Lung Infections

When I went to the doctor last Friday, part of the workup involved sticking a Q-tip up my nose to swab for influenza A. Sure enough, it came back positive--I really did get the flu. Talk about bad luck. On the bright side, I'm feeling a lot better now, and I don't have a fever any more. I just don't have any voice--none whatsoever. That made for a pretty hilarious PBL session yesterday. My group tends to be pretty rowdy, and sometimes it's hard to get a word in edgewise. Well, I was in no condition to duke it out with anyone, but my group members were awesome. Whenever I tried to whisper anything, the rest of the group would just stop talking. I don't think I've ever been this nicely accomodated in PBL when I wanted to say something! I had to leave a few times for uncontrollable coughing fits, but otherwise, the session was great. Ironically, the case this week is entitled, "Another Cough," and our seminars yesterday and today have been about lung infections. Here I am, continuing my class's pattern of someone coming down ill with the pathology of the week. I'm just glad that I didn't get sick at the end of the week, when we're going to be covering lung cancer. :-P

I went to clinic this afternoon, and my preceptor was sick too. The weather is still lousy, but all of the patients showed up except one of the 4 o' clocks. So we got done right at 5:00, and we mutually agreed to go home early and review my patient logs next week. I can't even imagine what the patients must have been thinking when we came into their rooms. First, I'd come in alone and get their histories in a whisper. I'd have to hold my own breath when I listened to their hearts so that I could actually hear anything. Then, my preceptor would come in with me, and the two of us would be examining the patient in between coughing fits. We were both way sicker than any of the patients we saw were. This just supports something I read once about how the worst place to be when you're sick is in the hospital. Why? Because that's where all the germs are.

Double Dose of Dentists and Doctors

I have had a pretty sucky past two days, maybe the worst since I started medical school. Where to start....Ok, about a week ago, I began having a toothache. Normally, I get my dental care when I go home to visit my parents during breaks. I've been going to that same dentist for a long time, and I only have to go once every six months, so why go try to find someone new in Cleveland? But this was an emergency, because we don't have another break until March, and I didn't think I could last for a month. I checked my health insurance plan, and it turns out that we do have dental coverage through the Case dental school. They'll even do regular cleanings for us every six months, and it's all covered. I managed to get myself an emergency appointment for yesterday morning.

The Case dental school is a pretty impressive setup. They've got a bunch of huge clinics in there, and the upperclassmen dental students work on patients with their preceptors. I wasn't 100% thrilled about being worked on by a student, but it's not like I can really complain. I mean, my patients let me poke and prod them in clinic all the time, so I'm really not in a position to say that I don't want to be a learning experience for a dental student. Plus, my tooth was really hurting, and I think I'd have just about let someone use rusty pliers on me by that point.

The student I got was very nice and obviously was trying her best. But she was slow, slow, slow, and she didn't do a very good job with freezing my mouth. She basically froze everywhere except the gum by the tooth she was drilling. So I had no feeling in my tongue, lips, or face on that whole side, but boy, I sure felt her drilling me! There was no way I was going to let her remove all of her torture contraptions, reinject me, and start over again though, so I told her to just keep going as fast as she could, and I'd do my best not to jump. I was pretty white-knuckled and had tears streaming out of my eyes, but we got through the drilling and she filled the tooth. So three hours later, the problem was solved, even if it wasn't the most pleasant experience during the actual procedure. (It took three hours because every time she did something, she had to get one of her preceptors to come take a look before she went on to the next part of the procedure. We also had to repeat the x-rays because the first set she got weren't right.) After that, I went home to chill a little.

I had woken up yesterday morning with a sore throat, but it was starting to get worse by last night. Then I started running a 102 degree temperature and coughing up a storm. So I emailed my learning objective to my PBL group and let them all know that I wouldn't be coming in today. I almost never stay home from school, and this is the first time I've ever missed a PBL session except for when I was away at that conference last fall. I didn't want to miss school today, but it turned out to be good that I did, because this morning I started vomiting too. In the afternoon, I got one of my classmates to drive me over to school, and I went to get checked by one of the docs in the clinic where I work on Tuesdays. My preceptor wasn't in today, but one of the other docs was. She told me that I probably had the flu. What!!! That is SO unfair! I got a vaccination last fall, and I still got the flu! It's actually possible for that to happen though, because the flu vaccine manufacturers have to guess which strains are going to be prevalent based on last year's strains, and sometimes they guess wrong. Lucky me.

On the bright side, the doc prescribed codeine to control my cough. I was a little nervous about taking it at first, because I still felt pretty nauseated, and nausea and vomiting are two side effects of narcotics. So I tried taking a half-dose, and it worked pretty well. I think I'll probably be ok with taking a full dose. Codeine is a highly effective cough suppressant. I was able to fall asleep for a few hours earlier this evening without hacking up half a lung. I still can't talk though without going into a coughing spasm, even with the codeine.

After the doc gave me the prescription, I went to get the codeine at one of the Cleveland Clinic pharmacies. While I was waiting for the pharmacists to make it up for me, I was sitting in a chair next to a large candy display. What a racket. I bet they sell way more candy than drugs in there. Every, and I do mean EVERY, kid who walked into that pharmacy with their parent made a beeline for that candy rack. It didn't matter if the kid was a toddler or a teenager. The same scenario then played out over and over again. First, the kid would ask for candy. The parent would say no. Then the kid would ask again, grab some candy, take it up to the line with the parent waiting. Nearly every parent eventually gave in and bought the candy for the kid after saying no multiple times. One guy who was there with his young son was the only parent who didn't cave in, not counting a second guy who carried his kicking, screaming daughter out of the pharmacy after refusing to buy her a piece of candy. All I could think was that if I had behaved like one of those kids, my parents sure wouldn't have rewarded me for being disobedient by buying me a piece of candy!

Cardiopulmonary Week

This week, we are covering pulmonary vascular disease. Our PBL case is a continuation of a case we had last year about a woman who got deep vein thrombosis (DVT), which is a blood clot in the large veins of the legs. You may have heard about DVT in the news. People who are immobilized (ex. bedridden or sitting for hours on an airplane) are at higher risk of getting them. The danger of DVTs is that pieces of the clot can break off and travel to the lungs (i.e., form a pulmonary embolism). Pulmonary embolisms can kill people if they're massive enough. This year, of course, our patient's problems are more complicated. But it's still cool to get a patient that we already "know" from before.

We had another pharm seminar yesterday, and today we had an anatomy session on the embryology of the heart. The actual lab part was mainly a review of the thorax anatomy that we learned last year, which was really helpful. This year I have a much better idea about what I am looking at in anatomy. I really like that we keep doing anatomy second year like this, because it helps to keep it fresh. For FCM, we had patient presentations again. One of my group members who was supposed to present was out sick, so we got out early.

I had clinic in the afternoon. The weather is still not so great, but most of the patients showed up anyway. There is this one older patient whom I've seen several times in clinic, and she came in today. She's always entertaining. Today she was telling me about how she is in such good shape for her age, and what she does to be in such good shape. Then she started telling me that if I follow her rules, I will be in just as good of shape when I get to be her age. She really is in pretty good shape, but it's still funny to hear her talk about it like that.

Kind of a Slow Week

I haven't had too much exciting going on this week since I didn't have any clinic on Wednesday after all. I was supposed to have had my first acute care session, but now I'm having it the Friday after next instead. That made this week pretty easy, which was nice, but it means that I'm going to have a three-clinic week in February now. Oh well. Not that I'm really complaining, of course, because I was very happy to have the extra time to study this week. Plus, it feels pretty luxurious to get home in the middle of the afternoon while it's still light out on a Wednesday!

We're still going through lung diseases. Wednesday's seminar was on chronic obstructive pulmonary disease, and today's was a pharm seminar on drugs for asthma. I really like the pharmacist who led today's seminar. She was the one that I worked with a while back when my longitudinal preceptor was away, and she is super nice and friendly. But this seminar just didn't seem to go well. I don't really even know why. I guess sometimes they just aren't a hit, and today was one of those times. Our POD seminar was on lung stuff too, and it was ok. Maybe it's just the time of year and the cruddy weather we're having, but eh, it's kind of tough to get too gung-ho about much of anything. Our PBL case had a happy ending this week at least, though.

Triple Clinics

This week, I have three clinics, but it isn't too bad since we didn't have classes yesterday for MLK day. I had the morning off and did my year 2 geriatrics clinic in the afternoon. It was a pretty easy clinic session. Basically I just had to do mini-mental exams and screen some patients for falling risk. We also had an audiologist in the rooms with us, so we did some hearing screens too. It was good that we had the audiologist, because I think every patient I saw was partially deaf. The geriatrician has this instrument that he can give to the patients to help them hear the conversation better. It looks kind of like a walkman. The patients put on the headphones, and it augments the conversation so that we don't have to shout at them. Apparently patients can also buy these instruments to use at home.

Since we didn't have class yesterday, we had two seminars today and no FCM. One seminar was on asthma/COPD, and the other was on pulmonary interstitial disease. It was nice having no FCM, but wow, four straight hours of pulmonary path was pretty intense. In the afternoon, I had longitudinal clinic like normal. The weather was pretty bad, so I thought some of the patients might not show, but most of them did.

Medical School Is Making Me Dumber

We finally got back our test results from the Comprehensive Basic Science Exam (CBSE) that a bunch of us took back in December. I'm pretty pleased with my score, especially considering that I've done no studying for the boards and still have 2/3 of the year to go. One thing that did kind of confuse me though was my subscores. Two of my best subjects were biochemistry and psychiatry, which didn't surprise me. The psych contains a lot of clinical research topics, and since I'm getting my MS in clinical research, all of those questions were pretty easy. I took biochem in college and then I studied it again the first summer in med school, so also no big surprise that I did well in that. But the third subject I did really well in was respiratory, which did surprise me because we haven't done respiratory pathology yet. Also, my worst subjects were neuro and musculoskeletal, which we had just finished covering a few weeks before I took the test. I was thinking, wow, I should stop going to medical school now and take the boards quickly, before all of my subscores in the rest of the subjects I haven't studied yet go down! Plus, I was a little bummed about the neuro subscore after I spent so much time studying neuro last summer.

I went to see Dr. Prayson about these results yesterday. Dr. Prayson is the pathologist who is now the Assistant Student Dean to help Dean Franco. (She's the Student Dean as well as the Admissions Dean.) He basically told me not to worry, because I could have missed or answered a few questions in some of these areas, and that's why my subscores are distributed so strangely. Also, he said that I'm starting from a very good place, and I should be pleased with my performance overall. It looks like I need to spend some more time studying neuro though, so I'm getting another book to do that for this spring.

Today was a pretty good day, even though Dean Franco totally busted me. Our PBL case had a relatively happy ending, and one of the pharmacists that I really like led today's seminar on antiarrhythmic drugs. Our POD talk was given by the infamous Steve Nissen, and it was phenomenal. I've gone to a few talks of his, and they've all been excellent. He's a great speaker, he does really cool research, and he's a maverick kind of guy who likes to stir things up. What more could you want in a speaker? After his talk, we were supposed to have a class meeting. I had to write an essay to get grad credit for the POD class, and it was due today at 5 PM, so I decided to skip the meeting and go to the library. I ran into Dean Franco later, and she commented about my not having been there. It turns out that the administration had passed out vouchers for us to take one of the online NBME exams (practice USMLE tests), and since the vouchers all had our names on them, she knew exactly who was and was not there. So I sheepishly apologized and told her why I didn't go. You have to understand, I almost never skip anything. Then the one time when I do skip, she busts me (though I don't think she was really mad at me). All I can say is that there is a very good reason why I don't ever play the lotto. :-P

If I Can't Be a Doctor, at Least I Can Try to Act Like One

I wound up getting the pharm learning objective for PBL again this week. It's about warfarin, and that is A-OK with me. Our seminar today was terrific. We went over to the anatomy lab and had a pathology session there. There were two pathologists. First, they gave us an intro in the classroom, and then we went into the lab and they showed us all kinds of hearts and parts of hearts. At one point, one of the pathologists took this bucket full of heart valves and just dumped them out all over the table for us to look through them. That was so cool. Most heart valves are supposed to have three cusps except for the mitral valve, which normally only has two. We saw some valves with one cusp, a bicuspid aortic valve (which should be tricuspid), and even one valve with four cusps. We also saw hearts that had hypertrophied. Some were big enough that they could have been cow hearts. There were also some hearts from young kids who had congenital heart defects and had died, which was kind of sad. But overall, this was a great session and it was awesome to see in person all the heart pathology I've been reading about in Robbins. I hope they'll do some more sessions like this.

I got a really nice compliment today from my standardized patient for communications. We were doing motivational interviewing. My actor was playing a patient who had an alcohol problem, and I was supposed to help him realize it. The story was that his wife had insisted he come in, but he didn't think anything was wrong. I wound up getting him to talk all about his family and work and how he'd been more stressed at work, and he hadn't been spending as much time with his daughters as he did before. He came to the conclusion himself that he should spend more time with his family, and that maybe drinking was getting in the way. My preceptors commented that I didn't push him as hard to get help as I could have, because he was clearly ready to stop drinking. Well, I didn't do that because he was supposed to be only pre-contemplative (not knowing he had a problem and not planning to change), not contemplative (knowing he had a problem and that he might want to change)!

When class was over, my group was heading out of the library. My "patient" was leaving at the same time, so I went over to him and thanked him for his help and told him that he was a very believable "patient." He told me that he had felt really comfortable talking to me and that he thought I was going to be a terrific doctor. I was surprised and also a little touched. He was only pretending to have a problem and I was only pretending to help him, but I had gotten deeply enough into playing my part that it had seemed real, and I tried to do and say what I really would have done and said if he'd been a real patient. I have to say that his compliment means way more to me than any positive feedback I've gotten from either of my preceptors.

It's a good thing that communications went well, because my cardiology exam practice session was rough. Since I didn't have time to review the cardiac exam video before class today, I was not well prepared, and I had the bad luck to wind up being in the first room by myself. The preceptor said, "Go ahead and do a cardiac exam like you normally would, and then I'll go through it with you." Oh boy, was I ever screwed. In clinic, I usually just take the patients' pulse and blood pressure, then auscultate (listen with a stethoscope) their hearts. But there are all kinds of other things that we're supposed to do for a full physical, most of which I only vaguely remembered. So I fumbled through the exam as best as I could, but it wasn't very good. I did remember to take the blood pressure by palpation first and do the exam from the right side, and the patient was super nice. But I definitely did not wow this preceptor with my cardiac exam skills. Fortunately, I had a couple of other students in the room with me for all the other stations, and I did a lot better once I had gotten my wits about me again. We spent time listening to murmurs in some of the other rooms, and that was really helpful. Again, the faculty had found some patients with overt, easily audible murmurs.

Deserted by My Preceptor?

This week we are learning about cardiac arrhythmias. Our PBL case is about a patient with an arrhythmia, and yesterday we had a seminar on the biochemistry of arrhythmias. That one wasn't the best seminar I've ever attended, but I really loved the one we had today. We went over to the EKG lab and had three stations. The first one was kind of repetitive from last year--we went into the electrophysiology lab and watched part of a procedure being performed. Then we had two stations about reading EKGs. One was by a physician who taught us about EKGs last year, and the other was with another physician who had made us a terrific booklet with explanations and examples of different arrhythmias and what they look like on EKG. I liked that third station the best, but we wound up having to leave before he was finished because we were already late for FCM. Two of my classmates did their patient and journal presentations like the one I did last week.

This afternoon I had clinic, and I got some bad news. My preceptor is planning to move out to one of the satellite campuses at the end of March. That will be in time for me to get my observed H & P done, but it will leave seven unfulfilled clinic sessions at the end of the year. I was planning to stop going to clinic in May anyway, because we are allowed to miss three clinic days and I haven't missed any yet. But missing all of my April clinics as well will be too many skipped days. I really don't want to have to go out to the satellite clinic, but it looks like I may need to go do a few sessions there.

Saved by Salt-Free French Fries

I had yesterday off, and I spent the entire day at home in my pajamas reading for school and watching the snow flurries falling softly outside my bedroom window. I have to say that when I don't have to go anywhere, I really like the snow. I got my learning objective done, and I even got all of the reading for today done too. I'm especially proud of that.

Our PBL case had a sort of happy ending--the patient survived, but she stopped at a fast food restaurant on the way home after being in the hospital for heart failure. It's pretty true to life, unfortunately. Patients don't even need to wait to be discharged to get their fill of grease, because there is actually a McDonald's in the Cleveland Clinic hospital cafeteria. I don't usually eat at the cafeteria, but whenever I have gone there, the line at the McDonald's stretches all across the room and around the walls. The interesting thing about this McDonald's is that they don't salt their french fries, as if a box of greasy, unsalted fries that don't taste good are somehow better for you than a box of greasy salted fries that do taste good.

The seminar was on endocarditis, which is an infection of heart valves. Pretty gross stuff, but interesting at the same time. Our POD talk was on the biochemistry of atherosclerosis, and it was decent. I'm glad that today is Friday though, because I'm ready for the weekend. The first week back is always a hard one.

PBL, Anatomy, and Echo Lab

Our PBL case this week is about congestive heart failure. I am doing the pharm learning objective, which no one else wanted to do. That's ok with me, because I like pharm. I have realized though that I suck at hearing heart murmurs. We had some heart sounds to listen to during the PBL case, and I really have a hard time hearing the diastolic murmurs. (Diastole is the point in the heart beat where the heart muscle is relaxing and the chambers are filling with blood.) Systolic sounds, which occur while the heart is contracting, are a lot easier.

Our anatomy session was really a body cavity embryology session. We didn't do much embryo last year, so we're doing it now. It's pretty complex, but kind of interesting how the embryo starts out as more or less a flat disk, and then it starts folding up in all different directions. I don't think I could explain the sequence of events from start to finish though. After Dr. Drake went over the embryo, we went through some prosections to review the chest anatomy. It was a really good review, and I understood a lot more this time around than I did a year ago.

We had a radiology station too just like we used to have last year. I don't know if I've ever mentioned our radiologist. He's awesome. First of all, radiology is just cool anyway. Plus, our radiologist is this really nice older man who has a British accent, so you have to imagine all of this being said with a British accent. He'll start out by showing us a CT of the chest and pointing to something really easy, like the aorta. And he'd say to me, "Can you recognize what this is?" Of course I would say, "The aorta." And he'll say, really enthusiastically, "That's right! It IS the aorta, isn't it! And look, here's the left ventricle attached to it!" I love the radiology station.

This afternoon, we went to the echo lab and listened to several patients who had heart murmurs. That actually really helped, because it's a lot easier to hear a murmur on a real person than it is on the computer, and most of these patients had really loud murmurs. But I still have a hard time making out the diastolic murmurs unless the murmur is practically audible without the stethoscope. I know it's shameful for a Cleveland Clinic medical student, but maybe I'm not cut out to be a cardiologist. ;-)

Back-to-Back Patient Presentations

We started our cardiopulmonary block this week, and so far it's been really good. Not that I'm surprised, because Cleveland Clinic is all about cardio everything. After I took the CBSE last month, I told Dean Franco that I didn't think I had done very well on the cardio path questions. She told me not to worry, because all of the CCLCM students come out of second year knowing cardio very well. Not that I'd ever doubt Dean Franco, but I'm glad to report that I can already see why that would be the case.

There are several things that I really like about cardio block. One, Dr. Stewart is in charge again. He ran our cardio block last year too, and all I can say is that he is a really cool guy. I didn't come here particularly gung ho about cardiology, but he makes it hard not to get excited about it. Next, there is only one seminar per day instead of two. Some of the speakers still go over the page limit for the assigned reading, but one person over-assigning work to us is nowhere near as bad as two of them doing it each day! Plus, we aren't crammed like sardines into the little conference rooms. Finally, the seminars we've had so far have been good, even the pharm one we had this morning. Yesterday's seminar was on hemodynamics, and it started out a little bit confusing, but it got better as it went on.

After seminar this morning, I presented my patient for FCM along with an article related to her disease. Two of us were presenting. I have to say that as annoying and unhelpful as FCM can be sometimes, today was a really terrific experience. I learned a lot by preparing my own presentation, of course, but I also learned a lot from my classmate's presentation. I wish we could do these presentations for FCM all the time.

This afternoon, I didn't have clinic like normal because we had the small group clinical reasoning skills class instead. I lucked out because none of my clinical reasoning group members were in my FCM group, so I presented the same patient a second time. Basically, after I presented the chief complaint, we went around the room coming up with hypotheses for what could be wrong with the patient. Then I presented the rest of the past medical history and the results of the physical exam. After I went, the other three students in my group did the same thing. It was really fun trying to figure out what could be causing the patients' symptoms, and I also felt like I was learning a lot too. I think a lot of my classmates liked it better than longitudinal clinic. I could go either way, but then, I really like my longitudinal clinic.

Last Day of Fall Semester

Yesterday I took the Comprehensive Basic Science Exam (CBSE). This is an exam covering the first two years of medical school that is put out by the National Board of Medical Examiners (NBME). They're the same people who write and administer the medical boards. There were four sections (Step 1 has seven sections), each with fifty questions, and we had a total of four hours to complete the exam. The questions cover everything from first and second year, with a heavier emphasis on second year subjects like pathology and pharm. Suffice it to say that the test was really hard, especially since we haven't covered half the material yet! I would say in each section there were about 25% questions that I knew, 50% of questions where I could eliminate the answers down to two or three choices, and 25% where I had absolutely no clue whatsoever. The good part is that I had no trouble finishing in time. In fact, I went through the entire test three times and was still finished 45 minutes early.

It's unbelievable how fast the time has gone by. I'm now officially halfway through my second year of medical school. We finished the diabetes PBL case, and we had two seminars today, one on hypoglycemia and one on the complications of diabetes. They were both pretty good. The first seminar leader asked me to pretend to have hypoglycemia, so I was shaking, sweating, having a headache, and then I "fainted." After we talked about the symptoms of hypoglycemia, she gave me a little bag of Skittles. I guess that is supposed to be a glucose source to take care of my "hypoglycemia." The second seminar leader is the same endocrinologist that I had endocrine clinic with last week. It was funny, because he remembered me, but he clearly didn't remember my name and he didn't want to have to ask me what it was again.

In the afternoon, I did some errands and went to the gym. I don't normally go to the gym on Fridays, but they are closing all weekend for Christmas, so I can't go tomorrow like I usually do. Then I wrote evals for my PBL group and cleaned the lounge refrigerator and microwave. We have a signup sheet to clean out the fridge every couple of weeks, so that wasn't too bad. But the micro was absolutely disgusting. I don't know when it was cleaned last, but it probably was years ago.

Grades for my MS classes came out today from Case: two As in epidemiology and clinical trials, and a B in biostatistics. I was expecting the clinical trials and stats grades, but the A in epi came as a pleasant surprise. Looking back over the past year, I realize that although having to do the extra work for the MS was miserable sometimes, overall I'm glad that I stuck it out. It's one of those things that isn't always fun while you're going through it, but the short-term pain is worth the long-term gain. I guess that is true of medical school in general.

We have SAQs and CAPPs to do over break like normal. I am planning to do them this weekend and get them over with by Monday morning at the latest. I also have clinical homework to do for my first week back in January, which involves preparing patient presentations for my FCM group and my clinical reasoning group. The clinical reasoning class is something new, and we are doing that instead of longitudinal clinic the first week. I just realized that I will be doing BOTH presentations on Tuesday of my first week back. Well, at least I'll get it all over with early. It looks like we go back to clinic as usual after that first week.

I want to wish all of my blog readers a Merry Christmas and a Happy New Year. I'll see you all next year. :-)

Double Communications

Our PBL patient is not doing so well. This case has turned out to be a lot more interesting than we had expected, because we had a diabetes PBL case last year too. But this one focuses more on the long term complications for patients who do not have controlled diabetes. Unfortunately, the truism that being an interesting patient is a bad thing definitely holds true here. The seminars were on gestational diabetes (pregnant women become insulin resistant and can even become diabetic while pregnant) and nutrition.

This afternoon we had double communications for four straight hours, which would ordinarily have been fairly painful. But, one of my group members didn't show up at all and another didn't get a chance to video an interview with a patient, so we actually got out about an hour and a half early. The first part of the session was about how to deal with family members being in the room. I got a mother-teenage daughter duo where the mother kept trying to take control of the interview. These were standardized patients, and the two actors I had were terrific. I would have totally believed that they were a mother and daughter for real. I was able to tone the mom down a little by turning my chair so that my side was to her and I was directly facing the daughter. I even managed to get her to leave the room, though she really didn't want to, and at that point I stopped. I could have kept going and done a sexual history on the daughter at that point, but I figured we've already done that lesson, and I'd gone on long enough.

The video reviews took another hour. I had been counseling my patient (a real one this time, the same interview that I taped last week) about smoking cessation, and I could have definitely gone further with that. When we got done, there were big, fat snowflakes falling outside. It was beautiful to watch, though what it did to the afternoon traffic was not at all beautiful. We haven't been getting too much snow yet this winter, but today is more than making up for that.

Clinic Christmas Party

This week we are covering diabetes in excruciating detail. All four seminars from yesterday and today were about diabetes, and our PBL case is about the long-term complications of diabetes. So, it was only fitting that today was my clinic's annual office Christmas party. I got off easy with just bringing jello. Other people baked brownies, made homemade mashed potatoes, and someone even brought fried chicken. Oh, and I shouldn't forget about the macaroni and cheese. All of which, while completely delicious, are exactly the types of diabetogenic foods that are going to ensure that many of us partygoers will be the future diabetic and coronary artery disease patients who keep the Cleveland Clinic prospering for the next several decades.

The other nice thing about today is that I got about an hour and a half off between seminar this morning and the office party, so I got through with most of tomorrow's reading. Our FCM class today consisted of each of us meeting with the small group preceptor for about ten minutes. I got to go right at 10:00 as soon as the second seminar was over. Since my group's preceptor has been gone the last few weeks, I almost blew the meeting off altogether. But I decided I should probably stop by to see if he was there, and it's a good thing I did, because he did show up. These ten minute meetings are pretty pointless. They are supposed to be for us to get and receive feedback. But the feedback we get is useless because it's oral and can't be used for our portfolios. And giving too little feedback to the preceptor has never been a shortcoming of mine. He told me that I should try not to be so frustrated with the class. I wouldn't say I'm all that frustrated, but maybe I just expressed my feelings about these ten minute meetings a little more strongly than I intended. :-P

A few of our patients didn't show today, and the clinic was pretty quiet in general except that people kept coming by the break room to eat party leftovers. The nurses tried to get me to take some food home with me, but I didn't. I am sure the only reason I don't already weigh five thousand pounds is because I never bring any junk food home with me. That being said, I did manage to eat three brownies during the course of the afternoon.

Surviving My MS

Yesterday was kind of a hectic day, but I did get my paper done in time, and I gave my presentation for class. I got a few good suggestions as well as one softball question from someone who missed the first part where I explained the rationale. So that's it. I'm officially done with my second MS class. One more week to go until break!

Today's seminars were on thyroid disease and autoimmunity of the endocrine system. They were both good ones. The first one was taught by the doc who heads this block, and he's a really energetic and enthusiastic kind of guy. The second one was a really good review of the immunology we covered last spring, and it also specifically went into how the immune system interacts with the endocrine system.

For POD, we had the group presentations on the projects we came up with last week, and these were much smoother than the previous time we did this. Our group was the only one that came up with the stem cell idea, which is cool. Last time, it seemed like all four groups pretty much came up with the same project.

I am incredibly tired but oh so happy to be done with my MS class. It's not that any of it is hard. It's just a lot of work sometimes. On the good side, I registered for my courses for next semester today, and I just realized that I have basically finished the entire MS except for my advanced stats class and the research year/thesis. That's pretty incredible. No wonder I feel so tired. I basically did all of my MS coursework except one class in one year while being a full-time medical student! I could do the advanced stats class next semester, but I decided not to because I want to have some time to start studying pharm and micro before the final push to study for Step 1. This year is just going by so fast....

Endocrine Clinic

It's fortunate that I got that book about women's health on Monday when I had the chance, because my learning objective for Friday is about hormone replacement therapy (HRT). There are two chapters in there describing all of the HRT drugs, and it is even readable and informative. The seminar today was about puberty disorders. That is some weird stuff. I hadn't realized though how young normal girls are when they begin puberty. I would have guessed about age 12, but that's just the average age when girls start menstruation. Girls begin developing breasts and pubic hair a couple of years earlier, around age 10.

This afternoon, I had endocrine clinic. My classmates who went yesterday were complaining that all they saw were diabetes patients. But today my classmate and I saw all thyroid patients, except for one infertility patient. I think this doc we were with must be a thyroid specialist. It was so busy in the clinic though that we really didn't get a chance to discuss anything with him much. Plus, there was also a fourth year med student working with him. So my classmate and I didn't wind up getting to do very much except for once when the doc had to leave the room to answer a page. That patient had hyperthyroidism and was willing to let my classmate and me both examine his thyroid. I couldn't really notice too much difference from a normal thyroid. Maybe it felt a little softer and slightly enlarged, I guess.

When it was time for us to go, the doc offered to let us stay on and keep following him and the fourth year student around, but my classmate and I had both seen enough for one day. The endocrine clinic was more interesting than I had expected it to be, but I was disappointed about how little we got to do compared to some of the other students in my class.

Rants of a Crank

Our PBL case this week is about premature ovarian failure, and it's an interesting one so far. We had two seminars yesterday, one on deficiencies of adrenal enzymes and one on menopause, to go with it. The menopause seminar speaker has written a book on the topic, and she gave free copies to anyone who wanted one. Her powerpoint slides were disgustingly pink, the presentation made annoying little cutesy noises every time she changed slides, and her talk was half science and half soap box. But it's amazing how getting a free book can make all of these sins of powerpoint presentations forgivable.

In the evening, CCLCM was co-sponsoring an event at the Maltz Museum so that all the Case medical students could see the Deadly Medicine exhibit for free. It's the same exhibit that I went to a few months ago, only this time we didn't get to go to Mrs. Lerner's house afterward. Someone cancelled at the last minute, so there was an extra ticket, and I was able to go back to see the parts that I didn't make it to last time. I didn't stay too long though because I still had to do some more work on my paper for my MS class.

This morning, we had seminars on osteoporosis and thyroid pathology, and then for FCM we had a "field trip" to the art museum. I had been asked to participate in the NMS block evaluation session, scheduled for today at lunch. But I couldn't do it, because I had to videotape myself interviewing a patient in clinic. This is a ridiculous new requirement that all the first and second years have to do this year, where we check out a video camera, print out a consent form, and take them both to clinic to video an interview with a real patient. I wouldn't have minded as much if I could have scheduled the day myself, but the school decided to make me do it today, which is about the worst day they could have picked all block for me. They had also scheduled me to have a clinical correlation today, so I had to go see someone in administration to get it straightened out. I dare say that I'm a pretty decent multi-tasker, but even so, I readily confess that I'm not so good that I can be in two different clinics at the same time.

The actual patient interview taping went ok once I got everything set up. As it turns out, my first patient consented to be interviewed on tape, and he was some kind of video camera whiz, so he even set it all up for me. It was good that I did the videotaping early in the afternoon, because as usual we were double booked from 3-5 PM, and all four of those patients showed up today.

I was completely puzzled by one of my patients. She wanted to get pregnant but couldn't, so she was interested in infertility treatments. She said she'd been trying to get pregnant for several years. That definitely fits the definition of infertility, which is an inability to conceive after one year or more of trying. I asked her about the regularity of her menstrual cycles and age of menarche. Both were normal and she hadn't noticed any changes in her menstrual cycles. Did she take birth control? No. Was she using condoms? No, she was having regular, unprotected intercourse. Did she have a medical condition that could interfere with her fertility? None that either of us could think of. How about her husband? He didn't have any known infertility problems. At a complete loss, I started going through her medications on the computer, and what do you know, she had been getting intramuscular injections of Depo Provera for the past few years. At that point, I excused myself from the room and went to get my preceptor. I suppose I could have just told her myself. But I figure this is one of those things where it's better for the patient to hear it from the physician and not some second year medical student!

A Day Devoted to Research

I had thought up until about a week ago that the final paper was due for my clinical trials class yesterday because I wrote it down wrong in my calendar, but I got a reprieve. It's not due until next week. So, I am going to be spending this weekend working on it, but I'm very, very grateful for the extra week! The other nice thing is that after next week, there will be no more crack of dawn Thursdays for me for the rest of this year.

Today we finished our PBL case and had two seminars on pancreatic tumors and ectopic hormone production. ("Ectopic" means that the hormone is being produced by tissue somewhere in the body that isn't supposed to be producing it.) We also had another one of those small group research planning sessions instead of the normal POD/ARM seminar. I was initially wary after how badly the last one went, but this one was a lot better. A big part of it is that our PBL case this week had several engaging scientific and ethical issues (unlike the last one we had to use), and we came up with a research idea that is actually interesting. I'm not sure how feasible it is, but it would be cool if it could be done. Basically, we want to look at pancreatic tumor markers to differentiate tumors which secrete hormones that are normally produced by the pancreas (ex. insulin) versus tumors which secrete hormones not usually produced by the pancreas (ex. growth hormone). Our hypothesis is that the former come from differentiated pancreatic cells, while the latter come from from pancreatic stem cells. The existence of pancreatic stem cells was only discovered quite recently, so it's a hot field.

This afternoon, I met with a researcher who I am considering working with for my research year. We discussed some possible ideas. I wasn't particularly gung ho about any of them, but he was open to me coming up with something else. So I really need to spend some time thinking about exactly what project I want to work on this spring and summer. Then I will need to start working on convincing someone to fund me for it. :-P

A Good ERB Day

This week's PBL case has been really interesting. I don't know who is writing the ERB PBL cases, but they're much better than the ones we had last block for NMS. These cases cover more ground, and we can't always predict from the getgo what is going to happen. We have even been getting into ethical issues like the pros and cons of genetic testing for the patient's children. It seems like an obviously helpful thing to do, but things aren't always that simple. What happens if there's not a clear treatment that would benefit the child, but now the child has this known genetic defect and can't get insurance as a young adult because the insurance company says he or she has a pre-existing condition? That doesn't even address the psychological distress that people can have due to knowing their genetic status. It makes more sense to do the testing if there is preventive care or screening that can be done, and also if the exact mutations are well-established. That didn't turn out to be the case for our patient though.

Today's seminars were on hypocalcemia and pituitary disorders. I was not initially excited about the hypocalcemia seminar, because it feels like we've beaten this stuff to death already. But it wound up being more interesting than I had expected. The speaker was the same guy who is in charge of our Friday POD seminars and who gave the semi-painful seminar on parathyroid differentiation proteins last week. He had assigned us to read a book chapter he wrote himself on pseudohypoparathyroidism, and it always makes me suspicious when profs do that. But I am glad I took the time to read it, because it goes into a lot more detail than Robbins (our path book) does.

Your body secretes parathyroid hormone (PTH) to keep your blood levels of calcium high enough. Calcium is very important for things like muscle contractions and intracellular signaling. It is so important to keep your blood calcium level high enough that your body will degrade your skeleton if necessary to accomplish this goal. That's where PTH comes in. If your blood levels of calcium get too low, you secrete PTH, and that causes your blood calcium to get higher by various mechanisms. People who have pseudohypoparathyroidism have low calcium levels, but it's not because they don't make enough PTH (which is the problem in true hypoparathyroidism). It's because their PTH receptors can't signal properly when PTH binds to them, which makes their blood calcium levels chronically low. Some patients are resistant to other hormones too since those receptors share some of the intracellular signaling machinery with the PTH receptor.

This afternoon, we had a communications session on patient education. One of my group members was absent and we didn't have a clinical correlation afterward, which means that we got out super early (2:30). So now I have the rest of this afternoon off. The three of us who were there were joking that one of us ought to volunteer to be absent from communications every time from now on. Also, it was snowing earlier, but now that has stopped too. Even though I am not a huge fan of snow, it really is beautiful while it's falling and when everything has just gotten covered with a fresh coat of it. Of course, it doesn't take too long for this whole city to get disgustingly dirty and icy slick, and that's when I start wishing I was going to med school in the Caribbean somewhere.

Too Many Tumors

Yesterday's seminars were both about tumors of the female reproductive tract. Today's were about tumors of the pituitary and adrenal glands. Our PBL case patient has tumors too. It's nice to know that people can get tumors of parts of the body that I didn't even know existed a year ago. On a happier note, most of these malignant endocrine tumors are fairly rare.

Today's FCM session was on motivational health promotion. My small group preceptor still wasn't back, but we had a sub this time, so I didn't luck out like last week. She started out by asking us how we were liking the class. I suggested that we just answer the questions we were supposed to answer and not discuss how we felt about the class. Luckily she didn't push the issue too much. As far as I'm concerned, it's irrelevant whether we like the class, because attending FCM is mandatory. We're all feeling tired, cranky, stressed, overworked, and ready for winter break. Take it for granted that every person in the room would rather be doing something else, and let's just get on with it. I don't want to even think about how lousy I feel right now, let alone have a whole gripe session about it.

The weather is bad today, so several of my patients didn't show up to clinic. I only wound up seeing two people. Of course, the ones who didn't show up were the 1:oo people, while naturally both of the 4:00 people came. We gave some flu shots and did some follow-ups, but all in all it wasn't a terribly exciting clinic day. I was sitting down while my preceptor talked to the last person, and it was tough for me to keep my eyes open. The room was kind of warm, and I was definitely doing that head jerk thing, so I decided that I'd better get up before I embarrassed myself.

Even My Blog Is for Sale!

I randomly stumbled upon an absolutely hysterical website today called BlogShares. Apparently they assign "market values" to blogs based on numbers of links and allow users to buy and sell shares in the blogs. My blog has mysteriously been listed on their site, and at the moment, is valued at B$1,000.00. This page explains how it works. At first, I didn't know whether to find this site to be disturbing or amusing, but the more I think about it, the funnier it gets. According to the website, I could register on Blogshares and stake my claim to my own blog as the owner, but it doesn't seem worth the trouble. I'll have to check back at some point though and see if anyone buys shares of my blog. :-)

Doc Opera was awesome. It's too bad the revisiting students don't get to come any more now that the show is in December instead of March. But for those of you who will be attending any of the Case programs next year, you should definitely at least go, and consider being in the show.

More Bad Pregnancy Outcomes

Yesterday I had my MS class in the morning. We're getting close to the end now: only two more weeks to go. Not that I'm counting the days until I won't have to get up for a 7 AM class any more or anything. ;-)

Today we finished the PBL case about the HIV positive woman who wants to have a baby. The story has a partially positive ending. The baby isn't HIV-positive, but he does have a genetic abnormality. What really got people fired up though are the ethical issues, particularly one of this week's CAPPs that revolves around the issue of a pregnant patient who refuses care. That's a sticky issue, because you can't force a competent adult woman to receive needed medical care, but most people would also feel a desire to intervene to protect the fetus.

The seminars were about pre-eclampsia (a type of hypertension that pregnant women can get) and ectopic pregnancies (where the fetus doesn't implant in the uterus like it's supposed to). Not exactly the cheeriest subjects. Our POD/ARM talk was supposed to be about pregnancy related disorders, but instead it wound up being about a particular transcription factor (protein) that is expressed by cells that are "destined" to become parathyroid hormone cells. The researchers discovered that if they knocked this protein out in mice, some of the thymus cells became parathyroid type cells and started secreting parathyroid hormone. However, this does not happen in humans. Well, on the bright side, at least I'll know what to do in case I ever get a mouse that is deficient in this transcription factor coming into my office for help some day. And I also wrote my second essay for MS credit based on this talk, so it forced me to pay attention. Now I only have to do one more essay in January.

Tomorrow is Doc Opera already. I really enjoyed it last year, and I have been looking forward to this year's show.

Medical Genetics

I've been getting quite a lot of exposure to medical genetics lately. First, I did my learning objective for PBL on genetic counseling and ethics. As I mentioned yesterday, this week's case is about an HIV-positive woman who wants to have a baby. Obviously, there are many legal and ethical issues that would arise, from preventing transmission of HIV to the husband, to avoiding transmission to the infant, to genetic counseling of the woman for birth defects of the fetus. Today's seminar was on the use of drugs (both legal and illegal) during pregnancy, which isn't really related to genetics. But then this afternoon, I had genetics clinic.

Genetics clinic turned out to be pretty interesting. I expected most of the patients to be babies, but many aren't. They range in age from little kids all the way up to old people. We did see one baby who was developmentally delayed. But we also saw one woman in her thirties with an unknown genetic condition that caused her to be mentally retarded and have some other physical abnormalities. Probably the coolest patient was a teenager who had blue scleras due to type I osteogenesis imperfecta. (The whites of people's eyes who have this condition really do look noticeably bluish--see picture.) His family was there with him, and his dad and brother had blue scleras also, but they didn't have the same history of broken bones that the patient had. The medical geneticist took pictures of the patients after we examined them.

The one thing I felt kind of bad about is that I was so tired this afternoon that it was hard to stay focused. Medical genetics is very cool, like a detective hunt. We were looking up all kinds of info about genes on line in between patients. But the problem is that there is a lot of downtime, and I had a hard time staying awake. I just hope the preceptor didn't think I was bored, because I didn't feel that way at all. If I were going to go into internal medicine, medical genetics would definitely be one of the specialties I would consider.

Reproductive Biology

This week we started reproductive medicine. Our PBL case is about another couple that is trying to get pregnant--this time, the woman is HIV-positive and the man is HIV-negative. The woman also has genital warts. These viral infections certainly add to the complexity of the case. The seminars are about all of the things that can go wrong with pregnancy. All I can say is that no sane woman should go to medical school until AFTER she has her kids. There is definitely such a thing as having too much information! Yesterday we talked about some of the infections that pregnant women can get, and today we learned about fetal genetic defects and placental problems. I have a much better appreciation now about why pregnancy is so dangerous for women. Throw in all of the genetic defects that the fetus can have, and it's amazing any pregnancy ever comes out right at all.

Our FCM seminar today was about alternative and complementary medicine. My group's preceptor didn't show up, so after twenty minutes I went to the library to read. That was an extra hour of reading time that I hadn't expected, but it was greatly appreciated. I'm actually going to be completely prepared for tomorrow's seminar.

We were really busy in clinic today. My preceptor and I used to only see six people on my clinic days, but now we're seeing seven patients each day due to a new departmental policy. You wouldn't think that adding one more patient to the schedule would be that big of a deal, but they are adding the last patient in the 4:00 time slot. So now the two of us really have to push to get everything done at the end. I saw five patients instead of my usual four. There was one diabetic, one with migraine headaches, one with a cold, one with moles that "looked funny," and one who just needed a checkup. It was a busy day, but I suppose I should be grateful that there wasn't anyone who was trying to get pregnant!

Happy Thanksgiving!

I found out today that the UP students had this whole week off, the lucky dogs. I can't complain though, because at least I got out of having clinic this afternoon. I was supposed to have breast clinic, but I withdrew because I would rather do genetics clinic next week. I've already done enough breast exams in clinic to last me a lifetime.

Both of our seminars today were yet again depressing, on cervical and uterine cancers. At least the PBL case had a happy ending. We were pretty rushed though since we had eight learning objectives plus three parts of the case to go through, and we had to fill out the weekly eval today too. I was unlucky enough to be the group leader this week, and although it was rushed, somehow we managed to get everything done more or less on time.

Anyway, I have the rest of this week off and I plan to enjoy it. I'm going for dinner with friends tonight and having Thanksgiving at a friend's house tomorrow. We have SAQs to do this weekend but no CAPPs. It really WILL almost be like a vacation. :-P

Spiritual Madness

Today was one of those crazy days where I think back on it later and kind of just shake my head. We had not one, not two, but THREE seminars this morning about prostate and testicular pathology. They were one after another, each with its own reading. All of them were great seminars, but three in a row was just a little over the top.

Then there was FCM. They had this guy from pastoral care come to give us a seminar. He was supposed to be talking about spirituality and how it affects decision-making in medicine. Instead, he wound up getting into a fight with about half the students in my class and half the preceptors too, because he was saying things like that ministers are the only people with proper training to help patients spiritually. That really got the doctors' dander up. He was also asking ridiculous questions like how we thought the case patient felt when she was having sex at the age of 11. Ok, first of all, this case patient is a composite, not a real person. Second of all, it's not like she was there and we could ask her! How the heck would we know what an imaginary person felt while having sex twenty years ago? The whole exchange was very hostile, and the FCM faculty wound up emailing the entire class this afternoon to apologize for the speaker's behavior. We didn't learn much, but at least for once I can say that an FCM session was exciting!

I had clinic in the afternoon. When I got there, it turned out that my preceptor was on vacation all this week and no one had told me. The nurses said I could go home, but I didn't want to have to make up the clinic. So I wound up working with one of the residents and his preceptor instead. He had a patient who needed a neuro exam, and he let me do it. At long last, I pretty much have the cranial nerve exam down, and no one has to prompt me because I forgot to examine CN 11 or something.

There is a pharmacist in our clinic who meets with patients, and I went into a room with her resident on one patient also. That was really interesting because I had no idea what the pharmacists did in the clinic. It turns out that they counsel patients with tough cases who take lots of meds. This particular patient was a diabetic who was completely noncompliant and was also hypertensive, obese, and dyslipidemic. The most interesting part to me was how different the focus was. The pharmacists really don't get much into the disease symptoms or mechanisms at all. After the resident presented to the senior, they were debating for 15 minutes about which type of insulin was best for this patient, and so I got a review of all the different long and short-acting insulins. When they were done, the pharmacist asked me what I thought we should do. I said, "Tell the patient to drink diet soda instead of regular soda." All the insulin in the world is not going to help a patient who drinks a six pack of sugar water every day!

The Problems of Women and Men

So far this has been a very depressing week as far as classes go. Our PBL case patient has genital warts and cervical cancer. The two seminars today, although interesting and well-done, were about breast cancer. This is going to go on for the rest of the week--tomorrow, we're covering male genitourinary problems, and Wednesday we're back to women. One interesting thing I noticed is that our pathology book has tons more coverage of women's health problems than men's. There are two separate chapters on women's health, one just on breast diseases and another huge one about diseases of the female reproductive tract. The sole men's health chapter is much shorter. I wonder if this is because there are that many more diseases of the female reproductive tract, or if we just know more about women's diseases?

Speaking of genitourinary tracts, this evening I did my GU exams at the Cleveland Free Clinic. It was quite an experience. Two of my classmates and I got there at 4:45, and we first got a pep talk of sorts by the woman who coordinates the medical student practice exams. She spent about half an hour telling us that we had to be professional, and giving us all kinds of ideas of how NOT to be professional that I would never have been clever enough to have come up with on my own if she hadn't described them in excruciating detail. Like, apparently in the past some med students have said they were going to the bathroom, but then bailed instead without telling anyone. She warned us not to sneak out of the clinic, or she'd have to report us to the school. I had to laugh, because as much as I was not looking forward to performing a digital rectal exam, I haven't come this far and worked this hard to let something like this stop me from getting my MD. So none of us bailed, and we managed to mostly stay awake during an incredibly boring video about Pap smears that, judging from the clothing the actors wore and the equipment being used, must have been made in the late 70s or early 80s.

After an hour of these torments, we were finally ready to do the female exam. Since there were three of us students, we were divided into one pair and one single person. I was the single person, and I had a sort of coach in the room to help me along with the patient herself. My standardized patient and the coach were super helpful, and once they started giving me instructions I got over the weirdness of the situation pretty quickly. First, we went through the breast exam, which I had done several times in longitudinal clinic already. No biggie. Then it was time for the pelvic exam. (We inserted the speculum, but didn't do the actual Pap smear.) I inserted the speculum and was able to visualize the os (opening) of her cervix on the first try. Then I tried to palpate her ovaries (I couldn't really feel them) and did the rectal exam. It wasn't too bad because I was so focused on what I was doing that I didn't even think about the grossness factor.

All that was left to do was the male exam. Since I was done first, I got to spend another 20 minutes one-on-one with the coordinator lady and hear about more blunders committed by previous medical students over the years. When the male standardized patients arrived, one of my classmates and I were paired together this time. That standardized patient was really awesome also. He started by explaining the exam, and then I went first. The male exam was a lot more uncomfortable for me than the female exam. The man was standing in front of me, and I was inspecting his penis and testes while seated, which felt pretty awkward. The weirdest part was when I was examining for an inguinal hernia. He didn't have a hernia, so I had to palpate pretty deeply into his inguinal canal to reach the inguinal ring. When he coughed I could actually feel his intestines move. After my classmate repeated the exam, we moved on to examining the prostate, which entailed yet another digital rectal exam. I was able to palpate the prostate, but it was hard to reach the far edges. Prostates are larger than I had realized.

We were finished at 9:00, and I was definitely glad to be done. Doing the GU exams wasn't as awful as some people make them out to be--you're so busy concentrating on the exam that you don't really have time to sit there and think about how gross it is. But at the same time, I am absolutely certain that I have zero desire to go into either gynecology or urology. Even though doing the GU exams wasn't all that big of a deal, I am definitely not looking to make a career out of it.

Conferences, Incontinence, and In Vitro Fertilization

The conference I went to yesterday was really good, but I'm glad it's the last one that I'll be attending for a while. It's amazing how much these conferences totally screwed up my schedule. I also missed my MS class (which I have to confess that I'm not especially sorry about) and a Dean's Dinner by Steve Nissen (which I am definitely sorry about). That was the first Dean's Dinner that I've missed since I started med school, and I would have loved to have gone. I've seen him talk once before about his work on intravascular ultrasound, and he was supposed to discuss that again last night. But apparently he wound up discussing the whole Avandia brouhaha due to his meta-analysis that was published earlier this year.

Our PBL case had a very happy ending, and our only seminar today was anatomy. This was a review of the genitourinary systems of the male and female. The talk at the beginning was about different kinds of urinary incontinence. One type, called stress incontinence, can happen due to an anatomic problem when pressure increases in the abdomen (ex. from laughing or coughing). The other type is urge incontinence, which is due to a neurological type of problem. The difference is important because urge incontinence can be treated medically, while stress incontinence tends not to respond to medication and has to be fixed surgically.

I met with my PA also and we discussed my portfolio essay and my plans for next year. Right now I am tentatively planning to do Core I (medicine and surgery) starting in July, then a block of research and electives starting in November, and then Core II (neuro/ob/gyn/psych/peds) in March. I would probably then do my Advanced Cores in July of my fourth year and start my research year afterward in November. This will give me time to write a proposal and get it approved by the CCF IRB.

Our POD speaker today (sorry, our ARM speaker today) is doing research in infertility and in vitro fertilization. He was a really engaging speaker who told us a bunch of interesting anecdotes about the early days of in vitro fertilization. For example, he was involved with the first in vitro fertilization that was done in the state of Ohio, which was in 1983, and he was the first person in the world to implant an in vitro-fertilized embryo into a surrogate mother. Currently he has a project that raises money to help pay for gamete storage and in vitro fertilization for lower-income patients who could not otherwise afford it. The program particularly targets young female cancer patients who are undergoing radiation that could render them infertile and incapable of having children at a later date.

The talk was certainly enjoyable and the research was very interesting. But I can't quite push this nagging thought out of my mind that as frustrating as infertility must be to people who really want a child, it's maybe not the most pressing problem in all of medicine. Why should in vitro fertilization deserve so much of our limited supplies of funding and brainpower? No woman is going to die if she can't become pregnant, and couples who cannot have their own biological children can always adopt a child. I'm not saying that this kind of research shouldn't be done or that the technology for in vitro fertilization shouldn't be used. It's just that there are plenty of life-threatening problems that could possibly be ameliorated by setting up foundations to subsidize health care costs for lower-income people whose jobs don't provide them with health insurance. For example, why isn't there a foundation to subsidize yearly Pap smears for low-income women so that they don't die of cervical cancer that could have been treatable if it had been caught earlier?

PBL, Pharm, Peds Clinic, and Portfolio

Today's portion of the CCLCM curriculum is obviously sponsored by the letter P.

Our PBL case took a little twist that seems kind of farfetched, but at least it kept things interesting. I wasn't able to find