If this week isn’t out to get my entire class, it’s at *least* out to get *me*. I decided the most exciting part of my day was finding a new men’s bathroom on the second floor of the med school today. No, I take that back. I get free Indian food tomorrow. That would be the highlight.

I’ve also come to the conclusion that the head and neck are God’s way of discouraging people from messing around up there. The cranial nerve nucleli seem to be the absolute bane of my existence right now. Or maybe the brainstem . There are just so many possibilities!

SUMMA is this weekend. Should be a fun (but exhausting) experience. 550 undergrads, 80+ high schoolers, and a day-long set of premed workshops.

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Stanford Anatomists Like Fettucini, Others Prefer Swedish Meatballs.

Superior Thyroid, Ascending Pharyngeal, Lingual, Facial, Occipital, Posterior Auricular, Superficial Temporal, Maxillary.

(I have several dirtier versions in mind, but Google SafeSearch is going to start blocking me if I continue. And I got an email from an 11th-grade teacher that said she was going to share the Self-Service essay with her class, so I’ll try to keep it clean, in case they find me.)

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To Zanzabar by Motor Car!

From top to bottom of the face:

Temporal, Zygomatic, Buccal, Mandibular, Cervical

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James Sabry came to give a guest lecture on the cerebral cortex, and you could instantly tell he wasn’t an academic: his lecture was too smooth, his presentation style, too inviting. He brought up a number of interesting thought puzzles that I had really thought about since a cognitive science class back in undergrad.

* Free will and the brain. Corante’s got a similar question , but try this one on for size. If thoughts, movements, senses–everything neurological–comes from neurons, where are the “free will” neurons that initiate thoughts or movements? If you have to activate a neuron to raise your arm in the air, where does the first thought come from, and the first neuron activation to activate all the other neurons in the relay? When I stick out my tongue, am I somehow willing neurons to fire? For their voltage-dependent sodium channels to somehow open on thought command? At the very beginning of the motion, you think (consciously or consciously), “I’m going to stick my tongue out.” But where does the initial movement come from? Is my thought somehow activating my brain? What’s upstream?

* Less unexplained, but still fun to think about: it takes time for your eyes to get signals, send them to the brain, and process them, to tell you what you’re seeing. ( Only 150 milliseconds, according to this report, but still. ) So think of it this way: everything you’re seeing has, technically, already happened. Everything you take for the present is actually 150 milliseconds ago. And what’s more–your brain knows to coordinate the video with the audio. Light travels much faster than sound–it’s why you see lightning before you hear the thunder–but if you’re talking with someone, you don’t notice the difference. Distances are shorter, sure, but the auditory neurons have a different pathway and slightly different speed than your visual neurons, but you never get the feeling that things are out of sync, or like you’re watching a poorly dubbed movie.

It’s these fascinating questions that keep me going. Keep me in awe and wonder. The anatomy and physiology, without their quirks and twists, are utterly boring. On that note, back to cerebellum function.

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By Uwe E. Reinhardt. Couldn’t have said it better than myself. Reinhardt is a health economist at Princeton; I’ve bolded my favorite line about halfway down. From The Denver Post, Guest Editorial :

bq(quote). Is there hope for the uninsured? Probably not.
Recent developments on the issue of medical insurance indicate that the nation still lacks the will to deal with this problem.
After a three-year study, a task force at the Institute of Medicine of the National Academy of Sciences a week ago published a set of principles and the bold recommendation that this nation move to universal coverage by 2010.
The institute’s work does not push the state of our knowledge on this issue much beyond what has been available for some time from the Henry J. Kaiser Family Foundation and the Commonwealth Fund. But the task force has distilled this vast body of research and policy analyses into six attractive, well-structured, authoritative and easily readable volumes.
Reasonable people will find it hard to disagree with the common-sense principles enunciated by the institute, or with its overall recommendation. Unfortunately, the task force ended its work in the time-hallowed Beltway tradition of offering readers merely a menu of alternative strategies for reaching universal coverage, all of them well known from past policy analyses, and each pitched to a different ideology. It would have been preferable if it could have agreed a single, authoritative IOM strategy for universal coverage that could help frame future debate. By recycling old policy options, the report in effect puts us back to square one, circa 1992 and even 1972.
‘s inability to settle on one recommended strategy reaffirms a proposition I recently offered brashly in the influential health policy journal Health Affairs, in a paper titled “Is there Hope for the Uninsured?” (see website http://content.healthaffairs.org/cgi/reprint/hlthaff.w3.376v1.pdf )My answer there was: “Most probably not.”
After studying health policy in this country for more than three decades, I have come to the conclusion that neither moral sentiments among the dominant majority of politicians, nor pure economic self-interest among the huge majority of well-insured Americans, nor political engagement by the uninsured themselves is likely to drive this nation toward universal health insurance coverage soon, if ever.
The sense of social solidarity that is the sine qua non of universal health insurance coverage just does not exist in this nation of individualists. Indeed, our tolerance for misery among folks who find themselves at the bottom of the economic heap is legendary in the international health policy community.
The large majority of the uninsured are members of low-income families. People in this economic strata – taxi and limo drivers, waiters and waitresses, nannies, gardeners and even support staff in physicians’ offices – will continue to work hard to make our lives comfortable, even if we do not help them get health insurance in return. And because we do not have to be nice to these people to make them work hard for us, we won’t be nice to them – end of story.
As if on cue to corroborate my point, Secretary of Health and Human Services Tommy G. Thompson’s swift reaction to the institute’s report was that universal coverage by 2010 “was not realistic.” The U.S. took over an entire, distant country in but a few weeks, but it could not manage to extend health insurance coverage to all Americans by 2010, if the politically dominant elite decided to do so? Can the secretary be serious?
Finally, if anyone saw hope for the uninsured in President Bush’s State of the Union address, I would challenge them to show me the budget figures for his vaguely worded proposals, or the number of uninsured the president would seek to cover. To the discerning health-policy wonk, the speech read more like: “I’d love to help you, folks, but just haven’t got any money left in the budget.” Indeed, in 2001, when the nation was looking at a $5.6 trillion cumulative budget surplus for the coming decade, Congress and the administration chose to draw down the surplus on tax cuts, rather than to help the uninsured. If there is a clearer statement on the moral trade-offs we are willing to make as a nation, I can’t think of one.
The only ray of hope is the growing anxiety among middle- and upper-middle class families whose well-paid breadwinners might lose their jobs to equally skilled but infinitely cheaper professionals in Asia and elsewhere. If that economic trend were to eat seriously into the hitherto smug sense of security enjoyed by members of this politically more engaged class, our politicians just may have to take the plight of the uninsured more seriously.

From Quote of the Day , Don McCanne’s single-payer health policy listserv.

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Another neat little factoid for you: allergies are caused because your body thinks it’s been infected with a parasite (think worms or some other gross intruders ).

Normally how it works: a special type of immune system cell, called a Th2 Helper Cell gets activated for some reason by a parasite’s proteins, and it then activates B cells that then produce IgE antibodies. (Antibodies capture materials to keep them from harming cells and tell other cells that there’s some invasion in your body.) Those antibodies bind to anti-parasite cells like mast cells , who are basically just sitting around, waiting to dump tons of chemicals around cells to hurt the parasites, or at least flush them out. The mast cells can irritate the parasites, but their chemicals also cause muscle to contract to dislodge the parasites or cause your body to secrete more mucus to make it hard for the parasites to hold onto body tissues.

And that’s how it works for allergies, too. Antibodies capture allergens (like pollen, mold, ragweed), and mast cells tell other cells to step up secretions–there’s a parasite around! That’s why you get a runny nose and watery eyes–your body’s trying to flush out what it thinks is a bunch of parasites in your nose, eyes, mouth, and sinuses.

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“The United States can always be counted on to do the right thing – after it has exhausted all other options,” quoth Winston Churchill.

The saying seems more and more apt everyday. So we’ve got a 1,000 page-long new Medicare bill that’s being spun as a solution to seniors’ pharmaceutical costs (it’s basically a huge payment to both pharmaceutical companies and HMOs), but it specifically prevents the government from trying to bulk-purchase drugs. Brilliant. So our seniors and our tax dollars are being wasted, and at the same time, California’s looking to buy prescription drugs from Canada for its prisoners . It could potentially save the state $30 million. In fact, *just* buying the top 5 most-purchased drugs from Canada could save the state $23 million. Again, the logic is astounding. We’re willing to buy drugs from Canada (Government medicine and government control! Run away!) at lower prices, but no one’s willing to even consider creating a bulk-purchasing plan for (gasp) all of California! Imagine how much money _that_ could save California residents and businesses!

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I attended a Santa Clara County Medical Association meeting tonight, and I couldn’t help but feel that the doctors were missing the forest for the trees. Jack Lewin, the CEO of the California Medical Association , gave a great talk about issues facing California physicians–ridiculously low levels of reimbursements from Medicare, MediCal, and the private insurance system, taking care of at-risk populations, suing the HMOs to force them to pay reasonable and fair amounts. I initially asked him a question about single-payer (surprise), but every other question that was asked had to do with administration. Business. Billing. “What can I do about Blue Shield sending a check to my patient?” “Who should I talk to about HealthNet losing my documentation?” On the subject of one health insurance billing system, three-quarters of the physicians knew the difference between billing as a “non-contractual” versus “contractual” patients for Blue Shield. They smiled at our medical student ignorance. “How silly of you to think you’re going into medical practice to help people! Don’t worry, you’ll end up sucked into this horrific system too!” I don’t want to work like that. Neither do my classmates. One leaned over and whispered, “Man, they know as much about billing and administration as we do about anatomy.” Imagine all the time they spent navigating the insurance system that could’ve been used seeing patients. Or reading more about the latest best-practices research. Or hell, spent with their families . The health care system is one that makes absolutely no sense. No one wants to be a part of it. And why should we have to?

After every question, I just wanted to shake them and scream “Single-payer!” (Yes, I have a slight flair for the dramatic.) And I’m not trying to be idealistic. I realize it’s not a golden bullet. I realize health care reform is politically difficult. I acknowledge it. Fully. But how can doctors continue to work on some sort of patchwork system–like suing the insurance companies, like the CMA did with the RICO lawsuit–but not fight for a long-term change? People seem like they’re willing to fight their own fights–but not fight for medicine as a whole, as well as their patients. It almost seemed as if the doctors were more willing to deal with the hassles of HMOs (which they cited as “the reason you never get to see your kids”), but aren’t willing to try another solution, even when it was staring them in the face.

Dr. Lewin made a great analogy of why doctors have to stick together. He gave an example of speaking to neurosurgeons last week, who didn’t care about struggling pediatricians or internists: once internists and general practitioners are replaced with nurses and techs, all physicians risk becoming obsolete.

But honestly, how much of this “doctors are barely getting by” mantra am I supposed to believe? I’m a medical student, and at the same time, still a member of the public. A lot of the questions discussed “How do we get patients to realize that doctors are hurting,” and “Universal health care does nothing to address low incomes for specialists.” The malpractice issue aside, who’s struggling out there? And I mean struggling . When you’re “struggling” to make car payments on the BMW or the 5-bedroom house, you don’t count. You can live a perfectly happy and satisfactory existence with a measly Honda and cheaper mortgage, can’t you? Isn’t it more the expectation of a certain level of income that’s the problem? Not the absolute income, but the level relative to one’s societal expectations as an all-important doctor? (Sidenote: would specialists and/or general practitioners not be willing to take a pay cut to have reduced administrative workload, increase the time they’re actually practicing medicine , and possibly increase the time with their families?) Maybe it’s my societal naivete of what it’s like to have children and mortgages and responsibilities greater than oneself?

“Political feasibility” and “tax increases” were cited as the reasons that single-payer wouldn’t fly. “The public would never support it.” “No one would be willing to pay for the tax increases.” I don’t buy either of them. The economics aren’t as bad as they seem –otherwise, how could any other nation be insuring everyone, have higher general health outcomes, and spend less? I’ll admit the political argument is a more worthy foe, but people also thought Women’s Suffrage was silly (“Women? Voting? HA!”), and even though Nixon opposed the Environmental Protection Act . The politically unfeasible can become common sense over the course of a decade. And I don’t buy the “marketplace freedom” argument, either. Your Holy Market would’ve had no problem if slavery still continued today.

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Oh Oh Oh To Touch And Feel Vestibules, Glossy Vaginas and Hooters!

I. Olfactory
II. Optic
III. Occulomotor
IV. Trochlear
V. Trigeminal (V1 – Opthalmic, V2 – Maxillary, V3 – Mandibular)
VI. Abducens
VII. Facial
VIII. Vestibulocochlear
IX. Glossopharyngeal
X. Vagus
XI. Accessory
XII. Hypoglossal

(That glossy vaginas part will probably get this site blocked by child-surfing programs, but whatever.)

Some Say Money Matters But My Brother Says Big Brains Matter Most

I. Sensory
II. Sensory
III. Motor
IV. Motor
V. Both
VI. Motor
VII. Both
VIII. Sensory
IX. Both
X. Both
XI. Motor
XII. Motor

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It always hits all at once for me. School picks up, personal problems come up, I’ve gotta learn a new technique for work ; I quickly feel overwhelmed. Now that my mind and body have adapted, I’m back to thinking it’s not so bad. This quarter’s definitely going to be more challenging and more difficult. I’m still loving Immunology, but over the couse of 5 pages, Neurobiology became my least favorite class.

Everything was going so smoothly, and then, out of nowhere, all these terms hit me across the side of the face. Tracts, and ganglia, and nuclei, oh my! There’s 30 regions of the spinal cord, 40 of the hindbrain, and 80 of the cerebellum. It’s definitely helping that we’re doing the head and neck anatomy at the same time–it’s helped me get your favorite anastomotic strucure and mine, the Circle of Willis down pat. I think I’ve also got the cranial nerves pretty well, which feels like quite an accomplishment.

I’ve also been busy at work on a single-payer website . It’s nowhere close to completion, but it’s entering an alpha stage, I guess. I’d worked on the design over break, and wrote most of the text over the weekend, but unfortunately it looks like I might not have time to keep it updated as much as I’d like to. Such is the life of a medical student. Anyway, if you have any comments (besides “screw you, you damn socialist”), I’d love to hear them.

PS: Oh, I also discovered a really addictive game last night: Zuma . From the makers of Bejewelled. Beware.

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