Pregnancy = a disease? and insult? an infection? trauma? underlying condition?

there are a few major themes of medical school that are consistent throughout whatever system about which we're learning, including:

- smoking increases your risk of everything,

- diabetes is only bad if it's not controlled, but if your glucose is high, it's involved in every organ system fast,

- don't mess with the kidney too much or you're not going to get better until you get a new one, and

- pregnancy is terrifying.

the photo above is from a real lecture that we had this morning and is supposed to be representing the "insults" to the heart that can cause systolic heart failure. Along with the pregnant belly on that slide is: coxackie virus (major cause of endocarditis), a glucose molecule (representing diabetes), Jack Daniels (not explaining that one), a bottle of erythromycin (which is a chemotherapy that is cardiotoxic), and mercury (which we all accept as a poison).

Other fun lectures that have really driven home this point include one that told us that our peak fertility is 24 (average age upon entering medical school: 26); another that explained in excruciating detail what happens to the pelvic floor after birth with the ever-so-lovely "hammock hypothesis". This isn't even getting into all the drugs you can 't take during pregnancy for fear of what they'll do either to you or your baby OR, maybe most terrifying, all the congenital birth defects we learn about - starting with chromosomal abnormalities or lungs that don't develop because the kidneys don't develop. And then all the things that can go wrong after birth: babies who have blood in their urine might have a disorder that will result in deafness, babies who start out walking fine but get progressively more and more fractures, babies whose hearts don't pump or stop working, not to mention all the things that babies are at greater risk of contracting, which is pretty much every illness.

whew. and I'm not even planning on being pregnant any time soon. It would be nice for at least one lecturer to acknowledge that at least half our class is female between the ages of 22 and 32 and planning to be pregnant sometime soon (if they haven't already), not to mention all the men in my class who will be fathers, and they could just say, just once: it's most of the time okay - or not just okay, but beautiful and magical and like nothing else you'll ever experience.

and then they could tell us all the scary stuff.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

"Childbirth is more admirable than conquest, more amazing than self-defense, and as courageous as either one."

-- Gloria Steinem

to give you my first born son

Every week I meet with a group of Bhutanese community members in our area who have recently moved to the United States as refugees. Some arrived a year ago, others a mere 22 days. We work through this "medical orientation program" that I developed with some of my fellow medical students. The program is designed to methodically go through seven important topics about health care in the United States so that they will be better equipped to use the system as they need it. The topics include everything from making appointments to confidentiality/consent to surgery to how to use the ER to mental health. We break into small groups and play-act a lot of scenarios as well as use lots of photos and props. At the end, I always ask them the two main questions of the session and somewhat pray in my head that they get them and the night hasn't been in vain.

One aspect of the program that I really enjoy is a consistent reminder of how hard it is to not understand and to not be understood - and how much more scary that is for someone who is not feeling well. On my first day of the previous session (our first), I asked one of the participants to tell me how to say "thank you" in Nepali, the language spoken by the Bhutanese community. I figured, if they were going to have to try to stumble through English every day all day, I could at least show them that their language would be hard for English speakers, and I thought maybe it would make them smile to hear me use Nepali words.

The man I ask tells me that "thank you" is said, "dhanyabad" (I'm not sure if I'm spelling that correctly). I ask another person who sort of speaks english - to confirm that my pronunciation is correct - "dhanyabad mean thank you?" (she nods yes). Awesome. At the end of the session, after I've asked the questions and wrapped everything up, I say - okay, "dhanyabad, we'll see you next week!" Everyone giggles, I assume at my pronunciation, and nods, Namaste, on their way out. I repeat this every week with the same response of giggles and nods and Namastes.

the final session arrives and one of the interpreters comes up to me and says, you know, Erica, I've been meaning to tell you - I know you think that dhanyabad means thank you, which it does. I just don't think it means it the way you mean it. We use dhanyabad to mean that we are really, eternally grateful. Look, it means, like, "I will give you my first born son I am so grateful - or something". GAHHHHH! and so then I feel like a total idiot and try to explain, but by this point, they all know me and have laughed it off that no one really accepts nor tells me another word for thank you.

so I keep saying dhanyabad and hope that it's just become a sort of inside joke, or at least that it makes them feel like, hey - we're definitely not the only people who have a rough time learning a new language - look at this crazy lady.

hey, if it helps them feel better able to take on the American Medical System, I'll take it.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

"On my fifth trip to France I limited myself to the words and phrases that people actually use. From the dog owners I learned "Lie down," "Shut up," and "Who shit on this carpet?" The couple across the road taught me to ask questions correctly, and the grocer taught me to count. Things began to come together, and I went from speaking like an evil baby to speaking like a hillbilly. "Is thems the thoughts of cows?" I'd ask the butcher, pointing to the calves' brains displayed in the front window. "I want me some lamb chop with handles on 'em."

-David Sedaris in "Me Talk Pretty One Day"

(a must read for anyone who has ever tried to learn another language for the first time while being in a country surrounded by it and only it)

10/20 in 2010

this week has been full of lots of decisions and realizations. I have finally admitted that I am taking the Boards and that it's okay to start at least thinking about them, I turn 25 really soon (a quarter century crisis approaching?), and we're choosing our clerkship rotations, which will set up the next year of my life (starting in February). often in medical school (and maybe just in life?) everything feels like it rains down at once.

so while I'm still figuring out where I'll be and how I'll keep all the important people in my life in my life, at least in terms of what I'll be doing, the next year of my life will look like this:

Psychiatry 02/28/2011-04/16/2011
Family Medicine 04/18/2011-06/04/2011
Pediatrics 06/06/2011-07/23/2011
Ob/Gyn 08/01/2011-09/17/2011
Surgery 09/19/2011-11/05/2011
Internal Medicine 11/07/2011-12/23/2011
Neuro/Outpatient 01/09/2012-02/25/2012

friends and family, note all important dates and which rotation I'm in, because it may be a big factor in how I can celebrate those important days. I'm already worried about missing my cousin's wedding (August 2011). stay tuned for updates on where I'll be.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

"am I right side up or upside down/and is this real/or am I dreaming?"

dave matthews, crush.

(I feel like I may have used this quote before, but it's one that for some reason often pops into my head at times of transitions)

The Choices We Make: Preference Theory

While visiting friends a few weekends ago, I talked with my friend Rachel about her research this summer in Europe on the ways women figure out the factors involved in their decisions on when to have children and if/how to reenter the workforce. She introduced me to this as an area of research (how cool) - and told me about Preference Theory, a theory created by Catherine Hakam about how our economic situation has shifted women into three categories of preferences regarding how they balance careers and families: 1) mostly career, 2) mostly family, 3) somewhere in the middle.

Hakim suggests that the features of our economic situation that lead to this choice being possible include:

*women being able to control their own fertility through contraceptive use

* women have access to all levels of the workforce

*there are more white-colored jobs (which may be more appealing to women)

*the creation of less typical work hours jobs (part-time, by contract, working from home),

*changes in social attitudes that support women making different choices

Hakim performed two huge studies in europe about how women made these decisions - or determined which preference category they fit into - with interesting results. She concluded that questions about women's preferences can predict employment and reproductive choices, but that this is not true in the reverse - that women in serious careers don't necessarily fit into the "career focused" preference group. She concludes this means that women don't rationalize their choices to fit with their preferences. It's a little confusing to me and I think may be confounded a bit by the age of the women she's asking - to predict (ostensibly, younger), and to reflect (most likely, older). But the times are changing - which you can read about in another article to check out, by another friend of mine working on these topics at the Center for American Progress in DC.

I'm so curious about the questions she asked people to determine their preferences. I was trying to think of my own (maybe you could help?):

- are you interested in being the primary care-giver?

- what percentage of caregiving are you interested in?

- how far would you like to go in your career?

- when do these promotions happen in relation to childbirth?

- what are you looking for in partner in terms of childcaring? (how important is this to you?)

- what are you looking for in a partner in terms of career aspirations? (how important is this to you?)

As all of my friends and family (male and female) start to get more serious about career paths and/or about families, there are lots of conversations about where we all fall on that spectrum and maybe more applicably, how do we work the middle?

thoughts?

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

"it's generally a good idea to carry possibilities in your pocket;

you never know when you might need them"

-Mary Anne Radmacher

Getting Physical

that's me in an apple tree!

friends at an apple orchard showing off all the yummy apples we picked.

This past summer I read Cutting for Stone, by Abraham Verghese, a fictional novel about a mission hospital in Ethiopia. I found myself envying the main character, Marion Stone's, introduction to medicine through learning to differentiate different pulses and what diseases they suggested. It's a technique used by many eastern medical practitioners, including Ayurveda. Some important types of pulses that we glazed over in my class, but if read correctly, signify serious disease include:

-pulsus alternans = alternating strong and weak pulse = usually signifies a problem with left heart systole (the major pumping action of the heart) and carries a poor prognosis.

-pulsus paradoxus = when there is an exaggeration in how much the BP decreases on inhalation = can signify COPD, cardiac tamponade (when the sac that the heart is in fills with fluid)

-pulsus parvus e tardus = the pulse is weak and late, relative to expected = signifies aortic stenosis

While we do learn physical exam skills along with every unit of material, and while our approach is very much learning how to fit together the pieces of the puzzle, I sometimes wish we had even more hands-on puzzling things out and that there was more emphasis on that process. Because how do they know we're listening to a heart correctly? Or counting the pulse correctly? No one really checks...

Last week, I practiced my first full history and physical on a standardized patient. It took almost two hours, including the feedback session afterward. It's designed to prepare me for next week when I do the same full exam at the family practice office where I work. Although we had learned and performed all of the exams before, I found that having to go through all of them all together was great practice because there's some awkwardness in transitioning from "okay, now I'm going to look into your ears" to "now I'm going to listen to your heart" to "now I'm going to stick my fingers all the way up in your armpit to feel for your lymph nodes now" or "now I'm going to press my fingers into your stomach - all over your stomach. All of these are incredibly important exams and in order to do them well, you have to be comfortable listening or feeling until you ACTUALLY hear or feel something, which often requires some patience and tolerance of awkwardness on the side of the patient, but also from us (especially at this point in the learning process, but probably forever).

Too many medical students (including me) and doctors have a hard time with that. In a new article in the NYT this week, Dr. Verghese argues for the importance of a good, solid physical exam. In the article he talks about diagnostic gaits, silver stool samples, requests patients make that can suggest a certain disease (if someone says, "hey doc, don't bump the bed" - consider peritonitis, an infection of the abdominal cavity lining), and the power of standing at the bedside of a dying patient (something no test can do). My personal favorite parts of the article are his questions to the residents working with him:

• Name five things that are better outside the body than in. (the answer appears in his novel: fluids, fetuses, foreign bodies, feces and flatus)
• Name at least 10 ways alcohol affects your brain (I wrote about my experience with this question with the neuropathologist at my medical school where I also thought it was an awesome question.

Best line in the article?

"Doctors and writers are both collectors of stories, and [Dr. Verghese] says his two careers have the same joy and the same prerequisite: “infinite curiosity about other people.”

yup. and that's why I like having a blog.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

And in a tribute of sorts - two of my favorite quotations from Cutting for Stone:

"You live it forward, but understand it backward."

-Abraham Verghese

"The key to your happiness is to own your slippers, own who you are, own how you look, own your family, own the talents you have, and own the ones you don't. If you keep saying your slippers aren't yours, then you'll die searching, you'll die bitter, always feeling you were promised more. Not only our actions, but also our omissions, become our destiny."

-Abraham Verghese

find yo mojo

(this is my sister's bf, phil, finding his mojo surfing in marblehead;
he is my favorite person to talk with about: rocks, oceans, and dinosaurs)

I took part in a panel discussion last week designed to give the first years some ideas about how to cope with their Human Structure and Function course - the most intense (time, energy, and brainpower-wise) time of medical school so far. There were about 10 other second year med students on the panel, each with their own advice about how to cope and succeed. Some of it seems medical school specific, but a lot of it was just good life advice.

Some tips included:

1. repetition is everything
2. repetition is everything
3. don't study what you have already learned (as comfortable as that feels)
4. start getting comfortable with doing things differently than the people around you - not everything works for everyone.
5. get a little bit selfish with your time, space, and energy - don't do things that don't fuel your fire, as much as they might work for other people

and my personal favorite: 6. FIND YO MOJO.

One of my fellow students said this to emphasize the need to find something (or somethings) to hold onto in medical school that a) make you feel like a whole person (not just a medical student); and b) make you happy. Another friend of mine refers to this process as "reconnecting to the source". I kinda dig that because I do think there's a global (communal?) energy that can move through all of us if we just choose to tap into it. not that it's always easy to tap into.

the moments where I feel the most tied to that energy are definitely the happiest and most fulfilling. Sometimes it happens as part of medical school - like when we learn something that just seems SO COOL or SO RELEVANT; sometimes I go out seeking it - like on a sunrise hike or in a yoga class; and sometimes I stumble upon it, while singing at the top of my lungs in the car or reading a New Yorker article while sipping tea in my kitchen. moments when it just feels like the world is a good and righteous place, and I'm exactly where I should be in it.

what makes you feel like a whole person? what do you find yourself doing when you feel like less than your best self to try to get back to it? how do you reconnect to the source?


~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"sometimes you must leap, she said gently,
and grow your wings on the way down"
-unknown

gatorade = diarrhea you can drink (aka welcome to renal physiology)

Life is a struggle

not against sin,

not against the Money Power

not against malicious animal magnetism

but against the hydrogen ions.

-H.L. Mencken, Exeunt Omnes, The Smart Set, 1919

and that's sort of how it feels today. I write a lot about the profound parts of medical school or the cool parts of being on the way to becoming a physician, but leave out a lot of the grueling details. We just started learning about the kidney this weak, which is arguably the most complicated organ in the body, and it's just not that exciting. It's super important - don't get me wrong - kidney failure is one of the worst medical complications one can have, so far as I understand it - but it's just not that glamorous (as much as our professors try).

our morning was all lectures on acid-base physiology in the kidney and began with the same quote that this post begins with: life is a struggle against H+ ions. The reasoning behind this was what our professor then proceeded to explain to us for the next um, four hours.

then I spent most of the afternoon reviewing the lectures from this morning to try to figure out just what IS the difference between metabolic acidosis and respiratory acidosis and are we more afraid of acidosis or alkalosis in general?

(answers: metabolic acidosis is caused by having too great a concentration of HCO3, whereas respiratory acidosis is caused by having too great a partial pressure of CO2; and we are MUCH more afraid of acidosis than alkalosis because it can make your heart stop).

luckily it was pouring and studying at my big kitchen table while drinking a hot water/OJ/ginger/honey combination that is supposed to help me feel un-sick was pretty alright.

and for fun (because life isn't JUST a struggle), an article from the newyorker about what it would be like if all the dieties got together and planned the world according to feng shui. amazing.

and PS: "gatorade is like diarrhea you can drink" is a direct quote from one of my professors - but I have to add that it's not like all diarrhea, only the kind that has electrolytes in it.

yup - medical school makes for strange conversations.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

"But there is suffering life, and there are defeats. No one can avoid them. But it's better to lose some of the battles in the struggle for your dreams than to be defeated without ever knowing what you're fighting for."

-Paolo Coelho, author of the Alchemist (and many other books)

Our Name is Our Virtue

Second truly free weekend. And this time I stayed in town!

The leaves have just started to turn and the air has just begun to crisp - nearly perfect weather for a nearly perfect weekend. It felt so long - which I guess is what happens when you're used to not having any time when you're not at least supposed to be working. Two and a half days felt like heaven. Awesome activities included:

*finishing the exam Friday before noon

*running all life errands in the afternoon (bank? check. groceries? check. laundry? check.)

*dance party extraordinaire

*big saturday brunch at the ranch house as everyone groggily woke up

*frisbee games in the yard for a few hours (playing with no time limit is the best)

*cider festival at Champlain Valley Farms (think: fresh from the farm food, cider tastings, as much apple pie as you can eat, and climbing in orchards for an afternoon)

*sunrise hike (up at 3 am, BEAUTIFUL ORANGE SKY over autumn foliage; asleep by 11 am)

*women's intramural soccer game for second seed in the finals (woke up just in time to bike to the field)

*watching Out of Africa cuddled on a couch with a bunch of wonderful people (who all fell asleep at one point or another during the movie since we had probably averaged about 10 hours for the whole 3 days previously)

a friend mentioned that he only recently started to feel like this has become A Place for him - no longer just where he attends medical school, but a community of people, a collection of special spots, a world full of memories. I second that so completely. Place is so tricky for our generation, but when it fits it feels so good.

now - rested and rejuvenated: onto Renal Physiology!

this is actually after the hike - I like it because it looks like Chris is asleep. (which he probably was)

~~~~~~~~~~~~~~~~~~~~~~~~~~~~

"listen to the music of the morning people dance and sing;

we're just one big family; and it's our god-forsaken right to be loved, loved, loved."

-Jason Mraz, I'm Yours