Life's Essential Ingredients Called Into Question

When you bake bread, there are some essential ingredients. Yeast, for example, as well as flour and water. You can't make the bread without these. Depending on what type of bread you are making, you might add raisins, eggs, or cheese. But these are non-essentials.

Life is a little like bread. You need six ingredients: carbon, nitrogen, hydrogen, oxygen, sulfur, and phosphorus. Or so scientists thought.

This week, researchers announced that they had discovered a bacteria at the bottom of a lake in California that was able to grow in arsenic instead of phosphorus. This might not sound like a big deal, but it calls into question basic assumptions about the nature of life, and its requirements. It also opens the door for an understanding of life that could exist in a different way -- possibly on a different planet where different elements and nutrients are available.

Phosphorus was thought to be more or less irreplaceable because it forms the backbone of DNA. It is also a key player in a molecule called adenosine triphosphate (commonly abbreviated as ATP), which is the molecule the body uses for energy -- and therefore survival. Arsenic, on the other hand, while very similar to phosphorus in its chemical properties, is toxic to many animals.

But this strain of bacteria -- when "fed" arsenic instead of the phosphorus that it normally would use -- was able to survive, and actually incorporate the arsenic into the positions that phosphorus would normally occupy.

What a beautiful example of adaptability of an organism, and of science pushing the limits of what we know so that we can gain a better understanding of our world, and of ourselves.

(Below is a picture of the bacteria.)

The Amazing Nature of ... Nature

A "nerd," by my definition, is someone who gets really excited about very obscure and detailed things.

I'm a nerd. I know it. And I'm proud of it. (Those of you who know me personally are, by this time, shaking your head in agreement. I'm sure of it. Go ahead, it's OK. I understand.)

What do I get excited about? These days, it's often biology lectures and readings. Yes, I find my biology textbook exciting (sometimes). But obviously, it's not the textbook itself that excites me; it is the content. The amazing nature of ... nature.

Here are some things that I've learned, things I think just about everyone will find pretty amazing. (Although I will let you be the judge.) In sharing these facts, I will also try to explore their context so that you get an idea of their significance in the broader scheme of things. Because that, too, is important. And amazing.

1) I was going to save this fact (my favorite) for last, but I can't help myself. It's too incredible to leave for the bottom:

The total length of an average adult's blood vessels (arteries + veins + capillaries) is equal to twice the circumference of the Earth at the equator. 

That just sounds huge ... and it is ... approximately 50,000 miles! Incredible indeed.

But why is this significant? Because this is how all of the tissues -- and all of the body's cells -- get access to nutrients and oxygen, as well as dispose of their waste products (especially carbon dioxide). In creatures with one cell or just a few cells, all of those cells can be exposed to the environment. So oxygen, for example, can diffuse into all of the animal's cells from the outside. But diffusion -- the process of basically "spreading out" to an even concentration -- only works over short distances. VERY short distances. It won't work over many cells. So as multi-cellular animals evolved, they evolved circulatory systems with blood vessels that carry nutrients and oxygen (and remove waste) to and from all of the cells.

The veins and arteries in animals aren't responsible for much of that transfer of substances; most of that happens in the capillaries -- tiny vessels made up of a layer of what are called "simple squamous epithelial" cells, which are thin and ideal for allowing things to spread across them. We need so many miles of these vessels because we have so many cells, and they all need access to oxygen, nutrients, and a waste disposal system. Without this circulatory system, we would cease to exist because our cells would not receive oxygen, and oxygen is required for our cells to turn the food we eat into energy that the body can use to do work. It all goes hand in hand. See, I told you it was amazing!

2) Everyone knows that when we exhale, we get rid of carbon dioxide. But why? Here is the reason:

Maintaining a constant level of carbon dioxide -- not too high, not too low -- is essential for keeping the body's pH at the proper level. 

OK, don't let me lose you here. Quick chemistry lesson: pH is a measure of the concentration of hydrogen ions in a solution. In more familiar terms: a measure of whether something is acidic or basic. A solution's pH is measured using a mathematical logarithm, so this relationship might seem backwards, but trust me on this ... the more hydrogen ions, the lower the pH (this signifies an acidic solution). The fewer hydrogen ions, the higher the pH (this signifies a basic solution). A "neutral" solution has a pH of 7. Human blood has a pH of about 7.4 -- just a tad basic. Change the blood's pH and you've got BIG, BIG problems. Because a lot of the substances in the blood (especially a class of proteins called enzymes, which help facilitate all kinds of cellular reactions) only function at a certain pH range.

So back to carbon dioxide. Carbon dioxide can dissolve in the body, reacting with water to form carbonic acid. Carbonic acid is very unstable, and it "deionizes" -- breaks down into its component parts of hydrogen ions and bicarbonate ions.

Did I just say hydrogen ions? Yes. So too much carbon dioxide in the body means that the blood will become too acidic -- the pH will drop below the normal 7.4 level. On the other hand, if you get rid of TOO much carbon dioxide (for example, if you are hyperventilating) your blood will not have enough hydrogen ions in it, and will become too basic (the pH will go up).

It's a matter of precise regulation, a biochemical masterpiece.

3) In the last fact about carbon dioxide, I briefly mentioned proteins. Let me say this first: I LOVE PROTEINS. And I'm not talking about steak or pork chops. (Although I love those too.) I find proteins immensely fascinating. Their structure, their functions, what happens when you lose a particular protein function ... everything. I have a whole "protein" blog post percolating in my head. But I will save that for later.

Here, I want to talk about high fevers, and why those are so dangerous. I'm not talking about a fever of 99 or 100 degrees. That's not a big deal. It's not fun, but it's not dangerous. I'm not doctor, though, so don't take my word for it. But according to the world-renowned Cleveland Clinic, a fever above 102 degrees F is "cause for concern," and a fever above 105 degrees F is a "life-threatening emergency" and should precipitate a call to 9-1-1.

But why? It has to do (in part) with the nature -- and denaturing -- of proteins. In essence:

A very high fever causes the proteins (especially the enzymes) in the body to denture -- lose their structure.

Let me explain. Proteins are a class of "macromolecule" ("giant" molecule) in the body. Each protein is made up of smaller units called amino acids that are chemically bonded together. Those amino acids each have particular chemical behaviors so that when the protein is put together, the amino acids interact to form a special three-dimensional structure. Think about two simple analogies and you will understand these interactions (on a basic level). Consider a magnet: opposite ends (positive and negative) attract, while same ends (positive/positive or negative/negative) repel. Same goes for the amino acids that are "charged" as either positive or negative. Then consider oil and water. Oily things mix together. Water-based things mix together. But oil-based and water-based things do NOT mix together. It is this way for amino acids with hydrophobic ("water-hating") properties and those with hydrophilic ("water-loving") properties. Put a string of amino acids together, each acid having one of these properties, and you will get a shape of some sort as there are chemical attractions and repulsions. That three-dimensional shape is very important for a protein's function. Change a protein's shape, and it can (often) no longer do its job. Or at the least, no longer do its job as well.

Back to fevers: how do these affect proteins? Well, temperature affects the chemical attractions and repulsions that the amino acids have with each other. If you raise the temperature of a protein's environment too much, its structure falls apart. Which means it can no longer do its job. Which is why a high fever can be fatal -- proteins, and a specific type of protein called an enzyme, are necessary for human life. They basically keep the body's machinery operating full time. Without them, we just stop working. And being. Not good.

See, I told you proteins are cool ...

4) OK, time to switch gears a bit here. I've been focusing, so far, on humans and human anatomy / physiology. But the rest of the animal kingdom is pretty nifty too. And there is a helluva great deal of diversity out there in terms of form, function, structure, etc. First on my list are ectotherms. More commonly (and incorrectly) known as "cold-blooded" animals. The proper definition of an ectotherm, in essence, is an animal that gains its heat from external sources. An example would be a lizard or a snake. An endotherm, on the other hand, produces its own body heat. An example of an endotherm is dog, cat, etc. (Humans are also endotherms.)

At first glance, you might think that ectotherms got the short end of the stick while endotherms have the more advantageous system, in all respects. Endotherms don't need to rely on the sun or other environmental factors for body heat. And this is true. Endotherms stay plenty warm even in Arctic environments, where an ectotherm would freeze to death in an instant. That said, endotherms don't have it all made. Think about it: How do you produce heat? You have to expend energy. So endotherms have to USE energy to produce their own body heat. Ectotherms, on the other hand, can use their energy for other things. And then they don't have to eat so much. Meaning they don't have to spend so much time looking for food. For humans who have access to Jewel, Dominick's, Albertson's, or Super Target, that's not a big deal. But if you're an animal that has to hunt for every morsel, having to eat less food is huge.

But how much less energy does an ectotherm consume, compared to an endotherm? We shall use an American alligator and a human (of a similar size) as comparisons. Take a wild guess here. What fraction of a human's energy do you think the alligator consumes, at rest? One-half? One-fourth? One-tenth? Not even close. One-twentieth. Yes, you read right:

An American alligator, at rest, consumes one-twentieth the energy of a comparably-sized human.

That said, relying on the environment for warmth (and cooling) has its drawbacks. If it's cold but cloudy, staying warm becomes more of a challenge. Endotherms have an easier time with thermoregulation -- keeping their bodies at a constant temperature -- because they produce their own body heat. And thermoregulation is important because of my favorite macromolecules again ... PROTEINS! The specific kinds of proteins called enzymes, the ones the facilitate chemical reactions, are very sensitive to temperature as I mentioned before -- both temperatures that are too high and temperatures that are too low. According to my biology textbook, for every 10 degree C (18 degree F) decrease in body temperature, the rate of those reactions that are helped out by enzymes decrease two- to three-fold. That's the body starting to shut down. So for an animal (including a human) to keep its body within an optimal temperature range is key to survival.

5) Now on to insects. Which, thankfully, tend to be the size of peas, for the most part. But why?

Insects are restricted in size because they have relatively inefficient respiratory systems.

When we think of respiratory systems, we usually think of the lungs or of gills. But insects have a different system called a tracheal system. Here is a picture of what the system looks like, using a grasshopper as an example:

Insects like this grasshopper have tubes that open up to the environment. Air (and oxygen) passively diffuse in from the outside and spread into smaller branched tubes, which bring the air into contact with most of the insect's body cells. Larger insects increase the efficiency of this system by using rhythmic body movements to compress and expand their air tubes to help spread the air through their bodies. Even so, this is a relatively inefficient system, compared with that of the lungs. The reason is that diffusion -- the spreading out of a substance to an even concentration -- only really works well across a short distance. In a small insect, this diffusion process works fine. But larger animals, from squirrels to humans, require a more "active" respiratory system. So no worries, you won't see a cockroach the size of a minivan any time soon. Phew.

OK, enough biology and chemistry for one blog post. Class dismissed. ;)

A Diabetic Condemnation

I don't often describe myself as "flabbergasted." First of all, I think it's an odd word. Second of all, it takes an awful lot to shock me that much. But I was definitely in a state of flabbergast today.

The stimulus? A rather traumatic translating session at the free clinic where I volunteer.

It all started out rather routinely. The patient was a middle-aged woman with unregulated diabetes. Her blood glucose -- which should be around 90 mg per 100 ml of blood -- ranged from the mid-100s to 200, according to the self-checks she did at home. This morning at the clinic, it was quite a bit above 200, and her previous visit it had been above 300. Not good. Really not good. Clearly, her current combination of medication and lifestyle wasn't working. But insulin wasn't an option, as she had tried it previously and suffered side effects that made her afraid to take it again.

The physician I was working with was obviously frustrated at her lack of improvement. He asked me to ask her what she'd eaten for breakfast, thinking that perhaps a sugary meal was to blame for the high blood sugar that morning. Turns out she had a licuado (shake) made of banana, strawberries, and milk, plus an apple. My guess is that she thought she was being healthy, while what she was really doing was causing her blood sugar to skyrocket with all of that natural sugar. (Yes, it's natural, and yes, it's fruit, but it's still sugar.)

The doctor shook his head. "She's eating like she's going to the electric chair," he said, half to himself, half to me. But clearly not to her. "Don't translate that," he hurriedly added.

I just sat there, a plastic smile on my face. What was I supposed to say? As a translator, I'm supposed to repeat everything that is said in the exam room in the other language so that it is as if there were no language barrier. But I couldn't bring myself to repeat those words. Less for fear of angering the physician than for fear of horribly upsetting the patient. But, I will admit, both fears were active.

I'm not saying the physician had any ill will toward the patient. Quite the reverse -- he was vocalizing his frustration at her non-compliance, her lack of improvement, and her potentially grim future. (The complications of diabetes include kidney, heart, vision, and circulation problems, among others.) But he did it in a way that was not inclusive, that didn't engage the patient, but rather left her out of the loop at her own doctor's appointment -- a place where she deserved to understand everything that was going on.

I don't know what I should have done. But I know what I won't be doing when I'm a physician.

The Laws of Motion (& My Thoughts)

To paraphrase Newton (and my physics book): An object at rest remains at rest as long as no net force acts on it. An object in motion (with constant velocity) remains in motion, with the same speed and in the same direction, as long as no net force acts upon it.

Question: Does Newtonian Dymanics apply to one's thoughts?

My thoughts, you see, seem to be traveling a million meters per second. Without an opposing force, they show no signs of slowing down. And physics is the culprit, the force that put my thoughts in motion in the first place.

Well, maybe not physics itself. My fear of physics. Even more precisely, my fear of not doing well in physics.

I realize that this is a rather irrational fear, one not based on any evidence. So far, I am doing quite well in physics -- I believe I am near the top of my class, in fact. A's on my homework, labs, quizzes, even my first exam.

I have an A in the class. So why am I afraid of it?

I'm not sure. Perhaps because physics doesn't come to me quite as naturally as chemistry or biology do. I really have to wrestle with the material in physics, sometimes on a problem-by-problem basis. It's tough and taxing. Or maybe I'm scared because I have seen people work really hard in other subjects and NOT get the result (i.e., the grade) they wanted, and I see the possibility of that happening to me in physics. They don't give out A's for effort, after all. Or maybe I'm letting the pressure get to me a bit, all the talk about needing to keep your grades up, to do well in your post-bac courses ... and I'm afraid that if I don't ace physics this semester and next, I won't achieve my end goal: getting into medical school.

Regardless of the reason for why physics produces a sinking feeling in my stomach, I need to deal with it as best I can. I don't think I'm going to transform my viewpoint and suddenly *poof* love physics (although I do find it interesting). No, I don't expect magic.

But I do need to exert a force on my thoughts to slow them down. Because according to Newton's laws, they'll just keep going unless I do something.

So here's my plan: surround my physics experience with positivity. That doesn't mean light scented candles or sing happy songs while I do my physics homework problems (too distracting, not to mention just plain weird). No, what this strategy means to me is that when I wrestle with a problem (or maybe more like five or ten of them), I reward myself in some way. I call or e-mail a friend, write a short blog post, or read (a non-school book) for 15 minutes. Do something positive after physics problems so that I associate the two. Ergo, physics doesn't seem so scary.

Will it work? Will the force I exert through my "positive associations" be enough to slow my racing thoughts? I don't know. There's only one way to find out. So here goes.

(Note: Giving myself the time to write this blog post was a "reward" for doing more than a dozen physics problems today in preparation for an upcoming test. And let me tell you, I feel pretty good about things at the moment ...)

Medicine: East and West

In mid-September, I attended a lecture on traditional Chinese medicine at Dominican University. I wrote this essay as an extra credit assignment for my biology class, but thought I would share it here as well.

When I think of the field of medicine, I think of procedures, treatments, and methods based on years (sometimes decades, or more) of rigorous research and scientific inquiry. With a father in medicine and a mother in nursing, that’s simply how I grew up. But my parents – and my liberal arts education – also taught me to approach new information with an open mind.

At Tuesday night’s lecture on Traditional Chinese Medicine by visiting Fullbright scholar Chia-Feng Chang, that was sometimes a challenge for me. Not because I went in with a closed mind, but because the core beliefs and philosophies of Chinese medicine are, in some respects, simply so very different from those of Western medicine. That said, I did take away from the lecture that there is more than one way to conceive of “medicine.” And I believe that each tradition deserves respect, regardless of one’s personal beliefs.

As a pre-medicine student, my plan is to focus the next several years of my life on studying the “hard” sciences – introductory classes such as biology and chemistry, and upper-level courses such as anatomy and immunology. So I had to keep my jaw from dropping when Dr. Chang said, “Anatomy is not essential to Chinese medicine.” Rather, she went on to say, practitioners of Chinese medicine see the body as an integrated whole rather than an assortment of parts. My immediate reaction to that was that, “Well, don’t you need to understand the parts to understand how the whole works?” I had a hard time wrapping my brain around Dr. Chang’s perspective, at a very basic level.

Another component of Traditional Chinese Medicine that was difficult for me to understand is in the field of pediatrics. According to Dr. Chang, Traditional Chinese Medicine physicians would examine the three middle fingers of a baby or young child and make diagnoses based on characteristics observed only from those fingers.

I think I found these aspects of Traditional Chinese Medicine difficult to comprehend because at its roots, Chinese Medicine is based not on scientific experimentation, but on the structural similarity of the human body to water, nature, and the heavens. In seeing these similarities, Chinese Medicine practitioners developed a theory that blood and Qi (energy) flow through a series of of  “circulation channels.” They then believe that all illness is due to congestion or blockage of Qi and blood. To cure an illness, the blockage must be relieved and flow and harmony restored to the body.

While the mystical aspects of Traditional Chinese Medicine do not appeal to me, they do to many people. And I personally know people who have benefitted from Chinese medical practices such as acupuncture and herbal remedies. So while I lean more toward Western medicine myself, I know it is not the only path. I respect the other paths; they are just not my own.

Caritas et Veritas: Love and Truth

On September 28, I attended a symposium at Dominican University about our school's motto: Caritas et Veritas, "Love and Truth." I wrote this essay as an extra credit assignment for my biology class. I thought it important enough to share here, too.


I couldn’t have asked for a better birthday present. Exactly 29 years after I entered this world, I was sitting in the Old Pool room at Dominican University listening to a discussion about how our school motto (“Caritas et Veritas” — “Love and Truth”) plays out in science and math courses. While not everyone’s birthday wish, perhaps, nor cause for celebration in everyone’s estimation, it was exactly what I wanted to be doing that day. Of course, the Caritas et Veritas symposium wasn’t held just for me – I’m not quite that egocentric – but I certainly took away plenty from it, on a personal level. And not necessarily what I’d expected ...

I’m a post-bac pre-med student. So clearly, I’m interested in science. What not everyone knows is that I’m also interested in literature. In fact, I was a high school literature textbook editor for nearly two years, specializing in American and English lit. So when I saw the lecture title, “A Gradual Dazzling: The Nature of Truth in Literary Studies,” my heart skipped a beat.

But honestly, the first three speakers (on ancient Greek drama, Romance literature, and contemporary Irish poetry, respectively) bored me. Not because the subjects were boring, but because the speakers were boring: they simply read from their (very technical, very specific) papers. I found myself struggling to follow along. Then Ellen McManus got up to talk about the field of Literary Studies, and trends in the field. I found myself wishing she had spoken for the entire hour. Each progression of the field, starting with the T.S. Eliot-inspired “New Criticism” (which saw literature as telling a special “slant” truth different from psychology, science, religion, etc.), to Postmodernism (truth is an artifice in ALL texts), to the influence of cultural / queer studies on literary studies (you must uncover the historical truths embedded within the context of the text) fascinated me. But the most recent development – called “Consilience” – has me rapt. Believers in this philosophy of literary study are also called “Literary Darwinists.” They draw on evolutionary science to understand literature, and believe that different kinds of knowledge (i.e., science, psychology, literature, etc.) should be linked together in a nested way. I find this philosophy, also called “vertical integration,” very interesting. I desperately want to find out more about it. (Note: I have already contacted Dr. McManus via e-mail and gotten her recommendation on two books about Consilience that she thinks are good places to start. My Amazon.com order is supposed to arrive this coming Wednesday ... and I can't wait.)

After the literature seminar, I attended “What does Caritas et Veritas Mean in Science & Math Courses?” I was interested in this lecture both because I am taking three science courses (physics, chemistry, and biology), and also because my chemistry professor, Dr. Daniela Andrei, was one of the panelists. The panelists talked about how veritas – truth – is evident in that there is usually a “correct” answer in science and math courses. Caritas – love – they said, is evident in their interactions with students. One example they gave is that they work very hard to teach critical thinking skills to their students through encouraging participating, making connections between old and new material, figuring out what type of question they are being asked, etc. After that section of the presentation, I asked a question: whether the presenters thought they could really teach critical thinking skills to students at the age of 18 or 20, or whether students needed to enter college with those skills already learned (and primed to be perfected). It wasn’t a rhetorical question; I was really interested in the answer. But I felt the question was dodged, or perhaps misunderstood. Professor Aliza Steurer responded that she believed you could learn at any age. Which I agree with, on a certain level. However, there is plenty of research out there that shows that students who don’t learn certain basic skills by early elementary grades (i.e., reading and certain math skills) are essentially screwed for the rest of their education. Now, whether this is a product of the quality of those students’ education or the plasticity of the brain is another matter. But I really do wonder whether students need to have acquired some skill set by a particular age, and past that age (which may be somewhat dependent on the person), they just can’t. Or at least, not as well or as flexibly or with as much dexterity. Motivation figures in as well, in addition to whatever base level of intelligence a person has. And when you start talking about that base level of intelligence, you get into the nature vs. nurture debate, going back to infancy (and perhaps even the womb) ... it becomes a very complex issue with perhaps too many branches to keep track of at once.

I think I’m fascinated by the whole issue because I had a very non-traditional educational upbringing, and I often wonder how that has affected me. My parents are both very well-educated (a family physician and a nurse with her master’s degree), and they worked from the beginning to create educational opportunities for my two younger sisters and me. Reading was a constant activity in our house, from day 1, for example. But the really atypical thing was that we were all homeschooled for several years (my first year of public school was sixth grade). Of course, we had textbooks. But that was only the beginning of our education. Area museums provided hands-on science, history, and art exhibits to engage us on those subjects. The local butcher had what we needed for every dissection possible. Chicago’s ethnic neighborhoods offered the chance to study microcosms of the world’s countries, up close (including a taste of each country’s cuisine). On vacations, we studied ecosystems and plant and animal life. Life meant – means – learning. How did all of that affect the way I absorb, process, and maintain information? I don’t know exactly, but I believe the effect was a positive one.

But I digress. The last session I attended was “Seeking, Detecting, and Even Deleting the Truth: How Neuroscience is Changing Our Understanding and Powers Over Truth.” I will address the last two speakers first. While I found the subjects – using brain imaging as lie detection and drugs to delete memories – to be interesting ones, I find them extremely problematic. From the evidence presented, it seems that there are serious functionality issues with the lie detection / brain imaging idea. I certainly would not want it used to test my guilt / innocence at this point in time. In terms of the memory erasure idea, while it does seem to work in rats (which is fascinating), I see some ethical considerations in using this on humans. Also, I would be concerned as to how this would affect the rest of the memory system. I found these two topics very thought-provoking, but not particularly practical.

I connected more with the first presentation, which more about the philosophy of science as related to Veritas (truth). First of all, I found Dr. Scott Kreher’s* definition of truth – “Truth is how the world really is” – to be very interesting. Not that I disagree with it, at this point in my life. In fact, I find it very appealing. However, had you asked me 15 years ago, I would have responded with a much different definition of truth – “I am the Way, the Truth and the Life. No one comes to the Father but by me.” That Biblical passage still rings in my ears more than a decade after I (very decidedly) left my conservative religious upbringing behind in favor of a more empirical approach to the world.

Dr. Kreher’s definition (or perhaps explanation) of science also intrigued me: Science is a set of processes that allows us to approach the truth. (emphasis added) If you think about it, that’s so obvious. Scientists so often replace old facts, hypotheses, even established theories with new ones, based on newly discovered evidence. Practicing science requires a certain level of humility. Yet so many people look at scientific discoveries as unalterable FACTS. They don’t question them, or think critically about them. I think part of the fault there lies with the media (of which I used to be a member). A scientific paper or study will come out, and the evening news will report it in a skewed way, for maximum shock value, as a truth (or nearly so). When really, as Dr. Kreher said, “We’re always just approaching the truth.”

As I said, the Caritas et Veritas Symposium was like a gift. At each lecture, I received something to ponder, to take with me. Not merely because I went to the lectures. That’s not enough. But because I brought myself, open and vulnerable, and willing to refine my own definition and understanding of Caritas et Veritas, both in relation to my education and to my life in general.



* My biology professor

Lost & Found In Translation

It's allergy season -- especially for those sensitive to ragweed, like Maria Juarez. * She came in to see the nurse practitioner at a local free clinic reporting a runny nose, itchy throat, sneezing, and wheezing -- all of which had lasted for weeks. She used to take an inhaler, but had run out. Over-the-counter allergy medications made her sleepy. Maria wanted to know if there were any better ways of controlling her symptoms.

Sounds like an easy enough clinical encounter, right? Except that Maria spoke only Spanish, while the nurse spoke only English. That's where Mark * and I, Spanish medical translators at that free clinic, came in. Our job was to translate everything that was said from one person to the other to make sure the appointment went smoothly. 

For people who live outside their native countries and who aren't fluent in the second language, this happens all the time. But for those of us born and raised within the same borders, it's something we rarely, if ever, have to think about. But while you read this blog post, it's something I want you to actively consider.

It's so easy to take verbal communication for granted: understanding, being understood. That is, until you can't understand, or be understood. I know from experience that this position -- especially in the medical context -- feels like one of powerlessness, of vulerability. And it is. You feel at the mercy of those around you because you can no longer fend for yourself. Nor defend yourself, for that matter. You must take others at their word. What other choice do you have? 

I had no other choice. I was 15, in a foreign country. And we're not talking on the other side of the border here. We're talking across the ocean, across continents. In China. Beijing, to be more precise. I had a fever, sore throat, reduced appetite, and was generally miserable. Was it an infection? Some rare disease? My high school chaperone thought not, but took me to a doctor to be on the safe side. 

While many of the young students we encountered in Beijing spoke English, this doctor evidently did not. Gestures and body language will only get you so far. Fortunately, there was someone to translate the Mandarin to English. This was more than a dozen years ago, so I don't remember whether the translator was a member of the doctor's staff or had come with my chaperone and me, but no matter. She was able to make the situation clear: I had a throat infection, and should take antibiotics for a week or so. I remember the doctor handing me a bottle with lots of Chinese characters printed on it, which was a little frightening (not being able to read for myself what was in the bottle). But again, the translator came to the rescue and explained the dosing instructions and contents. We thanked the doctor and made our way back to our hotel, much relieved. 

Looking back on the situation, I completely took that translator for granted. Very Eurocentric of me, expecting there to be someone who could speak English (although I can hardly hold that against myself at 15). But what if there had been no translator? I doubt very much that the Chinese doctor's message would have gotten through, and I certainly would not have taken any of that medication without knowing exactly what it was and when (and how often) I was supposed to take it. 

And now I find myself in the translator's role. A human cultural-linguistic bridge. I am helping to transform that feeling of powerlessness into one of power, into ownership of one's health care. And that feels like a job very much worth doing.

* Names have been changed to protect people's privacy.

There's Always Room for JELL-O

Any halfway decent cook knows that you can't put certain fresh fruits -- kiwi, pineapple, and papaya, to be exact -- into gelatin (commonly known as JELL-O). Well, you can ... but the gelatin won't set. Which rather defeats the purpose of making JELL-O, doesn't it?

Any halfway decent scientist knows why. And after Monday's biology lab, all of the students in Dominican University's Biology class (including myself) do too.

I will explain. But to do so, we must zoom in to what's called the "particulate" world, the world we can't see with our own eyes ...

The failure of the gelatin to set has to do with a type of enzyme (protein) called "gelatinase" found in those tropical fruits. (In case you were wondering: Yes, these fruits do contain protein.) If active, gelatinase breaks down the gelatin protein found in your typical packet of JELL-O, preventing the JELL-O from setting.

How does this work? Understanding this phenomenon requires a bit of biology and a bit of chemistry. (But don't be scared! It's actually really cool how this works.) Proteins, such as the gelatinase found in the tropical fruit mentioned, are organic molecules that have very important roles in the function of living cells (including our own cells). One role that many proteins have is that of an enzyme, or biological catalyst. These catalysts basically facilitate chemical reactions in living cells by reducing the amount of energy required for those reactions to take place. Without these chemical reactions, life would cease. So proteins (as enzymes) are pretty important to us, and to other living things.

Enzymes function as a result of a very specific three-dimensional structure. This structure is determined by the DNA that "spells out" the instructions for making the enzyme. Each enzyme, then, has its own unique structure. Because of this individualized three-dimensional structure, each enzyme usually fits, in the same manner as a lock and key, with only one other molecule (called a "substrate") and catalyzes a reaction there. So each enzyme does one specific job. The enzyme will not function (act as a catalyst) if a different molecule is present. This property is called "enzyme specificity" or "substrate specificity."

However, proteins are very sensitive. If they get too warm, or the solution around them changes in pH (how acidic/basic the solution is), then the protein can lose its three-dimensional structure. And when that happens, the protein can no longer bind with its substrate -- the key doesn't fit into the lock anymore. This is called "denaturing" of a protein.

Now let's return to the "macroscopic" world, the world we can see unaided by microscopes and chemical models. The world of the lovely, green, sweet-and-sour kiwi ...

Like all good scientists, once we learned the principles of how enzymes work, we tested them out. Using (yes) kiwis and (yes) gelatin. Raspberry gelatin, actually. The experiment was simple, yet elegant, explanatory, and enlightening. Here is my data chart. I will explain it below.

Assay of Gelatinase From Fresh Kiwi Fruit
Tube No.	Contents of Tube	Gelatin set?	Active Enzyme present?	Is the tube a control or test sample?
1	gelatin + water	Y		negative control
2	gelatin + water	Y		negative control
3	gelatin + known gelatinase	N	X	positive control
4	gelatin + known gelatinase	N	X	positive control
5	gelatin + fresh kiwi extract	N	X	test sample
6	gelatin + fresh kiwi extract	N	X	test sample
7	gelatin + boiled kiwi extract	Y		negative control
8	gelatin + boiled kiwi extract	Y		negative control
9	agar + fresh kiwi extract	Y		test sample
10	agar + fresh kiwi extract	Y		test sample

We tested 10 tubes of solutions (five different mixtures, each mixture done twice to see if we got the same result). After mixing the solutions, we set them all in an ice bath to find out whether they would set into hard gelatin, or remain as liquids.

Tubes 1 and 2 had only gelatin + water (no gelatinase). These tubes were what is called a "negative control" -- they had a known negative test in an experiment (no enzyme activity). Tubes 3 and 4 had gelatin + a "known gelatinase" -- an enzyme from a pineapple prepared by our lab professor. So as predicted, they did NOT set because there was active enzyme present. These tubes were "positive controls"-- a known positive test (enzyme acting on the gelatin). Tubes 5 and 6 were test samples -- tubes we were interested in the results of. And they behaved as predicted -- the gelatinase from the kiwi extract did interact with the gelatin and prevent the gelatin from setting! Contrast this with tubes 7 and 8, which contained gelatin and boiled kiwi extract. Remember that heat will "denature," or unfold, an enzyme. That's exactly what happened -- boiling the kiwi rendered the gelatinase ineffective, so tubes 7 and 8 did set (more negative controls). Tubes 9 and 10 were filled with agar, another jello-y substance, and fresh kiwi extract. This time, we were testing the "enzyme specificity" concept -- would the kiwi's gelatinase also work on agar, as well as the gelatin? The answer, we found, was "no." The gelatinase is specific to the gelatin, and would not work on a different substrate (agar).

As I said, simple yet elegant, and very hands-on. My kind of learning.

An End To The Silence

The few of you following my blog (thank you, by the way) will have noticed that I did not post at all during August. Or if you did not notice that fact specifically, you probably did observe that a good while went by without so much as a whisper from me. No worries, nothing is wrong. I'm not sick, I'm not dying, and as you saw from my two recent posts, I have not changed my mind about becoming a doctor.

So why the silence? Reason #1: busyness. August was the-month-to-get-everything-done-before-school. And when you have a family, a house, a husband, and other such life elements, figuring out how to manage them on a totally different schedule takes some time, juggling, and preparation.

Reason #2: business. Yes, I have my own business, called The Artful Diner. As with most artists, I won't be able to retire off my income from it, but the extra money helps, and I enjoy it. As the name implies, my work has to do with dining. And indeed, I make decoupaged dishware and beaded / wire-wrapped utensils to sell online and at art shows. At the end of July, I heard about a local art fair that I really wanted to participate in. I signed up, paid my fee ... and then realized I needed more inventory. So I spent the next several weeks in full production mode. (My dining room -- aka my "studio" -- still looks like a hurricane swept through it, much to my husband's delight.) Here is a link to my Etsy.com storefront, and a few photos of my recent work.

My Etsy storefront link: The Artful Diner



Here are some coaster sets I have painted and decoupaged with marbled paper (this is a new thing I am doing now):

Another new item for my online store this season is pillar candle stands. These are flat pieces of glass, with paper (and often vintage ephemera) decoupaged on the underside, on which you can put a tall pillar candle. The wax drips onto the flat, glass surface, and you just scrape it off. Here are a couple photos of those:

A set of six small decoupaged bowls:

A decoupaged serving tray, complete with a stand:

So rest assured: I have not been idle with my time. Between the life busyness and my business, posting on my blog fell between the cracks. But I missed writing during that time, and especially writing about science and medicine, so you may also rest assured that I will not let that happen again.

The Genetics Of Synthesis

"Synthesize." When I worked as a textbook editor at McGraw-Hill, we used that word all the time in our literature textbooks. (Usually in the context of asking -- rather, telling -- students to synthesize a number of elements.)

And now here I am, a student myself. And yes, I am synthesizing, too. But I will get to that shortly.

First, what is synthesizing and synthesis? It is, according to Merriam-Webster's online dictionary, "the combining of often diverse conceptions into a coherent whole." In other words, taking different pieces of evidence, material, readings, experiences, and so on and making sense of them when put together. It is an incredibly complex cognitive process, far beyond mere comprehension, even above analysis.

At the university level, it is rather taken for granted that students are capable of synthesis. Homework, quizzes, and exams require it. So to do well, it is necessary. But what is really exciting is the synthesis that happens independently of all of that required work. It may not boost your grade, but it should boost your confidence that you are understanding -- and connecting with -- the material. 

At least, that's what it does for me. It also encourages me that I am on the right track with what I am doing. Because making these kinds of connections (when it's not required by a professor, that is) requires not only knowledge, but interest. And a little passion doesn't hurt, either.

For me, the lightbulb flared this morning as I was reading my biology textbook. I will be honest -- reading that monstrous (read: insanely heavy) book was not what I felt like doing at 7:30 a.m. But I wanted to be prepared for my morning lecture, so read I did. While the whole selection -- relating the evolution of mammals -- was fascinating, the true reward lay in a nugget on the very final page: a one-paragraph blurb on a gene called FOXP2, thought to play an important role in human language. (And since language is one thing that sets us apart from our ape cousins, this gene is also thought to play a role in the evolution of Homo sapiens). 

"FOXP2 ... FOXP2 ... FOXP2 ... where do I know that from?" I asked myself as I finished reading. I knit my brow, cocked my head, and pursed my lips as I searched my brain for a possible link. Because I knew I knew that gene from somewhere. And then it dawned on me: my summer research. Olga had been looking for evidence of FOXP2 expression in her lung cell samples. Because while FOXP2 is involved in language development, it is also involved in cell proliferation (growth) in the lungs, and hence could signal the presence of stem cells. 

My eyes lit up and I laughed out loud. Synthesis indeed.

As I write this, I realize that maybe it sounds strange to get all warm and fuzzy about genetics and research. But I just can't seem to help myself.

Note: Of course, I had to tell someone who would really appreciate this "discovery." (Telling my husband, Geoff, didn't quite do it -- merely the letters "D - N - A" make his eyes glaze over). So I headed to my bio professor's office hours after my last class and told him I'd had an "interesting encounter with our biology textbook." That sure got his attention. We had a nice talk. He knows me a little better, and vice versa. One of the best parts of my undergrad education was getting to know my professors well and being mentored by a handful of them. I hope for that same kind of experience this time around as well.

The Honeymoon Will Soon End ... but that's OK

I am officially a pre-med student.

Correction: I have been for just over a week now. But it hasn't really sunk in yet, because this is still the honeymoon stage. All love songs, hugs, and kisses -- no slammed doors, curse words, or broken dishes (yet).

Everybody is still in friend-making mode; there are few cliques or ways to feel excluded, if you make an effort to be social. Everything comes easily at the moment: I still remember all that we have "learned" so far, even though I've barely touched a biology, chemisty, or physics textbook in more than a decade. Every grade is an A right now -- we haven't had any assignments, exams, or quizzes on which to lose points. The sun is shining, the future is bright, and everyone still has a chance to get in to medical school.

Soon that honeymoon will end. There will be late nights up studying before exams. And then the actual exams. Weekends lost to lab reports after hours spent in the lab during the week. The anxiety of eventually applying to medical school. The dread of not getting in.

So why do it? Is the destination worth it?

Hell no.

Don't get me wrong -- I can't wait to be a doctor. I think I'll be a pretty good one, and I have a feeling I'll enjoy it. But getting there is a long road. Years, literally, of your life. Anyone who thinks they can just push through without having any appreciation for the journey there will be incredibly miserable for an incredibly long time. And, I think, become bitter and angry about it. Yeah, that bodes real well for a person's bedside manner, doesn't it?

I'm one of those crazy people who actually likes school. When I'm interested in something, learning about it is a pleasure (most of the time -- ask me at 3 a.m. and I might tell you a different story). I'm excited about where I'm going, but I'm also excited about what I'll be doing along the way. And to do this, you have to be.

That's why it's OK that the honeymoon will soon end. Because when it does, that signals the beginning of a deeper, richer relationship with the subject matter. (For this school year: biology, chemistry, and physics.)  Sure, it will be harder. And sure, I may complain about that sometimes. I may struggle. I may even use four-letter words (*gasp*). But I wouldn't trade places with anyone.

Stay tuned.

ADCOM Q&A (learning from your mistakes)

Everyone makes mistakes. Even pre-medical students. And one trend I've noticed in the medical school interview questions I've looked at (this applies to job interview questions as well) is that the interviewers quite often will bluntly ask you about those mistakes or other shortcomings. For example, there is the infamous "What is your greatest strength and weakness?" question, which I have been asked in multiple job interviews. A similar medical school question I found online literally begins with these words: "What has been your biggest failure ... ?"

Clearly, though, if an applicant goes on for 10 minutes about how badly he did in organic chemistry, that's not going to go over well. That's why the question about your "biggest failure" ends with these words: "... and how did you handle it?"

So if an applicant did poorly in organic chemistry, explaining why he didn't do well -- such as that he didn't have good study skills -- and then what he gained from the experience -- such as that he developed better study skills as a result of his failure-- would be a much better answer.

ADCOMS want to hear us pre-meds admit that we're not perfect, and then talk about what we have learned from our mistakes, shortcomings, failures, weaknesses, and other "problem areas." Because failing is part of life (as much as I hate to admit that). It's what you do after you fail that sets you apart from other people.

The reality is, everyone falls down sometime. The question is: Do you get back up?

My answer is: YES. And here's an example from my childhood.

(Let me preface this example by saying that I was homeschooled from preschool through the end of fifth grade. So when I talk about my mom giving me a test ... it's because my mom was my one and only teacher from age 4 to age 10.)

When I was about 7 or 8, my mom gave me an impromptu spelling test. You know the kind -- the ones that are supposed to gauge where you are and where you need improvement. They're called diagnostic exams, I believe. As someone with something of a failure complex, I hated these exams because I never did well on them -- you're not SUPPOSED to do well on them. At the time, this point escaped me.

Anyway. I miserably failed this spelling test. I don't remember the number of right and wrong, and it's probably better that way. I was distraught at first. I had failed! What was I supposed to do? Then my mom sat me down and explained the purpose of this "diagnostic" exam. Her explanation brought some comfort. And in the end, while I was not necessarily happy that I had failed, I understood that the test pointed out some areas where I needed to improve.

And so I made it my absolute mission to become the best speller possible. I learned all the rules. I memorized the exceptions. I practiced spelling words until I was practically murmuring them to myself under my breath in the bathtub.

Then came time to take the exam again. And I aced it. All that work paid off -- I had learned what I didn't know, what I needed to work on, and I made it a point to not make the same mistakes again.

And guess what? When I attended public school a few years later, I went on to win several school spelling bees, and even a district spelling bee.

To this day I am a fantastic speller, and in my previous jobs, earned a reputation as such. All because I failed an elementary school spelling test and made up my mind that wasn't going to happen again.

And while I still don't like failing (although who does?!), I try to remember this example when I do. Because it proves that you can learn from your mistakes. And perhaps, that without making mistakes, we wouldn't learn quite so much.

ADCOM Q&A (working under pressure)

Being a doctor is, quite often, about working well under pressure. If someone stops breathing, for example, you better figure out how to get them breathing again, and quick! There is no time for consulting the Internet, a textbook, or (very often) other doctors. You must act. Now. Or someone might die.

That's why ADCOMS often ask pre-medical students a variation on this question (which I found on the Internet on a list of practice questions): How do you work under pressure? Give an example. What, in hindsight, were you most dissatisfied with about your performance? What did you learn from your experience?

"I'm no stranger to working under pressure," I thought when I read that question. And that is the truth. For the year and a half that I worked at the Forest Park Review, a local weekly newspaper in the Chicago suburbs, "pressure" was my constant companion. (And this was my first job out of college, so I learned it early.)

It was especially intense, though, on Tuesday mornings. That was deadline day, when the paper was sent to the printer. I would wake up at 2 or 3 a.m. in order to write a half-dozen or so stories and an editorial by 7 or 7:30 a.m. And then I would go to the office. What for? For another three hours of deadline drama: writing headlines, creating captions, approving page layouts, and so on. It was grueling.

But through it all, I had to be at peak performance. Exhaustion was no excuse. I had to get the facts right, get the dates right, and get people's names right. And do it all in captivating prose. Oh, right -- make that captivating prose in less than 700 words per story.  

But I didn't need any excuses. In fact, I kicked things up a notch on deadline day. I was intense, driven, focused. When I have a goal, and time constraints for completing that goal, I find myself subdividing time into estimated allotments for each portion of the task I have to complete. This helps me stay on track so that I don't spend too much time doing any one thing. On deadline day, that might mean 30 minutes for one story, and one hour for another. (I prioritized as well as subdivided.)

The process was intense, and I was intense during the process. It was hard to turn that intensity off right away. So when I'd leave the newsroom at around 11:30 a.m. or noon, snippets of stories would float through my mind. And I would question myself: Did I do X right? Did I change Y like I told myself I needed to? Maybe I should have opened that one story with another lede ...

Then when I saw the newspaper the next day, I saw the in most cases, yes, I did do X right, I did change Y, and in actuality the lede I opened on that one story with was fantastic.

I gradually learned to trust myself, not to second-guess myself in those high-pressure situations. Because I knew what I was doing, I really did, I just needed to BELIEVE that I knew what I was doing, and go with that. Because it was often the second-guessing that led to the mistakes.

This is an essential skill for a physician to have. There is often no time for second-guessing. Making a second guess might mean your first act is one moment too late. So trusting yourself, your skills, and also your intuition, is something that a physician must do ... is something that hopefully I will one day do.

ADCOM Q&A ... (an introduction)

ADCOM (ăd´kəm) n. An abbreviation that refers to a member of a medical school admissions committee. Can also refer to the medical school admissions committtee as an aggregate. ADCOMS are, essentially, the gatekeepers to medical school. It is their decision--based on a student's application, GPA, MCAT score, and interview--whether the student will be offered a slot at that medical school. Thus pre-medical students refer to ADCOMS with, alternately, fear, derision, and respect.

 -----                                                     

The above definition (my own) is the way most people think about the ADCOMS: cold and impersonal. And in a sense, they are. They have to make dozens of decisions, based on established criteria, in a limited amount of time. To do that effectively, you have to be a bit calculating and unemotional. (That is not meant as an insult, rather as a compliment.)

On the other hand ... ADCOMS are people. In fact, I know a handful of them personally. They smile, laugh, eat, sleep, do all the things we "normal" humans do. I have even found them to be helpful, if you can believe that. No, they are not the enemy. In fact, it would behoove more pre-med students to make ADCOMS their friends. But that is a topic for another day.

Right ... ADCOMS are people. Which means that, essentially, they respond as people, at least on some level. They possess curiosity and emotions, for example, which no amount of established criteria can completely wipe away. (That's my belief at least, however naive.)

Why do I care about all of this? The reason is simple: in a couple of years, the ADCOMS will hold my fate in their hands. So I need to understand what that means. And what that means is that I need to affect them -- to stand out above my peers -- in some way that says "Look at me! Choose me! I'm different! I'm the ONE!" I need to do this both on my application and during my interview. (Um ... in a slightly more subtle, professional way, of course.) Because there will be, literally, thousands of people just as qualified, on paper, as I am. And not all of them will get in. I want to be one of the ones who gets in.

So how do I do that? Well, there's no sure way, of course. The best way I can figure (other than do well in school, do well on the MCAT, volunteer, and get clinical experience, which are givens) is to get into the right mindset. No, I haven't gone all New Age-y. What I mean is to think about what the ADCOMS will likely want to know beyond my statistics, what types of things they are likely to question me about during my interview, and have my answers ready. And no, I'm not trying to predict the future and conjure up a list of questions that I will be asked.

My plan is two-fold: to prepare for common questions (i.e., "Why do you want to be a doctor?") and for common categories (i.e., medical current events), using sample questions to jump-start -- but not contain -- my thinking. Because the sample questions I have found online (and believe me, there are hundreds) are only a small slice of what could potentially pop up. I then plan to use this blog as a sounding board for some of my potential (but certainly not final) answers.

You might be wondering why I am giving away my strategy, and why I plan to give away some of my answers. After all, couldn't the ADCOMS, then, just ask me different questions than the ones I've prepared for?

To address the first issue: My strategy is not brilliant. It is common sense. So why hide it? In fact, I'd kind of like the ADCOMS to know that I can analytically approach something and realize it has a real-life, common-sense solution (as opposed to a nebulous theoretical one). There are plenty of pre-meds I've met -- very smart people, to be sure -- who have exactly zero common sense. I understand theory; I also understand real-world application. To be a doctor, you need to be able to understand both. So read on, ADCOMS!

To address the second issue: I don't plan to write a blog post about every single question or question type that I prepare for. That would take for frickin' ever. So I am not worried about showing my whole hand. Showing part of it, though, I don't think is such a bad thing. The medical school interviews I will (hopefully) have will be short, and there will be no way for me to communicate to the ADCOMS everything I want them to know about me. If they stumble upon my blog and discover some more pertinent information that puts me in a good light, even if it means they throw in a few more difficult questions during the interview, it is worth it to me.

As I see it, the ADCOMS and the interview are not what keep you OUT of medical school (which is how a lot of people seem to look at it), they're what get you IN. So best to embrace them, early and often.

Managing The Seagulls' Sh** (and other messes)

In my last post, I explained how I think that I might have a decent start when it comes to developing a good bedside manner--i.e., working well with patients. What I didn't take into account in that post, however, is that you don't only work with the patient. You also work with the patient's family. And that can create its own set of problems, dilemmas, and conundrums, as a hospice nurse I know explained to me this week.

Take the case of Mr. Martinez, * a terminal lung cancer patient. Most hospice patients have a DNR--a "do not resuscitate" order, which directs hospital and emergency personnel to NOT use life-saving techniques such as CPR or a ventilator, but to let the patient die naturally. Mr. Martinez, a native of Argentina, does not have a DNR, although he would like to have one. Why? Because his son, who still lives in Argentina, wants the father's life prolonged until he can make it to the United States to say goodbye to his father. The father doesn't have the heart to disagree. While this seems like a natural desire in a way, it really is very selfish, the nurse explained--it would mean keeping the father alive, perhaps in pain, just so the son can meet his own emotional needs. And it's not like the son never sees the father; he visits every couple of months, and has had plenty of opportunity to say a meaningful goodbye. Because what do you really gain from seeing an empty, non-communicative shell that's kept alive by a machine?

The nurse I know said this is a common situation--family members simply can't let go, even when the end is imminent. So it has become her job to try and convince the son--via e-mail, since he is in Argentina--to encourage the father to have a DNR. Not a task I envy, that's for sure. It's one that requires great finesse, compassion, and understanding. And a thick skin, to boot. All done in a one-way conversation, without facial expressions, body language, or vocal inflection--all tools that can be extremely helpful when trying to talk about something so serious and traumatic. 

Mr. Martinez's son, an out-of-town family member, is what one of the nurse's co-workers calls a "seagull"--someone who flies in, sh**s on everyone and then flies out. They want to help, and they (usually) have the best of intentions, but they don't really know the day-to-day situation or the intricacies of their family member's care (or health condition). So they rather muck things up. Often, they step in so aggressively and vehemently because they feel guilty for not being there on a more regular basis, the nurse told me, so they feel they must "fix" what seems "broken" to make up for that absence. When really, the opinionated assistance often does more harm than good. 

But it's not just the "seagulls" who can cause a wrinkle in a patient-care situation. Nearby relatives, even daily caregivers, can create serious problems, the nurse told me. She related the story of one family where two sisters were, in her words, "at each other's throats." Just about literally, it seems. One of the sisters actually called 911 on the other sister because she felt that sister wasn't appropriately administering the patient's medication. 

The kicker? The patient's problem was agitation. I doubt if sirens, police, EMTs, and whoever else showed up helped alleviate the symptoms the sisters *claimed* they were so concerned about. 

This is another situation that, as a health care worker, would be a sticky one to resolve (if a resolution was even possible--a temporary cease fire might be your best bet).

This is not to say that family members are always a source of trouble and ire. As the nurse told me, "Family can also be the greatest resource." When that happens, it makes the health care worker's job infinitely easier and richer. So you hope and pray for this scenario.

But for those times when the family members seem to be working against you rather than with you, I imagine you must tap deep into yourself for strength, composure, patience, and endurance. And still, even though it seems undeserved, compassion. Because while the family members may be making your life hell, you have to realize that their life is hell right now, too.

Come alongside. Understand. Empathize. And then maybe you stand a chance not of changing the family, but of helping them to decide to change themselves. 

* Names and details have been changed to protect patient anonymity.

 

Grocery Carts and Call Waiting: Why I'll Make A Good Doctor

The title of my blog is, obviously, "My Bedside Manner." So far, though, I haven't done much talking about my own bedside manner. Mostly because I haven't had much of a chance (aside from the summer I spent working in an ICU back in 1999) to develop one, officially speaking.

That doesn't mean, though, that I haven't thought about it. In fact, I've thought about it a great deal. And I've come to the conclusion that, in all likelihood, my initial bedside manner won't be so bad. It might even be a tad bit good. And hopefully, it will get even better as time goes on.

How did I come to this conclusion? It all started with my grocery cart dilemma. I was at the local Mexican produce market and had just finished loading my trunk with fresh fruit and vegetables for the week. I had parked about as far away as possible (not on purpose, believe me), and it was at least a sun-blazing 90 degrees outside. So when I saw a cluster of about a dozen other shopping carts circling a streetlamp in the parking lot, I was sorely tempted to wheel mine into the bunch rather than back to the storefront. But then I sighed, realizing that I am not the kind of person who leaves the grocery cart in the middle of the parking lot. It just feels wrong to me somehow, unnatural. I would have driven away feeling guilty, and I didn't want that. So I marched off toward the store, cart in tow.

After my sweaty walk back to the store, I returned to my car and switched on the AC. As I sat waiting for the hot blasts of air to cool down, it occurred to me that my reaction to the cart dilemma might say something about me as a person. It might indicate that I can be thoughtful, even when I don't know who will benefit from my thoughtfulness. That I don't like to make extra work for other people if I can help it. That I have a sense of responsibility, and that I take things seriously even when so many people around me (i.e., the other customers) do not.

OK, I will come clean: I am far from perfect. I do not always take the cart back. But I tend to. And so I think what I have just said has some validity.

I got to thinking more about that tendency to take the cart back. Not only what it might mean about me as a person, but also what it might mean for the kind of bedside manner I will have. Thoughtfulness, pitching in where needed, a sense of responsibility? These sound like components of a decent bedside manner to me, as well as a recipe for getting along with my future hospital or clinic co-workers.

"Are there any other clues as to my future bedside manner?" I wondered to myself. Driving home, I thought through some of my other habits (my husband would be more likely to call them "quirks," but then again he's allowed that privilege). Of course everyone has habits, but I was looking for habits linked to my ability to relate to others (especially strangers), and to care for them. Sure as Sherlock, I found my clues.

"Eva." She was my first clue. I don't imagine she gets called "Eva," which is her real name, very often during the 9-to-5 workday. But when I stop by the Student Union at the University of Illinois at Chicago for coffee, I do call my barista by her given name. We exchanged names a few weeks ago, and have had little chats ever since. (I've had to remind her of my name several times, which is fine--she has dozens of customers every day; I have only one barista.) I don't pretend that I've solved all the problems in her life, but I do believe that I've shown her the respect she deserves, but doesn't often get because she's working an "unskilled labor" job (and is surrounded by hoity-toity doctors who are more than happy to point that out).

In a hospital setting, that would translate into exactly the same thing: learning people's names, and using them. Rather than, for example, calling someone "the gall bladder in 241" or "the stroke in 332." Yeah, not much respect for the person there. Learning someone's name shows that you care about them as an individual person, and (in the hospital) not just about their disease or what kind of health insurance they have. That's pretty important for building the patient-doctor relationship.

Using a person's name is one important aspect of communication. Another is saying "thank you" when someone deserves it. Of course, when you're at the grocery store, most people say "thank you" when the bagger hands over the plastic sacks. I'm not talking about those automatic situations. I'm talking about going out of your way to thank someone, where it really makes them feel special and rewards extra effort.

I have found that this really goes over well with people. Although that's not why I do it. I do it, perhaps, because I like being thanked. Or maybe because my mom forced my sisters and I to write thank-you notes for every little gift we ever received as children, so it's ingrained in my head now. Regardless, I do it. Like when I was at the craft store the other day. The cashier rung something up as regular price. I thought it was on sale. Rather than tell me to go find another item with a more accurate tag, or call someone else to check on it, she went over to the shelf herself. Turns out, she was right. Regardless, I thanked her for making the extra effort to verify the price for me. She smiled, and I think she even blushed.

In the doctor-patient relationship, it's the doctor who's helping the patient, and who should be thanked. So my habit doesn't apply. Right? I wholeheartedly disagree. In any relationship, there is give-and-take. One has to help the other, and vice versa. Sure, the patient has come to the doctor looking for help, and it would be nice if the patient thanked the doctor, but that's not why the doctor does his or her job. However, the doctor can make his or her job a bit easier by saying "thank you" to the patient. This may not work in all situations, but it will in many. For example, a patient reveals something very personal that was difficult to say, but necessary to treating a condition. "Thank you," says the doctor. Or the patient comes early as requested to fill out some paperwork. "Thank you," says the doctor. You get the idea. The obvious corollary of this is for the doctor to say "I'm sorry" when he or she has done something wrong, is running late, etc. Both appreciation and apology go a long way toward building a relationship with someone, and maintaining that relationship. This is the philosophy I have developed so far, and the one I intend to implement in the future.

A common thread here so far has clearly been respect. So if I want to have a good bedside manner, I want to avoid disrespect (this is obvious, but bear with me). One of the most disrespectful inventions in the history of man, in my opinion, is telephone call waiting. It has its purpose, I understand. And I use it from time to time--but ONLY if I am expecting a particular telephone call, and one that is extremely urgent. If I am talking to someone, and another person calls, that second person can either leave me a voicemail message or call me back later. End of story. Because I consider it in very poor taste to interrupt my first conversation to (ostensibly) find out whether the second call is more important, and should therefore be given priority. This call waiting fetish says much about the "NOW" need in our culture, but I will not go into that. Suffice to say I ignore my call waiting 95 percent of the time.

OK, I admit, this one won't work in the physician setting. If, as a doctor, I am on the phone with a patient, I may very well get a phone call from someone else (another patient, the hospital, a resident, etc.) that may very well be urgent, but I won't know that until I find out who it is or what it is about. So I will have to make some philosophical adjustments here.

However ... my principal still holds in another respect: respecting a person's time. (Because when you break it down, that's a large component of the problem with call waiting. You're saying one person's time is more valuable than another's.) For example, if a physician is talking to a patient, that physician should, whenever possible, give his or her full attention to that patient. Doctors filling out patient charts while they talk to a different patient about a potentially life-threatening condition, and having to ask that patient to repeat things because the doctor was busy writing something down on the chart? That's not respectful. That's just like saying, "I've got another phone call. Hold on." Again, there will be plenty of urgent, and warranted, interruptions. That goes with medicine. So make those five minutes, if that's all you've got, count. That's my plan, at least.

Along with paying attention, there's another aspect to respecting a person's (and a patient's) time. That is running on time. Also not always possible, clearly, due to those aforementioned interruptions, emergencies, and so on. But I have seen a number of different medical practices at work--some run efficiently, others not so much. There are ways to running closer to being on time. Those ways sometimes cost money (i.e., salary for additional staff to process patients or shelf charts). But if your patients are happy, they are more likely to come back and pay you again. And if you, your patients' doctor, is on time, your patients are more likely to be happy. Because their time is valuable, too. Having sat in more waiting rooms than I'd care to think about, I heartily and readily acknowledge this.

None of this is to say that I am extra special, am grandly talented when it comes to interpersonal affairs, am a superhero, or am the next Dr. Schweitzer. Nothing of the sort. I'm just saying that these habits, which really (so far) have nothing to do with medicine, illustrate that I respect people in various ways and that I am willing to put myself in their shoes to make sure that respect comes across. And that, to me, is at least part of what having a good bedside manner is about.

Getting An Accurate Interpretation

Hormigueo (tingling). Escayalo (plaster cast). Expediente (patient's file). Presión arterial (blood pressure).

Two weeks ago, I didn't know any of this Spanish medical terminology. Sure, I'm fluent in Spanish, but these words -- as well as a few dozen (er, a few hundred) others -- simply never came up in regular conversation. I'm hoping that will change soon, as I have applied to be a volunteer Spanish translator at an urban clinic in Chicago. * Which means, of course, that I will need to know quite a bit of Spanish medical terminology to successfully do my job.

I never took this position lightly. But the more I think about it, and the more I learn about interpreting, the more I understand that "professional" interpreters can make the difference between a successful and an unsuccessful clinican-patient encounter, and between helping a patient making an informed versus an uninformed medical decision. I can help make that difference. I want to help make that difference.

When it comes to demand for Spanish interpreting, the need is only going to grow. According to a 2008 report from the U.S. Census Bureau, the Hispanic population is expected to grow from its level of 15 percent in 2008 to 30 percent in 2050. The percent of non-Hispanic whites is expected to fall from 66 percent to 46 percent -- meaning whites are expected to no longer be in the majority, although they will still be the largest minority. And my home state, Illinois, is one of the centers of the Hispanic population. A 2006 U.S. Census Bureau document ranked Illinois as number 5 in the nation in terms of size of Hispanic population (1.89 million). Cook County, IL, my home county, was also ranked number 4 in the nation in terms of Hispanic population size, with 1.2 million Hispanic people.

Along with that increasing number of Hispanic people comes an increasing number of "Limited English Proficient" (LEP) patients in the medical context. These are people whose primary language is not English (Spanish, in this case), and who have difficulty reading, writing, speaking, and understanding English. According to a number of scientific studies, this language barrier can cause many health care problems, as summarized in an article published in Health, Research and Educational Trust in 2006 ("Do Professional Interpreters Improve Clinical Care for Patients with Limited English Proficiency?"):
- less access to routine care
- fewer physician visits
- lower rates of preventive care
- less follow-up for chronic illness
- poorer understanding of Emergency Room visits (i.e., diagnosis and treatment)
- less satisfaction with care
- more medication complications

When it comes to Spanish, the problem is often not the lack of a translator. The problem is more frequently with the quality of the translation. Very often, "ad hoc" interpreters -- people who are untrained, such as family members, receptionists, or other people in the waiting room -- are used, which results in inaccurate and sometimes disastrous consequences. Sometimes, it is that the interpreters who are used are simply poorly trained. Because unlike courtroom reporting, there are no  national standards, or even guidelines, for health care interpreting at this time. The National Council on Interpreting in Health Care, an organization dedicated to promoting professional and culturally conscious interpreting, is working to develop a set of training standards (which are set to be done at the end of 2010). The idea is to eventually have national certification for interpreters.

Right now, though, we are far from that. And it is affecting patient care, sometimes dramatically. One study, published in 2007 in The Society of General Internal Medicine ("Are Good Intentions Enough?: Informed Consent Without Trained Interpreters"), found that Latina patients who were at a prenatal clinic being given the choice of whether to have amniocentesis were unable to truly give their informed consent to the procedure. In some cases, their interpreters did not fully explain what the medical practitioner was saying, either because of a lack of fluency in Spanish or a lack of medical understanding in general. In other cases, the procedure was not presented as being "optional," but as "simply the next step in the clinical process." In addition, it was often not communicated that there were any alternatives to amniocentesis (while a woman could have an ultrasound instead, although this test is not as definitive).

In short, the complicated nature of translating medical terminology, risks, benefits, potential complications, alternatives, etc. is something that requires more than being bilingual or "good" at speaking Spanish. It requires training and a fluency in medical terminology, in addition to privacy practices and other issues related to health care.

At the clinic where I want to volunteer, there is an orientation/training seminar where volunteers are tested on medical terminology to ensure they meet at least a minimum of requirements. In addition, I have spent hours (and I mean HOURS) studying literally hundreds of flashcards with words copied from my new best friend, the Spanish Medical Dictionary. I may not have to pass a set of national standards at this point, but I have my own standards. And I have set the bar high. Because I am serious about this job -- it's an important one, and it's even more important to do it right.



* I'm still waiting to hear back regarding my application; apparently they are currently reviewing my references.

Health In The Headlines: Life Span vs. Health Span

Good news, if you're a roundworm: researchers at Stanford reported last month that blocking the expression of a particular protein can extend a worm's life span up to 30 percent.

That is good news . . . right?

It depends on whom you ask. Clearly, the Stanford researchers, as well as other researchers who have studied caloric restriction (another method purported to promote long life) think so. But there is another camp of scientists dedicated to improving not so much life span, but health span.

So what does "health span" mean? According to the Macmillan Dictionary's online "Buzzword" feature, "health span" is "the period in a person's life during which they are generally healthy and free from serious or chronic illness." So the focus is on living better, as opposed to living forever.

Sounds simple enough, doesn't it? But this concept is really a very complex one which scientists are only beginning to grapple with, understand, and research. Ironing out some of the complexities, and getting more scientists, policy makers, and regular people to think this way, though, is key to making sure that "aging gracefully" is not just a catch-phrase.

One major problem in the world of aging research is a disconnect between the viewpoints of clinicians and "basic" science researchers on this very topic. In an article published in the Journal of Gerontology in 2009, authors Drs. James Kirkland and Charlotte Peterson write that "Geriatricians and others providing health care for the elderly have long recognized that disability, frailty, and age-related disease onset are the critical end points that need to be addressed in older populations." Hence, many clinicians are on the "health span" wagon. However, Kirkland and Peterson also claim that "Most investigators in the basic science of aging use survival curves and maximum life span as key end points for studies of effects of interventions, rather than health span or function." Hence many basic science researchers are on the "life span" wagon. And when researchers and clinicians are on two different wagons, little if any progress will be made in terms of going from the scientific "bench" to the bedside with new treatments.

What needs to happen, writes Marc Tatar, a biologist at Brown University, is first clarification of the health span concept. While Tatar explores a more scientific definition of health span than the one I previous listed, his comments relate to our more simple definition as well. For example, how do you define "healthy"? What is the threshold between healthy and unhealthy, in terms of time and quality of life? And even if you use baseline performance as a judge, that baseline performance declines over time -- how do you factor that in? These issues need to be resolved before any progress can be made, Tatar says.

Once some of that ambiguity is resolved, the next step is to develop a better animal model for studying health span, Tatar says. That will allow researchers to take results and translate them to human models. For example, researchers should look at how best to study osteoporosis -- clearly a factor in human health span -- in mice, flies, or worms (three of the best animals for studying aging issues).

Kirkland and Peterson agree that better animal modeling is needed, although they focus on the concept of frailty: "Frailty usually describes a condition in which a critical number of impairments occur in parallel, becoming evident after a threshold is reached, and if a stress such as an infection or injury is applied." They say that indicators of "frailty syndrome" include weakness, fatigue, weight loss, impaired balance, decreased physical activity, slowed motor performance, social withdrawal, mild cognitive dysfunction, and increased vulnerability to physiological stress.

According to Kirkland and Peterson, screening for frailty in humans is being developed and validated, and could be adapted for use in animals. Testing animals for frailty -- after giving them an anti-aging compound, for example -- could help show whether the added longevity compromised health span, and therefore whether the compound was potentially appropriate for trials in humans.

Living longer, obviously, can be a good thing. But only if that extended life is a healthy one. That's what the study of health span is about. And while the idea is catching on, it has some catching up to do.

Room To Breathe, Room To Vent

Of the dozens of patients I encountered the summer I worked in an ICU in the Chicago area, the person I remember the best is Mr. Chesterfield. * Rather, I remember Mrs. Chesterfield -- her husband was on a ventilator and was unconscious and unable to talk the whole time I was there. But Mrs. Chesterfield and I had some lovely conversations while I stocked the nurse's cart in Mr. Chersterfield's room, brought in new boxes of gloves, and changed the sharps box. She even sent me a thank-you note, telling of her appreciation for how I had encouraged and comforted her during that difficult time.

At the time, I knew the machine hooked up to Mr. Chesterfield was pumping his lungs full of air, breathing for him. But I had no idea how it worked, or what damage such a life-saving device could potentially cause. Until today's lab meeting.

Clearly, if someone cannot breathe on his or her own, having a machine do it is a good thing. There are several problems with using a ventilator, however. One is that using a ventilator at "high-tidal volume" -- which is sometimes required, when a person's lung capacity is diminished (from what I understand) -- can "hyperinflate," or overstretch, the lungs. This excessive stretching breaks the cell-cell junctions (sticky stuff that keeps the cells together). This necessary (but damaging) overstretching results in a condition called "volutrauma." In this condition, the permeability of the lung cells (specifically, alveolar epithelial cells) increases, which affects gas (i.e., oxygen and carbon dioxide) exchange, the spread of micro-organisms (and infection/inflammation), and the build-up of fluid. When volutrauma is taken to the extreme, according to one person in my lab meeting, you basically drown to death because your lungs fill with fluid. Not good.

Of course, when you breathe normally, you are also stretching your lungs -- perhaps about 8 percent. High-tidal volume ventilation might stretch your lungs about 20 percent instead. With that extra stretch comes increased permeability and the cell-cell gaps that create all the problems.

What one of my fellow researchers has found is that decreased levels of a particular protein seem to be linked with those cell-cell gaps and increased permeability. Increased levels of that protein may be associated with fewer gaps, called a "partial rescue." This means the protein could be a "therapeutic agent" for ventilator-induced lung injury. Which would be a huge deal, especially considering that many ventilator patients are older, and that the ratio of elderly people in the overall population in the United States is about to jump sky high.

Of course, there are plenty of issues to work out with this research. (I won't even start on those.) This is basic science, not even close to a clinical trial. But it's exciting to see how something happening in the lab next door could potentially save lives a few years (or decades) down the road.

And who knows? Maybe by the time I'm an anesthesiologist (a thought that has occurred to me more than once) this is a treatment I'll be using.



* Name has been changed to protect the patient's privacy.