BOOM

Intern year is no joke. The thrills and chills of being a physician, plus all of the documentation, disposition, and other administrative work to move things along. Boom!

Much to ponder...

As my MSTP training life comes to an end, in favor of a new chapter training in Ob/Gyn in Philadelphia, there remains unfinished business, unwritten reflections. Here's a list with brief abstracts. I hope to expand on each:

1. USMLE Step 1 - why is it so hard, so feared? In many ways, it's like an intense, fast-paced language immersion program, where you have to learn the language without the why or always the precise "how." It's a way to lay out the foundations needed to start learning medicine as it is practices. It requires one to learn the foundations and science of medicine without any of the art. How frustrating and challenging. Along these lines: how do we *define* the stages of training? Should the learning objectives, and the comparisons and contrasts between and among stages of training be better defined? e.g. should medical students not simply be told to, "understand the pathophysiology, treatment, and prognosis" of a disease, but also being given the caveat that, "you will not be able, nor should you be expected to, manage X disease clinically; in this phase you are to learn to recognize and understand the core principles of the disease."

2. Philadelphia abortion doctor found guilty of murder, having killed neonates after botched late-term abortions. Ugh.

3. Career decisions in medicine: how to separate the forest from the trees, and stop listening to advice from people who shouldn't be giving it.

4. Deeply understanding the role of healthcare providers -- why isn't this better emphasized in medical training?

5. Shout out to my Ph.D. mentor, newly-elected member of the National Academy of Sciences.

6. Deep gratitude for my teachers and mentors at the UCLA David Geffen School of Medicine and the MSTP.

7. Deep gratitude for my undergraduate education at Pomona College, and it's enduring lessons and skills taught.

8. Even while medical schools are emphasizing the success of humanities-majors-turned-physicians, should we be dismissing the value of a rigorous scientific education and how it can play a role in medicine? Has science become the "S" word in medical education? Part of the burden falls on scientists, who need to learn to be more art- and humanity-minded. It's on us, too.

I'm so tired

Nearing the end of the MSTP, and intellectually, I'm exhausted. Love what I've been doing, what I am going to do, but right now, I feel weary.

Time to re-charge.

UCLA pride

It's no secret that UCLA and UCSF have a degree of healthy competition when it comes to being "Best in the West" (although UCLA is BIW x 20+years). Here's an anecdote from this weekend I think to be particularly reflective of the trash talking supposedly going on between the two schools:

According to the David Geffen School of Medicine Dean, A. Eugene Washington, UCSF from time to time ridicules the warm weather loving UCLA people, making snide comments about bruin people. Some time into his tenure at UCLA, Dr. Washington was asked by a former UCSF colleague, "Well, what do the people at UCLA say about SF?" To which Dr. Washington quickly responded,

"Nothing."

#once a bruin, always a bruin.

Middle school failure = Medical school success?

Some compelling insights (albeit completely qualitative and non-quantitative in nature) into how struggling when younger predict future success: http://www.theatlantic.com/national/archive/2013/03/how-middle-school-failures-lead-to-medical-school-success/274163/ 

I recently failed at doing a relatively straightforward procedure on a patient, and the resident said to me, "don't beat yourself up," after I apologized. And at that moment, I made a pretty important self-realization: I am probably better off not succeeding at a given procedure, because I get too forms of feedback in the process: 1) I didn't succeed, but I figured out what some of the challenges of the procedure are, and 2) I got to see how the resident successfully performed the procedure thereafter. What if I had been lucky and succeeded right off the bat? Would I have the insight I (think I) have for the next time, had it just been totally easy for me? I think not. That's the beauty of the "failing" and getting feedback. And so, realizing that, I could earnestly say, "Yeah, no, if there's one thing I've learned in med school, it's that being unsuccessful at procedures and the like is all part of the job, and it's all an opportunity to LEARN!" Over-exuberance about failure aside, true that.

Gynecologic Oncologists

For the win, according to a new study out of UCI.

Also, when financial considerations come into play, private practitioners don't always do what's best for the patient (intraperitoneal chemotherapy is used less, in part, because it takes longer to administer without reimbursing any better than intravenous; although it's more complicated than that -- it's much more toxic and ridden with side effects).

If you or anyone you know is diagnosed with, or has signs/symptoms strongly suggestive of Ovarian CA, please please please go to a gynecologic oncologist, and preferably one at an academic center. Survival may depend on it.

And if it happens in seven years from now, please come see me.

On Age-Related Fecundity, Modernity, and "First World Problems" behind infertility

UPenn Medical Student Anna Jesus shares her story of realizing she had hypo/hypo infertility, got medical treatment to facilitate pregnancy before her eggs expired, while in med school.

But her amusing story brings up the First World Problem that is infertility in older women. Our society discourages and makes difficult child bearing in a woman's most fecund years (although 30% of causes of infertility are idiopathic -- completely unknown, meaning that as women become infertile regardless of age and as a result we don't know why and can't easily "cure" the "problem in these cases). For most infertile women, we've created the "problem." Anna Jesus's story suggests that we might need to "allow" women to become pregnant at a younger age.

In any event, here's an account of how I spend my days on Reproductive Endocrinology and Infertility:

Each day, I run into 10-15 friends or acquaintances in the Hospital in which I work. They ask what I'm on. I say, "Repro. Endocrinology and Infertility...a.k.a. First World problems!" Ha. Ha.

But it's kind of true. 100% true: REI is a medical specialty where, work on mullerian anomalies or legitimate structural (like uterus, tubes, ovaries, cervix, pelvis) or biochemical (various hypogonadisms, endocrinopathies, etc) issues relating to the speciality aside, a majority of the work is devoted to getting people who can't get pregnant, pregnant. And it turns out that, in many countries of the world, e.g. most places in the continent of Africa, there's no such thing as a doctor who actually addresses advanced maternal age, poor ovarian reserve, recurrent pregnancy loss, male factor infertility; nobody freezes and thaws eggs. No one does a Semen analysis or considers poor hypothalamic function.

Here in the First world, on the other hand, all of the above mentioned issues can be worked up, solutions crafted, and far more successful plans implemented. You can inseminate a uterus, you can induce ovulation, you can harvest eggs, artificially inseminate them (even inject sperm straight into cells), grow embryos, and then implant them in a uterus which thinks its already pregnant. You can freeze your eggs when you're 30, thaw and inseminate them at a later date. And on, and on.

But the major first world problem is this: women who either have major medical issues (prototypical younger infertility patient), or older women who have very low (1-5%) chances of getting pregnant as a function of their age, these women are those of First World REI. It's because we don't let people climb the corporate latter while raising kids; it's because people can't get enough help taking care of their kids because the government isn't very generous toward child-rearing, people just stay single longer and don't necessarily get into serious and long-term relationships until they are older (and then they are maybe in the middle of climbing the corporate latter), and then they finally have everything going for them: they are happy, well-off, well-adjusted, spiritually settled, and with someone else who has that, and then, right when you're FINALLY ready, you can't get pregnant. You can't.

So this is a first world problem, but it also reflects issues our society has created, which it exacerbates the problem for "driven" women who get old but want kids. REI gives them a chance they deserve, perhaps a chance they deserved when they were younger and more fertile. 

In third world country, women who don't have inherent problems with fertility, they give birth during their most fertile years. They don't use IVF because mostly they don't need it. and in the rare instances they need it, they either get charity, or usually nothing.

Chronic Traumatic Encephalopathy

Like a broken record, I continue to post on CTE and its prevalence in former NFL players. Now, UCLA researchers, several of whom are former colleagues and co-authors of mine (Drs. Barrio and Keppe) in research, tackle the problem. Check out this (http://www.espn.go.com/pdf/2013/0122/espn_otl_CTELiving.pdf) pilot study. I look forward to seeing what the impact of it is going forward.

Jared Diamond strikes again

This time, he compares and contrasts primitive hunter-gatherer and modern societies' child-rearing practices in his forthcoming book, The World Until Yesterday, an excerpt of which can be found here. The excerpt is definitely worth a read, and the book is next on my list.

My New Year's Resolution

My writing on this blog sucks.

It's obtuse. Constipated. Convoluted.

In the New Year, I resolve to put into writing that which I mean to say instead of filler words or phrases awkwardly assembled into incoherent arguments.

I will say what I mean.

That is all.

"The Signal and the Noise"

Nate Silver's first work of non-fiction reads more like an enthusiastic extended commentary within a science or economic journal, especially when compared with works by contemporaries like Malcolm Gladwell. This is no accident: Silver is a statistician, a numbers and predictions wonk. He's not into (nor, to my knowledge, extensively trained in) descriptive writing, and the brief interludes his accounts of discussions with scientists, politicians, and experts in various fields, his prose becomes awkward. But then he starts talking numbers. And the chapter sails on. Flush with new approaches to data analysis in a complicated world.

All that said, the analysis is stellar, and in the spirit of Freakonomics, S&N encourages us to approach real-world problems with a few great ideas:
1. A Bayesian approach is reasonable, especially when dealing with the probability of an event happening, and in which prior information ("Bayesian priors") is available.
2. "Noise" comes in several forms: data points that neither reflect trends nor are truly significant (especially true of rare events); noise is in the news all the time (storms, accidents, global warming, political polls, commonly held beliefs that are statistically un-proven and may in fact be completely wrong); trends in sports; misperceptions about money, the stock market, economies in general.
3. "Signal" is more of a pseudonym for well-collected and well-organized data that are neither 1) over-fit or 2) meaningless because of the uncertainty in of the prediction (in time or space); "Signal" also takes into account known knowns, known unknowns, and tries, as best it can, to leave wiggle room for the dreaded unknown unknowns.

Anyway, it's a good book. Give it a read!

Unimaginable

Gun violence continues to ravage the U.S.A.

I was particularly moved by this piece, penned by a pediatric ED physician. How a person, particularly a young and innocent child, dies from a gunshot wound, is important to remember in the midst of all the chatter about a New Conversation and a renewed interest in gun regulations.

Spoiler alert: it's gory and nauseating.

More NFL violence

It continues.

Cooper the body snatcher

Turns out the guy behind "Cooper's ligaments" in the breasts was pretty revolutionary. He seemed to get it, was far ahead of his time, and clearly was part of some crazy goings on in medicine in the 19th century.

Health Care

A couple thoughts:
1. The problem with health care reform advocates in this country is they fail to do what the pharmaceutical industry does so well: convince people first they have a problem -- ever seen those commercials telling people about a disease, such as, "Do your legs ever become numb? You may have peripheral vascular disease. Talk to your doctor," and the commercial ends without advertising a drug. It just states a horrible problem. Then, months later, after those adds have shown on several occasions, the next wave begins, in which the solution ("Plavix, an anti-thrombotic for vasculopaths.") is presented.
2. People don't get it: the government has been picking up the tab, in numerous difficult-to-define ways, for health care. Reform is just about trying to lower the bar bill. Get people to drink cheap beer instead of the top shelf stuff. No fancy soft-shelled crab. It's going to be happy hour pub grub, budweiser, some chips and salsa, and a pie for dessert. Still pretty good. Gets the job done. And doesn't bankrupt the country...we'll get there, and if I get paid less for it, that's OK.

why to not be obsessed with jobs

http://www.nejm.org/doi/full/10.1056/NEJMp1204891?query=featured_home

a very sensible and economical argument behind the misguided obsession with healthcare "jobs."

The graph says it all

Hospital costs soaring, mortality rates in-hospital holding steady. http://www.nejm.org/doi/full/10.1056/NEJMp1202628

fish oil fail

http://www.nejm.org/doi/full/10.1056/NEJMoa1203859?query=featured_home

guess the fish oil craze isn't all that it was billed to be...

One of those days

Today:

1. When I arrived this morning, I learned a favorite patient of mine died last night, somewhat unexpectedly.

2. I had to help break devastating news to a patient.

3. Clinic was a downer, with more sad stories...

And yet, I still love what I'm doing.

What's the question?

Knowing the question is the key to calling a consult.