Biochem is an absolute slog...even for someone who was once considering it as a career choice. It's surprising how much of it is sitting in the recesses of my mind looking somewhat familiar...but there's still a whole bunch that is completely gone.
I'm quickly falling back into a bad habit where I pretty much find any excuse not to pay attention to what's open in front of me...especially when my laptop is within arms reach. I'm going to have to start leaving the lappy in it's case with the battery and charger hidden in the next county until I get bored enough of reading/highliting/noting to do some questions.
Overall, I'm getting the feeling that First Aid isn't quite enough for many topics that QBank is tossing at me,it is REALLY just the bare bones of the topics/diseases. To make matters even more confusing, QBank also seems a bit more in depth than the NBME exams that I've taken at school...the two step logic jump that Kaplan is asking for is quite a leap at times. For example, the question will give a fairly in depth clinical presentation and ask where the chromosomal abnormality is, or clinical scenario and ask what drug should be given. They bash you over the head with the clinical presentation, but then make the second step slightly harder. I found the NBME's to be slightly less picky in the answers they give.
But for day two of torture, I'm ok with how things are going overall, I'm just hoping to see an upward trend in QBank over the next week or so.
5.19.2008
5.15.2008
A simple plan
So I have "successfully" completed second year...hooray! Instead of feeling a sense of accomplishment or relief, I'm feeling a sense of a lot of impending work over the next 5 weeks. You'll notice my OCD schedule above. I tailored it to where I'm weak...Heme/Onc, Cardio, Neuro and Renal (even though I did well on the NBME in Renal, I just lack all self confidence after the in-house exam that I took).
My class took a practice NBME exam a few weeks ago. I was in the 190's without studying at all. In fact, I was barely awake while I was taking it so I'm not too concerned with passing. My approach is more about getting the material to be fresh, making up for my weaknesses, and solidifying the big picture so that I can have a gut reaction with the questions that I'm still tentative on. I'm usually pretty good on standardized exams (SAT/MCAT) so hopefully those skills will carry on over.
Here's the breakdown for my strategy:
- 5 weeks
- 8-10 hours of studying per day. AM Run/Breakfast, Lunch and Dinner breaks and done at 9PM regardless of where I am.
- 1 catch-up/NBME/chill day tossed in each week to retain my sanity and show how I'm progressing. I'm only doing the first 4 NBME exams. 5&6 have been released, but I think that doing more towards the beginning will just stress me out.
- Green is Subject Based:
- Biochem, Behavioral, Micro, General Path, and Pharm...clustered towards the beginning because they're the basis of path.
- Orange is system based:
- First Aid is my systems based approach as a guiding outline
- HY Anatomy and Physiology for each system to refresh myself on the basics of how it works, innervation, etc.
- Rapid Review and BRS for the Pathology of each system
- Organizing notes placed into FA
- Pharm reviewed with the relevant pathology
- 50 RANDOMIZED Kaplan QBank questions per day
I'll definitely be posting about my progress, at least once a week. For now though, I have to go get a hair cut, do some laundry and get the rest of my affairs in order before I leave for VT.
5.11.2008
A call to action?
Alot of what I have been reading lately has gotten me a bit annoyed at the medical profession as a whole. Everyone from the media to the bloggers to the AMA to the PRESIDENT has been whining about the state of medicine today...perhaps we should try doing something about it.
There is a lot of negativity in the medical community over the current state of affairs. The field is being torn apart between the interests of the patients, the government, the insurance companies, the bureaucrats, the media, the physicians, the administrators and the pharmaceutical companies. Even within the individual components there are an infinite number of directions being pulled. It seems like every part of the medical world is pulling in a different direction in an attempt to topple one of the few human enterprises that has helped the world progress out of the dark ages in upon itself.
It's like one of those stupid vector problems from high school physics: the ultimate sum of the directions that everyone is pulling is 0...there is no direction, there is no movement. We have reached an absolute balance point where something needs to be done, but nobody knows which direction to push the damned thing because we're too busy trying to reconcile the millions of individual components that have created the mess in the first place.
And so we sit around in complacency, scratching our heads and bemoaning the fact that something needs to be done. We throw around half-baked ideas of government run medicine or completely free market medicine or Doc-in-a-box medicine and hope that someone has enough momentum to tip the damned thing in the right direction. Meanwhile, the problem just sits there getting more entangled as it is pulled in more directions.
We call it a health care crisis, but no one seems to be doing anything about it. A crisis implies a need for action...and to my 24 years of memory medicine has been in a state of crisis since the first Clinton administration (I was in 3rd grade by the way). We need a leader to take on this mess, cut it down to the basic issues (of how to provide health care for those in need/transfer money from recipient to providers/cut out the rest of the BS) and plow the solution through the steaming piles of divisive political BS that have hampered the progress of this country.
We predict a disastrous future without action to prepare for it...we need to prepare! Maybe it's time that we (as decent, rational, free thinking, American human beings) do something...
There is a lot of negativity in the medical community over the current state of affairs. The field is being torn apart between the interests of the patients, the government, the insurance companies, the bureaucrats, the media, the physicians, the administrators and the pharmaceutical companies. Even within the individual components there are an infinite number of directions being pulled. It seems like every part of the medical world is pulling in a different direction in an attempt to topple one of the few human enterprises that has helped the world progress out of the dark ages in upon itself.
It's like one of those stupid vector problems from high school physics: the ultimate sum of the directions that everyone is pulling is 0...there is no direction, there is no movement. We have reached an absolute balance point where something needs to be done, but nobody knows which direction to push the damned thing because we're too busy trying to reconcile the millions of individual components that have created the mess in the first place.
And so we sit around in complacency, scratching our heads and bemoaning the fact that something needs to be done. We throw around half-baked ideas of government run medicine or completely free market medicine or Doc-in-a-box medicine and hope that someone has enough momentum to tip the damned thing in the right direction. Meanwhile, the problem just sits there getting more entangled as it is pulled in more directions.
We call it a health care crisis, but no one seems to be doing anything about it. A crisis implies a need for action...and to my 24 years of memory medicine has been in a state of crisis since the first Clinton administration (I was in 3rd grade by the way). We need a leader to take on this mess, cut it down to the basic issues (of how to provide health care for those in need/transfer money from recipient to providers/cut out the rest of the BS) and plow the solution through the steaming piles of divisive political BS that have hampered the progress of this country.
We predict a disastrous future without action to prepare for it...we need to prepare! Maybe it's time that we (as decent, rational, free thinking, American human beings) do something...
5.10.2008
Reasons not to go to medical school
The Lone Coyote posted an interesting article the other day from Forbes that has gotten me thinking about my choices over the past few years and the state of medicine...did I actually know what I was getting into?
I thought that I knew what was up a few years ago when I started my pre-medical education. Do well in college, pad your resume with research and medical related stuff. Apply, get accepted and spend 2 years of studying your life away in the library followed by 2 years of being nearly purposeless in the hospital. Do some scut, apply for residency and get a job. Great, grand wonderful...piece of cake I would think to myself.
Then you get to a point where you've put in 8 years of higher education at your own expense and people call you Doctor. But you're paid less than burger flipping wages for 3-6 years of 30 hour shifts and night swing coverage while being to be one of the most productive members of the staff, bouncing around between services, all the while jumping through hoops to keep everyone happy so you don't get fired from your indentured servitude. Not too bad, I can do that.
Now you're 30-35 years old and just finally for the first time cut free from the bonds of the medical education system and expected to tackle the immense task of building a practice or desperately launching yourself into academia. You'll be paying off loans into your 50's and you're probably going to end up divorced 2 or 3 times with a couple different kids who hate you. You're going to be sued, you're going to kill 3 patients (on average). Whatever, that's like decades from now...not my concern.
Boy was I naive thinking that was all there was to it...
You build up a perfect little image of your future. I can distinctly remember thinking about all the cool things I would do, but I never really thought about what the nitty-gritty of being a doctor would be all about. I knew there would be missed soccer games/dance recitals/school plays/birthday parties...that comes with the territory. I observed a couple of shifts at UMass in college and pictured myself as one of the ER docs flying around in their Chopper. I worked at Children's Hospital and I saw myself becoming a surgeon and doing cool Pediatric operations like you see on TV. I sprained my ankle pretty badly and went to an orthopod's office and saw myself in a sports medicine practice dealing with sprained ankles and scheduling rehab for athletes. I still can see myself doing a lot of things...I must be delusional!
Soon I'm going to be pulling my head out of my books and getting to learn the practice of medicine for myself. I'm going to see it in all of it's horrific glory...and for better or worse, I'm financially destined to continue to this path to being a doctor.
I thought that I knew what was up a few years ago when I started my pre-medical education. Do well in college, pad your resume with research and medical related stuff. Apply, get accepted and spend 2 years of studying your life away in the library followed by 2 years of being nearly purposeless in the hospital. Do some scut, apply for residency and get a job. Great, grand wonderful...piece of cake I would think to myself.
Then you get to a point where you've put in 8 years of higher education at your own expense and people call you Doctor. But you're paid less than burger flipping wages for 3-6 years of 30 hour shifts and night swing coverage while being to be one of the most productive members of the staff, bouncing around between services, all the while jumping through hoops to keep everyone happy so you don't get fired from your indentured servitude. Not too bad, I can do that.
Now you're 30-35 years old and just finally for the first time cut free from the bonds of the medical education system and expected to tackle the immense task of building a practice or desperately launching yourself into academia. You'll be paying off loans into your 50's and you're probably going to end up divorced 2 or 3 times with a couple different kids who hate you. You're going to be sued, you're going to kill 3 patients (on average). Whatever, that's like decades from now...not my concern.
Boy was I naive thinking that was all there was to it...
You build up a perfect little image of your future. I can distinctly remember thinking about all the cool things I would do, but I never really thought about what the nitty-gritty of being a doctor would be all about. I knew there would be missed soccer games/dance recitals/school plays/birthday parties...that comes with the territory. I observed a couple of shifts at UMass in college and pictured myself as one of the ER docs flying around in their Chopper. I worked at Children's Hospital and I saw myself becoming a surgeon and doing cool Pediatric operations like you see on TV. I sprained my ankle pretty badly and went to an orthopod's office and saw myself in a sports medicine practice dealing with sprained ankles and scheduling rehab for athletes. I still can see myself doing a lot of things...I must be delusional!
Soon I'm going to be pulling my head out of my books and getting to learn the practice of medicine for myself. I'm going to see it in all of it's horrific glory...and for better or worse, I'm financially destined to continue to this path to being a doctor.
5.09.2008
Done with path
I've been laying in bed for the past few hours in the grips of insomnia. I haven't really been thinking about anything in particular, but I haven't been not thinking either.
I cannot believe that I am almost finished with the first two years of medical school. It has not been at all what I expected it to be. I came in with delusions of grandeur, ready to save the world and be passionate about everything that I learned. I was excited to escape the hum-drum rhythm of the working world, but I realize now that I miss having that rhythm in my life. I do not, however, miss sitting on the Mass Pike in traffic. I especially miss the sense of purpose that having a place to be in the morning gives me. I've been really bad about going to class this semester, not having anywhere that I absolutely had to be made me feel somewhat useless and didn't really give me the incentive to get out of bed in the morning raring to go.
I am looking forward to third year and all of the ridiculous new requirements it will bring. I think that I'll finally have a sense of my life moving forward again, that I'm ticking off the boxes that I need to get out of NY and into a career. Second year was an absolute slog for me, partially because I have made it so in my mind and partially because of the drawn out nature of our schedule. I think that having a new service to work on every few weeks, seeing new people every day, having someone tell me what to do and where to be will at least give me a reason to get out of bed in the morning, if nothing else. I'm also looking forward to the subjective grading scheme, where how hard I work has a bearing on how I perform. It seemed no matter how hard I worked this year that I always ended up in the same spot on the curve.
I think the greatest sense of accomplishment from second year comes when I look at the tattered, over-highlighted pages of my copy of Robbins. I read that damned book cover to cover, and while how much I retained is another story, I knew enough of all of it at some point to pass the course. That's a pretty cool feeling, that passes as soon as I realize the number of hours I spent hunched over a desk in the library.
Anyway, 2 more exams and then it's onto board studying. For anyone that's interested, I passed the in-house path exam and I'll be waiting with baited breath for the shelf results in 2 weeks. I'm off to try to sleep now...hopefully I'll get some shut-eye.
I cannot believe that I am almost finished with the first two years of medical school. It has not been at all what I expected it to be. I came in with delusions of grandeur, ready to save the world and be passionate about everything that I learned. I was excited to escape the hum-drum rhythm of the working world, but I realize now that I miss having that rhythm in my life. I do not, however, miss sitting on the Mass Pike in traffic. I especially miss the sense of purpose that having a place to be in the morning gives me. I've been really bad about going to class this semester, not having anywhere that I absolutely had to be made me feel somewhat useless and didn't really give me the incentive to get out of bed in the morning raring to go.
I am looking forward to third year and all of the ridiculous new requirements it will bring. I think that I'll finally have a sense of my life moving forward again, that I'm ticking off the boxes that I need to get out of NY and into a career. Second year was an absolute slog for me, partially because I have made it so in my mind and partially because of the drawn out nature of our schedule. I think that having a new service to work on every few weeks, seeing new people every day, having someone tell me what to do and where to be will at least give me a reason to get out of bed in the morning, if nothing else. I'm also looking forward to the subjective grading scheme, where how hard I work has a bearing on how I perform. It seemed no matter how hard I worked this year that I always ended up in the same spot on the curve.
I think the greatest sense of accomplishment from second year comes when I look at the tattered, over-highlighted pages of my copy of Robbins. I read that damned book cover to cover, and while how much I retained is another story, I knew enough of all of it at some point to pass the course. That's a pretty cool feeling, that passes as soon as I realize the number of hours I spent hunched over a desk in the library.
Anyway, 2 more exams and then it's onto board studying. For anyone that's interested, I passed the in-house path exam and I'll be waiting with baited breath for the shelf results in 2 weeks. I'm off to try to sleep now...hopefully I'll get some shut-eye.
5.07.2008
PATH
Pathology ends tomorrow after two exams (in house mid-term and an NBME shelf)...I'm counting down the minutes (approximately 960 as of midnight).
It's been a struggle and I have some issues with how the course was run. Overall, I feel like I have a fairly solid basis for taking on the boards successfully in about 46 days...but that's another issue...I still have to make it out of this semester in one academic piece.
Catch ya on the flip side.
It's been a struggle and I have some issues with how the course was run. Overall, I feel like I have a fairly solid basis for taking on the boards successfully in about 46 days...but that's another issue...I still have to make it out of this semester in one academic piece.
Catch ya on the flip side.
5.05.2008
Apologies
Increasingly, I find myself apologizing for being a medical student. It has gotten to the point where my reflex is to give a detailed schedule out through September and an account of what I'll be doing so people don't think that I'm blowing them off...I really am that busy and not going to be in town or free until September! It could be Mother's Day (Sorry Mom!) or my brother moving into his new house (Sorry Bro), or my friends marriage that falls in the middle of my surgery rotation (Sorry Guys! Enjoy my gift!) or my girlfriend's graduation ball (Sorry Hun), but it's always the same story...I have school, I cant get away. Yes, I have to study for a straight week before my exams, no I'm not stupid. Yes I have to study for 6 weeks straight for the boards, it determines a big chunk of my career. No I can't go to Vegas with you because I have to work 60 hours that week, I'm probably staying late most nights and I'm probably on overnight call that Saturday too...yeah, I'll see you at Christmas too.
One of my friends has been in town for work on and off for the past few months and I've turned down his invites for drinks a few times now. He's VERY understanding of the whole thing, but I'm just wondering when understanding runs out like it has with so many others...
What other career can you rack up $260k of debt and lose your personal life all before your first sub-minimal wage paycheck?
One of my friends has been in town for work on and off for the past few months and I've turned down his invites for drinks a few times now. He's VERY understanding of the whole thing, but I'm just wondering when understanding runs out like it has with so many others...
What other career can you rack up $260k of debt and lose your personal life all before your first sub-minimal wage paycheck?
4.29.2008
100th post...
100 posts...I'll dedicate this post to the fact that I've pretty much finished my pre-clinical medical education. Thanks for reading.
Looking back on the past 15,454 hours (or 21 months, 4 days...not that I'm counting) of my life, I'm not all that impressed by what I've seen. I've done a lot of sitting infront of books, I've run through 70+ highlighters, I've done a lot of memorizing but not a lot of learning. Every time that I think that I've mastered a subject, I go back and the foundation has fallen out from it. I try to look at the forest, but all I see are the individual pine needles. At this point, my exams test for ability to regurgitate random minutiae from Robbins, not for understanding of the material. Understanding material and being able to regurgitate sentences from Robbins on demand are very different. For one, I don't see the utility of being able to recite the translocations responsible for 15 different hematologic malignancies, or the cell of origin of one of the 25 difference neoplasms of the ovaries in the education of someone who will be a family physician, psychiatrist or emergency physician.
There has been a lot of wasted effort in my education, on both my behalf as well on the behalf of the AAMC/LCME who have an asininely archaic idea of what medical education should be. After June 23rd about 70% of what I've been forced to learn over the past 2 years will be vaporized from my short term memory. All those little interconnected neurons in my holding medical knowledge in my hippocampus will simply rearrange some microtubules and the hours I spent slaving over the pages of Robbins will spill out of my the distance reaches of my consciousness. Two years of my life be reduced nothing more than a few distant memories of sitting my ass in front of that same crappy carrel in the dingy basement of the library with the humming of the furnace and the fluorescent lights in my ears.
You would think that I would be sad that I'm about to reduce the intimate memories of approximately 1/12th of my life down to one simple experience that I like to refer to as "The Suck." But I'm not. You see, the past 21 months have been little more than a requisite right of passage into what I've been waiting to experience: LEARNING MEDICINE! Isn't that what I've paid for thus far? Didn't I go to medical school and not "memgurgitate lots of information that you probably will never see in the course of your career for the fun of it" school?
The ironic thing is that I'll probably look back on all of this in the middle of one of my over-night call shifts on surgery or OB and long for the days where I could sleep for 8 solid hours and control my own schedule instead of being abused on the floors. But for now, I'm hopeful that seeing and experiencing the management of patients and their various disease will re-ignite my failing passion for medicine.
Looking back on the past 15,454 hours (or 21 months, 4 days...not that I'm counting) of my life, I'm not all that impressed by what I've seen. I've done a lot of sitting infront of books, I've run through 70+ highlighters, I've done a lot of memorizing but not a lot of learning. Every time that I think that I've mastered a subject, I go back and the foundation has fallen out from it. I try to look at the forest, but all I see are the individual pine needles. At this point, my exams test for ability to regurgitate random minutiae from Robbins, not for understanding of the material. Understanding material and being able to regurgitate sentences from Robbins on demand are very different. For one, I don't see the utility of being able to recite the translocations responsible for 15 different hematologic malignancies, or the cell of origin of one of the 25 difference neoplasms of the ovaries in the education of someone who will be a family physician, psychiatrist or emergency physician.
There has been a lot of wasted effort in my education, on both my behalf as well on the behalf of the AAMC/LCME who have an asininely archaic idea of what medical education should be. After June 23rd about 70% of what I've been forced to learn over the past 2 years will be vaporized from my short term memory. All those little interconnected neurons in my holding medical knowledge in my hippocampus will simply rearrange some microtubules and the hours I spent slaving over the pages of Robbins will spill out of my the distance reaches of my consciousness. Two years of my life be reduced nothing more than a few distant memories of sitting my ass in front of that same crappy carrel in the dingy basement of the library with the humming of the furnace and the fluorescent lights in my ears.
You would think that I would be sad that I'm about to reduce the intimate memories of approximately 1/12th of my life down to one simple experience that I like to refer to as "The Suck." But I'm not. You see, the past 21 months have been little more than a requisite right of passage into what I've been waiting to experience: LEARNING MEDICINE! Isn't that what I've paid for thus far? Didn't I go to medical school and not "memgurgitate lots of information that you probably will never see in the course of your career for the fun of it" school?
The ironic thing is that I'll probably look back on all of this in the middle of one of my over-night call shifts on surgery or OB and long for the days where I could sleep for 8 solid hours and control my own schedule instead of being abused on the floors. But for now, I'm hopeful that seeing and experiencing the management of patients and their various disease will re-ignite my failing passion for medicine.
4.27.2008
What it's all about
If you've read this blog with any frequency, you know that I have an soft spot in my heart for cancer stories and patients who have been through the medical ringer with their diagnosis and treatment. My heart absolutely goes out to those abandoned souls who are left hanging without a physician who will advocate for them.
We had a patient presentation session this past week from breast cancer survivors treated by one of our faculty physicians. The stories of these women were sad and at the same time absolutely appalling. Between all of the mis-diagnoses, the poor attention paid to their needs, the lack of communication and the delays between procedures, it's a wonder that these women are alive at all. It reminded me why I wanted to get into this field in the first place and brought together a lot of what doctoring is all about.
-First patient: Hypodensity in one breast was missed over a fibroadenoma in the other breast. She was cleared for hormone replacement therapy. A year later, and she had full blown carcinoma that was being fed by her estrogen replacement...though that mechanism was not completely lucid at the time. Found the doc on campus and had everything taken care of and is still here to tell the story.
-Second patient: She made me extremely sad. She felt a lump, and had a mammogram done. She was diagnosed clinically with breast cancer on that mammogram. She requested a second opinion, and was sent to another oncologist at a prestigious ivory tower institution on the East Coast with another patient's films. The oncologist picked up on it right away, and repeat films were clean. Two years later, her films were not clean and so she returned to that same ivory tower practice to find that the physician had retired and left the practice in the hands of another doc. This guy was all about fitting in as many patients as possible. He drained the patient's cystic adenomas monthly for 8 months without biopsy, until one visit he stopped getting fluid. He looked at the patient and said "I think I made a mistake. Go see the receptionist, and we'll get you in for a biopsy." He didn't have an opening until 4 months later...so she left and came to our institution and found this doc who made everything all right, after a year of weekly chemo.
-Third patient: Basically got told by a doc at a NYC Cancer Mecca that she had breast cancer, and was not presented with the full amount of information that she requested. Great doctor, crappy care. The doctor gave her info and treatment options on a need to know basis and basically told her what she was going to do. She left out of frustration and found the doc at our institution who presented the entire picture of how they were going to get through it.
---------------------
The take home message that I got out of this session was that communication is 95% of being good physician. If you're not able to communicate what is going on with the patient, how you're going to fix it and what they need to do, the patient is going to lose faith in you from the get go. Your work lies in finding and correcting the errors in physiology and anatomy of another human being!!! This is not some computer simulation or lab animal or entry in Robbins that you're dealing with, it's a person and their life and their family. You can be the most technically knowledgeable and capable individual in the field, but what takes you that extra step ahead of the rest is the simple ability to explain the situation to a very scared person, who may not be thinking rationally, and to make them understand what you're about to do.
I see so many of my colleagues lacking in this regard, and I worry for their future patients and the future of medicine.
We had a patient presentation session this past week from breast cancer survivors treated by one of our faculty physicians. The stories of these women were sad and at the same time absolutely appalling. Between all of the mis-diagnoses, the poor attention paid to their needs, the lack of communication and the delays between procedures, it's a wonder that these women are alive at all. It reminded me why I wanted to get into this field in the first place and brought together a lot of what doctoring is all about.
-First patient: Hypodensity in one breast was missed over a fibroadenoma in the other breast. She was cleared for hormone replacement therapy. A year later, and she had full blown carcinoma that was being fed by her estrogen replacement...though that mechanism was not completely lucid at the time. Found the doc on campus and had everything taken care of and is still here to tell the story.
-Second patient: She made me extremely sad. She felt a lump, and had a mammogram done. She was diagnosed clinically with breast cancer on that mammogram. She requested a second opinion, and was sent to another oncologist at a prestigious ivory tower institution on the East Coast with another patient's films. The oncologist picked up on it right away, and repeat films were clean. Two years later, her films were not clean and so she returned to that same ivory tower practice to find that the physician had retired and left the practice in the hands of another doc. This guy was all about fitting in as many patients as possible. He drained the patient's cystic adenomas monthly for 8 months without biopsy, until one visit he stopped getting fluid. He looked at the patient and said "I think I made a mistake. Go see the receptionist, and we'll get you in for a biopsy." He didn't have an opening until 4 months later...so she left and came to our institution and found this doc who made everything all right, after a year of weekly chemo.
-Third patient: Basically got told by a doc at a NYC Cancer Mecca that she had breast cancer, and was not presented with the full amount of information that she requested. Great doctor, crappy care. The doctor gave her info and treatment options on a need to know basis and basically told her what she was going to do. She left out of frustration and found the doc at our institution who presented the entire picture of how they were going to get through it.
---------------------
The take home message that I got out of this session was that communication is 95% of being good physician. If you're not able to communicate what is going on with the patient, how you're going to fix it and what they need to do, the patient is going to lose faith in you from the get go. Your work lies in finding and correcting the errors in physiology and anatomy of another human being!!! This is not some computer simulation or lab animal or entry in Robbins that you're dealing with, it's a person and their life and their family. You can be the most technically knowledgeable and capable individual in the field, but what takes you that extra step ahead of the rest is the simple ability to explain the situation to a very scared person, who may not be thinking rationally, and to make them understand what you're about to do.
I see so many of my colleagues lacking in this regard, and I worry for their future patients and the future of medicine.
4.22.2008
Progress...
Part of the reason that I've been writing less is that I've been running a bit more and doing other outside funtime activities. That has provided me with a whole bunch of good feeling endorphins, incremental gains in fitness and a dose of sanity that nothing else has been able to provide to this point. I feel better, I've cut back on coffee consumption, I'm sleeping a bit better and I have a good excuse not to study. And the dress slacks fit better now too...which is always a plus.
I took my longest run in a while this weekend -5.3 miles- which felt great and I put in my first structured speed work since high school. I think the hardest part about getting back into running is that I'm still getting used to the fact that I'm a beginner again. I can't expect my body to pound out a decent pace like I used to, and it takes a bit of mental work to realign my perceived effort level with the paces/times that I'm putting up. So far the heart rate monitor is helping out with that aspect, I know where my lactate threshold is and where I need to put my heart rate to match my perceived effort, my feet just fall in line with the rest...kind of a cool quasi-physiological way to approach things. I'm also taking time to rest, which is helping out alot with the aches that plagued me for a lot of my earlier self-directed running.
I cobbled together a half-marathon training schedule that takes me up to the race in October. I'm almost sticking to it, except when exam weeks get in the way. I just hope that Surgery doesn't completely kill my hopes of finishing the race...but we'll see!
******************
I'm getting into the home stretch with classes, and starting to get all wound up for the boards in June. The nice weather is making it increasingly difficult to lock myself in the library with my good ol' pal Robbins, but I've been fairly good thus far.
Looking back on the first two years of medical school, it's been rough. It's not that the material is difficult to understand. It's the frame of reference that's been killing me all along. I'm an active learner. I learn by doing and seeing, not by staring at piles of notes and pages of readings. There is no way to actively learn pathology or biochem or any of the pre-clinical material, really. Seeing patients with their diseases makes the material stick more than the books do. It's just been the pure grunt work of slogging through the material until enough of it sticks, and that's led to some disappointing performances for me...like all of them. I've never felt less confident about what I'm doing in my life, and to have to live with that lack of confidence is draining.
Two weeks of torture left though, then a week of reading period/exams and then it's time for me to study for the boards. I'm looking foward to board studying, because I have a schedule that I'm going to stick to and it should be plenty to get a decent score on the step 1's. I'll probably continue to sneak in a post or two a week, updating about running/studying/life in general.
I took my longest run in a while this weekend -5.3 miles- which felt great and I put in my first structured speed work since high school. I think the hardest part about getting back into running is that I'm still getting used to the fact that I'm a beginner again. I can't expect my body to pound out a decent pace like I used to, and it takes a bit of mental work to realign my perceived effort level with the paces/times that I'm putting up. So far the heart rate monitor is helping out with that aspect, I know where my lactate threshold is and where I need to put my heart rate to match my perceived effort, my feet just fall in line with the rest...kind of a cool quasi-physiological way to approach things. I'm also taking time to rest, which is helping out alot with the aches that plagued me for a lot of my earlier self-directed running.
I cobbled together a half-marathon training schedule that takes me up to the race in October. I'm almost sticking to it, except when exam weeks get in the way. I just hope that Surgery doesn't completely kill my hopes of finishing the race...but we'll see!
******************
I'm getting into the home stretch with classes, and starting to get all wound up for the boards in June. The nice weather is making it increasingly difficult to lock myself in the library with my good ol' pal Robbins, but I've been fairly good thus far.
Looking back on the first two years of medical school, it's been rough. It's not that the material is difficult to understand. It's the frame of reference that's been killing me all along. I'm an active learner. I learn by doing and seeing, not by staring at piles of notes and pages of readings. There is no way to actively learn pathology or biochem or any of the pre-clinical material, really. Seeing patients with their diseases makes the material stick more than the books do. It's just been the pure grunt work of slogging through the material until enough of it sticks, and that's led to some disappointing performances for me...like all of them. I've never felt less confident about what I'm doing in my life, and to have to live with that lack of confidence is draining.
Two weeks of torture left though, then a week of reading period/exams and then it's time for me to study for the boards. I'm looking foward to board studying, because I have a schedule that I'm going to stick to and it should be plenty to get a decent score on the step 1's. I'll probably continue to sneak in a post or two a week, updating about running/studying/life in general.
4.21.2008
Yankee Stadium Revisited
Every time I head down to the Bronx to watch a ball game I get a few too many beers into me and awesomeness ensues:
I'm generally not a well liked person within the walls of Yankee Stadium, and I'm OK with that for the most part. I understand that two of the best teams in baseball play each other 18 times a year. I know that it's going to be a 4 hour game with plenty of action. I know that I'm going to be screamed at for the entirety of those 4 hours and every portion of my life will be insulted. I usually have a few drinks so that I can appreciate the atmosphere and lower my inhibitions about yelling insults at perfect strangers and their mothers. So here's how the night went:
shouting matches with the entire train car that lead to me being escorted to another car"spirited conversations" the whole way home.
EDIT: One of my friends that was at the game sent me the following link saying that this could have easily been me. I'm not a violent person by nature so I think he was a little bit off, but check it out anyway!
I'm generally not a well liked person within the walls of Yankee Stadium, and I'm OK with that for the most part. I understand that two of the best teams in baseball play each other 18 times a year. I know that it's going to be a 4 hour game with plenty of action. I know that I'm going to be screamed at for the entirety of those 4 hours and every portion of my life will be insulted. I usually have a few drinks so that I can appreciate the atmosphere and lower my inhibitions about yelling insults at perfect strangers and their mothers. So here's how the night went:
- Within about 30 seconds of opening the car doors in the parking garage, my friend and I are booed mercilessly. So we tailgated for a while because $10.50 for a Hineken is obscene.
- On the way up to our 3rd tier seats, I stop to buy a beer for the walk up to our alcohol free seating. The beer lady looks at me and says with the thickest accent she can muster "NO, I don't serve any Red Sox fans". The other beer lady came over and poured me a beer...and she got a tip too!
- We exit the concourse onto the third tier seating. My friend and I remained standing to finish our beers, and we were greeted by an intoxicated fan's "Hey, go F--- yourself and your mother". Officer Del Reye of the NYPD had a nice chat with him and I felt a little bit safer.
- Later on, I'm waiting in line for the Men's room (only place on earth I've ever experienced this) and I get my favorite insult of the night. "Hey! You in the Sox jersey! Your penis is attached to you vagina!" I looked at the guy for a second, marveling at his stupidity, and said "I don't even know what that means." He shrugged and left...by far the best insult I've ever received because it was hilarious for everyone
EDIT: One of my friends that was at the game sent me the following link saying that this could have easily been me. I'm not a violent person by nature so I think he was a little bit off, but check it out anyway!
4.12.2008
Quotes from the rectum
Ok so I have to share this one with everyone, despite how disturbing it is to me. So I had my standard male genitourinary and rectal exam a few weeks ago, and I just keep relaying one quote to everyone that asks how it went.
So we finished up the awkward exam of the male genitals (junk or twig and two berries if you will) and perenium (the taint or grundle for the anatomically disinclined). I've plucked this guys spermatic cords about 5 times and have had my finger up into his inguinal canal to feel his hernia...crossing all sorts of boundaries that I've never crossed with another man's junk, with minimal public display of discomfort. The patient/actor/educator turns around to the three of us males in the room and says:
"Hold up your hands."
We oblige. Pointing to the large-handed former football player, he deadpan says "Ok, you've got the biggest fingers, you're going to go first and open me up."
Great way to make things comfortable and welcoming for all with that visual aid...whilst I insert my fingers into your rectum...ugh.
Thanks for that again. I'll definitely be rushing to do my requisite 10 observed rectals on my surgery rotation in July after that experience.
So we finished up the awkward exam of the male genitals (junk or twig and two berries if you will) and perenium (the taint or grundle for the anatomically disinclined). I've plucked this guys spermatic cords about 5 times and have had my finger up into his inguinal canal to feel his hernia...crossing all sorts of boundaries that I've never crossed with another man's junk, with minimal public display of discomfort. The patient/actor/educator turns around to the three of us males in the room and says:
"Hold up your hands."
We oblige. Pointing to the large-handed former football player, he deadpan says "Ok, you've got the biggest fingers, you're going to go first and open me up."
Great way to make things comfortable and welcoming for all with that visual aid...whilst I insert my fingers into your rectum...ugh.
Thanks for that again. I'll definitely be rushing to do my requisite 10 observed rectals on my surgery rotation in July after that experience.
Lack of blogging motivation
So I've kind of been out of ideas for writing lately, and for that I apologize to anyone who still regularly checks in. I've been running away from school for the past two weekends since my renal path exam and the rest of my free time is being eaten up by a stupid group project.
I'm not quite sure why as a 24 year old medical student I'm still assigned group work. Honestly, I am quite capable of working with a group to complete an assignment as well as doing it independently. I think that group science report that I did in elementary school proved that skill set. But here I am again, trying to coordinate 7 other classmates to create a paper that will live up to the nit-picky expectations of the course director. I've realized that I naturally gravitate to these types of positions where I take on the burden of getting a group of people to pull in the same direction, and usually I do ok with them. Hopefully, we can get a decent grade out of this project for all of us, I've certainly done my share. Especially with rewriting the sections assigned to the the one member of the group that struggles to write a coherent paragraph. I figured the 5 non-native english speakers would be the dead weight in the writing department, but they actually write quite well...it was one of the two native speakers that gave me trouble...figures.
******************
So I got out to my favorite spot on earth this afternoon again: Fenway Park.
There's just something about the hustle and bustle around the ball park that makes me feel invigorated. Once I'm through the ticket gates, I like to immediately descend from the overly comercialized and family friendly Yawkey Way into the dimly bowels of the stadium that has stood there, almost unchanged since 1912. It almost feels like I'm traveling back in time amidst the smokey aroma of sausage on the grill and the white noise of 37,000 people vibrating through the concrete structure. Each descent brings back floods of memories of dozens of visits before, all rushing back at once. It's similar to what I imagine seeing your life flash before your eyes is like, but you can do it whenever you like for the price of admission. There's the usual, comfortable ritual of procuring the correct overpriced mass produced American lager for my dad in appreciation for the tickets he preennially provides, of walking down the ramp past the same souvenir vendor that's always there with the same old overpriced stuff, past the nacho/pretzel and hot dog/sausage, Papa Gino's, Beer/Peanut and Ice cream stands (yes, in that exact order). Waving to the same beer guy that's always there with some clever remark while he happily pours his brews in the corner by the entrance up to our section. It's a ritual that always feels familiar and yet always exciting and new...like nothing else I've ever experienced. If you've been to Fenway and sat on the third base side of the stadium, you probably know what I mean...it's the least renovated portion of the ball park and instead of feeling like a dump, which is what I'm sure many people would think, it feels like I'm walking back into an earlier time where nothing else matters except for enjoying the home team playing the classic american game.
For me, the real magic begins as soon as I emerge from the musty underbelly of the beast into the light and fresh air and echoing sounds of the park. I like to look up at the skyline over the right field wall and scan the outfield and just take a few seconds to absorb the atmosphere, and it instantly takes me back to the first few times that I visited the stadium back in the 80's and sat on my dad's lap and ate cotton candy and watched Wade Boggs (one of my favorite childhood players) play his heart out at third base and be the RBI machine that he was. It's a great feeling. The world could be collapsing around me (as it indeed it often seems to be these days), but I wouldn't really care if I had my butt in one of those cramped old seats. It really is a special place for me and holds hundreds of amazing memories that make me feel at peace and at home.
It's quite a stark and welcome contrast to my other life in New York, where I constantly feel out of place and like something is looming over me waiting to rend my soul to it's very roots. I wish I could better express what it is that I feel in words, but it's one of those intangibles that just nags at the periphery of my consciousness. Like when you walk into a room and absolutely know that something is out of place but you're not even sure what it is or why you have that feeling, but it's there nonetheless. I guess that I just don't feel at home there in NY and it adversely affects everything I do and weighs me down. I guess that strikes at the heart of the reason that I started writing this blog in the first place...to get over that feeling of living in a place that I will never be comfortable enough to call home.
I've come to realize over the past two years that discomfort is the place where I have to learn to be comfortable through many experiences (see "Notes from the Vagina"). However, making that leap from conceptualization to actualization is more difficult than it appears on the surface.
So that's a little bit about where I'm coming from in my life at this point, and it only took 3 overpriced, mass produced American lagers at my favorite place on earth to bring it out...hopefully I'll have something less touchy-feely to write about next time, but here's where my flow of consciousness went tonight.
Peace out girl scout...
I'm not quite sure why as a 24 year old medical student I'm still assigned group work. Honestly, I am quite capable of working with a group to complete an assignment as well as doing it independently. I think that group science report that I did in elementary school proved that skill set. But here I am again, trying to coordinate 7 other classmates to create a paper that will live up to the nit-picky expectations of the course director. I've realized that I naturally gravitate to these types of positions where I take on the burden of getting a group of people to pull in the same direction, and usually I do ok with them. Hopefully, we can get a decent grade out of this project for all of us, I've certainly done my share. Especially with rewriting the sections assigned to the the one member of the group that struggles to write a coherent paragraph. I figured the 5 non-native english speakers would be the dead weight in the writing department, but they actually write quite well...it was one of the two native speakers that gave me trouble...figures.
******************
So I got out to my favorite spot on earth this afternoon again: Fenway Park.
There's just something about the hustle and bustle around the ball park that makes me feel invigorated. Once I'm through the ticket gates, I like to immediately descend from the overly comercialized and family friendly Yawkey Way into the dimly bowels of the stadium that has stood there, almost unchanged since 1912. It almost feels like I'm traveling back in time amidst the smokey aroma of sausage on the grill and the white noise of 37,000 people vibrating through the concrete structure. Each descent brings back floods of memories of dozens of visits before, all rushing back at once. It's similar to what I imagine seeing your life flash before your eyes is like, but you can do it whenever you like for the price of admission. There's the usual, comfortable ritual of procuring the correct overpriced mass produced American lager for my dad in appreciation for the tickets he preennially provides, of walking down the ramp past the same souvenir vendor that's always there with the same old overpriced stuff, past the nacho/pretzel and hot dog/sausage, Papa Gino's, Beer/Peanut and Ice cream stands (yes, in that exact order). Waving to the same beer guy that's always there with some clever remark while he happily pours his brews in the corner by the entrance up to our section. It's a ritual that always feels familiar and yet always exciting and new...like nothing else I've ever experienced. If you've been to Fenway and sat on the third base side of the stadium, you probably know what I mean...it's the least renovated portion of the ball park and instead of feeling like a dump, which is what I'm sure many people would think, it feels like I'm walking back into an earlier time where nothing else matters except for enjoying the home team playing the classic american game.
For me, the real magic begins as soon as I emerge from the musty underbelly of the beast into the light and fresh air and echoing sounds of the park. I like to look up at the skyline over the right field wall and scan the outfield and just take a few seconds to absorb the atmosphere, and it instantly takes me back to the first few times that I visited the stadium back in the 80's and sat on my dad's lap and ate cotton candy and watched Wade Boggs (one of my favorite childhood players) play his heart out at third base and be the RBI machine that he was. It's a great feeling. The world could be collapsing around me (as it indeed it often seems to be these days), but I wouldn't really care if I had my butt in one of those cramped old seats. It really is a special place for me and holds hundreds of amazing memories that make me feel at peace and at home.
It's quite a stark and welcome contrast to my other life in New York, where I constantly feel out of place and like something is looming over me waiting to rend my soul to it's very roots. I wish I could better express what it is that I feel in words, but it's one of those intangibles that just nags at the periphery of my consciousness. Like when you walk into a room and absolutely know that something is out of place but you're not even sure what it is or why you have that feeling, but it's there nonetheless. I guess that I just don't feel at home there in NY and it adversely affects everything I do and weighs me down. I guess that strikes at the heart of the reason that I started writing this blog in the first place...to get over that feeling of living in a place that I will never be comfortable enough to call home.
I've come to realize over the past two years that discomfort is the place where I have to learn to be comfortable through many experiences (see "Notes from the Vagina"). However, making that leap from conceptualization to actualization is more difficult than it appears on the surface.
So that's a little bit about where I'm coming from in my life at this point, and it only took 3 overpriced, mass produced American lagers at my favorite place on earth to bring it out...hopefully I'll have something less touchy-feely to write about next time, but here's where my flow of consciousness went tonight.
Peace out girl scout...
4.04.2008
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.
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.
3.28.2008
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.
-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 familyvacation 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.
- 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
- 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.
3.26.2008
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...
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...
3.23.2008
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...
Bostonian: Hey guys, what's happening?
Guy: Back to hell
My thoughts exactly...
3.09.2008
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!
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!
3.07.2008
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"
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"
3.05.2008
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.
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.
***********************
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
I have my clinical skills exam this weekend, which should be fairly interesting. It's being held at the Morchand center, made famous by an episode of Seinfeld, you all know the one
Student #1: And are you experiencing any discomfort? Kramer: Just a little burning during urination. Student #1: Okay, any other pain? Kramer: The haunting memories of lost love. May I? (signals to Mickey) Lights? (Mickey turns down the lights and Kramer lights a cigar) Our eyes met across the crowded hat store. I, a customer, and she a coquettish haberdasher. Oh, I pursued and she withdrew, then she pursued and I withdrew, and so we danced. I burned for her, much like the burning during urination that I would experience soon afterwards.
Student 1: GONORRHEA!!!
Anyway, there's a a 100% chance that it will be nothing like that scene, but it should still be interesting...I'll make sure to report back. I survived my GYN exam with minimal emotional trauma. The ladies that ran the session were great and even though I was forced to desexualize the vagina, which was not an easy feat for me, they made it a very professional and educational experience. I am still afraid of the cervix though...it's one of the scariest organs that I've encountered.
***********************
Failure to Communicate
I've written a string of posts relating to my adventures through my oncologist preceptor's practice, and I think my experience came to an apex today. My classmate and I were telling our preceptor about what we thought we needed in terms of getting ready for our clinical skills practical and how we would both like to run through a H&P today to make sure we have everything down before the exam. So our first two patients were follow up visits, the first a schitzophrenic who was so gorked out on anti-psychotics that he cannot communicate and the second was a patient that we had already dealt with in the past who needed some theraputic phlebotomy.
Patients 3 and 4 didn't show, so we went out to the floor to do a consultation. We get to the patient's bedside, and my preceptor tells me to go ahead and do the H&P. Slight problem, the patient HAS NO LARYNX and has a GAPING TRACHEOSTOMY FISTULA without one of the tubes that you usually see. (PS-Don't smoke.) Ok...how to communicate with a man who cannot speak...
Bostonian: How long have you been hospitalized?
Patient: Gurgle gurgle gurgle... (mouths November)
(this is going to be easy)
I took about as complete of a history as I could have, got a general idea of what was going on in terms of what needed to be done and did as painless a physical as I could, because they poor guy was wasting away and had several exquisitely tender points on his body. I've never seen such a pitiful site. The skin was just hanging off of his leg bones, he had no muscle mass left just bones with some skin hung on them. Pretty sad. It was also my first physical on someone in bed...not my ideal way to practice, but a good experience none-the-less.
To make things even more happy, it turns out that he was MRSA positive and the only notation was in his chart, the nurses didn't mention it, there was no warning about contact precautions...nothing. So if I disappear from the interweb, it's because I'm hospitalized with MRSA pneumonia
3.01.2008
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!
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!
2.28.2008
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.
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.
2.26.2008
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.
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?
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?
2.25.2008
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
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
2.14.2008
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
2.13.2008
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.
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.
2.10.2008
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.
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.
2.09.2008
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.
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.
2.08.2008
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.
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.
2.04.2008
2.03.2008
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.)
(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.)2.02.2008
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)
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)
1.31.2008
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.
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.
1.23.2008
"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.
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.
1.21.2008
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.
1.15.2008
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.
--------------------------
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.
1.07.2008
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.
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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
------------------------
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
1.03.2008
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:
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
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
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
12.22.2007
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
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
12.15.2007
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.
12.12.2007
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!
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!
12.06.2007
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
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
12.05.2007
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:
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)
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