Medicine is a strange career, in comparison to most, in that a doctor does not go on their first true job interview until they are nearly 30 years old. Prior to that, its really just trying to get into college, then trying to get into medical school, then trying to get into the right residency…. but never really interviewing for a job, per se.
My first job interview was with Dr Kenneth Ward, then the chair of the University of Hawai’i department of obstetrics and gynecology. I was interviewing for an academic position, and the interview seemed to be going pretty well. We both liked technology, and were both Apple fans, so there was a fair bit to talk about other than just the job. Overall, we seemed to hit it off.
Then he asked me a serious question.
“So Nick, what was your greatest accomplishment in residency?”
This week in the news there have been a number of articles about a new technology that has allowed the creation of an embryo from three parents, and boy it is creating controversy.
Three parents you say?
Yes. Of a sort.
The case in point regards a woman who unfortunately had a child with a deadly mitochondrial disease. Mitochondria are organelles (“small organs”) inside each of our cells where ATP, our primary energy source, is made. Mitochondria are special in that unlike other organelles, they carry their own DNA. In the case of this woman’s tragically afflicted baby, defective DNA that could not support much life.
Geneticists have developed technology to create an healthy embryo without the defective mitochondria by placing a nuclei from the woman’s mitochondrially defective egg into a donor egg, after removing that egg’s nuclei. They then fertilized the new proto-egg with the husband’s sperm to create a new embryo. In essence, the egg had three parents – two in the nuclei, and a third one in the mitochondria.
And the world shuddered.
From all corners were cries of “we’re playing GOD!!!”. “We are altering the human race!!” “We’re no better than Mengele!!”
Most of this comes from a bright line we have put around genetics research that says we will not genetically engineer human beings. Legitimate bioethicists have felt that this is something we should not do, because of a ‘slippery slope’ towards eugenics. Religious radicals are just uncomfortable with advancement in science in any kind. They say it is because it is against God, but I think it is because a true understanding of how the universe works deprecates the validity of their religion, and thus sparks a crisis of faith.
But either way, most people think that manipulating human DNA is unethical.
I, for some reason, don’t see it this way. In fact, I couldn’t be happier that we have made this leap, and hope we keep leaping. We are coming to understand how we are put together, and in such we are coming to understand how to manipulate that process. That is exciting, not concerning.
We are not “Playing God”. For us to be “Playing God”, a “God” would have to have been the reason we came to be on this earth. And unequivocally, it is not. The evidence for evolution is so unbreakably strong that to claim that we are here because of “God” is purely ignorant. Humans are on this earth because our genes were selected for over millions of years, not because somebody put us here. If you believe in God, fine. But please don’t hold humanity back from our future by claiming that we are breaking your religious rules.
Even worse is the claim that to genetically engineer a human is akin to Nazi experiments. True, Hitler wanted to manipulate the future of humanity. But he didn’t want to do it by changing the genetic information of the future. He did it by murdering the people who were already here. To claim these are the same thing is an affront to geneticists, and is too good for Hitler.
In truth, I am absolutely head over heels excited to hear that we were able to eliminate a deadly genetic disease from a family through genetic means. What this means to me is that we are actually CURING disease, not just treating the symptoms that it produces.
Evolution is something that is terribly misunderstood. Its detractors really don’t get how it works. People who don’t understand it think it is about the selection of individuals over others, and thus don’t believe it could ever have ended up in us, but that is not really how it works. It is the selection of GENES that drives evolution, not the selection of individuals.
The problem in this case is that mitochondrial genes do not reproduce sexually, but are rather copied directly from their parent mitochondira, and as such they do not evolve. As such, problems in the mitochondria are passed on forever, never changing except by random mutation.
But now, for the first time, mitochondrial DNA is evolving. Perhaps not by natural selection, but it is evolving nonetheless. And that is exciting.
Don’t take this to believe that I am ignorant of the potential problems. But they are technical, not ethical. Obviously we can not open the doors to unlimited human experimentation, but this is a first step, and it is a good one.
Yesterday I was going through my closet and separating out a lot of clothes that I no longer wear to give to Goodwill. Among the many things I selected to never see again, I noted a tie that I wore to my original medical school interviews. An wow.. it was a problem. Did I really wear this? I then decided to actually put together the outfit that I wore to my interviews. And now I realize… its a miracle I ever got in.
I grew up in Oregon, where no one ever wears a tie, and no one ever dresses up. When it came to interview for medical school, I truly had no appropriate clothes. I consulted my father, who suggested the outfit you see here:
Note the tie that is missing the material in the back to allow the tie to line up. No problem there.. just use a paperclip. Really. While my father was trying to lead me in the right direction, little did I know this was the same father who fifteen years later would wear a tee shirt to my wedding.
So basically, I walk into medical school interviews looking like this:
Note the rather ill-fitting sport jacket, Mathlete regulation length tie, and unmatched pants that are too small. Ignore the pleats, they were actually in fashion then.
But how was I to know? I was a computer science major and a total geek. This was dressing up big time. I was fully expecting that when I went to interview I would be looking sharp.
Not so much. When I arrived to my first interview at Baylor College of Medicine I found myself terribly underdressed compared to all the Brooks Brothers suits sitting next to me. While I looked maybe all right, they looked good. And more importantly, they all looked the same, and I looked different.
And perhaps that was my mistake, in that this was what I was actually going for. I knew that a suit was the right thing to wear, but I had a rebellious streak in me that said ‘screw that! I don’t need to buy and wear a suit! What matters is my brain and what I have accomplished!” I also had a bloodstream that ran with Oregon blood, where most people respond to a person in a suit with the comment “so who died?” And so I proudly wore clothes that looked right out the closet of my University of Oregon math professor Schlomo Libeskind, who inspired my love for higher mathematics and modeled wearing beltless polyester pants up to his nipples.
Fortunately, I survived the process and indeed was accepted to medical school, though not as many as I thought I should have given my academic record. As I was looking back in this during residency interviews, I decided that this time was not going to make the same mistake twice! I was going to wear a suit!
And I chose this:
My mother had found it at a thrift store and extolled its beauty. It was in fact a suit, and it was in fact from a fine Italian brand. Furthermore, it was a suit that when new was quite expensive.
But what it was not was a suit that fit me. It was way too big then, just as it is today. Furthermore, being found at a thrift store, it was in fashion twenty years earlier, not at the time it was being worn. It was also brown, which still set me aside from all the other blue and black suits that interviewed for residency with me.
I did get some “nice suit” comments followed by furtive glances to the side or floor. As a person who now plays a lot of poker, I now realize that those comments were purely ironic. I also heard “bless your heart” in the South a number of times, which by the third year of my residency in Charleston,SC I knew was actually an expression of kind condescension.
Fortunately, despite this suit, I got into the residency I wanted. Apparently being the rare highly qualified male applicant to an OB/GYN residency was worth more than the ill-fitting suit cost me. And at the end of my residency, the chairman took me to a fine men’s store with the invitation “Son… they’re having a sale.. and you need a nice suit for your faculty interview.” ”But I have a suit!” ”Son… you’re going to a be a faculty physician… you need more than one suit.”
* * * * *
At the time, I didn’t think this dressing up business was important, but now as a faculty member I realize that it was. There is no doubt that on the days that I interviewed in those clothes, the faculty were laughing about me at the applicant review sessions. I have no doubt that at my medical school interview they were saying “how about that Fogelson guy with that sportcoat and no belt?” And at my residency interview I’m sure it was “how ’bout that huge brown suit guy!”. Of course, does that really hurt a person? As a person who interviews and ranks applicants, I can say that it almost certainly does. An applicant has only a few minutes to convince someone that on a very subjective level that they deserve to be in the medical school or residency. In the end, you hope that your interviewer is talking about how smart and accomplished you are, and not about how you were dressed. It seems so superficial, but that doesn’t make it not true.
So the truth is this: When you interview for a job in medicine, your clothes should be invisible. They should be well fitting, relatively conservative, and ordinary. They should be neither particularly bad nor the height of fashion, leaving your interviewers nothing to comment on other that what really matters – the person wearing the clothes.
When I interviewed for medical school, I interviewed at 8 schools and was accepted at one. I had great MCAT scores and way more medical experience than could be expected of any applicant. If I had been dressed like this I probably would have gotten into a lot more schools:
I recently had a manuscript rejected a second time. It gave me a few thoughts on what signs may mean that your manuscript will just never be accepted.
These are signs that your manuscript may not be fit for publication:
1) Your manuscript has been rejected so many times that the impact factor of the journal your are now submitting to is lower than the p value of your results.
2) You were just accepted for publication, but the editors have asked that prior to publication the manuscript be translated into Urdu.
3) Your last rejection letter included a suggestion that your manuscript be changed from a description of a randomized controlled trial to an comedic editorial.
4) You receive a solicitation for publication by The Journal of Irreproducible Results
5) You are now submitting to a journal that is peer reviewed by chimpanzees.
6) They have rejected your manuscript for insufficient banana content.
7) Instead of a form letter thanking your for your effort and desire to publish, the editors write you to tell you that your submissions are no longer welcome.
8) Unless they include bananas.
9) You are considering submitting to Cat Fancy.
10) You have decided that it’s far easier to publish via blog post.
There’s always Southern Medical Journal.
Some Cancer Humor
I saw a patient today who presented with a large vaginal cancer. I was discussing her care with my intern, and that it would make a big difference if the cancer were localized or if it had already spread to the lymph nodes. Based on her exam, I thought there was a pretty good chance it had already spread.
“The toothpaste is already out of the tube”, said the intern.
I replied “I suppose… but usually we say ‘the horse is already out of the barn‘ After all, like cancer, the horse wants to leave the barn and run. The toothpaste doesn’t want to leave the tube. It will stay there forever until you squeeze it out.”
A look of understanding hit the intern’s face…. then puzzlement.
“But Dr. Fogelson, it seems like its a lot easier to put a horse back into the barn than it is to put toothpaste back into the tube. If cancer was like the horse it would be much easier to cure once was spread.”
So there you have it.
Cancer acts like a horse at first, but then becomes toothpaste.
I wish I could say that when I’m done doing a little impromptu lecture on pelvic anatomy that there is something on paper worth saving, but well, there isn’t. Wish you could have been there.
Academic OB/GYN has now found its third home in Atlanta, GA. The blog got its grew up in Honolulu, HI, spent its teen years in Columbia, SC, and now has moved on and is ready for its first real date in Atlanta, GA.
In all this moving, there hasn’t been a lot of time to write blog posts or do podcasts, but I’ll be coming back soon with lots of good stuff. Atlanta is perhaps the best city I have ever lived in. I’ve been here a week and love it already. If any fans or friends live in ATL please let me know so we can meet up!
My move to Atlanta comes as a sabbatical from attendinghood, returning to the learning side of it all in an Advanced Pelvic Surgery Fellowship in the department of Gynecologic Oncology at Emory University. I hope to get some great material for surgical videos, though Emory’s policies for posting may be a bit restrictive – more research is warranted.
One of the great things about Atlanta is the incredible music scene. Every big act plays here. I just saw Idina Menzel tonight – just awesome. She played Chastain Amphitheater and there was daylight for the first 2/3 of the show. She kept saying it was making her nervous seeing all the audience watching her. Even virtuosos get nervous.
I recently had a chance to visit Celebration, FL, a town initially created by the Walt Disney company as an attempt to realize Walt Disney’s original dream of EPCOT, or the Experimental Prototype Community of Tomorrow. EPCOT was Disney’s idea of a perfect community – no crime, no unemployment, and every family with 2.3 above average children. That perfect community was created to some extent at Disney’s EPCOT theme park, but never became what Walt really intended – perhaps because his ideal image was a little too, well, Disney. However, long after Walt’s death a somewhat more realistic, if still a little Truman Show, version of EPCOT came to fruition – Celebration.
Celebration is a fascinating place. In some ways it is bizarre – assuming that one has never seen a town where every lawn is mowed on the same day, there is not a speck of flaking paint, the shrubbery is all perfectly trimmed, and everything is 50% more expensive than it should be. But in other ways, it is an amazing accomplishment – a community truly in the image of the Disney idea. A community Onstage. Particularly at its hospital.
Well folks – I’m in San Francisco at ACOG. In addition to the dinner monday, we will be doing a fair amount of ACOG content. Check back for daily summaries of what’s going on at ACOG, including podcasts with interviews with poster presenters and industry folks.
If anyone wants to come to the dinner monday night, please RSVP soon! We’ve got about 16 coming so far. Sage Healthcare is sponsoring, so come on out and enjoy some great food and drink and meet other fans of Academic OB/GYN!