Learning and trying not to forget

I can't help but think I took the red pill when I decided to enter the MSTP at UCLA. I had no idea what I would find, but I knew it would be too much to grasp at first. Or ever. And yet, two years and seven months into it, I'm starting to see the beauty of this journey all over again.

One might imagine that I'm about to launch into an (albeit weak) attempt at philosophizing [1] about the experience that is MSTP at UCLA. I am not. I just want to share some of my sentiments, now that I feel firmly entrenched in the PhD phase of my training. And I want to say that, while I do not endorse any one way at how to go about this, I will invariably focus on issues as they pertain to my roadmap. But others (Jeff, Anthony, et al) have much different roadmaps in mind, and I think they are finding similar satisfaction [2].

Which is to say the following: I do an overnight of call [3] in the Fourth Floor East Medical Intensive Care Unit (MICU) in the Ronald Reagan UCLA Medical Center (RRUCLAMC). I've watched numerous central and radial arterial lines get placed, I've seen a couple patients die, I've attempted (and failed) to draw an arterial blood gas, I've watched (and sort of helped with) endotracheal intubations, I've run when the words "Code blue team, code blue team," go up over the loudspeaker in the middle of the night. I've seen the spectacle of a patient being cardioverted during and acute atrial fibrillation episode, I've sat in on family meetings for parents whose grown children are dying, I've seen the same patients, in the units for months at a time, while pressors, ventilators, oxygen, blood, blood products, plasma, dialysis, fluids, antibiotics, keeping them alive for weeks and months longer than seems even possible [4]. In short, I've obtained a crash course into one of the most exciting and indeed "critical" areas of inpatient medicine, the ICU.

I started doing this unofficial-ICU-call-longitunal rotation in November, and I have since been in the unit, usually on a Friday night into saturday midday, every other week. I generally will arrive at campus on Friday morning at 7-7:30 a.m., do work in the lab until late afternoon/early evening, and then a call night begins [5]. I began this work when my class schedule prevented me from continuing my once-a-week clinical exposure. Logistically, the MICU call was the only way to continue some clinical exposure.

There's another reason, too. If you recall [6], I had become frustrated with some of what I had learned about scientific research. Basic science, it seemed, suffered from the same failings that evidence-based medicine (EBM) does, or of empirical and non-data-driven clinical care. And I was asking myself a series of questions about what I had gotten myself into [7]: Why was I doing this? Am I forgetting everything I learned in the first two years of medical school? What am I really trying to do?

I don't have answers to those quasi-philosophical questions, but the beauty of the last several months is that I don't even need answers to them. The ICU work, as infrequent (Q2wks) and humbling as it is (I really don't know shit [8]), has filled a small void. Somehow, since this has started, my research has flowed a little more nicely -- maybe because I take advantage of the time I am in lab, or maybe because I get a twice-a-month dose of why I am doing all of this. This isn't just the "I want to help people" sentiment. Certainly, when you watch young and old patients alike fading away from devastating illnesses, you can't help but feel some sense of sadness, sympathy, or frustration. But there's also this sense that, both at a very basic level (mechanisms, molecules and targets, animal models) and from the clinical perspective (drugs, monitoring schemes, preventitive measures) there are astounding amounts of work to be done by physicians, scientists, and physician-scientists. And this is not just for the new sexy cancer drugs, not just for the new stenting procedure for cardiac or neuro patients. I'm talking about really understanding the effects of endotoxin (LPS)-mediated septic shock. I'm talking about further nailing down what causes and how to treat Adult Respiratory Distress Syndrome (ARDS). Medicine spends a lot of time - in the hospital, the ICU - well documenting and observing these phenomena via critically low blood pressures, decreased oxygen saturation, multi-organ failure, positive disseminated intravascular coagulation (DIC) laboratory values, the list goes on. Physicians spend sleepless nights managing these patients. Researchers, who see around the corner to translational medicine, want to challenge assumptions that are in the textbooks and clinical references with fresh new experiments.

Not to belabor a point, but both medicine and research have much to contribute. I think that's cool, and I still want in [9].

Several final points:
Ultimately, the great challenges of medicine are not unlike the great challenges of our economy. We are still trying to figure out what causes disease, and yet we are treating diseases nonetheless. It's sort of like going with a one trillion dollar bailout to a problem without knowing exactly what caused the crisis in the first place and thus without quite knowing what to fix. Said Warren Buffett:

The answer is nobody knows. The economists don’t know. All you know is you throw everything at it and whether it’s more effective if you’re fighting a fire to be concentrating the water flow on this part or that part. You’re going to use every weapon you have in fighting it. And people, they do not know exactly what the effects are. Economists like to talk about it, but in the end they’ve been very, very wrong and most of them in recent years on this. We don’t know the perfect answers on it.

Replace "economists" with "physicians" or "scientists" or both. Needless to say, the quotation is more than applicable to how we approach numerous diseases. Our information is incomplete, our assumptions have been (and will continue to be) proven wrong. But you must keep flowing the water. Our basic sense of humanity requires it.

And so, more than ever, the MD/PhD path is for me. The rest is a mystery.



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1. The difference between philosophizing and sharing sentiments is sort of like the difference between using data to generate an exciting new model for some physiologic process (say a pictogram of vesicle fusion) versus simply sharing some exciting data. I would argue that here, and in most writings on this blog, we're simply trying to present our data, our observations, de novo, roughly as they happen and our thoughts about them (the data, observations) crystallize a bit. I doubt there's an MD/PhD or MSTP graduate out there who could package the experience into a philosophical model.

2. It doesn't matter what position you do it in, just that you're doing it...at least that's what she said.

3. This is a misnomer in my case. Medical students don't get "called." Case-in-point: two "calls" ago, the resident and intern with whom I was taking the overnight received a page from the Emergency Department for a patient w/ Diabetic Ketoacidosis needing to be admitted to the ICU. The resident claims she tried to wake me up by knocking on my door. "But you had my pager and cell phone number." But she didn't call. A weak knock, a med student doesn't respond, and it's just as well -- I get an extra hour of sleep, and it took the resident and intern no longer than thirty minutes to work the patient up and admit her to the unit. It probably would have taken twice as long if I was "helping." Which is also to say the following: medical students generally don't contribute much, especially if they aren't part of the ongoing care of patients (i.e. are on a rotation or a sub-internship, where they actually contribute little tasks to the medical team). Coming in for a night of call as a (quite inexperienced) medical student generally doesn't result in much help to anyone, except himself. It's this strange feeling of importance (white coat, "helping" make medical decisions) while being utterly inconsequential.

4. Or humane. Or natural. Or fair.

5. Sometimes a resident's page indicates a new admission, and at 4:30 pm I'm rushing out of lab to the ED, in scrubs and a white coat and feeling unsure of my uniform and skill set.

6. Go back to some previous posts, most recently one containing the sentence, "Yawn," or the phrase, "selling out but for less money," and you'll get the idea.

7. Admittedly, the risk of becoming overtly philosophical is highest at this point of the post.

8. If you really want, recall that I wrote these same words in a post during the first week of first year of medical school.

9. That's why I joined an MSTP. In some ways, this post feels like I'm re-writing my personal statement explaining why I want to join a medical scientist training program.

Applicant/prospective OPEN THREAD

In lieu of some posts that are brewing in my head (ICU post, research progress post, other details about the "pretentious" MSTP life), this post is an open thread for applicants and other individuals interested in MSTPs, either at UCLA or in general. So feel free to post away, and we'll offer our thoughts when/if relevant.