Poem: Ex Lap

An ex lap or exploratory laparotomy involves a surgeon opening up the abdomen to investigate for potential problems. It often involves "running the bowel" - following the length of the intestines to make sure they are intact.
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Ex Lap

I stop threading the bowel through the eye of my fingers
when I see two veins tracing your initials.
Why I left you, I can't say
but I nearly bend over
like a crane
to kiss
your name.

Why Philosophy

A couple weeks ago, I was asked a simple question: why philosophy? Why should it be studied, what does it offer to the philosopher, and what import does it have on a larger scale? I like questions like these. After all, it's a philosophical one, meta-philosophy, if you will. Philosophy is a central and irrevocable part of my life and my thinking. For me, why philosophy has been easy. Philosophy is beautiful; to me, it's the art of ideas and argument. I believe there is a fundamental value of studying beauty for beauty's sake; we admire great paintings and sculptures, listen to moving symphonies and operas, read the classics of literature simply for their own sake. In the same way, ideas move me, and philosophy, the study of those ideas and questions too basic to have a home in any other discipline, fascinates me.

We gather our ideas in some haphazard manner as we meander through life; some are inherited through family and culture, some are molded from personality, some are forged through experience and hardship, some are learned from others. Whether we are selfish or selfless, believe in fate or self-determination, trust in God, have a soul, abide by the law or break it in peaceful protest or flout it in singular defiance, these traits are an accumulation of random event and experience. Whether we believe in democracy or communism, capitalism or socialism, creationism or evolution, science as cure or curse seems to depend on who has influenced us.

To me, philosophy is the great equalizer. Descartes, often considered the father of modern philosophy, called upon us to discard all our beliefs and rebuild them rationally. It is fine to be an anarchist or nihilist or skeptic or utilitarian as long as those beliefs are supported by logic and rational argument rather than whims of parents, teachers, experience, or fate. Philosophy forces us to face our frames of reference head-on, and the beauty of it to me is that secure philosophical argumentation can change people. Many of my beliefs ranging from the existence of God to the limits of science to the nature of language to the importance of free will have been entirely governed by rational argument and the study of premises, logical steps, and conclusions.

My experience of philosophy has been a distinctly personal one; philosophy is not done in smoke-filled whiskey-laden bars, but rather the company of oneself. So what does it offer to society as a whole? This is a harder question for me to answer, and perhaps one in which I must take refuge in the popular perception of philosophy. Perhaps by having people ask and answer these questions, we add greater depth and meaning to our human experience. Certainly, we could go through our lives simply meeting those basic requirements of living: eating, sleeping, working, reproducing, but perhaps one of the qualities that makes us as humans different than animals is that ability to introspect, reflect, ponder, and question.

Image shown above is Jacques-Louis David's "The Death of Socrates," oil on canvas, shown at the Metropolitan Museum of Art, taken from Wikipedia, in the public domain.

Mystery Ride

Robert Boswell's Mystery Ride is the latest fiction novel I've read. I was introduced to this book in the first creative writing course I took, a sophomore at Stanford. We read the first three chapters as an introduction to character and tension, and I was intrigued. I then met Robert Boswell at the Napa Valley Writers' Conference last summer. I really liked him; he was a captivating lecturer and his stories are hilarious and discomforting at the same time.

Like most American novels, Mystery Ride is a story of a dysfunctional American family, tracing the interaction of several families in various states of divorce, affairs, infatuation, religion, teenage rebellion, and pregnancy. He sets this clash of culture on the backdrop of California and a farm in Iowa. His characterization is amazing, and the situations conjured by his characters have intense drama, emotion, and tension. The dialogue is witty, the character development is believable, and the details are vivid. I recommend this novel to any avid reader. In it, Boswell really attempts to capture what it means to love, what it means to live.

Image shown under Fair Use, from Amazon.com.

Certified

The residency list is in. Good luck to all my friends and classmates on the match! And thank you to friends, family, and faculty for helping me figure out my list. What I've realized is that on paper, many of the programs are nearly indistinguishable. All the ones I visited offer outstanding clinical training, and though case load and case diversity vary, the stipulations of the accrediting body ACGME narrow that disparity. Nearly all the places I visited offer strong research opportunities, send residents to fellowships, and prepare them for academic positions. Some have unique aspects - innovative research programs, simulator training, combined residency/fellowship programs, opportunities to do anesthesia on zoo animals. But I think each program distinguished itself through an ineffable yet salient quality - some mixture of personality, gut response, environment, attitude, dynamics, and luck. Though programs on paper only differ in details, my mental image and perception of them flowered with the visit. I don't think it was particular descriptors that differed: all programs were friendly, welcoming, cordial, professional. But at some interview days, I felt the residents were more similar to me or I found myself brimming with questions or I was simply happier.

In any case, I know my personality. I am never 100% certain of the right decision. But once a decision is made, I don't regret it. I really enjoyed visiting residency programs and I don't think I could say which ones were the best, only which ones seemed to fit me, my expectations, and my goals most closely. In any case, for the rest of the week, I'm going to blog about non-medical topics just to get a little distance from school and the rest of my life.

Robots

I like robots. They're cool. They're slowly making their way into medicine. The Da Vinci robot shown above is a surgeon-controlled robot that allows minimally invasive procedures such as prostatectomies. It acts similarly to laparoscopic instruments; the robot controls the tools and camera which allows a surgeon at a console to operate. The system translates the surgeon's movements into precise, fine instrument commands, filtering out tremor, and allowing greater range of motion. Safety features reduce operator mistakes. The surgeon experience may be better, allowing more ergonomic maneuvering than traditional surgery. Importantly - and often this is confusing for patients or the public - the robot never acts on its own; it's simply another type of instrument for the physician.

The data is equivocal; robots are expensive, robotic surgeries take longer than regular surgeries, and outcomes don't show that robots are superior. So I'm not sure how I feel about robotic surgery presently. Nevertheless, I think there's potential for robotic surgery and I think it adds to the repertoire of surgical skills. For example, laparoscopic instruments make me think of long arms that only operate at the elbows; in contrast, robotic instruments can have a wrist to allow rotation, flexion, and extension within the body. I also think that the safety mechanisms can improve patient care; obviously, surgeons with a mild tremor cannot operate now, but with a robot, would they be able to? Lastly, like telemedicine, could robotic surgeries allow surgeons to operate remotely? Certainly, we would not want this commonplace, but what if someone needed surgery in Antarctica? or the space station? (How a robot would get there, I'm not sure).

Image of the Da Vinci Surgical System made by Intuitive Surgical shown under GNU Free Documentation License, taken from Wikipedia.

Poem: What Guile is This?

I decided to attempt a form today. The Spenserian sonnet, while less known than the Shakespearean or Petrarchan, is one of my favorites with its interlocking rhymes.

What Guile Is This?
Edmund Spenser

What guile is this, that those her golden tresses
She doth attire under a net of gold:
And with sly skill so cunningly them dresses,
That which is gold or hair, may scarce be told?
Is it that men's frail eyes, which gaze too bold,
She may entangle in that golden snare:
And being caught may craftily enfold,
Their weaker hearts, which are not well aware?
Take heed therefore, mine eyes, how ye do stare
Henceforth too rashly on that guileful net,
In which if ever ye entrapped are,
Out of her bands ye by no means shall get.
Fondness it were for any being free,
To covet fetters, though they golden be.

Imitation is the sincerest form of flattery. Here is my sonnet.
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What Guile is This?

What guile is this, that crimson dress unfolds
over skirt of ivory, petticoat of lace,
white gloves concealing smoothness untold
and innocence framing such a charmed face?
For months we drilled this charmed race
waltzing in jeans, drenched in sweat,
our silhouettes sans poise, intention, or grace.
As weeks dwindled by, I began to forget
why I labored these figures and turns. Yet
the moment she stepped out, epiphany took:
she was as beautiful as the day we met
and my memorized steps fled with one look.
What transformation a Victorian dress bought!
(and no one noticed the steps I forgot.)

Chess, Computers, and the Future of Clinical Research

I just read an outstanding article titled "The Chess Master and the Computer" by Garry Kasparov in The New York Review of Books (Vol. 57, No. 2, 2/11/10). In this article, he recounts the Man vs. Machine battle of chess in the late 1990s and then explores the implications, psychology, and meaning of artificial intelligence overtaking humans in one of the greatest, timeless, and most complex games invented. I highly recommend googling and reading the article.

I love chess. As mentioned by Kasparov in the article, it is an amazing game because all the rules are defined and all the relevant information is available to players. Chess is predominantly a battle of strategy, reasoning, and planning whereas a game like poker also employs elements of psychology. But because chess is a transparent game, the information can be fed into a computer and with the right algorithm, brute force tactics can be employed; computers can try every single possible move and look at millions of possible scenarios to determine the optimal move. Interestingly, Kasparov argues that there has been much technology but little innovation; newer chess programs simply take advantage of faster processing speeds without changing the base algorithm.

I wonder what we can take from this in terms of computers aiding clinical decision making. The problem becomes even more complex with medicine because the information is incomplete and the rules are undefined. Take something as simple as a baby aspirin for primary prevention of strokes or heart attacks. Aspirin is well defined in secondary prevention - it reduces morbidity and mortality in patients who have cardiovascular disease such as coronary artery disease. But aspirin's risk-benefit balance is unclear in primary prevention - the effectiveness in healthy patients with no medical problems. Aspirin's risk is major bleed including gastrointestinal bleed and hemorrhagic stroke.

Could a computer help clinical decision making here? Perhaps. Randomized clinical trials, the gold standard of clinical research, have enrolled tens of thousands of patients, but the bottom line for most practicing physicians is the conclusion that mortality does not seem to change and the benefits and risks balance each other out. Computers, on the other hand, can process so much more information. What if computers knew unlimited information about each patient enrolled? Could the computer find trial subjects that were similar to the patient? Could patients be matched to research participants in terms of age, gender, frequency of doctors' visits, other medical problems, family history, ethnicity, alcohol intake? Could we compare even more obscure factors: socioeconomic status, job, marital status, impulsive or high-risk behaviors? Could a computer then identify a similar person and make an accurate prediction about whether aspirin would help? This level of processing would be impossible for a human, but for computers, the limiting factor is a database.

I think this may be the future of research. It reeks strongly of genomics, which has influenced me greatly. Computers can help us move towards personalized medicine by taking enormous bits of information - gene expression of 20,000 genes or a database of a hundred thousand research subjects - and extract from that a conclusion specific to the patient. It also departs from the dogma of clinical research that randomized controlled trials (RCTs) are the best source of data. I know this is heresy, but someday we might say RCTs are limited because they lump large numbers of people together when instead we should be individualizing and personalizing medicine.

Image from Wikipedia, shown under GNU Free Documentation License.

Preparation

"Chance favors the prepared mind." - Louis Pasteur.

Today, I went to an open procedures lab at the UCSF simulation center which was really fun. I practiced lumbar puncture, intubation, IV lines, intraosseous lines, and umbilical catheterization on models (it's run by pediatric intensivists). Hands-on activities are always fun for medical students, but no matter what we're doing, we're cautioned that the most important part of the entire procedure and the main determinant of its success is the preparation. Does the patient understand what you're doing? Did you get consent? Do you have the help you need? Are your supplies ready? Do you have space? Do you have time or are you rushing through it to make it to lunch? Have you thought through all the steps? Have you confirmed the indications and contraindications?

Third year medical students are lucky; the resident takes care of all the hard stuff: the needle size is selected, the patient is positioned, the IV setup is within reach. But now I'm really beginning to appreciate the importance of the set-up. In the procedures skills lab, I spent more time reviewing the preparation for each procedure than practicing the procedure itself, but that's the way it should be. Even outside of procedures, this is important. Whether it is calling a consult, delivering bad news to family, or reviewing records prior to seeing someone, preparation is everything. Success favors the prepared mind.

Image of Louis Pasteur is in the public domain, taken from Wikipedia.

Overheard

This is from a department chair of medicine.

"Max Planck once said science advances one funeral at a time. With modern medicine, people are living longer and longer, and thus we are slowing the advancement of science."

I laughed at this joke. Max Planck, of course, was caught in the heyday of quantum mechanics, a scientific revolution of immense magnitude. This Kuhnian "paradigm shift" has always fascinated me, and indeed courses in philosophy of science focus entirely on this change in thought. The Old Guard - physicists trained in the early 19th century - were absolutely baffled by black body radiation and the photoelectric effect because it did not fit in their paradigm of thinking. Even when the emerging scientists - Planck, Einstein, de Broglie, Heisenberg, Born, and Dirac - began to create a new theory to accommodate these phenomena, the Old Guard put up resistance. How could there be non-Newtonian physics? It's simply inconceivable, they felt.

But science advances one funeral at a time. As the old physicists passed, these new, brash scientists came into prominence and as they gathered momentum, they effected what Kuhn calls in The Structure of Scientific Revolutions a paradigm shift. Now, high schools teach quantum mechanics.

Medicine is not so different. We do so many things simply because of tradition. Why take 30-hour call shifts every 3 nights? Because the attendings did it back in their day. Why structure the day around rounds or the hospital around wards or residency funding around inpatient rotations or reimbursement around insurance company battles or litigation around case-law? Certainly in some or most of these aspects, we're doing what's optimal. But in order to advance medicine, we must not get locked in the past; otherwise, advancement is simply waiting for us to pass ourselves. Creativity, innovation, and change are the core of all our endeavors.

Image of Max Planck from 1910 is in the public domain, taken from Wikipedia.

Poem: New York, New York

New York, New York

"Now, this is a city" I said among unfolding arms and boughs of snow, cradles of coffeehouses and that scent of Starbucks roast, pinnacles and triumphs and towers of glass, sprouting chimneys gracing ash, blaring horns, cartwheeling staircases, skirting slalom those black-bag edifices astound! the smell of baking bread and baking desserts, that crumble of creme brulee, those crates of vegetables, the slit-snap of plastic restraints binding those newspapers, and strangers encroaching upon my space in that rumbling mausoleum, the seismic concrete, the snowbanks piled wet with the cries of sledding. escalators escalate! as we weave through department stores, forests of mittens, crowded monuments, a diversity of sound, the lights descending, the taste of urgency, migrating across culture and innovation in droves, we find peers in paleontologists, poetry in poltergeists, this city of scarves whose breath in heaves awakens.

Happy Valentine's Day

This picture is courtesy of my classmate Stephanie, from an article titled "You Are Always On My Mind" in the American Journal of Roentgenology. The choroid plexus in the left lateral ventricle is calcified. My friend Kate proposed this caption: "We all have a ventricle in our heart, but how many of us have a heart in our ventricle?" Happy Valentine's Day!

Image is shown under Fair Use for educational purposes, from the American Journal of Roentgenology, 2003; 181:170, Balaji, Jairam, and Chacko.

Match Day (Book Review)

Match Day by Brian Eule is a narrative account of three women as they approach that culmination of fourth year of medical school, match day. On match day, medical students across the country find out whether and where they are going to residency. To most, if not all, it's a stressful experience filled with uncertainty, second-guessing, and doubt. In this book, Brian Eule takes an almost anthropological approach in describing the entire process of specialty decision-making, residency interviews, and the ranking system. His only connection to medicine is his wife going through this process.

I picked this book up because the author describes his wife who went to Stanford undergrad and UCSF medical school. However, the target audience of the book is not third or fourth year medical students because we already know the nuts and bolts of the match process. Instead, I think those who would enjoy the book and learn the most would be significant others of medical students, pre-meds, or those early in medical school who don't fully understand this whole application process.

Image is shown under Fair Use, from barnesandnoble.com.

Basic Science

As an undergraduate and then a first and second year medical student, we spend much of our time learning the basic science, principles, mechanisms, and theory behind clinical medicine. Whether physics, chemistry, physiology, or pharmacology, we labor over the memorization of pathways and proteins, equations and formulas. But when we reach the clinical years of medical school and then postgraduate training, we leave all of that basic science behind. We focus on our doctoring skills and on the practical applications of what we know. In the busy days of rotations, if something isn't clinically relevant, it isn't relevant. If the basic mechanisms behind something are too complicated, then we hand-wave about it. For example, in hyperkalemia, calcium gluconate is given to "stabilize cardiac membranes." What does that mean, I wonder. Does it change the Nernst potential or activate ion gated channels? I used to think about that, but now on clinical rotations, "stabilizing cardiac membranes" is a sufficient explanation.

Nevertheless, basic science is fundamental in the education of an effective independently-thinking physician. We could easily just teach clinical medicine. In hyperkalemia, give calcium gluconate, insulin, glucose, bicarbonate, albuterol, kayexelate. In an anion gap acidosis, we memorize MUDPILERS as the etiology. We can teach this way, and often on the wards, we find ourselves using such shortcuts. But this is the way to train technicians, not physicians. I greatly appreciate technicians, and they are essential for many tasks, but doctors aren't technicians and training them in that fashion is a mistake. Like other professional schools, medical education is focused on teaching students to think. We want doctors who can reason, adapt, innovate, and create. By teaching the basic science, we make the intellectual connections that force the material to transcend dull memorization and take on a life of their own. In hyperkalemia, I think about how insulin and glucose work to shift potassium into cells; in anion gap acidosis, I think about why those etiologies increase the unmeasured anions. But beyond that, we don't want doctors who are dependent on textbooks, who cannot teach themselves, who cannot determine what research questions need to be asked, who cannot reason out how to approach a disease they've never seen.

Many people complain about the basic sciences, and I understand why. We entered the field to take care of people, not memorize equations and names of genes and proteins. And indeed, much of that fades in the clinical years and we look them up when we need them. But I firmly believe that the act of learning the basic sciences, drawing connections, struggling with problems, and finally integrating that knowledge sets a foundation for the rest of one's medical career.

I Miss Patient Care

Although teaching for this month is an awesome experience and a lot of fun, I realize I miss patients. I miss those dynamic interactions, both professional and personal - the rapport, the listening, the behaviors, the facial expressions, the questions, the trust. For nearly all physicians, patient interaction is why they entered the practice, the part they find most satisfying and most rewarding. Though I love what I'm doing now and think it's building a crucial skill set for me, I do miss working with patients. Medicine, after all, is a service profession.