Separation vs Stranger Anxiety

It was difficult for me to pay attention during our first behavioral science lecture of the block. The first topic we are covering is early human development. Since I am a father of two boys under two years old, I realize that it sounds strange I didn't find the subject interesting. While spacing out in class, I tried to pretend my disinterest was because I already knew everything about the topic. Surely, since I'm a decent parent and my toddler seems smart and well-behaved, early human development is a subject I've already mastered. Surely.

As I rode home on the bus yesterday, I was reading the notes for that lecture and came across a question about stranger anxiety and separation anxiety. I realized that I didn't know the difference between the two. I reflected upon the two concepts, and thought about my son's experience with these two different types of fears. Suddenly, the topic became very interesting to me.

The fear of strangers and the fear of being separated from a familiar object or person are two different things.  Separation anxiety usually begins at 6-8 months and peaks from 14-18 months. Stranger anxiety appears at about the same time and peaks later at 24 months. While different, they can still relate to and influence each other.

An example will be helpful to illustrate the point. When our son was 18 months old, he was old enough to attend the nursery at church while we attended Sunday School.  Initially, he was extremely uncomfortable in the new situation with a room full of new toddlers and a few new adults. Nonetheless, he would still manage to play and have a bit of fun in the strange new environment. When we would try to leave, however, he would cry maddeningly. That is separation anxiety. The same thing didn't happen at home when we left him alone in a room, so it's obvious that the separation anxiety was being compounded by stranger anxiety.

We spent a couple of Sundays in the nursery with him, and eventually he got over his separation anxiety with a little bit of help from a beloved Elmo doll. Several months later, however, the nursery moved classrooms and got new teachers. He couldn't handle that. Stranger anxiety attacked again, and it took a lot of comfort to get him over it. 

Many parents might not realize that separation and stranger anxiety are perfectly normal. It's normal for infants to use their parents as a secure base from which to explore the world. This kind of attachment is key to forming relationships in the future. Furthermore, children that have been neglected or abused frequently don't go through separation or stranger anxiety and have problems forming friendships later on.  Lack of anxiety is, of course, not proof of neglect, for some children simply have an easygoing temperament.

It's not a very exact science, which I suspect is part of the reason why I was initially disinterested. Even after writing this and briefly becoming excited about the topic, I have found myself again losing enthusiasm. I'll try to keep an open mind.

I am a medical student at BCM and all thoughts are my own. I am not a doctor. Please read the disclaimer.

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Give patients hope, give them a placebo

Some diseases don’t have a cure. For many people, there is no drug they can take or procedure that can be done to fix a particular health problem. These people are left without hope. When all that western medicine has to offer isn’t enough, is a placebo a viable choice? Is it ethical for a doctor to prescribe a placebo? Since a crucial element of a placebo is that the patient expects to be healed, how does a doctor prescribe a placebo without lying to the patient? Would the patient feel cheated if they found out they were prescribed a placebo? These are all complicated ethical questions without a clear answer. Nonetheless, I believe that there is a legitimate place for prescribing a placebo. Placebos have been proven to be better than nothing at all. They provide the patient hope, and it’s unethical to leave a patient hopeless when it’s within a doctor’s means to provide a positive expectation that can lead to a real physiologic response.

There is little precedent for using a placebo outside of an experimental study. Indeed, most definitions of a placebo include use in an experiment as a defining characteristic. Put another way, many experimental models cannot function without a placebo. For example, when doing an experiment to see how well a new drug works, there is always a negative control. The negative control is a reference point to see how the new drug compares to no treatment at all. However, if a patient knew they didn’t receive any treatment, they might expect to not get better and give biased negative impressions of how they feel. Conversely, if a patient knew they received a new experimental drug, they might expect to feel better and give a biased positive impression of how they feel. This problem is fixed with a placebo. Patients not receiving the new experimental drug are given a placebo such as gel capsule filled with water. Both doctor and patient can be blinded to what they are receiving, and the results will be unbiased.

Oddly, patients who receive a placebo can still get better. This is because the placebo effect is real, and it revolves around the patient’s expectations. Several different studies offer interesting proof of this concept. In one study, a group of patients with neurological conditions causing pain were treated with analgesics. In one group, the treatment was given secretly, and in the other group the patients were informed about the analgesic. The uninformed group reported significantly more pain than the informed group [i]. Failure to hope and expect relief prevented relief from coming. There was no placebo given in the study, but it demonstrated the placebo effect.

A different study attempted to eliminate the subjective results that accompany a patient’s evaluation of pain. The researchers mapped activity in the subthalamic nucleus of the brain in patients with Parkinson’s disease after drug and placebo administration. A significant amount of patients that received the placebo reported feeling better, but the interesting part is that those same patients experienced similar brain activity as the patients who received the real drug[ii]. The patients with the placebo were experiencing a real physiologic response in their brain that was associated with the same response as patients in the treatment group.

Another study brings even stronger proof of a concrete physiologic response to a placebo. Patients with asthma were given isoproterenol, a bronchodilator, and carbachol, a bronchoconstrictor. After administration of the drug, a plethysmograph was used to measure air flow through the lungs. If the patient was told they were given a bronchoconstrictor, they experienced more bronchoconstriction than being given it blind. Similarly, if they were told they received the bronchodilator, they experienced more bronchodilation than receiving the drug blind[iii]. The patients’ expectations about the drug they received amplified their physiologic response to it.

While it is not clear who will respond to a placebo, it is clear that some people do. For patients with diseases that have no effective treatment, the only option left is hope. Some patients put their hope in a combination of spiritual or alternative therapies, and many experience accompanying alleviation. However, many patients do not have any of these outlets for hope, and it should be the doctor’s duty to provide it. Thus, I propose that all doctors maintain a repertoire of inexpensive and innocuous folk remedies they can prescribe patients with no other options. The doctor can be frank and tell the patient the therapy is unproven but still maintain that it seems to help a lot of people. In this manner, the doctor is essentially prescribing a harmless placebo that has the potential to provide hope and real physical improvement to the patient.

---

[i] Colloca L, Lopiano L, Lanotte M, Benedetti F (2004) Overt versus covert treatment for pain, anxiety and Parkinson's disease. Lancet Neurol 3: 679-684.

[ii] Benedetti F, Colloca L, Torre E, Lanotte M, Melcarne A, Pesare M, Bergamasco B, Lopiano L (2004) Placebo-responsive Parkinson patients show decreased activity in single neurons of subthalamic nucleus. Nat Neurosci 7: 587-588.

[iii] Luparello TJ, Leist N, Lourie CH, Sweet P. The interaction of psychologic stimuli and pharmacologic agents on airway reactivity in asthmatic subjects. Psychosom Med. 1970; 32:509-13




I am a medical student at BCM and all thoughts are my own. I am not a doctor. Please read the disclaimer.
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Tragedy and Charity at BCM

Last week, something tragic happened to one of the BCM employees that helps with the audio and video on our lectures. His apartment burned down. I don't know many of the details, but apparently an oxygen tank in the apartment below him exploded. He didn't have insurance and he lost everything. He was planning on retiring next year.

Last week, something very touching happened at BCM. Partly via a collection bucket placed at the bottom of the auditorium and partly via a paypal donation portal setup by a student, students across classes donated close to $1500 to help him get back on his feet. BCM set up another deposit route for faculty to help out, and the red cross was invited in as well. Today, after our first lecture of the block, he came in front of us and humbly thanked us for our support and expressed his gratitude.

It's been pretty neat to see everyone come together to help out a member of the BCM team in need. I guess it's a silver lining to the devastating event. Hopefully there is nothing unique about the generosity of my fellow classmates, and hopefully this type of charity would be seen at any medical school. It reminds me that, for the most part, us medical students are a benevolent bunch. This kind of personality trait is something you almost feel forced to put on your AMCAS admissions essay, but I think it's mostly true for the majority of us.

But this just proves you don't have to be a doctor to help someone.



I am a medical student at BCM and all thoughts are my own. I am not a doctor. Please read the disclaimer.
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10 things I've noticed during my medical school exams

Testing has been pretty grueling recently. It hasn't been the funnest 3 days in the world, but tests are over and I made it through another rite of passage on the way to becoming a doctor. Another block is down and there are only 4 more to go. This means I'm now already halfway done with the preclinical coursework. Medical school goes so fast!

Anyways, I've put together a list of 10 remarkeable things I've noticed about medical school exams at BCM. Here they are:

10. The most time that I ever spend on facebook is right before an exam. No, it's not because I'm procrastinating or wasting time, it's because our class facebook page is constantly being updated with an inter-student dialog of questions and answers. I wonder if Mark Zuckerberg foresaw that!

9. Lazy last minute cramming on wikipedia is not as good as going back to the actual lecture material. Especially since we can restream lectures.

8. When I look at my handwritten review notes, I keep trying to "control f" for a word I wrote. I've been so spoiled by the magical goodness of onenote that I'm becoming incompetent with a pen and paper.

7. Study snacks, study snacks, study snacks! Our mentors provide the whole class study snacks all throughout exams. Beat that. Just ate a rice crispies treat.

6. Free breakfast! They used to provide donuts, juice, and coffee. This block someone made a stink about being healthy and they provided some sort of rice, turky, and egg white dish. I actually prefer donuts, but I can't complain too much.

5. Starting from the first and ending with the last questions on an exam, my mindset changes from wanting to do well to simply hoping I don't have to remediate. Simply praying I don't have to remediate. It's all about lowering your expectations.

4. Almost everyone becomes humble and gracious. This is because of #5.

3. I've gotten so focused that the questions from yesterday's exams were in my dreams last night.

2. Usually, before a test, you would expect the student body to be stressed out and tensed. While this was true for our first few tests, today the scene right before our pathology test was almost of pure joy. Everyone was happy. Weird, but it makes sense since we were all so thrilled to be only have one test left. Which brings me to…..

1. We get a vacation!! A lot of medical schools don't give students days off after tests. BCM does. Yessssss!

I am a medical student at BCM and all thoughts are my own. I am not a doctor. Please read the disclaimer.
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Basic pharmacology cheatsheet

This is what I'm studying for my pharmacology test tomorrow. You probably don't care... but I'm uploading it for memory's sake. I made the cheat sheet myself, so I shouldn't get any BCM faculty upset for posting it. I did immunology on Monday, head and neck today, and pharmacology and pathology tomorrow. Exams this block have been far more exhausting than last semester, but just one more day to go! Yea for medical school and yea for the 4 day weekend coming up.

Drug Target	Agonist	Antagonist
α1	Phenylephrine. Surgery to raise BP. Nasal decongestant. High dose might affect coronary artery	Tamsulosin (flowmax). Specific for bladder. BPH. SE: orthostatic hypertension Phenoxybenzamine. Also some α2. Irreversible. Rx pheochromocytoma. Prazosin/terazosin. Treat HTN.
α2	Clonidine. Reduces sympathetic outflow. BP down. Hospitals. α-methyldopa. Prodrug. Anti-HTN in pregnant women	Yohimbine. Promotes erection. "Natural viagra"
β1	Dobutamine. Cardiogenic/septic shock	β1>β2 : ABEAM, acebutolol, esmolol, atenolol, metoprolol
β2	Albuterol Salmeterol. Slow and long acting Terbutaline Ritodrine. Postpones delivery, uterus.	β1=β2 : Propranolol, timolol, nadolol, pindolol β1/β2 partial agonists: pindolol, acebutolol β/α blocker: labetalol, carvedilol (get decerase in PR without ↑HR)
NE release from noradrenergic neurons	Ephedrine. Nasal decongestant, asthma Cocaine blocks NE reuptake (also dopamine, serotinin) Amphetamine (Adderall) / methylphenidate (ritalin). Release NE. Impramine, amitrytaline (trycyclic antidepressents. NE reuptake inhibitor. Tyramine. Cheese.
M3	Pilocarpine. Ciliary and constrictor muscle. Glaucoma Bethanechol. Relax bladder sphincter, bladder wall contraction. Methacholine. Used to diagnose asthma. Carbachol. Used for glaucoma if pilocarpine ineffective Edrophonium. 10 min HL. ACh inhibitor. NM junction. Test for myasthenia gravis Neostigmine. 2-4 hr HL. ACh inhibitor. NM junction. Myasthenia gravis. Glaucoma Pyridostigmine. 4-6hr HL. ACh inhibitor. NM junction. Myasthenia gravis. Glaucoma. Physostigmine. 15-40 min HL. Enters CNS Echothiophate. Phosphorolates ACh esterase. Chronic glaucoma. Nerve gas.	Pralidoxime (PAM). Recovers ACh esterase (nerve gas antidote) Atropine. Nerve gas antidote. Ipratropium. M3 on large airways. Asthma. Glycopyrollate. Used to reduce secretions; in conjunction with neostigmine after surgery to protect HR. Oxybutynin. Rx overreactive bladder. Targets detrusor. Scopalamine. Also enters CNS. Transdermal patch.
M2/4
Nicotinic		Succinyl Choline. Depolarizing NM blocker. Malignant hyperthermia possible (Rx dantrolene) D-tubocurarine. Non-depolarizing NM blocker Gallamine. Non-depolarizing NM blocker Vecuronium. Non-depolarizing NM blocker Mecamylamine/trimethapan. Used in ER for HTN. Blocks autonomic ganglion
H1 (Constricts venules)		Diphenhydramine (Benadryl). 1st gen. Sedating Promethazine. 1st gen. Used as anti-emetic. Fexofenadine (Allegra). 2nd gen, non-sedating Loratadine (Claritin). 2nd gen, non-sedating
H2 (Dilates arterioles
COX		Aspirin. Irreversibly acetylates Cox1/2. Platelets (7-10 day lifespan) make thromboxane, endothelial cells (can make more COX) make prostacyclin. Acetaminophen. Cox1/2. good CNS preference (good antipyretic and analgesic) Ibuprofen. Cox1/2. From propionic acid. Indomethacin. Cox1/2. From acetic acid.

I am a medical student at BCM and all thoughts are my own. I am not a doctor. Please read the disclaimer.
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Why grandpa can't understand his granddaughters

I still kind of feel like death today, which didn't make my immunology test any easier. But it's over! And, since tomorrow are my head and neck exams, as part of my studying I'll share some fun medical facts about why older people lose their hearing. They lose it in a very specific way, which is very interesting!

Why Grandpa can't hear little girls (presbycusis)
It is fairly commonly observed that old people can't hear higher pitches very well. This age-related hearing loss is called presbycusis. Why is this? I drew a basic drawing of the ear to explain.

Basic diagram of how sound waves travel down the cochlea, offering a basic explanatory model for presbycusis.

The blue spiral is called the cochlea, and it has the actual cells (called hair cells) that respond to the energy from sound waves that send signals to your brain. So, the sound goes from outside, to your outer ear, across the ear drum and into the middle ear, transmitted through the bones in the middle ear to the inner ear, and eventually to the cochlea. Notice that the beginning part of the cochlea is sensitive to high pitch sounds and that the end is sensitive to low pitch sounds. The red arrows demonstrate sound waves moving up the cochlea.

For higher pitch sounds, that red arrow stops at the beginning. For lower pitch sounds, the arrow passes over the cells at the beginning of the cochlea and goes all the way to the end. Thus, the cells at the beginning get a lot more exposure to energy from sound waves than the cells at the end do, and they get worn out. That's all there is to it. Grandpa's poor cells that respond to higher pitches got worn out, but luckily the cells that respond to lower pitches get used less and still work.

The next time you talk to an older person with hearing difficulties, remember to speak in a lower pitch in addition to speaking louder. This might help some, but realize that speaking in a low pitch doesn't necessarily solve the problem since consonants are in the 2000-5000 hz range. Thus, it's hard to speak a consonant with a low hz, so you're best bet is to just speak loudly. The cells at the start of the cochlea that are sensitive to higher pitches where the consonants are heard are more likely to be stimulated by the intense energy waves that come with loud speech.

As a side note, babies develop their hair cells towards the beginning of the cochlea first. This means that the cells that respond to higher pitches are the first to mature. So, if you try to have really manly baby talk with a low pitch, that baby might not even hear you.



I am a medical student at BCM and all thoughts are my own. I am not a doctor. Please read the disclaimer.
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Medical Student Syndrome

I've been fighting a cold for the past few days, and this morning it got way worse. Monday is my immunology exam, so naturally I've been hypothesizing about all my possible immunologic defects. Did my cold get worse because I'm stressed out, and stress inhibits the immune system? Do I get colds more than most people? Maybe I have a deficiency in T-cell mediated immunity. After all, I had a herpes zoster infection when I was only 10 years old, and that's usually a disease that only old people get. It's when the virus that causes chicken pox gets reactivated, frequently because the patient is immunocompromised in some way. Or maybe I have a minor mutation in a protein responsible for natural killer cell activation similar to the SAP mutation in x-linked lymphoproliferative disease, which explains why I sometimes seem to have a hard time overcoming viral infections. Hopefully that doesn't give me a B-cell lymphoma!

But I digress.

Great knowledge brings with it the great chance for misapplication. This results in the hysteria known as medical student syndrome. A more interesting aspect of this idea is of the gross population in general googling their own symptoms. If I, a well-educated medical student, entertain the possibilities of having a bunch of diseases that I probably don't, it's easy to understand how why non-medical professional get scared by the terrible diseases they self-diagnose themselves with after surfing the web.

For some people, the equation looks like this:

Feeling sick + surfing the web ------>  diagnosis of death

I am a medical student at BCM and all thoughts are my own. I am not a doctor. Please read the disclaimer.
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Donating your body to a medical school

Yesterday I participated in what was probably the last dissection on a cadaver that I will ever perform. We dissected his larynx and pharynx. Afterwards, I looked at the body, and realized that we had basically turned it inside out. There wasn’t much left of it that hadn’t been cut into, examined, probed, and pinned. This cadaver, or rather I should say this person, had given literally every part of himself to be our learning tool—a tool in which there really is no adequate substitute. At the end of the lab, we all closed the tanks and put a white rose on top to honor the people who donated their bodies to our medical school. After our practical exam on Tuesday, the bodies will be cremated and either given back to the families or taken out to sea with an honoring ceremony.

In all honesty, it became difficult for me to maintain the awareness that the cadavers used to be people. It became one of those times when you lose the forest in the trees. You become so extremely focused on the fine details of each organ, muscle, bone, limb, blood vessel, and nerve that it’s all you care about. Even more, you start to feel that you are looking at pages of a textbook instead of a deceased human being. I’m not sure if this is necessarily a bad thing, but it’s an interesting process nonetheless.

There were moments when the humanity of the cadavers suddenly resurfaced. In particular, dissecting the face and especially the eyes brought thoughtful and reverent emotions to the surface. It also felt really weird. These feelings never lasted long, probably because I forced them out. Near the start of medical school, my tank mates all refused to look at the face of the cadaver and always made sure it was covered up with a towel. We were working on the extremities, so there might be some aspect of respect in keeping unused portions of the body covered. Still, I think it was more about being afraid to face the uncomfortable feelings that thinking about the humanity of a cadaver brings. If the towel came off, they got squeamish or even shuddered.

Almost everyone eventually got over this, and some students say they have come to view their cadaver as a good friend. Many feel it will be hard to say goodbye. I partly share this sentiment, although I wouldn’t go as far as to say that we are friends. I appreciate the time I was able to spend with the cadavers, and it is bittersweet to be finishing up with gross anatomy because I know I will probably never get the chance to do this again. My chance to learn anatomy as a medical student in the anatomy lab is basically over, and this fact almost makes me regret I didn’t cherish all the time I had with the cadavers. Although they are already dead, for me it’s almost like they are dying again. They only have a few days to live, and if I don’t spend time with them now then they will be gone.

Donating your body to a medical school is a big decision, and I admire those who are willing to do it. Oddly, and perhaps embarrassingly, I’m not sure I could do it. I’m probably too self-conscious. This is weird to say, because once you take off the skin, the inside of a human body doesn't even look tangibly human in most people’s perception anyway. I also consider the feelings of my wife and family. If I were to die, would they be alright with medical students cutting open my body for 6 months? Would they be happy I was serving others even after death, or would it be a painful reminder of my absence? These are serious questions, and it quickly becomes apparent that donating your body takes serious thought, reflection, and discussion with loved ones.

As I study this weekend for exams next week, I think I am going to go into the anatomy lab. If anything, I’m just going to go in and look at them. I might study a bit, but that’s not going to be the main purpose. I just want to experience the anatomy lab one more time, and reflect more on the wonderful opportunity these people have given me.





If you want to donate your body to BCM, you will need to contact them. Please see the contact page below and the associated FAQ.

http://www.bcm.edu/willedbody/index.cfm?PMID=2625

I am a medical student at BCM and all thoughts are my own. I am not a doctor. Please read the disclaimer.
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Healthy people are boring

Do I hate healthy people?

Today was one of my clinic days where I went to a pediatric office to practice my skillz. Unfortunately, there were 3 brand new patients to see the doctor today, which meant a lot of time standing around doing nothing while the doctor did a comprehensive oral history on the patient. Usually, we go to see the patient first, then we report our findings to the doctor, and then we go back in with the doctor as she cleans up our mess and finds out what’s really going on. When it’s a new patient, however, I can understand why the doctor wouldn't want to send in 2 medical students to give a first impression of the clinic.

Listening to the doctor interview the parents of the patients confirmed a hunch I’ve had over the fast few months: I don’t like healthy people. I’m keeping an open mind, but it’s starting to seem like healthy people are really boring. Sure, the 2 month old, 4 year old, and 5 year old new patients were really cute today, and it was fun to watch a girl’s eyes widen as she was told to eat 5 servings of fruits and vegetables a day, but to be honest it wasn’t that exciting. In the very least, listening to my pediatrician preceptor discuss health and health histories with healthy patients is extremely boring. Family medical history, grandfather’s lung cancer, blah blah blah blah.

I still get pretty nervous when I’m the one playing doctor and examining a patient, so it’s hard to comment at this point if I think it’s boring when I interview a healthy patient. The jitters still make everything exciting. Once the jitters fade I’ll have a better idea if I like healthy people or not. I have heard that once you do an internal medicine rotation and everyone is a non-compliant diabetic with hypertension and renal failure that it suddenly becomes really nice to see relatively healthy people. Right now, however, I don’t have that perspective and I want to see some interesting pathology.

Does that mean I like diseases more than people?

But I did see some huge tonsils today. That was pretty cool. This poor girl had tonsils so big they were almost closing off the back of her mouth. Her family had complained of snoring for a while now, and a sleep study confirmed sleep apnea. She got a referral to ENT and she should be sleeping better after surgery.

We learned how to do the ear exam last week, so today I got to see an ear so jammed full of crusty black and brown earwax that I couldn’t see anything. The other ear looked great to both me and the other student, but when the doctor checked after us she said it was infected. Since it was only the second person’s ears I have ever looked in, I guess I shouldn’t feel bad I missed it. The question remains, however, if I should fork out $500 for a good otoscope/ophthalmoscope or not. Eeek!



I am a medical student at BCM and all thoughts are my own. I am not a doctor. Please read the disclaimer.
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I love medical school

Almost every post here relates some reason about why I love medical school, about why I love BCM, about why medicine is so cool, how great the clinical experiences are, etc. Nonetheless, I thought I would start a new topic series dedicated exclusively to why I love medical school. Every time I have one of those moments where I just love medical school, I want to write about it. Someday, I might also generate some material about why medical school sucks, why I hate medical school, etc. While that day may come, I haven't had a lot of those thoughts yet, so I'll glory in the positive while it's here.

I have loved being surrounded by intelligent and motivated people. My peers have all worked hard to get here, and they're not about to stop. They are bright and intelligent, and most of them have good people skills. So far, I've only met a few out of the 186 other medical students that I wouldn't want to be my doctor. Prior to medical school, I spent 3 semesters at BYU. While I was there, I really enjoyed the fact that I was constantly surrounded by happy and caring and good people. It was above and beyond the average of the happiness and goodness I've seen at most other places. Here, the people are nice too, but the academic brightness is what really stands out. I can ask any other student a question, and they probably know something that will help.

I have also loved the insurmountable amount of material to learn. All throughout my academic career, I have always secretly laughed at the people who furiously take notes during class. Didn't they know that all the material is right there on the power point or in the lecture notes? The irony is that today, as Dr. Kretzer raced through hair cells and the organ of corti, I was typing away furiously for almost the solid 2 hours of lecture. And it's not just me. Almost the entire class always types and types away, completely focused on the barrage of new material and new words coming at us that seem to desire to suffocate our tiny brains with a data overload.

That was today, and we have exams next week. School is definitely getting more challenging than it was last semester. We have had 7 weeks of lectures, which amounts to more than 140 hours of class time, and we're getting tested on all of it next week. Plus the anatomy is cumulative from last semester, too. I guess this is when some people might say they hate medical school. To me, however, the challenge is invigorating and the material is very interesting, so it's all good. And I'm learning how to be a doctor!




I am a medical student at BCM and all thoughts are my own. I am not a doctor. Please read the disclaimer.
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Pregnancy sounds scary: Postpartum thyroiditus

I'll admit it: the thought of a creature growing inside of me sounds pretty scary. The thought of how it would exit my body is obviously a bit dreadful, but the entire process before that point is pretty frightening as well. In other words, being pregnant and having a baby is pretty impressive and scary stuff.

I am a man and will never go through that. My emotional response to this thought: gratitude, luck, relief. My wife has already gone through this twice. My emotional response to that thought: gratitude, gratitude, gratitude, thoughts of "blessed be her name".

I've seen my wife go through it, I've seen other friends and family go through it, and I've also learned a lot about it in medical school. Whenever we discuss side effects and complications of pregnancy in lecture, I can usually feel the palpable tension and dread of my female classmates filling the air. Sometimes I can hear it in the form of gasps and moans. Apparently, I'm not the only one who thinks that pregnancy sounds pretty scary.

With this in mind, I am starting a series of the unusual things that pregnancy can do to a female's body. Some might say that I'm doing this to feed into the pregnancy-phobia that can easily and understandably enter into the mind of a woman considering conception. Rather, I am doing this in honor of all you current or potential mothers out there. You all rock, so let me show everyone else some of the crazy things you have to go through just to become a mother.


Part I: Postpartum thyroiditus

The thyroid is a gland in the neck that secretes important hormones called T3 and T4. These hormones are crucial for regulating body metabolism, and they affect most cells in your body. Most cells in our body are constantly using energy to transport potassium and sodium in and out. As with any hormone, you can either have too much or too little.

• Hyperthyroidism
• Hyperthyroidism is when you have too much thyroid hormones. Cells are overactive, raising your body temperature, increasing your oxygen demands, increasing cardiovascular demands,  and frequently manifests as losing weight, irritability, a racing heart, and difficulty sleeping.
• Hypothyroidism
• Hypothyroidism is when you have too little thyroid hormone. Predictably, it manifests in feeling tired and cold and frequently is associated with weight gain.

After women give birth, they have a 7.5% chance of experiencing problems with their thyroid gland. It's not known exactly why this happens. Part of the cause is that, during pregnancy, the women's immune system is toned down to prevent it from attacking the baby. After delivery, the immune system rebounds and overcompensates, accidentally targeting organs like the thyroid gland.

Thus, postpartum women have a tendency to produce antibodies that target the thyroid for destruction. As the thyroid gets damaged, a lot of thyroid hormone gets released and the women first experiences hyperthyroidism. After this, since the thyroid is damaged, very little thyroid hormone will be released and the women next experiences hypothyroidism. What a rough ride! Most women get back to normal after a few months, but others experience permanent thyroid damage and will have to take replacement thyroid hormones for the rest of their life.

We are all pretty aware of the roller-coaster of surging hormones that women have to deal with ever month, and this adds another loop to that ride.



I am a medical student at BCM and all thoughts are my own. I am not a doctor. Please read the disclaimer.
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BCM and my cool classmates

This is a screenshot of a picture I posted to the BCM class of 2015 Facebook page back in August. It's a picture of my son, whose birth incidentally caused me to miss the white coat ceremony. The reason I share it is to point out the 80 likes I got on the picture and a reference to how cool my classmates are. BCM is full of really smart cookies, but everyone in my class is really cool. We get along really well, we share notes, we hang out together, and it certainly doesn't feel like a competitive mess with gunners left and right waiting to stab you in the back to get the higher score. It's a supportive atmosphere. It's nice.

Facebook has probably done a lot to bring our class together. Our BCM facebook page is always active and constantly being updated with jokes, study material, and other stuff. I've been a member of several other medical schools' facebook pages, and none of them were anywhere near as active as ours. That might mean we are a bunch of nerds on the computer too much, but I like to take it as evidence that we're sorta cool at the same time.



I am a medical student at BCM and all thoughts are my own. I am not a doctor. Please read the disclaimer.
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Old people love their drugs

I learned a couple of interesting statistics today in my pharmacology lecture about prescribing drugs for the elderly. For statistical purposes, the elderly include anyone over 65 years old.

• Over 10% of the elderly take at least 10 different kinds of medication.
• Over 40% of non-institutionalized elderly take at least 5 different kinds of medication. Since people that are in nursing homes or hospice care generally take more medication than that, the number of elderly who take over 5 different medications approaches 50%!

Our professor joked with us that, in general, the current elderly generation comes out of a doctor visit very satisfied if two things happen. First, the doctor must discuss a chronic but non-terminal disease that the patient has. Second, the doctor must prescribe a new medication.  For many people, these two things bring a sense of validation  and a sense that their time and money was well spent.

In all seriousness, this is a big problem. Every drug has a side effect, and multiple drugs have multiple side effects that can interact in bad ways not always obvious or foreseeable. Due to the tendency of many people to see different specialists across different fields, and to even shop around for different specialists in the same field, inadequate communication is a common occurrence. This communication lapse can easily occur between the patient and the doctor and certainly between the different doctors, and it can lead to prescribing multiple drugs that do the same thing or multiple drugs that should not be mixed.

Furthermore, there is a propensity for something called the “ADE prescribing cascade” to happen, which can make things worse. The idea is that someone is given a drug, and the adverse drug effect (ADE) is interpreted by the physician as a symptom of a new disease process. This warrants the prescription of another drug, which gives the patient a new side effect, another drug is prescribed, and so forth.

Since most elderly patients don’t know any more about the drugs they are on than which color pills they should take at which time, this only emphasizes that we should all make sure our elderly friends and family have a good primary care physician. They need someone who will take the time to sit down and think about the interactions between the different drugs that doctors across different specialties have prescribed. They need someone who will not overmedicate. They need a good medical home.

At this point, I have little interest in becoming a primary care physician, but it’s easy to imagine that they probably do more good for the overall health of a population in general than any other specialist.



I am a medical student at BCM and all thoughts are my own. I am not a doctor. Please read the disclaimer.
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The Magical Goodness of Onenote

Don't start medical school without Microsoft Onenote. Seriously. Microsoft Onenote is an amazing tool for medical students for many reasons. Here are a few:

• Organization
• Every single power point, PDF, and word document can be loaded into Onenote, allowing for every single lecture note and piece of review material to be instantly accessible with one program. Trust me, this is easier than making folders upon folders for all the different subjects.
• Search features
• Who doesn't love the control f function? In Onenote, not only do you have this search feature, but you can search your entire program (everything). Why is this useful? Let's say I hear a term that I know I've heard before but I forget what it is and when we learned it (this happens a lot). What do I do? With a few keystrokes I do a search for it, and seconds later I'm looking at the exact spot in the lecture power point from 6 months ago where we discussed it with my annotations. You can't beat that organization and accessibility.
• Annotation
• Annotating everything from PDF documents to powerpoints could not be easier. It's like a little piece of heaven.

You might have to try it before you really understand what I'm talking about, but I don't know anyone who has tried Onenote and not fallen in love with it.

This is a screen shot from one of my lecture notes

For reference, I provided a screen shot of the program. The left is where I can switch to different notebooks for each block (1, 2, 3, 4). The top has my different subjects for that block, such as anatomy, histology, cardiac, respiratory, etc. The right has my lectures or other review pages for the subject. 

I am a medical student at BCM and all thoughts are my own. I am not a doctor. Please read the disclaimer.
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Question: Should I send a letter of intent?

I received a question asking if I think it's beneficial for a medical school applicant to send a letter of intent. A letter of intent is when a medical school applicant sends a letter to the admissions office and explains why that school is their top choice, that if they are accepted they will for sure matriculate there. Some people will tell you that a letter of intent doesn't help at all while others may say it does. I'm first going to present my anecdotal experience and then offer some comments.

My anecdotal experience about letters of intent:
I interviewed at BCM early in the application cycle in September. I enjoyed the interview much more than I anticipated and was really impressed. My original aspiration was to go to the Mayo Clinic, but after my BCM interview I decided that I would be ecstatic to go to either BCM or Mayo.

More interviews came and went, and eventually I got accepted to the University of Maryland in Baltimore and the Medical College of Wisconsin. I sent an update letter in January explaining what I was up to, although at that point I didn't feel comfortable describing my intent as I was still interested in Mayo.

Here is where my story gets a bit unique: my wife and I were seriously considering joining HPSP to pay for medical school. HPSP is the military scholarship that pays your tuition and gives you a stipend, but you serve the military in return. However, due to BCM being a lot cheaper, we were thinking it wouldn't be worth it to join the military at Baylor. BCM also has tons of other academic and career opportunities that would be hard to take advantage of in the military. Military recruiters are super ancy to get you to sign your life away, so we thought it would be really helpful to know my status at BCM. Thus, in March I contacted the dean of admissions at the time, Dr. Eddins-Folensbee, and explained the situation. I told her that knowing if I still had a decent shot at BCM or if it was unrealistic would greatly help our family decide whether or not to joint the military. She replied that BCM was certainly in my range, but I should give them some more time and contact her again in 2 weeks. I contacted her 2 weeks later and she replied that she was sorry but couldn't give me any information, although they still had about 50 spots.

In April, I received notice that I was placed on the final wait-list at BCM. By this point, Mayo had rejected me and my hopes were pinned on BCM. In late April, we decided not to join the military, so I told Dr. Eddins-Folensbee this and explained BCM was our top choice.

In mid May, we were leaving for a 5 week trip to China. I contacted Dr. Eddins-Folensbee via email and explained we would be out of the country for 5 weeks, and that I would be available to communicate via email while in China if they needed to contact me.

A week before returning home, I decided to play a little trick. After being in China for 4 weeks and hearing nothing from BCM, I thought I had decent pretense to call the office and ask for an update and make sure I didn't miss anything being out of the country. It seemed that most people got accepted to BCM on Monday evening, so I figured there must be some sort of meeting Monday afternoon. I figured if I called Monday morning from China to express my interest, the office might be somewhat moved by my sincerity and give me enough brownie points to merit an acceptance. I made the call, and low and behold I was accepted the next day (June 14th)! Coincidence? You decide!


Possible morals of the story:

• Find a good reason to get in contact with the dean of admissions. Joining the military and going to China are pretty unique, and this probably made me stand out a bit.
• It probably helps to have already been accepted to one medical school when you write letters of intent. This gives you a bit of leverage and proves that you aren't just desperate to get in anywhere. I don't think it's too much to say: "Right now I am set to attend school X, but I would decline their acceptance and attend here if you accept me."
• Honestly, can it really hurt to let a school know that they are your first choice? If you pester them every week, maybe, but not if you are mature about it. You can't prove that you are being honest, but I would guess they would believe you.
• If you have some sort of major accomplishment (not just good grades) that happened after your interview, this is a good excuse to contact the admissions office.
• Even if it doesn't help, you will feel satisfied knowing that you tried your best. You will never have to wonder what might have happened if you had tried harder to stay in contact with the admissions office.

I am a medical student at BCM and all thoughts are my own. I am not a doctor. Please read the disclaimer.
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Fun Medical Facts II: The Nose

Today I learned some interesting things about the nose.

• Crying: pathetic vs disgusting
• When you cry, you notice the tears flowing down the outside of your face. However, there is a connection between your eyes and the inside of your nose called the nasolacrimal duct. This duct exists because a gland in your eye, the lacrimal gland, is always producing moisturizing fluid. Moisturizing fluid is a good thing, but constantly having fluid running down your face is socially awkward, so the nasolacrimal duct solves this problem. Tears are simply an excess of this fluid. So, when you cry, you also have an excess of fluid going into your nose. As Greg, our anatomy professor put it, this leaves you with a choice to either be pathetic or disgusting when you cry. I made an outstanding diagram of the situation below.
• 
  

The lacrimal duct connects the eye to the inside of the nose

• A clogged nostril
• Your nose is divided into 2 parts. Each part has 3 different conchae, which are small curly bones lined with mucosal tissue. They function to moisturize the air and get it ready for your lungs. It turns out these conchae actually need breaks and cycle through periods of inactivity. One half will take a rest while the other works. The resting half actually enlarges and experiences increased blood flow, leading to increased mucus production to aid in recovery. This can go overboard, however, and is how you end up with one nostril completely clogged up while the other one is clear.

I am a medical student at BCM and all thoughts are my own. I am not a doctor. Please read the disclaimer.
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