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.

Where'd I go?

Long Story Short:

My computer crashed and I've been busy studying for Step 2 of the medical board exam in the midst of a rather busy psychiatry service.

I'm still working on recovering everything from my old (Windows) lappy. Once that is done, I'll be more happy. Yes - that rhyme was sappy.

But at least I'm back.

Psyche Me In!

Just a brief update:

I finished the third day of my psychiatry clerkship this evening. The patients my team cares for are on the lowest acuity section of the floor, but that means there are a lot of interesting - and sad - personality disorders (versus the floridly psychotic). The learning curve is steep, but I think I'll get a basic hang of the topics in a few weeks. What I am really excited about is honing my interview skills. This is the perfect place for that.

Big News!

One of the things that has been keeping me from posting new entries here is a little project I've been working on for the past 4 or 5 months. Today, I received an email from the chair of UW's Medical History and Ethics department that opened with,

We are happy to endorse the plan for an ER Ethics course as you outline it, and look forward to providing it as an MHE offering.

Whoop Whoop!

I mean, "My, what a fine outcome. I cannot wait to see this effort come to full fruition." Or something.

The bottom line is that back in March, I was in the emergency department admitting a patient to the medicine floor when I ran into an emergency attending who I knew as a sophomore medical student back in what they call the day. We knew each other to be writers, so we caught up about each others' activities. She told me about a cool medical humanities 'zine she was writing a proposal for (since funded!). I told her about my gig at The Differential. And she mentioned an idea for teaching an ethics class based on cases from the ER.

Schreech!!! My mind and body did a double take.

I don't exactly recall what condition the patient I was admitting had, so will take some narrative privilege (and play the statistics) to report that I thought: "the guy with hepatic encephalopathy can wait a few more minutes." In truth, it was 3AM, we had already examined him and written orders and I was checking lab results in the fishbowl (which we call the central command center of the ER) before getting a couple hours of sleep. As usual, sleep takes the back seat.

The bottom line is that sleep was sacrificed for this project more than once. The opportunity to apply what has always been an extra-curricular (or at best co-curricular) interest in ethics to my chosen profession was amazing. As the chips lie today, this winter I'll be co-teaching (with the emergency medicine attending) a class to first through fourth year medical students called "Ethics in the ER." The curriculum is discussion oriented, is based on numerous actual cases, will employ a blog/discussion board and require a small amount of reading from medical humanities and ethics sources.

I think the curriculum we're developing is a unique approach in medical ethics education, and are excited about testing it and reporting our experiences for others to learn from and improve. I am also looking forward to a few more energized late nights turning theory into practice.

Getting By On Metaphor

I take my metaphor extended, not mixed. Need proof? Read my latest post at The Differential. It's about the residency application and interview process. I'm only at the opening round of the process, and I've already had to lean on allegory. If John Bunyan were a senior medical student, I think he'd approve.

I am only slightly comforted by the fact that my understanding metaphor rules out certain psychiatric diseases. Today was day one of my psychiatry clerkship, and I've already determined that I'm one major depressive episode away from a Bipolar Type II. (Anyone who knows me can appreciate the hypomania I've experienced over the years. I guess I'll just have to settle for cyclothymia. And as my psych attending pointed out today, people don't get admitted for cyclothymia - it's just to close to normal!

By the way, look for additional self diagnoses in the next 6-10 weeks. I hear it's pretty common on the psychiatry clerkship!

The HIPAA in the Room

I've been a little gun-shy of my posts on Hope for Pandora recently. It seems as though a Seattle medical version of big brother may be watching... watching blogs. One of my friends - a blogging friend and real-life friend - was asked to remove material or shut his blog down because a compliance officer at a hospital where we train was concerned that certain of his posts violated patient confidentiality. Check out Noel's blog, aptly named, Constructive Procrastination.

I have sought to maintain the integrity of my writing by anonymizing my stories or asking permission of my patients to write about them or folding several patients into one pseudo-fictional account in the interest of telling a good story. Each of these techniques fall within the guidelines of the Healthcare Blogger Code of Ethics. What bothers me is that my friend had also observed these behaviors in his writing.

What bothers him is the manner in which he was approached. I'll let him tell the story in his own words, which started a couple of weeks ago. It seems as though our hospital wants to have more control over what gets into the public domain from experiences inside the hospital. Since I have vague aspiration to publish some of my own expereinces in a format more commercial than a blog, this got my ears up. After all, I already write for lunch money over at The Differential. I contacted folks in the community relations department before starting that gig - I wonder if someone else is trying to enforce some element of control or oversight on writers like me.

I think that my hospital administration is a little out of its league right now. One in ten Americans have tried their hand at blogging or something like it. I'm betting that health professionals are no exemption to that. I'm a little worried about an Orwellian move here. Why isn't the Health Care Blogger Code of Ethics or something like it good enough?

The compliance office may be full of friendly faces and good intentions, but do they really know what they are trying to do? Fortunately, my friend has volunteered to provide a voice for us bloggers.

Facebook Pages

Here's a little entry to bring the blogosphere and the facebookosphere (?) a little closer together.


I've recently joined some Facebook groups that some of my readers may be interested in:

1. The American College of Emergency Physicians (ACEP), where I've started a little thread about ethics in emergency medicine.
2. The American Scientific Affiliation - a group of Scientists who are Christians... all perspectives are welcome - even extreme ones - but most of us seek paths that makes the two fully compatible.
   
3. The Student and Early Career Network of the ASA... there isn't a lot of support for younger Christians who are scientists. Perhaps this group could help with that.
4. Science Bloggers. Yeah, I think I am one of those.

Oh, and if you want to be my Facebook friend, drop me a note.

Seven Years

August 9, 2001: A day that will live in infamy. (Among stem cell researchers, at least.)

That's when President Bush announced his policy regarding human embryonic stem cell research.

In remembrance of this day, I wrote up my thoughts at the seven year point over at Clashing Culture. In a way, I am glad Bush made that speech. I probably would not have gotten so invested in science policy and the public communication of science, may not have involved myself with FOSEP, and would not have developed a self-conception of myself as a citizen-scholar.

Whoa...

Sovereign

Hopefully you've noticed that some battles between countries are not merely figurative (as in Beijing right now). As war breaks out between the small republic of Georgia and its enormous neighbor, one cannot help to recall parallels with previous conflicts between a superpower and a thorn in the side. And if you've any confusion about what I'm referring to, consider this snippet (made in Beijing, where the speaker had just eaten lunch with Russia's president):

“Georgia is a sovereign nation, and its territorial integrity must be respected,” Mr. Bush said in a hastily arranged appearance at his hotel. “We have urged an immediate halt to the violence and a stand down by all troops. We call for the end of the Russian bombings.”

It seems to me (in my simple mind) that Russia's just taking a lesson from the good ole U S of A. I would like to see the above quotation replace 'Russia' with 'America' and 'Georgia' with 'Iraq.' but that's just me.

With a Little Help From Your Friends

My latest article for Medscape's The Differential includes some tips about how to make the most of the teaching you'll encounter on your clinical rotations. If you listen closely, you'll encounter help from people all around you. Even from the gruffest nurses and most militaristic scrub techs. Check it out.

Podcast From the ASA Meeting

The talk I gave last weekend at the annual meeting of the American Scientific Affiliation about blogging as a useful tool for talking about ethics, science and religion in the classroom and in the public sphere is online. Listen to it here. It features my motivations for blogging, my experience here and at Clashing Culture, and some ideas about how blogs could play a larger role in dialogue about science and society in the public and within the mission of the ASA.

Man, is it painful to listen to yourself. Follow the link to the audio file at your own risk. I'll figure out how to post my slides, too.

I did talk a little about PZ Myers and Pharyngula as an example of discussions about religion that are more one-sided than I like. What did not come across until late in the discussion was how PZ linking my page once was a great boost to my activities on the web. For his notice and the associated traffic it brought I am thankful.

I did meet some other bloggers at the conference. One of whom lives about two miles from me.

Don't worry! There will be plenty of responses to the meeting coming up, mostly at Clashing Culture. See you there!