Friday, March 23, 2007
Our PBL time was about half the usual length today. We had one person's presentation on liver histology to go over, which occupied most of our time. Then a woman who works with the Liver Transplant Selection Committee came to talk to us about how the Committee operates. We asked her some questions, and then it was time to go to the actual meeting. We're attending the meeting instead of having a POD seminar today.
There are a lot of people on the Selection Committee, including several doctors of course, but also nurses, social workers, and other people who are involved with caring for transplant recipients. They gave us a packet with info about each patient so that we'd know what was going on. One of the patients they were discussing today needed a kidney transplant as well as a liver transplant, and so the kidney transplant surgeons were there also. It was interesting to listen to the discussions at first, but after a few patients, it got kind of monotonous. Everyone was approved for the liver transplant list, even one patient who didn't actually need a transplant yet. All in all, the best thing that came out of this experience for me was that after it was over, I talked to one of the Committee physicians about shadowing him this summer. He gave me his card and told me to get in touch with him.
One of my friends who is going to be a student in next year's CCLCM class is staying with me tonight and tomorrow. After that, I'm leaving to go on spring break. So I won't post anything more until the week after, when we start our endocrinology and reproduction block.
Thursday, March 22, 2007
I went to office hours for anatomy in the afternoon. I was the only one there at first, but then one of my classmates came just as I was leaving. It was hard to concentrate on what I was doing. I think that a lot of us are just tired and ready for the block to be over. I know that I am.
The second look started this afternoon. I didn't see any of the prospective students though because they were over at the Foundation House all day. (That's the really nice mansion where a lot of the swanky functions are held.) Tonight there is a bowling social activity (why do second looks ALWAYS involve bowling???), but I'm not going to go. It doesn't start until ten, and I have seminar tomorrow at eight as usual. Plus I'm behind with the reading for tomorrow, also as usual. :-P
Wednesday, March 21, 2007
Our seminar was fantastic. It was by the same person who did our last pharm seminar. I wish the course directors would get this pharmacist to lead all of our pharm seminars and not just the GI ones. We went over the cytochromes P450 and other aspects of drug metabolism. What makes her seminars so good is that she has us go over cases in small groups, and then we talk about them as a class. She also gives us a summary table of the most important info we need to learn at the end of the seminar. The material we covered was a really good segue into my PBL presentation since I had the pharm learning objective.
By now, our PBL patient is not doing very well any more. Well, we knew he was going to go downhill, so this isn't really a surprise. We had more time to discuss the social/economic/psychological aspects of the case, and we'll be doing more of that on Friday. I'm not totally thrilled that the course directors keep sneaking SLEEP issues into our PBL cases, but this case really has a ton of them because of the whole liver transplant issue. ("SLEEP" stands for Social, Legal, Economic, Environmental, and Psychological. It's part of the acronym "VINDICATE SLEEP" that we use sometimes when we're working through the case and coming up with hypotheses. Apparently we aren't the only ones who use it.)
Only two more days until spring break!
Tuesday, March 20, 2007
Our seminar had two parts. We had been assigned to read two articles relating to cholesterol metabolism and bile acids. The faculty divided us into two groups of sixteen, and we went over each article for an hour. The articles were kind of detailed, but the group reviews were really helpful. One of the interesting things we learned is that there seem to be receptors for fatty acids and cholesterol on intestinal epithelial cells. Initially, people had assumed that nonpolar molecules like these could just diffuse passively into the cells. Maybe they do to some extent, but it looks like that's not the whole story.
I had a really good time in clinic today. One of my patients cancelled, so I only saw three people. But it was really fun and laid back because we didn't have any required exams to do this week. I just decided what exam to do myself based on what the patient's complaint was. One of them had loss of sensation in the torso and one arm, so I tested the patient's dermatomes to try to localize which spinal nerves were affected. (Dermatomes are areas of the skin that are innervated by the same spinal nerve. You can actually go down the patient's body dermatome by dermatome and test each nerve individually.) It was really neat, because I alternated from the normal side to the affected side for each dermatome, and the patient reported a difference for several of them.
There was a seminar over at Case that I had hoped to go to, but I got out of clinic too late to make it in time. So I just came home instead.
Monday, March 19, 2007
Our anatomy session today had a review station, radiology, and we also discussed different types of inguinal hernias. (A hernia occurs when there is an opening in your abdominal wall somewhere, and your guts can poke through the hole into places where they shouldn't be.) None of our cadavers had hernias, but we saw a lot of pictures of hernias, and we talked about where the hernias would be if the cadavers DID have hernias. It's really amazing when you see how little tissue we have holding in our intestines. It's a huge contrast to the chest, where you've got the ribs keeping everything in place. Basically there's just some fascia (connective tissue) and some muscle, and that's about it. We had two stations highlighting the differences in male and female abdominal anatomy. Starting after break, we'll be studying the groin, so this is kind of an intro I guess.
The new PBL case is a really good one. The theme this week is about the liver, and the patient in our case took an overdose of acetaminophen (Tylenol). So we already know that he totally trashed his liver. This case has a ton of social issues. We're getting a lot of exposure to the ethics of how patients are chosen to be placed on the CCF list for liver transplantation too. We'll be talking about the criteria for selection tomorrow in FCM and also Friday when we attend the Liver Transplant Selection Committee Meeting. My learning objective is about the pharmacology and toxicology of acetaminophen. Good stuff. Plus, my schedule is finally easing up a little. So all in all, I'm really looking forward to the rest of this week.
Saturday, March 17, 2007
- Memorize all of the Review of Systems (ROS) questions for the pulmonary, cardiac, and gastrointestinal exams. You will be expected to complete these three ROS, and you're not allowed to take notes in with you other than what you write down there on your scratch paper. So be sure to memorize these questions before the OSCE if you haven't already done that.
- Memorize the history of present illness (HPI) questions. You'll definitely be asked to take a history of the patient's present illness, so be ready.
- Watch the Swartz video showing the pulmonary, cardiac, and GI exams. Swartz is the man. Do what he does, and you'll be fine with the exams.
- Sign up for one of the optional OSCE review sessions and go there with a list of exams that you want to practice. They have standardized patients for you to work with, and this is a good time to review some of these exams that you haven't seen in six months.
Here are some tips for performing well during the OSCE:
- When you write down the info that's posted on the door, don't forget to get the "patient's" name. Then when you walk into the room, make sure to look the standardized patient in the eyes, greet them by their "name," and shake their hand while you introduce yourself as a student. ("Hi, Mr. Smith, I'm John Jones, a medical student working with Dr. X....") The names are easy ones that you'll have no trouble pronouncing, and my observers all really liked that I greeted the patients by their names.
- Make sure to wash your hands before and after you touch each standardized patient. Forgetting to wash your hands is apparently a huge faux pas that is rumored to make you flunk the OSCE. So definitely make sure you do it.
- Pay attention to where you're standing when you perform the exam. I didn't realize this, but there are apparently "rules" about which side of the patient you are supposed to stand on while you perform certain exams. One of my observers commented about me examining the patient from the wrong side of the table. Just FYI, both the cardiac exam and the GI exam should be performed from the patient's RIGHT side. There does not seem to be any correct side for performing the pulmonary exam, as far as I know.
- Try to group the exams together so that you do not have to keep moving the patient more than necessary. In other words, do all of the seated exams first, then have the patient lie down and do all of the supine exams together as a group. Don't do some seated exams, make the patient lie down, then have them sit up again. This requires some pre-planning, especially for the cardiac exam.
- Explain briefly what each test you perform is designed to do. The observers really liked that I took some time to tell the patients why I was doing this or that. You shouldn't spend too long on patient education during the OSCE, but it's definitely helpful to do a minute or two of it for building good patient rapport. Actually, that goes for real-life patient encounters too. And along the same lines, make sure that you don't use medical jargon when you explain things to the "patients."
- Don't forget to ask about ALL medications, including herbals and over-the-counter drugs, when you ask what meds the patient is taking. A lot of people won't mention things like alternative medicines or over-the-counter remedies that they only take occasionally unless you explicitly ask them. So make sure to do this. Again, this is important to do with real patients too, because sometimes these drugs can react with prescription meds. Also, make sure to ask the patient HOW they take their meds, since sometimes they do not take them correctly. Have the standardized patient tell you the doses of each medication and when they take them. Finally, don't forget to ask the patients whether they smoke, use alcohol, abuse prescription drugs, or take recreational drugs. If they use alcohol, remember to ask the CAGE questions.
- If your standardized patient confuses side effects with allergies, make sure to explain the difference to them in a respectful way. A lot of people get confused about these things. But you have to let the patient know that if a medication has a bad side effect, that is NOT the same thing as being allergic to that med.
- For a patient who has some abnormality or pain, examine the NORMAL side first. This is especially important for patients who are in a lot of pain, because otherwise they might clench up their muscles, and you won't be able to complete the exam. Also, remember that for the abdominal exam, you should always auscultate before percussing, unlike most of the other exams where you percuss first.
- Try to be as gentle and sympathetic with your "patients" as possible, but still follow the exam procedures you learned in class closely. If the patient tells you that you are hurting them, apologize and back off a little. You can make some small modifications if you need to, but you still have to complete as much of the rest of the exam as you can. That's another good reason to always examine the normal side first.
- Give a suitable closing statement before you leave the room. It's very bad form to just walk out of the room at the end without transitioning well or letting the standardized patient know what you're doing. I told the "patients" something along these lines: "Ok, Mr. Smith, I think that's all of the information I need for now. I'm going to go get Dr. X now, and we'll come back and talk to you some more. It was a pleasure meeting you, and thank you very much for letting me examine you."
Be aware that the OSCE will probably be filmed, and you will be asked to sign a release form giving permission for this. You may choose not to sign the form if you do not want to be filmed. Also, you'll be given food (we got sandwiches and chips). Try to relax and have fun. If you totally ignore the observer in the corner, it won't seem as awkward to be watched, and you'll feel less nervous. The time really does fly by. I felt like I had just started the exam, and then all of a sudden they were knocking on the door to tell us that time was up.
Friday, March 16, 2007
We are finished now with our PBL case about the sick doctor. We didn't have as many learning objectives today, so we spent some more time discussing what the responsibility of the patient-doctor's physician was toward the patient's twin brother, and how he could fulfill that responsibility without violating his own patient's privacy. One thing that annoyed me is that we still don't know what kind of twins the two of them are. It makes a difference, because if they are fraternal (dizygotic) twins, then they don't have any more genetic similarities than any other pair of siblings would. Obviously if they were identical twins, then that's a different story. Hopefully they'll give an answer to that question in the case next year.
Our POD seminar today was FANTASTIC. It's easily one of the best we've had all year. The speaker was the same pathologist who had been doing our GI histo seminars earlier in the block. She studies Crohn's Disease and inflammatory bowel disease (IBD). Something really good that she did is that she just sat and talked with us instead of showing us endless slides of data, which made the talk very interactive and informal. People asked a lot of questions. One of the most interesting things she told us is that she got involved in this type of research because of her personal experience with someone close to her who has one of these diseases. Also, she convinced the gastroenterologists at CCF to take more biopsies of patients with IBD during their colonoscopies by writing in her path reports that she had received inadequate numbers of samples. It turns out that people with IBD are more prone to getting colon cancer, and the number of biopsies being taken were not in accordance with published literature guidelines for catching most of these cancers. Now it is standard practice at CCF to take enough biopsies, and she said sometimes she even gets more than the number needed. She was rightly proud of having instigated a change here that could literally save people's lives.
In the afternoon, I volunteered at CHI. The weather was kind of cold and gray, but we had a lot of people come anyway. I was doing the glucose and cholesterol tests again--I've gotten pretty good at getting blood by now, even from the people who aren't "bleeders." We started offering HIV tests today, and the nurse who was administering them was sitting at the next table from where I was. So I was able to watch her a little bit when things were slow at my table. It's apparently some kind of DNA test that uses swabs, not a blood test. I haven't done the HIV training yet, but hopefully there will be another session soon so that I can learn how to do it. I figure they'll probably do it this summer so that the new M1s can get involved too. We also had a patient with a positive pregnancy test today, so some of my classmates were able to help her with getting prenatal care. I was talking about it afterward with one of my classmates who does the social work for the CHI patients. It's kind of scary in a sense because there are so many things that a pregnant woman with no health insurance needs. But at the same time, it's a significant opportunity to hopefully make a difference in someone's life, even though we're still only first and second year students.
Thursday, March 15, 2007
You may remember the 1999 fiasco at U Penn involving Jesse Gelsinger, who was one of the first humans to receive experimental genetic therapy. Since there were apparently quite a few ethical mishaps that took place and are alleged to have contributed to Gelsinger's death, U Penn now has very stringent rules in place for genetic therapy clinical trials. The fact that the researchers plan to target kids made this talk especially interesting. There are tons of extra ethical concerns to take into account when it comes to kids, since they are not legally able to consent. It was an excellent talk, well worth getting up at the crack of dawn to attend it. Plus, I have now completed my first semester of seminar attendance requirement for my MS degree.
The clinical research class was pretty helpful today. We had all been asked to make powerpoint presentations of our methods sections. I went first, and the other students, the instructor, and the statistician who helps our class sometimes made some suggestions on how to improve it. I didn't know the answers to some of the questions, so I have made an appointment for tomorrow to discuss it with the physician who is helping me deal with the clinical part. In particular, I don't really understand what's going on with the stats yet.
Wednesday, March 14, 2007
PBL went well. We are still doing the case about the doctor with the twin brother, and it has some very interesting twists to it. Happily, I don't have a learning objective to do for Friday this time.
I spent a couple of hours this afternoon going over all of the questions we are supposed to ask patients for each review of system. (There is a set of questions that you have to learn for each organ system.) A bunch of us also viewed the physical diagnosis video that comes with our textbook. We were divided into four different groups for the OSCE. I was in the last group that went at 4:15, which is why I had so much time to review beforehand. The sessions are held over at Case at the Mount Sinai Simulation Center. There are three simulations: two that last fifteen minutes each, and one that lasts 30 minutes. In each case, there is an observer in the room with you who has a checklist and is there to verify whether you complete all of the tasks. I did the two short simulations first, then the long one. But half of the people did them the other way around.
Here's how it goes. You are not permitted to bring a cheat sheet into the room with you, but they give you scratch paper on a clipboard. You stand outside the door of the "exam room" where the actor (standardized patient) and the observer (one of the clinical preceptors) are waiting for you. On the door is a sheet of paper that gives you some info about the "patient" (name, vitals, complaint) and what tasks you need to do (take a history, perform an exam). You are able to make notes on the scratch paper. Then you go in there and begin the exam. At the end, the observer gives you five minutes of oral feedback, which is later followed by a written evaluation that goes into your portfolio as evidence toward your clinical skills competency. Each simulation is videotaped, although in previous years the tapes have not been usable. I will post some OSCE tips for you rising M1s later, but that is the general gist.
My first "patient" was there for a physical. I had to get his medical and surgical history, find out what medications he took, and ask about his allergies. Then I did a cardiac exam on him. Overall, this session went very well except that I was apparently standing on the wrong side of the patient while I examined him. The second one had a cough. I had to get the history of his illness, go through the pulmonary review of systems, and perform the pulmonary exam on him. This was my best exam. The observer really didn't have much to critique. The third "patient" was a woman who had abdominal pain. This was the thirty minute simulation. I had to get her history of illness, medical history, surgical history, medications, allergies, social history, go through the review of systems, and then perform an abdominal exam. I forgot to percuss her abdomen and ask her the CAGE questions for her alcohol use, but otherwise the exam went well. I was so focused on what I was doing that I didn't even realize until the end that the observer for this simulation was one of my communications preceptors!
Overall, the OSCE was a lot less stressful than I had expected it to be. In fact, it was even kind of fun. I am happy to say that I passed all three of the simulations, and as far as I know, so did everyone else. We are apparently going to be doing a few more of these OSCEs next year too. I'm exhausted now and pretty much just ready to crash. Unfortunately, I'm going to have to get up early though to finish my homework for my clinical research class.
Tuesday, March 13, 2007
Our seminar was about carbohydrate and protein digestion. At the beginning, we had an intro with all of us together in the library. Then we had to break up with half of us going downstairs to one of the conference rooms (yet again, I was in this lucky half), and half staying in the library. The assignment itself was really cool though. We were supposed to come up with a plan for a clinical trial to test a drug. So we talked about which patients to test, how to design the study, what endpoints to choose, and how to make sure it was ethical. It was fun to do the exercise, but afterward, we had to present our discussion to the other half of the class and they had to present their half to us. That format is definitely not my favorite.
Tomorrow we have the OSCE. It's going to be a long day, so I'm going to head home and start studying for seminar now. I still have to finish my PBL learning objective too.
Monday, March 12, 2007
Our PBL case this week is pretty interesting for several reasons, one of which is because our patient is himself a doctor with a twin. So of course this is going to get into issues of genetics and privacy as well as with the actual disease. My learning objective is about the digestion and absorption of carbohydrates. We're going to be covering that already in seminar, so I'm making my presentation into a quiz.
We had another class meeting after PBL. I wasn't sure why we needed to have another one after we just had one a few weeks ago. But it turns out that the administration just wanted to talk to us about summer research preceptors and our next portfolios, which are going to be due a few weeks after we get back from break. Fantastic, that gives me yet something else to work on during my break. I did find out about an interesting elective class being offered on research ethics though. I may try to take that during my research year since I need to take an elective for my masters degree anyway.
In the evening, there was a talk by Francis Collins, who is the head of the National Human Genome Research Institute. He was the leader of the Human Genome Project, which you probably heard was completed a few years ago. (They sequenced the entire human genome.) His talk was really excellent. There was a little something for everyone. At the beginning, he was going into some hardcore genetics stuff, but then toward the end, he began discussing the future of genetics in medicine. He suggested that eventually (maybe in about a decade), we will all be able to have our own genomes sequenced for approximately $1000. This naturally led into a discussion about the need to protect people from genetic discrimination by insurance companies and employers. There is currently a bill in Congress about this that has been proposed for the past few years but has not yet been able to go up for a vote in the House. Maybe it will this year.
Friday, March 09, 2007
Today is my last day as PBL leader. We didn't have a problem getting through all of the presentations today since there wasn't much case left. I presented my learning objective last since it was kind of long. But everyone else's presentations were short, so that worked out well. It was kind of ironic, because I had told all of my group members on Wednesday that they better not come in today with any more presentations having seventeen slides. And then guess who comes in having twenty slides? Yeah, well, do as I say, not as I do, right?
The POD talk today was on the genetics of colon cancer. I was worried that it would be kind of dry, but it was pretty interesting. Usually I'm not a huge fan of genetics and molecular bio talks, but this one was good because the speaker gave us lots of opportunities to ask him questions and basically let us direct the conversation. He also presented several small powerpoints about different research projects instead of one big long one with tons of slides of gels and stuff--having to sit through an entire hour of gels would make me want to shoot myself. His group is trying to come up with a way to test people for colorectal cancer using their genomic profiles. If it works, that will be a huge boon for people who are at risk due to their family history or just spontaneous genetic mutations. Oh, and for the record, I brought my own lunch again today.
Wednesday, March 07, 2007
I am still the PBL leader. Our normal tutor wasn't here today, but we had a sub. He didn't say much. We had a ton to do during class, so I had to really watch how much time people took with their presentations. Amazingly, we got through everything: all eight presentations plus the case. I don't think I got as much out of it though because I was focusing a lot more on how we were using our time than I usually do. We have eight objectives again for Friday, but it shouldn't be a problem to finish because we won't have much of the case left to go through. My learning objective is to review the histology of the GI tract. I am not excited about this one, but I know that it's one that will be good for me to do. I do have to wonder sometimes though if I have this hidden streak of masochism....
We had our last Clinical Skills class this afternoon. We have already covered all of the physical diagnosis skills that we will be learning this year. So instead of practicing new skills on standardized patients, the preceptors had us give a brief report of a history and physical on a patient that we had seen the previous week in clinic. I talked about a patient who had been having headaches due to high blood pressure. The session was videoed, and we have the option to make an appointment to review the video if we want. For communications, we did a full history for half an hour on a standardized patient. The one thing that was different compared to normal is that this time, the actors weren't following a script. They were telling us about medical problems that they really have. Coincidentally, my standardized patient also had a problem with headaches. I can sympathize, because I tend to get quite a lot of headaches myself.
This week is spring break for the M2s, so we don't have class tomorrow. I am very happy about getting the day off!
Tuesday, March 06, 2007
Personally, I don't think that banning all gifts from pharmaceutical companies is a very good solution. It won't reduce their marketing expenditures, because they'll just use their marketing budget in other venues like advertising directly to patients. It certainly won't reduce the influence they have on physicians and government officials. They'll just lobby in Washington more and advertise more at physicians' meetings and in physicians' journals and on TV. And it may interfere with the free drugs they give physicians that physicians can pass on to lower income patients, as well as the support they give to educational activities for physicians. I think that actually it would be better to allow all the major companies to give the same amount of gifts and have the same amount of access to physicians, and that way none can unduly influence physicians. But apparently the national trend is toward forbidding all gifts from Big Pharma whatsoever. Well, no one ever said bureaucracy made sense.
Our seminar today was histology of the liver. Geez, the histology overload is killing me this block. I never want to see another virtual slide again. To think I had ever even contemplated going into path! I have a hard enough time getting through a single chapter of the histo book, let alone three of them in a single week. The GI histo seminar leader is really nice and enthusiastic, but I still don't like histo. The pathologists keep telling me that a bad histo experience doesn't mean I can't be a pathologist though. Well, I guess I'll see how path goes next year, and then I'll have a better idea.
In the afternoon, I went to anatomy office hours and reviewed the blood vessels in the abdomen. I was the only one there, so it was a really nice, succinct review. Afterward, I went to a meeting for the next bone marrow registry drive. There is going to be a Minority Men's Health Fair here at CCF next month, and we're planning to try to register more minorities there. One other idea we came up with at the meeting was to set up a table at CHI and try to register some of those people as well. Most of the people we see at CHI are minorities and fairly young, so I think it is worth asking them if they're willing to register.
Tomorrow is going to be another really long day. I just have to hold on until spring break....
Monday, March 05, 2007
I am the leader for PBL this week. Our case is pretty chock full of stuff. We wound up with ELEVEN learning objectives today, which is absolutely insane. So I told the group that we had to combine some of them so that we wouldn't have more than eight, and we managed to get it down to eight. But it's still going to make Wednesday's session hellish, because we have to get through all eight presentations plus the second part of the case. My learning objective is about the normal gut flora. It's actually a pretty interesting topic, and not one that I knew too much about.
In the afternoon, I went over to the lab where I'll be working this summer to talk to them about my research proposal for my clinical research class. I'm working on the methods section now, and I have to present that next week for my class. I'm going to need to go back there, though, because I still don't know much about the statistics. The good news is that there are statisticians here that we can meet with, and they will write the stats section for me. :-)
Friday, March 02, 2007
Our POD speaker today was telling us about iron metabolism. It was a pretty interesting talk. I hadn't realized how many different proteins are required for us to have iron homeostasis. I thought the speaker also tried to make the talk fairly interactive, which is always good. And of course, I did not eat any of the food. Actually, that worked out well, because I took my PA for lunch as a thank you for taking me to the ER and staying all night there with me last weekend. We went on campus to Au Bon Pain, which apparently is a chain that has restaurants in a lot of hospitals. They serve breakfast and lunch there. It has become quite a favorite among the CCLCM staff and students along with the CCF patients. I had lasagna, and it's excellent.
Thursday, March 01, 2007
In the afternoon, I had a review session for the OSCE in a few weeks. We went through all of the clinical skills checklists with a standardized patient. Our patient was one of the people we had interviewed during our last communications class. Last time, he was portraying a problem alcohol drinker, but today he was normal. It's pretty funny when we get the same standardized patients in new roles. I feel a lot better now about some of the skills that we learned like six months ago. I barely remembered where the heart is by now, let alone how to do the cardio exam!