Tuesday, December 23, 2014

Welcome to the maze

"We only tell stories in the winter; otherwise the creatures that sting and bite may get you" Mary advised as we were finishing up charting for the day. Story-telling preserves the collective memories and traditions of the Tohono O'odham. Like all good stories their meanings evolve and transform with the passage of time and motive of the listeners. The mysteries of the TO traditions are still unknown and foreign to me, but I can appreciate the power of these stories. Especially this time of year when we are inundated with the Christmas narrative with which I have grown up and am most familiar. A baby in a manger, stockings hung on a chimney, wise men from afar, lights on an evergreen tree- Christmas traditions have different meanings to me now as Tina and I create our own celebration, then they did when I was a kid eagerly waiting with my brother for reindeer to land and Santa to bring gifts. Re-imagining these stories become timeless as memories of the past, current celebrations and thoughts of the future blend. (I already know how next year’s Christmas decorations will be bigger and better). It is not just Scrooge who must face Christmas ghosts-past, present and future- we all do. And so it is with other traditions. The most prominent image of the TO tradition is the "Man in the Maze" a powerful emblem of life's spiritual and physical journey. I was first introduced to this concept a year ago while embarking on an Arizona job searching tour. It is simple and profound. The teenager behind the sales counter at TOCA was the first person to interpret its significance saying, "it means different things to different people" then elucidated its role for her. It has been to a warm welcome that I have been granted the responsibility to serve the healthcare needs of the TO people through the services of IHS. This humbling responsibility is the start of an incredible journey - the entrance to the maze. As the adventures through the labyrinth continue into the New Year, honoring the stories and milestones of 2014 is paramount. 2014 has been a transformational year: passing my boards, finishing residency, getting married to the love of my life, traveling to India and Taiwan, moving to Tucson, starting my first job as a Family Physician, rehabbing a debilitating knee injury, supporting family through a medical scare, honoring the 1 year anniversary of my grandfather's passing. It was a year of endurance and growth, a year most characterized by joy. I am excited to discover what 2015 reveals and to further appreciate the timeless traditions of my own family and the TO culture.
http://www.wernative.org/SubTopicDetails.aspx?id=299&type=MyCulture 12/23/14

Wednesday, August 25, 2010

Need direction draft 1

I need to write a personal statement for residency applications. One thing medical school self-selects is for good standardized test takers (multiple choice) at the detriment to the essayist as is essential in undergraduate (and high school) academia. I am out of touch as a writer and need to get my act into gear to pump out a effective personal statement. My current concept is a personal statement is very much like a blog entry (or at least a well edited and hyperfocused blog entry). So below is a first attempt.

Several glaring errors about this draft... I am growing more and more convinced I want to do a combined psych/family or a psych only or a psych heavy family residency. This essay is focused on primary care aka FP. (partially because the patient in the vignette in the intro didn't need additional psychiatric care but rather a good FP). maybe future attempts should include several vignettes that emphasize why you need combined training? The other weakness in this essay is that it's focus is too "soap box" and falls short of capturing any of the personal part of a personal statement. Starting for me is always a major hurdle so even if my final is fundamentally different or unrecognizable from this draft... at least the ball is rolling.

Today, as I walked into see my patient, an 82 year old gentleman with chronic low back pain and a history of falls being managed by a pain specialist on methadone, I noticed a keratinized patch on the crown of his head that appeared consistent with bowen’s disease, a variant of squamous cell carcinoma. Asking my pain management preceptor about this finding he matter-of-factly announced he would have to see his primary care physician and that our focus was specifically the chronic low back pain. We need pain specialists to conduct the management of polypharmacy and chronic refractory pain, we need dermatologist and dermatopathologists to ID and treat skin cancers. The vastness of medicine and the pathologies of the human condition appropriately lead to a medical hierarchy dictated by chief complaint specific or organ specific experts to micromanage a patient’s symptomatology. However there is an immeasurable loss in the practice of medicine when you lose sight of the patient while looking for the disease; if you cannot see the forest because of the trees- you have failed. I have learned that good medicine is both patient-centered and interdisciplinary. No one physician can be expected to single handedly treat every medical condition but every doctor should be expected to treat the patient first, the disease, imaging, and diagnostic results later. As a family physician you are the best person to partner with patients and families to navigate and integrate the health care system. In the operating room the surgeon was once described as the captain of the ship an unquestionable and especially if someone you love is under the knife…an infallible director. That perspective does not mesh with today’s medical practice. Patients have the right to determine the type and extent of medical interventions they require, they are the captains. A physician then becomes the navigator, the GPS of healthcare guiding patients with preventative healthcare and appropriate management of chronic diseases and as needed redirecting patients who have made wrong turns or missed the highway exit. This is no small feat but it is essential and requires skills of collaboration (with colleagues and patients), a foundation of knowledge (life-long learning), and compassion. Family medicine is my calling because my strengths are in expertly managing patient care in all stages of life. This requires a substantial breadth of medical knowledge but success is at least equally based on the doctor’s adeptness in facilitating communication between patient and caregivers, consulting physicians, and addressing psychosocial and compliance concerns. It is in the tailoring of medicine to the patient that the art of medicine is performed. No disease is the same regardless if the etiology or treatment algorithm is unchanged because every patient’s perception and interaction with their pathology is unique. I am looking for a residency training facility that will not only establish the medical knowledge required to be a leader in the medical standard of care but also to be at my peak performance at practicing the art of medicine and the care of patients.

because I am writing really long posts today here's a link about personal statements i stole from some medical school (university of Alabama) via google. http://main.uab.edu/uasom/2/show.asp?durki=23485

• ERAS allows personal statements up to 28,000 characters (8 pages); however, personal statements greater than 3,500 characters (one page) may be ignored or viewed unfavorably.
• Multiple personal statements can be written to allow for program-specific submissions.
• Draft the personal statement in a word processing software (i.e, Microsoft Word) to give yourself an opportunity to edit and use tools like spell check. Cut and paste your final copy into ERAS.
• After you have pasted your personal statement into ERAS, but before you assign it to any programs, print a copy to make certain the conversion did not create any spacing or character problems.
• The final version should be no larger than one page in 11 or 12 point font. However, it should fill at least ¾ of the page or it may appear that you do not have much to say.
• Your personal statement must be grammatically perfect.
• Do not overuse the pronoun "I." Avoid "bragging." Do not use superlatives (very, really).
• Rely on several people to give critical reviews.
• Do not simply rehash your Curriculum Vitae in paragraph form.
• Use this as an opportunity to display your personality, not your accomplishments.
• It should be unique, and interesting. Imagine having to read 400 personal statements that all say "I have wanted to be a doctor ever since I saw a doctor treat...."
• The first paragraph must both grab the reader's attention and compel them to read more or clearly state why you want to match into the specific field.
• If your first paragraph does not clearly state why you want to match in the specific field, the last paragraph should.
• Consider using stories to highlight your strongest points. Rather than claim to be a good listener, tell a story about a resident who praised your listening skills. Readers remember stories much longer than they remember facts and statements.
• Include details in your story to give them life.
• This may be a good place to address any areas of concern in your record. If you want to do this, be careful not to sound defensive or victimized.
• Do not beg and plead.
• Do not flatter.
• If you cannot decide where to start, look at the answers you wrote on your MSPE Student Information Sheet. Which of those things do you want to make certain the program knows about you?
• Make sure that every sentence adds to your overall message.
• Stay away from the draft for at least a week between revisions.
• Ask several colleagues to proof for content.
• Ask several skilled people to proof for grammar.

Monday, October 6, 2008

Aditi likes yellow flowers.
and pink ones too

Monday, March 17, 2008

flying elephants

Video from You Tube.

Everyone has their moments where you do something stupid in a spontaneous instant of thoughtlessness and realize immediately afterwards that it was a mistake. Ideally these events are swept under the rug, never to be thought of again; however in reality embarrassing moments tend to be resurrected when you least expect it. Take a lecture of the neuroanatomy of the midbrain for instance. Our brains are amazingly adapted to process the information from our environment and focusing on that which is important. Undoubtedly, circumstances in our environment change and what was once environmental noise becomes acutely salient. Imagine walking down a sidewalk chatting on a cell phone. You don't consciously think about moving one foot in front of the other, nor do you have to visually focus on the stop signs, mailboxes, trees, fire hydrants, and other features you pass. You're aware of them but they don't command attention. In this mental zone, you cross an intersection and suddenly your brain surges and you notice the semi truck charging towards you-immediately stealing your attention and causing you to speed out of harms way. The superior colliculi in the midbrain tectum is responsible for directing this visual attention (FYI the inferior colliculi are involved in auditory processes). To beat a dead horse, this is also the area often involved in the startle response in horror movies ---the dark, eerie mood music before something or someone jumps from off screen and says boo (or worse)!

I first learned about the colliculi six years ago when I was enrolled in Introduction to Cognitive Neuroscience course as a freshman at DU. During midterms, I was having a study group in my room in J-Mac with a neighbor also enrolled in the course while my roommate was on his bed, studying for a computer science test. In a moment of inspiration when we made it to the superior colliculi on the review guide, I picked up my stuffed elephant and chucked it unannounced at my roommate, intentionally aiming to miss his body and enter his peripheral vision to "demonstrate" the function of the superior colliculus. Unfortunately I miss judged my own strength and aim indeed missing Kevin's body instead making contact on his laptop sitting on the desk which proceeded to slide off the edge onto the floor with a loud crash. The unintended consequence of knocking off his laptop with my stuffed elephant did indeed direct the attention of everyone in the room in disbelief both at me and at the humpty dumpty laptop now on the floor. Flushed red I offered my sincerest apology stuttering something like, "i'm so sorry, I was just trying to test your superior colliculi response, I didn't mean to hit your computer, I was just aiming at you..."

Fortunately, my computer science roommate was able to repair his computer without lasting deficits and he even accepted my explanation for the vicious elephant-computer assault. Furthermore I passed my cognitive neuroscience midterm blocking out most recollection of the study session completely. That was of course until last week when I was in a group study session cramming for the Neuroscience Systems exam tracing tracts from the spinal cord through the hind and midbrain sections. Although we were focusing on the anatomical/histological regions of the sections, rather than the functional, I turned to my study partner and said, "you know, the superior colliculi is involved in the startle response...we should test it out!" A little voice in my mind started screaming-NO DON'T DO THAT!!! Do you remember the last time you tired that???

Image from Dr. Bales- G. Bales / Medical Neuroanatomy / Brainstem Topography 3/10/08

Friday, March 14, 2008

Lions in the classroom

I’m not one for horoscopes but this month can’t be high for love and medicine. Within a week three of my neighbors in close relationships have broken up with their significant other; including me. As some of these friendships ended mutually others ugly I am abruptly reminded about the advice given to us during orientation week by a firecracker clinician, “make an investment in your tools (stethoscope, ophthalmoscope, otoscope, and sphygmomanometer) I’ve kept mine longer than my wife.” I refuse to believe that in a career focused around people in need, it is impossible to support the needs of those closest to us, our friends and family. We first need to make an investment in each other to give purpose and meaning to anything else we value…everything else is relative.

Equally interesting is the observation of how we react to the emotional stress of ending or changing relationships with those we value--by running into retreat mode. For me it’s been hyper focusing on school extracurricular---Montclair clinic, Trends in Autism conference, and cramming for Neuro – anything but emotions and the future, only immediate survival. For others it has been an escape home away from the “drama” of campus, and for the third, it has been to hide literally, from his soon to be ex in order to study. I am sitting here learning about the catecholamine drugs--- Fight or flight response –and the impact these neurotransmitters have throughout the body. It is hard to believe that it is as simple as neurotransmitter soup that has made the last few days (and coming weekend) such a challenge. One amazing attribute is the brains ability to override its most basic reflexes— including pain. One of the first tenets we learn in Neuroscience is that pain is a perception of nociception from the pain receptors of the body. You can have the nociceptive response without the pain – we’ve all heard horrific accounts from war heroes who continue without pain-despite mortal wounds, or tales of professional athletes who perform despite broken or sprained extremities. The alternative process—pain without nociception is all too common—chronic pain which can be equally debilitating. In light of that…neglecting emotional distress is probably as pathologic as chronic pain but today feels as necessary as retreating from the heat of battle despite injury that might otherwise redirect all attention.

Homeostasis—the process of being in balance is controlled by parasympathetic’s predominance in the balance of life. This “feed and breed” pathway sets the tone while the "fight or flight" provides reserves when we are threatened and need to escape. It’s amazing that we have a system that can persist by the very fact of forcing you out of balance. It’s equally amazing how any alteration in our proverbial “feeding and breeding” desires automatically throws us into the turmoil of fight or flight, as if we were being attached by a lion, despite the fact it involves those we love.

This semester has emphasized two very important facts --- Exams are NOT LIONS that require a full blown sympathetic response; neither are friends, girlfriends, and family. As med school consumes my life in the process of molding me into a future physician I need to discover ways to remain in homeostasis with my body and my surroundings –not in attack mode. Until then, I hope the adrenaline lasts until spring break when I hope to experience true catharsis.

"...because you can't fight a bear when you're urinating[from the caption]."
Image from Dr. Wong's Introduction to Autonomic Pharmacology lecture 3/10/08.

Wednesday, February 27, 2008

getting shit together

It is always fun to have visiting professors and clinicians give lectures. It helps to emphasize what other experts feel is most important, provides a measure of reassurance that what we are learning is consistent with our peers at Loma Linda, USC, UCLA, or UC-Irvine, and it forces students to be on their best behavior. Not to be overlooked, visiting professors provides another venue for bad jokes and sage sayings.

How do you hide a $100 bill from an internist?...put it under a dressing
How do you hide a $100 bill from a surgeon?---put it in a book
How do you hide a $100 bill from a plastic surgeon***You Can't!

To supplement our Blood and Lymphatic system we have had a visiting Harvard trained hematologist currently working at UCI med school present us the essentials of leukemias, lymphomas, and anemias. As the topics in our courses get more multifaceted and complex, ultimately there is a tedious amount of details to memorize. Clinicians who have "been in your shoes" and have years ago completed med school inevitably give a motivational introduction or conclusion to their topic. Each message has its own flavor but they all have a common trend-- it will all make sense in residency! As we approach our next exam weekend Doctor Howard conceded that there will be a lot to memorize. To put memorization into context he explained his most memorable med school moment to us before starting the 9th lecture hour of the day. Following a particularly difficult block at school he and his roommate decided it would be a good idea to host a party inviting all 160 students from his class and the 160 students from the second year class. His most enduring memory is of his downstairs neighbor coming up to complain that the plaster was falling off of the ceiling followed shortly thereafter by the police to break up the party. Having narrowly escaped legal disaster he successfully finished Harvard and moved on to bigger and better things- putting us through the memorization gauntlet. This musing is my attempt to keep things in perspective; what we remember is a heterogeneous mixture of facts we cram to memorize, random trivia that we never can forget, complex algorithms we use daily, and snapshots of the people, places, stories, and events that make life joyful and memorable. Despite my headache organizing drugs, symptoms, side effects, disorders, and the hours in a day, I cherish the ability to memorize and have memories.

Dr. Howard's parting words were the heirloom wisdom that he received during his first year of rotations from a chief resident: All you need to do to survive life as a medical student and later on as a physician is to remember the 4 laws of shit:
-know your shit
-do your shit
-give a shit
and don't take no shit

...Now I'm off to memorize this shit.

Tuesday, February 19, 2008

Picking apples, Bongos, and spotting

It is amazing how short 24 hours seems and how long 18+ hour days feel. Finally I've made it to the medical school people imagine--long nights, early mornings, lectures, libraries, mnemonics, microbes, drugs, and no time. Nonetheless, while the length of a day remains constant, I am still discover new ways to fit/replace/combine more activities into a day simultaneously juggling with what to excise. Fortunately it has not been a bitter pill to swallow as it is possible to find at least something pleasant in arduous work--studying all day at Panera Bread Company, reading flashcards at the gym, experimenting with new teas between study breaks. I have inevitably had to make some sacrifices to remain only moderately insane. I've started to occasionally exercise at the gym rather than going on hike: an inverse from my pre-med days; I'm eating Trader Joes frozen meals or frozen leftovers scavenged from the parents, or food of unknown origin left in the student commons rather than cooking or eating out; I've practically given up TVs, movies, this blog, free reading.... I have still appreciated life as it goes by in part because I have to mentally justify every distractor I indulge ensuring those activities that steal my time from studying are either required for sustenance (eating sleeping), civility (laundry, hygiene), academics (class, professional requirements), and most importantly sanity--because they represent who I am at the core. Some activities I could not give up regardless of other time constraints- I still have my grandpa's keyboard--always turned on, just in case I have time to run through one song between chores and school. I'm constantly connected to Google news or wikipedia. Currently, my chocolate cupboard is better stocked than my refrigerator. It is with this pseudo-rationalization my newest competitions for cram time is picking apples, slamming the bongos, and dizzily practicing spotting.

Adding to the chaotic schedule of February and March, affectionately known by faculty and OMSI students alike as hell month, is Bhangra and Hindi Film dance. My ever growing quest to better understand my culture and heritage has uniquely blended with my path to become a physician. I am now an active member of WesternU's SASA club or South Asian Student Association. I am spending a considerable amount of time dancing--in preparation for the International Medicine club's cultural day March 8th. Each movement has been creatively names as "The King" or "bird man" "puppet" "apple picking" "sexy squats" etcetera. Music and dance have always been a gateway into cultural appreciation. As much as I'm learning about the science of medicine, medicine as an art is interwoven in culture, yours and your patients so I am happy to replace study time with dance. I hope that even through my brain is saturated with pharmacology, microbiology, and pathology, I can organize Apples, Bongos, Birds, puppets, and the other steps associated with dance Bhangra dancing.

illustrations from Weili Zhang.