As a rotating intern, I spent time on the general surgical service. Traditionally, off-service interns are granted minimal responsibilities on the surgical service; they are akin to glorified medical students with M.D’s. Most of the rotators intend to become radiologists, dermatologists, or ophthalmologists. The administration is aware of the circumstances, and usually schedules accordingly. When I reflect back to my stint, however, this was certainly not the case. Somehow I was promoted to a level I was probably underqualified for, at least part of the time. Perhaps it was because I had mentioned to the team that Mehmet Oz once lectured to us about incorporating flaxseed into our daily meals.  Or maybe there was simply a shortage of bodies on service. Mind you, while some ophthalmologists spend a year in surgical internship, the only experience I had to draw from was one rotation as a third year medical student. Most of my time as a student was spent changing wound dressings. Here are a few notable instances that I was subjected to:

10. Consulted on 12 surgical cases while covering a service of 58 patients while on call. (A new pager battery died in a matter of 10hrs)

9. Incised, drained, and packed thigh abscesses on the floor. (I read a blog on how to perform the procedure beforehand)

8. Closed up subcuticulars in several inguinal hernias and lumpectomies.

7. Ate 10 chocolate chip cookies and drank 3 20-oz Powerades for dinner.

6. Served as first-assist in a laparoscopic J-tube placement on a woman with peritoneal mets–the case started at 8pm and ran 3hrs. I read a website how-to guide on the general progression of the operation. My responsibilities were minimal–just holding the camera at awkward positions, keeping the field clear, and working the 2nd alligator and dolphins.

5. Diagnosed an acute appy in the ED (cool!), but had to assist in the case at 4am. (I watched a video from some website in India beforehand to figure out where to put the trocars)

4. Replaced a G-tube that had fallen out of a floor patient (with guidance from a nurse and the instruction manual).

3. Placed a G-tube via endoscopy (with supervision from attending)

2. Hand wrote 16 progress notes in one morning.

1. Performed 50% of a lumpectomy including sentinel node biopsy and tagging. (Attending thought I was a surgical resident and did not listen when I explained that I was a non-surgical intern; I did however prepare for the case extensively beforehand)

The experience, while harrowing at the time, was actually extremely gratifying afterwards. Now that it’s over, I suppose that I’ve added to my adventures of residency.

* Note: In no way should the aforementioned anecdotes be construed as a reflection of those parties involved. Ophthosurgery and its authors hold no responsibilities to any parties mentioned on this website. Ophthosurgery is not liable for the use or interpretation of any content found on this website. See disclaimer for more details.

medicine work

My previous entry reinvigorated my thoughts on the trite debate on whether genius stems from nature or nurture. Neurology is fascinating in that so much of it remains a black box. Highly functional people have been found on incidental imaging to have absent lobes of the brain, likely stemming from in utero infarctions. Given the plasticity of the brain, is it possible to nuture a genius? Such topics make great (lame) discussions on a Friday night around the campfire.

In pursuing the nurture argument, I’ve created a thought experiment that involves my experience compared with that of a “genius”. Consider this an experiment with N of 1 (Usually, a study with N=1 is not generalizable). All of the following statements are true to the extent of my knowledge.

There is a non-fiction text written several years ago entitled “Countdown” that documents the lives of a few teenagers/people who are extremely gifted in mathematics. For the sake of argument, these people are “geniuses”. While I haven’t read the book, I believe that I am familiar enough with the characters to make relatively accurate assumptions to compare one of them to me. The “genius” will be referred to as Genius.

As follows, in reverse chronological order:

1. As a freshman in college, Genius took graduate-level courses, doing well in all of them and mastering the material with more fluency than many graduate students.
   1. As a freshman in college, I struggled with freshman Chemistry. I almost considered dropping out when I discovered that elements in the periodic table could have quantifiable charges instead of simply “positive”, “neutral”, or “negative”. Apparently my pre-college education was lacking.
2. As a high school student in California, Genius participated in numerous academic scholarly activities, and was well-rounded in athletics. He won many medals and awards.
   1. As a high school student in rural Appalachia, I almost got electrocuted in my house-building class when my partner thought it to be funny to connect live power (220v) to the wall outlet I was building for a laundry dryer. The course was entitled “house-building” because it taught us not only how to wire switches on walls but also how to construct a frame for a house.
3. In grade school in Mississippi, Genius was considered to be too talented for his teachers, and they had trouble keeping him intellectually challenged. His teachers would struggle to create tasks for him.
   1. In grade school in rural Appalachia, I was not challenged by the school curriculum. My teachers thought I was a nuisance to ask questions, so they put me in the back of the room cutting paper ornaments for Christmas decorations.
4. (From an excerpt of Countdown) During grade school,  Genius was invited to a summer math camp. He was excited.
   1. During that summer, Genius had a roommate who was there for similar merit. He also lost a game a chess to his roommate. Guess who his roommate was?

I think nuture deserves a point for this case. In fairness, the statements above are not intended to offend anyone, nor should they be construed to be snide comparisons. They are simply meant to stimulate debate. And if you are this aforemented Genius, please contact me. I’d like to see how you’re doing. You’ve been a great inspiration for me to bootstrap out of a failing American educational system.

misc life

There are two brothers who are well-known in academic ophthalmology in the U.S. Those of you in the field will know who I am referring to, but I will not mention names. Both of them are incredibly intelligent clinician-scientists. One of them is actually a genius. No, not your everyday “super smart” guy, but a real genius. He apparently is the youngest medical school graduate in the World Record books, and has wunderkind abilities akin to that of Mozart. No joke.

In any case, I had the fortune of meeting both of them during the residency interview season. They are known to be difficult interviewers; some have mentioned that they pose challenging dexterity tasks to their interviewees. One applicant was asked to pour water into a narrow-spout without spillage. Another was asked to throw some knots using 12-0 sutures (without loupes). One of them interviewed me for a spot at his program.

Going into my interview, I wasn’t too nervous about these menial skills. I had poured gallons of anti-freeze into the tiny tanks of cars in my lifetime working the blue collar jobs. Those long hours of video gaming sessions certainly honed my dexterity. What else could he ask me to do? Well, my interview took an interesting turn.

He did not greet me as I entered his office. He did not ask me to sit down, nor did he even look at me directly during my entire interview. His desk had stacks of papers scattered about, along with remnants of silk sutures, styrofoam cups filled with blue water, and 0.3oz bottles. I remember that he asked me whether the U.S. should invade Iran, and that I muttered that I didn’t think there would be any economic or political benefit to the U.S. if that were to happen. He subseqently made several arguments that suggested that I knew little about politics at all (which is probably true).

He followed up by asking me if I really was well-versed in college basketball. Yes! On my application, I had listed that I loved watching college basketball. Indeed, as a Blue Devil fan, I went to my share of basketball games. At the time, I knew who the best free throw shooters in the league were, and which teams had a decent shot at winning. I watched a lot of basketball. Try me! I told to fire away. And then he dropped the bomb on me:

“So, in a single-elimination basketball tournament with 128 teams, how many games will be played?”

Math eh? I didn’t see that coming. It sounded like one of those M$ or Cisco interviews rather than a medical residency one. Well, I gave it some thought:

In a tournament, there can only be one winner. Everyone else is a loser. Every match will produce one loser. So in a group of N teams, there must be (N – 1) losers. There will likely be (N – 1) matches. At the time, I was nervous. I wasn’t confident that my logic was correct. So I quickly ran through some arithmetic in my head: With 2 teams, there will be 1 match, with 3 teams…2. (Team 1 and 2 play, and then the winner plays Team 3, for a total of 2 matches). That logic seemed to work out.

I told him “127″. He asked me why, and I explained my logic. His only response was, “Not good enough.” He then stood up and motioned me out of the office.

Wtf?

I was miffed. During the rest of the interview day, I was thinking about the problem. I scribbled more computations on the lunch napkins, and I was convinced that I was right.

Now that it has been more than a year or so since that encounter, I am still not sure what he meant by his response. Did he want a formal proof? Based on induction alone, I could have shown with brute force the number of games needed for a small number of teams and induced the result for N teams. Or did he want something with a binary tree? Doing so would probably involve some base 2 logarithms which would eventually simplify to (N – 1). To this day, I am still baffled by the genius. “Not good enough?”  I guess I simply wasn’t good enough.

If any of you have any thoughts, please contact me. I’d like to learn something. This sort of stuff keeps me up at night.

medicine ophthalmology

A friend of mine introduced me to Intern, a recount of a cardiologist’s experience during medical internship. The author, Sandeep Jauhar, trained at New York Hospital–it is now known as NYP-Cornell. While internship is difficult regardless of where you train, his book details many of the experiences that still have gone unfettered by social reform, at least in NYC hospitals. Certainly, the unionized nursing staff in the city makes even basic morning labs and vitals a chore for the house staff, even to this day.

From what I saw as a student in the ivory towers, overnight cross coverage still remains harrowing, with an incessant onslaught of pages, difficult patients, and codes. What this experience amounts to is not only a learned resident, but a tome of unfathomable tales that you’d otherwise imagine only to be fabricated.

On one occasion in his book, Dr. Jauhar describes performing a paracentesis on an ascitic patient. He instructs the patient, with tubing in his peritoneum draining the fluid, to remain still while he checks on another patient outside. When Dr. Jauhar returns, bodily fluid covers the floor. When asked to explain why he moved, the patient stated that someone walked into his room and seized, knocking all of the ascitic fluid bottles over.  Frighteningly enough, that actually happened.

I had cared for an elderly gentleman (86-yr old) when I was a 3rd year medical student. He was bawdy and demented; on several occasions he would ambulate around pantless, and void in the hallways as if he were hoping that someone would slip on his urine.  His behavior was probably not entirely due to age; his brain was ravaged by neurosyphilis. One evening I saw him with a bruised forehead and ecchymotic eye. Had he fallen despite having a sitter? No, it turned out the sitter had punched my patient. I had a helluva time explaining that to my attending in the morning.

I’m relieved that I escaped from the city for internship. At times, however, I wonder whether this rite of passage would have made me a better doctor. It sure would have added to my list of stories I could reminisce over with friends at the bar.  Regardless, I’ll be back soon enough.

medicine medicine

I try to use generic-branded items as much as possible, for cost reasons. Most of the time the difference in quality is imperceptible; I certainly can’t identify a difference between Price Chopper and Morton salt. In some cases, the generic and the branded items come from the same manufacturing facility, like Jif and Great Value (Wal-Mart) peanut butter–they both came from the same facility in Georgia that was infested with Salmonella.

There is, however, a surprising difference in other products. I purchased a roll of “Ranch Wagon” clear plastic wrap on discount for $1. Saran wrap costs close to $4 for 100-ft, so I figured that it would be a huge savings. Wrong.  The trade-off comes in the form of pain and frustration every time I use it. You’d think all clear wrap were made to be equal, but this is not true. “Ranch Wagon” plastic wrap has amazing clingy properties only to itself–the moment it touches itself you will never be able to untangle the mess. It does not cling to anything else (bowls, silverware…etc), which makes it utterly useless for its intended purpose.

Saran wrap is constructed from low density polyethylene, usually laced with a lighter polymer to add some extra cling. I suppose the generic stuff doesn’t have the additional touch.  Lesson learned: never again will I buy generic plastic wrap.  I wonder if generic aluminum foil is comparable to Reynolds aluminum foil wrap…stay tuned.

misc food