Step 3

Partially because I am cheap, but mostly because I am lazy, I have put off taking USMLE Step 3 until now. Studying has made me realize how much I've forgot, but, I swear, I don't think I've ever heard about some of these things. Some examples:

• I vaguely remember VIPomas from medical school, but glucagonomas? And who knew that 67-90% present with migratory necrolytic erythema?


• Drusen, apparantly, are refractile deposits that can occur in the optic nerve head. (And there is an unrelated syndrome: drusen of the retina)


• Shouldn't I know by now that epiphora is the medical word for tearing? It's a nice enough word, but why do we need another word when we have one that is specific and not vulgar?


• A pinguecula, helpfully, resembles a pterygium. Actually, it turns out that both of these nodules on the conjunctiva are common.

As might be apparent, I know virtually nothing about the eye. It might be because I spent 1 1/2 days in medical school on ophthalmology. I don't think that any of these things will be on the exam, but the words are beautiful, no?

Update: Drusen were indeed on today's exam.

Red Tide

I find myself now, at 30, surrounded by people and things of my choosing, feeling nostalgic for an evening 16 years ago. Perhaps it is not strange, as I stand looking out on a gray sky and a gothic prison, that I think about a beach bonfire. It would have been late summer, when the tourists and the fog were both lifting. In the hills, a dry wind would blow off the oak trees and fields, bringing a smell of warm straw. A neighbor, a girl who seemed, even then, to be anorexic, invited me and drove me in her Turbo Volvo, of which she seemed inordinately proud. I don’t remember her name, but I do remember her telling me that her mother said, “women are like flowers, every time they have sex they loose a petal.” At the beach football player types and their girlfriends, a group I barely knew, drank beer surreptitiously.

Although I had lived on the central coast of California all of my life, I had never seen the waves lit up the way they were that night. It was as if the Milky-Way had fallen into the bay. In small groups the boys stripped to their shorts and dove in the shimmering water, leaving glowing trails. They swam around the point to a cave in the cliff, accessible only through an opening under water. Shivering and boasting, they dried themselves by the fire. Walking at the reflective edge of the sea with the moon reflected dozens of times on the waves, I felt that if I died then, it would be alright.

But now, I can’t help wondering, were even the innocent things we loved poisonous? Bioluminescence is the official word for what I saw that night, and tiny organisms called dinoflagellates cause it. These algae can cause a variety of fish and human ailments, including paralytic shellfish poisoning. Red tides off the California coast have become more common since 1991, when I first saw them, the increase attributed, at least in part, to increased agricultural runoff and warming of the ocean. They have been associated with fish and bird kills, and small outbreaks of seafood caused illness. Although periodic climate variations may have played a part in that year’s bloom, and the glimmering I saw might have been from one of the harmless varieties of the dinoflagellates, more likely that magical night was an early sign of global climate changes to come. And so I think about how easy it is to conflate beauty and “goodness”. I ponder danger, youth, and the limits of aesthetics as I watch the trash-strewn alley, the prison and the gray sky.

[Picture from Wikipedia's artice on Red tide.]

Ronald Mallatt

On the way to Home Despot today, I heard the tail end of This American Life. The profile of Ronald Mallatt, who recently wrote a memoir, was wonderfully strange: a boy whose father dies when the boy is 10 becomes obsessed with building a time machine so that he can see his father again. This obsession rules his life; eventually he becomes a physicist, specializing in black holes, but still secretly holds onto the idea. Finally he comes clean, and writes a scientific paper that relates to time travel. Although the reviews of the memoir all talk about how inspirational the story is, for me it brought up questions about how we define sanity, and about the uses of madness.

Reminded me a little of Fast, Cheap and Out of Control.

Being a patient sucks.

Being a patient sucks.

This is probably not news to most non-doctors, but since I’m a doctor, and as such, tend to avoid medical care at all costs, I rarely see it from the other side. There are many reasons that we avoid going to the doctor: pride, feelings of invincibility, lack of time, to name a few. But by not experiencing it firsthand, we can forget the fact that being a patient really sucks.

I’m not even talking about the doctor’s appointment. I found aspects of my recent trip to the gynecologist to be pleasantly regressive; it was comforting to be cared for, and to not have to make the decisions, even if parts of the interaction were disturbing. Like the Native-American-inspired semi-abstract 3-D wall sculpture of a vagina from which a baby’s head was emerging in his consulting room. And there was the off-handed mention that he had once had a patient just like me who turned out to have cancer. Not that he thought that I had cancer, no, no, that case was so unusual, and he probably would see only a couple more cases like that in his career. Cancer? That wasn’t even in the top 10 things I thought could be causing my problems. Not something that had showed up in my literature searches, and certainly among the possibilities that I had stayed up worrying about. Did he mention this to all of his patients? Or was he nervous because I’m a resident? Come to think of it, he did seem nervous. Maybe it was because there was a vagina on the wall?

No, it’s wasn’t the doctor’s visit. And, cancer-talk not-withstanding, I wouldn’t even call myself sick, so I can’t speak to the obviously suck-y aspects of illness. What has driven me to tears of frustration is dealing with getting the studies that the doctor ordered. I showed up for an ultrasound after 3 hours of sleep to find that the requisition hadn’t been faxed in, delaying the study for another month. I tried to get my blood drawn during a break but was unable to because the doctor had used a prohibited abbreviation, even though it was clear to everyone what he meant. Always, always, the doctor’s office is closed. The office staff is patronizing, instructions are vague, and the bureaucracy is inflexible. And I am doing this at the hospital where I work, all the time wearing my ID badge that says C, MD. I can’t imagine what it is like for my patients, whose parents sometimes have marginal literacy, who have real illnesses, who don’t have the resources that I have. And so, I vow to be more understanding. After I finish fuming.

When I was a child I wasn’t much for dolls. Stuffed animals, some, but actual baby animals, no, and dolls even less. I wasn’t the kind of girl who imagined her wedding and then imagined her children. As I became a teenager, I embraced a more radical feminism, and the thought of becoming a wife and mother seemed even less probable. In college, for one of my co-op’s yearbooks, I was asked about my plans for marriage. My answer was concise: Ha!

A few short years later I fell in love. We moved in together. I spent afternoons and evenings with our neighbors’ children, who were toddlers when I moved there. Alexi, the eldest, would come over when I came home from classes or clerkships, and we would read or draw for a while. Then, on many nights, she would help me cook, spinning the salad, and sit wordlessly with us through dinner. My closest cousin also had two children during that time, brilliantly charming to my biased eyes. Watching one, 3 or 4 at the time, while my brother had surgery, he asked me solemnly, “Will they have to cut off his head?”

I decided to become a pediatrician, in part, because it seemed like it would have a better lifestyle for a family. I waited a year to graduate from medical school so that my new husband and I could move together across the country. When it came time to choose a specialty, it became apparent that my plans to have a career that focused on international health would be difficult with a family. After much agonizing I chose a specialty with a much easier lifestyle. So many decisions, both large and small, were made on the assumption that I would become a mother. We even had a plan, unspoken at first, finally agreed upon explicitly, to have a child at the end of my residency.

And now, every month goes by with another negative pregnancy test. Every period becomes a betrayal. I find I cannot even speak of it without tears. Even though, on a theoretical level, I know that there is overpopulation. Even though the world seems like an unpromising place to in which to bring a child. Even though I know that even in the best of circumstances having a child makes people more unhappy, is difficult for the marriage, is hard on the body. Even though I’ve seen uncountable instances of the worst of circumstances, where a child destroys everything that the parents used to call life. Even so, I can’t imagine not having a child. The easiest thing is to not think about it too much, but even that can be hard. Many of my classmates, on the same biological timetable, are pregnant. One is adopting because she and her husband have tried for so long. At work, I’m surrounded by babies, some with grandparents only a bit older than me. It’s still relatively early, and I try not to get discouraged. Anyway, it’s foolish to believe that we can chart out our future. So I keep waiting.

Southbound on the Northway

I took this blog’s title from the name of a town in New York. As I was recently driving home from up-state New York, I was impressed by the poetry of the exit signs. Together, they amounted to a kind of “found” poem.

Round Lake, Burnt Hill
Suffern
The Oranges
Winters Run

The names reflect a certain sensibility of the founders.

Street Fight

Watched Street Fight last night. I strongly recommend this movie, which was nominated for an Oscar for Best Documentary. It is about the 2002 mayoral election in Newark, a city with similar problems to the city where I live. I expected it to be interesting because of my experiences here, and because it is an inside look at an election, but as the film progresses, the outrages build. A reminder of how fragile democracy is.

It also begins to explore self-defeating beliefs of some poor African-American communities; I think we may see this again in the upcoming election with respect to Barak Obama. Is he really black, and so forth.

Metaphors

Between subdivisions and cornfields lies the pond. The ice comes together like tectonic plates, groaning as it shifts. Samuel Beckett’s face comes to mind, lined and furious, and I think that’s how I’d like to grow old. (Is that possible for a woman?) The frozen mud crunches under my step. I approach the edge. Put a foot on the surface to gauge its strength. It shudders and creaks. Cracks propagate out. I push harder and harder. Suddenly the ice gives, my foot falls and water splashes up my leg. The noise and cold are surprising, exhilarating. It’s not that I don’t like my nice warm socks…


I head home.

Urgent Care

Recently, one of the other residents called me in to help out with a laceration repair on a 3-year-old boy. It was a small cut on his chin, and she had already numbed it up, but she needed some help holding him down. We have a tool called a Papoose, whic is a straight jacket with a bowling pin shaped hard plastic surface – it straps down the child’s body, his arms, and his head, but is really no match for a strong 3-year-old who wants to move his head. We put him in the Papoose, I leaned over him to hold down his face, and the other resident draped his face.

Like all children, he did not like having his face covered, and he began to object. He started with the simple:

“No
Stop
Get me up”

Then:
“I’m going to pee on y’all”

I had no doubt that he would. She started to put in the stitches, which he not seem to particularly notice compared to the trauma of being held down. He continued to call out, moving through the other phrases toddlers say:

“All done
All done
Bye-bye
Bye-bye”

Then the most heartbreaking for me, also common:

“I’m sorry, I’m sorry, I won’t do it again, I’m sorry”

Meanwhile, his brother and father lounged in the corner, laughing at “the little man”, and telling him to be quiet. He continued through several more rounds of the above phrases for about five minutes, as my co-resident finished the repair. Finally, though, it was too much, and he brought out the last tool:

“GET THESE MOTHER-FUCKERS OFF OF ME”

I was impressed that it took so long for the big guns. Such restraint for a 3-year-old.

bad for the clothes

Robert Frost on his theory of writing:

“A sentence is a sound in itself on which other sounds called words are strung. You may string words together without a sentence-sound to string them on just as you may tie clothes together by the sleeves and stretch them without a clothes line between two trees, but – it is bad for the clothes"

From Christopher Benfey's review of the new Notebooks of Robert Frost in the New Republic.