Friday, September 28, 2007

End of First Week of NMS

Yesterday I had my Clinical Trials class. It was as painful to get up at 5 AM as I expected it to be. But on the bright side, the classes are only two hours now instead of three hours like last semester. Also, a lot of the material we're covering is basically review from my previous three MS classes, and the book seems pretty readable. There are five of us second years taking the class, plus one fourth year and a bunch of residents and fellows. In the afternoon, I went to the lab to get the rest of my data so that I can start preparing my poster. I can't believe I only have two weeks left until I go to the conference. I'm really looking forward to it, except that I will have a ton of make up work to do.

Today we finished our PBL case and then we had a seminar about fractures. I'm just not all that gung-ho about bones. Too many molecules--it's a veritable alphabet soup. The SAQs that we had to do this week were ridiculous in terms of the specific details they were asking for. One of the CAPPs looks like a good one, and the other is kind of way out there. Well, I guess one good one out of two is better than nothing.

POD is now called ARM, which stands for Advanced Research Methods. I can't decide which acronym is sillier. But I had kind of grown to like POD because saying that you're going to the POD sounds like something out of a bad sci-fi movie. Going to the ARM just sounds...gross. Oh, and apparently the administration has come to the same conclusion that I did about having first year grad students take ARM with us. Namely, it is a bad idea because they just started grad school and they haven't had a chance to learn very much yet. Now they will be taking ARM next year as second year grad students along with the second year CCLCM students (the current first years). It makes a lot more sense to have second year grad students working with second year med students.

Anyway, our ARM speaker today was simply awesome. He works at the Museum of Natural History and his whole talk had us absolutely cracking up. It was quite possibly one of the best seminars I have ever attended, kind of an informative lecture and a comedy show all wrapped up into one. You know, when a guy can make a seminar about something as dry as bone mechanics interesting and even entertaining, that is saying a lot. I wish we had it on video. I would actually watch it again if I could.

Wednesday, September 26, 2007

Second Year Physical Diagnosis

We had a bone path seminar this morning, and it was actually pretty good. I make my judgment based on the fact that I paid attention without having to really force myself for nearly the whole two hours. Usually, my attention span starts lagging a lot sooner....I haven't forgotten some of last year's painful histo sessions yet. :-P

This afternoon I had my first physical diagnosis class. It's done a little differently this year compared to last year. First of all, only half of us have it at a time instead of the whole class. Last year all 32 of us had PD every other Wednesday afternoon, but now only half of us do, and the other 16 go on Tuesdays. Today we had a communications session that was more or less the same as what we did last year. But the physical diagnosis part afterward was really awesome. There were four stations set up in the four PBL rooms. We went in groups of four from room to room every half an hour.

The first room my group went to covered the legs. The standardized patient was this really funny lady who kind of talked back to the doctor while he was demonstrating the exams, so it was fun for us. In the second room, some podiatrists showed us how to examine the foot. Feet are yucky. No thanks. The third room demo was about examining the shoulders and arms. That one was ok, a bit lecturish though. But the fourth room demo was by far the best. This was the one for the spine. The two docs in there were both orthopedic surgeons, and they were pimping us, but it was done in a gentle and fun way. I am not a huge fan of orthopedics in general, but I liked this one spine guy enough that I am thinking about emailing him to see if I can go work with him in his clinic one day. I think I will ask him, but not this semester. There's just too much going on right now, like my 7 AM MS class tomorrow....

Tuesday, September 25, 2007

Seminars, FCM, and Clinic

We had two seminars today on the endocrine control of bone metabolism. It was mostly review from last year, but these seminars weren't too bad. Our FCM session afterward was about medical malpractice. We went over a case where a patient sued a doctor over a delayed diagnosis of lung cancer. The doctor possibly did drop the ball a bit. It wasn't an open-and-shut case though, because the patient skipped several appointments, so he majorly contributed to the delay himself. It was based on a real case, and the jury ultimately decided in favor of the physician.

Today was a long day for me because I had clinic. It was a pretty interesting clinic day. The first patient I had was ridiculously rude. When I introduced myself and went to shake his hand, he just left me hanging there and didn't take it. I took him over to the scale to weigh him, and he ordered me to put down fresh paper towels so that he didn't have to step directly on the scale. OK....then we went into the room, and I was taking his blood pressure after getting his history. He said to me, "Is this your first day in clinic? Because you're obviously not very experienced." At that point, I decided that we were both sufficiently turned off by one another that any further physical exam would be pointless, so I told him that I would get my preceptor for him and left the room.

This is the first time I have ever had a patient behave like this toward me. When I talked to one of the nurses about it, she assured me that the patient was just like that, he would have treated her the exact same way, it wasn't me, and I shouldn't take it personally. I didn't take it too personally actually, but I viscerally disliked this patient to the point that I think it would have been difficult for me to care for him properly if I were his physician. I think that I managed to hide my feelings well enough that he didn't know what a jerk I thought he was. But it definitely got me to start thinking about what physicians should do when they really dislike a patient and the patient seems to dislike them as well.

My next patient was completely the opposite of the first one. She was really friendly and seemed to enjoy talking to me. She was also very nice about letting me examine her. In fact, at the end of her visit, this patient was assuring me that she was going to schedule her next appointment on a Tuesday afternoon so that she could see me again. Well, I may not be able to please everyone, but at least I can please someone!

I was finished seeing all four of my patients by 4:00, so I wrote up a SOAP note and a journal entry. These are two new requirements for clinic this year. SOAP stands for Subjective, Objective, Assessment, Plan. It is the general outline of how physicians write up reports to go in the patients' charts. Subjective is the patient's story. Objective is what I found during my exam. Assessment is what I think is wrong with the patient. Plan is what treatment I am suggesting. We are also expected to list the patients' medications and look up their uses and whether any can interact with one another. It's pretty time-consuming, but I can see that this is going to help me learn my pharm cold by the end of this year. The journal entry is a research question that I come up with from one of the cases I've seen. There are about a dozen different subject areas that we can research and write about. I did mine on behavioral medicine (psych) because I was interested in whether emotional stress could be causing or at least worsening one of my patient's problems. It turns out that it can.

Monday, September 24, 2007

First Day of NMS, Maltz Museum, and Dinner at Mrs. Lerner's House

Today was a very long first day back, and I am going to be sorry I stayed up so late tonight for the rest of this week. But it was a really eye-opening experience and totally worth it.

For all of second year, we have PBL first thing in the morning on Mondays, Wednesdays, and Fridays, followed by seminar afterward. (This is the opposite of our first year schedule.) Tuesdays we have seminar first, then FCM. This works out well for people who have clinic or physical diagnosis on Tuesdays, because we get out at 11:30 that day instead of 12:00 now. Thursdays are still a day off for most people except for those of us who are taking MS classes or have Thursday clinics.

We had a ton of reading for today about bone genetics and collagen. I had printed out all of the articles before break. So I was unpleasantly surprised to come back today to find that one of the seminar leaders had changed all of the readings at some point while we were gone, and no one had bothered to email us to let us know. I talked to him about it. He said that the articles I read were better ones anyway and I don't have to read the new ones, so that was plenty of consolation.

Our PBL case is really confusing and hard to follow. We weren't really sure about the timeline for a lot of the patient's symptoms or visits. My learning objective is about the effect of anticonvulsants on bone, and it's a really interesting topic. I also went to the lab for a while this afternoon to get some more data and talk to my preceptor about making my poster for the conference next month. I didn't get it all done, so I'm going to have to go back Thursday after class and finish the rest.

This evening, I went to the Maltz Museum. I had never even heard of this museum and knew nothing about it until fairly recently. But there is a new exhibit that just opened there called Deadly Medicine. It is about eugenics during the Nazi era. The exhibit is on loan from the United States Holocaust Museum in Washington, D.C. Most people have probably heard of Dr. Mengele and his infamous medical "experiments" on prisoners. But one of the more shocking parts of the exhibit to me was that thousands of German babies were killed for deformities as minor as a cleft palate. The worst part about it is that the physicians, who were highly educated people and who took an oath to do no harm, were among the leaders in the eugenics movement. Not only did they condone the killing of these children, but they were the ones providing the pseudoscientific justification for doing it.

Today was the opening day for the exhibit. Mrs. Lerner was one of the sponsors responsible for bringing it to Cleveland, and all of us who attended the exhibit opening went to her house for dinner afterward. Most of the other guests were not physicians or medical students, but we had some interesting discussions about the exhibit. For any of you readers who are in Cleveland, the exhibit is well worth seeing and will be open here until January 20th. It will then continue touring other cities around the country. I think it goes to Atlanta, GA next.

Wednesday, September 19, 2007

FAQ # 31: What Masters Programs Are Available for CCLCM and Case UP Students?

Here is a more detailed list of masters programs for people who are interested in getting an MD with a masters degree either through the Case UP or CCLCM. In each case, I have posted how many extra classes are required for CCLCM students. I'm not sure how many extra classes UP students have to take for most of these degrees. But it's probably safe to assume that they take at least as many classes as CCLCM students do, if not more. If any of the UP students who are doing an MS read this and can give me more info on how many extra classes you need to do for your MS, I'd be happy to add that.

Biomedical Investigation MD/MS Programs:

1) Clinical Scholars Research Program (CRSP) MS: This is the MS program that I am doing, and it's one of the more popular choice for CCLCM students. It requires three extra classes on top of the regular CCLCM curriculum, plus two semesters of attending seminar for one hour per week. The two tracks are in Clinical Trials or Disease Mechanisms.

2) Biochemistry MS: This program requires three extra courses (nine hours), a seminar course (1 hour), and an exam. There are no tracks.

3) Epidemiology MS: This program appears to require five extra courses (fifteen hours). There are no tracks.

4) Nutrition: This program requires three extra courses (nine hours), a seminar course (1 hour), and an exam. There are no tracks.

5) Pathology: This program requires three extra courses (nine hours), a seminar course (1 hour), and an exam. There are no tracks.

6) Physiology and Biotechnology: This program requires three extra courses (nine hours), a seminar course (1 hour), and an exam. There are no tracks.

Other Masters Programs at CWRU:

1) Masters of Public Health (MPH):This is a very work-intensive masters program that will require ten classes above the regular CCLCM curriculum. It is apparently possible to finish this degree in the five years if you plan carefully and double up on classes during some semesters. Tracks include Adolescent Health, Epidemiology, Health Care Policy and Administration, Health Promotion and Disease Prevention, International Health, Public Health Research, or Urban Health.

2) Bioethics MA: This is another work-intensive masters program. According to the information sheet, UP students will need to take an extra 24 credit hours on top of their normal med school curriculum, which comes out to be around eight classes. This is apparently possible to accomplish within the normal four-year curriculum. CCLCM students are required to take an additional 18 credit hours on top of our curriculum, assuming that their thesis is done on a bioethics topic. If it is not, then an additional six hours (two classes) of elective credit must be taken.

3) Other Programs: I couldn't find any information about these programs besides the contact information for the program directors. But for the sake of completeness, it is also possible to get an MD/MS with the MS in Applied Anatomy or in Biomedical Engineering. In addition, there is an option for an MD/MBA.

Friday, September 14, 2007

Heart Center Tour and Class Stuff

Thursday I went to take a tour of the new CCF heart center. It's going to be absolutely incredible: ten stories tall, of which eight floors are for patient care. The top floor will have an outdoor patio and banquet area that looks out over downtown Cleveland and Lake Erie. The view is gorgeous. The nineth floor houses all of the emergency generators for the heart center and the new urological building. There are four of them, and they're enormous. The fourth through eighth floors will have patient rooms, the third floor will be the ORs, and the second floor will have the cath labs. It's going to be absolutely state of the art, and the best part of the whole thing is that it should be opening next summer, just in time for my class to begin our rotations.

It turns out that now we will not be getting our epi assignment until after we get back from break. I'm not thrilled about that, but if they give it to us the first week, it's still early enough to get it done and out of the way before things start getting too crazy with NMS. On the bright side, I am done with my second stats assignment, so at least that's something. In addition, the school has finally begun posting our assignments for next block on the portal. So I guess I'll start doing my school reading over break instead so that I can do my epi assignment during the first week of next block.

In general, I am a very organized person. But I can already see that I will have to be even more organized than normal in order to survive these next three months. I guess if I can make it through my second year of med school, most other things I do in my life will seem pretty easy by comparison!

Wednesday, September 12, 2007

Finished with Clinical Research Block

Yesterday morning, we had our orientation for the rest of this year. It started at 8 AM with a one hour pathology session. This was followed by about three straight hours of FCM course information. If the goal was to overwhelm us and overload us, I would say that the FCM course directors have succeeded admirably. (In this context, when I say FCM, I'm not just talking about the Tuesday morning class on humanities in medicine that we take. Physical Diagnosis, Communications Skills, and Longitudinal Clinic are technically also included under the broad heading of FCM, although we don't usually refer to them that way.)

I am feeling relatively skeptical about some of the plans that are in store for us this year. For example, we have to tape an interview with a longitudinal clinic patient. This requires us to check out a video camera and operate it successfully on our own, as well as obtain a patient's signed informed consent. I am not good at operating video cameras or any other electronic equipment. I can already forsee spending a few hours wrestling with the stupid camera in my immediate future. To make matters worse, the first years are also apparently being required to do this, and all 64 of us will be competing for the same five video cameras.

In addition, we are supposed to be doing these research hypothesis generation projects four times this year during POD. The interesting part is that they will be having first year grad students from Lerner working with us. Ostensibly, this is supposed to allow us to learn basic science from them and them to learn clinical science from us. The fact that even the least experienced person in my class already has significantly more basic science background than a first-semester grad student strikes me as being a significant flaw in this plan. In addition, the grad students will presumably not be attending our PBL sessions, so I'm not quite sure how they are going to know what we're creating hypotheses about.

The biggest change, of course, is that we will have clinic and clinical skills twice a week now instead of just once. That, at least, is something that I knew was coming. My clinic and clinical skills days will be Tuesdays and Wednesdays. We are also apparently going to continue having FCM (the class) in future years, although we've been assured that it will be done differently now that CCLCM is creating its own FCM curriculum and not trying to coordinate with the Case UP's FCM curriculum. I'm trying to be open-minded about it, because I do believe that the faculty is sincerely trying to improve the class. One of our sessions is apparently going to involve a trip to the art museum. Well, it may not be the best possible use of my time, but at least it should be fun to do. I'm also glad that they are finally going to have us learn to use Epic, which is the Clinic's electronic charting system. There have already been several times within the last year when I wished I was able to use Epic on my own, and we'll definitely need to be able to use it next year when we hit the wards.

In the afternoon yesterday, our class went through the second set of summer research presentations, and the last third of them were today. One thing I forgot to mention is that my summer PSS tutor from last year came to all of my PSS group members' talks. The eight of us from last summer's PSS group were spread out all over the three days, but our tutor still came to see every one of us give our talks and find out how we were doing. This is the kind of thoughtfulness that reminds me about why I chose to come to this school in the first place. It was incredibly nice of her to come listen to talks for three straight days considering that she has basically not seen most of us for an entire year, and she has been working with a new group of first years doing PSS this summer. To my old PSS tutor: if you're reading this, thanks again for being so supportive. :-)

At this point, all I have left to do is to finish my second stats project and do the upcoming epi project. These are both for my MS classes--the people not getting grad credit are done for the block. I am getting close to finishing the stats project, and we're supposed to get the epi one this weekend. It sucks that I'll have to do it over break now, but I don't want to have to worry about it during our NMS block. So I'm going to have to just suck it up.

Monday, September 10, 2007

Clinical Research Talks

It was really nice not having class this morning, but I still got up early so that I could spend some time rehearsing my talk a few more times. This is the last week of the block--not that I'm counting or anything! Like last year, we each are giving a ten-minute presentation about our summer research protocol, followed by five minutes of questions from the audience. My talk was today. The other two thirds of my classmates will go tomorrow and Wednesday afternoons.

Now that I've given my presentation, I would be completely done with school for this block except that I still have to write about a hundred evaluations. (I'm exaggerating, but only very slightly!) I also have to finish my second stats project for credit and wrap up a few other small odds and ends. It turns out that we ARE going to be getting an additional epi assignment. I got a solemn promise from the prof to get it to us by this Friday so that I can do it over break. Well, I can't say that working on epi over break was really my plan, but if I can just get it done before we start up with neuro block the week after next, I'll be satisfied.

It looks like we're going to be in for some cooler weather for the rest of this week. Even though it's only September, the lows tomorrow and Wednesday are going to be in the 50s or maybe even the high 40s. I hope this doesn't mean that we are in for a really freezing winter....

Friday, September 07, 2007

End of Clinical Research Block and More on PD Article

Our research proposals and research talk slides were due today, and we had our last stats group project presentations yesterday, so this has been a crazy and hectic week. I got my proposal turned in yesterday and my slides done this morning--I was on version number five by the time I turned them in to the research office. The funniest part about this whole thing, once I got over feeling annoyed about having to redo my slides yet again, is that my preceptor has made so many corrections to my slides by this point that he is now correcting his own corrections!

We talked about Steve Nissen's controversial meta-analysis of rosiglitazone (Avandia) this morning during journal club. Coverage of his article was all over the news a few months ago, because he found that there was a 43% increase in the relative risk of heart attacks in diabetic people taking Avandia. It was an interesting article in its own right because we had a very good discussion about the strengths and weaknesses of meta-analyses in general. (A meta-analysis takes several articles and pools their results together to come up with an overall set of conclusions.) But of course this one was particularly interesting since Dr. Nissen is a very prominent person and works here at the Clinic.

The second article was interesting also, though not quite as political. In that one, the authors were trying to calculate whether it made sense to screen patients' genogypes before giving them a type of drug called an ACE inhibitor. (ACE inhibitors are used to decrease blood pressure and improve kidney function.) The authors did some calculations and found that it does make sense to screen patients....assuming, of course, that their assumptions were correct. ;-)

There isn't much new information for me to report concerning Wednesday's Plain Dealer article. Yesterday there was an editorial in the PD commenting on their own article from Wednesday. The Clinic also released a statement in response to the PD article:

Cleveland Clinic has had a longstanding, mutually beneficial relationship with Case Western Reserve University to advance research, medical education and other institutional projects. That relationship has not changed and we continue to work collaboratively with the University. Recently, Case announced a new, 50-year, primary affiliation with University Hospitals of Cleveland that strengthened the relationship between those two organizations. At this time, it is unclear how that relationship may impact the Clinic in the future. The Clinic has a number of relationships with colleges and universities across the country and will continue to explore other opportunities as they arise. We cannot comment on specific discussions with other universities. Cleveland Clinic is proud of the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University and is fully committed to excellence in medical education, research and other scientific programs.

Wednesday, September 05, 2007

Finishing Up Research Stuff and Plain Dealer Article

Yesterday wasn't a particularly exciting day except that we got free books from one of the CCF rheumatologists who is a block leader for our upcoming Neuromusculoskeletal (NMS) block. She was telling us how previous students and residents loved this book and had gotten really interested in rheumatology because of it. I'm not sure that I'd go so far as to say that any book will get me all that excited about rheumatology, because NMS was by far my least favorite block last year. But I sure gotta love anyone who gives me free books! I spent the entire afternoon going over my slides with my research preceptor--to make a long story short, I pretty much have to redo them all over again. Although I wasn't thrilled about that, I have to admit that his organization is a lot better than mine was. Presenting clinical research is sure not very much like presenting basic science research.

Today more than made up for the lack of excitement yesterday, however. There was an article in this morning's Cleveland Plain Dealer claiming that CCLCM was going to be switching its affiliation from Case School of Medicine to Columbia. Dean Fishleder met with the CCLCM students this afternoon to discuss the article. Basically he told us that the article's conclusions were premature. It is true that the Clinic is looking at its options with other schools, but a new affiliation with Columbia or any other school is certainly not the done deal that the Plain Dealer made it out to be.

Monday, September 03, 2007

Labor Day

This whole weekend has been just gorgeous: sunny, mid-seventies. Unfortunately, I was indoors chained to this laptop for most of it. But this morning I ran the Miles for Smiles 5K, which goes through Cleveland Heights (one of the neighborhoods near the Clinic) and raises money for Operation Smile. I used to run road races a lot in college, but I haven't been doing much running since I started med school. So today I was in the back of the group, just jogging along. There was a man with his elementary school-aged son right in front of me. About half a mile into the race, the boy was worn out and started walking. His dad repeatedly kept trying to make him run and go faster, when it was clear that the boy wasn't in good enough shape to keep up that kind of pace. Finally, the dad gave up and just walked with the boy. I felt really bad watching this, because I didn't feel like I could really intervene or do anything to help, and also because now this boy will probably hate running and will never do it again as soon as he moves out of his father's home.

People put way too much pressure on kids, and on themselves too, during races. That's the downside of running sometimes--runners can be competitive to the point where it's hard to even enjoy the run for what it is. I'm as guilty of this as anyone. When I got to the two mile point, the volunteer standing there told me my time. My initial reaction was to think, "wow, I used to finish the whole 5K in less time than that, and here I'm only 2/3 of the way through!" But I reminded myself that the run was supposed to be FUN, not stressful, and I cruised in very comfortably at the end.

They had a raffle afterward, and I continued my usual streak of winning nothing. I must be the most unlucky person on earth when it comes to raffles. If there were 50 prizes and 51 tickets, I'd be that 51st ticketholder. :-P

Saturday, September 01, 2007

Journal Club and All Abstracts Submitted

Yesterday we had journal club. It has by far been my favorite class each week for the entire summer. This week's articles were one on whether Americans meet calcium requirements (the authors concluded that we don't) and a second one on whether treating people with prehypertension would help prevent them from progressing to full-blown hypertension (the authors concluded that it does). The first article on calcium requirements was particularly funny because there is no recommended daily allowance (RDA) for calcium. This is because we don't really know how much calcium people actually need. So it's kind of difficult to know whether the problem is really that people don't consume enough calcium, or just that the authors' admittedly arbitrary choice of a threshold was simply too high.

The second article was really interesting. I hadn't appreciated how progressive hypertension is. Normal blood pressure should be 120/80 or less. People who fall in the range above that but below full-blown hypertension, which starts at 140/90, are considered to be prehypertensive. The other sad thing is that most people become hypertensive eventually if they live long enough. So yet again, I am finding out that the key to good health is to stay young.

Yesterday afternoon, I finished my abstract for our school presentations, which will be the week after next, and submitted it. Today I got my abstract done for the conference I'm attending next month and submitted that too. I still have to make up my powerpoint slides for school and a poster for the conference, but things are finally winding down a little. We had a patient yesterday also, but it was another control.

Today is September 1, and a new, controversial CCF policy of refusing to hire smokers is going into effect. I've seen several people decrying it on the internet as discriminatory and overly invasive, so it will be interesting to see how things turn out. At this point, I'm not really sure how I feel about the policy. I can see some validity in the arguments for both sides. Plus, the arguments on both sides have been so extreme that it's hard to know what the actuality will really be like. I suspect the policy won't be as helpful in promoting health as the proponents claim, nor will it be as horrific a violation of privacy as the detractors are warning about.