I’d like to…

Program an addictive video game that teaches clinical knowledge. And then play it in order to study for boards.

Establish a program of victory gardens that supplies people with pots, soil, seeds, and the tools they need in order to tend small crops of vegetables. I’d then like to take half of the food and donate it to food banks.

Program a document system that combines a webpage with a spreadsheet, database, and a regular word processor. All online.

Be a trauma orthopedic surgeon. And an immunologist. And a physiatrist. And a psychiatrist. And a pain medicine specialist. Really I’d just like to combine these fields to treat people who are in large amounts of pain that restrict their ability to move around productively.

Own an apartment building. The top floor would be my penthouse and the roof would be my garden. I would include a pool at the bottom floors and garden rooms.

Own a coffee shop that turns into a bar at night. It would have flowers everywhere and would feature tango for five to ten minutes every hour. There would also be take-out.

Sleep regular hours…

Flickr Facebook and Video Games

It’s funny how my time during the day is spent.  While the college would like me to be “in class” I find it a) boring b) counterproductive and c)frustrating.  It’s frustrating because the lectures are boring.  It’s frustrating because the lectures don’t really prepare us for the wards or the boards or the “quizzes” for that matter either.  The “quizzes” seem to be mini-torture tests because they are almost always only 25 questions – but that means if you miss one or two questions you are already way below the mean.  It’s actually a lot more stressful than having a midterm and a final.

This frustration leads to some degree of exhaustion which results in me passing out for two to six hours directly after class – which is extremely counterproductive.

So instead I tend to do things that will be enjoyable during the day – occasionally I take naps, I read magazines, I take photos.  I enjoy these activities and it puts me in a position where I feel as if I can actually work effectively throughout the day.

Maybe it’s my blood sugar – I haven’t ever checked it, but first thing in the morning just isn’t my time.  I almost always feel hung over.  A few beers seems to destroy my day.  Flickr is easy to use.  Not much thought involved.  Facebook is easy to use.  Not much thought involved.  And video games can suck you in with the excitement.  The instant gratification – my generation is all about instant gratification.

One of the things that I wonder though is this.  In this world of instant demand/delivery – why is it that we don’t have learning tools that fit the needs and interests of the students?

I can instantly see how a person is doing on my facebook account.  I can instantly see photos that I took  with my digital camera posted on Flickr.  I can play games such as Mob Wars (my new favorite – I’m Knuckles Montagna by the way, come join my mob).  I can talk to people via Gmail chat, AIM, MSN, whatever.  I can use Twitter all day long if I wanted to.  But there isn’t really any opportunity for on-demand instant learning about something like renal function.

Why is that?

Why can’t I direct my browser towards a webpage that gives me patients to manage steadily.  Why aren’t there  more online patient simulators.  Major airline pilots go through hundreds of hours of flight simulation.  Why don’t doctors do the same with patients?  So much of medicine is repetition.  So much of medicine is practice… So much of medicine is memorization and learning to speak a new language.  Why not show us by multiple examples how to practice medicine.

Sometimes I get the feeling

That the Bronx is dying

Slowly breathing, chests are heaving, pollution spewing like phlegm and pitched notes on a broken violin

Dying

Violent deaths on sidewalks riddled with bullets and obesity

Bleeding profusely outside the fried chicken shack the smell of freshly charred bananas caressing

your last memories

Dying in vain

Dying in spirit, body, and name

Dying in agonizing pain

Suffocating

The Bronx, South South Bronx is dying – screaming for help silently

Impatiently waiting to be rescued

Fighting in the ER, fighting the streets in the streets

Fighting to balance their own battles that they didn’t have to luxury to pick and choose

Fighting and dying

Like soldiers in a civil war with their own country

Their own city

Their own borough

A bureaucracy that has declared a covert war against them all

The Bronx is dying loudly, sirens and salsa music wailing competing for ears and hearts

The Bronx is hungry for simple things like air and peace

Jobs and good food

More subway stops and taxi cab drivers who aren’t afraid of the thoroughfares

The Bronx is begging the factories by way of prayers and cellphone communication

Begging the factories to stop pumping pollutants into the air and water

Unfortunately the factory owners aren’t listening, because one of them somehow found the frequency that God’s been listening to and is trying to jam it.

Someone a long time ago threw a lever in the gears of democracy

Someone threw us in the gears of decency so they think grinding us up seems to oil everything else decently

Someone sold us some wolf tickets in sheepskin clothing

That’s why they used to use sheepskin condoms and that’s why so many people in the Bronx have AIDS

and are dying

I’ve got blood on my jacket and she is still smiling at me because I look fresh

Not fresh as in dope, but fresh as in alive and the Bronx, since it’s been dying for years, flocks to life wherever it can be found

Downtrodden and sick but vibrant and loud

I’ve never seen so many colors in my life

I’ve never heard so many languages in my time – even though they are all English

The Bronx is dying and I don’t know what to say about it other than

God Rest Your Soul you don’t deserve this.

Organizational Misbehavior

“They say he’s not my boss. I don’t have to do what he says…”

“I’ve tried telling them – I scream till I’m blue in the face – but they are just so resistant to it, and they remind me that I’m not their boss…I don’t have any power over them…I personally think it’s unprofessional.”

So began the gripes of the course leadership when I took my concerns about the didactic quality and lack of realistic expectations to them. It went much better than I thought it would. It was an extremely revealing conversation.

Many of you have read how angry I’ve been about the lectures and just how terrible some of the problems have been.  It came to a head a few days ago when after watching a lecture on video, I had an urge to email the lecturer angrily, and tell her exactly what I thought of her lecture…when I could only think of one combination of four letter words to describe it (____ing sh*t show – which technically isn’t ALL four leters) I decided to prevent irreparably damaging my career and I decided to take it to someone who seemed less threatening.

I set my aim at the course director.  I emailed him, writing my laundry list of gripes in a frustrated tone.  I wrote of helping to solve the problems.  I asked for a meeting the afternoon of the quiz.

Where many faculty would duck and dodge the situation, preferring to throw ancillary staff under the bus, he obliged my requests.

And in talking to him I realized something important about the medical school, its researchers, the lecturers, doctors, and support staff.
They work here.

And in their minds they don’t get paid nearly enough to deal with others.  In short, I realized that this is an organization and instead of being angry at the figurehead at the top of the totem pole, I need to exercise a little bit of understanding.

As I unloaded my gripes, he mirrored them.  He pointed out bigger faults.  Underlying failings of the course.  He did so quite freely.  He explained the power structure too.  I suddenly understood that the medical school – being a monolithic organization – had kneecapped its own ability to teach to the potential of the educators and the students.

One of the first lessons of good leadership is simple.  When you delegate tasks to a person, you give them the authority and resources they need to accomplish the tasks.  If you can’t necessarily give them money, you at least give them enough influence over the people who are going to be working with them that they can ensure that the job gets done.

The command structure in any organization is probably the most important thing that you can have.  Fires typically go well because everyone knows who their boss is.  The officer – whether they have 25 years or 25 minutes as an officer – is IN CHARGE.  They take directions from their officer.  They are told the relevant objectives.  They are asked what they need in order to accomplish the task.  They are then given what they can be given, and they are set loose towards their goal.

Each person in a fire department command structure answers to ONLY one person.  There are Captains, Battalion Chiefs, Deputy Chiefs, and Assistant Chiefs.  They can all tell you to do something – but YOUR boss is your boss.  In medical school, it apparently isn’t that way.  The lecturers boss doesn’t care about the lecture quality.  So it is typically terrible.

There is little continuity.  There is little accountability. People answer to three people, not one.  People have to play political games to get things accomplished.  Resources are competed for instead of managed.  Staff wastes time because they don’t have someone actively managing them.

This is why large businesses can be such huge wastes of talent, time, and capital.  The organization isn’t moving in a definite direction.  If you looked at the organization as if it was a person, it would be a huge, fat, schizophrenic person with megalomaniac delusions of grandeur.  Dancing like an idiot.  While trying to hold two or more concurrent conference calls.

If there was a strategic direction for the medical school, I’m sure the faulty don’t know about it.  They sure haven’t conveyed it towards the students.  There aren’t leadership development courses.  So everyone just does their thing, moving as little as they need to.  Collecting a paycheck, trying to figure out a way to get a raise, even if it hurts the entire school and themselves in the process.

At times it is staggering to think of the possibilities.  It then quickly progresses to being depressing to see the realities.  They just work here.

Thanks

But then again that’s why big organizations typically aren’t NEARLY as productive as they could be.

2am Epiphanies recollected at 1pm

So…

I left the library last night – the refrain from the security guard who had been through three times was something akin to:

“You guys are still here?  By the time y’all are finished Y’all better be some damned good doctors…Shiiit“

He summed it up perfectly.  I’d better be a damned good doctor by the time I’m finished.  I don’t have the luxury of not being a damned good doctor.  We’ve been lectured several times by physicians – and when asked – pointedly – how many times they’d been sued the answer was always more than one time.  One doctor had been sued twice.  One was sued four times.  They still practice.  Successfully too.  But the problem with medical school, as I see it, is that instead of gaining some type of deeper experience with the material, we are busy wading through disparately presented facts, in the hopes of organizing it quickly enough to memorize it so that we can regurgitate it.  We are completely unable to actually memorize and understand the material.

As I left the library I had another epiphany.  It was after all 2am, the perfect time for thoughts to hit you with such startling clarity it feels as if you were hit by a speeding Mack truck.

My train of though/epiphany went something like this:

“It’s two am.”

“God I’m tired”

“How did cytokine mediated T helper cell differentiation work again?”

“Oh yeah, that’s right – IL-4 induces Th2 helper cells…”

“How is that clinically relevant?  Asthma?”

“Oh yeah, don’t forget delayed immune responses with asthma”

“I’ll totally need to remember that at 2am one day…”

“Wait…it’s 2am”

“I need to remember it at 2am today“

The point of that whole little stream of consciousness was that I need to absolutely be able to commit this material to instant recall memory.  I need that to practice competently.  Again, I’d better be a damned good doctor by the time I’m finished.  I was up last night, at 2am, struggling – again, at 2am – because I need to get used to working my ass off at 2am, and then being fresh and ready the next day.  Because that’s what’s expected of physicians in training.

If you are at a hospital, and its’ September, and the doctor says “I’ve gotta go grab my attending” Thank him.  Say something along the lines of “you residents are waaay overworked and underpaid…Thanks dude/dudette”

It’ll go a loooooong way.  You’ll probably get more attention from that resident.

Other epiphanies that I had during the four block walk home:

- Always start laundry early, when you don’t need it.

- Shred sensitive documents early, when they haven’t piled up

- Ask for help early, when you think you might need it.

- Start projects early, when you still have plenty of time for things to take longer than you expected.

- Stop and have a drink – if you can.

- Backrubs really do mean a lot.  They really do help.

- Guys really should bring a small can of spray deodorant and a mini-toothbrush with them, wherever they go.

That’s about all I’ve got…Thoughts?

Every now and again I get the feeling

That I’d like to cure cancer, or HIV.  It’s mostly that I just get ideas about how one might go about designing a treatment for certain diseases…

What I envision right now is for cancer.

So in cancer, the cells typically have a certain behavioral pattern, where they make very specific chemicals that are in a certain ratio.  They are definitely unique, and they grow like weeds.  Most of the side effects of chemotherapy comes from us trying to kill cancer cells, and the only way we as a medical profession have differentiated them is by their growth rate – but all cells grow, so even healthy cells get targeted – especially healthy, dividing cells.

So what if we could infect cancer cells with virus proteins that only replicated when they were activated by a unique combination of proteins found primarily in cancer cells.

But that requires a huge needle to inject virus directly into a tumor.  I have an idea.

There is something called gamma knife surgery…it basically is already used to kill cancer cells

If we can find a way to get the cancer cells to increase their uptake of virus when radiated, then we can target a very low infectivity virus into the cancer cells in a very noninvasive maner by irradiating the cancer cells with a gamma knife – using even less radiation than we normally would.

The cancer cells would take up the virus, where the virus, exposed to the right conditions for its growth would do so.  The virus would then get chewed up by the internal mechanisms for the immune system, and we would get “sick” – our immune system would take care of the virus from there out.  We could tune things so that they only replicated twice before it didn’t have enough “oomph” to continue infecting cells, and very slowly take out cancer cells, to avoid prompting an enormous immune system response.

I really should be studying immunology, not proposing new ways to cure cancer…

One guy, fit to be tied

I hate cramming.

Or maybe its more that I hate myself when i feel the need to cram.  Or maybe I hate myself, when I feel the need to cram, and hate the system for making class so unpalatable that I feel like cramming on the last day before a quiz is better than going to class…only to have to cram on the last day before a quiz.

The fact of the matter is, everyone hates cramming.

People would rather be doing something else – sleeping, out drinking, dancing, going for long drives, riding their bikes, working out, watching paint dry, taking a shower, cleaning up their apartments, taking nighttime photos – really almost anything else other than cramming.

So why cram the day before an exam?  Because I procrastinated.

Procrastination is my last devil.  I’m going to slay it.  I SWEAR.  Not to any of you, but to me.  I HAVE to kill the procrastinating tendencies in my soul.  Only then will I unlock the potential that lies deep inside.  And that takes us back to why cramming makes us so angry.

Cramming is almost always a symptom of a) structural incompetence on the part of the education system but more so it is b) a reminder that we have, locked away, an endless reservoir of talent that is going unused.  So we naturally feel uninspired when we cram, because we feel as if somehow we’ve wasted ourselves, both before cramming – by doing what came naturally to us – and during the cramming, while we are toiling away, trying to memorize something that often confuses us only nominally.

Some of the greatest mathematicians were immensely creative people.  They were able to memorize all of the “rules” and “tricks” and they spent their time trying to solve problems according to the “rules” using the tricks.  Or they tried to circumvent the “rules”.  But in order to have that type of creativity, the rules had to come to them lightning quick – they had to have them committed to memory.

It’s not as if our schools don’t know what we need to memorize.  They just don’t really present things as if we need to memorize them.  When in reality we do.  If you want to teach people to understand, you do that, and you FOCUS on concepts.  Understanding is what gets the people the better grades.  They take a step back, start looking at the forest, making connections in their minds, mapping things out.

But if you want to teach people to memorize things.  You repeat them.  Over and over and over.  Repetition.  Dull, rote, drilling.  Repetition.  That’s how people memorize things.  Repetition works.  You form “knowledge habits”.  I still have a habit of knocking on the door to a bathroom.  Even if I know its’ unoccupied – a habit picked up in the fire department during training.  I can still recite the pump procedures for making a fire engine pump water – the result of doing it hundreds of times.  Repetition works – unfortunately our schools tend to de-emphasize memorization ability.  They emphasize “understanding”.  But how do you understand information if you don’t even remember it.

All of these are things that we think of when we cram.

Why don’t I remember this stuff?  Why is this so hard to keep straight in my head?  God I wish I had looked at this stuff earlier.

I do too.  One day I’ll have a patient’s life under my influence.  What I am able to recall is going to be the major determinant of what happens with the patient.

Oh well, enough procrastinating, back to studying…

Another damned idea

So we have viruses in the world right?

Things like HIV.

These viruses target cells that have receptors.  HIV targets cells via CD4 receptors.  We can form antibodies to HIV.  In animals where it is unable to actually infect them.  Animals like hell, I dunno, snakes.  Or in plants even – plants can form antibodies (I think?).

Another thing we can do, we can form things called liposomes.  They are little “fake cells” so to speak.  We know how to form tiny little liposomes, put stuff into them (maybe like radioactive tracer chemicals or fluorescent molecules)

So my question is this.  We want to get rid of HIV in a person.  How about we do something along this line.  Infuse the people with liposomes that have been filled with fluorescent molecules.  In the surface of the liposomes are two receptors (CD4 and CCR120) which are responsible for the infectiousness of HIV, and basically mediate the binding and endocytosis (swallowing) of HIV into CD4 T cells.  So the HIV grabs onto the liposome.

Now, we just do a dialysis of the patients blood – and while doing the dialysis – we sort out all of the molecules that are fluorescent.  This takes out all of the liposomes that are attached to HIV.  Could we do this with bacteria instead of liposomes?  We might even be able to then stimulate antibodies to HIV.

I think I just found another research project…

How To Really Teach A Medical School Course

Having seen what can pass for medical education in the first year, I’m somewhat disturbed by what us students actually know and retain.  There are definitely elements of our curriculum that both went by in a blur and were poorly taught.  There are lectures which put me to sleep – leaving me unable to see straight and unable to recall anything of importance.  The didactic method of lecturing to students is an efficient way of delivering a large, homogeneous amount of information to a diverse group of students…unfortunately it isn’t as effective as it could be – failing to provide students with a body of knowledge and experience that would enable students to recognize patterns of symptoms and understand the reasons for each of the symptoms.  Unfortunately medicine is an algorithm based discipline and to spend at least 1.5 years talking about the landscape without touching an algorithm is almost a travesty.  Unfortunately the real scientific skill in medicine is heuristics – investigation and problem solving – not rote memorization or regurgitation of “facts”.

The “best” students in the first two years are the ones who act as sponges – able to absorb as much material as possible – and then able to express it rapidly when “squeezed”…so curiosity helps a great deal – and I believe it helps a great deal in terms of actual patient treatment – when things don’t work according to plan – curiosity helps spur investigation of problems, helps spur additional strategies for treatment.  But, curiosity doesn’t always make a person pay attention to the patient.  It also doesn’t show you HOW to do something.   It may interest you in learning how to do something. Curiosity doesn’t always teach you the specifics of how to perform important tasks and skills.

Curiosity also doesn’t substitute for experience.  Medical students in my humble opinion, should be getting some amount of experience through every year – they should be on the wards, learning about symptoms, signs, asking questions, interpreting lab tests, seeing patient/physician interactions, learning how to do simple procedures and talking to patients a great deal.  They should also be reading textbooks as little as possible – instead, they should be reading scientific journal articles, lecture transcripts, and working on case summaries and reviews.  The primary people teaching first and second year medical students should be patients and physicians, in small groups.  Lectures, need to be high yield –preferably videotaped.  This generation of students learns in a different way than the previous generations.  This generation is not used to the delayed gratification of waiting for the answers through a lecture – this generation would rather ask the questions of someone who knows the answer and get feedback quickly.

Unfortunately, not giving students repetition in terms of information and skills in analyzing and interpreting information, is tantamount to staging a farce of education.  Several times I’ve heard that after the first two years of medical school, people are amazed at how much they’ve learned.  After the last two years of medical school – they realize they didn’t learn anything in the first two and realize that they learned a ton during their first two years.  I feel like this signifies a waste of time – a waste of money and ultimately a waste of resources for the medical system when it cannot stand to spare said resources.

In addition, if we fail to provide our next generation of doctors with profound experience before turning them loose on the patient population, aren’t we doing them (both patients and newly minted doctors) a disservice?  We have gone through the physiology of the cardiovascular system, yet I doubt that I or any of my fellow students could really do a quality job of diagnosing cardiovascular problems right now, much less formulate a coherent or thorough patient interview.  Now I say that, not to diminish my fellow students, but to say that at the end of each week of class, we should have something to show for it – something tangible.  We should know how to question patients.  We should understand what symptoms can be caused by the lack of physiological functioning within a particular portion of the body.  We should have an idea of the drug classes used to treat particular problems.

Ultimately, this criticism is worthless if I cannot at least point to some type of solutions.  The first soution I propose to reforming the standard American medical curriculum is to emphasize small-group learning.  This will work for a multitude of reasons – one, by having regular interactions with one professor, students are able to ask questions more effectively.  Also, participation is encouraged in a small-group setting as opposed to a larger lecture setting where questions and discussion can be viewed as socially inappropriate.  At my school, there is a person who asks questions in most lectures, and he is widely ridiculed for his propensity for asking questions.  The shame is, he will probably be one of the best physicians our school produces.  Small group learning eliminates these social barriers to participation, encouraging actual work while in class.

Secondly, in the basic science years, patient simulation is absolutely essential.  By starting simulations out with very simple information, and progressively incorporating more information, reminding students of key basic science concepts, simulations tend to lead students down the correct path of learning basic science material in order to actually understand what is HAPPENING with the students.  We have had one simulation so far this year – it was widely regarded as the best educational activity we have gone through.  It was complete with a quick rounds simulated by the professor who led the session.  Many of my fellow students felt that this was possibly the best thing we could have done in terms of understanding the actual physiology and how to improve things for the patient.  Since the simulation was also lumped in with a standardized patient simulation we all got to practice our interviewing skills, which was extremely important as well.  The history and physical examination is supposedly the most important part of our medical education – we should be engaged in it immediately.

Third, rounds – students are meant to be in rounds – having things expected of them – being responsible for knowing material.  Students should be seeing patients, hearing the constellations of signs and symptoms of diseases, practicing the construction of differential diagnoses, and hearing the treatments required for those diseases.  Students should be inside the medical arena early, learning things that you can only learn on the floors – not stuck in a classroom, asleep (as often happens to me).

Fourth, didactic sessions MUST be retooled so that they actually reach the intended audience.  They need to have notes/journal articles to study prior to the lecture, they need to have learning objectives.  Sample questions should be provided – but they must be difficult.  Sample questions that are simple and easy do nothing to expand the students ability to think critically about the information.

Lastly, didactic sessions should focus less on the basic facts – those things tend to do two things – attenuate student attention span and lull students into a false sense of security and understanding of the material.  Instead,  encouraging students to understand the connections between different facts, different systems, different processes, different cell types and proceses is a much more fruitful and effective pedagogical device.

That’s all I’ve got right now – all I can think of.

Larger Than Life

Thank You for your gift
Sorry I have to do this
I appreciate your time

I appreciate your sacrifice
I’m so sorry
We met like this

Under these circumstances
This is bittersweet
You gifted us your last words

Words in the form of organs
Sentences in the form of body systems
Punctuated with fascia
Narratives of a life

But Clark really thank you
Thank you for everything you’ve done for us
It means the world to us
It means the world to our patients

Your perfect example
Arms heaped with sinew
Muscle and tendon
Hands – enormous

Your large tendons and thick muscle bellies
Prominent liver
Huge heart

Midway through the first week while having difficulty
You showed us just how strong you are
We completed your name for you
Clark Kent

You see Clark
You sir are Superman
At least to us

You sir must have done something for a living
Something big
Something requiring strength

Your largesse evident in every phrase
Every lab
Every lesson

Thank you sir
Thank you for your perfect example
It means the world to us
It means the world to our patients

The four of us will see hundreds each year
The four of us will practice for decades
The four of us will think back to you

Your perfect example
And thus you gave of yourself a second time
And that is why you loom
Larger than life