Sleeping should revitalize you, not make you feel tuckered out

I am not one of those people who remembers my dreams often, but I had such a vivid dream last night that I woke up more tired than when I went to sleep. I dreamt that I was in Brazil vacationing with Farley. In my dream, I was going to fly to Argentina with some wine experts to get a surprise bottle of wine for Farley. Since I'm a worry wort, I spent much of my dream weighing the pros and cons of going on this wine trip and decided that traveling around South American with wine experts wasn't such a safe idea. Besides this debate, the rest of my Brazilian vacation dream, involved all the stressful, planning parts of traveling and none of the fun. This is especially strange because when I travel I have everything as well planned out as possible to decrease my stress and increase the fun and relaxation. Needless to say, this dream vacation wasn't a fun at all! One is suppose to feel refreshed and revitalized when she wakes up; but I was downright exhausted this morning after that dream. I shouldn't be too surprised; if anyone could stress herself out on an exotic vacation in her sleep, it would be me.

Berkeley

This morning when I was looking at flights heading home, I noticed that Southwest is having a super sale (though tomorrow). I wish I knew exactly when and where I'll be heading to in January, as I could have booked the ticket to the east coast for $100.00!! Isn't that crazy? As a coincidence, the other day I was thinking that it's been over two and a half years since I last saw one of my closest college friends, Mary. When I called to tell my parents that I booked my flight home after the Step, I mentioned the great sale and how long it's been since I've seen Mary. My Mom suggested that I call Mary to see if she has time for me to come down (My Dad, on the other hand, misses his little girl so much that he doesn't even want me to meet up with friends for coffee let alone go to California for a weekend). I assumed that Mary wouldn't have time for me to come visit as she is up to her neck in her lab work for her PhD dissertation. But, to my surprise, she said to plan the trip because she can arrange her schedule so that she doesn't have to go to lab much on the days I'm in town. In less than 24 hours, I went from not knowing exactly when I'd be coming home after the Step to booking my flight home and making a surprise side trip to see a friend.

I've been doing fairly well on the Step prep questions and feeling more and more confident the last couple weeks. But, the last two days haven't been so super, which can be at the same time discouraging and motivating. I also have the motivation of all the excitement after the Step. Assuming no two-day flight delays, I will be home for two Thanksgiving dinners (one at my Aunt and Uncle's house and the other at our neighbor's house) and I get to see one of my most beloved friends. I'm so excited about the fun to come after the exam that I feel like Popeye after eating spinach--I'm recharged, excited and ready to study!

I'm coming home!

Farley and I just booked our flights home for November 24th. Farley is heading home a couple hours before me, so I'm sure I'll be sad and crying at the airport (I hate to see him leave and this will be the longest time we've been apart in two years), but it is also going to be exciting to be home for Thanksgiving. I just hope that our flights go smoothly and that we are able to get all of our odds and ends finished in Miami before heading out. Speaking of things to finish up, I have a little test on November 19th so I should get back to my studies. See you soon!!

Two months, two weeks, and a number two pencil

To become licensed as a physician in the United States, one must pass the USMLE steps 1, 2, 2CK and 3. That is just to be eligible to apply for a license; it doesn't include all of the testing that physicians do to be considered board certified in their respective speciality. That is a whole other set of hoops to jump through and the process varies depending on the speciality. Obviously, one must complete a residency (and fellowship if sub-specialized) to be eligible to take the boards. I'm years (of if I go into hematology/oncology close to a decade) away from those exams, so I'm not as informed about all of the nuances involved.

Anyway, there is a little saying that to prepare for Step 1 you need to study for two months, for Step 2 you need to study for two weeks and for Step three you just need to bring a number two pencil. I've also heard that generally if you study for more than 2-3 months for Step one you will start to become inefficient and things will go downhill. Farley and I scheduled 2.5 months to study just for that reason. Today, I was grateful that I only need to keep up this pace for another month. No matter how nervous I am to take this exam, since it is such a monumental aspect of the early part of my career, I know that I couldn't keep up studying at this pace for more than 3-4 months. Many physicians have told me that they are not sure they'd go back to medical school again if they knew what they'd go through. Most of them said that the first two years are the worst, culminating with USMLE step 1. They added that the third and fourth years are better because you spend more time with patient, rather than just book learning, but that the intern year and the rest of residency are extremely challenging. I know that I have some of the most toilsome aspects of medical training ahead of me--clerkships, intern year, residency and maybe even fellowship--but I know exactly what those physicians were talking about. I'm glad I went to medical school, but if I had to start again from scratch knowing what I know, it would be a more difficult decision. Medical school is mentally, physically, spiritually, emotionally and even financially exhausting. It isn't going to get any easier from here, maybe more rewarding, but not any easier.

M.D.

During one of my USMLE Step 1 video lectures, the professor some funny things. He started out by declaring that MD does not stand for Medical Doctor (or Doctorate of Medicine) as we have been told. In reality, you earn your MD once you become a walking Medical Dictionary. He added that you must be able to describe the medical term using a normal vocabulary in 30 seconds or less--not 30 minutes and definitely not using 5 dollar words. Next, he proceeded to spend twenty minutes explaining why fat is yellow. Theoretically, I could have fast forwarded; but I was rather enthralled. I didn't know that if you get butter from cows at different time of the year the color changes based on the cow's diet. Nor did I realized that human vegetarians have brighter yellow fat than non-vegetarians. I especially enjoyed the end of the yellow fat discussion when he declared, "What you eat is what you are...everybody worries about what they look like on the outside. You're more interesting on the inside. That is what makes medicine interesting!" I only wish I could transmit his excitement in my typed words. And to answer your question, yes, he is a pathologist. Next he proceeded to say that, "Cellular Injury and Adaptation may not look sexy, but on an exam it will be. Trust me." Interestingly, I think I know what he meant; however, I'm pretty sure sexy isn't the correct word to use. But heck, he has already earned the title of Medical Dictionary and I have a couple years to go before I earn that honorific!

Better than I could have imagined in my wildest dreams...

Back home in Washington, there is some exciting news. The University of Washington has some medical students, as part of the WAMMI program, that do part of their training in Pullman. I guess it was just announced that they are expanding the total class size at UW's medical school and moving the Pullman campus to Spokane. It also sounds like students at the Spokane campus maybe able to do all four years of their training in Spokane. Also, the long awaited Doctor of Osteopathic Medicine school opened in Yakima, WA and welcomed their second class this August. There are definitely are more medical school seats in Washington than when I left for Dominica. This got me thinking about how my life would have been different if I would have gone to medical school closer to home. Obviously, it would be awesome to be closer to home, friends and family. I wasn't able to come home to say goodbye to grandma or attend her funeral and at least two weddings--and I'm only in my third year of medical school. However, there are a lot of great things I've been able to experience because of attending a Caribbean medical school. I have a lot of amazing stories to tell my children and grandchildren. Sometimes things in life don't work out as we imagine, but they turn out better than we could ever imagine. Here are some of the interesting, exciting and humerous things that have happened to me.

• Meeting Farley. I don't know how I would have met him without going to a Caribbean Medical school and I can't imagine going to medical school without him. Besides being my partner, he is my travel buddy. Here is a picture from the day we first landed in at the Dominican Airport. Note how close the plane is to the Atlantic Ocean. Not much room for error. They have since remodeled the airport; however, they still have limited flights (like no flying at night and they can only have small plans land).

• Speaking of traveling, I've done a ton of it in the last three years. Obviously, I've been to Texas twice to visit Farley's family and we hopped over the border to Mexico once. Of the Caribbean countries, I've been to Puerto Rico, Dominica, St. Lucia and Barbados. I have had lay overs in Martinique, Antigua, and technically Barbados on an overnight layover. We had to stay somewhere, so we stayed at the closest and most reasonably priced hotel we could find--it wasn't our fault it was a wind surfer's paradise and we were right on the Atlantic Ocean! Seriously, who gets to have overnight layovers in Barbados and stay at a beach resort? I may in fact be the most brilliant person ever--I'm still going to be a physician when I'm finished and I've spent my first two years of medical school living 50 feet from the Caribbean sea and having layovers in the tropics. Not too shabby, except for the insects, brown water and other hazards of living in a third world country, but third world living just builds character! After our first year of medical school, it was so expensive to come home that it was actually cheaper to go to Argentina for a week than to go home. Looking back, I can't believe that Farley and I did this, but opportunities to travel don't always arise and one has to take every opportunity she gets. When we traveled to Argentina, we had a lay over in Panama. I couldn't believe the Panamanian airport--there were NO Panama hats to be found. In fact, there was one restaurant and two hot dog stands in very large Panamanian airport terminal. On a bright note, this terminal was basically a mall of European designer stores and chocolate stores! I ate a lot of chocolate with my hot dog in the airport. But unlike in the USA, the airline gave us two meals, two snacks, and free wine (but since I don't speak Spanish and Farley was asleep, I didn't know the wine was free) on the six hour flight from Panama to Argentina. Guess, I didn't need a hot dog and chocolate after all. Below is a picture from April 2008 of Farley and me waiting for the ferry to go to St. Lucia. The ferry ride could have been lovely if I hadn't have been so seasick!

• Strange Critters on the island. Before classes started we went to the Cabrits (the national park that we could see from our apartments) to hike. It was a lovely day, but everywhere we went, there was a ruffling of the leaves and ground covering. I thought it was just the geckos at first: I was wrong. We were surrounded by galliwasps. Click on the link to see a picture of them on Farley's blog. They look like geckos, but they have really small legs and they move more like a snake. Another exciting creature was this insect found near the study space right before the first exam of medical school. Just trying to go to the bathroom was an adventure, you never knew what you'd see on the way:

• Getting caught between a crab and a four cows. Yeah, that really happened. We were having a date night first semester after an exam (it may have been our first exam that semester) and then we were trapped between a feisty crab and four cows. See here is the blurry picture of the scary crab to prove it! I didn't dare take a picture of the cows since they were lining up in an aggressive, military-like formation.

• Lizards. Giant Lizards that fall from the sky...or my third story apartment. Or that just decide to hang out in my apartment looking out the window. How about the one that decided to drop his tail as Farley was escorting him out and a gust of wind made the tail fly through the air toward me before it started flopping on the floor. If that wasn't enough, how about the lizard that died hanging upside down from my balcony ceiling. To top it off, that was just in Dominica. One of them, which I named Leo the Lizard, moved into my apartment the last time I lived in Miami. Lizards can't get enough of me.

• Animal herds: In Dominica they let the animals run free. I talked a lot about the cows, since they were everywhere. Heck, one even chased me as I was trying to go study. Now, that doesn't happen every day! But it wasn't just the cows running free in Dominica. There was a pack of dogs that went all over. I a little afraid of dogs since I was chased by two baby pit bulls when I was a toddler and I was bit by a dog in my pre-school years; however, these Dominica dogs were so harmless they didn't even scare me. They were, nonetheless, annoying. They'd brush up next to you as you carried your lunch and they'd try to get you to pet them (there are a lot of insects, bacteria and parasites on that island and I'm sure there were some creepy crawlers on those dogs--I sure as heck didn't pet them!). There was a cat that lived near my apartment and would try get people to feed her (I usually set something outside my door). I was most surprised by the goats running free in Dominica. Who would have thought that there would be goats in the Caribbean.
  

• Natural Disaster. Now so far, we have been extremely lucky and there have not been any horrible disasters anywhere I've been. However, there was one tropical depression in Dominica while we were studying there. The sea come up high and flooded the lawn near our apartment. The only good thing was that I got to take a nap (it happened near a test and I was extremely tired, so it gave me a few hours to rest). I can joke about the tropical depression because no one was hurt and the only damage reported was the dock near our apartment. Overall, if the only thing damaged was a dock, we were all lucky.

• Who could forget the time that I fell down the hill in Dominica and was covered in mud. I think I should have learned that going to my apartment if I forgot something while studying on campus, was almost always a bad idea. I would end up being chased by cows, attacked by insects or slipping on mud. That is how I earned the nickname "mudslide".


• Living in a Third World Country. It is amazing how much we take for granted in America. Living in Dominica reminded me that in many places of the world, water isn't safe to drink out of the tap, there are insects, parasites and bacteria with your meals, and the power will come and go. All of these things were very difficult for me to adjust to; however, I think not being able to get a hot shower with clear water had to be the most difficult. If it rained a lot in Dominica, the water would turn a brownish color (like really watered down coffee). The filtration system couldn't keep up with the demand when there was a lot a rain, which happened frequently as Dominica is a rain forest. First semester, the water heater worked but something changed along the way. I soon learned that if I wanted a hot shower, I needed to hop in between 4-7 pm because otherwise, it was extremely cold. I'm not even sure how the water got so cold as Dominica is almost always between 84-92 degrees. Don't even get me started on the insects in Dominica, I still have scars from the mosquito bites! However, Dominica has it's redeeming qualities too--some of the best sunsets in the world.

• Bats. I don't know if I've every blogged about the bats in Dominica. Usually, Farley and I saw them when we were walking on the trail at night either coming or going to campus. It was the most strange thing in the world because out of nowhere there would be this slight gust of wind and a black thing in front of you. Then it was gone. They really make little or no noise at all. Obviously, I was frightened as they'd fly by because I'd be so shocked and I hate all creepy and icky things. But they have sonar so they never hit us. One night in early 2007, however, I did come face to face with one of these flying, ugly creature. I had my wooden panels covering my windows open. I stepped out onto my balcony to enjoy the cool night air. The light from my room bled though the wooden panels and I heard an odd noise. I looked up and there was a bat lost and unable to navigate out of my balcony. Besides the wall of windows, two walls the ceiling and the floor were cement. The other side was open except for the railing and about a one foot hangover of cement. I think all of the cement towards the ceiling, where he flying around, had his sonar all messed up. In case you have not had the honor of meeting up with a bat face to face, let me tell you bats are really ugly. Clearly, I made a mad dash for my door, shut the wooden panels on my windows and hid--as if the bat was going to penetrate though the walls and attack me. I believe that there are only fruit bats in Dominica, but you know even fruit bats can have histoplasmosis or rabies!

• Living in Miami. There are few places in the world as unique as Miami. In fact, I think it is more essential to speak Spanish in Miami than it was in Argentina! This city is a mix of money, cars, beaches, model-like people on the beach, heat, humidity, Spanish culture, retirees, colleges and universities, insects, lizards, crazy drivers, and to my shock farmlands less than an hour away. But obviously, the thing I love to complain about the most is the drivers. I think I've mentioned before that Miami lost it's title of the country's rudest drivers, which it has held for the last four years. Yes, the rudeness of Miami drivers even impresses those from L.A.

• Rainbows: Living in Dominica really makes one have to be an optimist to survive. Medical school is so tough, let alone living in another country--a third world country--and being so far away from not only family and friends but also convenience, such as grocery stores. To survive, you really have to keep a positive outlook even when things don't go your way, both with the living situation and with school. I've never lived somewhere before that there was always a rainbow at the end of a storm other than Dominica. You could practically see a rainbow every day and usually there were two or three together in the sky. I think this is a cheesy metaphor for medicine. When times get tough, and they will, you've got to look for the light at the end of the tunnel, for the rainbow at the end of the storm.
  

I guess the bottom line is that things sometimes don't end up as I predict or think I want. But I'd never dreamt that all of these amazing things would happen to me. Being willing to take a risk and run off to the Caribbean to fulfill my dream of becoming a physician, is the best risk I've taken so far. Who knows what risks and opportunities will present themselves in the future!

Cold Front

Yesterday it was 60 degrees for the high in South Florida. Now, I know 60 degrees doesn't sound too bad to all of you up north, but I've grown accustomed to the 90s with about 99% humidity. It felt downright frigid. Today, our study day off, I was planning on going to to pool to read One Hundred Years of Solitude by Gabriel Garcia Marquez. However, mother nature had another plan: it was in the lower 70s. Now, I know I can't really complain too much, but I look forward to getting outside and enjoying Miami every Monday afternoon for a couple hours, so I was a bit disappointed today. I'm sure it will be back to the normal 80-90s the rest of the week--when I'm indoors studying for the USMLE step one exam. Speaking of the Step, I've put in my final date (the step is an application process in and of itself, which I started in July). It's getting down to crunch time!

Pharmacology Nomenclature is NOT fun

For the last few days, I've been doing my pharmacology review for the USMLE step 1. I know it doesn't exactly sound exciting; nonetheless, I'm excited about it. I think this is the third time I've reviewed pharmacology. The first was, obviously, on the island. The second was last semester (5th semester) during the UMBR course (University Medical Board Review course) that was offered in the evenings. There is a lot of memorization in pharmacology and I think multiple exposures are helping me remember the classes of drugs and the little unique things about each drug.

In medical school lectures, exams and the licencing exams, pharmacological agents are known by their generic names. At times last semester, I felt really dumb because patients would name off their medications and I wasn't sure what class some of the drugs fell into. The reason is that most people know drugs by the trade name (brand name). For example, other than a health care professional, who would know that Benadryl (trade name) is also known as diphenhydramine (generic name)? Honestly, who is going to refer to Benadryl as diphenhydramine--it's too hard to spell let alone pronounce. However, one advantage to the naming system of the generic drugs is that classes of drugs sound similar. Let's consider beta blockers, which are drugs that can be used for several different cardiovascular problems, such as hypertension and some types of heart arrhythmias. All of the generic beta-1 blockers end with -olol. If the drug is a non selective beta blocker (meaning, for example, it blocks beta-1 and beta-2 receptors), it has a slightly different ending, such as -ilol. As far as I know, the trade names, have no rhyme or reason. For example, some beta blockers:

• Acebutolol's trade name is Sectral
• Atenolol's trade name is Tenormin
• Bisoprolol's trade name is Zebeta
• Carvedilol's trade name is Coreg
• Metoprolol's trade name is Lopressor or Toprol XL
• Nadolol's trade name is Corgard
• Nebivolol's trade name is Bystolic
• Propranolol's trade name is Inderal LA

One day last semester, a patient told me he was taking Coreg. I felt so dumb that I didn't know what it was. I knew it was a heart medication because of the commercials, but I didn't realize it was a beta blocker. I sure as heck know what a beta blocker is! This is just one example of how confusing all of these drug names can be, especially when you are still learning. Thank God for pharmacists! It is a bit ironic that I'm finally feeling really confident with my pharmacological knowledge and in a few months I'm going to have to start seriously learning all of the trade names. Up until now, I've left learning the trade names on the back burner, as it isn't on exams and there is only so much room in my brain for information. However, next semester when I see patients full time rather than part time, knowing trade names will be more important since, as already mentioned, most people know trade rather than the generic names. I'm also going to start learning some important economic information--which drugs are available generically and which are not yet available generically. As obvious as it sounds, if patients can afford their medications, they are more likely to stick to the treatment plans and drugs available generically are much more affordable than those that are not. Thus, over the next few years I'll have to start learning what is available generically so I can suggest those medications when applicable. However, some of the newest and best drugs are those that are still under patent and therefore not available as generics yet. Oh, and every hospital has a different formulary (drugs they keep in stock)! It seems in health care, whether you are trying to learn medicine or receive medical care, you can't win for losing.

Women, Medicine and Health Care

I think it has been an interesting time in the news for woman lately. Starting on a positive note, yesterday it was announced that the Nobel Prize in Medicine was awarded to Elizabeth H. Blackburn, Carol W. Greider and Jack W. Szostak. Their research was on telomeres and telomerases , which are sort of like protective caps of "junk DNA" at the end of chromosomes. When the "junk DNA" is gone, most cells cannot make more and will die off. Stem cells and cancer cells are amongst the cells which can make more telomeres--thus they don't die off like other cells. That is a good thing with it comes to our stem cells and obviously a really bad thing when it comes to cancer cells. It has also provided information about aging. This research on telomeres and telomerases has taught the scientific community much more about the cell cycle and death than was probably anticipated when the Nobel Laureates started their research in the 1970. Yes, I said 1970s. This research was completed int he 1970s and 1980s and results of their research are so essential to understanding the cell cycle, that it is taught at the undergraduate level.

Getting back to my point, there have never been two women that have won the Nobel Prize in Medicine in the same year. In fact, between the years of 1901 and 2008, only 36 times have Nobel Prizes been awarded to women (to 35 different women--Marie Curie, has been honoured twice, with the 1903 Nobel Prize in Physics and the 1911 Nobel Prize in Chemistry won Nobel Prizes). There have been two winners in Physics, three winners in Chemistry, eight winners in Physiology or Medicine, eleven winners in Literature, and twelve winners in Peace. Less than half of the Nobel Prizes won by women have been in the sciences. It is so exciting to have two women win the prize for medicine this year! I've been reading some articles about the lack of women winners. Some have noted that the Nobel Prizes, especially in the sciences, are usually granted years after the research occurred and since historically women were not scientific researchers, women are for today's standards underrepresented due to a delay in time of research completion to recognition. Others have suggested that women have been overlooked. I'm not sure of the answer, but I'm extremely excited that two women have won the award in medicine this year and to top it all off, all three of the winners are Americans!

On the other end of the spectrum, I've read a few articles lately regarding health insurance and women. Did you know that in eight states being a victim of domestic abuse can be considered a pre-existing condition and you can legally and the District of Colombia be denied insurance? I guess from an insurer's prospective this makes complete sense. A women who is abused would be more likely to get back into another abusive relationship or even return to her abuser. It makes sense that an insurer wouldn't want to pay for the broken bones, bruises, ruptured organs that could ensue if they insured someone with this history. Insuring this person would probably not be a big money maker so I guess that the insurance companies don't want to pay. I, personally, cannot believe that it is legal in some places in the United States to deny insurance because they have been a victim of abuse. If the woman decides to leave, she won't be able to get insurance. I'm not sure of the laws, but I believe that the insurance companies would have access to any mental health medical records, so they would be able to see if a women went to a therapist for help.

I'm probably not the most objective voice regarding pre-existing condition and health care coverage. I've chosen to go into medicine, not because it is a business and a way to profit, but because it is a way to care for others and study science. I don't have a business mind. I guess I think about the patients as people not profits. I know that it isn't fair to blindly judge everyone working in the insurance industry, because they may also disagree with practices of the industry; however, insurance is a business. Maybe the problem is just that: insurance is a business. Health insurance isn't like car insurance. If someone is denied car insurance because he or she habitually gets into accidents, I can understand. In fact, not insuring the person may protect others on the road (presuming that the non-insured person doesn't continue driving illegally). However, if someone is denied health insurance what does that say? The person is too big of a liability. Does it mean that we as a society believe the person is not worth caring for? Now, I'm not an economist, businesswoman or a politician and I have not researched this enough (I do have a set of boards to pass), but what if we had insurance companies that were not-for-profit. What if the profits that insurance companies make, were put right back into the pot and used to care for those using the insurance that were sick. What if there were no pre-existing conditions that would deny someone coverage. I would feel better paying for insurance knowing that if I did get sick, I wouldn't have claims denied because I've maxed out the policy; since rather than making profits for a company, that income would be used to actually insure people are cared for through the entire duration of their illness.

I, like 63% of physicians, support a public plan in the health care reform. I don't know what would be best and I don't know how the best way to put a policy in place, but I know that we, as Americans, need to offer health insurance to all and make it affordable to everyone. I read an article on Newsweek about Italian health care. It didn't sound perfect, but everyone was covered by the state and then you could buy insurance to have things done faster. I don't know if a plan similar to the Italians' is the answer to health care reform, but we have to be able to care for our people here in American like they do abroad. We have to provide some security--I've never head of people anywhere but the United States going bankrupt because of a health problem. Americans are busy doing outstanding research in Medicine, so outstanding that that win Nobel Prizes, now can't we also take care of our people as well?