Rock the SAD Away

28 11 2010

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Apologies for the long hiatus since the last post: I believe I have been suffering from SAD (seasonal affective disorder), which is the onset of symptoms of depression (e.g., overeating of carbs, oversleeping, general lack of motivation to do anything) during the winter months (although it is also possible for SAD to manifest as spring-summer depression rather than autumn-winter depression).  Some have designated SAD as a leftover adaptive trait akin to hibernation while others have postulated about vitamin D deficiency and/or melatonin hypersecretion during the winter months as a risk factor of SAD (due to low levels of sunlight).  I think November is a bad month for me because the days are shorter than in almost any other month, the sky is darker, and the oversleeping means that I miss most of what little daylight there is.  The overeating and the lack of motivation to go to the gym or dress nicely means that my self-confidence has also taken quite a hit, which just feeds right into the delightful cycle of overeating, oversleeping, anhedonia, and unproductivity.

Of course, it doesn’t help that artificial lighting has been linked to overeating and obesity, because the decrease in natural light during November means the increase in artificial lighting.

But my point of this post is two-fold.  First, it was to explain and apologize for my lack of updating this site (but I’m getting better so expect more ramblings asap!).  But second and more importantly, it’s to point out that SAD can affect anyone, especially students who are already stressed at this time of year as it is (because of exams, assignments, papers, and balancing school, life, family, extracurriculars, and everything else during the holiday season).  SAD has been found to affect somewhere between 1% to 10% of North American populations.  So if you are like me, and you have been feeling particularly unproductive (I’ve pretty much just stayed at home watching old episodes of “The Nanny” while ignoring most academic, social, and personal responsibilities), it’s sometimes helpful just to know that there’s a reason for it that’s not your fault.  It’s good to know that I’m not just getting fat and lazy because something has changed in my personality and in my ambitions, but because I’m suffering from an illness.

And if you are suffering from SAD, November is almost over, so hopefully it’ll get better once the holidays arrive and the Winter Solstice has passed (meaning that the days will become longer).  But if you are strongly affected by SAD (or even if you just want it to go away), there are things you can do to fight it.

For me, what has worked is forcing myself to sleep earlier and wake up when there is sunlight.  Maximizing sunlight exposure makes a world of difference; regardless of whether it’s the placebo effect, vitamin D production, the sociocultural effect of being with my community during the daytime, or some other effect altogether.  What has also worked for me is making the effort to exercise, dress up, and be with people I care about, because doing things that make me happy and give me confidence will hopefully feed into a positive cycle of feeling less depressed and more energetic.  I’ve also been experimenting with turning on the heat in my apartment, because I realize that part of the reason I overeat and feel lethargic may be due to the fact a lot of my resting metabolic energy is dedicated to producing heat to keep my body and brain warm, which diverts attention away from other matters, like thinking and studying (good excuse, eh? =D).

If those tricks don’t work for you, you can try taking vitamin D supplements, using light therapy (bright light, or perhaps green light, which may suppress melatonin production – I’m buying a light box as I type!), dawn simulation (having lights gradually turn on just before the alarm rings to wake you up), and high-density negative ionization (releasing charged particles into the sleep environment – my light box also emits negative ions!), although I would suggest going into the primary literature to look at clinical trials to learn more about how effective these treatments are and whether they are likely to work for your demographic.

If these therapies still don’t work, you can visit a psychiatrist, who can then help with diagnosis and treatment, and may prescribe antidepressants, timed melatonin doses, cognitive behavioural therapy, or other treatments, depending on what is right for you.

I think the unknown is the scariest thing.  Knowing what we’re dealing with is half the battle.  And now, I can try to treat myself for a psychiatric condition (although it’s not really a stand-alone condition in the DSM-IV, and I don’t know that I would actually qualify as suffering from it according to the DSM…).

Hopefully with the onset of snow, the white, bright, cleanliness of it all will help me fight this SADness.

On a related note, I have decided to start petitioning for clocks not to be put back during the fall, for the sake of health!

November is almost over…


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Categories : Of Health & Medicine, Science Rules, University-Related

Walking Around Like A Med Student Zombie…

23 10 2010

Warning: This post has nothing to do with Halloween…

This is probably going to sound bad, but I’m going to say it anyway.

I’m bored…of school…

It’s probably not great to hear a doctor-in-training complaining about his lack of motivation in med school, but it’s true.

Just to clarify, there are some really bright moments when I am reminded of why I dived into this profession, such as when I get to hear the stories of physicians who have been working for 20+ years, or when I got to explore firsthand the intensity of a psychiatry emergency room and meet a patient who has persecutory delusions.

During those rare moments (they are truly few and far between in first year), I get so excited, and I cannot wait until I get into hospitals and clinics and get to interact with patients and hear their stories on a daily basis.

But until then, the truth of the matter is that we have to get through a lot of lectures on physiology, anatomy, pharmacology, cell biology, histology, embryology, and so on.  There are some hands-on labs and small group sessions with the intention of spicing things up and making lessons more relevant, and from my experience thus far, McGill plans the course extremely well and makes every effort to engage us in learning, but I still find a lack of motivation to study (despite some fantastic and passionate professors).

The truth is I feel guilty for being this way, because I feel like I am almost letting my future patients down, but the other side of me has listened to so many senior students, residents, and physicians tell me that a lot of what we learn in the first year and a half will not be used in actual practice, and what we do need to know, we’ll learn again in practice and in residency anyway.

So I’m feeling this way, not only because I’ve learned some of the material before, not only because the material is not always taught in the most engaging way, but most importantly, because I feel that what I’m learning now has no direct relevance to my future practice as a physician.  If it has no real relevance, isn’t this entire exercise another hoop-jumping spectacle?

I understand that the Basis of Medicine (BoM) is exactly that – trying to teach us the basics of medicine so that we have a fundamental grasp of the different bodily systems and how they work in isolation and synchronously in entire human beings.  I guess part of my frustration is that I had a lot of these types of classes in my undergrad years, and I kept telling myself that all of this will become much more stimulating and practical when I get to med school, and so I kind of set myself up for disappointment.  I just sometimes feel that it was a lot of hoop-jumping to get into medical school, and now it feels like even more hoop-jumping to become real doctors.

I was really looking forward to medical school because I was excited to get to take classes that I cannot wait to go to every day.

I think I’m just overly idealistic and impatient, but it doesn’t change how I feel right now.  For so long, getting into med school (and later, specifically so that I can become a psychiatrist and have those conversations that can help change lives) – that drove and directed me.  Now that I’m in, I still want to become a doctor, but the journey seems long and tedious, and the material we’re learning seems far removed from actual practice of medicine.

Until I get there, I need to find a new drive, a new motivation to keep me interested, a constant reminder for why I need to keep my head in the game and focus.

I need to find a new purpose.

“Purpose…it’s that little flame that lights a fire under your ass.”
– Princeton (Avenue Q)

Am I alone in feeling this way?  Or have you also felt, at some point, like you lost focus in something you’re supposed to be passionate about?  What did you do to get back on the horse?

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Categories : A Little Night Music, Of Health & Medicine, University-Related

Reflections on Cadavers…

26 09 2010

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Warning: Please DO NOT read this post if you are uncomfortable with reading details of what it’s like to learn medicine from dissecting a donor body.

Our professors told us that we should write down our initial thoughts and feelings about our first cadaver experiences, especially because we may never feel the same way again.

So here I go.

Walking into a room with 50 dead bodies is difficult to even type out, much less experience.  To see them covered up the way that you see them in movies and TV shows was, I think, more scary than actually uncovering the cadavers, because of the association we might have of the body bag to CSI murders and horror movies (at least this was the case for me).  It also goes to show how much power the unknown has.

The purpose of the cadavers, of course, is to help us learn anatomy firsthand, from the source, and I am so thankful for the donors who were courageous and generous enough to allow us to learn from them.  Personally, I really don’t think that I would be comfortable imagining my body being used in this way after I passed; for fear of being judged for how I look, because there are secrets about my body I would not be comfortable revealing to strangers, or in case someone recognized me.  As we dissect through and examine each part of the body, we really get to know and appreciate our donor in a way that none of his family members or friends experienced.  In some ways, it’s the most intricate and intimate way of understanding how someone lived – hidden secrets and signs of the past: silicon in the breast, hypertrophy in the heart perhaps indicating poor diet and exercise, a collapsed lung perhaps the cause of death.

Our lab instructor told us that in a lot of ways, these cadavers are our first patients, and I can begin to understand why.  Through exploring their anatomy over the course of the year, we uncover remnants of their lives, and we’ve already began to identify them as our people.  There is a memorial service at the end of the year in appreciation of the donors, and I can see myself being quite emotional at the thought of having to say goodbye to the friend who has given us and taught us so much, letting us get to know him in a way that even his family could not.  And seeing the families at the memorial service will be the first time we deal with the families of patients, in a sense, and that aspect is daunting in and of itself.  We really go on a journey with our cadavers, and at the end of any journey, I think there is grief at parting, for loss, and for the end of an era and the closure of a shared experience.

At this point, I just wanted to say that I recognize that it’s strange for me to relate to a dead body as if it were a living person, but to me, the conscious decision that donors make to donate their bodies, as well as the uniqueness of the individuals’ bodies, makes it impossible to forget that they were once living, breathing human beings with a myriad of personalities and thoughts and feelings.

And yet it’s kind of our job sometimes to forget that.

I had a problem cutting through the rib cage because the sound of bone crunching induced some serious cringing on my part.  One of my colleagues was hesitant to touch the cadaver for the first time and wanted someone to do that with her.  And yet others in our class were able to get right into cutting and dissecting without hesitation.  They were able to detach the organs in front of them from the individuals and get right into exploring and uncovering.  A lot of my colleagues were very excited to get the experience of cutting into real tissue, and I admit it was thrilling to feel how soft and delicate a lung is.

There were a few comments, jokes, and complaints about how much fat a particular cadaver had, for example, that I was not entirely comfortable with, but then I thought more about it.  I think that we all start at different places in a continuum: either caring too much or perhaps not caring enough that the bodies we are working with were once alive and deserves respect.  It’s extremely delicate to find the balance between being so overly emotional that you cannot listen to bone crunching without cringing, like I was, and being so detached and insensitive that cracks are made about an individual’s weight or condition without consideration that he or she was a human being with families and friends who loved them.  As a future doctor, one end of the spectrum results in paralysis to the point that you get overly involved and can no longer treat your patient objectively.  At the other end is, of course, the worry of disrespect to the patient and family, causing undue distress and perhaps the concern of not completely respecting the patients’ wishes due to paternalistic tendencies.

It’s easy to say that, of course, you should be respectful to the donor bodies, but I think it’s perhaps difficult for those not in the profession to understand that it becomes impossible to do your job if you’re constantly looking at him in the eyes and thinking about his past history and being so serious and so ridiculously careful that you are afraid to cut or dissect or even lean on or put things on the body for fear of being disrespectful.  We cannot be serious in that room all the time, because then we’ll all get depressed, so we lighten the mood with conversation and laughter.  Dissecting also takes all our concentration to ensure that the right things are cut or left intact in the right places, and that we do not cut ourselves or other people, so we really cannot be thinking about anything other than the particular task at hand.

I genuinely think that those who are meant to be surgeons are the classmates who spend their free time in anatomy lab dissecting the fat from the body so that the organs are clean.  They admire the beauty of the organs separate from the individual.  They are the ones who cherish every opportunity to interact with the body in this way.  I think that during surgery, it’s necessary to look at the heart or the intestines (or any body part in need of repair) as just a body part, so that surgeons can fix the problems with the technical precision of an engineer or auto mechanic.  Remembering the patient’s unique personality or familial situation is unnecessary, in this case, and can in fact be a distracting pressure that negatively impacts the surgery.  In the OR, being calm is much preferred to being emotional.  I always say that I don’t need my surgeons to be good conversationalists or remember what my major is or even smile at me; I just need them to be the best.

My point is that caring too much or caring too little are opposite ends of a pendulum, and I think this year will help bring us all to the middle.  For example, at the end of the lab where we cut through the rib cage, I was already accustomed to the bone crunching, and it no longer made me cringe.  I don’t know whether I’m grateful for that or not, but unfortunately, it’s a necessary skill to have.

I debated with myself for a long time before deciding to publish this blog post publicly.  My hesitation in posting stems from the concern that working with cadavers can be a very sensitive topic to a lot of people, and to me, revealing details of the personal relationships with our cadavers feels almost like breaching the doctor-patient confidentiality agreement.

The reason I ultimately decided to post this is because I think and hope it’s helpful to current and potential medical students to appreciate that they’re not alone in their mixed feelings and complex navigational processes surrounding this topic.  Posting this also forces me to record and clarify my own thoughts about the experience, and hopefully I receive feedback that I’m not completely alone either.

But most importantly, I wanted to publicly acknowledge the fact that it’s a struggle for medical students (or at least one medical student…), and probably even full-blown doctors, to find the line between caring too much and not caring enough.  I hope it’s clear that we do the best that we can, but each individual has to find the line for ourselves, and I’ve come to appreciate that it’s difficult (and unfair) to judge another person’s unique path to find balance, especially when we still have so much learning left to do.


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Categories : Of Health & Medicine, University-Related

Psychiatry Is…

15 09 2010

As the above cartoon demonstrates, psychiatrists have a bad reputation of being fake doctors who simply dole out drugs and call it a day.

I don’t think that is an overly accurate representation, and I certainly don’t think that it should be what the profession is about.  As I’ve said before, I think psychiatrists heal through conversations and targeted cognitive therapies, with drugs only supporting the efforts.  My interest in psychiatry is due, in part, to the fact that we do not understand any of the disorders completely, from etiology to how the drugs actually work.  Furthermore, not only do we not understand (to a significant extent) how the pills affect the complicated circuitry and rewiring of the brain, but the drugs also cause a myriad of side effects (because many of our pharmaceuticals act on molecular targets that are in many different brain regions and tissues outside of the central nervous system), from diabetes to sexual dysfunction to cardiovascular disease and obesity.

Through many conversations and readings, I’ve come to the personal conclusion and opinion that psychiatry is, or perhaps should be, the intersection between neuroscience, anthropology, and spirituality.

Neuroscience is quite obvious, I believe, because it is the scientific understanding of the mechanisms of the brain, and how the wiring goes wrong.  It is fundamental groundwork to delineate biochemical pathways and receptors that may be implicated in a disease so corresponding treatments are appropriate (e.g., increasing activation of certain serotonin receptors in the neuronal synapse is the method of action of many antidepressants), illuminate how synaptic plasticity is implicated in changes in the brain so promotion of these longer-term changes can be involved (e.g., Alzheimer’s is associated with a decline in the molecule allopregnanolone, which has been shown to promote new neuron growth and reverse cognitive deficits when administered in a mouse model of the disease), and describe how different brain regions can be more responsible for certain aspects of function (e.g., the amygdala is strongly implicated in our interpretation of fear, and recent research has focused on potential drugs targeting this area to change/block certain memories when we think about them again so that post traumatic stress disorder patients may be treated).  Undoubtedly, neuroscience, the scientific evidence of how the brain works and malfunctions, is an integral part of psychiatry.

Anthropology is the study of humanity, and cultural anthropology in particular is the study of how different cultures have evolved over time to think and act differently.  As applied to psychiatry, I think anthropology is necessary to understand how people all around the world have thought about the brain and the mind throughout history, which will inform why different cultures approach mental health in very different ways today.  How psychiatry is interpreted by a certain culture – whether it’s just part of everyday life like in parts of NYC, or associated with shamans as in areas of Peru, or dismissed as only being necessary when you’re crazy as within areas of Asia – and how that interpretation evolved over time should completely affect the way in which the topic of mental health is tackled in that region (affecting everything from nomenclature to promotion to treatment).  In countries where immigration is frequent, I think that understanding where the patient grew up and how different cultural factors may be significant for him or her is key.

Finally, spirituality, to me, is ultimately a personal journey to seek the meaning of one’s life and where one fits in.  This path is extremely individualized and complex, and it can include anything from religion to the implications of quantum mechanics and more.  Spirituality usually involves a greater understanding of one’s place in the world, and contributes to a sense of greater purpose, unity, and connection to others.  The reason I think spirituality should be a fundamental pillar of psychiatry is because understanding how a patient uniquely values and sees his or her place in the world is instrumental to being able to understand her or his thought process, motivations, and concerns.  We cannot help anyone without being able to step in the person’s shoes, and temporarily live in that person’s reality: what they value, what they believe, what they are proud of, what makes them happy, what makes them tick, and where they see themselves in the grand scheme of life.  When someone feels that they are finally and significantly being understood, that, in and of itself, makes a gigantic impact on the individual, and would undoubtedly catalyze further gains in treating, healing, and maintaining strong mental health.  Some criticize psychiatry for overly focusing on the negative, suggesting that spirituality should be appreciated and used as a psychiatric healing tool that focuses on leveraging the positive social emotions in an individual.

Together, I think the three disciplines make up a novel way of interpreting psychiatry: one that looks beyond patients as consisting solely of their unique make-up of biochemical receptors, and towards patients as unique individuals with unique beliefs, values, and psychological needs; placed within the context of culture and history.  I believe these factors should influence everything: from how the psychiatrist interacts with the particular individual, to the selected course of treatment.

But then again, what do I know?  I’m just a Med I.


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Categories : Of Health & Medicine

Of Autism And Vaccines – How Do We Communicate Science Better?

30 08 2010

There are very few things that I get full-out angry about, but the allegation that vaccinations cause autism is one of those few topics that make me furious.

A BBC article today posted that a mother of a brain-damaged teenager in the UK received a £90,000 payout from the government in response to the complaint that the teenager suffered his first epileptic fit 10 days after getting the MMR (mumps, measles, and rubella) vaccine as an infant.  I am not upset that the mother received the money; in fact, I’m glad that she has some funding to help deal with what must be a difficult illness with her son.  What I am upset with is the fact that this payout is, in my opinion, inaccurately publicized by an international news source, and the money is termed as a “compensation award”.

I have nothing against the BBC reporting what happened.  Unfortunately, my concern is that those who read this article will use it as evidence that vaccinations cause brain damage, because they might think, “Why would the government pay for it otherwise?”  I’ve always believed that scientists do a poor job in translating research findings to the public, and that is our fault.  However, the media doesn’t help when they publish articles like this.  I think I go too far if I try to say that it is irresponsible journalism, because they did put in the clarifications that the “decision reflects the opinion of a tribunal on the specific facts of the case and they were clear that it should not be seen as a precedent for any other case” and that “the ruling had no relevance to the question of a link between the vaccine and autism”.  Unfortunately, none of these explanations happen in the headline or the first six sentences.  I could be wrong, but I don’t think everyone reads to the bottom of every news article, and I’m concerned that society’s diet for sensationalized news and the media’s need to keep up with our appetite means that this article was meant to attract readers who want to use this news to fuel the anti-vaccine campaign.

Maybe I’m completely wrong about this – I hope I am wrong, but with celebrities like Jenny McCarthy strongly supporting organizations that encourage parents to doubt the validity of vaccines, I’m worried that there is a large subpopulation of people who buy the bad PR of vaccinations.  The reason this topic enrages me is because if babies are not vaccinated due to this type of misinformation, not only can the babies get sick and possibly die from those diseases, but herd immunity is lost and it puts entire communities at risk.

Misinformation of this nature is completely irresponsible and it kills, and it simply breaks my heart to know that babies are possibly suffering deaths that could have been prevented, not because of their fault, not because of their caretakers’ fault, but because poor communication between researchers, the media, and the public have led to poor reporting and other irresponsible actions that put all of society at risk.

I put the greatest burden on researchers, because I feel that we, as scientists, have an obligation to properly publicize our findings in order to educate the public on the relevance of our work to their lives.  We should not exaggerate our findings, nor undervalue them.  We are the source of information, so we need to be the most responsible, because if we start off the game of telephone with the wrong words, there is no way that the game can end well for anyone.

To illustrate the power and the necessary responsibility of the researcher, one needs only look at the Wakefield paper published in the Lancet journal in 1998, suggesting a link between the MMR vaccine and autism.  This paper lent great support to the anti-vaccine movement, and even though there were many concerns later on about the study’s tiny sample size, Wakefield’s conflicts of interest, and allegations that he manipulated the data, the damage was done as soon as the press conference occurred.  As with the chaos theory, once the butterfly flaps its wings, it can no longer control the results of its own actions.  Thus, despite the Lancet paper being completely retracted this year and Wakefield being found guilty of professional misconduct through unethical research, the bad seeds have long been sewn, and the anti-vaccine movement continues as a beast of its own.

In a small group session at school last week, we discussed whether press releases for scientific research should be peer reviewed the way that scientific journal articles are peer reviewed.  My opinion was and is that there is an even greater need for press releases to be peer reviewed, because scientists may have some existing knowledge background from which to judge the validity of a study’s findings, but many in the general population do not, so it’s extra crucial for the scientific information to be explained to the media and the public in an accurate, concise, clear, and cohesive manner.

I guess my frustration and sensitivity with this issue lies in my inability to think of how we can go about rectifying this huge gap between research findings and public understanding of science.

Any ideas?

P.S. Please read this peer-reviewed article for a review of the hypotheses and evidence (or lack thereof) surrounding the link between vaccinations and autism.

P.P.S. Below is a video news report on how US federal judges this year found that there is clearly no scientific link between vaccinations and autism.


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Categories : News-Related, Of Health & Medicine, Science Rules

Why Specialists Need To Understand the Entire Body

29 08 2010

I have no problem telling people that I want to become a psychiatrist, because even though my ambitions may change during my medical education, having a direction and being able to say it out loud helps keep me motivated to learn and it keeps me thinking about the relevance of what I learn.

In the near past, when I told someone that I wanted to become a psychiatrist, she questioned why I needed to learn about the other parts of the body.

It reminded me of when an old friend told me that her elderly mother had a heart condition that required medication.  The medication was not without side effects, but maintaining the heart trumps everything else, so she continued to take the medication.  Unfortunately, the edema (swelling) in her mother’s legs progressed to the point that she was no longer able to walk, so my friend took the day off from work and drove two hours (each way) to visit the cardiologist with her mother.  The cardiologist took a look at the EKG and other results that concerned him, and said that the medication was working fine, so there was no reason to change it.  He did not care about the edema, because the heart, in his eyes, is the only important organ to maintain.

It’s true that without the heart, we die, but what is the point of living without some quality of life?  Without the ability to walk outside or do anything independently, so that you feel trapped in your own home and have almost no choice but to become depressed?  With every stranger that passes by your wheelchair knowing that you have some debilitating illness, looking at you with pity and avoiding you (or at least that’s how you feel)?

Understanding the body as a whole allows for consideration of drug-drug interactions, side effects affecting other bodily systems, nutritional habits, hobbies, and individual patient desires that informs everything from how likely the patient will adhere to the prescribed medication to how well he or she will do on it.  Ultimately, I think that isolating organs or even entire body systems (circulatory, lymphatic, gastrointestinal, etc.) to treat risks the treatment being only a bandaid solution if it is not tailored to the individual’s life circumstances.  A patient may not take blood pressure medication if it means that she will not be able to play volleyball because of edema in her legs.  A mother of four young children may forget to take an HIV drug regimen that is three-times-per-day.  Someone who is homeless may not be able to travel two hours out of town per week to keep an appointment for a life-saving treatment.

Specialists exist because they are needed for in-depth study of the kidney, the skin, the eyes, etc. so that general theories of what can go wrong can be applied to the individual presenting with unique and rare signs and symptoms, but I think this specialized knowledge can never be taken out of the context of the intact human being.

But the question that was asked of me was specifically about why psychiatrists need to know about the other parts of the human body.  I think it’s a fair question, because psychiatrists tend to deal with what I always call the software of the human body (aka the mind or the intangible qualities of the brain that can distort personalities, create hallucinations, and debilitate memory).  Therapies in psychiatry include drugs, but drugs are meant to complement other therapies that may involve sitting in a chair and talking, like cognitive beahvioural therapy.  Most of the other fields in medicine are more concrete, requiring surgery and/or a cocktail of drugs, irrespective of trying to change how the patient thinks, so why should software specialists need to learn about the hardware?

The answer may be obvious to you, but other than inherent academic interest, it was difficult for me to come up with practical reasons for why a psychiatrist should have a firm grounding in how the rest of the body works, other than to avoid nasty drug-drug interactions and toxicities.

Originally, I thought perhaps the importance lies in understanding patients with co-morbidities (concurrent illnesses other than any psychiatric concerns), but then I thought that the patient’s subjective experience of the disease is probably more important, and I could always look up any disease that I didn’t know.

I then thought maybe the importance lies in increasing adherence, but the day-to-day factors that would affect adherence should be explored as part of the psych sessions anyway.

So as it turns out, that was the end of my extensive list of ideas.  So I decided to take a break from thinking, and that was when Dr. House came to the rescue.

In one particular episode, a young female CEO has intense heart failure with no indication of why, and it wasn’t until House considered her psychiatric symptoms that the underlying reason for her precocious illness was discovered: she was bulimic and using Ipecac to regularly induce vomiting, thereby destroying her heart.

The case woke me up from my naivety.  I realized that House is right: everybody lies.

While that may simply be truthiness talking, the reality is that if I become a psychiatrist, not all of my patients would be able to or want to open up to me and divulge all of their secrets right away.  Due to their circumstances, they may not trust me or perhaps they have the lost the ability to communicate coherently (as with some schizophrenic patients).  Medical training is one long course in pragmatic observation, and understanding the entire body allows me to notice clubbed fingers, a slight tremor in the arm, or jaundice in the eyes, and be able to infer details in the patient’s life (like bad habits or recent trauma) that he or she doesn’t want to tell me, didn’t know was important to tell me, or literally couldn’t tell me.

Essentially, knowing the whole body is critical to my becoming a good doctor and being able to successfully guide my patient’s treatment.  Who would have thunk it?

(P.S.: There is some recent evidence to suggest that optimism may alter immunological function, and possibly improve chances of survival and healing of any illness, so perhaps other medical fields can benefit from learning about how improving the mind literally improves the body, even beyond the placebo effect!)


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Categories : Of Health & Medicine

Take A “Me Day” Today!

17 08 2010

Today will be my first day of medical school, and I’ve tried to downplay how big a deal it is to me, but the truth is that my life is about to change forever.  This is not just more school for me; this is my dream being realized.  This is my greatest passion being pursued.  This is the first day of the rest of my life.  And mentally I am prepared, but only because I spent all of yesterday doing nothing.

Actually, that is a lie.  I spent all of yesterday emotional while watching episodes of Grey’s Anatomy on DVD.  I know it’s a tv show, but I’ve always been extremely empathetic (some may say overly so), even for characters on a tv drama (or even comedy), and I related to them even more than usual because in a very short time, I will have to make those same decisions that affect life and death, that challenge values and morals.  (All my Scrubs, House, and Grey’s Anatomy wisdom will finally come in handy!)

Watching Grey’s was my way of preparing emotionally for a very real future.  A future that up until today, was still the future.  And the only way I could confront this impending reality was to do nothing except watch dramas on tv.

And then I realized what I was doing: I was having a “Me Day”.

One of my most cherished mentors told me that she often schedules “Me Days” in her calendar so that she could do nothing but sit in front of the beach all day with a book or two, allowing absolutely no interruptions.  Her life is so busy that she needs to put these days in or she would never make time for herself.

Not everyone schedules “Me Days”, but I think we all need them to stay energized.  Looking back on the most stressful times in my life, I remember a lot of days when I felt like I accomplished nothing except watching an entire television season (or several) in one day.  I would get so upset with myself for “wasting” the day(s), but now, I think that they were vital for my mental well-being.  Some people go to the beach.  I stay at home alone practicing for the tv show marathon Olympics.  (I think I do this as an emotional workout and to put my own life in perspective, but that’s beside the point…)

Everyone’s definition of a “Me Day” is individualized, and my point is that what you do to recharge doesn’t matter, as long as you take the time to do it.  If you’re the type of person whose calendar fills up a week in advance, maybe it’s time to physically schedule in some “Me Time”.

Think back – when was the last time you took a “Me Day”?

While you take some time to ponder that, I will be diving headfirst into Frosh week and coming out a new June.  I will be meeting and bonding with the people who I will party with, study with, complain with, and who I will need in order to survive my many years to come: the future that has suddenly become the present.

I absolutely cannot wait.

See you on the other side!


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Categories : Of Health & Medicine, Random Thoughts About the Mind

Don’t Wait to Get Burned!

21 07 2010

I love getting sick.  

It is one of my favourite pastimes.

Now don’t get me wrong.  I don’t like getting seriously sick.  But when it’s a cold or even the flu – when it’s something manageable – I take it as my body’s way of telling me to slow down.  I’m doing too much and I need to stop.  I love my body for telling me what to do and for putting me in my place.  Not feeling well also has the unintended consequence of limiting how much I feel like eating, which forces me on a diet I could otherwise not maintain =).

Getting sick also provides a guilt-free way of getting out of commitments – everything from class to work to social engagements that you really want to go to but really shouldn’t – because your health needs to come first.  If we don’t have our health, we cannot achieve all of the things that we hope to achieve in life, so I appreciate my body taking me hostage and making me rest.

Falling ill also means being taken care of like a baby again.  Unfortunately, that trick only works when there are people who can actually be here to coddle me like a child…

It can be rewarding when you can successfully take care of yourself.  Whether that’s the effects of Tylenol, rest, and orange juice when I have a cold; the effects of physio and hot yoga on my knees; or the general effects of diet and exercise on my cholesterol levels, I respond well to tangible results of my efforts to prioritize my health.  It’s satisfying to be able to practice what I may preach as a potential future doctor, and it’s nice to know that I can take care of at least one patient.

Most importantly, not feeling well forces us to think about the underlying cause.  For me, the underlying cause is usually stress, both because stress creates an unnecessary burden on the immune system and because stress leads to the loss of priorities like eating well, sleeping sufficiently, keeping in touch with loved ones, and exercising regularly.  Obviously, the stress for me right now comes in the form of moving, and it means that I need to be realistic about what I can and cannot achieve in the short couple of weeks before I leave, and make action steps to achieve what I can.  Once I write out all the tiny steps leading up to a big step, like moving, I try to completely forget about all the steps until Google Calendar sends me a friendly reminder that it’s presently time to deal with this bite-sized, manageable piece of the step.  Planning to de-stress is the only way that I can.

Often, life keeps us busy, and our health becomes one of our last priorities.  It is not until something happens to us that we take a look at how roughly we’ve been treating ourselves, and decidedly make a change.

When I had to get physio for my knees, I started doing hot yoga to make them stronger.  When I found out I have high familial cholesterol, I eventually lost 20 pounds over the course of a year based on diet and exercise.  When I found knots in my left rhomboid, I started noticing all of the right-handed things that I do (like using a mouse) and tried to alter habits so that I am less biased in terms of muscle use (such as by brushing my teeth with my left hand).  Although these issues can be treated, treatment cannot compare to the effects of prevention.

My knees will always be so weak that I cannot run for an extended period of time, my high cholesterol has likely done its damage on my retinas and other parts of my body, and the knots in my left shoulder will need to be dealt with for at least a while.

Unfortunately, too often we wait until we get burned before we even realize that there is a problem, and I’ve been burned one too many times.  There are some things in life we do not want to wait to see the consequences of before making a change.  When one is addicted to nicotine, catches a sexually transmitted infection, develops clinical depression, finds knots in one’s shoulder, or realizes that existing relationships are not as strong as they used to be, one may find that the consequences of our decisions and actions (or lack thereof) may not have been worth the thrill of the risk, or the comfort of neglect, after all…


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Categories : Of Health & Medicine

My Final Paper @ UBC!

27 06 2010

That’s it.  I’m done.  Today, I have officially finished my last course at UBC (at least for the foreseeable future), and I become an alumnus.

I have had several conversations about being essentially graduated and I have mostly avoided talking about it.  Mostly avoided confronting this reality, because it should be a happy occasion, and it’s not.  But more on that later…

For now, I wanted to share my final paper for my HIV course below.  We were allowed to write on pretty much any topic we wanted in relation to HIV, and I wanted to explore why HIV transmission is still so high in the gay population even though education, prevention, and treatment programs have been targeted at this population for a very long time.

Please feel free to share any thoughts and comments!

“Exploring the Role of Psychological Factors in Decision Making for HIV Transmission & HAART Adherence in Homosexual Males

1. Introduction: Why Psychological Factors Matter for HIV in Gay Men

AIDS became thought of as a gay man’s disease starting around 1980, when gay men showed symptoms of PCP and the HIV virus was not yet discovered or attributed to AIDS.  To this day, in BC, there are over 150 new cases of HIV in men who have sex with men (MSM) per year, around 50% of all new diagnoses.  MSM also has the highest total HIV prevalence, ahead of intravenous drug users and heterosexual contact.  The question then becomes why HIV is still such a problem in the gay community today even though its members were many of the first to receive monitoring, treatment, and education for HIV. 

Our preventative and educative measures are failing because sexual decision making is a particularly complicated psychological issue for homosexual males, and this complexity extends to HAART adherence.  Here a distinction is made to focus exclusively on men who identify as gay, which is a subset of the MSM population.

2. Psychological Factors on Transmission

A study in Rio de Janeiro, Brazil (Elkington et al. 2010) distinguished between three domains of mental illness stigma and how each domain associated with sexual activity.  The domains included personal experiences of stigma (e.g., “Has anyone made fun of you because you have a mental illness?”), perceived attractiveness (e.g., “I am an attractive man/woman”), and the belief that having a mental illness restricts opportunities for romantic relationships (e.g., “People think men/women with mental illness are sexually undesirable”).  Even though there were three domains, only those who reported greater relationship discrimination stigma were significantly more likely to be sexually active and to have unprotected sex.  Even though these findings were regarding mental illness, they hold important implications for HIV risk behaviours in homosexual males.

The aforementioned study clearly outlined how stigma affects sexual behaviour, potentially contributing to the continual prevalence of HIV in the gay population.  Roehr (2010) describes how institutionalized homophobia and religious extremism have fuelled Africa’s HIV epidemic, as a gay Kenyan wedding leads to riots shutting down an HIV clinic for two days, two gay Malawians are sentenced to 14 years’ hard labour for hoping to wed, and Uganda proposes capital punishment for homosexual acts as well as punishment for families, friends, and colleagues who do not report them.

Though to a lesser extent, such institutionalized homophobia can be witnessed even in the developed world, with examples including the Don’t Ask, Don’t Tell policy and state bans on gay marriage in the United States.  Even in Canada, where gay marriage is legal, institutionalized homophobia still exists with such antiquated policies as banning men who have had sex with at least one man since 1977 for blood donations.  This blood donation policy saved many lives when technology failed to accurately screen blood for the HIV virus.  However, that is no longer the case, and the policy today stands as discriminatory behaviour against MSM, an institutionalized judgment that MSM, even though they were born this way, are all public health risks regardless of the individual.  Martucci (2010) describes how in the US, federal Committee members used the underlying flexibility in the meanings behind the term MSM to justify continuous support of a similar policy there.  Just because there is a higher prevalence of a virus in a certain population, it does not justify such institutionalized discrimination.

Unfortunately, although reversing institutionalized homophobia is important, that is only the first step in eliminating homosexual stigma, as individual homophobia will still exist in the community.  On Britain’s Tonight programme, Afraid to Be Gay, members of a community admitted to accepting gays in public but not being comfortable with seeing homosexuals holding hands on the street or performing in sports.  This type of individual homophobia is passed on within families and within communities, and it will take governmental policies and support to educate and eradicate this homophobia over many generations.

Homophobia in the community also leads to internalized homophobia in the individual, and this has been linked to unprotected anal sex when individuals believe that getting the virus is based on fate rather than choice, or when they are overly optimistic about the effectiveness of HAART (Yi, Sandfort, & Shidlo 2010).

In the aforementioned study about mental stigma in Brazil, an interesting point that was articulated was that being victims of stigma (e.g., being made fun of for being gay) and having a low self-image (e.g., not feeling sexy) do not necessarily lead to risky sexual behaviour.  However, feeling that others will not find them attractive or will not want to be in a relationship with them led the individuals to unprotected sex and multiple partners.  This is a key finding that can be applied to the gay population, because it addresses one of the reasons why gay males may not use condoms or be monogamous even though they may understand these risks for HIV.  Part of the issue is again that stigma has forced many men to hide their sexuality and lose hope in ever having an open relationship with another man.  This created a culture of substituting multiple-partner sex for relationships, and many gay males may find sex as the only form of validation for their attractiveness to other males – the extent of a relationship for many.  Thus, when long-term relationships seem unattainable and sex becomes the highly valued substitute, it becomes difficult to negotiate safer sex.  This is confounded by the low proportion of gay males in the male population to begin with.

The ability to negotiate safer sex as a vulnerability to HIV transmission is often a psychological barrier for homosexual males.  For younger gay males, selecting older partners is common for many reasons, including because the proportion of males coming out increases with age group and because of personal partner preferences.  Coburn and Blower (2010) describe how the selection of older sex partners is an important risk factor for HIV infection for young MSM because HIV prevalence is very age stratified, with prevalence in older men (over 30) almost twice as high as in younger MSM (less than 30 years old).  However, young gay men with older partners are at risk for HIV not only because of the greater chance of encountering HIV, but because young men are at a disadvantage when negotiating safe sex.  This could be because of trust for the older man in terms of sexual decision making, physical inability to refuse unsafe sex, a heightened desire to please his partner, and/or other reasons.  This imbalance of power in decision making is reminiscent of a similar gender imbalance in many heterosexual couples.

3. Psychological Factors on Adherence       

Unfortunately, stigma not only plays a role in how HIV is transmitted, but it affects treatment decisions, as well.  For example, internalized heterosexism, or the internalization of societal anti-homosexual attitudes, are not only associated with unprotected receptive (but not insertive) anal intercourse with HIV-negative or unknown HIV status partners, but also with HAART non-adherence indirectly, through increased negative affect and more regular stimulant use (Johnson et al. 2008).  Interestingly, this highlights the common conflict between internalized homophobia and being the receptive gay male partner.  However, more importantly, it underlines the need for mental health experts to help address potential internalized heterosexism in HIV prevention and treatment with HIV-positive, and –negative, gay men. 

Adherence in HIV-infected gay men is dependent on a complex and interrelated set of circumstances, including the availability of “MSM-friendly” health providers, cultural factors (such as fear of being deported or family/religious repercussions), concerns about physical appearance, practical considerations (like being able to remember to take the drugs), motivational prerequisites (believing in HAART and wanting to treat the HIV), and the availability of emotional support (Brion & Menke 2008).  A key observation is that all of these factors influencing adherence is directly or indirectly related to the need to feel accepted and embraced in one’s community.

One successful method of maintaining adherence to HAART has been the practical support of gay male partners (Wrubel, Stumbo, & Johnson 2008).  This support included reminders that were regular or situational; instrumental assistance, such as setting out medications at dose time and picking up refills; and coaching support, including situational problem-solving and shaping behaviour by offering affirmations.  Unfortunately, the prevalence of long-term monogamy in gay males is low, in part due to the previously described stigma, thus limiting the practicality of partner support for many in the HIV-positive gay male population.

One type of counselling intervention administered prior to initiation of HAART and combined with follow-up phone support during HAART suggested cost-effective prolongation of the individuals’ lives, but only modest benefit for prevention of HIV transmission (Zaric et al. 2008).  Such an intervention may be an avenue to explore, but the study also suggests the need to clarify how individuals view treatment versus transmission.  Whether individuals see treatment as prevention or completely separate the two will help dictate future health policies and programs to educate and treat the public.

4. Conclusion: Implications for Change

Walch et al. (2010) looked at community attitudes toward homosexuality as a function of age, education, race/ethnicity, religious affiliation, political party affiliation, and personal contact with homosexual individuals and persons living with HIV/AIDS.  All factors, besides race/ethnicity, were associated with homophobia, but a significant portion of the variance in homophobia was predicted by having personal contact with homosexual individuals.  This finding is important because it suggests that eradicating homophobia simply requires getting to really know, and one presumes to like, a homosexual individual.  This helps explain the importance of gay celebrities, like Adam Lambert and Neil Patrick Harris, in changing the tide of public opinion, and it also points to potential directions for government intervention, such as leveraging gay celebrities to have discourse with students in schools about homosexuality and homophobia.  In Afraid to Be Gay, famous rugby player Gareth Thomas had a dialogue with students about how homophobic comments hurt him, and he was able to start helping students understand why their actions and words matter.

It is this author’s opinion that homophobia is the single most important underlying issue leading to the prevalence of HIV transmission in the gay male population.  In order to change this, education about homosexuality, HIV, and homophobia needs to happen in high school, when students are starting to think independently from their parents and are starting to form lasting values and opinions about the world.  This stage of life is where governments need to intervene to start eliminating homophobia from this generation on.”

IHHS Final Paper References


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Categories : Of Health & Medicine, Science Rules, University-Related

Why All University Courses Should Be Like This.

20 06 2010

I learned about the video above from the HIV course I’m taking at UBC (IHHS 402).

The video is of our former Canadian Minister of Health (and current Minister of other portfolios), Tony Clement, talking about InSite at the 2008 International AIDS Conference.  InSite is a centre on E. Hastings where addicts can come with their drugs to a place with nurse supervision, clean needles and other drug use equipment, and non-judgmental support.  It has treated over 1000 overdoses (and prevented deaths), it has encouraged more members of the community into detox programs (there is a detox centre upstairs called OnSite), and there are dozens of peer-reviewed scientific articles supporting its necessity and success (I suggest starting with a search on “Insite” or “harm reduction” on pubmed.com or Google Scholar).  InSite is based on a model of harm reduction, which is about reducing the harmful consequences associated with recreational drug use, but that is not what this post is about.  I could comment on how both the BC Supreme Court and the BC Court of Appeals both supported the continued operation of InSite but the federal government still intends to use taxpayers’ money to appeal to the Supreme Court of Canada, but that is not what this post is about, either (but I invite you to read about it).

In the video above, Mr. Clement loses some cool near the end, concerned that someone will put this video on YouTube (he was right to think that someone would).  I could write about how I believe he is misinformed about some of the issues surrounding harm reduction, such as his belief that harm reduction is akin to palliative (end-of-life) care, but that is not what this post is about.  I could describe how I think Mr. Clement’s views on harm reduction may be due to the misunderstanding that addiction is a choice rather than a mental illness (and often a manifestation of a long history of psychological isolation, neglect and/or abuse), but that is not what this post is about, either.

Those who know me would know that I would do anything to avoid confrontation, and this post touches on a controversial topic much more than I am usually comfortable with, but that is what this blog post is about.  This HIV course has taught me enough to make me speak up, and I think that is what all university courses should strive to do with their students.

University courses are not just supposed to educate, they are supposed to bring awareness of subjects so that we, as students, can be inspired to take that knowledge and change the world with it.

University courses should tell us about issues in the world that make us excited, angry, depressed, and frustrated so that we are motivated to do something with our bountiful knowledge.  We are privileged to be able to go to university, and I think we have an obligation to take our position of privilege and do something with it.  We may run into walls or even run the wrong way for a little while when we’re impassioned and on fire, but I think that is what we are supposed to do, at least when we are just starting out.

I wanted to share the following journal entry for my HIV course, because writing this was when I realized how this course has changed my life.

“As I reflect on my progress through this course, I realize that my first week was about being overwhelmed with information and feeling powerless.  My second week was about realizing that education equals power to make important changes.  And this week, my third week, has been about passion.

This course is really more of a journey than a course.

Going to the Eastside Pharmacy was life-changing.  Never have I thought that I would be interested in working at a pharmacy, but that was because I never visited a pharmacy that was so integrated into the community.  By integrated, I mean that members of the community literally cannot survive without the pharmacy.  Every staff member knows every client by name and knows exactly what each client wants.  Alex, the owner, happily gives out timbits when they’re available, and he fed me a delicious lunch even though I should be paying for their food to thank them for the amazing knowledge and experiences bestowed upon me.  I learned more there about the harsh realities facing members of the community than at any other placement, and it may have been because the clients there were willing to divulge stories of their lives to the pharmacy staff the way they would unload on family members or close friends.  Alex lets women sleep in his pharmacy because he knows that they need their rest during the day if they are to be able to protect themselves at night.  What other pharmacy would do that?  What other pharmacy would console, hug, and then personally make an appointment for a patient at a clinic that doesn’t make appointments just so the patient could deal with her anxiety?  What other pharmacy would urge their patients on the streets to go home when it’s late and waive drug dispensing fees for them when necessary?  When we heard that a woman died after being beat up by her pimp, the staff members mourned the passing like they would a dear friend.  Eastside Pharmacy does all of this because these individuals are not their clients or patients, but their extended family.  The staff members work there at lightning pace because they know their family members cannot stand to wait too long.  They are all grateful to be able to work there and make a difference for their extended family.  I may be wrong, but I think very few pharmacies in the world are this valuable to their community.  I am thankful to have been able to have been part of such a cornerstone for the community, even just for one day.

At Eastside, a client told a pharmacist that another pharmacy in the DTES was offering to “lend” $20 a day for methadone clients.  I did not fully understand the ramifications until it was explained to me…  Since methadone is the prescribed substance (often mixed with Tang orange juice!) most often used as part of heroin replacement therapy, the government offers extra money incentive to pharmacies that will accept methadone prescriptions, for fear that not enough pharmacies are willing to serve drug addicts.  The problem with this incentive is that it allows for criminals to take advantage of the system.  Pharmacies that “lend” $20 a day to methadone clients are essentially drug dealers that want to make the extra money from the government and will bribe clients to go to them.  Furthermore, these pharmacies are legally obligated to watch their clients consume the methadone to ensure that they are getting the medicine they need and not selling the substance outside, but the drug-dealing pharmacies often do not care whether the clients use the methadone or not.  Learning about such criminal activity makes me angry, not just because they are stealing tax payers’ money, but because they are ruining people’s lives.  When you have a pharmacy that is out to make money rather than care for their patients, you mess with the community’s lives, and that is not ohkay.  It is infuriating, and learning about this crime was one strong reason for why I have decided to pursue lifelong work in public policy.

The other bit of inspiration that has led me to wanting to dedicate part of my life to health policy came from Thomas Kerr.  When he explained how the RCMP repeatedly paid researchers to try to overturn evidence for harm reduction, how the government used their influence and power to discourage and ban funding for harm reduction, and how the former Minister of Health Tony Clement completely misunderstood what harm reduction is all about, I realized that scientists need more people on the inside of government and policy making to help translate fact into policy.  I do not really believe that government officials would intentionally deny scientific fact – they are simply at the mercy of public opinion and the media.  They need experts who can help them understand the scientific evidence for important matters like harm reduction (and climate change) and how policies need to change, but they also need these same experts to work with them to develop a strategy on how to educate the public and garner popular support for these controversial decisions.  This is a niche that I believe needs to be filled, and it is a niche that I think I belong in.

I have looked up McGill’s Health Policy Fellowship program, and I will be finding out more information about how I could possibly integrate an education in public policy into my MD-PhD.

So you see, this week to me has been about passion.  Passion to not let this course just be like any other course.  Passion to take what I have learned and do something important with it.  Passion to take action, get out there, and make a change.”


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Categories : Of Health & Medicine, Science Rules, University-Related

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