Moving

I have moved to http://rumorsweretrue.wordpress.com

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I know it's a pain in the ass, and I apologize. The new place has everything I've written since the first day of first year (whereas this site only began in my second year). Things are better categorized and navigable. I like the layout and the ease of use as well.

So, sorry for moving. The Drunk-Driving post will be finised at the new site after my exams this monday.

See you at the new place, topher.

Grand Rounds 2.52

Grand Rounds is up at Tundra Medicine. Go read the week's best writing from students, nurses, doctors, etc.

Drunk Driving

I do not care much for scare tactics. It is a right of passage in high school that a local police officer comes before the entire student body to give a lecture on the dangers of drunk driving. I remember hearing about it beforehand that this guy used scare tactics and would show us a bunch of car crashes that claimed the lives of teens 'just like you'. Most of my friends thought, “Cool! I like car wrecks. Let's see who totaled his car the worst.” Slide after slide of cars bent around trees, charred from fires and road scenes cleared of everything except a little blood on the asphalt clicked by. We would snicker to each other, “Wow, that guy must have been going fast.” Sure, we were being callous on purpose, but the consequences just couldn't register anyway. Then he brought out the beer goggles.

These were thick plastic lenses that horribly distorted your vision. He lectured us about the level of alcohol in your system after a single beer, and how you were drunk after just two. Don't believe me? I'll show you what it's like for someone your age after two beers He asked someone to come onto the stage to wear the goggles, and he would let us all laugh at our friend's inability to walk against his best efforts to just ‘maintain’. That’s when the officer would yell sternly, “That’s what it’s like when you’re drunk! Not funny, is it!” What a bag of mixed messages.

Presentation style aside, we didn’t take him seriously because we knew the magician’s trick. We had all been drunk and, from that, we all knew that those goggles were far from our experience. Inebriation after two beers was far from our experience. His mistake was trying to shock and scare us into doing the right thing when giving us the information about alcohol's effects and trusting us to make the right decision might have worked. After all, regardless of what is said in a lecture hall, the decision was going to be ours.

The reason I am relating this: it was not until I was in medical school that I was given all of the information about alcohol that would have been so useful then. Though I long ago recognized the unacceptable risk of driving drunk, it’s only now that my decision feels informed. I do not see why this moment has to come $100,000 later, eight years out of high school. Worse, I recognize that very few people are ever in this position to learn it.

I'm going to try over the next few weeks to lay out everything that I have learned in the past two years that has helped me reconcile my experience with alcohol with the science of alcohol. I want the person interested to understand the greater story of how our body and brain interact with alcohol, why understanding it is exciting in and of itself, and how knowing all of this might help you put your own experiences into a context more helpful than a car crash.

It is my hope that you can make the decision yourself, informed.

***

The brain is divided both in shape and in function. In shape, we are used to thinking of a left brain and a right brain, but the biggest differences are between higher and lower function. The classic picture of the brain is of the mess of infoldings that is split down the middle. This is your cerebral cortex with its left and right hemispheres. The highest of your thoughts live here. Pronouncing a word, telling a joke with the right emphasis, drawing a picture; all of it is happening somewhere inside those folds. Not every spot is created equally: some of the areas in your cortex are incredibly important (being able to speak) while others are less important. For example: Phineas Gage. The most famous survivor of brain damage, Phineas was a railroad worker who accidentally triggered an explosion that sent a railroad spike through his cheek, left eye, and into his brain. The only thing that changed was his personality. James Shreeve writes “[i]n place of the diligent, dependable worker stood a foulmouthed and ill-mannered liar given to extravagant schemes that were never followed through. ‘Gage’, said his friends, ‘was no longer Gage’.” Even so, he was still alive and functioning.

It is hard to understate how incredible an idea this is. There are parts of our brain that, should they go missing, we may never care. There are parts of our brain that when damaged, merely change aspects of our personality. Remove the entire brain and we certainly die. Exactly how much of the brain could be whittled away before we could no longer live? What parts are essential to life and what is going on there?

***

Why do we drink? I am not trying to be philosophical, but I am trying to reduce the urge to what it is: it pleases us. We drink in celebration, to lower inhibitions, to blunt depression, to satisfy addiction. The ways in which alcohol is used and abused are not important for the discussion here, but I do want you to appreciate how powerful a motivator our own pleasure can be.

In the 1950s, two scientists performed a famous experiment on rats. To map the brain (even now in neurosurgery) the physician will electrically stimulate an area and test for the expected response. Imagine a patient awake, with his brain open to the air, as a surgeon electrically disrupts certain areas looking for the portion of the brain that stores “mammals”, for example.

“Okay Jimmy, I want you to name every mammal you can think of.”
“Elephant, dolphin, tiger, ...daaaaaa”
“Got it!”

Today’s neurosurgeon benefits from a rough map of the brain that has been established over years of investigations. But what if you didn’t have even a rough idea? What if you were back in the 1950s? Peter Milner and James Olds decided to poke around.

They experimented by implanting electrodes into the brains of rats, electrocuting them, and watching for the effects. They found that with a certain placement, the rats appeared to experience ecstasy on stimulation. Had they found the rumored “pleasure center”? Next, they introduced a lever into the cage that the rat could press at will to send a stimulus directly to its brain. What they found was disturbing: the rats would press the lever 2,000+ times an HOUR. They rats wanted it more than food and water. They would press it until they died.

***

This post will be completed at my new home, The rumors were true

Six months

Six months. In six months I will have taken the USMLE step 1. I will go home, pack my bags, and get on a plane. In six months I will be in Southeast Asia.

I will swim with fluorescent algae. I will push my arms through the water and watch as their outline of my arm glows green/blue and then fades. I will get out of the water and watch the drops fall clear and splash brightly against the sand. It will be like cold, liquid fire.

Vietnam, Laos, Thailand, Cambodia. Two months between the USMLE and Clinicals in New York. My backpack, my roommate, and the $4000 I didn't spend on a Kaplan course.

Southeast Asia. Six months.

Can't wait.

Psych 0-5

Another psychiatry experience today. This man hallucinates fisherman turning into giant frogs. He describes smells coming to attack him. He was jealous of his brother's success so set fire to his mother's house. He tells us all of this while smiling. He says that his sister, who died years ago from GI cancer, visits him in recurring dreams. She keeps trying to have sex with him, he says. He's missing a leg. Really 'missing' it, as in, can't remember where it went. His file says that after setting fire to his mother's house, he attacked his guards in prison and they shot him in the knee. No heroic measures were taken to save the limb.

All of that sounds interesting except I can't focus on any of it. There's a patient in the courtyard outside the window whose been playing the guitar for the last two hours. He's a very good player and singer. I wish I were outside and far away from this guy's problems.

I told my roommates today that I was very close to ruling out psych altogether. They all laughed at that: "Like you could ever be a psychiatrist." I'm not offended by this at all because it's just so completely true.

SHOUT*!

Every once in a while, I write home to my family.



My landlady just popped and brought the baby over. While my roommates are cooing over how cute he is, I ask if I can hold him. Want to know a cool trick about babies?

If you let a healthy baby's head drop suddenly, it's arms will reflexively extend and grasp. I think this is a defense against falling from the mother's arms. Instead, I like to use it in the following context where "*" means dropping the baby's head.

"Now waiiiit a minute. You know you make me want to SHOUT*! Come on now, SHOUT*! Come on now, SHOUT*! Come on now, SHOUT*!"

By the way, this never gets old.

Greetings from St. Vincent.

Medical school is much different now. The material is coming like a flood, and every second you spend marveling at how much work you have to do you're ending up farther and farther behind. Procrastination, I'm learning, is a luxury I don't have.

Instead of teaching me how the body breaks, they're teaching me how to fix it. I know this is the point of medicine, but I swear to you that over the last 18 months I completely forgot about it. I'm also learning that the body, while split into the parts of heart, lung, liver, etc., is still connected. Say goodbye to the days of easy questions that dealt with just one of these systems and say hello to the ricocheting questions that begin in the stomach, enter the heart and leave the spine. It's all much harder, but in the way that it should be. I'd be disappointed if this ever got any easier.

Alice is ten feet tall and drugs are fascinating. Learning all of their names, side effects, contraindications and uses is like getting the keys to the car when you're sixteen. That you'll crash the car is a given, but dammit if it isn't exciting! What's worse, while I'm getting excited over a few names and a basic understanding, I still have no concept about delivery method, dosing, chronic v acute management, which drugs are more expensive and which drugs have conflicting benefits in the literature. I'm going to be stupid for a long time yet.

The school is REALLY trying to help us look the part for clinicals in New York. To get that newbie shine off of us, we're getting soiled in the local hospital. Everyone goes twice a week to round with physicians and answer questions incorrectly. It's great.

Embarrassed to ask a 60-year-old about her sex life? Newbie shine.
Hesitant to lift a woman's breast to listen to her heart? Hope you don't get any blood on your scrubs? Can't tell a collapsed lung on an xray? Newbie shine.

It's slowly coming off.

Anyway, the work is killing me and I have to disappear for a month. I'll write again when some funny things happen. Oh, other things that happened since I last wrote:

Went to Milwaukee to give a speech. It went well. Went to Michigan for vacation with the family and became more tan than I ever was in the Caribbean. Went to Alabama for research. I got to dissect a fresh cadaver, which was incredible. The 70-foot stained glass window I made was finally installed in my patron's home. I'm very proud of it. My youngest sister took off for College in Colorado. I'm very proud of her.

SHOUT*!

This is what I'm talking about

The other day I had some sour grapes over my experiences in Psych. My feeling was disappointment over the disconnect between what I read from folks in the field and what I experience clinically. For those that don't get the chance to surf as much, The White Coat Rock has two excellent posts today:

Drugs, Hugs, Hags, and Has-Beens:

"There is nothing lamer than people who live a sort of drug-filled, hedonistic lifestyle, then come to see the light and become crusaders against what they once enjoyed. You find this occassionally, former hippies or scenesters who suddenly find religion and then go around telling everyone 'Yeah, I did this stuff, and really enjoyed it too. But I realize now it was wrong, and you all shouldn't do what I did.' Hey, you had your fun, so keep your fuckin' mouth shut and let others find their own paths.

That is my brand of anarchism: don't let anyone tell you what the limits of your experiences on Earth should be. It's your right to fuck up. Just don't whine so much if you find yourself down and out."

Personality, or Lack Thereof:

"I've been in a pissy mood recently. Inexplicable. Need to remember to leave my knife at home. Can't afford to get into any knife-fights.

Anyway, I've been thinking about personality disorders recently, since we talk about that a lot on the psych wards. I don't like the idea, never have. As far as I can tell, the personality disorders were invented by psychoanalysts who got frustrated by patients they couldn't pin on a discrete diagnosis on, but who had enough indiosyncrasies for the therapist to suspect they 'just weren't right.'"

The Bell Curve

Those outside of medicine, I want you to know this: doctors are doctors because they know medicine. They are not doctors because they are great teachers. And who teaches future doctors? Doctors do. For students looking to learn, it's the lottery of the bell curve. Will today's doctor also be a great teacher, an ok one, or confusing? Most of us will end up drawing in the middle. This week it feels like I'm on the losing tail.

To the clinical tutors I have had this past week, this is my open letter to you:

If you ask me to take a patient's history, then let me. Do not interrupt me because you think that asking her about her work with the church is irrelevant: I am trying to assess her physical activity and social support. This will of course vary if she simply attends or if she helps in community building activities. Savvy?

Every time you interrupt me, don't kid yourself that it is for my benefit. You have, in your mind, the order of questions that you would ask. I know you think it's the best, but it can't be, because every single tutor has a different order. What you ARE doing is upsetting my rapport and rhythm, confusing both the patient and me. So, if your goal was to teach me, you're steering us into rocks.

When I ask the patient, "So what brings you here today?” they always respond with their chief complaint. Never has one of them responded with "the bus" or "my Dad" or "my legs." Every time you interrupt me to say that I should have asked that question in such a way as to preclude these responses, you are proving to me, beyond doubt, that you are only interested in finding ways to assert yourself. It's like being taught by a smartass fifth grader. Stop it.

If there are two of you overseeing the group, agree beforehand as to which of you will be the leader. When you interrupt and contradict each other, it's bad for both of you. My options here are to assume that one of you doesn't know what he is talking about or that one of you is an egomaniac who has to assert himself. Nice teamwork.

If your goal is to mold students in your own likeness, then lead by example. If you quietly do an amazing job and explain to me why you make certain choices, I might just decide to emulate you. Slinging mud at other doctors and then bragging about being clean does not impress me.

How are these things not blindingly obvious?

When you pimp me, what are your goals? If you want to teach me how to think like a physician, then lead me with your questions in that way. If you want to show me that you know more, then please, continue to ask the same question repeatedly, basking in the six minutes it takes before someone's dart in the dark hits your bullseye.

I feel like I owe you, the reader, an example.

The physician is asking us about the presentation of a complete break in the femur (thighbone) that is displaced (pieces are side by side). We say immediately that the thigh will be shorter (because the broken pieces slide up against each other since the attached muscles are still pulling). However, we were missing something.

"What else would you see?"
"Bruising?"
"What else?"
"Patient is in pain?"
"What else?"
"A bump where the femur is displaced?"
"What else?"

Pretty annoying, right? Doesn't exactly have you thinking like a doctor, does it? Here's my idealized version of the same conversation:

"Why is the thigh shorter after the complete break?"
"Because the attached muscles are still pulling."
"Do those muscles simply pull in one direction?"
"No, sartorius is involved in external rotation."
"So what else would the muscles do to the leg that is broken?"
"Oh, externally rotate it!"
"Correct."

I haven't had that tutor yet. I'm waiting for the law of averages to give me some time on that better part of the bell curve. When I get there, I'm going to try to become a sponge. For now, I'm trying to stay Teflon.

Wasted Mind

I have no idea if this is normal. Going to school in the Caribbean is great, but it isn't the US, and for that reason I always catch myself wondering if my experience is a "normal" experience comparable to my US studentdoctor peers. Here goes:

I'm still in M2 and the school is interested in giving us a lot of clinical exposure before the clinical years. It's the logic of pre-kindergarten. Twice a week I'm off to the hospital with my roommates to sample Peds, Med, OBGYN, etc. In addition, we have Clinical Skills, a class where we take non-sick volunteers and try to work them up for the Congestive Heart Failure that they don't have. So once a week I'm reporting a 3rd heart sound that I don't hear or a nodular liver in another healthy person at the urging of the tutor and feeling very silly. I am fine with all of this.

I am not fine today. Today, an announcement was made in the morning that there will be no Clinical Skills lecture before we see our patients. Mind you that this is four hours away and there will be no effort made by ANY of the physicians available to give a talk, even briefly, on how to conduct a psychiatric exam and the special challenges therein. Almost forgot: I heard a RUMOR that we were interviewing psych patients today. I'd like to get these sorts of announcements from the school before the day of, maybe posted somewhere, but that doesn't happen with the frequency that logic would dictate.

So with no preparation we enter the room. The psych patients will not arrive for another half hour because they have to take their meds at the hospital before being bused over. What?! I don't consider myself a cruel man, but it's going to be hard evaluating someone for a psychiatric disorder when they're TRANQUALIZED. Can't we leave them unmedicated for a while, loosen the leash and let them explore the space? Don't I need to SEE the problem if I'm going to learn to DIAGNOSE the problem?

"You feel fine? You don't know why you're here? You feel happy?"
"This patient is being treated for schizophrenia with delusions of persecution," says the tutor.
"Well the patient can't seem to remember any of that right now."
"That's because he's medicated." I know, you dolt.

What a waste of my time. I could have played tennis against a brick wall this last hour and at least had pit stains to show for it. And what a missed opportunity! This time the patients actually HAVE the problems that we study. I couldn't have been given a heads-up about this for some time to prepare? I hope such poor execution isn't normal.

***

So much of what I read online is written by folks in Psychiatry. We've all read House of God, some of us have read Mount Misery, and all of it seems fascinating. Who doesn't like leafing through the DSM and thinking of the people in our own lives? The mind is why I loved and studied philosophy. It's why I did well in Neuroanatomy. Hell, I've cut a brain out of someone's skull and held it in my hands. It's exciting that so little of what goes on in the brain is understood because that means there is so much more room for discovery. To hear people talk about the patients they treat, the things they say and the sometimes profound shifts in personality that medication can induce makes me want to abandon my dream of surgery and dive right in. I'll admit that, as someone who likes to write, the laziness of just reporting the absurd that someone else invents is attractive.

Instead, it's like hearing about the greatest tasting strawberry icecream and not having a tongue to taste it.

I won't do something stupid and level judgment against a discipline because of a few patients but I will say that, so far, I have not liked psychiatry one bit. I don't have the patience. I don't like staring at a talking rubicks cube, trying to figure out the right moves to let some bit of truth slip out. I don't like feeling that I have to trick a patient into contradicting himself to help him understand something. I cannot stand the repetition. I don't like seeing people tranquilized, or talking to people with no memory, or watching someone fidget and pick at herself uncontrollably. I know that these people need the help to beat those problems; I just don't think I want to be there for any part of that journey. I'd rather just read about the successes.

I hope it gets much much better. I'm afraid that it won't. Any words of (dis)encouragement would be welcome.