The Serious Diagnosis

The serious diagnosis is a polite middle-aged woman with a hopeful smile sitting on the side of the bed, with her husband in the chair across from her, as you carefully tell them what it means to have ovarian cancer.

The serious diagnosis is the teenager who just found out he has lupus nephritis–without any other signs or symptoms of lupus–and that he might be on hemodialysis soon if high-dose steroids and chemotherapy don’t work.  He has a three-month-old infant.

The serious diagnosis is the young Japanese woman in her twenties who survived congenital biliary atresia in childhood by receiving the Kasai procedure.  Thin and small, with large, deep yellow eyes (her bilirubin is in the twenties), she’s constantly teetering on the edge of death.  She is the definition of gravity and patience.  She picks out a few English words each day to ask about the chance of having surgery, to ask about her need for blood, and to say that she’s hungry.  Almost a hundred days into her hospitalization and innumerable packs of red blood cells later, she passes away.  Death did not surprise her;  she accepted it long ago.

The serious diagnosis is the twenty-four-year-old man whose roommate called him a “sissy” and whose girlfriend is annoyed with him for complaining of pain in the roof of his mouth for the past month.  He’s a little agitated as he tells you his story, as if he just witnessed a shooting and is reporting it to the press.  He learns that he has acute myeloid leukemia in blast crisis.  Tragically, he is already in irreversible DIC (disseminated intravascular coagulation) upon admission to the hospital.  He is soon intubated and sedated and transferred to the ICU.  He dies several days later, edematous with so many units of fresh frozen plasma.

The serious diagnosis is the young woman from Poland with pancreatic cancer who traveled across the Atlantic to get chemotherapy that may, if she’s lucky, extend her life by a few weeks.

The serious diagnosis is very disruptive, especially for young people with previously normal lives.

The serious diagnosis is the middle-aged writer whose left leg has been heavy for the past week.  She’s unable to move it on your exam.  Her CT shows brain tumors.  An eventual lymph node biopsy reveals metastatic melanoma.  She accepts hospice care.

The primary team discusses the serious diagnosis in hushed tones.  Silence hangs heavy as team members reorganize their personal perspectives on life.

The serious diagnosis was the five-year-old boy diagnosed with type I diabetes in the 1960s.  After college, he worked as a draftsman.  It didn’t feel right, so, one day, he put his pencil down, walked out of the company, and went into acting.  Even though he only had minor roles, he has no regrets about his acting career.  He was able to retire early.  It’s all about marketing, he tells you while standing in the examination room.  (He avoids sitting because of his severe neuropathic pain.)  He says that anyone can be an artist, but only the business-minded succeed.  He’s here to be evaluated for a pancreas transplant.

The serious diagnosis is the young man with head and neck cancer who was lost to follow-up when his otolaryngology clinic disbanded.  Months later, he is admitted to another hospital system.  His face looks like a balloon inflated on one side and deflated on the other.  The cancer is deemed inoperable.  Some days later, he suddenly exsanguinates in front of his family and a resident and an intern not much older than himself.  The only thing they can do is bring buckets to catch the blood.

The serious diagnosis is the VIP patient with irreversible lung disease that flared up, landing him in the ICU.  He has an upcoming speech in front of thousands of people, his wife keeps reminding you.  His son flies in from the Ivy League.  You’re greeted by frustration every time you walk into his room.  The patient, however, remains very calm and accepting of his situation.

The serious diagnosis is the brilliant mathematician and pianist who read every published paper about his refractory myeloma and deliberately chose a very toxic chemotherapy regimen.  You’re following him in the aftermath of his decision.  In the past week, you’ve seen him lucid only once, for a few minutes.  He said something very wise, but you no longer remember it.  He’s delirious, in renal failure, and anemic, skirting death closely, closely.  A year later, you’re walking out of oncology clinic when you see a vaguely familiar man with a full head of hair walking in.  Several seconds later, you realize he survived.

This piece was republished by KevinMD.com on 2/5/15.

The Limits of Fiction

Gabriel García Márquez passed away recently.  A friend posted his thoughts on not having ever read any of his novels and, in fact, not reading much fiction at all after college.  Although I’ve read the most famous novel by Márquez, as well as several of his short stories, I didn’t consider them particularly life-changing.  Fiction, generally, is never life-changing for me, even though I love a good story.  I don’t read much fiction, either.  Why is this?

It’s because fiction is simulation, with all the statistical weaknesses of simulation and more.

For example, in medicine, my line of work, every several years there’s a new paper about the projected demand for this or that type of specialist.  Time almost always proves these papers wrong.  This is because they start out with a few assumptions, but never all the relevant assumptions, and then they proceed to model the projected workforce needs.  Did they take regional clustering of physicians into account?  (Usually, they did not.)  Did they take into account the multiple locations at which physicians work?  (In at least a few papers, they did not.)  They might use a Markov projection model or some other model to predict the future, but did they predict the Affordable Care Act?  No, they did not.  They could not have predicted it.

So, all of these studies are fraught with serious problems and are kind of a waste of time if you’re looking to read a paper and come away more knowledgeable.  Hopefully, they were well-written so that you could at least enjoy the language.  (Usually, they aren’t!)

Fiction, similarly, is simulation.  In On Writing, Stephen King describes the act of writing fiction as analogous to carefully excavating a fossil from the ground.  You put characters and situations together and then you quietly observe.  You record your observations.  The story was always there–it just needed to be excavated…or simulated in a believable or interesting way.

Therefore, because fiction is simulation born from the far-from-omniscient mind of another human, I don’t trust fiction to ever tell me the truth about things or to be a sufficient basis for changing my life.  It is, after all, fiction.  I just enjoy the beautiful language, the way that it brings characters and situations together and resolves tension, the simulation of situations and places I might never experience for myself, and I appreciate that it exposes me to the creative trajectory of the author’s mind, which often expands the realm of possibilities in my own mind and my capacity for wonder.  All of this makes reading fiction worthwhile.

If I wanted to change my life, however, I would look at high-quality, evidence-based data, or I would make changes and monitor how they affect me–in effect, applying the scientific method to my own life.

Additionally, I’ve long since realized that fact truly is stranger than fiction.  I’m satisfied with the mind-expansion I get from nonfiction, and I trust that the world is much more complicated than anyone’s fictional rendition of it or of any other world.  For this reason, documentaries, biographies, natural history, and exploration of the world on my own terms are much more interesting to me now than ever before.

Update 1/19/15:  Check out these fascinating articles on how stories–fictional or otherwise–change us!

The Power of Story

How Reading Can Change You in a Major Way

Birdwatch to Increase Bandwidth?

My father and I drove to High Island today to check out the spring migration of birds from Central and South America.  High Island is the first piece of land many of these birds encounter after flying over the Gulf of Mexico.  They’re tired, hungry, and thirsty, so they descend upon the woods of High Island, often in mixed flocks, and are often so tired that they allow humans to approach at close range.  If conditions are right and there’s a “fallout” of birds, you can see more than a hundred species in a small area.

Birding depends so much on serendipity that going out with the sole intent to birdwatch is pretty risky.  Today, however, was a definite win!  I’d seen tanagers only a couple times in North America, but today we saw so many that I lost count.  The weather was fantastic.  We saw a scissor-tailed flycatcher (male), gray catbirds, summer tanagers (male and female), scarlet tanagers (male and female), rose-breasted grosbeaks (male and female), wood thrushes, an Eastern kingbird, a northern waterthrush, a white-crowned sparrow, northern cardinals (male, female), a male indigo bunting, a cerulean warbler, a male Baltimore oriole, a male orchard oriole, a common yellowthroat, a yellow-throated vireo, a Kentucky warbler (we watched it catch and eat two plump caterpillars as it flitted through the undergrowth), an Eastern wood-pewee, an Inca dove (unlike the other dove species around here, it sounds like a rattling rattlesnake as it takes off), roseate spoonbills that were nesting, great blue herons, nesting snowy and great egretscommon gallinules, and other birds.  (I didn’t have a field guide with me, so I used a mnemonic link system to remember these species as we hiked.)  Most of the songbirds were all over the fruiting mulberry trees.  The tanagers were so busy gorging themselves that they hardly paid any attention to me as I photographed them from as close as a few feet away.  In true Texas fashion, some people a mile away were clay shooting or something and blaring extremely loud oldies music.  In the quiet woods, the birds would flinch every time the gunshots went off.

However, this article isn’t about birding on High Island.  (If you’re interested, here’s an active photo blog of birds seen there during spring migration:  High Island Birding News.  The photos are phenomenal.)

(This article is also not about the unpopularity of birdwatching among young people .  Birdwatching is so unpopular, especially among young men, that my male friends and I stood out during a trip to High Island several years ago and were interviewed by Texas Parks and Wildlife staff and given free T-shirts.)

This article is about bandwidth.  If you can identify birds and know a few things about them, then your outdoor activities will be more meaningful and enjoyable, because instead of calling every flying vertebrate a “bird” (or a bat, in North America), you have more context and therefore a greater understanding of the same experiences as the person next to you with no knowledge about birds.  You have more bandwidth.  You’re more alive.  You’re less likely to buy wild land and pave it with asphalt or concrete.  You’re less likely to be bored.  You need less to be happy.

And that, I think, is what birding is really about.  I hardly ever go out just to birdwatch anymore.  I birdwatch while I’m running, cycling, or hiking.  It adds a lot of depth and interest to these experiences.  I feel more alive for knowing what’s going on.

Similarly, when I started learning guitar, it completely changed how I listened to music.  It massively expanded the range of music I could listen to without being bored,  because I now had a better understanding of what it takes to create music.

Learning Ruby with Codecademy

Screen shot 2014-04-16 at 7.19.17 PM

I just finished the interactive Ruby course on Codecademy.  I highly recommend it!  It’s a free, interactive, engaging introduction to Ruby and is much more fun than reading a book.

I initially learned some Ruby (while learning Rails) back in fourth year of medical school and liked it a lot.  I then didn’t get to use it for years and sort of forgot it (but you don’t really forget…when you get back into it, it feels like reconstituting powdered milk or something: things come back to you pretty quickly).

I haven’t programmed seriously for a decade and was surprised at how much came back to me while taking this course.  I even remembered some esoteric stuff from C++ (I used to program in C++, Java, Lisp, and several other languages before I left computer science for medicine).

When I was a computer science undergraduate student, the emphasis was on theory, not on practical stuff like web programming (which was, quite frankly, rather looked down upon).  If you knew how to create websites, it was usually because you taught yourself.

Slow Down to Speed Up

Before I had a guitar instructor, I would learn a new piece or exercise by breaking it into chunks.  I would learn each chunk individually and then merge it with prior chunks until I could play the entire piece.

I still do this, but I’m also doing something else that’s at least as effective:  I practice each new piece at a tempo slow-enough to be able to play it in the correct time from the get-go.  At first, this tempo is very slow (like 30 beats per minute).  This is harder to implement than it seems, because our tendency is to hurry up and learn the piece yesterday.

I started using this practice strategy after my guitar instructor told me that the best guitarists he’s known have all started out by practicing very slowly.  He even suggested that the more slowly and correctly you’re willing to initially practice, the higher your eventual zenith of skill.

By implementing this strategy, I’ve witnessed a seeming paradox:  practicing very slowly helps me to progress more quickly.  Because I’ve always been learning piece X in the correct time, I no longer suffer from a major problem I had before:  awkward pauses “baked” into the song because I was faster in some sections than in others, thereby practicing these differences into the song itself even though they didn’t belong.

This strategy of slowing down to speed up is useful in other domains, too:

Running:  you want to start out slowly, both during each run (to warm up), and also when you’re just starting out as a runner (too many people make the mistake of doing too much too soon, thereby getting injured and not being able to run for weeks or months).

Strength training: lifting weights slowly (and lowering them even more slowly) may help you gain strength more quickly than otherwise, at least in the initial stages of a strength-training program.  It also reduces the risk of injury.

Learning to draw:  you start out very slowly, creating contour drawings, respecting negative space, assessing value, and carefully gauging perspective at every step of the way.

Mathematics/hard sciences:  you don’t rush over complex material; instead, you work through it carefully, taking more time to explore ideas you haven’t fully understood.

There is a time to speed up, but that time arrives only after you’ve worked slowly enough to gain significant skill.  For example, after you’ve mastered a song at a slower tempo, you can speed it up.  After you’ve gained some fitness, you can consider incorporating interval training in your runs.  After you’ve learned to draw with as little internal processing (stereotyping) as possible, you can start to incorporate gesture drawing into your practice sessions to increase your speed of drawing.  After you’ve learned, say, a section in your physics text and have solved some problems, you can consider timing yourself.  After you’ve learned a language, you can start to read more quickly to improve your overall comprehension (because questions that arise are often resolved by info you encounter later in the reading).

The Old Physician

The Old Guitarist, by Pablo Picasso

The old physician has been around the block longer than you’ve been alive.

The old physician is frustrated by electronic medical record systems because he is a two-finger typist.

The old physician immediately recognizes that rash…and scrapes it off herself, prepares it in KOH prep, and sees hyphae under the light microscope in her office before you’ve figured out how to order the appropriate test in Epic.

The old physician has had the same secretary for the past thirty years.

The old physician falls asleep during noon conference.

The old physician remembers that unusual presentation of multiple myeloma from back in 1988 when you weren’t even a pre-teen and were probably playing the original Nintendo.

The old physician has sternoclavicular osteoarthritis from years of holding X-rays up to the light.

The old physician wrote the original paper on that cool diagnosis you just made.

The old physician actually invented/improved that procedure/device you just performed/implanted.

The old physician had a retinal detachment but returned to work the next day.

The old physician thinks several levels deeper than you along that diagnostic tree.

The old physician has seen a few unusual presentations like this one before.

The old physician doesn’t trust computers.

The old physician is a local celebrity in certain remote parts of the world for his medical mission work.

The old physician can rule out almost any disease by looking at a urinalysis.  Why didn’t you order a urinalysis?

The old physician practically built this division or hospital up with his bare hands.

The old physician goes by his first name only with other old physicians.

The old physician misses the days when the giants roamed the halls.

The old physician remembers what this disease used to be called.

The old physician doesn’t take vacation.

The old physician is a little upset that she’s back to working full-time after the stock market crashed.

The old physician doesn’t need labwork or X-rays to make that diagnosis.

The old physician’s car was parked in the hospital garage when you showed up this morning and was still there when you left this evening.

The old physician has been seeing this patient in clinic since before you were conceived.

The old physician is beyond anyone’s comprehension.

I Thought the G Major Chord was Impossible

When I first started learning guitar, back in July, 2013, everything was going well until I encountered the G major chord in my first week of practice.  I couldn’t play it.  Not only could I not play it, but I couldn’t understand how I could possibly ever play it.  It just seemed absolutely impossible.  The GarageBand tutorial I was using at the time wanted me to play it in second position, which means that the index finger of my fretting hand was over the second fret:

One variation of the G major chord, as illustrated in wikiHow

I had a guitar with a steel-string neck (narrower than a classical neck) at the time.  I persevered against my doubts to see if I could make any progress at all over the next days and weeks.  I practiced the G major chord every single day.

A few weeks later, I was able to play it.  I couldn’t play it well, but this was much better than not being able to play it at all.

By this time, I had enrolled in Introduction to Guitar, an excellent, free guitar course by Thaddeus Hogarth on Coursera.  After a few weeks, he taught us the G major chord, but in first position, which meant that my pinky needed to cover the third fret on the first string.

I was still getting the hang of it in second position, but I definitely couldn’t play it in first position.  At all.  I’ve encountered a chord position I absolutely cannot play, I thought to myself.  Finalmente.

Doubtful and conflicted, I reluctantly practiced the G major chord in first position every day, until, one day, I could play it.

I then bought a flamenco guitar.  It had a classical neck.  The chords were somewhat harder now, because the classical neck is wider than the steel-string neck.

After weeks, months, I was able to comfortably play the G major chord in both first and second positions.

Learning a musical instrument is like being very overweight and going to the gym and seeing all the fit people:  you want to give up immediately because you’re so far from where you want to be. Only a few people persevere.

Now, when I pick up my guitar with the steel-string (narrower) neck, the G major chord is amazingly easy for me in both first and second positions.

I can hardly believe I ever thought it was impossible.

Postscript:  I later discovered that my narrow-necked guitar is unplayable at the higher frets because the string height, or action, is too great.  I realized this by trying out other guitars.  I could play Spanish Romance on those guitars but not on mine.  If you think your guitar is unplayable, you can take it to a guitar tech for a setup:  optimization of action and intonation.