Its Rightful Place

Some pundits have commented that President Obama's inaugural address lacked the catch phrase or memorable line that JFK or FDR offered us in "Ask not what your country can do for you, ask what you can do for your country" or "We have nothing to fear but fear itself."

Perhaps this is true, but what I remember is:

We will restore science to its rightful place, and wield technology's wonders to raise health care's quality and lower its cost.

Let's focus on that first part:

We will restore science to its rightful place.

Does that mean the science adviser's office will be moving back into the West Wing???

Of course the inaugural address has the potential to be all talk. In his weekly address, he indicated that he will triple the number of fellowships in science. Initially, I wondered if this was at the graduate student, post-doctoral fellow or some other level. But then I found a report on whitehouse.gov with more details about the recovery plan.

With regard to the science in its rightful place goal, it looks like one step is

tripling the number of undergraduate and graduate fellowships in science, to help spur the next generation of home grown scientific innovation.

I wonder where all of those students will go after they have their science degrees? Will industry support them? Because I'm pretty sure academia won't. What about those young scientists who are finding it difficult to get their first grants?

Moving on, I think we should talk about the inaugural promise to wield technology's wonders to raise health care's quality and lower its cost. How exactly will we wield the wonders? According to the same Recovery Metrics document, the US government hopes to

computerize every American’s health record in five years, reducing medical errors and saving billions of dollars in health care costs.

Riiiiiggght... This one needs a little talking about.

I recently finished interviewing at 12 emergency medicine residency programs. As part of this, I toured some of the country's busiest emergency rooms; in many places I donned scrubs and saw how things worked 'on the inside.' Many places do have an electronic medical record (EMR), but some hospitals said that they probably wouldn't have a system in place by the time I finished residency (that's in four years). So that's a first strike against this goal. If the emergency departments - who provide primary care for more than 50 million Americans and are the first access point for unscheduled medical problems for everyone else - don't have an EMR, how will everyone's record be computerized?

This problem aside, there are additional barriers that need to be overcome if a 5 year goal is to be achieved.

1. A standard computer laguage that all EMR platforms use, so when patients move from one office to another or from one system to another, their info can be brought up in the same interface. As it stands now, this is not even standardized in the same hospital. In many places the emergency room's EMR is different from and cannot communicate with the hospital's!
2. For patient safety to be increased, more time and/or staff needs to be allowed for computer entry. In emergency rooms with medical records, I was amazed by the amount of time residents and attendings spend in front of computer monitors instead of with patients. In place of noting information on a clipboard while talking with patients, doctors have an extra hugely time-intensive step of data entry. Technology needs to improve. What about notebook style touch screen terminals? Except that would increase cost...
   
3. Is computerized care better? This seems to be a moot question, because everyone's headed in the digital direction. I'm probably just not well enough read on this topic, as the VA health system and large HMOs like Kaiser are all computerized. Are improvements to care there because of computers, or because everything's in the same system?

I see the computerized record as one of the important first steps in developing a single-payer model of health care, but the biggest impediment I see is getting the companies who make EMRs to talk to each other.

I applaud both of these goals of training more scientists and making health care safer, but want some more details, too.

Pride

What! You haven't heard of pyroptosis?

It's the hottest thing in cell death!

Well, except for my wife...

Illegal Questions

How old are you? Do you have kids?

My latest article at The Differential focuses on one component of my interview experience: illegal and inappropriate questions. Check it out, and if you are so inclined, back me up! And while you're there, check out a companion piece by co-blogger Anna Burkhead ponders another ageism related issue.

By the way, special thanks to DrugMonkey for inspiring the legwork to sort out the legal and social rules for this topic.

January 20, 2009

Thank you David Horsey.

Next Stop: Rank Lists

Interview season is finally over for me. So I've removed my handy reference of programs and interview dates from the side banner. I still need a convenient link list to organize program websites for the places I've been. Here's a chronological list.

• UCSF Nov 20
• U of Chicago Nov 25
• Northwestern Nov 26
• Harvard Dec 1
• Boston Medical Center Dec 2
• Yale Dec 3
• NYU/Bellevue Dec 5
• Highland (Oakland) Dec 23
• NY Presbyterian Jan 5
• Penn Jan 6
• Wash U (St. Louis) Jan 12
• Stanford Jan 16

I suppose I could have built a bookmark folder, but this cut-and-paste enables me to check back from any compy... The next deadline is February 25. That's when rank lists are due. We haven't decided if we will publicize our list, but I'm guessing the cards are going to fall close to the electronic chest.

I Blog, Therefore I Am

Instead of attending the ScienceOnline'09 conference, I was working on sorting out where my life's next stage would be set. But that didn't keep me from following some of the discussions about web publishing. One really interesting conversation worth your attention is the argument over the dichotomy between writers' lives online and in the real world. Dr. Free-Ride makes an insightful statement about the topic.

We may think of ourselves as being a particular kind of person on the inside, but from the point of view of the world we share, it's hard for me to believe that we aren't largely constituted by the stuff be bring out of ourselves. And I don't think that there's a principled difference between the stuff we bring out of ourselves in a three-dimensional conversation transmitted by sound waves and the stuff we bring out of ourselves in a blog post. Both are instances of communication that give others at least circumstantial evidence about what kind of person we are.

This supports my own approach to blogging. I blog because the internet affords a potentially interested audience for expressions that it is logistically difficult to find interest in off-line. And the people I meet on- or off-line will hear the same story, whether the word are printed or spoken. In the end both forms of communication end up shaping our futures, whether by design or accidental. Dr. Free-Ride continues,

Our past is out there on the internets. But testimony about our past would be available even in the absence of the internet (unless, once the recommendations are signed and sent, you've arranged for the speedy demise of all those who mentored you -- something against which I recommend in no uncertain terms). Opting out of leaving an online footprint is not going to give you full authority to tell the story of who it is you are and how it is you came to be that way. Your "authorial intent" in living your life matters, but the lives your life touches give their own testimony, and sometimes the story takes a turn you neither expected nor intended.

Right on! Would I be involved at Virtual Mentor or at WebMD or as an ethics teacher if I hadn't tried out this blogging thing a few years ago?

No Way!

I Would Walk How Many Miles?

I'm working on a post over at The Differential about all the traveling I've been doing to interview at residencies around the country, and am curious about the number of miles that residency applicants travel (by plane, train or auto) in a given interview season. Anyone have any ideas?

Virtual Mentor

In the process of preparing for my Ethics in the ER course, I've encountered a number of resources that folks interested in medical ethics may find useful. Every so often, I'll review and link them here. The first feature is Virtual Mentor. This is an online open-source journal published by the American Medical Association as a resource for teaching medical ethics. The content is decided by a panel of resident physicians and medical students with interests in ethics. The outcome is a forum for important conversations about current topics in health care. This month's issue, for example, addresses homelessness.

Each month, the journal posts editorials, literature reviews, policy positions, and my favorite section: case analyses. In general, the articles are interesting and accessible. Contributions are short to medium length, are written by qualified authors, and most of the time include varied viewpoints. The journal exists on a platform that is easy to use with .pdfs of every article and has some extra features like a podcast and a quiz from every issue. I understand that the entire journal will soon be listed in Pubmed. VM also compiles an excellent library of case studies and analyses from each of its issues. If you ever are curious about a particular issue in medical ethics, I recommend you consult this case index first.

Disclosure: I am an issue editor for Virtual Mentor's 2009/2010 year and am looking forward to assembling an issue related to emergency medicine ethics.

Ethics in the ER

This recent Wednesday was the first meeting of the Ethics in the ER course that I am co teaching with Harborview ER doc Stephanie Cooper. Our goals are to expose medical students to how the complex medical decisions made in the emergency department often demand a quick assessment and resolution of ethical dilemmas. The ER (especially in urban hospitals) is one place where physicians will rely on ethical principles every day.

So we've put together a course that features 20 minutes of lecture, 30 minutes of instuctor-led case reasoning, and an hour of student group reasoning. As the class moves forward, we will increasingly role play the fast pace neeed in the ER.

Since I'm a blogger, we're using a blog to enhance learning. If you want to follow along, feel free to stop by and read the students' posts. I'll be posting thinking exercises and links to relevant stories over there every week. There is also a course website, where you can peruse our reading list and syllabus. We're hoping to publish some of our motivations and experiences with this venture, as we are unaware of other efforts along these lines...

Vote for The Differential

The Differential, a blog written by medical students for medical students (and others) has been nominated for a 2008 Weblog award. (I write articles over there.) If you read that blog or are inclined to vote for it, visit this site before January 13, 2009. You can vote every 24 hours.

Caged Animals

While my wife and I were recently on furlough to her hometown in Oahu, we learned of a remarkable attraction: The Honolulu Zoo is currently the custodian of three tiger cubs. Now, I'm no huge fan of zoos. For me, it's a fine balance between sadness for caged wildlife and animal exposure and fundraising for conservation. When it comes to baby tigers, though there's something else at play. For example, in my wife's and my search for a residency, Washington University is high on our list because, yes, the St. Louis Zoo has FIVE baby tigers. (Actually, their lab medicine program is awesome - I haven't interviewed there yet.) But when we were visiting my in-laws and heard about the baby tigers, we took the day with the worst weather to visit the zoo.

It wasn't just caged tigers we saw... The first clue that something was up was that on a reasonably nice December afternoon, the longest line in Waikiki was not at the surfboard rental shop or the shave ice shack. It was at the zoo!!!

Exhibit A:The astute observer will find my wife in this image and the reason for our visit in the upper right corner. I wasn't about to stand in a line to see ostriches and elephants, so when I went up to the entry to ask if the tigers were on display, I was told bruskly that I needed to return to the line and wait to get the answer. Not the friendly zoo staff you'd imagine helping a lost child find her parents... The reason for the line was clear at the ticket counter. Everyone was being frisked by large crew-cut men with cords hanging from their ears. Why, what a nice purse you have there, sir! Broad shoulders, too. Do you work out?

But you know what an increased prevalence of body fat less than 10% linebacker types in "casual apparel" means...

...Barack Obama was at the zoo!

When we arrived at the tiger exhibit, not a feline was to be seen. Evidently, they were 'back-stage' for a special tour by some special guests. The perimeter was well secured.

See Exhibit B:
Those are some pretty heavy duty tiger-guards! You'd think the jungle predator (the tiger) could fend for itself. Note: the people behind the security were not ordinary zoo-goers. They were part of the Obama party. I think the Obama girls are seated on the park bench just over the Red Sox fan's right shoulder. They had just come out from a special feeding, play or education session with the tigers. At that point it came to pass that the first caged animal I actually saw at the zoo emerged from the brush. The tall man in the picture is Mufi Hannemann, Honolulu's mayor and presumably Obama's host. All joking aside, it was pretty amazing to be so close to the president-elect. I thought it would be more likely to see the family-elect in my wife's hometown: Kailua. It's unlikely that I'll ever see him in his natural habitat (Washington's corridors of power). After I got this photo, I moved on to the real attraction of the day: the tiger cubs. I was on crude digital camera videography duty. (My sister-in-law is the photographer of the family.) But I did snap this shot of one of the cubs.
Now if only there were a residency for Susan or me in Hawaii...

The Open Laboratory 2008

Remember when I used to blog about science?

Lately I've been defending a position that scientists and engineers ARE needed in emergency rooms. But these arguments have been confined to physicians' offices in Boston, Chicago and San Francisco. I've neglected (or spared) you my vision (or opinion). So too have posts at my other blogs trailed off, the correction of which would be on my list of resolutions, if I made them.

But here's some good news to jump start my 2009 blogging efforts: Hope for Pandora has been included in The Open Laboratory 2008 for contributing one of the top 50 science blog posts of the year.

Those of you who've been with me the longest may remember my "Dear Reviewer" post from about a year ago. It's a lovelorn account of the complex relationship between author and peer reviewer.

I've read several of the other posts (over the year and this morning) and am honored to be in such good company. Head over to A Blog Around the Clock for the full list, and stay tuned for how you can get your hands on a hard copy or .pdf.

Interviews Continue

In the process of making some of my last reservations for airfare and hotel, I cannot help but think about how fortunate in these ever-worsening economic times we senior medical students are to have a say in where we will work next year. It seems more of a pain than a privilege to have to jet across the US in search of the best-fit residency. But as each interview unfolds and as I'm toured the guts of America's hospitals, and as I observe how emergency departments operate on this coast or that, I feel tinges of conflict. Here I am with great opportunities - only one of which I will pursue - while the patients I'm chomping at the bit to meet, treat and advocate for face the converse: evaporating opportunity, escalating suffering and vanishing resources.

When framed this way, I ponder canceling the rest of my interviews. My pro&con lists from each program pick out relatively small differences between places. In the end, I know I must continue on for another few weeks. While the next month may consist of greenhouse gas guilt, travel fatigue and missed loved ones, the four years of residency will consist of lost sleep, steep learning curves, stresses of responsibility and the anguish of bearing witness to great pain and suffering. It will be important to live in a context of a supportive environment. Academic, social and even political and geographic context will play a part in my decision to rank programs. After then, it is up to the big computer in the sky to decide where is best.

We Escaped!

We flew on a different airline and to a different city than initially planned, but on Sunday night, my wife and I escaped the clutches of the winter storm currently incapacitating Seattle. I overheard one Southwest Airlines employee say we were the last plane to leave Seatac. I'm not sure if that was on Southwest, or in the whole airport. I wouldn't be surprised if it was the latter: we had to wait for more than 30 minutes just so the snow could be cleared on the tarmac between the plane and the runway. Our departure insured that our luggage did not make it into any "sorry, your flight was canceled, please collect your belongings in baggage claim" collections like this:


Susan was able to get to her interview at UCSF on Monday. I spent the day in the UCSF emergency departments for a 'second look.' Today, I interview across the bay at Oakland's Highland Hospital.

There are several reasons to be glad not to be in Seattle! It would be fun to play in the snow and all, but it turns out there's a reason why the city couldn't handle an inch of snow last week: Seattle refuses to use salt on its roads and the sand they do use is not enough to ensure safe motorist transit. The stated reason is the salt might impact Puget Sound's endangered salmon populations. Some biologists argue sand is actually worse because it fills the spaces between streambed pebbles such that insects and other fauna important to waterway health perish. Seattle is the only municipality (according to one article) that has a ban on salt. Sand is also 20% the cost of salt. My guess is that only the tincture of time and climate would benefit this picture:

With grades up to 20% in places, it's Mr. Sun who can restore normalcy to Seattle. Given this time of year's 8 hours of sunlight and perpetual winter clouds, I wish everyone there a hearty good luck! That packed ice takes a lot longer to melt than the fluffy stuff the kids are playing in. From a distance, Denny Way looks more like a ski slope than a road. In fact, there were intrepid young men snowboarding down Queen Anne Ave., NE 70th St., and I'm sure many others.

Snow Geese and Flying Home

On this Solstice Eve, the Pacific Northwest is getting slammed with a winter storm. And winter storms, we do not need! On Wednesday night Seattle received 1-2 inches (in most parts of the city), and look what happened:

Yes, that is a passenger bus that slid down a steep grade and plowed through a guard rail resulting in a cantilevered installation over I-5. Note the topography in the background. It's a good thing Seattle doesn't get winter weather very much. Susan and I are visiting our parents for the next two weeks, and hope to be able to leave Seattle tomorrow by plane. We also interview in the Bay Area on Monday and Tuesday! We'll be heading to the airport by bus extra early to account for difficulties from the the expected 4-8 inches of snow. If you want to see the view of the weather, here is a webcam view from the NOAA station across the street from where we live.

But we wanted to experience just a little bit of the current snow, so just as this evening's snow started to fall, we took a stroll around the golf course near our apartment. We were surprised to see a flock of about 30 large white birds circle and land on a nearby snow covered fairway. Upon closer inspection, I confirmed that it was a small gaggle of snow geese. I can only assume that they were in transit from the North Slope of Alaska to winter grounds in California or beyond.

At the time of writing, the snow has completely obstructed our view across Lake Washington. Unlike this Seattle-softened Midwesterner, I expect these birds to know what to do in the cold...

Science News

Among many other strong choices for science advisers, it appears an outspoken advocate for curbing greenhouse gasses has been selected to serve as chief science adviser for the Obama administration. John Holdren, a past president of American Association for the Advancement of Science, had to cancel a meeting at Harvard to fly to Chicago. According to journalists who are familiar with these escapades, this probably means he is meeting with Obama about a job. The AAAS blog reports this, as does a NYTimes blog. About climate change, he says,

I am one of those who believes that any reasonably comprehensive and up-to-date look at the evidence makes clear that civilization has already generated dangerous anthropogenic interference in the climate system…. What keeps me going is my belief that there is still a chance of avoiding catastrophe.

Sounds pretty okay to me. He also was involved with Pugwash and was part of the crew that accepted a Nobel Peace Prize in 1995 for nuclear non-proliferation work.

What I want to know is if he will get an office IN the White House. You may recall that GWBush kicked his science advisers out in favor of them occupying space down the street.

Random Musings

• 14 gauge needles are huge.
• Work hours debates continue.
• Teaching is fun.
• An electrified skeleton of a deer is feeding on the tundra that is our balcony.
• Did I mention how large 14 gauge needles are? I mean, an arm vein with a 14 gauge catheter seems to lose more blood (and faster too!) than a catheterized wrist artery... I've the bloody scrubs to prove it!
• Must... Get... Out... Into... Sun.... SOON!
• Thanks fto an anesthesia rotation, not only do I now check out people's veins when I meet them ("Could I get a 16 gauge into that antecubital?") but I inspect their chins. ("Start with the MacIntosh, or go straight to the Miller?")
• There are plenty of real people out there that think about more than, well... see above.
• Soon, I will be pulled in only one direction: the beach.

Note to Self:

Hey Robey!

When you have the time, write some blog entries about the latest Papal statement ("Dignitas Personae,") about in vitro fertilization and stem cell science and some of the responses to it.

Or maybe something about the scandal of free religious expression in the Washington State capitol building.

Or even about how the magi's part in the Christmas story provides a pretty good metaphor for a healthy interplay between science and religion.

I'd imagine each of these to be a good fit over at Clashing Culture, the blog I started about science and religion, which I have sorely neglected in the past few months. In the interim, get back to work!

Eagles

One thing I know about wherever we end up next year after the residency search is that I probably will not be able to sit in my living room and take pictures like this. (This bird was probably 20 meters from my window.)


Granted this is an out-of-focus shot with a point-and-shoot digital camera, but that I can see this on a regular basis from where I type away on my various projects is one of several reasons why my wife and I will miss Seattle. I just wish I could have gotten the snow covered mountains or Lake Washington in the background of this shot. But really: yesterday, I saw a bald eagle, a red tailed hawk and a Cooper's hawk in the span of a few hours.

Intubation

Today, I intubated my first (human) patient. I used a MacIntosh laryngoscope to displace the epiglottis so that I could insert a breathing tube down a patient's windpipe (trachea) so that she could be comfortably anesthetized during a surgery to remove her thyroid. The anesthesiologist had let me insert the plastic tube twice on other patients while he held the blade. He then let me do #3 from start to finish. #4, however, was not so successful. The patient's short chin and other factors made for a difficult process. At least I got one!


And let me say, my experience ventilating mice was not of much use as preparation. (I've probably intubated 750 rodents.) In the case of the mouse procedure, a cotton swab is the laryngoscope and a 10-100 piece of beveled tubing is the endotracheal tube. Evaluation of proper intubation (visualizing vocal cords, seeing fog on the inside of the tube and symmetric chest inflation) is however the same...

I can usually put patients at ease when I sew up their cuts if I say I've lots of practice stitching mice. Based on today, neither anesthsiologist nor patient will learn of my previous 'experience' with rodent intubation...

Delta Work Hours?

Last week the National Academies' Institute of Medicine released a report recommending that medical resident work hours be curtailed even more than they were five years ago. This is based on some pretty solid research, mostly from a sleep study group at Harvard. The report is the subject of my latest post at The Differential, which if you're in academic medicine, you should definitely read (if not my post, the report). Unfortunately for me, if the accreditation group makes any changes it will likely be AFTER my intern year when I'm expected to work 30 hour shifts...

Update 12/9/08: My post is getting a lot of comment activity, particularly from resident surgeons who are proudly defending the fact that they violate their 80 hour limits and love it! Check it out! By the way, Pauline Chen at the NYTimes wrote a biased "I didn't have work hours limits when I was a resident and I turned out just fine, thank you!" article about this issue. And there is lively discussion of the topic at the Times' Well Blog as well.

4th in 5 Days

I'm in NYC ready to interview at the NYU/Bellevue emergency medicine residency. It's my 3rd city in 4 days, and tomorrow will be my 4th interview in 5 days. On my day off, I observed for a few hours in the New Haven hospital before going by Amtrak to NYC. I'm not particularly tired, but I do miss being home. Some things that have made this trip easier include:

• Traveling by train in the northeast is easy: show up at the station, get on the train, work in peace and quiet for a few hours, get off the train & you're there.
• Staying with friends from med school is great. Since I took 4 years to do my PhD, my classmates are all 4th year residents and therefore very knowledgeable hosts. It saves lots of ca$h, too.
• Traveling light is a must. For me, that's a bike messenger bag and a shoulder garment bag.

Negatives include:

• Not seeing or talking to my wife much - The three hour time zone difference further complicates the fact that she is working a night shift and sleeping days, and "everything's in a fog" for her.
• Gum on transit seats. Bad form folks... If only we were in Singapore! My impromptu road extraction kit lacks a key solvent. Hopefully the friendly neighborhood dry cleaners will be able to help me next week. My evaluators will have to look REALLY CLOSE at my backside to notice the gum remnant!
• Answering the SAME QUESTION over and again. At least my response stays the same each time.

Well then! Enough from me...

Dr. Goatee

In searching the internet for possible residency interview questions, I stumbled upon some other 'tips' about interviewing. Most notably, one site from Rush University offers the following prescription for a successful personal presentation:

Dress should always be conservative, tasteful, neat—and comfortable.

Have the appearance of a successful, mature physician, not a medical student.

MEN should wear a suit, not sport coat or khakis.

• Navy or gray, solid or pinstripe.
• White or pale-blue shirt.
• Conservative tie: solid, stripes, or small pattern (red or navy).
• Keep jewelry to a minimum.
• Short hair, preferably no goatees.

It's not just the Chicagoans at Rush that offer this advice. I found websites penned by schools from LA to Boston arguing for a clean shaven face. But there are other things I noticed about these suggestions:

Dress should always be conservative, tasteful, neat—and comfortable.
Okay, I buy this. Comfortable helps when you're running to catch your next flight, too.

Have the appearance of a successful, mature physician, not a medical student.
I think I have this down, what with being older than most of the residents at some programs; in five interviews (three schools, so far), I've received the follow-up question, "How old are you?"

Men should wear a suit, not sport coat or khakis.
Okay, I'll give here. Although when I interviewed at UW for the MD/PhD program, I wore khakis and a tie - no jacket. Look where that got me!

Navy or gray, solid or pinstripe.
Evidently black is out?

White or pale-blue shirt.
Whoops again. I don't own white or pale blue.

Conservative tie: solid, stripes, or small pattern (red or navy).
My real goal here is: not ugly.

Keep jewelry to a minimum.
Nickle allergy keeps this in check for me.

Short hair, preferably no goatees.
Does a shaved head count for short hair? Maybe shaving up there will cancel out the apparent transgression I make with this:



I did end up shaving, but it was the top of my head...

EM Interview Questions

There are a number of standard residency interview questions that candidates are asked in the interview circuit. A Google search will provide you with some stock questions you should be prepared to answer. For various reasons, I tend to take advice from those sites with a grain of salt. So here are some actual questions I've been asked on my emergency medicine residency interviews.

• How did you decide to apply to our program?
• Where will you be in 10 years?
• You've a different background than many applicants. Describe your trajectory in deciding on emergency medicine.
• What have you been reading?
• What is Wunderkammern? (A hobby I listed on my application.)
• So! What do I need to know about you?
• Which of your letter writers do you admire the most?
• What questions about our program can I answer for you?
• How would you respond to (insert complicated ethical dilemma here)?
• What are you doing the rest of the year?
• What are your plans for the holidays?
• What courses are you enrolled in this year?
• Why emergency medicine?
  
• Where else are you interviewing?
• Why (insert city here)?
• What will your first book be about?
• How have you responded to a situation of personal conflict?
• What areas of emergency medicine need the most work?
• Do you want to go back to Seattle to practice EM?
• What do you do to relax?
  

I'll give periodic updates to this list. I've only interviewed in three places. Do any of you co-applicants have any additions?

Titles

A few weeks ago, I shared what would I thought could make a good title for a book. I still like it a little while later, but am thinking that catchy isn't the only requirement for a title's success. The content has to be interesting, too.

My recent extravagance in carbon expenditure - also known as residency interviewing has triggered some interesting publication ideas. Of course, the best idea has already been acted on by another frequent flier. Fortunate to get window seats in the exit row for my past 3 flights, I could concentrate on the view below rather than avoiding broken patellas or DVTs. And I got to thinking that the maps in the back of the airlines' magazines hardly provide useful information for the curious window-sitter.

So why not publish a guide to the most trafficked flight corridors that explains where you are, the topographic formations, and cloud formations from 35,000 feet?

One good reason is that other folks have already thought of this. A title printed in 2004 (Window Seat: Reading the Landscape from the Air) and one in 2007 (America from the Air: A Guide to the Landscape Along Your Route) look to be complementary resources for the curious traveler.

Both look interesting, so I put them on my Amazon Wish List. Maybe there is still room for my ideas, but the core concept has already been done... One author even thought about providing an interactive CD for use in your laptop! (My idea was to adapt my book for a handheld computer.) So much for my business plan! I should stick with medicine.

Inner Viewing

You can expect my posts over at The Differential to focus on interviewing for the next few weeks. After I finished my interview at the UCSF residency last week, I jotted down a few tips for future interviews. The article is now up over at the MedScape blog.


Stay tuned for more tips. Both here and there!

Obama Lit 101

In real life (i.e. not on this blog), I'd been pretty critical of John McCain's medical history of melanoma so was pleased when he released his medical records, limited that they were. Back in the early primaries, I was equally critical of Barack Obama's smoking habit (correction: smoking addiction). That issue just faded away. Where is it now? Evidently, Obama may still be smoking. Michael Kinsley of the Washington Post thinks it's okay that he's fibbing about quitting. I'm not so sure I agree with that, but I am sure about it not being okay that the next president smokes. We need some health advocacy groups to jump on that (if it's true).

What have you heard about the next president lighting up?

Today is the Day

Today I interview at UC San Francisco for a spot in their emergency medicine residency. It is the first interview of many for me, but is one of my very top choices. I've spent the last month working in San Francisco General Hospital, and really like the place. Granted, it's the only academic ED I've worked in thus far...

Well then... Here goes!

back to days

brain is jelly.

granted, it's spicy cranberry jelly.

jelly none-the-less.

perhaps returning to daytime shifts will help me out!

This is What I'm Signing Up For...

Several of my friends have suggested I respond to Pauline Chen's recent article in the New York Times about the treatment of medical interns during the first year of residency. Her article is provocative, and I am planning to offer a response (from a soon-to-be intern), but am still digesting it. Stay tuned.

Really Tough Stuff

Lately, I've been complaining about the residency application process on this site and elsewhere in the non-digital world. It's been nice to be on rotation and have daily reminders of why you are going through the cumbersome process. Sometimes however, giant "reset" buttons come your way. Gianter (grammar intentionally misused) then catching a DVT or sewing a laceration, and not quite like the reset weekend to help me switch from day to night shifts that I wrote about this morning.

The reset I'm referring to tonight is more important. Today I visited a blog that I had not been to in a while. It's Ben Towne's online journal.


Ben is the three year old son of one of the pastors at the church I attend. He was diagnosed with an aggressive neuroblastoma last August (2007). Ben and his family have endured ups and downs of treatment and remission, hospitalization and time at home. They have had a large body of supporters, many of whom may have never even met Ben. I count myself as one of the folks who first heard about the family's story in a pew and have followed it by periodically reading the blog.

Much of the art of medicine is related to empathy with patients and families we encounter them in the hospital or clinic. It's a gift to be able to achieve this emotional skill, and it's one that can always find a new place in the physician's toolkit. There is even more to learn from witnessing non-medical aspects of patients' experiences. Some people go into medicine because of these experiences: a grandparent who may not have received the best care, a sibling who couldn't be saved from a disease, or a friend who was paralyzed in a car accident. I was not one of these people. That's why it has been a privilege to follow along with the Towne family's trials. Their web journal also makes it easier for me to think about and pray for them.

After aggressive radiation and chemotherapy, Ben's tumors are back with a vengeance. There is little that medicine can do for him except control his pain. The family has taken him home from the hospital and will pursue comfort care for him. By any account they have a tough road ahead of them. Yet, the journal reports this week that:

Many times last night Ben told [his mom] not to worry and that he loves her.

If you are inclined to pray, meditate or reflect about Ben and his family, I am sure that the Townes would appreciate it.

Fog Horns

It's a reset weekend.

After doing mostly 6AM to 2PM or midday shifts, my schedule necessitates my transitioning to an inverse circadian rhythm. After two days off, I have one 2PM to 10PM shift, and then five 10PM to 6AMs. Just like flying across country there are a couple of tricks for adjusting that I'm trying to follow. Today, I:

• Slept until 9:00 AM
• Plan to have a late breakfast
• Am contemplating each toot of a distant foghorn
• Will take a midday bike trip (via BART) to my parents in the East Bay
• Plan to eat dinner as my second meal
  
• Anticipate catching up on my writing late into the night

Tomorrow, I plan to:

• Sleep in even later
• Wait for the (forecasted) morning rain to cease before returning to San Francisco
• Take an evening jog
  
• Eat lunch, dinner and a late night snack
• Study some topics in emergency medicine
  
• Sleep from 1AM to 9AM (Monday)
  

Then I'll have to figure out where is the best place to sleep during the day...

A similar plan worked for me when I flipped from 12 hour day shifts to the converse while working at Harborview. Stay tuned for the outcome.

Interviews!

Wow!

The stress of the interview season is still crescendoing for me. I've a couple of rejections, a fair number of invites (see column at right) and a couple of programs I still haven't heard from in cities where my wife is very interested in training. Now that she is heading off for her first trip (New York, Baltimore, St. Louis, Boston, Chicago in two weeks), I'm of course antsy. Trying to fit in a couple interviews in each of the cities she likes is maddening! Especially when there are optional but strongly recommended social activities the night before or after the interview, making logistics quite painful. And I haven't even started to purchase airfare!

So it goes. I am glad to be in San Fransisco learning more emergency medicine and seeing how a residency works. Being from a city without a residency program is a real handicap in terms of knowing what to look for and assessing for fit. I'm having a great time here in spite of the stress of organizing a travel agenda. Any readers out there having the same struggles?

Health Care PRN

Will all of our pre-election excitement be lost to follow-up?

Now that there's a new guy headed to the White House, it's time to put some of those ideas about improving access to health care on the line.

I ramble about this and other topics over on The Differential today. Thanks for reading.

My First Rejection

The University of Pittsburgh declined to interview me for their residency program, but there are a couple of others who have extended an invitation (see running panel at right). I'm still playing the waiting game for the other 20 programs...

And I'll still root for Pitt basketball and football...

It is Finished

And so it came to pass that on Nov. 4, 2008, shortly after 11 p.m. Eastern time, the American Civil War ended, as a black man — Barack Hussein Obama — won enough electoral votes to become president of the United States.

Read the rest of Thomas Friedman's editorial here.

Obama

Good for health care

Good for peace
Good for science & innovation
Good for education
Good for the environment
Good for a better society

I guess those are the main things I care about when I go to the polls. My remaining hope is for:
An Obamaslide

Make your own logo at Logobama.

And no matter your political preference, make sure you vote today.

Bummers

How would you feel if after being treated for a traumatic car accident, the ER doc comes back to tell you there's probably a tumor in your lung?

The Daily Commute

or, "How Biking in San Francisco Reminds Me of Rugby"

After a week of commuting between San Francisco's Haight-Ashbury neighborhood and the Mission by bicycle, it occurred to me why I'm having so much fun going to and coming from work: it reminds me of rugby! Some readers may know that I played rugby for three years at the University of Pittsburgh. It was a club sport and I played on the B-side for all but the last 4 months or so, but I stuck with it because it kept me in shape, I was always learning new strategy and it was certainly a good way to release stress during difficult semesters. After I realized the other night that commuting by cycle provided the same thing for me here, the similarities just kept piling in. Here's my running list:

1. Both are excellent sources of aerobic exercise.
2. Biking safely in SF requires the hyper-alert mental status that keeps a rugger from getting clocked.
3. Ruggers and bikers must remain aggressively protective of their space.
4. This is the first time since rugby I've consistently worn stretch pants.
5. I get up really early to ride.
   
6. I work out late at night.
7. Showers twice a day in odd locations.
8. Climbing Haight St. kind of reminds me of running stairs.
9. Avoid taxis at all costs.
10. "Why are all of my clothes sweaty?"
11. There are some rules that must always be followed and there are others that you can get away with breaking most of the time.
12. There will always be folks who are much faster, in better shape, have more skill and are harder core than I.
    

Well, that's all that comes to mind for now. The bottom line is that I'm having a great time in SF, even if it's mostly consisting of working long hours, staying in to study and commuting between the two. By the way, I found this excellent website that plots a course between A and B on a bike that takes into account hill grade, total distance and more.

Medic Ride-Around

I just returned from 10 hours on a paramedic rig in San Francisco. This is part of the emergency medicine rotation at San Francisco General. It was a rather interesting day. Not very busy, but busy enough that I only napped for 10 minutes around 1:30 PM.

The cases included:

1. A morning commuter who fell in a crosswalk, skinned her knee and was bleeding from the head.
2. An older gentlemen one week out from a prostate surgery who had bloody urine and pelvic pain.
3. A kid who fell in gym class onto a tennis court and had midline neck and back pain.
4. An eleven year old who was post-ictal from his first seizure.
5. A different eleven year-old who konked heads with a classmate playing football.
6. An elderly diabetic woman who fell at the food pantry and incurred a non-bleeding scratch on her knee. She later offered to dance for us - for a fee.

Three of these went to a hospital. The medics apologized for not having any 'interesting' cases, but one pointed out that his favorite kind of day is one where no one gets hurt. It was interesting to me to see what people call 9-1-1 for, and the expense incurred for it. That's a difficult thing to get my mind around. And I'll have to think about that a little more.

Hello. I'm Thomas. And I'm a Blogaholic.

Okay.  It's time to dive head-first into the medical blogging controversy.  One of my colleagues at the University of Washington is interacting with administration there to possibly set guidelines and recommendations for medical blogging.  He's got me thinking again about this issue.  As you recall, I thought a lot (and still do) about the line between sharing a patient's story (anonymized) and respecting her rights.  I settle with asking patients or masking identifying facts so much that the patient would not recognize the account as his own.  You can imagine there are a lot of people who have things to say about this.  I respond to my professional society's position in this week's article for The Differential.  Check it out if you have the chance.

Regarding blogaholism, I actually do score positively on the CAGE screen for blogging (A and E).

2-10

Warning: humdrum domestic details ahead!

My first shift is today from 1400 to 2200. Last night I prepared by staying up until 11:00 PM. Today, I tried to sleep until 8 or 9:00. This morning, I'm reading emergency medicine stuff for a few hours, am soon going to track down some biking shorts (be very afraid) and a reflective vest, and will head over to the San Francisco General around 1:00 so I have time to shower and get my hair done. Then, since I have tomorrow off, I think I'll head over to the East Bay to get some computer work done. Now I just have to find a library where I can set up shop working on my various writing projects...

Next Stop: San Francisco

Well... actually, I'm flying into Oakland, staying with my parents in the East Bay and then heading over to SF proper to get the lay of the land before Monday's orientation to the San Francisco General emergency medicine clerkship. I'll pick up my brand new Trek 7.3 this weekend!!! My first shift is on Tuesday, I'll be riding along with medics on Thursday and much more. My overnight shifts are all grouped in my third week, which is nice, and I have scheduled my residency interview the last week of the rotation.

Now if I can just figure out what I need to pack...

Last Day

Today is going to be crazy. Just like the last 70 days.

After ten consecutive weeks of psychiatry, I'm going to miss hour-long interviews, the wait and see approach to care, the challenge of nurturing behavior change and all of the talking. I'll also miss the daily case studies of brain pathology.

• The amazingly disorganized schizoaffective homeless man who saluted me every time I asked him a question and could recount amazingly accurate historical accounts of the Pacific Theater in WWII.
• Entering into the dark, empty, wide-open room at the edge of a cliff and offering one pinhole of light (i.e. Washington Sate Law) to move a suicidal patient to the next day.
• Having to stand back when an extremely psychotic patient is immobilized for her own safety and then being there when she is able to speak in cogent sentences.
• Seeing the effects of drugs and alcohol that all of the commercials warn about.
• Learning that it's actually not uncommon for a manic person to be found naked, directing traffic. In fact, it's pathomneumonic for mania.

Psychiatry, you've been good to me. I'll see you again soon.

Diagnose This

For no apparent reason, I've woken up at 5:15 or 5:30 without an alarm for the past week.

I wonder if this application process is taking a toll on my sleep architecture.

Clinical Knowledge

My USMLE Step 2 Clinical Knowledge score came back in record time. As you will recall, my score on the costly sandwich (CS) exam was PASS. Today, three weeks to the day after taking the 9 hour computer exam, I received my score report. I PASSED, and scored higher than I did on Step 1 (which I took back in 2003).

Since my score was higher than I expected, and lower than most of my peers, I've decided to share some data about how well the USMLE World practice software package prepared me and the accuracy of one practice exam score predictor, provided by medfriends.org. Those who know I'm an engineer at hear will not be suprised by the following chart.

Plotted on this graph are score estimates from sequential practice exams I took using the USMLE World software. That software grants you acces to a couple thousand practice questions and prepares exams composing of 46 questions each. I averaged the raw scores of the six most recent exams made of questions I'd never seen. That average was input into the medfriends.org tool and plotted on the date. The averages are rolling. The turnover was 4 exams (adjacent data points share from 1-3 individual scores in their average. On the scale above, the horizontal line is 184, or passing. You can see that my trend was dangerously close to that cutoff. But considering my poor showing on Step 1 back in '03, I knew I needed to buckle down.

Shown in red is my actual score - a 209. This is below the national mean, but right about where I'd hoped to be. The one data point immediately before the exam - that was the free USMLE practice exam provided by the exam company. I recommend you take it. not only, will it make you feel better, my experience was that combined with the score estimator, it was a better predictor of my actual score.

Finally, you may ask: why is he advertising such a low score? Well - there's a good chance that residency programs already know my score. If you're reading this because Google brought you here, maybe you'll appreciate seeing a self-reported score that isn't in the 240 range. If you're reading this because your my friend, thanks for being my friend!

If you haven't taken the exam yet, hang in there. Take some time to focus on the material, practice with question sets, and try to take some time off to prepare. I wouldn't, for example, recommend studying at the same time as taking a required psychiatry clerkship.

Jump Into Sound

One of my patient's chief complaints today currently tops the list of titles for my first book, should I ever get to that point. The phrase carries multiple meanings ranging from dark to playful.

Jump Into Sound

What do you think?

Interviews

I've another article up at The Differential today. This one's about the anxiety associated with interviews. Not interviewing patients - interviewing at residency programs. Except that right now, my anxiety is centered on waiting for interview offers. For those playing along at home, I'll be updating a list (on the panel at right) of which cities you may be able to find me over the next few months. I'm linking the programs' websites, too (as much for my own utility as for your curiosity). Next week, I'll fly to the Bay Area for a month-long emergency medicine clerkship at San Francisco General Hospital.

Physician Heal Thyself

I've been a bit under the weather lately, and considering that I currently cannot see more than 50 feet out my window which can typically see mountains 50 miles away, that's saying something. Getting sick as a health provider adds conflict to the first directive of "do no harm" and lumps additional irony to the proverb, "Physician, heal thyself." Medical student status adds another wrench to the mix. I've written more over at The Differential.

Powell Endorses Obama

This entire segment on Meet the Press is worth watching, but I want to direct your attention to the part of his statement beginning at minute 4:27.



Right on, General Powell!

"What if he is?" and "Is there something wrong with a 7 year old Muslim-American kid who believes he or she could be President?"

These are the questions we SHOULD be talking about. And "Muslim-American" in that question should be interchangeable with atheist or agnostic or Hindu or Jewish...

2008 FOSEP Enegy Forum

In 2004, Seattle's Forum on Science Ethics and Policy (FOSEP) hosted an informational event about stem cells that attracted more than 700 people to the University of Washington Campus. This election year, a new group of graduate students has put together what promises to be even more timely. If you are in or near Seattle on Thursday, October 16, this event will be worth your time. Check out more at FOSEP's web site, or click on this poster for more information.

Take This Class

Click for a larger image. Email me with questions.

Clinical Skills

I am pleased to report that the United States Medical Licensing Examination has found me:

• capable of integrating a clinical encounter
• competent with communication and interpersonal skills and
• proficient with spoken English.

In sum, I passed the clinical skills portion of USMLE Step 2. Step 2 CS. The CS stands for Costly Sandwich. As in $1500. Or in my case, $500 each. For those outside of the medical education circle, this is the exam where senior medical students (or international medical graduates) fly to one of 5 American cities to take an 8 hour examination that consists of interviews with 12 standardized patient actors. The closest spot for me was in LA. The exam costs about $1200 not including lodging and airfare. There is a "free" lunch.

Register Today!

Have you registered to vote yet?

If not, today is your last day to do it if you want to vote in the most important election in my lifetime.

Rock the Vote has a really easy online registration in whichever state you're in.

Just Do It!

Going Crazy in the PES

Lately I've been thinking a lot about what the difference between psychiatric illness and normal variation. Admittedly, this is due to my frequent proximity to mental illness with my clinical rotations. My latest post to The Differential could blur the line a little more than usual. It's a must-read for my family and close friends. Can you figure me out?

Role Model

I'd someday like to be a Caleb Burhans of science, medicine and society. Don't know who that is? I didn't either until I read today's New York Times feature of him. Or, if you're oriented more to screen than print, watch this clip:



I found it an inspiring example of following one's interests and passions.

Carnivals!!!

My fellow bloggers,

Are you looking for some carnivals to showcase your best writing? Listen up!

Like so many of my extra-curricular interests, blogging has fallen a bit behind in the face of licensing board exams, finals, and long hospital work hours. It doesn't help that my current bus lines do not have wireless... But you've seen an increase here and at The Differential of late. I am really excited about what is going down over at Clashing Culture in the next two weeks. Thanks to the strong work one of my co-bloggers there (Mike, also known as Tangled Up In Blue Guy), Clashing Culture will be hosting not one, not two, but three carnivals in the next two weeks.

On deck over there is:

• October 8: Carnival of the Liberals ... Liberal politics hosted by Mike
• October 8: Four Stone Hearth ... Anthropology hosted by me
• October 15: Carnival of Evolution ... Evolution hosted by Mike
  

If you want to submit to any of these, click on the links above to either connect to a web form or to email the host.

it is finished

Step 2 Clinical Skills is in the rear view mirror, and I'm driving the speed limit. Which is only 55 on the freeway passing though my municipality.

Why only the speed limit? It's all those gruesome traumas I've seen in the ED were for folks driving ABOVE the limit...

Anyway.

I'm pretty sure I won't have to take the exam again.

Blame it on Congress

Before we all scream about how congress didn't pass a bill to give $7x10^11 to a bunch of fat cat bankers...

...don't forget about:

The bankers who lied to themselves.
And the loan applicants who lied to the lenders.
Oh! and the lenders who didn't care they were being lied to.

Boy, am I glad to be liquid!

Practice Question

A 30 year old colleague approaches you for a curbside consult. A friend of his who is 4 days status post a recent comprehensive psychiatry exam is now complaining of malaise, headache and frequent urination. He has rhinorrhea, and is complaining of frequent sneezing and a "throat tickle" that requires frequent clearing of his throat. He denies throat pain, ear pain, nausea or vomiting. Your colleague humored his friend with a brief physical exam. On exam, there were engorged nasal turbinates with profuse clear discharge, there was a mild white discoloration of pretonisilar pillars; tonsils were absent. His breath smelled faintly sweet. Bilateral mobile, tender, 3 cm sub-mandibular nodes were appreciated. Chest exam was clear. Further history revealed nocturnal urinary retention and dry mouth that awakens him several times at night. A thorough social history indicated the 'friend' felt a sense of impending doom, especially when presented with web-based tutorials. Your differential diagnosis includes:

A) Antihistamine use
B) Panic Disorder
C) Viral upper respiratory infection
D) USMLE Step 2 CK
E) Sleep disorder NOS
F) Caffeine dependence, sustained
G) Specific Phobia

Eloped

My latest article at The Differential is about the medical use of the word, "elope." It probably won't get as much interest and commenting as my last article about firing patients and abortion.

Some of the critical comments responding to my entry suggested it was inappropriate for me to draw similarities between firing psych patients because you cannot help them any more and referring patients to another provider if you are uncomfortable not performing a procedure (namely, abortion). At the core of my argument is my concern that patients get the best care available, and that they should seek said care from the best individual able to provide it. Most of the rest took the opportunity to voice their own opinions about abortion in medicine. Some of my critics argue that all doctors should be willing to provide abortions (that's not going to happen). One reader questioned my disclosure that I was 'uneasy' with providing abortions myself. I'm not sure how to respond to that... Finally, one reader has argued that we must get over the fact that the country is divided about abortion. I would argue that adopting this perspective would effectively invalidate half of your patients' beliefs.

500 Coyotes

Earlier this week around 6 AM, we caught a glimpse of a bushy black-tipped tail. And this evening, there was the familiar refrain of yip yaweeee. What a great way to celebrate my 500th post! The introspective coyote, searching for his reflection in pavement puddles is not a bad representation of the recent self examination I've been doing in the residency application process.

I'm guessing this season will have more rain and introspection. Hopefully, more coyotes too!

Happy 500 to me!

More than Meets the Eye.

I love living in a world where this is news.

When the transformer malfunctioned, operating temperatures rose from below 2 Kelvin to 4.5 Kelvin -- extraordinarily cold by most standards, but warmer than the normal operating temperature.

Isn't this so much better than what's her name's what's it called?

Controversy!

Abortion, psychiatry, firing patients: three issues that elicit strong emotions. So if you suffer from a panic disorder, you may not want to...

Read my latest entry at The Differential to get my take.

Otherwise, carry on!

ERAS

I just finished uploading my personal statement, applied to 30 emergency medicine programs and shelled out $365 to the Electronic Residency Application Service (ERAS). That's just one dollar a day to feed an orphaned... wait, that must be something else. I'm just glad I have the opportunity to continue my training to be a physician. Since my wife and I are both applying, we have selected ten cities that have programs that appeal to both of us. They include (from west to east):

The Bay Area
St. Louis
Chicago
Atlanta
Pittsburgh
DC/Baltimore
Philadelphia
New York
New Haven
Boston

This is the end of one stressful task (applying), and the beginning of another (hopefully, interviewing!). Read my personal statement here.

Palin, The Alaskan

My favorite local editorial cartoonist points out that just because you're from Alaska, doesn't mean you have the interests of wilderness in mind. And by one perspective, it's likely that your idea of custodianship is more akin to pillaging. We Washingtonians have an interesting relationship with Alaska politics: we're big trading partners, AK is a frequent vacation destination, most of the fishing fleet docks in Seattle's Ballard neighborhood, we share a medical school - okay that last one's not SO big a deal... This is the third or fourth consecutive shot at Go. Palin that Horsey has taken this week. I guess it's one way we look out for or meddle in the business of our neighbor to the north.

Me, In A Page

Lately, I've been diverting most of my wordsmithing to a one page document that may be the single determinant of where I spend the next four years of my life. Putting these ideas about science, medicine and society into a page has me really excited about a career in emergency medicine.

*****

One late summer night in Harborview Medical Center's emergency department, an exasperated medicine resident turned to me with a rhetorical question: “Who would want to treat homeless, drug-using prostitutes?” When I immediately thought, “I do,” I knew I was home. This epiphany at the end of a month in Seattle’s level one trauma center cemented my commitment to a career in emergency medicine. Contributing to the trauma team, working with a diversity of cases, the rapid progression from presentation to diagnosis to treatment, and the societal issues I pondered after each shift all conspired to entrench my connection to the ED.

My path to a career caring for the acutely ill started with dreams of building life support machines. As a clinical technician for the University of Pittsburgh's artificial heart program, I learned that invention and patient care have a tendency to interdigitate. The image of science and medicine clasping hands framed my motivation for earning a bioengineering PhD. I developed innovative new surgical, molecular and tissue engineering techniques as part of my thesis project to improve the viability of embryonic stem cell-derived cardiac tissue replacements for use after myocardial infarction. Long hours in the lab doing thoracotomies on mice and measuring with echocardiography the extent to which we were repairing infarctions introduced me to the importance of intellectual and manual dexterity in medicine. Experience suturing hundreds of rodents enabled me to consider each human laceration repair a new artistic challenge. My first successful ultrasound-guided basilic vein cannulation opened wide my appreciation for sonography in the ED. Emergency medicine requires mastery of numerous techniques and knowledge from many disciplines; this environment of collaborative innovation makes EM a perfect career for someone like me who wants to combine multiple skills and interests to provide the best care for patients.

The notion that today’s scholars have to focus narrowly on subdivided fields in order to make contributions to society contrasts with my perspective that the actors of social change must think deeply in multiple fields. As a graduate student working with human embryonic stem cells, I learned firsthand not only how scientific research occurs in the context of social and political concerns, but also that scientists and physicians are obligated to contribute to public dialogue. I am as proud of defining 'blastocyst' and 'in vitro fertilization' for stem cell research legislation in Washington State as I am of my labwork to further the potential of cardiac regeneration. Through a science policy group I co-founded, I planned campus-wide conversations about genetically modified food that spurred constructive conversations that continue more than three years later. Hosting President Clinton's science advisor to engage the University of Washington about the future of research funding in America offered a glimpse into the importance of sound science policy.

However, one needs look no further than county hospitals' waiting rooms to see that innovation in patient care is not merely a scientific enterprise – it needs to be a social one. Our current policy morass of underserved health care in America establishes emergency medicine as the front line for individuals seeking to heal people and the system. Solutions are not easy to find, especially from within the academic ivory tower; some of my understanding of the complexities of urban health care is grounded in relationships I've built over four years as an STD counselor for homeless teens. I aspire to be the emergency physician who draws on experience treating the neediest of patients to facilitate difficult conversations about health policy.

The ED is not merely a safety net. Challenging ethical dilemmas that emerge from a diversity of diseases, the urgent presentation of humanity in crisis, and the varied manner in which people respond to acute illness demand that emergency providers have ethical reasoning skills at the ready. The emergency room is a laboratory for teaching medical ethics; I hope to translate an “Ethics in the ER” course I developed for medical students at the University of Washington into a training tool for tomorrow's doctors. My experience designing this course has helped me understand better that educating others is a critical element of the practice of medicine. Teaching forces me to shore up topical understanding and requires communication accessible to a range of individuals: patients, students and colleagues. I look forward to an EM residency that provides both teaching role models and opportunities to refine my own skills.

Scientist, activist, writer, ethicist, engineer, doctor: for me, each of these roles supports the others. Rather than a collection of titles in separate contexts, I prefer the simple title of citizen-physician. There is deep meaning in the patient-physician interaction, both in the literal space of a sick person seeking care and as a metaphor for how physicians can improve society. My diverse and well-developed interests are ingredients for a career in emergency medicine that steps beyond discrete disciplines to address patients’ immediate health needs and improve the practice of medicine.