Update 6: Se7en

Whereupon which our anti-hero discovers Gwyneth Paltrow's face in an unexpected location.

I'm eating a brownie from Veggie Planet for breakfast. And then I'm going to scurry over to Langdell to take a practice test before lunch.

In other news, there is no other news.

Today's studying soundtrack selection of the day:

Update: Sit in Stupor
I've already decided to abandon my previous plans to take a practice test and have delayed it until Friday--at which point, I will have technically gone over all of pre-clinical medicine. Right.

• Cloudy weather (corneal cloudiness) makes me wanna hurl. (Hurler's syndrome, or mucopolysaccharidosis I)
• Clear weather (no corneal cloudiness) is huntin' weather. (Hunter's syndrome, or mucopolysaccharidosis II; time to get into a helicopter with Todd!)
• It's so gauche to have glucose in your cerebrum. (Gaucher's disease, from lack of a glucocerebrosidase.)
• Alternate: Fabrics and ceramics are things gals are into. (Fabry's disease, characterized by alpha-galactosidase deficiency and accumulation of ceramides.)
  

Udpate 5: Seven Ate Nine

Then what happened to eight? I bet eight was smart and escaped from Seven the numeric cannibal. About one week left. Officially one week left to study.

Today, I'd like to share one of my secrets for success: gum. Previously, I already told Helicobacter that it was decidedly unwelcome in my gastrointestinal system. But if I remember correctly, another way to help neutralize acid is through salivary secretions since they're basic (they're -OH-so-good).

Mentally, I'm in a rough shape. I'm studying biochemsitry now, and I don't remember a lot of the biochemical reactions. For instance, did you know that phenylalanine (essential) is processed into tyrosine (not-quite-essential) by phenylalanine hydroxylase? And if that doesn't quite work out, tyrosine becomes essential? And the result is phenylketonuria, which apparently makes people smell "musty." [Insert grimace here] Maybe Old Spice should start a targeted ad campaign (from the top of a horse).

Anyhow, back to it I go...

Update: Sit and Stagnate (in Langdell)

• No one noticed that in my original posting, I mixed up tryptophan and tyrosine. *caterwaul*

New memory aids that make no sense but will still be helpful:

• "Anne Fabryni likes ceramics." (There's a professor named F-a-b-i-n-y. That's close enough.) For Fabry's disease, which involves a mutation that leads to accumulation of ceramides.
  
• "Neiman's picked the sphinx." (In my head: Neiman Marcus for some reason decided to select the Egyptian Sphinx.) For Neimann-Pick diseases, which causes the accumulation of sphingomyelin.

Also:

• You, you get a, get a car. car.
• You, you get a, get a car, car, car

Update 4: Nein nein nein

I'm writing a morning post today, but consider this a valediction forbidding mourning. I'm pretty determined to crank out some results today. I'm equipped with a fresh notebook (I've already filled 3 spiral notebooks with notes in the past few weeks), bananas and granola bars, and a new addition to my studying soundtrack.

What I *wonk wonk wonk* is what you *wonk wonk wonk*.

Update: Sit and Wonder
Today's deep musings brought to you by aggravated studying

• Does "sinopulmonary" mean within the lungs of a Chinese person? China China China?
  
• His tone was loopy because of hydralazine and procainamide. (Anti-histone antibodies in drug-induced lupus)
• (Glucogenic) Arginine met his valentines, (Ketogenic) Leucy and Lysa. (Both) He said, "I-saw-Leucy (isoleucine); she's phenomenal." And then took three tryps to see her. (Essential amino acids--h/t to Chensi)

Update 3: Ten Daze

Heads-up-seven-up (what the heck did that ever mean, anyway?)!

I've been in the law school library since 10 am this morning. That makes almost 8 hours up in this joint. And I'll be here for 2 more hours before heading home at 9 pm. If I were a law student, I'd be annoyed at how many poorly dressed, on-edge med students there were in my library.

Aside from second-years studying for boards, there's also a tremendous number of first-year students in Langdell right now. I don't remember what I was doing on Saturdays during first-year, but rest-assured that it was not studying in the HLS library. Perhaps that's why I don't know anything now, come to think of it...

On a more concerning note, I'm about to drink my third Oxo mug of coffee, which basically means that I'm hopping over the 10-cup mark for today. But for now, it's either a power nap or this--and I figure that the diuretic effects will help keep me awake/alert, too. So here's my haiku to peptic ulcer disease:

Hey, H. pylori,
Heads up! You aren't welcome here.
Occult bleeding? Gross.

Update 2: Eleventh Day Trifling

Later tonight, I'm going to a potluck/mixer for first- and second-year students interested in primary care. I'll be carting along two things, well three, really:

1. My iPhone with apps on it to study for boards in between conversations (Ok, this is a joke, but maybe it shouldn't be.)

2. Some variation of this cranberry-broccoli salad

3. And some type of trifle so that I can use the extra whipping cream I have in the fridge

Until then, you can find me at my kitchen table, studying bizarre muscle and nerve injuries. If your knee ever opens like a drawer, please seek medical attention.

Update 1: Twelve Days

So there was a change of plans. Shocking, really.

Realizing that I hadn't studied biochemistry yet (at all), I decided to put off the diagnostic test until today. I'm not sure if the tapestry of events unfurled as I'd hoped since I got side-tracked with studying hematology and actually didn't tackle much biochem. Alas.

The good news, however, is that I scored higher than I'd predicted on the diagnostic. There were huge gaps in my knowledge base, but I think that a combination of answer elimination and guessing helped me to pull through.

The test did identify some glaring weak spots, though. My weakest section by far is musculoskeletal. This isn't surprising at all, and I'll be focusing on this system tomorrow. What was rather disappointing was that my next weakest sections are gastrointestinal and endocrine/reproductive. Considering that these were the last two classes that I took during 2nd year (and that I worked really hard in them), it looks like I have some reviewing in my near future.

In other life news, I assembled my "restaurant to-do list" that is coupled to my boards studying. Today, I went to Veggie Planet, which is a vegetarian restaurant in Cambridge. I had the "Henry's Lunch," which was a pretty delightful experience: roasted butternut squash, caramelized onions, rosemary & sage, goat cheese and asiago cheese. Mmm mmm good. Up next is sushi at Genki Ya. Sweet potato tempura roll, here I come. (Reminds me a bit of Miya's in New Haven, actually! Sans messy sake-bombing.)

16 days and counting

Hello, world. I'm back. Kind of.

As of today, I'm a little more than 2 weeks out from my scheduled date to take "Step 1" of the national medical licensing examinations. The next several days promise to be filled with sweat (it is hot in this library), stress (I'm hoping I'm not H. pylori-positive), and raucous laughter (read: delirium).

I figure that this is a period on which I'll want to look back in the future, explaining the existence of this entry and the many others that will hopefully follow.

In this pseudo-inaugural post, I'd like to sketch out the timeline of studying I hope to accomplish prior to test-date. In general, I am hoping to average about 10 hours of studying per day. That may seem like a lot, but I've actually finished classes for second year and have a rather flexible schedule. To make it all ursine-approved/bearable, I am actively scheduling in "fun," along with an aggressive attempt to try different restaurants in Cambridge and Brookline.

Tomorrow, I hope to take a practice test that will hopefully give me an idea of how far behind I am in studying. Per usual, I am not keeping to an ideal schedule--by a long shot. But also per usual, there is a chance that I'll be able to crank out acceptable results by gritting my teeth and being ridiculous. But more on this tomorrow.

For now, it's time for a dose of coffee and perhaps a power nap.

Live from Harvard Law School,
DT

PS - Yes, I am excited that I'm studying where Elle Woods could have studied in Legally Blonde. Thanks for asking.

DR Update 6: Strike 3, Doctor Out?

Dominican love for the baseball is pervasive, and this adoration appears to have spread to the workplace. The national fasciantion with strike outs is only matched by a country-wide tendency to engage in labor strikes.

Strikes, or huelgas, are dime a dozen (doce por peso?) here. Last week, there was some type of strike (so non-newsworthy that I couldn't find an article on it) that blocked transportation between the capital and Baní. The result was that the Baní hospital's HIV doctor literally could not get to work. And since he's the only physician with expertise on antiretrovirals, no patients received HIV-related services that day.

The latest newsoworthy strike involves health care professionals. Doctors and nurses are striking for 72 hours across the country, apparently. The government is assuring Dominicans that health care will not change as a result of this labor action. However, I cannot imagine how a significant decrease in hospital staff will not harm patient care. This is an area in which a doctor's elevation of the patient's interests above his/her own may limit what types of protest are ethical. It will be interesting to see what comes of this latest huelga.

DR Update 5: Ruh Roh!

UPDATE: Crying wolf. Todo está bien.

From the headlines, Red Alert!...

Los organismos de socorros se reunieron esta tarde de urgencia para informarle a la población que a partir de las ocho de la noche de hoy y hasta el próximo jueves una activa onda tropical provocará intensas lluvias, por lo que declararon alerta roja para ocho provincias y alerta amarilla para seis. La información el presidente de la Comisión Nacional de Emergencia, general retirado Luis Luna Paulino, el director del Centro de Operaciones de Emergencia (COE) general Manuel Méndez García, la directora de Meteorología Gloria Ceballos y representantes de otros organismos.

Basically, there's a tropical wave (apparently a pre-storm) in the Caribbean. We'll be enjoying intense rain and wind gusts until next Thursday. (#)*$#%

Something tells me that living on a dirt road will not be a benefit in the upcoming week.

DR Update 4: Project

So why exactly am I here in the Dominican Republic?

This is actually a surprisingly difficult question to answer since there are many reasons, some of which have changed.

Originally, I was going to come to Baní to help the organization Infante Sano evaluate its new HIV prevention program, a type of PMTCT (prevention of mother-to-child, or "vertical," transmission) project. Infante Sano is a non-profit NGO that does work both in public Dominican hospitals and in two organizational clinics in underserved communities near Baní. Recently, the organization received a grant to improve access to HIV services in catchment areas of its clinics. One of the goals was to provide rapid HIV tests at the community clinics to increase uptake of the test, receipt of results, and the proportion of HIV-positive, pregnant women receiving preventive services. Well, it turns out that the program hadn't figuratively hit the ground by the time I literally hit the tarmac at the Santo Domingo airport. Thus, my goals necessarily had to change.

As I mentioned earlier, I realized soon after arriving in Baní that my language skills (or lack thereof) would severely constrain my work. Thus, the project created by my supervisor here seemed daunting: in 6 weeks, I was to learn about counseling and testing in a local hospital and translate lessons learned to a feasible community-based rapid HIV testing program. In other words, I was told to create the program that I came here to evaluate. There was also talk of my improving my Spanish so much that I would be able to provide community-based HIV counseling. [Insert joke about pigs flying and H1N1...] Fat chance.

Despite speaking Spanish as well as Sarah Palin stays the course, I did manage to learn a lot about hospital-based counseling and testing in recent weeks. The program is impressively robust and has integrated counseling, testing, and clinical services. The doctor on the service is also extremely dedicated to his patients, and I've learned a lot about HIV care in resource-constrained settings. (These constraints are relative, of course, and our neighbors in Haiti definitely have it much, much worse.)

Despite this limited success, I've started my fourth week here in Baní, and it's time to start promoting rapid HIV testing in the communities served by Infante Sano's clinics if we want an iota of a chance to cultivate any community interest in HIV testing. But herein lie several problems... First, half of the staff (including my supervisor) is gone for a full week, having traveled to Boston for a strategic planning process. Second, we don't actually have any rapid tests yet--and it's not even certain that we'll be able to get our hands on any rapid tests before I jet off. Third, we don't know what type of sample is required for the rapid test; if serum is required, we would have to draw blood and spin it down. Since we don't have any lab equipment, this situation would be a kiss of death for community-based testing. Fourth, my fact sheet on the rapid test is still unedited and unprinted.

So I proceed, fingers crossed. We'll see how it goes...

DR Picture Update 1

Location 1: Baní

Baní is my "home base," where I live and where I work. As mentioned earlier, I live in an apartment above the office of Infante Sano with other volunteers form the United States. One day, we had a coworker over for dinner and decided to make dumplings. I had to dig really deep (read: to my genes) and pretend that I knew how to cook Chinese food. I think the DMPLG gene is by the PNGPNG gene on the q arm of chromosome 4.

Making dumplings at the apartment, putting all of the comida china/pico pollo places to shame. Other person pictured is Lindsay, a pediatrics resident from Children's Boston.

Pot stickers (pegaollas?) in the DR. w00t.

Climbing a tree in a public park in Baní...

One fun cultural difference between the US and DR is that people here really like to pose for photographs. This is an attempt to emulate that proclivity--in other words, my being a huge poser in multiple ways. (So meta...)

Location 2: Barahona

Before Lindsay left, we traveled by guagua (bus) to Barahona, closer to the Western border of the DR with Haiti. The beach in this region is truly spectacular. We ran into a Peace Corps volunteer on the guagua, and he was on his way to act as a translator for a medical mission. This is a really convenient location for a medical mission, don't you think?

Los gringos at Casa Bonita in Barahona. This is what work is like every day. Or not :(. All of the doctors from the medical mission jumped into this pool soon after. Once I heard someone mention CME (continuing medical education), I ran for the hills. You've already met Lindsay. The other person pictured is Erik, a volunteer from Virginia who's going to start medical school soon--the poor soul.

We met a Peace Corps volunteer who literally lives on this beach. Where can I sign up for Beach Corps service?

Location 3: Cambita Garambito (near San Cristóbal)

Cambita is a campo (small town in the countryside) where the family of a coworker lives. Cambita comes from the work for bartering, which was a major form of trade here prior to the development of dollar dollar bills (peso peso bills?). I've made several trips over to hang out with my coworker's family and friends.

The baseball field in Cambita. People are sure serious about their baseball here in the DR.

Los gringos, otra vez. The volunteer on the left is Amy, a nurse-cum-future midwife-cum-international development superstar.

On the way up a mountain, Erik's car overheats and pulls an Old Faithful.

Crashing at some person's vacation home. (Seriously. We went there to hang out in someone else's back yard--which was a great call. You'll see why in the next picture.)

The scenery was ridiculous. The person in pink is Yosely, my coworker. Other people pictured are her family and friends.

DR Update 3: Activities of Daily Living

Sorry about the lack of updates recently. I'm going to try to write more regularly for the rest of my time here in the DR. This entry is dedicated to documenting some of what my day-to-day life is like here in Baní.

Luckily, I'm living in a very modern apartment. The kitchen is well-stocked, complete with gas stove and refrigerator-freezer. I also had the good fortune of moving into the last available room in the house, which has its own bathroom. In other words, I have way more personal space than I lived with last year when I lived in Vanderbilt Hall. All of this said, there are still a few aspects of life that are different:

• I live in an apartment above my office: My daily commute is literally 15 seconds as I walk down the stairs--shorter than my mini-trek to TMEC from Vandy. But I can't 2xAV (experience at supernatural speeds) office work. My bedroom is the room behind the brick on the second floor.

• I take bucket showers: There's often not enough pressure from the water pump (la bomba), and I take bucket showers with water that I set aside in a pail. I've been amazed at how little water is necessary for a thorough scrubbing.
• I wash clothing by hand: And thus, I'm pretty sure that my clothing isn't very clean... After I finish scrubbing, I use a nifty centrifuge to expedite the drying process before hanging the wash out on the line.

• I ride around on the backs of motorcycles: The most accessible form of transportation is catching a ride on the back of a motorbike, or motoconcho. For about 30 pesos (<$1), I can catch a ride from my house to the center of town.
• I don't have AC: I didn't have AC when I lived in New Haven or Washington, D.C., either. But in those places, I wasn't super paranoid about insect bites (thanks, micriobiology class!)--and I had screens on my windows. Nowadays, I either sleep with the windows closed (and fan at maximum speed) or with the windows open (wearing a gallon of OFF!).

More on my life and project in the next update!

DR Update 2: Swiss DEETs

I'm currently wearing 30% DEET, of the "Deep Woods Sportsmen" variety from OFF! I've been using this stuff almost constantly since my first-year micriobiology course left me a bit paranoid about dengue fever and day-biting mosquitoes. I've managed to keep insect bites to a handful during my time here, but I'm not sure how long my chemical stockpile will last. Hopefully, I won't be feeling and "bone-break" symptoms anytime soon.

Update: I've exhausted my supply of 30% DEET, so I'm now using 15% OFF! Sport. One benefit to this change is that the new spray smells like strawberries as opposed to a chemistry lab.

DR Update 1: Language Barrier

I would write this entry in Spanish, but it has been evident during my first 5 days in the Dominican Republic that I speak Spanish about as well Heidi Montag integrates by parts. I've actually been surprised at how difficult it has been for me to understand what people are saying, even at a very basic level. It's true that Dominican Spanish is notoriously fast and often drops syllables. However, the level of my language ineptiude has transcended so many barriers that I am now winning a game of Tower of Babel limbo. At this rate, I am approaching the ground in a truly asymptotic fashion.

Hopefully, in the next few weeks, my Spanish will drastically improve. I've already learned quite a few words, and I'm making an extensive vocabulary list. I'll describe my work in an upcoming entry, but suffice it to say now that I'll need much better language skills if I'm going to do anything of substance. (My original project, which required less speaking, is no longer feasible. It was focused on program evaluation using patient data, but given that said program still does not exist, it will be hard to evaluate it!)

So far, my inability to communicate has been very humbling but also very frustrating. Not being able to express myself has been bothersome since I am used to having a good command of the English language--especially techincal English. On Friday, I tried to explain to my supervisor that I had worked last year with individuals who had comorbid diabetes with HIV/AIDS; that we thought that the protease inhibitors in their combination ARV therapies may have caused insulin insensitivity; and that I'd heard from many people that diabetes was harder to manage than an HIV infection since the latter only requires taking pills whereas the latter requires continual monitoring. As you probably can infer from my previous statements, this attempt was a complete disaster!

For now, I'm going to concentrate on seeking opportunites to practice speaking Spanish so that I can improve my ability to communicate. Fingers crossed, and knock on wood.

Este verano.

Tomorrow, I'm jetting off to the Dominican Republic for 7 weeks. I'm working with the non-profit Infante Sano ("healthy baby" in Spanish) on a project to improve access to HIV testing for pregnant women. Our ultimate goal is to prevent vertical (mother-to-child) transmission of the virus.

In addition, I'm going to be learning Spanish furiously. This will be my first immersion experience in which my coworkers will not speak English. My project involves interviews of Spanish-speaking doctors and nurses. Hopefully, by the end of the summer, my fluency will be much better.

Contact

This isn't the Jodi Foster movie, but it basically lasted as long. I'm talking about the length of time it takes me to put in one of my contacts.

I visited the optometrist a few days back to get my annual eye exam. These days, I'm pretty much convinced that med school is ruining my vision, so I fully expected news that I needed new glasses. For kicks, I also decided to get a contact lens exam.

Well, come to find out, my vision hasn't gotten worse. (Really?... I'm skeptical.) I did, however, get a new contact prescription--for one that corrects less, not more. According to this optometrist, my lenses (same prescription for both eyes) had been overcorrecting for one of my eyes, and it's better to undercorrect rather than overcorrect. Surprise?...

One-third of me is over my head.

A study in Health Affairs last month looked at the amount of money that physicians (in private practice) spend on overhead costs of interacting with insurance companies. The findings were extremely interesting and show just how much money doctors spend on things outside of actual patient care. Perhaps the most striking result was that primary care physicians spend nearly one-third of income, including benefits, on paying for staff interactions with insurers.

One out of every three dollars.

This statistic is outrageous and should be more prominent in discussions about health care reform. However, if you read the statements from the American Medical Association, all you see are proclamations on how patients are best served by private insurance--and that the public option in Obama's policy proposals is a bad idea "for patients." All of this talk persists even though an independent analysis from the Commonwealth Fund has shown the potential for a public option to save as much as 30% through mechanisms such as lowering administrative costs. With 45 million Americans completely uninsured and millions more underinsured, decreasing health care spending that doesn't fund actual care should seem like a prudent option--one that is, dare I say, good for patients. (You know, like the ones who are not getting any health care because they have no insurance and can't afford out-of-pocket costs. Not to mention the people who have their health plans revoked due to post-claims underwriting and rescissions.)

It seems that political pressure has already caused the AMA to backtrack a bit. An email that I received from the Massachusetts Medical Society stated that the AMA has decided to avoid "closing any doors" in analyzing health care options. Regardless, I hope that more physicians step up to the plate and advocate for reform options that are good for the health of patients instead of focusing on options that protect physician pocketbooks.

I'm [Rosetta] Stoned.

I've been using Rosetta Stone during the past few days to brush up on Spanish. First of all, I can never remember the word for kitchen sink: fregadero. But of greater interest, there is a picture in Level 3, Unit 1, that looks oddly like... me.

For those of you who somehow speak worse Spanish than I do, the sentence roughly translates into: "The man has his hands on his knees." The phrase may as well be "El hombre se parece a Swiss Beats, pero con un BMI normal."

Emm One Done.

I apologize for falling off the face of the blogosphere for the last 6 weeks like a Columbus-detractor, circa 1492, who'd gotten to an edge of a flat world. But now I'm back, and I hope that my posts will be more regular now that I don't have to worry about exams.

The last time I wrote, I was concerned about H1N1 influenza, whose outbreak happened to coincide with the virus module in my microbiology course. Since then, H1N1 has has been declared a pandemic, but I've been preoccupied with learning bacterial identification via culture methods and the "hallmarks" of cancer--the latter of which almost sounds like neoplasia has its own line of greeting cards. Two classes and an integration week later, I am officially done with M1, or my first year of medical school.

Now, it's time for my last summer break (*dramatic pause*). Medical school blatantly disregards human concepts of time and seasons. First, as "days" on each planet of the solar system last for differing numbers of Earth-days, the first "year" of classes at HMS actually lasts 10 months. Subtraction implies that I have about 2 months of a full year left, and that's basically how much time I have before classes begin in mid-August. Also, medical school, in all of its professional glory, attempts to capitulate "normal adult life," in which summers cease to exist. After M1, there are no more summer vacations. (I have a potential 4-week vacation next year if I somehow manage to study for USMLE1 during the school year and take the test almost immediately after classes end. Fat chance.) Thus, I'd better make this 8 weeks or so count since it's going to be my last prolonged (>1-3 weeks) time away from school/work for a while.

For now, I need to focus on getting myself home to Georgia!

Con-flu-ence

Cross-post from Drs. in Training:

Last week, we began the virology block of the first-year microbiology course. One of our earliest lectures was on respiratory viruses, with a particular focus on influenza. Aside from learning that influenza has a segmented genome that gives it great potential to jump between species, we also discussed the risk for pandemic flu. In fact, our weekly problem-based-learning module focused on influenza and public health in the face of an unexpected epidemic.

Fast forward to Tuesday, when the CDC announced that there were then-isolated cases of a type A H1N1 swine influenza on the West Coast. We were sent a link by our course director to the CDC website, partially in an effort to show us that what we were learning was applicable to the real world. By the end of the week, we needed no more convincing of this fact. News had come that an epidemic of porcine influenza was shutting down public services and infrastructure in Mexico. Talk of a burgeoning pandemic began.

During this whole time, I couldn't believe how synchronized my education was with current events. The importance of knowing what neuraminidase is seemed to have suddenly jumped exponentially, to the point where I heard people discussing the protein on a plane ride last Sunday. (Neuraminindase is the molecule targeted by antiviral agents such as osteltamivir, or Tamiflu.)

Then, last night, I learned that I may have what is a front-row seat to witness public responses to influenza. First, we received an email announcing that there was a suspected case of porcine H1N1 at the Dental School. Then, around 11:15 p.m., we received the following email from our Dean:

HMS and HSDM leadership has been working closely with public health officials today to understand the significance of a potential H1N1 case at the Dental School. As a precaution to protect your health as well as the health of the broader community until more information is known, both medical and dental school classes are canceled for Friday, May 1. Also, students should not go to the hospitals for clerkships, PCE classes or any other activities. Classes are canceled at HSPH as well...

Also, because there currently is such limited information, students are encouraged to stay home and to refrain from participating in public activities. Again, we emphasize that this is being recommended purely out of an abundance of caution, after careful consideration and with an interest in protecting you and the health and well being of our community.

It turns out that the suspected case is actually a dental student, which may explain why classes have been canceled. (I live on campus, about 400 meters from my classroom, so this "don't go to school" recommendation doesn't seem particularly meaningful in my case.) Word traveled quickly, soon to The Globe.

Thus far, this confluence of information has been a little overwhelming. I feel a general lack of agency, especially since we have been advised essentially to quarantine ourselves. The results of the diagnostic tests for the suspected case have not come back yet, and it is uncertain what the response will be if the student tests positive. For now, there's little to do but sit and wait.