We Work in the Dark

Morning ritual

2010-10-24T09:35:00.000-07:00

I dreamt of luscious hotel entrance to my simple apartment. Outside the world at every entrance, the lobby stretched so wide, you could traverse its length and arrive at entirely different neighborhoods and sub-worlds. and this is delightful, the notion of my humble home, the foundation and enclave, wrapped in grandeur, sweeping staircases, marble floors, silver platters, the bustle of a million maids and butlers in well pressed uniforms, a gorgeous big world, with a safe place in its heart. I dash up the stairs endless palace stairs, and i am small again like the little pig character of children's books, like the little girl who lives in the waldorf astoria, the world of beauty is big and i am joyously scurrying. But i must take a regulation staircase, a back way a fire escape i follow a woman, she gets off on four. I must arrive at six, and there is a severance of the staircase, an Escherian optical puzzle. I cannot get to the next floor.

And i wake.

I am in my brother's bed in my childhood house, the walls are plastered thickly with the gleam of sports cars and buxom women lounging upon them. My head is thick with cementing mucus in hidden crevices, weighing my mind and my skin is so dry with desert air it is crackling. There were other dreams, they are ephemera.

The day ahead seems dull. Somewhere in the larger picture progress must be made--on my medical training, on my research. I am short on money, someone at the university has delayed the check until i report my findings. What have I found? I have been meditating that at 28 I am not really a Young Woman anymore. A youngish woman. Long ago already i was Madame over a Mademoiselle, though i have neither married nor reproduced. I have a man i love, he is gently coy about these things. In the mean time, amid the clinic and the wards, the excel spread sheets and nights of sleepy love, the rolling hormonal sine waves keep time on my ovaries, which are in turn neatly bound and chemically gagged with FDA approved contraception.

Men do not generally face their finiteness for decades, but for women it begins at 35, and it begins in the pelvis (all things begin in the pelvis), then radiates outward.

The school counselor accuses me of escape into abstraction in my philosophizing (or perhaps it is i who accuses, and she who nods). The disciples of the mind think there is a different truth, the one that is bound up in the tangles and rolls of the individual psyche, the particulars of the organisms trajectory, of its shapes and deformities, of the particular drag and gravity in its subjective cosmos, and the course of collisions with other creatures. Perhaps each atomized vector can be integrated and an elegant tale can be told, the story (stories) that will predict the future. Like their brethren in physics, the disciples of psyche chase the mystical with the sober pretense of trading in mundane tools.

Oh this poor isolated animal. The French find the isolation inevitable and pitiable, the americans an aspiration and a celebration. I do not want to be alone. Life begins with a expulsion from another. It begins with separation and a life desperate for union again. The end carries the parabola forward to its inevitably lonely conclusion. But after we are gone, the fungi take us back, and we are reunited with all again. Dénouement, resolution, or catastrophe.

Remarkably un-comforting.

Yesterday my heart broke watching an injured bee, journey steadily across the suburban bathroom floor. Why was there a bumble bee in such an inglorious place? (And why do we hate flies and admire bees? We punish one for ridding the world of feces and rotten meat, and adore the other for cavorting amid the flowers and filling our cups with honey). (Actually this is quite reasonable). (The bees furthermore, are better dressed).

Once i have had my morning coffee, the meditations on death dissolve, like mist in the rising sun. Dreams flee, existential ennui and its attendant abyss constrict to a neat quiet scar line. In the glorious light of the frontal lobe, well fueled by the metabolic storm of caffeine, purpose begins. We trade out the dark shadows of existence, dreamscapes and Dostoevsky for the neat, clipped descriptions of the New England Journal. The disciples of physiology (like those who study spheres, and the mappers of mind) don the heavy cloak of coffee cups and linear regression models and the work of the world continues.

Moving!

2010-10-14T10:26:00.001-07:00

Soon! (this blog i mean)

Foreign Medical Graduate

2010-10-12T10:43:00.000-07:00

From Verghese, My Own Country

"I had once tried to reach Dr. Patel, a cardiologist, to see a tough old lady in the E.R. whose heart failure was not yielding to my diuretics and cardiotonics. I called his house and his wife told me he was at 'Urology Patel's' house, and when I called there I learned he and 'Pulmonary Patel' had gone to 'Gastroenterology Patel's' house. Gastroenterology Patel's teen-age daughter, a first-generation Indian-American, told me in a perfect Appalachian accent that she 'reckoned they're over at the Mehtas' playing rummy,' which they were."

An Indian traveling salesman explains how to find a place to eat in a strange town: Count the number of Patels in the phone book and multiply by 60. "That will tell you size of Indian community. . . . Take my word: less than 10 Patels means no Indian restaurant. If more than 10, you call, say you are from India, ask them where to go to eat."

* * *

As Dr. Verghese traces the spread of the [HIV] infection, he also examines its effects on his own attitudes, and on his relationships with his patients. He identifies the less-than-lofty, self-congratulatory "front-rank soldier" pride of doctors who treated AIDS patients in the early days of the epidemic, before the mechanisms of transmission were better understood. As he considers his patients in Tennessee and their willingness to confide in him, he wonders how much it has to do with their relief at finding a doctor who is a foreigner, an outsider. "To come to a doctor's office, even a distant doctor's office, and tell their sexual secrets to a Caucasian face that could just as well have belonged to a preacher, a judge or some other archetypal authority figure in their town, might have been difficult." He is also direct and straightforward about the toll that his involvement with his patients takes on his wife and young children -- and ultimately on him as well, as the patients, one by one, begin to die, as he dreams repeatedly of his own infection and death.

* * *

The story of all these people -- brothers and sisters, parents and children, doctors and patients -- is the story of a small city whose departed sons begin returning, one by one, sick with an infection that even the medical professionals of Johnson City had assumed would never hit close to home. Thus the doctor who sought security and a better life in the American South finds himself treating some of the sons of that South who had fled, searching for safety, acceptance and a fuller, freer life.

It was, as Dr. Verghese ultimately chronicled it for a medical journal, "the story of how a generation of young men, raised to self-hatred, had risen above the definitions that their society and upbringings had used to define them. It was the story of the hard and sometimes lonely journeys they took far from home into a world more complicated than they imagined and far more dangerous than anyone could have known."

Fluids, Fetuses, Foreign bodies, Feces and Flatus

2010-10-12T10:14:00.000-07:00

SCIENTIST AT WORK | DR. ABRAHAM VERGHESE
Physician Revives a Dying Art: The Physical [excerpts]

Dr. Verghese (ver-GEESE) is the senior associate chairman for the theory and practice of medicine at Stanford University. He is also the author of two highly acclaimed memoirs, “My Own Country” and “The Tennis Partner,” and a novel, “Cutting for Stone,” which is now a best seller.

At Stanford, he is on a mission to bring back something he considers a lost art: the physical exam. The old-fashioned touching, looking and listening — the once prized, almost magical skills of the doctor who missed nothing and could swiftly diagnose a peculiar walk, sluggish thyroid or leaky heart valve using just keen eyes, practiced hands and a stethoscope.

Art and medicine may seem disparate worlds, but Dr. Verghese insists that for him they are one. Doctors and writers are both collectors of stories, and he says his two careers have the same joy and the same prerequisite: “infinite curiosity about other people.” He cannot help secretly diagnosing ailments in strangers, or wondering about the lives his patients lead outside the hospital.

“People are endlessly mysterious,” he said in an interview in his office at the medical school, where volumes of poetry share the bookshelves with medical texts, family photos and a collection of reflex hammers.

His sources of inspiration include W. Somerset Maugham and Harrison’s Principles of Internal Medicine. In addition to his medical degree, he has one from the writing workshop at the University of Iowa.

Dr. Verghese trained before M.R.I. or CT existed, in Ethiopia and India, where fancy equipment was scarce and good examination skills were a matter of necessity and pride. He still believes a thorough exam can yield vital information and help doctors figure out which tests to order and which to skip — surely a worthwhile goal as the United States struggles to control health care costs, he said.

A proper exam also earns trust, he said, and serves as a ritual that transforms two strangers into doctor and patient.

“Patients know in a heartbeat if they’re getting a clumsy exam,” he said.

He left Ethiopia at 15 for two years of premedical studies in Madras, India, and then returned to Addis Ababa for medical school. By then his parents, worried about Ethiopia’s stability, had moved to the United States. But he had no desire to leave.

“I loved that land,” he recalled.

The medical training was rigorous. Students spent a year dissecting a cadaver, and then had to pass grueling essay exams.

“It was almost brutal,” he said. “But it left us changed in some fundamental way, like formatting a disk.”

Medical students in the United States today spend far less time studying anatomy — too little to learn it well, he said, shaking his head.

***

He worked in Tennessee during the early days of the AIDS epidemic, before there were any effective treatments. Before AIDS, he said: “I must have been a conceited ass, full of knowledge. AIDS humbled a whole generation.”

He came to know many of his patients and their families. He visited their homes, attended their deaths and their funerals. One patient, near death, awoke when Dr. Verghese arrived, and opened his shirt to be examined one last time.

“It was like an offering,” Dr. Verghese said, with tears in his eyes. “To preside over the bed of a dying man in his last few hours. I listen, I thump, I don’t even know what I’m listening for. But doing it says: ‘I will never leave you. I will not let you die in pain or alone.’ There’s not a test you can offer that does that.”

***

“What’s the most important part of the stethoscope?” They stared at him. “The part between the earpieces.” They moaned.

“Name five things that are better outside the body than in,” he asked, not mentioning that the answer appears in his novel: fluids, fetuses, foreign bodies, feces and flatus.

Dr. Verghese smiled. “I am here to astound you,” he said.

Full NYT Article

The Stanford 25: Exam Techniques Every Doctor Should Know

There are* in fact stupid questions

2010-10-04T17:24:00.001-07:00

There are in fact stupid questions. In fact, there are several. Further fact: the majority of things a medical student might say at any given moment will likely fall into the classification of stupid question, even if in other contexts they are reasonable questions. For example "where is the bathroom?" and "How do i stop the patient from biting me?"

Statements can also be stupid questions ("But i do not know how to do a cardiac massage.") as can inquisitive looks and breathing too loudly near the surgeon.

Stupid questions are punishable by smirking, derision, public lashings, private lashings through vivid evaluation remarks ("Please express to your parents my great sympathy for their having birthed a child too stupid to know how to dose diuretics properly" "Your usefulness to the team ranks below latex gloves status post rectal exam but above small puddles of body fluids to the left of the nursing station") and being physically assaulted in the operating theater (using proper sterile precaution) with either very expensive surgical instruments or fecaliths. Please note that any damage incurred to surgical equipment will be added to the student's tuition. Also any patient specimen used as a projectile didactic tool will need to be retrieved by the student and expediently returned to the pathology lab.

In conclusion please arrive to clinic or your respective ward teams knowing everything and kindly avoid making eye contact.

Curriculum Vitae- in comic book form

2010-09-27T10:57:00.001-07:00

The Heart of Medicine

2010-09-23T20:56:00.001-07:00

"To practice medicine with good spirit does not mean to be in a place where there is no noise, trouble or hard work. It means to bring your calm and loving heart right into the midst of it."

http://www.theheartofmedicine.org/

A Very Beautiful Old Man

2010-09-11T11:02:00.001-07:00

HANS KEILSON, a Jewish doctor, psychoanalyst, poet and novelist who fled Nazi Germany.

“I’m 100 years old and 8 months, and the last 8 months have been the hardest.”

A Physician Examines His Novels

Some Dreams I have, Largely in Order of Priority, From Most to Least

2010-08-29T21:33:00.001-07:00

(1) Have a living room

(2) Get a Dog

(3) Get a really nice coffee making machine

(4) Finish medical school

(5) Get Netflix streaming {x} done

(6) Have a dish washer

(7) have a daily commute that is less than 20 min

(8) Have a garden

(9) Finish residency

(10) learn more statistics

(11) get a TV

(12) finally finish reading Proust

(13) win a Nobel Prize

Things i learned while backpacking 14 miles over steep terrain with a 40 lb pack

2010-08-09T21:56:00.000-07:00

1. i should probably work out more
2. when faced with the decision of pooping in a hole you have to dig and not pooping for a few days of strenuous activity it is very unwise to choose not to poop
3. Bears are wily, clever, motherfucking super beasts. And scary. Cuddly. but also scary.
4. Mosquitoes do in fact bite brown people of equatorial origin who suspect themselves of having a heretofor unidentified hemoglobinopathy based on absolutely no laboratory or clinical evidence whatsoever.
5. I hate motherfucking mosquitos.
6. i would like to devote my entire scientific career to single handed crushing every mosquito on this planet
7. i would be a great humanitarian hero if i did.
8. I probably won't.
9. Sigh.
10. Hyponatremia is no joke. gatorade can bring back life.
11. deer. kind of creepy.
12. Backpacking. WTF. really? you strap 40 lb to your back and then walk over steep terrain and leave behind centuries even millenia of sacrifice and progress like buildings with walls and indoor plumbing?
13. There is profundity in the pursuit of one's own limitations and how odd it is that in the clarity of daylight and serenity we file our lives in impeccably rational filing systems (work, fun, love) arranged by elegant narrative orderings, but in those dark moments, we find the mind has in fact cross wired everything by a far murkier robust system of visceral domains: despair (the gasping desperate blind rage towards the mountain top, the ghostly 3 am of another gloomy call night pummeled by hunger for sleep), triumph ( the 360 degree view of the California Sierra mountains, the bright light and echo of civilization when stepping outside of a hospital to a noon time healthy bustling San Francisco) and transcendence (the floating away when letting drop 40 lb of either camping equipment or neurosis)
14.Nature totally kicked my ass.

How I would name the rainbow

2010-07-26T10:42:00.000-07:00

Blood that is oxygenated Red
Beta Carotene
Jaundice Yellow
Bile Green
Botched IV Contusion blue
Blood that is deoxygenated Purple
Poop Brown
Necrotizing Fasciitis Black

I am on a Diet

2010-06-12T10:36:00.000-07:00

Indeed. The D word. such stigma. It conjures...i don't know this: anal retentiveness. vanity. a puritanical disdain for pleasure. It pictures to me the concession to middle age when we have forfeited the incessant consumption of youth and its utter ignorance of consequence and taken up the mantle of the Ice Man Cometh, of promises perpetually made and forever broken, ruthless cycles of New Year's Resolutions, and the fool target of multibillion dollar vultures who use gym membership, shakes composed of saltine cracker debris, methamphetamines, veganism as a shrill cover up for eating disorders, anything anything! to devour you, the gullible, guilt plagued inert outflow product of wanton american greed and the easy way. It is a deadly cliche.

All such things of course reveal the countours and kinks of my own neuroses as much (more) than of my binge-purge society. Meh, what are you going to do.

My body, its a good piece of work. Its only got 27 years and a couple hundred miles on it. After spending the last several years meticulously reviewing all the horrible possibilities of illness and monstrous betrayals of genetics, I have become tremendously grateful for health, and humbled by how quickly it can and does flit away. (Death, dudes. Its totally going to happen). But so far, a little asthma, a touch of neurosis, minor scratches and a rather unfortunate intolerance of this particularly excellent local brand of hot salsa (I'm sooooooorry everyone who had to sit within a 4 foot radius of me during my impassioned 1 year denial of this, but it was so tasty!) but over all good working parts. Lungs fill up with air, heart pumps, limbs move. My body works hard for me, carrying heavy books, sitting long uncomfortable hours squinting at small writing, listening carefully to heart sounds, staying up for 36 hour call shifts, running to both catch and dodge out of the way of violent muni busses, and above all it lets me dance and cuddle people and other delightful somatic activities. So i want to treat it right and make it happy.

And I do that by giving it unlimited access to burritos and beer.

So Dieting. Why would self denial be a good thing? also i hate being told what to do. Even by me.

Alas, the 19 year old triumphant obliviousness that abuse of one's liver and unlimited pizza binges carries on without consequence, has turned out to be less than fact. Some combination of age, hormones,deriving meals from vending machines, the use of food as an anxiolytic and anti depressant, and exchanging 2 hours daily work outs for an activity regimen that consists mostly of seeing how long i can balance a cereal bowl full of soy milk on my burgeoning belly (more challenging than it appears)--these alas, were also subject to the laws of chemistry and physiology and thus the relentless upward march of BMI.

I still love my body and it continues to work hard for me. Aesthetically I like strong ladies with squishy butts and i am digging my squishy butt. But I envisioned the next five years of call nights and vending machines and the trends of my disappearing waistline, that small detail of a robust family history of diabetes and heart disease, my idle advice to patients to 'just change your diet and eating habits and quit smoking and all your diseases will go away!' And eventually i will not be aesthetically pleased. I will make babies and it will worsen with hypothyroidism. I will be a rotund dumpling*. I will have insulin resistance and osteoarthritis.

*The Sri Lankan body destiny - Sri Lankan women come in 3 basic shapes. The most common is very very very tiny. MIA is a classic example. The second most common is Dumpling - big butt, boobs, hips on a short frame. Good for childbearing and and pretty adorable in aunties and grandmas. Least common but most inspirational is the tall athletic Sri Lankan girl who is a compete badass at basketball.

So. Body. I have been spoiling you. We've got to get you in shape. It will be better in the long run. You will thank me later.

Disclaimer: poetic license allows me to discuss body as third person object but i strongly abhor mind-body dualism.

So i began the Halt the BMI Diet this last Monday (only after an amazing weekend camping trip of gluttony and eating an entire bag of Mother's frosted animal cookies--you know, that shit with sprinkles. Hella good). I am hoping to lose 15 pounds over 16 weeks and then reassess how i feel. I hope that it is modest enough that i can figure out how to adapt it to a long term maintenance approach.

My previous attempts at 'eating healthy' has mostly consisted of vague commitments of 'I will eat some vegetables and less pizza'. Currently I am trying to consume net 1500 calories per day, with 1 day a week where I am off diet. If i eat an entire bag of Mother's frosted animal cookies (hella good) on that one day off, it probably will render the rest of the days moot, but i think this might be an important psychological safety valve and allow for longevity of the task. This week i have not quite succeeded, being on average 150 net calories over. I am keeping track with an overall satisfactory iphone ap Lose It. Generally it is a good ap; a disadvantage is that if you eat a lot of sri lankan, ethiopian, or any non-mainstream food, and you must sort of hodge podge it together based on the ingredients. This tracking alone has been revelatory. Despite a biology degree with extensive study of metabolism and several years of medical school and plenty of time advising other* people on how to manage their diets, I was surprised at how poor an intuition I have for the energy density of foods.

For example - hummus. You can eat hella hummus, feel really full and its like, not very much calories. But - granola. Despite its reputation as hippie food, the caloric impact (and glycemic index) is equivalent to eating several crumbled up cookies. Also even if you're like Look at Me I'm Eating a Salad for Lunch! but then you put a shit ton of cheese and nuts and avocados on your salad, it can be the equivalent of eating a pizza. But faced with finite budgeting, it became an exercise in revealing the value of food for me--e.g. I fucking love cheese, nuts and avocados and these taste really good on salad. But granola can suck it. Likewise white rice, which is just a mind boggling calorie sink of tasteless nothingness.

Working out will hopefully also be a big part of this endeavor, but i haven't yet figured out in what way. I have always loved dancing and capoeira and running around in circles for no reason at all, and it is a source of mental health and joy for me. The feeling of blood rushing to my head and the psychological impression of making myself strong and mighty is tremendously satisfying. It is also my experience (and i think documented in many studies) that it also increases my appetite and i am pretty sure i consistently eat more than i burn, so i am not sure it makes much difference in weight. So for now, my exercise activities will continue as they have before--sporadic, for fun & muscle flexing, while i focus on sorting out my meals.

At the end of the day, i love food. It is a source of joy, pleasure, comfort, and a way to commune with others. I do not want to be alienated from this and begin to view it instead as a source of anguish, conflict, or as a barrier to my health and well being. But I think i have already alienated myself from food by slurping it down mindlessly, using it as opiate, inhaling cafeteria breakfast burritos with desperation and flurry. Some of that can't be entirely helped since i have committed to certain goals and a lifestyle (i.e. medical training) that is also a source of meaning and joy. But I hope during the coming months of mostly sitting on my ass and data-analyzing, the Diet will be an exercise in eating more mindfully and thoughtfully.

less money

2010-06-01T20:08:00.000-07:00

Due to the fiscal crisis in California, the Office of the Registrar has absorbed reductions in its state-funded budget totalling approximately 29 percent since 2008-09. To avoid reducing essential services, we will increase fees for miscellaneous services such as transcripts and diploma mailing on July 1, 2010. We regret that we must take this action to maintain our services.

Thank you for your understanding.

Sincerely,
Office of the Registrar

A comparison

2010-05-22T14:30:00.000-07:00

Who I would like to picture myself as

Confident, razor witted, curmudgeonly, secretly wise.

with awesome biceps.

Or

Powerful, commanding, seductive.

The boss of stuff.

But mostly i feel

Concerned. Nice. Cutesy. Terrified.

Or bureacratic. Paper tiger. Effete and futile.

But i think, someday, i will learn to flower as myself.

Things i want a lot but cannot afford

2010-05-21T10:37:00.000-07:00

My funding this year is pretty miniscule. And it is coming to my attention that my perpetual hiding in higher education will end one day and i will have loans to pay. A lot of loans. Like, numbers with a great multitude of zeros that follow them. Also that residents don't make much money. (on the other hand since my only other proper jobs have been in cafes, book stores, and grading logic homework, being a resident will be the richest i will have ever been and i am quite excited). Despite this, i have discovered over the last several years that (1) i like nice things (2) that despite what i was otherwise led to believe by Berkeley Bohemia, it can cost quite a bit of resources to experience nice things (time, attention, and money).

Ah, but to live in San Francisco, to be devoted to a great art, to be youngish...so a la Hemingway's Moveable Fest, I will sate my appetite by aromas. To begin, a menu.

Things i desire and cannot afford (in time, attention or money)

1. A haircut
2. To fix Ravelstein the shattered iphone
3. beautiful lingerie
4. a car
5. a parking space to the put the car in
6. a television
7. time to watch a television
8. a knowledge of films
9. a thoughtful fashion sense
10. healthier eating habits
11. regular massages
12. membership to an institution with a sauna
13. children
14. a dog, to watch/herd the children
15. an apartment with a living room
16. a garden
17. a knowledge of Wittgenstein
18. travel to faraway lands and then staying at midrange hotels instead of haggling with broken down hostels with no running water
19. to whisk my sweetie away to a beautiful place with no worries (for a little while)
20. world peace

an overhaul

2010-05-20T22:53:00.001-07:00

bc i find it physiologically difficult to study multiple choice questions for more than 10 hours a day, and bc i like to sit in front of my computer instead of engaging in aerobic exercise, and bc i have the time and space to reflect on my training, existence and future (at the expense of you, the taxpayers of California, and me the future loan payer), and above all bc i have a gorgeous sexy new love affair, namely with a shiny 2010 macbookpro (aka Osler's Beast, alas to replace my previous beloved machine, ruthlessly stolen) i am inspired to relaunch a different purpose with my online blathering ("different" as in having one at all).

I am searching now meticulously through examples of other doctor and medical student blogs and finding many good things, to my pleasure and joy. I will hand pick some eventually. for now i will share this from Axis Deviation.

25 Things I Didn't Do Before I Entered Medicine

Wake up before 8am.
Go to sleep after 2am.
Look forward to sleeping nearly every night.

Wear a shirt and tie to work.
Shave more than three times a week.

Stick my finger up peoples' butts.
Ask people how many people they’ve slept with.
Ask men to tell me about their erectile dysfunction.
Ask for men to show me their penis.
Dread seeing vaginas.

Be able to tell police officers what to do (in the hospital, at least).
Talk with police officers.
Talk with prisoners.

Slam the phone on people.
Hate pagers.
Hate anything that beeps.

Drink at home, alone.
Want to drink this much.

Be thankful I am alive.
Hope that certain people would die.

Struggle for money.
Dream of money.
Despise people with money.
Despise people.

Wish I didn't enter medicine.

studying

2010-05-20T12:19:00.001-07:00

Studying for the second boards has so far been profoundly different from the first boards. One reason is because i am not also hyperventilating in an attempt to finish and properly format a master's thesis. Yet another is that all these abstract lists of previously nebulous and nonsense strings of fact have profound meaning.

Third year was hard for lots of reasons, not least of which is constantly being surrounded by death, suffering and dramatic events. This is of course the point, as the entire existence of the job depends on people getting run over by cars and having heart attacks. I suppose the training is so long so that after several years of seeing it, instead of weeping and gasping at the sight of hemorrhage or the slow overtake of a human life by a monstrous cancer, as a normal healthy human being should, instead one is competent technician and numb enough to do something useful. Technician in the broadest sense--to be able to insert a swan ganz catheter into the right place to speak and drug away an impending suicide attempt to break devastating news with compassion. All very difficult techniques.

The technique matters. The knowledge matters. The most important thing i did third year i suppose was observe. And the funny thing about having such intense imprinting of the memory given its tremendous affective weight and existential gut kick, is that the most odd facts have seared themselves into my brain. Cocksakie virus is the number one infectious cause of myocarditis = 38 year old man in the ICU, h/o of hodgkin's, heart failure, delayed biopsy, his powerful muscular chest strung with endless tubes and wires, his aghast stoic young wife sits by in pink sweat pants. He dies the next week. Never treat sinus tachycardia= M&M rounds with the senior resident who did precisely that in the midnight transfer, a 32 yo woman decompensating from sepsis, shot up with beta blockers, the resident presents the facts with a steady strong voice, but i see her crying in the hall later. Aminoglycoside nephropathy, serotonin syndrome, cardiac tamponade -- how odd these are, how real, how their string of greek and latin artifice become such moments of terror, anguish...and potential triumph.

the multiple choice test is suddenly a richer, more interesting thing.

What to do next

2010-05-14T10:01:00.001-07:00

Here are some career fantasies:
(1) Finish medical school
(2) Finish residency

and then?

I think i am in love with HIV. It is too rich, too big. It is horrible, ruthless. It attacks us through our love lives. It is wiping out, has wiped out an entire generation, entire societies. It travels with tuberculosis. It revolutioned immunology. It is a disease of gay men, of Africa, Haiti, of hemophiliacs and children who had no choice.

The glory days of HIV in San Francisco, the sheer terror and fear of a deadly miasma that takes the young and bohemain, the time for great courage, the time of surgeons drenched in poisoned blood, came and went. now the battle is quieter, it is tedious, but it still there. Now it is a battle of pharmaceutical patents and global distribution of testing equipment, of chipping away at lymphoma and heightened rates of diabetes and salvaging kidneys in old age.

So then. what would i do? get work. Begin working.

emphatic addition to previous post

2010-05-10T23:40:00.001-07:00

A new oath

2010-05-10T22:21:00.000-07:00

A few weekends ago, i went to a day long retreat of medical students in some nearby forest. I joked it was a hippie get away for medical types. Indeed, we arrived at an old building embedded in a bay area secluded forest, decorated with healing wheels and crystals and our facilitators were gentle and soft spoken. But the building in its regular life most often hosted retreats for those dying of cancer. And our facilitators were a palliative care physician and nurse, whose daily work was in hospice, in guiding fellow humans to their end of day, ensuring that foley catheters were functioning and that morphine was sufficient; but also that people might die with dignity in the company of those with compassion and humility in the face of the greatest abyss.

I went because i was hurting, hurting for myself, i knew that car ride through winding Hwy 1 with my classmates would be therapy i was desperately thirsty for, to salve the hurt that was mostly in my ego. I had finished my clerkship year of medical school and the year previous that had careened wildly through my master's write up. I was exhausted, overstimulated, and felt desperately inadequate. I spent the year in a fishbowl, perpetually under evaluation, and i in turn watched the patients in another embedded fishbowl, while they did godless things, like bleed, give birth, suffer, die, come to life again. An onslaught of human triumph and tragedy and very little sleep in between. I felt shattered and confused. I felt alone.

I cannot describe all the beautiful things about that day amid the quiet trees and these other people winding through their own journey. But i was salvaged indeed, and i was glad to work again. A nice exercise we did towards the end was make our own sort of Hippocratic oath, which was then sort of edited together. I found it very moving, that these future surgeons and emergency room docs and psychiatrists and general practititioners (some to be interned as soon as June) were so soulful, and i was inspired by their passion for their work. Here is are some snippets, as well as the collected oath we formed:

Personal MISSION STATEMENTS

v v v

Help me to approach every patient with patience, even if I am exhausted and overworked.

Guide me to remain sincere, sensitive, and humanistic in my practice despite how many patients with similar presentations I have seen

v v v

Help me let go of fears, prejudices and distractions, so that I can be truly present with patients

Help me apply technical skills within the context of trust and compassion

Help me make decisions that support healing of the whole patient, and not merely fixing of parts

v v v

May my work be an artistic expression

May it be a practice of grace

May it be a movement of justice

May my work be a dance towards self

May it be a reflective reading of the poetic prose of human experience

v v v

Help me to listen—to hear the story, to understand what is being asked

Help me to see—to observe carefully and unveil the truth

Give me the knowledge and patience to teach so that the people I care for can care for themselves and others

Help me to touch—to feel, to discover but also to mend and reassure

Teach me to find and share peace in the face of sickness, death and life

v v v

Help me to hear with my mind and heart

Help me to stand in power

Help me to remain compassionate, present and invested

Give me strength to know when to keep going and when to stop

v v v

Help me to care for myself as I care for others

Guide me as I develop wisdom to go along with knowledge

v v v

Help me to be courageous in walking with patients in their suffering

Help me to serve with relentless hope and compassion

Help me to be confident and authentic in who I am as a physician

Help me to be innovative in how I provide care

v v v

Hold me long enough so I know I can stay or go anytime

Keep my eyes open to that moment when patients are ready to really feel what is going on

Calm me

Remind me that I always can choose

v v v

Collective:

Guide me to remain sincere, sensitive, and humanistic in my practice despite how many patients with similar presentations I have seen

Help me let go of fears, prejudices and distractions, so that I can be truly present with patients

May it be a reflective reading of the poetic prose of human experience

Give me the knowledge and patience to teach so that the people I care for can care for themselves and others

Remember to always be present, honest, and human

Help me to hear with my mind and heart

Guide me towards balance professionally and personally

Help me to be present to each person I encounter, with humanity

Help me to be confident and authentic in who I am as a physician

Calm me.

I want a dog

2010-05-09T15:22:00.000-07:00

Dude! Bruce Lee! Dude!

2010-04-26T23:31:00.001-07:00

One of my life long idols is my grandfather. He was a school teacher, had a master's of fine arts, was handsome, loved by the ladies, a fellow of virtue and known to win all the fights in his youth. He owned a motorcycle. And his hero? Bruce Lee.

It cannot be overemphasizedd how cool Bruce Lee is. He is so cool!

This guy was phenomenal. Who on earth has been fitter? here is a listing of his feats:

Lee's striking speed from three feet with his hands down by his side reached five hundredths of a second.
Lee could take in one arm a 75 lb barbell from a standing position with the barbell held flush against his chest and slowly stick his arms out locking them, holding the barbell there for 20 seconds.
Lee's combat movements were at times too fast to be captured on film for clear slow motion replay using the traditional 24 frames per second of that era, so many scenes were shot in 32 frames per second for better clarity.
In a speed demonstration, Lee could snatch a dime off a person's open palm before they could close it, and leave a penny behind.
Lee would hold an elevated v-sit position for 30 minutes or longer.
Lee could throw grains of rice up into the air and then catch them in mid-flight using chopsticks.
Lee could thrust his fingers through unopened cans of Coca-Cola. (This was when soft drinks cans were made of steel much thicker than today's aluminum cans).
Lee performed one-hand push-ups using only the thumb and index finger.
Lee performed 50 reps of one-arm chin-ups.
Lee could break wooden boards 6 inches (15 cm) thick.
Lee could cause a 200-lb (90.72 kg) bag to fly towards and thump the ceiling with a sidekick.
Lee performed a sidekick while training with James Coburn and broke a 150 lb (68 kg) punching bag.
In a move that has been dubbed "Dragon Flag", Lee could perform leg lifts with only his shoulder blades resting on the edge of a bench and suspend his legs and torso horizontal midair.

A. Badass. Motherfucker.

That's really all I have to say.

.

Summary points of health care reform

2010-04-26T10:24:00.000-07:00

A nice summary

(1) Expands coverage to about 33 million people by 2014 (50% private, 50% public support); 95% eligible Americans would be covered: 83% now

(2) Does this by a combination of expanding Medicaid coverage, mandating that all individuals be covered (with certain exemptions), and mandating that private businesses cover workers for firms with >200 employees (WalMart issue)

(3) Estimated costs of $965 billion/10 years

(4) Pays for expansion by combination of increased revenues and cost containment

(5) Lets states create insurance exchanges to broaden and cheapen insurance options for those not covered

(6) Extensive and income-adjusted subsidies for low income families

(7) Penalizes employers that don’t provide coverage

(8) Expands Medicaid coverage to all under 65 population with incomes <133% of Federal Poverty Level

(9) Require states to maintain CHIP thru 2015

(10) Increases taxes on high income persons, beginning 2011

(11) Cracks down on Medical Savings Accounts, “Cadillac insurance plans” and Medicare Advantage Plans (to get new coverage $)

(12) Some charges to health insurance plans and pharma

(13) Health insurance reform
--Eliminates preexisting conditions
--Jawbones insurance plans re “loss ratio” (>85%)
--Kids can stay on parents’ plans until age 26
--Eliminates lifetime expenditure caps
--Covers prevention services
--Gradually closes the doughnut hole for Medicare Part D

From Steven A. Schroeder, MD from talk: Revisiting American Health Policy: Why Change Comes so Hard

A great distance

2010-04-22T22:35:00.000-07:00

"You cannot be a happy go lucky stoner and be a resident at the same time," a beloved friend chides. He is still himself but there is the intern's fatigue about him.

I am looking at this website: http://bohememusings.blogspot.com/

Although the young woman is much more stylish than i ever had much inclination to, her prattlings about cake and prettiness are eerily similar the sort of thing that filled my journals at 22, with the additional insouciant reference to Heidegger or LSD or some other nonsense. I read it now with marvel and a feeling of...coldness, such creatures exist? such beauty, such frivolity, imperviousness to the misery and blood and shit of this world? I suppose they are called young women.

So is it really med school that has numbed it all up, or is the inevitable revelation of decay?

The only constancy appears to be cake. I suppose the beauty persists, pervades, moves and seeps from lace and plastic bangles, to the detritus of daily life.

Tomorrow we begin again

2010-04-19T14:49:00.000-07:00

k. its a Nike commercial. But u know, its good. i like it.

Sometimes you need a soundtrack.

The swirling inside

2010-04-17T10:23:00.000-07:00

Fascinating

The B.N.P. says it stands for many things, but chief among them is an implacable belief that Britain belongs to indigenous white Britons. Until a judge struck down the provision last month, the party had a whites-only membership policy. It favors an immediate end to immigration and the repatriation of people of foreign descent.

In 2006, the party won 12 of the 51 seats on the Barking and Dagenham Council, its strongest showing anywhere in the country. This time, it hopes to secure 14 more seats, enough to take control of the council, its 300 million pound annual budget and its 9,300 employees...

“I’m not a racist, but they’re letting so many of them in,” complained Bill Greed, 66, speaking of foreigners. “They come and sign on for benefits. A lot of the children in schools don’t even speak English. There’s so many illegal ones that the government can’t even find all of them.”

The B.N.P.? “I agree with what they’re saying, but not with how they go about it,” Mr. Greed said.

Mick W., a 20-year-old maintenance worker who did not want to give his last name because he is employed by the Borough Council, said his family waited a decade for decent public housing while immigrants with large families leapfrogged ahead.“I don’t mind the ones who come and get a job,” he said, “but all they do is claim, claim, claim.”

From NY TimesVoters’ Concerns on Immigration Spin British Campaign

And i think i understand this. I can empathize, this cautiously worded frustration of one's own neighborhood, limited resources now distributed over larger denominators of outsiders. And surely here, in this other land, we are all immigrants, and a little bit self conscious no, of what we are taking, no?

And yet. And yet .What is it, the berkeley education, perhaps? And yet, i, the devoted anglophile, who gazed longingly at the filthy Thames as a child and heart swelled with utter love for the gilded smoggy face of the London towers and curls up at night with Bertrand Russell, who thinks affectionately of all things british, fetishist of Newton and tweed and has been thoroughly chained and colonized in the English language to obliteration of whatever tropical deviance there might have once been...a great snarling rises and says Shut the Fuck Up. The gold on your clock faces is from the mines of brown nations, you have built your empire with guns, your delicate tea cups are filled with the sweat of my distant grandparents, you deliberately incited war and broke the backs of millions to build a wealth the world had heretofore never seen and now you grumble when the gates break down.

But this is not fair of course. All of the wealth did not go to the Barking burroughs. And the english were very good at abusing those within their society as well as those in distant lands. And here i am, a plump little fruit of colonization, enjoying a saturday morning in the distant protestant bastion of California, drinking coffee from columbia and pasteurized milk. The sins of our fathers can so quickly dissolve in the crisscrossing lines.

Conveying the Art

2010-04-14T09:39:00.000-07:00

Junior Physician: "How did you get such good judgement?"

Senior Physician: "Good experience."

(Long Pause)

Junior Physician: "How did you get such good experience?"

Senior Physician: "Bad judgement."

The One to Blame

2010-04-13T11:57:00.001-07:00

Describing the path of medical training (or most schedules of work in American society) the notion of working 90 hours a week (benevolently reduced from the previously typical 120 hours) or showing up to work 6 am Monday morning and leaving at 2 pm on Tuesday morning, and all the while handling several sharp objects, toxic medications, and various tubes jammed into the actual veins and bowels of very ill fellow human beings--well its all sort of odd. Doctors in training are of course made of the very same veins and bowels, and have those same pesky requirements of other mammals, namely sleep, food, and the occasion to stop standing. In the medical profession such inconveniences are consoled by profusely attending/manipulating those other* needs of social mammals: acceptance, hierarchy, self importance and a good boy! pat on the head.

It all seemed very strange and i like most sensible people (including Congress) was skeptical of this tradition. [j/k neither I nor Congress nor most people are very sensible at all, but it is no less a reasonable stance]. I was then very shocked to realize the origin of this barbaric method of training that seemed oblivious to the triumphs of industrial society and the invention of the weekend, was invented by no other than my long hero, the pathologist and great teacher, Dr. William Osler.

"Perhaps Osler's greatest contribution to medicine was to insist that students learned from seeing and talking to patients and the establishment of the medical residency. This latter idea spread across the English-speaking world and remains in place today in most teaching hospitals. Through this system, doctors in training make up much of a hospital's medical staff. The success of his residency system depended, in large part, on its pyramidal structure with many interns, fewer assistant residents and a single chief resident, who originally occupied that position for years. While at Hopkins Osler established the full-time, sleep-in residency system whereby staff physicians lived in the Administration Building of the Hospital. As established, the residency was open-ended, and long tenure was the rule. Doctors spent as long as seven or eight years as residents, during which time they led a restricted, almost monastic life.

He liked to say, "He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all." He is also remembered for saying, "If you listen carefully to the patient they will tell you the diagnosis" which emphasises the importance of taking a good history.

The contribution to medical education of which he was proudest was his idea of clinical clerkship — having third- and fourth-year students work with patients on the wards. He pioneered the practice of bedside teaching making rounds with a handful of students, demonstrating what one student referred to as his method of "incomparably thorough physical examination." Soon after arriving in Baltimore Osler insisted that his medical students attend at bedside early in their training: by their third year they were taking patient histories, performing physicals and doing lab tests examining secretions, blood and excreta.

He diminished the role of didactic lectures and once said he hoped his tombstone would say only, "He brought medical students into the wards for bedside teaching." He also said, "I desire no other epitaph … than the statement that I taught medical students in the wards, as I regard this as by far the most useful and important work I have been called upon to do." Osler fundamentally changed medical teaching in the United States, and his influence spread to medical schools across the globe."

The prisoner in every man

2010-04-12T10:44:00.000-07:00

"It is generally thought that common-sense is practical. It is practical only in a short-term view. Common-sense declares that it is foolish to bite the hand that feeds you. But it is foolish only up to the moment when you realize that you might be fed very much better. In the long-term view common-sense is passive because it is based on the acceptance of an outdated view of the possible. The body of common0sense has to accrue too slowly. All its propositions have to be proved so many times before they can become unquestionable, i.e. traditional. When they become traditional they gain oracular authority. Hence the strong element of superstition always evident in 'practical' common-sense.

"Common-sense is part of the home-made ideology of those who have been deprived of fundamental learning, of those who have been kept ignorant. This ideology is compounded from different sources: items that have survived from religion, items of empirical knowledge, items of protective skepticism, items culled for comfort from the superficial learning that is* supplied. But the point is that common-sense can never teach itself, can never advance beyond its own limits, for as soon as the lack of fundamental learning has been made good, all items become questionable and the whole function of common-sense is destroyed. Common-sense can only exist as a category insofar as it can be distinguished from the spirit of enquiry, from philosophy.

"Common-sense is essentially static. It belongs to the ideology, of those who are socially passive, never understanding what or who has made their situation as it is. But it represents only a part--and often a small part--of their character. These same poeple say or do many things which are an affront to their own common-sense. And whent hey justify something by saying 'It's only common-sense', this is frequently an apology for denying or betraying some of their deepest feelings or instincts...

"There is another reason why they sense that Sassall's way of thinking is a privilege, but as a reason it is less rational. Once it might have been considered magical. He confesses to fear without fear. He finds all impulses natural--or understandable. He remembers what it is like to be a child. He has no respect for any title as such. He can enter into other people's dreams or nightmares. He can lose his temper and then talk about the true reasons, as opposed to the excuse, for why he did so. His ability to do such things connect him with aspects of experience which have to do be either ignored or denied by common-sense. Thus his 'license ' challenges the prisoner in every one of his listeners."

From John Berger, "A Fortunate Man"

On Primary Care

2010-04-04T08:37:00.000-07:00

I think the appeal of primary care which i didn't appreciate until i saw patients have really bad or no primary care is that it appeals to the editor in people. The power of the word is not the word itself, but like sculpture, all the words removed. Like the good news story with impeccably gathered facts, the complicated patient has a million and one rabbit holes to be lost in, and sometimes they are worth pursuing with full investigative and management gear on. But sometimes not, and if you let all the jumble sit there as it is, you lose the point all together. And so it becomes the fine art of editing--reducing medications, streamlining self care plans, construing an elegant model of health that engages the patient, yourself and all the other people invested in this person's well being. Medicine has always prided itself in the elegance and cleverness of its diagnostics, but it seems to me (at least in American medicine) this idea of the elegant therapeutics is still relatively new (perhaps the Cubans have long been far ahead?), what with the forced hand by economic factors and the revelation that you can't put 80 year old people on 27 different medications and think thats going to be totally innocuous.

I have been think about it like this

2010-03-24T22:28:00.000-07:00

I used to think that I was a hard worker. But I am pretty sure i have never worked as hard as i have worked for the last two years. And the realization that i will work even harder in the future is very frightening. And the reflection that there are people all over the world who work even harder than this and are less rewarded, and less comfortable--this is humbling. But then, it makes me feel, maybe we are all in this together. And then the work has meaning, and the hardness has meaning. And purpose, this feels good.

The Immortal life of Henrietta Lacks

2010-03-11T17:30:00.000-08:00

I still can't believe how amazing this is.

The Immortal Life of Henrietta Lacks (aka HeLa): The history and ethics of research on human biological materials

Henrietta Lacks, known to scientists as HeLa, was a poor Southern tobacco farmer who worked the same land as her slave ancestors, yet her cells—taken without her knowledge—became one of the most important tools in medicine. The first “immortal” human cells grown in culture, they are still alive today, though she has been dead for more than sixty years. If you could pile all HeLa cells ever grown onto a scale, they’d weigh more than 50 million metric tons—as much as a hundred Empire State Buildings. HeLa cells were vital for developing the polio vaccine; uncovered secrets of cancer, viruses, and the effects of the atom bomb; helped lead to important advances like in vitro fertilization, cloning, and gene mapping; and have been bought and sold by the billions—yet Henrietta Lacks remains virtually unknown, buried in an unmarked grave.

Henrietta’s family did not learn of her “immortality” until more than twenty years after her death, when scientists investigating HeLa began using her husband and children in research without informed consent. And though the cells had launched a multimillion-dollar industry that sells human biological materials, her family never saw any of the profits. The story of the Lacks family—past and present—is inextricably connected to the dark history of experimentation on African Americans, the birth of bioethics, and the legal battles over whether we control the stuff we are made of. For more information, visit www.rebeccaskloot.com

§ See a full description of the book here: http://www.rebeccaskloot.com.

§ Also see the author's blog to learn more about the book and the author’s approach.

§ Listen to Ms. Skloot's interviews on NPR's on Fresh Air and Science Friday.

§ The New York Times featured the book here and reviewed it here.

§ Read an excerpt from the book here.

Summary of things that were fun in fresno

2010-02-28T20:27:00.001-08:00

Things i did
(1) getting to know classmates
(2) driving, easy parking
(3) Stay in a Victorian bed and breakfast in Reedley, CA
(4) drive up a mountain in Kings Canyon National Park (even if it was too snowy and i couldn't go further without snow tires)
(5) Thrift stores in Reedley, ca (excellent selection)
(6) The Tower District: thrift stores, antique stores, cafes, book stores that are never open, la boheme de Fresno
(7) Eat Ribs at Famous Dave's
(8) Basque food (apparently there is a very old Basque community in Fresno)
(9) Write some haikus
(10) Go to Target a lot

Things i wish i did
(1) Go to Yosemite
(2) Go to flea markets and farmer's market
(3) Go to the hmong war memorial
(4) Go the public library to learn more about local sites and history
(5) Go to the underground gardens (http://www.undergroundgardens.info/Tours.html)
(6) Drink more
(7) camp in the foothills
(8) practice Spanish
(9) succeed in finding the local capoeira group
(10) visit an evangelical mega-church

Some resources
Fresno Famous: http://www.fresnofamous.com/node/90
NY Times travel: http://travel2.nytimes.com/2006/05/05/travel/escapes/05hours.html

Goodbye, Fres-YES

2010-02-27T08:18:00.000-08:00

I am the last remaining person at the med student compound. Outside it is raining heavily and there is the eerie central valley fog that is as mighty as anything that has rolled over the Pacific to devour San Francisco, but much creepier because, where does it come from? It settles from the sky, rises from the ground, and i am in a hidden forgotten land. A land rife with every known restaurant chain store known to man, but hidden no less.

7 weeks of my training in neruology and psychiatry in these rich agricultural lands have been completed. I have been here before, i know i saw such a small thin slice of this world. But like most natural phenomonon each slice and sub slice contains an infinity of complexity as well as paperwork.

In reflection, i have learned to improve my neurological exam and psychiatric assessment. I can consistently elicit a brachioradialis reflex, i can better judge intent for suicidality, i can recognize emergency overdoses of anticonvulsants, antipsychotics and anti depressants, and what to do (in theory) for status epilectus (but in fact, i would probably hyperventilate and hide behind a resident, shouting "ATIVAn"). In fact, most problems appear to be addressed with ativan, and very bad ones with ativan and haldol. I know the procedure for legally hospitalizing someone in a psychiatric facility against their will.

More broadly i have watched the pain of veterans, and feel greater empathy for the jingoism of Red America. Warriors, willing and unwilling alike, appear to be made of the same stuff of everyone else, mostly fragile human flesh, including the fragile souls--neurotransmitters and all. Their mangled limbs and head trauma, their PTSD and alcoholism, sprung from World War II, from last year in Afghanistan. A few were never put back together again. And those for whom the wars was the good times, and it was a life time of hard manual labor, that was what relentlessly ripped away at their nerves and tendons their might sinews now collapsing at age 55, the oxes and mighty bears of our society now cringing from perpetual pain, and the betrayal of their lungs and heart. Young and old, all men, used up by and for our ferocious society. The ones that were ok--well they had wives. Wives of fragile flesh, frail and leathered, tediously listing their husband's medications, heartily wheeling his obese body through narrow halls, observing his forgetfullness, his saddness, his incontinence that he was too ashamed to describe himself. We discuss this amid the aging creeking VA halls, plastered with mighty photographs of bomber jets, flags, the president's picture. Perhaps this is the greatest therapy of all. The reminder that the pain and sacrifice had meaning. That these were the glories of battle wounds, and not the mere decrepitude assigned to all mortals.

And i have watched the coldness of hospitals, and i have shamefully relished it. The clinic, the clinical, the analysis of the most devastating tragedies. So you want to kill yourself? Tell me about that. So you are on dialysis and you are afraid to die? So you are 30, beautiful, strong, smart and suddenly woke up with hemiparalysis and been diagnosed with HIV this morning? So you have 48% Total Body Surface Area burns and face multiple operations? So during your entire childhood you were sexually abused brutally and your family refused to help you? So all your children died in this automobile accident that has also completely mangled you? So you have lost your job, your wife, the vision in your left eye due to diabetes and are now impotent? So you have a few months to live from your metastatic cancer? So you are afraid of death and pain and loss?

How does that make you feel?

Yes you can ask these things while looking people in the eye. Sometimes, you might even help.

In the city of Fresno, there many daily triumphs and tragedies. On the final day a shoot out between cops and a rural compound brings down 3 officers and fills the ICUs wall to wall with red eyed cops and their devastated partners, children, brothers, sisters. But you walk out again from the front doors and you believe like everyone else beyond those walls, that you will live forever.

Signs of health

2010-02-09T20:37:00.000-08:00

If you listen to a single Lady Gaga tract on a loop for over 40 minutes everything can STILL BE FINE.

The Chapter on How To Listen

2010-02-09T19:17:00.000-08:00

Overt experience: "He yelled at me"
Covert experience: "Thoughts about death come out of nowhere and flood my mind"

Overt experience: "I spend about three hours every night in some bar"
Covert experience: "Before she comes over I plan everything I'm going to say."

Overt experience (expressed): "I got very angry and shouted at her"
Covert experience (felt, but not expressed): "I was delighted that he failed, but I didn't let on."

In the morning, the mad house

2010-02-08T21:53:00.000-08:00

They keep the psychiatric department in the basement. At night i read teenaged novels on vampires and high school romance. In the morning i ask cavalierly about childhood sexual abuse, the precise description of the bleeding pigs they hallucinate on their hospital gowns, the million and one ways they have tried to off themselves. This man says another man is waiting for him, and every night for a month he packs his bags until the morning his family found their sweet and smiling grandfather was lying in the yard his throat slashed with his own pocket knife. Another woman tries to overdose on the trazadone prescribed to her dog. And yet another yet another, he must be kept from yanking out his lines, he thinks they are snakes, then he licks his blood. And a dignfied grandmother fondles herself in front of her astonished children.

And they are so normal, and it is so clinical, they are you are me, my mother your uncle, the mad are among us, we merge and we flux we check in and out at the front desk, we all have demons, some are quieter than others.

And these horrors are not so horrific at all, everything is endured, and cleanly consumed in the beeping and the flurry of nurses, and neatly filed charts, with brightly colored tags, like little ants we have made a place for everything, at least for a little while.

Not so Daily Haiku #6

2010-01-24T09:31:00.000-08:00

The decor is hip
Skinny mocha latte grand
addiction is weird

Not so Daily Haiku #5

2010-01-24T00:25:00.000-08:00

Cold blue desert sky
At the funeral, we sob
Snowy mountains watch

Not so Daily Haiku #4

2010-01-18T22:24:00.000-08:00

I went to the gym
I made a nice home cooked meal
I did not do work

Escapism

2010-01-17T14:55:00.001-08:00

When i was 16, i found it to be rather annoying. Age 21-23 were only mildly less angsty, but far more thrilling.

I was profoundly uppity. How disgraceful, i thought, were backward looking people. Youth is a frivolity. May I let it be with grace may i not fear responsibility nor cling to juniors department clothing. Great sorrow must be faced, the work of the world attended to, and excessive, higher quality alcohol consumed

But the work of the world is as tedious as it is exquisite. 16 is an annoying time. But its virtue is not yet realizing how annoying all the other years are as well. Thank goodness wanton escapism serves to last us the decades.

The Right Stuff

2010-01-15T07:50:00.001-08:00

This very bloody morning as i am bumbling around my dark room confused as to what city i am in (Fresno) or why i am in a carpeted room (University housing) or who is that dark body in the distance (roomate), and i think to myself, you know what--all those personality tests are WRONG. I am introvert. I want to be alone. I am neurotic. I want be a misanthropic hum bugging micro-scholar and pshaw to being a warm blooded creature.

I finally sat down to read the paper a mere 40 minutes later, and as the coffee melts the ice in in my veins (and withdrawal in my brain), the NY Times apparently writes an article called: "Do you have the 'Right Stuff' to be a Doctor".

This is of course a sore spot. For all intents and purposes, if i just keep showing up for the next 4-6 years, the state of California will in fact license me as a physician. But what a big bloody if. Showing up is hard, particularly when its between 4-6 am.

The article proceeds to outline a study that indicated that personality testing was a better predictor of how well students did than other variables, like MCAT.

"The investigators found that the results of the personality test had a striking correlation with the students’ performance. Neuroticism, or an individual’s likelihood of becoming emotionally upset, was a constant predictor of a student’s poor academic performance and even attrition. Being conscientious, on the other hand, was a particularly important predictor of success throughout medical school. And the importance of openness and agreeableness increased over time, though neither did as significantly as extraversion. Extraverts invariably struggled early on but ended up excelling as their training entailed less time in the classroom and more time with patients."

There is a caveat of course: “If a medical school is all about graduating great researchers, then I would tell them not to weigh the results of the personality test that heavily,” Dr. Ones said. “But if you want doctors who are practitioners, valued members in terms of serving greater public, then you have to pay close attention to these results.” Research monkeys need not be nice, or really even sober. Just very OCD.

That was upsetting as i was just beginning to really embrace my future as a curmudgeon.

Somewhat daily haiku #3

2010-01-14T20:50:00.001-08:00

I heard the story
I examined the body
I like doing this

Not So Daily Haiku #2

2010-01-13T22:57:00.000-08:00

I got it all wrong
The diagnosis is wrong
The gym does not help

Mood Indigo, p IV (final)

2010-01-13T22:56:00.000-08:00

"Sleep is the best meditation." ~His Holiness, the Dalai Lama

Mood Indigo, p III

2010-01-12T21:30:00.000-08:00

From The New York Times

Behind the promotion of Western ideas of mental health and healing lie a variety of cultural assumptions about human nature. Westerners share, for instance, evolving beliefs about what type of life event is likely to make one psychologically traumatized, and we agree that venting emotions by talking is more healthy than stoic silence. We’ve come to agree that the human mind is rather fragile and that it is best to consider many emotional experiences and mental states as illnesses that require professional intervention. (The National Institute of Mental Health reports that a quarter of Americans have diagnosable mental illnesses each year.) The ideas we export often have at their heart a particularly American brand of hyperintrospection — a penchant for “psychologizing” daily existence. These ideas remain deeply influenced by the Cartesian split between the mind and the body, the Freudian duality between the conscious and unconscious, as well as the many self-help philosophies and schools of therapy that have encouraged Americans to separate the health of the individual from the health of the group...

All cultures struggle with intractable mental illnesses with varying degrees of compassion and cruelty, equanimity and fear. Looking at ourselves through the eyes of those living in places where madness and psychological trauma are still embedded in complex religious and cultural narratives, however, we get a glimpse of ourselves as an increasingly insecure and fearful people. Some philosophers and psychiatrists have suggested that we are investing our great wealth in researching and treating mental illness — medicalizing ever larger swaths of human experience — because we have rather suddenly lost older belief systems that once gave meaning and context to mental suffering.

Mood Indigo, p II

2010-01-12T20:31:00.001-08:00

"Be kind whenever possible. It is always possible."~His Holiness, the Dalai Lama

White Coat, Mood Indigo

2010-01-12T20:16:00.000-08:00

From New England Journal

"Although rates of depression among students entering medical school is similar to that among other people, the prevalence increases disproportionaly over the course of medical school"

"Why does being a medical student increase the risk of depression? Raymond believes that students’ coping strategies and
personal health deteriorate as they progress through medical school. Students “see themselves going into a very narrow tunnel,” she said. “A lot of the depression we see halfway through the [first] year — it’s a reaction to having constricted themselves down to studying these subjects in a very intense way. It’s pretty unidimensional.”

Symptoms of depression in medical students can be difficult to distinguish from the effects of the stress inherent in student life. Students often dismiss their feelings of despondency as a normal emotional response to medical school, where they live from test to test and don't take time for themselves.

"It's hard to ask about depression in medical students, because you ask about sleep, and all medical students aren't sleeping," explained Angela Nuzzarello, a psychiatrist and dean of students at Northwestern University's Feinberg School of Medicine in Chicago. "They are overwhelmed, they are working hard, and they aren't having fun socially. . . . Of course they are fatigued."

The emotional and academic challenges involved in becoming a physician wear on students. Their initial encounters with illness and death may unmask psychological vulnerabilities. Such encounters often resonate with unresolved episodes of loss or trauma in the student's past or come as a shock to those who have had little experience with death. The treatment of death as a part of the daily routine may appear cold and calculating to students, who may fear becoming emotionally detached. Some become overwhelmed by the emotional toll of caring for others.

Students may become depressed at any point in medical school, but Gartrell has found that the period of greatest distress occurs during the third and fourth years, when students rotate through the hospitals and clinics. "In the clinical years, there's just far greater commitment of time, plus as match pressure begins to emerge, it's an extremely stressful time for a lot of people," she said. Students are often separated from friends and classmates and must work with a constantly changing set of residents and attending physicians, which contributes to their sense of isolation. Gartrell said that many of the female students she sees are worried that the mounting demands of training and clinical practice will not allow them time to find a partner, marry, and have children. Haynes noted that the increase in sleep deprivation during rotations may also expose mood disorders."

Daily Haiku #1

2010-01-11T21:59:00.000-08:00

Fresno, its easy
Well, you can park anywhere
That is about it.

Storming

2010-01-07T23:27:00.000-08:00

Hrm

" 'The art of any art is the art of obsession,' she said. 'This is not something that people in general tend to understand. They encourage you to be well-rounded, which bemuses me in a society that tends to reward the specialists – the obsessives – those who decided to excel at one thing instead of becoming good at a hundred or competent at a thousand.' "

In another note, the psychiatry professor ruminated outloud to the lecture hall full of med studnets,"Yes most of you have class C personality disorders, thats probably how you have got this far in your training."

per wikipedia:
Cluster C (anxious or fearful disorders)
Avoidant personality disorder (DSM-IV code 301.82): social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation and avoidance of social interaction.
Dependent personality disorder (DSM-IV code 301.6): pervasive psychological dependence on other people.
Obsessive-compulsive personality disorder (not the same as obsessive-compulsive disorder) (DSM-IV code 301.4): characterized by rigid conformity to rules, moral codes and excessive orderliness.

Debated with M the merit of 10,000 hours, while he casually took apart his electric keyboard and reconstructed it.

Journeys

2010-01-03T11:24:00.000-08:00

From: NY Times

Every year in October, when the Nobel Prizes in chemistry, physics and medicine or physiology are announced, the predictable parade of American honorees is reported on television and in the papers with a combination of patriotic glee and almost total befuddlement about the nature of the work being honored. Hardly anyone pauses to think about the educational system that has been so fabulously productive in turning out scientists in this country. It is a system limited to about 120 research institutions, and at the upper, rarefied reaches of that system are the elite universities. As James Anderson, chairman of Harvard's chemistry department, puts it: ''The students here are spectacularly good, very bright, very committed. They want to win Nobel Prizes, and some of them will, and some of them want to do it before they're 30.''

Graduate study in the sciences, however, is a very unsentimental education. It requires the intellectual evolution from undergrad who can ace tests of textbook knowledge to original thinker who can initiate and execute research about which the textbooks have yet to be written. What is less often acknowledged is that this intense education involves an equally arduous psychological transition, almost a second rebellious adolescence. The passage from callow, eager-to-please first-year student in awe of an often-famous faculty adviser to confident, independent-minded researcher willing to challenge, and sometimes defy, a mentor is a requisite part of the journey.

2009

2009-12-31T10:13:00.001-08:00

This time last year: Nicaragua, Leon’s ancient stone cathedrals with bullet holes, joyful children with firecrackers in the street, large papier mache puppets, a beautiful young man swimming in the empty Pacific, we are gliding through tropical waters, sitting and sweating on sacks of grain on converted school buses, sobbing, sobbing, sobbing, laughing

Resolutions last year: Improve posture, eat more lentil mush, survive school

Month 4: turned in a thesis. Declared a master of science. Passed my first medical licensing exam.

2 months of surgery, touch my first pancreas, see my first brain, place my first suture, run my first trauma

Watched a man die. And be brought to life again. And die again.

8 months of no breath and ascending madness.

Accrued frozen pictures:
(1) Code blue in the cath lab, a frenzied tableau framed in the window. The lone cardiologist quietly exits, drops his mask in the dark, curses softly. His wire punctured her heart. On the x-ray screen there is the dying woman’s rib cage, and the delicate bones of the intern’s hand pumping rhythmically. On the machine, all the bones are the same.
(2) The sun rise in the ICU
(3) The neurosurgeon’s precisely placed bolt in the doll faced toddler, 10 physicians and nurses crowded in the room staring intently at the ICP monitor, the wrong line, the wrong wave, the numbers incompatible with brain life, the machines still breathe, his cheeks are still pink.
(4) The labor suite had 9 women: the single new mother, her own mother, the ob-gyn residents, the students, the nurses, they strained against her body, like the soldiers in the famous photo—the soldiers of Iwo Jima, the women giving birth. The room was too warm, thick with everyone’s sweat, smelled of blood and shit. We are women too, the pediatric resident and me. We greet the only male in the room, a small wriggling gray thing amid the women, the blood and the shit.

1 more year of San Francisco, the warm glow of the city by the sea, now a maze of obstacles: a place to park, the bus to catch, shouting madmen to avoid, the young and carefree to resent.

A year to be weary of what is to come. A year to revel in the things I have seen.

2 years seeing the beautiful young man, who endures my madness, who fills me with light.

Bowls of lentil mush consumed: 1.6

Resolutions next year: Survive school. Nurture mental health. Build strength, build skill. Stop whining. Love the boy. Love the tribe. Buy fewer lattes.

The Final Manifesto

2009-12-30T15:00:00.000-08:00

by Joshua Mehigan

1. We see you.
2. We know who you are.
3. Your ideas are worthless.
4. Your aesthetic is stupid.
5. Your “technique” is a welter of narcissism, superstition, and habit.
6. All your little tiny ideas, all your whoring attempts at creation, and you yourself are nothing, nobody wants you, we despise you, it’s in our nature.
7. You should be kept as a pet.
8. You are a Philistine, the Paul Bunyan of decadence, an acromegalic fraud.
9. You are a minnow, a speck, a stain.
10. The genre humain is sick, and you are to blame.
11. You are a necrophiliac.
12. You are a museum of irrelevance.
13. It will take years to make Art vital and important again.
14. You are from this moment forbidden.
15. As the Italians say, Parla quando piscia la gallina.
16. We are here now.
17. Our aesthetics is empirically grounded.
18. Our taste will be raised to principle.
19. You and your band of jays will be flushed out.
20. Yes, Art is resurrected today: Victory is ours!
21. History will forget you and salute us.
22. Here you are, and here is oblivion.
23. This is the final manifesto, and the only one.

Judgement

2009-12-23T10:06:00.000-08:00

i am a smart geek, a guy this author wants to sleep with, a person who loves excess verbiage, confirmed 90s literati, someone who can start a fire. A liar. A drinker of scotch, good at crosswords, a girl who keeps a journal, a conspiracy theorist, (bigger than even the orwellian), a person who has read only one book my my life and it was to kill a mocking bird (and it was assigned reading in the 9th grade); a girl who loves guys in skinny jeans, a man who owns a cottage (one with an adjustable rate mortgage), a man who uses the words 'dubious' and 'tenacity'. I am that kid in your philosophy class with stupid tattoos, i am a premature ejaculator. I moved to Thailand after high school for the drug scene, I can quote the comic guy from the Simpsons I am a youth group leader that picked my nose in the 4th grade, a girl who cannot spell "leheim", who bought the first generation Amazon Kindle, i turned vegan to cover up my eating disorder, i played Creep while smoking pot and having sex, and I took care of my dying grandparents. Some of these are lies, some are not.

You too can stereotype people by their favorite author: Readers by Author

Fantasy Receptionist

2009-10-28T16:19:00.001-07:00

My favorite television shows now are Mad Men and The Office (if you consider the Daily Show in its own category). These are both good shows and nicely made and obviously someone put lots of talent and work into making these so very lovely. But I suppose some amount of my ravenous consumptions of these fantasy worlds—one in which everyone is elegantly fashionable and self assured in their discontent and racism/sexism and the other in which everyone is exquisitely absurd and thoroughly bathed in the light of pitch perfect witticism—is my fantasy to be a receptionist.

In this other life, I am a very happy secretary/receptionist/personal assistant. I bathe not to make up for lost hours of sleep but so I may smell fresh and brighten the office. I wear heals. Rather than scrubs and awkward ratty student white coats I wear clothing that comes with a waistline. I have a bee hive and in this fantasy world, I wear long bright red false nails not outlawed by the CDC. They only mildly hinder my typing speed and make a pleasant clackety tip tap noise.

As a receptionist, I am hot. This is helped by the fact that I don’t have to arrive anywhere at 530 am. Nor do years of cortisol overload lead to peculiar weight distributions, terrible skin, and a diet consisting of vending machine products. I don’t worry about getting sued if my cleavage shows, and I don’t have to worry about offending people by putting my boobs in their face while I examine their ear wax and nose hairs. This is because I will not be examining their ear wax and nose hairs. I can wear short skirts and offensively ugly earings that will not get caught in my stethescope. I will not have a stethescope.

Instead of 2 years of pre med, 4 years of medical school, 4 years of residency required for training, not to mention the additional 2-6 years spent discovering genes, reconstructing the health systems of small nations, and dicking around to salvage one’s mental health, I can get pretty good at a particular office space in less than 1 year. I can already type very well you see. My handwriting is very good. And I am excellent at filing, especially when stoned.

At 5 pm, I depart and arrive at my single young woman urban apartment, and I kick off my heals and lounge on a luxurious piece of furniture which I have purchased with my single young working woman salary (which is actually a positive rather than a negative number). I sensuously pet my cat and speak in a deep throaty voice to this creature of my day’s adventures. I am allergic to cats, but in this other life I may as well eliminate other burdensome details of this one.

A girl friend calls, shall we get cocktails and pick up handsome men, and I will say no dahling I must finish my novel tonight. I make dinner or someone makes it for me, and it has real vegetables in it. I drink an after dinner brandy, since in this other life I am mentally healthy and I do not worry about a single drink dissolving my threadbare semblance of sanity and wildly sobbing for the next several days. I type. In my underwear. What the hell, I am so mentally robust I have a beer. I have 2. I smoke a cigarette, which in this other life is sexy and not so bad for you and does not prompt me like a little seal into reciting cardiovascular outcome statistics and mortality rates for small cell lung carcinoma. I fall asleep in soft sheets.

On the weekends I attend a vigorous pilates class, followed by a bloody mary. Followed by another one. I sit around in my underwear some more, typing, scratching my belly, smoking drinking napping. I have a boyfriend and he is actually something I have kept from this life. I call him poopsie, but in the other life he permits this. We have a wild and exotic love life and frequently fly to tropical islands

Of course, in this other life, I would not be a particularly good secretary, as the same things that offend me about being a medical student would persist: being bossed around. Detail orientation. Doing meaningless work. I would forget things. I would stare away into space. And it is true, I would dearly miss being up to my elbows in intestines. I would miss poop jokes. Would miss being a voyeur of birth, sickness, triumph, death (so that i may remain a philosopher). The novel i will write in this life will be less boring. I can wear the heels tomorrow.

The Geek Girl rises

2009-08-08T09:37:00.000-07:00

A series of event

Akward bookish childhood--> embrace nerd/geek identity

college--> find i am not alone--> become emboldened

begin pseudoactivist stance of the underrepresented presence of the Geek Girl in popular culture. Contemplate implications for gender roles in society: why are 50 per cent of math bachelor degrees given to women but less than 20 percent to physics? Why do women outnumber men in higher education, all the more in communities of color? why in Beauty and the Geek are the beauties always female and the the geeks male? and what of the beautiful geek?

Contemplate neurophysiological implications: is geek on the autism-Asperger's spectrum? why is Asperger's more prevalanet in males? What are the neurolodevelpmental underpinnings of girls speaking before boys? the role of testosterone and estrogen in cognitive function? Why do chromosomal abberations that give a deficiency in either result in passive individuals? and why are there so few studies?

The geeks inherit the earth and their base is the South Bay. They also take over Wall Street and the White House, the former to our collective regret.

Today i saw a poster for Paper Heart. I roll my eyes with snobbish contempt at instant pattern recognition--oh another 'indie' movie with that pale technicolor aesthetic, scrawly text, 'low budget' charm and whimpery cooey soundtrack. But then i noted that the heroine appears to be a very dorky looking, chubby brown Asian girl.

woot!

a debate begins "how to seduce a geek girl" spawns "4 tips for Understanding 'Girl Geeks'
http://jezebel.com/5332327/4-tips-for-understanding-girl-geeks

And i realize i don't know why so late--the geek is cool. And like all great triumphs of outsiders who become recognized, the bittersweet prize--assimilation, and thus--obliteration.

"The history of 'geek':

1515-1916 A "fool, dupe, or simpleton"

1916-1970s A circus sideshow performer who bites the heads off chickens.

1970s-1980s Derogatory term for a socially awkward or unattractive person. Usually male.

1990s A computer genius with stock options. Possibly worth billions. (In the 1980s, these were called "nerds".)

2000s and beyond Actors, models, talk show hosts, iPhone owners, fans of the top grossing movies of all time, anyone whose job description is more complicated than "shopping" "

Disclaimer: i have been told i am but a nerd and a dilletante, not a geek proper. that's cool.

Malaise

2009-07-26T11:50:00.000-07:00

I have settled into a 6 day hangover that began Tue night and has had no intoxicating percipitant. It continues unabated. How i dislike everything.

What could be the cause? I have taken almost 9 years of advanced education and training and done what the modern well-to do intellect does far too naturally--repeatedly ramming this education at the excessive dissection of my own neuroses. Is it the cold weather? am i hypothyroid? Is it a subclinical sinus infection? a dopamine failure? Perhaps i have been too inattentive to self reflection? A shortage of quiet meditation? Am i paralyzed by choice in the modern ennui of post industrial capitalism? Is my mental hygeine insufficient? And so goes the differential diagnosis of the incompletely trained young physician and meta-physician.

In my lucid moments i suspect i have merely run out of the shrill and hysterical enthusiasm that kept me afloat for the several weeks of surgery following the soul sucking devastation that is commonly known as the USMLE step 1 exam. Surgery and inpatient medicine furthermore was a great novelty. Plenty of dopamine to keep one afloat. The outpatient medicine scene i had wrongly assumed to familiar and thus easier. Although i do not arrive home in stuperous exhaustion every day, i maintain baseline level of anxiety that is mostly associated with a constant confusion as to where i am supposed to be at any given moment.

Its true, there is no 3 hours of excruciating rounds. No feigning interest in the 43rd hernia surgery you've seen and still don't get as its just a lot of flimsy layers being poked at and wasn't cooper's ligament in the boobs or something? So now i have arrived in the exotic lands of outpatient medicine and the time has come to open my soul to a new land, a new people, to patients who are not obtunded under anesthesia and have rich and complicated lives outside of the clinic, usually involving eating too much, smoking too much, etc.

Whatever the etiology of my malaise, the self-medication has remained worrisomely the same since age 14 - eating, internet, a bowl and someimes a passage or two of Bertrand Russell.

It is in these moments that the road ahead seems despairingly long. The thought of being a doctor, being organized, caring about other people, having responsibility, having any job at all, seems pointless and horrible and wouldn't i rather be...what? balancing a bowl of cereal on my gut and watching cartoons with lewd humor?

Such despair is often moderately improved with a well titrated dose of caffeine, usually with a little creme. At that point i am assured that i would indeed like to have a job, a meaningful, interesting one that affords me whatever minimal illusion that i am Part of Something Bigger, and making things on sum better rather than worse, one that i would like to be Very Good At, and always inspired to Do Even Better, and one with a steady income to boot, so as to allow funding for said bowl of cereal.

Week 6

2009-06-03T08:54:00.000-07:00

The ICU continues to be frightening, but now not because it raises the questions of mortality or displays the prone bodies of the helplessly sick, but mostly because i still don't understand the vent settings.

All things can become conquerable, once they are named. Once they are named, divided, classified. Once they are named, translated and become a puzzle of cognition, technique, logical and mechanical resolution.

Grand Rounds today: surgical education. It began with a typical display of graphs. Outcomes, surveys, studies. Rigor was demanded, plus or minus p values. A new laparoscopy lab has been built, the bottom line, measured. Interns were made fun of. Papers were published. The last speaker (the one that i thought was smirky, that pimped us on Charcot's triad on day 1) ended with a discussion of his mother's death and the meaning of teaching: this [life] too shall pass. In teaching, the work caries on. We lift up others to see the future.

I got a bit teary.

Spock, 1. Kirk, 1.

Medical Student Presentation Guide

2009-05-27T13:10:00.000-07:00

This is a rather amusing if not entirely didactic guide to patient presentations

A complete History and Physical must be obtained with the resident on the floor and written up for Dr. Miller and the teaching resident.

Presentation of morning rounds must be focused and concise. Specifically:

Give a one-line introduction with: age, sex, diagnosis(es)
Brief HPI with chief complaint, length and type of symptoms, medical interventions (if any)
ER course: Vital signs, exam in ER, interventions
Floor course: Exam if different from ER, interventions
Your plan: Medical management, studies required, etc.
Concise, effective presentations are very difficult to synthesize. To help you do this, use the intern who is assigned to the patient to figure out what information is pertinent, and give a trial run of your presentation to him or her.

You should practice your presentation and time yourself. The goal is less than two minutes! Remember to include what you feel are the PERTINENT positives and negatives. Your senior resident will ask specific focused questions if they require more information. Again, let me emphasize that we realize this is a difficult task. If you feel uncomfortable or unsure, talk to one of the seniors on your team and they can guide you through your specific areas of concern.

Examples:

Bad:

This is a three year old cute little girl who has been having a hard time breathing for awhile now. She has a doctor who manages her asthma with a bunch of different medicines but things weren't going so well, so she came to the ER with her Mother, sister, and baby doll, Mrs. Bigglesworth. Apparently, she has been in the hospital before with this and mom says she misses a lot of her preschool because of her wheezing. Mom things that she is worse in the spring but she was a little fuzzy on that point. So today after ballet class mom saw that Sissy was breathing hard and they decided to go to the ER after getting Mr. Misty at the DQ on the way, by the way Sissy got blueberry which worried the ER staff who initially thought she was cyanotic. Anyway, in the ER she was breathing fast and working hard so she was given Albuterol nebs and some prednisone which she vomited twice so she was enrolled in Steve Gordon's asthma study and given Dexamethasone. She was OK on q2 nebs so she came to the floor where she is still on q2 but looking a little better. Here on the floor, she was breathing around 68 breaths per minute and was having a hard time talking but she looked otherwise well and in no distress. Her immunizations are all current but mom is not sure if she should get the new heptavalent pneumovax. Currently, mom says that she can talk in five word phrases and she easily walks up and down stairs unassisted. Her exam on the floor is as follows. HR 118, RR 50, BP 111/68, head circumference 50 cm. Today, I think we should consider spacing her nebs to q3 hours in preparation for early morning discharge tomorrow since I know we are in a bed crunch.

Good:

This is a three year old moderate-severe asthmatic female who presented to the ER at 8 pm last night after having an increased work of breathing for one day that was refractory to Albuterol q3 at home. This is her fourth hospital admission, no PICU admissions, and no intubations. Her home regiment includes Albuterol nebs PRN, Flovent 44 mcg with spacer and mask BID and PO prednisone PRN severe exacerbation. Her triggers include cats, seasonal allergies and cold weather. Her mother and brother are also sever asthmatics.

In the ER, her respiratory rate was 68 and her O2 sat 90% on room air. Her exam revealed diffuse wheezing and pan retractions but was otherwise unremarkable. She was given IM Dexamethasone as per Dr. Gordon's protocol; Albuterol with Atrovent times three then two Albuterol nebs q2. Her respiratory distress improved significantly and she was admitted to 10 South for further management.

On the floor her respiratory rate was between 35-40, O2 sat greater than 98% with 1 liter nasal cannula O2, wt=14 kg (59th %). She continues to have diffuse wheezing but now has only a little nasal flaring. She continues on Albuterol q2 but appears to be in less distress this morning.

Today, I want to continue her nebs at q2, continue her steroid regimen and get Pulmonary to consult for asthma teaching.

Day 6 and 7

2009-05-04T16:40:00.000-07:00

First call. probably good that i can't really twitter or fb in hospital. but many observations over 30 hours lost. maybe for better?

it was quiet for trauma. the ER was mostly full of non surgical stab wounds and DTs and the like. But after 8 pm two appendicitis cases. I scrubbed in on both.

I felt dorky for admitting it-these are bread and butter surgeries and laparascopies to boot--but how can i resist being insanely excited at my first OR experience? I wore gowns, double gloved, had a mask, got yelled at by the scrub nurse--everything i dreamed of! that beep beep of vital signs, the inappropriate jokes by the anesthesiologist. I even got to suture one of the ports. However i did a terrible job and we had to steristrip it (its only a 1 cm scar, i promise!)

tried not to be irritating to the residents, but they taught a lot. got to sleep 3 hours, more than most of the other medstudents this week

prepped for presentation at GI/surg conference but a surg resident did it instead, which is good bc his was much better. i got excited and spoke up, but it felt funny, a sense of breaching hierarchy. should make note of this in future--not so much to cease as to proceed with caution.

Felt pretty shitty and out of it for rest of day. Really tired, really hungry, feet hurt, back hurt, was kind of smelly, tried to speak coherently, but felt good in a deeper way, like i was doing something really tough like travelers and military and well, surgeons, do.

Biked home. took best shower in a long ass time.

Day 6

2009-05-02T20:30:00.000-07:00

had day off. spent previous night with bf eating frozen pizza and salad.

Day 5 examined first prison patient. Remarkable for being unremarkable. Had a lump in his butt. Officer left the room during the butt exam, which caused some distress, but distress was unfounded. In general, first time examining a real patient's butt (although not a real rectal exam). Turns out to be equally weird as examining their chest, head, etc, but not weirder. Slightly weirder trying to remove someone's orange prison pants beneath their shackles, since they are handcuffed and can't remove their own pants. patient was regular, not weird or violent, and that was helpful. Two male genital exams have both been less weird than majority of female exams, but then also less invasive. I hate pelvic exams too.

afternoon spent suture workshop, practice sutures on decomposing pig feet. gross

Day 6 maybe have a cold. Went to capoeira anyway. still really out of shape, so weird to be desperately breathless--for some reason it is so beautiful and i love it, when i think about pts with COPD or intubators, and the reason i can't breathe is because i did 30 cartwheels, not because my lungs are not viable. It is frivolous and i am so grateful for the frivolity, for my health, for breath, which can leave us anytime. we all become patients one day.

Day 4

2009-04-30T18:27:00.001-07:00

First rounds this morning. Start at 6 am. The ICU is still a little bit scary. Doesn't end til 930 am. People seem disgruntled that the med students (us) are not doing what they are supposed to be doing, even though they realize we do not know what we are supposed to be doing.

We are supposed to be removing and replacing surgical dressings. We have to figure out how to do this by tomorrow at 6 am.

The rounds go until 930 am. The senior resident is dashing and charming and it is amazing how intimately he knows each of the 40 patients. The interns are post call and irate. We stay out of their way.

The clinic is over flowing. They are depending on us to keep the flow, even though at this point we cause more delay than speed. There is only one attending. Patients wait for 3 or 4 hours shivering in their gowns.

I examine a mans genitals with great authority. He has an enormous hernia and a painful swelling of his testicles. His penis is retracted. He is an ex-con, a "street warrior," his skin scarred and bruised from knife fights and heroin skin popping. He has an odd affect, a mood disorder. He follows my directions. I examine him with gloves. When i return the attending examines him without gloves and has me do the same.

I watch a pretty nurse practitioner who is about my age, expertly pull a drain from a man's stomach. She is someone like me--a normal person, a young person--but her hands and her brain are like magic. She helps me figure things out and i am grateful for her patience.

We do not end for several hours. At 2 i realize it has already been an 8 hour day.

I receive an email from a star graduating student who responds to my fretting about the future. She tells me not to fret. I believe her. She tells me to work really really hard. I believe her.

Day 3

2009-04-29T19:44:00.000-07:00

Grand rounds are boring

Found out board scores. Yay i passed. Sob, my score is lame.

Fret about future.

Thrown into clinic. Handed charts. Examine. Attending is mildly frightening. Patient gets off cell phone when i enter; "can't talk, the doctor is here." He meant me?! Attending turns out to be kind of really cool. Learn more in 2 hours then in 2 weeks. Survive.

Home. Fret about future. Decide to push on.

Day 2

2009-04-28T07:56:00.000-07:00

More orientation. Does not begin till 10, even though i woke up at 6 and tomorrow i will wake up at 430.

there is still much hope in the air.

feel like the hardest part of med school is letting go of one's particularities of previous identities--namely, that of ditzy intellectual, which was a fun role to try to develope. its not as funny to have a ditzy doctor. its kind of scary. but changing such a thing brings up profound difficult questions of identity, habitus, and change. did i once develope such a role as one puts on garb, an arbitrary pair of pants found in the free bin--or did it seem a good way to deal with the fact that i have terrible short term memory? Is it essence or is it mere garb one puts on and off a deeper essence? is there no essence at all, this illusion of self?!

no time for difficult questions! have to review abdominal vasculature.

Goals

2009-04-26T21:42:00.000-07:00

General Goals

The overall goal of this clerkship is to provide the environment needed to have you develop into a humane, sympathetic, knowledgeable and sophisticated physician. Further, our aim is to teach you to apply the background in pathophysiology you acquired in the pre-clinical years to the diagnosis and management of surgical patients.

Specific Goals

Toward this end, the faculty will expect that you will learn to:

Obtain a complete history and perform an accurate physical examination in approximately one hour.

Formulate a differential diagnosis after obtaining a history and examining a patient.

Devise a scheme of reasonable and appropriate laboratory and other diagnostic tests leading to the establishment of a diagnosis; become familiar with the availability, cost, and limitations of laboratory and other diagnostic procedures.

Formulate a plan of therapeutic management for the patient; if surgical procedures are included in the plan, be familiar with the risks and alternatives.

Be able to represent the clinical information to others in a coherent, succinct manner.

Acquire and expand on a core of surgical knowledge, including developing an awareness of sources of information, their limitations and scientific merit.

Develop a sophisticated clinical judgment, applying your knowledge of pathophysiology to clinical surgery.

Learn to interact and deal with professional and nonprofessional personnel, patients and their families encompassing social, ethical, psychological and medical aspects of such interactions.

Irreconcilable Aesthetic Differences

2009-04-14T21:03:00.000-07:00

I like girls with biceps, beautiful girls with pretty smiles and rippling arms, i love girls with big hips and poochy bellies and the sound of singing, off key alone, harmonious when shouted, all of us together to the sound of simple instruments, the sort that must be struck.

I love breasts. I love the breasts of women, big giant full breasts described in metaphor, a variety of full figured summer fruit found throughout numerous geographical regions, and i love small tender breasts lean soft and pointy like flower buds, also found in a variety of ecological niches, even very harsh ones. I love the breasts of old women, when everything has dried away and hardened, the breasts of old women are still soft, even when they hang over tripping hearts, brittle ribs, when there there are worrisome calcified tumors, that sit like ominous pebbles, amid plump moss and velvet fragile skin.

What is beautiful is sweat, smelly sticky endlessly flowing salty damp cool sweat on hot skin, puddles on the floor, drenching sheets

What is beautiful is urine, smelly pussy yellow brown red and bloody, urine the secret of the soul, the window of the humors, frothy urine full of secrets, full of stories. What is beautiful is blood, dangerous sanguine, blood is still full of ghosts (they are called viruses now), and is still thick and dizzying and terrifying and life and death can be foretold in the vile.

Beauty, what is beautiful, do you love me, do you find me beautiful, this is what i find beautiful. Things like flowers, and sunrises, and an adorable list of multiple daily things that surround us but go unnoticed unless we are intoxicated. Also--things that are seemingly ugly, but on further inspection, and with the right soundtrack are also very beautiful, like the items of urban decay and industrial waste and secret worlds like prisons, hospitals, bohemia and crackheads on 16th street. Also--lovers and things that have to do with love. That is very beautiful. So too is youth, healthy food, mathematical patterns in nature, well engineered machines, you and your self esteem, small children and their mothers.

I also agree that red lipstick and young men with well defined and graceful bottoms are also very beautiful. Also, young men with glasses and computer programming skills, all though this is less commonly shared. Several types of well decorated pastries and most of the major works by Immanuel Kant--those too.

And you?

when journeys lead to dead end bus stops and small disasters

2009-03-13T18:50:00.000-07:00

thesis sux. filling in the references. reminded of all the cool papers i read. deeply dissatisfied to what i made from them. what was missing? what was it that really moved me? and how did i lose sight of it? hmm.

Its really quite simple- Your Budget Guide to Cosmological Well Being

2009-01-22T12:41:00.000-08:00

"...a neuroscientist named Jaak Panksepp who identified a series of core 'emotion system' in aminals: seeking, play, care, and lust (on the positive side) and fear, panic, and rage (on the negative).

" ' The rule is simple,' Ms. Grandin writes, 'don't stimulate rage, fear, and panic if you can help it, and do stimulate seeking and also play.' "

In the intellectual history of this strand of thought, i would organize it as follows:

Hitchhiker's Guide to the Galaxy's Comprehensive Conclusion to Total Metaphysical Inquiry
"42"

Hitchhiker's Guide to the Galaxy's Comprehensive Principle of Behavioral and Psychological Guidance
"Don't Panic"

The Grandin Moral and Social Corrolary to the HGGCPBMG
"Don't Panic Others either"

I suspect if i optimize the applications of these principles, i may save myself tens of thousand dollars on future shrink fees. Failing that, i may earn tens of thousands of dollars by developing it into a self help book.

AAAAAAAAAAAAAAAAAAAAAAACH

2008-12-18T16:08:00.001-08:00

I just found my entire thesis covered in 2 pages in some book. I mean this dude disposed of 2+ years of work and 60 pages that i have yet to write, in a much smarter way, in 2 pages!!!!

on the upside: my ideas are not totally crazy--they seem to be consistent with what he is saying. and he is a famous philosophy professor at haaaahvard who has been working on this issue for decades.

on the downside: he did it in 2 pages!!!!!!!!!!!

my life is useless.

hot fantasies when avoiding work

2008-12-15T11:18:00.001-08:00

Makes me breathe heavy, it gets me by.

Some Common Laws of Research

2008-12-14T21:52:00.000-08:00

[written by: the internet]

1. When you don't know what you're doing, do it neatly.
2. First draw your curves, then plot your data.
4. A record of data is essential, it shows you were working.
6. To study a subject best, understand it thoroughly before you start.
7. If you can't get the answer in the usual manner, start at the answer and derive the question.
9. If that doesn't work, start at both ends and try to find a common middle.
10. In case of doubt, make it sound convincing.
11. Do not believe in miracles---rely on them.
12. Team work is essential. It allows you to blame someone else.

RULE OF ACCURACY
When working toward the solution of a problem, it always helps if you know the answer

RULE OF FAILURE
If at first you don't succeed, destroy all evidence that you have tried.

RULE OF REASON
If nobody uses it, there's a reason.

Wiener'S LAW OF LIBRARIES
There are no answers, only cross references

Murphy's LAW OF RESEARCH
Enough research will tend to support you theory.

Finally: No experiment is ever a complete failure. It can serve as a bad example.

Two Articles on the Tumultuous Act of Thinking Clearly

2008-12-14T18:59:00.000-08:00

(1) On David Foster Wallace

Consider the Philosopher
NYTimes

Excerpt:
"But Wallace was also wary of ideas. He was perpetually on guard against the ways in which abstract thinking (especially thinking about your own thinking) can draw you away from something more genuine and real. To read his acutely self-conscious, dialectically fevered writing was often to witness the agony of cognition: how the twists and turns of thought can both hold out the promise of true understanding and become a danger to it. Wallace was especially concerned that certain theoretical paradigms — the cerebral aestheticism of modernism, the clever trickery of postmodernism — too casually dispense with what he once called “the very old traditional human verities that have to do with spirituality and emotion and community.” He called for a more forthright, engaged treatment of these basic truths. Yet he himself attended to them with his own fractured, often-esoteric methods. It was a defining tension: the very conceptual tools with which he pursued life’s most desperate questions threatened to keep him forever at a distance from the connections he struggled to make"

(2) On HLA Hart

A Philosopher's Humanity
By CARLIN ROMANO
The Chronicle Review

The desire to portray great thinkers as disembodied argument machines remains a powerful force in analytic philosophy. Think of it as a slice of amour-propre, part of the arrogant wish to be seen as timelessly, noncontingently right about everything. It can move acolytes to depict thinker-heroes as dynamos of pure intellect rather than peers, mere featherless bipeds whose thoughts bear clear markings from their beliefs, fears, and weaknesses.

This distinctive distaste for a philosopher's humanity applies in analytic philosophy with extra force to homosexuality. In the standard canon, the editing began with the predilections of ancient Greek philosophers and continues right up to modern times.

Decades ago, for instance, W.W. Bartley published his maverick biography of Wittgenstein, arguing that the great Austrian philosopher also led an actively gay life that appeared to include cruising for rough trade. Analytic Wittgenstein scholars, who specialized in presenting their man as a kind of shoebox of epistemological propositions they thought he hadn't put in the right order, screamed bloody murder.

The most egregious recent effort to deny a great philosopher's inconvenient humanity, to attack its link to his work, targeted Nicola Lacey's A Life of H.L.A. Hart: The Nightmare and the Noble Dream (Oxford University Press, 2004), a brilliant mix of tightly reported intimate biography and expert intellectual assessment.

In it, Lacey, a professor of legal theory at the London School of Economics and Political Science, accurately describes Hart (1907-92), holder of the Oxford Chair of Jurisprudence from 1952 to 1968, as "the preeminent English-speaking philosopher of law of the 20th century," the man who "more or less reinvented the philosophy of law, reviving the English positivist and utilitarian tradition."

Celebrated for The Concept of Law (1961), his classic articulation of his new jurisprudence, Hart drew on the ordinary-language philosophy of J.L. Austin and, to a lesser degree, on Wittgenstein's notion of "meaning as use."

Both influences led him to reject a conception of law as naturally or necessarily moral. Hart regarded a legal system as a social fact, identifiable by the internal relations of its rules, its habits of obedience, authority, and responsibility. More concretely, in Law, Liberty and Morality (1963), Hart wrote, in what many consider the 20th-century sequel text to John Stuart Mill's On Liberty, an essay against excessive criminalization of morality that influenced English law reform in the 60s and 70s.

Like many of his colleagues, Hart largely avoided anecdotes, biography, and detailed sociological evidence because it didn't fit with proper Oxford philosophical method. Clear, precise, and commonsensical, he kept his personal life out of his books.

Lacey's study consequently hit the jurisprudence community like a Kitty Kelley exposé implanted in a Festschrift. Invited to write the biography by Hart's widow, Jenifer -- an accomplished figure who taught history at St. Anne's in Oxford -- Lacey received apparently unlimited access to Hart's papers from his wife of more than 50 years and mother of his four children.

Lacey doesn't let that access go to waste. In one startling, early example, we read that, in 1937, while considering a career shift from London barrister to Oxford philosophy fellow, Hart wrote to friend Christopher Cox, "I am or have been a suppressed homosexual (I see you wince) and would become more so (I mean more homosexual and less suppressed) in Oxford." Hart's concerns about his sexuality prove a leitmotif throughout his subsequent diaries and letters.

Hart also castigates himself as a recurrent depressive, an insecure thinker, a sloppy researcher, and a careerist concerned about "keeping up appearances." Described by one friend as "spiritually anglicized," Hart seesawed between playing down his working-class Jewish origins and expressing sudden pride in them. At times a snob with an Oxford brand of "insider's arrogance," he could ask an Indian grad student whether there was "a single interesting idea" in Indian philosophy. Late in life, after a newspaper story falsely claimed that Jenifer had been a Russian spy in the 1930s, Hart suffered a nervous breakdown that required shock treatment.

Lacey's book, however, is not pathography. She admires Hart, whom she knew, and interweaves the story of his career and thought with sharp set pieces about his work in MI5 intelligence during World War II, as a London barrister, and as a teacher at several Oxford colleges. Packed with exquisitely acerbic quotations and stark snapshots of the elbows thrown by academic figures like Isaiah Berlin, A Life of H.L.A. Hart reveals an internationally renowned yet troubled thinker who preferred to present himself as imperturbable.

But Lacey's achievement triggered an attack on her this year by New York University philosophy professor Thomas Nagel, author of -- unsurprisingly -- The View From Nowhere. Complained Nagel in the London Review of Books, "I felt that I was learning too much that was none of my business. Hart was a figure notable, and admirable, for his discretion, reserve, and unpretentious dignity. The turmoil that went on beneath that surface was his affair."

Nagel never tells the reader exactly what disturbs him. As Ben Rogers commented in a subsequent review of the book in the British magazine Prospect, "homosexuality doesn't carry the stigmas it once did -- Nagel's refusal even to mention it is odd."

More troubling, Nagel tries to delegitimize Lacey's intellectual project while praising her for a "superb job of assembling the data."

First he asserts that Lacey's "claim that the personal material is needed to write an intellectual biography is a pretense." But he offers no support for the charge. Were Hart's homosexual proclivities and left-wing politics irrelevant to his famous 1960s debate with conservative judge Patrick Devlin, which Lacey says provided "the nearest thing to a manifesto for the homosexual-law-reform movement"? Was Hart's uncomfortable involvement in the World War II execution of a man for treason irrelevant to his death-penalty views?

Nagel also maintains that despite Lacey's distinguished academic position, she is "not equipped ... to deal with the philosophical background. When she talks about the 'paradox of analysis' or about the differences between J.L. Austin and Wittgenstein, she is lost." Upping the insult quotient, Nagel maintains that Lacey "seems to have a weak grasp of what philosophy is," a claim he repeats several times.

False in every respect. Lacey, far more industriously than Nagel, backs her statements throughout. She even nails Hart's glosses in the margins of a Max Weber volume from which he denied drawing ideas. Indeed, she quotes Hart as acknowledging the very links Nagel denies. In his diary, Hart expressed his belief in "a connection between my deficiencies as a husband and the whole sexual and emotional immaturity on the one hand and this gross incapacity for the organization and care of detail: this lack of care, this obsession with frontal attacks on major positions."

Why the distortion? Lacey simply doesn't share Nagel's typical analyst view that ahistorical, nonsociological, fact-free reasoning is the end-all and be-all of philosophy. While expressing great respect and affection for Hart, she indicates early on that her feminist and Foucauldian appreciation of power's role in shaping institutions makes her more critical of Hart and his facts-lite analytic jurisprudence than she once was.

Indeed, Lacey utterly foresees Nagel's line of insult. She specifically anticipates his assertion that Wittgenstein thought understanding "has to be pursued primarily by reasoning rather than by empirical observation," noting "Wittgenstein's emphasis on the embeddedness of language games within social practices." In her view, Hart, like Nagel, never adopted an approach to reality as reportorial as Wittgenstein's because it "undermines the pretensions of philosophy as the 'master discipline' which illuminates our access to knowledge about the world."

And those are precisely the pretensions Nagel promotes. When his would-be demolition job sputters, Nagel simply starts hectoring Lacey with the P-word. He insists that Hart's greatness "was the result of a specifically philosophical talent applied to this material. It was philosophical reasoning and philosophical clarity that enabled him to formulate and test hypotheses ... and he could not have made his great contributions by any other method."

But is logical reasoning the exclusive gift of tenure-stamped philosophy professors? Just as dictatorial regimes dubbed "People's Republics" don't fool anyone, philosophers who insist on an imperial conception of their subject persuade no one but themselves.

Lacey, whose wealth of information and textual references suggest a far more broadly educated intellectual than Nagel, thanks psychologist Adam Phillips for helping her resist "the impulse to make a life story neater than life itself." The sad upshot of this latest sighting of the disembodied thinker is that a champion of "philosophy" thinks truth matters less than keeping up appearances.

Carlin Romano, critic at large for The Chronicle and literary critic of The Philadelphia Inquirer, is a fellow at the New York Institute for the Humanities, at New York University.

The Glory of its Squalor

2008-12-09T10:59:00.000-08:00

"Then it came to me: what Paris had lost... was its pungency. Gone was the acrid Gitane-Gauloise pall of any self-respecting café. Gone was the garlic whiff of the early-morning Metro to the Place d’Italie. Gone were the mineral mid-morning Sauvignons Blancs downed bar-side by red-eyed men.

Gone were the horse butchers and the tripe restaurants in the 12th arrondissement. Gone (replaced by bad English) was the laconic snarl of Parisian greeting. Gone were the bad teeth, the yellowing moustaches, the hammering of artisans, the middle-aged prostitutes in doorways, the seat-less toilets on the stairs, and an entire group of people called the working class.

Gone, in short, was Paris in the glory of its squalor, in the time before anyone thought a Frenchman would accept a sandwich for lunch, or decreed that the great unwashed should inhabit the distant suburbs. The city has been sanitized."

OMG!!!

2008-11-16T10:26:00.000-08:00

there exists a word for my experience with thesis, this particular school program, possibly all of medicine, and urban american life!!!!

Anomie, noun
-personal state of isolation and anxiety resulting from a lack of social control and regulation
-in contemporary English, means a condition of malaise in individuals, characterized by an absence or diminution of standards or values. When applied to a government or society, anomie implies a social unrest or chaos.

Viva la capitalism!

Garfield Minus Garfield

2008-11-12T17:37:00.000-08:00

New York Times Op-Ed Columnists in order of Douchiness

2008-11-09T21:36:00.000-08:00

Ranked from least to most:

(1) Gail Collins
(2) Frank RIch
(3) Roger Cohen (cloying, but sweet)
(4) Paul Krugman
(5) Nicholas Kristoff (not exactly douchey, but sometimes offensive in dumb oblivious way) (but so adorable!)
(6) Bob Herbert
(7) Maureen Dowd, David Brooks (tied)
(6) Thomas Friedman
(7) Billy Kristol

not ranked: Charles M. Blow (picture=too-cool-for-school)

The Nun's Litany

2008-10-23T11:07:00.000-07:00

(by TMF)
I want to be a playboy's bunny
I'd do whatever they asked me to
I'd meet people with lots of money
and they would love me
like I loved you

I want to be a topless waitress
I want my mother to shed one tear
I'd throw away this old sedate dress
slip into something a tad more sheer

I want to be an artists' model
An odalisque, au naturel
I should be good at spin-the-bottle
while I've still got something
left to sell

I want to be a cobra dancer
with Little Willy between my thighs
I may not find a cure for cancer
but I'll meet plenty of single guys

I want to be a brothel worker
I've always been treated like one
If I could be a back-street lurker
I'd make more money
and have more fun

I want to be a dominatrix
which isn't like me, but I can dream
learn S, and M,
and all those gay tricks
and men will pay me to
make them scream

I want to be a porno starlet
(for that I'll wait till Mama's dead)
I'll see my name in lights of scarlet
and get to spend every day in bed

I want to be a tattooed lady
dedicated, as I am, to art
Characters bold, complex and shady
will write my memoirs
across my heart.

Addendum

2008-10-21T19:28:00.000-07:00

Dear Self from the Past:

Don't you think a medical student doing mediocre weekend philosophy for an unnecessary degree is a mean and stupid idea?

Sincerely, Self from Right Now

I hate my thesis

2008-10-21T18:35:00.000-07:00

I hate my thesis.

Why is Bad Posture Fasionable?

2008-10-12T15:11:00.000-07:00

as are vacant gazes, frowns and wide-footed stances? People may mistake this for a cerebellar lesion. Or life threatening coma.

Intact motor functioning!

school

2008-09-22T17:52:00.000-07:00

oh yeah. hypomania. crashing despair. self loathing. self flagellation.

self absorption.

i miss you, summertime.

What the fuck is wrong with the republican party?!

2008-09-13T16:21:00.001-07:00

I'd hate to be yet another ranting liberal, but i can't motherfucking believe this shit is still going on.

In Office, Palin Hired Friends and Hit Critics

Why don't people like america?
did the tv do this?

Populism:

2008-09-12T17:12:00.000-07:00

Claiming it is a sham, the day you spend cursing

the brie cheese you've smudged on your iphone.

Cynicism: a free verse poem

2008-09-11T14:25:00.001-07:00

Gosh darn it, nothing really seems subversive anymore.

You can't even make up a new perversion, before its already on amazon

for 29.99. (plus s&h)

The information age is lame.

Yesterday I learned

2008-09-11T12:14:00.001-07:00

the word ALEXITHYMIA - lit., no words of feelings, or an inability to articulate feelings in language (=some ex-bfs?)

(jk!)

I also learned that the average physician-in-training acquires 20,000 new words into their vocabulary during medical school and residency. (There are about 275,000 words in common usage in the English language; 185,000 in French)

No studies have yet examined the impact of this on average physician scrabble scores.

Politics is ruining my life

2008-09-03T21:37:00.000-07:00

God, when this motherfucking presidential election ends and i stop compulsively reading the NYTimes (and The Economist; and Wall Street journal; and The Daily Show; and Colbert...), then spending 2 hours per hour of reading being incensed, another hour writing angry letters to the editor, and half hour wondering if said editors have alerted security--I can get some fucking work done.

More on Women

2008-09-02T23:14:00.001-07:00

"Stan, why do you go on so much about women?"
"Because I want to be one."
"What?!"
"From now on, I want you all to call me Loretta."
"But Stan, why do you want to be a woman?"
"I want to have babies."
"You can't have babies!"
"Don't you oppress me!"
[The Life of Brian]

I had wanted to raise holy hell about this article:

(1) Girl Power at School, but Not at the Office
"I used to think that perfection was the pathway to success. Not so, according to women I have interviewed who have reached the apex of their professions. Rather, it can lead to paralysis. Women, I have found, can let perfectionism stop them from speaking up or taking risks. For men, especially if they are thick-skinned, the thought of someone telling them “no” tends not to be viewed as earth-shattering."

What a smoldering steaming pile of bullshit. Ms. Seligson's sweeping and unsubstantiated cultural professions on behalf of all womankind, and then her trite reccomendations for cubicle decay ("girls do brag!") tempt me to rip out pages of Marx, crinkle them up, and meticulously stuff them into my eye socket. (and here i am, a market liberal, middle class meritocrat and everything)

but a thoughtful, more systematic (and substantiated? whatever, i have no journalistic integrity; i can revel in all the blog-ular steaming piles i want to) refutation of all the dumb presumptions in this article will have to wait.

Instead this may be the most fascinating article on the subject i've seen yet:

(2) Feminism and Freedom
"In 1991, the culture critic and dissident feminist Camille Paglia...described women's studies as 'a jumble of vulgarians, bunglers, whiners, French faddicts, apparatchiks, dough-faced party-liners, pie-in-the-sky utopians and bullying sanctimonious sermonizers. Reasonable, moderate feminists hang back and keep silent in the face of fascism.'"

"Women in the West did form a movement and did liberate themselves in ways of vital importance to the evolution of liberal society. Feminism in its classical phase was a critical chapter in the history of freedom. For most of the world's women, that history has just begun; for them, classical feminism offers a tried-and-true roadmap to equality and freedom. And even in the West, there are unresolved equity issues, and the work of feminism is not over. Who needs feminism? We do. The world does. Women everywhere need the liberty to be what they are--not, as contemporary feminism insists, liberation from what they are. This we can see if we look back at the history of women's liberation--not as it is taught in women's studies departments, but as it truly was."

Vindications of the Right of Women and the rifle wielding abolitionist Puritan--a fascinating ancestory to the Western Woman: bleeding heart do-gooder and the fierce independent, intellectual and family matriarch, sexual transgressions and mama bear of the den, Paine and Burke, and fifty other jumbled up polarities. How delightful to trace it to historical legends and archetypes: Wollenstein and More.

"Truth be told, there are also great numbers of contemporary American women who would today readily label themselves as feminists were they aware of a conservative alternative in which liberty, rather than "liberation," is the dominant idea. Today, more than 70 percent of American women reject the label "feminist," largely because the label has been appropriated by those who reject the very idea of a feminine sphere." --how fascinating!

I am intrigued by this alternative duality personified by Wollenstein and More: civil liberty and social responsibility, respectively. The educated, radical elite and the masses, respectively. That the first was to spend 100 years villified as a wanton tramp; and the latter is today trivialized as a do-gooding priss.

hmm. hmm. hmm. i agree with nothing yet; especially ingratiatingly sweeping generalization of "woman's nature" (as one should likewise be highly skeptical on statements of "human nature"; how else would philospher's be employed? bless the devil in the details). i ain't saying it ain't there, its just messy: some of it has a basis, and the rest is shit piled on top. In many cultures men are actually very interested in the domestic sphere. Why are some helping professions (of women) labeled "caring" and others (of men) labeled "heroic"? Why are men usually entirely left out of the discussion? i am provoked and enticed.

(fine, philosophers are not by and large employed; but how else then would cafes the world over stay afloat without them?)

Orwell the blogger!

2008-08-25T19:21:00.000-07:00

i am your fan.

NYTimes article
Like any good political blogger, Orwell devoured the news, making clippings and looking for shifts in public and government opinion, Professor Seaton said. “He’s partly obsessed by the newspapers because of the start of the world war,” she said. “The diary is written against this almost traumatized understanding that there is going to have to be a second world war.”

The Orwell Diaries

How timely!

2008-08-25T18:05:00.001-07:00

Family values, bitches!

This article is interesting. I think i agree. but i am not sure. Maybe because it is kind of very heteropresumtpive. And because there's a messy class story to consider (there's always a messy class story to consider). And because i have met many little girls who also like to be bad and/or ignite explosives. And finally because i have forgotten who it is I was originally tyrading against. I will mull all of this over some more

Real Men
In popular culture, rare is the man portrayed as wise, strong and noble. In film and music, men are variously portrayed as dolts, bullies, brutes, deadbeats, rapists, sexual predators and wife-beaters. Even otherwise easy-going family men in sitcoms are invariably cast as, at best, bumbling, dim-witted fools. One would assume from most depictions that the smart, decent man who cares about his family and pats the neighbour’s dog is the exception rather than the rule.

From this broad, experiential education in the ways of men and women, I reached a helpful conclusion that seems to have escaped notice by some of my fellow sisters: men are human beings, too.

Our cultural assumption that men only want sex has been as damaging to them as to the women they target. Here is how a recent graduate summed it up to me: “Hooking up is great, but at some point you get tired of everything meaning nothing."

Modern wellness

2008-08-25T17:55:00.000-07:00

"Beets are the new spinach."
"What was the old spinach?"
"Kale."
"Well then what's Kale?!"
"Don't be stupid."

Gender Theory

2008-08-25T13:24:00.000-07:00

pisses me the fuck off.

In that way that journalism often pisses me off--it may do good, is even necessary, but there is so much fuckin bullshit in its name.

Most ways of talking about Men, Women, Manliness, Womanliness, Transgenderness, Queerness, DykeFlamingFemmePansyButch, Whatmakesaleader, Representation-in-upper-echelons-of-Academia/Politics/Fortune 500, is bound to piss off somebody and quite reasonably, everybody.

Stepping aside even the issue of theory being required to be remotely logical, thoughtful, internally consistent or striving towards truth, lets leave that, and even then: I am so angry. And angrier that sometimes factions of feminists do the worst damage of all.

It seems coming from the left or the right, the upshot is this: "feminine"=bad.

empowerment = act like a man

acting like a man around this society frequently means to be materialistic, ambitious, self absorbed, excessively career oriented, aggressive, inconsiderate, amoral and over all a swaggering dick.

These things in small quantities may very well be fine traits and contribute to a robust and groing economy. but we're talking parts per million here. Usually, neither men nor women nor non-gender-binary-abiding trannies should behave like that, its very irritating.

Some day a treatise: in defense of softness, in defense of kindess, in defense of listening and good manners and thinking about others. And a motherfuckin defense of machismo in the way it once meant: a self sufficient man, a family man with a sense of dignity and courage. Of women who have grace and fortitude. Ladies, Gentleman, can we get some motherfuckin elegance, please.

Love, in 21st Century San Francisco

2008-08-20T15:46:00.000-07:00

Rousseau's grim assessment of modernity:

This condition can be summed up as individualism., not that virtue of rugged self-sufficiency as prized in American folklore, but a needy isolation in the midst of society. Rousseau foresaw the collapse of all the structures that tie men together. Common humanity is only an abstraction that has no effects on individuals and produces no felt common good. The new philosophy and the new natural science has reduced men to atoms without natural connectedness. Everyone needs everyone else, but no one really cares for anyone.

Hobbes said that all are naturally at war with each all, and in spite of some disagreement with that formula, Rousseau accepts that civil society is founded on that premise. Civil society and the relations among men in it are only extensions of that war by peaceful means, substituting various kinds of competition and exploitation--mainly economic--for mortal combat. The primary relationship is constituted by contract, that is, between two individuals who remain individuals entering into a contract valid only as long as it contributes to the individual good of each. The links between them are artificial and calculated and, above all, tentative. In this condition, man's defense system is always on alert.

The psychological effects of this unending alert are devastating. A being concerned only with himself has to spend his time worrying about the intentions of others and trying to hide his own from them, threatening, flattering, lying. In his selfishness, he forgets himself. His soul goes wandering out over the world of men and never returns, while he becomes hypocritical, envious, vain, slavish, measuring himself relative to the success or failure of others. This is the condition of alienation.

--adapted from Alan Bloom

How to become estranged in bars

2008-08-20T13:24:00.001-07:00

"Socrates can go naked where others go clothed; he is not afraid of ridicule. He can also contemplate sexual intercourse where others are stricken with terror; he is not afraid of moral indignation. In other words he treats the comic seriously and the tragic lightly."

Douglas Adams on Technology

2008-08-18T23:39:00.000-07:00

1) everything that's already in the world when you're born is just normal;

2) anything that gets invented between then and before you turn thirty is incredibly exciting and creative and with any luck you can make a career out of it;

3) anything that gets invented after you're thirty is against the natural order of things and the beginning of the end of civilisation as we know it until it's been around for about ten years when it gradually turns out to be alright really.

Apply this list to movies, rock music, word processors and mobile phones to work out how old you are.

I dream of

2008-08-15T15:32:00.001-07:00

more bookshelves.

Who Reads What

2008-08-15T12:11:00.002-07:00

An exquisite observation, delivered c/o W. Hu on her facebook post.

1. The Wall Street Journal is read by the people who run the country.

2. The Washington Post is read by people who think they run the country.

3. The New York Times is read by people who think they should run the country and who are very good at crossword puzzles.

4. USA Today is read by people who think they ought to run the country but don't really understand The New York Times. They do, however, like their statistics shown in pie charts.

5. The Los Angeles Times is read by people who wouldn't mind running the country -- if they could find the time -- and if they didn't have to leave Southern California to do it.

6. The Boston Globe is read by people whose parents used to run the country and did a poor job of it, thank you very much.

7. The New York Daily News is read by people who aren't too sure who's running the country and don't really care as long as they can get a seat on the train.

8. The New York Post is read by people who don't care who is running the country as long as they do something really scandalous, preferably while intoxicated.

9. The Miami Herald is read by people who are running another country but need the baseball scores.

10. The San Francisco Chronicle is read by people who aren't sure if there is a country or that anyone is running it; but if so, they oppose all that they stand for. There are occasional exceptions if the leaders are handicapped minority feminist atheists who also happen to be illegal aliens from any other country or galaxy, provided of course, that they are not Republicans.

11. The National Enquirer is read by people trapped in line at the grocery store.

12. The Atlanta Journal & Constitution is read by people who have recently caught a fish and need something in which to wrap it.

Mighty Women, A series

2008-08-14T17:25:00.000-07:00

As summer dwindles, momentum gathers for the coming storm: school.

Here is installation 1 and 2 on some of the Women in my Life.

(1)
A. is a Professor of Medicine and the Assistant Director of a small research focused program within A Prestigious University. She is Illustriously Trained, patrician and dignified. Perhaps in her forties or fifties, she has a husband and grown children. She is beautiful and charming. Perfect manners and neatly coifed hair, a Midwestern accent dotted with exclamations, soft sweaters and impeccable posture. Sometimes you are not sure how big she really is, because she is somewhat cute, somewhat petite, but she is somewhat of a Giant. Her gaze is exacting, her knowledge is sweeping, and her disapproval of poor thinking, gentle and piercing. She is a Physician, and carries the dignity of her profession as elegantly as a single, glinting, imperceptible gold chain. If you are held in rapture just enough, you may eventually see, just beneath the rectitude, the cultivated discipline, the neatly drawn lines, that furious drive, you can see A. at 23, a fierce young thing, a little bit neurotic, a little bit humorless, in that florescent hospital gaze, meticulously carving tracheotomies into the throats of the comatose, Bates and CMDT piled and dog eared by her side. Every Monday morning I can feel her Not Looking At Me, because my write-ups are 2 months overdue.

(2)
K. is a family doctor for souls lost amid Violent and Forgotten Urban Decay, and has been for decades. She is in her late fifties perhaps early sixties, stout, dykish, hoarse, asthmatic and commanding. She looks perpetually either startled, disgruntled, or outraged. As most of her patients have a line up of bullet wounds, insurance companies that hold out on their insulin, and the complicated pharmacology of titrating blood pressure medication with a cocaine addiction, such reactions are often unsurprising. She has the manner of an old general, who has seen the trenches of human misery For a Very Long Time. She eyes the idiotic green recruit (i.e. second year medical student) with a mixture of exhausted, patient irritation; stunned disbelief at the magnanimous extent of true and utter ignorance; and then that faintest, slyest wink, a genuine excitement for this the Next Generation, who eagerly, if clumsily, take up arms in her wake.

I Love this Man

2008-08-14T12:19:00.000-07:00

Raymond Tallis

Physician, Poet, philosopher and Playwright

If there were a statue of the Unknown Polymath it should look like Raymond Tallis: rangy, bearded, wide-eyed with disciplined wonder. For 30 years he has been rising at five in the morning to write for two hours before going off to work as a doctor. He has been a GP, a research scientist, and a professor of gerontology, one of Britain's leading experts, who has published more than 70 scientific papers and co-edited a 1,500-page standard textbook of gerontological medicine. But in the solitary hours of the early morning he has also been a distinguished literary critic, poet and philosopher who has written a radio play about the death of Wittgenstein.

The contrast between the social and biological aspects of medicine is very important to him. It goes to the heart of his complaints about modern consciousness theory. Medicine, he is sure, has made all its progress by treating human beings as complex machinery, or at most as animals to be analysed like any other part of biology. That is how we gain knowledge. But the purpose of this knowledge is to treat people, who cannot be reduced to biology: "The science, the art, the humanity of medicine is a supreme expression of the distance of humans from their biology." Medicine may progress by analysing the brain, but - he insists - what philosophers need to explain is the mind, which is a different thing altogether, however much it depends on a properly functioning brain.

Redemption

2008-08-13T11:12:00.001-07:00

I've changed my mind.

I stumble into the cafe 3 hours later than i usually do. Across from me are two young men scientists. They are handsome, cool and breezy. One lounges on the couch by a neat 4 inch pile of papers hand scrawled with graphs. the other is hunched over a table, his legs drawn up like a suave prowling thing. Both are dresssed in the uniform of sassy hipsters. Both stare intently but self-assuredly into their laptops. The one on the couch has a small but hard earned paunch righteously obtained by shunning outdoor activity for the laboratory. They are both cool cats, our generations watson and crick.

shit yeah. i'd swim, eat, breathe data to be as hip as these motherfuckers.

Take away point: working sucks. looking cool always seems fun.

Heroes.

2008-08-12T19:49:00.000-07:00

Grumbling is assuaged by alternatives.

Jonathan Mann , MD, MPH

Jonathan Mann was a central advocate of combining the synergistic forces of public health, ethics and human rights. He theorized and actively promoted the idea that human health and human rights are integrally and inextricably connected, arguing that these fields overlap in their respective philosophies and objectives to improve health, well-being, and to prevent premature death.1

Mann proposed a three-pronged approach that has appropriately acted as a fundamental explanation of the relationship between health and human rights. First, health is a human rights issue. Secondly (and conversely), human rights are a health issue. Human rights violations result in adverse health effects.2 Thirdly, linkages exist between health and human rights (a hypothesis to be rigorously tested).3 Literature substantiates the effects of the first two points, but Mann and colleagues proceeded to call for the validation of the third point and challenged the world to practice it.4 His work led to the development of the Four-Step Impact Assessment, a multi-disciplinary approach of evaluating interdependent and overlapping elements of both disciplines of Human Rights and Public Health.

With this framework, Mann attempted to bridge a perceived gap of philosophies, correspondence and vocabulary, education and training, recruitment, and work methods between the disciplines of bioethics, jurisprudence, public health law and epidemiology. Furthermore, Mann knew that the history of "conflictual relationships" between officials of public health and civil liberties workers presented challenges to the pursuit of what he called a "powerful" confluence of health and human rights – a positive approach.4

While conflict between disciplines exists, Mann thought it important to first raise awareness of these challenges. In the spirit of negotiation and acting as mediator, Mann pointed out that such an intersection of fields can only benefit if a common ground in philosophies is uncovered and planted with a flag of cooperation.

Mann’s biography is itself a compelling narrative, perhaps a treatise of a man who was both visionary and practical in the pursuit of health and rights for all. He advocated non-discrimination, an ideal that reached beyond borders regardless of race, ethnicity, sexual orientation, gender, socioeconomic status, and access to care. He was born in 1947, the year the Universal Declaration of Human Rights (UDHR) was drafted, and died in a plane crash with his wife in 1998 while on the way from New York to Geneva for a United Nations (UN) AIDS vaccine conference. He was a gifted academic who spoke fluent French and rallied many to the cause. He served in several roles at the Centers for Disease Control and Prevention (CDC), and in 1986 founded the World Health Organization’s (WHO’s) Global Program on AIDS. Mann had raised nearly $100 million in funding two years later. "The program was himself [Mann], a secretary and one typewriter," said colleague Daniel Tarantola.5 Later, in 1994, Mann directed the launch of the journal Health and Human Rights, published by the François Xavier Bagnoud Center for Health and Human Rights, which he also helped to establish.6