Abby Normal

Even once you’ve made a hash of the legs, arms, thorax, axilla, and back, a cadaver still looks like a person as long as it has a face. There is, however, a pretty clear moment when it becomes difficult to look at the body and still see a person. That moment is roughly when you’ve finished bisecting the face with a hacksaw. We did that last week. Other than seeing the inside of the nasal cavity and pharynx etc., there’s something else that goes along with bisecting a face. That something is the sneaking suspicion that you're just no longer normal by basically any standards that don’t use other med students as a rubric. From the horror of opening the hazard bag back in September to now, I’ve certainly been desensitized at a pretty steady pace. The rest of my journey away from normalcy belongs to my schedule / social life.

To start with, most people look forward to the weekend arriving as quickly as possible. I look forward to Mondays. Once finished with an exam, I get a blessed few hours of time to unwind. Mondays are great. Thanks to the complete lack of overlap in schedule freedom, this limits my ability to see people outside of my classmates. While that doesn't help in my efforts to retain some semblance of normal, lacking the chance to get out from under responsibility once in a while makes the biggest impact. I don’t find that I’m envious all that often, but here we are. I am absolutely sure that I’ve chosen the right path and I don’t regret my decision in the slightest, but I do occasionally wish I had some freedom. For the majority of my college friends, leaving college meant taking a job with hours and a paycheck. The hours may be fairly extensive, but they are at some point released from responsibility and given time to do other things. The sort of things that require some disposable income and somewhat flexible schedules, like travel. For that, I’m envious. That’s the hardest part of school, the inability to get the occasional release from responsibility. If I’m awake, there just isn’t a situation where my top responsibility is anything other than studying. Not that I study every waking moment but rather that anything I do outside of studying comes accompanied by that nagging understanding. I'm not looking for pity because I knew what I was willfully getting myself into, but if you wonder why people complain about medical school then here's your answer.

A Baseball Rant Based in Biochemisty

Every now and then, something in the news actually correlates to material from one of my classes. Mark McGwire admitted today to using steroids during his record-breaking 1998 season. I, for one, am completely surprised. I know I am certainly as muscular or more muscular than McGwire was in '98, and that just happens. It's a burden, being Adonis. I can easily do several pushups. Anyway, I honestly was surprised at the outrage raised by Big Mac's announcement. Not because I couldn't believe that McGwire was on something but rather because, during his playing days, he openly admitted to taking Andro. When we manufacture testosterone or estrogen (or other steroid hormones), our bodies start with cholesterol (see handy diagram, courtesy of Wikipedia). Andro is two bouts with enzymes from becoming DHT, and Andro was legal when McGwire took it. Granted, Andro isn't converted entirely to DHT and also leads to estrogen formation (whoops).

Today McGwire admitted today to taking a different substance that was illegal while he used it, most likely dihydrotestosterone (DHT). If you're looking to add muscle mass that's probably a good way to go, what with DHT being an anabolic steroid and all. Also, Major League Baseball deemed it illegal. But Andro? Not until after McGwire retired. McGwire was probably getting the same result and MLB didn't care. For a league and public that make a huge fuss over use of illegal substances*, they sure don't seem to care much about the details. This is akin to trying to eradicate bakers by making flour illegal but allowing bakers to purchase wheat and grind it themselves. I'm not a biochemist. I had a one-hour lecture in which maybe five minutes were dedicated to this process. That's why it's difficult to believe that the people advising Major League Baseball on these issues didn't know the same information. Absurd.

*Which is to say nothing of the rampant use of amphetamines in the previous generation of ballplayers. Hank Aaron used them.

Focus

Another question I’ve had with regards to the first two years of medical education regards the teaching time proportion of clinical skills versus the well known evils of basic sciences. For the record, I think CMS is doing a pretty good job striking that balance. Most schools have a class like Essentials of Clinical Reasoning that teaches differential diagnosis and the basics of how to think through the process of diagnosis, testing, and treatment. I feel fortunate to attend a program that places emphasis on the physical exam and History of Present Illness. We’ve been told that nearly 85% of diagnoses can be made from the HPI / physical alone, yet apparently plenty of third-year medical students show up for clerkships lacking the skills to properly examine or question a patient. Couldn't schools afford to back off on the level of detail in Cell Biology in order to better prepare students in skills that could help make better doctors and cut down on the cost of healthcare?

I’ve just finished reading a book called “Every Patient Tells a Story” (Thanks, Faye and Ron) by Lisa Sanders. Dr. Sanders writes for the New York Times as well as acting as the medical consultant for House. Told through a series of vignettes, Sanders dedicates a considerable portion of her novel to stressing the value of “the lost art” of good physical exam skills. It should come as no surprise that the availability of high-tech testing devices has caused physicians to shunt diagnostic authority. Why trust techniques that are older than Abe Vigoda when you can convince the atoms in a patient to align their spins and tell you their secrets? Sanders argues that the physical exam allows you to find, in about thirty minutes, items of concern you may not know to look for with tell-tale signs that give almost as much certainty. While she doesn't bring up the issue of cost, that's a massive concern as well. Testing is an expensive burden on the system if used egregiously.

What does this have to do with me? A week before winter break, we were tested on a full* head-to-toe exam. Over the first half of our school year, we learned the exam one system at a time. Then, with an instructor in the room and cameras rolling, we took turns with a partner playing either the patient or the doctor. 30 minutes, 110 items on the checklist, an ophthalmoscope, an otoscope, a reflex hammer, a stethoscope, a tuning fork, a tooth pick, a cup of water, and our mental list. Hi, I’m Aron Bender and I’m a first year medical student. It’s nice to meet you. We’re going to conduct a full head-to-toe physical today. I’ll go wash my hands and we’ll begin. Our exam skills are incomplete, however. I can technically perform each of the items on the exam list, sure. I've never actually heard Mitral valve stenosis or felt a thrill. I guess this goes back to the 10,000 repetition theory.

On a somewhat related note, how and why I get nervous will always be a source of amusement to me. I’m ordinarily able to remember each of the list items because they follow in a logical progression through each system and I’ve done each technique a dozen times or more. I neglected the Babinski test until the very end of the exam when it struck me that I hadn’t done it. Always the bullshitter, I told my patient / fellow med student that I like to finish with the Babinski because I’m already testing vibratory sense in his big toe. Put in the mock exam room with a clipboard-toting fellow at drafting distance behind my right shoulder, my calm went to hell. It’s like someone drove a hovercraft into my mental office, sending all the neat stacks into a flurry. Two weeks later in one of my Dad’s exam rooms with a real patient, my nerves leave my brain alone. Sterile situation? Panic! Out in the field? Cool. Despite the way I approach problem solving, the way I process information, and the only way I accept argumentation, there’s a portion of my brain that must like being the last outpost of irrationality clanging around in there.

* Rectal exams will have to wait until next year. I can live with that.

Retention

I got out of bed this morning to the realization that I’ve finished 1/8 of med school and 1/4 of the classroom portion. My first week of school honestly feels as distant as my arrival to college. Either I’ve aged that much over the last few months or I’ve forced most of those memories out in favor of the molecular cell bio from the first few weeks (that I’ve already mostly forgotten the details from). There are a few questions that I want to explore and I realize the format of these Blogspot blogs doesn’t have great readability, so I’ll break them down into separate posts. Since I have a few weeks somewhat off from studying, I’ll imagine I’ll be writing quite a bit. Aided mostly by the frustrating quantity of information I’ve had to gulp down, I’ve been questioning the traditional teaching methods of the first two years of medical school. This has been a frequent topic of discussion amongst my peers as we grouse about the level of detail in our basic sciences course. So, on to the first question.

Will I retain the majority of what I’ve learned? I can’t speak in definite terms for the future Aron, but I can say with reasonably good certainty that I won’t remember the specifics of almost everything I’ve learned in basic science classes. Odds are I’ll re-learn everything at least once more, and then choosing a specialty will cause me to become very intimate again with the details of a particular region or system.

My trip to Boston over Thanksgiving helped me understand that much. Between my sister the resident or my brother-in-law’s two visiting friends (an M3 and an M4) gave me the opportunity to test this hypothesis. As I was preparing for a cumulative biochemistry exam, I’d occasionally throw out a simple quiz to see what remained important down the road. With all three sitting in the room, I offered up HMG CoA Reductase and was met with blank stares. Despite the emphasis by professors that this particular enzyme is important (it’s the rate limiting step in cholesterol synthesis and as such is the target for the family of drugs like Lipitor), it wasn’t until I recited its purpose that all three had knowing nods. It’s probably important to note that none of the three are headed towards cardiology, because then my question would have produced different results. Still, with the amount of energy we spend learning the names and function of nearly every enzyme in metabolic pathways, did it all go to waste?

I don’t think so, or at least not entirely. One of the biggest problems early on is that we learn fine detail about small parts of the body without having a good idea of how the whole body works together, the function of each organ involved outside of it’s job with respect to the task in question, or much of the clinical ramifications. My professors have done a good job interlacing vignettes throughout our learning, which certainly helps anchor concepts and remind us that pathology stems from errors in processes we learn about in basic sciences. Down the road, I’ll continue to remember the general concepts well enough to understand disease processes. Still, if it’s the concepts that are important down the road, why not shift some of the weight of focus onto concept?

Getting Dumber

The main point of my blog is to capture the process of medical education and the psychological / sociological changes I experience along with changes in my perspective about medicine. As an M1, the latter will have to wait a year or more. Without exposure to the practice of medicine, my opinions on topics like reform of healthcare are roughly the same as before I entered school. I also wanted to make sure that friends and family know that I'm still breathing. The sharpest amongst you may be able to deduce that my ability to write is very much dependent on my ability to breathe so we can check the last one off. I haven't yet succumb to any of the plethora of diseases I'll learn about and then momentarily worry about having.

So you get to read about my brain. With each passing day, I grow more stupid. Not regarding topics like biochemistry or physiology, but rather... everything else. I wrote previously about the occasional bouts of craziness stemming from a very intense and singular focus. A new symptom of Medschoolemia emerges: loss of ability in facets of every day life, especially spelling and language, both written and verbal. While in Boston over Thanksgiving (I had a lovely time and I did not save you any cannoli), I was having a conversation with my sister. I spent roughly five minutes trying to come up with the word "insecure" as a descriptor. Five minutes. Couldn't do it. This sort of issue now occurs daily. While I doubt anyone would have accused me of being one of the all-time great orators prior to this, I fear that having a conversation with me lies somewhere on the spectrum between talking to Porky Pig and Marcel Marceau. I'd have gone with Harpo but he'd hand you his leg and make a sandwich with your tie, and who wouldn't enjoy that? Hopefully winter break provides the opportunity to do things like read for enjoyment and spend time not packing my brain. I just may get more functional as a result.

*Note: After proofing this, there were quite a few errors in grammar and there probably are a few I haven't found yet. I wasn't kidding. I've become an illiterate.

Speed Dating with Cadavers

If you’ve ever learned even a small bit about the Theory of Relativity, you’ve heard about the almost nonsensical concept of time dilation. Get yourself the latest spacecraft capable of going the speed of light and set off for a month. Come back and find that more time has elapsed back home than did for you, even though you were alive and fiddling with hyperspace cup holders for the same nominal period that your friends sat at home and made toast. Med school is like that. My days feel long and drawn out, but every once in a while I look up from whatever I’m reading and a week is gone. An entire quarter blew by, and I could go for some toast.

The last day of each quarter of the M1 year consists of an anatomy practical. 100 stations, 100 students, 100 minutes. Each of the ~50 cadavers is tagged in one or more locations and we have the privilege of identifying the structure. There are also about 20 questions on osteology tagged on a skeleton or loose bones to go along with rest stations scattered throughout.

The anatomy practical should be mostly binary, but 60 seconds runs away like the antelope that found the meth lab. In areas like the brachial plexus or with branching areas of arteries, there’s usually sleuthing to be done. Relationships are quite important, and running through a set of mnemonics or mental images lays waste to that minute pretty quickly. Scribble down “Semispinalis Capitis m.” then the buzzer sounds and it’s off to the next body like some Polish gameshow. (I don’t watch a lot of Polish television so if I’m wrong about their content, I do apologize. But I did hear that The Offiszcz is pretty good.) Talking with a few classmates, we all found that the most difficult part was sorting out the mess in our heads. For each compartment, we learn the contents separately. In the anterior thigh, I know which muscles are where. In a separate mental layer, I know how the femoral artery enters, branches, and continues through. In yet another layer, I can see the femoral and obturator nerves and their branches. Arriving at each body sets off another round of flipping through mental notecards. It's always strange to get tested in under two hours on content that required something like 40 hours in lab, 20 hours in class, and well more than the two combined in study. Long live the scholastic process.

The Hazards of a Narrow Focus

Insomnia isn't a normal part of my daily routine. In fact, I've been augmenting a typical seven+ hours of sleep at night with a twenty-something minute nap in the afternoon (I'm fairly certain that I have med school-induced Mono). When the thought of running face first into a wall crossed my mind for a fraction of a second, I knew my week had caught up with me.

Last Monday was a brutal exam, one for which one of our professors apologized in advance. After three exams in two weeks, we had an almost unreasonable amount of information to put down in an almost unreasonably short period of time. As a result, I spent the majority of my waking hours over a five-day period cramming biochemistry into my brain. Saturday night I had dreams about biochemistry. During a study break with some football on Sunday, a Lipitor commercial I was not paying attention to caused me to actually say "HMG CoA reductase!" out loud in a sort of Pavlovian response. That's probably not normal.

I can't really complain about the amount of work I've had to (and will continue to) put in. That's what med school is all about, after all. So while the percentage of my time taken by school doesn't really bother me, it's the occasional theft of my sanity that does. Since my primary interactions are with stressed-out med students, I rarely get a change of scenery. During the week, I have enough variation between class, lab, and a smattering of subjects that I can keep it in check. Weekends are for exam preparation and that generally means subject matter from one or two classes, no distractions, and some added time pressure. It's little wonder that I can't get my brain to shut up on Sunday nights.