Things I do

I occasionally go to this cafe on West Gray - aptly named WEST GRAY CAFE - mostly because there's no one there and since they know me I can get away with ordering a coffee and mooching internet / power for hours. It's not bad. Sometimes I'll get some fries / onion rings and I won't get judged for that either. 


Pretty boring so far, right? Well the real treat in a DITLO D is the journey there. If you could follow me around - pretty difficult since I'm both a defensive driver and somewhat maniacal* - would notice that I BUMP to music. And I only do this when I'm alone. Old school Eminem? D becomes the brown rapper on Montrose. Literally. Driving with my left hand, busting out beats with my right, windows down, sunroof open, volume pretty high and rapping out loud. Any song, you name it, after a few listens, I've got the lyrics down, and it's showtime. 


Most recently, I was bumping to Telephone by Lady Gaga. It's actually an insanely good song. It's not even some veiled reference about her rejecting some dude, which is what I thought initially. If you listen to the lyrics carefully, as I've had to do you'll hear - 

Not that I don't like you,

I'm just at a party.

And I am sick and tired

Of my phone r-ringing.

She's just at a party and is like - fuck this phone! I'm just going to dance and ignore it completely and possibly get drunk off bub. Also, not text anyone, either. That entire song is about JUST. THAT. 

Eh, eh, eh, eh, eh, eh, eh, eh, eh…

I sound like I have terrets**, weaving my little sports car in and out of lanes. People sometimes find me in the middle of my song and wonder if I need an MRI. Truth.


In any case, I can totally understand . Quick story, sometimes you'll have a chick over, watching a movie or something and things are about to get serious when you hear that familiar iphone mail notification sound. I can't onomatopoeia that sound very well. That sound often happens 5 times in a row in 10 seconds, which means the listserv administrator just approved 5 messages and they were all instantly pushed to my phone. And I, like a conditioned crackhead, put a pause on the serious moment and reach for my phone. This fucking junk mail (wilderness medicine / rotation swaps / SIMS / etc etc etc) is piling up and I gotta delete it. 


Fail.


Fuck this phone!


Other than that, a lot Lady Gaga's songs sound the same. I couldn't tell the difference between Lovegame and Just dance for the longest time. 


Lady Gaga is a pretty shitty artist. Yeah, I said it. 

*: Which is not dangerous. I'm predictably maniacal, which is safe. It's unpredictability that makes drivers dangerous. 
**: lol. 

Saturday morning

Saturday mornings have changed. I remember when I was 6, it was - get up as early as you can and switch on that tv with the volume as low as possible. I always had excellent hearing so I can pick up that high pitched whine the old CRTs used to produce if my sister woke up earlier than me. Why mute / low volume? My parents didn't like me watching too much tv anyway. Standard. Well, of course they knew I was up - I used to giggle like a jackass at every bit. Easily amused then, easily amused now. This would continue until 10-11am when the cartoons stopped. Of course that was a sad time. I knew it was coming from Friday evening. 'Just enjoy those few hours in the morning, D!'. Nah, I'm a realist. The end of the cartoons meant that teaching would start. Mostly math, but sometimes science. This meant I was always 2-3 years ahead in math and had a general idea of how things worked. Archimedes principle and TMNT go together in my head; they were imparted around the same time. By 6-7th grade most of the concepts being taught were so second nature to me I was surprised no one else knew. I was a goddamn genius back then. After teaching came market time and it's pretty evident I didn't learn anything there, lol.


Saturday mornings changed into version 2. All this time I realized my parents would sit in the living room talking about the rest our family, making calls to India, essentially, discussing policy. One of these days I realized that I could do both. I think it was when I was dragged there to say hi to relatives over the phone, mostly as a formality. And I hate formalities. In any case, I used to finish my cartoons and listen to the dysfunctional family. If there's one thing I learned, it's that you need both of these things to produce some massive family drama: 

1. An inability to shut the fuck up.

2. Stubborn people that hold grudges forever. 

If you even took one of these things out of the picture, 80% of the drama would cease. Mostly, it was a lot of me and my parents playing Steve Irwin watching the drama unfold. One of these days I'll comment about a typical Brahmin family hierarchy and how it functions. Anyway, the drama made things more interesting. Of course, within the drama were implicit lessons on behavior and social norms and responsibility (to both family and community) and loyalty. By this time, the math and science lessons had tapered. More.. social lessons. 


The hallmark of Saturday mornings version 3 were the lack of cartoons. It sounds sad saying that I don't watch cartoons anymore, but have you seen the latest ones? They're horrible. I used to think Looney Tunes and Tom & Jerry were made in my time, but I was surprised to find them to be pretty old. It's like America watched some pretty awesome cartoons for decades (which both adults and kids could enjoy - my dad used to watch loony tunes with us) and then realized she wanted stupid shit like "Ed, Edd and Eddy" and "Yu-Gi-Oh!". Pokemon was another one of those horribly mediocre cartoons. They were things that only kids with ADD would enjoy - formulaic, mind-numbing and just plain old fucking boring. So am I sad? Not in the least. I like not having a seizure every Saturday morning. Version 3 continues. More family drama. More stories. Sometimes I sleep in, wake up around 1030am and get the abridged version of all the stories. Maybe I'll ask for elaboration if one strikes me as particularly amusing. Maybe I'll offer my own solutions; they often include baseball bats and broken bones. 


I think I just described 1/14th of my life up until 18 years old, and pretty much every Saturday morning when I'm back in Plano. Speaking of which, I should go back sometime. 

The Skeptic

I usually get to lab around 7-something in the morning, which is earlier than almost everyone else. Truth be told, I've been trying to work in a 630am arrival schedule but my sleeping times have been much less resilient. In any case, I get some reading done in the morning - mostly stuff on my Google reader feeds.

This morning, I found this entry - Desiree Jennings on 20/20 - and had an epiphany:  (you can see a summary of my epiphany in a comment at the bottom). Most, if not almost all of the problems associated with the perception of science by the general public can be attributed to one word - proof.

With all the stories I'm hearing about people changing biology curriculuae, the anti-vaccination movement, I would be very happy if more people were scientifically literate, which is different from really knowing science in itself. I don't expect everyone to become a scientist, or major in a hard science; it's up to you how much you like flipping burgers, but I do expect people to be scientifically literate, or in the least, be amenable to be taught it.

I won't talk about scientific literacy now.  However, I can give my understand of proof from a medical perspective. That too, I'm going to talk about a very specific (but incredibly important) aspect of proof - causation.

MEDICAL CAUSATION, as I will call it. Actually, it's a summary of Hill's Criteria of Causation, a very eloquently put together set of tenets which I think are pretty easy to understand (for the non-scientific audience). It's important to note that there are rigorous numerical methods behind each one of these, except maybe #4. Let's begin.

Say you want to comment on ... vaccines (or the mercury they have). How would you know what effects they have? How would you prove that vaccines actually caused this effect? How would you prove that a vaccine causes autism? I'm not going to go further with this question; I don't have the data nor do I wish to really turn anyone away. Let's talk about apples, and how apples may keep the doctor away.

How to prove one thing causes another: 
The Tenets

With a short commentary on each.

1. Temporal relationship - The cause must come before the effect. You must eat the apples before your number of doctor visits start to decrease. Simple enough, right?


2. Dose-response gradient - The more of the 'cause' you have the more of the 'effect' you have. The more apples you eat, the more doctor visits are avoided. Still pretty simple, so far.

3. Consistent association across studies - In similar and/or different situations, the cause still produces the same effect. The more different situations you have, the stronger this tenet becomes. E.g. Your cousin finds that when he eats apples, he avoids doctor visits. Your aunt/uncle/neighbor/sister/brother/sick lady across the street/cancer patients/people in third world countries all find this same effect. Thus the association is consistent across studies (different population groups). 

4. Face validity - The association makes sense, applying common sense. E.g. Eating apples makes you healthier, so somehow you avoid doctor visits as you get sick less often? If this was something like, every morning you wake up and snap your fingers twice and that decreases your # of doctor visits, well, that doesn't make too much sense. It lacks face validity. Apples --> better health --> less doctor visits? Might make sense, thus, has face validity. 

5. Strength of association - This one is the hardest one to throw out there without statistics. Basically, how strong is it? Probably best to look at the example for this one. E.g. One apple avoids 20 doctor visits vs 100 apples avoid one doctor visit. The former is a much stronger association than the latter. Let me take a stab at explaining it. In the latter, the fact that you're eating more apples probably means you're eating healthier in general, which would certainly decrease the # of doctor visits. In the former, the implication is strong that there might be something in the apple itself that does the trick, not any personal habits you may have picked up.


There are more tenets to Hill's criteria, but I feel like if you understand these 5, you're well on your way to understanding medical causation. Particularly important are 2, 3, and 5. #1 is easy to understand and easy to refute if it doesn't exist, #4 is murky and dependent on how far research has advanced. 2, 3, and 5 however, will hold true regardless of how much research has advanced.

More on this, and proving things, and scientific literacy later.

Bias

I was reading a few things today, and that got me thinking.

I'll start with a disclaimer, which everyone in medicine can more/less ignore :

===MDs+associated staff ignore===

Patients often present to the ER or clinic with a host of problems, many of them chronic problems (e.g. hypertension, diabetes, high cholesterol) and one or two (hopefully not more than that) acute problems that brought them to the ER in the first place. General medicine teams admit the patient and (try to) manage all the problems, but if it's a more involved case, then consults are requested. Cancer and oncological emergencies almost always involve Heme/Onc consultations. Severe respiratory distress will command an ICU* consult, and they might decide to admit the patient to the ICU. Any sort of neurological problem might warrant a neurology consult.

Another reason to get a consult (in this case, a specific MD's consult) is if a patient is admitted into the hospital and his** particular MD staffs that hospital. He might want to come see that patient, and being familiar with the patient's history. Which, brings me to my next point.

The first thing you do is get a 'H&P' - history and physical. There are various handy templates to write all this stuff down on. You generally have a one-sentence about what's going on with the patient, whether they're stable and maybe a few vital signs but other than that, you're flying solo (comment on why I think this is a good idea below). The history consists of a fuckton of questions. An absolute fuckton. As an example you might ask the patient - "What brings you in today?", and they'll say one thing (again, hopefully just one) - "cough". Then you begin. When did it start? How many times do you cough? How painful is it? Do you cough anything out? Do you cough at night? Does it get worse at night? Better during the day? The opposite? Anyone else in the family sick? Do you have any other symptoms (might want to list a few) with your cough? There are a few mnemonics to help you formulate a list of questions, but it's good to get as many details as possible, as fast as possible. You then move on to other things like a medical history, a surgical history, a social history, a family history, medication history, etc. Each of which comes with it's barrage of inquiries.

You then do a physical exam, and if you're pressed for time, you will do a focused physical exam. Does that mean if a patient comes in with cough, you don't look at their legs? Yes and no. If he's young and has a clean medical history, there probably is no need to. If he's old and having a bit of difficulty breathing with exercise (you would find this in the history), then you might want to check for pedal edema (swelling around the ankles) - maybe his cough is from fluid spilling into his lungs (which would spill into his legs as well in a similar mechanism).

I'm not sure how much sense I'm making here, but I hope I got the point across that there are a ton of questions, and then, an exam. So you'll get your twenty thousand questions (+exam) from the general medicine team which is admitting you, and twenty thousand questions (+exam) from every consult service, as they have to do an 'H&P' when they consult as well.

tl;dr -  ಠ_ಠ All of it is important. Read it...

 ===MDs+associated staff ignore===

I remember when I was in my St. Luke's month of medicine on the Heme/Onc consult service, patients would (rightfully) complain and moan about the millions of questions that are being asked. And it's true, a lot of these questions sound very much the same.

But in reality (otherwise this post would be pretty short), the questions really aren't. Each consult service has this beautiful thing called BIAS. Now, bias usually comes with its own negative connotation, but it's immensely helpful in organizing patient care and teasing out details about this patient's history.

So I would ask my twenty thousand questions, and because I was on the Heme/Onc service, I would follow an oncology line of questioning. I would focus my history and physical on just that. The general medicine team might have details for me about the patient's cancer, but because I have instilled myself with a predilection for oncology, I would very likely find out more. Makes sense so far, right?

Well what if a patient comes in with a problem that isn't so clear? A good general medicine team (almost all are) will pull in all sorts of seemingly zebra but necessary consults. Who knows what underlying mechanism might be causing that cough - maybe it's a nephrology thing and he's spilling protein into his urine... maybe it's cancer and there's a small tumor causing an obstruction. You want your oncologist / nephrologist / pulmonologist / infectious disease consult to be fighting (reasonably) for their view of the etiology. You want to encourage them to ask as many questions as they want, almost arrogantly proving (or maybe, disproving) the need for their consult.

There is only one right answer, and if the general medicine team has done the right job in picking consults, you'll have your answer, very, very quickly. And an expedient answer is in the best interest of all of us.


So I'll be asking my twenty thousand slightly different questions concordant with the team I'm on, in the best interest of everyone around.

Also, +exam.

*: BTGH calls it MICU, which throws me off because I keep thinking mobile intensive care unit (ambulance) instead of medical.
**: I would have written his/her but I think current style is to say just "his" which encompasses both? Somebody correct me.

You can tell a lot from...

The inside of someone's fridge. I borrowed this idea from a friend who had a pretty atrocious [inside of a fridge] situation. Yes, Varun, I'm talking about you. I would post pictures from his atrocious fridge, but I don't have permission. Yet. Get some real food, dude. Let's take a look at mine!

Done guessing what they all are? Labels below. 

(click for a bigger picture)

I know what you're thinking. What the fuck is argula and why does this clown have it in his fridge?! Well let me tell ya:

Eruca sativa (syn. E. vesicaria subsp. sativa (Miller) Thell., Brassica eruca L.), also known as rocket or arugula, is an edible annual plant. It is a species of Eruca native to the Mediterranean region, from Morocco and Portugal east to Lebanon and Turkey. ... It is used as a leaf vegetable, which looks like a longer leaved and open lettuce. It is rich in vitamin C and potassium. It is frequently cultivated, although domestication cannot be considered complete. It has been grown in the Mediterranean area since Roman times, and is considered an aphrodisiac. ...It has a rich, peppery taste, and has an exceptionally strong flavour for a leafy green.

Now you're probably thinking - Damn, did I just get told?

Yes. By Chef D.

(Chef D likes to hide his face from the public.)

Actually, towards the end of medicine they had this vegetarian sandwich with cranberry sauce and spinach and it was hella awesome. So I decided I would make a sandwich with cranberry sauce (and argula) and it was epic:

Your final thought - Why does D have a glass of whiskey next to his sandwich? The sandwich is for me, the beer, not whiskey (Samuel Adams, because I cannot stand beer as it tastes like shit) is for the fruit flies. They love it. Ahh, sweet death. 

My final notes:

• I love marmalade. Is it obvious?
• I got that apron from Ikea. Manliest apron I could find. 
• Argula is fucking expensive.
• That white splotch on my plate is mayo.
• Mrs. Bairds Honey Oat bread is pretty damn good.
• I went to Kroger and saved $6.18 using my card. Total bill : $18.44. That's 25% off.
• There is another honey dew melon, some oranges, a few potatoes, and a few zucchinis in my vegetable drawer below.
• I'm a pretty bad cook.
• Tomorrow's lunch is going to be epic. 

Now if only I had better teeth. (To be fixed soon!)