Now in no way do I mean to offend anyone with breasts or any breast connoisseurs, but they sure made my first physical exam a little more difficult. Friday was our first standardized patient interview, and while my patient was no Kramer , I couldn’t help but feel nervous. Not only had I never tried to do a full history on a stranger, let alone a physical, but I’d never tried it on a member of the opposite sex.

We had 20 minutes to complete a focused history and do 3 parts of the physical exam–heart, lungs, and abdomen. Time goes much faster than I expected–it felt like the history was a quick five minutes, leaving me to somehow stretch the physical out to at least 10–but it ended up working out fine. I tried making conversation, and I think it went well, but I think I must’ve been flush red the entire time. I was sweating like mad. The patient was complaining of “chest pain,” but she ended up pointing more toward her abdomen. She said it was a burning pain that radiated up to her esophagus, and worse with coffee and alcohol. Myself being a heartburn sufferer, I was pretty sure I had my diagnosis (even though that wasn’t the point of the exercise). After the history was complete, I moved onto the physical exam. I had a quick introductory session to “patient gowns” and “draping” before the exercise, and tried to do my best. Listened to the lungs and such, then moved over to the chest. I nervously, but non-chalantly tried to explain to the patient that I’d be examinining her heart, and went for it. Conclusion? Breasts make it much harder to find the heart apex. I just kind of lifted the breast with one hand, using the patient’s gown, and tried to listen, but couldn’t find it. Tried again. Couldn’t hear a thing.

I guess practice makes perfect.

My preceptor and I reviewed my tape, and he said I did well, but I cannot stand seeing myself on television. No one can. I walked into the room completely awkward, shoulders clenched. We had a list of “things I did well,” and “things I can improve,” and it’s just much easier to find things you did poorly. Drop the shoulders! Look at the patient more! Quit saying okay so much! Awkward, awkward, awkward.

It’s kind of a weird ending to the session, because you don’t know enough to truly diagnose anything, so you generally make up some sort of fake conclusion, like, “Okay, I’m going to go report this back to the attending so we can figure out what’s causing you this pain.” Or, as my friend Melissa told the patient, “Well, good luck with that cough!”

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How much of our medical and biological technology is breaking down Mother Nature’s selection process, and how much will it affect evolution in the future? The basic tenet of evolution is that individuals that are “more fit” in the population can reproduce more readily, have more offspring, and therefore become a greater proportion of the population. But say, as a lecturer said as a hypothesis, that we develop fertility technologies for patients with diseases who normally would not reproduce. These diseases could, potentially, be passed on to offspring, keeping the alleles in the population.

What’s the ethical balance between providing for people to have the right to reproduce and the ethics of bringing an individual into the world with a costly, painful, and difficult disease or syndrome? Is it always better for everyone to have lived and lost? There’s always the suggestion of adoption, and while I think everyone should be allowed to reproduce, is it fair? It’s a gray and controversial line, but in my experience, you have to work with the cards you’re dealt. You can’t always get what you want in life. Is it fair? Right? Just? No way. But there are things in life that you have to work around and work through, rather than try to change or “repair.” To me, it seems like a cop-out. Not everyone can be above the mean. It’s inherently impossible.

My friend Marc isn’t willing to bring a child into this world–a sad, depressing, unfair world, in his view–regardless of any mutations in his alleles; wouldn’t it be worse to bring a child into the world already with a serious disease?

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There’s plenty of data and quantitative analysis about health insurance, but here’s a little qualitative from the NYT: For Middle Class, Health Insurance Becomes a Luxury . Something’s gotta break soon, now that the middle class are being affected, of course.

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As I was doing the daily blog read-thru, I came upon an entry from a boy and his computer about LGBT acronyms and a minor rant about intersex individuals. While I can’t agree with his comments, I think they’re fairly common and understandable. I posted a comment there, but I’ll try to explain things in a little more detail here–both on the “acronym issue” and do a little intersex education, seeing as though I just finished reading a chapter on it about 20 minutes ago. From A Boy:

bq(quote). It may be somewhat less than charitable of me, but it’s a pet peeve of mine. All those gender taxonomy terms strike me as code words for some political agenda – in their usage, I mean. They’re as often used to bludgeon the “less enlightened” as they are to actually refer to anything. I don’t feel like I’m prejudiced against anyone – I actually do my best to judge people by the content of their character, like Dr. King said. But to do that, I feel somewhat hypocritical using all those labels. If the differences between genders are supposed to be so unimportant (ideally) then the labels should be just as unimportant, or so I grok. But I realize why it happens, I guess. If you can’t take your own gender role for granted in society at large, I can see why the label becomes important. But even so, the distinctions are largely artificial and political, and I have a low tolerance for artificial and political things of any kind.

Yes, the LGBT acronym keeps getting longer. Now it’s branching to LGBTI, and even LGBTIQQ (Lesbian, Gay, Bisexual, Transgender, Intersex, Queer, Questioning). Yes, it’s long and unwieldy. But it’s constantly growing, because it’s constantly trying to be inclusive of individuals of gender or sexual minorities. Sure, there’s probably some political component to it, but it’s definitely not the main reason (nor is it the most brilliant of political strategies). Believe it or not, sometimes you don’t feel like you’re a respected or even acknowledged individual in this society unless you fit into a fairly limited definition of “normal.” This resonates within the gay population, and thus, there’s been a movement to represent other individuals that don’t fit into the male/female dichotomy.

If you know nothing about intersex individuals, here are the Cliff’s Notes: Intersex individuals are people that generally have some sort of genetic code such that the process of sex differentiation does not occur as normal. So, there’s a molecule that doesn’t function properly, or a receptor, or some sort of biological pathway is disrupted. So, you can have a person that identifies as a male, but genetically is “XX” (female), or you could have an “XX” female that identifies as female, has female genitalia, but no ovaries. There are many causes, and many variations. And since people generally don’t understand these conditions, or don’t care to, and these conditions are very rare, these individuals have felt like there’s no place for them in society. If I’ve gotten any of this wrong, please feel free to contact me, as always.

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Been too busy and concurrently lazy to post lately, but I figured I’d give a couple updates and lessons I’ve learned:

* If you think it’s a cervix, it’s probably an ejaculatory duct. We had an anatomy walkabout (where they pin different things and we have to ID them) on the abdomen and the pelvis, and, yet again, I made a stupid mistake. Maybe it was from the lack of sleep. Maybe I’m just an idiot. Now maybe this is me setting my standards too high, but I think if they pin the ejaculatory duct, I should reasonably be able to tell that the answer “cervix” probably ain’t right. Especially when there’s a penis right there on the body. Urology, proctology, and ob/gyn have just been ruled out.

* The medical community is not telling you the truth about your amniotic fluid. When you take health class, or ever talk about pregnancy in class, the amniotic fluid is just this vague fluid that somehow develops to cushion the infant. It’s just kind of there, and you don’t generally ask what it is, or how it got there. And now I know why. Y’see, the amniotic fluid is basically, uh, fetal pee. It’s quite a beautiful cycle. You drink your pee, pee it out, bathe in it, and drink it again. No, really. If you’re really all that curious, there’s much more information about it , but really, ignorance is, without a doubt, bliss.

* It’s all about who you know. I just got a job working with the Virtual Labs Project , and I’m pretty excited about it. I’ll be doing some Flash animations and slowly learning how everything works, but I ended up finding out about the position from an older med student who saw my website and thought I had potential. Sniff. I’ll try not to get too emotional. Thanks, Phil .

* Damn. The body is amazing. Glad to report that my sense of wonder continues to develop. Just going over heart sounds on Friday, I was reminded at how mind-boggling it is that all these complicated things are happening, every beat, in the body. Muscles squeeze, valves fly open or snap shut, pressures rise and fall… and it all happens so naturally and quickly that to begin to understand it, you have to really slow down the process in your head. But then, you realize that the dynamics change so quickly that it’s almost impossible to follow the process real-time in your mind. Although your heart has no problem pumping, without stopping, for 76 years. I won’t even being to talk about its development, save for a quote from a Embryology professor: “It’s as if you had to make a cruise-liner engine from a tiny speedboat motor, in the course of 9 months, the only other stipulation being that you’re never allowed to stop the engine from running.”

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I was gonna post something to this effect, but never got around to it, so I guess I’ll just let the NYT do it: A New Way to Unclog the Arteries .

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The Robert Wood Johnson Foundation was kind enough to give everyone in the class a copy of On Doctoring , a collection of stories, poems, and essays about the practice of medicine. I started reading it last night, and wanted to share a couple of interesting quotations and passages.

bq(quote). “One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”
– Frances Weld Peabody (1881-1927)

bq(quote). Surgeons must be very careful
When they take the knife!
Underneath their fine incisions
Stirs the Culprit– Life!
– Emily Dickinson, Surgeons Must Be Very Careful

Also, take a look at this illustration of a 17th century physician during the plague era. The description from the book:

“The gown was usually made of leather, as was the mask. The mask had glass windows over the eyes; its long beak was filled with antiseptics. In his gloved hand the plague doctor carried a wand to assess the pulse and to avoid direct contact.”

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A genetic counselor came to speak to our class yesterday about cystic fibrosis, and mentioned that a lot of the patients at Stanford have a “low illness tolerance” for birth defects and congenital or genetic disorders. The “clientele” are generally upper middle-class, well-educated, driven, hard-working couples that want the best for their children–as every parent does–but are seemingly more willing to terminate a pregnancy if there are any signs of possible problems. This brings up an array of interesting topics, and I’m especially fascinated by the Gattaca -like creepings and parallels. That a certain subset of the population would be genetically selecting out “less fit” children brings up a whole other set of questions. Is this just the next phase of evolution–the priveleged, intelligent elite now can create, on average, more genetically-elite children? Where does the testing end? Even if the latest “gay gene” discovery turns out to be less definitive than its discoverers predict, is that next on the list?

And so we stumble upon one of medicine and science’s greatest fears: that normal can’t be defined. Or quantified. Or pinned down. Pointed at. “There. That’s normal.” Sure, give me 10 people’s weights, I’ll calculate their mean value, the median, the mode, standard deviation–I could statistic the hell out of the numbers–and we’re nowhere closer to defining human normalcy. It comes up all the time in anatomy. Our cadaver has no obturator artery , but instead has a big side artery off his external iliac. Normal? Maybe not, but I doubt he ever knew the difference. After I asked if some arterial calcification was “normal,” my instructor reminded me that physicians are hesitant to ever use the word alone. It’s always quantified, “normal range,” or described as “common variation.”

“Duh,” you say. We’re all different. And unique and special. Joy to the world. But it’s more than that. It’s not just some superficial idea; it has consequences for how we define ourselves, how we view the world, how we practice medicine. The obesity epidemic has been a target of a great deal of media coverage and health discussion, but the main indicator, the body mass index , has been increasing across the population for the last century. It’s only now that it’s getting to the point where an excess of weight is causing health problems. Rewind to 1850, and a high BMI was probably considered extra-healthy. Cliched anecdote in point: if I had a nickel for every time my Nana squeezed my abdomen and said “we gotta fatten you up,” well, let’s just say I wouldn’t need to be on financial aid.

One of the most striking examples is the cochlear controversy in the deaf community . I first did some reading about the issue for a bioethics class in undergrad, and it’s hard for me not to see both sides of the issue. Basically, the argument goes like this: some in the deaf community see no problem with being deaf. There’s a culture, a language, and a community for the deaf, and some don’t feel like deaf people (especially children) should receive cochlear implants, which allow some people to become hearing. Doing so for all children means the end of the deaf community–like some sort of cultural genocide. And the other side argues that, yes, if the technology is available, people should be able to receive it.

It’s an even more controversial question when you apply the concept to homosexuality. If you could take a pill to turn straight, would you? If you could detect some sort of gay protein in the womb (it would, of course, fold like a rainbow, and be known in the literature as Fabulous ), would you terminate the pregnancy? It’s no easy question, and I think partially depends on a society’s tolerance, but it’d be an entirely different world without the contributions of gays. Many contributions probably wouldn’t have happened if the men and women in question had been born straight. So, even if it’s not considered normal, is it necessarily deleterious or detrimental? Or maybe we can use evolution itself as a barometer of normal. The argument goes that if homosexuals had no survival benefit for their kin (or more likely, siblings or siblings’ kin), it would have been bleached out of the human phenotype pool a long time ago.

There’s definitely an underlying assumption that any adversity in life (or abnormality) is inherently A Bad Thing. And while I’m not arguing that a person suffering from a tortuous, chronic disease is A Good Thing, my short term adversities have been the experiences that have led to my greatest long term gains. Or, better put by my mom, “Don’t worry, the dorks in high school always end up better, anyway.”

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Friday we were to see our first patient, and take a social and family history. We were given a list of patients that had been suggested as good possible first-interviewees, and had obviously consented to talk to first-year medical students in pairs. And everyone seemed to have a great experience. Except Celine and I.

We nervous enough as it is, but as we entered the patient’s room, she was talking to herself, eyes closed, on her side. We initially talked to her nurse and she explained that she was awake and slightly demented, but came to fairly quickly. We introduced ourselves and tried to just get to know her–not even work on the histories–but didn’t get far. Her voice and mouth were weak with age, and her slight accent made it even more difficult. We tried to ask her some questions about her life, but she kept returning to the notion that she needed stitches to repair a gash which was gauzed and already healing, according to the nurse. It was an incredibly tense situation–neither of us sure how to respond–but we kept probing. I can still feel the buckets of sweat dripping down my back, feeling completely helpless. She started telling us that “if we really wanted to help people,” and really wanted to help her, we would call a doctor to stitch her up. She then told us that “no one listens to you when you get old,” and made me start to feel absolutely terrible.

As we were talking to her–or, in my case, just nodding and saying “mmm-hmm”–I caught this weird glimpse of her. I was looking in her eyes, staring right into them, and I had this momentary flash, like I was able to see her as a younger woman. Before the dementia. Maybe it’s just that she resembled someone I knew, but I walked away with this completely pierced feeling, like I saw some part of her–just for an instant–that she was trying to desperately reveal. Or maybe it was just my anxiety and nervousness coloring my view. I’m not sure either way, but I can still picture her face and eyes, and that flash of recognition. Or acknowledgment. I don’t know which.

Note : I added a bit to the disclaimer page about privacy and confidentiality. All names and features of patients are changed, and always have been–just wanted to make sure it’s clear.

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I figure at least first year you’re allowed to completely embrace your new found medical edification and knowledge, even on Halloween. Or maybe especially on Halloween.

I wasn’t alone. At our med school party, we had: the greater and lesser sacs, a megakaryocyte (complete with plates all over her), an ectopic pregnancy, and, of course, I went as Dermatome Man ( what’s a dermatome? ). Warning: image may frighten and traumatize small children. And yes, we followed Netter to get it right.

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