Sunday, July 17, 2011

MCAT: Friend Or Foe?

"The MCAT is your friend."

This is what Richard Levy, who runs, is very fond of saying about the Medical College Admissions Test, which is required to get into medical school. His philosophy is a good one. Befriend the exam, and the process of preparing for it, or succumb to what he calls FUD - "fear, uncertainty, and doubt." And if you fall prey to that, you are less likely to do well. Which can kill your chances of getting in.

I don't plan on taking the MCAT until next April or so. But I have decided to start studying, slowly but surely, beginning now, in my own effort to make the MCAT a dear friend. Why? Because this exam tests your knowledge, comprehension, understanding, and ability to analyze and synthesize four year-long college science courses: General Biology, General Chemistry, Organic Chemistry, and Physics. That's eight (count them, 8) semesters of hard-core, scientific material.

The test is divided into four sections. For each section, the Association of American Medical Colleges (AAMC) posts a content outline that describes what you're supposed to have learned in your courses. Below are the test sections, with links to the content outlines on the AAMC's Web site.

1) Biological Sciences (BS)
2) Physical Sciences (PS)
3) Verbal Reasoning (VR)
4) Writing

That's pretty helpful information, at first glance. But if you take a closer look, things can easily become overwhelming. The Biological Sciences PDF outline is a whopping 17 pages long, and the Physical Sciences PDF is 10 pages. Quite a bit to know! And the exam doesn't just test your recall - you are presented with passages to read, and then questions associated with those passages. So you really have to understand the concepts, not just have memorized equations or defintions.

The BS, PS, and VR sections are each worth 15 points, for a top possible score of 45. The writing portion is graded on a letter scale, between a J (the lowest) and a T (the highest). In 2010, according to the AAMC, the mean MCAT score was a 25, and the 50th percentile writing score was an O.

That score likely won't get you into medical school. You really need around a 30 or so, at least, to be competitive. Upper-tier schools such as Harvard probably won't give you a second glance without a score in the mid-30s. For MD/PhD programs, which I am seriously considering, the mean score of accepted students is about a 35, from what I have read. That's a tough score to achieve. Hence starting to study now.

In terms of preparing, myriad options exist. There are several test prep companies that offer formal courses (which can put you out as much as $2,000). Yikes. Another way to go is the self-study route, which is what I'm doing. Many companies put out MCAT study books on the various subjects, including practice questions. However, these books are not cheap. Luckily, I have a dear friend who took the MCAT a couple of years ago and saved her study books - more than a dozen of them - and gifted them to me. This saved me hundreds of dollars, literally. And I can study at my own pace. This might not work for everyone, but I am a very self-motivated person, and good with utilizing my free time. So I think I will be OK.

I'm also a good test-taker, fortunately. While I get nervous like everyone else, it doesn't affect my score - once I get in there, sit down, and have the exam in front of me, I can focus and get the job done. In addition, I did very well (straight A's) in all of my coursework so far, and hopefully a good bit of that material has stuck. I've taken everything except Organic Chemistry, which I will take this coming year. So this summer and fall, I will be reviewing what I took last year (Biology, Chemistry, and Physics).

But more than that, I will be learning about the MCAT itself, what kinds of questions there are, how to approach the exam in terms of time management (you have just over a minute for each question!), that sort of thing. So that hopefully, when April comes, the MCAT and I will indeed be friends of the most familiar sort. That's the goal, at least. I'll keep everyone updated on my progress.

Friday, July 15, 2011

Nigerian Medical Conference Update

Traditional Nigerian clothing
and head wrap, similar to
what I saw at the gala
The Nigerian medical conference I went to last weekend, put on by the Association of Nigerian Physicians in the Americas (ANPA), was incredible. I truly felt welcomed by the Nigerian medical community, never more so than at Saturday night's gala and banquet. Everyone was dressed to the nines - including many people in traditional Nigerian clothing - and there was fantastic food and dancing to African music. My friend Nneka and I left around 12 p.m., and the party was apparently just getting started!

But of course, while the gala was fun, there was so much more to the conference - so much substance. The first day's symposium focused on women's health. There were three presentations that especially made an impression on me. The first was on bleeding disorders in women, and it focused mostly on Von Willebrand Disease. One of the researchers in the lab where I am actually works on this topic, and presented her most recent findings a couple of weeks ago. So I was familiar with the disorder. (I had previously never heard of it.) Apparently, it is a cause of postpartum hemorrhage, and a factor in maternal death in Nigeria - which is a huge (and preventable) problem in the country.

Another presenter focused on the issue on maternal health in Nigeria, specifically how much progress has been made in achieving the Millennium Development Goal #5 (which has to do with improving worldwide maternal health in specific ways by 2015). She quoted some statistics that were just horrible, including:
- 358,000 maternal deaths in 2008 (and she said most of those occur in the developing world)
- 50,000 maternal deaths in Nigeria in that year
- the majority of those deaths are related to hemorrhage and hypertension, which are completely preventable given the proper medical care and proper medical access (which she said were very much lacking in rural Nigeria)

There were two Nigerian Ministry of Health representatives who were at the conference, and they took exception to this presentation on maternal health. One of them got up during the Q&A and (in a very emotional way) blasted the presenter for not giving Nigeria credit for the strides it has taken to improve maternal health and for focusing on the negatives. So the whole thing got very political, very quickly. Which made my Nigerian friend Nneka a bit uncomfortable, but I found quite interesting - to see different sides and perspectives on an issue, both the outside and the inside view. (The presenter was Nigerian, but had come to the United States at age 2, so was not seen to really have a true "Nigerian" perspective.)

The other presentation I found to be especially interesting that day was on breast cancer, and was given by a professor from the University of Chicago. She talked about cancer in general in the developing world, and how it is so much more likely to cause death because of the lack of adequate diagnosis and treatment, as well as the prevalence of ER- breast cancer (which is an especially lethal type of breast cancer) in younger African and African-American women.

The Day 2 seminar that I went to focused on the Foreign Corrupt Practices Act (FCPA), which is federal U.S. legislation that was enacted in 1977. The purpose of the seminar was to educate the Nigerian physicians on how to appropriately do business between Nigeria and the United States without running afoul of this law.

The FCPA basically prohibits bribery, aka "corrupt payments," to government officials in order to gain some sort of business advantage, influence decisions, obtain/retain business, etc. That sounds simple enough, but the law is actually very complex. And it is made all the more tricky because corruption in Nigeria is a big issue - according to the presenters (who were all lawyers), Nigeria ranks 134 out of 178 on a world-recognized corruption perception index.

What makes the law so difficult, in part, is that these improper payments can include charitable donations, political contributions, and other non-monetary gifts such as travel, entertainment, and food. Also, the definition of a government/foreign official is very broad - it can include employees of state-owned companies, which in many countries where health care is partially or completely public, includes physicians of state-owned hospitals and clinics.

Apparently, the U.S. government is pretty serious about enforcing this law, too. The presenters included a list of fines that several major companies had paid, and they were in the hundreds of millions of dollars.

One thing I found especially interesting was that while the law is very detailed, there is still a lot of gray there, which is complicated by local practices. For example, one Nigerian physician brought up the issue of gift-giving, which is a cultural practice in Nigeria. One of the lawyers said that if the gifts were of little value and not likely to influence decisions, it's OK. For example, giving away a notepad is fine; handing out a gold watch is a no-no. That's a pretty clear-cut case. But where do you draw that line?

Another interesting aspect that an audience member brought up was that while the United States has this legislation, other countries - such as China - do not. Which allows them to go in and basically develop monopolies in the area, because they aren't held to the same legal/ethical standards.

A troubling facet of this presentation was that according to the presenters, there is a huge number of pharmaceutical and medical device companies that are being investigated under this law. I guess this isn't really surprising, but it is indeed troubling.

After the conference was over, I sent thank-you notes to the president of ANPA and the chair of the Chicago/northwest Indiana chapter of ANPA. I received responses within hours, from both of them. Both men thanked me for the feedback, welcomed me to any future ANPA events, and encouraged me in my future medical career. I was even invited to participate in medical missions to Nigeria at some point!

I've always thought of myself as going to Latin America in the future, and I still intend to do so. But after this conference, I have definitely developed a new interest in Africa as well. I would love to visit there, as a start. Now if only flights were just a tad more affordable ...

Wednesday, July 6, 2011

Making A Difference, One Starfish (Or Patient) At A Time

One of the things I look forward to in medical school is doing an international rotation. What that means is that during my third or fourth year, I would go to a foreign country to learn (and help) in hospitals or clinics there, working alongside that country's physicians, nurses, and other medical practitioners. This is actually one of my requirements for a medical school - that it offers such an opportunity. When I become a physician, then, I also want to spend some time volunteering abroad.

I recently relayed these goals to a doctor I know. His response was as follows (I'm paraphrasing here): "Oh, that's just a big Band-Aid. It helps the doctors feel better about themselves, but it doesn't really do much for the patients."

OK, I know that working in a third world country on a short-term medical mission trip doesn't solve all of the region's problems. But I do think that it can make a difference in some individuals' lives. And isn't that what medicine is about, at least in part? Being there, in a room with one patient, helping that person make changes for the better, whether it is prescribing a medication, figuring out a plan to help the person lose weight, or putting a plaster cast on a broken arm?

When I talked about the situation with my mom, who is a hospice nurse, she shared a story with me that really encapsulates that desire to help an individual:

A man was walking along a beach where thousands of starfish had been washed up by the tide. The starfish were slowly dying, drying out in the hot, tropical sun. Then the man saw a small boy on the beach. The boy was stooping down and picking up one starfish at a time and then throwing them back into the ocean. The man walked up to the boy and said, "What are you doing? There's no way you can make a difference to these starfish." The boy picked up another starfish, tossed it into the waves, and replied, "I made a difference to that one."

I realize that I can't save the world. But I do believe I can make a difference, one patient, one person, at a time. Going into medicine, I have to believe that.

Tuesday, July 5, 2011

Something To Look Forward To: A Nigerian Medical Conference

In my current situation, it helps to have things to look forward to. They can be little things, like going out for gelato with my mom after cleaning out junk from my old house yesterday, or bigger things.

This Thursday through Saturday, I have something a bit bigger to look forward to - I'm going to a Nigerian medical conference. It's the annual conference of the Association of Nigerian Physicians in the Americas (ANPA), and luckily for me, it's being held in a swanky Chicago hotel this year.

In case you're scratching your head, wondering how in the world I got invited to a Nigerian physicians conference ... no, I am obviously not Nigerian. But I have a dear friend who is. In fact, I met her at the 2010 OldPreMeds Conference. (OldPreMeds is an organization that hosts an online forum for non-traditional pre-medical and medical students, and I have been involved with the group since last year. Click here to visit the Web site.) My friend was living in Washington D.C. at the time, but she moved to Chicago in January to complete her pre-med classes at one of the universities here. She registered for the ANPA conference, gets to bring a guest, and voila - my invitation.

I'm really excited about the conference - some of the seminars are focused on Nigeria, which should be very interesting. Others are more global in nature. My minor in college was International Studies, so those global issues have always fascinated me.

The conference is organized into themes: Women's Health, Children's Health, Health Care and the Foreign Corrupt Practices Act, Responsible Conduct of Research, and Medical and Dental Education in Nigeria.

Among the seminars I will be attending are:
- Women and Bleeding Disorders
- Infertility in Women
- Cancers in Women: Innovations in Therapy
- Female Circumcision: Controversies
- Overview of the Foreign Corrupt Practices Act
- What Does Professionalism Mean in the New Age?
- Conflict of Interest in Research and Academia
- Teaching Biomedical Sciences in Technologically-limited Medical Schools: A Nigerian Experience

The speakers are from across the United States and the world, and the attendees will be as well. So not only will it be a great opportunity to learn, it will be a chance to network with people I might never meet otherwise.

I will definitely post more post-conference to let you all know what I thought, and some of what I learned.

Sunday, July 3, 2011

Health In The Headlines: Telemedicine

Is this - telemedicine - the future of health care? "Visits" with the doctor via video conferencing?

No, I don't think so. We all have plenty of in-person appointments with our doctors to look forward to, so not to worry. But I do think telemedicine may be part of the future of health care. And for some people, it already is. People like Deanna Ventura, who live too far away from the medical specialists they need. Ventura, who has Parkinson's, was recently featured in a story about telemedicine on National Public Radio (click here for the online version of the story). She has been seeing a movement disorders specialist at Johns Hopkins - 343 miles from her house in upstate New York - for the last four years via video conference calls, according to the NPR story. From my impression, she seemed very happy with the arrangement.

That NPR story piqued my interest, so I decided to do a little digging into the issue myself. Here is some of what I found - and what I think about it.

First of all, what exactly is telemedicine? How is it defined? According to a report by the Institute of Medicine (Telemedicine: A Guide To Assessing Telecommunications For Health Care), telemedicine is:

"... the use of electronic information and communications technologies to provide and support health care when distance separates the participants" (44).

But what does that mean? This definition includes video conferences, sure, but also telephone calls, e-mail messages, the sending/receiving of still images (such as X-rays), and the computer-based processing of other medically related data. This committee's definition also includes consultation, administrative, and educational uses of telecommunications (but I won't really go in that direction).

And in reality, a lot of what falls under this definition is already going on in health care today. We have all talked with our doctors on the phone; some of us may have exchanged e-mails with physicians as well. And if you have a test done at one facility, your doctor (who is at another facility) often gets the results or images electronically - that is all telemedicine, technically. 

The use of video, though, is what tends to get people's attention. That seems like something new. But while it may be new to most of us, it's actually not a novel idea. According to one article I read,* the first use of telemedicine in this context took place in 1959, in the form of a two-way, closed-circuit microwave television system used between the Nebraska Psychiatric Institute and Norfolk State Hospital (also in Nebraska). 

Since then, though, telemedicine hasn't exactly caught on. There are several reasons for this. One reason is licensing. Doctors are licensed in the state in which they practice, which makes them unable to practice across state lines, thus limiting telemedicine's reach. The Institute of Medicine report referenced the possibility of creating a national telemedicine license. But that is a long ways off, if indeed it ever comes into being. Another reason is that health insurance companies usually will not cover telemedicine "visits." So people are either left to pay for them out of pocket, or, in the case of Deanna Ventura (of the NPR story), rely on external fundraising to foot the bill. In addition, there has been little evaluation of telemedicine, in terms of quality of care or cost. This, according to the Institute of Medicine report, leaves people leery of adopting the technology. And finally, there is the issue of technology itself. As we all know, technology changes almost daily. Finding the appropriate, compatible technologies to use for telemedicine is incredibly difficult, especially when you must take patient privacy and confidentiality into account. 

That said, medical practitioners are finding interesting, novel ways to use existing (and commonplace) technology. Millions of people across the globe use the iPhone (including myself). One article** I found on PubMed described how physicians used the iPhone 4 FaceTime software to videochat with each other and share images of a patient's foot that had a limb-threatening infection, and needed emergency surgery. Here is a section of the article explaining what was done:

"A patient with a limb-threatening infection was taken on an urgent basis to the operating room. With no prior planning except for text messaging, the surgeon consulted with 2 surgical colleagues to discuss incision planning, requirements for resection, and subsequent surgical staging (Figs 2a–2d). The “FaceTime” application was managed by an operating room technician under the direction of the operating surgeon" (215).

And here are the images captured on the iPhone 4 (warning: these are a bit graphic).

If I had been that diabetic patient who needed emergency foot surgery, I would have been quite willing to have my surgeon consult with another surgeon via iPhone. If I were Deanna Ventura, didn't drive, and lived too far to see the specialist I needed, I would be happy to see the physician over video conferencing. But if I could, I would still prefer to see a doctor in a face-to-face visit. That's just me - I like the personal contact. There are times, though, when that's just not possible. And that's where telemedicine extends medicine's reach. 

*Breen, G., and Matusitz, J. (2010). An evolutionary examination of telemedicine: a health and computer-mediated communication perspective. Soc Work Public Health 25, 59-71.

**Armstrong, D.G., Giovinco, N., Mills, J.L., and Rogers, L.C. (2011). FaceTime for Physicians: Using Real Time Mobile Phone-Based Videoconferencing to Augment Diagnosis and Care in Telemedicine. Eplasty 11, e23-e23.

Saturday, July 2, 2011

Gen Chem Comes To Life

While working in the lab last week, one of my tasks was to isolate DNA and RNA using TRIzol. It was a long protocol involving lots of pipetting, mixing, and centrifugation. And of course, lots of waiting in between steps.

But the protocol isn't what I want to talk about in this post. It's the preparation I did in advance of starting the RNA and DNA isolation. To do this isolation, you need to make a number of solutions and dilutions. So as we were prepping for the procedure, my lab supervisor handed me several bottles of concentrated solutions and a powder and basically told me to go at it.

Hm. Right. For about 5 seconds, I stared blankly at my composition notebook and calculator. Then I realized that this was exactly what we had learned to do in General Chemistry last year. We had never actually made the solutions - merely done the word problems from the book - but the concepts were the same.

So I took the bottle of sodium citrate that I was supposed to use to make a 0.1 molar solution in 10% ethanol, wrote down the molar mass off the bottle, and calculated how many grams I would need to make 10 mL of the solution (remembering that molarity is moles per liter). Then I took the 100% ethanol bottle and diluted it 1:10 (making 10 mL) in a 15 mL plastic tube. After that, it was simply a matter of mixing the powder in the 10% ethanol. Easy, right? Yep, easy - if you paid attention in Gen Chem - which I did.

By the time I finished with the sodium citrate solution, my confidence had shot up. So diluting the 1 molar sodium hydroxide to 8 millimolar was a cinch.

But the proof is in the pudding, right? So after I finished isolating the DNA, I went to the NanoDrop - this awesome machine that measures the concentration of nucleic acids based on a teeny tiny drop (1 - 1.5 microliters) of the solution - and checked the concentration. More than 900 nanograms per microliter! That sounds like nothing, but for a DNA concentration, it's quite a lot. And it's more than enough to run the future reactions we want to do.

When I actually use something I learned in class, it reminds me that yes - these classes truly serve a purpose. And that is a good feeling.