Life is a jar full of golf balls

This has been circulating on facebook, I really like it:

When things in your life seem almost too much to handle, when 24 hours in a day are not enough, remember the mayonnaise jar and the 2 Beers.

A professor stood before his philosophy class and had some items in front of him. When the class began, he wordlessly picked up a very large and empty mayonnaise jar and proceeded to fill it with golf balls. He then asked the students if the jar was full. Th

ey agreed that it was.

The professor then picked up a box of pebbles and poured them into the jar. He shook the jar lightly. The pebbles rolled into the open areas between the golf balls. He then asked the students again if the jar was full. They agreed it was.

The professor next picked up a box of sand and poured it into the jar. Of course, the sand filled up everything else. He asked once more if the jar was full.. The students responded with a unanimous 'yes.'

The professor then produced two Beers from under the table and poured the entire contents into the jar effectively filling the empty space between the sand.The students laughed..

'Now,' said the professor as the laughter subsided, 'I want you to recognize that this jar represents your life. The golf balls are the important things---your family, your children, your health, your friends and your favorite passions---and if everything else was lost and only they remained, your life would still be full. The pebbles are the other things that matter like your job, your house and your car.. The sand is everything else---the small stuff.

'If you put the sand into the jar first,' he continued, 'there is no room for the pebbles or the golf balls. The same goes for life.

If you spend all your time and energy on the small stuff you will never have room for the things that are important to you.

Pay attention to the things that are critical to your happiness.

Spend time with your children. Spend time with your parents. Visit with grandparents. Take your spouse out to dinner. Play another 18. There will always be time to clean the house and mow the lawn.

Take care of the golf balls first---the things that really matter. Set your priorities. The rest is just sand.

One of the students raised her hand and inquired what the Beer represented. The professor smiled and said, 'I'm glad you asked.' The Beer just shows you that no matter how full your life may seem, there's always room for a couple of Beers with a friend.

I'd like to add my own picture to it (when life - or the board in front of you - seems a little too complicated, I just have to remember that the mayo jar still fits a couple of beers :)

Liver vs muscle

My roommate and I decided last night that if we were to date a type of organ, we would most definitely date the liver! Not muscle, or fat, only liver. Liver is selfless, makes so many things for other organs, doesn't keep things for itself, while muscle, well, those damn selfish muscles, they take all the things for themselves and they don't give anything back. Very selfish. Livers are the nice guys. Muscles the assholes. I think. I might. Be. Losing. My. Mind.

Broken system

Last time I mentioned a little bit about the different aspects of medicine: knowing the science and being a people's person are equally important to this process of becoming a doctor. Since last time I wrote, I have had some pretty awesome experiences on the clinical side of things. I got my assigned spot for this thing called PLACE - Patient-based Longitudinal Ambulatory Clinical Experience. This a newer thing most medical schools are trying to do to "get first year students out of the library" as my preceptor explained to one of her patients last week. My assignment is at a private office nearby with a young internist. Based on the location, I thought that this would not be very exciting: it's like when I go to my primary care doctor, it's usually to get records for something, get a vaccine or a prescription for something when I have a sinus infection. Well, it turned out to be pretty interesting after all, although she admitted that I just happened to be there on a day when more of her "trouble" patients were in the office. The idea of the program is to pick a patient and try to follow him/her for an entire year through all of his or her health care appointments. This obviously only works if someone actually goes to see the doctor at least somewhat regularly; and then let's not even talk about the scheduling nightmare that might arise from trying to go to the doctor with a stranger every time they go. We didn't really have enough time to discuss this aspect very much, since she was seeing patients every 15 minutes, with about 2 minutes in between to talk about them, but two of the cases we saw together were really interesting and might be good for follow-up; although I am a little hesitant because neither patient was particularly friendly, had some clear emotional problems and I just really doubt that anyone would enjoy a first year medical student following them around when they are probably already anxious enough trying to deal with their health care issues. What was pretty cool though was that my preceptor allowed me to talk to each patient myself before she interjected. I was supposed to elicit what's called the "chief complaint": basically, why is the patient there, and then try to find out more about it. I know it sounds trivial, but believe me, when a flesh and blood sick person is sitting in front of you, it's not that easy! 

The other thing I got to do last week was to volunteer at the NYC Free Clinic. The idea behind it is this: every Saturday, a bunch of med students form NYU and two attending physicians see uninsured patients who have been seen by social workers previously. We offer all kinds of services for free. Most people want and need a lot of blood tests, pap smears for women, STD testing, vaccines, etc. But the coolest thing is that if they need it, they get referred to Bellevue, and NYU still pays for the follow-up visit. Now, as someone who has always had good insurance through school or work, and never had to deal with a situation that nearly 50 million Americans have to deal with daily, I had a pretty skewed idea about "the uninsured". While I was volunteering at the ER before med school, we saw tons of really really poor people there, who literally had nowhere else to go; lots of them homeless, drug addicts, living in shelters, etc. But what's even more frightening is the number of people who are just like me - similar age, social status, education, etc - who are also uninsured. 

This past Saturday, I was in charge of the labs at the clinic. That meant I had to go through the lab results of people who had any lab tests done from the week before, and discuss with one of the attendings each of the cases, and if something was off with any results, contact the person for follow-up. So I got to look through many many charts and many many test results, and I would say that the majority of the people who go to the free clinic are young, very young, and mostly women. In 2 weeks, when I get to be on a real clinical team, I am sure it will be much more interesting - although I quite enjoyed the lab experience too, I looked up so many different drugs and lab values, and got to discuss them with a physician, who was really cool and very knowledgable and caring (ok, here I also have to admit that I had a not-so-flattering view about primary care/family doctors, but damn, I am just starting to realize how freaking important it is that they are good doctors and they know their shit!!).

I have been so privileged my whole life - in terms of my health, my opportunities, the family and place I was born into, and also my health care. I have never before been forced to think about this very much, because honestly, it's so easy to ignore the problems when you don't have to deal with them personally. These past few weeks, however, I have been thrown head first into thinking about the health care system. I really like it that they are putting a huge emphasis on this at a place like NYU: a huge academic medical center with billions of dollars in endowments. Despite this, there seem to be many socially conscious people here, who are trying to change the system from the bottom (aka by educating the youngest generation of future physicians about the need for change). 

Just some things I have seen in the past 6 weeks: 

A woman in her early 40's just discovered she has a rare genetic enzyme deficiency that is causing her lungs to slowly fail. She should be on enzyme replacement therapy for the rest of her life but her insurance company is currently denying her claims because she "does not meet all the criteria" the insurance company has set for that particular disease to be covered. On top of that, her two teenage children have both inherited one bad copy of her gene, making them at higher risk for future lung disease. When they turn 26 and they have to get their own health insurance, depending on the political climate and the health care law at that time, they might be denied coverage for pre-existing conditions. So in a case like that, is it better to know that you at risk for something? Why is this not medically confidential information? How is this fair? On top of all that, after going through an insane few weeks with the new diagnosis and trying to figure out her insurance benefits, she found out she was pregnant. How will she be able to afford another child?

A man in his 40's who has had a history of serious heart disease, including a heart attack in his 30's, lost his job and therefore, his insurance for a few years, and so his heart disease has been unmonitored for years. He just got a job, a new insurance plan, and is now back at the doctor's office. Blood pressure sky-high, not on any meds. Still reluctant to see a cardiologist because he is worried about the high co-payments and he is afraid to go back on medication because he is not sure he can afford it month-to-month. 

A young woman without any insurance getting her first gynecological exam ever. She is having sex for the first time; she does not want birth control because how the hell would she pay for it? The doctors inform her that the free clinic also offers abortions. She says "that's great". 

A medical student in his early 20's who has just been diagnosed with type I diabetes. He discovers that injecting himself with insulin several times a day is really inconvenient, especially when he is seeing patients all day in the hospital. So he applies for the insulin pump. He has the university-negotiated student health plan that I also have. With one of the biggest private health insurance companies in the US. They deny his claim. He fights them for 10 months before they finally approve his insulin pump. Endless phone calls, emails, letters, lawyers involved by the end. 

That's all I could think of for now, but I am sure that there are endless stories like these ones. I've only been in medical school for 6 weeks! 

The system is broken. Completely broken. So how about this new universal health insurance plan that Obama has been so enthusiastic about? Sadly, the more I learn about it, the clearer it becomes to me that it is not even close to universal, it will still be really expensive and unfair in many ways, and it does not change anything about the way private health insurance companies operate. And honestly, if I didn't have insurance, I would rather pay the ~$700 penalty for not having it than buy a plan that costs over $2000 a year. As a side-note, insurance linked to employment is a dangerous thing, especially in an economy in which more and more people are losing their jobs; and their options. 

A couple of weeks ago, I went to a student conference on single payer health care systems. Single payer is the system used in nearly all other industrialized countries in the world. It does not equal socialized medicine as some Americans like to argue. It is also not just an idea: Vermont is the first state in the US that has voted on and accepted a new single payer health care bill, to go into effect in 2017 (only then because the new Affordable Care Act aka Obamacare has a restriction on the date when it can go into effect). Of course, Vermont is a tiny state, with no major metropolitan areas, and only 14 hospitals total; but it's proof that this is not a crazy idea even in this country. Of course, being from an Eastern European country, I am all too familiar with a socialized single payer system, which is also broken. In different ways. But I don't want to talk about that. Ideally, in the US, the system would be government funded but privately run. Funded through the savings that would amount to billions of dollars if all the administrative overhead associated with private insurance companies (eg. the 10 months long fight over the insulin pump - how much money could be saved if that wasn't necessary??) was eliminated, also reorganizing the way tax payers currently pay for things like Medicare an Medicaid, payroll taxes, and some individual taxes based on income. (On a side-note, currently, in employer-based health care, the CEO of the company pays the exact same premium as does his secretary.) People think that their taxes would sky-rocket if there was a single payer health care system, but it's just not true. We currently pay for some amount of health care expenses in our taxes, and there is so much waste in the system, that lots of money could be saved. The other thing is about choice. Especially on the conservative side, people love to talk about how Obama is taking away our choices, our freedom. (Of course, choice is only good when it comes to insurance, not when it comes to women's reproductive rights.) They talk about our freedom to choose our insurance plan, our doctors. Bullshit! I don't have a choice of health care plan,  never had. My school offers exactly one crappy plan, that costs me over $2000 a year, plus copays, etc, and if I was diagnosed with diabetes, they wouldn't even cover an insulin pump! I don't have a choice of doctors either. If a doctor I want is out of network, I might as well pay out of pocket! Choice is an illusion! 

Yesterday, we had a guest lecturer from Weill Cornell, a physician who is committed to advocating for single payer health insurance. He calls it "medicare for all". He gave us an hour and a half long overview of the history and current state of the US health care system, talked about some of the changes that are happening currently, about the politics and the economics behind it. I am little surprised by how politically outspoken our professors are. Not surprisingly, being in NYC, all very liberal so far; I think more and more people are realizing that something needs to change drastically. He showed us statistics that showed that by 2050, the average cost of health care premiums for a year will exceed the average income in the US. That is INSANE! And looks at this from today's NYT! This is a step in a completely wrong direction. 

The article states that there is already a shortage of physicians in the US, and that is expected to rise, especially in primary care. Already, a primary care doctors sees patients pretty much every 10 minutes throughout the day. And that is in NYC, where, I am assuming, there isn't that much of a shortage. But then why would I want to go into primary care when I will be in over $200,000 in debt when this little adventure is over? No matter what, I will have to do at least a 3-year residency. I'll be 36 then. If I was to go into primary care, I could start working after those 3 years; even get some of my debt forgiven if I decide to work in certain areas of the country where the shortage of primary care physicians is especially acute. But then again, I could do a one or two year fellowship, let's say in Oncology, do some research, which, with my background, would only make sense, and then come out on the other end as a specialist earning so much more money than a primary care doctor. I am not in this for the money. But a $200,000 debt hanging over my head in my late 30's is less than ideal. 

That was a bit of a digression. But my point is that the system is BROKEN! On a lot of different levels. Something needs to change. I have never thought of myself as much of an activist or trailblazer, but maybe it's time to look for ways in which individuals can make a difference. I am not so sure what that it yet, but I am looking.  

What happens when you eat sugar

Right about now, photographic memory would come in really handy!

(that's glucose metabolism, by the way, more accurately, just a smallish part of it)

Drawing blood

I have to admit that I am drowning in work at the moment, but I just have to take time to write about some stuff. Med school has gotten pretty overwhelming suddenly. Today is exactly one month since I started; yet it seems like I have been here for so much longer. It's crazy. I guess they took it easy on us for these first few weeks. We just had an exam 2 days ago, and we have covered so much new material since then, that I feel like I am already weeks behind! How is this possible??

And then when classes and the amount of new information become so overwhelming that I just want to hide in a dark corner and cry... then, I am reminded of why I am here. Human things. Every week, we have a 2-hour "class" when we meet in a small group of 8 with a physician. We have the same physician for the entire year and maybe even beyond. My preceptor, is what we call her, is really amazing: a pediatrician at Bellevue, she is the kind of person I can just tell loves teaching so much. We have to do specific things in our weekly 2 hours, like learn to measure blood pressure, take other vital sign, do physical exams, etc, but she also just talks to us about what it's like to be a doctor, about her path, her family, work-life balance (she has 3 kids!), and she brings cookies every week! We can ask her anything, talk about anything, be silly, serious, whatever. It's really 2 hours when I don't worry about the million steps in embryogenesis or the proteins involved in every singe signal transduction pathway in the cell!

Next weekend, I am also starting this new thing called the New York City Free Clinic. It's an NYU-sponsored clinic for the uninsured that's nearly completely run by medical students: there are only 3 attendings there every day. As a pre-clinical student volunteer, I have to go every other Saturday, work with a clinical students and see patients, do labs, refer them to NYU-affiliated physicians if they need some further care. The cool thing is that NYU also takes care of their follow-up appointments, meaning that they can go see specialists for free, at least as long as their care is connected to what they went to the clinic for in the first place. Tonight, I had to do training to be able to do this next weekend (more training to do next week). Part of the training was to learn taking blood. Because we will be taking (or at least attempting it) blood from these poor uninsured people. I don't want to go into the moral implications of this; is it ethical that these medically underserved populations have to deal with getting stuck by first year medical students? (Of course, this is not the major issue here, but let's not talk about that.)

So the older students showed us how to do it, in about 3 minutes. Then we were paired up. Wow, that first moment when you have that needle in your hand and you actually have to stick it into another person, it's scary as hell! I was constantly asking "does that hurt??" "I am so sorry!!" The first 2 times, it didn't go into the vein. Poor guy was holding up pretty well. Then he went, and got it on his second try (I do have pretty good veins). It took me two more tries on different people with better veins, but in the end, I did get it on a more muscular guy with nice veins. When I saw the blood rush into the base of the needle, I was so happy!

There are so many things that go into being a physician! It's not that I didn't know that before, but I am just now realizing how different all of those things are. Of course, you have to know the science, you have to be a compassionate person and care about the people you are treating, and then there is this manual side to it. What if someone is just flumsy? They could not be a surgeon for sure. But even simple things like drawing blood and measuring blood pressure are not all that trivial.

The point is, there is sooo much to learn! At this moment, it seems utterly impossible that I will ever be able to learn all of this! Even just embryology for this next exam! But let's hope things will come together eventually. And that next week when I go and see real flesh and blood patients in my all-too-white white coat, I will stand up to the test.

Legos

3 words I thought of when I took these: heaven, hell and home.

Right by the water near the middle is NYU Med Center

Views from Long Island City this morning. Looks like lego land.

Funny. Hungarian section at the neighborhood grocery store. 

Standardized everything

Phew, thank god the DNC is finally over. That is, the Democratic National Convention. I've been distracted by endless speeches for the past few days. To be honest, I wasn't that impressed with tonight's speech from the president. He seemed maybe a bit tired. But Bill last night! Whoa! And Michelle the day before! Maybe the smartest decision of Obama's life was to marry that woman. I literally cried 4 times during her speech. But ok ok, now that it's all done, I can get back to what's important: work work work!

Yes, school has been pretty intense. Every afternoon when we get out of class, I start thinking how much time I have - after having worked endless hours in the lab, getting home at 2pm seems really wrong - and then suddenly, it's dark out and I am still looking at the same slide of the lecture from this morning trying to decipher one thing or another. So yeah, now I understand why our afternoons are free. We need every minute of them to study!

Ok, that is a bit of an exaggeration. I take very frequent brakes. Like right at this moment. Even though I have about 30 pages to read. But it's for our "softer" course, called Practice of Medicine. It's where we are supposed to learn how to behave as doctors. Not the hard science, the facts, but the grayer areas, like how to communicate better, what's a good patient interview like, how to make patients trust us, how to do a physical, and so on. Funny thing is, we have our first lecture tomorrow, on what apparently is the most important part of any physician's life: the patient interview. I say this is funny because I would have really appreciated it if this was let's say, last week. That's because earlier this week, we had to do what's called our first standardized patient encounter. Yep, everything in the country is standardized, especially when it comes to education. Not to complain or anything. Better than other methods I have seen.

So what is this standardized patient encounter? Just what it sounds like. They hire actors, train them how to behave with us (they are really good at acting like real patients), how to react to certain patterns in our behavior, oh and they all have a particular disease. Or a particular reason to come see the "doctor". So here we are, 15 med students in our 3rd week of medical school, all wearing our brand new (whitest it's ever going to be) white coats, and we line up in front of 15 doors, all of which describe a certain scenario. We can take notes, read the scenarios for a few minutes, then there is a mysterious overhead voice that tells us to enter the room. First lesson: you should knock! I only did because I heard the guy next to me do it first. Phew. Little things you wouldn't think of when you are nervous and doing this for the first time.

My first standardized patient was an older lady who had had a heart attack and could not quit smoking in the month since discharged from the hospital. I actually had a lovely time talking to her. I felt like talking to my Grandma. In retrospect though, I said some really silly things. I also didn't ask her some really important things. The other two encounters I had were not as pleasant. I felt awkward, uncomfortable, stupid, I wanted to seem more confident than I was, which totally backfired. In any case, it was a first experience, for which we got absolutely no training (I do understand they were trying to set a baseline for everyone, but come on!!), but still. I can handle the hard science. I can generally communicate with people. But when you are in a room alone with a middle aged man who is asking you about colonoscopies, well, some guidelines would have been nice.

Kind of felt like this:
http://whatshouldwecallmedschool.tumblr.com/post/23099936760/every-time-i-talk-to-a-standardized-patient
(Btw, this tumblr, #whatshouldwecallmedschool is pretty freaking hilarious!)

Ok, now I am going to read what I should have said to those standardized actors, excuse me, patients, the other day.