Sunday, February 26, 2012

Thailand and a Didactical Satire

We have finished all the lectures for the Blood and Lymph course and we take the last test on Tuesday. I only did average on the test we took this last Tuesday which put me at an 85%. One of the professors mentioned that in all his years with patients, not a single one had ever asked what grades he got. I made a mental note to grill one at my next physical. I would love to say, "I so totally owned your anatomy grade!" and then pray that he doesn't pimp me on anything. Perhaps that can be the subject the conversation with the doctor the next time S goes into labor.

Just so you know, pimping in medical school jargon refers to professors or attending physicians repeatedly peppering students with relevant or arcane queries, often with the intention to embarrass. The first time I heard the term, I had a vague sense that med student trafficking to Thailand was on the rise. Proponents of the practice say that it "strengthens the spine," and is a "nonthreatening way to start dialogue." Opponents call it abuse and that it's use reflects the insecurity of senior physicians to show vulnerable students who is boss.

The only teacher we've had that has done it to us so far was so far over the top that it was comical. After guesses that I gave, I got told to do the honorable thing and hang myself, fall on my sword, drink poison, etc. I thought it was kind of funny, but I'll suspend further judgement until years three and four when I expect it to begin in earnest during rotations.

In the meantime, I found the following video hilariously accurate in portraying a med school lecture. Every single thing has happened too many times to count.

Monday, February 20, 2012


We have a close friend who is undergoing treatment for anorexia. One of the things that she keeps saying is no one understands what it's like unless they've gone through it. Well-meaning friends tell her, "Just eat more," but she says something they don't understand is that it's not about the food, it's about control and giving up control is never easy.

I won't pretend to understand what she is going through, but the situation does make me ask why it happens and how it starts. A cursory search on the internet indicated that beauty magazines and pop media are to blame. In fact, the American Medical Association recently condemned extreme photo alterations.

"The appearance of advertisements with extremely altered models can create unrealistic expectations of appropriate body image. In one image, a model's waist was slimmed so severely, her head appeared to be wider than her waist," said Dr. McAneny. "We must stop exposing impressionable children and teenagers to advertisements portraying models with body types only attainable with the help of photo editing software."

While a fork may make it easier to be fat, I bet if you took all the forks away obesity would still be a problem. In the same light, it seems a bit too simplistic to blame the media for individual problems.

"It (anorexia) is seen as a regressive solution to demands posited by the patient’s preparing to exit from
the family of origin while feeling unprepared and overwhelmed by the prospect. Control over food and weight appears to take on undue significance and increases motivation that propels the adolescent to diet and to strive to meet unrealistic goals for their appearance, initiate abuse of food as a form of mood regulation, both inefficient attempts to deal with personal feelings of lack of self-worth, emptiness, and inadequacy. Dieting and binge/purge cycling then initiate a whole host of biological counter-regulatory measures which create their own demands and influences on mental states and appetite regulation, often leading to a intensification of fears of weight gain, body image distortion and deficient satiety regulation in response to food intake. "

-Steiner et al. European Journal of Child and Adolescent Psychiatry

Age defying, skin clearing, race changing, hair enhancing, weight dropping, pro-pixel intensifying, fauxtanical hydro-jargon, microbead extract technology.

Why eat healthy and exercise when you can just look like you do? No need to rely on healthy body image or self respect anymore. Just out of curiosity, I downloaded a trial version of Adobe Photoshop Elements 10 to see what I could do with a random picture. Youtube has some amazing walkthroughs on the photoshopping process. Turns out, you can change backgrounds, restore hair, change race, and quite a bit more.



Beauty to this extreme is unattainable - for the rest of you.

Sunday, February 19, 2012

Blood and Lymph

Blood and Lymph is halfway done (it's only a three week course.) I still have mixed feelings about the way the class is set up. I do like that it is more clinically based...what makes this kind of anemia different from this other type, malaria vs basesiosis, Epstein Barr Viral infection vs cytomegaloviral infection, etc.

 I'm not quite convinced that the small groups are the efficient answer. By now, I optimistically remember maybe 10% of what I learned in gross anatomy. To fix the retention problem, we are in groups of 8 and assigned a workload too heavy to complete individually. We teach each other our area of specialty. I knew how to do well in the past courses, changing the format is very disorienting. Also, I have a big problem with the higher proportion of sub-par lecturers. I have listened to quite a few lectures in my lifetime and I'll be listening to quite a few more, and here is a list of things to NOT do when you are the teacher:

1.) Talking in monotone. Six hours is a long time to listen to one pitch.
2.) Rehearse your presentation. I can read your slides too. Tell me what you want me to know from them, give me some interesting connections and insights, or spare me that hour and let me know I should just study on my own.
3.) Pace yourself. I can't decide whether too fast or too slow is worse. 
4.) Don't make real-time lecture mandatory. Everything is recorded. You can buy my presence with points, but you have to win my attention. If no one is coming to your lectures, try listening to one to find out why. (Don't try guilt either...make your presentation worthwhile and we'll all be happier.)
5.) Don't ask us questions. (Most of the lectures are streamed live from the parent campus so we have limited interaction with the lecturer. If they ask us a question, it takes an order of minutes to find a microphone, turn it on, adjust volume, and respond. Additionally, if students from the mother campus answer, it's lost to us.) Technology gets in the way of real interaction.

We have our first test on Tuesday and I'll suspend final judgement until the course is over.

Sunday, February 12, 2012

Prop 8 Revisited

An interesting week on the gay marriage front. In 9th Circuit Court of Appeals, California's marriage amendment Prop 8 was struck down again. Part of me is so glad I chose to not go into law. Reinhardt, author of the majority opinion, wrote that "the People of California may not, consistent with the Federal Constitution, add to their state constitution a provision that has no more practical effect than to strip gays and lesbians of their right to use the official designation that the State and society give to committed relationships, thereby adversely affecting the status and dignity of the members of a disfavored class." He explains that enacting such a law is beyond the ability of voters and their representatives. That's a sticky statement and the implications are a touch too paternalistic for my taste.

I don't know how big of a difference there actually is between taking a cookie away after it was given and never giving the cookie in the first place, but apparently the difference is big enough attempt a deed worthy of Chuck Norris and declare the constitution unconstitutional.

"Whether under the Constitution same-sex couples may ever be denied the right to marry, a right that has long been enjoyed by opposite-sex couples, is an important and highly controversial question. It is currently a matter of great debate in our nation, and an issue over which people of good will may disagree, sometimes strongly. Of course, when questions of constitutional law are necessary to the resolution of a case, courts may not and should not abstain from deciding them simply because they are controversial. We need not and do not answer the broader question in this case, however, because California had already committed to same-sex couples both the incidents of marriage and the official designation of ‘marriage,’ and Proposition 8’s only effect was to take away that important and legally significant designation, while leaving in place all of its incidents. This unique and strictly limited effect of Proposition 8 allows us to address the amendment’s constitutionality on narrow grounds."

Since judges aren't supposed to be politically motivated, and theoretically can't declare the constitution unconstitutional, United States District Court of Northern California left many people scratching heads trying to figure out how the constitutional amendment added to California's State Constitution by popular vote was dismantled by plaintiffs and United States District Chief Judge Vaughn R Walker (never mind that he himself is gay) when Proposition 8 was challenged back in 2010.

Chief Judge Walker couldn't just come out and say the constitution is unconstitutional (the jovial masses might chortle at such an oxymoron), so he walked through the back door and tell the public that popular vote can't possibly amount to anything since the populace was not fed the same arguments that were presented in court.  The court proceedings proceeded dismally from the first day for proponents.  Four of the six expert witnesses, Loren Marks, Paul Nathanson, Daniel N Robinson and Katherine Young, decided not to testify after all.  Perhaps they feared the same pulverizing attack that shattered the testimony of the remaining two witnesses David Blankenhorn and Kenneth P Miller.

Blankenhorn was founder and president of the Institute for American Values and testified on marriage, fatherhood and family structure.  Walker decided that Blankenhorn "lacks the qualifications to offer opinion testimony and, in any event, failed to provide cogent testimony in support of proponents’ factual assertions." Blankenhorn stated that 1.) allowing gays to marry will deinstitutionalize marriage, 2.) kids raised by parents biologically related do better than those raised in other environments, 3.) that his research has led him to conclude there are three universal rules that govern marriage that will be violated: (1) the rule of opposites (the “man/woman” rule); (2) the rule of two; and (3) the rule of sex.

Unfortunately, Blankenhorn did not research the biology of #2 so that opinion got thrown out, he couldn't provide a rebuttal to plaintiff's definition of marriage so #3 got thrown out. In reponse to #1, Walker stated, "To the extent Blankenhorn believes that same-sex marriage is both a cause and a symptom of deinstitutionalization, his opinion is tautological. Moreover, no credible evidence supports Blankenhorn’s conclusion that same-sex marriage could lead to the other manifestations of deinstitutionalization."

Miller, a professor of government at Claremont McKenna College, fared only marginally better because "Miller admitted he had not investigated the scope of private employment discrimination against gays and lesbians and had no reason to dispute the data on discrimination presented" by plaintiffs. "Miller did not know whether gays and lesbians have more or less political power than African Americans, either in California or nationally, because he had not researched the question."

To sum, all of the proponents' arguments, opinions, and witnesses were systematically destroyed and only the plaintiffs' weighed in on the now very lopsided scale. It makes me wonder just how defensible opposition to gay marriage is.

Of course you can say that gays can't ruin the concept of marriage any worse than heterosexuals have.  And you'd probably be right. And honestly, the Church does not need a tax exempt status to exist because if God wanted, He could let the prophet know where a mountain full of gold or oil is to take away the financial burden.

In fact, I am hard-pressed to find any defensible logic that opposes gay marriage although t tries and makes some very good points that could be the correct response to the mysterious "discrepancies between the arguments in favor of Proposition 8 presented to voters and the arguments presented in court." LGBT advocates should know that members of the Church of Jesus Christ of Latter-day Saints oppose gay marriage because God, through His prophet, commanded us to.

As difficult as it is to find defensible logic that refutes gay marriage, it is impossible to find one that supports it that can't also be used for other obscure unions. One example of many, the plaintiff's expert witness Edmund Egan, the chief economist in the San Francisco Controller’s Office, said during the proceedings that allowing gays to marry will increase revenue for the city and state through payments for an increased number of marriage certificates. Perhaps a group of five individuals (why not 3 girls and 2 guys?) wish to enter into a group marriage. That would have to be 2.5 times the revenue from the same marriage certificate, right?

It seems to all come down, at the very least in a progressive logical argument, to where you draw the line. I draw the line before gay marriage, group marriage, and bestial marriage. Others may draw the line where they will.

Going Viral

S's parents came into town last weekend along with L, Mom, and Dad. We didn't do much more than laugh and tell stories and we were all okay with that. C loved every minute of it. It blew her mind to realize she has four grandparents. You should hear her retell Dad's baby chipmunk story. 

I didn't get much studying done. I closed shop after lecture on Friday at 3:00 pm and didn't touch study materials until Monday which did not leave much time to prepare for the test on Wednesday. This test was about whatever bacteria were left over after the first two tests, antibiotic classes and modes of action, and the entire subject of viruses. Just because that description fits into one sentence doesn't mean  it was easy.

Antibiotics alone were rough. Fluoroquinolones, penicillins, macrolides, aminoglycosides, tetracyclines, cephalosporins, and the 10 or so stand-alone antibiotics each work in a different way, have different generations of drugs, and have about 10 major drugs within the category. Memorizing a mnemonic that size would be just as hard as memorizing the silly things in the first place. Additionally, there are six classes of DNA viruses and thirteen classes of RNA viruses that cause human disease and some are enveloped, some are icosahedral, some use intermediates, some are mitogenic, some confer a proclivity to cancer, some are airborne contagions, some replicate in oropharyngeal epithlium. Up until the hour before the exam I still didn't know which was which.

There is a God in heaven and He does care how well I do on my exams. With the test at 10 am, I got to campus when it opened at 7 am and went through my notes and my problem areas, but didn't make much headway until about 9:10. For a currently inexplicable reason, Heavenly Father decided I needed a jump start in a big way and I learned more in twenty minutes about viral classifications and features than I learned the entire two weeks leading up to the exam. Those questions were the easiest on the exam and I had them memorized in such a format that the answers were very obvious. Walking out of the test, Heavenly Father and I had a little conversation that went something like this:

-Me: "Wow, you know viral replication patterns, Baltimore classifications, and enveloped status too?!"

-Heavenly Father: "Yes, I invented the replication pattern and enveloped status, don't you know? The credit has to go to David Baltimore for his classifications and it is a simplistic way of looking at things, but it's okay for a first time exposure, I guess."

With immunology, infection, and therapeutics done we are moving on to studying systems. Blood and Lymph is the first one and as of right now I have mixed feelings about it. I found a groove that worked with all the memorizing of silly molecular details presented in lecture. I'm not sure how the test questions are going to be, but our assignments are more like, "how do you tell that this fever is a different disease process than this other fever." Seems to be more clinical which could be interesting, but I'll wait to see how fair the tests are before administering judgment.

In early August, a 42-year-old woman comes to the emergency department because of fever, rigors, frontal headache, and severe myalgias for four days. Episodes occur up to four times daily and last 20 to 40 minutes. She has been taking acetaminophen for the fevers and myalgias. The patient returned ten days ago from a one-week vacation on Cape Cod, Massachusetts. While there, she hiked regularly in the sand dunes and swam in the ocean. She has no past medical history. She has no known drug allergies. On physical exam, she appears ill. Temperature is 40.2 degrees C, pulse is 120 per minute, and blood pressure is 110/70 mm Hg. She has no rash and no enlargement of lymph nodes, liver, or spleen.
Initial laboratory studies:
Reticulocyte count is elevated
9.8 g/dL
Leukocyte count
4200/μL; 82% segmented neutrophils,
5% bands, 10% lymphocytes, 3% monocytes
Platelet count
Serum creatinine
1.2 mg/dL
Serum alanine aminotransferase
88 U/L
A Wright-Giemsa-stained peripheral blood smear is shown:

  1. What is the differential diagnosis?
  2. What is the pathogenesis?
  3. What is the epidemiology?
  4. How is a definitive diagnosis made?
  5. How is the patient managed?
  6. What are the potential complications?
  7. How can the infection be prevented?