Author Archives: Justin Fiala, MD Candidate

About Justin Fiala, MD Candidate

Justin is currently in his third year of medical school at UIC's College of Medicine, and is hoping to pursue a career in internal medicine. He has a strong interest in addressing the health needs urban communities and is part of the College of Medicine's Urban Medicine program. Aside from academics, Justin enjoys cooking, listening to public radio, and perusing the New York Times website. He is also a trained pianist and self-professed lover of all kinds of music.

Call Me Dr. House

Let me preface this by saying that I don’t regularly watch the show, but this week I had my first “Dr. House” moment — and by that I don’t mean that popped a Vicodin and got belligerent with my colleagues. Rather, I had my first light-bulb moment, where all the seemingly disjointed aspects of my patient’s signs, symptoms and hospital course came together to form a text-book presentation of a rare disease.

Here’s how the magic happened (disclaimer: certain aspects will be changed to ensure the privacy of the patient, and no identifiers will be used). He was a 20-something year-old with no past medical problems, who, though completely healthy just several weeks ago, came into the ER complaining of flu-like symptoms (malaise, aches, and fever) for the week prior, with severe right-sided chest pain which began only 2 days before. In the ER he was found to be febrile, with findings on chest X-ray suggestive of pneumonia with a small amount of fluid (known as an effusion) surrounding the lungs. Thinking it was a run-of-the-mill community-acquired pneumonia, he was started on Levaquin, a commonly-used and appropriate antibiotic for such a case, and was admitted to the general medicine floor for monitoring.

Up on the medicine ward he began to show signs of significant respiratory compromise, with his O2 saturation (the metric used for determining how much oxygen someone is actually getting into their blood — and subsequently their organs) dropping below safe levels. In response to his worsening condition he was given supplemental oxygen and taken for a stat CT scan of his chest. In this type of instance, a CT offers a fast, reliable way to view the lungs with a level of detail that a plain-film chest X-ray lacks. With regards to this patient, what they saw on the scan was worse than they had anticipated from the X-ray.

Scrolling through the results it was obvious his lungs were in bad shape. There were, indeed, infiltrates (a radiologic term basically meaning junk that shouldn’t be there) within the lung tissue proper, as suggested by the chest X-ray. But what jumped out most was the extent to which the fluid first seen on the X-ray had progressed. This buildup of fluid within what’s called the pleural space (the space between the lining of the chest wall and the lining of the lung itself), isn’t all that unusual in hospitalized patients, but in this case was complicated by infection. From the looks of the CT, it was clear that the patient had what is called an empyema, which is a build-up of pus and all kinds of nastiness within that pleural space. But unlike your every-day effusion, in the case of an empyema, the body tends to react aggressively and wall it off, making it harder for antibiotics to penetrate and work their magic on the infection.

So even though the presence of the empyema itself wasn’t good news, at the very least, they had a partial diagnosis: the chest pain and the trouble breathing were being caused primarily by this infectious buildup of fluid that was pressing on his lung and making it hard for him to take a breath. Now the only problem was that the patient was becoming hemodynamically unstable, a sign that the infection had progressed to such a point that the body was beginning to lose control. His heart was racing, his blood pressure dropping, and he was spiking a high fever, making a secondary diagnosis of sepsis a very real possibility. Of the various causes associated with this condition, the admitting doctors suspected that the culprits were bacteria in his blood, and drew several samples for culture (along with a good number of other samples for a slew of different tests and analyses). Meanwhile, they knew they needed to tap the fluid that was building up, both to relieve the pressure and get a sample of the fluid itself for analysis and culture. But hospital bureaucracy being the way it is, this took about a day and a half to execute, during which time, though hemodynamically stable, the patient continued to spike fevers and labor with each breath.

And as if all this weren’t enough, while convalescing in the ICU (Intensive Care Unit) waiting for his tap, the patient began to have some transient swelling localized only to the right side of his face and right upper extremity. Now, localized swelling can mean many things, but the way it presented in this patient suggested the formation of a clot in the veins around his neck or upper extremities, which was confirmed with a venous ultrasound which was able to visualize an active clot in his right internal jugular vein. Now, in the average 60+ y/o hospital patient, venous clotting is not unusual, and is something that is actively addressed due to the serious complications it can cause down the line. But even in those patients for whom it’s more common, it is much more likely to occur in the lower extremities. Needless to say, in a young, previously healthy individual such as our patient, it was highly unusual. So the hematologist chalked it up to local trauma to that area and ordered close monitoring for any progression of the symptoms or signs that the clot was expanding.

When they did finally get the interventional radiology team to sample the fluid, for the most part it was what they’d expected: a turbulent (signifying a build up of pus), bloody mix, although the amount of fluid that they were able to drain was less than anticipated. This was because the empyema had walled itself off into various little sections, termed loculations, which, in itself, is never a good sign. It was clear that the patient would need a surgical procedure called a thoracotomy and decortication to enter into the infected, scarred pleural space and tear down all the loculations, such that the full extent of the fluid buildup could be manually drained.

Enter: the cardiothoracic surgery team, who, after hours in the operating room, managed to successfully rid our patient of all the infectious build-up that had set up shop around his lung. The surgeon noted that the pus had extended all the way from the patient’s armpit down to the base of the lung, and was the most extensive empyema he’d ever dealt with. And so, with 2 chest tubes in place to drain any subsequent build-up (and prevent another empyema from establishing itself), the patient was sent to the ICU for close monitoring to ensure that his breathing was stable in the first few days following the surgery.

When he was finally deemed stable enough to breathe on his own, he was transferred to my team on the general medicine floor; his chart — which at this point contained countless progress notes from the various specialists, ICU doctors, and residents who had been taking care of him up to that point — came along with him. It was my job to make sense of this mess of information and present it to my senior resident, so that we would be able to pick up his care where everyone else had left off.

This was no easy task; the binder holding all the various records, notes, and test results was bulging, and looked like it was about to explode. But page by page, I went through the chart, deciphering the chicken scratch and trying to fit the pieces together. Why was such a young guy in such bad shape? He had none of the risk factors for having bacteria in the blood (e.g. intravenous drug use) and wasn’t chronically immune suppressed (e.g. in patients with HIV), and moreso, had no history in his family of excessive clotting, which might have explained the clot in his jugular vein. Then I came across the results of the blood cultures they’d taken soon after the patient arrived at the hospital. Turns out they were positive for an organism called Fusobacterium necrophorum, an uncommon pathogen in general, which is even less common in terms of bugs that can enter the blood and cause sepsis, like that seen in this patient.

And yet, that name, Fusobacterium necrophorum, sounded familiar — probably something I’d come across during the massive information binge leading up to my USMLE Step 1 exam — and prompted me to look a little further into the matter. A single database search is all it took: lo and behold, that this little Gram-negative bacterium was the key to making the diagnosis.

It turns out that the patient had a textbook presentation of what’s called Lemierre’s Syndrome, a series of specific signs and symptoms all due to infection with Fusobacterium nerophorum. The French bacteriologist, Andre Lemierre, first described the syndrome in a series of young, previously-healthy, male patients presenting with sore throat, fever and respiratory distress in the early 1900′s. The patients all had the commonality of Fusobacterium in their blood, along with symptoms of recurrent fever, violent chills (termed rigors), respiratory distress (due to lung involvement), and in many cases, infection of other organs as well (including the liver, heart, and even brain).

He realized that the sore throat they were suffering from was due to the Fusobacteria itself, and that once in the tonsils, the organism had free reign to enter the blood stream via the tonsillar veins. This is where it gets interesting. The organisms have several factors on their outer surface that, in certain individuals, can cause blood to clot more easily, leading to an event called supperative thrombophlebitis, in which a clot made up of platelets (normal components of clotting) and large numbers of bacteria, sets up shop in a vessel (in this patient’s case, the right internal jugular vein) and just hangs around, throwing off little bits of clot and bacteria that travel to the rest of the body with every heartbeat. This allows the infection to spread from the initial site in the tonsils to the rest of the body, and also explains why the lungs are almost always involved in patients with Lemierre’s Syndrome — after all, the lungs are one of the first places that oxygen-poor blood from the veins travels as it’s pumped through the heart to be re-oxygenated. In other words, this was the pathophysiologic process underlying our patient’s empyema!

Still, one thing was missing from our patient’s story. He noted having had flu-like symptoms for the week prior to his admission to the hospital, but never mentioned a sore throat, which was one of the tell-tale signs of Lemierre’s Syndrome. This seemed like a set-back, but everything else seemed to fit into place so well. What’s more, I knew that much of the time the notes written when a patient is admitted to the hospital are imperfect and lack bits of useful information (which is why most any attending will tell you to always hear the patient’s story yourself). So I went into his room and took my own history of how exactly everything had played out, only to find that he had, in fact, had a sore throat, with swelling and pain which was worse on the right side (the same side as the clot!), but which had improved shortly before the onset of the flu-like illness and respiratory problems.

And with that, the diagnosis was sealed: bacteremia, supperative thrombophlebitis, pneumonia and parapneumonic empyema due to Fusobacterium necrophorum pharyngitis. In short, textbook Lemierre’s Syndrome.

On an extended course of high-dose, intravenous antibiotics, our patient slowly improved and was able to go home (albeit still on a massive dose of oral antibiotics for several weeks), having come through a rare and serious infection which, back in the days of Lemierre, would have most likely killed him. Lucky for him, it’s 2012, and antibiotics really do work. (Modern medicine for the win!)

But you can throw antibiotics at an infection all day, and there’s a good chance the patient will improve. Nonetheless, there is something incredibly fulfilling in making the diagnosis, and getting to the very bottom of what is going on. As a budding physician, I find myself continually humbled by the herculean processes of diagnostic medicine, but find near-limitless inspiration in the magic I felt in that moment of discovery, when I was finally able to give a name to the previously nameless entity that was afflicting my patient. That “House” moment is what keeps me going, and reaffirms that medicine really is where I belong.

Fun, Tedium, or Misery: Time Flies Regardless

Is it just me or does time keep passing faster and faster?  Chalk it up to a quarter-life crisis (that’s right, I’m assuming I’ll live to be 100), but I can’t help but feel that the epiphany I’d heard so many others articulate regarding the increasingly fleeting nature of time, is finally dawning on me.  I’m reticent to say it, but I think I’m getting old.  Okay, okay, let’s not go crazy, I’m getting older… that’s right, that wonderful little suffix makes everything a little bit more palatable.

Really though, I look back on events that don’t seem so long ago in my memory only to realize that high school was actually A LONG TIME AGO.  Then I look back on my years in undergrad and realize – all with increasing anxiety, mind you – that that too was A LONG TIME AGO.  In fact, if you asked me this very moment what the first two years of medical school were like, I’d have a hard time articulating it.  Why? Clearly it’s because my noggin’ isn’t quite the same with the ravages of age (maybe I’m being a little melodramatic here).  But when I sat down the other day and actually thought it out, I came to the realization that these days I find myself increasingly absorbed in what I’m doing.  In other words, I think just maybe this time warp is a natural part of the transition from school to career.

Granted, medical training is a unique hybrid between these two entities, with the particular stage I find myself in serving as little more that a glorified limbo between education proper and burgeoning clinical competency.  That said, I am very much still in school, and for all intents and purposes will be in perpetuity (the joke is that in medicine the light at the end of the tunnel is actually an oncoming train).  But what has come with this academic year, in particular, has been an introduction to the day-to-day life of a physician, full of less-than-ideal schedules (6 days on, 1 day off), exhaustion, and responsibilities unlike any I’ve had to take on before.  All in all, if I thought I was busy at any point prior in my life, I was sorely mistaken.  My life this year is defined by the rotation I’m on at any given point, with everything, my emotional state, sleep habits, and social life (this aspect has taken the biggest hit) following suit.  Now granted, at least part of this is attributable to the insular environment of a hospital itself—let’s be real, with regards to time, a hospital floor is just about as disorienting as a Las Vegas casino.  And when Saturday and Sunday become nothing more than potential workdays, the very structure of the 7-day week loses significance as well, making the weeks and months blend together seamlessly.

But beyond this is the fact that the work itself is enveloping, the way any day-to-day, goal-oriented work can be.  Seeing patients from admission, through their plan of care, all the way to discharge offers a never-ending list of tasks to be accomplished, which seems, above all else, to be the driving force behind this speeding of time.  There never seem to be enough hours in a day to get all the orders written, consults managed, and topics researched, just as there never seem to be enough days in the week when insurance companies are pushing to get a patient discharged and your treatment plan requires more time.  Constantly-moving deadlines like these keep time flying at such an astonishing pace.

But, being human, we get used to it in the same way we get used to pretty much everything.  What was initially overwhelming becomes the norm; we habituate.  And this habituation seems to be the reason for the confusion when we finally pause for second, take a step back, and wonder where the hell all the time went.

So what do I make of all this?  Well, to hearken back to the early days of Facebook (there’s an epiphany for you: it’s been around for over 7 years now) “it’s complicated.”  While there is absolutely something to be said for letting your work or other aspects of your life consume you – think of the physicians, artists, economists, etc  that have changed the world thanks to their dedication – I shudder to think that this is all there is to look forward to.  It may be easy to sink into the complacency of quotidian tasks such that time begins to fly by unnoticed, but if it means living a life unfulfilled, then what’s the point?  So my new goal is to take a step back more often, and consciously make an effort to separate myself from my education/work to appreciate other aspects of my life (people, experiences, etc) that have contributed to the person I am, such that I don’t lose them as time keeps accelerating.  Nothing will stop the years from coming, but when everything else seems to be a blur, I’m hoping that this will at least give me a few moments of clarity.

Under Pressure, Overwhelmed, and Without a Plan: Making an Endless To-Do List Work for You.

I’ve been thinking recently about the colloquial phrase, “Putting things on the back burner,” a line commonly used when people are trying to prioritize and make sense of the seemingly endless list of tasks that lies in front of them. But it got me thinking, even on the biggest, heavy-duty, industrial stove there are only so many back burners. And even in the hypothetical case in which there are, in fact, an infinite number of burners, logic follows that too many pots on the stovetop will burn the kitchen right down.

At this point you’re probably thinking, “OK, really? Pots and stoves? What the hell is this guy talking about?” But bear with me for a second.

What I’m really talking about is being able to keep a cool head even when you’re completely overwhelmed by the million commitments and obligations weighing on you.

And though it may seem like I’m going off on another tangent, let me set up another analogy: any packed schedule is like a busy emergency room. In both cases the key is triage. From the French “triere” meaning to separate, sift, or select, the term refers to the process of prioritizing the issues at hand (in the case of the ER, literally prioritizing the patients) by certain criteria to ensure that the most pressing matters are taken care of first. So big deal, right? This doesn’t sound all that different from everything you’ve been told about time management before. But if you take it to the next level, it really does make some sense.

In the ER you triage based on urgency, i.e. which patients have the least time before they take a turn for the worst or whose treatment is time sensitive, letting everything else kinda hang out in the waiting room for a while, knowing that they can be assessed AFTER there’s been some stabilization of the acute matters. Treat your obligations the same way.

Make a list and ask yourself, “What are the deadlines that absolutely MUST be met?” and, “What can I (to come full circle) put on the back burner while I get the pressing issues dealt with?” You’ll be surprised how well his first step of delineation sets the stage for clearing out your to-do list. This is because an honest assessment of the various commitments you’ve made (regardless of whether they’re personal, work-related or otherwise) accomplishes two separate tasks simultaneously: it is both an accounting of all that you have to accomplish, and an assessment of what’s most important to you and at least some assessment of the reasons why.

Once this list is made the next step is to make some plausible estimates as to how long each of the most urgent tasks will take, and (if they exist) what points are safe to stop at. Think of it as the point when you’ve finally stabilized the patient who’s been bleeding all over the place and can step away for a few minutes to take care of other business. Splitting seemingly insurmountable tasks up into bite-size portions like this not only makes it easier to stomach, but also allows for more flexibility in fitting everything in. If you’re sure you’ve stopped in a good place AND have a set time slated for when you’ll get back to working on the project, there’s no reason to fear, or feel guilty about, stepping away from a big task. In fact, often times just starting a big project and making some headway alleviates a good deal of the initial anxiety and may help with that overwhelmed feeling.

And guess what, once you’ve done all this and the groundwork is laid, much of the heavy lifting is done. Admittedly, you have to leave some room for flexibility. But with a plan of action which is well-thought-out and straight-forward with regards to the amount of time and effort it is going to require, your chances for success are much greater. Even better, by getting the pressing stuff out of the way first, your workload only gets better as you go, until before you know it, your rough period is done, and you can relax a little bit. Like the ER doc who’s faced with a waiting-room-full of patients, by facing your overwhelming schedule head-on you’ll get through it and live to breathe a well-deserved sigh of relief when it’s all done.

You Say You Want a Resolution?

The new year is here, and that means it’s time for resolutions of self-improvement and an end to the over-eating, over-drinking and general over-indulgence that seem to come part and parcel with the holiday season.  The solution to this resolution?  The gym.  Unfortunately, the new year also means the beginning of claustrophobia-inducing crowds in pretty much any health club anywhere, as over-zealous individuals, eager to work off the aftermath of pumpkin pie, cookie exchanges and celebratory glasses of champagne crowd the weight room and the cardio machines, making it near impossible to get a fulfilling workout.

That being the case, I thought I’d convert this post into an advice column of sorts, giving some nuggets of wisdom that I think may help maintain this heady can-do go-to-the-gym feeling of new year resolutions beyond the end of January and well into 2012 and beyond.

First off, let’s start by talking about mindset.  Seldom is there anything worthwhile that is easily won, and fitness and many of the other lifestyle changes often contained within new years resolutions are no different.  Whether the goal is weight loss, academic diligence or finally ridding yourself of any number of recalcitrant bad habits, you have to be realistic.  Although it may be possible to go to the gym after several months (maybe even years) of sedentary living and run 4 miles, lift some weights AND do some yoga poses, you will hate yourself in the short term — i.e. the next day — and it will likely ruin any chances of success in the long-term.  Rome wasn’t built in a day, and neither is the physique of a Roman soldier. Treat a new gym routine as if you’re trying to learn a new language and admit to yourself that you’re going to have to take it slow at first, gradually building endurance and adding new exercises to your routine (more on that a little later).  With time, you’ll have a plethora of exercises to choose from and the stamina to make it through pretty much any routine, so much so that boredom will no longer be an excuse for not working out.

It’s important to remember that, in essence what you’re doing is reprogramming your body for activity, which at a biochemical level involves altering any number of metabolic and physiologic processes.  This is no easy task, and, surprise surprise, takes time.  Unfortunately, it also hurts, is pretty unpleasant, and, let’s be honest, will probably continue to feel that way even months into a solidified routine (although hopefully less so).  DISCLAIMER: If there’s a reason that you’re at risk for cardiovascular events or any other reason that medically excludes you from normally working out, you’re a special case and should discuss any new exercise regimen with your doctor.

Otherwise, the fact of the matter is that after the initial rush at the beginning of a workout, the following few minutes will — and should to a certain extent — feel incredibly uncomfortable.  No doubt you know the feeling when all the adrenaline’s gone and you start to get winded.  Yep, this is the part where every part of your body seems to be screaming at you to quit. And if you turned the treadmill up to 9 out of 10 in delirious optimism, maybe it’s time to slow it back down. But by all means, keep doing something, even if it means going at a slower pace.  Otherwise, the bulk of the benefit is lost if you quit at this point.

After all, it’s only after this period that your body actually starts to utilize its energy stores and significantly burn calories.  And more importantly in the moment, it’s only after this period that your body starts to supply those wonderful endorphins and (recent research suggests little-known chemicals termed endocannabinoids) that start to make things bearable once more.  Point being: do whatever it takes to get yourself over that initial hump.

So now what?  You’re miserable on a treadmill, right?  Wrong.  Whether cardio, weights or floor exercises, there are countless ways to work any given group of muscles.  Beyond just reducing boredom, as an added bonus, changing things up also continually pushes the body to its limits, and keeps you from plateauing, meaning that your workouts remain ultra-high-yield.

But let’s be real for a second.  Time is limited and work/school are exhausting.  And who wants to head back out to the gym after returning to the comfort of your home?  Let’s face it: the gym is never the number one place that people want to be at the end of a long day.  All this brings me to my next point.

Cut the excuses.

Think about it.  Amongst the countless new years resolutions seldom do you hear, “Stop copping out” or “Start taking accountability,” despite the fact that failure to accomplish these two tasks is at the base of pretty much every failed new years resolution.  If lack of motivation is the reason for not going to the gym, then find a way to reward yourself (Häagen-Dazs  dulce de leche ice cream, anyone?), or if you’re like me, who refuses to leave my apartment after a long day on the wards for anything short of escaping a fire, take your gym bag with you so that there’s no longer an excuse to go home first.  As mentioned above, keeping with a resolution demands a hefty dose of reality, so get real with yourself.  Chances are that any excuse (barring a prohibitive medical condition) has a logical solution that you’re not seeing — whether it be consciously or otherwise.

So make the resolution to outlast the mass of “resolution-aries” that will be crowding the gym for the next few weeks, and meet the challenge of developing a routine that works for you head on.

It Gets Better

Last year one of my good friends and classmates had the idea of making an “It Gets Better” video on behalf of the UIC community, specifically soliciting the stories of those associated with the College of Medicine, be they physicians, residents or students.  What resulted was something more genuine and better-edited than I ever could have imagined, and something which I am truly proud to have been a part of.

For those who may not know, the “It Gets Better” project was started by columnist and gay rights activist Dan Savage early last year in response to a string of LGBT teen suicides, and consists of youtube videos directed towards teens who may be considering suicide due to any number of factors, with sexual orientation being the main focus.  The project spurred an outpouring of support and videos from celebrities, professionals, and random people gay, straight, and anything in between, all to get the message out there to young people in a troubled place, that things do, in fact, get better.  Below is the UIC College of Medicine’s video, which was officially premiered earlier this month:

http://www.youtube.com/watch?v=R9rr0exEOmo

In the spirit of the video, I thought I’d use this week’s post to speak a little bit about my own experiences, and comment on how positive an experience coming out has been in both my professional and personal life.

Personally, I would say I knew from a young age that something was different. And although I wouldn’t self-identify with the label until much later, I pretty much knew.  God knows the signs were there: dancing to the Spice Girls in the 4th grade talent show, a keen interest in pop music and none whatsoever in sports, I was basically a walking stereotype.  Nevertheless, when confronted with even the prospect of being gay I was petrified, so much so that it took until late in my teens to really start to accept that it was true, even if I didn’t know how to deal with it, or want to openly embrace it.

For the longest time I viewed it as a fault, obsessing over my grades and academic performance in order to compensate for the one thing I knew I couldn’t control that would ultimately disappoint my parents.  Strong academics became the façade that protected me against questions.  Why didn’t I have a girlfriend?  Oh, I was too busy studying.  Why no interest in sports?  I was just the nerdy type and preferred science (this one is still completely true).

Regardless, that plan only worked for so long, and eventually the pent up stress and angst came to critical point.  College had brought new challenges and stressors, and I could no longer function as I once had.  I had initially felt that UIC was too close to home to get that fresh start that people talked about with college, and once I realized this wasn’t the case, was so disappointed with myself for once again creating a lie for myself to live in.

This led to a nasty bout of depression and low self-esteem, the likes of which I’m sure each of those teens was experiencing.  I was just fortunate enough to have made it past those moments (because it was not a one time thing) and get to a point where I was at least able to begin a process of introspection.  It was a dark place, indeed, but the more I was honest with myself, the more accepting I became.

The process of self-examination and reconciliation went on until sophomore year when I decided I’d finally become comfortable enough with myself to begin the slow, perpetually awkward process of coming out.  Anyone who’s been through it knows: you don’t come out once; you come out over and over and over again.  It’s an arduous process, but one that is necessary.

So I started with one close friend, and then expanded to a larger group, then eventually got myself to the point where whenever I was in a social setting I could be comfortable being introduced along with the title “gay.”  It was certainly an evolution, and one that took a good amount of time.  But as comfortable as I became with myself and my friends, I still had extreme resignations about coming out to my parents.  For some reason, they were the ones that I most expected to be un-accepting.

Now this was not completely off-base.  Growing up with the fear of the inevitable (i.e. having to eventually come out) I had long since picked up on their attitudes towards LGBT issues and gay people in general, and from what I had seen, it wasn’t looking good.  My dad, despite having grown up in a very diverse part of Chicago, and not a racist bone in his body, was the polar opposite when it came to “the gays.”  He listened (and still does) to Rush Limbaugh and quoted Fox News on a regular basis, so needless to say, I was less-than optimistic about how he’d react.  And my mom, although not nearly as vocal, was on a similar plain with regards to the subject.

That said, I had strategically come out to my siblings well in advance of telling my parents, knowing that, even if it randomly came to light, and things turned ugly, I would have them on my side.  Lucky for me, that didn’t happen.  Although incredibly uncomfortable, and still-makes-my-stomach-churn awkward, things turned out alright.  When I finally told them my dad was taken aback, while my mother said that she had always known… not from the Spice Girls dance, but rather, the fact that I’d always only had girls for friends growing up.  Go figure.

Point being, as awkward as it may be, it is who I am.  And the experience has shaped me in myriad ways which are hard to completely pin down.  Above all else, the harsh introspection that came with the depression led me to a level of self-assuredness and confidence which continues to mold my decisions and interactions with people to this day.  Furthermore, clinically, it has meant that I am slow to judge; I see patients with the mindset that I will never fully understand their context, though I will do everything I can as a clinician to empathize and understand.  After all, anyone who saw me during my turbulent period was privy only to the façade, and had no idea what was stirring beneath.  In just recognizing this fact with my patients, I feel like I will have done them a service.

And so, to finish this post off, allow me to repeat yet again that IT DOES GET BETTER.  With time come perspective, growth, acceptance, and ultimately the ability to help others who find themselves in a similarly difficult position.

Podcasts: When You’re Too Tired to Study and Your Music Just Won’t Do

With a daily commute that takes 1 hour door-to-door, I find myself on the train a lot these days, which adds up to a lot of free time.  And while reading or studying would pretty much always be the ideal use of my time, at 4:30 in the morning, usually on about 5 hours of sleep, my attention span really isn’t addequate for processing detailed information.  So, this begs the question: how do I fill this time?

Sleeping may seem a logical conclusion given the generally fatigued state that I currently exist in.  But remember, I’m on the El, and from a common sense point of view, sleeping on public transit is never quite a good idea.  Rather, the answer, for me at least, has proven to be podcasts.

To be completely honest, it took me a while to come around to the idea of the podcast; I don’t know exactly why, but I never felt totally comfortable with the medium.  At least part of my initial gripe sprung from the fact that I am a PC user and didn’t like feeling trapped in a system in which there was no good way to bypass iTunes.  The program was slow on my computer and was just plain inefficient when it came to updating podcasts that renewed their content daily.  And this paired with the fact that I seldom actually plugged my phone in to update it, led me to believe that podcasts just weren’t for me… that is until recently.

Enter: Stitcher Smart Radio

This little app for the iPhone and Android platforms transformed the way I consume news and other media, and completely changed the way I felt about podcasts.  This free app allows users to search for their favorite podcasts — as well as live radio stations — and organize them into separate playlists that update free of any physical computer connection, all the while streaming the content so that it stays off of your hard drive.  What is more, the interface is incredibly user-friendly and saves where you left off, and allows you to go back to archived episodes, both tasks that are much more complicated if done through iTunes.

But enough about the technicalities, and on to the content itself.  If I had to ascribe an overriding theme to the podcasts that comrpise my “Favorites” playlist, it would be programs that force me to think or question what I think I know.  The following is a short blurb about a few of my favorites:
The Moth: A favorite from NPR, “The Moth” is a podcast of live story-telling performances (think a poetry slam, but with narratives instead of poems), each revolving around a different theme each week.  Sometimes the stories are laugh-out-loud funny, sometimes more somber, and often some combination of the two.  Regardless, they never fail to give you a glimpse into someone else’s unique experiences and the bits of wisdom they gleaned in the process.

In Our Time With Melvin Bragg: Recommended to be by a friend who spent a good deal of time in England, this podcast comes from a radio show that airs on the BBC4.  Apparently, the numbering system for the various BBC stations indicates how mainstream their programming is, with 4, as you may guess, being the most esoteric of the bunch.  And the podcast is no different.  Each week the host, Melvin Bragg, chooses a random topic (and I do mean random: everything from dark matter to Nietzche, to Chinese trade during the Ming Dynsasty) and invites experts in the field from some of the premier English and American universities to contribute to the discussion.  For someone who enjoys knowing a little bit about everything, this podcast is a must.
This American Life: Another NPR favorite, “This American Life” takes on a different theme each week, and develops anywhere from one to three stories around it, often incorporating original pieces by authors such as David Sedaris and others in the process.  It’s another one of those shows that never fails to make me think about the uniqueness of our experiences in shpaing who we are and how we view the world.

RadioLab: The only bad thing I can say about this podcast is that it doesn’t update nearly enough.  “RadioLab” takes seemingly random topics in various fields, be it science, or literature, or general interest, and over the course of the show, weaves an incredible storyline centered around a given idea.  If that sounds confusing, it is.  But it’s also pretty amazing when all is said and done, and always leaves me with my wheels turning.

If any of these sound intriguing, or you sound like something you might want to give a try, then by all means, download the app.  And if that’s not a possibility, google some of these shows and visit their respective websites.  Often you can stream or download the podcasts for free, and if not, the various NPR syndicates around the country air these shows, and offer free streaming themselves, (Chicago’s local iteration of this can be found at www.wbez.org).

So give it a try!  Happy listening!

Doing What You Love: Not So Easy After All

So here’s the scenario: you’ve worked yourself to the bone during undergrad, dedicated hours to studying for the MCAT, made it through the application process, and got into med school.  For discussion sake we can even throw in the fact that you’ve made it through the first 2 years, and have passed the USMLE Step 1 exam with flying colors.  So the uncertainty is over, right?

WRONG.

Now begins one of the most stressful periods of all: the one where you decide what you actually want to do for the rest of your life.

As far as I’m concerned, one of the biggest draws of pursuing a career in medicine is the flexibility.  Within the various fields and sub-specialties of the profession is a whole spectrum of lifestyles, pay scales, and types of work.  And while this is wonderful in terms of the seemingly limitless possibilities, it is equally stress-inducing when you start to consider the gravity of actually making this decision.  Standing at a similar crux right now, it’s clear that this is no easy feat.  Starting to look at possible trajectories for the rest of my life has forced me to be more honest with myself than ever before, and has made me address some of the “big” questions that I’d long pushed to the back burner: What do I want out of life?  What kind of lifestyle do I want?  Where, geographically, do I want to end up?  Do I value prestige over community service?

In terms of beginning to tackle some of these questions,  it seems to comes down to – the principle which translates to any life-determining decision – is a good deal of introspection (i.e. knowing yourself well), admitting the ego-traps that exist (do you want to be a surgeon because of the social cache/what you’ve seen on Grey’s Anatomy or does the field truly fascinate you?), and recognizing that there’s a good chance that nothing will fit 100%.

And so, during this all-important, insecurity-exacerbating 3rd year of medical school I’ve been going through my core clinical rotations with the intention of sorting things out.  Each rotation lets me sample a given field and gives me a snapshot of what life might be like were that my ultimate choice.  And this has allowed me to keep a running tab in my mind of what I’ve loved/been fascinated by as well as those fields that weren’t such a good match.

Unfortunately, a series of snapshots also means that the perceptions I’ve gotten aren’t completely representative of the field as a whole.  After all, the people on a given rotation, along with other factors like the institution-specific experience (e.g. maybe pediatrics at UIC is a more fun experience than at Cook County), can affect the overall perception as much as the actual workday or the field itself.  And though imperfect, it’s the best metric I’ve got.

That, paired with specific areas of interest (for example in the first 2 years of med school I loved learning all about the kidneys and reproductive endocrinology whereas GI and cardiac physiology/pathophys were more taxing to study) will hopefully start to narrow down the field.  In my case, I just keep telling myself not to succumb to the temptation of pursuing a career in something that pays well or is prestigious (dermatology, radiology or anesthesiology) at the expense of hating waking up for work for the rest of my life.  And while this hasn’t quite gotten me to a final decision yet, it certainly has cut down the number of possibilities.

So what’s the conclusion to the beginning scenario? Unfortunately, that uncertainty is a fact of life, and not just in medicine, but in any field.  All you can do is remain honest about your options and where you want to end up, and maintain the flexibility to consider new options when they present themselves, even if this means reassessing things you thought you had figured out.

Time Management When You Have No Control Over the Clock

Whenever I’ve gone to talk to my advisor the topic of balance comes up.  Don’t get me wrong, there’s a good reason; it’d be wonderful if I could efficiently fit everything and everyone that matters into the time allotted in a given week.  But let’s be real… finding balance is always easier said than done.  With a demanding schedule, impending exams, and obligations to friends and family, I’m lucky if I can make it to Friday without a laundry list of things I’ve put off due to lack of time.

I’m constantly reprioritizing in my head, playing the role of triage nurse, in a never-ending effort to determine what  things need to be done acutely and what things can (and will) wait.  And while, at times, this habit has the potential for disaster (everyone’s had that test that they’ve procrastinated studying for just a little too much), I’ve found that at the end of the day, it tends to be quite effective in terms of helping me keep my head above water and accomplish what I need to.

I think this ability to sort through everything and prioritize, along with a healthy amount of flexibility (i.e. a willingness to move things around) makes for a situation in which I have the maximal amount of control over an often less-than-ideal situation.  Recently, this has meant coming to terms with the fact that, with regards to my schedule, the locus control is completely in someone else’s hands.  This has forced me to roll with the punches of a workweek which is constantly changing, and has made me learn to block off whatever schedule I’m given, and work with what’s left over – regardless of how little it is.

A lot of this has to do with being completely honest about some of my less-desirable habits/mannerisms and streamlining my schedule to compensate for them.  For instance, on any given day I have to be at the hospital too early to go to the gym beforehand, which is what I would do in a perfect world.  Yet, I know that the end-of-the-day fatigue is a strong deterrent from getting me to go afterwards.  So I honestly assessed my behavior patterns, and realized that if I went directly home after work, that’s where I’d stay.  In other words, once comfortable, there was little chance that I would leave my apartment again to go to the gym.  The solution?  Shoving the bare minimum needed for a workout into the bottom of my work bag each morning, such that I have no reason whatsoever not to go on my walk home from the train (it just so happens that my gym is conveniently situated equidistant from my apartment and the L).

And while I am indeed tired at the end of the day, it’s something I forget about the instant I actually walk into the gym.  I’ve found that if I can circumvent a maladaptive behavior that would normally make me put something off, I more often than not overcome the toughest part of the problem.  And once I’m doing things in a more timely manner, there happens to be more time for the more enjoyable things in life.   And even if this isn’t quite the case and you still can’t fit everything in, at the very least, come Friday the to-do list is markedly shorter.

Feeling Comfortable In Your Genes

I don’t have a TV, so I tend to fill my time with news (the NY Times is my chosen source most of the time) and other things of interest like podcasts (if you’ve never heard of Radiolab, it’s worth checking out) and a group of YouTube videos from a series of conferences called TED.

In a nutshell, the TED conferences get the smartest minds in the world together in one place to hear experts in any number of fields talking about pretty much anything.  Below are two of my favorites: The professional opera singer with idiopathic pulmonary hypertension (a progressive disease where the lungs stiffen for unknown reasons) and the Harvard neuroanatomist who has a stroke and lives to tell about the experience.

TED Talk: After a Lung Transplant: An Aria

TED Talk: My Stroke of Insight

And while things like this may sound esoteric, the lectures – which usually average around 15 minutes in length – never fail to inspire me to think, question, and wonder.  And rightly so, considering that the mantra of the series is “Ideas worth spreading.”  Hence: today’s post.

Several weeks ago I watched a TED talk about the future of medicine, given by a well-establish physician from Boston.  This doctor had recently gotten his DNA analyzed by a company called 23andme (www.23andme.com), and was convinced that this new-found accessibility to our own specific make-up would fundamentally change the way we treat disease.  The fact is, the incredible advances in genetic technology over the past decades have made DNA analysis available at a price point low enough to be accessible to the average person, something which Watson and Crick could have only dreamed of when first pontificating about the nature of DNA.  If used properly, this technology can be a powerful tool, not only for medicine, but for getting to know ourselves more completely as humans.

I say that because not only did this analysis give the doctor details about predispositions for certain diseases, or other characteristics that are genetically linked; it also gave him detailed information about his ancestry, dating back eons, which helped connect him with others in the online community of people who had also used gotten their DNA analyzed, and who were genetically similar.

So, in a moment of complete geek nirvana, I looked into the site myself, and, given the endorsement in the TED talk, figured it was legit enough to warrant spending the $100 for the analysis. I had been sitting on some money I’d earned from a piano-playing gig for some time, and figured that this was as good a reason as any to spend it.

So I registered, and 2 days later received my sample collection kit in the mail – really no more than a specialized spit-collection tube with some liquid preservative – and donated a hefty sample of saliva (they do the DNA analysis on cells found in spit that have naturally sloughed off from your cheeks, so it’s completely painless).  I then shipped the kit back and waited the perfunctory 6 weeks for the results.

Earlier this week they finally came in.

Having what I’d say is a solid base of knowledge in genetics, I must say that the company does a very good job presenting the information on a number of different levels, so that it’s understandable to both the lay-person who barely knows what DNA is, and to a geneticist (or doctor-in-training) who can appreciate the details of the analytic techniques and scientific evidence behind the results.  That said, what I found was completely unexpected and fascinating.

To track maternal lineage (i.e. the ancestors from your mom, maternal grandmother, maternal great grandmother, etc) they use something called mitochondrial DNA, which is only inherited from the mother.  This is different from any other piece of DNA in your cells (located on your chromosomes), in which some comes from the mother, some from the father. That said, because this mitochondrial DNA comes only from the mother, it offers a way to continuously backtrack and look for differences in this type of DNA which suggest differences in origins.  For instance, certain patterns of mitochondrial DNA are seen almost exclusively in Sub-Saharan Africa, while others are prevalent in certain parts of Asia, the Americas, etc.  In essence, knowing your specific type of maternal/mitochondrial DNA means knowing genetically where your ancestors came from.

For me, this turned out to be a surprise.  Although I know the most recent generations of my mother’s family came from Europe (I had always been told Lithuania), the genetic analysis showed patterns associated with recent ties to the Middle East, most commonly seen in populations of Saudi’s, Yemeni’s, and  Ethiopian Jews.  This specific pattern is markedly rare in Europe, which I found odd until I came upon the caveat that this specific genetic marker is also found in a small number (about 3%) of Ashkenazi Jews, the ethnic branch of Judaism usually associated with the European continent.  I always knew that I was an Ashkenazi Jew, but always assumed that it was of some non-descript Eastern-European subset.  What this data suggests, though, is that my ancestors have the most recent ties to the Middle East out of the Ashkenazi ethnic group, and are genetically more closely related to the peoples of the Arabian peninsula than those of the European continent, something I found completely fascinating.  My vanity also make me wonder if that’s the reason I seldom get sunburns and tan easily… but then again, maybe I’m stretching.

You can read the full report and learn more about mitochondrial DNA here.

Regardless, this information gave me an interesting sense of self-awareness with regards to my cultural roots, as well as my place within the human species a whole.  Furthermore, stepping back and looking at the diagram geneticists use to map this type of information, the common ancestors and inter-linkage make me wonder why we are so quick to jump to divisive measures, when we are all so closely related.

Look for next week’s post on the medical aspects of the analysis, and in the mean time check out the TED videos linked above, and the full report on my maternal DNA pattern (haplotype).

 

**I have no financial ties or vested interest in 23andme, and did not receive any incentive for including their company in this post**

Teenage Patients, Personal Hurdles: A Week on Adolescent Medicine

It wasn’t THAT long ago that I was a teenager… at least it doesn’t feel like it… or at least it didn’t used to.  But this week, counseling teens on the adolescent medicine service, I feel like I’m really starting to show my age.

The idea behind adolescent medicine, which as a field is very young, is to address the issues, both medical and psychosocial, that can affect a young adult’s health, all the while trying to establish a positive patient-doctor relationship such that they don’t fear coming to the doctor in the future.  It’s a novel concept, and is admirable for a number of reasons, top among them being the incredible amount of time and personalized attention each teen gets.  The average interview lasts anywhere from 30 minutes to an hour and focuses on elements of the patient’s life that are seldom addressed in other fields of medicine.  And this is with good reason, as honest discussions early on about a number of health topics such as contraception, substance abuse, eating habits, depression, etc. can have a significant impact later on.

The difficulty, however – especially for a medical student— is being the one to start these discussions, only to then walk a fine line between compassionate professional and concerned peer.  Admittedly, there are points when the conversation completely consumes me, momentarily taking me back to the mindset I had when I was their age.  But then I snap out of it, and find myself wanting to give advice, all the while constantly fearing that I will sound like I’m lecturing them.  At the risk of oversimplifying the matter, being the one wearing the white coat is intense.

After all, many of us did things in our youth that would/may have been advised against by a medical professional or other authority figure at the time, and it’s hard to embrace the hypocrisy and assume that authoritative role.  Sometimes you want to yell at them; sometimes you want to laugh and dismiss an issue that doesn’t seem all that significant, because you’ve been through something similar, and well, you turned out alright, didn’t you?; and sometimes you just want to hug them and share parts of yourself as freely as they are doing with you.

But at the same time there is that distance and professional decorum that you have to maintain.  You have to remain calm, because a lecture is seldom as effective as a discussion; you have to take every issue seriously, because different context means that what was insignificant for you may be life-altering for them; and although compassion is good and necessary, it ultimately can’t be so excessive that it impairs your objectivity in treating them.

Anyone who made it through the rigors of high school and lived to tell about it knows that the extremes of adolescence are just that: extreme.  And as if it weren’t exhausting to go through the first time, it’s just as tiring to experience through these young patients.  To make sense of why they’re behaving a certain way or understand exactly what they’re thinking I have to suspend the logical reasoning, introspection, and foresight that I’ve garnered over the past several years of adulthood and put myself in their hormonally-charged, peer-influenced, teenage shoes for a hot minute.  Unfortunately, this takes a lot more effort than I ever would have guessed, and has led me to the disconnect that I mentioned at the beginning of the post.   I may be the closest one to their age in the office, I’ve never been more keenly aware of the fact that I’m no longer a teenager.  I guess the title of student doctor is finally starting to shift more towards the “doctor” part… I mean, it was bound to happen at some point, right?

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