End of the Road

Something special happened this week: I added a co-author. He goes by Chill Clinton, is my main man, mentor and future roommate, and he’s written this article as a dedication to all of this spring’s new graduates. Enjoy.

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It’s not just the best lump-in-the-throat tearjerker of 90’s R&B, it’s a theme in medical education. My academic road has taken me from college, to graduate school, to medical school. After four years of exams, all-nighters, weird smells, and more exams, I’ve come to the end.

Truthfully, it’s not the END of the road for me as student of medicine. A law of our world is that once you find the top of one ladder, you are at the bottom of another. We climb the ranks through college, medical school, residency and so on (I suspect anyone who works can relate to this hamster wheel). However, we can’t stop learning just because our ranks change. What’s unique about medicine is how quickly your training can become obsolete. Some studies estimate that half of what we are taught in medical school turns out to be irrelevant and/or obsolete in as little as ten years. As former Dean of Medicine at Harvard Charles Sidney Burwell once said, “”Half of what we are going to teach you is wrong, and half of it is right. Our problem is that we don’t know which half is which.”

This is a frightening concept. Imagine spending years mastering French, and half of it becoming irrelevant every ten years. Good luck ordering that baguette, Pierre.  You would have to buy new books, take new classes and put in countless more hours, despite having “mastered” the language years before. The top linguists in the world would have to re-educate themselves every few years. This is precisely the predicament of doctors charged with keeping abreast of the latest scientific and therapeutic advances. New guidelines and protocols are published on a daily basis, and a physician is professionally and legally responsible to provide the most current and proven level of care.  Older doctors like to look back and joke about the archaic methods of their medical school and residency days (icepick lobotomy anyone?), but the irony of the situation is that, at the time, the practice was cutting-edge.

In his biography of cancer, Emperor of All Maladies, oncologist Siddhartha Mukherjee discusses how Boston Children’s Hospital experimented with folate as a treatment for leukemia during the first half of the 20th century. The results were horrendous.  Today, we use anti-folate medications to treat leukemia. The original idea of using folate in such a way is now akin to putting out a fire with gasoline. We look back at this and scoff. However, the irony is that these doctors at Boston Children’s Hospital were at the time considered the leading leukemia specialists in the country. This begs the question, what are our “experts” doing today that will seem archaic, and downright dangerous in the future? Which part of my current training will future students scoff at? We can only guess.

This phenomenon pervades all areas of life. Ask your grandparents’ or even parents’ generation about smoking cigarettes. It was an accepted and regular part of everyday life. Now, smoking is so dangerous to your health that it is investigated on every health and life insurance form in the country. We now know that members of that generation were unknowingly destroying their bodies by smoking. But what are our cigarettes? What is destroying our health every day, about which we are simply oblivious? Will our kid’s generations have a checked box on insurance forms about drinking Mountain Dew? Just as before, we can only guess.

My education has taught me that medicine is a world of uncertainty and imperfect information. I have seen terminal cancer patients make miraculous recoveries, and I have seen healthy 20 year-olds die of the flu. Instead, we live in a world of odds and percentages. We are trained to say that diseases are “less likely” instead of “impossible”. Certain drugs and procedures are “more likely” to treat an illness, but no doctor will say that it “definitely” will. In the best cases, our educated guesses are backed by data from large clinical trials. In the worst, we are trying to take out an anthill with a shotgun from 50 yards. Knowing which treatments will stand the test of time is a frustrating but necessary part of the process. *As interesting as it to watch the VICE special Killing Cancer or the 60 Minutes special about using HIV and polio viruses to treat previously untreatable cancers, we must all realize that despite the incredible technology that exists in the world, medical research is a rough trial-and-error process.*

The reality of ending medical school is that your training and education are never over. Even the best doctors in the world have to re-educate themselves on daily innovations in their fields. Although this is a daunting task, it is nonetheless why some of us are drawn to medicine… the never-ending puzzle. It is fascinating to face the reality that things we know as facts and truths change with each passing day. It highlights the fact that medicine as a field is still in its infancy. There are laws of physics, geometric proofs, yet there are very few concrete principles of medicine that cannot potentially be disproven. Medicine therefore progresses and improves by challenging what we know. I will leave you with a quote from one of my favorite movies as a kid (and screw it, as a 27-year old), Men in Black. As silly as it sounds, this scene gets it: about how what we know is a dynamic and constantly evolving process, and the excitement of what we will learn tomorrow.

“Fifteen hundred years ago everybody knew the Earth was the center of the universe. Five hundred years ago, everybody knew the Earth was flat, and fifteen minutes ago, you knew that humans were alone on this planet. Imagine what you'll know tomorrow.”

“Fifteen hundred years ago everybody knew the Earth was the center of the universe. Five hundred years ago, everybody knew the Earth was flat, and fifteen minutes ago, you knew that humans were alone on this planet. Imagine what you’ll know tomorrow.”

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Rafting the Rio Chone

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Those firmly indoctrinated need not read on. Those who point out the anecdotal nature of this evidence will have data from their last publication audited by statisticians. All who attempt to find motive in this work will have their last year’s billing record scrutinized by hospital administrators.

-Adapted From Mark Twain’s The Adventures of Huckleberry Finn.

When I first laid out this paper, my plan was to write a direct, scientifically planned and measured comparison between the delivery of care in the urban and rural settings in Ecuador. My pre-trip reading assignments highlighted the often conflicting nature of international public health initiatives and global trade. This awoke my inner economist (dormant since college), and I began to drum up all kinds of fancy concepts, such as moral hazard and inelastic demand to work into my analysis of the Ecuadorean health system. As I began to write, outlining my observations from the urban setting of Quito and the rural one of Chone, I found that my experience here had uncovered few new facts on the topic of urban and rural disparities. Rural hospitals have fewer supplies, fewer specialists, and functional air conditioning than their urban counterparts. None of this was unexpected. It would have been easy to write a wordy comparison of the two settings going into minute detail of why exactly rural populations are underserved. Instead, I chose to change my assignment. I feel that I am stretching the limits of allowed creativity in medical school, but seeing as this is my last assignment, it would be meaningful to make it my own. I hope my anxiety over this decision does not permeate the pages that follow, as my graduation depends on them being accepted.

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High School Slim

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Pre-dance tic tacs. No doubt.

Let’s talk about public healthcare delivery. Not policy, delivery. Let’s lose the forest for a trees for a second, forget the big picture and dig into what it looks like on the streets.

Aside from being my favorite all time movie, the Wood is a real place in LA. I’ve never been, but the news and early 2000s hip hop lyrics tell me it’s a rough place. There’s a similar neighborhood here in Chicago, and I just finished a month there. I’ve now seen people arrested in the clinic, ordered lunch daily through bulletproof glass, and experienced the miracle that is Harold’s chicken shack. Let’s talk about that.

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Cue Ball

Kiss these beautiful locks goodbye

Kiss these beautiful locks goodbye https://www.stbaldricks.org/participants/rashard

Sometimes you just have to shave it all off. St. Baldrick’s day, February 19th, is one of those times.

First, it’s called St. Baldrick’s. Bald-Rick. I was born to do this.

Second, it’s a rad charity. Family, friends and caregivers get their heads shaved by current and former cancer patients. My stylists will be Grace, from this article and another patient from this month. We’re all ditching the “hair” look for Spring 2015 – I think it’s going to catch on. They’re pumped. I’m pumped. Always wanted to wax my dome.

Third, if you’d like to donate, they’d like your money and it goes to a fantastic cause. St. Baldrick’s money allows kids at three different Chicago hospitals to be enrolled in Children’s Oncology Group clinical trials, which bring them the latest and greatest cancer therapies from all over the world. It is truly the best thing going in pediatric research right now, and the adult world could take more than a few hints from their system.

https://www.stbaldricks.org/participants/rashard

If we can scrape up $2500 I’ll frost my tips before the big day.

Don’t hold your breath

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I’ve seen the mountaintop and there are miniature horses there

“Boxing in handcuffs” is a line I wrote on an application that describes my third year of school. That’s the year you emerge from the lecture hall and they let you loose on some unsuspecting hospital floor. It’s your first taste of two overarching themes in medicine: you can’t know everything, and you can do everything perfectly and still not win. Learning and accepting these simple facts can pound you. That doesn’t mean they have to, though. It’s “boxing in handcuffs,” not “getting your ass kicked while handcuffed.”

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Grit and Grace

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I call for ya yesterday… and here ya come today

I’ve seen a lot of kids get new cancer diagnoses this month. Each case is different, but there are a few common threads. One is that everyone wants to know EXACTLY what is going to happen. The scary but true answer is that we don’t know. If we did, you could type your symptoms into WebMD and have Amazon send you a few pills, cutting out the middleman with the stethoscope. Wouldn’t that be great?

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