The Lingering Shadows

Three days ago, on Thursday, I moved from Troy, MI to Wauwatosa, WI. I'm now about half a mile from the medical campus and tomorrow begins the week-long orientation, not to mention another state and another time zone. Though I've been working towards and waiting for this day, now that it's here, lingering shadows are cast from the dark corners of my mind.

For the last 18 years I've lived in Michigan. For the last 5 years I've been at the University of Michigan-Ann Arbor. One does not live somewhere for so long and simply unplug from it all. It's strange and difficult for me to describe this sentimental feeling. As I was packing and unpacking, it seemed as if everything I touched had some memory attached to it. It was the kind of nostalgia that makes one tremble and cry inside.

The biostatistics notes: how we hated that class, how we discussed the homework and the coding, how I somehow managed to pull an "A" in that class. The cancer epidemiology notes: the class I often fell asleep in (the room tended to be cold, and that certainly didn't help) and sat near Yoshi and Wei. The HBHE class with Alicia and the other genetic counselors: how Alicia and I feverishly worked down to the last minute on our final paper and project of the course together (it was quite a novel idea). The genetics book I took with me: heartfelt memories of my time as a GSI. The pathophysiology book I took with me: Dr. Martin Philbert and his amazing lectures that left us enthralled (his British accent certainly helped).

There are other memories too. The PHAST (Public Health Action Support Team) trip I took with a few other students to Beijing and Tianjin, China for a week over Spring Break. I have a scroll that I bargained for in a market with Derrick and the xun that Jackson gave me when we met up briefly in Beijing the second night I was there. The old UMS concert booklets that reminded me of the concerts I saw with friends. The trio I composed but was never played.

Then there were the more intangible memories for which there are no objects to serve as reminders. The late night pizzas with Jackson and Jeff in the dorms freshman year. The massive orgo study sessions. The smaller (and more fun) genetics study sessions in the YK Lounge of South Quad with Shari, Sohil, and Kavya. Playing TNL (thunder 'n' lightning) at the CCRB. Memories of watching Jackson and Dan play Guitar Hero in their apartment senior year. The mini-course on HIV/AIDS that Jackson and I taught to 10 Honors freshman during our final semester of undergrad. The 3-movement string trio that began our trio group with me, Marla, and Shari. Friday night Jewsian dinners with Rui, Jen, and Shari (later simply friday night dinner while watching House MD and Heroes with Shari and Alicia, after Rui and Jen graduated and left). Late night bubble tea (and sometimes popcorn chicken) or coffee runs after studying at the UGLi (Undergrad Library).

The list goes on and on and on. Truly, undergrad (and to an extent, the one year of grad school) comprised the best years of my life thus far. Why had I so planned and looked forward to the future? Why I had I always kept my eyes focused on something ahead? Ann Arbor was more than a home, UM was more than a university - they changed me without me even noticing. How will this next step in life change me? Where will it take me?

It feels as if I've left a part of me behind in Michigan, a version of me that does not want to leave or age or face the future. These lingering shadows - these memories - make me sad that my friends are scattered across the US, and verily, around the world. Perhaps never again will we all be concentrated in a single city. We will dream and reminisce of the days gone by, perhaps with a smile, or perhaps with tears. I always thought it strange that people cry during graduation, and sob softly while attempting to smile for photos together, and hug and embrace as if after a tragedy. But now I believe I have some sense of what that feels like because as I packed and got ready to leave, I realized that a part of me was not ready as tears welled up in the corners of my eyes.

But as Jackson said, "Yeah, we had some good times. But I think it's also good that we should now start working toward our careers." Well said and true; mark my words, we shall see each other again at the end of this stage of life. So long as we remember, the lingering shadows will not fade.

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The Dream

Last Friday I ordered my white coat for the White Coat Ceremony on August 14th, the last day of med school orientation. In a way it's almost surreal, as if to say "Wow, this is really happening!" I'm sure it's going to feel even more surreal the closer it gets to orientation.

At the risk of sounding cliche, being a doctor was a dream I've held for a long time. Though it wasn't until the end of high school and undergrad that I seriously considered going into medicine, the impetus and desire was there much earlier. It was one of those rosy-colored dreams where I had my own clinic with my own nurse and patients who loved the care I was providing. This iteration of the dream lingers still.

Further iterations have become progressively more ambitious. For a brief moment I had aspired to become the head of a department. I quickly dismissed that because I would never want to deal with the administrative aspects of the job description nor do I have any interest in being at the center of some hospital politics.

My most recent iteration of the dream has become quite involved. My current medical interests lay in pediatrics, medical genetics, and endocrinology. I suspect that if my current interests remain unchanged throughout med school, I'll likely have to choose between medical genetics or endocrinology - I would do my residency in pediatrics and then a fellowship in either medical genetics or endocrinology, but not both because then I would be in training for way too long.

In the current dream I would be an "academic" physician practicing medicine at a major research university. While my interest in conducting medical research has waned considerably in the last year or two, I would not mind doing research 1-2 days a week; also, being in academia keeps me updated at the forefront of cutting-edge medical research and technologies. Hopefully I would still have my own clinic and not be "bound" to work in a hospital all the time. Furthermore, if I do end up pursuing the medical genetics route through pediatrics, there's the possibility of my friend Alicia working for/with me one day as my genetic counselor.

But the main reason I would go into academic medicine is for the prospect of one day teaching a course. As I've posted before, teaching has been one of the most rewarding experiences of my life thus far. If I could practice clinical medicine, stay up-to-date on research, and teach, that would be the ideal. Yet, I'm often left wondering how much I would have to sacrifice to achieve this latest iteration of my dream.

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The Path

Pardon my absence. Unfortunately I am not blogging from China because due to powers out of my control I was not allowed to go. Instead I've been at home wallowing in boredom and lethargy. At least I saw the movies Star Trek and Up - great movies by the way.

With so much time on my hands, I might as well elaborate on "the path" to medicine. It is one of delayed gratification almost to the point of torture and insanity. Even reaching the light at the end of the tunnel is no guarantee of a break from all the money, hours, blood, tears, and sweat that went into the journey.

Here are my prospective thoughts on the path - perhaps I'll return and let you all know how things turn out in the end (at least 7 years from now).
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The Beginning
I would argue that this path starts sometime at the end of high school or the start of undergrad. To embark on this path one must be certain and focused on it. One must be determined and have a sense of where he/she is going in life before they can pursue it. No one goes into medical school half-assed or without some sense of why he/she is there. Once the determination is set, various things must be done to verify that it is not all a mistake.

Such things include hospital volunteering, biomedical research, core biology and other physical science classes, and doctor shadowing. It is rarely easy to devote enough time to all of these and still maintain the requisite grades for medical school, much less a calm sense of self. And then there is the MCAT, a foreboding test that is a standard equalizer in a sense amongst all applicants.

The Application
The application process is a long and arduous one. Unless you know you're an amazing applicant, most applicants will apply to at least 12-15 medical schools. There is first the AMCAS primary application that is sent out to all medical schools you apply to. Then the medical schools that want to consider you will send you their secondary application, often filled with many essay questions and other details to fill out.

Then, when the medical school is satisfied with your grades, MCAT score(s), extracurricular activities and achievements, as well as your answers to their essays, they might invite you for an interview. The interview is both a good sign and a daunting undertaking. Based on how well you connect with your interviewer(s), how you answer and ask questions, and what impression you give, you'll either be accepted, wait-listed, or rejected.

Medical School
Now you're in medical school. After the first year you can say goodbye to being debt-free (if you ever were in undergrad), goodbye to traveling over the summer, goodbye to sleep, goodbye to hanging out - goodbye to practically everything except classes and studying. I feel that only the most well-balanced and most efficient time-managers among us can survive beyond becoming consumed by medical school.

The first two years consist of grueling coursework and studying, all in preparation for the USMLE Step 1 (US Medical Licensing Exam) taken at the end of the second year of medical school. The last two years consist of rotations in the various medical departments to get a flavor and experience of what the different specialties in medicine are like. The fourth-years must then apply and interview with hospitals to obtain a spot in a residency program in a process called "the match." All over the US on a specific day at a specific time in March, fourth-year medical students all receive their residency placements. I hear it's a day filled with much crying - whether it's crying for joy or disappointment.

Residency
Now you're done with medical school. You are a doctor now but must first gain the experience to make yourself an effective and capable doctor. And so for at least the next 3 years you are an intern (the first year) and resident (the remaining years). Your meager salary of $40,000 to $50,000 and 80 work hours a week is like a slap in the face for all the work you've done in medical school to get here. If you worked the 40 hours a week of a normal person, you would only earn $20,000 to $25,000 a year. And always looming over your head is the $150,000 debt (on average) that you had to borrow to afford medical school - let's not even mention the interest on that.

After residency you may opt for further specialized training in a fellowship. You tell yourself that you'll be able to relax and sleep after residency, that you'll have time to take a vacation every now and then to travel, and to make "real" money. You realize the follies of such thoughts.

Attending
Now you're an attending physician, done with your medical training and top of the food chain now, as it were. Your hours are more relaxed (generally) and you are at the top of the pecking order. Yet, you're often still on call, and you can't really get away for a vacation because there are always patients, and of course the patients come first. Is there ever time for yourself?

There are overhead costs that you hadn't anticipated before, especially if you plan on opening your own private practice. Such costs can include: office rent, heat, water, electricity, lab tests, paper, nurses' salaries, receptionist salary, malpractice insurance, supplies, internet, etc. All this might cost upwards of $100,000 (I don't know the true figure). And oh yeah, you still have a good chunk of that borrowed $150,000 that you still have to repay (plus interest). You have to fight insurance companies for every cent just to fill your bottom line.

What is this? A business? This is not what you signed up for when you started medical school. When did medicine become a business? Why are there limits on how and what you can do for a patient to ensure the best care? And of course, the threat of a lawsuit by a particularly disgruntled patient looms over your head.
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The path is a curious one - a noble and honorable path at its core. But why then does it contain such "suffering?" Is this how the best doctors are made? You have sacrificed sleep, friends, family, vacation, traveling, current fortune, all for the promise of doing something better later . . . much later. You have taken on a tremendous amount of debt, long hours with comparatively horrendous pay, battle the broken system tooth and nail for not only your patients, but also yourself.

It's curious that once you embark on this path people outside the field assume you have it made. Sacrifices? Well at least you have money. No life outside the clinic/hospital? Well at least you have money. Traveling? Well you have the money to do it (too bad you're now old and patients will hate you for taking time off while they're sick). What is up with this fixation on money? What use is money if you can't use a lot of it for things you want to do? When a good chunk of it goes to repaying debts? The most valuable thing for physicians is not money but time, and there's simply precious little time for the physician him/herself.

The most difficult thing on this path is balance: the ability to not lose yourself along the way. It's too easy to let medical school, residency, and being a physician control your life that you miss the things most people cherish in life - hearing your baby's first words, seeing your baby's first steps, attending your kid's games, attending their graduation, traveling, a nice night out.

My greatest fear is that medicine will consume me whole, and that I'll lose myself and all the little things I enjoy in life in the process. And no, I have no answers. But I pray that I find them along the way.

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On Being a GSI and Teaching

This last semester, Winter 2009, I was a GSI (grad student instructor) for the undergraduate class, Bio 305: Intro to Genetics. My position required of me - each week - to attend the two 1.5-hour lectures, teach three 1-hour discussion sections, and hold 4 hours of office hours. At the beginning of each week all the GSIs (6 of us total) met with the professor teaching the course to plan and "standardize" which topics and problems we'd be emphasizing and going over in discussion sections. Also we had to proof-read, take, and proctor the exams for the course.

For me, being a GSI and teaching was perhaps the most fulfilling and rewarding grad school experience. I knew the moment I walked into the classroom that I wanted to make a difference in the minds of my students - I wanted them to think critically on genetic problems and issues, to understand the growing importance of genetics in medicine and society, to see that we've come so far and still barely scratched the surface, and above all to care about the subject. I don't know if I achieved this, as it was very ambitious, but I think I was met with some level of success.

I had several practical aims. The first aim was to get a high attendance in my sections. Discussion sections were completely voluntary and anyone could go to any GSI's sections. In this respect, I succeeded. I usually had at least half attendance in my Tuesday section and almost full (if not full) attendance in my Friday sections. In fact, several students from other sections regularly came to my discussion sections! The second aim was to explain the material as clearly as possible. Genetics is a difficult subject to conceptualize, so explaining the material is quite a challenge. But I've repeatedly received positive comments about how I explained things. And my third aim was to link the material to health, medicine, and society to help illustrate the importance of genetics. I used examples such as taking a family history, inherited diseases, stem cells, and cancer.
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Halfway through the semester, all new GSIs had to be observed by a senior GSI. The senior GSI would sit in a class, observe, and in the last 10 minutes of class, ask the new GSI to leave and ask class to be open and honest about the strengths and weaknesses of the new GSI. When I met with the senior GSI who observed me, she said, "Of all the observations and evaluations I've done, yours was the easiest, quickest, and most positive. They had only good things to say about you."

In my last discussion section for the semester, one of my students (a male nurse who's older than me) brought his two little kids - age 3 to 5 - to my discussion section. I guess somehow he felt that my discussion sections were necessary enough to attend, even though he could've easily skipped to take care of his kids? (Btw, his kids were adorable, and I just so happened to bring cookies that day, and they loved them.)

Upon turning in her final, one of my students said to me, "You're literally the BEST GSI I've ever had. I'm not even kidding, seriously. Thank you."

When another one of my students turned in her final, she said, "I just wanted to let you know that you are probably THE best science GSI I've ever had. One of my friends actually transferred into your section because his GSI sucked and I told him that you were amazing."

And at one point while I was proctoring the final, the professor herself came into the lecture hall and whispered to me, "Several students in my office hours tell me that you do a great job explaining things to them. Good job, I thought I should tell you."

And lastly, my friend Emily (whose friend is in one of my discussion sections) tells me, "So my friend Kate says you're her favorite GSI."

Clearly from the "testimonials" above, I must be doing something right, right?
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I'm not sure what it is I do exactly, I sort of teach on-the-fly with a very bare-boned lesson plan in my head. I do what I feel like would most benefit them in the 1 hour (well, 50 minutes) we have together. I have, however, identified a few things I think have helped a lot:

1. Make it relevant.
Students tend to not like the theoretical stuff. They need a way to take the concepts learned and integrate them into something they can relate to on a personal level. I often used the example of cancer genetics, because it fits so well with many topics. I also tried to link up some concepts to things like cardiovascular disease, family history, etc.

2. Organization.
It definitely helps to know what you're doing, what order you're doing it in, and how long you expect it to take. Even better if you've internalized that organization so you don't have to always have it in front of you.

3. Reflecting questions.
As I work out a problem on the board or present a concept, I constantly ask my students about the next "step." What happens now? What do you think I should do? Why do you think this is? How do you think this works? Etcetra. They may not always answer (and in one of my classes, they rarely did answered), but they are thinking and considering. This is much more effective in office hours where they have "nowhere to run." I force the students to try to solve the problem on their own, with me basically giving them sign posts and clarifications - only give directions if they're lost.

4. Visual learners.
I always draw up a diagram on the board and describe what I draw as I draw. Genetics is not a very tangible subject, so you have to somehow make things visual so they can more easily and readily comprehend it. Also, you have to actually draw it out, it does no good to just flash a picture or a diagram up. You need to walk through how the diagram's constructed, and explain what makes it tick, so to speak.

5. Understanding their needs.
I think one of my greatest assets is that I understand where many of them are coming from. It wasn't so long ago that I was "in their shoes." I understand what many want out of the class (that is, nothing to do with it) and I hoped to make them actually interested in genetics so that things stick in their heads. So I put myself in their shoes, "If I were taking this course again, what would I want to learn? What would make it interesting and relevant? What do I want to take out of it?" With that in mind, I try to meet them at that level. The professor actually remarked (with a hint of sarcasm), "No wonder why they liked you. You're a pre-med GSI for pre-meds."
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It usually brightens my day when I have to go in to teach my discussion sections. And it feels pretty damn good to receive such high praise and comments about the way I teach. Teaching is rather fulfilling, I find. You see the light bulb turn on, the confusion melt away into clarity and understanding. You see that glimmer in their eyes, and you know you've reached someone, you've piqued someone's interest. And perhaps that someone will take that interest and do something great with it.

I've learned as much from teaching as (hopefully) my students have learned from me. I've learned what works and what doesn't work when explaining complex ideas to people. I've learned how to better handle and answer difficult or vague questions. And overall it has only helped me to become a better and more confident communicator. These are all critical skills for me as a future physician, and whatever else I may be along the way.

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Prologue: Past and Present

In order to guide the future, one should be aware of the past and the present. While the future is unpredictable and is subject to change at a moment's notice, it's still important to keep certain things in mind. Hopefully this blog shall progress accordingly.

In Spring 2008 I graduated from the University of Michigan-Ann Arbor with my Bachelor's of Science in Biology. At this point, I had applied to 17 medical schools and 1 school of public health. I had gotten 3 med school interviews and been placed on 3 wait-lists. I got into the one school of public health at UM, my now alma mater.

After graduation, I wrote a letter of intent to the Medical College of Wisconsin (MCW), my first choice among the places I interviewed. At the same time, I accepted my acceptance to the UM school of public health (UM SPH) for the Hospital & Molecular Epidemiology program just in case.

In early July, I got a phone call from the director of admissions at MCW. Here was the situation. I was really high up on their wait-list, perhaps in the top 10 or so. If anyone had declined their acceptance, I would almost certainly get a spot in the entering class of 2008-2009. But because it looked like that wouldn't happen, he made me a special offer. He would guarantee me a spot in the entering class of 2009-2010, provided that I met all the requirements for admission anyway and that I did not apply to any other medical schools in the next application cycle. I readily took his offer.

So, for the 2008-2009 academic year, I was at UM SPH working towards my Master's in Public Health (MPH) in Hospital & Molecular Epidemiology. I worked in a genetic cancer epidemiology lab, mostly on colorectal cancer. Also, winter semester I was a graduate student instructor (GSI) for the undergraduate course, Biology 305: Intro to Genetics. Being a GSI totally rocked (and I was pretty good at it, if I do say so myself), and is definitely worth a post at a later date.

Right now I'm at home, relaxing and not working this summer immediately before medical school. I have a trip to China for the month of June that I'm really excited about. I'm still uncertain as to whether I will complete my MPH at UM or MCW, or at all. Stay tuned for the stories and excerpts of my life, as well as commentaries on things that interest or concern me.

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Prelude: Things In Passing

Here I am, first post. This blog starts at an intersection of the end of one stage in my life and the beginning of the next. It has been a good and long year at UM School of Public Health (SPH), and now I'm ready for the next stage: med school at the Medical College of Wisconsin (MCW).

I had been ready to leave UM and Ann Arbor since graduating last spring, 2008, with my B.S. in Biology. Now I find myself truly leaving and it's just a bit surreal. In the last 2 weeks I walk through Ann Arbor just one more time, taking pictures of the scenes I will miss.

How fast we move through life, and the older we get the faster time seems to flow. What have we missed in passing? If we could slow down, what would we do? What would we see? What might we notice?

Before I leave Ann Arbor, I would like to remember some of the things we don't really notice but that give Ann Arbor it's unique flavor - some of the things in passing:

The mural on the side of Potbelly's on the corner of State St. and E. Liberty.

On the ceiling of the alley to the back of MI Theater on E. Liberty.

Scenes in the alley behind MI Theater on E. Liberty.

Wall of the parking lot on Menard St. next to Nickels Arcade.

Nickels Arcade between State St. and Menard St.

A wall on Catherine St. between N. Ingalls and Glen St.

Random sidewalk art.

Gnome on the med campus near Med Sci II on Catherine St.

Wall art in the alley next to the Safe Sex Store on S. University.

Random spirits outside a store corner on State St.

A fire hydrant on the corner of State St. and N. University.

On a bench outside the Undergraduate Library (UGLi).

Yes, I will miss Ann Arbor. I'm glad I slowed down enough to see these scenes one last time before I leave. Who knows, the next time I'm in town, they may no longer exist - worn away by time or covered up by tomorrow's graffiti. All the more reason to remember these snapshots.

It is time to say goodbye, it is time to say hello, it is time to bring on the day.

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