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.
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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.

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"

-Faster!-
"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.

Gonorrhea!!!!

Gonorrhea!!!

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.
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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!

Autopsy

My phone rang at 9:02 AM and pulled me from my 4th snooze cycle of the morning. Guess what, it was my group's turn to observe an autopsy...at 10:30 AM. So we gathered our group up and trudged through the frigid NY morning to the ME's office. After a very brief history of what had happened and what we were expected to record and write up, we entered the morgue...the other worldly place that you see on CSI or Law and Order.

Now being a second year medical student, you're not really used to seeing naked dead people on a slab. You're not used to the smells of a dead body. You've maybe seen a handful of patients, most of them semi-clad and in pretty good shape, all things considered. Sure you saw your cadaver in anatomy and hacked it to bits over the course of 4 months, but that guy was drained of bodily fluids and smelled pleasantly of fixitive and fabric softener (we used a mix of Downy and water to keep things moist). However, this was a living, breathing human being not more than 8 hours ago, and now he's D-E-A-D in front of you, on a slab, still kind of warmish. It was kind of an eerie feeling to be standing there looking at a complete stranger dead in front of you. You almost feel that you should be mourning the passing of this poor soul, or comforting a family member. But it's just you, the dead body and some creepy guy holding a HUGE scalpel.

So you take it all in stride and begin looking at the outward appearance of the body. Standard things like height, weight, eye color, pupil diameter, scars/identifying marks, lividity, just a general survey of what's going on with him. Then that creepy dude in a surgical gown and face shield comes in an makes the standard Y-shaped incision in about 2 seconds. He then dissects the layers of flesh and muscle from the rib cage so he can make a merciless series of cuts through the ribs and clavicles with his little reciprocating bone saw, being sure to shred the subclavian vessels thereby pouring about 2 pints of blood into the now open body cavity. Seeing this can make even the manliest of men feel queasy and I watched one of my group members run out the door to get some fresh air. Blood has never bothered me too much, and my first cup of coffee had put me in a good place gastrically so I just stood there about 2 feet from the body taking notes. Elapsed time: 5 minutes.

Once the chest cavity is opened, the tech goes about systematically removing each organ piece by piece, recording the weight of every organ. Then, one by one, the organs are dissected by the pathologist and sliced serially to see if there is any pathology happening. Every detail is carefully organized, noted and dictated. It's a tedious process, but a necessary one when you have no prior medical history to go on and are essentially screening for EVERYTHING that could possibly go wrong with a person who suddenly dropped dead in front of their family. I actually saw that it is possible to access every bodily cavity with a strong arm and a 16-gauge needle...I was floored. Samples of every bodily fluid imaginable are sent for analysis and toxicology. Several tissues are also sent for toxicology.

Total time to completely turn a body inside out and look at every organ thoroughly: 90 minutes. It was basically anatomy on speed, with a whole lot more gore and stench. If you think that you learned a little too much about your cadaver in Anatomy lab, I can tell you what my autopsy patient had for dinner a few hours before he died (rice and black beans). I highly recommend that everyone see an autopsy at least once in their medical training as it will give you a perspective on pathology that you've never experienced before. It will also make you think that being a pathologist might be cool for about 30 seconds. But then you get a whiff of the contents of the small intestines and you realize that you really don't want to eat very much for the rest of the day.

Third Year's Shaping Up

I've gotten my assigned rotations for next year and it was exactly how I planned it! It's nice to be able to look at this list and see the light at the end of the tunnel:
Second year
Classes end May 13th
Step 1's on June 21st

Third year
Orientation- June 27th- July 1
Surgery- July & August (I'll probably spend the entire summer in the air conditioning)
Family Med- September (light schedule...maybe I'll sneak in a couple Sox games!)
Neuro- October (Perhaps a light schedule...playoff tickets with the Fam/GF?)
Peds-November & December (A moderate schedule, maybe I'll get some shopping done before break?)

-Winter break-

OB/GYN- Jan-Feb (I'll be nice and rested, so I don't kill anyone)
Psych- Feb-Mar (I'll need to be medicated after above rotation)
Elective- (2wks Anesthesia/Rehab requirement or EM...not sure yet) March
Medicine- April-Mid June (Maybe it will help my step 2's?)


Fourth year...
Apps, aways and then the slide until match day...graduate May 2010.

Only 804 days to go.

Forgetting Learned Helplessness

Behavioral scientists developed an animal model for depression. The model works on the premise that if you repeatedly expose an animal to a noxious stimulus that it can not escape from, the animal will become desensitized to the pain and basically become depressed. Usually it's performed with rats on an electrified grid. It is called the "Learned Helplessness" model. Many medical school professors have deemed it necessary to move these experiments into human trials...more specifically, they're trying their methods on us, the medical students.

This is my informal declaration to the investigators:
Over the past 18 months, I have been provided so much noxious stimulus in the form of crushing debt, sleep deprivation, impossibly difficult exams, stupid busy-work assignments, painfully boring lectures, and excruciatingly drawn out small group exercises that I have achieved a level of Learned Helplessness the likes of which I have never experienced. I actually hit the bottom of that depression before the end of last semester. I pretty much had given up hope of ever being more than mediocre. I was doubting whether I was worthy of the admission that my institution had even given me. I wondered if I would even want to go back to this grind. I even looked into transferring back home, but the chances were slim given that my application would basically state "I am a miserable med student 3 hours away from everyone he cares about, unable to strike a balance between the demands of medical school and the desire to put the pieces of the former life that I had built up over the past 24 years back into shape."

I took my winter break to look long and hard at what was happening to me. I realized that I had pretty much just reached the end of my wits focusing on how miserable I was and that was distracting me from everything at school. Instead of focusing on studying, I was thinking about being unhappy which lead to some very inefficient studying. Instead of going to lecture, I was laying in bed thinking about how much lecture sucked. Instead of focusing on doing my best, I was focusing on how I hard everything was. I looked around at my classmates and several of them were going through the same thing that I was. I told myself that things had to change this semester, that I had to make more room for the things outside of medical school because all of my free time is going away in a few short months when I hit the wards. I told myself that I have to make my study time as efficient as I could.

So I've been working at it. I've been diligent about paying attention to my girlfriend. I've been good about calling and talking to my parents and brothers and friends whenever I still have the time. I've even managed to fit in a few days of skiing in here and there. I put myself ahead of the curve on my last set of exams instead of on the back side of it. I almost feel like I'm back on track, or have I just learned to forget my helplessness?

Open Wide...

We've had a few lectures in our Physical Diagnosis class in the past week. The first year Oral Surgery residents (dentists) are required to attend these classes since they have no real experiences in physical diagnosis outside of staring into the mouths of patients. I can see some of the material being useful for the general assessment of a patient, especially the head and neck portions of the exam!

What I don't see is how the GU, breast and rectal exams have ANYTHING to do with oral surgery...it gives "Open wide" a whole new meaning

Someone else understands!!!

My dad sent this to me. I'm about 97% this artist ran into me on the train...kind of scary. My favorite part of the picture is the kid in the lower right hand corner giving the proverbial "stink eye." I've seen it a couple hundred times just for wearing a hat or T-shirt around...even I'm not stupid enough to wear my jersey on the subway. (I don't want to get the curse of A-Rod on it). Anyway, I found it buried in my inbox and had to post it as it captures so much of what I've experienced over the past year and a half...over 6 million people disdaining my mere existence.

Back to Back exams tomorrow. Pharm and Path...should be fun. I'll get some substance back into my posts next week.

PS- Happy Pitchers and Catchers

REM rebound

So the pharm textbooks describe a phenomenon called "Rebound REM" when using sleep aids. I actually have experienced it a few times over the past few days...it's basically really, really vivid day dreaming...with my eyes closed...sitting in front of Robbins.

Needless to say, I'm pretty tired and have since stopped with the sleep aids because of the fog they put me in for the morning hours and the time spent staring off into nothingness.

Pats were screwed?

So I was wasting a little bit of time on the interweb this evening after a nice day of pharm in the library and stumbled upon this poorly made video:

http://www.i-am-bored.com/bored_link.cfm?link_id=27384

It basically shows in excruciating detail how the Giants were given an extra 50 seconds of time over the final 1:30 of the game due to errant stoppages and mysterious, unannounced clock resettings. Pretty interesting stuff.

Better living through pharmacology!

I've been destroying my sleep architecture for years with alarm clocks, caffeine abuse and late nights writing blogs/studying/partying/goofing off. It's pretty sad when I look back and consider that the majority of my waking hours are regulated by caffeine. But it's a necessary and acceptable evil in my world.

To make matters worse, I'm now having trouble falling asleep. So after reading Pharm all day, I've decided to chemically regulate my sleep habits with a touch of diphenyhydramine and some melatonin. I doubt that the melatonin will do anything since there's no proof that it even crosses the BBB, but the diphenyhydramine is definitely kicking in now so I'm gonna go catch some Z's.

Now with More Patient Wisdom in every box!

Another Wednesday, another happy Oncological encounter, Now with more patient wisdom:

For better or for worse, patients in the VA hospital are of a fairly unique breed. They don't resent medical students, they don't say "No Residents! I only want to be treated by attending physicians." They sit there and patiently tolerate our awkwardly in-depth histories and our bumbling attempts at physical examination. Not only are they amazing folks, they also feel the need to leave us with deep, meaning full comments on the experience of being a patient.

Enter Patient Biker Dude. CC: Itchiness, headaches, dizziness. Preceptor knows the patient and tells us to skip the history.

OncoDoc: "Bostonian, do the physical. Other guy, do the physical afterwards"
Bostonian: "His spleen seems to be enlarged"
OncoDoc: "We'll discuss that after Other guy has his turn"

Biker Dude's spleen is literally the size of a regulation NBA basketball!!! He actually has a long-standing polycythemia secondary to some kind of neoplasm, platelet count is about half a million, he's been having all kinds of CNS disturbances lately so he came in to get checked out. So we're shooting the breeze while he has his therapeutic phlebotomy (read: BLOOD LETTING!!! Literally dumping 450 ml of this guy's blood into a giant glass bottle. I thought they stopped doing that in 1800's). Biker dude is telling us how we have to be able to read patients and interact with them in kind. He tells us that he will only come to see my preceptor, 45 miles away from his home, because the oncologist closer VA tried to remove several hundred ml of blood therapeutically with a 10 ml syringe (Sticking the patient multiple times until the patient said that he'd had enough), gave him the "run around" with scheduling appointments and spoke down to the patient on numerous occasions. The way Biker Dude sees it, without veterans there would be no VA hospital and this doc wouldn't have a job, so why is he being treated like crap? Towards the end of the chat this gem comes out:

Biker Dude: "...and I don't like to be treated like a N*****!!!"
Bostonian and other medical student: Being the polite, east-coaster medical student gentlemen that we are, we pick our jaws up off of the floor, smile and nod and wish him good luck. Preceptor doesn't even bat an eye while typing up the chart.
Biker Dude: Walking out the door, placing his western-style hat on, raises his hand without turning around "Best of luck to you fellas, God Bless!"
OncoDoc: (Thick Indian Accent) "You see, this patient does not like being talked down to. Always treat your patients with respect!"

Nothing like a good racial slur followed by a hearty blessing to warm your heart...
**********************************************

Then there was the patient with a history of alcohol abuse who couldn't remember how he got HepC and was surprised when told he had a mass in his liver. I'm guessing that it wasnt the only memory missing from that time in his life. He tells us that he read some patient education material saying that most people with HepC don't even know that they have it.

Normally, I have a little bit of trouble finding the liver edge, but this guy had a nice firm cirrhotic liver sticking down 2 cm below the ribcage, he must have been a hard drinker back in the day. Favorite quote from him:

"These things just keep sneaking up on me..."

He must have missed the part of pamphlet where they said "you've got a significantly increased chance of hepatoma with HepC, which is only exacerbated with heavy alcohol abuse." Lucky guy caught it pretty early. His last sonogram was negative a few months ago, but this one caught it.
**********************************************

Then there was a sweet old man getting his chemo for a fairly involved pancreatic cancer, optimistic as all get out that he's going to beat this thing. He was chomping at the bit to look at the graph of his tumor marker levels (CA19-9 I believe) which wasn't scheduled until 2 month from now. Damn near broke my heart. He kept on telling us that we were very brave for going into the medical field, that it took a special person to be able to look into the eyes of a patient and honestly tell them exactly what is going on. It felt like trying to hold a straight face after being kicked in the gut.

His infusion pump signaled that his chemo treatment had finished, he smacked his lips and said "Good to the last drop." His optimism was very heart warming, yet it was still a sad interaction knowing his prognosis.
**********************************************

Every day that I go through this routine, I wonder when my emotions are going to stop being dragged into the process. I vacillate between abject horror at how poorly these patients are being treated (both medically and socially) by so many of their private physicians, laughter with the patients at the funny moments, sad when my patients are crying, solemn as I recuperate after a mere 3 hours of precepting. I haven't really had a problem putting on the professional mask when the white coat goes on in front of the patient, it's when the white coat comes off and I have to go back to the library that I start rehashing and actually dealing with my feelings. I don' think I could do this for the rest of my career without developing a serious substance abuse problem.

I'm finding that the work of an oncologist is a labor of frustration, of integrating all of the loose pieces of the patient's fragmented medical care, of attending to the emotional, spiritual and medical needs of the patient, and of patiently waiting for the disease process to respond. I'm not a patient enough person to deal with that kind of waiting for results and that level of craptastic discontinuity of patient care.

Reason # 57 why medical school sucks

18-24 inches of light, fluffy, west-coast style powder fell over the Green Mountains of VT in the past 24 hours. I studied CNS pharmacology. I could be spending a weekend (like that guy) with my brother or my girlfriend skiing some of the BEST SNOW CONDITIONS EVER, but instead I'll be chillin in the library with Robbins, Cecil, Golijan and Katzung getting ready for my exams. Stupid priorities...Stupid expensive medical education...Stupid Bostonian for making responsible life decisions.

The next week of my life...

SUPER BOWL!!!!

What better way to celebrate being alive in America than gorging on super greasy meats, consuming too much beer, yelling and screaming at overweight men in spandex on a large-screen LCD TV and watching stupid commercials? GOD BLESS AMERICA (and the cath lab)!!!!!

Hopefully the good Eli Manning shows up (like week 17) and makes this an interesting game...LETS GO PATS!!!! (This was the overtime kick that began the dynasty...I was sitting on the metal benches, about 5 rows from the top of good-ol' Foxboro Stadium. I payed about 3 times what the ticket was worth, and another $30 for parking, walked about 2 miles in the snow to the stadium along Rt 1, shivered/froze in the 20 degree blizzard, was disappointed/angered through 3 quarters of mediocre football, couldn't even legally buy a beer because I was 19, and then witnessed one of the greatest 4th quarter comebacks of all time. THAT made it all worth it.)

One of those days

Do you just ever have one of those days where the world conspires to keep you from being productive?

9AM- Roll out of bed ready to rock and slam about 30 pages of Robbins down
10 AM- After showering and breakfast, I get a text reminding me about a brunch that I agreed to attend
11:30 AM- Old college friend calls to catch up, cant get him off the phone for an hour
12:30 PM- Finally get down to studying
1:30 PM- Free lunch for Chinese New Year
2:30 PM- Check on friend who just found out her father is dying and has to fly across the country
3:30 PM- Get stuff from library to study with friend
7 PM- Free dinner
9 PM- Leave free dinner to check email, call girlfriend
10 PM- Open blogger, get distracted by 35 other things
10:27 PM- post blog
11-12 PM- read Robbins until unconscious, go to bed
12-1 AM- lay in bed angry at self for not getting enough done today. Fall asleep, start a similar day tomorrow

Pages of Robbins read: 11
Percentage of optimistic work goal met: 32%
Efficiency of studying: 5 of 16 waking hours (less than 35% efficient study day)

Words of wisdom...

Usually when I relay the words of a patient, it's because they made me laugh or were so ridiculously ironic in the context of the situation that most people would have become incontinent in the situation. This isn't one of those times. Suprise...another week at preceptor, another depressing medical story.

WWII veteran in his 80's, presenting to VA Oncology clinic seeking treatment for one of his many cancer related complications. For 80 something, this man has it really well together and the history is going all too smoothly. He relays in exquisite detail the past 20 years of his medical history with exact dates and physician names...better than most 40 year olds I've worked with.

Start the physical and start to get the story about his PICC line, and in the middle of his story the patient starts to lose it. He's so frustrated with the private oncology group currently administering his chemo that he cant help it. Apparently they make him pay in full before he sees the oncologist, 3-4 times per week. During a recent hospitalization, the oncologist asked to do a series of non-invasive tests that the patient assented to, and a marrow biopsy which the patient declined until he talked to his PMD about it. Not five minutes later was the oncologist back to do all of the tests and the biopsy. It's not like you can just sneak in a biopsy without the patient noticing. Anyway, the patient reminded the oncologist that he had not consented the biopsy, that he needed to call his PMD to understand why they needed the biopsy. The oncologist apparently threw a temper tantrum and stormed out of the room.

Long story short, he is VERY dissatisfied with his oncology group treating him like a piece of meat. He feels helpless when dealing with them and the fact that the doctors wouldn't listen to him makes him very unsafe and unsettled. He made sure, in his grandfatherly tone and through the tears of frustration, to tell us to always be sure to listen to our patients, to show empathy and human dignity and honesty to our patients. It was the most touched that I've ever been in dealing with a patient and I hope that his advice never is forgotten forgotten by the two of us.

Just another reminder that the white coat isn't as impenetrable as it seems.

"Ain't my job..."

One of the things that I'm quickly learning through my preceptor sessions is that there is a pervasive attitude of "it's not my problem" present in the medical community. I've seen patients bounced around between 3-5 doctors telling them different and obscenely wrong bits of information, ignoring complaints of pain and even missing completely classic presentations of their specialty's bread and butter. It seems that the oncologist is the place that people come for complete care addressing all of their symptoms. It pretty much horrifies me every week.

Case in point came today: A pleasant elderly gentleman came in for a routine oncology follow up expecting some blood work. I'm expecting a fairly simple history, a well correlated physicial and about 30 minutes of discussion about what the blood work showed. Instead we we're launched into his current symptoms of his last 18 hours of orthopnea, sleeplessness, dry cough and A Fib. Concerned that it was his third episode in 2 weeks, he presented at a local heart clinic that morning. The cardiologist got the same history that we did, listened to the heart sounds and sent this poor patient on his merry way with a slight change in his meds and an order for an ECHO later that week. Great, the guy is in congestive heart failure and a CARDIOLOGIST let him walk out the door to buy himself a trip to the ICU on a vent before the end of the week.

So we start taking the history, and by the time we get through the Chief Complaint (step 1 for those who don't know) my preceptor looks over at me and then takes control. He specifically targets every key point in the history for someone in CHF. He ends the history, looks at me, points his finger and says in his thick accent "This is a VERY CLASSICAL PRESENTATION...you'll never forget this." We start the physical: laterally displaced PMI, elevated venous pressures, rapid pulse, bilateral crackles at the lung bases, pitting pedal edema, 3/6 holosystolic murmur, essentially the textbook CHF presentation...you get the idea. The Oncologist calls the Cardiologist to tell him that his patient is in CHF, he's being admitted to get it back under control. Here's the kicker: After this whole ordeal is through, the patient asks my preceptor if the Cardiologist did a good job. My preceptors response: "Out of professional courtesy, I'm not going to comment on that."
---------

Not surprisingly, this whole event was quite unsettling for me. How could a man in the midst of acute onset congestive heart failure be allowed to leave a cardiologist's office when he is quite clearly about to buy himself a vent in the next week? How could a second year medical student elicit more pertinent points in 2 minutes of taking a history than a cardiologist? It is just plain irresponsible to let someone in this shape leave your office just because he's old and not in acute distress. If I take one thing from this whole physical diagnosis class it will be the importance of a thorough history and physical. Yes, the time crunch and meeting patient quotas are an excuse, but letting someone this sick leave your office is absolute negligence and laziness. A quick listen to the lung bases in a patient with a holosystolic murmur while your steth is in your ears still may have been a good idea? A quick "How are you?" Perhaps listening to the patient would have given you the clinical picture of someone in heart failure? I'm angry that people like this are allowed to practice medicine, but more so I'm scared of who will be taking care of the people that I care about.

I'm a real boy!!!

I just got back from a nice long weekend up in the Mountains of Vermont skiing Jay Peak, drinking heavily, and generally feeling like a real person, despite the fact that I was with a group of medical students. It's amazing how not seeing medical books for 3 days, heavily enforced drinking penalties for mentioning anything medical school related, and not having to ask new people about every crevice of their personal life in excruciating detail has helped to make my life feel balanced again...although the amount of Pharm and Path that I have to catch up on has officially become daunting and will throw me off kilter sometime probably within the next 36 hours.

Another one bites the dust: Oncology Revisited

As part of out physical diagnosis class, we are assigned to a preceptor site in order to practice our physical and history taking skills. Joy of joys, my preceptor is an Oncologist at a VA hospital. As I've already posted, oncology is not even on my list of career list, but I gots to do what I gots to do and I put on as positive a demeanor as I can muster at this point in my young medical career.
--------------------------

I walk in the door 10 minutes early, get a cup of coffee and have a quick introduction to the office staff and nurses. We've got 2 patients on the docket for the day. The first patient is cooperative, pleasant and even humerous at times in spite of his scars, his fair prognosis and his lovely home situation. His history went about as smoothly as I could have dreamed, and we were only responsible for vitals and a head and neck exam, which had several pertinent positives related to his prior surgery. His BO was just 2/5 so, I could deal. I was thinking to myself that if every patient were like this, oncology might not be so bad. We went over the history and physical quickly before the next patient and nothing but good comments.

Then the shadow of the next patient and his 6'4" son darkened the door, but not my elevated mood...yet. Patient was wheeled in the door by his son and after a cursory introduction we got down to business.

Bostonian: So, why'd you come in today?

I could tell but the look in his son's eye that he was not a happy fellow and that the proverbial . It was about as obvious as his name "PAUL" branded across his belt. He launched into a story about how they had been bounced around between 4-5 doctors, the last two without even a perscription for his father's 8/10 pain presumably related to the softball-sized necrotizing axilary mass that had been misdiagnosed twice as an abscess with clean cultures and cytology. The son wanted answers, then and now. I kept it together...

Bostonian: Since it's your first visit, the Doc and I need to get as much information as we can in your words so we don't miss anything. So any other medical problems?

Son looks at me like I have 2 heads and again son launches off on a tirade of how his father had 15 surgeries for his diabetic feet, stents for his CAD, a complicated small cell lung CA and now this on top of it all. It's all in this packet. Can we just look at my dad's lump, get something for his pain and get the hell outta here? He tossed the tome onto the desk. I looked at my preceptor for help...

*****
Now as part of my medical education, I've already had about a year of training in how to take histories and practiced them in a little pediatric office, as well as the ED this summer on a few patients. We learned a nice little outline form of questions that flows from one to the next, how to be empathic, how to extract what we need from uncooperative patients, how to deliver bad news and how to deal with our own emotions. NEVER ONCE did they attempt prepare me for dealing with a large and aggravated man who is uncooperative and afraid to hear what is going to come out of one of our mouths: that his father is dying. Another smooth day 1 experience...just like I expected.
*****

My preceptor took over at that point. Needless to say, these folks were having a tough time understanding what was going on. I sat through probably one of the most painful patient encounters I've ever witnessed that stemed from a non-native English speaker trying to distill oncology down into plain English for a patient that was not willing to listen and jumped to about 50 conclusions that were incorrect. As a medical student, I cannot actually offer medical advice nor council anyone on medical matters...just ask questions and poke at them. I have never bitten my tongue so hard in my life to keep myself out of trouble. 60 minutes later, when the patient education portion of the interview was over, the doc had managed to get the pertinent points across to the son and their case worker that would schedule everything for them, I needed another cup of coffee and some quiet time. We debreifed quickly and I left as fast as possible.

My worst nightmares of oncology came to life before my very eyes: telling someone that they have months to live, no cure for what they have, you're going to have side effects in the attempt to make the rest of your life a little bit longer, your family is going to suffer, you are going to suffer.

I have never felt so exhausted at the end of a day. When I got home, I sat down and drank a nice deep glass of whiskey in silence while staring at the wall, vented to my girlfriend for 20 minutes on the phone and watched some mindless TV. A week later when I have to write up the H&P, I can barely bring myself to do it.

What is it in me that causes the visceral discomfort of telling someone that they're going to suffer and die? Whatever it is, I don't want it to go away. It may have been one of my least fun experiences in the clinic, but I felt like a human being for the first time while wearing the white coat. The armor was chinked.

Here we go again (again)

Just started up again with classes this morning: 3 hours of pharm...which wasn't all that bad considering that have a Bachelor's in Chemistry. Hopefully it will continue to be mildly interesting for the rest of the semester so I can pull myself out of the academic P=MD quagmire I put myself in.

------------------------
On a different note, responding to a comment that I received on an earlier post ranting about medical education philosophy asking for suggestions on how to address my rants:
I honestly don't know if there is a viable way of addressing my concerns of being left to my own devices to learn the super-detailed basic sciences that will have little, if no relevance to my future career. At my institution, we're basically thrown 200 pages of outline, reading assignments and small group assignments at the begining of a semester along with a copy of Robbins. For each subject section, we're given a cursory overview of the relevant topics, a few shallow ventures into interactive learning/problem solving and an all-but comprehensive review of what we'd expect to see on microscopic/gross inspection. And then we are examined to a very detailed level that I somehow manage to never quite prepare adequately for. There is no remedy for this problem because the vast amount of exquisitely detailed knowledge we're expected to amass over a short period of time is determined by the NBME and the content of the USMLE.

I guess my personal problem is that I get bogged down in all of the details and checking off all of the learning objectives after reading them twice and don't have an accurate way of ensuring that I have adequately prepared to answer questions about the material. Unfortunately, our learning objectives are somewhat vague in comparison to the depth we're expected to prepare. I suppose that having something more than a vague list of clues as to the depth of prep needed would be helpful, as would a self assessment tool to guage where I am at. We are provided a bank of old exams, but they are in no logical order for me to organize my studying. I suppose that if there was a better resource for me to ensure that I had prepared to the proper extent for the exams that I am expected to take, I might be better able to achieve the learning goals.

For what it's worth, I think that the current system of medical education needs to be severely overhauled to incorporate an integrated knowledge of basic science and clinical information and that the Steps of the USMLE need to be done away with. But for the time being, we just have to deal

The year of the Boards

Happy 2008! Ok, so it's January 3rd, but I haven't really been in the mood/had anything to write about until today. It's hard to find something to write about when you're sleeping 10 hours a night and catching up with the family and friends that are still close to home. It's been nice but far from entertaining to read about. I feel like my time off has helped me get my head on straight again and get my life back into perspective. I finally feel balanced again, which should last all of 3 weeks, but at least I'll have that going into one of the busiest/most challenging semesters of my life thus far.

Anyway, I finally got around to ordering all of my Step 1 materials, registering for the exam and laying out a schedule (over $1000 later). Here's my current plan of attack:

• Mandatory mock board in April at school and taking a look at where I stand after that
  
• The free NBME exam the day after classes end to give me an idea of what I am weak in to guide me in my overall studying.
  
• 6 weeks of studying with 1 integrated catch-up/Qbank day per week to allow for some level of flexibility/sanity/mixing it up.
• A goal of doing 50-100 random Q-Bank questions per night with explanations to get into the groove of answering questions
• 1 timed NBME exam per week to show me where I stand (in place of the Qbank/catch up day) for the final 4 weeks leading up to the exam
• 2 days of focused review based on Qbank/NBME indicated weaknesses right before the exam

Hopefully, that will be good enough to get me a 230, but my confidence in my academic abilities has been pretty much crushed over the past semester in Path since I rode on the back side of the curve for most of the semester. I'm a SD above average in all of my small group sessions, but I'm just not testing well and I'm not exactly sure how to remedy it.

I've taken a look at how I studied for the exams thus far and it looks like I'm getting bogged down in all of the nitty-gritty details and losing sight of the big important themes. Putting off studying for way too long between exams hasn't helped either. If I stay on top of my stuff and incorporate Rapid Review/BRS/First Aid as a frame work to fill in the nit-picky details from Robbins and Cecil, I should be able to kick myself over to the other side of the curve. Between that and doing questions before the exams, I should start doing better. But only time will tell

Merry Christmas

I scraped by my ass by my latest path exam...apparently I was supposed to prepare for a clinical cardiology exam instead of a cardiovascular pathology exam. That wasn't what the syllabus or the previous year's exams said, but such is life. I still passed the class...but this P=MD after weeks of studying my butt off is just sucking the life out of me. I don't know what I'm doing wrong but it's quite disheartening to study your face off for 3 weeks straight and walk out of an exam to find out you're barely pass the class because of your awesomely half-assed performance. Regardless, I'm still class of 2010

Fortunately, I've got the next two weeks off to get my head on straight, re-evaluate what I'm doing wrong and set up a plan to get me through step 1 and into third year with my sanity and relationships in tact. Oh yeah, I get to spend time with my family and non-medical friends too!!! Merry Christmas to all, and I'll be back in the new year

Take care,
Bostonian

I've lost that lovin' feelin'...

(Cue Anthony Edwards: "I hate it when he does that!")

For about the umpteenth time this year, I've lost that lovin' feelin' that I had when I was a pre-med, came again for about the first 3 weeks of medical school, and then again for the first few weeks of this year after my fun EM internship. Whenever I walk over to the library, I feel the life being drained out of me. Whenever I look at Robbins, I'm told I get what has been described as "a really pathetic look" on my face.

So I am pondering:

Why is it that the entire medical education process is built around separating us from the things and people that we care about and totally immersing ourselves in the material? I spent 22 years of my life focused on becoming a well-rounded individual with interests outside of medicine, with relationships beyond the walls of my educational institution, with emotions, creative energy, compassion and a decent credit rating. Hell, I even ran a half marathon at one point at sub-8 minute mile pace.

But all of that is gone now, at age 24. I gave myself away the second I put on that short white coat and signed away my first master promissory note. I can rattle off obscure medical facts with out blinking, but I can't have a normal conversation with friends from high school. I can talk to a schizophrenic and elicit the history of his life, but I can barely hold a 10 minute phone conversation with my mom or my girlfriend without long silences. I know the intricate workings of the human body and mind, but I'm losing touch with my own soul.

I suppose that if this was the former USSR circa-1965 and my parents and local government officials had determined that I would be a physician from the age of 3 because I was good at the knock off Soviet version of Operation, this total dedication of my life's energy to Mother Medicine would be a bit more palatable. But, I guess that physicians are made and not born... and hundreds of thousands have gone through this training process and come out alive and with their minds somewhat in tact.

5 days...until freedom, sleep and feeling like myself again.

Under Pressure...

::Cue Queen::
Dun dun dun dundundun dun...
Dun dun dun dundundun dun...

8 mere days left until winter break...3 cumulative exams to go...
I can't wait!!!

I'll post again soon!

Holy Crap!

More than 1000 views of this page, many of which are not my own!

Thanks for reading my drivel, if it gets your through your day, more power to you.

If you come here to anonymously spy on my suffering, there's plenty more coming up you're a sick person and should probably seek professional help, you sadist you.

Seriously, thanks for reading

BinNY

Demotivation

I know that it's perfectly natural to go through up and down periods within medical school, but I swear that I swing back and forth faster than a bipolar crack addict.

This morning, I had a great amount of difficulty dragging my sorry ass out of bed to study. I walk through the cold over to school, and as soon as I get through the front door I can feel my shoulders sag and my posture slouching and the joy being dragged out of me as I head into the library for a little bit of light reading (Viruses...hooray). 20 ounces of black coffee couldn't even get my sorry butt motivated.

Later this same day, I head to a mandatory small group session with one of the fourth year students and I almost enjoyed interacting with my small group in yet another extremely inefficient clinical correlation exercise...the leader actually managed to get a discussion going and some interesting tidbits were addressed and some of her knowledge was thrown down and the session actually ran itself instead of morphing into mandatory lecture time like usual. I finally felt like I was actually learning something that might be clinically relevant in my career, instead of staggering through endless lists of cell markers, random correlations pulled from pubmed and obscure diseases that have an incidence of 1:10,000 in a tiny corner of Bulawayo province of Zimbabwe.

Then again tonight, I head on back over to the library with my dinner and my virus reading, same life-sucking feeling, same slouching posture, same falling asleep in the pages of my book out of sheer disgust. I try chewing gum...still can't concentrate. I try taking a dinner break...still can't concentrate. I try commiserating with some of my study buddies...can't focus. Finally after about 6 hours of on and off productivity, (consisting of 2 class transcripts, phone calls to mom and the girlfriend, an hour of screwing around with classmates, 30 minutes of dinner, and at least 6 bathroom breaks) I threw in the towel and headed for home, defeated by viruses and my own demotivation.

All I can do is remind myself of a few things:

• 903 days until graduation.
  
• 1.5 years finished, $117,000 spent on school
  
• 7 months until I am released onto the wards and Step 1 and the end of this pointless suffering in the bowels of the library.
  
• Most importantly, 2 weeks until Winter Break: sleeping in, skiing, family and friends around, no Robbins, no Murray, my dog, and contact with the real world outside of my personal hell. Basically, I get the things that matter in my life back firmly in my possession for 2 entire weeks (probably for the last time until 4th year, but I'll face that realization later on...with a healthy dose of angst and scotch)
  

The Debt Card

So I've noticed a couple debt postings over the past week, so I'm hopping on the bandwagon too. I just received my bill for the spring semester of year 2: I now owed something on the order of $117,000. I've never even seen $1000 in cash, I can picture $100, but I cannot fathom owing that much money without having seen more than 10% of it hit my bank account at one time.

To bring that down to my level, I've come up with some nice equivalents to help myself out. Please stick with me until you find an equivalence that hits home:

• A Mercedes Benz SL550 with every option possible- $120,000
• A house somewhere in the mid west
• A Fender Stratocaster owned and played by Jimi Hendrix himself
• A 36' YACHT
• 75 Karats of Diamonds attached to a platinum necklace
  
• Over 9 pounds of solid gold at the current price of $795.20/oz.
  
• 80 years eating 4 items off the dollar menu at Wendy's every day

Now, lets keep in mind that I've wracked up this debt over the course of the past two years, so about $57,500/year. It would probably seem that I could live a cushy lifestyle on that. However, subtracting out tuition, books, car, health insurance, rent and everything else, I'm left with about $10,000 for the incidentals of daily living. It would be amazing if that just included food, gas, girlfriend, and fun, but I'm also stuck paying for professional clothing, books, mandatory medical equipment, mandatory exam fees, professional association fees, ...all on just over $27 dollars a day.

I am currently projected to have something on the order of $260,000 in debt after medical school. Sure it's "good debt" but really, I'm going to have to enter a fairly lucrative and short residency to actually be able to pay it off in a reasonable amount of time. My repayment plan calculator says that I'll be paying $3,000 a month at 6.8% for the next 10 years and that I will actually end up paying on the order of $360,000 when all is said and done. 6 digits of interest...great. At that rate, I'll be 26 when I get my MD, 29 by the time that I enter repayment after deferring for residency and 39 by the time that I finish repayment. Something to think about when you're filling out your AMCAS while watching Scrubs/Gray's Anatomy and thinking how awesome your life is going to be.

Medical Education Philosophy Rant

Forest or trees?
Looking back on the last exam block, it seems that there is something inherently wrong with the way that I am being educated. I get the joy of trying to cram 3-500 pages of material into my brain and regurgitating it in the form of trivia questions and little black circles. How many of those circles I bubble in correctly corresponds to my grade, which in the context of the performance of 200 of my peers determines a small portion of where I will be allowed to work in the future and what I will be allowed to specialize in. It's an asinine process where I'm not really retaining a whole lot of material that matters. Instead I'm focusing on memorizing which CD's are expressed in which developmental stages of which WBC cancers...and it will have VERY little to do with the rest of my career from here on out. I'd assume that the forest was more important than the trees, but apparently we're going to examine every cell of every tree in the forest.

Multiple guess/Alphabet soup
Loosely thrown into the mix is an attempt to get interaction from members of the class in small group sessions. Unfortunately, these sessions turn into more of a lecture than a discussion/problem solving exercize. My concern comes when I'm actually going to have to make diagnoses and see patients and interact with other physicians. Will I see the patterns, will I know what tests to order, will I even know what to look for when it's not presented in a multiple choice format. It's not as if people are going to present with the choice of ABCD or E with me able to bubble in the correct choice with only the price of my grade on the line. These will be people's lives, and I don't even know how to make a differential diagnosis work or even what should be listed together. But I can tell you the different markers on the different flavors of Non-hodgkins lymphoma...what is more important in your future physician: performance on a multiple-choice exam or knowing how to diagnose a patient??? I saw an article from AAMC that the Step 1 is being re-thought.

I think what has bothered me most about my very expensive education thus far is that I could have learned most of the material with about 6 books and a ticket to Body Worlds at the Museum of Science...

Re-dienchanted again...

I pretty much have the non-hormonal, non-gonadal, medical education-based version of PMS these days. I'm deeming the acronym NHNGMEB-PMS. At my lovely institution, epidemic NHNGMEB-PMS seems to flair up every 6 weeks with intense spasms of anxiety, grouchiness, eating crappy food, not sleeping well, excessive caffeine consumption and excessive distractability. I think it's spread by the special human body louse that lives inside every copy of Robbins. The natural reservior seems to be restricted to second year medical students. There's another variant that affects first year medical students to a similar degree, but the etiology and timing is slightly different. I'm sure it happens other places with different frequencies.

Anyway, it's just about exam time again and I've been studying diligently for the past several weeks, I've even been ahead of the game at a few points. Now that I'm getting closer to exam time and taking some practice exams...they're not looking so hot. I don't actually know what I am doing wrong, or how many more lines of Robbins I could memorize and randomly recall at the whim of a very convoluted "All of the following, except" type multiple choice question. That combined with one of the hardest sections in Path (Blood cell disorders and Cancer) is not making for a very rewarding studying experience.

Such is life here however, I'll do what I can, but it's not going to be pretty getting these exams back. I wasn't exactly in the running for AOA in this lifetime, but I'd at-least like to be riding high on the curve (i.e. not failing miserably). Putting a positive twist on it: maybe having to know this level of detail now will make the USMLE's seem a little bit easier????

I'm off to bury my face in some Micro...and boost my ego a little by not miserably failing a practice exam...I'll post after the exam.

The List Shortens...Heme/Onc

Heme/Onc

To begin, any subject that has enough detail to make a pathologist complain about the amount of detail automatically turns me off. I think I read "but that is beyond the scope of this text" four times in the most detail oriented sections of that damed tome of Path. Robbins and Cotran basically wave the white flag of surrender.

Hematopathology is the detail masochists' dream subject. There are officially 2-bagillion distinctly individual pathologies of blood cells recognized in Robbins, each coupled with it's own set of complications, prognostic indicators and cytogenetic/molecular nuisances and uninformative name. Then there's the verbal diarrhea explaining the difference between the cell types, the uninformative naming schemes, the treatments, the lab value changes...and my head just exploded. Oh, and everyone of these damned patients presents as being tired and having lost weight.

And then there is oncology. God bless the person that can go to work every day and tell at least one person that they have cancer. I swear that half of Robbins is devoted to neoplasms of each organ system, and the equivalent to watching a Fox special "When good cells go bad". I'm going to leave it at that out of respect to the people that toil to keep those pesky neoplasms at bay...it's something that I never could do day in and day out.

The list shortens...OB/GYN

As I take my little whirlwind tour of potential medical specialties in Pathology and Microbiology, I have knocked off about half a dozen specialties from my list if possible career choices. I'll make this a regular installment for your reading pleasure.

Disclaimer: If you are interested in any of the fields that I mention or are currently working in aforementioned specialty or potentially grading me/evaluating me in anyway, please understand that this is nothing more than my somewhat twisted justification for not going into your field. I respect you for doing what I never could. Please don't mess up my life over my poor attempts at humor.

OB/GYN-
Between my microbiology lectures on STD's and a couple of less-than-pleasant encounters with some purulent cervices, genital warts, fungal infections and unpleasant/irresponsible pregnant mothers-to-be I couldn't run away fast enough from this specialty.

"But what about bringing a beautiful new life into the world?"

Listen. I've seen the TLC series about making the baby or whatever (while switching between "Mythbusters" on Discovery and Sportscenter). The horribly violent act of bringing a human child onto this Earth is utterly horrifying to me. You couldn't pay me enough to be on the business end of a hormonally imbalanced woman passing an 6-12 pound bowling ball of a HUMAN BEING through a slightly elastic tunnel that is roughly the size of a roll of dimes in its relaxed state. At 3 AM. On Christmas Eve. In a blizzard.

The female body may have taken millions of years to become a baby producing machine, but the female mind/consciousness has been evolving away from that role over the past century or so. I am not getting in the middle of that argument or spending the rest of my career catching the equivalent of a vaseline-covered football worth a couple million dollars as it flies out of an angry vagina that's being torn to shreds.

"But there's plenty of fun surgical procedures without the long surgery residency!"

Yeah, but there's also cutting into an oriented x 3 mother that is anesthetized from T12 down, sewing back together that now septic birth canal, being sued because I wasn't gifted with Randy Moss' hands, being sued because mom died of DIC or being sued because some baby I delivered as a resident didn't become MENSA material because I may have made a mistake, at 3AM, on Christmas Eve, in a blizzard.

OB/GYN...you are the weakest link...GOODBYE!

Professional Organizations

Just a warning for all of you med students/physicians out there.

So you just started medical school, you're sensory overloaded, strapped for cash and looking for any free thing that you can get. Your friendly AMSA rep runs up to you and says "Sign up and get a free Netter's!" and your gut reaction is GREAT! You get your Netters for free and a fancy little card showing you your benefits of joining AMSA shows up a few weeks later. Take a little look at what you're signing up for.

Here's the mission statement:The American Medical Student Association is committed to improving health care and healthcare delivery to all people; promoting active improvement in medical education; involving its members in the social, moral and ethical obligations of the profession of medicine; assisting in the improvement and understanding of world health problems; contributing to the welfare of medical students, interns, residents and post-MD/DO trainees; and advancing the profession of medicine

I'd like to point out how the second to last concern of the group is contributing to the welfare of medical students. Funny thing is that their associated lender is part of the probe by NY AG into the predatory lending practices...Good job AMSA...good job.

Parallel Universe

Sometimes when I'm dealing with other medical students, I feel like I'm entering a parallel universe where human interaction and expression of emotion has become some weird hybrid of what it should be. Granted, I was born and raised in New England which makes me a bit emotionally stunted, thereby warping my perspective slightly. But I digress...

Seriously though, a production is made out of every little happening. Case in point: I tried to go out to dinner with my room mates last night...a simple task in my former life. But here in the Twilight Zone, the roommates disagree on time and no compromise can be reached. This leads to other grievances being aired, crossing of arms/stamping of feet, awkwardly silent rides to the restaurant, awkward silences over dinner, and general discomfort for the Bostonian in the middle of all of this. Oh and the temper tantrums...don't forget those.

I've noticed that this toddler/kindergarten level of maturity also extends thorough a good portion of my class and it's frustrating to think that I will have to cater to these types of personalities for the rest of my career. Hooray future doctors of America!!!

SOX WIN

Obligatory post...sorry. I love this piscture of Pap...

Overall, this year was probably the best years of baseball that I can remember, but the World Series was kind of bittersweet. Do I miss Shaugnessy's Curse of the Bambino? NO! But there is something missing in my soul...it's that potent longing that only a lifetime of being a lovable loser can bring. 86 years of disappointment no longer tug at my heart strings. Billy Buckner letting the ball through his legs in the '86 series doesn't make me quite as angry. Falling to the Tribe in '95 and '98 and losing to the Yanks in '99 are just distant memories from my adolescence. The heartbreak of the 2003 game 7, 11th inning ALCS loss that forged my love of the Sox no longer makes the bile rise in my throat. 2004 put all of those things to rest. The fatalist Sox fan is gone from my soul.

There was no elation this year for me, just satisfaction and a lot of hope for the next few years. With the young core of players that have come up through the farm system, a passionate owner that cares about his fans and team, competent management at the helm and another red banner hanging over Yawkee Way for me to look up at, I am satisfied.

Getting my groove back

So a funny thing has happened over the past two weeks. After my last post, I found myself battling some of the same feelings that I had addressed: Med school sucking, wondering why I would ever put myself through this, wondering what my motivation in all of this is, etc. The motivation problem is what has come to the forefront of my mind as of late. I just can't seem to come up with a single concrete answer other than the $94,000 that I've racked up in debt over the past year and a half.

Is it for my family? No, my parents are proud of me no matter what. Is it for my kids? No, I probably wont have them for a while thanks to the inter-state relationship that I'm in for the foreseeable future. Am I doing this for me then???

At one point, somewhere back in the application process, I was doing this for me, to give myself a solid career where I wouldn't just be a cog in the wheel of industry like my father and brothers, merely making a product to make a paycheck. I would much rather a career where I could look back at the end of every week of work and see that the hours of my life that I am investing into my career had a positive impact on the lives of others...and be compensated for my skills and time.

Well, I wish the naive younger version of me had known the sacrifices he'd be making in the near future for that fulfilling career and decent paycheck. I look at other people my age that are traveling the world in their free time, keeping themselves healthy at the gym, starting their marriages, starting their families, broadening their social networks, finding their niches in careers and generally living life.

And then I look in the mirror and see my life, filled with sitting in front of a couple of books, in a small group discussing that pile of books or in an auditorium listening to the highlights of those books. No impact on other people, nothing but the same 200 faces day in and day out, the same books day in day out, nothing to look back on at the end of the week to say to myself "wow, I actually contributed to humanity today."

I think the lack of a rewarding feeling in the pursuit that I spend the majority of my time in is the worst part of this whole process. I'm literally working my butt off, spending weeks of my life glued to a chair for nothing but a number on a piece of paper...ok so couple of numbers (Exams, USMLE, Clinical Evals and shelf exams, Deans letter, interviews and the actual match). My life for the next 3 years is lined up for me and I feel like a cog, just what I wanted to avoid... pointless, unrelenting, unrewarding toil.

Like I've said a couple of times now: It's hard to look past all of this to the actual practice of medicine when your head is burried in the pages of a book and won't be coming out for some time now.

Advice about med school blowing hard...

I received a comment on one of my older posts commenting that the writer had found me by Googling the phrase "Med school blows." In the absolute lack of anything else to write about, I'm gonna throw down some knowledge/experiences...be prepared for awesomeness!!!

So you've spent the last 5-10 years of your life working towards this moment: getting into medical school. Now that you're here you think it sucks and you might have made the biggest, most expensive mistake of your life? Yeah, welcome to the club Anonymous. Many medical students have what I like to call an "Oh Shit" moment once they get into the day to day slog of medical school. I had one of those moments myself about 3 weeks into school for my first set of exams, and look at me I survived it!

It's VERY easy to get caught up in the feeling of "THIS STUFF BLOWS A GOAT" especially around exam time. It's even easier when you've just left a fairly easy job where you worked 40 hours a week, drank your paycheck away and really had very few cares when the clock hit 5PM. The transition was rough for me anyway. I imagine you have just come to the painful realization that you didn't want to study Anatomy and Histology. To be completely honest, you're going to realize that you don't really want to study Biochem, Physio, Neuro, Psych, Path, Pharm, Micro or Ethics either. So that begs the question why you signed up to be tortured for the next 4 years of your life whilst paying out of your ass for it?

Well it took me almost the entire first year of school to figure this one out. You'd figure someone who made it this far would be bright enough to conjure a silver lining somewhere in the midst of the shit-storm. Well, after a particularly rough final set of exams for Neuro, including a mini-board that was actually my worst exam performance in medical school, I did some soul searching. As with any good Irish fellow, my soul searching included copious amounts of whiskey and beer. I find that they help to slow down my brain to the point where instead of just making decisions based on the immediate situation, I take time to evaluate the entirety of the situation...it may sound like BS, but it works for me.

I looked at the big picture: Was this truly what I wanted? What am I doing here? What would I be doing otherwise? Why don't twinkies go bad for 40 years? Where did I put that bottle of scotch? You know, the important global questions.

I came up with a few very important answers that changed how I look at things:

1.) Medical School is not truly what I wanted out of life. Anyone who want's that is just plain SICK. What I wanted was to have a nice easy life where everything comes to me with minimal effort and I don't have to work very hard at all to get where I want, and I want oompa-loompas to bring me candy while I swim in a river of chocolate. That sort of life is not a possibility for me since my parents are neither wealthy nor willing to let me waste my life like that (and oompa-loompas aren't real either...sadly).

Short of that, what do I want out of life? I want to pay back my loans, to have a medium sized family and a good dog that will actually listen to me off the leash, to leave a lasting impression on a few of the people that I encounter in life and a job that changes on a daily basis and is somewhat unscripted so that I don't get too bored with it. In short, I want to look back on my life 45-50 years from now on my death bed and be able to say "Damn, that was a good life!" How can I have all of that? By going through with this beast.

2.) I am here at school to learn to be a physician. Physicians are not born, they are not pampered into existence. They are nearly ordinary people, broken down to a steaming pile of humanity by medical school, and then rebuilt into a slightly less steaming pile of humanity that is then baked by the heat of residency, forged by the flame of fellowship, and then made to crumble by the weight of debt, malpractice insurance, and CME obligations.

In other words, the training process sucks. It was designed by a bunch of single geeks at JHU with no aspirations outside of medicine. It always has sucked. It will suck more for the people that come after me...but it's not what the reality of your medical practice will be. If you can just look past the mountains of stuff that you have to learn in order to be certified competent by the NBME as a physician, you can then be tortured by a state liscencing board and allowed to pass and live your life how you want and take your career/life whereever you choose! I know it's tough when you're staring at Netter trying to memorize the Brachial Plexus (Roots, Trunks Divisions, Cords), but there is more to medicine than rote memorization.

3.) If I weren't here, I would probably be sitting in some analytical chemistry lab at some Ginormous Pharmaceutical Company in Connecticut (which shall remain nameless) pushing samples of the latest batch of "old-wrinkly-penis de-wrinkling" pills into a GC/MS while slowly growing my pension and counting down the days until I could retire. I could get married, pop out 1.5 kids, buy a modestly sized house in a modest neighbor hood, sending my kids to modest schools, living a modest life as quality inspection monitor number 1234 of 2000. There could be no imaginable fate worse than that for me. So whatever cool ideas that you've concocted in your exhausted, sleep-deprived mind as an excuse to quit, make them seem mundane and temper them with the fact that you'd have to pay for them somehow and the act of paying for them would take more time than the fun you'd actually have.

4.) Twinkies, Cockroaches and Dick Cheney will be the only things to survive the next nuclear holocaust. Hostess designed them as the perfect food, and well they did a little bit too good of a job. By the way, the bakery where the twinkie was originally created was torn down and replaced with a Nordstrom/Neiman Marcus. Hows that for progress??? Yeah, I got to visit (was dragged into) the Tiffany's that stands where the loading docks once were with the girlfriend a couple weekends ago...the place got a slightly different feel to it these days. I digress...

So anyway, Anonymous here's my advice, all wrapped up in a nice package:

-The first year of Medical School is not what the rest of your life will be like. You're studying random medically-related trivia at this point. Next year, you'll learn more medically relevant trivia, but it's when the good stuff your learned first year goes bad, which makes it slightly more interesting, like a Fox special. Third year, you lose all of your freedoms by becoming the lowest ranked person in the hospital...but you get to see patients and tell their stories to everyone else and pretend to be a doctor. Fourth year, they let you think you've learned something and allow you some freedom to sleep to choose what you do. Then depending on your specialty you get paid too little to work too much in residency for a few to several years. Finally, when all that's over, you can get a real job and have President Hillary Clinton (in her second term) signing your paycheck. (Or you can join the rebel forces and strike out on your own in private practice.) (Or you can avoid the whole ordeal and do a few fellowships and wait for the next fix.)

-It doesn't get better, you just learn to accept the crap they pile upon you more easily.
-You'll slowly realize that you will indeed, some day, need this knowledge to figure out what the hell is wrong with someone. That is why you're studying it after all.
-As much as this profession sucks, someone has to do it...it might as well be you doing it.

My suggestions
for the short term:
Go back and read the lies in your personal statement and secondaries, realize how naive you were. Laugh at yourself for not thinking this through better a year ago. Have a beer or 3. Write "I will not commit to 7 years of torture without thinking it through ever again" on a white board 50 times for emphasis. Pass out, wake up and remember the previous night from the white board, laugh because it's so true.

Medium Term:
Schedule a day to shadow in the ED of your school's affiliated hospital, put on your short white coat of indignation and listen to the patients' stories about why they're there, listen to the doctors' story about why they show up there day after day. Schedule a day in the Pediatric Oncology ward, read stories to the kids, play with them, talk to the doctors and nurses about why they go back to that floor day after day after day. Go to Hospice for a day, go to psych for a day. Lather, Rinse, Repeat with anyone else in the hospital.

Longer term
Go back to your room. Sit by yourself in the quiet and listen to why you're there. Write it down on your blog, read it whenever you're feeling like all of this isn't worth it. If you can't hear anything, you're not listening hard enough. If you honestly can't find one redeeming reason deep down in your soul to grab on to that makes all of this worth it, give up your spot, give as much of your loans back as you can, and get the hell out of dodge before you've bought a house that you'll never live in. Being miserable for the rest of your life is not worth a couple letters after your name.


What's the point?
Remember who you were, learn who you'll be, do something about it...that's all there is to it.

Best of luck
~Bostonian

Back in the saddle...

Well, I've had a busy past few weeks that have completely derailed my blogging. Between a transcontinental flight, baseball and barely surviving my path exam, I've been somewhat distracted. However, stay tuned for more regular updates to the drama that is my life. I'm going to try to mix in some different styles of writing other than just ranting about how much reading about/being tested on the pathological happenings of the human body sucks the life out of you. Stay tuned...
~Bostonian

PS- As much joy as I feel at the downfall of the Yankees, I also feel a great deal of empathy for Joe Torre and the position that he has been forced into by account of the maniacal George Steinbrenner III threats/whims. To quote Seinfeld: The man fires people like it's a bodily function

P=MD?

Well, I actually managed to survive and pass both of my exams. Path was probably the most angst-inducing exam that I have ever been subjected to. 3 hours, 168 questions. I'd say for about 20%, the extent of my knowledge of the subject was covered in the question and the answers were just flat out beyond what I had absorbed from the readings.

Micro was mercifully fair, except for the level of depth we were expected to know about fungi...which I neglected to cram into my already over-full brain. Overall, last friday was a rough go at it for me and I'll need to severely modify my exam preparation techniques if I'm going to make it out of this year alive. I questioned my worthiness as a medical student a few times, and even pondered a career in the fast food industry for a few minutes. But I survived, with only a few gray hairs to show for it.