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

Keeping the End in Sight.

27 07 2010

As of this moment, I am still stressing over my impending permanent translocation across the nation.  There are many things I can be doing instead of writing this blog post, but I needed to take a break to write in this blog.  Because it is a weekly ritual.  Because it is cleansing.  Because it is part of critical maintenance for my mental health.

I cannot put into words how much I appreciate those of you who have taken the time to read this blog, and comment, but the truth is I write these posts as much for me as for anyone else.  To record my journey through life, through change.  To remind myself of where I come from and how I got to today.  To have a written history of my values and opinions, so that I can question myself if they change.

As I continue to pack and sell all my belongings, I feel overwhelmed – my head swirling incessantly of to-do items.  My greatest fear of the moment is that I drop something critical in the midst of this chaos.  The physical chaos of my apartment.  The mental chaos in my mind.  The emotional chaos from the inside out.

I realize that it is now, when I am stressed beyond belief, that it is more important than ever that I take steps to maintain my mental health – my sanity.  Writing in this blog is one way to support this endeavour.

This post constitutes a written agreement to myself that I will not let the tiny details and logistical failings that are bound to happen in the next week set me back.  At the end of this week, I will be sleeping in magnificent Montreal with wonderful new individuals waiting to be met, and I will know that I have made it all possible myself.  I will remember how stressed I was this week, and I will laugh at the silliness.  

For the first time in my life, I will be able to say that I stood on my own two feet.  I moved all by myself (with a lot of support from everyone around me, but I was the driver and not the passenger).  I chose McGill.  I sold our cars.  I arranged for the movers.  I know what exactly was thrown away, what exactly is in each box, and which boxes are being shipped to China instead of Montreal.

For once in my life, I am the master of my own domain, and it is strange.  I am living under my own roof, in control of my possessions.  In short, I am on the road to independence.  And that is the bigger picture.

Whatever we go through, I believe there is a lesson to be learned.  Nothing is wasted experience or wasted time.  We grow, we make mistakes, we try not to make them again – not necessarily in that order.  What gets us through those impossible days is knowing that we will make it through them, and we will become better people for it.  

When I was in the Science One program at UBC, it was the toughest year of my life.  My average dropped 15% from my high school average, and mostly due to a self-fulfilling prophecy.  There was a night when I just laid on my bed in the dark, staring at the ceiling, and I could not breathe.  I could not breathe because a project due tomorrow was worth 5% of 27 UBC credits, and I had not started.  I did not know what I could do, and I felt like the greatest failure in the world.  

That year was hell for me, but it forced me to swallow a lot of hard lessons.  Lessons about how my pride got in the way of asking for help.  How the greatest obstacle to my success is always me.  How I always try to do too much (this lesson still being learned and refined…).  How I will always fail when I choose activities based on what sounds good rather than what feels right.  And how nothing is a substitute for pure hard work.  

That year was hell, but that year prepared me better for the rest of my undergraduate career (and possibly my life) than I think anything else could have.  

So often, when we are going through torturous experiences, we wonder why in the world we could be so unlucky (or why we chose this for ourselves).  It is interesting to note, though, that it seems to be these same experiences of adversity that create our world’s greatest leaders.

I think that we are only failures if we don’t learn from our mistakes, if we do not make something of our rough journeys, if we do not create better selves from our fragmented pieces, if we do not turn the threats into opportunities.

I suppose that the more intense the experience, the greater the potential reward.  That belief is what will get me through the rest of this week…

The next station is Montreal.  Montreal Station.  Independence Drive =).


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Categories : Random Thoughts About the Mind, University-Related

Letting Go Is Hard To Do…

6 07 2010

In the last couple of weeks, I have avoided talking about the happiness of finishing my last course at UBC, graduating, and heading to McGill because it means that I finally have to face the reality that I have to leave.  And with that, I have to deal with all the delightful chores that accompany such a move.  For me, the hardest part of this entire process is picking what to hold onto and what to let go.  Unfortunately, I don’t just mean my possessions.

Picking which clothes to donate, which boxes of class notes and papers to throw away, and which pieces of furniture to sell suggest an extended metaphor of having to make some similar decisions regarding connections, attachments, and relationships.

Relationships change over time for many reasons.  

As we grow up, our values and beliefs may begin to deviate from our parents, and especially as we leave the nest, we may have to break off the patterns of old relationships and individuate separately from each other (parents need to grow separate from us, as well!) before forming a new type of bond with them.  My counselor was explaining to me how sometimes parents cannot recognize that their children have become different people, and it can be hard for them to accept that a new relationship needs to form.  Accepting that parent-child relationships evolve can be difficult, and for some, it may be impossible.

But friendships evolve as well.  A good friend of mine explained how she and her best friend in high school were practically twins, but she went into one faculty at UBC, and her friend went into another, and now after they have received their degrees, they have almost nothing in common.  Personally, I believe our experiences as undergrads make such a lasting impact on who we become because the adolescent/young adult years are when our prefrontal cortices are most sensitive to synaptic pruning by our experiences.  The prefrontal cortex is implicated in memory formation, executive function, decision making, and expression of personality, so how this brain region develops is key to who we become as individuals.

Certainly, relationships with our most intimate partners change over time, as well, as our passions or underlying values may no longer align.  Or perhaps they never did, but the sparkle of getting into a new relationship prevented us from seeing that from the beginning.  I enjoy the tv show How I Met Your Mother precisely because in all its humour, they portray relatively realistic perspectives on relationships.  The main character, Ted, falls in love with Robyn, and the audience may think that they fall into an annoying on-and-off relationship the way that Ross and Rachel did on Friends.  However, the writers cleverly jumped off of that boat, because in the end, Ted wanted children and loved growing roots in one place while Robyn loved being unattached and spontaneous.  Their core values were not aligned and in my opinion, two people cannot be together without that.

Having said all that, I can accept that all relationships will change over time.  However, I find myself refusing to accept change that is forced upon me by the reality of having to move to a new city.  I find myself still creating roots for myself in Vancouver, making great new friends and connecting with new people, even today, because I desperately want to hold on to my city, my home.  It is as though a tornado is coming to uproot me and I am trying to resist with all my might.

And then I thought about Toy Story 3.  I remember loving that movie, and I remember so many people raving about and crying at the movie.  And why is that?

My theory is that it’s because the movie is about the universal feeling of loss or questioning of one’s purpose and love when situations change.  Parents see children off to college.  Children deal with leaving the nest.  Someone older may have to confront the changing meaning and focus in their lives as they retire from their career.  And of course, all of us have dealt with loss in one way or another.

The movie resonated with everyone because it was about what happens when an unavoidable situation forces us to make decisions about who we want to be, where we want to go, who we want to spend this new chapter of life with, and what we have to give up.  

I have fiercely procrastinated from everything I have to do to move, because I’m scared that all of my existing relationships will change.  Not being able to hug my dear friends, give them high fives, or hang out in a group playing baseball or board games will inevitably change the nature of my friendships.

I fear that when I leave, I will lose my friends.  But I realize now that that is a mistake.  I should really look at moving as a blessing, because I am forced to realize how much my friends mean to me, so I have to make a conscious decision to make the effort and keep in touch.  It is a blessing that I get to head to a whole new city, where new friends undoubtedly abound.  It’s like in Toy Story 3, the toys head to a new home in the end and leave their old one, but they always have the memories with Andy, and now they get to form new ones in their new home.  Andy is my Vancouver, and the toys’ adventure and goal to stay together, well that should be how fiercely I fight to maintain the important relationships in my life, even if a whole new chapter is about to begin.  If they are important to me, I need to find a way to integrate them into my new life.  (Sorry if I spoiled the movie for you…)

I guess at this moment I can finally accept the fact that I have to move on with my life and embrace the new.  I have to learn from some of my closest friends, who I think the world of: Take the leap and jump into the wind, knowing that you have prepared yourself enough for a soft landing, trusting that this wind will take you where you are supposed to go.

Oh, man.  I need to pack.


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Categories : Random Thoughts About the Mind, University-Related

What Does It Take To Become An Adult?

6 07 2010

Today, one of my best friends and I had one of the biggest disagreements we have ever had, and it got me to thinking:

What does it take to become an adult?

He said that he wanted to repay his parents for his college tuition and living expenses and then buy his own place to live, and that, to him, was growing up and becoming an adult.  My visceral response to that was extreme disagreement, but I had to dig deeper within myself to understand why.  Financial independence and owning my own place would not make me an adult, in my opinion, although these are certainly cultural milestones for growing up, along with getting married and having kids.  The problems I have with these milestones are multifactorial.  In a recent How I Met Your Mother episode, the main character, Ted, buys a house in reaction to his mother marrying a second time, essentially “lapping” him in terms of relationship milestones.  He cannot control falling in love, getting married, and having children, so he does the one thing he has control over: buying a house.  The issue I have with this line of thinking is that it puts a time pressure on getting to these so-called milestones, even though many in today’s society do not fall in love until their 40′s, 50′s, or 60′s.  Furthermore, some of us may never get married or have kids.  Does that mean we will never grow up?

My argument was that it is our mental growth, and not physical possessions or milestones, that make us an adult.  When we start to understand another person’s perspective, when we see shades of grey to any controversial topic, when we have understood our passions and gained the skills to dedicate parts of our lives to them, these are the types of milestones that really matter.  These are the milestones, in my opinion, that make us adults.  We are not allowed to drive, smoke, or vote before a certain age, mainly because it is an arbitrary number assigned to when our cognitive abilities, on average in the general population, have developed to a level that allows us to make rational decisions about these important matters.  At least this is the hope.  

I realize now that my own definition of what it means to be an adult comes from my mother: she always told me that physical assets can come and go, but no one can take the knowledge and the experience away from my mind.  (She may or may not have taken Alzheimer’s into account when she said this…)

But then I thought about my blog post on moving to Montreal.  When I wrote that, I genuinely believed that moving to a new city by myself, apart from my parents, and starting a whole new life there on my own, contributes greatly to my becoming an adult.  I guess it means that the physical changes in my life complement or help express the cognitive changes that have allowed me to become the person that I am today: an independent and competent adult who can take care of himself in a brave new world.

So what are the pre-requisites for no longer being a child or an adolescent?

In the end, I think the answer is highly personalized and it’s a combination of physical milestones and mental growth.  I think I had such a visceral response to my friend’s initial argument because I am not going to be able to afford to buy my own place for a very long time, and I can’t be sure of what the future brings, so I was hesitant to agree to any standard of adulthood that would not classify me as an adult any time soon.  But this type of narrow-minded thinking is exactly the lack of mental growth that, based on my own criteria, would render me a child.  And in any case, is never being an adult really so bad?

I don’t know… what do you think?


Comments : 4 Comments »

Categories : Random Thoughts About the Mind, University-Related

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

Seeing Beyond What We Want to See…

15 06 2010

The following is one of my journal entries for the HIV/AIDS Care & Prevention course I am taking at UBC (IHHS 402).  It is the best course I have ever taken at UBC and I am thankful that I get to end my UBC journey with it.

I wanted to post it because I find it demonstrates the power of opening oneself up to seeing beyond what we want to see, and how that makes all the difference in the world…

“Thinking about my journal entry last week, I realized that the course seemed to focus on the negative because I chose to focus on the negative. A classmate told me that she looked at the course as unveiling knowledge of the pertinent issues surrounding HIV/AIDS so that we as a collective can work on improving the situation. Rather than looking at it as depressing, she chooses to look at the course as empowering, and she is right. We need to know what stigma is and what the current situation is in the Downtown Eastside and for other vulnerable communities so that we can work to make it better. That is what this course is about: empowerment.

It is funny how deciding to change one’s perspective changes everything.

This second week has opened my eyes to the optimism of the current situation regarding HIV/AIDS. Mark Tyndall joked about no longer needing this course in 2030, and I can finally understand why he would say that. It is because there is hope.

The Dr. Peters Centre showed me what all support centres strive towards. It is truly holistic patient- (or participant-) centred care, with harm reduction, non-judgmental therapy options (like acupuncture, music therapy, and spas), and free healthy meals. I was shocked when Ellie, the dietician, told us that one of the prerequisites for becoming a participant is being HIV+. I was shocked because nothing at the centre reminded me of HIV and I had forgotten. The Dr. Peters Centre simply strives to provide the comforts of home to participants, and the participants are simply striving to live their lives to the best of their ability. The centre is a model residence, and the only issue is that it is too small.

When I visited the Lion Hotel and received a tour of the Downtown Eastside by the Tenant Support Worker that was working there as part of Lookout, I was struck by what a fantastic community the Downtown Eastside (DTES) actually is. I passed by so many of the buildings on Hastings, etc. before, without daring or caring to look inside of them. When I finally stopped to take a look on Thursday, I found Francisca Sisters passing out hundreds of free hot and generous lunches to people in need. The Living Room making delicious pasta salads for dinnertime in their pink kitchen, and providing activities for members, including karaoke, trips to the Museum of Anthropology, and swimming. As my talented tour guide expressed, food is not the issue in the DTES. In fact, community is not the issue in the DTES, either. I saw so many residences full of life and people just getting on with their lives. At the Lion Hotel, the landlord was building an interactive social area complete with a television so that the tenants could have a place to gather and build a sense of community and ownership. Everyone in the DTES cares about each other, and I am so proud of that community and to be part of it in some small way.

It was interesting to learn about the Woodward (a whole block of buildings being developed at Hastings & Abbott, kiddy corner to Victory Square), and how it is an experiment with $1.1-million condos built directly next to social housing for lower income individuals (aka the previously homeless), complete with an SFU campus site. I think that experiments like this is the beginning of the destruction of stigma and segregation, but only if done carefully.

There is tangible hope that the HIV virus can be stopped if we can stop it from manifesting as a social and political illness. And I personally believe there is hope that the underlying causes – prohibition, institutionalized homophobia, lack of support for the Aboriginal population, stigma, etc. – are changing for the better. One day at a time, but it is progress.

And that is what this course is about: the progress that all of us can help make in this world with the proper awareness that this course provides.”


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Categories : University-Related

Learning to Embrace the Scientist in Me…

4 06 2010

As my peers graduate this week, I think about what my B.Sc. will mean to me.

As a scientist, I am equipped to question the accepted beliefs of today and create questions to direct the future.  Just because marijuana is illegal, is it more dangerous than nicotine or alcohol?  How do we rectify national and international stigma (and lawsuits) surrounding InSite and other harm reduction centres with scientific evidence that it works much better than prohibition of drugs?

We, as scientists, are taught to base our beliefs on the evidence rather than the norms of the day.  We are made to understand the importance of critically assessing the primary literature instead of solely embracing Wikipedia.  Some of us are inspired to do the research ourselves, which will inform environmental, health, and even political policy.  These lessons are some of the distilled essences of what we have learned in our years.  This is the value of our degree that will carry us into success in whatever profession we end up in – law, medicine, student development, science, business, public policy, government, advocacy, NGOs, community development, or whatever the case may be.

As a scientist, I’ve noticed a tendency in myself (and others) to avoid being labeled as just a scientist, because it carries a lot of stigma.  ”You are a scientist, so you must be wanting to go into medical school.  Everything you do must be a calculated move to go to medical school.”  And so to avoid such judgment, we identify as everything else before we identify ourselves as scientists.  We avoid talking about our love for science or medicine, because in some ways we are forced to feel ashamed about it or fear the pressure of telling others coming back to bite us if we end up not applying or not being accepted into medical school.  We, as science students, are forced to live through the assumption that we are all applying to medical school (which carries all sorts of negative connotations) and then we are also judged if we decide that we genuinely do not want to do medicine (“Aww…it’s because you weren’t accepted, isn’t it?”)

Every one of our journeys is unique, and we should not have to justify our decisions to anyone but ourselves.  I realize as I’m writing this that as I am taking an intensive course on HIV/AIDS this month, my vocabulary and strong ideas around lingering stigma in the community have carried over into this blog post about scientists and doctors.  It is a little bit of a stretch to compare the stigma around IV drug users or HIV+ patients or homosexuality to that of scientists, but I’m taking the metaphor there anyway!

The bottom line: Yes, I love science.  Yes, I am going into medicine.  And no, that does not define who I am, but it is certainly an important part of it.

I am embracing the scientist (and the future doctor) in me, and no one is going to stop me!  I encourage you to do the same =).  My very good friend, Ms. Nancy Yao Yao, certainly knows how to embrace her inner medical nerd (or is it geek?  I hear there are big differences…).

My B.Sc. in Pharmacology at the University of (Beautiful) British Columbia prepared me uniquely for the world, and you are going to know it!

So congratulations to my amazing classmates and friends who are graduating this month – celebrating the incredible personal and professional journeys together for the last four or five or six or seven years of our lives.  I encourage everyone to embrace their inner scientist, artist, human kineticist, Sauder-ist or whatever you may be, and find the lesson(s) in your degree that you can use for the rest of your life, in whatever profession, conventional…or not!


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Categories : Science Rules, University-Related

Why making hard decisions is important.

16 05 2010

Today I officially get offered a position in the UBC MD/PhD program (a program where at the end of 8 years I get both my medical degree and my PhD).  Today, I officially thank them for the opportunity and respectfully decline.

This means that officially, as of August 17th, I will become an MD/PhD student at McGill University in Montreal, Quebec.  I’m a little teary-eyed and emotional as I write this, because sending the email to let UBC know of my decision means that I have made my decision.  When I talked with my mother before today about booking my flight, packing, finding movers, finding an apartment close to the medical building at McGill, getting car insurance in Quebec, and on and on and on about the details of starting a new life in Montreal, it all seemed like a fairytale – dreaming at a distance about what could be.

But today.

Today I am emotional because I officially close the door on UBC.  I close a major chapter in my life.  I choose to leave the place I’ve called home for 17 years, physically leave the people I love, and uproot.

It’s hard for me because I don’t feel like a grown-up.  I don’t feel strong enough to leave all the people I need to support me.  I don’t know if I have the strength to start a new life in a strange, though sexy, city.  I don’t know if I can handle all the financial matters (the loans, lines of credit, credit cards, scholarships).  I’m not sure what lab I will do my PhD in.  My French is poor, and nothing is certain for me in Montreal right now.

And those are the exact reasons why I must go there.

Ask Nathan Tippe.  I was literally jumping for joy and screaming in the UBC Centre for Student Involvement when I found out about McGill accepting me.  I told everyone I know and I was sure that I would go to McGill regardless of whether UBC decided to accept me.  And then, of course, UBC had to go and ruin everything by offering me a position with their program.

I started creating excuses for myself on why I should backtrack on my word to myself.  I told myself that financially it would be easier to stay at UBC.  I have friends who mean the world to me in Vancouver.  I can more easily find a place and move and it’s safe and it’s comfortable.  I have connections here that I should leverage to make the best of my education.  Ultimately, it boiled down to being afraid to leave my comfort zone.

Then, I had a chat with a friend I respect tremendously, and she got right at the heart of the issue.  Were you excited when you found out about UBC’s offer?  The answer…was no.

Not because I don’t love UBC – it’s my home and it’s the community that has allowed me to become the person that I am.  But at some point, I have to leave the nest.  I can always come back to do my psychiatry residency here, but I need to first leave in order to appreciate what UBC uniquely offers.  I don’t want to take life here for granted.  I don’t want to stay because it’s the easy thing to do.  Besides, Montreal offers a little taste of Europe in the heart of Canada, the ridiculously beautiful Quebecois, four universities that focus on collaboration, leading international brain researchers and clinicians, and culture oozing out of its pores.  I think I can probably make the next 8 years work…

Elisa Kharrazi posted a quote from one of my favourite poems today: “Two roads diverged in a wood and I … I took the one less traveled by”.  Difficult decisions are important, because they force us to take a look within ourselves and challenge who we are.  We are forced to consider our values and our strength, and understand what our fears are about the road less traveled.  Matt Corker’s post on a similar topic was particularly inspirational and timely for me, and I highly recommend it.

Today I take the first step on a journey that lasts 8 years.  Today I make a hard decision and I grow up.


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Categories : University-Related

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