Blondes and Brunettes

I've been called a lot of things, but a pathologist is not one of them. So far in my medical career, I can think of very few things that have evoked an extreme, visceral reaction, but Thursday's pathology presentation got to me. Now, the first time I saw the face of my anatomy body I was a little uneasy. The smell during the disembowelment at my first autopsy was unpleasant, but nothing I couldn't push through. These things don't compare to the way the "teratoma" made me feel. How our professor went on about her "favorites" made me a little sick. I think I might have thrown up in my mouth a little bit. I have said before that the microscopic side of medicine is not nearly as interesting as gross pathology. Well, I'd probably like to ignore this part of the macroscopic as well.

A teratoma is the most common neoplasm of the ovary. It is usually benign, but only in terms of its possibility for cancer. Its morphology is by no means "benign." Not at all. It is called a teratoma because its growth is derived from multiple tissue types. Normally we define a neoplasm as either "benign" or "malignant," pertaining to its ability to metastasize and spread to other parts of the body. These tumors generally stem from an abnormal growth in tissue. Many times, if a neoplasm begins in a certain part of the body, the cells multiply from that single origin. If the tissue was of a glandular genesis, we use the term "adenocarcinoma." If it was derived from the melanocytes of the skin, it's call "melanoma." The teratoma, however, is derived from multiple tissue types. A mature teratoma is pictured above (but look at your own risk). It can grow gut tissue, respiratory tissue, teeth, hair, neuronal tissue... you name it, it's got it. Frankly, it's kind of gross.

Now from a professional standpoint, these feelings are irrelevant. I would never break poker face in the clinic, lab, or in front of a patient. The old EMS adage applies: no matter how gross it is, pretend that you've already seen it a thousand times. But sitting in the back of the MBRB lecture hall, I'm allowed to grimace a little. It looks painful, and it's hard to imagine teeth and colon growing in my ovaries (fortunately, I don't have ovaries). I also think it has something to do with the way it was described. Pathologists should avoid using food metaphors all together. Saying that a hydatidiform mole looks like a "cluster of grapes," or that endometriosis resembles little cysts of "chocolate" is not appealing, especially before lunch. I just want to eat in peace. Personifying teratomas should be banned as well.

This here is a brunette teratoma. You can see her molars and incisors, but it looks like she lost her front two teeth... Oh! Here's a blonde. She's obviously not as mature as her brunette sister. Pun intended!


No no no no no NO NO!  You know what?  Let's just ban medical metaphors in their entirely.  Thank you.  Genital warts don't look like cauliflower, and your birth mark doesn't look like Jesus!

Like I said, fortunately I don't have ovaries. This has been an important revelation over the past week (if you haven't figured it out yet, we're studying the female reproductive system). Men are simple. Your testes either descended or they didn't. There are only a few types of testicular tumors, and the most common has a good prognosis. In a women, everything can go wrong. You can have ovarian cancer, endometrial cancer, cervical cancer, vulvar cancer, ectopic cysts in your neck or stomach that menstruate each month (!!!!!), endometrium in the myometrium, and all this crazy stuff. And don't get me started on the menstrual cycle with all the hormones that are being secreted and fluctuated. In fact, "Dear Girlfriends of Past, Present, and Future... you win." Jamie Foxx can blame it on the alcohol, but sweetheart, just blame it on your period. I don't understand what's going on inside of you, but it's nuts and I want no part of it. So, women, you can have all the babies you want and enjoy that "special bond," because I don't want it. I don't need an estrogen/LH surge or menopause.

Kendall Marshall, if you're out there, then I'm sorry. I retract last week's blog post. Find your own baby daddy.

Pantana Rob's

There are important things life, and then there's Carolina basketball. Friends, family, work: these are the staples in life that make each day worth living, but they pale in comparison to the way that Roy Williams, Kendall Marshall, and the "Cream Team" make me feel (by the way - dear analysts, you can keep calling them "Blue Steel" all you want, but as long as our scrubs are 4 white guys and an Asian, they will always be the "Cream Team"). March Madness consumes me nowadays, especially after being spoiled as a freshman and "super-senior" with national championships each April. My blood pressure teeters on malignant hypertension during each game, and it's wonderful. This is the only time I can go from wanting to have Kendall's babies after a nice pass down court, to declaring him a cheating whore 60 seconds later after missing the front end of a 1 and 1. Dook-Carolina games and the NCAA tournament are the alpha and the omega of my season, and I have been blessed this year to see Carolina beat Dook in the Dean Dome and have them make a Sweet 16 run. So bring it on Syracuse/Marquette, whoever you might be.

It is with this joy (and nervous energy) that I opened up "Pantana Rob's" for the opening game. If you're not familiar with the Chapel Hill bar scene, Pantana Bob's (affectionately known as "Bob's" or "P-Bob's" by most) is an outdoor bar on Rosemary Street. It is a goto on beautiful spring days and summer nights. It's deck has wooden benches, TVs, and hosts a variety of frat-tastic 18-somethings in button-down shirts, croakies, visors, and salmon khaki shorts with a hint of J-Crew boxers peeking out the tips, near mid-thigh of course.  Pantana Rob's on the other hand only seats eight, and thigh cut shorts are a no-no. The guest list this Friday evening included Dinushika and Sarah, Klara and Evan, Alan and his Laura, and me and mine. I pulled out the big screen television so that 9:15pm Carolina - Long Island University game could be watched amidst the outside air. We dined on jalapeno and parmesan burgers (my own recipe!), southwestern beans and corn, appetizers, and topped it all off with a delicious carrot cake. The white ruskies and wine a-flowed, and the weather at 7pm was a perfect 75 degrees and sunny. It was great company on an absolutely perfect evening (especially since Carolina won). One could not ask for more on one of the last days of Spring Break. It was a calming way to begin "March Madness."

And the Madness continues! Not just with with Harrison Barnes and Co., but now with Spring Break behind us, the Boards and third year are fast approaching. We finish off school with two final blocks: Reproductive Medicine and Musculoskeletal/Dermatology. After that I have a few weeks of studying on my own before Kelly and I are (hopefully) heading to Morocco, Egypt, and Turkey. However, with what's going on in the region right now, I feel like our trip is day to day. July 1st will be here before I know it.

But back to Kendall's babies. If I had fallopian tubes, I would give him both. It would be an honor to bear his children, and I wouldn't even cry for alimony. Today, he dropped a UNC record number of dimes to get a money win against a physical Washington team that was severely underrated. Oh, the tournament atmosphere! And every moment reminds me of the great moments of years past: holding hands with John Sands during the 2005 championship game, in the Dean Dome, 15,000 fans screaming, tied 70-70, then 75-70 and sprinting to Franklin. Or how about 2009? Celebrating at Top of the Hill and looking down at the fire-happy crowd.  It makes me miss the days of sending my bracket into my Mother's work, schooling those lawyers in some NCAA b-ball and buying a Xbox with the spoils. Then there was 5th grade, when I got into an argument with my teacher about the merit of the ACC tournament as a measure of a team's success (she went to Maryland, ugh - and by the way, I was right: UNC lost the ACC tournament in 2005 and 2009, then went on to win the national championship, maybe 2011 too??). Damn I love March Madness.

If only Dook had lost today, it could have been a perfect weekend.

So it's back to school. Back to the lectures, exams, question banks, and long days. Fortunately, I have another UNC game to look forward too. That will carry me through the week. So just one final thought before I turn in and succumb to the week ahead...

Drew who?

From Prinzmetal's to Pneumonia: Comm Week #5

Boone saved its best week for last. I spent these past few days on my last mini-rotation out in Western, NC with my Pediatrician, using as much time as I could to "act like a third year." Unlike weeks prior, I saw each patient by myself, I presented the findings to my doc, and I came up with a short assessment and plan. I performed a full interview and focused physical exam, and (attempted) to come to my own conclusions. It is the closest I will get to actually being "on the wards" with an attending until July 1. It was fortuitous that my pediatrician had much of the week on call, so time was spent rounding on patients in the hospital in the mornings, then I saw "acute" care patients in the office that night. "Acute" is in quotes because technically "the sniffles" count as an acute condition. "The sniffles," however, have a wide variety of potential diagnoses: from a cold or the flu, to strep throat or pneumonia. I worked each of them up and moved on. I kept my presentations to 30 seconds or less, and got much more efficient as the days progressed.

For some patients, I knew exactly what was going on. I would look into an swollen, erythematous mouth, and it screamed strep throat. Pulling on the ears with fluid-filled, nasty looking tympanic membranes? Otitis. Seal-barking cough? Croup. I suggested we order a strep test, antibiotic, or breathing treatment. But other times I totally missed the ball. There were definitely ups and downs. From a medical standpoint, this week was by far the most interesting. I sat in on a Marfan syndrome consult, met my first patient with Turner syndrome, saw a kid with 5th disease, and worked on a differential for a 17 year old with chest pain.

And then other times I totally missed the ball.

The peak for me was on Thursday morning. The night before, a 17 year old girl came with her mother to the clinic, presenting with a progressive onset of crushing chest pain. About a year ago, she started have very short bouts of heart palpitations, sometimes accompanied by mild chest discomfort. At first she chalked the symptoms up to stress or coffee, since the episodes were rather infrequent. But steadily over the past few months, the pain had gotten worse and worse. She finally came into the clinic because now she was having trouble breathing. The pain had gotten so bad that she would have to lie down for an hour or so until the episode subsided. And now over the past month, these episodes became daily.  The pain was never associated with exercise, and it always occurred at night. The previous evening, the girl was given asthma medicine to see if helped, but to no avail. She met us in the office at 0900.

My pediatrician and I saw the patient together. He asked all the questions, and performed a full focused physical. Commonly, reflux or epigastric pain can mimic cardiac angina. However, her episodes never directly followed meals. Teenagers are also prone to swallowing pills without water... I still do it just to show I'm tough. Unfortunately, pills can lodge in the esophagus, causing ulcers that burn holes through the mucosa. Our patient was taking a medication, but she started well after the chest pain began. It was clear that she was going to see a pediatric cardiologist, since one visits the clinic every other week. The whole situation sounded familiar to me. Young female with crushing chest pain, always at night, not associated with exercise... honestly it sound like a multiple choice question I've heard. So I mustered up the courage to throw it out there. "Hey Doc, what about Prinzmetal's angina?  It is possible?  I was met with a smile. That could be a possibility.

I don't know. It was nothing big, but it was kind of cool to come up with something on my own that wasn't "ear infection" or "the flu."

Literally two patients later I totally missed pneumonia. The one physical exam technique that I've felt mildly competent with over the past year and a half has been auscultation of lungs. I think I can hear breath sounds pretty well, given that I've heard a ton of wheezing from asthma, and fluid-filled lungs in CHF patients through EMS. So I felt confident. And then next thing I know I'm telling a mother that her child's lungs sound clear to me (NB: I always finish up with, "But we'll let the real doctor make the call." I'm not that experienced, and I don't want parents thinking I'm their definitive diagnosis). My doc walks in and BOOM: those lungs on crackling and popping. Good thing I qualified my assessment, but I couldn't have instilled much confidence when I quickly reported in my presentation that the lungs were "clear to auscultation."

Oh, how quickly the mighty fall.

So I'm a ways out before being any good. I'm not ready, but I'm getting there. It's good experience, although I think that next year is going to be a shock to the system. Well oh well, on to Spring Break! Too bad I won't be in Peru this year :(

Goodbye, Boone!

The Male Physical

There have only been a few things in medical school for which I've shown apprehension (besides tests, of course). I was nervous for the first standardized patient we encountered, the first Community Week, and certainly the first round of Asheville interviews that were conducted last week. But I would say the Men's Health Exam was the cause of the most foreboding. The female pelvic exam? Not so much. I hadn't even seen a pelvic exam, and that probably mediated my apprehension. Perhaps it was the fact that I've seen the male exam, experienced parts of it myself, and have seen patients endure it rather uncomfortably that made me antsy. I have seen a number of patients go through this awkward encounter (the prostate exam specifically), empathizing with their plight. These patients were uncomfortable, but not in the same way as a kid getting a couple stitches after falling off a bike. It wasn't pain. They are placed in an unenviable situation that cultural norms identify as a degrading rite of passage: now at the mercy of your body, you now accept preventative medicine to its fullest. You're 50 years old; prostate exams are the beginning. Next come PSAs, colonoscopies, statins, aspirin, and Centrum Silver. And it all begins with your pants on the floor.

As a patient, the entire male exam is met with trepidation. A 13 year old is worried he might get an erection during the exam.  If my physician is a female, will I'll be embarrassed? If my provider is a male, does that mean I'm gay? What if I'm not normal? What if it hurts? Will my mom still be in the room? Will my dad still be in the room? Etc. And these concerns continue throughout life, even though the specifics usually evolve. What if I pass out? What if I have an STD? What if I have cancer?

So it was with this internal conversation and foreboding in mind that I learned the the Men's Health Exam on Wednesday night. My concerns were different, but directly correlated to those of the patient. What if I hurt them? What do I do/say if they get an erection?  What do I do if I find an STD? Or cancer? What if the patient defecates? What if the patient has been sexually abused? What if the patient thinks I'm coming on to them? All these concerns are real and honest, and they were also all addressed.

For all you guys out there, think about how long your male exam takes at the doctor's office. The full exam should comprise of a penile exam, testicular exam, inguinal hernia check (the "turn and cough" thing), digital prostate exam, and rectal wall sweep. Five parts. Now as a young, healthy 24 year old, I've only routinely received the first three. But even then, I only vaguely remember my pediatrician doing a quick "penis check" (tighty-whiteys flipped down, tighty-whiteys flipped back up, penis is there, everything checks out). I think at one point I remember turning my head to cough, but I also had an obvious inguinal hernia when I was nine. If my memory is correct, most Men's Health Exams as a child took less than a second or two (and my doctor was one of the top docs in the DC area; check the Washingtonian). My pediatrician in community week is similar, although I watch him check to make sure both testicles have descended in the young'ns. (I assume that my doc back home did the same thing, and was just too young to remember. If not, he got lucky, because I have two happily and healthily descended testicles today, just hanging out in my scrotum.). The rectal exams I've seen as a student have been relatively quick too.

So why did we take more than four hours to learn an exam that takes a second or two to perform? Answer: it shouldn't take "1 Mississippi, 2 Mississippi" to do!

One of the things that I love about UNC is that it's a patient-centered school. We did not discuss one technical aspect of the exam for first two and a half hours. Instead, we talked about the patient's concerns (sexual orientation, sexual function, confidentiality, finding pathology), the provider's concerns (see above), how to take a sexual history from a new patient ("do you have sex with men, women, both, or none?"), and ways to put the patient at ease. We learned how to normalize, intellectualize, educate, and acknowledge. We learned about some of the ways patients may describe or engage in sex. Some new ones for me at least were "docking," "felching," and "frottage" - nota bene: looking these up is only for the adventurous. We also heard about the patient who was worried she might have contracted HIV during "oral sex." A few minutes into the conversation, the provider (who was thoroughly confused at that point) asked what she meant by "oral sex." "Why of course! My boyfriend and I were talking dirty on the phone!"

Communication is key.

So it was not until then that we began learning the technical aspect of the exam. We learned how to examine the penis (inspection always before palpation): how to visualize the meatus, how to ask about tattoos, Prince Albert's, and look for pearly papules. We learned how to palpate the epididymis, testicles, vas deferens, and inguinal ring. I now know how to "make a gun" with my pointer finger and thumb, and perform a prostate exam. I now know that even though you may feel like you have to pee during the exam, you won't (because my finger is firmly pressing down on your urethra). And we learned how to correctly do a rectal sweep. All in all, this took me a good 10 minutes (mostly comprised of Parts I through III). It's not fast, but it's thorough...

I now see the patient's fears in a new light, along with my own. Those four hours didn't teach me how to do a perfect prostate exam, but at least I feel more comfortable doing it, and, in addition, I have the tools to put the patient at ease. In the words of the great Daniel Tosh, "And for that, we thank you."


Oh, and on an unrelated note: next year I'll be in Asheville :)