My last blog post for students beginning college is about motivation. It is important that new students start by choosing a career path they truly like. There is a difference between seeing yourself in the future, doing something you imagine you are good at, versus arduously training for it everyday, and eventually experiencing what it is like living that career path you now only feel curious about.

For instance, you may like the piano a lot, and you might dream of becoming a concert pianist one day. You might imagine playing like one of the great pianists, whose skill makes music seem so easy to perform. Yet, when sitting at the piano and actually practicing scales, arpeggios, chords, and studying music theory, you might realize how difficult the process is, how many hours of practice you need to see improvement, and how difficult it actually is to play the music you once thought wasn’t as difficult. The amount of practicing for some works by, say, Rachmaninoff (e.g. Third Piano Concerto, Op. 30), might take years to excel at, and that requires patience and lots of resilience, overcoming drawbacks and stagnation in the process. There is a difference between the illusion of liking something versus actually doing so.

Wanting a career involves enjoying the journey and seizing the process, with its ups and downs. Not every part of a profession is enjoyable, however, there can be an internal drive capable of pushing you forward and overcoming difficulties. Being a physician, for example, involves sleepless nights at the hospital, typing SOAP notes and doing all kinds of computer work. Nurses go through a similar ordeal in large hospitals. Yet, knowing that you are doing this to improve the quality of life of people, and understanding that your contribution is noble and valuable to those around you, can be your driving force to stay motivated.

When it comes to studying in college, not even all courses you’ll take will be enjoyable. There are mandatory subjects you may have to complete in order to move forward with your major, which you may not like at all. Even in these circumstances, it is possible to find sources of motivation. Aside from realizing there’s a greater good in what you do which you don’t like, you could also build and sustain motivation by realizing that the class you are currently enrolled in, or the assignment you are currently working on, is only momentary, and that you will soon be able to move on to study things you’ll find more enjoyment in.

Generally speaking, we could say that motivation comes from intrinsic sources, which arise from your desire for personal growth as well as your interests, and there are also extrinsic sources of motivation, which involve external things you hope to accomplish, as well as things that you don’t want as a consequence of not getting your work done (e.g. lower grades, failing classes, and staying in college longer than you should).

Motivation while studying can also be developed through an adequate study environment and by avoiding distractions. Listening to non-distracting music (or background noise, instead), or not listening to any music or sounds at all, might be helpful. Likewise, finding a good, gratifying place for studying, might be very important to keep you focused. For instance, I keep a very tidy workspace at all times. Order keeps me motivated and encourages me to finish tasks. I couldn’t study in a messy environment. Apps such as Cold Turkey and Freedom might be of additional help. These apps turn off or block access to certain apps that are a source of distraction, such as YouTube or social media apps. Taking breaks while studying, yet making these breaks consistent in length, will make your academic experience more enjoyable and will keep you on track of the course.

Finally, I would like to add that relaxation, emotional health, and quality sleeping are extremely important to keep yourself motivated. Successful academic achievements as a result of your motivated hard work will serve as an encouragement. Part of succeeding is knowing your academic limitations, and not overloading yourself with excessive work. Avoiding perfectionism, which is often unrealistic, is also crucial to avoid frustration and stay motivated.

Often, it so happens that you are in charge of your own motivation, whether it be through being realistic or responsible in your actions.

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Lesson: module 7, slides 2, 8-11, 21-29.

Research is different from simple searching of facts in that it is done to broaden understanding of wider topics and the relationship among variables within such topics. Research is motivated by curiosity and often leads to more questions, going beyond what is easily accessible around you. Research also involves creating new knowledge that isn’t readily available. This concept is related to the following progression:

Data —> Information —> Knowledge

First, the investigator recollects facts in their rough form, known as data (e.g. a set of temperatures in degrees Farenheit throughout the day, a month, or a season). Then, the investigator interprets this data, turning it into knowledge (e.g. realizing that temperatures are colder during certain times of the day or days in which they were measured). Finally, if the learning process goes more in depth, the investigator uses this information to create new ways of understanding of the world around us, thus creating new knowledge (e.g. concluding that, in relation to previous years, there’s been less colder days during the same period temperatures were taken in the current study, thus suggesting this could be the effect of global warming).

Searching for facts isn’t bad in itself. It is how we begin learning about a subject. Through proper, targeted searching of facts, it is possible, for example, to establish an adequate research question. Searching for information is part of studying anything. Therefore, searching for facts is necessary for learning.

When doing research, it is important for students to know how to discern between good and bad sources of information. For this, it is very important to ask questions about the source’s reliability, quality, and utility of the source. Some resources, such as Wikipedia and other Wiki resources, might be extensive but lack proper citations and may not have completely verifiable information. Wikipedia, though, has a vast amount of information, significantly more than other encyclopedias, such as Encyclopedia Britannica. Yet, the latter has verifiable sources, meaning it has been thoroughly reviewed for accuracy, something that Wikipedia still lacks in a large number of its articles.

In the process of searching and researching, it is also relevant to know how to enter key terms (boolean operators such as AND, OR, etc.), know which search engines to use (e.g. www.search.com), and know what types of research exist, and which of those are more useful for our current research (cross-sectional, cohort, metaanalysis, etc.).

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Lesson: module 6, slide 3, 9, 10, 14-18, & 20-22.

Part of effective study involves engaging on a topic in a deep way. Going over a lecture or reading in a shallow manner can result in hours upon hours of fruitless, ineffective study that might even lead to failing a class. Even if the student is able to pass a class by studying superficially, it is very likely to soon forget what has been read.

One way to retain information is through adequate note taking strategies. This can be done in a lecture or while reading a chapter from a textbook. For subjects in the humanities, note taking can be done effectively with the Cornell Method, with which facts can be listed chronologically, with bullet points and indented subcategories. Other note taking strategies for subjects in the humanities include drawing diagrams and charts. Color coding notes helps focusing on the central ideas of a lecture or chapter.

Taking notes for subjects from lectures and textbooks in the sciences and math is not quite the same, in my opinion. For example, a lecture on thermodynamics and mass and energy analysis of control volumes requires jotting down the most important equations and understanding important concepts, such as mass flow rate and the conservation of mass principle. Additionally, it would be important to learn how certain steady-flow devices work, including nozzles and diffusers, turbines and compressors, throttling valves, mixing chambers, and heat exchangers. These kinds of notes are not chronological, and may require extensive use of diagrams to understand the association between terms, as well as charts, to compare quantities and properties among them.

Making a habit of note taking is important since doing so frequently is better than on rare occasion, especially right before an exam. Finally, it’s necessary to realize that note taking is not just done to interiorize concepts by maintaining focus during a lecture, but also to go back and review what has been written down. For the latter to happen, one must take notes with plenty of time in advance.

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Lesson: module 5, slides 7, 10, & 13.

I recall not having a study method many years ago. Someone I knew back when I began my college life once showed me ways to study more committedly. However, it took me years to understand these steps and I often fell into the habit of unstructured reading and studying – “lazy reading”, so to speak. Over the years, I’ve learned a thing or two, and would like to share that with students who are beginning their studies in college and are facing new academic challenges.

Reading articles, novels and textbooks efficiently requires concentration. Multitasking impairs effective reading, especially when studying from a textbook for an exam. There are several techniques to improve concentration when studying from a textbook, including breaking down studying into equal portions, separated by brief moments of relaxing “rewards” (the so-called “Pomodoro Technique”), as well as studying in the right environment, whether at a library or a cafe, or at a place where both concentration and pleasure can be found. Meditation before engaging in reading is also important, as well as asking yourself why it is important to go through the process of reading and studying something, especially if it is hard or if you are not particularly motivated by a particular subject.

During the study process, active reading involves engagement. Passive reading is doing so without a plan of action, waiting for whatever comes in the next paragraph, without a real desire to discover what is on the page. Active reading helps create associations which improve long-term memorization. Structuring this process with the SQ3R (S – skim, Q – questions, 3R – read/recite/review) reading method can be very helpful to study as efficiently as possible. It consists on first, going over, or skimming, the reading from a bird’s eye view, paying attention to any titles, subtitles or words in bold present on a particular chapter. While skimming, it is important to ask questions about the reading, taking as many notes as possible throughout the chapter at stake. These questions will later help guide you through the reading, making it easier to understand. Then, of course, comes the reading portion of studying the text, but while doing so (after each section, for example), remember to recite in your mind (or out loud) important parts of the reading as you go over it. Finally, it is necessary to review what has been read. Recapitulating a section of a chapter at a time, and then doing so for the entire chapter, is crucial to interiorize the material.

Last but not least, it is crucial to study with time in advance. Always pay attention to lectures and try to read a certain section that you know will be covered during lecture beforehand. I advise you to start dedicated study for an exam two weeks in advance. Doing so earlier might lead to forgetting the contents if not reviewing adequately, and doing so in less than two weeks might cause you not to cover all the material in a way that will be effective for the exam. Starting dedicated study the weekend before the exam is usually a terrible idea.

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Lesson: Module 4, slide 5

It is well known that Buddhism embraces the idea that living in the present moment while not dwelling on the past or anguishing about the future is necessary to live in harmony with oneself and follow the path to enlightenment. Does instant gratification help us live in the present moment? It briefly appeaces our anxiety, for certain, but doesn’t help us seize the present in a righteous way, as living in the here-and-now must be accomplished with a perspective of the consequences of our current actions.

Wild animals fulfill their basic needs in generally simple ways. They do so by feeding themselves when hungry, finding shelter when cold, or sleeping when tired. They don’t worry about the past or stress about the future in unnecessary ways (e.g. a bird builds a nest as it plans to brood its eggs on it, which is necessary for the continuation of its species). Thus, one could say that wild animals succeed at living mainly in the present moment and at times in the future because their survival depends on it. Unlike them, many people tend to avoid facing foreseeable uncomfortable challenges in the future by irresponsibly engaging in distracting activities. This illogical and contradictory reasoning process is the phenomenon known as procrastination. In my opinion, it ensues from a lack of evolutionary neurological development of the human brain.

I believe the human brain is not a final product, so to say. It is still evolving, which explains, for instance, why there are so many psychiatric disorders that wild animals don’t present, and why we often fail to succeed in our interpersonal relationships, whether in romance, our relationships with coworkers, or the interaction among groups of individuals (e.g. differences among ethnic groups, which often leads to armed conflict). Our emotions and analytical thinking grapple with one another. In the case of procrastination, anxiety brought up by several reasons (e.g. perfectionism and fear of failure, fear of success and rebellion against authority) blinds objectivity and practicality.

Additionally, with the advent of the internet, smartphones and social media, the world in which we live today is increasingly full of distractions that encourage the procrastinator to triumph in his misdeeds. Likewise, there is a tendency to engage in multiple life projects simultaneously, especially in highly developed countries (which coincidentally suffer from higher levels of stress). To illustrate the latter statement, students in the US often have the opportunity to double major in college, and they have the opportunity to join integrated programs (e.g. BS/MS, MS/PhD, Medical Residency/MS), thus doubling their amount of academic workload and fueling on stress and anxiety.

In order to avoid procrastination effectively, I advise students and working professionals to address the anxiety that causes it. Simplifying one’s life when possible, and engaging in meditation or mindfulness can certainly help. Pursuing cognitive behavioral therapy might also be a smart strategy to challenge the natural tendency for procrastination that afflicts many.

I have written an article that deals with the subject of anxiety and depression, also from an evolutionary neurological standpoint, back in April 23, 2019, titled The Neurological Source of Depression, which I believe can bring interesting additional insights: https://u.osu.edu/juarez.41/2019/04/23/the-neurological-source-of-depression/

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Lesson: Module 3, slide 6

Proper online communication is essential for efficient collaboration among team members in any kind of organization. I will focus on collaboration in basic science and medical research.

Basic science research in the laboratory, specifically, that involving experiments, requires continuous data recollection. In experiments involving animals, for instance, this involves skill acquisition (e.g. surgical techniques and peritoneal drug administration) through training. This training requires adequate communication among research team members. Data recollection must be done in a clear and organized manner so that all researchers can access it and understand it. Schedules must be put out with time in advance in order to know when participants will be available for all required weekly interventions so that there won’t be details in required procedures. Group members need to meet, whether in-person or online, so that they can report their progress within their assigned tasks, so they can find answers to arising questions throughout the research, and so that they can be updated on any new procedures and plan changes. The principal investigator must maintain close communication with fellow investigators and other team members, so it can be made sure the research is being conducted according to standards.

Keeping an online schedule with the lab’s weekly activities (meetings, inspections, etc.) is highly recommended, as well as communication via cellphone chat groups and video calls using reliable platforms such as Microsoft Teams and Zoom.

It is important for students that begin working at a laboratory to focus realize that professional communication must be maintained at all times. E-mails must follow an adequate pattern, with an adequate subject line, introductory greeting, a concise, clear message, and a proper closing with the student’s full name. Investigators in a laboratory might friendly and kind, but they will always expect formal and respectful communication.

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Academic Email (Module 2 – Slide 8)

The last thing I would like to talk about concerning my rotation with Dr. VanKoevering is his research. Dr. VanKoevering, who previously obtained a bachelor’s degree in Biomedical Engineering, is currently involved in very interesting projects, such as 3D printing.  

Three-dimensional printing is an evolving field of biomedical engineering, where certain body parts can be reproduced thanks to a specialized printer which uses materials such as titanium alloy, inert polymers, silicone, and hydrogel. These printers work with sub-millimeter resolution at rapid speed and are able to create highly-detailed structures, tailored to a patient’s anatomical needs. 

With 3D printing, it is possible to create prostheses, wearable devices and implants (bioresorbable or permanent) that make up for missing body parts in certain patients, such as the ear, nose or jaw. Surgical models for preoperative planning and which serve as intraoperative guides can facilitate surgical precision. With this technology it is also possible to manufacture educational models for patients, anatomy students, as well as for the purposes of surgical simulation. Finally, 3D printing can be used in tissue engineering to make scaffolds and even for bioprinting. 

Preoperative planning can now be taken to the next level, through digital planning. Dr. VanKoevering, an otolaryngologist that specializes in facial tumors, uses this technique to determine the exact dimensions and shape of bone grafting he will need to rebuild a mandible, or a parietal bone. Research indicates that surgical/digital planning saves between 62 and 85 minutes of OR time (and up to 100 minutes in head and neck surgery), reduces blood loss, increases reconstructive accuracy, improves bony unions required for a better osteosynthesis, improves tumor localization, and, most importantly, reduces surgical complications. 

I had the privilege of seeing the da Vinci Surgical System in action during one of Dr. VanKoevering’s surgeries at the James Cancer Hospital. This is a minimally-invasive device which allows surgeons to freely operate in narrow or closed spaces where doing so with the naked eye and with the hands would require larger surgical incisions and probably less refined surgical technique.

Even though I had heard about this device, I had never seen it being used in the operating room. The device consists of surgical arms supported by a robotic device which is located right over the operating site. Simultaneously, this robot is operated by the surgeon, who uses manual controls located in another component of the da Vinci Surgical System, that’s across the operating room. This control station allows the surgeon to visually zoom into the surgical site with the help of a camera, and his hand/finger movements are repeated in real time on the robotic arms. The surgeon’s module also has a microphone, which allows the surgeon to speak at a normal volume while the device magnifies the sound of his voice, allowing for better communication across the OR. The device is very versatile, as it even makes corrections in movement, in the event the surgeon makes an accidental hand movement which could harm the patient. The two modules of the device are connected by cables across the OR. There was no use of WiFi to connect the surgeon’s controls to the robotic arms.

The surgeries most commonly performed with the da Vinci robot include, most commonly, gynecologic, renal, and cardiac valve surgeries. This time, though, I had the opportunity to see a tonsillectomy on a tonsillar cancer patient. The procedure lasted about an hour, and it included extraction of local lymph nodes for pathology studies, to test for metastasis.

As one would expect, this device can be used to operate at a distance. For example, patients in rural and isolated parts of a country could benefit from having a surgery without the surgeon being present. The surgeon could be operating from a different city, or even a different country. This technology, however, has not yet become reliable enough to permit this to happen, in part due to concerns regarding loss of wireless signal to maintain the real-time nature of the intervention. A minimal lapse between the movements of the surgeon’s hands and the robotic arm movements could lead to mistakes during the surgery, which may be catastrophic for the patient.

I think this technology, even though it’s already twenty-five years old, has a lot of potential and a bright future, in the field of telemedicine and long- distance surgery.

I had the opportunity to see some interesting cases in last week´s clinic hours. Dr. VanKoevering, whom I shadow, specializes in tumors of the skull base and sinonasal cavity, mostly sees adult patients. I would say the majority of his patients have or have had cancer, and many of them are heavy smokers, which is often a causal factor for this type of disease. 

This time, I was particularly interested in understanding computerized tomographies of the skull base. Previously, I had studied CT scans, but from a medical perspective. Now, I have been reading more about the science behind this essential imagining technique, which consists of sending x-rays across multiple planes of an anatomic structure, such as the skull, producing a three-dimensional image. X-rays, like gamma rays, alfa and beta particles, are a kind of ionizing radiation, able to knock out electrons from atomic nuclei with its high energy (the wavelength of most X-rays lies in the range of 0.01 nm up to 10 nm. This corresponds to an energy range of 100 keV down to 100 eV). Therefore, the CT scan is like a set of multiple planar radiographies taken of a body part, and as such creates a considerably higher amount of ionizing radiation. In excess, this radiation can alter atoms and produce changes in cellular DNA. Therefore, its use must be minimized as much as possible. 

The release of electrons from the atoms x-rays collide with rely on the photoelectric effect, described by Einstein (who won the Nobel Prize for discovering that photon energy is quantized). X-rays occur when electrons are liberated from a heated filament, or cathode, thanks to thermiomic emission. Then, with the help of a high voltage, the liberated electrons move towards a metal target, which acts as the anode. When short-wave electromagnetic radiation reaches its binding energy level and collides with surfaces, it produces the emission of electrons. When these high-energy electrons collide with the atoms of the metal target (anode), X-rays are produced. 

But this science doesn’t yet explain how images are actually imprinted on an x-ray film. A traditional x-ray detector consists of a film based on a silver iodide emulsion. The exposure and development of this film isn’t that different from how photographic films are developed. In the case of digital x-ray detector arrays (in use since the early 2000’s), a scintillator layer converts x-rays to visible light, which is then detected by a pixel array. 

The types of CT scans include sequential, spiral, electron beam tomography, dual energy CT, CT perfusion imaging, and the PET CT. CT scanning of the head is usually used for detection of stroke, tumors, cysts, trauma and hemorrhage. In these images of the head, it is possible to identify dark (hypodense) structures, which indicate the presence of edema and infarction. Often, cancerous tumors are accompanied by peripheral edema and tissular death (infaction). Bright (hyperdense) images could mean either calcifications or the presence of a hemorrhage. 

I think it is fascinating to have the opportunity to understand CT scans both as a physician and as an engineer. Having both a medical and technical understanding of an imaging study such as the CT scan, can give more ideas to the scientist, to improve existing technologies and develop new ones.     

Since mid-January this year, I’ve had the pleasure of shadowing Dr. VanKoevering, an otolaryngologist at The James Cancer Hospital, one of the best medical centers of its kind in the United States, as ranked by U.S. News & World Report. I’m thrilled by this new experience, for which I think writing about is very much worth it.  

As a medical student, and later, as an international medical graduate, I’ve shadowed multiple surgeons in the past, in large hospitals in Vienna, Austria, Aarhus, Denmark, Samara, Russia, and, of course, the US. However, this rotation is different due to the fact that I am able to see patients in surgeries and medical rounds from the perspective of a biomedical engineer, something I’ve never experienced on past rotations. 

As all engineers do, the biomedical engineer applies natural science and math to solve problems in our society and improve already-existing technologies, but, unlike the others, focuses on biological sciences and medicine in a unique manner that addresses human health and disease. As an IMG and future biomedical engineer and researcher, I want to acquire a round understanding of the human body, in order to provide better treatments and develop more efficient medical devices. 

During this ENT surgery rotation, I’ve seen several types of craniofacial cancer, including sinonasal undifferentiated carcinoma, low grade sinonasal adenocarcinoma, sinonasal malignant mucosal melanoma, nasopharyngeal carcinoma. Often, these cancers are highly aggressive and have very poor prognosis. Also, many of these patients (a large portion of them heavy smokers) require partial removal of their larynx, including their vocal chords, which leaves them unable to speak. 

One of the medical procedures I’ve seen thus far in this rotation is the tracheoesophageal puncture, TEP, which allows patients to speak again by connecting the esophagus with the trachea, causing vibrations in the esophagus that mimic the function of the vocal cords as air passes through them. 

Another device I’ve seen during my rotation, which has called my attention, is the flexible nasopharyngoscope, which uses fiberoptic or digital chip-on-the-tip technology. Its scope diameter varies from 1.9 mm (pediatric model) to 6 mm (adult model). It is possible to attach a high-resolution camera to the scope’s viewing port, allowing the health provider to visualize the area of interest as seen from the tip lens of the device. The tip which carries the lens is flexible, providing a field of view of up to 90 degrees by maneuvering the angulation control knobs located in the control body of the device. It is primarily a diagnostic device (e.g. evaluation of sleep apnea, venopharyngeal insufficiency, fiber endoscopic evaluation of swallowing, FEES, done by a speech therapist) with assistive therapeutic applications (e.g. visual tool for excision and debridement of nasopharyngeal cancerous tumors and their biopsy, removal of easily accessible foreign bodies, tracheostomies, and vocal cord injections for vocal cord palsies). It is generally a safe device which doesn’t generate complications; however, it is not totally exempt from them. These include mucosal tearing, bleeding, sneezing, laryngospasm (in less than 1% of procedures), gagging, and damage to anatomical structures, which is extremely rare with the use of flexible scopes, as opposed to rigid ones. The two main contraindications for its use include acute epiglottitis and croup. 

This is the first of four entries I intend to make on this subject. In doing so, I look forward to encouraging people to learn more about this exciting topic.