When a Smile is More Than a Smile

Was standing in line at the grocery store today. Short trip, picking up a few forgotten items. Was staring off into space when the lady in the next line over motions for me to go ahead of her. It's OK, I said, but she insisted.

It was a very touching act, the feeling of which words cannot adequately convey.

Touching, because a complete stranger noticed and cared enough to reach out. Inspiring, because that single, simple act, became more than that the instant it was offered. It brightened my day. I left the store with a smile. Smiled at the three random strangers passed along the way to the car, two of whom smiled back. It created instant goodwill amongst complete strangers that likely grew stronger with time.

What a beautiful lesson. We often get lost in thought as we carry out mundane activities. While we're doing one thing, we're thinking about something else - reminiscing about past events, worrying about the future, trying to remember all the things on the to-do list.

We forget to stop and truly live in the present.

We also forget that the way we CHOOSE to interact with those around us has a tremendous impact than we often underestimate.

That in passing a stranger on the street, a furrowed brow because of other worries, can be misinterpreted as distance. Dislike. But the same situation, done with a smile, though unexpected, contributes to the sense of community, and may lead the receiver to pass along the good feeling.

The act itself doesn't matter. It is often the simple, unassuming acts that don't seem to matter much - it didn't really matter if I got out of the grocery store a few minutes earlier - that are most priceless for the potentially endless spread of goodwill among those who receive and pass it along. And all we need to do these things, is to remember to be present.

I'm sure the kindness behind the grocery store lady's initial act continues to ripple this afternoon.

I know it has, for me.

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“Kind words can be short and easy to speak but their echoes are truly endless.”
-Mother Theresa

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Bottled Water

Do you drink this?

Or this?

Guess where they got it from?

Local tap water.

That's right, folks, them there is some MIGHTY expensive tap water.

photo credit 1 & 2

So some of you know about the recent penis post inspired by our friendly neighborhood urologist.

Now, if you have statcounter, there's a function called "keyword analysis" or "recent keyword activity" that gives a list of the search terms that bring people to your webpage. (Don't ask me why I still bother to check this, when I should be reading and edu-macating myself. That's a story for another day.)

Because of that penis post and this handy-dandy statcounter function, I now have a ready source of partly entertaining but partly "too much information" look into what people type into their search engines.

And since the penis post, the "search terms" list has never quite been the same.

Check this out:

Num Perc. Search Term
drill down 2 22.22% list of funeral songs for flute
drill down 1 11.11% struggles of resident doctors
drill down 1 11.11% i'm 14 my penis is 5.5 what condom size would this be
drill down 1 11.11% get out of tunnel vision
drill down 1 11.11% funeral songs classical
drill down 1 11.11% small penis -spam
drill down 1 11.11% why do asian man have smaller penis
drill down 1 11.11% do i have a short penis
9 100.00%

People, I can't even try to make this up.

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Oh, Histiocyte, oh histiocyte

Why are you, oh, so confusing?
(a la 'oh christmas tree' tune)

Seriously, what is up with the histiocytes?

Not only can they be the regular old histiocytes that phagocytose debris (reactive), they can also be foamy (a la parasitized macrophages), be xanthomatous, be a proliferative disorder (benign OR malignant). There's more of what they can do that's just not coming to mind.

Who ARE these superpower cells? And why do we know so little about them?

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Speaking of histiocytes, someone REALLY needs to look at the field and simplify the names. Jeff Callen? Vicky Werth? Anyone??

Look, why is Langerhans cell histicytosis also called Class I histiocytosis or histiocytosis X? Why does it comprise multiple named entities such as Letterer-Siwe disease, Hand-Schuller-Christian disease, eosinophilic granuloma, congenital self-healing reticulohistiocytosis (which is also called Hashimoto-Pritzker disease)? I understand that historically, they've been poorly understood, and that the numerous names reflect the lack of understanding and aggrement regarding their origins. But with the advent of electron microscopy and the development of immunohistochemical stains, we're now pretty sure that they're all related. Perhaps all variations along a theme? Along a spectrum?

I'm sure congestive heart failure probably had some misnomers and different names along the way, while it was being worked out. But once it got worked out, medicine as a field got together to simplify their nomenclature. Now you got just plain old CHF and diastolic CHF.

So now all we need is SOMEONE to stand up and say, enough with all these ridiculous names. Let's consolidate what we know today, lose the dead weight, and move the field ahead. Lump the problems and how to think about them into ways that make clinical sense.

Let's be lumpers, not splitters. I'm sure Letterer, Siwe, Hand, Schuller, Christian, Hashimoto, and Pritzker don't mind anymore...

photo credit electron microscopy of the classic Birbeck granules

"Organic" Dry Cleaning?

Have you noticed your neighborhood dry cleaner's new sign?

"Environmentally friendly dry cleaning." "Organic dry cleaning."

What the heck does that mean?

Unfortunately, most of it is just meant to make you feel better. It's hard to be "environmentally friendly" if you understand what goes on after you drop off the fancy clothes.

*****

Dry cleaning is not really "dry."

Your clothes actually go through a wash and dry cycle in a machine not unlike the domestic washing machine. But instead of using detergent, a dry cleaning fluid (solvent such as perchloroethylene) is used. After a wash and rinse, the extraction process recovers dry cleaning solvent for reuse. The garments are then tumbled dry and ready for pressing/finishing.

Interestingly, the use of petroleum based solvents for dry cleaning started in the mid-19th century. Given the high flammability risk, the dry cleaning industry played with several permutations of cleaning solvents until perchloroethylene was created. Since the 1930's, perchloroethylene, or "perc," has been the gold standard dry cleaning solvent.

Perchloroethylene, despite known toxicity risks, is still the most common solvent in use. Even if you don't use a dry cleaner, or don't go very often, the following should make you think twice:

The general population, excluding dry cleaners, is also exposed to PERC at low but measurable levels in the air, drinking water, and food. Visiting dry-cleaning premises is considered to be an important source of exposure, and clothes that have been subjected to commercial dry cleaning with PERC have been shown to be a source of indoor air pollution. In addition, contaminated building materials from dry-cleaning premises may represent a long-term reservoir of PERC.

Recent studies have shown that individuals who live in a neighborhood occupied by dry-cleaning establishments may be exposed to sufficient amounts of the chemical, resulting in measurable concentrations in their blood and in exhaled breath.

Given the results from animal studies and the bad press, perc has been labelled the bad boy of dry cleaning chemicals, which has left the dry cleaning industry scrambling to try to find the next gold standard. And in the black and white world of "good" versus "bad," "environmentally friendly" is often used in the loosest of ways, as in "we don't do perc, so OBVIOUSLY we are environmentally friendly."

*****

What exactly are these "environmentally friendly" alternatives?

Hydrocarbons (DF-2000 made by none other than Exxon, EcoSolv from Chevron, modified blends such as PureDry) - slightly less flammable and explosive than Stoddard solvent; not as effective as perchloroethylene. According to the local dry cleaner, this is a "completely non-toxic" alternative. However, a review of EPA data would suggest otherwise. It's probably not as bad as perc, but it's not environmentally friendly, and it DEFINITELY doesn't fit my definition of non-toxic. If that isn't enough, would you like to find yet other ways to contribute to big oil's pockets?

Cyclic Silicone decamethylcyclopentasiloxane (GreenEarth) — slightly less flammable and explosive than Stoddard solvent; not as effective as perchloroethylene. Reported to degrade within days to SiO2 (sand), CO2 (carbon dioxide), and H2O (water), but toxicity tests by Dow shows increased incidence of tumors in female rats. Thought to be a potential carcinogenic hazard.

Liquid CO2 — reported to be superior to perc; machinery is very expensive. A relative new-comer to commercial use. Thought to be the least toxic of all current dry cleaning options. No known toxicities from CO2 dry cleaning to date, but it's a relatively new method. Anyone interested in participating in a real, live experiment?

"Wet cleaning" with regular water in computer-controlled washing machines - doesn't clean garments as well as industrial grade solvents.

*****

What's the take home point from all of this?

Be an informed consumer.

Not all garments that are currently dry cleaned need to be dry cleaned. Even if the tag says so.

Ask what your dry cleaner means by "environmentally friendly."

Pick your poison - try to chose the least toxic of the alternatives.

At the very least, know what happens to your clothes and try to minimize your exposure to potentially toxic chemicals.

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Generation Y

Yahoo Finance has a great article on the differences between Generation Y and the Baby Boomers. Here are some excerpts:

They won't do work that's meaningless.

These kids grew up with parents scheduling every minute of their day. They were told TV is bad and reading is good, and are more educated than any generation in history. They just spent 18 years learning to be productive with their time, so they're not going to settle for any photocopying/coffee stirring job.

They won't play the face-time game.

We've known forever that it isn't necessary to be in the office from 9 to 5 every day to get work done. But many of us have missed family events only to sit at a desk all day getting pretty much nothing done because of the stress of missing a family event. And there didn't used to be any option -- if you wanted a successful career, you made sure co-workers saw that you were putting in the hours.

Generation Y wants to be judged by the work they do, not the hours they put in. And what could be more fair than this? In fact, a good portion of the workforce has been requesting flextime for decades, but the requests have gone unheeded.

We have Gen Y to thank for forcing the switch, because if Gen Yers can't leave the building whenever they want, they'll walk out the door and never come back. Face the truth: Boomers weren't willing to go that far, but they sure are benefiting from it. Now they have more opportunities for flextime, too.

They're team players and don't do rank.

If you've climbed a corporate ladder your whole career, then it's probably inconceivable to you that Gen Y doesn't care about your title. But it's true -- they don't do rank. Chances are they saw their parents get laid off in the '80s, so they know how ephemeral that special rung you stand on is and they don't want to waste time trying to get there.

Generation Y played on soccer teams where everyone participated and everyone was a winner, and they conducted playground politics like diplomats because their parents taught them that there's no hierarchy and bullies are to be taken down by everyone. And Gen Yers take these values to work -- they expect to be a part of a team. Gen Y believes that no matter how much experience an individual has, everyone plays and everyone wins.

They have no patience for jerks.

Generation Y changes jobs every two years, typically because the work isn't a good fit, or the learning curve isn't steep enough, or they don't like their co-workers. And Gen Yers will disengage from a jerk before trying to get along with him or her, according to a report by Stan Smith, national director of Next Generation Initiatives at consulting firm Deloitte. They have no desire to bother with somebody they don't like.

This is really how we all should function. After all, according to research by Stanford professor Bob Sutton, the cost of putting up with a jerk in a company is about $160,000. Moreover, Harvard researcher Tiziana Casciaro found that people hate working with high-performing jerks so much that they would rather work with someone incompetent who's nice.

It's actually easy to appease Gen Y. Give us a supportive environment to work in, and treat us as colleagues. If you're loyal, we'll be loyal back.

Now, I wonder how much it costs to put up with a jerk in an academic setting?

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Feeling Incompetent?

It's the 2nd or 3rd weeks for most new interns and residents.

The first month sucks. Actually, the first week of any rotation sucks, but the first month(s) of internship/non-prelim year is the worst.

As an intern, you wander the halls afraid you're going to kill someone with your incompetence. If this is you, DON'T WORRY. Many have gone before you with the same incompetence, the same fears, and learned how to be comfortable in their new role. Besides, four years of medical school does a pretty good job of preparing you for a medicine internship. (Now, that's not to say it's not terrifying to pronounce a patient or run a code for the first time. But the comfort level will come with time.)

Trust in the process, and just take it day by day. Besides, you've always got your resident, fellow, and attending for backup.

If you're starting your "real" residency after a prelim internship, it's in some ways worse. You, as a member of this group (ophthalmology, radiation oncology, dermatology, etc), probably did very well in medical school, and did well during internship. Now, all of a sudden, you're thrown into a different sub-culture, where the jargon is completely different and the field has little resemblance to what the prior five years of training has taught you.

You were so glad to finally reach this point, to be DONE with your preliminary year, and finally be able to do what you want to do for the rest of your life. Except, now that you're here, you have NO IDEA what the heck is going on. You're very grateful to have matched in the field, but as you struggle to even understand the language these people speak, you're secretly afraid that whoever let you in made a HUGE MISTAKE. And when these people find out about their mistake, you just might find yourself... unemployed.

After a crazy day in clinic, where you understood just the bare minimum needed to get by, you go home determined to make yourself smarter. These fears are amplified as you try to read the assigned reading from the text of choice.

Little did you know that "reading" has turned into a veritable ordeal.

You get out the fat book. Twenty pages of reading, you think to yourself. Should be done in an hour, and then I'll go for a run. Except as you read the first few sentences, you realize that you need a dictionary to understand what you're supposed to be learning. So you get that handy medical dictionary you bought as a first year medical student. And try to look up all these fancy new words. And realize that if you can find 50% of them in this book, it's a good day. So you add something else to your ever-growing "to-do" list - "buy a SPECIALTY dictionary."

In the meantime, you try to make do. After all, you can find some of the words in the "regular" medical dictionary. So you look up a fancy word, like, say, parakeratosis. And the definition is not much better than the word itself.

"Abnormal retention of the nuclei of the keratinocytes in the stratum corneum."

As opposed to orthokeratosis. And, you scratch your head, how is that different from hyperkeratosis? or acanthosis? and how is acanthosis different from acantholysis?

Or perhaps the word of the day was spongiosis:

"Intercellular edema, most commonly in stratum spinosum."

Hm, you think to yourself - which of the many layers of the epidermis is the stratum spinosum? And why does this other text refer to the malphigian layer?

Startled, you realize that fifteen minutes have gone by while you've tried to figure out the above, and chiding yourself for getting off topic, you go back to reading the text. Three sentences later, you come across parakeratosis again.

Aha, you think, I know what that means. Or wait, is that orthokeratosis? Or hyperkeratosis? You end up having to look it up, again, because, although you just read it fifteen minutes ago, it already flew out the other ear. And before you know it, it's several hours later, you're only on page 4 of the assigned reading, and you had better get to bed since you have to get up in a few hours.

Such, is the life of a new resident.

*****

Your friends who went into other fields have a hard time understanding why you're exhausted by the end of a week. Actually, you're not even sure, until you realize that even though medicine internship meant you were in house for many more hours, there was down time. Whereas now, you run around like a headless chicken while in clinic then try to read gobbledy-gook for several hours a night. And truly feel like a headless chicken, for all the amount of material you seem to be (not) absorbing.

It's also an isolating time, because you struggle, maybe for the first time, with your feelings of utter inadequacy and feel like you're the only incompetent one. Because your colleagues always seem to know what they are talking about when they pipe up.

*****

Here are the truths:

Truth:

Everyone in your class is equally incompetent.

You just don't see it because you're not working side by side, like on the medicine service. Every single person has the same feelings you're having, and like you, they're trying to keep their head above water and not show how hard they're flailing.

Truth:

It is okay to not know, and it is very normal to feel completely overwhelmed. It's a new field that you've never been exposed to before.

Truth:

You are still the great person you've been so far, (no, you haven't been slowly getting dumber during internship) and you too, will learn all the material with time.

Truth:

That after nights of beating your head against the books, one day you'll understand parakeratosis. And spongiosis. And how spongiosis is different from acantholysis. And why that will make you a better physician.

It will all come with time.

Just put one foot ahead of the other, work hard, and try not to stress too much. You've already done the hardest part. Enjoy life. Take care of yourself. The year will be over before you know it. Although you may not feel all that much smarter throughout the year, pretty soon, you too will be welcoming a new group residents. And their naivete will show you how much you've learned in the first year.

It's a tough year, but you'll make it through with flying colors. We have faith in you.

But don't ever forget how hard it was when you first started out, and because of this, don't forget to extend a hand to the next group.

Take care of them the way you were - or wish you had been - taken care of.

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Life is But a Dream.

Watched "The Family Stone."

It's a good family movie.

Was struck by how happy vastly different and somewhat dysfunctional the Stones were, and yet how happy and complete they were at their family gatherings. Yet at one of their Christmas gatherings, we learn that Mother Stone, who really helps pull the family together, is terminally ill.

The movie ends with a future Christmas gathering, where Mom has passed, but her family still gathers as they always have.

You see that life, long as it sometimes seems, is but a passing dream. Something that comes and goes, like the whooshing in and out of a long breath. So real when it is happening, but no more than a fading memory as soon as it's passed. That people are born and die, and when they die, what's left of them is merely fading memories held close by those that loved them. But we also see that although people die, they don't die, because who they were reflects in the places they'd been, and the things they'd done, and in each of those whose lives they'd touched.

So the moral of the story is that

Life... is shorter than we think.

That we should enjoy each moment of this precious gift.

That we should unabashedly live, and learn, and love.

That we should cherish those who happen to cross our paths.

Give to those around us.

Try to make it a better place for our having been here.

And never forget that life, this wondrous life...

Is but a passing dream.

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Do Women Talk More Than Men?

If you believe urban legend and cultural stereotypes, women use an average of 20,000 words a day. Men? 7,000.

Newest data, recently published in Science, would suggest that men don't necessarily talk less than women.

Mehl and Pennebaker et al looked at 396 college students and measured the number of words they used in a day.

Women, 16,215. Men, 15,669.

Men on average spoke 546 words less, which was not statistically different.

But there was a 45,000 word difference between the most and the least talkative persons. So it's not a matter of women talking more than men. Talkative people just talk more than non-talkative people. Maybe we're just programmed to think that women talk more so we notice a chatty woman more than we notice a chatty man...

Or maybe there are changes as people age. There certainly are couples where one person is the talker and the other is the listener - but are more of the talkers women?

Just think, if you study that, you TOO can be published in Science.

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Fifteen Minutes of Anonymous Fame

Derm Resident Finds Lessons Beneath the Surface, by Nicholas Genes, MD, PhD

In the competitive world of dermatology, one resident has decided to take frequent pauses to reflect on the meaning of her experiences. She shares her thoughts anonymously on her blog, Wandering Visitor. I corresponded with her recently about her writing and her preconceptions about her work.

Dr. Genes: You come across as a very thoughtful, introspective writer. I recall entries in which you lamented the dehumanization of medical training, and others in which you talked about how your peers disappointed you with some of their behaviors. So I was kind of surprised to learn that you're a high-powered derm resident (judging by your approach to the inservice exam)!

Wandering Visitor: Contradictory, huh? Well, I take work very seriously. My job is to learn how to be the best physician I can be for my patients. In real life, I'm an eternal optimist and an artsy-fartsy type with my "head in the clouds." I don't take myself too seriously and am very laid-back. It's medicine and it's the responsibilities therein that have really grounded me. In some ways it's good; I've learned to be more serious, more responsible. In other ways, it's not so good; I've become more anal (although much less so than many coworkers), more blunt, and I care much more what people think of me (which is no good, and I'm trying to get back to "normal").

In terms of becoming the best physician, part of that is not losing the humanity (that we all have) in the process. It's about learning what really is important, which I've been struggling with this year -- that what my attending thinks of me is not that important (besides that they think that I'm competent), and that I'd rather spend some more time with the patient rather than shuttling them through like a piece of meat.

At times it seems like I don't really belong in medicine. But what drew me to derm was, among other things, how happy people were, and I'm still trying to find a balance of what I want out of a career in medicine.

Dr. Genes: Some months you write a lot about medicine, about patient encounters, healthcare, and the process of residency. Other months, it's more about nature, or travel, or food. Is this because of your schedule? Is writing more of an escape for you, or more like analysis?

Wandering Visitor: 'Tis the cyclic nature of life. I write whenever the mood strikes. There are just times when there are thoughts that need to be worked through, or lessons that need to be put down somewhere. A lot of my posts are reminders to myself so that I don't turn into something I never wanted to be.

Sometimes I want to write more about work but don't. Derm is too small of a field, and anonymity is important. (I think there are something like 400 residents a year in the country. The average derm program has 1-2 residents a year, and a "huge" derm program has maybe 7 residents per year.)

Dr. Genes: You started your blog for many reasons, but you seemed a little unsure of the medium and the message you wanted to convey. After a year and a half, do you have a better idea of what blogging does for you and for your readers? I have a sense that you're trying to capture and communicate good behavior and good intentions. Would you be happy if your blog made readers more thoughtful, more conscientious?

Wandering Visitor: I started the blog because one of my friends has an amazing blog. In reading theirs, it was not only hilarious, but just a great way of keeping in touch, even though we were thousands of miles away. It's definitely evolved since then. I'm not blogging to keep people updated, and it's not a "diary" of my life (how boring!).

The blog is something that I hope people find interesting, but also something that, 10 years down the road, I want to be able to look at and use to remember that inspirational patient or great life lesson that came up along the way.

For me, life is about learning what is important and throwing away what is not. It's about cherishing the moments one spends with another individual, and in being able to offer the other person what they seek -- companionship, understanding, a listener. The posts are random thoughts in the process of life, and I would be very happy if they offer a reader what they meant to me.

Dr. Genes: What blog entries have you enjoyed the most?

Wandering Visitor: My favorite posts are the ones where I feel like I learned something important, or where something that I fundamentally believe in was reinforced or taught to me in another way. I also like the ones that push the boundaries of what we know and do not know (near-death experiences, meditation, neuroplasticity), because people often create a comfortable box of knowledge, don't realize that they have become stuck in there, and fail to appreciate the mystery of our world.

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Residency is a Roller Coaster

T'was the first day of the "new" year.

I went to sleep last Friday a lowly 1st year resident, and woke up Monday still a lowly, but "movin' up in the world" (finally!) 2nd year resident.

You don't get many sleeps like that in a lifetime.

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It was a weird day. It was weird that the graduated 3rd years were no longer around. It was weird that the 2nd years are now the seniors. And it is VERY weird that we're supposed to know something more than we knew just a few days ago...

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We met the first years this past weekend, and their coming has fully snapped me out of the funk.

Residency, as a wise senior once said, is a roller coaster ride. It's got its highs and it's got plenty of lows, and it has one too many of those scare-you-shitless sudden drops where you're not quite sure what hit you, why you can't even scream, and when the heck the darn drop is gonna end.

And at the end of the day, you wonder why the h*#! you ever set foot on the ride and vow not to be so gullible again.

Which is all fine and dandy, except you're stuck on a three year (or more!) roller coaster ride.

So you either resign yourself to a sorry fate, bemoan the upcoming peaks and troughs (number yet unknown), and become more and more bitter by the day, or you use the quick breathers between the dreaded uphill climbs and the even worse sudden drops to think about how you can make the ride better for those that come after you.

Now, you know that there's no way of changing the ride itself. That would take engineers, and metal-workers, and - let's face it - the ADMINISTRATION.

Won't happen during this three year ride.

But instead of sitting in a roller coaster car with five other people you don't trust, wouldn't it be so much better if you liked the other occupants in the car? After all, ya'll did step into the same shit unwittingly, with (varying degrees of) the same naivete, and while others may not show it, EVERYONE's stomach churns when those drops come around the corner.

As we move up in the "ranks," we have the opportunity to set the tone in the car. If the senior residents take care of everyone, the first years will start out in a supportive environment and hopefully learn by example. You can't change the co-residents who have been around the block and choose to be nasty. But they're gone, or on their way out. And, unlike the ingrained thoughts of some who have gone before, just because YOUR roller coaster ride was from hell and back doesn't mean that the next group has to suffer. In fact, BECAUSE our roller coaster ride was unpleasant means that NO ONE who follows should have to suffer. And since we're not administrators, or engineers, or metal-workers, let's start small. Hopefully, by a benign application of peer pressure, the first years can learn that it's NOT okay to undermine each other. And it's NOT acceptable to stab each other in the back. That, instead, it's much better to take care of each other. After all, they're young, and naive, and impressionable.

Such are the thoughts brewing in the head.

The thought of being able to support the incoming class - to work towards creating an environment where they feel safe - has been very inspiring, and is now one of the main goals for the rest of the year.

Because, since we're all stuck on the same shitty roller coaster ride that is due for scheduled renovation in the year 2090, we might as well support each other and make the best of the three year ride.

Who knows, if we take care of each other, maybe the drops won't be as terrifying. And maybe, the younger ones will be inspired to do the same for those who follow.

Such, is my wish.

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