Autopsy

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

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

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

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

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

Third Year's Shaping Up

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

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

-Winter break-

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


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

Only 804 days to go.

Forgetting Learned Helplessness

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

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

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

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

Open Wide...

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

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

Someone else understands!!!

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

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

PS- Happy Pitchers and Catchers

REM rebound

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

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

Pats were screwed?

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

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

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

Better living through pharmacology!

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

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

Now with More Patient Wisdom in every box!

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

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

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

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

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

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

Nothing like a good racial slur followed by a hearty blessing to warm your heart...
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Then there was the patient with a history of alcohol abuse who couldn't remember how he got HepC and was surprised when told he had a mass in his liver. I'm guessing that it wasnt the only memory missing from that time in his life. He tells us that he read some patient education material saying that most people with HepC don't even know that they have it.

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

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

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

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

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

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

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

Reason # 57 why medical school sucks

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

The next week of my life...

SUPER BOWL!!!!

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

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

One of those days

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

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

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

Words of wisdom...

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

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

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

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

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

"Ain't my job..."

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

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

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

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

I'm a real boy!!!

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

Another one bites the dust: Oncology Revisited

As part of out physical diagnosis class, we are assigned to a preceptor site in order to practice our physical and history taking skills. Joy of joys, my preceptor is an Oncologist at a VA hospital. As I've already posted, oncology is not even on my list of career list, but I gots to do what I gots to do and I put on as positive a demeanor as I can muster at this point in my young medical career.
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I walk in the door 10 minutes early, get a cup of coffee and have a quick introduction to the office staff and nurses. We've got 2 patients on the docket for the day. The first patient is cooperative, pleasant and even humerous at times in spite of his scars, his fair prognosis and his lovely home situation. His history went about as smoothly as I could have dreamed, and we were only responsible for vitals and a head and neck exam, which had several pertinent positives related to his prior surgery. His BO was just 2/5 so, I could deal. I was thinking to myself that if every patient were like this, oncology might not be so bad. We went over the history and physical quickly before the next patient and nothing but good comments.

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

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

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

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

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

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

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

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

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

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

Here we go again (again)

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

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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

The year of the Boards

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

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

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

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

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

Merry Christmas

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

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

Take care,
Bostonian