the staggering consequences of pride...

i was chatting earlier with some ladies in the nurse practitioner program here at the university... i had been aware for awhile that the np (nurse practioner) program gets you out the door and into the clinic in a third of the time with a little less than half of the debt, none of the liability and hooks you up with a union to boot. not too shabby. you take a small hit on your income, but if you are in it for money please get out because you are ruining the profession. so to all candidate md's interested in primary care on upto anesthesia, why why why do you want to be doctors? tell the truth - is it because of the md? those two letters come at a hefty cost. believe me, i'm stained thoroughly with this sin, i like the thought of being the final authority, of being an md, doing the sign off, stopping the buck etc... but truth be told, deep down in places i don't talk about, its power - i know myself and i know the world enough to know its true. will i actually be the only final authority? the answer is simply, no. even with my md i won't. because increasingly np's are taking over primary care and advancing on other specialties, e.g. - my physical to matriculate into med school was completed by an np.

it makes perfect sense why primary care residencies have dropped off precipitously and will continue to do so, who in their right mind would ever go into primary care with an md when you can do it with an np? four years med school plus three years residency plus a negative $200,000 versus 2.5 years of school no residency and 100K max tuition (fyi np students after attaining their nursing degree pay by credit, go ahead and ask a med student and see if they know that) the only thing that doesn't make sense is why anybody would be surprised by this.

i have observed:

1. first year med students get up later than anyone i have ever met, its atrocious. i see everybody in the house leave in the morning and at what time because i sit right by the front door to my dorm and study every morning starting at 6:30 a.m. where i meet the guard coming on shift and exchange pleasantries and wouldn't you know its the p.t. and nursing students who are normally out by 7:30? a small cadre of md students do the early run, but you can't convince me with the argument that we study late because i've been privy to one of these 1 am study sessions and it can be described by many words but definitely not efficient. plus everybody knows nmda and ampa upregulation (keys to long term potentiation) happens while sleeping - consolidate those memories (on a side note my seven and a half hours of sleep a night in tandem with my tenacious yet seasoned optimism is my proven method for devouring this curriculum)  

2. the cost of med school will easily surpass $200,000, easily. actually tuition alone is $195,000, can i get a troubled med student relief program? as ashamed as i am to admit this i'm almost happy that the government is spending like carter because it probably means carter era inflation, which will discount my exorbitant tuition retrospectively

3. everyone - by this i mean from dean down to fellow first year has indicated that the first year of med school is a wash and fourth year is a vacation - that is the truth, whether you want to hear it or not is up to you. med school should be 3 years and residents should get a raise by about 20%. how much would that cost? medicare pays the bulk of resident salaries - there are 2x10^5 residents in the US today, lets give everyone a 20K raise - total cost 4 billion - a miniscule fraction of the cost of the iraq war, tarp, obama stimulus, bush's stimulus (remember that one), and finally drum roll please... it would be roughly one one-thousandth of the total annual cost in health care in the US, remember health care spending is like 15% of gdp (13 trillion). yes, giving those tired overworked house officers and residents (that keep the hospital going too) across the country a flat 20K raise would be one one-thousandth of the annual spending. and do you know what i would do with it? pay back loans faster, its a joke, so don't worry i couldn't actually "use" it. unless of course we are in a carter ahem i mean obama hyper inflationary phase in which case i would use it to buy food.

4. gross curricular inadequacy (where is nutrition?, where is micro? parasitology? patho? not till second year, if it all, and only briefly, how do i master this in a three/four week block. why is it that n.p.'s do it first year? where is pharm? where is intro to the dealing with the business of pharm? why is there a summer break? we don't need it a summer break. life is to cozy.

5 pervasiveness haughtiness - i have had several conversations with fellow classmates who shall remain nameless that have indicated gross deficit in health economics awareness to the point where i wonder if basic accounting or health economics should be in the curriculum. 

6. the moral hazard of pass/fail system: before the md students here skewer me, i know many have fought and died to bring us this wonderful system, and i know it is the reason i am friends with my fellow classmates as opposed to foes - but the short truth is that its being abused. we all know the universal truth that you get what you pay for in life, and if something is given to you for free you will not respect it, with every right comes a responsibility yada yada, so i am witnessing academic slippage, "i can still pass with a 70", "do we have to know that?", "hey, i still passed" it goes on. the the nonclinical years of med school culminate in usmle step one -thus every nonclinical experience in the first two years should be geared towards that exam, here the tell us not to even worry about it until three months prior-  the slippery slope of the pass/fail system that was initally and mercifully designed to depressurize the hyper competitive type a neurotic, but the cost is apparent - we are losing respect for the material. most want to do well - and most are silent - but the ground beginning to shake.

recommendations

1. md's unionize, i don't care if its illegal - everybody knows justice is for sale in this country, so get the law passed somehow, everyone else in the healthcare sector with the exception of the hospital volunteer is unionized. there needs to be a consolidation in physician leadership and the ama is not cutting it.

2. med school needs to be three years only, the time wasted here in first year is unimaginable, the motivated, cost sensitive should not be punished for the maintenance of an archaic system. it saves money, and would expiditously advance our career.

3. med students wake up! we are losing ground on all fronts. our own self discipline is wanting. our rights are being impinged to greater and greater extent. 

4. residents get a raise and a thank you. i know old timer they didn't have it as bad as you, but guess what they have different problems in this age that are worse than anything you ever went up against - you hours may have been bad, you may have gotten screamed at on a daily basis by the attending - but you may never have practiced defensive medicine, paid outrageous malpractice, sued multiple times, worked for an hmo, were buried in paperwork, or buried in a quarter million dollar education debt. life today is harder because there are a lot more people, more drain on resources, less trust in the world (especially for md's), revolving door of daily appointments, cost of living increases outpacing wages for decades

but despite all that, i still think i got it so good, i love what i'm doing

haaha

Desiderata; Latin for desired things.

Desiderata

Go placidly amid the noise and the haste,
and remember what peace there may be in silence.

As far as possible, without surrender,
be on good terms with all persons.
Speak your truth quietly and clearly;
and listen to others,
even to the dull and ignorant;
they too have their story.
Avoid loud and aggressive persons;
the are vexing to the spirit.

If you compare yourself with others,
you may become vain or bitter,
for always there will be greater and lesser persons than yourself.
Enjoy your achievements as well as your plans.
Keep interested in your own career, however humble;
it is a real possession in the changing fortunes of time.

Exercise caution in your business affairs,
for the world is full of trickery.
But let this not blind you to what virtue there is;
many persons strive for high ideals,
and everywhere life is full of heroism.
Be yourself. Especially do not feign affection.
Neither be cynical about love,
for in the face of all aridity and disenchantment,
it is as perennial as the grass.

Take kindly the counsel of the years,
gracefully surrendering the things of youth.
Nurture strength of spirit to shield you in sudden misfortune.
But do not distress yourself with dark imaginings.
Many fears are born of fatigue and loneliness.

Beyond a wholesome discipline,
be gentle with yourself.
You are a child of the universe
no less than the trees and the stars;
you have a right to be here.
And whether or not it is clear to you,
no doubt the universe is unfolding as it should.

Therefore be at peace with God,
whatever you conceive Him to be.
And whatever your labors and aspirations,
in the noisy confusion of life,
keep peace in your soul.

With all its sham, drudgery, and broken dreams,
it is still a beautiful world.
Be cheerful. Strive to be happy.

-Max Ehrmann ~1920

Slow slow calcium and other musings...

Recently in lecture we were covering synaptic transmission in the nervous system. Among the multitude of neurotransmitters that endlessly and constantly communicate within the living central nervous system, calcium stands out as the primary mechanism that initiates these turgid bundles of neurotransmitters to expel themselves into the synapse. What I found particularly interesting was that at one moment the professor remarked, "And here is where everything really slows down, calcium must be pumped into the presynaptic terminal where it binds to a calmodulin dependent kinase which leads to a phosphorylation cascade... ultimately on the order of a few milliseconds."
A few milliseconds, slow? This guy must be rough on customer service agents. But then I thought in a relative manner, really if that is slow then what is small? Well I thought if you can't see it, then something is small. What is the smallest thing a human eye can see? I looked it up, I learned something. The way in which the "smallest thing" that can be seen by the human eye gets measured is through a technique of two point discrimination. Two points are placed near each other and when they become close enough such that you can no longer discriminate the two, there you have it, the limits of you perception (more on my limits later). But what is interesting is that the smallest distance (you would think) a human eye can see is not a distance, but a measure of angle. Nifty, two dots a meter apart are easily discriminated at one meter, but not so at 10 kilometers, so the limits of perception are given as an angle, in this case... drum roll please... roughly one arc minute, or one 60th of a degree. What this means is that lets say you are one meter away from a piece of paper, you theoretically could discriminate two points separated by 300 microns (check my math please), or 0.3mm. So that distance, for lack of a better term, is small. Right, right, so bacteria range in that size. Second, isn't interesting that there are ten times the number of bacteria on my skin right now than cells in my body! (not just dirty old me, everybody) Ten times all my cells, true story. So there is "lot" going on of which I'm blissfully unaware. In fact a "lot", is like the professor's use of "slow", there is a microcosmos of activity festering away now on a nanoscale that is too "small" for me to perceive. But it affects us, anyone who has ever had a bacterial infection will confirm that. Think how outlandish, how preposterous, how ignoble germ theory must have been when it was originally conceived, yet how right.
Back to slow. What are the limits of my temporal perception. What is the smallest unit of time between which I can discriminate? I have no idea, I want to say that it is well above a microsecond, and even then I'm being generous, its probably a few milliseconds after five pots of coffee. In a blink of an eye...? yep thats 50 milliseconds. Theoretically, the smallest unit of time in the universe is a Planck unit, the time it takes light to travel one Planck length, brought to us by our beloved master physicist Max Planck whose instructor once dutifully advised the young Max, "don't go into physics because almost everything is already discovered" (man if we only had teachers like this today!! sheesh). Yes this phenomenally small unit of time is roughly 10^-44 seconds. OK do you understand thats like 10^23 zeptoseconds (yes thats a real prefix), a whole mole of zepto seconds!!! Before you stop laughing consider that one Planck unit is also 10^20 yoctoseconds!!! Stop laughing, its ridiculous but true, there is both such a thing as yoctoseconds and God only knows what is happening in the universe from yoctosecond to yoctosecond. Physicists get all hot and bothered when they measure the half-life decay of the helium-9 outer neutron in the second halo to be 7 zeptoseconds, and even then in the blink of eye this decay could have happened 10^18 times, in the blink of an eye. And even then, its not like we can record every yoctosecond for ten minutes and then look back and see what happened, no we can be philisophically aware that a yoctosecond occurred, thats it, but time on that scale has no meaning to us practically, so does that mean its not relevant? There are serious limits to the perception of time imposed by our central nervous system, such that just as absurd as germ theory may have been, what is going on between the milliseconds? What life, energy, or force is happening and on what scale in the between time? To some form of life that exists for only an attosecond (10^-18 seconds), calcium uptake into a presynaptic terminal for one single synaptic transmission would seem like a galactic event, it would seem like billions of years to us residents of a Planckian attosecond universe.
There is so much going on in this world, so much to think about, so much creativity, so many ideas, but only so many yoctoseconds. No matter what your relationship to time, you have got to spend it wisely, get up and be active, think, respond, love and live, because dude if you're LUCKY, you're gonna get eighty years. And thats only like 10^30 zeptoseconds.