I couldn’t find this anywhere online, so for the love of all medical students studying for Boards, it’s a big ol’ list of the rheumatic diseases and their associated antibodies:

Antibody	Disease
Anti-Basement Membrane	Goodpasture’s Syndrome
Anti-Centromere, Anti-Scl 70	Scleroderma (CREST)
Anti-ds DNA	Lupus/SLE
Anti-epithelial cell	Pemphigus Vulgaris
Anti-gliadin	Celiac Disease
Anti-histone	Drug-induced SLE
Anti-IgG, Anti-RF, Anti-CCP	Rheumatoid Arthritis
Antimitochondrial	Primary Biliary Cirrhosis
Anti-neutrophil	Vasculitis
Anti-platelet	ITP
Anti-cholinesterase	Myasthenia Gravis
Anti-endomyesial	Celiac Disease
Anti-Jo 1	poly or dermatomyositis
Anti-SSA, Anti-SSB	Sjögren’s Syndrome

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The Zetia/cholesterol bit from last month and the tight glucose control deaths stuff has made me take a skeptical look… at medicine itself.

The old adage is “trust no one” in medicine, but sometimes, I think, maybe we should apply that to medicine itself. It’s certainly humbling to realize that what we hypothesize to be true and what seems to make sense to us, even from a physiologic theory, and even with supporting data, might not necessarily be true. It’s an important reminder–to both physicians and patients–that we’re all unfortunately human. That we don’t have all the answers, that even with the best of intentions–and best of knowledge–we can be wrong. After all, what is medicine but humans trying to understand, grasp, and alter insanely complex biological systems that have been under development for hundreds of millions of years? We set limits, values, and numbers to help us decide “what’s normal” and “what’s disease,” but in reality, they’re gross, gross simplifications we accept so that we can triage, differentiate, and make sense of what’s going on inside that black box that is the patient’s body.

It doesn’t mean that there are no absolutes, or that medicine or science is flawed more than anything else is flawed, or that there are not facts. Just that the physician who thinks he is always correct and is master of the human body is doomed to fail and do harm. I tie it back to this great quote from MedRants about unintended consequences:

The law of unintended consequences is what happens when a simple system tries to regulate a complex system. The political system is simple, it operates with limited information (rational ignorance), short time horizons, low feedback, and poor and misaligned incentives. Society in contrast is a complex, evolving, high-feedback, incentive-driven system. When a simple system tries to regulate a complex system you often get unintended consequences.

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Edwin Leap:

I believe physicians are unhappy because they believed the great lie.

What was it? What was the lie and when did doctors learn it? The lie was this: ‘if you become a doctor, your profession of medicine will be all you need for happiness and fulfillment.’ In short, physicians learned to validate themselves by way of a profession.

I believe my generation of physicians never grew up with a great lie. We knew we wouldn’t make the most money (or at least, we should have known this); we knew that medicine was time-consuming, but we chose it anyway. And the medical schools chose us for our diversity, life-experiences, and well-roundedness. They’ve selected out for people who have taken time off before school (almost half of my graduating class), who have had other careers, who have explored other interests. Found other things besides medicine that make them happy.

Look at the fields that are incredibly popular today: they either make a lot of money, offer a good lifestyle, or both (I’m looking right at you, ophtho). We want to have free time outside of our careers. We want to have families and relationships. Sure, we’re ready to make sacrifices, but we weren’t told a lie–or maybe we just never believed it. We’ve had the opportunity to study abroad; we’ve been exposed to foreign countries and cultures; we have taken courses in religion, anthropology, linguistics, sociology–and we know there are more things to life (exciting, interesting, thrilling ones at that)–besides a job. (For Dr. Leap, that appears to be his faith.)

Now, perhaps this is to the detriment of our future patients–that their future doctors want more out of life than just being great doctors for them. Perhaps it is for the benefit of them. I guess only time will tell.

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This blog, like my medical school career, seems to be wrapping up. Expect a bunch of long-winded, well-thought-out, strongly-opinioned posts on broad topics like “What’s wrong with our health care system,” “What I would ideally like to see to fix it,” “What I would realistically accept to fix it,” “Why it’s great to be a medical student,” “Why it sucks to be a medical student,” “What needs to change in the pre-med and medical school curricula,” “What needs to change in Boards Exams,” “Being Out In Med School and Residency Apps,” and of course, just to cause a controversy, “What needs to change in America.”

Back to “The Somogyi Effect vs. The Dawn Phenomenon.” (Answer: hypoglycemia at 4am in the Somogyi effect!)

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I for one am spending it with my significant other, my boards review book.

But it’s not all bad. There’s a new Indiana Jones trailer out.

And rejected Shoebox Greeting Cards:

Oh, and by the way? Paget’s Disease? I hate you and all the damn questions about you.

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Thanks, Dr. Bryce Swanson, DO, for recommending Rapid Slim SX to me on TV! I know you’re only a “Resident Physician,” but you said you read the study about Rapid Slim SX and it’s going to work, right? You’re in your last year of Anesthesia Residency , so you’re clearly an authority on weight loss. Which is why it surprised me that in your “Talk With Dr. Bryce Swanson” you glaze right over the health benefits of weight loss.

As an anesthesiologist, I would’ve thought you would’ve spoken most about how obese patients are more challenging to manage in the operating room, due to their decreased chest wall compliance and decreased functional residual capacity or talk about any of the other health benefits of weight loss (decreasing insulin resistance, decreases in cancer risks, etc). But instead, when you’re asked “In your opinion, what are the benefits to losing weight?” you say “I think that losing weight helps a woman feel better inside and out. She’s more confident, she’s more energetic, she regains that spring in her step because she likes the way she looks,” and mention that “also” there are health benefits. I’m also scratching my head, Dr. Swanson, because you say that “A major diet overhaul must be gradual so it can be sustained over time,” but then you go on to say that “I would recommend RapidSlim SX because it delivers amazing weight-loss results so quickly and because available published research reveals it to be a superior formula and brand.” [my emphasis] (Also, superior to what? And what’s the “available published research?” I can’t seem to find it, even though you flaunt the study all over the damn website.)

I’ve also been quite impressed with Chief Scientific Officer Marvin Heuer, MD’s work history . (Thanks, Angry Doctor!) I also love his resume , with most of his publications being listed as “Submitted for Publication.” I should fatten my resume that way. I’ve got TONS of things I could submit for publication!

Hey, if it really works, and you really believe in it, Dr. Swanson, that’s great. But a little more intellectual honesty might get you a lot further. (But I guess that doesn’t really sell pills, does it?)

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As I am counting down the days until I can get Step 2 over with (T-minus 10!), I’m going insane memorizing diseases I will never see in my lifetime. I need some laughs. So I’m asking everyone to please post their favorite medical joke. (And plus, it’d be a great chance to see people’s faces and comedic timing.) Oh, fine, if you’re anonymous, I guess you just can post the text, but come on, video is sooo 2008. (If you use YouTube, tag your video as “ medicaljoke ” so they’ll be easier to find.)

Either comment or email me the Youtube link or your blog posting, and I’ll start a running list here on this blog post. And if you don’t have a blog, just leave a comment! Please! I’m begging you! Help a guy escape from the hells of Boards reviewing. I’ll start:

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You know, that’s the thing about socialized medicine. There’s no motivation for innovation. There’s no research or development. It all comes from The United States of America. Except, apparently, growing new bones for a patient using stem cells harvested from the patient’s own adipose tissue.

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(‘Cause everyone’s been asking, “So did you get a job?”)

I find it best to begin at the beginning.

In your final year of medical school, you have to decide in which specialty you want to train . This could be anything from “Internal Medicine,” where you would become an internist, to “Pediatrics,” where you’d become a pediatrician, to “Urology,” where you’d become a urologist. Radiology, Neurosurgery, Emergency Medicine–it’s all there. (Except some Internal Medicine specialties, like cardiology, endocrinology, which require you to do an internal medicine residency and then another training session called “Fellowship.”) Anyway. You decide your specialty, and then try to figure out where you want to train for residency*.

So while you’re figuring out where you would like to train for residency (based on a number of factors like reputation, location, research opportunities, etc.) you’re preparing an application for these residency programs. It’s a big electronic folder of things like grades (if your school has them), board scores (standardized national exams everyone has to take), letters of recommendation, evaluations from your time working in the hospital, extracurricular activities, research, and a one-page personal statement. So you submit that to a big centralized clearinghouse called ERAS , which charges you a fee based on how many places you apply to
. Depending on how competitive your specialty is (orthopedics, radiology, anesthesia are often at the top), you may end up applying to an insane number of programs. Like 40. This can be $500-$600 just to apply.

You want to get your application in ASAP, because residency programs can start downloading parts of it as soon as you pay, and can start offering you interviews whenever they want. Technically, they don’t have your full application until November 1, when your medical school releases your “Dean’s Letter,” a summary of your performance during medical school and sometimes has a ranking, grade, or keyword (“Graham is a good candidate,” vs “Graham is an outstanding candidate”) to differentiate students at the same medical school. But anywhere between late October and early November you’ve heard from most programs via email as to if or when they’re going to offer you an interview. For some of the more competitive programs, you may only get offered one or two dates (“Please come interview November 28 or 29”). It’s then a scramble to quickly email/call the programs back and confirm the date you want. You’re constantly balancing booking programs with trying to group them regionally, so you’re not flying back and forth across the country all the time. Because yes, you are paying for this yourself.

So you go around to different programs and interview. You’ll usually interview with 3 or 4 faculty or residents (at least in my experience), both for you to get a feel of the program and its faculty, as well as for the program to get to know you. You get a tour, breakfast and lunch, and often there’s a social event the night before to get to meet the residents outside of the hospital environment. They tell you the specifics about the residency program, why the program is unique or special, you get a chance to ask questions. (In fact, often the most common question you’ll hear is, “So, what questions do you have?”) And as I said before, you’re paying for all of this yourself. Airfare, hotel, meals on the road–it’s all on you**. I lucked out and had friends in every city where I interviewed (Thank you Eric, David, Sam, Deepika, Jesse, Eric, Eugene, Ed, Kenji, Dave, Allison, and Mike, I owe you all BIG TIME!) but still the process will end up being expensive for me to fly all over. People trying to match as couples often spend around $5,000 interviewing, depending. This is of course just loan money, so by the time we’ve paid it off it’s tripled in cost. But I don’t have ideas for a better system–you gain a ton by going to the institution and seeing it yourself.

Now to the Match part of it. I explain it this way. By getting an interview, you kind of have a potential job offer. How it works is this: the med student ranks all the places he or she interviews. The residency program ranks all the candidates they interview. Then a big crazy computer program ( The NRMP, lovingly known as “The Match” ) … matches everyone up. There’s a good explanation of how it works here. The Match favors the resident, so if two programs rank you #1, but you rank program A higher than program B, you go to program A.

Everyone finds out where they match this year on March 20, 2008.*** Technically we’re all supposed to find out at the same time–that is, students on the East Coast would find out at noon their time, and on the West Coast we’d find out at 9am, but often your friends on the East Coast are already calling and texting and emailing their results early, ahem. And then, July 1, or around there, you start your internship.* You are contractually obligated to go where you’re placed, so right now the thousands of medical students about to graduate and I are all anally pouring over our “Rank Order Lists,” to decide how we want to rank places.

And that’s the Match for you!

* Residency is the name of the training process you go through to become a doctor in a certain field. The length of residency depends on the specialty: pediatrics, internal medicine, and family practice are three years, others are four, some like plastic surgery or neurosurgery are seven. Internship is the name of your first year of residency, no matter what specialty. Most of the time you do your internship as part of your residency program, in some specialties like anesthesia, dermatology, ophthalmology, you do your internship separate from the rest of your training.

**There are some programs that will put you up in a hotel, or pay for your airfare, but these are rare. Often programs will have setups so that you can stay with a resident, however.

***There is a terrible thing called “Black Monday,” which happens the Monday before Match Day, where people who didn’t match at any program find out, and then have to enter “The Scramble,” where they quickly try to find an open residency spot somewhere, often not in their chosen field. (Knock on wood this doesn’t happen to anyone.)

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Great online resource for orthopedic testing of the knee, shoulder, and ankle from this professor at UC Fresno. Also available as a Podcast , so you can download the videos to your computer (or iPod, I guess!). Pretty cool.

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