The Perpetual Student Finally Graduated!

...after 4 years of undergraduate followed by 1 year of work experience followed by 8 years of an MD and a PhD in Biochemistry, I'm finally done.

Yes, that's right folks. Eight days ago I graduated from medical school (I finished the PhD last year), so now I'm officially a mud-phud (MD, PhD). I consider myself very fortunate and blessed to have finished in a reasonable amount of time. Sometimes it can take 8 years to do just a PhD alone.

So now I'm officially done with school forever! ...um sort of. I'm afraid I can't give up schooling without a fight. In 2 weeks, I'm starting a residency program in Internal Medicine. Residency is still sort of like school, although they do pay you, which is nice.

I actually ended up matching into a combined residency-research-fellowship track at the Mayo Clinic in Rochester, MN. It may take me another 8 years to finish it! Internal Medicine (2 to 3 years), Research (2 years), and Hematology/Oncology fellowship (3 years if I double board, 2 if I single-board in either Hematology or Oncology).

I'm looking forward to this next stage of life. Life will definitely be different in Minnesota for a native California boy and his native Californian wife! Our almost 3 and 1 year-old daughters will probably be just fine - snow is fun when you're a kid.

Here are a few pictures from graduation:

Algorithm for Choosing a Specialty

I ran into this wonderful algorithm for choosing a medical specialty. Even though it's meant for entertainment value, it's actually surprisingly accurate.

Choosing a Medical Specialty

Now that I’m nearing the end of my MD-PhD (1.55 years to go!), I’m going to have to actually decide what specialty to call my own. It’s rather comical as I think back on the many different areas of medicine I was convinced I’d go into, only to change my mind the following month, etc. Since I’m in the dual-degree program, I’ve had even more time than the typical medical student to ponder what field I’d be happiest in; or if I even want to see patients at all, or just do 100% research after finishing.

I remember in college, I applied to medical schools with the goal of doing Internal Medicine followed by a fellowship in Infectious Disease (a subspecialty of Internal Medicine). I was doing research in a lab studying Virology and I had the opportunity to work on some ideas for vaccines against Hepatitis C. I loved what I did and imagined myself continuing this type of research and seeing patients in this field. However, then came the beginning of graduate school, and my work on DNA damage and repair moved my interests toward Medical Oncology (also a subspecialty of Internal Medicine). Following that, during the first two years of medical school, our classes in Histology, Cell Biology and Pathology grabbed my attention, so for a while I imagined myself doing Pathology as a specialty. But then came our Neuroscience course, which was so well-taught and interesting that I convinced myself I would do Neurology, a notion which was furthered by a physician-mentor of mine who was a Neurologist. Even though all these ideas came quite early in my education, I was very serious about looking into each one. I would research a bunch of different residency programs on the internet, talk to physicians in those fields, etc.

Then came my first exposure to patients. My first clinical rotation was Pediatrics, and I loved it. In order to combine my previous interests, I decided I’d do… Pediatric Neuro-Oncology! Talk about specialized. But I was so convinced I wanted to do this that I even paid out-of-pocket (several hundred bucks!) to go to a medical meeting in the local area devoted to central nervous system germ cell tumors, which is even more specialized (this is a rare sub-class of brain tumors). I contacted several physician-scientists who did Neuro-Oncology to get their perspective, and needless to say, they were surprised to be hearing from a student who still had a few years left before he’d even started a residency, much less a second fellowship (a Pediatric Neuro-Oncology fellowship would be an additional 1 to 3 years after 5 or 6 years of previous residency and fellowship).

Unfortunately, the meeting I went to was way over my head, and I kind of lost interest. In fact, at this point some exciting things were happening with my research in the lab, so I kind of lost interest in doing a residency altogether, and wondered if I should just do research 100% after getting the MD-PhD. This idea persisted until I attended a conference geared toward medical students doing research. The people I met and the talks I attended were so inspiring that I decided I really wanted to keep active in both worlds of clinical medicine and basic science or translational research. I did more clinical rotations interspersed with research in the lab. I really enjoyed psychiatry (I almost considered it, but not enough to look up any residency programs) and was fascinated with aspects of OB-GYN, especially High-risk OB. But then, my wife was pregnant with our first child at the time, so it kind of makes sense why I had a lot of motivation to learn.

The following year I did more research toward my PhD, interspersed with my Internal Medicine and Surgery clinical rotations. I also had an opportunity to do a 2-week elective in Radiation Oncology, which I had become very interested in through a friend. Perhaps it was due to my friend’s enthusiasm, but even before I did the elective, I convinced myself that’s what I wanted to do, and I again looked up a ton of residency programs, etc. However, when I finally did the elective, it just didn’t hold my interest. At least it would be easy to rule out!

When I finally did Internal Medicine, I told myself “Now THIS is why I came to medical school!” I not only enjoyed my in-patient hospital experience at the very busy county hospital, but I even loved the out-patient clinic experience (I never liked clinic much in the other specialties). Around the same time, I went to that same conference for medical students again and met some physician-scientists successfully conducting labs doing translational research in Infectious Disease and seeing patients part time. This reinforced my decision for Internal Medicine and now I was convinced I would do an Infectious Disease fellowship, coming full-circle to what I wanted to do since I was in college. This meant, of course, spending lots more time looking up residency/fellowship sites on the web and pondering which places also had the best research programs in that field, etc.

I wasn’t too interested in Surgery when I started it several months later. By the end, however, I became less sure of Internal Medicine. General Surgery was so interesting and the traumas and operating room experiences so exhilarating, and there was a need for research here as well. Hmm… maybe I could do Surgical Oncology… Well, I haven’t been inspired enough to look up residency programs in Surgery yet, so maybe that’s a sign that I shouldn’t pursue that path any further.

During and after all these experiences, I know my parents don’t believe anything I say now about what specialty I’m going into (my wife still does – bless her soul… or at least she says she does). Nevertheless, I’m pretty sure that I’ll be applying to Internal Medicine residency positions in the latter part of 2008. I don’t have to decide now, but I’m still thinking either Medical Oncology or Infectious Disease as a subspecialty. Feel free to tune in during the next several months to see if I change my mind again…

The Other Side of the Operating Table

Here's another article I wrote for a medical conference about a year ago. A medical student's up-close perspective on his daughter's birth. Enjoy...

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It's 11 pm on a weeknight and I'm in scrubbs. I'm taking my last call night for the OB-GYN rotation, and I'm hanging out on the Labor and Delivery floor at the University Medical Center waiting for some action. The patient I've been following had her water break before she got to the hospital. Now she has a fever. The OB on call is worried about chorioamnionitis (infection of the placenta), and the baby has had some heart-rate decelerations during the mother's contractions, so it looks like we're headed for a C-section. Within the hour, I find myself scrubbing in. This is the 5th C-section I've been a part of, so I'm used to the routine. Before I begin to scrub in, the patient is given spinal medication for anesthesia. She has to sit up on the table and bend over, arching her back for 20 to 30 minutes while the anesthesia resident tries to find the right spot to put in the needle. It looks mighty uncomfortable - she's been having contractions the whole time. Time passes and we're finally ready. Just before we begin, her husband comes in and sits next to her behind the surgical curtain on the anesthesiologist's side, so he isn't able to see the surgery. He is very conspicuous, with his white "husband/dad" gown over his clothes, while all the medical staff wear blue.

The first incision is made. I'm right there in the surgical field, along with the senior OB resident and attending physician. Even though this is my 5th time in a C-section in the last few weeks, it's still fascinating. Everything goes pretty quickly. We move through skin, fascia, muscle and fat layers, making use of the cauterizer to stop bleeding as we go. I say "we", but really all I'm doing is holding a retractor occasionally to pull skin and fat down for the doctors as they dig deeper. Finally we're in the peritoneal cavity, and I see them moving aside the colon, I think I see spleen, a little bit of liver, and of course, the big thing in the middle is the uterus. Thin cut on the uterus… sploosh - here comes the rest of the amniotic fluid and there's the baby's head! Out comes the baby, head first, then shoulders, then the rest. Nice loud cry, baby slightly bluish but mostly pink skin, moving around nicely - looks like an Apgar score of 9 (anything over 7 is good). The resident holds up the newborn daughter for mom and dad to see for a few seconds… then the baby is whisked through a window and taken care of by the NICU transition team. Baby's out of sight now. In a routine manner, the uterus is whipped out of the body cavity, sewn up tightly, then put back inside. Soon the attending gives me what I asked for before the surgery - practice suturing on the abdominal muscles, which is relatively easy for a first-timer. This is my very first suturing job, and it's something I have to do to get "signed off" if I want to pass my OB-GYN rotation. Of course, now everything slows down. It's so much harder to suture on a live person than when I practiced with string at home! After several failed attempts to make a surgeon's knot, I just tie a regular one, and then things get faster. During those few seconds when I was fumbling, I had just a few fleeting thoughts about what the husband must be thinking. Even though he couldn't see, I'm sure he could hear the attending physician’s words "you can do it - it's just like tying your shoe" and "there, you got it… oh almost". I didn't dwell on this, though. Finally, the attending leaves me and the resident to staple the skin incision closed. After a few minutes of clean up, the patient is pushed out and down the hall, holding her baby for the first time - a touching moment.

It's 4 months later now. It's 5 am, and once again I'm at the University Medical Center on the Labor and Delivery unit. This time, I'm not in my scrubbs - I'm in shorts and a T-shirt, and my wife has been in labor for 17 hours. For the last 3 hours, she hasn't progressed past 6 cm of cervical dilation. Our OB physician comes in and very compassionately explains to us that she really feels we need to do… that's right - a C-section - because our baby is likely too big to pass through the birth canal. Several nurses and the doctor wheel my wife out of the room and down the hall to the operating room - the very same one I'd been in several times as a medical student just 4 months previous. Now I'm the husband. Now I get to wear the white gown while all the doctors are in blue. This time, I'm not allowed in the operating room until my wife is completely situated and they're ready to do the incision. As I sat beside my wife, who desperately needed to hold my hand and feel my support, I couldn't see what the doctors were doing. I was on the other end of the operating table this time. But I knew what they were doing. With each sound, I knew what stage of the operation they were at. I was very thankful that day that we had a private doctor. No OB residents were part of our medical team. But even better, no medical students were in the room, waiting for their chance to try their first suturing job. Suddenly, I knew we were close to the moment of truth. The doctors had opened the uterus and were getting the baby out. It sounded like they were having a bit of a difficult time at it though… oh, there she is! Wow, she's a big baby! 8 pounds, 11 ounces, even though this was only the 37th week of pregnancy! All covered with vernix and blood, crying loudly - that's my girl! Then she was in the next room, and I held my wife's hand during the closing up of the incision. A few minutes later, and I was in the room with the pediatricians, with my little baby girl. While my wife recovered, I gave my newborn daughter her first bath, and took part in the physical exam and hearing tests. Then we went to be with mom, and we were quite the happy family.

The next 4 days in the hospital were difficult. Taking care of a baby is a big job! Especially when mom is trying to recover from a C-section. And then our baby became jaundiced, and she wouldn't latch on to breastfeed. Two common problems that happen with healthy newborns. These are things that as a medical student I wouldn't have thought a big deal at all. Not so when you're the parent! Each day the pediatrician would come in and report to us the total and direct bilirubin levels (they kept rising) and the percent weight loss (this also kept rising). It was somewhat frustrating and difficult. I kept thinking about differential diagnoses for jaundice and weight loss in infants. Would my daughter eventually eat better and clear the bilirubin, or did she have some pathological hemolysis (destruction of red blood cells is a cause of jaundice), and end up needing to stay in the hospital? Would she develop failure to thrive?

None of these bad things happened, thankfully. Now a little over two weeks later, things have been settling down. Baby is healthy and eating well, with the jaundice receding and her weight increasing. Mom is making a fine recovery and doesn't need as much pain medication anymore. Yes, we're a little bit sleep deprived, but it's not even close to being on call as a third year medical student and getting paged by your resident to do a history and physical on a newborn in the E.R. after 1 hour of sleep. I think the most important thing I learned through all of this is that even minor problems and concerns of patients and their family members are a really big deal. Being a patient or the close family member of one is no fun. However, the experience can be made easier by wonderful, compassionate, supportive doctors, nurses, etc. (of which we thankfully had an abundance). I hope that this experience will make me a better doctor and healer.

A different approach to the dual degree

I wrote an article in a newsletter for a medical conference over 2 years ago about my unique way of getting an MD-PhD. What follows is a modified version of the original. Some things have turned out slightly different than I envisioned here, but it's still accurate for the most part.

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MD-PhD. Sounded a tad excessive when I first heard about it. Seven to ten+ years of schooling in addition to residency and fellowship/post-doc. After all of that, it seems like it’s almost time to retire! Is it really worth it? This is a big question for many who consider committing to such a program. And how should it be done? Break up the MD in the middle with the PhD (as is traditionally done)? Immediately after finishing the PhD is arguably when you're the most skilled and ready to go onto a good post-doc. Also, starting to see patients after not having studied any medicine for 3 to 6+ years can be a difficult experience, trying to catch up with your colleagues who had only 3 to 6 weeks between their second and third years of medicine. Are there better alternatives? The following is a synopsis of my path toward joining an MD-PhD program, why I think the dual degree is worth pursuing, and why I think the route I'm taking is very beneficial.

When I was a Biology major at my fine undergraduate institution, I worked in a virology lab and really enjoyed research, yet I was intimidated by the prowess of the professors, all giants in their fields. As I compared myself to them, I doubted my ability to contribute to research. Since I was interested in medicine also, medical school seemed like a logical option. Instead, upon graduating I landed a job as a research associate at a near-by cancer research center in a lab doing DNA damage and repair. After working there for one year, I committed to being a graduate student in the same lab as I followed my mentor to a different university. That year of focused research without classes helped me to build confidence that I had something to offer as a researcher. Data I obtained laid the foundation for two later publications in a peer-reviewed scientific journal.

During my first two years as a PhD student in biochemistry, in addition to taking graduate classes and continuing my research, I was given the freedom to explore medicine, as this university had a medical school. I took a few medical school classes, helped tutor some struggling medical students in biochemistry, and also shadowed an oncologist who does both clinical and basic-science research. These opportunities were invaluable in opening my eyes to the benefits of getting both degrees. By receiving training in both basic science and medicine, I realized I could more effectively identify the most pertinent medical questions that need to be solved, work on solving them, and thus carry innovative research to the bedside in a more significant way. After these two years, and knowing much better what I was getting myself into, I then applied and joined the MD-PhD program there and took the first two years of medical school. Though research-time was very limited, I also attempted to work on my PhD. I found that my previous three years of research in addition to a finished thesis-proposal helped greatly in being more efficient in lab during this time.

Now having taken USMLE Step 1 (the first of many “Board” exams) about a month ago, there has been another twist in the road toward my dual degrees. Instead of going back to the lab for 1 or 2 years to finish up the PhD, I was given the freedom to start the 3rd year of medicine and split it into two years. Each rotation I do will be followed by a rotation in the lab, e.g. pediatrics, then 3 months research, then internal medicine, then research, etc. for two years. If my research isn't finished by then, the 4th year of medicine could likewise be split into two. The pros? I will be just as fresh for the hospital wards and clinic as the rest of my class, a luxury many MD-PhD's forgo as they do two years of medicine, followed by their entire PhD, and then finally start to see patients. Also, the 3-month-on-3-month-off plan will potentially help with the rut that graduate students can get in when they lose motivation and productivity because of lack of direction. The cons? I'm sure it will be hard to jump back and forth, especially with getting meaningful research accomplished in short blocks of time. But if I'm going to be in both medicine and research as a career, now is the best time to practice and get good at jumping between both worlds.

Through my research and medical interests, I have been very excited about the field of neuro-oncology, particularly in the pediatric population, and have had the opportunity to contact some leaders in the field about my interests. I hope to eventually be seeing patients as part of a multidisciplinary team, developing new therapies for brain tumors and bringing them to clinical trial. Hopefully the abysmal prognoses for some of these tumors will turn into high remission rates or cure rates, as has happened in the last couple of decades with leukemias and lymphomas through the hard work of researchers, clinicians, and physician-scientists.

In summary, freedom to test the waters in each stage has been extremely important for me. Doing research solid for a year gave me the joy of immersing myself in a project without the pressure of classes and it rekindled my passion for research. Taking a few medical-school classes before jumping into the MD-PhD program gave me an idea of what I was getting into. Having had three years of research previous to doing medical school gave me a set of eyes for possibilities that I never would have had straight out of college. I believe my current 3-month-wards-3-month-research plan has great potential, but a final evaluation of that will have to wait. In the mean-time, I'm having the time of my life and couldn't be happier about the direction each new turn in the road has taken me. Even if I'm old and grey by the time I finish all my training, I still think it's worth it.