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Long Reads

End of the End of the End

Graduation. An event that had been so far off for so long, my dazed mind refused to believe it could actually be happening. And yet, here it was, a weekend of visitors and ceremonies and celebrations swirling around me in a blur of regalia and purple orchid leis.  As with everything else in this eight-year adventure, everyone was immediately confused. My “graduation” consisted of two hooding ceremonies (where the doctoral hood is presented) occurring in two separate locations on Friday, and one commencement (the walk across the stage to receive a diploma), in which I was walking twice.

Presumably this hooding business is related to a historical hierarchal system in which more senior scholars got warmer outfits, but in SoCal it means wear extra deodorant because there is going to be some perspiration. Each student is called up in their tam and gown, kneels on the stage, and people important to them place the hood around their neck and fasten it around the back while somebody reads things about them. At the same time, in order to keep the hood from sliding too far down the back, the student has to partially unzip the robe and secure a loop with a safety pin or around a button. In order to appear confident and graceful, I’d practiced this move (okay, went through it once, but come on, how hard could it be?).

PhD hooding came first, presented by my mentors Salvador Soriano, PhD and Kerby C. Oberg, MD, PhD, people who respectively chaired my thesis committee and helped me survive the MD/PhD process. In typical Loma Linda University fashion, the grad students were meticulously arranged in a very specific non-alphabetical order that had no relationship to the order in which we’d be receiving the hoods. Our path from the seats to the stage went down steep stairs, the kind that force a choice between “watch your step” and “smile for the camera.”

My turn. Heart rate increasing, I shimmied clumsily past the other seated graduates and into the aisle, dark blue hood over my arm like the napkin of a maître d’. I took a deep breath and began my descent: Look-step, smile. Look-step, smile! I arrived at the stage without incident–which is where my competence ran out. Kneeling down, I unzipped the gown too far, revealing my white dress shirt without so much as a drink first from the crowd. My hands were shaking so much I couldn’t fasten a snap–a button was impossible. I fumbled until Soriano and Oberg finished their part before giving up and standing, which caused the hood to slide up toward my neck. I quickly pulled it back down, feeling it sliding again while I smiled for the camera and hoped there wouldn’t be a motion blur in the photo. Somewhere in here they finished reading my abstract, leaving me on stage as the silence descended. Awkward or not, this was my moment, by golly, so I took what was likely only a few extra seconds to hug each mentor in turn before returning to my seat.

For over two decades, Alzheimer’s disease has been thought to be caused by accumulation of amyloid beta protein in the brain. Unfortunately, amyloid-reducing therapies have failed to treat the disease. Here, I present and defend an alternative hypothesis in which amyloid does not cause Alzheimer’s disease, but rather is part of the defense mechanism against a more likely cause of the condition: dysregulation of lipids, such as cholesterol. This hypothesis is supported both by current studies as well as my own work. In mice, I found that amyloid precursor protein is necessary to regulate cholesterol under conditions of cellular stress seen in Alzheimer’s disease. In humans, I developed a novel blood test to potentially quantify the disease state. Overall, my studies will help expand our understanding of neurodegeneration, provide a new means of identifying individuals at risk of developing Alzheimer’s, and open a potential route for treatment.

Contrast this with later in the program, when we were given four roses to give out to loved ones. Since all of mine were sitting together, I efficiently distributed my flowers and returned to my row. It was completely empty; a quick glance around revealed that no one else was even close to finishing. I sheepishly shuffled back to my family, where the official photographer captured a picture of us taking pictures.

When the ceremony ended, Rachel slipped out, perfectly executing a previously-made plan to pick up food for our family before the next hooding began. Naturally, in the reception area we came upon a catered dinner, about which no prior announcements had been made. Poor Rachel had to make a detour by the house to drop off her food, arriving at the reception after much of the crowd had already dispersed.

Before long it was time for me to assemble at the next campus location for the medical school hooding ceremony. I removed my blue hood in preparation for the kelly green one. My classmates milled about fielding confused calls: Unlike the graduate school, there were no instructions about what the hooders were supposed to do or where they should sit. For this one I chose Rachel for obvious reasons and Soo Kim, MD, as among other things she helped me write my personal statement for residency application. As the start time drew nearer, we began to realize that no further information about how things were going to go was forthcoming, and with Mark’s help everyone in our party was able to get seated together.

Mid-ceremony, they began explaining how this whole hooding process was going to work in a needlessly-complex tangle of exceptions and alphabetical orders. Surprisingly things went rather smoothly, characteristically due to the efforts of office staffers-turned-stage-managers who had a buffer of people queueing offstage where they could be appropriately arranged prior to their name being called.  This time I didn’t bother attempting to secure the hood, instead standing up carefully to prevent sliding long enough for the picture. Unlike the graduate school, my medical school class included well over a hundred people, and given that my name is in the Cs, there was a lot to sit through afterward. Rachel started a game of hangman.

Michael A. Castello moved to Loma Linda from Baltimore, MD in 2010 to join the MD/PhD program; today he leaves with a PhD in Physiology, an MD, and considerably more gray hairs. As eight difficult years come to an end, he is happy to be surrounded by some of the people who believed in him–even when he didn’t. He will be going to UCSD for residency in child neurology.

Climbing into the front seat of a car in regalia is a bit challenging, and as it turns out, one I was unable to do without managing to rip the stitches on one of my hoods. Saturday Mark took a bunch of pictures and Rachel saved the day again by re-sewing the hood together.

For some unholy reason medical doctors are obsessed with mornings, and the Sunday commencement ceremony was no exception. We had to start lining up at 07:30, the processional started at 08:30, and gunner families were allowed to start reserving seats at 05:30. I thought that would be my final kick in the pants from the university, but I was wrong. In a snafu emblematic of the past eight years, I was informed that I was one of two people whose diplomas had been mis-printed, and the “overnight shipment” of the replacements didn’t arrive in time, because of course it didn’t.

I walked in with the graduate students wearing the blue hood and discovered I was seated in the front row. It didn’t stop me from texting, but it did make me extra-vigilant about where the cameras were pointing. Flooded with neurotransmitters, my brain hyper-focused on each new action. Stand with the grad students. They didn’t screw up reading my last name. Walk. Look out into a featureless crowd and smile. Return to my seat. Quick costume change from blue hood to green hood. Line up again with the Cs. It’s starting to sink in now that this is it. Name. I can’t contain my smile this time, my grin looks like Jack Nicholson’s Joker. Back to my seat again. Suddenly it’s over and I’m walking out wearing both hoods and carrying two diploma covers.

“Let’s see it,” Mark says as we take pictures. Earlier events long since lost to a flood of emotions, I open the case: It contains an IOU.