Life under the quill

Student loans. You love them, you hate them. Reagan made them taxable. Bush cut pack on Pell Grants. Now, private banks jockey for every student as baldly as those credit card companies that hand out free T-shirts to freshman on Orientation day. Well, Obama and Congress are attempting to make Federal loans FEDERAL loans. What, they're not, you say? No, right now students are required to have their federal loans serviced by a private lender who will skim off some interest and then sell it back to the government within a year for a profit.

This is the dashed off letter I wrote to my congressmen. Most of y'all are out there in the working world, but if you still have student loans hanging over your heads, think about writing your congress people. I could have written it better I suppose but I felt getting it sent was more important than perfection. If you can improve on it, please do.

And with that, good night!

I recently heard about the bill currently under debate to eliminate private lenders from the federal student loans system. I have to say that I completely endorse this change. Please support this bill.

Last year I left the workforce to attend medical school. Since I am supporting myself, all of my tuition and living expenses come out of loans. I spent hours sifting through seemingly identical loan packages from various banks only to then wonder all year whether my choice would still be in business by the end of my studies. At the end of the year I received a letter saying they resold the loan to the US Dept of Education.

As a student, I would MUCH prefer to deal directly with the government and not undergo the uncertainties of private banking, which seems to only be in place to earn a year's worth of interest at the expense of myself and the government. This system needs to end and it can end now with your support.

The weather is glorious, I'm caffeinated, and I'm in a cafe with my love, so what could possibly be wrong?

Well, in reality nothing much. Life is on a strong upward trend. However, this trend involved moving A's stuff, driving 11 hours and moving my stuff all over four days, soon to be followed by picking up A's stuff and collecting furniture from all over the greater Cleveland area off Craigslist. The cats are freaked the heck out. Their tails are shaking and K is hiding under the bed in distress. B is appeased with the comfort of a soft new rug that he can roll around and shed upon, but the house is in a state of disarray. I've slept in a different bed each of the last three nights and not gotten good sleep in any of them. And we just realized that in the last several days of moving we haven't done a thing about the wedding, we're spending money like water, and the new place won't have internet until tomorrow. Gah! 48 hours without internet! How can we survive!!!

So yeah, life is not so bad, it's just kind of a giant kludge of stress. However, we continue to love our new place, I have wonderful friends who hauled all my furniture up two flights of stairs, and above all, I am with my love! Just a few more days of hauling furniture and cleaning out the old place and I can "relax".

Better buy that couch soon. Relaxing on a wooden chair is just not quite the same.

Believe it or not, I'd never actually read Fahrenheit 451 until this year. I finally picked it up on hearing that Ray Bradbury was still alive and kicking. Though I am very familiar with his short stories, this was the first novel of his I've read.

This is a book which has perhaps evolved in meaning over time. When it was published, the image of Hitler's book burnings was still recent memory. Even so, Bradbury apparently said this book was not about censorship, but rather about "how television destroys interest in reading literature, which leads to a perception of knowledge as being composed of 'factoids', partial information devoid of context". In that sense it has become even more relevant than in the past. The main character's wife is completely absorbed with entertainment. She spends all her time in the living room interacting with her fictional (online) friends and constantly has a Seashell (iPod) plugged in her ear. She has essentially stopped up all of her senses with artificial inputs -- and this seems all too accurate a depiction of today's world.

This book also seemed relevant to the current demise of the newspapers. Fahrenheit 451 mentions this and how people hardly even noticed when they were gone. We are now in an age when news has become "infotainment", i.e. just whatever the audience wants to hear, or rather, whatever will keep them hooked longest. It's not intended to pacify as Fahrenheit 451 suggests, but rather to create a harmless focus of people's attention. Let's all talk about Brad and Angelina or Kate and Octo-mom instead of politics and ideas. My first real understanding of this trend was back in 2003 when I realized CNN had a design team for the second Gulf War, complete with a theme song and banner. It had once been a news organization -- now it was entertainment. The internet is hailed as the new alternative. However, while the internet can be a unifying force, it appears to more often be a Balkanizing one. People no long listen to "objective" news but find Rush Limbaugh or Air America, O'brien or Olbermann, or whatever pleases their sensibilities. No one need ever be challenged. There's pap for everyone. If you don't like what someone is saying, just flip the channel.

The world hasn't yet become the world of Fahrenheit 451. More books are being published than ever before. However, I do think that the dangers of passivity still exist. We can choose to live in a world of our own construction. What will that mean for the rest of us?

Today was my first meeting on the Board of my alma mater's Alumni Association. On the plus side, I knew two of the three other newbies. They overlapped with me at Tech to varying degrees. The rocket engineer is going to fashion school to design a comfortable bra for well-endowed women -- finally, an engineer solving what is essentially an engineering problem! -- and the other is recently engaged so we had much to talk about. The third newbie, well, he won an Oscar two years ago for technical effects.

It's always a strange experience at Tech. I feel very much at home there, the culture is wonderful, but it is also incredibly humbling. Some make the most out of their humility, such as the woman to my left at dinner, fellow alumna Sandra Tsing Loh. Others are simply brilliant, designing the Mars lander or winning a Nobel Prize and getting appointed as Secretary of Energy. Invariably you hear about the successes. It only takes one or two a year to make you suddenly ask what you have done with your life.

Is it a lack of ambition? Is it a lack of direction? A lack of imagination, for as Einstein once said "Imagination is more important than knowledge"? On the other hand, times like these are when I get inspired again. It is a little humbling, but the inspiration outweighs that. How do you create the one and not the other? I think it's respect. Every person in that room went through the same four years, whether they are now a stay at home mom or the most recent Nobel Prize winner. Smarts aren't the issue here. And thus it is that I come home thinking not "I am not worthy" but "how can I use the gifts of education I have been given?" Simply passing does not interest me. Surviving med school is too low a bar. How can I make the most of where I am today?

The New York Times just released the full text of Obama's address in Cairo. It's a fascinating piece, partly because a similar address would not play well in America. The Obama campaign had to hush any mention of his muslim relatives and remove women wearing the hijab from photos during the election. Now that he's standing in a muslim-majority country, he's free to use his middle name to his advantage.

I am always grateful when Jon Stewart points out the similarities between the rhetoric in Bush's and Obama's speeches. It's useful to remember that not all things are diametrically opposed and that some positions, especially regarding foreign relations, remain the same. However, I cannot help but feel that this speech really is different, and not just different in my memory. I clearly remember Bush making an aside during a State of the Union address and speaking to the Iranian people. To paraphrase, he basically said "We know you're really a peaceful nation, so would you please rise up and overthrow your government?" In contrast, we now have our Leader giving a major speech in a foreign capital with so many elements that would never be in Bush's speech:

A greeting and thank you in Arabic

An introduction explicitly acknowledging the errors of colonialism and Cold War politicking

Multiple quotes from the Koran

Support of religious freedom including the right to wear the hijab and donate to Muslim charitable organizations

A statement that we do not presume to tell a country which form of government it is allowed to have

A promise to expand scholarships and exchange programs to promote exchange between muslim countries and the U.S. in both directions.

Of course I'm picking and choosing here a little. A republican would find it far too conciliatory and a muslim extremist would bristle at the suggestion girls need to be educated. But I like the line that Obama is walking here. I continue to be proud of the direction we're taking, and I hope that four years (at least!) of actual diplomacy will help heal some of the rifts of our world.

I'm beginning my new job this summer, working on preclinical medical curriculum, and as part of our process we are being exposed to a whole set of educational tropes, ones I've never seen before. The directors of the program helped design my school's new curriculum three years ago and are both MDs and MEds. Now some of the articles seem like a formal formulation of the abundantly obvious -- well, most of them really -- but occasionally one of them makes me stop and think.

( Rambling on Learner-Centered Teaching )

I know a couple of you out there are actually in education. Any references you found particularly good?

Wouldn't you know, the first book I pick up after finals are over is about 12 generations of doctors! It's fictional of course, and indeed it's brand new fiction, so I was taking a gamble. Sadly, this gamble wasn't really up to snuff.

The book is a series of short stories, each a vignette about a different doctor in the family. It purports to be a mini-history of medicine highlighting the weird. There's trepanation and lobotomies and mesmerism. If you like freak shows and Ye Olde Oddity Shoppes, then this might be the one for you. It's an interesting concept for a short story collection, but it just doesn't quite work. The family isn't really a family of doctors, it's a family of charlatans, fools, and madmen. It's clear the author has the barest interest in historical accuracy. She puts a major event for that time period in each story, framing it like Forrest Gump, then cobbles together a character or two to subject to some outdated medical procedure. The book dwells in the grotesque for the pure pleasure of it. With similar sloppiness, the dates for the family tree at the front of the book do not match up to the storyline with characters listed as dead in the same year when the story explicitly describes them as dying years apart. It's a small thing, but it occurred multiple times, and is the kind of detail I'd like an author to work out before the story even gets to the publisher.

Perhaps I'm too much of a fan of medical history. I found this book to be an attempt at titillation for those uninitiated in the past, but for me it was pretty shallow. It was a quick read and certainly better than some out there, but I wouldn't really recommend it.

This review is about a month old now, but med school ate my life in May so only now am I getting to it. I was spurred on to finally read Dr. Jekyll and Hyde about the time I saw a lecture on possible inspirations for the novel, and had my Jekyll and Hyde sort of day.

I somehow missed reading this in high school. My English teacher was a wonderful man who had us reading Hesse and Par Lagerkvist instead of Austen and Stevenson, assured that we would catch up later on those more famous authors. It's taken me a little time, but I finally picked up this collection of Stevensons stories. Jekyll and Hyde is quite simply brilliant. I'm going to disregard the editor who wrote an annoying introduction trying to frame the whole story as a front for homosexuality, when the metaphor would so much more easily be filled by drug-taking behavior, or even more simply by moral quandary. It's so much better a story as a philosophical piece. The last chapter, written as a statement by Dr Jekyll, shows his fear at his loss of control but also shows the appeal of the enterprise in the first place. Is our morality bound by true virtue or simply the desire not to get caught? If one could exercise one's vices in freedom, would you? And more importantly, what does the exercise of one's vices do to one's innermost character? I've always felt that habit is a key element of our morality. You don't shoplift or steal from work because the habit of bending your own morality makes it more pliant and flexible for the next time, just as bending a piece of metal gradually weakens the joint until it breaks. A habit of virtue creates character just as a habit of dissolution leads inexorably to ruin. Habits are difficult but not impossible to alter, and in this case Jekyll took the wrong road.

I don't mean to imply that this is a morality play. It's much more a psychological drama. I wish that I had been able to read it for the first time as it was read then. It was the Psycho or Sixth Sense of its time. But the wonder of it is that even knowing its secrets, it's still a fascinating novelette. Stevenson, what a wonderful author you are!

I didn't want to jinx it, but now that it's over I can officially say I'm done with finals! The exams were long but fair. Our main exam was a five hour long problem set with essay questions. I'm usually pretty fast, but this time it took me 4.5 hours and some of my classmates didn't even finish. Today we had our practice board exam. Each block they test you on material covered in that block and all the previous blocks, so it gets longer and longer -- 152 questions on everything from embryologic lung development to end stage renal disease.

But now? Now I am done. Since today's exam is really just for practice, the celebration began yesterday. We all went out for burgers at the local joint. I started reading a book from the library, just a regular fiction book. I took a nap on the couch. It was lovely! (Amazing what our standards for joy are these days!)

And it's hard to believe, but I'm now done with my first year of medical school. I've been in school for ten months, gotten engaged, and am preparing to move into my first apartment. It's not my first, of course, but it's the first I'll have a hand in decorating. When I started this journey I knew I'd enjoy the learning part, but I thought I might have to give up my "life". Turns out everything is coming up roses.

Recently I mentioned among friends that I'd never been to a shooting range. Lo and behold, one stepped up and said there was a range just 20 min drive away and he'd happily take me. "Great", I said, "let's go after finals." "You might enjoy going before finals, for the stress." And so it was, that two days before my first final, I found myself holding a 22 caliber Beretta and aiming at a poor innocent cardboard target.

Why? I suppose it's something I have become curious about in the last few years. I'd never want to own a gun, but knowing how to shoot one seems like one of those skills one should have before the impending zombie apocalypse or the rollover of the Mayan calendar. Besides, I'd have a greater appreciation for all those action movies I so enjoy.

Things I learned:

A clip is a pez dispenser for ammunition

You really do pull back and cock a pistol

Those things are damn loud even WITH ear protection

John Woo's flying shells are far more realistic than the tidy gun battles of TV crime shows.

I didn't try shooting far, but I can certainly shoot straight at "self-defense distance". That poor cardboard cutout didn't stand a chance. When D dropped me off at my house again, he said "I have something for you" and handed me the shell casing of my very first shot. I may or may not ever go again, but it was certainly memorable.

...and now we return to our regular programming of researching interfaith ketubot and pulmonary histopathology.

We're learning "pharmacology at the extremes of life" -- that's babies and elderly for the uninitiated. Turns out you want to be aware not just of dose per kg body weight, but the ratio of surface area to body mass. Babies? They have one quarter the ratio of area to body weight compared to an adult. Now I want to go back to that old trope "assume a spherical baby!"

This week was Clinical Immersion week, that week they take out of each block when we put on our white coats and enter the hospitals for some direct application of our knowledge. This week was better than previous ones. We had excellent teachers and a lot of the material gets to the heart of chronic disease. We discussed EKGs and ECHO (heart ultrasound) and pulmonary tests. We went into the ICU, talked about MRSA infections, and listened to lung sounds. We spoke with patients coming in for heart failure, dialysis, aortic stenosis subsequent to bypass surgery, diabetes, liver transplant. It was an all inclusive cardiopulmonary extravaganza!

( Moments from the week )

This week has given me a lot of faces to put to conditions, a lot of direct understanding of the theory we've been reading about. Oh, we rarely learn much new material in our few hours here and there, but it is incredibly useful for retention and understanding. I'll be glad I have the summer "off" but I'm actually gonna miss the hospital. Who'da thunk?

Swine flu. It's getting everyone in a tizzy. The WHO raised the threat level to 5 and yet it's not even a cover story on the CDC website.

So, in answer to the recent questions I've gotten about swine flu, here are a few numbers...

Given the reported cases so far in the US (and probably lots more people have gotten sick but not gone to the doctor about it), the mortality rate is 0.3% or really pretty low. Just for a comparison, I thought I'd take a look at West Nile, the outmodish plague that is "so 2005". Now, no one cares about West Nile anymore. It's not called "flu" and thus it doesn't roll off the tongue right after "pandemic". But last year we had nearly 1400 cases of West Nile with a 3% mortality rate.

So folks, don't worry about the flu. Go ahead and cover your mouth when you sneeze and wash your hands. But be sure you put on some bug repellant too.

I reserve the right to retract this statement if trends go wildly different from where they are now, but personally I'm not too worried about transmission until we get back into flu season.

The weather outside is alternating between spring showers and bright sunshine, so it's very hard for me to get the appropriate sense of impending doom that comes with finals. In two weeks I will begin my finals week, covering all material related to heart, lungs, and kidneys. And let me tell you, they are intimately interconnected. Your heart and lungs manage the body's internal combustion system and exhaust delivery service. Your heart and kidneys manage blood pressure. Your lungs and kidneys manage acid/base balance so that you don't go all alien and have acid flowing through your veins. It all works together like clockwork ... mostly -- that is, if clockwork were plumbing and occasionally needed a roto-rooter.

I know I should feel impending doom, but mostly I'm enjoying it. For an engineer, the lungs and heart are pretty simple. They are pumps. The end. OKay, they're a little more complicated than that, but with a little basic thermodynamics and some E&M thrown in, you can pretty much figure out the whole thing, and the important stuff is visible with a light microscope. The kidneys are another matter. They are incredibly complex, and some of the important pathophysiology can only be identified with an electron microscope. Nephrology appears to have been designed by a tribe of gnomes who enjoy labyrinthine interconnected mechanisms and clinical disorders that constantly overlap. All of the signposts have multisyllabic names like Crescentic-and-necrotizing-glomerulonephritis or names which are virtually identical but signify completely different but overlapping syndromes ("nephritic" and "nephrotic" come to mind).

I would rather spend all day looking at apartments, planning the wedding, and biking for 30 miles in the glorious weather, but instead I'll crack open my Renal Pathophysiology book and start trying to figure out these little buggers. Two weeks till finals and three weeks till I am one quarter of the way to an MD!

Today was the last day of my anatomy elective. I identified the pterygopalatine ganglion on the inner surface of the nasal cavity. I described all the bony foramina that the facial nerve passes through in order to send parasympathetic innervation to the lacrimal and submandibular glands. I diagrammed the structures of the larynx and described the action of all muscles acting on the vocal cords. And soon, I will celebrate in the age-old college tradition of sharing pizza and beer with my classmates.

Whew! That was a bear. It was an incredibly intense class, taking 20 hrs a week between preparations and lab time, and eating away primarily at my social life but also significantly into my study time for med school. I got home and immediately after grabbing a few grapes for a snack, I sat down and started doing all those things I haven't had time for, like calling around for a new apartment. I also expect I'll see a few wedding reception sites now that I have my afternoons back. I was capable of doing a few things outside of anatomy (such as that caving trip, and a lovely 20-mile bike ride yesterday), but now the rest of med school will seem a pleasant relief in comparison.

Welcome back, life! I've missed you!

Today was an odd sort of day. This afternoon at school I decapitated our corpse. Then I changed into a long black dress, put on my mascara, and went into a chapel with Tiffany windows to sing Bach cantatas.

( More details than you would care to know about decapitation )
After all that it was rather lovely to sing. The Bach cantatas went very well and I was pleased to have a few folks in the audience. We also had the pleasure of watching the other half of the performance, including a remarkable performance of the 5th Brandenburg concerto with a truly virtuosic harpsichordist. It may have been an odd end to the day, but it brought a little beauty to balance the brutality of the afternoon.

Everything in balance in my life, that's my motto, with the emphasis on the everything!

It's a funny thing to say, but I am so proud of and grateful to my body for surviving with aplomb the rigorous weekend I just put it through. Let me give you a sample...

Friday I walked Relay for Life (an American Cancer Society benefit) for three hours, running for about 1 mi of it despite my recovering cold.

Saturday I joined in celebrating C's bachelorette party at a piano bar, drinking many libations to my friend and joining in sing-a-longs deep into the night, getting home at 1:30am.

Four hours later I woke up, got dressed and ready to go caving at Laurel Caverns in Pennsylvania. At 5:30am I didn't feel like much breakfast, so I took a yogurt to eat before we dove in. Ten hours later I emerge with 20 classmates from the depths, covered in mud and STARVING! The cave was much more technical and far more fun than I expected, requiring no real equipment (just a helmet), but involving multiple climbs, squeezes and crouching. We were climbing and exploring for a good three hours but we did have the satisfaction of reaching the very depths of the cavern beyond which the river disappears in a slip of rock far too small for a human to pass. This is just one of the benefits of joining the Wilderness Medicine Interest Group! (The other benefit being their fall rafting trip!)

So yes, after all that I think my body performed beautifully. No headache, no hangover, no aches and pains, just a little well earned hunger pangs. Body, you didn't ask for what I put you through but you stood by me every step of the way! I'm gonna treat you with the best fresh veggies and proteins and no caffeine you could possibly hope for. You deserve it!

The title of this post is not in the least metaphorical. Today I listened to my heart and a few others. Our session was led by a remarkable doctor, one who absolutely loves teaching and takes his time with it. Oh, we'd been to lecture and heard a recording several weeks ago, but there's nothing like sitting down and listening to get you used to having a stethoscope in your ears.

My heart had regular rate and rhythm. (Good thing!) You could hear clearly how it accelerated when I breathe in and slowed dramatically on breathing out. I heard a quick separation in the first heart sound, lu-lub dub lu-lub dub and wondered briefly what it meant until the doc told us all to listen specifically for that since it's perfectly normal. In order to hear it you have to be in a receptive state yourself, calm your breathing. I imagine being a cardiologist is something like the biathlon, but instead of skiing and sharpshooting, you race from ward to ward and then you enter a meditative state to hear the infinitesimal sounds.

The best part of the afternoon was following our teacher into the hospital in search of interesting heart sounds. We had the pleasure of listening to three very patient very generous ladies. One had heart failure, one aortic stenosis, and one mitral regurgitation. The terminology is unimportant but the people, well, the people were beyond lovely: an 82 year old who didn't look a day over 65, a 92 yr old with Alzheimer's who nonetheless was the picture of politeness and insisted on shaking our hands, in A's case several times. It's strange to think that here we are, taking up their time and invading their personal space and yet they are so welcoming. Part of it, I'm sure, is that hospital stays lead quickly to fear and boredom and anything is a break from that. But these patients didn't have to share their stories nor have five novice students placing cold stethoscopes over their greatest physical flaws. They were doing a service to us merely out of the kindness of their hearts.

May I be ever grateful and may I continue to find kind patients and patient teachers.

Today was a good day.

It is good to aknowledge stress, to remind myself that I do have my limits.

This week is particularly stressful because

I had an oral exam on history-taking this afternoon for which I felt ill-prepared since I'm one of half the class that is NOT shadowing a doc this semester.

Tomorrow I lead discussion in my small group so I have to be doubly prepared to discuss metabolic acidosis and acid buffering in the kidneys

Because I'm taking off Friday, I have to take both my normal anatomy quiz for Wed AND my quiz for Friday in addition to the group practical exam at the end of lab.

Friday's case is more extensive than Wednesday's and so instead of learning in a group I'll have to research it all on my own before I have any hope of answering the end-of-week quiz.

I still have to complete my taxes which are necessary for financial aid which are necessary for continuing as a student!!

Time is rapidly running out for identifying a wedding site for my prime vacation time.

And on top of that, in two days I will fly to Chicago to spend Passover with A's family as the new fiance! Of all of these things, this is actually the most relaxing. I've met almost all of them before, and even if there will be questions and ideas and acres of attention, they will all be well-meaning and full of love. I can take that kind of pressure!

I'm also noting that while Case, like many med schools, is pass/fail, and while they profess to have few major exams, I have four tests, quizzes, or practicals in the space of 28 hours. No wonder I'm a little stressed!

Today my Athleta catalog arrived advertising swimsuits just as a spring snowstorm blankets the daffodils. To cap this otherworldy day, I had the wonderful experience of extracting a human brain! Oh, I thought the heart was cool, and I felt the spinal cord topped that, but the brain really beats them all!

( Bonesaw, chisel, and hair shears )
The brain is an amazing thing, and I count myself lucky to have been able to see this lab. This is something we "don't have time" to do in med school ourselves, so my poor classmates not taking this elective will be left studying human brains that they haven't had the satisfaction of excavating from their own skulls. Knowledge by discovery is so much more exciting!

So, I think nothing else this week will quite compare. I'm going to walk around the rest of the day like a zombie, occasionally emiting the groan "BRAAAAINS!!" And for the rest of my life I will have a much greater appreciation for the work that Dr Frankenstein must have put in to create his monster. Being a mad scientist isn't just evil, it's hard work, and they should be appreciated for that!

And now I return to being a normal human being. A mound of mac 'n' cheese? Perhaps a little too brain-like for tonight, thanks.