100th post...

100 posts...I'll dedicate this post to the fact that I've pretty much finished my pre-clinical medical education. Thanks for reading.

Looking back on the past 15,454 hours (or 21 months, 4 days...not that I'm counting) of my life, I'm not all that impressed by what I've seen. I've done a lot of sitting infront of books, I've run through 70+ highlighters, I've done a lot of memorizing but not a lot of learning. Every time that I think that I've mastered a subject, I go back and the foundation has fallen out from it. I try to look at the forest, but all I see are the individual pine needles. At this point, my exams test for ability to regurgitate random minutiae from Robbins, not for understanding of the material. Understanding material and being able to regurgitate sentences from Robbins on demand are very different. For one, I don't see the utility of being able to recite the translocations responsible for 15 different hematologic malignancies, or the cell of origin of one of the 25 difference neoplasms of the ovaries in the education of someone who will be a family physician, psychiatrist or emergency physician.

There has been a lot of wasted effort in my education, on both my behalf as well on the behalf of the AAMC/LCME who have an asininely archaic idea of what medical education should be. After June 23rd about 70% of what I've been forced to learn over the past 2 years will be vaporized from my short term memory. All those little interconnected neurons in my holding medical knowledge in my hippocampus will simply rearrange some microtubules and the hours I spent slaving over the pages of Robbins will spill out of my the distance reaches of my consciousness. Two years of my life be reduced nothing more than a few distant memories of sitting my ass in front of that same crappy carrel in the dingy basement of the library with the humming of the furnace and the fluorescent lights in my ears.

You would think that I would be sad that I'm about to reduce the intimate memories of approximately 1/12th of my life down to one simple experience that I like to refer to as "The Suck." But I'm not. You see, the past 21 months have been little more than a requisite right of passage into what I've been waiting to experience: LEARNING MEDICINE! Isn't that what I've paid for thus far? Didn't I go to medical school and not "memgurgitate lots of information that you probably will never see in the course of your career for the fun of it" school?

The ironic thing is that I'll probably look back on all of this in the middle of one of my over-night call shifts on surgery or OB and long for the days where I could sleep for 8 solid hours and control my own schedule instead of being abused on the floors. But for now, I'm hopeful that seeing and experiencing the management of patients and their various disease will re-ignite my failing passion for medicine.


What it's all about

If you've read this blog with any frequency, you know that I have an soft spot in my heart for cancer stories and patients who have been through the medical ringer with their diagnosis and treatment. My heart absolutely goes out to those abandoned souls who are left hanging without a physician who will advocate for them.

We had a patient presentation session this past week from breast cancer survivors treated by one of our faculty physicians. The stories of these women were sad and at the same time absolutely appalling. Between all of the mis-diagnoses, the poor attention paid to their needs, the lack of communication and the delays between procedures, it's a wonder that these women are alive at all. It reminded me why I wanted to get into this field in the first place and brought together a lot of what doctoring is all about.

-First patient: Hypodensity in one breast was missed over a fibroadenoma in the other breast. She was cleared for hormone replacement therapy. A year later, and she had full blown carcinoma that was being fed by her estrogen replacement...though that mechanism was not completely lucid at the time. Found the doc on campus and had everything taken care of and is still here to tell the story.

-Second patient: She made me extremely sad. She felt a lump, and had a mammogram done. She was diagnosed clinically with breast cancer on that mammogram. She requested a second opinion, and was sent to another oncologist at a prestigious ivory tower institution on the East Coast with another patient's films. The oncologist picked up on it right away, and repeat films were clean. Two years later, her films were not clean and so she returned to that same ivory tower practice to find that the physician had retired and left the practice in the hands of another doc. This guy was all about fitting in as many patients as possible. He drained the patient's cystic adenomas monthly for 8 months without biopsy, until one visit he stopped getting fluid. He looked at the patient and said "I think I made a mistake. Go see the receptionist, and we'll get you in for a biopsy." He didn't have an opening until 4 months later...so she left and came to our institution and found this doc who made everything all right, after a year of weekly chemo.

-Third patient: Basically got told by a doc at a NYC Cancer Mecca that she had breast cancer, and was not presented with the full amount of information that she requested. Great doctor, crappy care. The doctor gave her info and treatment options on a need to know basis and basically told her what she was going to do. She left out of frustration and found the doc at our institution who presented the entire picture of how they were going to get through it.

The take home message that I got out of this session was that communication is 95% of being good physician. If you're not able to communicate what is going on with the patient, how you're going to fix it and what they need to do, the patient is going to lose faith in you from the get go. Your work lies in finding and correcting the errors in physiology and anatomy of another human being!!! This is not some computer simulation or lab animal or entry in Robbins that you're dealing with, it's a person and their life and their family. You can be the most technically knowledgeable and capable individual in the field, but what takes you that extra step ahead of the rest is the simple ability to explain the situation to a very scared person, who may not be thinking rationally, and to make them understand what you're about to do.

I see so many of my colleagues lacking in this regard, and I worry for their future patients and the future of medicine.



Part of the reason that I've been writing less is that I've been running a bit more and doing other outside funtime activities. That has provided me with a whole bunch of good feeling endorphins, incremental gains in fitness and a dose of sanity that nothing else has been able to provide to this point. I feel better, I've cut back on coffee consumption, I'm sleeping a bit better and I have a good excuse not to study. And the dress slacks fit better now too...which is always a plus.

I took my longest run in a while this weekend -5.3 miles- which felt great and I put in my first structured speed work since high school. I think the hardest part about getting back into running is that I'm still getting used to the fact that I'm a beginner again. I can't expect my body to pound out a decent pace like I used to, and it takes a bit of mental work to realign my perceived effort level with the paces/times that I'm putting up. So far the heart rate monitor is helping out with that aspect, I know where my lactate threshold is and where I need to put my heart rate to match my perceived effort, my feet just fall in line with the rest...kind of a cool quasi-physiological way to approach things. I'm also taking time to rest, which is helping out alot with the aches that plagued me for a lot of my earlier self-directed running.

I cobbled together a half-marathon training schedule that takes me up to the race in October. I'm almost sticking to it, except when exam weeks get in the way. I just hope that Surgery doesn't completely kill my hopes of finishing the race...but we'll see!

I'm getting into the home stretch with classes, and starting to get all wound up for the boards in June. The nice weather is making it increasingly difficult to lock myself in the library with my good ol' pal Robbins, but I've been fairly good thus far.

Looking back on the first two years of medical school, it's been rough. It's not that the material is difficult to understand. It's the frame of reference that's been killing me all along. I'm an active learner. I learn by doing and seeing, not by staring at piles of notes and pages of readings. There is no way to actively learn pathology or biochem or any of the pre-clinical material, really. Seeing patients with their diseases makes the material stick more than the books do. It's just been the pure grunt work of slogging through the material until enough of it sticks, and that's led to some disappointing performances for me...like all of them. I've never felt less confident about what I'm doing in my life, and to have to live with that lack of confidence is draining.

Two weeks of torture left though, then a week of reading period/exams and then it's time for me to study for the boards. I'm looking foward to board studying, because I have a schedule that I'm going to stick to and it should be plenty to get a decent score on the step 1's. I'll probably continue to sneak in a post or two a week, updating about running/studying/life in general.


Yankee Stadium Revisited

Every time I head down to the Bronx to watch a ball game I get a few too many beers into me and awesomeness ensues:

I'm generally not a well liked person within the walls of Yankee Stadium, and I'm OK with that for the most part. I understand that two of the best teams in baseball play each other 18 times a year. I know that it's going to be a 4 hour game with plenty of action. I know that I'm going to be screamed at for the entirety of those 4 hours and every portion of my life will be insulted. I usually have a few drinks so that I can appreciate the atmosphere and lower my inhibitions about yelling insults at perfect strangers and their mothers. So here's how the night went:

  • Within about 30 seconds of opening the car doors in the parking garage, my friend and I are booed mercilessly. So we tailgated for a while because $10.50 for a Hineken is obscene.
  • On the way up to our 3rd tier seats, I stop to buy a beer for the walk up to our alcohol free seating. The beer lady looks at me and says with the thickest accent she can muster "NO, I don't serve any Red Sox fans". The other beer lady came over and poured me a beer...and she got a tip too!
  • We exit the concourse onto the third tier seating. My friend and I remained standing to finish our beers, and we were greeted by an intoxicated fan's "Hey, go F--- yourself and your mother". Officer Del Reye of the NYPD had a nice chat with him and I felt a little bit safer.
  • Later on, I'm waiting in line for the Men's room (only place on earth I've ever experienced this) and I get my favorite insult of the night. "Hey! You in the Sox jersey! Your penis is attached to you vagina!" I looked at the guy for a second, marveling at his stupidity, and said "I don't even know what that means." He shrugged and left...by far the best insult I've ever received because it was hilarious for everyone
Regardless, the Sox lost 15-9 that night and I went home a very unhappy Bostonian. Fortunately, this time, I didn't have to take the train home and get involved into shouting matches with the entire train car that lead to me being escorted to another car"spirited conversations" the whole way home.

EDIT: One of my friends that was at the game sent me the following link saying that this could have easily been me. I'm not a violent person by nature so I think he was a little bit off, but check it out anyway!


Quotes from the rectum

Ok so I have to share this one with everyone, despite how disturbing it is to me. So I had my standard male genitourinary and rectal exam a few weeks ago, and I just keep relaying one quote to everyone that asks how it went.

So we finished up the awkward exam of the male genitals (junk or twig and two berries if you will) and perenium (the taint or grundle for the anatomically disinclined). I've plucked this guys spermatic cords about 5 times and have had my finger up into his inguinal canal to feel his hernia...crossing all sorts of boundaries that I've never crossed with another man's junk, with minimal public display of discomfort. The patient/actor/educator turns around to the three of us males in the room and says:

"Hold up your hands."

We oblige. Pointing to the large-handed former football player, he deadpan says "Ok, you've got the biggest fingers, you're going to go first and open me up."

Great way to make things comfortable and welcoming for all with that visual aid...whilst I insert my fingers into your rectum...ugh.

Thanks for that again. I'll definitely be rushing to do my requisite 10 observed rectals on my surgery rotation in July after that experience.

Lack of blogging motivation

So I've kind of been out of ideas for writing lately, and for that I apologize to anyone who still regularly checks in. I've been running away from school for the past two weekends since my renal path exam and the rest of my free time is being eaten up by a stupid group project.

I'm not quite sure why as a 24 year old medical student I'm still assigned group work. Honestly, I am quite capable of working with a group to complete an assignment as well as doing it independently. I think that group science report that I did in elementary school proved that skill set. But here I am again, trying to coordinate 7 other classmates to create a paper that will live up to the nit-picky expectations of the course director. I've realized that I naturally gravitate to these types of positions where I take on the burden of getting a group of people to pull in the same direction, and usually I do ok with them. Hopefully, we can get a decent grade out of this project for all of us, I've certainly done my share. Especially with rewriting the sections assigned to the the one member of the group that struggles to write a coherent paragraph. I figured the 5 non-native english speakers would be the dead weight in the writing department, but they actually write quite well...it was one of the two native speakers that gave me trouble...figures.

So I got out to my favorite spot on earth this afternoon again: Fenway Park.

There's just something about the hustle and bustle around the ball park that makes me feel invigorated. Once I'm through the ticket gates, I like to immediately descend from the overly comercialized and family friendly Yawkey Way into the dimly bowels of the stadium that has stood there, almost unchanged since 1912. It almost feels like I'm traveling back in time amidst the smokey aroma of sausage on the grill and the white noise of 37,000 people vibrating through the concrete structure. Each descent brings back floods of memories of dozens of visits before, all rushing back at once. It's similar to what I imagine seeing your life flash before your eyes is like, but you can do it whenever you like for the price of admission. There's the usual, comfortable ritual of procuring the correct overpriced mass produced American lager for my dad in appreciation for the tickets he preennially provides, of walking down the ramp past the same souvenir vendor that's always there with the same old overpriced stuff, past the nacho/pretzel and hot dog/sausage, Papa Gino's, Beer/Peanut and Ice cream stands (yes, in that exact order). Waving to the same beer guy that's always there with some clever remark while he happily pours his brews in the corner by the entrance up to our section. It's a ritual that always feels familiar and yet always exciting and new...like nothing else I've ever experienced. If you've been to Fenway and sat on the third base side of the stadium, you probably know what I mean...it's the least renovated portion of the ball park and instead of feeling like a dump, which is what I'm sure many people would think, it feels like I'm walking back into an earlier time where nothing else matters except for enjoying the home team playing the classic american game.

For me, the real magic begins as soon as I emerge from the musty underbelly of the beast into the light and fresh air and echoing sounds of the park. I like to look up at the skyline over the right field wall and scan the outfield and just take a few seconds to absorb the atmosphere, and it instantly takes me back to the first few times that I visited the stadium back in the 80's and sat on my dad's lap and ate cotton candy and watched Wade Boggs (one of my favorite childhood players) play his heart out at third base and be the RBI machine that he was. It's a great feeling. The world could be collapsing around me (as it indeed it often seems to be these days), but I wouldn't really care if I had my butt in one of those cramped old seats. It really is a special place for me and holds hundreds of amazing memories that make me feel at peace and at home.

It's quite a stark and welcome contrast to my other life in New York, where I constantly feel out of place and like something is looming over me waiting to rend my soul to it's very roots. I wish I could better express what it is that I feel in words, but it's one of those intangibles that just nags at the periphery of my consciousness. Like when you walk into a room and absolutely know that something is out of place but you're not even sure what it is or why you have that feeling, but it's there nonetheless. I guess that I just don't feel at home there in NY and it adversely affects everything I do and weighs me down. I guess that strikes at the heart of the reason that I started writing this blog in the first place...to get over that feeling of living in a place that I will never be comfortable enough to call home.

I've come to realize over the past two years that discomfort is the place where I have to learn to be comfortable through many experiences (see "Notes from the Vagina"). However, making that leap from conceptualization to actualization is more difficult than it appears on the surface.

So that's a little bit about where I'm coming from in my life at this point, and it only took 3 overpriced, mass produced American lagers at my favorite place on earth to bring it out...hopefully I'll have something less touchy-feely to write about next time, but here's where my flow of consciousness went tonight.

Peace out girl scout...


Renal Failure...

I'm having a little trouble walking after that exam.

The combination of being flustered and under prepared for the depth of material was infuriating. I felt completely lost for about half the questions, which should get me into the "I should still be able to pass the course" range. It was renal, hepatobiliary and GI with clinical correlations and lab correlations. I could have had Robbins and Cecil open on my desk with a boarded pathologist, a nephrologist and a gastroenterologist sitting next to me for the exam whispering answers into my ear and I probably still would have struggled.

Good job course director, you have crushed my will to continue on in medicine yet again...off to to nice and easy pharm exam and then to crawl into a bottle of something alcoholic until Monday.

Ode to a Kidney...

Oh Kidney, you rend the joy within my soul.
You do so much, so elegantly, without complaint.
Yet I cannot fathom the depths of your pathology.
Your glomeruli confound me.
Your tubules vex my very soul.
Your electrolytes confuse the living shit out of me.

In short kidney, you make me want to curl up into the fetal position...
I suffer from neophrogenic anxiety and acute interstitial glomerulo-I-FREAKING-HATE THE-KIDNEY-itis.