New Side Bar Items

I'm going to add a few new side bar items:
-A count down until I take the boards
-A link to my Runner's world workout log for anyone that might want to follow along with that progress.

Goals and Expectations

Most people think of their new year's resolutions in December/January and break them by February. Since I'm an amazing procrastinator, I've set a few new goals for myself over the next few months:

- Finish out the year on a strong note (ie stop slacking off!!!)
- Carry that momentum through studying for the boards (June 23rd...yikes)
- Do above average on the boards (220-230 range)
- Keep running a couple times a week to maintain sanity/health
- Go into 3rd year with a positive attitude, especially with our school's "academic mecca" surgical clerkship in July as my first rotation
- Come out with a decent grade and something positive from the experience to set the tone for family vacation medicine and the rest of the year
- Finish a half marathon with girlfriend in October
- Help my brother do some work on his new house this summer and stay in better touch with him
- Overcome the relentless beer potomania that arises with every path study session

I'll let you know how they go.


Post Match

With all of this Post-Match hoopla, I'm feeling pretty good about things. My school matched a bunch to MA based EM residencies, so I'm pretty pumped about my prospects of getting back up to the Boston area.

The downside of being a second year is that everything seems so far away when you have the rest of path, step 1, a year of mandatory clerkships, Step 2, aways, ERAS, and interviews to get through. Looking behind me though, I'm almost done with Pre-clinical. I just have a few more pre-clinical requisites to get through include my Male GU exam this weekend/the second time I have to put a finger into someone's rectum for a check mark.

I'll probably be away from the blog for another 2 weeks since we have exams coming up and I'm behind as usual...


Spring break

Carrying my clothes back into my building from my car, I ran into a couple of my classmates.

Bostonian: Hey guys, what's happening?
Guy: Back to hell

My thoughts exactly...


Clinical Competence

We arrived at the Morchand Center For Clinical Competence at about 11 am and had a nice little introduction of how the exam will run. The basic rules are that you get an hour to elicit a full H&P from an actor in 1 hour. Every move and every word are recorded on videotape for your school and you have 15 minutes of review/critique at the end. Three sections on the grading- History, Physical and Patient Interaction. The administrator kept calling it "an experience". Oh and was it ever.

There is a big cloud of mystery that hangs over the Morchand center at my school. Mostly it is talked about with a tone anxiety and whispered rumor. I've heard stories of people failing for pretending to give immunizations, I've heard of people failing for not taking it serious enough, I've heard of people completely freezing and forgetting large chunks of the history...there's a lot of rumors. My roomate got reamed for being "excessively happy and not respecting the patient" the day before I went. Not exactly the comforting aura of puppy dogs and rainbows like you'd expect.

Having done one full H&P on my own, and briefly practicing over the past few days, I was somewhat worried about the physical. I knew that I was solid on the history and patient interaction, but I haven't quite gotten the complete physical synthesized to the point where it flows. I had planned to spend about 2o minutes with the complete medical history and then move to the physical for the remainder, and I hit around 25 minutes...not too bad. What killed me was the neuro exam. It's so long, and my oncologist preceptor kept telling us that we didn't need to know the complete neuro exam no matter how much we asked to go over/practice it. Guess what Doc...we needed it. So I didn't finish my neuro exam or get a chance to wrap up the session...but the rest of everything went fine.

My patient was actually quite friendly and cooperative with me, and even managed to joke around with me despite having unstable angina. I was somewhat unsettled when I went over to the sink to wash my hands ended up staring directly into a camera mounted on the wall. I made sure to give the camera guy a little wink, so maybe that will show up on my eval. The most interesting part of the feedback came from the patient who told me what it was like to be my patient...and it was all pretty positive. I guess those empathy classes worked.

Overall I think it boosted my confidence in communication and showed me what I have to work on in the physical: PRACTICING!


Notes from the vagina

As I've written in the not so distant past, my pelvic exam experience was not as traumatizing as I had predicted it would be...irreparably scared for life, yes, but I have gained a lot of respect for the vagina and female pelvic exam models. I'll also say that I cannot conjure a more awkward than three guys sitting around a woman in the lithotomy position in a small exam room while another woman explains the finer points of her...ahem...anatomy. Completely in role play.

Here's some of the more interesting feedback points that I received from my lovely teacher Fay (who liked to be called Faymous...and had a pretty sweet tat across the left side of her abdomen) and my silent mental responses:

-Please put your thumb down-
"Sorry! Apparently when I'm nervously prodding around a woman's privates for the first time with 4 people observing me I lose track of where my digits are..."

-You don't have to press quite that hard-
"Sorry! I'll be more gentle...I don't know that you were so sensitive down there, I barely moved my finger. I guess the wince of pain was my first clue"

-Push harder-
"But didn't you just say softer? I'm so confused"

-Pull down from your shoulder, not your arm-

"I don't know what that means!!! This is my first time using this medieval torture implement"

-Stop being so polite, look down there not up here-

"Sorry, you're the one that keeps talking to me. My mother taught me to look at people when they're talking, not to stare at their vagina!"

-You had good technique with that walking motion, you might need use that on a woman with a larger clitoris-
"I just had a vagina instructor compliment me on technique...I am the most awesome clitoral inspector ever! I have reached a new low in my life, I shall tell no one"

-You'll notice that there's some cervical mucous and some red pigmentation, that's normal since I'm pretty much mid-cycle-
"Don't gag, poker face, poker face...it kind of looks like someone sneezed on your cervix...don't gag, don't laugh...poker face. "

-What would you say to a woman who is sitting something like this? (knees close together)-

"How do I say spread your legs without saying spread your legs? Uh, uh...I have to ask."

-Make your sweeps bigger-

"size does matter...poker face"

"hehe...not the first time I've heard that...PROFESSIONALISM!!!"

-You were very gentle and it wasn't entirely an uncomfortable experience once you made your movements smaller-

"Thank you??? My confidence has increased at least 0.5% because of your backhanded near-compliment."

-You did a good job of making words into plain English, not too dumbed down, not too complex-
"Sweet, that's what I go for...can I leave now instead of watching the other guys violate your womanhood? No? Ok...I'll just watch sweaty guy and overly confident guy who did this last year, but failed pathology violate you. I feel dirty being here. Maybe if I stare at the poster on the wall behind her it will look like I'm paying attention. Stop calling my attention to your vagina...No I was just all up in there, I don't need to see your cervix again I don't think it has changed in the past 7 minutes...fine I'll feign interest"


Work out wagon

The combination of my pathology class, every patient that I've seen with diabetes thus far and a few of the MI's I saw over the summer have prompted me to get back on the workout wagon. Oh yeah, and the indignity of pannus retraction that I've seen on a few occasions. I fell off that wagon about 6 weeks into first year with the advent of "oh-crap-I-have-to-study" as one of the dominant emotions in my life. I've done some on and off running since then, but I've been feeling increasingly like crap, not had the energy to get out of bed, put on some apple shaped weight and generally become less than the healthy person that I once was. Seeing fatty streaks, atherosclerosis and ruptured plaques was pretty much like when I watched "Scared Straight" 20 years later back in the day...3 months later and I'm finally getting off my arse to do something about it.

The last time I self-coached myself through a half-marathon, I ended up needing 3 months of PT and a year of rest before I could run without pain. So, I bought myself a nifty heart rate monitor (Suunto t4) that has an interesting physiologically based training effect measurement that it uses to schedule in workouts and emphasizes not over training. Anyway, I'll occasionally be posting about running/working out with this infernal machine strapped to me as catharsis from time to time, so bear with my lameness. I'll probably put it away come time for my surgery rotation (I mean lose the majority of my rights as a human being) anyway.



I have my clinical skills exam this weekend, which should be fairly interesting. It's being held at the Morchand center, made famous by an episode of Seinfeld, you all know the one
Student #1: And are you experiencing any discomfort? Kramer: Just a little burning during urination. Student #1: Okay, any other pain? Kramer: The haunting memories of lost love. May I? (signals to Mickey) Lights? (Mickey turns down the lights and Kramer lights a cigar) Our eyes met across the crowded hat store. I, a customer, and she a coquettish haberdasher. Oh, I pursued and she withdrew, then she pursued and I withdrew, and so we danced. I burned for her, much like the burning during urination that I would experience soon afterwards.

Student 1: GONORRHEA!!!

Anyway, there's a a 100% chance that it will be nothing like that scene, but it should still be interesting...I'll make sure to report back. I survived my GYN exam with minimal emotional trauma. The ladies that ran the session were great and even though I was forced to desexualize the vagina, which was not an easy feat for me, they made it a very professional and educational experience. I am still afraid of the cervix though...it's one of the scariest organs that I've encountered.

Failure to Communicate

I've written a string of posts relating to my adventures through my oncologist preceptor's practice, and I think my experience came to an apex today. My classmate and I were telling our preceptor about what we thought we needed in terms of getting ready for our clinical skills practical and how we would both like to run through a H&P today to make sure we have everything down before the exam. So our first two patients were follow up visits, the first a schitzophrenic who was so gorked out on anti-psychotics that he cannot communicate and the second was a patient that we had already dealt with in the past who needed some theraputic phlebotomy.

Patients 3 and 4 didn't show, so we went out to the floor to do a consultation. We get to the patient's bedside, and my preceptor tells me to go ahead and do the H&P. Slight problem, the patient HAS NO LARYNX and has a GAPING TRACHEOSTOMY FISTULA without one of the tubes that you usually see. (PS-Don't smoke.) Ok...how to communicate with a man who cannot speak...

Bostonian: How long have you been hospitalized?
Patient: Gurgle gurgle gurgle... (mouths November)
(this is going to be easy)

I took about as complete of a history as I could have, got a general idea of what was going on in terms of what needed to be done and did as painless a physical as I could, because they poor guy was wasting away and had several exquisitely tender points on his body. I've never seen such a pitiful site. The skin was just hanging off of his leg bones, he had no muscle mass left just bones with some skin hung on them. Pretty sad. It was also my first physical on someone in bed...not my ideal way to practice, but a good experience none-the-less.

To make things even more happy, it turns out that he was MRSA positive and the only notation was in his chart, the nurses didn't mention it, there was no warning about contact precautions...nothing. So if I disappear from the interweb, it's because I'm hospitalized with MRSA pneumonia


GYN/Breast and GU/Rectal exams

So I've got one of the aspects of medical school that I have dreaded to this point coming up in a few days: The GYN exam. I've seen a few pelvic exams and even with the most experienced hands, it's an unpleasant prospect for the patient as well as the examiner. Appropriate to nothing, our chapter of AMWA just put on their performance of the Vagina monologues, which only adds to the comedic fodder/anxiety that I'm going to experience.

It's not so much the vagina that creeps me out, it's the fact that I have to insert portions of my body into portions of someone else's body that have until this point in my life only been broached from an extracurricular/recreational angle. Not only that, but I'm probably going to have to have my face far too close for comfort fairly close to a complete stranger's vagina, inflicting the torture that is the duck-billed speculum and cervical swab. And then this poor lady has to endure the entire line of medical students serially going through the same horrible exam. I feel really bad for the patient having to go through the discomfort of us clumsy students clumsily poking about in her nether regions. At the same time, I find the cervix is one of the most repulsive and horrifying places that I have ever visited in the human anatomy (although that opinion is heavily influenced by ED patients and you can only imagine the state of hygine of someone who presents to the ED with "purulent discharge" for 3+ days).

To be fair, I'm equally put off about having to poke around some dude's wedding tackle and then place my finger into his rectum. The poop chute is meant as an exit physiologically, and anyone that's willing to get paid a couple hundred dollars to have a bunch of strangers insert their gloved fingers into his chocolate starfish is suspect in my book. I think the most painful aspect will come from the referred pain of having to check for inguinal hernias by following the path of spermatic cord up through the inguinal canal with my finger, a maneuver the requires inverting the patient's scrotum up to the level the inguinal canal and having him cough...ouchie I'm getting shivers just thinking about it.

All kidding aside, I have to thank these people for their willingness to volunteer their bodies and the opportunity to learn from them because they save us from having to train on each other. I personally don't want any of my classmates going near my anus with their knobby little fingers. So thank you, and to show my appreciation, everyone gets two packets of surgilube on whatever is being inserted into their bodily orifices!