookin.

Intimidating?  You bet.  Exciting?  You bet.  It's a close-knit network that it's an honor to join.

All future posts will be at

Thanks so much for reading, and I hope you follow me to PLoS.

Tuesday, July 19, 2011

On Proposing Solutions

No one likes to be wrong.  I would wager that most of us don't even like to be disagreed with.  That's why the most popular articles and thoughts tend to be the ones that are--literally--popular.

My sister recently wrote a very good article on the ethical challenges of prenatal testing.  It was a clear, articulate overview that identified and explained the arguments on both sides--reproductive freedom vs. discrimination.  But when it came to proposing a possible way to approaching a solution, she confided in me that she was hesitant to take a stand.

"I just like to say '...and this is the problem.  These are the issues.  Everything is hard,'" she told me.  I found myself agreeing with her, noting that I tended to do the same.  "I'm comfortable identifying blurs.  But someone has to draw the lines," my sister said.

Ilana did end up suggesting a solution in her article.  But her reluctance to to do stemmed from her desire for her article to be well-received.  And to be well-received, people have to agree with it.  Obviously, this is particularly relevant for those of us who are young, low on the totem pole, and have fewer credentials we can stake an opinion on.

In our medical ethics course, we learned the relevant issues at stake in specific medical scenarios.  We could identify values and conflicts.  But at what point should we go beyond saying, "This is an example of the overmedicalization of normal variation" and actually attempt to draw lines in the sand?

It is hard to disagree with the aforementioned quotation.  Draw a single line, though, and the entire class will poke holes in your argument.  There will be rebuttals, counterexamples, and slippery slopes.  This is the point of an ethics class, of course.  But what about in a more public forum, one that is less conducive to debate?

Say, an article.  It is not fun when an audience pokes holes in your article.

There are certain people who I admire who do not hesitate to propose bold, original theories and solutions.  Paul Graham and Penelope Trunk come to mind.  Yet these same people are also accused of oversimplifying the issues at stake, or being too confident, or being too argumentative.  They are either loved or hated.

I think most of us would choose to be simply "liked" rather than "loved and hated."

But this is also why we have far more articles with themes of "this is a complicated issue with no easy solutions" than we do with "here's an innovative proposal that just may work."

I know I can't please everyone, and it's intimating to propose in a public forum something that won't.  Still just a medical student here.  Still twenty four years old.  Still scared to death of being "hated."

But I recognize that often the most polarizing figures are also the ones who change the world the most.

Thursday, June 23, 2011

Making it Worse

"So how great are you at handling weird shit?"

The instant message box popped up from an acquaintance.  We barely knew each other beyond our sparse interactions online.  Apparently there was no else online to talk to.

With weak reassurance from me, he dropped the bombshell.

There was no right way to react, he admitted.  There was also nothing in particular he was looking to hear.  Still, I felt more impotent with each response I gave.

Empathy led to sarcasm.  Additional questions led to evasion.  Expressing uncertainty about how I was reacting led to silence.  I was sure I was making things worse.

He had some whiskey and left the keyboard for awhile.  When he came back, the subject was over.  He thanked me for listening.  "I don't know how I'm supposed to feel," he finally said.

Me neither.

I chalked up my incompetence to my barely knowing him.  Surely if I knew him better, I'd know exactly which conversation buttons to hit to help him cope.  But I didn't know him at all.  This was the first time someone who I barely knew confided in me something life-changing.

We learn a lot of things about how to react to raw vulnerability in people we don't know.  We have our stock phrases and tricks about how to validate feelings.  "This must be hard for you." "I'm sorry."  "Take all the time you need.  "This is not your fault."  "A lot of people go through this."  "Your reaction is normal."

What I didn't learn until now is sometimes nothing--absolutely nothing--works.  Sometimes it's the moment, sometimes it's the person, sometimes it's both.  And so you have silences, and missteps, and too many apologies.  Out of desperation, you say inappropriate things like, "I'm pretty sure I didn't do anything to make it better, but I hope I didn't make it worse either."

You may make it worse.

But maybe the game is rigged.  Maybe every door to making things better is locked.  Maybe I'm not the person with the key.  Maybe there's nowhere to stand but in the hallway, offering nothing for now but a bit of body warmth.

Note: I asked for (and received) consent to write this.

Monday, June 20, 2011

Finished Year, Unfinished Business

The jury's still out on reflective first year sentiments, but it's been gratifying to share my thoughts back from the very beginning of medical school.

I had the honor of reading my "Letter to a Young Doctor" on the medical documentary series White Coat, Black Art. The radio show ran on the Canadian Broadcasting Corporation (Canada’s national public radio and television broadcaster--similar to America's NPR or PBS).

Link to audio--my piece is at 22:00.
Link to June 10 show description.


I'm officially a "rising MS-2," or second-year medical student.  During the last few days of school, we were asked to write a two-page reflection statement about first year.  I meant to write something original, but it proved difficult.  Nothing I was thinking seemed remotely appropriate to hand in to a person who could be writing my recommendation letter.  I didn't (and still don't) really feel anything at all right now.  I don't feel particularly learned, or empathetic, or acculturated right now.

The dorm is quiet.  Our lecture hall/study center is quiet.  In April, the former second years became third years.  They started on the wards in their respective hospitals.  They no longer spend long hours in the computer labs studying for boards or mingling with our class in common areas during lunch breaks.  They no longer live with us either; many have moved out out of the dorm to be closer to their hospitals or because they finally desired their own bathrooms.

Right now, we exist in a strange sort of orphan limbo.  The former second years are no longer in our proximate space to give advice, guidance, reassurance.  The incoming class will not be arriving until August.  Without other classes for comparison, perspective is difficult.  The changes do not become evident simply because it's the current assignment.

I am a guest editor of the AMA's ethics journal Virtual Mentor.  One of my main responsibilities is to describe a clinical situation in which the physician faces an ethical dilemma.  I write a short narrative depicting the situation--the doctor, the patient, the setting.  Then, there's what the editor in chief calls the "trigger."  There needs to be a very specific event that occurs that ignites the dilemma.  It could be a patient's question, a lab result, a colleague's comment.  A solicited author then writes commentary on my proposed situation and "trigger," using a larger ethical framework to buttress arguments.

The "trigger" in various clinical situations constitutes the backbone of the journal's cases is appealing to me on a number of levels.  It is a concrete and focused way to think about nuanced and abstract philosophical issues.  The "trigger" is unique, and yet it isn't.  Although physicians may not have experienced identical situations to the ones proposed, likenesses make the situations realistic and relevant.

What I'm missing right now is the trigger.  Perhaps it will be a former second year laughingly recalling how terrified I was before our first exam.  Perhaps it will be when an incoming first year asks me how it's possible to memorize the names and functions of nearly every muscle in the human body.  Perhaps it will even be when a patient tells me that I what I said was particularly sensitive, or knowledgeable, or clear.  What I do know is that staring at my computer screen has not been the trigger.

Out of desperation, diplomacy, and a desire to be honest, I ended up smushing together two previous blog posts as a reflection.  Both had triggers: a USPS mishap, and a late-night perusal of PubMed.  Both accurately represented thoughts from various points during the academic year.  Both (I believe) were reflective.

I'm still waiting for a trigger before I can wax poetic about the entirety of first year.  Luckily, there are no deadlines this time.

Wednesday, June 1, 2011

Final Countdown

I would love to think about things other than viruses, worms, and fungi, but alas--it's going to be two more days until I get that luxury.

Last exam of the year this Friday.

Integration week (no details on what exactly this entails. some things? all things?) from Monday-Thursday next week.

Then medical school will be one quarter over.  Wow.

Can't wait to look up from the grindstone and think a little more about life since last August.  Soon.  So soon.

Saturday, May 14, 2011

"Five" "Fun" Facts About Bacteria

No illustrations for this one.  I'll leave image searching to the hardy, the curious, and the self-punishing.

...Right.  So today I'm going to talk about bacteria.  For those of you who want to read about interactions with humans, now's your chance to click away.

I haven't seen a real patient in a month.  Last week during Patient-Doctor we went to an art museum.  Before that were videotaped exams during which we interviewed standardized patients.  (Best moment: Me: "You mentioned you were hard of hearing.  Do you wear a hearing aid?" Patient: "What?")  Next week is our final reflection session, which will have a few Doctors, ~80 Medical Students, and no Patients.

Don't say I didn't warn you.

Some interesting things about bacteria that are interesting to me and maybe not to you but hopefully to you too:

1. We are outnumbered 10:1 by bacteria on our own turf, our bodies.  (Note: this is by number only.  I'm not sure about volume.  Most bacteria are only a fraction of the size of human cells.)

2. I used to think "flesh-eating bacteria" (necrotizing fasciitis) were a certain species of superbacteria that you somehow pick up (thanks, Cabin Fever).  Actually, they're normal bacteria species (or certain strains of normal bacteria) gone bad--instead of causing superficial skin infection, they chomp all the way down to the muscle and nerves underneath.

Many kinds of bacteria can be "flesh-eating," and the scary part is that we're all harboring them on our skin, in our throats, and in our GI tracts right now.  They're just not in "flesh-eating mode"--and no one knows exactly what factors in the host or the bacteria trigger the often fatal change.

2a. The less scary part is that nectrotizing fascitis is rare.  One doctor said he saw two cases in six years.

2b. (Jim Henson, creator of The Muppets, died from it in 1990.)

3. Actually, the whole "normal bacteria turned bad" thing is true for many infections.  About a quarter of us have several strains of Strep in our throats... but we don't have symptoms of the disease. A similar percentage of us have Staph on our skin, in our nose, in our GI tracts, and in our vaginas.  Our immune system generally keeps them in check.

4. A vaccine for Lyme disease was developed and made it to the market but was withdrawn because of anti-vaccine sentiment.  This is the only example of an approved useful vaccine that is currently not available to the public.

5. We are in a continual arms race against bacteria.  We develop an antibiotic that doesn't let bacteria build their cell wall.  Bacteria select for an enzyme that neutralizes our antibiotic.  We make an antibiotic that inactivates the enzyme.  Bacteria select for modifications of their enzyme that don't get inactivated by our drugs.  And so it goes.

5a. Note the wording: bacteria "select for" traits that evade our weapons.  The mutations exist before we introduce our weapons--they don't develop in response to them.  Now the bacteria with previously arbitrary mutations survive, prosper, and share their genes with their friends, lovers, and daughters.

5b. MRSA (methicillin resistant Staph aureus) was first documented in 1961.  Now, about one third of people harbor it.  Although it used to be found only in hospitals, now it can be acquired in the outside community as well.  It is resistant to not only methicillin but many other drugs in similar classes.

Exam on Monday.  More facts must come, or I'm not going to pass.
Until then.

Sunday, May 1, 2011


I recently ordered thirty dollars' worth of books from a private seller on Amazon.  In return, I received an empty box and a refusal from the seller to reship the goods, blaming USPS.  USPS predictably remained impenetrable and bureaucratic, offering no recourse or refund.

The innocent woman working in my dorm's business office caught me mid-rant, and she commiserated.  "After working here for 15 years, I see what happens--you wouldn't believe how often.  Now, I never ship anything using USPS."

Years of experience had exposed her to not-entirely-uncommon mishaps that many individuals do not realize exist.  As a result, she had lost faith in the system, preferring to opt out.

I stayed angry for a few days.  But would I use the system again?  Probably.  I wondered how many mishaps it would take for me to change my mind.  I wondered if one expensive loss would be enough.

When I was an undergraduate, I was friendly with a clinical geneticist.  She was in her late thirties, and she and her husband had opted not to have children.  "There's just too much that can go wrong," she told me.  There were too many ways chromosomes could break and realign themselves, too many ways a vital piece of genetic material could be lost in a single cell division, too many dangers in utero that could cause physical and mental deformities.  "I don't think I'd be able to handle taking care of a child like that."

As a genetic counselor, she explained to couples the risk of having a child born with a particular disease or condition.  It was also her job to counsel the parents if said child was born with said condition.  Her days were spent considering unlikelies and talking to people whose lives had been touched by unlikelies.

I wondered if she had suddenly come to her decision after an especially sad case, or if her realization had been gradual after years of cumulative sadnesses.  I wondered if her risk-averse perspective was in her best interest.  She admitted that her biggest fear was regretting her decision twenty years down the line.

A little knowledge may be a dangerous thing, but what about a lot of knowledge?

I've felt my own perspective changing in medical school.  You spend your days studying mishaps.  Sometime's it's the likelies: one in two men will eventually get cancer, as will one in three women.  Many times, though, it's the unlikelies: the debilitating autoimmune attacks, the odd bowel obstructions, the random vessel ruptures.  My classmates and I routinely joke that it's a miracle we've made it this long.

Sometimes it seems as though being alive is an unlikely in itself.

I wonder if this sort of thinking is accurate on some level.

I wonder how this perspective will change my decisions.

I wonder if it will be for the better or worse.

I wonder if we're going to go through life permanently skewed.

But I suppose there's no opting out.

Monday, April 25, 2011


The anatomy article is running today.  I want to be a writer--not for my diary but for the public.  I know I've got to be open to scrutiny.

But damn if I don't feel entirely dissected right now.  On display, vulnerable.  The irony hasn't gone unappreciated.

Friday, April 22, 2011


It was a story incomplete.

The very last post I wrote about anatomy lab was a reflection on our donor, the night before we dissected his head and neck.

A few of my anatomy posts have been stitched together by a gifted editor and will run as a front-page story and feature in the Health section of the Los Angeles Times this coming Monday.  Several times, the editor asked for more concrete details about dissection above the neck.

It would mean I would have to think about it, and worse, write about it.  And there was a good reason that since November, I have done neither.

I am ashamed about what happened in lab.

We had a ceremony honoring our donors in January.  The pieces read and thoughts expressed were elegant, kind, and thoughtful.  That is the way I would like to remember anatomy.  But, in a way, reflections are sugarcoated.  They are certainly honest, but by definition--they occur after much thought.

What happened in lab occurred with no thought and is no less honest.  The day after I wrote the post reflecting on our donor, we entered lab to begin the dissection.

There was the saw—our way into the brain.  The only other time we had interacted with bone was when we banged through the kneecap with mallet and hammer to observe the joint and cartilage inside.  It didn’t feel particularly disturbing, since orthopedic surgeons basically do the same thing.  Above the neck was different.  On no level, in any instance, would a doctor ever do what we were about to—saw through the skull.

Our donor ceased to become human for me after we peeled off his facial skin like a mask to reveal the small muscles underneath.  Without hair on his head, chin, and brows, he was a specimen.  This made the next part of our task considerably easier—cut through skull, reveal brain, pull brain apart, distinguish cranial nerves that control our five senses and movements.

When you saw through a skull for ten minutes, the room—your world—becomes that skull.  You inhale dust particles, acutely aware of where they came from.  Saw against bone shrieks, notes stumbling, uneven in pitch and length.  It is anything but mechanical.

It was surreal to watch my labmate in scrubs, apron, and goggles, with saw raised in hand.  He looked no different from a madman in a horror movie.  Were we the same people who wore suits to our school interviews and gushed about how much we wanted to help people?

There was no analogy my mind could make, no particular moment in my memory that in any way compared to this one.  The whole situation seemed nothing short of ridiculous.  For some reason, the absurdity made me giddy.

I giggled.  Instructors like to use the term "nervous laughter," but I didn't feel nervous.  I felt outside myself.

My reaction was contagious.  All four of us breathed in dust and formalin and laughed above the roar of the saw.  Dentures flew out of the cadaver’s mouth and clattered onto the floor.  In this warped reality, we took this in stride and giggled harder.  Of course, I thought sarcastically, when you cut through someone's head, their fake teeth fly at you.  What else could I expect?  It was a nonsensical situation; we responded in kind.

Back in my room and in street clothes, I called my mother and described the scene in vivid detail.  When she reacted with the appropriate concern, I told her, “No, no, you don’t understand.  It was really funny!”  I was convinced.

I sobered up after a few minutes, horrified about what I had done.  I asked my mom what kind of person my reaction made me.  “It’s a coping mechanism,” she said.  “But I didn’t feel like I had to cope with anything,” I protested.  “That’s the point, isn’t it?” she said.

If everything we do is to rationalize or make ourselves feel better, what isn't a coping mechanism?  Does that make it justified?  Does that make irrationality rational?  That was the first time in my life I have had a public reaction that I could not bring under control.  It's difficult to think about, so I don't very often.  But when I do, I still struggle to make sense of it.

Or maybe it's all just nonsense.

Friday, April 8, 2011

"What Do You Think Caused Your Disease?"

Our first assignment for medical school involved reading and discussing Anne Fadiman's The Spirit Catches You and You Fall Down, which describes how a clash of two cultures (medical and recently immigrated Hmong), miscommunication, and misunderstanding led to tragedy.  Poignantly narrated, the book had the take-home message: if a patient does not agree with a physician's reasoning why a disease developed and how it can be cured, then even the best treatment won't help because the patient will not stick to it.

In the novel, Hmong parents believed that their daughter's seizures were caused by spirits and not overexcitable neurons, so they relied on traditional healing methods (prayer and sacrifice) instead of medications.  Although perhaps the story represents an extreme example of a mistranslated message, unfortunately more minor ones do exist and can often impact care.

Does the diabetic patient understand why monitoring blood sugar is vitally important?  Why should someone with celiac disease avoid certain foods?  Does a smoker realize the extent to which he worsens his COPD when he goes through a pack a day?  Is it ever okay to have a drink when you have hepatitis B?

The answers to these questions help physicians understand how patients see their disease--and, as a consequence, what sorts of measures and discussions can best help them manage it.

Hows and whys from a patient's perspective are called "the explanatory model."  To boil it down, the conceptual framework includes:
What do you call the problem, What do you think the illness does, What do you think the natural course of the illness is, What do you fear?
Why do you think this illness or problem has occurred?
How do you think the sickness should be treated, How do want us to help you?
Who do you turn to for help, Who should be involved in decision making? 
Why do you think this illness or problem has occurred? How do you think the sickness should be treated, How do want us to help you? Who do you turn to for help, Who should be involved in decision making?
No doubt these questions are key.  In fact, this is what we learn to inquire about during our patient interviews, somewhere between taking the history of present illness and the social history.

But, we are not doctors.  We don't yet have the finesse or the time or the practice to incorporate all of these questions in a brief standard interview.  And, in my experience, what usually comes out is an ugly stand-alone question:

"What do you think caused your disease?"

So far, patients I have interviewed have included those with congestive heart failure, arthritis, spinal cord damage, severe abdominal pain, leukemia, cirrhosis, and hepatitis.

I have cringed with awkwardness upon asking this required question.  How could a previously perfectly healthy 63-year-old recently diagnosed with leukemia possibly answer?  The patient with cirrhosis claimed he never drank.  The patient with hepatitis blamed an unsterilized tattoo needle from when he was 19 (which my preceptor later said was an unlikely reason).  I can only imagine the discomfort in the room when I pose a lung cancer patient this question.

I'm not sure how patients feel when I drop this inevitable inquiry.  They generally answer with "I don't know" (which is completely understandable given the nature of many illnesses) or something unrelated.  At that point, I get even more uncertain.  I do not have the knowledge or authority to correct them.  It's not my responsibility right now to comfort, diagnose, or treat them.  I'm not their physician, I do not report to their physician, I am not part of their care in any way, and I will never see them again.  I simply write down their answers to present later.  I feel guilty.  I feel tense.  I am embarrassed for embarrassing them.

My patient interviews are strictly non-therapeutic.  At best I'm a comforting presence and at worst I'm an annoyance.  Nothing about the above question is comforting.

Perhaps I should buttress it with additional questions so that it doesn't land in the room from left field.  Perhaps I should phrase it differently.  But it's difficult to improve when I'm there on a simulated fact-gathering mission without providing the logical consequence of treatment, relaying information to a care team, discussion, or counseling.

To the patients I have asked this question: I apologize.  I'm sorry that you may not feel comfortable disclosing to a 23-year-old first year medical student who is not a part of your care that your heavy drinking to cope with your divorce may have led to your cirrhosis.  I'm sorry that I had to ask you why you think you got cancer, as though I expect a philosophical discourse.  It's just a contrived question right now for training purposes--a piece of a puzzle that is so out of context that it's a disservice. In a few years, I promise I can try to help.

Tuesday, April 5, 2011

Jargon Deciphered

Because it was 3:30 am and I had exhausted the contents of cute kittens on the Internet, I found myself on PubMed.  Just for fun, I decided to type in the name of a common medical condition that a family member has to see if anything interesting had come out on it.

I couldn't believe how much I could glean from the dense titles.  Not only did I recognize individual terms, but I understood larger concepts about why those terms could and should be related in the first place.  All of a sudden, I had context.  I could recall a few characteristics about a certain physiologic condition, a few underlying mechanisms about a cell signalling pathway, a few cytokines, a few relevant diseases.

This is the first time I have ever understood anything on PubMed unrelated to very narrow research projects.

"Leukocyte adhesion deficiency."  "Subclinical left ventricular dysfunction."  "Population-based cohort study."  "Fumarates."  "Hyperkeratosis."  "Thrombocytopenia."  "Ankylosing spondylitis."  "Serum IL-16 levels."  "Suppression of VEGFR2 expression in human endothelial cells."

Now it is 4 am and I feel that--despite the doubts--something indeed has happened to my brain this past year.  My classmates and I moan how much we have forgotten about the little we seem to have learned--and that there is still so much out there that we don't have the slightest clue about.  This may still be true.  But the frustration over the details I have forgotten is now outweighed by sheer amazement as I interpret the cumbersome jargon-y titles that had been out of reach to me mere months ago.

Interestingly enough, this insight did not come after an exam, during a lecture or discussion, or even during regular hours.  It snuck in, on the tails of cute kittens on YouTube, on a quiet Monday night/morning.

I still cannot fathom the day when I will ever be an authority on anything.  But then I consider the 16-year-old me who began her first research experience in a laboratory while taking AP Biology.  I committed hours of (often fruitless) background research on PubMed--wading through foreign and incomprehensible knowledge and concepts, lost and lacking any way to distinguish what was relevant and the big deals from the smaller ones.  From that vantage point, breaking into a literate scientific circle seemed decades away.

Thinking about that version of me, I still cannot quite believe where I am now either--breaking in.

Tuesday, March 29, 2011

In Color

I'm starting to understand why graphic pictures on cigarette packs are so effective.

We are studying pathology, which is the human body gone wrong.  The photos--taken from autopsies--are gross, meaning their structures can be seen with the naked eye.  Cirrhotic livers are littered with bumps and scars, the heart dies and leaves a band of black tissue behind, the lungs are stretched so far that they can't pull in the air they need.

There is something very different and disturbing about seeing things that you can actually "see"--as compared to the symbols and cartoons that we use to represent molecules and pathways on a micro level.  Even when we observe microscopic slides of real damaged tissue, it is easy to underestimate how dysfunctional things are.  We see waves of immune cells, distended vessels, air spaces filled with dark masses (bacteria).  Yet these light and dark splotches, lines, and dots are still too abstract to scream "disease" to the novice eye.  Looking at a slide of a healed pulmonary embolism (blood clot in the lung), one of my classmates asked how we could be so sure it had even been there.  It looked like a bump, an outpouching of the vessel it blocked--a slightly different shade of pink, with a few wavy layers of scarring.  We squint and analyze, trying to distinguish it from "normal."

The instructor then showed a gross photo of a similar "bump" at autopsy.  It was big.  It was brown.  It looked rotten.  It was impossible to miss.

Color is important.  Microscopes show our bodies in hues of pink and blue from staining; textbooks are overzealous for learning's sake and use the colors of rainbow to differentiate.  However, real color is difficult to forget.  A gangrenous foot turned black.  A yellow scar on the heart, refusing to pump blood.  A vessel spilling bright red blood into a cavity reserved for fluid or air.  The sickness is sickening--to any eye.

Wednesday, March 9, 2011

"Med School Just Got Real"

There's nothing like a massive physiology exam that sucks all the words and thoughts out of you. They're somewhere inside my brain, but the nuances of respiratory/cardiology/renal/GI/endocrinology keep rising to the top. That, and the desire to nap for the umpteenth time today.
I believe this is the first course that has broken the barrier between student and student-doctor. It's not biochemistry, or anatomy, or epidemiology, or health policy--it's medicine. The nuts and bolts of how our bodies function. The exquisite mechanisms our organs and cells use just to stay normal. Integration. Complexity. Regulation. Secretion, absorption, growth, flow. Feats of chemistry, physics, engineering (premed requirements make a cameo!). How we can meddle with it all when something goes awry.
It's fascinating how far research has come in explaining how everything works--and still, how much is conjecture, yet to be elucidated via a precise pathway or even concept. It is humbling to learn about the big picture... but frustrating to study the pixels.
We've covered a textbook's worth of physiology content in just over a month. Some sticks, some bounces away. Thank goodness they tell us we'll re-learn this in future classes, and on the wards as well. My brain's RAM is nearly maxed right now.  The last few days have been mundane--hanging on by a thread to pass that next exam. I suspect I'm not alone, but others seem to be hiding it well.
As one of my classmates said, "Med school just got real."

Friday, February 25, 2011

Can Seven Comments Help Explain $17,000?

Update: Now on the Hastings Center Bioethics Forum.

A study this month in Health Affairs found that the gender pay gap for starting physicians had widened from $3600 to nearly $17,000 over the last ten years (after adjustments for specialty and hours worked).  The authors hypothesized that the main reason for this was that women are intentionally choosing lower-paying jobs because these jobs provide greater flexibility and family-friendly benefits.  Though they do not deny that gender discrimination may exist, they have doubts that it has gotten worse in the last decade.

" would be difficult to believe that discrimination, after a period of quiescence, has actually been on the rise in recent years," they write.

I do not know if gender discrimination is on the rise.  I do believe it is still a major problem in the medical community.  I have taken flak for this perspective, and I have elicited considerable backlash.  But, I present the content of these reactions as evidence of the problem. 

I am a student blogger for Medscape's The Differential, a community composed of medical students and residents around the world.  In other words, these are the people who will eventually be our colleagues and employers.

I wrote a post on Medscape linking to my analysis on this blog, as well as adding few anecdotes.

I received the lowest average rating I have ever gotten for a post.

I also received comments (36 total, discounting my own).  I have excerpted seven of them.  Six of them were within the first eight responses to my post.

Right off the bat (comment #1), a commenter argued that gender discrimination was logical.  Why?
"If a male and female both apply for an important position (suppose, a physician at a hospital, or CEO of a large company) and they have the exact same qualifications, and perform exactly as well as each other in the interview, (and seeking the same salary, if this is negotiable)...
As the employer, who would you hire?
For a female, the opportunity cost of childbearing (i.e. working for your hypothetical hospital / company) represents a huge loss of utility for you, the employer. She would be unable to work during the final 6 weeks of her 40 week gestation (and will most likely have maternity leave for much longer than that). Furthermore, the hormonal and mechanical factors of childbearing will greatly reduce her ability to perform at her best during weeks 28-34 of gestation (e.g. going to the toilet every 30 seconds)." 
 [Later on, this same poster added:
"- The employer has the right to decide his (or HER) own strategy for choosing the "BEST" candidate. This is what I believe a rational employer MIGHT do (for a position such as a physician or a CEO):
- If a male and female candidate had the SAME qualifications, SAME interview performance, and are negotiating for the SAME salary - and everything else is equal - then without further information (about future childbearing status), I would DEFINTELY choose the man. (Because they have equal likelihood of having a child, but if/when it happens the woman will require more time off work).
- If I knew the female had a Tubal ligation (but I am clueless about when/if the man intends to father a child) then I would DEFINTELY choose the female. (i.e. I am choosing the "sure thing" over a risk)
- If I knew that neither of them intended to start a family, then I would be INDIFFERENT."] 
Some commenters agreed with this biological rationale:
"I'm not saying sexism doesn't exist, but like the first commenter... intelligently said I believe this difference in pay check has more to do with pregnancy and the inevitable loss of money and utility for the company than anything else.... After all, if equality is what you are looking for, you can not work less than a man and expect the same pay check just because you are a woman. So, because of the biological diferences between men and women, I think job opportunities, salaries, roles, and available activities for both men and women will never be totally equal, and that has nothing to do with sexism but biology." [Comment #2]
"I think the only way a woman (or a man, for that matter, if the idea of paternal leave is a policy) could demand equal payment with the other sex is to prove that they are incapable of having children....which is fairly extreme. I'm very sensitive to the equality of women, but we must also be careful about 'overswinging' the pendulum." [Comment #8]
Other commenters questioned behaviors of women:
"There are dozens, literally, of other factors that congtribute to salaries in addition to simply hours worked. It is the misunderstanding of this issue, or the failure to recognize the true nature of this issue, then causes people to scream sexism... Of course there are those people who want to see sexism every where because it helps explain their own lesser position." [Comment #6]
"Here is my question for the self-titled "hyperfeminist", sexual organs aside, do you believe that men and women are different?  If not, I have no further comment. If so, do these characteristics differences translate to some sort of difference in their ability to perform work?"  [Comment #32]
Still other commenters argued that discrimination did not exist or that women were actually being favored:
"Men are judged solely on how much money they make and therefore work harder to make more money. Women are not judged solely by their salaries and numerous studies that are not ideologically biased have shown that women make different choices in where they study, what they study, how long they study, what extra work they do, etc that all explains the gender gap in salaries. Work done by Professor Stephen Cole at SUNY Stony Brook shows that there has not been gender bias in medicine since the 18th century... look at med school admission rates that far back and it has been proven."  [Comment #4]
"I completely agree, after reading this article I feel that these feminist views further support my belief that no matter how equal job opportunities, salaries, roles, etc becomes, certain women will never be satisfied. I feel "Hyperfeminists" are the reason why some men make sexist jokes or feel that women are treated unfairly well (i.e. admission into higher education is highly favorable for women at this time)." [Comment #3]
I am disturbed by the immediate responses for two reasons: 1) the community they come from, and 2) the fact that comments are fairly thought-out and presented as logical, non-sexist perspectives.

Commenters believe that it is legitimate to discuss average differences between two groups (males and females); I do not disagree.  

But when does a preference for particular individuals constitute an "ism" (which we have laws against)?  As the original poster pointed out:
"You want to hire a junior doctor at the local hospital. Two candidates - Andrew and Brett, are applying. They came from the same medical school, with the same marks, and perform equaly well on the interview. They desire the same, fixed salary. 
During the interview, you are impressed that Andrew is an extremely talented violinist in his spare time... and you are equally impressed that Brett is an extremely talented vert-ramp skater (i.e. "skateboarder").
However, Brett reveals "I am very passionate about my skating, and don't think I will stop any time soon. I'm always very careful, but there is a 50% chance that I'll have a fractured tibia in the next 10 years. It's a risk that I'm willing to take, and life is all about risk - however it means I might be out of action for 4 months".
Moral question: is it fair to choose Andrew over Brett for this reason alone? (All else equal)."

The obvious point the poster is trying to make is that yes, in this case, the discrimination is fair.  I would like to distinguish employer judgement in a hiring decision in a particular instance from an "ism," though.

In my opinion, an "ism" that should not exist occurs after a few criteria have been satisfied:

1) When group generalities become rules for individuals--e.g., in who to hire and how much to pay them.

2) When individuals have no control over the group to which they belong.

3) When one cannot (or reasonably be expected to) hide the group to which he or she belongs.

4) When it is nearly impossible to predict how an individual will do the job based on the group he or she belongs to.

Where it gets sticky, of course, is where to draw the line.  Gender, race, height, weight, religion, age, health.  The list goes on.  And what about certain professions with different standards?  At what point can employers choose their workforce without being accused of an "ism"?  

I don't pretend to have all answers for all situations, and so I am narrowing my scope to gender in medicine.  The aforementioned comments, I believe, constitute a form of sexism.

Commenters claim their views are grounded in the economic model we work within. That is fair, but--wrongly, I believe--there is nothing said of the normative, or "what ought to be."  Without this consideration, there is no impetus to address existing inequalities on a larger scale.

Later on, one commenter summed it up particularly well:
"Reading this thread I am impressed by the amount of tacit sexist comments and thoughts made by supposedly intelligent, 'progressive' students. I think it partly explains why we see this widening of the gap- just bringing up the idea of gender equality elicited such responses as, "we must also be careful about 'overswinging' the pendulum," (um, aren't we talking about how we're actually moving in the opposite direction?), and "there are those people who want to see sexism every where because it helps explain their own lesser position" (the entitlement of this comment makes me nauseous). Even more troubling is that these students seem to lack the awareness of how their comments come across, as if they wouldn't consider themselves sexist in the first place. I'm grateful to see some responders on here that seem as equally appalled as I, but the ratio of ignorant sexist comments to intelligent ones is disheartening."
Perhaps comments only select for the most vocal opponents.  But these are their attitudes, and one day they will be choosing our starting salaries.

Tuesday, February 15, 2011

"Don't You Want to Know What I Used to Do?"

Ms. R, a retired nurse, lives with her husband in Dorchester.  She has two adult children living nearby who she sees regularly.

By the time I get to a patient's social history--almost always elicited last after an exhaustive 25-minute interview--I have about one or two minutes to learn about their marital status and children, who lives with them, other social support, occupation, and hobbies and interests.

With my head spinning from trying to create a coherent narrative from non-chronological, incomplete, inaccurate retellings of current and past medical problems, I often do what a first-year on autopilot would: I skimp.  I rush.  I don't think.  I use standard questions.

"You mentioned your husband.  How long have you been married?"

"Do you live alone or...?" (We give the least agreeable option to normalize it.)

"Do you have children?"

"Do you still work?"

"What did you used to do?"

Those questions usually suffice to sum up a patient's identity for the write-up.  I have his daughter's age, so I cut his ramblings about her college accomplishments short.  He's an avid fisher; it's unnecessary to hear which fish get him most excited.  She's a homemaker; the fact that she's always longed to go back to school doesn't merit a place in the chart.  Tick, tick.  We move on to items I can write down.

It's a nonintuitive balance.  Though we're told to inquire about our "patients as people," their most interesting details get truncated in favor of the bland standard summary.  I suppose this makes practical sense.  But I don't particularly appreciate the sixth sense I've developed to gauge when a patient is getting "off track"--when I know I can stop listening and not miss anything pivotal, when I think about my next question or my last question, when I configure a strategy to guide the patient back to what I need in my write-up.  When it's just not "important" or "relevant."

Some months ago, I interviewed Ms. S, a 94-year-old woman with an ear infection.  Her medical history was fairly uncomplicated, she was incredibly talkative and intelligent, and she laughed a lot.

"You mentioned earlier that you sprained your ankle a few years ago when you were trying to move a table.  Do you live alone?"  Yes.

"Have you ever been married?"  No.


I stopped.  I couldn't ask how long she had been married.  I couldn't ask about when her husband passed away, or what from.  I couldn't ask about her children or grandchildren.  My brain, on autopilot, stumbled to make some sort of transition.  This lady was missing a large chunk of her social history.

She gently asked, "Don't you want to know what I used to do?"

Over 70 years ago, she worked on the atomic bomb (unbeknownst to her at the time).  For thirty years after that, as part of her job with the government, she had traveled around North America, South America, Europe, and Asia.

"I had a lot of boyfriends," she volunteered, unsolicited.  "But if I married, I'd be discharged.  I didn't want to lose that part of my life."

"It sounds like you enjoyed that," I added dumbly.  She rightfully took that as a cue to share even more.  I know most of it wouldn't make the write-up, but this time I listened and made no attempts to guide.

I walked away humbled.  Social history had always seemed so straightforward and formulaic.  Yet this woman had defied the formula, and 70 years later, she seemed happy and complete.

I aspire to that.

Happy Valentine's Day.

Note: Certain medical, social, and temporal details and quotations have been changed to preserve anonymity (while hopefully not altering the narrative and message).

Tuesday, February 8, 2011

This is a story without a title

This is a story about a story that may or may not be mine.

Sleep is the only thing that makes sense to me.  No one tells me that it isn't real.

A lot of things aren't real.  I wake up--late, because the sun is already on its way down--in a bed that I think must be mine.  That part is real.  The bed is there, and I'm in it.  Of course it's mine.

My clothes are on my chair, right where they're supposed to be.  My mother puts them there each night.  She doesn't like it when I call her my mother, for some reason.  She says I'm married to her, and that her name is Sadie.  Which is funny, because that's my mother's name.  I think it's also my wife's name.  My wife sometimes lives with us.

I wish she'd stop coming in.  I want to sleep.

There's something about food and pills.  Something about me and what I need to do with them.

I know she's doing her best.  I want to sleep.

It's not nice not to listen to her.  If she wants me to eat and take pills, of course I need to do it.  She's usually right about these things.

She talks to me, and I listen and sometimes talk back.  I'm sure I'm saying things that are tiresome; not because I remember saying them but because anyone who visits will eventually look tired of me.

No one really visits.

My brother lives across the street and I'm supposed to meet him outside.  I am trying to get the door open, but it must be stuck.  For some reason, my mother is screaming at me.  I usually stop when she does that, but this is important.  I need to meet him to tell him the thing we will talk about when I meet him.  Good God, why is she still yelling?

Anger.  It's been many minutes since the door got stuck.  It's dark outside and my brother is probably dead by now.  I know he's dead.  I remember his funeral; we shivered in our thick wool overcoats and gloves because it was winter in New York.

I really, really, really hate when this happens.  When things that are supposed to make sense make sense but backwards.  It's like I can see the future, except the future is sometimes the past.  She knows that I know that there are horrible things wrong going on inside my head.

She's short with me today.  I must have said something recently.

I think it's time to go back to bed.  My mother wishes I could stay away from the bed since I use it so much.  I'm tired.  It makes sense to use it when you're tired.

I want to sleep.

The sun is still outside my window.  It's on the wrong side of the sky.

It feels less bad to be here than in another place.  It feels good especially when I close my eyes and when real and not-real no longer matter.

Saturday, February 5, 2011

How to Finance Health Care, Part 2

Four weeks of Health Policy and it's over.  For those who can't understand why anyone would choose a profession being around sick people all the time, I would say that it seems infinitely more depressing to spend a career analyzing our impending economic collapse due to advances in medical technology.  As for what we've learned?  More about that in future posts, but suffice to say it's all about trade offs.  (Pro: it could be beneficial for the patient.  Con: it's expensive.)

How did the course alter our knowledge and opinions?  Seems that our self-proclaimed enlightenment did not persuade us to change our views on financing health care.  (Note: this is a different survey from the last and thus a different sample.)

At the beginning of the course (N=49):

At the end of the course (N=39):

At the beginning of the course (N=49):

At the end of the course (N=39):

Perhaps it's a good thing that we managed to be educated while holding steadfastly to our views.  This sample size of one learned quite a bit from a very unbiased course.

Friday, February 4, 2011

Don't Rule Out Sexism So Quickly

The media is abuzz about a recent study that found that the gender pay gap for newly trained physicians is widening compared to ten years ago.  Adjusted for specialty and hours worked, new female physicians made an unexplained average of $16,819 dollars less per year than new male physicians in 2008.

These adjustments counter the claim that the pay gap exists because women go into low-paying specialties and that they tend to work fewer hours.  That's good.

However, what's not so good is that the authors favor some hypotheses over others when explaining the gap.  They speculate that women are intentionally choosing lower-paying jobs because these jobs provide greater flexibility and family-friendly benefits, such as not being on call after certain hours.  Women may negotiate these conditions of employment which come at the price of commensurately lower pay.  This is certainly a fair hypothesis.

This is also the hypothesis that the media is picking up on.  It's intentional and not imposed; it's unfortunate but not unjust is the subtext.

But there is perhaps too widespread of an acceptance of this theory.

Why do the authors prefer this explanation over others in the first place?

The authors state that they cannot rule out other theories, such as gender discrimination and women being worse negotiators than men.  The main reason they say these theories are not consistent with observed data hinges on a single, pivotal point: that, in 1999, using the same adjustments, starting salary differences between men and women were not statistically significant.

"...we are unwilling to accept the theory that women have become worse negotiators in recent years," the authors write.

" would be difficult to believe that discrimination, after a period of quiescence, has actually been on the rise in recent years," they also write.

" the late 1990s, women and men earned roughly equivalent salaries after observable factors were adjusted for," they add.

I think we need to look at 1999 more closely.

Time to get back to basic stats: what determines a significant difference?  The answer is usually a p-value of 0.05, which is arbitrary but accepted.  This means that if the study were conducted repeatedly, 5% of the time, the "significance" found would be a false positive, due purely to chance.

In 1999--without adjusting for specialty or work hours--new women physicians earned an average of $151,600 versus $173,400 for men (a 12.5% salary difference).  About 17% of this difference ($3,600) remained after adjustments.

In 2008, women earned $174,000 compared to men's $209,300 (a 17% difference).  Roughly half of this difference ($16,819) remained after adjustments.  Clearly, the unexplained adjusted starting gap widened.

But unexplained starting salary differences between men and women in 1999 were not found statistically significant.  Why?  The p-value was 0.08.  In other words, there was only an 8% chance that the difference in findings were due to chance.  But, in the world of statistical significance, 8% is simply not 5%.  (In contrast, p < 0.001 in 2008.)

So, if we repeated this study 100 times in 1999, 92 times we'd find a difference between starting male and female salaries.

Is it misleading to state that the pay gap in 1999 was not statistically significant?  No.

Is it misleading to state by the late 1990s, women and men earned roughly equivalent salaries after observable factors were adjusted for?  Only if you think that a $3,600 difference (~17% of the unadjusted salary figure) with a p-value of 0.08 is "roughly equivalent."

Onto the bigger questions: how does the 1999 data affect the author's conclusions for 2008?

The authors toss the sexism hypothesis mainly because they suggest that gender discrimination has been in a "period of quiescence" due to the 1999 data.  This is a far greater leap than what the 1999 data actually suggests.

The authors toss the women-are-worse-negotiators theory for the same reason.

All of this lies on the very large assumption that in 1999, things were fine and dandy.  They could have well been.  But there is only an 8% chance that they were.

(Update: additional thoughts here.)

Tuesday, February 1, 2011

Third Space Magazine Linked in Wall Street Journal

It's an honor to be listed alongside such established, prestigious magazines as the Bellevue Literary Revue and Pulse.

We currently capture the voices of HMS students and physicians, but we are looking to expand to other medical communities.  As a free online journal, we are accessible--and we want to access more!  Featuring prose (nonfiction or fiction), poetry, artwork.

Submissions welcome at  

Sunday, January 23, 2011

Do Medical Students Know How It Feels to Be Uninsured?

Up in the Ivory tower, do tomorrow's doctors know what it feels like to be without insurance?  About one in three Americans between the ages of 18 and 24 is currently uninsured, and about one in four of those ages 24-64 is.  Harvard requires us to have insurance while we are in school.  Have our classmates ever been without?

N=55 for this survey.

Age (N=53)
The mean age of the respondents was 23.75 years, and the median was 23 years.  About 90% of those who answered were between the ages of 22 and 25.  The oldest student was 33.

Types of Insurance (N=55)

Respondents were not restricted to a single choice, and no time period for a type of coverage was specified.  Thus, coverage types may or may not have overlapped.  All students had had at least one type of insurance: 11 students had had one type, 22 had had two types, 19 had had three types, and 3 had had four types.  Age did not correlate with how many types of insurance a student had had.

All but one student (with private non-group) had been on either dependent or school-based coverage at some point.  All three students on Medicaid had also been on school-based insurance at some point.  One student ("other") had received coverage via an international organization during an internship.

Uninsured at any point? (N=55)

Since Harvard requires that we have health insurance to attend (and Massachusetts has an individual health insurance mandate), the base assumption was that all students are currently insured.  Only one student mentioned in the free-response that s/he was between insurance plans and was planning to get insured soon.

Just over one-third of students had been without insurance.  The average age of this group was 24.5 years, and the median was 24 years.

Regarding the two-thirds of students who had never been without insurance: the average age of this group was 23.35 years, and the median was 23 years.

An F test revealed equal variance between the two groups (p=.00015).  A two-tailed homoscedastic T test revealed a significant difference between the ages of the two groups (p=.039).

Characterization of uninsured period (N=20)

To determine the nature of the uninsured period, I asked two questions: 1) How long total have you been uninsured, and 2) Why were you uninsured?

Answers ranged from one month to 10 years, so a strict average would not be helpful for characterization.  Instead, I will divide time periods into short- (<6 months) and long-term (>1 year) periods.  The reason I chose this classification is that no one was uninsured for a time between 6 months and 1 year, suggesting a natural break in the data.

Short-term uninsured period (N=9)

Three students answered one month; the rest answered "several" or answers between 2 and 6 months.

Six of the nine students described the reason as being in an "in-between" period: either between schools, jobs, or plans.  Two more mentioned simply not buying a plan, and one mentioned being unable to afford private non-group insurance.

Long-term uninsured period (N=11)

All three students who had been on Medicaid were in this group.  Six students mentioned cost, four students mentioned that their parents did not have coverage, and one student mentioned having a part-time job without health coverage.

Revised graph of insured vs. uninsured

No other questions about demographics or attitude were asked.  This is simply a snapshot of 55 first year HMS students.  Slightly over one third of them have been without insurance at some point, and one fifth of them have experienced being uninsured long-term.