Go West Young Man!

My romance with the west coast started in July of 1998. This happened when in a sort of twist of fate, I landed a fellowship in Infectious Diseases at the University of California in Irvine.

I saw California for the first time in May 1996. I didn't think much of it at the time. "Sure it has a lot of sun and the Pacific", I thought, "but I had those also when I was in the Philippines."

I was there to visit my cousin Mana Ning Llamera-Iskra, her husband Mark(who took me out to lunch, very nice guy!)and their kids Eric, Brooke and Ian. They live in Weschester, L.A.. Eric, who's the eldest and must have been 15 at the time, took me to the usual touristy places: Universal Studios, Disneyland, Magic Mountain/Six Flags, etc.. We must have done the big roller coaster, which was Eric's favorite ride at Six Flags, more than half a dozen times.

I was also there to visit Anna Q. who was still Ms. Taylor then. That was the first time I've seen her in over a decade. She and ex-husband Brian, took me to even more touristy places: Rodeo Drive, Hollywood, Stars Walk of Fame, the Chinese Theater. We also drove along the coast starting from Palos Verdes and visited all the piers and beaches from Venice Beach, to Manhattan Beach, to Redondo Beach etc., and culminated in Malibu. I also visited a friend in Irvine, whom I've met on a trip to Europe about 8 months earlier. I saw Laguna Beach, Newport Beach, Dana Point and the UCI campus for the first time. I also did some horseback riding in Tustin. On the whole, it was a fun and pleasant experience. But it never occurred to me, and in fact, it was never in my wildest dreams that I would be living out in California. All I thought was that it was a nice place to visit but my life would continue as I knew it back in New York, where I thought I belonged. Boy, was I thoroughly wrong!

Fast forward to 1998. I was living in Orange County. My apartment was practically two blocks from my main training hospital, the UCI Medical Center. Right behind the complex was the famous Crystal Cathedral where I attended Sunday services. It was also only a stone's throw away from the Block at Orange which is a southern California-style open-air shopping mall and amusement center. (Think Starbucks next to Saks Fifth Off, next to board skating place next to Wolfgang Puck's next to Borders and the theaters. The shops are individual buildings but they all have a few common plazas or focal areas with lots of open-air dining.) My place was only about a mile or two away from Disneyland, The Pond(a concert hall), and the Anaheim Stadium where the Angels (baseball team) hold court. Less than one mile from it is Old Town Orange with its smattering of good restaurants, one of which is a film location for the 1996 Tom Hanks directed film,"That Thing You Do!". Very close to it is Chapman University which is well-known for its Film School. I had a good-sized studio apartment which was nice and aseptic enough for me. The apartment complex had well manicured gardens, a clubhouse, barbecue pits, a golf driving range( I did practice!), four tennis courts, a swimming pool, a gym (only used once or twice)and two jacuzzis (which I really liked to use to unwind especially at night after my hospital work).

Hospitals. UC Irvine Medical Center is considered the one and only county hospital in OC and is well known for its cancer center, neuropsychiatric center, bone marrow transplant, kidney and liver transplant services. It is also noted for its top caliber Urology and OB-Gyn departments.

I learned a lot of Infectious Diseases under an excellent faculty. Not only were they experts in their fields but they were also very amiable people. This is one thing that struck me right away when I started working there, that the attendings, in general, were more approachable, less hierarchical compared to their east coast counterparts. I enjoyed working with Drs. Jeremiah Tilles (Virology, particularly Enteroviruses, Immunology; Harvard grad)), Geeta Gupta (Epidemiology, TB, HIV specialist; also from Harvard), Laurie Thrupp ( Bacteriology, Microbilogy, Infection Control; Stanford grad), Don Forthal(Virology and Immunology; from UCLA; trained at CDC and studied measles with Filipino scientists in 1980's), Winnie Huang( Transplant ID specialist, who also did her residency at SUNY!), Ming Tan(Chlamydia specialist; UCSF grad), Alan Barbour (Lyme Disease specialist and author; originally from U of Texas), Catherine Diamond(Epidemiology, STD specialist; MD-MPH from U of Washington; gave me a poetry book as a Christmas gift and attended one of my poetry readings), Marcia Alcoloumre(HIV Specialist; U of Oklahoma alumnus).

As a fellow, I did consults for the different specialties including the ICU/SICU, Burn Unit, Transplant, Oncology, Surgery, ENT, Orthopedic and Medicine Services. There was usually one medicine resident and one or two medical students who rotated with me and were part of the ID team. Of course there was always an attending assigned for that month whom we went to rounds with everyday.

One of my most favorite activities was the weekly Microbiology-Pathology rounds where we would discuss and study very interesting clinical cases and correlate them with their micro/path laboratory findings. It was a very valuable and very fascinating way of learning for me: poring thru the microscopes, looking at actual cultures/agar plates and histopath results and discussing them with the attendings and the microbiology lab staff.

My least favorite part was being called by residents or fellows and attendings from other deparments to approve usage of certain restricted antibiotics in the hospital. I must have been an object of scorn by not a few other doctors for being a strict "vanguard" of these restricted medicines, a power which I did not hesitate to wield if I deemed it was appropriate.

What was also quite unique with my training there, is that we had attendings from the community who would volunteer, pro bono, to be our ward ID attendings for the month. They were all former ID Fellows who now have successful private practices in Southern California who wished to give back to their alma mater. In turn, it gave us, the fellows, a different perspective in ID management, not just the "ivory tower"or academic perspective of the specialty but also how it is exactly done in the "non-academe" real world.

I learned a lot of Infection Control Management at UCI MC: contact vs. airborne precautions or isolation procedures, judicious antibiotic usage control in the hospital to prevent emergence of resistant organisms, management of occupational exposures to HIV (e.g. needle stick injuries), investigation of clusters of infection in the hospital, surveillance of infection control rates , etc.. TB management was also big at UCI (and in the US as a whole; while back in the Philippines TB cases were a dime a dozen). UCI doctors really get excited if they see a TB case. We even had a bimonthly multidisciplinary TB conference where pulmonologists, public heath doctors, surgeons, internists and ID docs meet to discuss the approach and management of complex TB cases. I was also sent to the National Jewish Center for TB in Denver, Colorado for a two-week seminar to learn from the national experts about the disease.

Part of our requirements as fellows was to do lecture-presentations for the faculty and our co-fellows. I remember doing presentations on Typhoid Fever in HIV and Neurocysticercosis. I introduced the Oxazolidinone class of drug to the ID Division for the first time when Linezolid came to the market in early 2000. I was invited to do a lecture on Sepsis to the UCI second year med students' Physiology Class. I did smaller presentations on antibiotics, drug interactions in HIV meds and TB meds etc.

At UCI, I also followed patients in the clinic. The ID clinic was almost exclusively HIV. This is where I learned the nuts and bolts of HIV management and follow-up of patients with opportunistic infections. I had a few non-HIV patients, one of them was a patient with neurosyphilis who I had to do a couple of spinal taps in the outpatient, as a follow-up on his response to treatment.

In the two years of training, each fellow is expected to do a research in whatever field of ID one is interested in. I was so lucky to be involved in the lab of both Dr. Tilles and Dr. Forthal who were very conscientious, prolific and successful researchers in virology and immunology. A young, ambitious, dynamo of a researcher, Dr.Martina Berger, also came on board the year that I joined UCI. Martina was from Austria and studied in France and was at the Lyon WHO Virology lab before she was invited by UCI. Our project was to isolate epitopes or proteins (from plasma) that are unique to HIV long term non- progressors(those who are infected by HIV but did not develop full blown AIDS even after many years of infection) and not found in rapid progressors. The methodology was very elaborate and involved many complex steps to achieve our objective. The project was also quite labor intensive, tedious and at times called for long unholy hours in the lab. I have to say I had fun while doing it, the cultures, running PCRs, Western blot gels etc..

The experience was at times fraught: the fatigue, the frustration when things didn't go right as expected, then analyzing and reanalyzing where we could have done it wrong, reexamining what step in the methods needed to be modified. But there was also that priceless feeling of exhilaration when finally in the dark room, the gels illuminate with the UV light signalling that "eureka" moment when we, at long last, had isolated the proteins. And then the jubilation when these proteins were "sequenced" later and really turned out to be significant findings. We were quite successful in our experiment there. And the last time I heard , the study is still ongoing and being refined by the UCI ID research team. The significance of this study is quite huge, if you think about it. Because these proteins may be potentially immunogenic, and therefore may be the first step in the development of a potentially successful HIV vaccine!

Before I left UCI in 2000, I was invited to do research by Dr. Alan Barbour (renowned Lyme Disease specialist and researcher). Dr. Forthal and Dr. Thrupp(another close mentors of mine)also suggested to seriously consider it as a career track. However, I had to decline the offer at the time, as the approval for exchange visitor visa waiver came and and I was required to work in a medically underserved area of the US for two years to be able to apply for a green card. Otherwise, I would be asked to go home to the Philippines for two years before I could come back to the US in any capacity. With the contract secure in my hands, it was a rather difficult decision to make. It was with a heavy heart that I called Dr. Barbour and told him how sorry I was to decline the offer. But he understood what my predicament was, and where I was coming from. He asked me to give him a call when I'm done with my waiver and if I'm still interested. I will always miss basic science bench research. I realized this is really something that I love. This is something that I might still go back to in the future of my ID career.

VA @ Long Beach. About 20 miles from Orange., the VA Medical Center @ Long Beach in nestled in large campus next to Cal State Long Beach. The VA rotations were more relaxed than those at UCIMC. Plus, I was already familiar with the VA system having worked at another VA hospital back in New York. I really enjoyed working with my attendings there as well. There was Dr. Robert Kaplan, who was the Chairperson of the ID Division at the time, who is also a theater actor, and had done acting with his wife since he was a med student back in Harvard. He invited me to watch plays in a community theater where he and his kids were acting in. I also showed him some of my poems and he appreciated them as well. There was the inimitable Dr. Steve Berman, who was the HIV Clinic director. There were Dr. Rodney Wisnow and Dr. Laury Mulligan, all outstanding professors. They all made me confident in my management of patients and guided me when difficult issues arise in consultations that were asked of me from different departments of the hospital.

Loma Linda. Another part of the fellowship program was a special training in bronchoscopy done at the Loma Linda Medical Center and at the VA Medical Center in Loma Linda. This unique curricular requirement (most if not all other ID fellowships don't have this) was apparently a response by the UCI ID division during the height of the first wave of the HIV/AIDS epidemic when the pulmonologists, who are traditionally the sole brochoscopists in any given hospital, were overwhelmed by the sheer volume of bronch cases (especially of Pneumocystic carinii(now jeroveci) pneumonia, TB and Mycobaterium avium intracellulare infections). So the ID docs thought that it might be a good idea if they learn to do it themselves and so it would be an integral part of their diagnostic armentarium in the management of pulmonary infections. In any case, I thought it was a wonderful idea, except that the Loma Linda training centers are about an hour's drive from Orange County. I had to begrudgingly do this for the first couple of weeks, but later on, I realized the drive wasn't really that bad. Plus, I had the chance to explore that part of San Bernardino county. I can tell you, though, it can get hot (as in, 100 degrees Farenheit-hot)in Loma Linda!

Randomly interspersed during my entire training were numerous extracurricular activities and travels which are now distilled memories that I will always cherish. There were those visits to L.A. with Annallee and David and our celebration when I passed my board exam ( I took the two day exam near Torrance and stayed with Annallee during the time)and I was officially given the title, Diplomate of the American Board of Internal Medicine in 1998); visits with my med school classmate, Shirley Albano (now Aluquin), who was living in a posh Brentwood high rise and was doing a fellowship in Sports Medicine at Cedars Sinai Hospital at the time; Mana Ning and kids; Auntie Nora's family in La Mirada; my Auntie Madou and her family in Calabasas, then Oxnard. I also had friends outside of my hospital circle and we would go out to different restaurants , visit Palm Springs (took the tram up to the snow-capped rocky mountains), visited Palapas, Lake Arrowhead, Sacramento, Squaw Valley and Lake Tahoe (breathtaking views in winter!) and San Francisco; bike ride to Ramona and Lake Elsinore; the occasional trips to Las Vegas; the very nice visits by my Mama, Papa, sis Ann, Auntie Linda in Orange; visits by Dodong Jun, my med school friends Jojo Libiran, Cesar and Ariel; my cousin Bing Mozar and her family with auntie Jula; Mana Ning, Mano Bill and their kids enjoying the pool and the jacuzzi; surprise visit by my childhood friends Robert Pingul (whom I took to Laguna Beach and the Spectrum) and Peter Sy who was actually there during my last day at my studio apartment and helped me(with Annallee, Mano Bill and DDJ) move my stuff to the hauling truck! There was that white water rafting/shooting the rapids at the Kern River in Bakersfield, organized by my co-fellow, Patrick Anastacio(Italian body-building surfing dude, real nice guy); learning how to play golf with my med students at the Sta. Ana Golf Course. There were conferences that I attended in Philadelphia, San Diego, and San Francisco. There was also the bimonthly poetry reading sessions that I attended and participated in at the local Borders Bookstore near my place. It was a rather productive two years, I would have to say. I even joined the local Bally Fitness gym!

I soon realized that my initial apprehension that the laid-back pace of the west coast will soon bore me to death was totally unfounded! The fast beat and aggressive almost dog-eat-dog world of New York was good especially for somebody like me who was young and "fresh off the boat", but the life offered by California was even better. I found out that I actually thrive, perform and live better when the the milieu is more relaxed, the work environment is more collegial and the ambient temperature is closer to what I have been acclimatized to since I was born in that part of the hemisphere that's near the equator. I (totally!) don't miss the snow!

I have a lot to be thankful for and a lot of people to thank for my very successful, unexpectedly eventful stint in Orange County, California.

(Next up: Finding Hollister, the Continuing Saga in California)