Sunday, August 4, 2013

Over There, Here and There, and Back Again

I was driving home from Larry's Produce this afternoon, and as I was admiring the green trees swaying in the wind and the golden hillsides in the distance with the groupings of dark green trees reflecting the late afternoon sunlight in a spectacular fashion, I began to think of the television show Little House on the Prairie. As I go around the bend in the road, I see a hill that looks just like the one the credit scene for LHOTP, I'm sure you know which one I mean, but nevertheless:

Of course, after watching the video, the hillsides really have nothing much in common, other than the slope (kinda) and the presence of some grass. It makes sense, though, that I would associate the golden Californian hillsides reminiscent of the LHOTP television show as I live near Southern California, where it was filmed. But this is not about LHOTP, no matter the fond memories of the show I still harbor from my childhood, but instead about my reflection on travelling to distant lands and my impression of my home, as it has been for nearly 2 years now. That said, some of those LHOTP episodes were terrifying -- bag full of kittens thrown in the river? Crazy masked rapist coming at the kids with a pitchfork? Albert's opium withdrawal? Good stuff.

I returned a few days ago from being overseas for nearly 2 months. The first portion of the journey saw me working as a Doctor in Training at a hospital in Israel -- I'm sure I'll be sharing many stories and insights from my month in the Israeli hospital in posts to come. The last month I was able to meet up with my wife in Western Europe, where we wandered from Amsterdam to Paris down to Barcelona and then to London, where we have some family. Much impressive scenery -- from natural to man-made was seen, digested and appreciated (although the full gravity of the appreciation may come later.) The other day I was coming back from Walnut Creek on Highway 4  and I took the back way, which I like to do when possible and my recent venerable tourist inside of me roared to life and had me grabbing my phone so I could record the drive. 

While I don't know if I'll stay in the San Francisco Bay Area after this phase of training is complete, living here has been a pleasure and it is good to be home. 

While June is just over a month past, it feels like my experiences in Israel are buried beneath a month of travelling and other new and exciting experiences (and French wine, Belgium beer, etc) -- this makes sense, as this is exactly what happened. Thankfully I have a fairly detailed log of all my clinical escapades in Israel and I look forward to incorporating my insights into future posts. 

Saturday, April 20, 2013

Pathology Induced Paranoia

All day yesterday, during lectures and then while studying with some friends, I couldn't help but to refresh the  thread on reddit that had the continuous updating of the manhunt in Boston. Most of you are probably aware of reddit, and if not that site, other internet forum boards.

In no way am I the first to reflect on this stark change in how many people receive their news, but I'll throw in my two cents concerning what this means for the future for us as a culture, but also for main stream media outlets.

Last summer we saw the shooting during the Batman premier in Colorado (Huff Post referencing redditgood concise article about reddit's coverage) and the subsequent coverage paradigm shift from cable news to personal accounts and direct police scanner updates on user submitted content derivation sites (i.e., reddit). Of course, there are also links to television station streams, local and national, other "official" news outlets, but also other social media sites, such as Facebook and Twitter. As has been the case in the last few large tragedies, someone starts a thread and begins to aggregate links and information as it comes in. Naturally, skeptics will say that this is a very dangerous format, as early information is often wrong, especially when it is taken straight from police scanner broadcasts. Well, as we've seen so much in the cable news arena, they aren't exactly careful to fully vet their resources, and even worse, once a mistake (or lie) is broadcast, they can run as many retraction statements as they like, but they can't take it back. What I've found to really appreciate about the format the forum provides is that it has been customary to go back and strikethrough the erroneous statement, and add explanation of what happened. Compare this version of information delivery to watching cable news where they have to fill every second with compelling programming, which more often than not, leads to pointless and silly interviews and speculation.

I'm not a dyed-in-the-wool conspiracy theorist, but I do not trust mainstream news, in almost any form (especially commercial news, with stakeholders and profit margins to maintain), to provide me an unbiased narrative. Some outlets are kooko conservative and some are lib-tardish, and we all know which outlets fall under which category -- fine. However, no matter what specific demographic's eyeballs they are fighting for, they are all fighting for the same thing: larger market share, which leads to larger ad revenue, which leads to content delivery which aims to draw attention, not properly inform. This isn't news, obviously, but it may be news to the stakeholders when this format of news delivery fades into oblivion.

It may not be reddit that puts Fox and CNN out of business, but most people in my generation and younger feel as I do about mainstream media, and rightfully so. But the real question is whether or not crowd sourced news delivery will be able to provide a higher level of fidelity when it comes to the facts. A random user of a website, who has no journalistic training, much less an obligation or any accountability cannot be expected to perform the same as a (note, I say "good" journalist here, as my faith in actual journalists to act with any obligation to fact or accept accountability is also very low, even though I realize much of this is due to network pressure to err on the side of sensational, the end consequence is the same) good journalist should conduct him or herself.

I also am wary of individuals with malignant intentions when it comes to information dissemination; this could be official (government, corporate) disinformation, criminal intent, or just your classic 4chan neckbeard trying to stir the pot for amusement. This is the other side of the coin that allows blatant falsehoods to persist. I would argue that because there is an active component and constant communication, if there is something false posted or written, others with firsthand knowledge can refute the false claims. If I'm watching CNN, I have to rely on the same people who lied to me in the first place to put things right.

This past week also saw some of the downsides that can come from people that fancy themselves as a modern day Hardy Boy or Nancy Drew. Numerous false identifications were made, which of course, led to Facebook pages being besieged by wishes of ill will. Before the FBI released images of the suspects in the Boston bombing, there were numerous threads with people providing their own analysis of available footage and still images. This is not, in my opinion, closely related to the capability of a forum to provide a higher level of news delivery, but is indicative of the impatient tendencies that reside in us all. It would happen on the internet whether or not these live update threads were being created and maintained as events unfold.  

The bottom line is this: when a large news event happens I no longer turn turn on the television, nor do I go to an explicitly all news website (the exception is the BBC site if the event is off US soil) but for now, I go to reddit. In the future, who knows what forum will be available, but it won't be anything CNN, FOX, MSNBC or their ilk have to offer.

Saturday, February 16, 2013

Ureters are patent bilaterally and the mucosa is pink and moist.

When I was making the rounds across the country for various medical school admission interviews, they all, for the most part blend into one black and blue cheap suit day filled with nervous, forced smiles. All the schools have little idiosyncrasies in terms of how they run the day, but you can expect the information session, the tour of the facilities and then the actual interview -- usually in this order. One school, which hosted me for what was my second or third interview had a tour guide who was not a student, which was the case in all of my other interviews. I might not remember this fact, if it were not for the guide telling our group, while touring the cadaver lab that he/she suffered from a terminal disease, and was trying to get the school to allow her to donate her body to the cadaver lab. This struck me, and a few of my fellow interviewees as strange as we gave each other sidelong glances to make sure we weren't the only ones surprised by this.

Thinking about this now, it actually seems like less of a strange thing. Having spent many, many hours in the cadaver lab, I am still awed by the gift that all these individuals have made for the benefit of us students. That being said, the emotional element is practically gone, and time in the lab is primarily all business -- med school will do this, as there is not time to reflect on much other than what needs to be done next, and anatomical studies are just another task, at this point. While I'm not sure I'd really want to have a person's body I knew in the cadaver lab where I was spending time, it is now something that I can understand, as I would feel honored to have my dead body serve a usefulness beyond acting as a meat vehicle for the real me.

Here's to that tour guide -- hopefully they're still giving tours and telling wide-eyed pre-meds about how they could one day be cutting the body that is standing in front of them, open.

Sunday, January 20, 2013

Analogy Overdose with no Narcan Shot to be Found

Inadvertently, I found myself listening to a presentation by a potential Academic Dean, who was presenting herself and her philosophies concerning the education of medical students -- in essence, an opening salve in what could eventually be a job interview. Often times, if there is no other pressing issues, I spend lunch in the lecture hall with my headphones on. It is nice to get some quiet time and get organized for the rest of the day. Despite having my nice headphones with me, I found myself actually paying attention. It didn't hurt that the presenter last (or is currently, perhaps) worked in Oregon, and briefly discussed the residency position situation, which is about as big of a hook for me as there is.

Most of the mechanisms she proposed to use for medical student education are things that I've heard before, nonetheless, they seem sound and logical. Whether or not this particular school is implementing all of these ideas or isn't, is a very difficult thing to assess. After all, if one jumps in to a fast flowing river, it is very difficult to know what the river was like the day prior, much less ten years before. When hitting every boulder when floating (hopefully) down the rapids, it is not easily detectable if the flow rate of the whole river is changing at that moment. My point is, it is hard enough to be a medical student and trying to understand the philosophies that shape the overall, grand course of the "river" takes energy that is not always available.

Once in awhile, however, it is nice (and valuable, I'm sure) to be able to take a step back and try and understand why and what we're doing -- especially during the first two years, which is full of rote memorization and processing of abstract jargon. One of the points this candidate made highlighted the difference in the volume of material that schools mandate be understood, and/or memorized and regurgitated on a test. In no way, shape or form was this an "old" person, either. I won't venture a guess as to her age, but I'm sure she is not more than a couple of decades outside of her medical school education. Her point was that there is no way that memorization of every drug, technique, disease and treatment can, nor should be done. She went on to highlight her overall model of medical education, with plenty of good things to say.

I kind of lost her at the issue of memorization, and the ever-increasing volume of material that should be memorized -- note, I say should because, there is plenty of things that a physician does need to have stored in their heads. Of course, finding that balance is, admittedly, very tough. Unfortunately, since I'm the one doing the heavy lifting with the memorization, I wish there was an easier way. There may not be. But, no matter where that balance is, even if it is the best balance possible, there will still be more to memorize.

So, what does this mean? I think that medical schools should do a much better job of teaching students how to learn. First semester rolls around, and all the students are still feeling good about just getting in and then they're hit with the curriculum. Perhaps some of the students have a method of studying that allows them to organize, process and then comprehensively understand and then regurgitate the testable material. Most don't. I didn't. I thought that since I had a demanding undergraduate education, coupled with fluctuating, but at times heavy employment hours and plenty of extracurricular activities. I figured, that taking a 30 hour/week job while enrolled full time in school, and then coming to med school and having nothing else to focus on other than med school would make things easy. Perhaps this put the workload of medical school curriculum demands in perspective, but I had so much more time during my undergraduate years. What this means is that even though I thought I had good organizational skills, and a solid ability to enforce my discipline needs, I didn't have the means with which to immediately tackle the requirements of med school. Of course, like most other med students, it doesn't take all that long to acclimate to the accelerated pace and increased pressure but the acclimatory stage is not easy. However, the steep learning curve is necessary, as I believe that being comfortable with the overall level of work that being a physician demands starts with med school.

My argument is not that we need to be cauddled, nor that memorization is no longer needed. What I want from my medical training is guidance in how to most efficiently learn (in general), find information and then integrate it into my ongoing education and eventual practice (not that education ends, but I'm referring to formal training.) Nearly all med students show up on day one with motivation and willingness to work hard, and I want that raw energy to be morphed into tools and not wasted on rote memorization that surely will fade into obscurity, over time.

When I was a young teenager, and was newly obsessed with all things skateboarding, my friends and I would pour over all available magazines and the few company produced skateboard videos that were available. We would watch skateboard videos (VHS, of course) to tape failure, often to the point where I would have anywhere from 20 minutes to over an hour of footage memorized to the point where I not only knew what trick was being done at every moment of the video, but where it was being done. For the most part, I could give a brief profile on each skater being featured. Where they were from, if they were pro or not, what companies they rode for, and what their (if they were pro) board graphics looked like.

Of course, this was during an era where videos were, almost exclusively, produced and released by companies. Some companies released more than others, of course, but in general, it was a few years between major productions. Magazines were released on a monthly basis. There has always been Thrasher and Trasnworld, and for a few years there was Big Brother (oh how I miss you!) and a handful of transient, short-lived publications. I would read each monthly offering as if it were scripture -- I would have each page memorized, I would read, and re-read over and over, and then I would tack the best photos to my wall.

These days, there are more companies (I'm not actually sure about this, but one thing is for sure, the industry as a whole is much larger than it was 20 years ago), more riders, more publications, more company produced videos. Perhaps most importantly (in significance and magnitude) there is more individually disseminated content. Youtube alone (again, I'm pulling these numbers out of my nether regions, but my point still stands) probably has as much skateboarding related content uploaded every month as I was exposed to during all of my teenage years combined! Of course, much of this content isn't quality, but the very fact that mediocre and "beginning" levels of skateboarding are readily available make it easier for other new riders.

The analogy being made here is one that can be applied to just about any other field, hobby or industry in the world. Information dissemination has, and continues to grow at incredible rates. I'm not judging the quality, but that is really not the point. If I (and I shudder at the thought) were a 13 year old boy right now, who just fell in love with all things skateboarding, I would have no problem finding skateboarding related material. I would most likely not watch videos over and over (at least to the extent that I did with those old cassette tapes) and re-read magazines over and over. I might, however still tack photos to my wall, but they would probably be printed on a photo-printer and might be of myself and friends and not some pro in California (I know, I know, I now live in California...) that I've never met. However, what I would be is much, much more selective about where I found my sources of skateboarding data. Contrast to the 13 year old version of me in the '90's, where I was a voracious "hoovering" vacuum for any skateboarding related morsel I could find. The modern day "little-shit" me would have certain websites, channels and blogs that I would pay attention to and this would still be more than I could memorize. New content comes too fast, trends come and go, with local variances and riders are motivated (mostly by larger financial incentives, but also from a larger limelight, and all the trim that comes with being "skater famous") to constantly push the boundaries and baseline of trick capabilities, in that keeping up with all the newly released material is impossible.

It is important to note that while in this analogy, skateboarding has become more popular in the last 20 years, this same dynamic would still be at play even if the greater popularity was stagnant or had even declined. There would still be more information available, despite less participants overall.

Of course, in the medical world, I would be hard pressed to state whether or not there is more research being done today versus 20 years ago, but that is not the issue at hand. Especially for medical students. The issue is that the overall pool of data that we are expected to master continues to grow. Along with this is the increasing bounty of study tools, whether it be for actual school content integration (think digital flashcard programs, anatomical guides, etc) to full blown board-prep tutorials. These are all good things, but weeding through the voluminous variety is difficult and something a med student can't waste a lot of time on -- of course, each one has different points of value for each individual, who has different strengths and weaknesses, and, of course, different mechanisms that allow for the most efficient manner of comprehension, retention and regurgitation.

I'm okay with memorizing, and I recognize the need (despite the pain involved) for it. I'm not sure how this could be done, or what this would look like manifested, tangible and integrated into a medical school's curriculum, but I would like more instruction and guidance concerning how to best learn. Perhaps this isn't a problem, and I'll eventually get to a point where I know myself so well and I'll have my techniques down to such a sharp point, that the continued integration of new data (especially data that contradicts that which has guided my treatment algorithms!), techniques, philosophies and ideas will be second nature. Perhaps some day it will be like this, but just like being able to mentally walk through all 20-some minutes of Blind's "Video Days" or every minute of 411 VM's #3 is not of much value (other than nostalgic, which is not with out value intrinsically) to me now, even if I was still involved in the skateboarding world (business world, that is), so is memorizing lab values that will change over time. I don't want my knowledge base to be filled with unnecessary Video Days and 411 VM's 20 years from now, and that is what I want out of my medical education (yes, among a few other things), to be able to increase my plasticity potential and ongoing ability. Oh, and the other main thing I want from med school? More big, important sounding words with which to wow the blogosphere with; that right there is worth $45 a year!