“I wish I could go to bed”

14 02 2014

This came in via Medscape, which a Medical Education/Newsportal most of us subscribe to. It’s a compilation of reflections from the Medscape panel on “Why we practice Medicine”

If you have a subscription, you can see the rest of the slides here.





Every Pre-Med should read this

15 10 2013

While at the infinity pool at school, I had this discussion with my friend about what the philosophical basis of Medicine is. What exactly is Disease and how do or can we know for sure? There are no easy answers to that, though I get the inclination that the boundaries of the question and the lenses we use to look at it, change slightly depending on the problem at hand. I went around looking for answers and discovered that there is an entire field called the Philosophy of Medicine. I bumped into an article at the Internet Encyclopedia of Medicine discussing these perspectives. I felt that it gives a good overview on the theory and practise of Medicine and the fact that I am now more familiar with the subject, it is easier to understand the philosophical jargon. I feel that the article gave me a better philosophical foundation to understand both the evolution of ideas in Medicine and added some colour and structure to thinking about the field. I’m planning to read around the subject, with more content to come!





#archive The 3 Secrets of Highly Successful Graduates

31 08 2013

This is a really interesting piece of career advice I bumped int on Facebook.





Perspective I

19 07 2013

While I was trying to channel my anger into something constructive, I ran into a bunch of pictures in a feature by FSTOPPERS on Tom Hussey’s Reflections. It’s an eye opening look at the elderly staring back at a reflection of their younger selves. Hussey has a great portfolio on his website and you can see the entire collection here.

This something I ponder about a fair bit, in conjunction with reflections on Death, partly because that seems to be the next stage.  I’m surrounded by the elderly at work, so I am rather surprised/ashamed that I haven’t had the Old Age and Death conversation with anyone. Perhaps it’s the language barrier, perhaps I’m just caught up with the routine. I’ll do that the next time I see someone who might be willing.

That’s probably me in 40+years. If I live that long.

 

 





Of Logos and Evidence Based Medicine

22 11 2012

One of my friends was on exchange and I noticed a logo on the said friend’s facebook profile.

Looks familiar?

It kind of resembled my own school’s medical society logo.

NUS MedSoc Logo

I recall, back in my first year, we had a short lecture on the history of medicine and the lecturer briefly spoke about the logo, with an amused look. Apparently there is a bit of confusion with regards to the symbol and strictly speaking, the Stockholm school uses it the way it should be, based on its roots.

The winged rod with two intertwined snakes is actually the Staff of Hermes (Mercury in Roman Mythology), known as the Caduceus. Some historians interpret it to symbolise “balanced exchange and reciprocity” which are values which drive commerce. Since Mercury is the “the messenger of the gods, guide of the dead and protector of merchants, shepherds, gamblers, liars, and thieves” this has come to symbolise all these aspects. It’s often erroneously used by Medical Societies, especially the commercial ones, and this can be traced to it’s adoption as the symbol of the US Medical Corps in 1902. Wikipedia covers this in more detail in a very readable fashion.

The actual symbol representing Medicine, based on Greek mythology, is the Rod of Asclepius, the god of healing and it comprises a single snake twined around a rod, as below.

The Actual Rod of Healing

 

After a lecture today though, I think the (misused) logo can potentially be re-interpreted in the light of Evidence Based Medicine (EBM).

Simply put, EBM is an approach where we use evidence to analyse treatments (and lab tests, physical exam techniques etc) to objectively figure out whether our treatments (or tests) actually work. This might seem like a mundane question to those outside of the field, because, if someone takes a pill and gets better, a treatment works right? The reality is a little bit more complicated than that. As a counter to that, I might ask, how do you know that the pill made someone better? They might have gotten better anyway in a few days. In addition to this, for long term illness, one sometimes has good days and bad ones.  With this in mind, researchers (who are often Medical Doctors, but this can involve people from various healthcare fields) design studies to tease out the various factors so at the end of it, one can be confident that the treatment is effective.

An extra element of complexity is added when we consider the fact that certain treatments can be potentially harmful. Drugs sometimes have side effects or may have dramatic effects which can cause harm under various circumstances. An example is the use of “blood thinners” to prevention ischemic strokes due to blood clots choking the blood supply to the brain. Blood clotting (or coagulation) is a chemical reaction where proteins in the blood clump together with cells to form a clot. The clotting of blood is important to prevent bleeding but in diseases of the blood vessels, there is an increased tendency for blood to form a clot and block blood vessels.  Blood thinners, or more accurately, anti-coagulants, impair this process. They don’t actually make the blood thinner. However,  in a legitimate bleed, you still do want the blood to solidify and cause the bleeding to stop. A consequence of blood thinners is that the bleeding may not stop in the event of an injury.

With this in mind, it is imperative that Doctors use research and figure out how to balance the risk of an uncontrolled bleed versus the risk of a stroke in diseases of the blood vessels. Part of this strategy is to use the right drugs (some are weaker and hence less likely to cause bleeding) and to understand the patient and disease better (those with severe disease may still need stronger drugs). These days, there is a cost element that doctors need to be aware of, and we also know that the more complex a treatment, the less likely patients are to accept it and it may be more difficult to follow it. What this means is that our role has become more complex and we need to “balance and negotiate” a multitude of factors when we treat people.

If you dig around a little, there is this uncanny symbolism to the myths and paraphernalia associated with Hermes. A publisher used the staff as an emblem with a biblical quote reminding one to “be ye therefore wise as serpents, and harmless as doves.” Seems a lot like an exhortation to be a critical thinker but to balance it with empathy for patients. Hermes is also the “messenger of the Gods” and seen as a guide. Doctors are often looked up as people who “know the science” and there is a huge expectation upon us to be able to communicate this to patients, to help work with them to tailor their treatment. He is seen as swift and cunning and a navigator, and people expect us to be on their side when it comes to navigating the vast an complicated realm of healthcare.

I smugly laughed back in my first year when the lecturer potentially interpreted the Medical Society’s logo as representing the “commercialisation” of medicine. However, knowing this background it seems amusingly appropriate.

And the bit about Hermes as the god of Gamblers? Here’s a quote from the Oxford Handbook of Clinical Medicine (aka the Medical student’s pocket bible).

“Rather, medicine is for gamblers. Gamblers who use subtle clues to change their outlook from pessimism to optimism and vice versa”

 





Welcome Doctor Google [satire]

24 10 2012

I was randomly trying to look up information for a report when I discovered this trick. I cannot believe that Google is actually sifting through pages to give you a differential diagnoses. I think at this rate, Google will achieve self-consciousness by the time I graduate. They might also add in an empathy module. As such, maybe I should just quit school and focus on rehearsing my “would you like fries with that?”*

 

*Or “ni yao fries?”





“There is no such thing as a happy period”

18 10 2012

The menstrual cycle is an extremely well coordinated process involving four main players that act together like an orchestra. They are the hypothalamus, the anterior pituitary gland, the ovary and the endometrium” – Professor K. Arumugam, from A practical approach to problems in Gynecology for the undergraduate.

I happened to be reading that guidebook since I’m doing an Obstetrics and Gynecology attachment. The first time I talked to my friend about this quote, she bluntly remarked that it must have been written by a guy. And it’s true. Despite what the professor says, most of my girl friends would agree that a period is less like an orchestra and more like a Justin Bieber concert gone bad. The more time I spend in the Gynecology clinic, the more I am convinced of this fact. I am constantly surprised by the fact that women could have hidden such a large part of their lives from us men, though I feel that part of the reason is that we never really asked. I think the next time I’d be prepared to listen a bit and offer a hug and some anti-inflammatories.

In this context, it was absolutely hilarious when a friend shared this article with me about how a disgruntled boyfriend posted a complaint on the Facebook page of a Sanitary napkin company. I think Adweek has covered the story really well, including the original post on Facebook together with the company’s HILARIOUS video response. I strongly suggest you read the article.

To my guy friends, I think there’s a bit more we can do to make the world a better place. To my girl friends, Cheers mate!

 





Self Doubt and Medical School

3 10 2012

“During my initial years as a graduate student, I certainly didn’t enjoy an unshakable sense that I had found my true calling. The beginning of doctoral training can be rough.”

So goes a recent article I read on my friend’s Facebook wall. I felt guilty for going online two days before my psychiatry exam, but I’m glad I read it.

I always tell people the story of how I got into medical school. How I was going to be an engineer all my life (a computer one, I discovered in JC) and then in the military, my vocation allowed me to immerse myself in the medical profession and it occurred to me that perhaps, “medicine is just a different kind of engineering”. That line sure impressed the interview panel and I did get in. Though, that seemed like a misunderstanding  in the first two years, where they load you up with the “basic sciences” before they let you loose onto patients in the hospital.

In the first two years, nothing made sense (well, almost). It was literally Greek to me and my professor’s repeated insistence that “see, you don’t need to memorise, you just need to understand!” came across as nothing short of a lie. It isn’t downright wrong, I have realised, but you need to figure out a coherent way of reminding yourself of what you have understood. I started out at the bottom of class and somehow managed to make my way to a more acceptable, above average. I also realised that the trick really was to understand, and once you a) understand a bit of Greek and Latin and b) try to make sense of things, it a lot more fun to learn.

In my second year, it got worse in a sense. There was a crap load more content, tutors went on and on and on explaining how the immune system works, when they could have simply said, this works by a darwinian algorithm with a positive feedback loop that amplifies the appropriate signal. You can see how much geekiness that statement is loaded with. All this while, I had this sickening feeling that I was in the wrong place, everyone was better than me and that inauspicious amount (according to the Chinese) on my government bond which had a lot of fours in it, was a bad omen and I should go back to the familiar field of computers.

I have a lot less self-doubt these days. We do rotations in various hospital departments and if you draw a chart, it starts off at a medium height, then peaks much higher a few weeks into the posting when you realise the sheer scope of your ignorance. Slowly, as the exam comes closer and you’ve had more time to make sense of the subject matter, it takes a slight dip (or rise, depending on how well prepared you are). It then, at least during the exam, stabilises to a lower level.

Over time, I have come to accept some amount of self doubt as necessary for being rational and for the sake of progress. I think 100% confidence is something that generally does not exist in the sciences and although I can accept that we can assume certainty in a practical sense, we can never be 100% sure about anything and pretending to be that is either inaccurate, stupid or downright dangerous. Doubt is an interal part of the reasoning process an although you never get rid of it, I enjoy the practise of wrestling with it to come up with a final answer. As and extension of this, I have always tried to cultivate a healthy skepticism about what I’m being taught in school (one of my mentors drove this point home really well) and have tried to understand the limits of my abilities. The field of medicine has a history of falling prey to erroneous idea, but we take pride in being open to correction and improvement.

Early on, a couple of things were important in keeping me going. I realised that I came from a unique background and had a unique viewpoint which no one else had. I think I’m the only guy in class who asked “if you use Valium to treat alcohol dependence, can you use alcohol to treat Valium dependence?” That probably stunned the tutor for a minute. She probably thinks I’m a retard for asking that question, but I don’t care.

I had some really cool friends. My BFF and I would have these random speculations in class, it keeps us awake. I would say evolution, he would say design. I had these two friends in the hostel who really helped me study and understand stuff (yes idiots, I’m talking about you). We would stick to a particular accent during an evening of studying, which resembled drunk Greeks arguing rather than medics. Our exams ended later than everyone else’s so the other students in the hostel would mockingly ask us if we were studying for the next semester.

We got taught by some awesome tutors who had these vastly different personalities. This really convinced me that, because Medicine was such a big field, I could either find a nice spot where I fit in, or create one, or better still, I don’t have to fit in and that can be a strength.

Yet, one of the biggest lessons was when I was talking to my classmate in the lift one day. S/he was someone who’s at the top of his/her game. I cannot remember how the conversation went, but s/he just blurted out that s/he was worried about whether s/he was in the right place, doing the right subject and if s/he could cope. I’m confident that there are people who are sure, who, have wanted to be doctors all their lives, but I doubt these are the majority. You barely know what you are doing when you are 18, and I got lucky, even at 20, to say that I’ve made the right choice.

I have come to understand that this is the cooolest thing I could ever be doing. I’ve seen birth and death, in the same night, almost. I am looking forward to delivering babies in a few weeks. I’ve had my hands inside someone, while they were still alive. Probably saved a couple of lives already. Got bitten by a patient. Played cards with another group. Spoke to recovering drug addicts and people who were in the midst of a suicide act when they were rescued. Listened to a hundred hearts. Seen someone’s heart and breathing stop (in preparation for surgery). We had a tutorial where we discussed how to deal with a patient who feels his life being messed up “is God’s Will”. We spent an entire day talking about marijuana, booze, ecstasy, heroin. We talked about Dragons*, Angels, Pink Elephants and miniature humans running around in the wards. Next time I complain about how I can’t go partying with you, do remind me what a heck of a time I’m having.

Self doubt can be scary for some students who have had straight As since as long as they can remember. They get thrown into an uncertain, unforgiving environment, where things are not exactly black and white anymore. It’s uncomfortable, but I think that’s what makes medical school fun. I’m glad to have all these amazing classmates and I’m sure they’ll turn out fine 🙂

*Chasing the Dragon is a Euphemism for smoking heroin. Pink Elephants and Lilliputian hallucinations is what some alcohol addicts might report when they are going into withdrawal. Angel dust is a street name for a drug called PCP.





Dangerous Psychos

28 08 2012

Image from the Straits Times Press

 

It’s my psychiatry posting and I happened to do a bit of pre-reading last week by pulling out this book. It had a cute title and the language seemed pretty reader friendly. I am generally not impressed by the content of medical or scientific books directed to the lay public, but this one had a lot of important information beyond just the medical. This paragraph really forced me to reconsider stereotypes.

The reality is that it is rare for mentally ill patients to ever be dangerous to others. Yet this group, insignificant as it inevitably is, receives a disproportionate amount of attention in the media, which, as a result of sensationalistic reporting, creates an aura of  ‘dangerousness’ around psychiatric patients, tarring all with the same brush.

The reality is that violence is so ubiquitous in society that the act of incarcerating a few individuals gives little (if any) extra safety or public protection. There are far more dangers in society than the potential risk posed by the mentally ill. Dangerous drivers, for instance, cause far more potential harm, as do industrial companies that flout safety regulations

There’s a lot more to that tiny book (106 pages) and I highly recommend you take a look. It’ll be available in the NUS Library once I return it, in a couple of days.

The other very real problem is that the mentally ill might be dangerous to themselves.  Sept 10th is World Suicide Prevention Day, and although I think it’s sadly ironic that it’s commemorated a day before some of the most horrendous suicide attacks in recent history, I think it’s an important message that a) it’s unfortunate that people should feel so crappy that they want to kill themselves and b) this might be largely preventable, if they get help early.  As I mentioned in a post on my old blog, there’s stigma associated with getting psychiatric help, which, in the 21st century, we shouldn’t be having. It’s ok to see a counselor if you think you can’t cope, there’s absolutely nothing wrong with that and it doesn’t make you a weak person.

If you ever contemplate suicide, drop the Samaritans Of Singapore (SOS) a call at 1800-221-4444 or an email at pat@samaritans.org.sg. They’ll know how to help.





Med school advice … from The Devil

24 07 2012

Mephistopheles and Faust, 1925 illustration by Harry Clarke

While on my trip to Frankfurt, my friend took me to visit the Goethe House and I was inspired to read Faust to complement that. Goethe, who lived in the mid 1700s is considered one of the greatest German writers. His play Faust is about a bet that the Devil makes with God to prove that he can lead the best of men astray. Faust the protagonist, is a polymath dissatisfied with his academic  knowledge and makes a wager with the Devil

This is an excerpt from Section IV – The Study which I copied from Project Gutenberg’s edition of Faust (You can skip my sappy commentary and read the original uninterrupted). While Faust is away and getting ready to travel, a student approaches his study. The devil disguises himself as Faust and imparts his pearls of wisdom to the student. The devil in this scene  comes across as part wise senior and part troll. I am including some interpretations, which may not have been intended by Goethe, but it’s a fun exercise.

MEPHISTOPHELES (_aside_)

I’m tired enough of this dry tone,–
Must play the Devil again, and fully.

(_Aloud_)

To grasp the spirit of Medicine is easy
Learn of the great and little world your fill,

Doctors are human too, hence the essence in Medicine is simple. Applying it requires understanding of both the large scale (populations, clinical signs) and tiny (bacteria, genes)

To let it go at last, so please ye,

You will forget most of the stuff you learnt in the first few years

Just as God will!
In vain that through the realms of science you may drift;
Each one learns only–just what learn he can:

You can study alot but there is only a limited amount of information you can fit into your head

Yet he who grasps the Moment’s gift,
He is the proper man.

Paying attention to what is in front of you now, i.e the patients in all their intricate glory, is ultimately what will help you

Well-made you are, ’tis not to be denied,

Yes, you are the creme-de-la-creme

The rest a bold address will win you;

I’m not sure what this means but perhaps it’s something like, people will give you a fancy title.

If you but in yourself confide,
At once confide all others in you.

I think there are two interpretations here. Firstly, if people feel that you can keep your mouth shut (i.e What happens in Vegas stays in Vegas) people will trust you. The other could mean, if you’re in tune with your own emotions, it’ll be easy to empathise and understand people.

To lead the women, learn the special feeling!
Their everlasting aches and groans,
In thousand tones,
Have all one source, one mode of healing;
And if your acts are half discreet,
You’ll always have them at your feet.

Don’t know what on earth he’s saying here. Really.

A title first must draw and interest them,
And show that yours all other arts exceeds;

Half of it is in the title. Heard of the Placebo Effect?

Then, as a greeting, you are free to touch and test them,
While, thus to do, for years another pleads.
You press and count the pulse’s dances,

Yes. Patients trust you. And they will let you examine them in ways no one ever has. Of course, you are interested in things about them which no one else ever would be, like the number of times their heart beats in a minute.

And then, with burning sidelong glances,
You clasp the swelling hips, to see
If tightly laced her corsets be.

So apparently, someone with a loose corset is innuendo for being a loose woman. Alright, here’s where you listen carefully. Whatever your patient’s background, you treat them with respect. Don’t be a douche bag and take advantage of them. Or somebody gonna get hurt real bad.

STUDENT

That’s better, now! The How and Where, one sees.

MEPHISTOPHELES

My worthy friend, gray are all theories,
And green alone Life’s golden tree.

Medicine is about life and death and it’s not meant to be entirely studied from a book. Go out there to the real world and see it for yourself, it’s pretty exciting. Also medical textbooks are damn boring.

STUDENT

I swear to you, ’tis like a dream to me.
Might I again presume, with trust unbounded,
To hear your wisdom thoroughly expounded?

MEPHISTOPHELES

Most willingly, to what extent I may.

STUDENT

I cannot really go away:
Allow me that my album first I reach you,–
Grant me this favor, I beseech you!

The student is so overwhelmed by the prep talk that he demands an autograph.

MEPHISTOPHELES

Assuredly.

(_He writes, and returns the book_.)

STUDENT (_reads_)

_Eritis sicut Deus, scientes bonum et malum_.
(_Closes the book with reverence, and withdraws_)

This is a quote from the Bible. Genesis 3:5 says, “Ye shall be as gods, knowing good and evil”. I’m warning you here. Once you start studying, you will never look at the world in the same way again. Your side of the world will be full of death, disease and suffering. Though, I won’t say that is necessarily a bad thing, you did sign up because you want to help people right? Nonetheless, your worldview will take some adjusting and once it does, you will come to … well, that’s a topic for another time.

MEPHISTOPHELES

Follow the ancient text, and the snake thou wast ordered to trample!
With all thy likeness to God, thou’lt yet be a sorry example!

This reminds me of my high school days when we did a little bit of literature. I actually read through a study guide for this chapter and two posts by a Professor of the Arts. I didn’t like the study guide too much, it had a different interpretation than which I intended but the Professor’s ideas on the Biblical quote and Gray is all Theory are interesting.