Of Pretense and Persuasions

Friday, July 28, 2006

Road to Normalcy

Today was the worst day ever on my Psychiatry Rotation... not so much because of Psychiatry but because I was having multiple episodes of anxiety. I lost my ID card, ran into NIB, had to have those awkward 'goodbye, it was nice working with you, heh-heh' conversations, and had to sit quietly in revulsion as I watched the Ward Staff infantilize my entirely competant patient.

I made up for it in the evening. Cooked dinner for/with a friend ... this girl who, more or less, is a reflection of my spirit. She's a nursing student I met recently. She meditates, she runs, she's crunchy organic, she's also been to China, has the same relationship issues, ... totally, my kinda girl. I mean, we are both obsessed with avocados, bananas, tofu, broccoli and dark chocolate. She's one of those people who makes me feel like I'm at home and that I am understood.

We went out to Hot Tomatoes with a few of her other nursing friends. It was so refreshing to meet other people; so nice to get out at night and walk the streets devoid of fear. I've never been to Hot Tomatoes ... or any Bar/restaurant in New Haven for that matter. Fortunately, I've learned by now how to have fun at a Bar with friends and not feel lame for not ordering anything with alcohol. I can thank Sanjay [the Shanghai one] for that lesson. What's more is that I was fairly talkative ... which goes to show that I have developed the ability to talk in group situations. So, if anything, Psych has been useful in teaching me how to talk to people. Exposure Therapy there, for you.

Dr. Fox tells me that I interview patients like a fourth year psych resident. He says I display extreme comfort in talking to people. I find this all very amusing since four or five years ago, this was very much not the case. That was when I used to run away from people; and sometimes, I guess I still do run away from people... but not so literally, and no so often.

Oh -- and the other anxiety provoking issue: I'm having a minor crisis about moving. Everyone who said they would help me is abandoning ship. Everyone except NIB [Nice Indian Boy]. But I'm too tired to even start worrying about that one.

Thursday, July 27, 2006

I appear to have some major cognitive distortions with regards to my self-image. I always thought of myself as a shy, socially-inept, and awkward girl. The psychiatrists I work with, however, are generally dumbfounded by this image because, well, I guess I don't come off as shy, socially-inept, and awkward. I dunno. Maybe I've changed without realizing it. I certainly don't feel like I'm "acting" or pretending to be someone I am not. In fact, for the first time in my life, I feel entirely comfertable being myself while at work, complete with all of my idiocyncracies and goofiness. One of my resident's tried to come up with an Axis II [Personality Disorder] diagnosis for me, and failed. I tell you, this is seriously the first time any one has ever diagnosed me as "normal." Me! Normal! Imagine that! The last time I ever felt like I was "normal" was in 3rd grade when I gained entry into the "Popular Group" at school [hah! the first and last time that ever happened!]

Maybe I've lost some of my awkward nerdiness and become cool. Naah. I think its just that I've found a home amongst similarly awkward and nerdy people. I think that's it. I'm among people who are just as weird, if not weirder, than I am -- so I come off looking like I'm normal.

Anway, I think I'm going to come up with a list of good and bad things about psychiatry. So far, I can think of only one significantly bad thing: you are tied to your patient population, which limits the extent that you can travel or take time-off. In that vein, you can't really do major humanitarian type-work as a Psychiatrist. I mean, I guess two years ago when the tsunami hit India, Sri Lanka, etc .. a lot of Psych M.D.s went over to deal with tramatic stress issues ... but I'm not sure how much they could really have done. I'm trying to say that its not a profession with skills that you can really travel with. [?]

Something I learned about Psychiatry this week that is good: Its really one of the few professions [M.D. wise] where you can really do clinical and research work at the same time ... and, importantly, do both of them well. In other professions, it becomes abundantly clear that one or the other responsibility gets shafted. In psych, its much easier to balance the two. And plus, your hours are pretty sweet.

Wednesday, July 26, 2006

Presentation went extremely well today. I love Advil.

Tuesday, July 25, 2006

Ah, the stories this picture could tell...

Things to Stress About:

1. I have to do a presentation tommorow on ... Stress! And how it kills brain cells! This is majorly stressing me out since its basically going to be me talking to a bunch of M.D.-Ph.Ds who know a helluva lot more than I do. Even worse is the fact that I haven't actually started working on my presentation yet. Aaaaaaaak! Shoot. I think I just lost, like, five neurons there.

2. Moving. Moving is stressful. Moving without any plan on how to move, even more stressful. I have no idea how I am going to migrate. I have no car; I don't even know how to drive. Two good things: I don't have much stuff and I do have friends. The only problem with the latter is that one of the "friends" who offered to help me moved [of his own accord, mind you ... no begging was involved] is a seriously nice, super-intelligent, ridiculoulsy-good looking Indian guy. ... and.. um.. this makes me nervous. Although, come to think of it, I think I'm more bothered by the fact that I might have to ask a member of the male species for help than I am about anything else. The idea seems to violate my internal code of wannabe-buff-girl ethics.

Otherwise, life is dandy.

Things that make me happy:

1. My Chief-Resident is AWESOME. My attending is, frankly, ... unattentive ... but my Chief makes up for it. He's one of those people who leave you wondering how it is possible for a person to be so nice. And he's brilliant too... a friggin' human encyclopedia. He's probably in his mid-to-late 30's but he's still got this childish spark to him which I think is beautiful. I like people who don't grow up ...

Sunday, July 23, 2006

















Wow.
Click on the image for more goodness.

I'd like to do several rotations abroad. Mumbai sounds good; South India sounds better. South America, Africa ... possible.

Friday, July 21, 2006

I keep falling in love with the world and can’t help but wonder if that’s a bad thing. That is to say, sometimes I find myself wondering if a person is capable of feeling or expressing only a finite amount of love in their lifetime. And, if that were true, am I being so flagrantly wasteful with my feelings at the current moment?

By the term ‘love’ I don’t mean the “I want to marry you”-type of love, but the “I think you and this world are so radically awesome”-kinda love. Maybe my feelings are generally indicative of the contentment I feel with my life, my job, and my environment right now. Indeed, in spite of all of the pain, the sadness, and the extreme suffering I encounter daily, I find myself content, fulfilled, and inanely happy.

I love my patients, regardless of how mentally debilitated they appear to be. Each, in their own right, is so breathtakingly beautiful; so breathtakingly human. They evoke in me such a staggering amount of compassion, combined with respect, that frequently I find myself struggling to maintain professionalism. It takes everything in me to maintain my composure and to not bust out with something to the effect of, “You go girl! You can do it! I believe in you!”…. Although, come to think of it, perhaps medicine would be better off if Docs did speak that way… :)

I love my teachers – the residents, the attendings, and the individual tutors. Sometimes, I find them to be complete punkasses when they yell at me for doing something wrong or when I find them doing something that I think is wrong … but for the most part, I am flattered by how generous they are to me with the gift of their time and the gift of their knowledge.

I am even starting to love my environment. It used to be that I hated New Haven. Now however, I have discovered small miracles in the city and beyond that have made me inanely happy: Lyman Orchards, Miller’s Pond, East Rock Park, Farmer’s Market, Fresh Yoga, Prospect Hill Community Garden; Criterion Theater, The Rice Pot, The Pantry, Payne Whitney Gym, Barnes and Noble, Edge of the Woods, and Nica’s.

I think that a lot of what I feel is consequent to the inner stability I have started to accrue. Which is to say, I am far more comfortable with being who I am, however quirky [euphemism for ‘odd’] and imperfect as I happen to be, than I have at any other point in human history. I have, once again, entered The Zone: academically, spiritually, and athletically. My days are characterized by solid discipline and complete focus. I go to bed at 8:00 pm and am at my desk by 4:00 am. I eat well and exercise wisely. I work because I like what I do; not because I have responsibilities to attend to or hours to put in. I pay attention to myself, my dreams, my whims and caprices. I pause to appreciate the humor and the magic of my life. I am open to the possibility of new dimensions to my experienced reality and am okay with the uncertainty regarding my future direction.

That being said, I don’t always wear rose-coloured glasses. In order to be cognizant of the problems in our society that can damn well be fixed, you can’t go around pretending that everything is great. Things that suck, need remedy. Things that are good can be made better. I’ve been talking to Dr. Fox and Dr. Rourbough a lot recently about reintroducing the concept of humanity into the delivery of health care. Why not change the sterile, concrete architecture of mental institutions and hospitals into something far more vibrant and nurturing? Why not shift our focus from “sick-care” to ‘health-care” and finally do something about preventive health care? Why not sink more money into social support services for home-based care than institutionalized settings where the sick come to get sicker?

Sometimes, I am frustrated by the failings of the System within which I work. At the same time, however, I appreciate these challenges – indeed, almost seek them out – because they incite creative thinking. That is, they force you to reevaluate the status quo and ask you to come up with a better solution. Problem solving as I love it!

Thursday, July 20, 2006

What's In a Name? Part Deux

As of late, I have been getting a lot of medical spam. I scanned the fine print of one of these e-mails yesterday and at the end, I noticed it read "You are getting this email because you have printed an article or an abstract in such and such journal." I was largely put off by the whole thing because, in fact, I hadn't published an article in Such and Such journal.

Then at work yesterday, something came up and I had to do a PubMed search about my former lab at Stanford. Guess what? Turns out I actually do have a publication in a journal called Brain Research. And I never even knew. The only issue is that they misspelled my last name; adding an extra "o." My God, the indignity!

Here's a link to the article.

Gene therapy in the nervous system with superoxide dismutase.

Abstract:

Neuronal death following necrotic insults involves the generation of reactive oxygen species (ROS). We investigated the effects of antioxidant gene therapy on ROS accumulation after exposure to either sodium cyanide, kainic acid or oxygen glucose deprivation (OGD). Specifically, we generated herpes simplex virus-1 amplicon vector expressing the gene for the antioxidant enzyme CuZnSOD. Overexpression of this gene in primary hippocampal cultures resulted in increased enzymatic activity of the corresponding protein. CuZnSOD significantly protected hippocampal neurons against sodium cyanide insult and the subsequent lipid peroxidation. However, it did not protect against OGD- or kainic-acid-induced toxicity. Moreover, CuZnSOD significantly worsened the toxicity, hydrogen peroxide accumulation and lipid peroxidation induced by kainic acid. As a possible explanation for this surprising worsening, CuZnSOD overexpression increased glutathione peroxidase activity in the presence of sodium cyanide but had no effect on catalase or glutathione peroxidase activity in the presence of kainic acid. Thus, cells were unlikely to be able to detoxify the excess hydrogen peroxide produced as a result of the CuZnSOD overexpression. These studies can be viewed as a cautionary note concerning gene therapy intervention against necrotic insults.

Tuesday, July 18, 2006

To Do List:

1. Set up a health spa which provides preventive health education, teaches yoga and mindfulness/meditation, provides Chinese massage therapy, has workshops on stress reduction/healthy coping strategies and has a gym. The target population would be low-income mothers [so, ideally, childcare would also be a part of the center]. Or, I guess, in order for the idea to be financially feasible, there could be a means-based paying scale ... with scholarships or extra incentives provided to increase participation of low-income mothers. There are a few crunchy spas out there, but they are only for rich people and are usually set up in the middle of some southwestern desert or another. Honestly, how many poor, hardworking mothers have the time or money to go and eat granola in the Arizona desert? Pfff.

2. Be the songwriter, storyteller, poet, artist, filmmaker that I want to be. Write things that fundamentally change the way people think. Tell the stories which rarely get told. My role models in this world are Arundhati Roy and Deepa Mehta, two women of incredible strength, beauty, and resilience.

3. Work out a partnership between Doctors Without Borders and Engineers Without Borders. I hear there is also a group called "Clowns without Borders" -- I am a little skeptical about that one.

4. Understand how society allocates political power and why that process gives some people the power to create social change and pushes others into social isolation. I would like to understand the dynamics that underlie the feminization of poverty. Understand the medicine of marginalization.

5. Learn magic.

6. Hike the Picos de Europa in Northern Spain.

7. Run the Delhi Marathon.

8. Arrainge an exhibition of my artwork in the Med School library. My current project involves a series of paintings of women of colour.

9. Learn Medical Spanish.

10. Set up a chocolatery that sells Fair Trade African Chocolate exclusively. I highly recommend this chocolate. [Social entrepreneurship]

11. Do a "Make Poverty History" campaign at Yale. Design & sell radical and cool t-shirts and fair trade items [like, chocolate!] -- donate proceeds.

12. Design worksheets for health behavior change [using motivational interviewing strategies] for patients.

13. Learn how to play my guitar properly.

14. Learn squash. Eh... scratch that. It seems to elitist and too Ivy of a game.

15. Be a yogini.

Monday, July 17, 2006

Of Goodness and Badness

The Good:
  • I got my Step 1 USMLE scores back today; suffice it to say, if I wanted to match in an ultra-competitive program such as neurosurgery, my board scores would be very helpful. Honestly, though, I feel like none of this nonsense really matters anymore. It was important for me to do well because I needed to prove to myself that I wasn't a complete idiot at medicine. But as far as matching in a competitive residency is concerned ... pffff. At this point, I would much rather move to San Francisco to run a chocolatery that sells Fair Trade African Dark Chocolate exclusively than go about business as a neurotic surgeon. All that I feel is important to me now is this: I would like to work with the indigent. I would like some travel/adventure -- but within limits. And I would like to raise my children [all 12 of them which I plan to adopt]. Oh. And the marathon. Musn't forget the marathon.
  • That being said, I can't take credit entirely for my ridiculous scores. Thank you mommy, for feeding me pure vegan food, soy ice cream and organic dark chocolate every day for the two months I studied. Thank you, Anna, for taking me out on a movie break and starting me on the path to social reintegration after six weeks of living like a hermit. And thank you, everyone, for believing in me at times when I no longer believe in myself.
  • More good news: I got new running shoes! I'm a complete sucker for products endorsed by Runners Magazine.... its really sad. But I needed new shoes.
  • I continue on my spree of Random Acts of Kindness: I made a very pregnant friend of mine very happy by surprising her an anti-boredom care package [She is on mandatory bed-rest]. I'm always surprised at how easy and fun it is to increase the universal sum of human hapiness.
  • Work at my new psych site finally felt good today -- I've finally got my own patient to work up independently. I like teamwork, but I also like taking charge of stuff and getting $hit done independently. I bonded with my Attending over nerdy research stuff -- turns out, my "useless" research in college [all 3 years of it!] may actually further his OCD research here. I also bonded with Boris, the resident from Kiev. I talked to him about my life in Russia and my work at the womens' psychiatric clinic there. He later invited me over to his house for dinner with his wife and baby -- ah, Russian hospitality... I love it! I'm not sure how much more Borsh soup I can handle in this lifetime though. We might just do lunch over here at the hospital.
The Evil:
  • I have been majorly depressed by my ER tutorial with a psychoanalyst this evening. I am tired as hell, having been up for 20 straight hours. Not only that, but I'm wound up becuase the guy was practically a Dementor [a la Harry Potter]. He sucked the soul right out of me. This is really only the first time that I've felt this intense feeling of suckiness regarding Psychiatry. He talked at me for 4 hours about suicide among female physicians ... actually, correction: he didn't really acknowledge me much --- he was mostly focused on the other med student present who, well, many members of the male species find to be ridiculously good looking. So not only did I feel depressed [because all we really talked about was suicide amoung female physicians], but I also felt entirely disconnected becaue I am not leggy, beautiful, white and blue-eyed. He also kept mentioning how his wife died four years ago and that made me feel sad ... he seemed like a broken man.

Paper A Day
I will try to review a paper a day, and idea borrowed from Anand of the Ergodic Walk. I'm not sure how successful I'll be, but hopefully posting my reviews on this here bloggie will add incentive.

Efficacy of ECT in Depression: A Meta-Analytic Review

Pagnin, D, Queiroz V, Pini S, Cassano G.

This study compared the efficacy of ECT over pharmacological approaches to treating depression. The study found that ECT is significantly superior in all comparisons [ECT vs placebo, vs antidepressants in general, vs TCA, vs MAOIs] and validated ECT as an appropriate therapeutic tool for treating depression.

Electroconvulsive Therapy : A Selected Review

Greenberg R, Kellner C

This article is a basic review about ECT. ECT is used most commonly in MDD, although it has also been shown to be useful in treating other psychiatric conditions including bipolar disorder, schizophrenia, PD, and NMS. As yet, there has been no evidence to suggest that any antidepressant medication is more effective than ECT in treating depression. Another advantage of ECT is that the response is usually faster than with antidepressant medication. In order for ECT to be effective, the seizures that are triggered should last at least 15 seconds and no more than three minutes. Of note is the fact that relapse rates in the 6-12 mo after ECT exceed 50% and are particularly high in the first few months after the initial response. The paper indicates that “there is preliminary evidence that nortriptyline-plus-lithium may be a safe and effective combination that may significantly reduce relapse rates of depression.” This suggestion is applicable to the treatment of my patient and I will bring it up with the Team at Rounds next week.

Sunday, July 16, 2006

I am a Simple Farmer

Again, my plans to study the weekend away have been thwarted. Two hours after I started off on a simple trip to my neighbor's apt to acquire packing tape [for my impending migration], I found myself in the middle of a blueberry patch at Lyman Orchards, collecting berries in a small basket and surreptitiously stuffing some in my mouth. Ummm ummm goodness. We also found a raspberry patch and acquired some more mmm mmm goodness there. I'm doubtful that these are organic, but I reason the antioxidants in the berries should balance out the carcinogens/pesticides that they are consumed with. Eh. Whatever.

Following the berry incident, I found myself being whisked away to Miller's Pond for some pseudo-swimming. Actually, more like, pseudo-wading, as I am averse to the whole concept of swimming. I believe our prehistoric ancestors emerged from the primordial sea for a reason and I would like things to stay that way for me. Nonetheless, I didn't mind watching my friends swim while I roasted myself on a lakeside rock.

So that was enough tomfoolery for the weekend. I have to turn in a never-ending write-up on a patient with depression [treated with ECT] that I admitted on Friday. I'm working on that right now ... intermittently watching Main Hoon Na, a movie that just cracks me up. I lent it to my friend George, the med school librarian, whom I've [for better or for worse] converted into a Bollywood addict and he only just returned it to me. You know, sometimes I just really enjoy engaging in entirely brainless activities and nothing gets anymore brainless and hilarious than Bollywood. The fact that it is so stupid is what makes it so good.

Anyway, I'm on call tommorow night in the Emergency Room.... which means, no 8:00 pm bedtime for me tommorow.

Medical Complications of Anorexia

I'm doing the workup on a person who came in with a diagnosis of "end-stage anorexia" [wtf?] but, on the ward, demonstrates no classic anorexic behaviors. She has had severe wt loss and looks like a skeleton, so I've been keeping tabs on any possible medical complications I need to look out for:

Cardiovascular: Bradycardia, CHF, Dysrhythmias, EKG abnormalities, MVP, Pericardial effusion, Orthostsatic hypotension

Derm: Acrocyanosis, Brittle hair, brittle nails, carotene pigmentation, Edema, Hair Loss, Lanugo hair, Russell's Sign

Endocrine: Amenorrhea, Diabetes insipidus, hypercortisolemai, hypothermia, low T3 syndrome, pubertal delay

GI: acute pancreatitits, Barrett's esophagus, constipation, delayed gastric emptying, Eso/gastric rupture, fatty infiltration and focal necrosis of liver, gallstones, intestinal atrophy, mallory weiss tears, SMA syndrome

Neuro: Cortical atrophy, Myopathy, Peripheral neuropathy, Seizures

Skeletal: Osteopenia, Osteoporosis, Osteoporotic fractures

Brownie points for anyone who know's what the terms highlighted in red mean. Sounds like a good assignment for Mrs. P.M. [ehem].

PHARM Note: My patient is hypertensive and came in with a prescription for Clonidine. Why is this impt? Because the side effects of clonidie include nausea, vomiting, contipation and anorexia. We took her off of it.

Thursday, July 13, 2006

On Not Being Nice

It has only recently dawned on me that my approach to psychiatric therapy is entirely flawed.
This notion came like an epiphany to me yesterday as I watched my resident behave like a complete harda$$ to this woman [a crack addict] who had come to the Mental Health center looking to be enrolled in a substance abuse research study. At first, I found myself utterly annoyed with my resident. The guy displayed absolutely no empathy towards this woman. His interview consisted of reading out loud questions in rapid-fire sequence from an admittance form and scarcely making eye contact with the woman. In the end, when he discovered that she was HIV+, he happily showed her the way out -- you see, her comorbidity disqualified her from recieving the experimental treatment.

I was aghast. I could not believe that the Team was not giving her any sort of rehab treatment for the simple fact that she did not meet their requirements for the research study. The indignity of this all bothered me so much that I managed to get the help of a social worker to find this woman a safe place to stay for the night. But even still, I was livid.

As the woman waited for the Staff to process her discharge papers, I sat quietly next to her trying to understand my own feelings and also trying to find the perfect words to say to her. I failed on both parts. There, in front of me, sat a woman who had hit rock bottom. She had no money, no property, no friends, and no family. The only things she did have was an addiction. And the only thing We offered her was a clean pair of sweatpants [absurd given the fact that it was 85 degrees outside].

As she waited for her papers, I asked her what she looked forward to in her future -- she said the hope of living to see the day when fear and crack did not rule her life. I think I then tried to mumble something about seeking role models and acknowledging how difficult her life has been, but I was really floundering, so after a while I just sat there and silently raged against everything that I felt had gone wrong with this patient.

I was pissed at the world for constructing her history as it turned out to be. I was pissed at my resident for behaving so gruffly with a woman in need. And I was most pissed at myself for being so impotent and so entirely useless.

I am gradually starting to see that my emotions and my desire to empathize with patients need to be controlled before they turn me into a good person who is a bad psychiatrist. You see, according to the dogma that governs Western Psychiatry, a psychiatrist must maintain neutrality at all times. You are supposed to be distant; you are supposed to be cold; you are supposed to be a world class harda$$. So that whole thing about my patients at the VA loving me [yah, I had three old dudes ask me to marry them] ... that was actually a bad thing. You are not supposed to display empathy; you are not supposed to make encouraging statements -- and, according to our Thursday afternoon didactics, if you find yourself rooting for your patient or going beyond your neutral boundaries, there is a likelihood that your patient has Antisocial Personality Disorder. According to Dr. Mundy, these are the patients who wheel you in, who try to make you feel sorry for them, who will play every card in their deck until they get their way. They lack any degree of remorse for the crimes they have committed, but they can still make you fall for them.

I finally got hold of the records of the crack addict I spoke to earlier. The chart was nearly five inches thick and fell on me like a ton of bricks [literally and figuratively]. The woman had basically lied to me and my resident about every aspect of her life. Suffice it to say, this woman has done some very bad things which I can't even bring myself to write [we're talking on the level of internecine warfare]. I found that so confusing because when I had looked at her, the only thing I saw was someone who was fundamentally good but who, thru ill-luck and circumstance, had become slave to an addiction. Perhaps this speaks volumes about my naivete. I want to believe that people are good; I want to believe that people are kind; I understand that we all have our faults and yet still I believe we all carry a spark of the Divine.

I suppose I should be feeling sad and jilted for being completely hoodwinked by this pitiful woman. But really, I don't. Rather, I find myself struck by the complexity of the fabric of our human existance. There is just so much that makes up the story of our lives : things beautiful and bonny amidst terror and tragedy. My, what a world, what a world.

General Housekeeping Notes

  1. The time stamps on these posts erroneously give the impression that I never sleep. 'Tis not true: I get 8 hours a night. The stamps are pacific time. Add 3 to get New Haven Time.
  2. However difficult it may be for you, please do refrain from sending me flowers, large packages of gifts, and loving letters in the mail. Come the end of this month, I will commense upon a nomadic journey [across town]... crashing at various places along the way. I will not have a stable address until the end of August. So until then, hold off on your gifts.
  3. Turns out, I will not be jetting to California in August as I had planned. Much sadness on my part as I had some impt business to attend to there. Nonetheless, I suppose it is only fitting that should spend the week of my birthday helping to deliver babies here at Yale, New Haven Hospital. The irony of it all tickles me silly.
  4. My Schedule:
    • 7/31 - 9/10 Ob/GYn
    • 9/11 - 10/08 Surgery A
    • 10/09 - 11/05 Surgery B
    • 11/06 - 12/03 Surgery C
    • 12/04 - 12/31 Break
    • 1/01 - 1/28 Med I
    • 1/29 - 2/25 Med II
    • 2/26 - 3/25 Ambulatory Med
    • 3/26 - 4/22 Clinical Neuro
    • 4/23 - 5/20 Ped I [in Pt]
    • 5/21 - 6/17 Ped II-- out pt

Wednesday, July 12, 2006

Ma, what's for lunch?

Ninety percent of the conversations I have ever had with my mother have focused around what I have eaten for the day. In college, I remember times during which the world would be crashing down upon my shoulders due to some philosophical life crisis or another and the only thing my mother really wanted to hear about was what I had for lunch that day. Ah, leave it to Indian mothers to consider only that which is practical.

I have, as late, been taking better care of myself. Astounding, I realize. It used to be that I wasn't even capable of taking care of a plant, let alone myself. Now, however, I have discovered how much better I feel when I eat properly, play outside and meditate daily .... ah, the luxery of the Psych rotation.

I was particularly proud of my lunch today. Its pretty typical of what I normally eat: apple, carrots, salad w/ nuts and tofu [protein!!!], and some fruit [in this case, a nectarine and some strawberries and blueberries]. The strawberry-blueberry idea came from my brother, of all people, who recently pimped me on a question about the fruit with the highest levels of antioxidant [per wt, I assume, not sure though]... blueberries.

And no, I do not intend to consume the entire bar of chocolate for lunch. It's only there as a matter of artistic liberty - the picture just didn't look complete without it ...

Tuesday, July 11, 2006

I'm sitting here in the dark, waiting excitedly for the sun to rise. Accoring to theweatherchannel.com, that's about half an hour away. The sun rising is equivalent to a gun going off at the starting line for me: its signals the start of my morning run. I have completed my morning rituals: got up at 4, downed a small cup of soy yogurt [mmmm protein!] with a cup of tea, packed my lunch, and listened to the Fanaa soundtrack. As I wait for the sun, I have been contemplating the possibility of a marathon or half-marathon in the near future. As much as I still dream of a marathon, I am fearful that the damage done to my body would be too great a cost. Besides which, the training required could never survive my surgery rotation [9 weeks away! eeeep!]. On the other hand, a half-marathon is very possible. The training is not too far from what I already do, and I'm aided by the confidence that I've already run that distance without much trouble [on my birthday, some years ago]. The only issue would be getting my a$$ to the gym to cross-train, something I do not like. I am a creature of habit: I like to run every day and nothing else. Oh, the Sun's up! Yummy!

Sunday, July 09, 2006


How I Got a Life : The Best Weekend Ever

I was telling my resident last Friday that I abhor the weekends because they are so boring compared to my week in the Psych ward. JM, the PA student, looked over at me with this expression that screamed, "dude, you need to get a life." So this weekend I tried; with a great deal of help from my friends. On Saturday, I took a city bus to Lighthouse point with two girls from med school. We just sat and roasted ourselves on the beach for a few hours looking out to sea. Note that I no longer look pasty white as I will come winter. Also note my recent purchase of a Colorado-cowgirl hat. I think it makes me look rugged ... or at least, thats the look I'm going for. It certainly triggers much commentary from random strangers ... most people assume I'm a recent immigrant from Texas. After the beach, Tarka and I bummed around town for several hours -- we acquired matching Swiss Army knives [better not to ask why I bought mine], sat on the steps of the Music school laughing at the parade of Indian families that drove by looking desparately lost [must have been some function or another going on nearby], and then we ended the day with an attempt to break into the Physics building. We managed to get into the Molecular Bio building. ... and from there, we took the underground tunnel into Cell bio and then Astronomy ... but no Physics. We stopped when we discovered a door with a Radioactive warning label. We decided then that we had had enough adventure for the day and turned back.

I spent most of Sunday buried in Paul Coelho's new novel "the Zahir." Zahir, in Arabic, means visible, present, incapable of going unnoticed. According to the Encyclopedia of the Fantastic [Faubourg Saint-Peres], "it means someone or something which, once we have come into contact with them or it, gradually occupies our every thought, until we can think of nothing else. This can be considered a state of holiness or of madness."

I was mulling over this thought when Maggie called, and when Maggie calls, that means there is always good mischief to be done. This time we went out to the Rice pot [a new Thai restaurant on State street -- perhaps the best Thai food I've discovered in New Haven!] followed by a movie -- the Pirates of the Caribbean sequal. It was simply delightful to spend the entire weekend bumming around with my gals. Oh man, who knew that Medical School could be so ridiculously enjoyable!

Friday, July 07, 2006

Addiction Treatment

According to Dr. Fox, in the setting of substance abuse, abstinence of 18 month duration almost guantantees that a person will be protected from future relapses. Only 2 - 3% of people who can stay clean for 18 months or longer actually relapse. This is highly encouraging news. Another factor that helps promote abstinence is a supportive family environment. Halfway houses - uh uh - bad news. Most times there are drug dealers waiting outside to prey on the weak; social darwinism for you. The next best option, is a structured living environment such as the Q house here.

Motivational Interviewing

Today I did a presentation on motivational interviewing techniques for health behavior change. It went pretty well. Actually, very well. The attending, nurses, and resident here are so nice and supportive. So even if I presented gobbledigook, they would still think that I was awesome. That aside, motivational interviewing strategies to remember:
  1. Ask pt about their typical day
  2. Ask pt about causes and consequences of stress
  3. Assess importance, confidence and readiness for health behavior change. Ask scaling questions like, "if 0 was not impt and 10 was very important, where would put yourself at?" Follow up with, why so high/low? If x, why not x-5? Stimulate motivational statements made by pt.
  4. Do the Katz box to analyze pro/con of change/no change
  5. Analyze previous successes and failures
  6. Brainstorm solutions WITH the patient being the active decision maker.

Interview Tutorial

Today I had my tutorial with Dr. Fox. A word about Dr. Fox: he remembers your name. Everyone's name -- from the janitor cleaning up patient vomit to the chief resident whom he briefly met three months ago. He remembers people, places, daughter's graduations, etc. And its no wonder people love him. He connects, no matter who you are. Its awesome. That aside, I interviewed this guy who absolutely amazed me with his resilience. This guy went thru hell and back, twice over, I tell you. If you can imagine the worst of the worst, he has it, experienced it or did it. And yet he has forward thinking. He's intellectually brilliant and has found a place here where he can help out people who are far more physically and mentally debilitated than he is. He can find value in his existence and perservere. At one point in the interview he said to me, "I'm such a coward." And I was like, "I disagree. You've been through a lot and I admire your strength." I was genuine and I think he realized that I wasn't just saying fluffy nice things [and those who know me know that as I rule, I avoid fluffly statements of nothingness]. Patients hate that sort of thing.

Anyway, prison. Brutal. Our incarcertation system is the embodiment of pure evil. Very sick things happen in there and it breaks my heart to hear about it. As Dr. Fox put it, sometimes its hard to tell who should be on which side of the jail bars.

Psych ER

And thus ends my rotation in the Psych ER. I will miss it certainly. I love the fast pace of things, I like the quick plans, the immediacy of what you do and how much you get done. Its cool. Its real action. The most impt thing here is the Team. Yeah, people are always transitory and in flux, but we all work together and help each other out. My main man here is a fellow PA student; damn that guy dragged my ass thru this rotation by helping me figure out the computer system. That was the hardest part. He's the guy I packed a lunch for. We look out for each other. Yup, that's what team work is all about. Its been fun. Now onward ho!

Thursday, July 06, 2006

I take particular glee in committing Random Acts of Kindness. Its most fun when its anonymous. But looking out for the friends who know you is also important. I packed lunch for a friend of mine who always forgets to bring his own. I'm not sure how well he'll take to the organic-denser-than-lead bread from which I made a soy-nut-butter sandwich. Or how much he'll be into the soy-nut-butter. But hey, its lunch. Indian women are genetically predisposed to feeding people [sometimes by force], and I am no exception!

Oink.

Tuesday, July 04, 2006

When I was younger, July 4th was always marked by a family trip to the rodeo to watch buckin’ broncos, police-dog chases, and the usual parade of fireworks and antics that Coloradans generally find entertaining. Since I moved away [for college and med school], July 4th has been a day of deep contemplation for me. I usually find myself idle with nothing to do; and when I have nothing to do, I start psychoanalyzing myself to the extreme.

Seven years ago, to the day, I went thru the most severe existential crisis of my life. As far as existential crisis’s are concerned, my understanding is that you are supposed to have them in your early 20s, when you’ve just graduated from college and have no idea what to do with your life. Being as weird as I am, I decided to have mine at age 15. In my diary, I appear to have titled the entry as “The worst day of my life.” In retrospect, that statement seems a bit histrionic, but I was a teenager, so what can you really expect? I was in Cambridge, MA that summer – living at MIT and doing some oddball research with headless zebrafish at Harvard. In this setting, I found myself spending the entire July 4th holiday puzzling over the “What do I do with my life?” question. My response, in part:

What do you want to do with your life? I know. I want to make other people happy so that I can be happy. I want to help people. I want to be the best type of person I can be. I want to lead a good life, stand up for what is right.”

When I look back at this moment, I always find myself both embarrassed and in awe of the simplicity of my thought. The unhappiness of that day came, I think, from an inability to define how exactly to “make people happy” or even how to figure out what, in this confusing world, is “right.” Seven years since, I can’t really say that I’ve arrived much closer to the Truth. I feel like I still live by the same core values [which is to say, I believe that the purpose of my life is to increase the general sum of human happiness] but the how and the what are still anyone’s guess.

Today, the winds of caprice are telling me to become a Chinese Massage Therapist. I’m serious. I’m telling you, if you want to master the art of sending a person to heaven and back, this massage therapy is something to look into. I got a massage this afternoon and, dude, I feel better than great.

Saturday, July 01, 2006

Muscle strength is often rated on a scale of 0/5 to 5/5 as follows:

  • 0/5: no contraction
  • 1/5: muscle flicker, but no movement
  • 2/5: movement possible, but not against gravity (test the joint in its horizontal plane)
  • 3/5: movement possible against gravity, but not against resistance by the examiner
  • 4/5: movement possible against some resistance by the examiner (sometimes this category is subdivided further into 4/5, 4/5, and 4+/5)
  • 5/5: normal strength

Heart Murmers:

  • Grade 1 – very faint
  • Grade 2 – quiet but heard immediately
  • Grade 3 – moderately loud
  • Grade 4 – loud
  • Grade 5 – heard with steth partly off chest
  • Grade 6 – no steth needed

Deep Tendon Reflexes

  • 0 : absent reflex
  • 1+ : trace, or seen only with reinforcement
  • 2+: normal
  • 3+ : brisk
  • 4+ : nonsustained clonus [repetitive vibratory movements]
  • 5+ : sustained clonus

Reflexes & Main Spinal Nerve roots

Biceps – C5, C6

Brachioradialis – C6

Triceps – C7

Patellar – L4

Achilles Tendon – S1

First Step Toward a Resilient Immune System

Thursday afternoon one of my patients coughed all over me. Today, I'm sick as a dog. My "happy pills" [a.k.a. Tylenol multi-symptom] have not done much for me besides make me hyper inspite of my cold. The weird thing about doctors is that they never miss work, even when they are horribly sick. Odd, I thought, but understandable given the work load that must be shared. Sigh.

Delirium

Yesterday, I did the work-up on an elderly man experiencing visual hallucinations. I learned really one interesting fact: that urinary tract infections can cause delirium, especially in the elderly [like, men with benign prostatic hyperplasia]. So what's the work-up of a patient with delirium? Labs! Labs! Labs! The most impt would be a urine screen for esterase and WBCs. And imaging [CT or MRI]. You can't do MRIs on anyone who has metal in their bodies.
Hierarchy

I must say, my experience with Psychiatry so far has been awesome. The residents and attendings are extremely supportive, helpful and encouraging. In the ER, the MDs are excited about teaching and I learn an incredible amount. I'm given a lot of responsibility and work with the resident and attending to figure out the plan [impt because I really don't know anything!!]. After two years of pedantic learning, getting the chance to do things, to play doctor, to play detective, is simply awesome.