Sundance USA

This was the second year that the Michigan Theater participated in Sundance USA. Last year, the featured film was Cyrus, and one of the writer/directors (The Duplass Brothers) as well as Jonah Hill (one of the stars of the film) flew to Ann Arbor and answered questions about the film after the showing. This year, the theater was honored to not only show an official film selection from Sundance 2011 (Win Win) and a selection of shorts from 2010 as a part of Sundance USA, but was able to add an additional film (Cedar Rapids) that was filmed in Ann Arbor and the surrounding areas.

The 2010 shorts were in general quite entertaining. Some were better than others, but I think the night was carried by two short films in particular: Wisdom Teeth is an animated short about pulling a stitch out after a wisdom tooth extraction that is a bit disturbing, but really great; Drunk History is a live action film about what happens when Jen Kirkman drinks two bottles of wine and then talks about Abe Lincoln. You can watch Drunk History at the link above, and many of the other shorts have made it online at this point, so check them out!

Both the films from this years festival were great. Last night we saw Win Win for Alicia’s birthday. Paul Giamatti was fantastic, and although I found it to be kind of sad, it was really quite funny throughout the film. I forgot to bring my camera last night, but grab my fancy new camera bag tonight before the show. We saw Cedar Rapids, which was also a bit of a comedy-with-a-moral. Filmed in Ann Arbor and set in Cedar Rapids, Iowa, it was a premise that was immediately familiar to me. I enjoyed seeing shots of the Broadway Bridge and the old power station (both on my walk to the farmers’ market).

Before the show started, the mayors of Ann Arbor and Cedar Rapids, IA took the stage, with Mayor Hieftje presenting the Iowan mayor with a key to the city.

Following the show, the director answered questions (and thanked all of the extras who had shown up for the screening)...

I’m hoping both of these films will gain broader distribution, but look for them in a town near you, and watch for a Sundance USA event near you next January!

Hello history taking…

From AMSA On Call:

Post #5 of the "Back to the Wards" series focusing on the transition from research years back to the medical school and clinical rotations.

Last week I saw a real patient by myself for the first time. Granted, my actions had absolutely no bearing on his care as I was only seeing him as part of my program's official reentry clinical experiences, but nonetheless, I saw a patient by myself. It was profoundly different from every other experience I’d had conducting a history and physical examination. Unlike practicing with a friend or a standardized patient, this patient wasn’t directly evaluating my skills.  There would be no debriefing with him at the end of the afternoon to discuss whether or not he thought I had adequately checked for organomegaly on the abdominal exam (aka, enlarged liver or spleen), or how I might have more carefully guided him through a recounting of his past medical history. Unlike previous sessions where I was observed directly by an attending physician, there was no doctor present. There was no instructor correcting my percussion technique or reminding me to ask about medication allergies, or noting carefully that I should have been more diligent about screening for domestic violence. Unlike clinical examinations, and unlike many of my clinical experiences to come, there was no time limit. I had as much time as necessary to meander through a history and struggle through a physical exam. All of these differences did make the whole experience less stressful, but highlighted for me the value of having patients who are either truly performing (as my colleagues and standardized patients had done), or those who recognize that they are being watched by a doctor as part of a clinical exercise and put on their best helpful patient facade. Instead, I got a friendly and talkative gentleman (carefully selected for me by the charge nurse) who assumed I was a nurse and wound his way through a baffling series of events that proved to comprise his entire life history, occasionally touching on episodes related to his medical condition.

As a student training in public health, I firmly believe that the social determinants of health are as important as any explicitly medical issue. You’ll note that in the previous sentence, however, that I place those two things on equal grounding, indicating that a good history has to lead to a good understanding of what medical issues and interventions led the patient to the current state, as well as the social issues and interventions along the way. At this point, I can safely say that I am not a good history taker. I am excellent at establishing rapport with the patient, am careful not to interrupt too soon, aware that data suggest that responding too soon to the first things a patient says can lead the history taker astray (possibly missing more urgent problems further along in the patient’s story), and generally leave the interaction with a vast knowledge of the patient’s children, eating habits, and hospital preferences.  I am not yet excellent at knowing when to redirect a conversation in a more productive direction (say, to illuminate some aspect of the past medical history), or how to suggest that a topic of conversation may be inappropriate (for example, the patient’s perception that an outside hospital is inferior and begins listing examples). Striking the balance between empathic confidante and authoritative information-seeker is difficult, and I’m convinced that this is not made easier by small stature, female sex, and clinical inexperience, none of which is easily disguised on the wards. So what is the rusty and inexperienced clinician (dare I even call myself that at this point) to do? Fortunately, interactions with those further along in this process suggest that ultimately, clinical experience overcomes most additional barriers, and that it becomes easier to matter-of-factly state, “No, I am the medical student/doctor.” This, fortunately or unfortunately, depending on how you look at it, leaves me with only one option, and only one recommendation for you, dear readers, should you find yourselves in a similar position: practice. That’s right. As in all things, I can only hope that if I try and try again, eventually I’ll succeed.

A very big concert

Last Sunday was a very big concert for the Life Sciences Orchestra in just about every sense of the world. It was the 10th winter concert for the LSO, marking a decade of physicians, public health faculty, graduate and undergraduate students and many others making music together. It was remarkable (according to reputable sources) that an non-professional orchestra put together Mahler’s Second Symphony, which is a substantial piece of music to say the least. It was a big commitment for audience members to listen through 90 minutes of music without an intermission. And finally, it was a big group of musicians: over 100 singers and nearly 100 musicians according to the official press release. I still feel a little overwhelmed by the whole thing!

In case you missed this one, mark our next one on your calendar: Thursday, April 22, 7pm at Hill Auditorium. We’ll be playing:

Beethoven: Egmont Overture
Dvorák: Cello Concerto, I Mvt.
Berio: Ritirata notturna di Madrid
Falla: Three-cornered Hat (Suite No. 1)
Ravel: Rapsodie espagnole

The economics of muffins or, why I love Ash

To eat all the muffins at once, or not: a discussion of rational decision-making

By A. Knittel

Objective: To determine whether to save all the muffins for later, eat all the muffins now, or to define a mixed strategy, saving some of the muffins and eating some now.

Analysis: When a fresh batch of muffins is prepared, the rational individual is faced with a series of decisions about the fate of said muffins. Saving the muffins for a later time would ensure that the individual had a ready supply of snacks, but the muffins lose value because they become something to be enjoyed in the future (and so are discounted). Eating all of the muffins in one sitting, however, invokes the possibility of diminishing returns. After eating 9 muffins, eating the 10th does not bring the same level of joy that the first did.

Given this dilemma, the rational muffin eater is left with the following options: a series of differential equations estimating the maximum utility for a given number of muffins, or a game theoretic model where one player aims to eat all the muffins immediately, the other aims to save all the muffins, and the optimal strategy for each is a mixed one.

Conclusion: The maximum muffin utility clearly occurs when there is a balance between the amount of time, though both analytic approaches require calibration using observed preferences for muffin eating.

Acknowledgements: I would like to thank Ash for providing critical comments during the development of this manuscript. She deserves most of the credit, though any remaining errors are my own.

***
Many of you know that I listen to a lot of podcasts each week. I listen while I walk the dog (2 x 15-45 minutes x 7 days), I listen while I ride the bus (2 x 10-20 minutes/day x 5 days), I listen while I cook dinner (20-50 minutes x 3-5 days), and sometimes I listen while I knit or while I work out (30-90 minutes x 1-2 days). Having done the quick math, you’ll realize that I listen anywhere between 6.5 and 21 hours each week. One of my favorites is the Planet Money Podcast that started at the peak of the financial crisis, but which has expanded to cover a variety of topics from an economic point of view. In recent months I’ve also added the Freakonomics Podcast to my repertoire. Though I am by no means an economist (and become frustrated when they try to take over disciplines I care about), I do enjoy a bit of the economics every now and then. Enter Ash.

As many of you know, I enjoy Ash all the time. She is on my short list of the most awesome people ever for a variety of reasons, none the least of which is her ability to highlight the econometric potential of every situation. By way of explanation for the above, the following is a (slightly modified) conversation:

Me: Um... I just paid $2.50 for a muffin. I think I might bake some stuff tonight to bring into school.

Ashleigh: Seems wise.

Me: Can you freeze things like muffins easily?

Ashleigh: Yes. They aren't quite as good, but they do freeze well.

Me: I think the freezing would not only be the best option for storage at school, but would eliminate the "I feel a tiny bit hungry so I’ll eat 10 muffins from my desk" option.

Ashleigh: But muffins taste so good at desks.

Me: But i think the literature is clear that the 10th muffin is less good than the 1st (when they are eaten all at once).

Ashleigh: Yes, that's true.

Me: So if i freeze them and bring them in then I can eat 1 at a time at my desk.

Ashleigh: Maximum utility from the set number of muffins... depending on the discount rate.

Me: How would the discount rate apply to muffins?

Ashleigh: Well, if you enjoy immediate gratification like the rest of the humans... there will be a muffin discount rate. I'm pretty sure there will be a positive one in this case.

Me: I see. So the pain and suffering of waiting for the next muffin will diminish the enjoyment compared to just eating them all.

Ashleigh: Basically the principle of a bird in the hand is worth 2 in the bush.

Me: A muffin in the hand is worth 10 in the freezer? But what if you have 1 in your hand AND 10 in the freezer? Then it is a question of whether the future discounting is more than the diminishing return, right?

Ashleigh: Yes, you've got it.

From there we may or may not have spent a total of several hours trying to work through the differential equations (which got ugly quickly) and also some game theoretic models, each time reaching the conclusion that we needed more concrete information about the preferences.

Basic Muffins

adapted from How to Cook Everything, by Mark Bittman

3 tablespoons melted butter, canola oil, or other neutral oil
2 cups all-purpose flour
1/4 cup sugar
3 teaspoons baking powder
1 egg
1 cup of milk (I used a mixture of rice milk and water... I really need groceries...)
1/2 cup hazelnuts
1/2 cup raisins
1/2 cup frozen strawberries

Preheat the oven to 400F and grease a muffin tin. Chop the hazelnuts, raisins, and strawberries in the food processor. I did them separately, but you could probably just throw everything in there. Mix the dry ingredients and set them aside. Beat together the egg, milk, and butter/oil. Dig a space in the dry ingredients, and pour the wet ingredients into it. Using a spatula, combine the ingredients by stirring and folding rather than beating, and stop as soon as all the dry ingredients are moistened. The better should be lumpy and thick, but quite moist. Stir in the nuts, raisins, and berries.

Spoon the batter into the greased tin, filling them about 2/3 full (avoiding further mixing of the batter). Bake 20 to 30 minutes, until they are browned and a toothpick comes out clean. Serve warm (even if you freeze them; Ash recommends toasting after they are thawed).

MLK and gratuitous dog photo

Yesterday was one of my favorite holidays during the school year. I’ve been attending the Martin Luther King Jr. Symposia here at UM for a long time (in fact, this may have been my 10th!), and I really enjoy the chance to take a brief break and hear someone interesting talk about something important. This year’s symposium, with the theme “We the People… Realizing the Dream?” was kicked-off yesterday morning by Shirley Sherrod, the former USDA Director of Rural Development in Georgia who was fired after some remarks she’d made were wildly distorted in a right-leaning media frenzy. Her message encouraging each person to consider what she/he could to to promote social justice was a welcome one, and I enjoyed her talk, despite of the frequently strong religious tones that don’t resonate particularly well with me.

Even before the question and answer period ended after the keynote address, I headed over to the hospital for the Health Sciences MLK event featuring Sherman James speaking about the legacy of health disparities from the Civil Rights Movement. I wasn’t able to stay through the entire talk, however, before I headed up to the 7th floor of the hospital to… see a patient by myself! Fear not, nothing I did made any difference (for better or worse) in the patient’s care. I’ll post more about how that went later in the week.

To close, I’ll remind you all what sunshine looks like:

This was only taken over the weekend, but already seems so distant after a day of “ice pellets” falling from the sky.

A troubling start

I had high hopes for Michigan’s new governor, Rick Snyder. Although I lean more than a little to the left, I understood the push I saw in the last election cycle for fiscal responsibility in our state government. What I had hoped, however, was the Gov. Synder would focus his energies on fixing the economic woes of our state, and leave behind the extreme social conservatism that Michigan Republicans seem to love. His first few weeks in office would suggest that this is not the case. As reported in Between The Lines, Synder’s appointment to head up the Michigan Department of Human Services is Maura Corrigan, currently a MI Supreme Court Justice. For those of you who have been around for a while, you may recognize her name as the justice who ended second parent adoptions for same-sex parents in 2002. As Jay Kaplan of the ACLU points out in the BTL article, in spite of not having a case before her, Corrigan encouraged another judge to stop the adoptions that were only taking place in Washtenaw County, which he did by ordering the circuit clerical staff to not accept any more adoption petitions from unmarried couples. Many would consider this (*cue scary music*) judicial activism. This does not bode well. If the state government is looking to stop the brain drain that is devastating our economy, I think making Michigan a favorable legal climate for all families (married parents or not) is a great start.

Changing great expectations

From AMSA On Call:

Post #4 of the "Back to the Wards" series focusing on the transition from research years back to the medical school and clinical rotations.

When I started medical school, there was substantial debate swirling about changing residency work hours, particularly for interns who were putting in untold hours at the hospital clearly to the detriment of their personal wellbeing, and potentially to the detriment of patient care.  These arguments sparked discussions of the best way to train physicians to work independently, how to maintain continuity of care without endless work hours, and even how to measure progress on these issues.  Ultimately, resident work hours were limited to 80 hours per week and shifts limited to 30 hours.  AMSA helped to draft the legislation that implemented these first changes, and continues to advocate for better conditions for residents and students. 

As I’m preparing to return to the wards, the controversy has flared again, though this time regulations have already passed.  The 80 hour work week remains in place, but first year residents (interns) may only work 16 consecutive hours.  (In addition, as detailed in news articles here and here, stricter rules for how residents should be supervised were added, and other regulations to improve patient care and resident safety were also included.)  On the whole, I’m happy to see medicine becoming a safer and more user-friendly profession, and hope that reduced physician burn-out will be a additional consequence of these regulations. 

In spite of these hopes, I nonetheless struggle with what a friend recently termed “competitive suffering.”  We’ve all experienced it before.  It’s what happens when you moan that you didn’t get enough sleep because you were writing a paper or studying for a test, and a colleague counters that he/she hasn’t slept in a week because of all of the work that needed to be finished.  Similarly, it occurs when one med student complains about an overnight shift on an OB/GYN rotation, and someone immediately pipes up that their transplant surgery rotation has required an unendingly flexible schedule and many sleepless nights.  Lately, I’ve noticed that it also happens when I express trepidation at the nights of call and night float I’ll be expected to work as a medical student, and my friends remind me that when they were in medical school, they were frequently in the hospital overnight, and that call expectations for medical students were much greater.  This often follows with exclamations of how much they learned at night because no one else was there, or of how amazing the patient was that they admitted in the morning and followed for a full 24 hours.  How is a returning student to deal with this, as medical student expectations are shifted with those of residents?  Certainly stepping back and saying “Wow, you had a rough go of it.  They sure do things differently now!” rarely feels like the right option, but most of the time, I think it is.  I try to remind myself that I learn more when I’m awake, and that my retention is laughable when I haven’t been able to sleep.  If that’s not enough, I think about the friends I’ve been lucky enough not to lose to drowsy driving accidents, or patients they’ve been lucky enough not to lose because of a sleepless error, and remind myself that these regulations mean that I’ll need to rely a little less on luck.

A year of knitting…

Always interested in tallying and keeping track of things, I was interested to see how much I had knit in the past year. As was totaled in the side bar before the new year, I’d knit just over 4 miles of yarn in 2010. According to Google, this is roughly 258,509 inches. If you figure that each stitch is a bit less than an inch, it is safe to say that I’ve knit over a quarter of a million stitches this year. But what exactly does that mean? It turns out that with a cool quarter mil, you can make the following items:

18 baby items (3 set of baby mittens, 6 baby hats, 1 baby sleep sack, 4 pairs of baby booties, 1 baby sweater, 1 baby sweater vest, 2 bibs)

1 dog sweater

8 shawls/scarves/cowls

1 hat

2 pair of mittens/gloves

2 pairs of socks

2 dishclothes

5 bangles

2 garments (1 sweater vest, 1 cardigan)

Not too shabby… Here’s to another year of crafting!