Tuesday, December 29, 2009

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.

Saturday, December 19, 2009

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?

Monday, November 30, 2009

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.

Saturday, November 7, 2009

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.

Tuesday, October 20, 2009

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.

Wednesday, September 30, 2009

A Clockwork Orange Tonsils

The title will make more sense later. Bear with me for a minute, as I have two topics to touch on. After a particularly difficult exam on Tuesday (and a few classes), we had the opportunity to participate in what our Essentials of Clinical Reasoning professors call Patient Day. I described, earlier, the process of taking a History of Present Illness (from here on: HPI) from a standardized patient. Patient Day involved three real patients, sixteen white-coated M1s, and some other form of medical professional to moderate. For each of the three patients we talked to, we were tasked with eliciting an HPI, a medical history, and a psychosocial history. As there were sixteen of us at a time, we were supposed to take turns asking appropriate questions and follow-ups in the general order in which we were taught. That has to be disorienting for the patient, or at least reminiscent of a firing squad.

So why Anthony Burgess? As the first patient described her symptoms (achalasia) and we asked about discomfort, she said that she occasionally had "The Sickies". Viddy this, my droogs. I then spent one of my precious questions attempting to, in a roundabout manner, get the patient to explain The Sickies without my having to ask directly. Turns out that The Sickies are nausea. Add another hurdle to the process of extracting information from a patient: deciphering their personal lexicon. Hopefully that will also serve as a reminder to make sure I'm translating my thoughts back to them as well. May I share another vignette? You're nodding slightly, so I'll continue. This also involves a guessing game for those with medical background. Answers provided later. I once had a discussion of a similar nature with my parents about their patient population while in residency at LA County Hospital. I may be smudging some details, but so be it. They would see patients who, when asked about medical history or current illness, would say they had Smilin' Mighty Jesus* or Fireballs in the Ucherest**. After consulting with people who had been around LA County for a longer period of time, they realized what their patients were telling them. Even though early medical students have limited exposure to patients, it's clear we not only have to understand our patients but make sure they understand us.

Another interesting part of the medical education process? The blurts. We see a lot of PowerPoint slides in lecture every day, on the order of hundreds. Most classes make a point of adding in clinical correlates so that we have some idea why we should care about Type I collagen or Superoxide Dismutase. A byproduct of the way my brain works is that I'll link inexorably two facts to the degree that I'll see one somewhere and my brain will blurt out the other. Case in point? Tangier Disease. Learning about lipid metabolism, we learned that a mutation in a particular gene causes a defect in cholesterol transport, eventually leading to buildup in the tonsils (and other organs) that gives them an orange color. A day or two after that lecture, I heard someone say "tangerine" and my brain tripped over itself rushing "orange tonsils" to the tip of my tongue. I'm sure this is healthy and not in any way a sign of insanity. Also, did you know that your brain literally sends words to your tongue via a series of tubes like at the bank? Anatomy is neat.

* Spinal Meningitis
** Fibroids of the uterus.

Monday, September 21, 2009

Leaving Behind Variation

Leaving Los Angeles in favor of Chicago meant, amongst other things, the loss of any sort of change in elevation. Cycling or running in LA was fantastic. I could be out the back door and up into the Santa Monica mountains in a manner of minutes. I've taken my bike out a few times here and, to the great surprise of no one, the topography is crepe-like. With more potholes. I guess that makes it more like injera.

CMS changed their curriculum this year to aim for better integration of material. That change includes a switch from a strictly midterm/final structure to a schedule involving weekly Monday exams. Sure, that has a negative impact on my weekends, much in the same way that engaging in a chainsaw fight with a lumberjack would have a negative impact on your appearance. There is an upside to this, though. Instead of the absurd levels of stress that accompany preparing for one week of mid-terms or finals with that quantity of material available, my classmates and I face a significantly less daunting but more frequent task. As a result, I find that I've been maintaining a fairly constant (and pretty reasonable) level of stress. Finals week in undergrad usually left me a mental wasteland, which I usually followed with a fairly significant refractory period. Flat may be boring for cycling, but flat is much better for exam schedule.

A quick cadaver update. My initial reaction to meeting my cadaver was a mixture of shock and disgust. That was three weeks ago. Last week, I prepared for my 1:00 pm anatomy lab by watching dissection videos while eating lunch. Desensitization spreads quickly. We've now gone through all back muscles, completed a laminectomy, opened the front to get to the chest muscles, and thoroughly dissected the shoulder, arm, wrist, and hand.

Monday, August 31, 2009

And Now for Something Completely Different

Honestly, it's the smell of formalin more than anything else. I have had very limited exposure to dissections. In AP Bio (Senior year of high school), we dissected sharks and clams and I wasn't brilliant at it. On the back of that raging success, I met my cadaver* this afternoon. Then my lab mates and I proceeded to expose the back muscles for our first real dissection on Friday.

Blind expectation, or in my case dread, just isn't the proper way to prepare for an event of this nature. I tried to mentally steel myself ahead of time to avoid the inconvenience / embarrassment of reacting poorly. Whether or not that was necessary, I'll claim victory. Still, nothing I could imagine quite captured the actual feeling of unzipping the disaster bag to reveal our lab group's cadaver. It isn't that I expected the body to sit bolt upright and start recreating Thriller. That would be silly. And horrifying. And then probably hilarious. However, of my interactions with humans over the course of my life, the totality have been with those of the living and breathing variety.

This is something new and new is generally difficult, especially when new has been soaked in formalin. What really accentuates the problem is my lack of familiarity with any real part of the process. Compare with the common experience of trying a new food, say ostrich. Eating is nothing new, certainly. Everything around the ostrich is probably familiar too, especially if it's an ostrich burger. You nibble, you decide that ostrich is much like other meats you've had in burger form, and you're comfortable again. We're pretty good about handling something new when we can wrap it in a bundle of familiar. According to a great piece by Malcolm Gladwell (one of my favorite reads), that's one reason a squeeze bottle of ketchup is such a big hit with kids: the ability to maintain a little bit of home in enemy territory. Perhaps I'll bring my bike to lab and do our Friday back muscle lab on the wind trainer.

Also, how in the world does the stench of formalin get through two layers of nitrile gloves?

*In case you were wondering, our cadaver is male, probably 75 or so years old, and something like six feet tall. It should also be noted that I am incredibly grateful for the opportunity to dissect a cadaver.

Tuesday, August 25, 2009

We Talkin' Bout Practice, Man

We're thrown fairly quickly into the fire. Mind you, it's not a conflagration, rather a controlled burn. Today, with seven days of lecture under my belt, I walked into a mock exam room and took a History of Present Illness (HPI) from a standardized patient. I haven't even met my cadaver yet (stay tuned, as that happens this coming Monday). Sure, my classmates and I have attended a lecture on the content of an HPI as well as a lecture on professionalism and communication in the exam room setting. It also helps that we are presented with very straight forward cases by actors/actresses trained for this purpose. I might have been slightly nervous knocking on the door of the exam room and introducing myself, but the experience was fantastic.

While buried in the tall weeds of first year basic sciences material (to date: Embryology, Clinical Molecular Cell Biology, Biochemistry, Anatomy, and Physiology and Histology will join the fun shortly), Essentials of Clinical Reasoning provides a little glimpse of why my classmates and I are here. You may consider it strange that we are learning to conduct a short patient interview that produces something like 80% of all diagnoses before we are anywhere near equipped enough to generate a differential diagnosis. I wondered that myself.

As it turns out, there's more nuance to an HPI than I could have imagined. I'm not sure it struck me before, but much of the information necessary to start diagnosing a patient comes directly from the experience of the patient and must be extracted carefully. They know where they hurt, when they hurt, how much they hurts, what has made their pain better (or worse), and so on. Quickly generating a good rapport with and getting useful information from a stranger takes practice. While our standardized patients were forthcoming and cooperative, that won't always be the case. At some point, I'll likely be dead tired, too hungry, or grumpy and will need to get useful information from someone who is uncooperative. I won't always be so lucky as to get a smiling patient with one symptom and no other problems. So, why did I find myself in a white coat asking a faux-patient about her recent onset of stomach pain after seven days of lecture? As one of the Associate Deans is fond of saying, it takes 10,000 repetitions to master something.

That's one.



Monday, August 10, 2009

Definitely Not Chicago

I decided, during my many hours of driving across the country (~33 hours if I recall correctly), that I'll try to package my posts here into one of three three formats: status updates (like today), occurrences, and general musings. We can work on the names. Status updates should serve to keep you all, my friends and family, abreast of where I am at and what is going on in my life in general, working again under the assumption that I'll not call or write nearly enough emails. In the "occurrences" section, I'll try to capture some of the interesting or humorous events that help compose the experience as a medical student. Finally, I'll try to occasionally trot out a longer post with some more depth on topics like the current healthcare system from the eyes of a potential almost doctor. Hopefully I can suppress my desires to post lengthy diatribes about the lack of proper cuisine in Waukegan.

On to the status update: I made it to Waukegan. Thank you to my college friend Ali who graciously drove across the country with me. I have an apartment somewhere between Park City and Waukegan, about 5 miles from campus. As Rosalind-Franklin is a small institution, on-campus housing is limited. Can't wait for snow.
Orientation starts tomorrow and class begins a week from today. The journey has begun and the excitement level slowly rises. So too does the humidity level. One of those has lead me to feel damp.

Wednesday, July 15, 2009

Genesis


So I've started a blog. More than one of you (you know who you are) have requested that I do something of this nature so that you have some way of keeping tabs on me. That's fair. I know my tendencies and odds are I won't call or email as much as I should. Hopefully I can keep with this, as it's a rather easy way for me to at least partially satiate my friends and family in their quest to occasionally have a clue what I'm up to.

I've been thinking about it, and I have several goals for the blog. First and foremost, I do want a way for all of you to be able to know what's going on. Secondly, and here is where I think the most interesting material will come form, I want a place to catalog the goings on of a med student. Sure, I'll try to con classmates into taking pictures when I inevitably pass out again (more on that in a minute). I've also heard a lot about how med students end up experiencing an awful lot of cognitive dissonance and it should be fun to try to capture the changes in my views (and hopefully I'll be a good representation of my soon-to-be peers) on topics like, well, medicine as I go through this process. That's the plan. I'll do my best to stick with it.

On to the fainting. After running the gamut of emotions yesterday, Uncle Leon the Urologist invited me to come see a prostate biopsy this morning. Simple outpatient procedure aided by rectal ultrasound. I've seen significantly more gore in the OR/ER. Something got to me, however, and I began to get lightheaded. In an effort to feel better, I walked away from the procedure to the sink at the corner of the room, figuring some air would help, and down goes Liston. I woke up slumped against the counter with Leon trying to get me to smell some ammonia. I always knew I'd have some trouble with anatomy lab early on, so I guess this was some foreshadowing of one minor hurdle ahead. I still can't believe I get to go to med school. Someone wave some ammonia under my nose, because I must be unconscious.