Ramblings on healthcare, medical education, and life with a spinal cord injury

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Blog Relocating! New Address!

I’m moving the blog to a new platform, and with that I am changing the address. From now on, the address to use is http://blog.chrismcculloh.com/ and it is hosted on the Svbtle network. ALL NEW CONTENT WILL BE POSTED THERE! And in order to get things going, I’ve already published a few things there.

PLEASE UPDATE YOUR BOOKMARKS/LINKS! There is a new RSS feed over there. I will keep the current site up as an archive, but I will no longer post anything new here.

Thanks, and see you over at the new blog!

March 12, 2013   No Comments

How We See the World

I’m a fan of the show The Big Bang Theory. It’s absolutely hilarious, and being somewhat of a nerd, I get a kick out of a lot of the humor in the show. At the end of each episode, Chuck Lorre, the show’s creator, briefly puts up vanity cards. They generally contain a paragraph or less of text, and they flash on the screen for about a second. You need to DVR the show or watch DVDs and pause the program to read them, but they’re usually hilarious, or poignant, or completely random. He’s done this with most of the shows he has created. I thought one of his more recent ones was particularly awesome:

CHUCK LORRE PRODUCTIONS, #400

I’ve been told that if you change your mind, you change the world – or at least the way you experience it. Let’s take a moment to examine that. The presumption is, if you thought the world was a hostile, ugly place filled with awful people doing awful things, that is what you’d see. Your mind would naturally seek out confirmation for its preconceived ideas (e.g., if you’re intent on buying a red car, as you go about your day you’ll see lots of red cars). If, however, you were able to sincerely change your mind and see that we are all God in drag, that we are the conscious aspects of a perfect universe which had to create us so we could bear witness and stand in awe before its loving magnificence, then that is the soul-shaking reality you’d be greeted with each and every moment of each and every day. In other words, it is entirely our choice as to what kind of world we live in. With a simple decision, we can suffer in the darkness or play in the light. We can be angry, frightened and enslaved, or loving, joyous and free.

I know. It’s a toughie.

People sometimes ask me how I’ve been able to deal with facing some of the challenges I’ve faced and come out with a positive attitude. I think Lorre has summed it up perfectly. It’s because I’ve chosen to have a positive attitude, which is certainly not always an easy thing to do. Everybody gets down on themselves at one time or another, and it’s very easy to fall into the trap of having negative experiences and beginning to focus on the negative things. But it’s also possible to let the negative things go after expressing anger or frustration, focus on the positive things, and then life begins to appear more bright.

A toughie indeed.

March 2, 2013   No Comments

Having a Disability vs. Being a Woman

Which is worse? Just kidding. And yes, the title of this is just a bit inflammatory. But bear with me, it has a purpose. And, well, it’s a pretty funny title.

When I first started the clinical portion of medical school, I wondered how patients would respond to a medical student who entered using a wheelchair. I worried that they would all look at me funny and talk down to me, and think I was just there to observe, and not to participate. And sure, over the last several years, I have gotten the occasional odd look. But it’s rare. Much more rare than I thought. People most often don’t show any visible reaction, and are quite good at getting down to business and telling me all about their bowel movements.

Once in a while, I’ll get comments filled with just a bit too much adulation. I know they mean well, but I’ve gone into a room to examine a patient and had another person in the room tell me, “oh, it’s SO wonderful you’re doing this! Wow, that’s just amazing!” And I do understand that a doctor who uses a wheelchair is not an everyday occurrence, so I don’t have any negative feelings at all toward people who take it a bit too far. I know they mean well, and I appreciate the sentiment. But there comes with it the subtle back-handed complement based on the idea that they’re surprised I’m not a shut-in living in my apartment.

But to get back to my original point, the overwhelming majority of my patients just treat me the same as anybody else. And even when traveling around the hospital when not wearing my white coat, people see the scrubs or the tie with a stethoscope, and I tend to always get “Good morning, doc!” Or, “Hey, doc! How’s it going?” (The first time someone I didn’t know said that to me, I couldn’t help but crack a big smile.) So I’ve come to realize that, at least when in that setting, I am seen as a doctor. It took a while to realize that, but I have. And I suspect that imparts some confidence that I subsequently can draw on, making my presence that much more appropriate and easy to realize. People do see me as a physician, even when I introduce myself as a medical student – which I only have to do for two months more!

What does this have to do with women?

I went into a patient’s room during third year with a resident I was working with, who was a woman. The resident proceeded to explain what was going on, and what the treatment approach would be. And as soon as she was done, the patient turned to me and asked if it was the right approach. The patient didn’t say, “well, she’s a woman, she doesn’t know, is that right?” And I could have chalked it up to just asking for another opinion. Until it happened several other times with other residents, in other hospitals, with different patients. And always only when I worked with female residents, never with male residents.

Just today, I went into a room to see a patient I’d seen yesterday. Yesterday, the patient referred to me as his doctor. Today when I entered with my female attending, he was on the phone and said, “I’ll have to call you back, the doctors and nurses are here.” All of the nurses in the hospital wear all white scrubs. The attending had on a white lab coat, and was dressed in appropriate doctor clothing. The women appear to notice it as well, as whenever I see that kind of thing happen, the women tend to quickly use the word ‘doctor’ and re-state their role. Never in a confrontational manner, just an introductory statement.

On one of my interviews, we were on the hospital tour, walking around in our nice little penguin suits, as a man passed us. He looked at us, smiled, and commented on how good we all looked in our suits. He congratulated us on being, “future doctors and nurses.” One of the female applicants quipped something funny in response, and seemed to have gotten that kind of comment before.

I’ve come to feel over the course of the last several years that I have seen more overt biases toward women in healthcare than I have to a man who uses a wheelchair. Perhaps that’s because people have pre-existing ideas of what a nurse is supposed to be, while nobody has ideas about doctors who use a wheelchair. Interesting side note, one of the executive producers of the TV show House said that House was originally intended to use a wheelchair, not a cane. But Fox rejected that idea. And now back to our regularly scheduled program..

The stereotype of a nurse certainly is of a woman – and it would seem to be a correct assumption to make more than 94% of the time. These nursing statistics, from Minority Nursing Magazine, are quite interesting. According to them, men only account for 5.8% of the nursing population. And the average age of RNs is 46.8. So if one is going to make any assumptions about the gender of one’s nurse, assuming your nurse is a woman is probably a pretty safe bet. Not that I would encourage anyone to generalize, of course.

But assuming that any woman one sees in the hospital is a nurse is not quite so safe. According to the AAMC (American Association of Medical Colleges), 48.3% of medical degrees awarded in the US in 2010 were to women. That doesn’t mean 48.3% of physicians are women, since there’s a lot of graduates practicing from older classes that were significantly more male. But it means we’re doing a much better job of balancing things now.

It’s something that I feel I’ve observed enough to have noticed it, and of course, now I remember each incident even more vividly since I’ve seen it several times already. And certainly, people come to every encounter with their entire life’s experience. I guess that when I started medical school, I never would have guessed that I would see such overt assumptions made about women in this day and age, without at least as many overt assumptions about me.

But it turns out, I was the one making the overt assumptions about me.

February 28, 2013   3 Comments

Exercising the Brain

One of the things I was always proud of when I was younger was the ability to adapt and pick up new things very quickly. Technology, theories, processes – whatever it was. I saw people generations older than me, and they had such difficulty with things like programming a VCR, or using a computer, or even a microwave. I chalked it up to a technology-related phenomenon, and ascribed it simply to the difference between growing up in very different ages.

Then as I got a little older, I found I had less patience for certain things. Things that, as a teenaged idealist, I would have gladly done the very long, very complicated way – because it was the “true” way to do something the way I wanted, rather than the shorter, quicker way that pretty much got me to the same endpoint. (For the geeks out there, compare using Gentoo and building everything from scratch, spending hours alone on something like glibc, compared to using a package management system and having things installed in seconds.)

I’ve often wondered whether or not differences between younger and older are generational, or are simply a function of changing brain activity over time. It’s made me worry that I too may someday succumb to those changes, although I always tell myself it’ll never happen. This thought process was again triggered this morning when I heard an older person (probably late 60s-early 70s) saying that he can’t be bothered to figure out technological devices anymore, and instead depends on a family member.

Are those differences a function of people having less patience for tasks that are (seemingly unnecessarily) overly-complex? Or are they a function of changes in brain function over time? And if they are related to changes in brain functioning, what can we do to prevent it? Is it related to the tendency to learn less as people age?

The brain, like many other things, falls under the “use it or lose it” umbrella. In my first year of medical school, a Ph.D. neuroscience researcher told me that, through his own studies, he found that newly-formed synapses can begin to degenerate if they are unused for only a few weeks. Now, this was relating to neuroplasticity and in the context of me forming new synapses by exercising. However during brain development and maturation (the so-called “critical period“), we form tons of new synapses. And during that time, if we are not actively using them, they degrade.

So how does that relate to age-related decline? Are we losing synapses, critical to thinking, if we don’t actively exercise the brain by continuing to think critically and learn? My instinct has always been that, yes, we do. And that the best way to ensure the brain continues to function at its highest possible levels is to never stop learning, and never stop thinking critically. And every time I think that, it makes me even happier that I’m in a field where my job will involve learning and critical analysis until the day I die. Or quit. Although I’m not sure which I expect to happen first. I’ve also wondered if this is all true, does it mean these age-related changes tend to be less pronounced in people who spend their lives in academic professions?

Today I did a little research on the matter, and came across an interesting article from JAMA, entitled “Neurobiological Changes in the Hippocampus During Normative Aging.” The hippocampus is critical to things like memory, especially spatial memory, and is often a focus of study with respect to aging. The study goes on to state that there is neither a great loss in the number of neurons in the brain associated with aging, nor is there a loss in the biological function of those neurons. What does change, quite significantly, is the synaptic relationships. In one region, a 24% reduction in the number of synapses was observed in older brains compared to younger, which correlated to a concomitant decrease in measured electromagnetic fields in the brains. There is some attempted compensation by the synaptic potentials being larger, but it doesn’t seem to be enough to make up for the losses.

So the number of synapses declines, so what? Can we stop it? Do we really lose it if we don’t use it? It turns out, studies have shown that synapses are strengthened by repeated use, a process we now refer to as long-term potentiation, which has separate phases: induction, and early and late maintenance. LTP does change with age, decaying faster in the older brain, and those changes appear to be more pronounced in cases where it is used less. So it does become more difficult as the brain ages to form new memories, and it becomes easier to forget things. And that becomes even more significant when we don’t use our brains as much.

But that’s just a tiny point in a much bigger discussion, and certainly one can’t abstract synaptic changes in one specific region of the brain to the entire organ. But it’s nonetheless fascinating. People who become stagnant in other areas of life, progress on a weightlifting or exercise routine for example, often tout changing things up as a way to get past a plateau. Challenge oneself, the theory goes, and you force your body to grow and adapt to something new, rather than depending on muscle memory. If you get bored on your routine commute, you might change things up and go a different way.  You see new scenery and aren’t as much on auto-pilot.

Why not the same with the brain?

Challenge yourself to read about, learn about, think about, or try something new. Make it a habit. You might find that you even get better at doing the things that are at this point routine.

That’s what I’ll be doing to help ensure this gelatinous mess inside my skull keeps working to the best of its abilities. Or at least, the ones I’ve still got left.

February 26, 2013   2 Comments

A Funny Thing Happend On the Way to the SICU…

Now that residency interview season is over and programs and applicants have all submitted and certified our rank lists, I thought I’d share a funny story that happened at one of my interviews.

We were on the hospital tour, and being an interview for general surgery, we were taken to the SICU. In this particular hospital, as in many hospitals, several buildings have been joined together that were not all built at the same time. And as is often the case when this happens, the floors were not at exactly the same levels. So when connecting from one building to another, there is a bit of an incline.

We were walking up that incline, and just as we got to the top, I felt something squeeze my right arm around the triceps. I looked to my right side to see what happened, and saw a guy standing next to me that I hadn’t talked to at all that day.

“I figured you must have some serious guns!”

So naturally, he proceeded to grab my arm. Seriously?

I’m not sure why he felt compelled to invade my personal space and touch me when we hadn’t even said as much as “Hi” to each other prior to then. He said it with a smile, and he didn’t appear to intend any malice. I just think he’s somebody who doesn’t understand the concept of personal space.

It was an incredibly awkward experience, a story which I’ve relayed to several people and just laugh about at this point.

So guy who groped my arm, if you ever happen to wind up reading this, please, don’t randomly touch people you don’t know.

February 23, 2013   No Comments

A Gift

One of the questions I get asked frequently is how I’m able to participate in surgery.  It’s a perfectly valid question, especially when using a manual wheelchair to get around the hospital.  The primary issue when using the manual chair isn’t as much the process of scrubbing itself, although there are inherent challenges to that. But the main problem is how to move around the room while remaining sterile. As soon as I touch the wheels, I’d be contaminated. So the end result would be requiring someone, which would probably end up being the circulating nurse, to move me around as needed.  This is certainly less than ideal.

When I was back in rehab, I wrote about how I might participate in surgery using a standing wheelchair. It was somewhat a treatise in theory and planning. I also referenced Dr. Peter Galpin who has already done such a thing in the 1980s. Two years ago, during my first year in medical school, I contacted Dr. Galpin and we spoke on the phone at length about mechanics and details. He was fantastically helpful, both in sharing ideas and his experiences, and also in offering to write letters on my behalf to anybody that might be helpful. I also spent time in several ORs with surgeons, getting exposure to the environment and the unique challenges I would be faced with.

I quickly came to the conclusion that in order to fully maximize my time in the OR, I would have to somehow get ahold of a standing wheelchair – which is no easy task. It’s not something insurance generally pays for, as it’s not “medically necessary.” They’re out of my price range as a student. They’re not rented, because they’re only required by a very small segment of the population and it’s not cost effective to rent them. So suffice it to say, the only option was to somehow have one purchased or provided to me. I pursued a number of sources of funding, mostly running into dead-ends. Dr. Galpin had gotten state funding through disability services offices, so I started down the path with the Ohio Rehab Services Commission. I’m still working on that after more than a year and a half.

One of the outlets we tried at the recommendation of my physiatrist here in Cleveland was the Craig H. Neilsen Foundation. They fund programs supporting SCI research and rehab, and so with the help of my physiatrist and one of my deans at school, we applied for an institutional grant (they don’t give individual grants) for the Case School of Medicine. The application was for a power standing wheelchair, to allow students with SCI to fully participate and attain a medical degree.

The application process took over a year from start to finish, but, our grant request was ultimately approved! In late November, I met with the manufacturer and vendor of a particular brand of standing power chair and we went over the various options and specs. The order was placed, and the chair delivered at the beginning of January. Literally on day two of my long-awaited surgery rotation.

So my eternal gratitude goes out to the Neilsen Foundation for the wonderful opportunity they have given to me and hopefully to future Case Western medical students who will also be able to use the chair. It truly is a wonderful gift that helps to further level the playing field and give those with different physical abilities the opportunity to maximize their medical educations. I know it has already proven to be an invaluable asset in the past month on surgery, not only in the OR, but also outside of it in various other clinical settings. It has enriched my education, and I hope it will be able to enrich the educations of future students to follow me. When I think about how many things I would have missed out on without it, it is quickly very clear just how great an asset the device truly is.

And for that, the Neilsen Foundation has done something wonderful. I can only imagine the other ways in which they’ve further helped those living with spinal cord injuries, and I hope they are able to continue funding worthwhile research and rehab projects for a very long time.

February 6, 2012   2 Comments

Emptiness

Lately I’ve been feeling a certain kind of emptiness. Like something’s missing; there’s a hole that.. didn’t used to exist. It’s as though I’m less than my former self. You see, I recently had two of my wisdom teeth taken out and now there’s these two holes toward the back of my upper jaw.

Actually, the procedure did not at all live up to its unspeakable legend. Perhaps because they were only the uppers, which are supposedly easier to extract than the lower wisdom teeth. Perhaps because they just wanted to come out so badly. Perhaps because I’ve got a great dentist here in Cleveland (this is probably the real reason). But both were done in under forty-five minutes, with the only pain being from the local anesthetic injection (the one on the inside of the roof of the mouth always hurts, despite the topical numbing agent he applied first).

The more interesting part was the cab ride. My driver was an interesting guy who immigrated to the US, although I’m not sure from where. I told him I worked around Case Western, but didn’t mention working in healthcare or being a medical student. Which he didn’t assume, as he spent several minutes railing against science for its lack of progress on such things as curing AIDS and making paralyzed people walk. He said nurses only care about themselves and not about their patients (boy, my experience has been nothing but the complete opposite – most nurses I’ve interacted with care very deeply about their patients).  And he mentioned something along the lines of how awful it was that those scientists haven’t cured me yet. I chose not to get into a heated debate, and merely stated that it can be frustrating how slow things seem to move sometimes, but that people are actively researching these topics heavily.

After bashing people in healthcare, he proceeded to tell me about how his wife left him.  He returned home one day, and she was just gone – no explanation or anything. I won’t pretend to know the details of his marriage or make any assumptions, but his caustic, constant negativity certainly didn’t make me want to talk to or spend any more time with him than was necessary.

Later in the ride he asked “who cooks for you?” and if I have brothers or sisters to help out. I gave him a somewhat quizzical, “I cook for myself,” with a look intended to convey that his question was quite silly in nature. Now, don’t get the idea I’m a master chef whipping up four-course meals every day. I’m not, and I don’t. I never have. But I cook the same as I always have, no more, no less.

He looked back and said something to the effect of, “I feel sorry for you.” Not in a condescending way – at least, not intentionally. “Don’t,” I said, and I proceeded to explain why he shouldn’t and that he shouldn’t think of my life as any different from anybody else’s. I mean, sure there are the obvious differences. But I’ve never been a fan of the whole pity thing. Plenty of people in life have to do things a little differently than what’s typical. He was surprised.

I guess here’s where I could fairly easily segue into the loneliness of his life, but I try not to make assumptions like that. What I do know is that I wouldn’t want to live my life with such a negative outlook on people and events as the driver seemed to demonstrate. To me, that seems a whole lot more un-fun than living with a spinal cord injury. But I don’t know anything about his life, and it could be vastly different than I perceived on what could have just been an abnormal day for him.  We all have those. However, the experience has made me even happier that I’ve got the positive outlook I do on life. It’s made me appreciate how my approach to challenges isn’t, “oh, I can’t do that,” but rather, “hmm, ok, how do I do that?”  And that makes me happy.

Several days later a guy at a bus stop did a very nice favor for me in a completely respectful, non-condescending way that really was incredibly positive. But I have to leave something to tell for next time…

August 24, 2011   1 Comment

Renamed the Blog

I decided to rename the blog. The old name, “Spinal Cord Injury and Healing,” was appropriate when I started writing and the goal was to document my rehab and recovery. Since then, the purpose of the blog has changed and although it still serves to encompass my progress, it focuses equally, if not more so, on my experiences as a medical student. I wanted a name that would at least reflect my positioning on both sides of the healthcare delivery spectrum. So “Delivering and Receiving Healthcare” it is. At least until I can think of something better.

The URL won’t change, since that would break incoming links – although I may add a secondary URL and attempt to migrate to using it. But if I do, the old one will always continue to work.

July 12, 2011   2 Comments

Made it to Grand Rounds

Just a brief post to note that my recent story regarding almost cursing out an attending was selected for inclusion in this week’s Grand Rounds! For those unfamiliar, Grand Rounds is a weekly selection of the top medical/healthcare-related blog posts. Each week, it is hosted by a different blog and the host for that week picks out the stories. This week, it’s hosted by Doctor Fizzy, who publishes A Cartoon Guide to Becoming a Doctor. I’ve been enjoying her humorous cartoons for a while now, and if you’ve any association with healthcare you’ll probably crack up at them.

So thanks, Doctor Fizzy! Incidentally, this grand rounds was a lot more exciting than the ones we have to attend at school, which require our presence prior to 8am! Can you believe it? How rude!

July 6, 2011   No Comments

Just One Teensy Step

Two days ago, I took a huge step forward. No, not that kind of step this time. A metaphorical one. One of the major rites of passage in medical school is taking the first part of the US Medical Licensing Exam, or USMLE, as it’s cleverly known. The test is administered over the course of several years in three sittings, known sequentially as Step 1, Step 2 and Step 3, and taken after second year of medical school, during fourth year, and during the first year of residency, respectively. Medical students tend to refer to this first part as “Step 1,” or “boards” or “that $*#^% test.” I’ll just stick with “Step 1″ for now, this being a family kind of place and all.

One must pass all three in order to apply for a medical license in most states, I believe. Step 1 is an eight-hour marathon of questions. There are seven sections, each containing 46 multiple-choice questions and lasting one hour. You get 45 minutes of break time, plus a 15 minute tutorial that you can skip and add to your day, thus providing 60 minutes of break time to allot as one sees fit. And any time you have remaining when finishing each one-hour question block is also added to your break time. Take three sections back-to-back, then a full hour off, then four sections back-to-back if you like. Or take all seven straight through and be done in seven hours if it’s your preference. Based on solid advice from a good friend, I brought plenty of caffeinated beverages, fruit, snacks and a small lunch. Way too much, but better safe than sorry. Rather than one huge break, I took 5-10 minutes between every section with a bit longer for lunch and just tried to maintain a steady pace all day long.

It’s hard to overestimate the stress that this singular exam can put on students, and it’s important to keep one’s mental state in check. Yes, residency program directors do look at Step 1 scores as an initial guideline for who to invite for interviews. And it’s one of the biggest single components of a residency application. But of course, it’s not the only part. We were given eight weeks of time to prepare ourselves and even at the end, there’s always something more you could have studied. One more time to have gone over the microbio notes. One more time to review pharm. Just once more, I need to look at Wegener’s granulomatosis.

But it’s ok, because no matter how hard you study for this beast, there’s always just a little more that could be done. And what’s interesting is, I’m okay with that now. This is drastically different from when I took the MCAT five years ago. I left that test freaked out, thinking I should have cancelled my test right then and there because I was in such a daze that I was sure I’d bombed it. Well it turns out I didn’t bomb it, so I’m glad I didn’t cancel my score.

This time I didn’t even feel that urge to cancel it or feel overcome with concern. It was a test I’d known about as being a gargantuan stepping stone since long before I applied to medical school, and one which I’d been concerned I’d approach with great trepidation. But none of that was present. I just felt…relieved. Relieved to know I was done. Relieved to know that I’d spent as much time as my sanity would allow preparing. Relieved to know that I’d worked hard to get to that point. Relieved to know it was time to get my life back.

Phew.

June 26, 2011   No Comments