Worst-Case Scenarios vs. Occam's Razor

If you are friends with me on Facebook, you know that for the last six weeks I have been on my third-year pediatrics rotation. One of the key points that they focus on for babies' appointments (but that was not tested at all on our SHELF exam, which was frustrating - that's a rant for another time) is developmental milestones. 

Around the age of 12-18 months, most kids reach a point where they start to learn at least one new word every day, and they become nervous or even outright frightened at strangers. Around the same time, they may develop night terrors (in their deepest stages of sleep, that they usually don't remember, and often frighten parents or babysitters more than the the toddlers).

Around preschool/elementary school age, as most of you do remember, children start getting nightmares. They can't always tell what is real and what is not, and it manifests in sad and terrifying (and very memorable) images that haunt their REM sleep until they learn to remember what is real, and keep the bad dreams at bay.

Nowadays, as I learn a new skill or diagnosis or other piece of knowledge every day, it's again what I don't know that terrifies me. In my first two years of medical school, we learned the physiology of the human body and the pathophysiology of the many diseases that can ravage it. That was our equivalent of night terrors - terrifying information that we did not always fully grasp, and much of which is hazy in our minds after we are tested on it. And while medical student syndrome runs rampant ("Oh God, I totally have the symptoms I'm studying!"), I'm sure it is much more frightening or annoying to our parents, significant others, and non-medical friends - the ones who have to deal with us telling them about the latest disgusting disease manifestation we saw, or comfort us when we freak out about tests and grades and our careers. The ones who, when they asked us about their own medical issues, got the WebMD-style complete differential on the worst things that could be happening to them ("oh, your stomach hurts? Well, it's probably just gas, but maybe you're bleeding internally or you have a tumor or an intestinal blockage or... tell me more about your pain!").

Now, in third year, we struggle not only to relearn all of that information and then some, but to apply it to patients, and to retain it beyond just the next test. Because now we are in the second half of our training, and what we do now, more than anything before this, is going to shape our future careers. So we have to prove our medical knowledge and skill, and that means facing our nightmares - all the incredibly complex diseases that preoccupy us at test time, but which are only rarely seen in the field. We have to be on our guard and watch for the signs carefully, without becoming alarmists who forget to rule out common things and ignore Occam's Razor (thus panicking patients and annoying attendings). 

What worst-case scenarios do you fear in your job? In your life? I'm not talking about stuff like death and safety that most people share - what are the ones specific to you? What do you think about and then have to stop and remind yourself that that is not the only scenario, or that there is an easier way?

Ten Opinions in a Row (Volume 2)

1. Shazam is an amazing app. I use it like it's my job. Then months later, I go back to listen to some of things I've tagged on it and I'm either saying "Oh, this song is still awesome!" or "Why on Earth did I tag this?!"

2. When I get interested in a new band, I get into their history, the biographies of their band members, their discographies, at least to some extent. From there, if I really like the sound of the musicians, I start looking into their side projects. Recently I got into Toto. This is a band where 6 studio musicians got together to start jamming. The number of side projects, guest appearances, and studio ghosting is too high to count. Guitarist Steve Lukather is EVERYWHERE in pop/rock.

3. Words trigger lyrics in my head. At the office at which I'm rotating, the bathroom has a sign that says "Please...Aim to Please." I see that and think "Please, at ease, now let me drop some more of dem keys" and start rapping "Gz and Hustlas" by Snoop Dogg. Not a good thing in a pediatric office. But a fun song.

4. The main reason I like songs like that is because lyrics are the last thing I listen to in songs. I listen to the drums first (of course, being a drummer), then the bass/guitar/other instrument hooks, and then the vocals and how they all flow and blend together. And then I try to isolate each part just to see if I can. And THEN I notice the content of the lyrics. That's why I can tell you all about the backing tracks and samples of my favorite rap songs, and nothing about their lyrics.

5. Changing up your Pandora stations can work wonders for your studying/busy work. I have been shuffling through 4 or 5 stations for the last six months or so. I switched them all out, replacing them with a few similar artists and a few very different ones. The renewed energy is beautiful.

6. The fact that Jenny McCarthy has been given a more public voice on The View is not a good thing, as too many people take that show seriously, and too many of them are mothers or grandmothers who will end up denying their children vaccines. I can only hope that the debate is smart enough to debunk the myths she insists on propagating (though it's a long shot).

7. That said, I can understand that Jenny McCarthy is very much a mother trying to find answers. I've realized that most parents, when something goes wrong with their children, will fight tooth and nail to get answers, fix their kids, and make sure it doesn't happen again. It's just unfortunate that Ms. McCarthy latched on to fake data created by a now-disgraced former physician who was trying to get famous.

8. I do not believe in playing Christmas carols before Thanksgiving (or Halloween). Give Thanksgiving its due - the holiday has a great message (idealistically, not historically). And the food is better than every other holiday out together.

9. That said, my two favorite Christmas carols are "What Child Is This?" and "O Holy Night." The second one became a favorite almost solely due to Richard Marx's version.

10. I think the only reason to go to Dunkin' Donuts is if you like their donuts or if you need your coffee a little weaker or with more artificial flavoring (before cream or sugar). Otherwise, Starbucks or Tim Hortons are better in nearly every way.

India: The Microcosm That Should Spawn A Revolution

(It should be noted that this post was inspired by the recent posts about the "Save Our Sisters" and their "Abused Goddesses" campaign, as well as comments by friends of mine.)
I've been to India several times with my family. I used to chuckle at my friends in elementary school who, when I told them I was going to India, would ask if I was going to sleep in a tent. If they had cars, or just rode on elephants and rickshaws. If they had toilet paper (admittedly, in some places that question was somewhat valid).

I would chuckle and talk about my grandparents' houses, and the cars (including the auto-rickshaws), and the fact that India was mostly in the twentieth century, even in the rural areas. My mother once told me that India's elementary school education was better than the one I was receiving in the United States - though I would later learn that she was exaggerating to challenge me to learn more and try to match my cousins halfway around the world. I still hear those words ringing in my ears when I think about my life in the U.S.

I take great pride in my Indian heritage, and it's something I strive to know more about (even though I haven't taken as much time to learn the language and customs as I maybe should). I have extremely fond memories of taking walks with my late grandfather there, traveling through jungles, turning my head to take in huge cities, and viewing the most beautiful temples and palaces. In my first long entry on this blog I discussed some of the funnier things in India and my interactions there, but that was pretty tongue-in-cheek.

While I am very proud of that Indian heritage, there are things about the country of India itself in which I am extremely disappointed. And they are summed up and brought into harsh light with this ad campaign:
http://www.buzzfeed.com/regajha/indias-incredibly-powerful-abused-goddesses-campaign-condemn

Normally Buzzfeed is associated with fun lists and lame information aggregations, but this is a particularly good use of the website. This campaign is beautifully designed, and I hope it reaches a great many people, especially in India. As stated in the article,

"The campaign simply and effectively captures India’s most dangerous contradiction: that of revering women in religion and mythology, while the nation remains incredibly unsafe for its women citizens."

Now, I know a lot of Indian people. I know there are good people there, I've seen them. But the bad apples make the reputation, and Indian news lately has been full of them. India tries to pride itself on the fact that it is coming into modern times and on par with the Western world. Unfortunately, even in the Western world some things have not changed the way they should. These news stories of women being abused, raped, tortured, and killed make me sick to my stomach. And it makes me sad for the people who don't know the beauty of India, because these perverse people obscure the good parts. And this doesn't just apply to India, either. These tragedies should hit close to home for all of us. Our so-called "modern Western civilization" is just as guilty of such horrors.

I remember being distracted from admiring the mighty Red Fort because my sisters were clinging to me as we walked through, because there were boys just standing to one side, leering at the girls. At least they were quiet, not making catcalls or grabbing their crotches. Just staring creepily. If I had thought anything I could have said would have made a difference, I would have (And again, I don't fool myself into thinking this only happens in India. As I progress through my medical training, I see this in hospitals far too frequently).

Unfortunately, it's a matter of culture, in so many places. It's the way of thinking, and it has been for generations of misguided men and women. The world over, far too often we see the gut reaction of, when a woman is raped or assaulted, the first questions asked are, "Why did she wear that? Why did she walk through there? Why was she asking for it?" Far too often, the right questions aren't asked: "What was her abuser thinking? Where is he and how can he be stopped from doing this again? How can we make this right?"
That is wrong. And it needs to change.

We can figure out why she wore that dress. It probably wasn't because she wanted every man to know she was "asking for it." For the most part, it was probably because she thought she looked nice in it, and felt like looking good that day. For herself. Not for anyone else. No one should think they have any right to her, or any claim over her. While there is a call for safe behavior that should be heeded, this kind of "ownership thinking" has to stop, not only in India, but everywhere, including the United States. It's disgusting, it's outdated, and while it's slowly becoming less common, it's not changing fast enough.

I don't want to speak in absolutes, and as a medical student and a scientist I don't like to use the words "always" or "never." I know that the sad things I've talked about in this post aren't always the story. But the fact that they happen at all is sad. I started this post as a rant about India and its outdated beliefs and unfortunate way of thinking...but I realized as I wrote it that this topic is globally relevant. It's a universal travesty. And, starting with you and me, it will take a global revolution to resolve it.

10 Opinions in a Row...or "A Quick Study Break"

I needed a break from my 10-hour study day. My good friend Aaron (on whose blog I guested about a month ago here) wrote a blog post based on Buffalo's WGR550's segment "10 Opinions in a Row" where they just talk about whatever they want. I stole the idea from him - things that are too short to blog about, but may be too long for a Tweet or not funny enough for one of my Facebook statuses. Anyway, here goes:

1. Not all tattoos are bad. The all-or-none attitude is limiting in all aspects of life, and no more so than here. There are some that are meaningful, at least to the person sporting them. If that's how a person wants to express themselves, or they feel so passionately about it that they want to display it on their body...that's not a bad thing. However, some of them do make my inner grammar nazi cringe: http://www.stumbleupon.com/su/A4x6sC/:5rh3x!2q:HYT_8-l3/tosh.comedycentral.com/blog/2013/04/30/10-tattoos-with-typos-to-make-you-feel-better-about-your-life/

2. As a recovering grammar nazi, I cringe when I see other people do it, because I've realized how truly annoying it looks and is (even though I'm still guilty of it). If it's something professional that needs correcting, then yes, it may need judging/correcting. Or if they ask for a grammar check. But if someone posts something on Facebook and your only response is to correct their grammar...that's not funny. It's annoying.

3. I think lipstick is the most unnecessary of all the makeup items. It can be done tastefully, I'm sure, but almost every time I see it on a girl I find myself wishing I was looking at her normal lips.

4. Studying sucks. That's all I have to say about that.

5. Watching British comedians is awesome. Partially because of their accents, and mostly because I love stand-up and some of the people I watch are hilarious. But it's also partially because they make jokes about things in the news and pop culture that I know nothing about and when I look those things up it's like "sweet, more useless knowledge for my trivia skills!"

6. I went through a phase where I had all but phased the word "like" (as a filler word) out of my vocabulary. That phase has since ended. I miss it, because I judge myself every time I use "like" as a filler.

7. Whenever I watch a video on YouTube, especially a music video, I always scroll down to the comments because I love seeing people say something super negative or bigoted and then everyone else coming back and bashing them for it. It's not something I'd partake in, but it's a guilty pleasure to look at.

8. Drummer thought: I could watch Stewart Copeland, Matt Cameron, and John Bonham play the same basic beat for 10 hours and still find it fascinating.

9. I've said this on Twitter, but the half-hawk hairstyle is not attractive. I don't know why it's so popular now. I will be really happy when it goes away.

10. I love it when celebrities, especially older ones, handle their own Twitter/Facebook, respond to people, and actually post funny Tweets or pics of themselves doing funny/awesome things. For example, go look at Sir Patrick Stewart's Twitter. He posts a lot of advocacy-related Tweets, especially related to child abuse awareness, but then he'll something like this:

pic.twitter.com/3HarOgEm2z
— Patrick Stewart (@SirPatStew) June 11, 2013

What a badass.

Just a Redirect to My Latest Post.

No real post here today because it's over at my good friend Aaron's blog. I wrote a post for his weekly Guest Blog Monday feature. Check it out here. And have a good day!

Just a Story About a Boat...and Some Sentimentality.

It’s sometimes interesting what you remember well and what becomes less vivid over time. In 2006 I went on a cruise with my family that took us around the Caribbean. I was 17 and not old enough to drink, gamble, or do any of those “adult” things. Being that age is tough on a cruise, because even though it had plenty of activities for kids, I wanted to do the “adult” things. At that time I didn’t even care about getting drunk – I just wanted to go sit with a beer in the bar and watch the bands play. I know – weird. But I had never seen so much music in one place before!

As for those activities for kids, they had a sort of “kids club” that we could go hang out at and that had daily games and stuff, but the problem with being 17 and on the upper end of that age range is that you had to accept the idea that the program had to be designed to accommodate both my age group and kids as young as 12 or 13, and as most people know, those 4-5 years make a huge difference. My younger sister, an innocent 14-year-old at the time, was also hanging out there and her presence always made the hair on the back of my neck stand up because I knew she was watching me just as much as I was watching her, though it was less protective and more aspirational (at the time).

I met an interesting group of people on that boat, and each would go on to make a lasting memory that still lives with me today.

Alcohol can make you creepy. My best friend on the boat was Eric. He and I hung out pretty much every day of the cruise. I don’t remember what we bonded over, but there was definitely an instant connection. One night I couldn't find him for a while, which wasn't a big deal – there was a lot going on that night. But while exploring later I found a group of teenagers drinking, and in the center of the group was Eric holding a bottle of vodka. He told me he had taken a swig and not felt anything, so he had chugged half the bottle. He was very drunk now, and was attempting to hit on some blonde who was clearly not having any of it. I had flirted with girls before, but I had never really witnessed someone (or myself) actively hitting on them. I wasn’t sure what to make of it, especially since the girl was not into what Eric was selling. I ended up having to walk Eric back to his room because he was too drunk to know where he was on the boat (first time babysitting a drunk person, but definitely not my last).

At one point we were exiting the elevator and I got held up by Drunken Duncan (I’ll come to him later) for a moment, only to realize that Eric had wandered off to a group of girls who we’d seen on the boat before – the kind of 12-year-olds who wear excess makeup to make themselves look older. Not realizing their age in his inebriated state, he tried his drunken charms on them before I could stop him, and when I came out of the elevator and saw them running away, I knew we were in trouble. I tried to steer him back to his room, but we were accosted in the hallway by the girls’ mother who was quite angry at my good friend. After explaining that I was taking care of him, and receiving another verbal warning from her, we kept going. After a ring-and-run incident where I ended up getting caught (though with no ramifications) because I lingered too long and the guy came out, we finally made it back to his room. We rehearsed what he would say to get past his parents and how he could avoid getting caught, and then I let him go.

The next day I found him after dinner and he told me he had almost made it, but then when he’d tried to urinate before going to bed, he’d ended up vomiting all over the bathroom. He was genuinely sorry for putting me through everything that had happened, but I was just glad he was okay.

Alcohol can also isolate you. Drunken Duncan was a man who I only saw a few times that week, but he always had alcohol in his hand. He was a vodka guy. The night I walked Eric back to his room, Duncan was in the elevator we rode in. Always stumbling. And always alone.

Nowadays when I drink, I always enjoy myself and I do hit on women (when I’m single). However, I’m always on the lookout for my own creepiness, always trying to gauge a woman’s responses, and I work hard to make sure that if she doesn’t look like she’s into it, I leave her alone. And I always remember that I don’t want to get so drunk so often that I become the drunken loner.

British accents are incredibly attractive. I met two British girls close to the end of the cruise. It was one of those random nights when I wandered the boat late at night and among other people my age, I discovered this pair. I think there was another guy there too, but I certainly wasn't paying attention to him. We talked about future education plans, music, adventures on the boat (theirs had been crazier than mine), and plenty of other stuff. That was the first time I’d realized that anyone besides me knew of the boy band Five. Obviously Five had a solid fan base back in the day, but I only knew their cover of “We Will Rock You” and their single “Slam Dunk (Da Funk)” from a Disney channel movie. And no one else I knew had heard of them until these two. I don’t remember the girls’ names, nor do I even remember what they look like…all I remember is the sound of their voices and being overwhelmed at my first dose of mysterious foreigner passion. I still think of them every time I watch Kate Beckinsale or Keira Knightley.

If you’re dancing on a girl and your sister sees you, you’re gonna have a bad time. No real explanation here…it was just awkward locking eyes with my sister across the room when I was grinding on a girl at a dance party.

Girl drummers are hot. ‘Nuff said. I still wish I’d listened to my parents and auditioned for the cruise’s customer talent show so I could’ve shown her (the ship’s house band drummer) my chops.

If you ask me where any of these people are today...I couldn't tell you. Eric and I were friends on MySpace for a time, but I got rid of that account years ago, and thus eliminated my one connection to any of these people. So why did I tell this story? I think whenever I come to a point in my life where I have to leave people behind or separate myself from friends, I think of this adventure. Because even though I never talk to those people anymore, it's been 7 years and I haven't forgotten them. And I was only with them for a week.
To all the people with whom I went through undergrad who have graduated and moved on, and especially now to my friends in medical school who are all currently going underground, just as I am, to study hard for our USMLE Step 1 exam and then off on separate roads through third- and fourth-year rotations...I won't forget you. Even if we don't talk for a while...I look forward to whenever you come back into my life, because you've definitely got a place in my head. Even if it's just a drunken babysitting night, an awkward moment, or a fun accent. Cue the Phil Collins.

Medicine Waxes Poetic (Yeah, Like That Never Happens To Me)

     Well, it's been a really long time since my last post, but this past school-year was pretty insane, so I guess I have an excuse. Friday was the official last day of classes of my second year of medical school. Which means now it's just a steady push to taking the USMLE Step 1 exam and reaching what has been the light at the end of our current academic tunnel - third year. Actually rotating on the hospital floors.
     It can't come fast enough, because sitting for hours in our dungeon classroom was starting to wear down our last nerve. But as I've posted here before, there are always bright moments, the ones that remind us why we med students put ourselves through this.
     Geriatrics (the practice of medicine as it relates to elderly people and their health) was not anyone's favorite course, and making the trip to a nursing home to meet with our patient once every couple of weeks could sometimes be seen as an inconvenience.
     Still, as the course finished, and we were required to reflect on our experience, some of us realized that we had definitely learned something or at least found something to shape our learning as doctors. (Of course, there were always a few patients who were temperamental, uncooperative, or who attempted to seduce the young medical students assigned to them...).
     Anyway, my partner and alphabet-buddy (our names are side-by-side on the class roster) Kellie thought we could best reflect on our patient in the form of prose poetry. It's no Whitman or Wilde or Kafka, but it definitely conveys the lessons we learned from a rather interesting elderly woman.

EM. A Reflection.

Ironic.

That was what our experience with EM was.

"Hi EM. We are medical students from UB, do you mind if we ask you some questions today?"

"Sure, I've got nothing else to do. Have you been here before? You look familiar".

"Yes, we've been coming every other week for a few months."

Ironic that we gained so much from getting to interact with the same patient for the whole semester when she struggled to remember who we were.

Ironic that we learned so much about her and her life and her personality, yet she could only remember our faces.

Ironic that our experience with her defined so many aspects of medicine that had before been abstractions.

Perseveration, dementia, activities of daily living - intangible before EM exemplified them.

Ironic that by now we may only be abstractions and faint memories to her.

Repetition.

"Now we are going to ask you about your level of independence, do you need assistance dressing yourself?"

"No. How old am I again?"

"You're ninety-one."

"Ninety-one! Oh, I don't believe you! I guess I am doing pretty well for my age"

"Yes you are. How about cooking, do you need cook for yourself?"

"No, they take care of all of my meals here."

"Good. Do you need assistance using the telephone?"

“No, but I have three sons and I call them every week.”

“That’s great!”

“How old am I?”

“You’re ninety-one”

“Really? Wow!”

EM has dementia and repeats herself often.

EM showed us that in medicine it’s important to practice repetition.

The same steps should be followed and the same questions should be asked, no matter what the situation is and who your patient is.

Misleading.

“EM, compared to other people your age, overall do feel like you are better or worse off than them?”

“I think I am doing pretty well for myself. I am pretty healthy. How old am I?”

“You’re ninety-one.”

“Really? I don’t believe you! I’m doing pretty well then aren’t I?”

“Yes you are. Do you feel like you have trouble with your memory?”

“Well, I am getting older, and everyone has trouble with their memory when they get older and I guess I am no different.”

“Ok, now we are just going to ask you a few questions to assess your mental status. Can you tell me today’s date?”

“No. Living in a place like this, you don’t need to know the date. Everyday is the same.”

A person with dementia can be very misleading.

The information EM gave us wasn’t always correct.

If what the patient is saying doesn’t seem right, you have to go look for the truth.

Familiarity.

“I am going to name three objects, can you repeat them back to me? Apple, penny, table.”

“Apple, penny, table.”

“Good, now remember those, because I will ask you them again. Can you spell the word world backwards for me?”

“D-L-R-O-W”

“Great, now can you tell me those three objects I had you remember?”

“No, but they weren’t really that important for me to remember, were they?”

“Well, no, I guess not. That’s ok.”

“How old am I?”

Familiarity allows you to learn so much more about a patient than their health.

Familiarity helps you realize that your patient is trying to cover up their disabilities with their personality.

Familiarity can mean expressing amusement at a patient’s joke.

Or the realization that the patient can’t confront their own illness.

Familiarity is knowing when EM’s illness is talking for her, and when she genuinely means what she says.

Gratitude.

“Well EM, this is our last time meeting with you. Thank you for spending the time to meet with us this semester.”

“Of course, I like helping young people learn. Did I tell you that I have three sons?”

It’s people like EM that are the real teachers in medicine.

The ones that make us realize that patients are more than just their conditions. More than just symptoms. More than just a diagnosis to be reached.

Symptoms and diagnoses can’t express approval or accept gratitude. But EM did, every time.

Fuel.

This experience has further fueled our excitement for our future careers and for the relationships we will build with our patients.

The irony of learning medicine, the repetition of our day-to-day, the search for what a patient actually means, the familiarity to find it.

All of these and more EM taught us, and fueled our desire to learn and do our best.

“You’ll both be great doctors some day.”

And she meant it.