WILTIMS #329: It's my birthday, I can post if I want to...

Two years ago today, I was sitting alone with my anatomy book in a desolate Taco Bell/KFC celebrating both my birthday and the first day of classes with some stale cinnamon twists. Now, as I write this, I'm riding the subway into the city to meet my SO for dinner and a show, after a long day working in a hospital. Crazy what a couple years can do.

Today's new psych clerkship experience was having a patient I only knew from walking through another unit suddenly become one of my patients. My supervising doc was very surprised at my familiarity given that I shouldn't have known him. Actually, he was one of the patients that inspired last Friday's post about the utility vs futility of talking to temporarily helpless patients.

I would walk through the hallway by his room and, even though I was a total stranger to him, he called me over and talked. At first the conversation seemed rational, but it quickly took a turn for the bizarre. He's a hard guy to just walk away from though, so I probably spent a good 20 talking to him. I wound up doing the same nearly every day last week. Part of what seemed so interesting was that I had no reason to know him; so unlike all the other patient interactions I have in the hospital, this time I wasn't searching for an answer or gathering back story - just talking.

So today his business became my business. And I quickly discovered that I already knew a lot about him even though I hadn't intentionally tried to discover anything through our prior conversations. Simply listening to people, with no need of special techniques or added motivation, is all you need to learn about them and build a relationship. TIL.

WILTIMS #225: Think before you think

I've noticed a change in the way that I think, and I'm not sure if I like it. I've started wanting an H&P (history and physical) on my friends and relatives. Now, I don't mean that I literally want to peek into their medical records; it's more that I have come to expect a certain amount of background information before addressing a problem. When I'm asked for advice by people I know, I go into "doctor mode" and immediately want more information than it's socially acceptable to ask for.

One of the most important things you learn early in medical school is that your ability to diagnose and treat is most directly affected by the quality of your history and physical. You can't rule out or rule in anything if you don't have all the appropriate information. Doctor-patient privilege is a powerful thing, allowing you to ask anything - with the understanding that the conversation is confidential, useful, and may help to solve the problem at hand.

I want that same ability for certain situations. I want to be able to call timeout on our normal relationship and deploy this higher standard of listening, but that's just not socially feasible most of the time. Now, I think this is usually fine when the problem is medical; people naturally expect to have to share details if they bring up a medical problem on their own. But with interpersonal problems, issues at work, or in academics, there is a level of discretion employed that you simply get to bypass in medicine.

If a friend is asking for serious non-medical advice, I go into "problem solving mode" (a close relative to "doctor mode"). It's fun. It turns even terrible situations into puzzles. If I can just see all the pieces, eventually I will solve it. But this is a false analogy. There are times when the broken pieces will never add up to a full picture. When problem solving doesn't help. When all a person needs is comfort and understanding. This is a scary route to desensitization and it is plotted out by the most benign and even well-meant reasoning.

For years we are trained to elicit a problem, break it down into useful pieces of information, elicit more info if needed, and then start offering solutions. That's great, usually. But in real life, we aren't hearing the problem from an exam prompt or even a patient in a clinical setting. These everyday questions come from friends, from family. They probably aren't telling you their troubles because you're a doctor or medical student, but because you are a person close to them who they can trust to listen and reassure them. Sometimes they already know the answer to their problem. Sometimes they aren't sharing everything because the problem is too personal and you figuring out the solution (using your mighty problem solving skills) will only bring more pain, not less.

To any med students reading this, try to keep in check the wonderful, powerful ability you are honing to someday save untold lives. Your ability to problem solve is part of what makes you special and able to apply the vast knowledge you are accumulating, but it also can isolate you from your fellow humans if you let it dominate your thought process.

TIL*: Uremic pericarditis kills dialysis patients in blizzards. This is part of why only certain vehicles are supposed to be on the road in snowstorms. The average healthy peron can go a couple days bundled up and playing board games. But if a person in renal failure can't get to a dialysis clinic (thanks to roads blocked by accidents or stranded cars) they die - often from this form of pericarditis (inflammation in the tissue and space surrounding the heart). Stay off the roads in an emergency!

*It's a new record! I'm three days late on posting this one, but I'll be damned if I don't maintain my post-per-day-of-class run. Apologies for the delay!

WILTIMS #77: Anarchy in the classroom!

Today we had our first Medical Ethics classes and, amusingly, our first ethical dilemma was with the class itself. We were meeting in our small groups and our instructor didn't show. At first we thought that she was just running late or going off an old schedule. 10 minutes after the latest possible start time we sent out a few students to see if the other classrooms all had their instructors and we found one other that had been similarly abandoned.

Collectively, we tried to decide what to do. Who do we contact? Do college no-show rules apply? Could they trace it back to us if we left? Is it somehow more ethically wrong to ditch an ethics class than a normal class? Eventually we decided to take our own attendance and then some people left while others interrupted another room to ask what to do. Those of us who stayed joined the neighboring room for the second half of the class.

TIL: "Up the butt" may not be the most eloquent way to explain "suppository". It is recommended we use "inserted in one's bottom or rear".

A doctor can refuse to take any patient. A doctor cannot, however, refuse to see a patient with whom they have already established a doctor-patient relationship. The doctor must give the patient a reasonable amount of time (a few months) to find another doctor before the doctor can refuse care.

Telomerase carries its own RNA primer. Let me back up a bit... DNA polymerase, the enzyme that helps make new copies of DNA from old copies, requires an RNA primer to help it initiate replication. Think of it like the little metal guide at the end of a zipper^* that helps the slider attach to the teeth. The problem is that the RNA primer isn't stable and will be degraded, leaving the DNA strand a little bit shorter. To make sure that the important information coded by the DNA isn't lost after multiple cycles of replication, the cell adds a whole bunch of non-coding repeat sequences. These chromosomal end caps are called telomeres. Eventually, these do run short and need to be built back up.

That's where telomerase comes in. This is an enzyme very similar to DNA polymerase that's sole job is to add telomeric repeats to the end of chromosomes. It gets around DNA polymerase's primer problem by providing it's own primer. It then extends one strand of the DNA until it is long enough that another primer can be added and DNA polymerase can take over.

*Apparently this is called an "insertion pin" by zipper aficionados