Making a pact

The one thing I had to remind myself about “my” clinic here is that although I am not in the villages of Gujarat – the clinic is in the more rural areas of this city (Vodadora), but it also serves a majority of the villages’ population. The other day we had a family ride a bus for 4+ hours for this visit. We required them to get some blood work, and therefore, convinced them to take the bus the next day to allow for a thorough check-up. At first, I found myself comparing the patients those I took care of in Southern Maryland last month and felt so disheartened because these patients were so out of touch with the medical system, but I had to remind myself that I have to compare them to patients of Baltimore.

Today I think I want to focus on the fact that here, more so than America, patients are SO reluctant to believe in “medicine.” But that reluctance leads to an interesting pact. The way my doctor convinces his patients to take blood pressure medications, diabetes, or cholesterol medications – is by almost making a deal. That you can try to change your lifestyle, do yoga, take your herbs.. and in addition take this medication until we reach ____ goal. If you are able to do all that, and we reach that goal, then I will decrease/stop the medication… and we’ll see how it goes from there. Although this deal exists in the US, I haven’t seen doctors do it in such a forward manner there – its more implied. It is also more we have to stay on medications for life to maintain this goal… rather than the mentality that combining everything we may be able to maintain that goal without “external” medications. I think that integration is key because its hard to fight a battle against a disease while you’re also fighting the persons habits too, but its motivating to all when everything can be combined.

Obviously there are negative impacts of this disbelief in medicine as well, and actually almost disinterest in one’s health – in the past two days, I have seen more “resistant” diabetes and hypertension than I have in the US. These patients are stated to be on 2-3 diabetes medications or blood pressure medications, with really high blood sugar and cholesterol counts. But, I realized its not as much resistance, as non-compliance.

 

Welcome to India…

I wanted to first start with an attempt to describe the scene here, although I realize now that will be difficult. Growing up, I’ve heard numerous times that doctors here in India can average seeing >100 patients a day, and I just couldn’t imagine how that’s possible. But just after one day, I realize what that means.

I’ll start by describing the clinic and my first impression:
The clinic is a two bed office space with a 7-bed in-patient hospital upstairs. So, I walked in and joined my attending in doing rounds on the inpatients. And in the first room (which I believe had 5-6 beds) was a patient with possibly recurrent tuberculosis, directly adjacent to a patient with CVID (a congenital immunodeficiency!). I’m not even sure I need to add in any more words there to express my shock about that!!

And then after rounds, the remaining of the day we spent downstairs in ‘clinic.’ This was a true test of brainpower for sure. The doctor has the scheduled patients, but in between the patients, other patients would bring in their lab results and xrays for additional follow up (here radiology doesn’t come with a written impression, but the patient instead just brings in their own copy). In addition, the doctor would receive phone consults. So, at a given time – there were up to 5-6 patients in the room – one on the bed, 2-3 in the consulting chairs, and the rest crowded behind.

But yet, the doctor with precision could manage this, and I believe the patients felt taken care of (that I can’t vouch for yet). There most definitely isn’t HIPA here. One thing I’ve learned in the past few months in outpatient internal medicine is that these doctors are truly geniuses – they have an impeccable memory, not only for diseases and medicines, but also for the patient’s entire story! Even amidst what feels like a zoo to me, the doctor himself knows all the patients names and their family’s entire history, whereas I’m still trying to figure out if the xray in front of me is from the wife or the husband.

My first step in my training here is unconditioning my instincts – for example, an elevated MCV = B12 deficiency here, not alcoholism. Elevated IgE isn’t a sign of allergies here, but rather worm infestations… and learning gujarati for all these fun things!

 

A post from the past

This post is reminder to my future self, for the day that I become a sub-I, Intern, and possibly an attending. Its supposed to be a letter from that frightened, scared, timid, yet somewhere deep down inside smart medical student that’s awkwardly tripping over the chairs, trying their hardest to make doubled sided copies, but still has the capacity like a dry, cracking sponge to absorb knowledge within msec. Being a medical student is a hard, complicated position — you are expected to know things without ever having seen them in play. You are expected to be a part of the team, even though you dont receive updates/pages/information from correspondenants. You have to stay proactive, even though you can’t place orders, or really have any authority to do much of anything. So, its really the people that the student interacts with that makes the world of a difference in their education and so here are a few things that have stood out from the people who have really influenced me, that I want to make sure I remember when I’m really tired, really overwhelmed, and just trying to survive myself as an intern. And this could be advice to future third years that I wish I knew when I started.

1) See one, do one, teach one. Remember this rule. Even if you think the student can’t do anything, allow them to come in with you and watch you get consent, or watch you handle that really difficult patient. Cause one day, they will have to do it. And next time, supervise them doing it… you have nothing to lose. It may take a few more minutes, but it will save a few minutes in the future.

2) Involve the students in the plan. Ask them what they would do, allow them to make mistakes before the actual time comes where the mistakes could impact patients. or explain to yourself and them why you are doing what you are doing. Cause chances are it may help you catch a mistake or make you think, is what I am doing really necessary?

3) Encourage them to report physical exam findings. Or when you hear a crazy murmur, feel that liver tip, or see that crazy cavitating mass, call the student in to see it with you.

4) Remember that small words of guidance or gestures of appreication/criticism go a long way. Don’t ignore the student. Be honest and let them know what they could do better to help you or themselves, or what they are doing well already.

Here’s a part for students that I can’t re-phrase as things I should do:
– Remember that your role there is to learn: Pay attention to the small details that each person does, and next time offer to do something that they were doing. Even if its just grabbing a piece of gauze, having it ready shows that you noticed that they needed it. You thought one step ahead and realized its necessary, which is one step in the right direction to doing patient care yourself.

– Keep asking yourself why. Why did that patient get fluids? Why did they receive Antibiotics? How did they decide to give them Drug A vs Drug B.

– Dont get frustrated. Remember that you are not an intern, your goal is not to make a direct impact at the time of action. Its to see, learn, and digest and regurg hopefully in the future.

– And remember at the end of the day to take care of yourself. Eat, rest, and when things aren’t going on, dont hesitate to open a book, or ask to leave. You are a full time student still after all.

When I had thought about writing this email I thought I’d have so much to say, so much to change, but I realize just a few little gestures would make a big enough difference. And no, I dont know how to be a good medical student yet, but I do hope that I will not forget what it feels like to be one.

 

Our Canine Sense

One commendable thing in the science field is that we haven’t completely carved out a one way path in terms of research, limiting the definition of progress as things that move towards modernity. People are encouraged to search in the most primitive and most advanced ways for things that simply could help make health care and our understanding of the body better.

Here’s an article about dogs being able to sense “sickness”. After all, if a dog is a man’s best friend, it should be no surprise that they can sense changes in their owner.

Just thought it was an interesting article that shows not only how intelligent dogs are, but also highlights how science research isn’t just limited to formulas and discrete methods that lead to a diagnosis, but how everything that affects the human body is fair game.

 

Discovering distractions through distractions…

So, ironically, I found this article posted on one of my facebook friends “status” messages (thanks Yubraj!) as I was distracting myself from my studying. But its a brilliantly written article analyzing the effect of distractions on us and our future generations. So when you have time between your actual work and sifting through your distractions, I recommend you check it out.

http://nymag.com/news/features/56793/

There were many stunning facts and antidotes that stood out to me, and humorous little analogies and oxymorons that made me snicker (like mindful web-surfing, mindful Twittering), but one thing that stood out was this paragraph:

“Only in the last ten years—thanks to neuroscientists and their functional MRIs—have we been able to watch the attending human brain in action, with its coordinated storms of neural firing, rapid blood surges, and oxygen flows. This has yielded all kinds of fascinating insights—for instance, that when forced to multitask, the overloaded brain shifts its processing from the hippocampus (responsible for memory) to the striatum (responsible for rote tasks), making it hard to learn a task or even recall what you’ve been doing once you’re done.”

No wonder I can’t remember anything I learned in medical school! and I have to admit that while reading the article, I checked my email at least once…

And its true that we are at the brink of evolution right now, where our body has to adapt to our new way of learning, information searching and social interaction. And that eventually, hopefully, all of this will come out to the benefit of the user, but until then, it is a good reminder that we’re not there yet.

 

Circle of life

“From the day we arrive on the planet
And blinking, step into the sun
There’s more to be seen than can ever be seen
More to do than can ever be done”

Today when I left my local library, I couldn’t help but realize how the library epitomized the idea of the circle of life. As i walked out of the library with a huge backpack full of books (and my laptop of course), I ran into a family that included a mom and two boys. The boys were carrying huge homemade shoulder bags STUFFED to the brim of books they were returning. We were both hunched from the burden of our books…and it also reminded me that not too long ago (a decade or so ago), I was in the same position. So excited to come back to the library to search the shelves for new books and new genres.

And with each progressive year, I have slowly moved up through the stacks from the childrens books –> YA –> Adult Fiction –> Non Fiction! And not only does the library embody my own circle (I’ve studied at the same location when I was younger, for my MCATs and now again for my boards), but its always uplifting to be surrounded by the old man with a cane using the library as his way to get up to date with all the new gadgets that have surfaced. And right next to him, are the teenagers that are searching the movie isle and magazine rack… and through it all you hear the wail of the child, trying to be pacified by the storytime that’s going on in the room next door.

And through it all the librarians get to see the circle keep spinning. The librarians get to see all the books circulate through so many hands (people of all ages!). And they also get to see each individual’s path unwind, follow them as they grow up, until one day they stop coming…. but they can still hold onto the hope that one day they will return (either a future test will bring them back, or maybe a new family).

And underlying it all, the library still holds a vast of knowledge that is yet to be taped for everyone (the librarian, the frequent visitor, and the kid who’s coming for the first time!). “There’s more to be seen than can ever be seen.” Unlike Simba’s father, Mufasa, I cannot show a little kid all that there is to explore, but rather can enter through the same door and be astonished by the same sight of never-ending growth.

 

Sugar Throw

The NEJM recently published an article on the public policy case for increasing taxes on sugared beverages. With the recent obesity epidemic, increasing awareness of the current economic times and an heightening emphasis placed on “green” movements, increasing taxes on sugared beverages (from sports drinks to sodas) could help fight all three with a penny-per-ounce tax.

Instituting a penny-per-ounce tax could raise up to $1.2 billion in New York State alone. The tax revenue could be used both directly and indirectly to help fight the obesity epidemic. The revenue raised from this tax could be used to support obesity prevention programs (esp those geared towards children) and to also lower the cost of “healthy” foods. Consumers may be more likely to support the tax if they can see a tangible benefit from their taxes. Additionally, an increase in the cost of the item, would hopefully directly reduce consumption, as consumers would think twice if the price difference between a healthy orange juice and orange soda is decreased. If the increase in tax is substantial enough, it could directly reduce sugar consumption up to 10%.

What I found to be the most shocking is the following figure: The rising cost of fresh fruits and vegetables vs sugared beverages.

Of course there are many arguments against instituting a sales tax against a specific type of food. One, its food discrimination, why should one food item be singled out over another? And also shouldn’t more focus be placed on education so that the consumer can have the freedom to make an educated decision rather than one externally forced by the government/affordability? And could it possibly lead to something as extreme as the Boston tea party? We may see elementary school kids refusing to pay their tax on their 20 oz soda, throwing it overboard into the atlantic 😉 (the fish would be happily producing more carbonated bubbles then!)

Also, for those economically inclined, they argue that “excise taxes” which would be targeted as a fixed cost per ounce provide incentive to buy less, unlike sales taxes which merely encourage the purchase of less expensive brand names or buying in bulk. “In addition, manufacturers generally pass the cost of an excise tax along to their customers, including it in the price consumers see when they are making their selection, whereas sales taxes are seen only at the cash register.”

But one thing is for sure, that items containing refined sugar have not faced the same price increase as fresh fruits and vegetables, and instead of viewing it as singling out a food item, it could be argued that the market is now focused on equalizing costs. It could help the green movement by unconsciously helping consumers buy “healthy foods”, while also helping to fight the obesity epidemic by reducing accessibility (while still focusing on education). I’m not sure whether taxation is the answer or not (it does seem like quick, easy fix to a deeper problem that needs to be addressed more from the inside), but one thing is for sure is that fresh foods and vegetables (even juices) need to be more affordable.

Here is the article for those interested:
Ounces of prevention

 

Living the life of luxury

“Learning how to focus on the moment” could help our body combat the negative effects of chronic stress. “but we dont have the luxury to do that.” How ironic is that statement? In a society where we have the luxury of cellphones and laptops, unlimited hot water, oodles of food, thousands of networking and entertainment options, we dont have the luxury to focus on ourselves?

Yesterday, we had a talk on Mind-Body Medicine (i.e. the effects of stress on the body and ways that we can counter it). The lecturer began with the physiological process that leads to the release of “stress” hormones and the effects that those hormones have on our body. These effects included everything from increased blood glucose to help the body deal with the “stressor” (i.e. run away from predators) to decreased wound healing and immune function to save energy for our “flight our fight mechanism”. And so what happens when our body is under chronic stress? Acute stress would be defined as when you release stress hormones in response to an event, and then after a few hours the body returns back to a “normal state” where those hormones aren’t around. But as stressors stick around in our life, our body could eventually lose its resilience and therefore, be unable to return to baseline after a stressful situation, creating a state where we have “stress hormones” floating around in our body all the time…. and that’s where mind-body medicine can come into play. It helps the body return back to baseline, and reverse some of the adverse effects of chronic stress.

The first technique that he mentioned is meditation, by which he’s not talking about a spiritual or religious experience, but merely learning how to focus on the moment. ironically, though, this is where he stated the simple obvious that we’ve learned to accept in our society: “We don’t have the luxury to do that.” We don’t have “the luxury” to take 5 simple breathes, but we have the time (probably even simultaneously) to text, im, facebook message, surf the net, watch tv, access things from all over the world… but we can’t access ourselves?

So I just wanted to remind us to take the time in our “packed” lives to take even a minute to just focus on ourselves. In whatever way is right for you — whether its taking a jog outside, doing jumping jacks in place, praying, or just sitting with no thoughts going through your mind. Just remember in the end there’s nothing to lose, not even a penny.

 

“Mary Christmas”

I always shy away from making posts about my clinical encounters because I want to be able to respect patient confidentiality and all of that other shenanigans. But, yesterday, I had my introduction to the nursery which was definitely a noteworthy way of starting of my new year. These babies are born in 2009, a quarter of a century after me!

A line my teacher said really stood out to me — she said the babies don’t have a history, they are just a clean slate. Of course, she is referring to the patient’s medical history and making the point that the important information we have to collect all has to do with the mom. But this is true in all aspects, they have nothing developed – their viewpoints, their character, and even their head size! Its all so malleable (physically and theoretically speaking — the head is so soft and the fontanelles not closed).

Most of the newborns were less than 24 hours, but there was this one which they called “Mary Christmas” because she was born on Christmas Eve. And during the pregnancy, her mom had supposedly utilized any and every drug imaginable… and so now she was going through drug withdrawals. And her mother left her less than a day after her birth. Where is her mother Mary now? I couldn’t help but think what has she done to deserve this? Less than 3 weeks old, she is already addicted and abandoned. And the most striking part is, she has no say in her situation. Its similar to the civilians in Gaza, or why the “nicest patient” you have is the one that’s suffering from metastatic cancer. No one ever really gets a fresh start, a “clean slate”, do they?

At least she will be put up for foster care in 30 days, and maybe then she will finally get a second chance to start the new year?

 

The story of my medschool career…

Breaking news: More than 30,000 people in the US are suffering from “powerpoint poisoning” yearly!

This was the culminating slide to our presentation on toxicology. Not sure which is worse arsenic poisoning or powerpoint poisoning?