Thursday, November 30, 2006

I'm Movin' to Hawai'i!

Maybe someday.

If you've read some of the earlier posts, you know I'm in love with the place. So are 99% of Americans who visit. But it's not the weather. Or the water. The gorgeous scenery. Or the paradise-like picture that one gets on a leisurely vacation that I'm in love with.

I like the people. I like the culture - that they are laid back, not anal, not always in a rush. That when they say "Hi, how are you," they want to know the answer to that - it's not just a longer form of saying hello. That with a hand signal of "hang ten" they will stop for the pedestrian crossing a busy signal-less street. That ohana is more than who gave birth to whom. That an elderly stranger will stop you in the grocery store and ask for help with the groceries. That you would not think twice about doing so.

I've had the good fortune of meeting a few Hawaiian patients in clinic. Several have been from the Big Island and they've all happened to mention, unprompted, that I'd fit in there. And proceeded to tell me about their small hometowns. They sound lovely.

The most recent experience really moved me. Met a family from the Big Island, and it really made my day to chat with these people about life and Hawai'i and community. I've been trying to figure out what exactly about the interaction made such a profound impact and am still not sure I've a clue. Am certainly very happy in the city I'm at now - there's nowhere else in the "mainland" I'd rather be. Am very grateful and content with where life is at now. Tired, many times, but very happy.

Perhaps it's a case of "grass is greener." I don't think I'd be as happy being far away from immediate family. And I'd never consider moving anywhere else. But Hawai'i... so tempting...

Maybe it'll become clearer with time. Maybe I'll never put a finger on it. Or maybe in a few years, I'll be posting daily pictures of semi-rural Hawai'i - one never can tell what the future holds...

photo credit

Sunday, November 26, 2006

Bah, Humbug!

Watched A Christmas Carol yesterday. I think there are several movie versions on Dickens' book - this one was with Patrick Stewart.

No matter how many times you read/see/hear the story, it's absolutely a classic. Here are some memorable parts:

Fred's wife: Why do you never get upset at your uncle (Scrooge)?
Fred: Because I believe that actions have their own consequences.
-- aka good mantra to chant the next time so-and-so gets your blood boiling! ;D
'They are Man's,' said the Spirit, looking down upon them. 'And they cling to me, appealing from their fathers. This boy is Ignorance. This girl is Want. Beware them both, and all of their degree, but most of all beware this boy, for on his brow I see that written which is Doom, unless the writing be erased. Deny it.' cried the Spirit, stretching outits hand towards the city. 'Slander those who tell it ye. Admit it for your factious purposes, and make it worse. And abide the end.'
The journey of Scrooge's change of heart, for it represents that the future is not laid in stone, and that we all have the potential to be better people and create a better future for ourselves and those around us.
And to end with, a beautiful quote:

"I will honor Christmas in my heart, and try to keep it all the year."

May everyone find what they are looking for at this time of year.

photo credit

Thursday, November 23, 2006

Happy Thanksgiving!

Tis Thanksgiving Day, the start of the holiday season. I may be a big cheeseball, but I love this time of year... the festivities, the happy music, but mostly, the chance to gather with loved ones, look back on the year, and enjoy the time we have together.

Here's wishing you and your loved ones a great Thanksgiving, and a most wonderful holiday season! :)

Tuesday, November 21, 2006

Don't Get Raunchy with Mr. Open Sores

We see a lot of infectious diseases.


Due to the nature of the specialty, we happen to touch skin lesions. A lot. Some of the older attendings rarely put on gloves and will touch most skin lesions with their bare skin. Those in the armpits. The genitals. Even the oozing lesions. Or the occasional bloody ones. Most of us are not that brave yet. And we certainly don't want to catch something...

I've recently seen a bunch of young men with genital herpes and other sexually transmitted diseases. And because of these nice young men, I'm thinking about changing the way I start a clinic visit.

I usually start off with introductions, then shake hands with the patient. Am rethinking the hand shake. Having grown up with many brothers, I am well aware that many men do not wash their hands after doing a #1. Or touching themselves. Which is all fine and dandy, except when they have a syphilis ulcer on their penis, genital herpes, or some other unpleasant disease that I would rather not personally experience.

Perhaps hand-washing greatly reduces the risk. Or perhaps not. And maybe I'm just overreacting. It's almost a subconscious response though, much like you start scratching when you're with a friend who has flea bites. Or hallucinate scalp itchiness after your daughter's friend has lice. Either way, I'd hate to be the one to report that hand-washing is indeed ineffective at reducing viral transmission risk.

Oh, and just a message out to unsuspecting partners or potential bedmates, I know this isn't sexy, but if I were you, I'd take a look around and make sure there are no funny looking spots before hopping in the sack. Granted, you can still catch herpes from someone who has no obvious lesions, but for heavens sake, don't get raunchy with someone who has obvious open sores...

And don't expect Mr. Open Sores to tell you he has a problem. I can't tell you how many incredulous stares I've seen when I tell people with genital herpes that it is contagious, they can give it to their partners, so they should really use protection when possible, and let their partners know.

photo credit - You lucked out. I was going to use some graphic pictures in an effort to shock some sense into people, but decided that everyone should be able to keep their lunch down... maybe next time. :)

Friday, November 17, 2006

Things Far Greater than You or Me

Aurora borealis. Watched a documentary on the northern lights and was awe-struck.

The lights are caused by the collision of charged particles in the Sun's solar wind with atoms in the Earth's upper atmosphere. The collison energizes the gases in the atmosphere, which then converts this extra energy to light.

Apparently the best times to catch these lights are during winter in the northernmost regions - if you're here in the U.S., that would be Alaska, from Sept/Oct to Feb/March.

Another addition to the "to-do" list. Better move this one up higher - braving the cold of wintry Alaska sounds like it takes a little brashness of heart. :)
Did you know that Nov 17-19 of each year is the best time to view the Leonids? The who, you say? It's an annual meteor shower from the comet Tempel-Tuttle.

Here's what I learned:

A comet is a "small" body in the solar system composed of rock, dust, and ice. They orbit the Sun, and can have a "coma" (atmosphere) or a tail, both of which are effects of the sun on the comet body.

Each time the comet swings by the Sun, the interaction produces small particles that spread out along the entire orbit of the comet. This is called the "meteoroid stream." As we also orbit the Sun, if the Earth's orbit intersects with a comet's orbit, the Earth passes through the meteoroid stream at roughly the same time each year. We Earthlings see the intersection as meteor showers.

Meteor showers appear to "radiate" from one point in the sky. They are named after the constellation that the radiate from - hence, the Leonids radiate from the constellation Leo.

Why do they seem to radiate from one point? Because of our viewing perspective. Think of it this way - if you stand in the middle of a railroad track and follow the rails as far as your eyes can see, the tracks seem to converge to a single vanishing point on the horizon. Which you know is impossible, because the tracks are parallel. Perspective, my friends. So meteor particles travel their orbit at about the same velocity in parallel paths, and from where we stand, they look like they start at the same point in space.

These meteor particles enter our atmosphere at high speeds, creating the streak of light that we see. Most of the particles are very small and burn up long before reaching the earth's surface. The larger pieces that do reach the earth's surface are called meteorites.

Very cool, huh? Astronomy is such a fascinating field...

Wednesday, November 15, 2006

Avoid the Flu - Be Happy!

In 2003, Sheldon Cohen et al published a study called Emotional Style and Susceptibility to the Common Cold in the journal Psychosomatic Medicine.

They took 334 healthy people, noted their emotional tendencies (positive versus negative emotional range), gave each study participant nasal drops with cold viruses, and studied who got sick.

They found that people with a "positive emotional style" had a lower risk of developing a cold. In addition, the people with the "negative" emotional styles experienced more symptoms that were not thought to be due to the cold.


Harvard psychologist Daniel Gilbert has been getting press about his book, "Stumbling on Happiness." Here are some of his conclusions:

- We're not very good at remembering how happy we've been in the past
- We're bad at predicting future happiness
- We're OK at stating if we're happy in the moment

Apparently, "genes" and "culture" influence us to have bad theories about happiness. Gilbert notes that the genetic drive to procreate leads us to think and believe that having children will bring happiness. His research shows that having children has a small negative effect on happiness. When he asked people in the moment how happy they were interacting with their children, it was the same level of happiness as doing housework (!!!), and less happy than where exercising (!), grocery shopping (!!), sleeping, and hanging out with friends. He hypothesizes that the general sense of happiness of having children comes from those few moments of joy that we tend to remember ten, twenty years down the road. And, since we're supposedly not very good at remembering how truly happy we were in the past, we selectively remember the great times.

The cultural part is that we live in a culture that encourages us to buy, have, use. That marketing leads us to believe that if we only had this or were able to buy that, we'd be happier.

Money has an effect on happiness, but not in the way we're used to thinking about it. It can bring happiness to the very poor, but apparently after about the $50,000 mark, there's not as much happiness gained per increase in income.


Pew Research Center collected survey data on happiness.

They called over 3000 adults in the continental U.S. in 2005.

Here are some of their results:

Marriage and Kids:
- Married people are happier than unmarried people (43% to 24%)
- Kids don't make a difference: Unmarried people without kids are as happy as unmarried people with kids. Same is true for married people.

- Young people are less happy than older people. (28% vs 38%)
- The happiest group: men 65+. The unhappiest group: men 18-29.

- Working people are as happy as retired people (35% vs. 36%). Hmmm...
- People who feel rushed are less happy than those who aren't. (27% vs 42%)
- Suburbanites are happier than city folk. (36% vs 31%)
- Sunbelt people are happier than their counterparts in the cold. (37% vs 32%)

- People without are as happy as people with. ('cause they don't know what they're missing! ;P)

- Healthy = happy. (48% vs 15%)

- College grad happier than non-college ( 42% vs 30%)

- People making $30,000 to $100,000 have a similar level of happiness (~35%)

- Those making less than $30,000 have a slightly lower level (25%)
- Those making greater than $100,000 have a slightly higher level (50%)

- Conservatives are happier than liberals (40% vs 27%)
- More religious people (measured in this study by attending more church) are slightly happier

What do you think? Anything else you think brings us happiness?

Picture of a picture - an insect described on one of the trails in a Hawaii rainforest

Saturday, November 11, 2006

The Meaning of a Medical Visit

I think we're taught wrong in medical school. Or perhaps I just learned it wrong.

I used to think that being a physician was about treating patients' diseases. If Mr. X has hypertension, the treatment is antihypertensive medications. If Mr. Y has diabetes, we need to get control of his blood sugar. If Mr. Z comes in with a spot that looks like skin cancer, it needs to be biopsied. If it's skin cancer, we need to cut it out.

All this is still true. But not the whole truth.

These are all knee-jerk responses to different diseases that we see in patients. We're taught to hone our skills continuously so that we can best detect and treat disease. We're taught and tested and mentored so that our physical exam is done well. There are classes that teach you how to ask your questions so that you get the answers you need to make a diagnosis. There are classes (can you imagine!) that teach the budding medical student that there are two agendas during each patient encounter. The first is the agenda that the patient has - why they are here. The second, most importantly, is the physician's agenda - to treat the high cholesterol, to talk about weight loss, to freeze a precancerous skin lesion. You do this because there may be medical issues that do not bother the patient, but treating these today may prevent health problems in the future.

You feel good if you're able to take care of issues on your agenda. After all, if you cut out a skin cancer, you did good, right? If you push down the blood pressure, you're decreasing the long-term strain on the heart, right? Perhaps.

But in truth, what you did during that visit is no more than what you did during that visit. Increasing a patient's Metformin dose is nothing more than just that. If she does not watch her diet, the medication change may not have any effect on blood sugar control. Which means that she's still at the same risk for long-term complications. Cutting out a skin cancer is nothing more than the physical act of removing a skin cancer. It does not mean that the cancer will not recur. Or, in the case of more serious skin cancers, that the patient will not die from the disease.

All medical decisions are based on the presumed benefits and risks of treatment. If the benefits greatly outweigh the risks, it makes sense to proceed.

There are certain situations where it is easier to guestimate these things. If it's a young person with a precancerous lesion, the temporary discomfort from liquid nitrogen is worth the possible prevention of a future skin cancer. In a patient with advanced dementia, who cannot understand who you are and what you're doing to them, who has a short expected life span, it may be more humane to leave them be and not inflict pain for long-term benefits.

But weighing risks and benefits presupposes that we can predict the future. It assumes that a 25 year old man will outlive a 73 year old woman. It assumes that a healthy 80 year old man may tolerate general anesthesia better than a 70 year old with multiple medical problems. All good assumptions, but really nothing more than educated guesses based on prior experience. Which are not always correct.

We tend to forget that we're all "terminal" patients with a common fate. Who knows what our "prognosis" is? Can I say that I will be here next year? No. Can I say that Mrs. Y will make it through the month? We can only say that it is likely but never for sure. If I send an apparently healthy 85 year old patient to the OR for a melanoma excision, am I doing good by the patient? Perhaps if he makes it out alive and well. And if he lives to 95 or 100 without a recurrence of melanoma. What if he dies on the table because the cardiopulmonary stress test of the situation unmasked latent disease? Did I still do good??

I don't know what the answers are. The only conclusion may be that we are responsible for the intent behind the decision. That we should carefully weigh important factors, provide a medical recommendation, and discuss the risks and benefits with the patient. That what happens after that is a complex interplay between life and fate far beyond our control.

But perhaps what's important is not your agenda or my agenda. Perhaps it's the recognition of the weaving strands of life that bring together the lives of two people for a special occasion. And perhaps the truth is that the most sacred part of medicine is to see this, and know that it is not what we do that matters, but how we do what we do.

photo credit

Tuesday, November 07, 2006

Smell 'em Roses

I decided to slow down.

As a resident, you're judged by how good the higher ups think you are. Ard part of being "good" is not only medically knowledgeable, but efficient. If you know the medicine part, the faster you are, the better. Because, by golly, if colleague A can see 5 patients in two hours, and colleague B can see 6, but you've seen 8, then you must be very efficient. And smart.

So there's a temptation to push yourself to go, go, go. See the patient fast. Do the exam fast. Don't stop to write the note for the encounter until the clinic is completely over. Grab the next chart and GO!

Unfortunately, as much as you try not to let this speediness spill over into the actual encounter with the patient, it does. You're in a mindset that is ready for action, for the next thing, and when you have an elderly gentleman rambling off about how his neighbor comes over on Sundays instead of answering the questions, you can get frustrated. Then you get frustrated at yourself that you're getting frustrated with the poor man. Some may even get used to this rushed feeling, and think that all working hours are supposed to be carried out at this pace. And anything that slows you down from this pace becomes a source of frustration. At the end of the day, you're left exhausted, having pushed the physical limits, gotten frustrated over silly things, and forgotten to enjoy what you do. All of which can lead to burn out.

Then one day you realize that it doesn't have to be this way. Who says you have to go so fast? Why do you care whether someone else thinks you're better because you're faster? Your job is to take care of the patient, not, as is oft mistaken, to please your boss. And the patients can be such a source of enjoyment in medicine. You realize this fundamental truth and begin to slow things down to a normal pace again, allowing for time to enjoy each patient, to really hear what the patient says and doesn't say. You may sit with Mr. Z for the extra five minutes because it means a lot to him to tell you about the ping-pong championship he won in his youth. And you may spend a few more minutes with Mrs. Y because she's had a bad day and needs to vent. You take the time to cherish the special circumstances that allow for the meeting of two complete strangers. And you regain the pleasure of taking care of others.

It's an amazing thing. Like making the time to stop and smell the roses. Try it sometime - you might like it...

Thursday, November 02, 2006


I'm perpetually amazed at the resilience of patients.

Melanoma is one of those diseases that dermatologists dread. While some patients with thin melanomas do OK, patients with thicker melanomas can have a significant increase in mortality rates compared to their peers without melanoma. And the thing about it is, once you cut out the melanoma and do all you can do to try to get it out of your system, you then play the waiting game. As in, you sit and wait, and hope it never comes back. But it might. And you don't know where.

Or, if you've just been diagnosed with a melanoma, you need to schedule a surgery to get it all out. Which means you have to wait for the surgery date. Which means you know that the melanoma is still on you and shedding its cancerous cells into your body. Now, we know that cancer cells often start shedding way before they actually metastasize. And shedding does not necessarily increase the risk of metastasis. Specifically for melanoma, there have been studies that look at the several week delay between the biopsy and the surgery, and there have been no detectable difference in outcome between the two groups. So it's technically safe to wait. But put yourself in their shoes. How would you do if you knew you had cancer and you had to live with it for the next two weeks? Not a good place to be.

Melanomas are given a "stage" from I to IV. Each stage has a different prognosis, with stage I being the most benign to Stage IV being pretty dismal. At certain stages, because the risk of cancer recurrence is so high, even after you've had surgery to completely remove the melanoma, it's advisable to have adjuvant therapy. One of the adjuvant therapies is Interferon. Which you have to take for a year, gives you chronic fatigue, but may decrease your chance of recurrence from "pretty darn high" to "moderately high." Is it worth it? Maybe. Because if you don't do it, will you regret it when the melanoma comes back? How does one make such a hard decision?

And yet our patients do all these things. And most of the time, they do it calmly and gracefully, really serving as an inspiration to us all.


Melanoma can have a horrible prognosis. I still remember the young mother of two who had metastatic melanoma. We never found the primary melanoma was. Her disease was diagnosed because acute abdominal pain led to a liver ultrasound, which showed metastatic lesions found to be melanoma on biopsy. A pan-CT after that showed mets everywhere - brain, lung, liver. It was heartbreaking.

Seeing cases like this make us tell everyone that the sun is NOT good for you. While UV rays are not the only cause, it's the only one that we can control. We see people with melanoma and people dying from melanoma. It's not a good death.

Nowadays the people with skin cancers (often older) talk about the lack of sunscreen back in the day, and about how no one ever told them that sun was bad. Well, here we are, fifty years after their youth, and we, as a society, are not doing much better with the information we've acquired.

How many people are still baking on the beaches? How many teenagers go to tanning salons to look "healthy?" You try to get the word out, but what fifteen year old is going to believe or care that she may get skin cancer? Even if you don't get cancer, is that temporary tan worth the wrinkly, sagging, damaged skin that will come about with time?

photo credit