Becoming doctor superman: on the journey of trying to know it all

They say to become truly educated is to begin to realize how little you really know. I used to not understand this—it seemed the more I learned, the more I knew. How could it be different? This changed in medical school. It was only then that I began to feel more and more ignorant with each passing day of my education.

Each day in medical school a gigantic bounty of knowledge rains down from the heavens. Learning at the pace demanded of us is likened by many to trying to drink from a fire hose—a comparison I thought was silly before I realized it was accurate. The curriculum of medical school is roughly what one might expect—most of our time is spent learning about the human body in health and, more predominantly, in sickness. Our curriculum overflows with sessions on how to recognize, diagnose, and manage disease. But our discussions of these maladies are (almost always) limited to only what is clinically relevant. Which is to say, much much more could be taught to us about these diseases than what actually is.

Every now and then I steal a glimpse of what lies beyond clinical relevance. Due to either a special interest or (more often) a profound confusion, I venture beyond the lecture material and open a textbook or look up a scientific paper. The land beyond clinical relevance is terrifying for its immensity and overwhelming complexity. Each disease is its own world; the clinical exhibitions are like the shadows these vast and complex worlds cast onto a wall. Each day in the classroom projects the images of ten, twenty, or even (on a busy day) thirty new worlds. And there are enough human diseases to suggest that this pace could continue for the rest of your natural-born life.

Our time in the lecture theatre is punctuated by clinical encounters with real patients usually once or twice per week; these occasions reveal entirely new forms of ignorance. For one, these episodes expose an endless parade of patients I don’t know how to treat. What’s more, additional dimensions of disease make themselves known. Rigorous scientific, conceptual understandings of diseases as entities in their own right are nudged aside by human, narrative impressions of disease. Of course one can’t just forget about all the science, but rather one has to consider the science at the same time as all these other dimensions. Diseases aren’t objects; their sole realm of existence is in the lives of people.  It’s hugely important that a doctor learn to interact with all the humanistic aspects that a patient brings to bear, and since each patient is a different human, each patient encounter is potentially educational. Thus it becomes clear from time in the clinic that even if you succeed in learning and understanding all the scientific aspects of disease—the signs and symptoms, the pathophysiology, the genes involved, etc.—there is still more to know.

A bit of cognitive dissonance arises from the fact that, although our education is not designed to have us know everything, we are in another very real way expected to know everything. The expectation is present in society at large—don’t you want your doctor to know everything??—as well as in most medical schools. I recall a pre-exam review session in one of the first courses of the first year, Blood & Immunology, in which a classmate asked the professor what were the most important points from one of the assigned readings. There were many assigned readings in this course; my friend was asking about one in particular that had been prepared as a word document by the professor and contained everything we could ever hope to know about neutrophils (one of the bacteria-killing cells of the immune system). This document was, as you may imagine, a bit on the hefty side, and my classmate was curious as to which main points of emphasis we should observe.

A wave of confusion swept across the professor’s face. His colon tensed and his spine stiffened with indignation. The notion that any portion of his beloved assigned reading might be unworthy of our deepest consideration or command something less than our full attention was, to him, unfathomable. Our laziness baffled him. “This is medicine!” he exclaimed. “You have to know it all!”

In a very real way, this is what one signs up for when one accepts an offer of admission to medical school. On the very first day of orientation, the Associate Dean of Medicine said to us “From this day forward, your education is no longer for yourself. It’s for your patients.” There may be some irony in attending a lecture on the topic of sleep while you yourself are months behind on your sleep, or in hearing your dietetics professor recommend no more than 400mg caffeine daily when you are pretty sure no one has ever made it through medical school on that paltry amount (sincere congratulations to anyone who has). But to indulge too deeply in this irony is to miss the point of the whole endeavor.

The struggle is not in vain. The workload that at times seems crushing is necessary to develop the skills and knowledge needed to enable the project of medical practice. There are tantalizing glimpses of competency along the way that foreshadow a future of—hopefully—expertise. A few weeks ago I correctly made a diagnosis of adhesive capsulitis, a rare cause of shoulder pain. That same week I glanced at a patient’s chart and knew from their list of current medications—furosemide, digoxin, and metoprolol—that they were suffering from congestive heart failure. Baby steps but steps nonetheless. Of course I will never know it all, and neither will any other doctor (and of course neither will any med student!) But as always the safest bet seems to be to aim high, fall short now and then when it’s unavoidable, and then continue to aim high again.

 

Mexico, module 2, and the subversion of science

Last week I guzzled tequila on a Mexican beach; today I sip coffee in the Neil John MacLean Health Sciences library. My peers and I recently finished “Module 1” of medical school — we’ve now covered all the normal anatomy and physiology of the human body — and spring break came as our reward. For myself and forty classmates, the break provided a prime circumstance for a trip to Mexico. For eight glorious days we lived amongst palm trees, went on adventures both in and out of the resort, and most importantly had a chance to enjoy each others’ company in a non-academic setting. We returned late Sunday night to begin Module 2, the module of disease, early Monday morning.

Just before leaving to Mexico, I glanced at a piece in The Atlantic titled Scientists Brace for a Lost Generation in American Research. Here I learned of President Trump’s plan to cut the budget of the National Institutes of Health (NIH) by one-fifth, a decrease of $5.8 billion. I quickly knew I had something to say about this, but I put my thoughts on hold and went to Mexico. Upon returning to Canada I read a bit further and found it’s actually worse than I initially read: in addition to the $5.8 billion cut scheduled for 2018, Trump also plans to reduce the budget by $1.2 billion between now and then. Since Trump’s inauguration in November there’s hardly been a basis for optimism regarding funding allocation to science, but one might have thought the NIH would be dealt a better hand. Cuts to the Environmental Protection Agency (EPA) are unsurprising, but in fact EPA is losing only $2.6 billion whereas the NIH is losing $7 billion (although proportionally EPA is losing one-third of their budget). Of all the reductions to science funding the Trump administration is seeking, the cuts to the NIH are to me the most depressing.

The NIH is the largest biomedical research agency in the world. It currently operates under the directorship of Dr. Francis Collins, the physician-scientist who brought the Human Genome Project to completion ahead of time and under budget. The great majority of the NIH’s budget (over 80%) is used to create approximately 50,000 competitive grants, which are disseminated across more than 300,000 researchers at more than 2,500 universities, medical schools, and other research institutions. Another 10% of the budget supports projects conducted by the 6,000 scientists in NIH’s own laboratories. In total, the NIH invests upwards of $32 billion dollars each year into life-enhancing and even life-saving biomedical research. This makes it the largest funder of health research in the world.

Scientists don’t ask for much. As the Atlantic piece notes, the work of a scientist is arduous and often unglamorous. (My own experience in a research lab testifies to confirm this.) Advancements and discoveries come at the cost of several lifetimes of work. A research scientist undergoes a decade (sometimes closer to two) of gruelling training to prepare them for a career of investigation and experimentation. Their life’s work is to discover new knowledge that will reduce human suffering brought on by disease. To this end they sacrifice their time, their energies, and their passions. They undertake all this willingly, at the prospect (if not the certainty) of making very little money. All they require is sufficient funding to afford the technology required to test their hypotheses. This technology is almost invariably expensive. Much of health research takes place on the molecular level, for this is the scale at which our biology plays out in its pure, irreducible form. To journey down to this level to test a hypothesis is to become a participant in a strange and mysterious world, a world to which our only access comes in the form of cutting-edge technology. Affording this technology is where the NIH and other similar bodies become involved.

Over the last century or so, life expectancy in the US has increased by thirty years. A lot of this is to do with better healthcare, which comes about only by more health research. Much of health research relates to ameliorating the betrayals transgressed against us by our own bodies. These betrayals are mostly on the molecular level. Cancer is, in a basic sense, the result of betrayal by the cell cycle, such that it ceases to regulate the division of a certain population of cells in the body, allowing them to proliferate unbounded by normal biologic constraints. Multiple sclerosis is a betrayal by the immune system, such that it sends a population of T-lymphocytes to demolish the myelin sheaths that your brain and spinal cord require for proper function. Myocardial infarctions (heart attacks) and strokes are a betrayal of the blood-clotting system such that a clot ends up somewhere it shouldn’t and cuts off the blood supply to an organ, causing tissue death. These betrayals are the direct result of natural shortcomings of our body, part of our innate biology. Overcoming these shortcomings is tantamount in a very real sense to thwarting nature, and Mother Nature does not thwart easily or cheaply. Again, here arises the need for the NIH.

As if the betrayals by own our bodies weren’t enough, we also have a hostile external world to contend with. The first course of Module 2, the course to welcome my classmates and I back from break, is a two-week introduction to Infectious Disease. I find this a neat subject — there’s something sexy to me in the concept of the battle, the notion of waging war against tiny microscopic enemies endowed with powerful weapons. For millions of years these weapons gave the microorganisms dominion over us — it’s only in the last couple hundred years that we’ve roused our ingenuity to devise new technologies enabling us to stand up for ourselves. How many of these technologies exist in part thanks to funding from the NIH? I’m not sure. But once again, standing up to microorganisms is tantamount to standing up to Mother Nature, and Mother Nature does not back down without a fight. A reduction in science funding depletes our war chest and leaves us vulnerable to the natural order of things, which, if you consider the life expectancy of Homo sapiens in the pre-scientific era, is far removed from a circumstance of human flourishing. The smallpox virus killed over 300 million people in the 1900s alone before it was eradicated. That’s one person killed every hour for approximately the next 35 thousand years. It’s worth mentioning death by smallpox involves a great deal of agony. The smallpox-free world we currently enjoy is a world provided to us by health science research. In fact, the NIH helped fund the eradication.

Joy Hirsch, a professor of psychiatry and neurobiology at the Yale School of Medicine, was quoted in the Atlantic piece as saying “It takes only one savage blow to halt our dreams of curing diseases such as cancer, dementia, heart failure, developmental disorders, blindness, deafness, addictions—this list goes on and on.” A reduction of $7 billion to the NIH budget may be just such a blow. It’s not uncommon to see science take blows from one societal faction or another; the intelligent design movement, the anti-vaccination movement, the flat-earth movement, and others have all sought to subvert science in their own way, and have all enjoyed some amount of success. But if humans are to continue to progress and flourish, it’s imperative that science be allowed to progress and flourish. Our continued success as a species depends on science, and science as an enterprise is in the safekeeping of society.

Responding to the NIH funding crisis, Kelly Cosgrove, another professor at Yale, remarked “We will miss important discoveries since most breakthroughs are based on years and decades of baby steps. The hare will win, the tortoise will lose, and America will not be scientifically great.” If the subversion of science continues, I fear it will be even worse than Dr. Cosgrove indicates. How big an impact will a loss of $7 billion have? I’m not sure. Trump’s plan will have to pass through Congress before it becomes a reality, so who knows the magnitude of loss we’ll actually see. Nevermind where this money is going (it’s going towards defence, mostly to fund construction of the wall, but that’s not the point). Even if we consider no other aspect of health science research than its utility, this alone seems to me enough to support and defend it. What advancements do we deprive our future selves and our children of by taking money away from the NIH? In practice we’d never know, but as a thought experiment it’s depressing. Let us do what we can to ensure this thought experiment does not become reality.

To Sleep or Not To Sleep?

Most of those who know me have probably, at one time or another, heard me say something disparaging about sleep. “Sleep is a poor substitute for coffee.” “Sleep is a symptom of caffeine deprivation.” “Sleep is foolish and nonessential.” Remarks of this character tend to leave my mouth on a semi-frequent basis.

I can’t deny the necessity of sleep, and I won’t pretend to be immune to its nourishing effects. An abundance of scientific research affirms the need for sleep; restful sleep of a decent length is apparently advantageous to cognition, the immune system, and even the metabolism. I can’t argue with these findings. My quarrel with sleep is not a scientific quarrel but a philosophical one, borne of looking at the world and seeing both what is and what could be. We spend nearly a third of our lives practically comatose. This seems to me to be a bit of a waste (“design flaw” comes to mind). Although its effects pervade the body at large, sleep is generally understood to be a process of the brain. With this in mind, it’s trivially easy to imagine a brain that doesn’t need sleep. We don’t need to know everything about the brain in order to make this claim, we need only postulate that there’s no physical law ordaining all complex information-processing systems to undergo mandatory periods of rest. If we grant that no such law exists, we need only imagine a different brain in our heads than the one we happen to have. If this strikes you as too fanciful, hopefully we can agree it’s at least possible to imagine a brain needing far less sleep than ours currently does.

Given my attitudes towards sleep, medicine may be the ideal field for me. Medical students and residents, as well as our attending physicians, are no strangers to sleeplessness. Dr. Chase of House M.D. once compared medical school to “a competition to see who could stay awake the longest”. This comparison does in fact extend to the real world. A classmate shared this image with me, a few weeks into the schoolyear, captioned “Med school sure is pulling a number on my already messed up sleep…”

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Medical residents have it much worse. Residents (so-called because they used to literally live in the hospitals) can expect to work 70 – 100 hours per week, in shifts up to 26 hours in length, with a call-schedule of one in every four nights. (Actually, there are some exceptions that allow for 36-hour shifts). This might sound like a lot, but it’s actually much less than it used to be, back in the days when there were no limits on consecutive number of hours worked and no limits for the frequency of on-call duties. My sole family member in medicine, a great-uncle in B.C., once told me of a full Monday-to-Friday workweek in his residency during which he slept only four hours. These four hours came in the form of one hour on Monday and three hours on Thursday. I have no idea how many of the remaining hours were spent practicing medicine, but my educated guess would be “pretty damn close to all 116 of them.” A week quite like that is no longer kosher, but in certain specialties (pretty much anything surgical, for example), the current reality is not far from that.

Do attending physicians have it easier? Yes, but just as in residency, it depends on the specialty. I recently spoke with a neurosurgeon who reported working twelve-hour days six days a week, and being on-call one in every four nights. Call is busy for a neurosurgeon; if one is on-call, one can expect to work. Additionally, this particular doctor takes time in his evenings to review the imaging scans that will guide him through the next day’s scheduled procedures, and, as if this weren’t enough, he also likes to phone his patients on the eve of their procedures and touch base with them, answer their questions, discuss their concerns, etc. When I heard all this, I was amazed. What a stupendous amount of effort! More impressive still is the fact that he’s been in practice for a few decades, so if anything, this is the more relaxed portion of his career. While certainly more relaxed than the life of a neurosurgical resident, it’s a life far from idle. That being said, according to the stats, this individual is above average even among neurosurgeons.

Neurosurgeons are among the busiest of doctors, but they’re not the busiest and not even atypically busy (see the table below for a comparison of most major specialties). Consider neurologists, the non-surgical doctors of the brain (my top choice of specialty when I started medical school). Including the time spent administering care while on call, the average Canadian neurologist works 67.6 hours per week (actually slightly more than the average Canadian neurosurgeon). No matter how you slice it, that’s a lot of hours. Add in a half-hour lunch break and you’re looking at 14-hour days Monday through Friday, 12-hour days Monday through Saturday, or 10-hour days for the entire week. The actual distribution of time spent working will be different than that, but not necessarily in a way that’s preferable. How does one find time to work ~68 hours per week and still sleep eight hours each night? Most likely, one does not.

Table 1. Average weekly hours per medical discipline. Data obtained from CMA profiles available online. Cardiac surgery appears to be the busiest.

Medical Discipline Hours worked per week excluding on-call Hours per week spent in direct patient care while on-call Total hours worked per week
Anatomical Pathology 50.5 12.1 62.6
Anesthesiology 51.6 12.1 63.7
Cardiac Surgery 69.6 11.4 81.0
Cardiology 58.7 10.0 68.7
Dermatology 48.3 3.3 51.6
Diagnostic Radiology 45.6 5.8 51.4
Emergency Medicine 47.3 3.3 50.6
Endocrinology 51.2 6.8 58.0
Family Medicine 47.0 6.1 53.1
Gastroenterology 49.3 10.0 59.3
General Pathology 47.2

n/a

47.2
General Surgery 54.3 14.7 69.0
Hematology 48.6 8.7 57.3
Internal Medicine 47.1 11.7 58.8
Medical Microbiology 49.5 10.3 59.8
Medical Oncology 52.5 4.0 56.5
Neurology 57.8 9.8 67.6
Neurosurgery 51.5 13.1 64.6
Nuclear Medicine 48.6

n/a

48.6
Obstetrics & Gynecology 48.6 13.5 62.1
Ophthalmology 50.2 4.9 55.1
Orthopedic Surgery 57.0 12.6 69.6
Otolaryngology 52.6 6.1 58.7
Pediatrics 47.0 9.6 56.6
Physical Medicine 48.1

n/a

48.1
Plastic Surgery 58.8 10.5 69.3
Psychiatry 46.2 4.4 50.6
Public Health & Preventive Medicine 41.3

n/a

41.3
Radiation Oncology 51.4 3.3 54.7
Respirology 50.6 8.7 59.3
Rheumatology 54.6 6.8 61.4
Urology 56.8 13.3 70.1

There’s more than one way to think about sleep. I once went on a date with a girl, an athlete, who told me “sleep is a weapon.” (Apparently I don’t know better than to raise my concerns about sleep while on first dates). Something that can boost your cognition, boost your immune system, and boost your metabolism does perhaps deserve the title of “weapon” in at least some sense of the word. For an elite athlete, a weapon like that may make all the difference in competition. However, I am (assuredly) not an elite athlete, and I’ve found that although I presumably feel roughly as good as the next guy after a good night’s rest, in all my usual activities (studying, writing, even test-taking), sleep doesn’t lead to much difference in performance. In a sleep-deprived state, I can still do everything I want to, and do it roughly just as well — the only difference is I’ll feel just slightly worse as I do it. This is a downside I often don’t mind living with. Two affirmative examples from my life that suggest I’m not totally alone: my sister Christie, a law student at a top school who works constantly and tirelessly on numerous projects of human rights and social justice; and Dr. Soheila Karimi of the Regenerative Medicine Program, a prominent stem cell researcher focusing on multiple sclerosis and spinal cord injury whose lab I worked in as an undergrad (and where I plan to return f0r the next two summers). Both of these individuals sleep only a handful of hours per night (quite a bit less than me, even for all my hostility towards sleep), and in productivity, outshine me by quite a lot. Not everyone needs the full eight hours per night, and it seems plausible to me that both my sister and Dr. Karimi tolerate low levels of sleep with comparatively few side effects, but there’s obviously an element of determination and willpower at play, and I can’t help but wonder if maybe this is enough to account for their apparently-reduced sleep requirements.

Insofar as I’m deprived of sleep, it’s partly because I’m busy and feel I need the extra hours, partly because I’ll occasionally use “sleep-time” as “fun-time” (if there are six hours in a day to spare, is it better to sleep for all six? Or is it better to relax and do something fun for an hour or two, using only the remainder for sleep?), but also partly because life is short and I don’t want to forfeit any more time than I have to. Just as Damocles in the ancient tale bearing his name, each of us lives life under a precariously-dangling sword that is poised to drop at any moment. The late Christopher Hitchens spoke and wrote about living life as if he was always operating on the margins of a potentially great harvest of future knowledge, living life as if he hadn’t yet done anything like “enough”. This resonates with me. In Unweaving the Rainbow, Richard Dawkins writes

After sleeping through a hundred million centuries we have finally opened our eyes on a sumptuous planet, sparkling with colour, bountiful with life. Within decades we must close our eyes again… Who, with such a thought, would not spring from bed, eager to resume discovering the world and rejoicing to be a part of it?

To put it the other way round on Richard — who, with such a thought, would even want to go to bed in the first place??

Christopher Hitchens also said “It will happen to all of us that at some point that you’ll get tapped on the shoulder and told, not just that the party’s over, but slightly worse: ‘The party’s going on, but you have to leave.'” I don’t know when the day will come that I’ll be asked to leave the party, but I know there are things I want to do before that day comes, and in this context, life appears to be an emergency. A long emergency, but an emergency nonetheless. (This idea is also developed by Sam Harris in his talk Death and the Present Moment.) Is it reasonable to spend one third of an emergency in a slumber? I’d prefer not to, but it appears we humans may have to. Thoughts of this sort form the basis of my annoyance with sleep.

I asked my great-uncle how he survived the near-sleeplessness of residency. His response was brilliant: “I wasn’t always smiling, but I was happy to be there.” When you’re passionate about something — be it the rights of our oppressed fellow citizens, or the eradication of grievous illnesses, or something else entirely — the need for sleep can take a backseat. Given the brain’s ability to change itself, and given the ability of psychology to affect change all throughout the body, I can’t help but wonder if maybe this passion is enough to literally reduce a person’s requirements for sleep. This would explain people like my sister and Dr. Karimi, it would explain people like my great-uncle John and other medical residents both past and current, and it would explain people like the neurosurgeon discussed above. I used to fantasize (if that’s the word) about a future pill that would eradicate or somehow fulfill the need for sleep. (This would probably not be forbidden by the laws of physics and so probably not impossible in principle, but probably too complicated to ever be attained in reality.) Maybe we don’t need pharmacology for this — maybe the right motivation can suffice, at least to a certain degree. I haven’t yet attained the truly legendary levels of sleeplessness that certain acquaintances of mine have reached, but a career in medicine is a privilege for which I’ll happily forfeit a few hours’ sleep if and when it comes to that.

Happy holidays!

-GM

PS None of this is actual medical advice — just my thoughts!

Touching Brains

When life is busy, it can be hard to stop and appreciate the significant moments as they occur. This is hard even when life is not busy — busyness just makes it more difficult. When life is moving fast it’s hard enough to just keep up, nevermind appreciate the moments as they occur. Busy or not, life is always in motion; the moment always fleeting, always running away from us. In Unweaving the Rainbow, Richard Dawkins writes it feels to him as though “the present moves from the past to the future, like a tiny spotlight, inching its way along a gigantic ruler of time.” If we apply this analogy to life in medical school, the spotlight accelerates to a breakneck speed, careening down the ruler like a runaway freight train. Avoiding academic failure requires some form of running alongside the train; pausing to drift at its side for a moment’s contemplation is easier said than done. Learning to drift in this way is a skill that requires diligent effort and discipline.

It occurs to me that many people — medical students or otherwise — feel that they’re on the losing end of the race with the runaway freight train. Most people I talk to feel there aren’t enough hours in the day to accomplish all they hope to. Medical school only exacerbates these sentiments, as our schedules are packed with courses and extracurriculars and riddled with exams. For example, today’s Neuroscience midterm marks the sixth exam in just slightly more than two weeks. In this time there was the Cardiovascular System final and the Respiratory System final, midterms in Clinical Reasoning and Population Health, a two-station Objective Standardized Clinical Exam (OSCE), and the above-mentioned Neuroscience midterm. We don’t get time off for exams; these were all scattered amongst the usual 9 – 5 schedule of coursework. This fast pace makes it hard to stop and, as they say, “smell the roses”. This is unfortunate, as big events are happening all the time! In the past four days, for example, I was honoured to participate in my first surgery (obviously a very minor role, but still exciting), clinically examine strangers for the first and second times, and perform Christmas carols alongside several classmates for the patients of the Children’s Hospital. These moments are all worthy of reflection. I could probably write about any of them, but instead I’ve chosen a different topic: somewhere in the past weeks’ busyness was my first hands-on experience with the human brain.

Part of the curriculum of our modular courses, the ones that teach us about the various organ systems, is to learn the relevant anatomy of the systems. We’re in a 4-week neuroscience course right now; neuroscience entails neuroanatomy. Our education in anatomy includes hands-on lab sessions with human specimens that have been generously donated to our program (this thought alone is grounds for significant reflection). Our first neuroanatomy session was roughly two weeks ago. The supervisor of my upcoming research project was one of the instructors. Anxious not to appear incompetent, I had been up late into the morning hours cramming my brain full of as much neuroanatomy as it could hold (a situation that only now strikes me as ironic.) We entered the lab to find rows of tables, each with a skull on one end and a large bucket on the other. The class had been split into groups of six, and each group was given one skull and 1.5 brains — one full brain, and one single-hemisphere (my group was awarded a left hemisphere). The brains had been placed into the buckets and were afloat in a preservative bath. My proximity to the bucket nominated me for the task of reaching in and removing the brains (I was feeling fairly eager, so this worked out well). Armed with our printed instructions and under the guidance of several circulating instructors, we set to work on the task of hands-on study.

Before I carry on here, a quick word on the brain. The brain sends electrical impulses throughout the body; these impulses control the body. That, in a sentence, is the nervous system. One special type of cell, the neuron, is responsible for both the generation and the conduction of these signals, both inside the brain and out. There are roughly one hundred billion (100 000 000 000) neurons in the human brain. Most of these brain-dwelling neurons send signals to one another, forming the complex circuitry of the brain. Some send signals through the base of the skull into the spinal cord, itself made of neurons, which projects neurons to all the other sites of the body. Whether current does or does not flow from one neuron to another is the basis of the brain’s computational abilities. The site of connection between two neurons, through which a signal may pass, is called a synapse. Each neuron in the brain is linked up to about 1000 other neurons, making for a total of one quadrillion synapses (a million billion, also written 1015 or 1 000 000 000 000 000) in the average human brain. This is a staggeringly large number. It’s not surprising that the brain is so complex, given its remarkable capabilities. What is surprising is the ordinary appearance of the brain.

I’m not sure what I expected of the first meeting between my hands and a brain. I hadn’t given it enough forethought to have any specific expectations, but in retrospect I was anticipating the awesome complexity to be somehow indicated by the experience. This expectation was not met. Holding a brain in the palm of my hands was definitely a thrill, but the magnificent complexity I knew to be present was not able to be deduced by mere observation. Had I not been told it was so, I would have had no idea I was cradling the most complicated object in the known universe. This is because the brain, like so much of the world, doesn’t look like what it really is. This vast network of a hundred million billion connections, through each of which electricity either does or does not flow at every given millisecond, whose circuitry controls the body and produces the mind, appears to be scarcely more than a folded-up piece of meat.

This relates to a fact about the limitations of our sense organs. Our sense organs, powerful as they may be, evolved to detect a limited range of phenomena — specifically, medium-sized objects moving at medium speeds — and even within these constraints, quite a lot of what goes on is unavailable to us. Vision, our sense for detecting electromagnetic radiation, allows us to see only the tiniest fraction of electromagnetic radiation that exists in the world. Our sense of smell picks up only a small fraction of molecules that exist.  The model of the world created in our brains is powerful, extremely useful for survival, and often tremendously beautiful, but it has many notable limitations. Certain things are simply beyond what we can expect of a brain built by natural selection. The realm of the microscopic was unavailable to our ancestors and so unavailable for the action of natural selection, therefore we’d expect events on this scale to be beyond what we can probe with sensory experience. The complexity of the brain itself is realized on a microscopic scale, so it’s unsurprising that this affair is hidden to casual observer. In short, evolution wouldn’t be expected to build a brain capable of appreciating the brain. The world we experience is beautiful, but the true world is much more beautiful than we can appreciate by sense alone. Thankfully, we have science to take us beyond the realm of sensory faculty.

Returning to the earlier topic of mindfulness: not every day will contain dramatic milestones, but every day contains something worth appreciating and reflecting on. It’s up to us to be mindful and watch for these things. The path to appreciation, to happiness, always leads through the present moment, because the present moment is all we really have. As author Marianne Williamson puts it, “No matter what time it is, it is always now.” Life is ultimately the sum of a long series of present moments. In his talk Death and the Present Moment, neuroscientist and philosopher Sam Harris elaborates on this point:

“The past is a memory; it’s a thought arising in the present. The future is merely anticipated, it’s another thought arising now. What we truly have is this moment…and this. And we spend most of our lives forgetting this truth, repudiating it, fleeing it, overlooking it, and the horror is that we succeed. We manage to never really connect with the present moment and find fulfillment there, because we are continually hoping to become happy in the future. And the future never arrives.”

Thank you all for reading. Please comment below! I wish you all the best with your future happiness and mindfulness.

– GM

Adding Value and Other Shifts in Thinking

Roughly two months ago, right around the time I started medical school, I created this blog and sat down to write the first entry. I figured I would write about my path into medical school — that seemed like a logical first entry for a blog titled “Mr. Med Student”. I got about 500 words deep into this project before I realized that my path into medical school makes a very uninteresting story. There were no great adversities to overcome, no crises or spectacles, no theatrics and no drama. I was blessed to have a straightforward path into medicine, but this left me with nothing to write about. My sole idea deflated, I discarded my plan to have a blog and resumed life as usual.

I’ve now been in medical school for nearly three months, and I realized today that I’ve managed to learn some things. I don’t mean just the medical curriculum — which goes without saying — I mean that I’ve learned things about life. I’ve detected two shifts in my thinking. Both shifts represent things that I should have figured out long ago, but alas I can at times be a bit slow on the uptake on these matters. Teach me about chemistry or immunology and I can learn that fairly quick; teach me about life and… well, good luck to whoever tries. Those lessons apparently need be drilled into my head with quite a lot more vigour and repetition before they begin to stick.

The first detectable shift in my thinking is that I now view my time in a completely different way. With the demands of medical school, time is at a premium like never before, and I find myself respecting my time in a way that’s new to me. I find I no longer have a willingness to participate in activities that don’t add value to my life or the lives of others. The things that don’t confer value in some way are excised without hesitation. I don’t mean to be grand about it — it’s not as if I’ve become some paragon of productivity with no time for trivial matters and no need to ever relax. Value comes in different forms, and everyone appreciates certain forms more than others. There’s value in relationships — the right relationships, that is — and spending time with loved ones. The act of helping others can add value to our own lives as well as those helped. I find value in creative engagement, so I tend to spend some time producing music and reading about things that interest me. Of course there’s value in our own happiness, so sometimes finding value is as simple as binge-watching a Netflix series or pouring yourself a considerable portion of wine — arguably not “productive” activities in the typical sense of the word, but stress-relief is an important contributor to mental health, and mental health can only decline so far before productivity begins to wane.

The pursuit of value will look different from person to person, but there are some commonalities. Dull, tasteless relationships have to go. Living for others more than they would live for you has to go. Wasting time on things you don’t care about has to go. The philosopher Sam Harris wrote “We often behave in ways that are guaranteed to make us unhappy.” I think Sam’s right, and I think it often has to do with failing to realize and/or act on what’s important to us. Respect your own time by filling it with the things that matter, and be courageous in the pursuit of value.

The second shift in thinking is less self-centred than the first, and something I think I knew once upon a time but forgot somewhere along the way: always remember that every person you meet is going through things you know nothing about. I entered a time of personal difficulties a few weeks back, and mental health became an issue. Fortunately, my classmates and I have a crew of highly-trained mental health professionals at our disposal to help us get through such times with minimal disruption to our education. Unfortunately, the majority of this crew was on strike at the time due to failed contract negotiations. I was left to navigate these murky waters mostly on my own, although the remnants of the mental health team were able to help me defer a midterm exam by a few days, and this proved very helpful.

When life is going well, the pressures of medicine are an enjoyable challenge; when life goes poorly, they become a crushing burden. It occurred to me that I, two months into the term with a strong science background and a relatively easy life (no children to care for, no debt from the previous degree, a healthy family, etc.) was probably not the first person in my class to feel crushed by this burden. I realized that many of my friends and peers had probably felt this way at some point over the last several weeks, and I couldn’t help but wonder — who? When? Why had I failed to notice? Were they doing better now? Who among my classmates was suffering at that very moment? What could I do to help? I began paying more attention to the emotional conditions of my classmates and realized that an easy life was the rare exception. Not everyone was going through a crisis at that moment, but everyone I talked to had problems and seemingly everyone was stressed. I took this realization as a firm reminder to try to be nicer to people. I also resolved not to pass judgment on someone for struggling with what I thought should have been within their capabilities. You never know what disadvantages someone is working through — play it safe and treat them well.

A boring exposition about my path into medical school didn’t seem like the sort of thing that could add value to anyone’s life — I thought this topic stood a better chance. I’m not sure what future entries will be like. Perhaps I will continue to learn new lessons (slowly, no doubt) or maybe medical school itself will inspire some new topic. I’m not sure. In any case, thanks for reading. Hope to see you back!

– GM