Primary Endpoints

Apparently one week is the time limit before I start getting sarcastic feedback on a pause in blog-posting, so to appease the likes of CW (and to kill some time on a Friday night before going to bed), I'll try to make up for lost time and provide a quick overview of the last week.

In reverse order:

FRIDAY

Today marked the end of my 6-week Primary Care Clerkship which consisted of 6 weeks of working in different clinical settings. In theory, I was supposed to be learning the foundations of family medicine, but in reality things turned out a little different. My most valuable experiences turned out to be in emergent/urgent care settings and an ENT's office. Unfortunately, the time once a week that I spent in the residents' internal medicine clinic at the Mothership turned out to be a complete bust x 6 weeks. During those afternoons, I worked diligently perfecting the art of being polite and interested-looking while sitting in a corner of the exam room as the resident interviewed patients. Fortunately, I had other experiences to fill the learning-void. One of the most valuable was working in the urgent care clinic of The Center. Some highlights:

• Diagnosing a woman with superior vena cava syndrome. A very, very, very sad case, but interesting from an academic point of view.
• Working up a man with the chief complaint of "I want to go left". This guy had a very strange sensation of wanting to go left. He could walk straight if he focused, but if he was in autopilot mode, as most of us are a lot of the time walking from one place to another, he found himself frequently making non-sensical left turns, e.g. down the wrong hall, into doorways, etc. He was completely neurologically intact, although his wife had noticed what sounded to be like complex partial seizures or periods of profound inattention (more so than most wives get from their husbands). When I asked him to write a sentence for me as part of a mental status test, he wrote "I am scarid[sic]". Right frontal brain tumor. Nice guy with a wife and 3 kids.
• Bowel obstruction, bowel obstruction, and bowel obstruction.
• Trying to find a cause for a woman's hyperkalemia. CT scan -> adrenal met. Possibly adrenal insufficiency? Interesting to think about...
• Realizing that I've learned a thing or two during my third year of medical school and rediscovering the enjoyment of treating patients.

The other useful clinical experience was working in an ENT's office on Thursday afternoon. I think ENT is my #1 backup if Rad Onc doesn't work out. A couple of pearls I learned:

1. Childhood screening audiograms are not as low-yield as some people may argue. I saw one patient with profound sensorineural hearing loss who was a brilliant, articulate man (although with a speech impediment secondary to being almost completely deaf without hearing aids) who is now working as an executive for a non-profit, but was thought to be mentally retarded until the age of 8. When his home town ENT discovered the hearing deficit that was missed my teams of Johns Hopkins physicians, he promptly took the boy's medical record documenting his "retardation" and physically tore it in half in front of him.
2. An acute otitis media in an adult is NOT normal. Requires further workup to rule out the presence of a predisposing anatomical or functional defect.
   
3. It is possible for a nasty, white plaque on the larynx of a smoker to come back benign.
4. A very smart and talented ENT refuses to use nasal decongestants. Saline sprays only for rhinosinusitis.
5. Acute, persistent hearing loss is an emergency as it may represent a condition that may be alleviated or limited in some way by corticosteroids.

Anyway, getting back to today: took my primary care exam, met with my advisor, talked with Dr. K about a letter of recommendation (she asked me if I was an "outstanding" student, referring to the "code words" used in Deans Letters; wasn't quite sure how to respond to that one), and had a very productive meeting with the statistician I'm working with on the liver IGRT project--a very bright, thoughtful, and professional fellow. Sitting in his office talking about endpoints and probabilities and teaching each other stuff captured what I think is great about academics: mutual teaching and understanding. Like I said, a very edifying and productive discussion. Afterwards, I had to work on dosimetry data for this patient whose treatment planning data existed on an old tape drive that was was buried in one of the medical physicists offices. Fortunately for us, we got the data off. The tape that was put in after was devoured in a most savage manner by this relic of information storage. After spending two hours piddling around on an agonizingly sluggish Unix machine, it was off to SB's for a celebratory dinner in honor of CW leaving her job for a much better-paying one. Unfortunately, a windowed office had been replaced with a cubicle. The Hawaiian chicken was superb.

THE REST OF THE WEEK I'm getting tired of writing and you (and I) have better things to do, so again in outline form:

Thursday Slept in. (Whoops! Was I supposed to be in the Ob/Gyn clinic? I prefer to spend my mornings doing something where I'm not actively ignored. Sleep works, too.) ENT office. Studied.

Wednesday Urgent Care at The Center. Dr. Bos was very complimentary as I left, which always helps with the ol' confidence levels.

Tuesday
Please don't laugh: Today I shared a poem as part of my geriatrics assignment. We were supposed to come up with a "creative response" to a geriatrics home visit, and I took this challenge personally, as Dr. D had joked that if you were a math nerd, you could just read a poem someone else wrote. Here it is for your enjoyment (or potential blackmail material):

Chocolate cake
At ninety-eight
Seems to provide its share of grace
When eaten every day
After your morning tea.

Who would have thought
A bejeweled pill box
With who-knows-what pills inside
Serves instead to remind
Of a daily dose of Ghirardelli’s
Open next-to at your bedside.

Perhaps that’s what quickens the mind.
A 30/30 mini-mental status exam finds:
Penny, Pink, Apple—
“Why that’s what they used to call me!” you say.
Apple.
And your blouse is an apple-green.

“Where is the school
To learn such careful script” I think
As you write out a sentence
Quote
This is an interesting test
Unquote.
A vanishing line of
Of poise and propriety
And conscientious serifs
On the numbers of your clockface.

Sitting on the couch
Eyes bright and broken ears
Earnest to grab a piece of the conversation
And add some genteel wit.

Will you go back to bed when we leave?
To lie on your side
Like the child we saw
When we walked in the room?
Waiting for nothing, watching.
Or maybe just thinking about the next party.

Well, it’s time to go.
And I agree:
It will be fun to make it to one-hundred.

Tuesday night - This month's best spending of money that I don't have: a Counting Crows concert at the Town Hall. It was a great performance of the August and Everything After Album along with several songs from the upcoming Saturday Nights and Sunday Mornings album. I was struck by the uncanny resemblance of the lead singer, Adam Duritz, and a certain drollish groundskeeper:

I'm set for a new personal best of concert-attending this year after The Police and Guster.

Monday - I'm sure I did something. Oh yes. I volunteered at the Cornell Free Community Clinic and had a patient syncopize during the physical exam. Anxious guy + really deep breaths on the lung exam + possible seizure history + "I feel sick--something's happening" = don't leave a 2nd year medical student alone in the room while you run to get something for the patient to throw up in.

Sunday - Church, etc. Saw Brother R leaving the meeting before us. It reminded me of the time I met him in the 66th and Columbus building while I was working there. Without recognizing him initially, I asked him and his wife to help as volunteers. They of course said Yes and only had to be prompted a few times.

Saturday - My last Roosevelt Island multi-stake social. In fact quite possibly my last church dance-type activity. I've come to the conclusion that such events are actually probably very low-yield for "meeting that special someone" and that I prefer visiting with friends and getting to know people under other circumstances. This opinion probably has some relation to my Level Zero dancing skills and everyone's high distractibility factor when the theme is to "see and be seen". Plusses of the activity:
1. Getting to visit with some folks I hadn't seen in a while, including DH, a fellow Ram now living in Philly.
2. Running along the East River back to the tram to catch up to the UES folks on their way to grab a bite to eat. Despite my prior hunger pains (the food at the dance was gone upon our arrival), I felt like Flash Gordon: the speed, cool night air, and the city skyline at night shifting with my changing perspective as I ran were great relief. Maybe we should have stake running activities.
3. Finally getting some food at a diner on 63rd.

Well, that's all for now folks.

Great quotes from the last couple of days...

"The urinary system is God's greatest mistake." - lecture on geriatric medicine.

"I didn't call them sweats or sweatpants, just 'pants'... That's because they were the only pants I had." - Elder S.

"My kindergarten teacher thought I had ADD. And she was right." - Elder C.

"The other possibility is to renormalize. Did she renormalize from the Alpha?" - one medical physicist to another

Do's and Don'ts

HOW TO...

1. Lose the respect of your fellow physicians: Use a patient's permanent medical record to joke about the innuendo-laden flirtations that you and the patient regularly exchange.

2. Get poor medical care: Tell otherwise diligent doctors how to do their job and insist on VIP treatment.

3. Reclaim your humanity at the end of a long and stressful day in the ER: Take a few extra moments to make sure a patient can call her kids to let them know she's okay. Kudos to Dr. Bos.

4. Know if someone's sick or just crazy: I wish I knew.

The Weekend After Labor-Day Weekend

Unfortunately, no cool pictures from this weekend, but here's an amusing one from the files. It looks like this rather interesting driver sacked an animal from one of Dr. Seuss' books and is carrying it off to a Rastafarian BBQ (location- Central Park rollerskating contest):
EVENTS SINCE LAST POST:
1. Gave a tour of the hospital to the new first year medical students. It's amazing how bored I can get after hearing myself talking for what seemed like three hours straight. (I found myself feeling kind of guilty about using the same jokes and "off the cuff" comments with the different groups.) During the first tour, I was leading the herd into an elevator to go to the ICU floor and lo and behold, there in the elevator car was Sorens in his long white coat and scrubs. Sorens is one of my best friends from growing up in SLC and now he's doing his surgery internship at the Mothership. We chatted for a bit, but he was in a hurry off to do important Real Doctor stuff for the Alex Cooper bariatrics team. I'm not sure if he understood my hidden message in our conversation: "Help me! My medical education has been reduced to this!" Seriously, I don't mind things like giving tours every once in a while, but usually I volunteer for them, rather than being assigned to it as part of a Primary Care Clerkship (I had to miss working at the ENT office in the afternoon, one of my few learning opportunities during the week). Best question asked by a member of the tour group:

Cute girl: Thanks for pointing out the outpatient pediatric clinic so professionally. By the way, my name is ___. Why don't we get together sometime?

Well, that might not be exactly how it happened.

2. Sick on Friday. Staying up until 4 AM working on my Primary Care Paper probably didn't help. Got to review some interesting data (endarterectomy indications, carotid stenting, cardiovascular event prevention with statins, osteoporosis therapy, and many more!), but the timing could have been better.

3. Driving range at Chelsea Piers on Saturday. My 5 and 7 iron were doing awesome, but women and children who saw me hit with my driver ran away into the streets in tears.

4. Sunday. Church was good. I'm in a great ward with some great folks. On my way back afterwards, for some reason I spent a lot of time thinking about probability spaces and somehow that developed into thinking about the importance of books in transmitting not only knowledge but ways of thinking. Afterwards, an impromtu dinner with friends in which SB made a noble effort to introduce several of the group to the virtues of yams. Later on, I discovered that the word "Gnomes" is not in my cell phone's dictionary for texting.

One more picture from the files:
The top of Wrong Mountain Peak from Catskills Trip v1.0. It was a great view anyway.

This just in...

A revelation from the scientific community! Granted, I think a study based on speed-dating is bound to show some superificiality bias.

Labor Day

The weekend started with a run in Central Park on Saturday followed by the US Open that evening with MO who was visiting from SLC. She had an extra ticket from a match that got rained out two years ago and was thoughtful enough to invite me along. It didn't take long to get contentious: we had a bit of a bet going on regarding the Peer vs. Vaidisova match, which I lost (I cheered for Vaidisova, using exceptionally loud clapping). MO enjoyed her victor's spoils and I had to endure the losers Walk of Shame to the snack bar to get hot dogs before the Blake match started.

The next day began with playing hookie from my ward and going to sacrament meeting in the Union Square building since I needed to catch a train up to Meadow Farm in Duchess County. I got a few strange looks in the chapel carrying two bags with a tennis racket sticking out of one, but I gave them no heed and quickly slipped out afterwards to catch an Amtrak train north to Rhinecliff. The ride up was beautiful:

Unfortunately, there was no one with whom such a great train ride was shared. Alas,...
Upon arrival, I had to pass by the Beast:

There was also much excitement about the alcohol-powered stove that WD made out of Diet Coke cans. No picture here, folks, but I can assure you that I saw it with my own eyes and foolishly waved through its flame my own fingers.

After reading, working on crossword puzzles, and some Frisbee, a roaring campfire was made. I found myself contemplating the meaning of life and whether or not my leg hair would spontaneously burst into flame from sitting too close:
I was the Firestarter, JB (watched by his wife, LB) was the Keeper of the Flame:
PS was also a co-fireperson, but this was overshadowed by his role as right-hand man to WD (also pictured: LM, me, and RM singing our hearts out):


Cooking hot dogs and marshmallows-
After letting the fire die down, we walked out into a nearby meadow to enjoy the night sky. The Big Dipper hung low just beneath the horizon and the Milky Way was bright enough that you could make out the dark band that runs through the middle of it. The stars and the night sky are among the most humbling things to watch (right next to babies). I found myself thinking how strange it would have been to have lived eons ago and spent every night looking up at the stars and to die without ever knowing what they were and what was up there.

The next morning found me sleeping in on the floor of the pool house where I'd spent the night as the rest of the beds and couches were full. I slept surprisingly well. I could have woken up earlier when little JS and RS came pounding on the windows, but I was able to feign sleep long enough for them to become distracted. I knew I was really just delaying my promised Pokemon card game with them, but it bought me a few extra hours of precious sleep in a nice and quiet room lit with sunlight coming off the pool.

Waking up, I decided to go for a run (LM had already gone without me). Having gone west during my last visit, I chose to explore the roads to the east. Feeling an obligation to provide some documentation of my journey for my blog, I took my camera with me. Surprisingly, I found that I was actually much more energetic as I occupied my mind with thoughts of interesting pictures and witty observational comments. Such opportunities were not a few:

An honor system vegetable stand with vegetables and money jar still in-place:

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Interesting. Nothing is left under the "Free" sign in front of someone's house -

I didn't notice this hill when I was running down it. Going back was a different story:
One of the more polite signs warning you that you weren't welcome, although I took this picture mostly to capture an image of the beautiful scenery that surrounded me wherever I turned:Not pictured: wild turkeys, rumored long-haired cows, way too much roadside trash, and a nice old lady in front of a barn who said Hello.

Well, I'm actually boring myself typing this and need to get to work on some things. Highlights of the remainder of the trip:
1. I finally learned how to dive.
2. No one was seriously sunburned.
3. A delicious steak dinner was served with corn on the cob, pineapple-flavored coleslaw, and cobbler (for dessert).

After getting back to the city, LM headed back to D.C., RM had to work that night, and PS, WD, and myself did whatsoever we would with our time before closing the book on a great weekend.