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Reflection on Pediatrics: Rotation 3

In Uncategorized on September 29, 2012 by David

For the first five months of third year, I have been rather shielded. I have seen a few emergencies, scrubbed in intense surgeries, and seen very sick patients, but for better or worse, I have never seen a patient pass away. Major things happen and tragedies occur, but I had never seen it firsthand. I would hear about it through sign-out, or in passing, or through notes, but I had not experienced it firsthand. Medicine is long lulls of calm punctuated with sudden, rapid, and chaotic activity.

I was on my week at the newborn nursery and spending a night with the delivery team and the intensive care nursery. I had been forewarned about this delivery, a term neonate with significant defects including malformation of his lungs. He was comfort care – he wouldn’t live long, but the goal was for him to spend some time with his mom and to let her hold him before he passed away. The resident saw that it was already pretty late at night, and asked if I wanted to go home. I thought it was an important point in my training, and even if I wanted to, I couldn’t turn away. I could go home, but what kind of doctor would I be if I could not deal with death?

The delivery started at 10:30PM, when most of the day time visitors, the volunteers, and much of the hospital staff had gone home. The baby came out blue, floppy, and not breathing – a bad sign that could mean poop stuck in the baby’s airway, significant lack of oxygen even in the womb, or many other things. The neonatologist immediately intubated the kid, breathing with a bag mask, putting in IVs, warming and cleaning him off. The kid’s face was misshapen – smaller and more narrow – and getting a tube in his mouth to breath was hard. Flicking him on the foot, he would not cry but would open his eyes and weakly moved his arms. They listened for lung sounds, heard a faint heart rate, drew blood to check his oxygen levels, they were low, and gave saline through the umbilical vein. After a while, his oxygen levels were going down and his chest was no longer moving. What happened? X-Rays were taken and he was reintubated. Flicking him on the foot, after a while, he would not move. He just looks asleep. It’s sad when an adult dies, but it is a Greek tragedy when an infant passes away.

It was about 1AM when I got home. I was in shock when the dad came by to hold him. I felt so distant and so emotionless when we took him to be held by his mom, to be baptized. I felt numb, distant, cold as I walked home through the fog. I wanted to talk, but I didn’t know what to say. I wanted to journal, but no words went on the page. I wanted to call someone, but couldn’t think of anyone to call. My classmates were all busy with their own rotations; no one would want to be bothered at 1AM in the morning.  It would be strange to talk to people I haven’t talked to a long time, or to talk to someone about this who wasn’t in medicine. I wanted to call my parents, but didn’t want to bother them – my dad was sick at the time, and I was worried that my mom would be superstitious and take it as a bad omen. I had no one to talk to, and it felt very lonely.

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The Bottom 47%

In Uncategorized on September 19, 2012 by David

My name is David, and I am a third year medical student. Being in school, I am one of the 47% of Americans who did not pay federal income tax last year.

As a medical student, I am proud of my future profession. I am proud of a future of taking care of people in times of need and am still inspired daily by the tremendous impact physicians have on patients.  Working with world class teachers and doctors, I recognize my time in medical school is truly precious. I feel blessed for this opportunity to learn and grow – one day, I hope to provide the best possible care of my patients. Even with supportive parents, school is expensive. I take out loans to pay for my education, and I believe in an America where everyone is afforded the opportunity to invest in the future. Because of my investment into my future, I did not earn an income last year. I am one of the 47% of Americans who did not pay federal income tax.

I am proud of the work I put in to get where I am today. I have worked long hours and spent many long nights in the library to reach my ambitions. However, even though I work hard, I do not believe I got where I am alone. I am here because of supportive parents, who drove me to the library during summer vacations and picked me from after school activities. I am here because of a school system that prioritized math and science education, even when budgets are tight and tough decisions need to be made. I am here because I am American, and our country supports education and promotes opportunity.

As a medical student, I have seen firsthand how broken our medical system can be. I hate how physicians and hospitals have to shape care to the whims and desires of insurance companies. I have seen patients suffer as we wait for permission to perform life saving surgery and radiation therapy. After working in the hospital, I can no longer believe in a world where healthcare is not a human right, nor do I want to live in a world where insurance companies decide patients’ fates.  Although I do not agree with all parts of healthcare reform, I am proud of a president that attempt to tackle difficult questions facing America.

I am a Christian. I believe in the death and resurrection of Jesus Christ, and in a God who loves those who do not deserve his love. I do not believe these core principles are consistent with a president who will not care for the most vulnerable half of America. Although I did not pay income tax last year, I do not believe I am “lazy”, “entitled”, or “without responsibility”. I do not believe a man who can characterize half the nation in such broad strokes embodies my ideals, beliefs, or hopes, nor does such a man look out and see the same America I see.

I am usually not political. I did not vote in 2008. I try to hide my views during discussions. However, recent remarks have solidified my views of this election. I agree with Mitt Romney that this election is a competition between two divergent visions for the nation. But after seeing the contrast between the two perspectives, I believe in Barack Obama’s vision of the future. I have seen firsthand how this land of opportunity let me reach for my dreams, and I want to keep the American dream alive for many more after me.

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Reflection on Family Medicine, Rotation 2

In Uncategorized on August 22, 2012 by David

Just as my internal medicine block showed me how much I really enjoy medicine,  of taking care of people, and understanding how things work, family medicine reminded me that there is more to life than just medicine. The last eight weeks have been amazingly fulfilling in an entirely different way. Reconnecting with old friends, hanging out with new friends, and working on side projects, there are so many things that I enjoy in addition to great medicine.

To be fair, there was great medicine on family medicine. Some really interesting pathologies, really nice patients, and learning extremely useful skills in dealing with the kind of illnesses, malaise, and disease that affect most individuals, including me and my family. But if I had to be honest, the most memorable part of the last eight weeks was what I did outside of medicine.

For the first two weeks of block 2, I took vacation to work on a side project with Aron. We took over and squatted in a conference room in Mission Bay for the entire two weeks, and proceeded to work. For almost every day during that time period, our routine would be to drive to Mission Bay about 9AM, review what work we need to get done, work until 7-8PM (with lunch mixed in the late afternoon), summarize what we did that day, and then go home and grab food. Since it was Aron’s first time in San Francisco, we checked out a few of my favorite food places in San Francisco – I almost got Aron to do the pho challenge at Pho Garden. Haha. It was a learning experience in how to deal with people, as we had to deal with working to find a new mobile developer and close things out with our old mobile developer. It was also eye opening on how unpredictable and challenging work can be – some of the things that we imagined would take the least time in fact took the most time, and our initial goals for the two weeks turned out to be quite optimistic. Regardless, it was an amazingly fun experience, to be able to work hard on things that I was passionate about with people who share similar goals and similar work ethics. The tail end of the second week was also July 4th and Grace came to visit Aron, and it was fun showing them around the bay area. Hopefully I can convince more friends to move over here. Haha.

The next six weeks was my actual Family Medicine rotation. On Mondays, I was at Palo Alto Medical Foundation in PA. It was actually quite enjoyable to drive down the 280 early in the morning, listening to the radio and getting lost in my thoughts. Since it was a far drive, and I don’t often have the opportunity to visit south bay, I took full advantage of my time and went to see lots of people. I hung out with Brian, Irene, and Michael a few times – intern year is surprisingly chill relaxed for them. I guess without evaluations looming overhead, it is really just an opportunity to learn, immerse yourself in the medicine, and enjoy the time. I stayed overnight with Brohaus a few times, it was good to see all of them again. Even after 5 years now, some things never change. Haha.

On Tuesdays, I had my longitudinal clinic in Radiation Oncology/Head and Neck Cancer at Mt. Zion in the afternoon. The pathology is really amazing, and it continuously reminds me how much more there is for me to learn. I stand around awkwardly without the answers when patients ask me questions. Thursdays and Fridays were General Family Medicine at Lakeshore, here in San Francisco. That was a great experience, as I really felt like I had autonomy and able to do more for my patients. I learned a lot about the general aches and groans that all people face, things that I face – from knee pain after running to slightly elevated cholesterol with a poor diet. Deep down, I still feel like a little boy, but I feel both honored and surprised that people take my recommendations seriously. Seriously, what does David know? 😛

Wednesdays was didactics and geriatrics home visits. Seeing geriatric medicine really reminds me how precious life is, as we grapple with the challenges of end of life care, goals of care discussion, how to minimize the symptoms of neurodegenerative disease, and how to cope with the inevitable frailty and loss of reserve. After seeing elderly patients and seeing the natural, although sometimes not graceful, decline we all face, I am skeptical by how some people view the future and longevity. Calling it a singularity, or the idea that exponentially increasing knowledge will somehow naturally result in miracle cures for a longer, healthier life, these ideas are just our generation’s reframing of the fountain of youth. Idealistic but unrealistic. It is perhaps telling that no one with rigorous medical or biology training champion this idea of singularity, but is rooted in the optimism of electronics and software development where rapid change in the rule. The discussions on Quora always start with Moore’s law – that there is accelerating innovation in electronics and hardware, and with sufficient handwaving, that can be translated to medicine and health.  I think there are physical laws of nature that naturally dictate how long we can give, and better nutrition or supplementation will only result in diminishing returns. Immortality is just a dream of the young. Enjoy the time we have here.

For the next six weeks, I am on Pediatrics! With kids! Maybe I will be more optimistic about long life there! 😛 Hopefully I don’t get sick! Haha. Cheers to a good time at Parnassus.

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Reflection on Medicine, Rotation 1.

In Medical Musings on June 22, 2012 by David

It’s amazing how many things happen in the hospital and how much responsibility that I have, even as a medical student. I told a patient with metastatic renal cell carcinoma that he was going to die. I closed at the end of brain surgery for a patient I admitted and talked to everyday for more than week. I interpreted for a mandarin speaking patient who came in with nonspecific chest pain, and left with a CABG, and developed a stroke and became aphasic. It’s a sign of how sick our healthcare system when you know your patient has less than a year to live, but it’s her insurance status rather than her prognosis that guides what tests we order and what procedures we do. It’s hard to talk to Utilization Review, even at one of the strongest safety net hospital of one of the most affluent counties in the United States.

But what’s most shocking to me, and what I have the hardest time struggling with, is how quickly lives can change. It’s amazing how one day, you can come into the hospital with no complaints, minor fatigue and just feeling under the weather, and leave a few days later after brain surgery and a prognosis on the order of weeks to months. Or you can come in with nonspecific chest pain, a normal EKG, one borderline troponin, and what can be described just as well as the prodrome of viral gastritis, and be sent for a CABG. It’s especially hard to think that you are doing the best for your patient, offering invasive but life saving procedures to patients who have no insurance, when you call to follow up and find out your patient who you advocated for to get a CABG developed a stroke postop, become aphasic, and stayed in the ICU for a week.

Mr. Y was a monolingual mandarin speaking gentleman who went to the ED with some non-specific chest pain after two days of the stomach flu. He wasn’t the most cultured gentleman, but he reminded me of my dad. He was a rather loud gentleman, with no sense of an indoor voice. Like my dad, he was a smoker. I still remember discussing with the team, whether he needed to be admitted – with some nausea and vomiting (perhaps because of the viral gastritis?), some exercise intolerance, and some nocturnal orthopnea, but with negative troponins, a normal EKG, and more concerned about his nausea and vomiting than about his chest pain. His chest pain seems to be chronic – perhaps an outpatient stable angina work-up would be enough?

As the only mandarin speaking member of our cardiology team, I spent a lot of time talking with him. We had long conversations on why smoking cessation is important and what it means to eat well. To me he complained about the hospital food, and I laughed in his face when he told me that he got the nurse to get him a hamburger and fries from the hospital cafeteria. I sat with him during his catheterization, and I translated for the cardiology fellow as he told Mr. Y that he had bad triple vessel disease, that there was nothing interventional cardiology can do for him as his coronary arteries are too bad and the plaque too diffuse for stents, and would probably need a CABG. I laughed at him again when right after he heard the news, and then told us that he was hungry because he was NPO for the entire morning and asked if someone could get him McDonalds now that we are done.

As a physician, there is so much responsibility. The idea of informed consent is hard, who can truly understand the implications, ramifications, advantages, disadvantages, challenges, and harms of an invasive procedure. It was especially hard for a patient like Mr. Y. Monolingual and poorly educated; Mr. Y was a migrant worker working as a masseuse in a mall in South Bay as the rest of his family was in China. When I asked for an emergency contact, repeated as the likelihood of CABG became greater, he could not name anyone. He was alone, in a country that does not even speak his language. Although I sat down with him and described to him in detail the surgery, he was almost indifferent, almost resigned in his trust of the medical team. Asking him to explain concepts back to us, all he would say is “I don’t really understand, but whatever you say I need, I’ll do.”

He asked me if a CABG was dangerous, and I looked him in the eye. “This is a very invasive surgery, they will need to open your chest and perform major surgery. There is the risk of complications, but we believe that this surgery can help you and we recommend you get the surgery.” I thought we were doing a good job. SGFH doesn’t even have a cardiothoracic surgeon – we called Moffitt/UCSF, got carotid ultrasounds, and PFTs, and kept him inpatient until the following week. I thought it was a triumph, an expensive surgery for a poor patient – an egalitarian use of resources and a good advocacy on our part.

One of the assignments for the medicine clerkship was to call a patient after discharge to help us think about discharges and to assess patients understanding and management after they went back home. During my last week, I finally got around to this assignment. I called his phone three times during the last week. Only on the third call did someone finally pick up, but it wasn’t Mr. Y. It was a nurse at Moffitt/UCSF. Mr. Y was still in the hospital so many days after the surgery? The nurse was actually an ICU nurse. Mr. Y suffered a stroke after the CABG, and this was his 5th day in the ICU. He was now no longer able to speak, aphasic and needing to be transferred to back to SFGH – potentially for a long stay before long term placement.

It’s always said that life is fragile, and that we should cherish each and every moment, but is so hard to know and truly internalize this bitter and cold truth. It is hard to be an advocate for people who depend on you when in there is so much uncertainty, so much risk, and so much danger behind every choice. As physicians, our job is to provide predictability, stability, and comfort. To explain, reassure, manage, care for, and love our patients. Even that alone is hard.

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My Greatest Fear

In Goals, Medical Musings on March 7, 2012 by David

This past week, we had our last FPC session of the year. In our small group this past year, we have talked about a lot of the most important issues, like our experiences with death, that we don’t have time to talk about during the clinical curriculum. As we transition to the clinical curriculum,  we were asked “what is our biggest fear/worry as we start on the wards?”  It’s hard to imagine that almost two years have gone by, and I will soon be starting in the hospital. As I am about to start on the wards, my greatest fear is unintentional change.

During first year, in FPC one of my classmates talked about her older brother. Now a transplant surgeon, she recalled how he’s changed throughout the course of medical training. He was recently divorced and now just throws himself at his work, without much to his life outside of this. She still remembers him as the kind, gentle, and intelligent person he once was, but her heart breaks for the kind of person he has now become. When his parents are sick, he is a great resource – able to consult to chair of the GI department when they have a medical problem – but over his caring core is an abrasive shell. Being an attending surgeon, in command of surgical field, one comes to develop an expectation of how the people around you will treat you – and this expectation bleeds through into the other, more important, relationships. For better or worse, medicine is a very hierarchical culture. You can be treated poorly by the people above you, especially as people are busy, tired, end frazzled, unfortunately, this normalizes this kind of behavior when you advance, and can affect how you act in other aspects of your life.

That is my greatest fear. To one day, look into the mirror and not recognize the person I have become. Third year will most likely be a busy year, and be over in just a blink of an eye, and I don’t want to wake up next year and wonder how did I get where I am. As we grow older, no one intentionally becomes arrogant, aloof, cold, or impatient, yet these are adjectives that we find can too often describe adults. If we are being honest, these are traits that can especially describe physicians.  In medical school, we hear stores of surgeons throwing temper tantrums when the smallest of things go wrong. A rock’s natural tendency is to roll downhill –  to go with gravity and slide in the path of least resistance. It is just too easy be complacent and without intentional direction, to slip up.

And unfortunately, that is my natural tendency. I am arrogant, too confident in my achievements and accomplishments, even as in my heart I recognize that it not by my ability alone. I am impatient. The past two years, to my dismay, I have felt that my tendency is to be impatient. I am rushing for place to place to study.  I am too easily annoyed when I have to wait on others, yet ironically I am habitually late – making other people wait. Although I usually enjoy talking to people in passing, I find myself avoiding eye contact so I don’t waste time making small talk. As the next year to be even busier, I will need to consciously prioritize relationships and keeping up with people.

Ultimately, I think that my solution. To have meaningful change, I will need to prioritize and have goals. Next year will be the most challenging, the most tiring, and the most important year of my life so far. But in addition to all that, it will also be the best year of my life yet, the culmination of so much of what I have worked for so long. I will see, learn, and do so much in the next year. The next twelve months, as I study for the boards and then go off to the hospital, will be a stressful experience, but it is precisely this stress that is our impetus to improve, grow, and learn.

Originally written on 02/26/2012

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Year In Review.

In Goals, Misc. on July 11, 2011 by David

It’s been a little more than a year since I came to San Francisco. I arrived June 10th of last year to start research. This past year has been the hardest year I have ever had. I had a difficult time adjusting to San Francisco, felt far from home and alone, and was not sure about my identity. I really enjoyed medical school and my new peers, but throughout the first year, I felt a sense of turmoil – a tension and conflict between who I am, who I seek to be, and how others perceive me.

Coming to medical school as an MD/PhD, I thought a joint degree would be an opportunity to delay choice. I both love medicine and science, and was not sure what I really wanted to what I ultimately wanted to pursue. I felt privileged to have this great opportunity, but for me there was the constant tension of the realization that to do something great, one would need to specialize and ultimately choose one passion. I hoped that over the course of eight years, I would be able to better understand myself and can reevaluate my choices and options. I thought a joint degree would give me more exposure to both science and medicine, and the tools to pursue both.

But having finished my first year in medical school, I have conclusion that a joint degree is not simply the sum of medicine and science training. It is something different – in the middle yet entirely distinct. It is not equal parts medicine and research, it is an intersection that can only be described as medical research that takes elements from both but also rejects characteristics of both. And with this training comes the implicit expectation that one would end up doing medical research, not medicine or research. Although not entirely explicit, I felt MSTPs had a subtle sense of disapproval for those who ultimately ended up in solely medicine or solely science, so many graduates end up in the twilight zone I’ve termed medical research.

For me, being MSTP felt like a source of constant conflict. When doing research, I dream about being back in school and in clinic. When bored in class, I daydream about what I could do with these idle hands back at the lab. There was a tension, partially driven by a sense of urgency in knowing that the training is so long and wondering why I am wasting time, but mainly driven by a sense of mistaken identity.

Truth be told, I never felt truly comfortable in the role of MSTP. They are big shoes to fill. I never liked it when there were jokes about MSTPs being smart. In fact, I actively disagree. I think MDs are no different from MSTPs in terms of ability, just a different in interests and background. I squirm when singled out as an MSTP, because with the title comes expectations. An expectation that I enjoy all kinds of science and all types of research, when in fact developmental biology and other vast fields of science bore me to death. An expectation that I don’t enjoy the “touchy-feely” stuff, although like science, there are aspects I really like. The conflict has struck at the very heart of me – ultimately, this past year, I was not sure who I am and what my identity was.

Conversely, If there is anything I am sure about, it is that one needs to focus to succeed. To have too many fingers in too many projects, one will surely fail at them all. Throughout both high school and college, I always got myself involved into many projects, many interests, and many activities. I had a hard time distinguishing “many” from “too many”. Although I was fortunate to never crumple under the weight of too many responsibilities – things always worked out, I see now that this is a sign of immaturity. It is a sign that I do not know what I am truly called to do. I reminded of a good quote – “beware the barrenness of a busy life”. Despite the constant pressure to be busy and productive, I will take the next month to be still, to be calm, and rest before I start again.

I have decided that life is too short to live by other people’s expectations. There is a quote that really stuck with me – “The measure of a person is a how many uncomfortable conversations he or she can initiate.” In fact, I am glad that I had a difficult year. I had the opportunity to grow as a person and more realistically solidify my self-identity and expectations for the future. The discomfort is only a sign of growth.

I look forward to living for myself again.

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Identity

In Christian, Goals on July 1, 2011 by David

This week, Google came out with Google Plus (Google+) in an effort to challenge Facebook’s dominance in the social sphere. As people spend more time online interacting with other people they know in real life, the social internet has an increasingly important role in our collective consciousness. One of the main critiques of Facebook, one that Google seeks to distinguish itself, is the unwieldiness of having one all encompassing online identity.

The premise is that people act differently in different situations and with different people. You might send nerdy starcraft videos to your high school friends, share awesome pictures of surgery with your medical school classmates, and be professional with your professors, bosses, and co-workers. At its heart, I think the premise is true – our actions are products of both our environment and something internal – a fluid dynamic ‘identity’. Both in real life and online, our identity is in a state of flux, and our actions change based on our mood, social norms, and expectations.

But ultimately, what is my identity? Identity is supposed to be something that is inherent in oneself – that is constant across situations and expectations. In church, the pastor is going over a series seeking to define identity, in particular, what it means to have an identity in Christ. What is common to me? What is the whole of me, that is true regardless where I am and who I am with?

Outside of Christ, people seek identity in three main areas. They define themselves by what they do, what they have, and what they desire.

What I do: I am a medical student. I am one who has worked hard for many years for the privilege of treating people in need. I am one who has stretched oneself, and continues to stretch oneself to fit in this conforming standard of one who is compassionate, professional, intelligent, and authoritative. Ignoring Christ, I am one who is prideful – feeling that spark of pride when I wear white coat and can answer someone’s question. As a medical student, I am selfish with my time – in service, in relationships, and in many other things I am always nagging by this sense of “let’s make sure I’m not wasting my time”, “how can this help my career”, and “should I be studying now? Is this activity worth my time?”. Despite the best motivations, my career in medicine is not Christ centered, and despite my best attempts, I cannot put to death my worldly ambitions.

What I have: I am an Asian American. I come from an upper middle class household, with a strong nuclear family. I love my parents, my sister, with the fullness of my heart. Yet because of this, I am not willing to accept Christ. In Mark 10:37: it is written, “He who loves father or mother more than me is not worthy of me; anyone who loves son or daughter more than me is not worthy of me.” After reflection and contemplation, I think even in the here and now, that has not changed. I do not love the rest of the world, any of it or all of it, or even God, with the fervor with which I love my parents and sister.I love them because they have loved me unconditionally. My parents would love me regardless of what I do and who I become. I love my family because they have taken care of me when I am weak, when I am broken, and when I am distraught. When I feel abandoned, tired, alone, or isolated, I know that I am only as far as I am from my family. I do not feel the same love for Christ as I do for my parents and sister. Jesus’s love has never been as real to me as the tangible love that I feel from my parents and sister. Anything anyone can say about God and why they love God, is true, infinitely more true, for my love of my family.

What I desire: My desires are selfish. I desire a girlfriend. I want someone to celebrate my victories with me, and someone with whom to share my defeats. I want someone who share my ambitions, but also someone who does something completely different that I can appreciate. To be honest, I don’t know what I want.

To be perfectly honest, in many ways, I rage against this idea of Christian identity. In the things I do and the things I prioritize, I very much want to live for myself. For me, is Christ my identity – at the core of my being – or is it just a Circle – just a shell that I put on and off when I am in certain environments?