Zihua Update

We've been a couple of days in Zihuatanejo (and its neighbor, Ixtapa)... still no sign of Tim Robbins or Morgan Freeman.The small fishing village in the 50's has exploded into a twin city of 100,000. Zihua still has a small-town feel, but the planned tourist destination of Ixtapa is a jungle echo of Waikiki. Smaller, more wild, cheaper, less crowded, but still a service oriented place. What caused the population explosion? First, a paved road from Aculpolco, then one from Mexico City.

I have found some Wunderkammern specimens. So far, the skull from a large reef fish, a beautiful lobster tail, and some ribs and fin bones - some of which are 40 cm long. I'm still trying to figure out what they are. A women on a little taxi boat thought they might be dolphin; she also thought the skull was a chicken bone...

Much Needed

As I type this entry, I am sitting under a thatched beach umbrella in Ixtapa, Mexico. My hotel's wireless internet extends all the way to the breakers, so I can take in the sea and salty air with my feet in the sand, a limonada con gas in one hand, the internets at my fingertips and my head in the shade. (For added fun, try mixing the phrases above... head in sand etc.)

I'll be back to Seattle and to life as a fourth year medical student in a few days.

Clue

Activity on this blog been down of late, mostly 'cuz I've been busy finishing my Ob/Gyn clerkship. Well, then there's that pesky truth that I mostly write for myself.

But I thought I might get one guess for my previous riddle. Yes, it was complicated and as my first blog riddle, maybe too hard. My wife suggested I turn the puzzle into a joke. So here's your first clue:

A surgeon, a pathologist and an oncologist are on a hike in the forest when they encounter a burly tree (See the recent post for a picture). Curious, they sit down to ponder their discovery. The surgeon proposes they cut open the burl. The pathologist thinks that's a good idea; she whips out her pocket microscope to examine it. The oncologist goes on about a two-hit hypothesis and proposes dumping toxic chemicals onto the tree's base. What do you call this conclave of MDs?

And your clue is this: the answer is the same as one of the items in the pathologist's possession.

End of the (Medical) School Year

I've a couple recent posts up at The Differential. One about how to approach your medical school or residency personal statement was followed with an excellent comment by an admissions officer. My recent piece is a friendly parody on Jonathan Larson's "Seasons of Love (525,600 minutes)" from Rent. It is after all a new year for medical trainees. While you're over there, check out the introductions from The Differential's two newest bloggers.

A Woodland Riddle

Anyone out there up for a riddle?

When I was in Fairbanks for my obstetrics and gynecology rotation, I was fortunate to have a few days off so I could get out and experience the Alaskan landscape. Alaska is so big that it is impossible to make generalizations about the land. The people, the flora, the geology, the weather - it's difficult to write about the place without over-generalization.

One thing about interior Alaska that is hard not to notice is the trees. Having lived in the Pacific Northwest for several years, I've rediscovered a connection with the colossal organisms that define the landscapes here. Evergreens are, after all, the reason Seattle can claim the title of Emerald City. It isn't surprising that one of the first things I noticed after landing in Fairbanks was the diminutive stature of the area's trees. Black and white spruce, paper birch, alder and poplar are the main species there. And none of them grow much taller than 40 feet! Old growth forest consists of tree trunks less than a foot in diameter. The short growing season conspires with the extreme winter cold to limit tree height and diameter.

There is something else peculiar about interior Alaska's trees. There is a much higher frequency of burl formation there than any place I've been. Woodworkers know burls to be valuable sources of figured wood. Laminates, sculptures, and bowls derived from burls are things of beauty. Hikers and orcharders know burls to be those funny bulbous growths along the trunk, roots and limbs of trees. One of the more affected trees I encountered on a hike is shown at the left.

The strangest thing about burls is that no one really knows what causes them. Theories range from insect infestation, mechanical damage, genetics, fungus and soil contents. What I know is that when a medical student who has been a biomedical researcher and is an amateur woodworker encounters these misshapen trees in the forest, the first thing he thinks of is a riddle. That's right, the trees speak to me! This one said:

You doctors, you searchers, you cutters of flesh;
You sawyers, you sculptors, you dry aesthetes:
Gather together to crack my mystery.

So then, my witty readers... What do you think it all means? What was this telling me? How and when might we be able to figure the etiology of this I'll put up what I think it was telling me next week, and provide grades on your responses. I hope some brave readers will offer solutions to this mystery, first.

Exam Branching Diagram

To assist your complete understanding of my medical school experience, I have prepared the following flow chart detailing the way I feel before taking an exam, immediately after the exam, the grade result and what I think on my way home from the exam. Granted, we usually don't get the grades until weeks after, but I'm the blogger, so I'll present the information the way I want to.I bet you want to know how I felt after each of my clerkship exams... Even if you don't want to know, there's a reason I want to tell you:

• Pediatrics: Blue-Green-Orange-Red
• Family Medicine: Orange-Red-Blue-Blue
• Medicine: Green-Blue-Green-Orange
• Surgery: Blue-Orange-Orange-Orange
  
• Ob/Gyn: Blue/Green --> The exam is tomorrow! --> Green
  
• Psych: Ask me in September
  

The point of this little exercise is to indicate how poor I am at predicting:

1. Readiness for an exam
2. Whether I knew the answers
3. What grade I'd get on the exam
4. My mood after taking the exam

Careful readers will notice that I haven't aced many exams. Don't worry - that doesn't mean I haven't done well in medical school. Depending on the clerkship, the exam consists of a variable contribution to the final grade. And I don't REALLY hate medical school. SOmetimes I think that I do, however.

5 x 10^6 Firefox Downloads!

It's time you thought about updating your browser. Version 3 of the free open-access Firefox web browser is live! What? You don't surf using the best web browser? Only 18% of all browsing is done on the Firefox platform? (Microsoft's Explorer carries 75%.) You better get busy and download
now!




If you can see it (some people block pesky ads), click on this button to download Firefox with the especially useful Google toolbar. If you do it today, you'll contribute to the world record goal of 5 million downloads in one day. And I think I get a dollar for referring you. Need any more rea$on to jump on the bandwagon?

Grand Rounds

From Alaska to the South Pacific, they're blogging about medicine. And David at Marianas Eye has got the best from this week. Head over there for a large collection of clever lead-ins for each entry to Medicine Grand Rounds.

Workshopping a Personal Statment

So you're trying to write your medical school or residency application personal statement? Are you stumped? Do you feel like your missing something? Do you have writer's block? Here's a little exercise modified from my school's residency application handbook to help you get your ideas out. I've been pondering drafts of my personal statement for a while, but the exercise of sitting down and answering these questions helped me fill in some of the gaps.

* What are the skills valued by specialty? How have you demonstrated them?


* Has coursework shaped your specialty decision? How?


* Have you had any experiences outside of school that were significant to you personally and professionally?


* Do you have any other interests and experiences that demonstrate your values and individuality and may be a resource to a residency program? List them!


* What is the reason for applying to your specialty of choice?


* What are the characteristics of an attractive residency program?


* What are your personal and professional goals? Including practice location, style, and emphasis...


* Does your family status impact your vision?


I left some space so that you can imagine your answers. Or print this out and write them down. Or type between the gaps. It's not enough to think about them. Put your ideas in writing and your statement will come together more fully!

Butting Heads

All evening, I've felt like I'm butting heads with this manuscript I'm trying to rewrite for resubmission. Now that it's midnight where I am, it's too late to finish everything to my satisfaction. It's also too late for me to strap on my antlers. When I return to this paper tomorrow night, it better be ready... ready, that is, to butt heads with CaribouTom!

No caribou were harmed in the filming of this post.

On Blogging in Medical School

Nick Genes, an MD/PhD emergency medicine resident, was recently asked the question, "What is your advice for medical students?" It was part of a feature of him in the Student British Medical Journal. He answered:

Start a blog. As I wrote in a column for Medscape, medical school is a transformative but isolating time. A public journal can update friends and family who might otherwise not hear as much from a preoccupied student. Blogging also prompts reflection and records intellectual and emotional growth. Medical student bloggers also make connections with other students who are considering the same specialties or places to train.

I'd say this is spot on. Whoa - an MD/PhD blogger who went into emergency medicine... Cool!

Arms

My experiences in the Ob/Gyn clerkship these past weeks have revealed to me that being up in arms about something is very different than being up to your arms with something. Or up to your elbows. Whatever. I'm going to keep the field at arm's length.

Google Me!

Just to be clear: I, Thomas Robey am neither a senior vice president of investor relations for Time Warner nor an otolaryngologist in Milwaukee, WI. Nor am I a Khoros computer language programmer or a Rotten Tomatoes film reviewer. As fun as those things all sound, I'm happy with who I am and what I'm doing now.

The Liability of Academic Blogging

It's been almost 8 years since I've had to sell myself. I'm again at that stage in life. It's coming time for me to shape up my curriculum vitae and personal statement for residency applications. And here's the dilemma: do I talk about blogging in my essay?

First, a step back for context: I'm fortunate in that I have some friends at hospitals where I hope to match. Some of them are even in the programs I'm applying for. One friend, in particular, has volunteered to be my insider agent at that school. I'm quite happy about this, because she is a very good student and will be an excellent ER doc - probably a professor - someday. It's nice to have folks who believe in you, but sometimes I worry about favoritism. Where is the line between the good-old-boy cronyism and networking? Anyway, she's already connected me with folks who will be helpful in my application process. My interest and dedication to the ethics and policy of science and medicine is one thing that makes me unique compared to other applicants, so this is part of her description of me. A description which often includes 'blogger.'

Ethics and policy is the way my commitment and passion for improving 'the system' takes form. In graduate school, the main way that I did this was by organizing events and bringing people together under the umbrella of the Forum on Science Ethics and Policy. Now that I'm busy with medical school, I work in ways that allow me to contribute to and learn about the contextual issues of science and medicine on my own time. Reading and writing, mostly. And this is where blogging comes in. I write other things - like the review article about urgent care clinics' impact on the ER safety net I've been working on for a couple of months, or the syllabus for a med student clinical ethics course, or those pesky responses to reviewers for my work in graduate school, but blogging is where I transcribe a majority of my ideas.

My blog does not have a lot of readers. At first, my main goal was to increase readership. Readership does grow slowly with quality content, but it grows much more quickly via self-promotion, links from big bloggers and writing on oft-searched topics. I even wanted to be assimilated by the ScienceBorg at one point. Getting this attention is no longer my priority. When I started blogging, it was primarily to find a voice. These days, I use my blog as a laboratory where I experiment with writing. I had no idea how cathartic the activity would be, and my interest in writing has since spilled over into two other (much more widely read) blogs and a (sorry, no public access) personal diary. Dare I say that 'blogger' is now a key part of my identity?

So how does this all fare in the world of residency applications? Despite efforts on the part of a philosophy professor in the bay area, the notion of blogging is still taboo in academia. (Note to said philosophy professor: is there any way you could seed this trend of legitimate academic blogging in some of the institutions just to the north of you? :-) --> j/k) I believe that in the right format, blogging is a legitimate academic activity. Even so, I still tend to de-emphasize blogging and use words like columnist and writer to describe what I do. Blogging is just a means to ends activity anyway: the end could be as broad as 'increased understanding' or 'better writer,' or as specific as 'a book' or 'drafts of opinion pieces in journals and newspapers.' And all of these ends should help me be a better academic, right? So why am I afraid to present the means in my personal statement?

UpToDate Up To Date

Earlier this year, medical students from Wyoming to Alaska were up in arms about the University of Washington's canceling a heavily-used electronic medical reference called UpToDate. I was in the minority of voices saying, "Good Riddance." Not because I didn't use or like the resource, but because the company exerts a profit-motivated monopoly on medical guidelines. UpToDate wanted to charge gazillions of dollars to provide articles that the authors write for free!

I had gotten used to the slightly less organized and less thorough eMedicine articles when my university's library portal indicated,

UpToDate - Good News!

Renewal for the coming year pending. We expect confirmation the first week of June ...

The so-called confirmation hasn't come yet, but it looks like the threat of cancellation and the uproar from UW docs and students combined to renew the subscription. Whatever. I'll still use UpToDate, but I have another arsenal of tools at my disposal now, too.

Reducing and Reusing, if not Recycling in the OR

Over at The Differential, I recently wrote about waste in medicine; lots of stuff gets thrown away, especially in hospitals. One of medicine's most egregious offenders is the OR. Items ranging from blue towels to cautery equipment to paper drapes to laparoscopic instruments to suture to bowel staplers all are pitched at the end of each case. In the past few weeks I've enlisted the help of scrub techs and circulating nurses to cut down on the footprint of the cases I'm involved with. Here's what we came up with in the reusing category:

1. Suction irrigators run on 8 AA batteries and are designed to run for two hours. After the case, the irrigator is pitched - including the pump. If you salvage the batteries from each suction irrigator used for ectopic pregnancy or cholecystectomy cases you assist with, you'll amass 10 hours of digital camera usage per irrigator, or put another way, a lifetime powering of remote controls per surgery clerkship.
2. Blue towels are the sterile, lint free linens that surgeons dry their hands and arms on after scrubbing but before donning gown and gloves. For folks like me, who 'scrub' using the germicidal alcohol-based Avagard chlorhexidine cleanser and come into the room 'dry,' there's a good chance that towel will go unused in the case. This makes a perfect car-drying towel. (For after you go through the automatic car washes, of course - they save water and reduce toxic runoff.)
3. Specimen containers are especially useful for my natural history collections. (See my entries on Wunderkammern for clarification.) The sterile cylindrical canister that comes with Foley catheter kits is good for spices when you go camping. Unused but opened pathology specimen containers work well for storing small parts. Any clean container works well for storing captured insects or categorizing bark samples or some other random hobby.
4. Sutures are thrown away all the time. Many ORs save the packets for student use and practice. Before grabbing extras off of the scrub tech's Mayo tray, be sure to ask. Not only because there's a chance open suture is contaminated with patient parts, but NEVER TAKE ANYTHING FROM THE SCRUB TECH'S MAYO TRAY!

It's hard to reduce consumption when you are a student. Since embarking on this mission, I have noticed that some providers are careful about ordering disposable items into the sterile field, asking for tools to be ready but not opened until it is absolutely necessary. This saves the patient money and reduces consumption. I'd say that counts as killing two birds with one (unopened) stone. Not that I'm advocating avicide.

Recycling will be a tough thing to implement in the OR. Most paper gets contaminated with blood, poop or iodine. I don't think we want that stuff getting into the recycling waste-stream. In the end though, shouldn't reducing and reusing decrease carbon footprint even more than recycling? Anyone have other ideas about reducing waste in the OR? Or in the hospital?

Denali!

Details later. I've got to focus on school for a while.

The abbreviated version is: phenomenal views, lots of animals, fantastic hiking, a national park anyone could fall in love with...

Interior Alaska's Granite Tors

Tors are spires of metamorphic rock at the top of hills, bluffs and mountains, often in stark contrast to rolling hills on which they sit. In most cases, tors are the residual volcanic rock from old mountains that has not eroded like its surrounding substrate. They often appear as old and weathered spires. Remember the hilltop ruins where Frodo Baggins was stabbed by the witch king in The Fellowship of the Ring? That's what tors look like. Over the years, humans have associated tors with sacred places. The celts thought them to be hilltop sanctuaries of the gods. I think some of them look like chickens.

And yes, my mind's eye does often employ MSPaint highlights in the field. Maybe the spruce grouse we saw on the way up to the ridge put poultry on my mind. Perhaps I was a little hungry 10 miles into our journey. Or maybe I was thinking about my friend Atis. It was the first weekend we had off since his wedding!

These chickens - I mean tors - are important clues to interior Alaska's natural history. As a nice little article from the University of Alaska Fairbanks points out,

they have a special significance, for they are monumental proof that Pleistocene glaciers did not cover the areas where the tors are found. If glaciers had covered the areas, the tors would have been scraped away by the ice. Thus, the tors demonstrate that central Alaska was open to the migration of plants and animals even during the height of the last glaciation.

Interior Alaska has been a really nice place to see a surprisingly diverse collection of flora and fauna. Not being frozen for thousands of years is a good reason. Another (much more recent) cause is that the area around Chena Hot Springs was recently scorched by a sizable forest fire so the areas we hiked through were in various stages of recovery. GoogleMaps actually caught the fire with its satellite! It wasn't the exact location of the hike, but it's close enough...

What the satellite could not capture was this cute hoary marmot. If the rodent had known the satellite was taking pictures, however, I'm pretty sure she would have posed just as much as she did for me.


This hike was unique in that its primary goal was to explore a geologic formation. It was a mammoth walk to see some mammoth rocks. We did the entire 15 miles in one medium to long day. Stopping for lots of scenery and snack breaks, we finished in about 8 hours. The granite tors trail is one of a quite nice collection of trails in the Chena River valley. Trailheads are along Chena Hot Springs Road as you drive from Fairbanks to, well Chena Hot Springs. If you're okay with walking though some burnt forests, this hike will reward you!

All photos may be enlarged for better viewing...

A Whale of a Time

When in Valdez a few weeks ago, my wife and I took a glacier and wildlife boat tour of Prince William Sound. We couldn't get very close to the Columbia glacier, but we did see a trove of wildlife. Including breaching humpbacks. I don't have time to crop them into figure-like insets, so here are a few glimpses. Seeing these whales kindof made me feel like I was saving for retirement...

The classic fin shot:
A good breach, if a little skewed on the horizon...

Those mountains in the background were 100 miles away.

The forecast doesn't look so swell for this weekend at Denali. I've heard that it's nice there no matter the weather.

Teenage Sex

In the past 16 hours, I've removed extensive perineal condylomas (laser ablation) from a 14 year old and removed a tubal ectopic pregnancy (laproscopic excision) from an 18 year old. Well, I "assisted" with the procedures... Ectopics occur in 2% of pregnancies, are fatal to the fetus and very dangerous to the mother. They must be removed ASAP - hence the call at 10:30 tonight. Genital warts are far more common. I think every human is infected with at least one of the more than 100 human papillomaviruses (HPV). Some of these viruses cause plantar warts, others are to blame for genital warts, yet others predispose women to cervical cancer. If you have an immune deficiency, the virus can turn you into a tree. HPV ranges from benign to deadly. (GUESS WHAT! There's a vaccine for the HPV's that most often lead to cervical cancer! If you're reading this, you're too old - you've already been exposed. But your 10 year-old-daughters haven't. Give them Gardasil. They'll thank you...)

But this gets me back to the point of this entry. Teenagers are having sex. Remember back in the '90's? There was lots of talk about safe sex, safer sex, harm reduction, and a catchy little phrase, "safe, legal and rare." What was the outcome of such openness? Some say there was hypersexualization of pop culture. Wait a minute... Wasn't it an earlier generation that subscribed to free love? Hmmm... It turns out that a concerted campaign to educate teens of the risks of sex and ways to make it safer ACTUALLY reduced the amount of sex teenagers had. Whoa...

Any scientist who's tried to publish the results from a new knockout mouse knows that showing an effect of the intervention is not enough. You need to also show the 'rescue.' Basically, turn the mouse back to the way it was before the change and see if the outcome reverts. Well, whadaya know? The last 8 years HAVE BEEN JUST THAT! Abstinence only, no talk of condoms, no pregnancy preparation no nothing with public money have all combined to flip the culture from the previous decade. That decline in age of first intercourse and encounter frequency stops. It's been in a holding pattern. Well, at least kids aren't having more sex... yet... Teen pregnancy is up this year (first time in 15 years!) and 1 in 4 teenage girls have an STD.

It doesn't take the chairman of the department of population and family health at Columbia University to point out that "abstinence education spends a good amount of time bashing condoms. So it's not surprising, if that's the message young people are getting, that we're seeing condom use start to decrease." But John Santelli went ahead and stated the obvious in a Washington Post article that got me all riled up after a day of medical treatment of the effects of teen sexuality. Sure, comprehensive sex ed will be blamed. (Hey, Jimmy! we sure learned some swell things in school today - you want to do some homework later?) Oh, and don't forget about R-rated movies. And the internet. And hormones. And those perverts at Planned Parenthood.

Humans cannot divide asexually. If we don't talk about the consequences of our species' tendency to rely on genetic recombination, someone else will. It will be your kids' doctors, delivering their babies or treating them for gonorrhea, HPV or worse.

"Just say no!" didn't work for drugs. It looks like it doesn't work for sex, either.

Let's talk...

Photos as Proof

The pictures I take tend to fit into four categories:

1. Fun Portraits
2. Scenic or Art Shots
3. Proof Photos
4. "I could blog about that someday"
   

Of these, you'd probably expect to see the last variety here. But since I'm explaining this to you, and included a cryptic third category, you should have picked up that I'd post type 3. Proof photos are not of the best quality, composition or interest, but they do prove that you've seen what you claim. Celebrities, animals and landmarks find themselves in this category. You get to see some animal proof photos from a trip we took to Valdez, Alaska a couple of weekends ago. Arranged in a photo montage, here is evidence of both black bear and brown bear sightings. The black (on the left) is a clear call. The brown, spotted at mile post 3 of the Richardson Highway (where the road to the pipeline terminus turns) was with a cub. Note the pronounced shoulder as she trotted across the road and the large, round ears. Black bears can be brown in color, but methinks this was a grizz!Anyone able to support or deny this claim?

Update 6/8! This is definitely a black bear that happens to be brown. Grizzly bears look a lot different. Had to go to Denali to gain the needed experience to make this assessment...

What's That Smell?

Warning:

You may be exposed to potentially toxic memories of smells from the floor by clicking here. It's a post of a lighter note at The Differential this week.

For a more serious article while you're there, read Ben Bryner's take on the $1000 exam medical students have to take between their third and fourth years. (That doesn't count flying to a distant city for lunch.)

Test Tube Verdict!

It's clear to me who came out ahead in the presidential primary race. Note the mold-free samples at far right. Sure, the berries are quite oxidized - black in fact - compared to the original blue presentation. Remember what those blue berries were called? They were fruit from the blue marble tree, harvested from a tree in Honolulu. So there we go!

My test tube predictor says, "Obama for President."

Thanks to Ted Howard for taking this photo!

Alaska + Animals = Alaskanimals

It's fun to be in Alaska for the summer. The birch trees budded, bloomed and filled their limbs with leaves in about a week. The animals don't mess around either. As soon as it thaws, the fauna get out to load up on calories. Our animal list is phenomenal so far. And it's only been three weeks. Even less if you nix the time we spent removing gall bladders and delivering babies. So in 5 days, we've seen...

Hmmm. No one likes a list. Now that I've uploaded the files to my laptop, I'll periodically post pictures of what we were able to catch with the camera. Hopefully, I'll catch up before we go to Denali this weekend. The first two animals are two of my wife's favorites. Ironically, I've also found specimens of each for future use in Wunderkammern. In one case, a hoof and another case a foot. Lucky for me. Not so lucky for the donor.

Clashing Culture

I'm in the process of starting a new group blog called Clashing Culture. It's meant to be a place where atheists, agnostics and Christians can contribute and discuss posts that deal with the intersection of science and religion. So far, Mike Haubrich (Tangled Up in Blue Guy) has signed up. We're looking for more authors. If you are interested, drop me a line.