Medical School

The Purpura Plot: My Mother’s Patient Story

One morning in 1990, twenty-four-year-old Jing woke up with a peculiar sensation in her legs. She peeled back the bedsheets, timorously peered under her pyjama-pants, and gasped. Her legs were covered with small, purple blots, making them look like canvases onto which an artist had splashed ink all over. Her husband of a year rushed her to the local hospital in Beijing.

When my mother recounted the incident more than two decades later, she remembered being unusually calm. “We didn’t know what it was,” she recalled. “So I didn’t feel much fear.”

“We didn’t know what it was,” agreed my father. “So I was pretty scared.”

Jing’s doctor told her that she had thrombocytopenic purpura. Purpura, the Latin word for “purple,” described her symptoms caused by bleeding underneath the skin. A blood test revealed the reason: Jing’s platelet levels were dangerously low (hence “thrombocytopenic”). On a subsequent visit, it dropped even further. Her doctor suspected that the cause was immune-mediated and wanted to draw Jing’s bone marrow for further assessment. There is a possibility, he suggested, that she would need a bone marrow transplant.

Since around the 1900s, China had become more or less receptive towards Western medicine. Suspicion of Western influence, exacerbated by the Opium War with the British in the previous century, and of practices such as surgery, which admittedly must have seemed horrifying to the uninitiated, had started to give way to a grudging admittance to the efficacy of Western therapies. By the end of the century, Western medicine and Chinese folk medicine were often practiced in tandem, sometimes within the same institution.

But the culture of medical practice in China remained Chinese. The doctor’s position of power and as wielder of knowledge was to be respected and not questioned. The very idea of empowering the patient must have seemed laughable. Jing’s doctor simply told her that her disease was caused by problems in blood production, which may be fatal.

“He made it sound very scary,” said my mother, twirling her hair uneasily. “There was no comfort at all.”

“And you didn’t expect it from him?”

“He’s the doctor.”

The doctor’s attitude was officious and apathetic. Yet the interactions between Jing and her physician typified the strained relationship between doctors and patients in China even today. Physician remuneration is tied to drug sales, so patients often do not trust their prescription-pad-happy caregivers. During my visit this past summer, I discovered that several of my friends and relatives were routinely prescribed antibiotics as a way to “control inflammation,” without their knowledge of what caused inflammation and how antibiotics should be taken. In this medical climate, visiting a doctor is often seen as a last resort when one is sick.

Jing did not want her bone marrow taken from her (“I found the idea invasive,” she said). Her doctor gave her “some steroids” to take to “boost her immune system” and sent her home. Jing spent the next two weeks in bed as she awaited her fate. Her husband would rush home after work every day. “Still alive?” he would ask. He was only half joking.

What surprised me was that neither of my parents sought further explanation for my mother’s disease. That they did not seek a scientific explanation was expected: education in China at that time did not cover much biology, and neither of them had majored in the natural sciences in college. But neither did they attempt to explain her disease using the traditional Chinese medicine paradigm, which was popular then and now. Nor did they claim a spiritual explanation, which would have been common in my grandparents’ times.

“Why didn’t you find out more about your condition?” I asked.

She shrugged. “We were young. We didn’t know much. The doctor said to take the drugs, so I took the drugs.”

Blissful ignorance shielded my mother from much stress. She was also lucky. A brief search on Medscape revealed that her doctor had treated her for immune thrombocytopenic purpura (ITP), which turned out to be what she had. If she had had the similarly symptomatic thrombotic thrombocytopenic purpura (TTP), which has a mortality rate of up to 90% if untreated, the outcome might have been very different.

Jing began taking the drugs. It made her plump, which, in a picture of her next to my scrawny father, made her seem disproportionately bloated.

“Didn’t that affect your self-image? Your outlook on life?” I asked.

“I think it was a combination of youth and ignorance,” said my mother. “I grew up in a rural factory town and had just moved into the city. I was full of hope for the future. Even the doctor’s insensitive words could not touch that. I just had a feeling, at the time, that I would recover.”

“Did you tell your parents? Your friends?”

“I didn’t want them to worry. I did everything as usual. I did feel tired sometimes, but the possibility of dying, which the doctor had suggested, never crossed my mind.”

She showed signs of recovery. The purple blotches soon faded and her platelet count began to rise. She grew even plumper from the steroids. Her parents, unaware of their daughter’s condition, thought she was just getting fat.

“I am their eldest daughter. I was in the city and they were back home in rural Shanxi. I’d always carried a lot of the responsibilities in my family, so naturally I expected myself to brave this alone.”

For the next three years, the purple blotches occasionally reappeared, but less frequently and severely each time. Finally, when she became pregnant three years later, thrombocytopenic purpura left her for good.

 

 

Standard
Medical School

Applying to U.S. Medical Schools as a Canadian Student

AMCAS, the American Medical College Application System, is opening in a week. This time last summer, I had just started gathering materials for my application. It was not a simple process. What made my case especially tricky was that I was a Canadian citizen applying for US medical schools, and I had many Canadian-specific questions that I could not find online resources for. For my fellow Northerners, here are some of the issues I struggled with and answers to them.

First off, what are Canadians to American schools? Technically, we are international students, which due to financial, social, and political factors places us at a disadvantage for many schools. That said, we are better off than students from other countries. After all, most schools prefer applicants who have had some education at a Canadian or U.S. post-secondary institution.

In this post, I will offer some practical takeaways from my application cycle. There are two caveats for my readers. First, these are based on my personal analyses as an Ontario applicant, and individual cases may vary. Wherever possible, I try to include how I’ve obtained the information so that you may check for yourself. Second, the U.S. schools I considered are generally pretty good schools, which limits the relevance of my points. I believe a career in medicine requires both a sense of idealism and of realism. This article focuses on the latter.

Phase 1: Pre-med years

Picking courses

The first dichotomy between US and Canadian schools is how they view the GPA. Both of them require pre-requisite courses that vary by school. But, to the best of my knowledge, Ontario schools do not care what courses you pick beyond that. There are certain restrictions, such as Toronto’s requirement of taking at least 3.0 upper year courses in 3rd and 4th years, but besides those, humanities courses are treated the same as science courses, even though the former are notoriously stingy on marks. GPA cutoffs are usually harsh, so a lower-than-cutoff transcript is unlikely to be given a chance (see here).

On the other hand, US schools tend to factor in the estimated difficulty of courses. A student who has a less-than-stellar GPA may still have a very good shot if she made it up with challenging courses or courseloads, strong extracurricular activities, and/or a well-written personal essay (more on these later). Hence, the GPA, while still important, is seen in the context of the entire application package. This is probably why Harvard had an entrance GPA of 3.8 whereas Toronto’s was a whopping 3.96 (2015 stats).

The practical consequence is that if a student is considering only Ontario schools, she might favour getting a high GPA over taking interesting but potentially challenging courses. If the student is also considering US schools (especially top tier schools), she might be better off picking courses she is interested in.

Extracurriculars

The AMCAS only allows you to include 15 activities as opposed to the 40 slots available on OMSAS (the Ontario medical application system). However, you are asked to write a sizeable paragraph describing your role in each of these 15, then pick 3 to write mini-essays on them, so do not include “resume padding” experiences. One cow-sized duck trumps many duck-sized cows. In other word, quality over quantity.

For top-tier American schools, leadership is the key point. Research is also highly valued, perhaps more so than many Canadian schools. But even for research, they look for independent thinking and initiative, in other words academic leadership.

Phase 2: The Application Process

How do schools view Canadian students?

It depends on the school. Yale is citizenship-blind. Columbia accepts Canadian students but not other international students. UCSF sent me this email:

Canadian citizens are considered international students and therefore not eligible for any federal student aid. International students who meet our eligibility criteria may apply but should be aware we very rarely accept international students.

Once again, we Canadians are a bit of a hybrid animal, so the best way to find out is to email the school yourself.

The vast majority of U.S. schools do not allow international students to apply for their MD/PhD programs due to restrictions on federal funding. Keep that in mind if that is your career path.

In terms of school names, most schools claim to treat every undergraduate institution the same way. That said, according to my friend who graduated from Yale Med, school names may carry an unofficial, or “soft,” power as a deciding factor. A majority of students who matriculated at Yale went to relatively well-known institutions, but students entering those schools were probably intelligent and capable in the first place. I went to the University of Western Ontario, which is not considered “top-tier” worldwide, and made use of the opportunities I had. Ultimately, it is the student rather than the school that counts.

When should one submit their AMCAS application?

As early as possible without sacrificing content. Because many U.S. schools use rolling admissions, submitting AMCAS on the official deadline in November would dramatically decrease your chances. This is different from OMSAS and could very well usurp a strong application. Beware!

The Personal Essay

The personal essay is familiar to most American students, as it is an integral component in undergraduate admissions. Canadian schools generally have no such requirement. In Ontario, only Toronto Med requires something similar to this with their Brief Personal Essays.

I cannot overstate the importance of this essay. There are plenty of smart applicants with similar scores applying for the same schools. At the end of the day, there is a qualitative element to the process which is best exemplified in the personal essay.

Letters of Reference

The OMSAS requires 3 letters of reference that are sent to every school. The AMCAS allows up to 10 letters that can be individually assigned. American universities often have premedical committees that writes a committee letter for the applicant, which includes comments about the student from several professors who know him or her. Although it includes multiple authors, a committee letter still counts as 1 letter out of 10.

As Canadian students, we may have to compensate by seeking more individual letters. For example, I sent a total of 6 letters to Yale. Some schools, such as Duke, restrict the number of letters, in which case you would have to contact the school about it. A good rule of thumb is to secure letters from 2 science professors and 1 non-science professor who have taught you, 1 volunteer reference, 1 extracurricular reference, and all your research supervisors.

Lastly, alumnus connections are more important for U.S. schools than Canadian. If one of your reference letters comes from an alumnus of the school (not necessarily school of medicine), it may be helpful to your application. In my case, I assigned 1 of 10 letter to specifically tailor to a particular school.

Phase 3: Interviewing

Work in progress. Check back later.

 

Have a question? Leave it in the comments below! I may not include it in the post if it’s too general, as I would like to focus on issues faced by Canadian students applying to the U.S.

Standard