CCLCM Student Blog

Neurology Consult Service and Neurosurgery

2009-03-31T19:53:00.000-07:00

I will be spending the next three weeks on various inpatient neurology teams: consult service this week and next week, and then inpatient neuro the last week. There is not much difference between the consult and inpatient services in terms of what we do. The main thing that distinguishes them is whether neuro is the primary team that admits the patient (inpatient), versus the secondary team that comes to see the patient at the request of the primary team (consult). Most of the consults are made by the surgery and medicine teams for patients with delirium. It's not the most interesting patient population in the world, because we had plenty of delirious patients when I was on medicine and surgery. But it's ok.

Yesterday morning, I had neurosurgery clinic, and that was a good experience for a couple of reasons. First, I got out of having to go round on the consults. Second, the patients were not seeing a surgeon for delirium! The surgeon had a cool operation planned for that afternoon, which she said I could scrub for if I wanted. I got permission from my resident to go scrub, and it was one of the most amazing things I have ever seen since I started medical school.

The patient was a teacher who began having headaches several months ago. The headaches got worse and worse, and he also started having seizures even though he had never been diagnosed with epilepsy before. An MRI of his brain showed that he had an enormous tumor. The surgeon had already operated on him once but couldn't get all of the tumor out because it was too close to vital brain structures. So the patient had come back to have a special surgery done where a neurologist would help the neurosurgeon figure out how much tumor debulking (removal) could be done without affecting the patient's mental functioning.

Although the patient had gotten local anesthetic, he was awake while the surgeon was working on removing the tumor. He had to be awake so that the neurologist could test his cognition. While the surgeon was cutting away slices of his tumor and brain, the neurologist had him doing tasks like counting, identifying pictures on notecards, reading words, and performing mathematical calculations. At one point, the patient was counting, "20, 21, 22, 22, 22, 27...." When that happened, the neurologist told the neurosurgeon not to cut any deeper. There was still tumor left, but the surgeon couldn't remove any more of it without putting the patient at risk. So at that point they starting closing the wound and the surgery was over.

One thing you may be wondering is whether the patient was in a lot of pain while the surgeon was cutting into his brain. Although all of your body's pain receptors go to the brain, there are no pain receptors in the brain itself. So once the surgeon had removed the patient's scalp, skull, and dura (the tough covering of the brain), the patient didn't feel any pain in his brain. Also, after the neurologist told the neurosurgeon to stop cutting, the anesthesiologist did put the patient to sleep so that he wouldn't have any pain while they were replacing his skull and scalp.

Today was a regular day on consult service, and as I said before, we mainly got a bunch of delirium consults. I did an H&P (history and physical) on one patient, which can be a pain sometimes if the patient is delirious. That's because they aren't the most reliable historians, and sometimes they don't want to cooperate with being examined. But I didn't have any problem with that today. Also, I don't have to preround tomorrow because I have a second morning of neurosurgery clinic. That's the last opportunity I will have to escape being on consult, unfortunately.

I should mention that I really like my senior resident, but the attending seems kind of unenthusiastic about neurology and even life in general. I'm feeling like this could be a long two weeks.

LCME Site Visit and Neuro Rotation

2009-03-27T19:48:00.000-07:00

Case's LCME review began on March 22. (Remember, the LCME is the organization that accredits all American and Canadian allopathic medical schools.) The review took place over several days because the committee members had to meet with various faculty, administrators, and students on both campuses. I attended the clinical student meeting, which was held over at Case during lunchtime on Wednesday. Since I was scheduled to have outpatient neurology clinics that day, I was given permission to leave the morning clinic half an hour early and come back to afternoon clinic an hour late. Unfortunately, somehow no one told my afternoon preceptor that I would be late, so I had some explaining to do once I got to his clinic!

After all the flurries of emails we got from the administration, the meeting itself was kind of anticlimactic. There were two other CCLCM upperclassmen, as well as several UP upperclassmen and several reviewers. I think the reviewers are all administrators of some type at other medical schools. Most of the questions they asked us were pretty basic things, like who we would contact if we got stuck by a needle (depends on the hospital, but at CCF, you call the exposure hotline). Surprisingly, the reviewers wanted to know if our rotations required more than 80 hours per week. That work-week limit is actually for residents, not medical students, but Case has an 80 hour work-week rule in place for us anyway. We also got asked about why the OB/gyn rotation had received such low evaluations by M3s and M4s in both programs. I haven't done OB/gyn yet, so I couldn't add much to this discussion. But I was already dreading it based on the horror show stories I've heard from friends, and today's discussion didn't do much to allay my fears. :-P

It will take a couple of months for the reviewers to decide whether our school can be reaccredited. Once the LCME decides that we've passed muster, Case will be accredited until the 2016-2017 academic year. That's a long time. To put it in perspective, I will be done not only with residency but even with fellowship by then, assuming I do a fellowship.

This week, I also had some neuro peds clinics that were kind of awkward. Since I haven't had peds yet, I don't know very much about the development of children, and the pimping was pretty painful for me. One child's parents had brought their 14-month-old toddler in because the child wasn't walking yet. The attending asked me in front of the parents if this was normal or not. Beats me! I have no idea what age children normally learn to walk. It's not like I have any kids at home to study! (For the record, children learn to walk around age 12 months, but it is not considered to be a problem unless they're still not walking after around 15-18 months.)

On my last day in the headache clinic, I had a patient with trigeminal neuralgia. This is a pain syndrome that occurs in the distribution of the fifth cranial nerve (the trigeminal nerve). The patient gets an intense, shooting pain down one or more branches of the nerve. Commonly, the second branch (V2), which innervates the middle of the face, is affected. (See picture.) It's not known exactly why trigeminal neuralgia occurs, but it may be associated with a blood vessel compressing the nerve. When I examined the patient, I unfortunately reproduced her pain, even though I tapped her face lightly.

One other thing I learned was that I haven't been using the reflex hammer correctly. My preceptor explained that it should be more of a movement in the wrist, and I've apparently been using my entire arm too much. I practiced on several patients, and she said I am starting to get the hang of it. Who ever knew that hitting people's tendons with a hammer could require such perfection of technique!

Starting Neuro Rotation

2009-03-24T20:11:00.000-07:00

This is my first week on neurology. So far, it's been really intense! Not that I expected it to be a cakewalk, but the Block III* administrator went out of her way several times to warn us about not missing conferences, and to emphasize that we have to go straight from the conferences to our clinical responsibilities. We have conferences twice a day (morning and noon), and I'm on outpatient this week, so there's really not any downtime for me to read about my patients or catch up with my logs. I feel frustrated, because by the time I get home at night, I've already seen too many patients to even remember them all.

I went to talk to my physician advisor about this problem, because it was making me feel a little stressed. Now, my PA is not the type of person who would ever condone slacking, but she did suggest that I could probably take a little time here and there to chill out and read. We agreed that I certainly should not ever miss any of the required clinical time or the teaching conferences specifically created for the students, but that maybe missing the resident-oriented conferences once in a while might be ok. I thought that was a fair compromise, and it is helping me relax and enjoy the rotation a little more.

The actual clinic part has been pretty interesting so far. There are several different kinds of specialized neuro clinics, and I think it's kind of random which ones we get assigned to work in. Some of the other students are doing Parkinson's or MS clinics, which I didn't get. But I have a couple of days of headache clinic, and it's really interesting. There is a program at CCF called IMATCH, which is for patients who have chronic headaches. It's common to see patients with medication rebound headaches. These are chronic headaches that are due to taking too much pain medication. If the patient tries to stop taking the medications, the headaches come back with a vengeance, so they keep taking more and more of them. That just feeds the vicious cycle.

IMATCH patients spend three weeks coming to the headache clinic. In the first week, they start by getting a multidisciplinary evaluation by neurologists and psychologists. This is to help determine what kind of help they will need to overcome their headaches, or at least to learn to manage the pain to a tolerable level. For the rest of the first week, the patients lie in a dark room, where they get IV infusions of pain medicine. This is tapered down over time to help break their dependence on pain meds. Patients also get physical therapy and counseling to help them cope better with the discomfort and manage headaches more effectively.

For the record, I have a lot of sympathy for people who have migraines. I get migraines myself, but sometimes I have to go out and do things anyway even though I have a migraine. If I take medicine to abort the headache to a more dull pain, I can usually do my work even with that background level of pain. It's not the most comfortable, but it's doable. So I asked my preceptor how bad a person's migraines have to get before they become so crippling that the patient can't function normally anymore. She told me that the difference between me and the patients who get seen at the clinic is that I have pain, but they have a pain syndrome. The pain controls their lives, and they feel too helpless to live their lives normally. She also explained that it was important to make the patient's expectations more realistic. Even when I take pain medications, I understand that the headache may not go away completely, and I don't expect to be completely pain-free. Apparently some patients have difficulty coping with any pain at all.

I have one more day in the headache clinic this week. Even though the headache clinic is really interesting, I'm kind of disappointed that I won't get to do all of the other clinics too. But I'm glad that I had some time to see how the IMATCH program works. Plus, the preceptors who work in the headache clinic are really good and like to teach. I can already tell that neurologists are impressively smart and knowledgeable about medicine.

*Note that Block III in the new curriculum is an eight week block for neurology and psychiatry. I am part of the last group of students going through the old curriculum, which didn't have a Block III, but we are taking these two rotations with the first group of students going through the new curriculum. Don't worry about it if you're confused, because all of us are, too. :-P

Master CCLCM Match List

2009-03-21T20:18:00.000-07:00

This post contains the combined match list for all CCLCM graduation years by specialty and hospital. I will keep updating this list as future classes match.

Anesthesiology

-Cleveland Clinic (2009)

Dermatology

-Yale (2009)

Emergency Medicine

-Cincinnati (2009)

General Surgery

-Brown (2009)

-Wash U (2009)

Internal Medicine

-Beth Israel (Harvard--2009)

-Cornell (2009)

-Duke (2009)

-Michigan (2009)

-Stanford (2009)

-UNC (2009)

-Vanderbilt (2009)

-Yale (2009)

Neurosurgery

-Emory (2009)

-George Washington (2009)

OB/Gyn

-Beth Israel (Harvard--2009)
-U. Hawaii (2009)

Ophthalmology

-Cleveland Clinic (2009)

-UCSD (2009)

Orthopedics

-Hospital for Special Surgery (Cornell-2009)

-UCSD (2009)

-Utah (2009)

Pathology

-Mass General (Harvard--2009)

Pediatrics

-CHOP (U Penn--2009)

-Duke (2009)

Rad Onc

-Rochester (2009)

Radiology

-U Penn (2009)

Urology

-Cleveland Clinic (2009)

-Wake Forest (2009)

End of Rads

2009-03-20T14:06:00.000-07:00

On Wednesday, I finished writing my teaching case report, which is on something kind of esoteric that the attending will hopefully find interesting. I'm still not at all enthusiastic about rads, but I can honestly say that I feel a little more comfortable with reading films. So at least that's something--not that it makes me feel any better about having my circadian rhythm knocked totally out of whack because of sitting in a dark room all morning. Adding to my general sense of misery, it seems like the UH radiology department is one giant petri dish these days. Whatever it was that was going around has now come around to me, and I've been sick all week.

At least it's over now. I'm sure in another week or two I'll be on call, and I'll start looking back on these last two weeks as some kind of nirvana of getting out by 1 PM every day. But wow, as important as knowing how to read films is, I can't imagine a specialty that could possibly be more effective at inducing me to fall asleep instantly than radiology. I honestly don't know how people do it for an entire career. But the radiologists have my utmost respect, not only because they enjoy this stuff, but because they have an extremely impressive command of anatomy. In particular, they have a very good sense of where tiny objects like blood vessels are located in three-dimensional space, which is something that I often don't quite have the knack for.

The LCME site visit starts this weekend, and the administration is tense on both campuses. All week long, Dean Franco has been sending us emails about LCME things, reminding us about what we have to do, how to act, etc., over and over. I've reached the point where I don't read the emails any more. It's not like an LCME site visit is something you can study for, and it's not like I'm going to jeopardize Case's accreditation by behaving unprofessionally at the meeting!

2009 CCLCM Match List

2009-03-19T19:45:00.000-07:00

Match Day! Things were pretty quiet in the UH radiology department today, since all of the M4s were gone for match day. We found out today how our own first graduating CCLCM class did in the match. All of the students matched.* For those who are interested, here is the much-anticipated 2009 CCLCM Match List:

Anesthesiology
-Cleveland Clinic

Dermatology
-Yale

Emergency Medicine
-Cincinnati

General Surgery
-Brown
-Wash U

Internal Medicine
-Beth Israel (Harvard)
-Cornell
-Duke
-Michigan
-Stanford
-UNC
-Vanderbilt
-Yale

Neurosurgery
-Emory
-George Washington

OB/Gyn
-Beth Israel (Harvard)
-Hawaii

Ophthalmology
-Cleveland Clinic
-UCSD

Orthopedics
-Hospital for Special Surgery (Cornell)
-UCSD
-Utah

Pathology
-Mass General (Harvard)

Pediatrics
-CHOP (U Penn)
-Duke

Rad Onc
-Rochester

Radiology
-U Penn

Urology
-Cleveland Clinic
-Wake Forest

*You may have noticed that there are only 29 CCLCM students who entered the match. One student in the first class left med school at the end of the first year, and two others have postponed entering the match in order to earn additional degrees.

You may also be interested in reading the Cleveland Plain Dealer's article about the first CCLCM match.

Radi-Holiday

2009-03-13T15:09:00.000-07:00

This week, I started a two-week radiology elective at UH. I had wanted to do it at CCF, but the radiologists there only let people do rads for four weeks. I can't do four weeks since I have to start my next core block of rotations in two weeks. This was probably a blessing in disguise, because radiology has to be the most boring rotation I have ever done.

Picture this: we come in at 8 AM each morning for an hour-long conference that mainly consists of people throwing films up and droning on about them. The room is nice and warm and dark. Actually, so are the rooms where the radiologists read the slides. Some of the residents enjoy teaching, but many basically ignore us. So I've been spending most of my mornings either reading or dozing off, depending on my inclination.

At noon, there is a second conference, similar to the first. By then, I am usually too hungry to doze off, so I read my radiology case book. This is not a required book. I just bought it on my own so that I could hopefully learn something about radiology. After lunch, all of the med students clear out. That is the best part of each day.

So far, I have rotated through ultrasound, chest imaging, ER/bone, nuclear medicine (by far the most interesting), and CT. But overall, the interesting : boring ratio is way too low for this rotation to be of much use. It's not just me who feels this way--one of the other med students dropped the rotation altogether a couple of days ago.

Besides boring me to death, this rotation is totally disrupting my circadian rhythm. After I've been dozing off in a dark room all morning, it's not so easy to fall asleep at a reasonable hour that night!

CAM Paper Part IX: Conclusion and References

2009-03-06T18:27:00.000-08:00

Conclusion
Although some physicians may be skeptical about the benefits of CAM, they should still educate themselves about CAM for several reasons. First, a significant proportion of patients seen in a primary care setting would like to try CAM or are already using it. These patients may ask their physicians for advice about CAM therapies they have seen on the internet or heard about from friends. One survey study found that patients who use CAM expect their physicians to be knowledgeable about CAM and to make referrals for CAM treatments as appropriate.(4)

Second, patients are often misinformed about CAM modalities, and they are at significant risk of making misguided decisions based upon unreliable information.(2) Informed physicians are in a better position to empower their patients to make informed decisions about the pros and cons of CAM. Physicians can also play a significant role in guiding patients away from harmful CAM therapies, as well as steering them toward alternative CAM therapies that do not interact with conventional drugs that patients may also be taking.

Finally, a physician who is indifferent or openly negative about CAM may undermine the trust between patient and physician by making it difficult for the patient to initiate a discussion about CAM. There is evidence that younger physicians tend to regard CAM more positively compared to older physicians, which may facilitate discussion of CAM by younger physicians.(3) However, all physicians should be prepared to objectively discuss CAM with patients, even physicians who are skeptical about the benefits of CAM. Approaching patients who inquire about CAM with a nonjudgmental attitude provides the physician with an opportunity to improve the therapeutic relationship while educating the patient.

References
1. Barnes PM, Powell-Griner E, McFann K, Nahin RL: Complementary and alternative medicine use among adults: United States, 2002. Seminars in Integrative Medicine 2004; 2: 54-71

2. Ernst E: How the public is being misled about complementary/alternative medicine. J R Soc Med 2008; 101: 528-530

3. Sewitch MJ, Cepoiu M, Rigillo N, Sproule D: A Literature Review of Health Care Professional Attitudes Toward Complementary and Alternative Medicine. Complementary Health Practice Review 2008; 13: 139-154

4. Ben-Arye E, Frenkel M, Klein A, Scharf M: Attitudes toward integration of complementary and alternative medicine in primary care: Perspectives of patients, physicians and complementary practitioners. Patient Education and Counseling 2008; 70: 395-402

5. Riccard C, Skelton M: Comparative analysis of 1st, 2nd, and 4th year MD students' attitudes toward Complementary Alternative Medicine (CAM). BMC Research Notes 2008; 1: 84

6. Moyer CA, Rounds J, Hannum JW: A meta-analysis of massage therapy research. Psychol Bull 2004; 130: 3-18

7. Ernst E: Chiropractic: A Critical Evaluation. Journal of Pain and Symptom Management 2008; 35: 544-562

8. Keating JCC, K. H.; Grod, J. P.; Perle, S. M.; Sikorski, D.; Winterstein, J. F.: Subluxation: dogma or science? Chiropractic & Osteopathy 2005; 13: 17-26

9. Miller K: The evolution of professional identity: the case of osteopathic medicine. Social Science & Medicine 1998; 47: 1739-1748

10. Gevitz N: Center or Periphery? The Future of Osteopathic Principles and Practices. J Am Osteopath Assoc 2006; 106: 121-129

11. Ernst E: Acupuncture â€“ a critical analysis, Journal of Internal Medicine, Blackwell Publishing Limited, 2006, pp 125-137

12. Martin DP, Sletten CD, Williams BA, Berger IH: Improvement in Fibromyalgia Symptoms With Acupuncture: Results of a Randomized Controlled Trial. Mayo Clinic Proceedings 2006; 81: 749-757

13. Shapiro K: Natural Products: A Case-Based Approach for Health Care Professionals. Washington, D.C., American Pharmacists Association, 2006

14. Clark K: Nutrition Strategies for Managing Joint Pain, The Professionals’ Guide to Diet, Nutrition and Healthy Eating IDEA Health & Fitness Association, 2004, pp 62-65

15. Wheatley D: Medicinal plants for insomnia: a review of their pharmacology, efficacy and tolerability. J Psychopharmacol 2005; 19: 414-421

16. Westfall RE: Use of anti-emetic herbs in pregnancy: women's choices, and the question of safety and efficacy. Complementary Therapies in Nursing and Midwifery 2004; 10: 30-36

CAM Paper Part VIII: Herbal Remedies III

2009-03-05T08:18:00.000-08:00

Nausea
Several herbs are used to treat nausea, most commonly ginger, peppermint, and cannabis. All three have been shown to have mild anti-emetic properties for chemotherapy, motion sickness, and post-operative nausea. Only ginger has been shown in clinical trials to be effective for morning sickness, but anecdotal reports suggest that peppermint and cannabis smoking are also effective for morning sickness. Cannabis in particular has a long history of being used to treat chemotherapy-induced and HIV drug-induced nausea. Ginger and peppermint should be used cautiously in pregnancy due to a possible risk that they promote menstruation. There does not appear to be any contraindication for the use of cannabis in low to moderate doses.(16)

Cold and Flu
The most popular herbal remedy used to treat cold symptoms is echinacea; in fact, echinacea is the most popular herbal remedy on the U.S. market in general. Although it is very popular and has a long history of use, echinacea may not be very efficacious against cold symptoms. Some studies did find that echinacea could shorten the duration of a cold by one or two days. In addition, there is no evidence that echinacea can be used prophylactically to prevent colds. There are few side effects due to echinacea, but people who are allergic to ragweed and other pollens may be at risk of having an allergic reaction.(13)

Other popular natural products use to treat colds include vitamin C and zinc. These two agents may provide a modest decrease in cold symptoms, but the evidence in favor of either agent is not very strong. Vitamin C is generally safe, although it may cause GI symptoms at very high doses. Zinc can cause anosmia (loss of the sense of smell) if taken intranasally. As with echinacea, neither zinc nor vitamin C can be used as a prophylactic to prevent catching a cold.(13)

Common natural products used to treat the flu include elderberry and ginseng. Elderberry appears to have reasonably good efficacy in reducing the duration of flu symptoms based upon the results of two clinical trials. The main side effect is GI symptoms. Ginseng may be useful as prophylaxis against the flu based on two preliminary trials. However, it has some potentially troublesome side effects, including insomnia and possibly cardiac effects. Oscillococcinum is a popular homeopathic remedy used to treat the flu. Since it contains no active ingredient and is considered to be a placebo, there is no contraindication against it.(13)

Cholesterol Reduction and Cardiovascular Disease
Common natural products used to lower cholesterol include dietary oats, psyllium fiber, soy, plant sterols, policosanol, garlic, and omega-3 fatty acids. The effect of eating oatmeal is very mild, yielding a drop in LDL of about 6 mg/dL. One clove of fresh garlic per day can lower total cholesterol about 5%. Psyllium, plant sterols and soy can decrease LDL about 10%. Policosanol, a waxy substance that can be made from beeswax, can decrease LDL around 20%, and also increase HDL about 20%. Omega-3 fatty acids are used to lower triglycerides. None of these compounds has any major side effects, but policosanol, garlic, and omega-3 fatty acids could possibly increase some people’s risk of bleeding.(13)

Along with garlic and omega-3 fatty acids, other compounds used for primary and secondary prevention of cardiac disease include coenzyme Q10, hawthorn, arginine, and carnitine. Coenzyme Q10 decreases blood pressure and improves heart failure symptoms, and has few side effects. It should not be used concurrently with doxorubicin. Hawthorn appears to improve heart failure symptoms and increase exercise capacity. It may potentiate the effects of digoxin. The amino acids arginine and carnitine are well-tolerated and improve exercise capacity in patients with heart failure. Vitamin E should not be recommended, as it does not decrease the risk of cardiovascular disease. In fact, the mortality rate increases with high dose vitamin E.(13)

CAM Paper Part VII: Herbal Remedies II

2009-03-04T08:17:00.000-08:00

Benign Prostatic Hyperplasia
Saw palmetto extract can be used to treat benign prostatic hyperplasia (BPH). It inhibits 5-α-reductase, the same enzyme inhibited by the prescription drug finasteride, thereby preventing the conversion of testosterone to dihydrotestosterone. Studies show that saw palmetto is efficacious and generally well-tolerated. Other natural products used to treat BPH include pygeum and stinging nettle. Pygeum works by a different, poorly understood mechanism. The limited published data support its efficacy, and it is well-tolerated. There is no evidence to support the use of stinging nettle for BPH.(13)

Menopause Symptoms
Black cohosh and soy are two commonly used natural products that may provide some relief to post-menopausal women suffering from symptoms like hot flashes, night sweats, vaginal dryness, mood disturbance, and poor sleep. Soy, as mentioned previously, has few side effects except that there is potentially a risk in women with a history of breast cancer due to the phytoestrogens. Black cohosh is thought to work by stimulating estrogen receptors, although it is not an estrogen analog. As with soy, there is a possible risk due to black cohosh in women with a history of breast cancer. In addition, black cohosh has been associated with liver damage in rare cases. Other natural products sometimes used to treat menopausal symptoms include dong quai and evening primrose oil. Neither of these extracts has been shown to have any efficacy.(13)

Although bioidentical hormone replacement therapy (BHRT) is actually a synthetic product, some women prefer it since the hormones are identical to the hormones present in pre-menopausal women. In contrast, prescription drugs like Premarin, which actually is a natural product, contain different estrogens that are not present in humans. BHRT is customized for each woman, which may help decrease the incidence of side effects. As with conventional hormone replacement therapy, BHRT should be used at the lowest possible dose for the shortest required amount of time. The risks of BHRT are thought to be similar to the risks due to HRT, possibly including increased chances of cardiovascular events, breast cancer, endometrial cancer, and clots.(13)

Depression
St. John’s Wort is a popular natural product used to treat depression. The extract contains several compounds that are thought to affect mood, probably by inhibiting reuptake of monoamines. This mechanism of action is similar to the mechanism of TCAs. However, there is also evidence that the active components of St. John’s wort affect other neurotransmitters like GABA and glutamate as well. There is evidence that St. John’s wort is effective in mild to moderate depression, but not in severe depression. Common side effects include GI upset, skin reactions, and sexual side effects. More worrisome is that St. John’s wort has many interactions with other drugs since it induces multiple CYP 450 enzymes. St. John’s wort may also be teratogenic and should not be used by pregnant women. Finally, since St. John’s wort prevents the reuptake of serotonin, it should not be used along with serotonergic prescription drugs such as MAOIs and SSRIs because of the possibility of serotonin syndrome.(13)

Other natural products that are used for depression include SAMe, inositol, and omega-3 fatty acids. The data for SAMe suggests that it has some efficacy in depression, but SAMe can cause a manic episode if it is taken by bipolar patients. The data on omega-3 fatty acids also are suggestive of efficacy in depression. However, the data for inositol are too preliminary for it to be recommended currently. Regardless of which agent is given, any patient with depression, especially major depression, requires psychiatric care.(13)

Insomnia and Anxiety
The sleep-inducing properties of kava kava are well known. Kava kava extract rapidly induces sleep and does not seem to cause any long-term side effects during the day following its use. Although kava kava appears to be efficacious in treating anxiety and insomnia, it has been banned in several countries due to its potential to cause serious side effects. Specifically, several case reports of patients who developed hepatitis severe enough to require a liver transplant have been published. At this time, kava kava is still available in the United States as an unregulated dietary supplement. However, it should not be used by alcoholics or other patients who have liver disease.(15)

Valerian is a safer and therefore more promising alternative to kava kava for insomnia and anxiety. It appears to induce a natural sleep pattern after being used for several weeks, and there is no evidence that it is habit-forming or has any significant side effects other than causing vivid dreams. The one potential downside of valerian is that the onset of action is several weeks, and patients may need to use a stopgap hypnotic like a benzodiazepine while waiting for the valerian to take effect. However, although valerian does not seem to effectively induce sleep acutely, it does aid with maintaining good sleep patterns over the long term. It also appears to decrease sleep latency and increase the amount of slow-wave sleep, both of which promote a greater feeling of being well-rested the following day. These qualities may make valerian useful as a treatment for chronic insomnia, especially in the elderly.(15)

Another promising herbal treatment for insomnia and anxiety is aromatherapy with essential oils like lavender and chamomile. Lavender is commonly used as the oil rather than ingested, while chamomile is usually ingested as a tea. In both cases, it appears to be inhalation of the essential oil that produces the hypnotic effect.(15)

CAM Paper Part VI: Herbal Remedies I

2009-03-03T18:04:00.000-08:00

Herbal remedies and other natural products were used by 19% of adults during the past 12 months according to a 2002 survey.(1) The ten most commonly used herbal remedies were echinacea, ginseng, ginkgo biloba, garlic supplements, glucosamine, St. John’s wort, peppermint, flax and fish oils, ginger, and soy.(1,13) Other commonly used herbal remedies include chamomile, bee pollen, kava kava, valerian, and saw palmetto.(1) Some common natural products are described below in relation to the conditions they are used to treat.

Dementia
Ginkgo biloba is an extract from the leaves of the ginkgo tree that contains multiple natural products. It is used to treat Alzheimer’s dementia instead of or along with acetylcholinesterase inhibitors like donepezil. Studies have found that modest memory improvement can occur with use. The mechanism of action of ginkgo biloba is not known, but it is thought to be related to the extract’s anti-inflammatory properties. In addition, the flavonoid component of the extract is an antioxidant that scavenges the free radicals thought to be involved in the pathology of dementia. The most commonly reported side effect of ginkgo biloba is gastrointestinal symptoms. However, ginkgo biloba antagonizes anti-platelet factor, thereby inhibiting platelet aggregation. Thus, physicians should be aware of the potential for bleeding with ginkgo biloba use, especially if the patient is taking anticoagulants. In addition, gingko should be discontinued for several days before the patient undergoes elective surgery.(13)

Other natural products sometimes used for treatment of dementia include huperzine A and high dose vitamin E. Huperzine A is a natural acetylcholinesterase inhibitor that appears to be as effective in treating dementia as prescription acetylcholinesterase inhibitors. There is some evidence that high dose vitamin E may slow dementia progression. However, the doses required for this use are toxic. Thus, vitamin E should not be recommended to patients for the treatment of dementia.(13)

Osteoarthritis
Glucosamine and chondroitin are the most popular natural products used to treat arthritis. Both are normal components of cartilage. Glucosamine may stimulate synthesis of proteoglycans and glycosaminoglycans by chondrocytes, as well as inhibit cartilage breakdown. Chondroitin also stimulates chondrocytes to synthesize cartilage components, as well as having anti-inflammatory properties. Not only do both supplements show efficacy against pain in clinical trials of moderate to severe osteoarthritis, but glucosamine may even retard progression of the disease. Since they have different mechanisms of action, glucosamine and chondroitin are often used together. The onset of action for both compounds requires several weeks, and patients should take other pain-relievers such as NSAIDs in the interim. In addition, diabetic patients taking glucosamine may have an increase in blood sugar levels. Chondroitin appears to have some anti-coagulant activity, and this should be considered in patients taking prescription anticoagulants. Chondroitin is contraindicated in men with prostate cancer since one of its components (versican) is overexpressed in prostate cancer.(13)

Other natural products used in the treatment of osteoarthritis include S-adenosylmethionine (SAMe), capsaicin, avocado/soybean oils, and omega-3 oils. SAMe appears to be effective for symptom reduction. However, it is expensive, and the quality of supplements is highly variable. In addition, SAMe should be avoided in patients who are taking other serotonergic drugs, as well as in patients with bipolar disease. Capsaicin is effective for relieving limb osteoarthritis and other musculoskeletal conditions. Its biggest advantage is that it is topically applied. Avocado/soybean oils appear to be beneficial for osteoarthritis, have no side effects, and can be used along with glucosamine/chondroitin.(13) Omega-3 fatty acids are found in fish and flaxseed oils. There is some evidence that they have anti-inflammatory effects. Although osteoarthritis is not initially an inflammatory disease, many patients do develop an inflammatory component as the disease progresses. Omega-3 fatty acids may have an anti-coagulant effect in high doses (over 3 grams), which should be considered in patients on prescription anti-coagulants.(13,14)

Osteoporosis
The most common supplements taking to prevent onset or progression of osteoporosis are calcium and vitamin D. However, natural products like soy and ipriflavone are also used. Ipriflavone has the strongest evidence in favor of its use, but its effects are significantly less than those of prescription drugs like bisphosphonates. In addition, ipriflavone may increase the concentration of other drugs by inhibiting cytochrome P450 enzymes, and it can cause lymphocytopenia in some patients.(13)

There is less evidence in favor of increased consumption of soy-based foods for decreasing the risk of osteoporosis. However, soy consumption has multiple other benefits. These include improvement of post-menopausal symptoms and a decreased cholesterol level. In addition, there are no side effects due to eating soy, with the possible exception of women with a history of breast cancer due to phytoestrogens present in soy. In general, natural products like ipriflavone and dietary supplements like soy can be used to help prevent development of osteoporosis. However, women who already have osteoporosis will almost certainly require a prescription drug like a bisphosphonate.(13)

CAM Paper Part V: Acupuncture

2009-03-02T18:08:00.000-08:00

Although the practice of acupuncture is commonly associated with traditional Chinese medicine, there is evidence that acupuncture actually dates back several thousand years in the histories of both Eastern and Western medicine. The Chinese conception of acupuncture revolves around the idea of qi, or vital energy. More specifically, traditional Chinese medicine holds that health is a state of balance between two opposing forms of qi called yin and yang. According to this theory, each person inherits a form of qi that circulates throughout 14 meridians (channels) in the body, thereby nourishing and defending it. Diseases are thought to be caused by a disturbance or blockage of qi, which leads to an imbalance of yin and yang. Thus, the purpose of acupuncture is to correct this energy disturbance and bring yin and yang back into balance.(11)

Several theories have been proposed to explain how acupuncture alleviates pain, and there is some evidence in the literature that supports these ideas. Examples include stimulation of A delta fibers in the skin, activation of enkephalin-producing interneurons, release of endorphins, activation of descending pain control pathways, and modulation of the pain control center in the brain. In addition, modern practitioners sometimes associate yin and yang with the sympathetic and parasympathetic divisions of the autonomic nervous system.(11)

Acupuncture involves inserting fine needles into any of 365 specific points on the meridians. (The number of points was chosen to correspond to the number of days in a year.) Needles may be used alone therapeutically, or they may be used along with electrical stimulation, ultrasound, or heat. Conditions that are commonly treated with acupuncture include back pain, myofascial pain, and arthritis. There is some evidence that acupuncture is useful for treating some forms of pain and certain other conditions, including fibromyalgia, nausea and chronic back pain.(11,12) However, other conditions do not appear to be effectively treated with acupuncture, such as headaches.(11)

Despite the existence of multiple studies showing improvement in several conditions after acupuncture treatment, there is a strong possibility that acupuncture is mainly effective due to the placebo effect. The original acupuncture studies showing efficacy were necessarily performed unblinded; that is, both the patient and the acupuncturist knew whether or not the patient had received acupuncture. However, when sham acupuncture is used as a control in acupuncture-naïve patients (a single-blinded design), most studies show no difference in improvement between the groups. Patients who choose to try acupuncture commonly cite the possibility that it will help, curiosity, and their belief that conventional medicine will not help. Thus, it appears that the patient’s beliefs about the effects of acupuncture have a strong effect on their subjective perception of pain.(11)

I was able to observe the importance of patient belief in the effectiveness of acupuncture. Those patients who had the most confidence in the treatment reported the greatest relief of their symptoms. The acupuncturist, a practitioner of traditional Chinese medicine, mainly treated patients suffering from chronic pain conditions such as osteoarthritis. He attributed his patients’ problems to “weakness” in certain organs, especially the liver, kidneys, and heart. Beyond that, the acupuncturist did not really explain the causes of the patient’s problem or how his therapies worked. He did not ever mention concepts such as qi, yin, and yang. In fact, when patients directly asked him how he knew a particular organ was weak, he would respond that his diagnosis was based on prior experience. Essentially, he was asking the patients to trust his judgment without any explanation at all. Unsurprisingly, the more skeptical patients did not benefit as much from their treatments.

Each acupuncture treatment began with an examination of the patient’s energy. If the acupuncturist felt that the patient’s energy was low, he would have the patient go into a special room set aside for raising energy. Here, the patient would be asked to hold a metal bar in each hand. The metal bar was connected to a machine that provided electrical stimulation. The patient would sit holding the bars for several minutes, and would then be moved to another room for the acupuncture treatment. After having the patient lie down, the acupuncturist would insert needles one by one, usually in the patient’s feet, legs, hands, and arms. Some patients also got needles in their ears, forehead, and neck. It was not made clear how the acupuncturist decided where the needles were needed. Finally, the needles were connected to a machine that provided electrical stimulation.

Along with needles, the acupuncturist used several other modalities. For example, he asked one patient whom he diagnosed with a weak heart to take a Chinese herbal remedy that he said would strengthen her heart. The bottle’s label was printed in Chinese, and there was no way for the patient or me to know what was in it. She asked him what it did, but all he would say was that it would help her weak heart. Another patient who was diagnosed with a weak liver was treated with a magnet placed over the right side of her abdomen. The acupuncturist also manipulated this patient’s energy level by passing his hands over her body without touching her. This patient had full faith in the efficacy of acupuncture, and she reported having significant pain relief.

I came away from this experience feeling very skeptical of acupuncture for at least two reasons. First, unlike the chiropractor, the acupuncturist made no pretense of being a physician or using science in his treatments. His diagnoses of weak organs do not have any correspondence with any diseases recognized in Western medicine. Even more discomforting, the acupuncturist made no effort to offer explanations or education. In fact, he discouraged patient questioning by simply saying that he knew what he was doing based on experience. It is possible that this implicit command to just trust him was at least in part a cultural disconnect, but his attitude would probably not be acceptable to many Western patients.

CAM Paper Part IV: Osteopathy

2009-02-27T18:04:00.000-08:00

Osteopathy is now regarded as a part of conventional medicine. Osteopathic physicians, who make up approximately 5.5% of American physicians, are fully licensed in all 50 states and have the same scope of practice as allopathic physicians. In addition, there is no longer a significant difference between allopathic and osteopathic medical school curriculums, and osteopathic principles like holistic medicine have been adopted by allopathic physicians.(9) However, since osteopathy arose as a competitor to allopathic medicine in response to the inadequacies of allopathic medicine of that time, a discussion of osteopathy is still appropriate here.

Andrew Taylor Still, the founder of osteopathy, was deeply affected by the inability of allopathic medicine to save his children from dying of meningitis. He became a harsh critic of many then common medical practices like blood-letting and purging, which he felt did more harm than good. Several of the principles advocated by Still continue to form the philosophical basis of osteopathic medicine today. These include focusing on health rather than disease, treatment of the entire patient rather than a reductionist approach, and relating the structure of the body to its function.(9,10) In the early days of osteopathy, practitioners treated patients with musculoskeletal manipulation (osteopathic manipulative treatment, or OMT) in order to restore their structural integrity and thereby their health. Still and other early osteopaths were opposed to the use of drugs, although osteopaths later acknowledged the importance of teaching pharmacology to their students and noted that drugs were useful and even necessary in some situations.(9)

Osteopathic principles and practice are heavily intertwined with competing medical systems. For example, although allopathic medicine is widely considered as following in the tradition of Hippocrates, the reductionist perspective that has historically characterized allopathic medicine was actually espoused by a second school of medicine that was the rival of Hippocrates. In contrast, the osteopathic principle of restoring the natural condition of the body to promote health is more in keeping with the ideas espoused by Hippocrates.(9) Second, many of the ideas held by Still were also held by Palmer, the founder of chiropractic, including an aversion to the use of drugs, rejection of the microbial theory of disease, and the belief that manipulation could be used to treat all human diseases.(7,9) In fact, some evidence suggests that Palmer learned his manipulation techniques from Still.(7) In spite of these similarities, osteopathy, unlike chiropractic, evolved over time to become part of conventional medicine.

In modern osteopathic practice, there continues to be overlap between osteopathy and these two other medical systems. An osteopathic physician’s office and practice are indistinguishable from any allopathic physician’s office and practice. Patients come in with the same complaints of sore throats and back pain. However, there is potentially some difference in how osteopathic and allopathic physicians treat patients who present with musculoskeletal pain. This is because an osteopathic physician may choose to use OMT along with or instead of muscle relaxing-drugs.

Upon observing an osteopathic physician perform OMT, I was struck by how similar it is to chiropractic musculoskeletal manipulation. In addition, the osteopathic physician and chiropractor used the same accessory modalities to treat patients with musculoskeletal pain, including heat, cold, and ultrasound. However, this osteopathic physician rarely performs OMT in his practice, in keeping with published reports that only a minority of osteopaths commonly treat their patients with OMT.(10) He pointed out that the current health care system often makes it financially and temporally impractical to perform OMT even when it would be helpful. For example, he is not able to bill many HMOs for OMT. Also, he does not have time to perform OMT when he must book patients every 15 minutes in order to keep his practice solvent.

CAM Paper Part III: Chiropractic

2009-02-26T17:58:00.000-08:00

Chiropractic was defined by Daniel Palmer, its founder, as “a science of healing without drugs.” However, the underpinnings of chiropractic are not rooted in science. In fact, Palmer himself noted that chiropractic ideas could not be researched or subjected to experiments, and he considered chiropractic to be akin to a religion.(7)

The theory behind chiropractic is that disease is caused by spinal subluxations.(7) In medicine, subluxation is the term for a partial joint dislocation. However, this word is used differently in chiropractic, where a subluxation is a more abstract construct that refers to functional or structural changes in the musculoskeletal system. These changes are thought to compromise the integrity of the nervous system, thereby affecting the patient’s organs and health.(8) Palmer furthermore wrote of what he called innate intelligence, which is related to the body’s ability to heal itself. This innate intelligence cannot function properly in the presence of subluxations. Thus, the goal of chiropractic is to detect and correct subluxations via spinal manipulation in order to allow innate intelligence to flow freely throughout the nervous system.(7,8)

Currently, there are two basic camps of chiropractors, the so-called “straights” and the “mixers.” Straights continue to accept the ideas of Palmer, including his theories of innate intelligence, subluxation as the cause of all disease, and spinal manipulation as the cure for all disease. Thus, the straights use only spinal manipulation to treat their patients, and they do not work with conventional physicians. In contrast, mixers view themselves as more of musculoskeletal pain specialists, especially for the treatment of back pain. They use other forms of treatment along with spinal manipulation, and they are more likely to work with the medical establishment. Early in the history of chiropractic, Palmer claimed that mixers were essentially defiling its tenets, but today, mixers comprise the majority of chiropractors.(7)

Spinal manipulation, also called adjustment, is performed by applying a force to a specific joint with the intention of moving vertebrae beyond the normal range of motion, but not far enough to cause damage. These manipulations are believed to break down adhesions in joints, affect mechanoreceptors in the joints, inhibit C-fiber-mediated perception of pain, and/or modulate function of the central nervous system.(7) A clicking sound often occurs during an adjustment as the stuck joint is released.(8)

Most patients who visit chiropractors are self-referred, and many of them come to chiropractors due to the inability of conventional medicine to adequately treat their pain. Chiropractors who are mixers mainly treat chronic pain caused by musculoskeletal problems, especially back and neck pain. Along with spinal manipulation, they may also use heat, cold, electrotherapy, herbal remedies, nutritional supplements, massage, meditation, and other non-pharmaceutical therapies. Mixers may also use conventional diagnostic tools such as radiographs and blood or urine analysis. Compared to straights, mixers are more willing to acknowledge that part or even most of the effect of chiropractic is due to the placebo effect. Unlike straights, mixers are also more willing to accept the idea that immunization is beneficial.(7)

The chiropractor with whom I worked was easily identifiable as a mixer. Along with spinal manipulation, he made use of heat and cold, massage, ultrasound, electrotherapy, and herbal remedies. For example, he recommended echinacea and high dose vitamin C to one patient with bronchitis. In addition, he openly acknowledged that certain conditions were better treated by allopathic or osteopathic physicians, and noted that pharmaceuticals were necessary in some circumstances. In keeping with his general open-mindedness toward conventional medicine, he presented himself as a chiropractic physician, and even stated that he considered chiropractic to be mainstream rather than alternative medicine. Finally, he described the science coursework he had taken in great detail to one of his patients and me, particularly emphasizing his training in physics and biomechanics. If he believed in Palmer’s ideas about subluxations or innate intelligence, he did not at any point indicate that.

The patients whom this chiropractor treated were mainly chronic pain patients. At the beginning of a session, he would test each patient’s range of motion and ask the patient to rate his or her pain level on a scale of 0-10. Next, he would palpate the patient’s vertebrae one by one, asking the patient if there was any pain at each level. Then he would begin adjusting the patient’s spine. Several patients were elderly and had arthritis, especially back and joint pain. These patients were treated with a mixture of lumbar spinal manipulation, heat, cold, ultrasound, and massage. There were also a few patients who had been rear-ended in car accidents and were suffering from whiplash. The treatment for whiplash was similar, except that the chiropractor focused more on manipulating the cervical spine rather than the lumbar spine. At the end of each session, the chiropractor would again ask the patients to rate their pain on a scale of 0-10. In every case, the patient’s pain had diminished, sometimes all the way down to the zero level. The patients generally agreed that the treatments were helpful.

CAM Paper Part II: Massage Therapy

2009-02-25T17:56:00.000-08:00

Massage therapy (MT) is defined by the American Massage Therapy Association as including manual soft tissue manipulation that can involve holding, causation of movement, and/or application of pressure to the patient’s body; these manipulations must be done for the purpose of improving the health and well-being of the patient. MT can have many forms, with wide variations in duration of treatment, types of touch, apparatus used, and body sites treated. In addition, MT has been studied as treatment for a large number of illnesses and symptoms, including anxiety, depression, pain, rheumatologic diseases, asthma, migraine headaches, MS, PTSD, diabetes, cancer, and even HIV.(6)

Several theories have been proposed to explain why and how MT provides benefit to patients. The most commonly cited hypothesis is the gate control theory of pain reduction, which suggests that the more quickly transmitted pressure stimulus interferes with the slower pain stimulus, thereby decreasing pain reception by the brain. This could explain why MT improves subjective perception of pain. Another common idea is that MT may shift the autonomic system from a predominantly sympathetic state to a predominantly parasympathetic state. Effects of MT like slower heart rate, reduction of stress hormones, and a feeling of calmness could be explained by this theory. Other proposed explanations for the mechanism of MT include increases in serotonin levels, mechanical effects that reduce adhesions and fibrosis, indirect effects via improvement of sleep, and the one-on-one personal attention that occurs during a MT session. This last hypothesis is particularly interesting because it may also explain the efficacy of psychotherapy in improving many of the same symptoms.(6)

Anecdotally, the patients whom I observed having MT were very enthusiastic about its benefits. One patient came to the massage therapist because of a sinus headache. She stated that the treatment improved her symptoms of sinus pain and pressure, as well as decreasing the bags under her eyes. The therapist treated her by applying deep pressure with a circular motion over the patient’s ethmoid, maxillary, and frontal sinuses. She also manipulated the patient’s facial skin by using shallower touch and applying a cream. Throughout the treatment, the therapist spoke with the patient, explaining what she was doing and even telling us about her personal theories concerning how MT works. Furthermore, the atmosphere in the room promoted relaxation with soft lighting, plants and pictures suggestive of a natural setting, a warm massage table, and aromatherapy.

CAM Paper Part I: Introduction

2009-02-24T17:51:00.000-08:00

Complementary and alternative medicine (CAM) can be defined as a diverse group of therapies and products that are not considered to be part of conventional medicine. Patients may use CAM to treat a wide variety of conditions, including back problems, colds, neck problems, joint pain, anxiety, depression, rheumatologic problems, digestive problems, chronic pain, insomnia, and other chronic conditions.(1)

Currently, CAM is very popular with patients. A national health interview survey found that in 2002, 36% of American adults had used some form of CAM within the previous 12 months, not including prayer. According to the survey, the most common non-prayer CAM modalities used by patients included natural products, deep breathing exercises, meditation, chiropractic, yoga, massage, and nutritional therapies. Interestingly, prayer for improved health, performed either by the patient or by others on behalf of the patient, was by far the most commonly used form of CAM. Inclusion of prayer as a CAM modality increased the percentage of adults using CAM in the past 12 months to 62%, and the percentage using CAM at any point in their lives to 75%. The popularity of CAM may stem at least in part from patient dissatisfaction with conventional treatments for chronic conditions such as pain.(1)

Multiple surveys suggest that physicians, medical students, and other healthcare providers have limited knowledge about CAM, although some studies have found that physicians would like to learn more about CAM.(2-4) In addition, physicians tend to have more negative attitudes about CAM compared with other healthcare providers like nurses and pharmacists.(3) There is some evidence that the attitudes of medical students toward CAM tend to become less positive as they get further along in medical school and become more entrenched in the conventional medicine model.(5) This may help explain why only about one quarter of surveyed patients reported that they had tried CAM because their physician had suggested that they try it.(1)

Unfortunately, patients themselves are often misinformed about CAM.(1) The rise of the internet has generated a confusing information overload, much of which can mislead patients and possibly even harm their health.(2) Patients commonly self-medicate with CAM and often do not tell their doctors or pharmacists about the nutritional supplements and herbal remedies they are taking.(1-3) Furthermore, physicians opposed to CAM may overstate the case that all CAM is useless, while practitioners of CAM may overstate the curative powers of CAM or claim that the medical establishment wants to suppress CAM.(2)

As a result of the proliferation of misinformation and lack of reliable information about CAM, patients often hold misguided beliefs about CAM therapies.(2) For example, many patients believe that “natural” equates with “safe.” However, herbal remedies and other natural products may interact with prescription drugs, as well as have toxic effects of their own.(2,3) In addition, many patients believe that using CAM therapies will save money. However, the few studies done on this subject suggest the opposite, namely that use of CAM increases costs for healthcare compared to conventional healthcare alone.(2)

This paper will review some of the more popular forms of CAM, including both the theory and practice of these therapies. It will not be possible to cover every form of CAM that patients might discuss with their physicians. However, my hope is that this paper will be a good starting point to help educate current and future healthcare providers about CAM. Although prayer for improved health is the most common form of CAM, it will not be covered here in order to focus in greater detail on several of the physical and chemical CAM modalities that are popular among patients.

Complementary and Alternative Medicine

2009-02-23T18:04:00.000-08:00

This week, I started an unlisted elective in complementary and alternative medicine (CAM). An unlisted elective is one that is not listed in the Case elective course catalog. With the school's permission, you create it yourself. The impetus for me to want to study CAM was that I have had multiple patients in clinic asking me about herbal remedies, acupuncture, and the like. I have to admit that I am woefully ignorant about these subjects, and so were many of my attendings. Even though some doctors think that alternative medicine is bunk, my experience is that a lot of patients believe in it, so I thought I should at least understand a little about it.

For the elective, I am reading a book about herbal remedies used for various purposes and some articles about the history of alternative medical systems like osteopathy and chiropractic. I am also spending some time shadowing an osteopathic physician (to see manipulation), a chiropractor, an acupuncturist, a massage therapist, and an herbalist. At the end, I will write a ten-page paper about all of these alternative therapies. Since so many people are interested in CAM, starting tomorrow, I will post each section of the paper online, including my references.

For those of you who want to learn more about CAM, please keep in mind that there is a lot of biased and self-serving misinformation about CAM out there on the internet. (Actually, there is plenty of misinformation about medical topics in general, but it's especially problematic for CAM.) If you would like to consider using CAM therapies for your own health care needs, I recommend that you discuss CAM with your physician. In addition, you should educate yourself about CAM by only visiting websites that provide reliable, evidence-based information for consumers.

One of the best sites I've seen is hosted by the National Institutes of Health (NIH). NIH is a government research organization that funds much of the medical research done in the United States, including clinical trials. You can find a great deal of reliable information about many types of CAM by visiting the NIH's National Center for Complementary and Alternative Medicine webpage.

Done with Preventive Medicine

2009-02-20T18:37:00.000-08:00

After a small snafu with getting my answers uploaded, I was done with the online test by Monday night. It's pretty much all about hypertension. My advice for other Case students taking this elective is to only read the module on hypertension and then do the test. The other modules are not very helpful for answering the test questions. It's also not necessary to read all of the linked additional readings.

I hope it doesn't sound like I think this elective is fluff just because it wasn't organized the most efficiently. Actually, it helped reinforce some things I had learned in my medicine rotations, which is good because preventive medicine is covered on Step 2. Plus, I learned a few new things too, the most surprising of which is that there is conflicting evidence about the utility of restricting salt intake in hypertensive patients.

Even if the effect of restricting salt intake on blood pressure is small, it's probably still a good idea to encourage people to eat less salt, because American diets are ridiculously high in sodium. But getting patients to restrict their salt intake is very difficult, because there is a lot of salt in just about every processed food in existence. Try looking at some nutritional labelings on the packages even for sweet things like tomato sauce and cookies the next time you're in the supermarket, and you'll see what I mean. It doesn't help that food without salt tastes bland to most people, either.

Phlebotomy and Online Preventive Medicine

2009-02-13T15:53:00.000-08:00

On Tuesday, I took an optional day-long course at CCF to learn how to draw blood. It was free, and phlebotomy seems like a useful skill to have, so I figured why not. There were four of us who did it. First, we were shown the different types of needles and tubes for collecting blood. Then we each went out with a phlebotomist to draw blood on actual patients. Each time you draw blood, it is called a "stick." We had to get eight sticks to be certified. My phlebotomist didn't have very many patients on his list, but two of them let me draw their blood and I got them both on the first try. Then I got my last six sticks on some of the other phlebotomists who were coming in to change shifts. There was one I couldn't get, but I thought getting 7 out of 8 sticks was pretty good for a novice like me!

I'm doing an online elective this week and next week so that I could go out of town. It's on preventive medicine, and there are a bunch of modules we are supposed to read, followed by an online test that we have to take. The online test has 31 questions, which looked pretty scary until I realized that the first 15 are in groups of five that go together, and the last 16 are in pairs with one multiple choice and one essay. It's going pretty fast. I already am pretty much done with the whole test. The modules are another story. They are really long, and they have different reports and articles linked to them. It would take a lot longer than two weeks to read them all, so I decided to start working on the test and then just read the relevant parts of the modules as I went along. That made things a lot more efficient.

We had an afternoon seminar today on biomarkers, which I missed since I'm not there. I can't say I'm terribly broken up about this. :-)

Last Week of Toxicology

2009-02-06T19:43:00.000-08:00

This was my last week of toxicology. We each had to give a 40-minute presentation today. Mine was on alcohol withdrawal. It turned out to be a really good topic, since I had at least one alcoholic patient on my medicine rotation who we thought might be having withdrawal. The problem with hospitalizing alcoholic patients is that since they can't get a drink in the hospital, they can start going through withdrawal a day or two after they get admitted. Alcohol withdrawal is a serious problem, and it can kill the patient. The worst symptoms come with delirium tremens and include seizures, delirium, hallucinations, nervous system dysfunction, and electrolyte disturbances. Of course, fortunately not all patients get delirium tremens. But the ones who do need supportive care.

I also gave a brief presentation yesterday about absinthe, which is a drink made from wormwood extract. It is said that the artist Vincent Van Gogh was under the influence of absinthe when he cut off his ear. There are several alkaloids (chemicals) in wormwood that could cause the symptoms of "absinthism" (seizures, hallucinations, problems walking). But it turns out that the major ingredient in absinthe is alcohol! No wonder these people were stumbling around like drunks and hallucinating. They were alcoholics! It is still not legal to make absinthe in the United States, but they do have it in Europe.

Next on the agenda is preventive medicine, which is an online elective that is really an excuse for me to get out of Cleveland for a couple of weeks.

An Artificial Asthma Attack

2009-02-04T16:01:00.000-08:00

Over the last couple of weeks, I've been getting increasingly short of breath while walking. Now granted, I'm not currently in nearly as good of shape as I was before med school, but I'm still in good enough shape that I should be able to walk a mile without getting short of breath!

So I went to the doctor, and I ended up getting some lab work, a chest x-ray, an echo, an albuterol inhaler, and an appointment for lung function tests. These tests measure how much air you can inhale and exhale by having you breathe a full breath of air in and out of a machine with your nose pinched shut. The machine measures the speed and amount of air you're moving.

Today was the day that I took the lung function tests. One of these tests is called a methacholine challenge, and its purpose is to see if the patient has asthma. How, you may ask, is the test performed? Well, the patient inhales a drug (methacholine) in periodically increasing amounts. After each dose, they have to keep inhaling and exhaling air into the machine to measure their lung function. Meanwhile, the tech administering the test watches to see if the patient's airways close up enough to diagnose them with asthma.

When I tried it, the first few doses weren't that bad. By the fourth dose, my chest was starting to feel a little tight. The fifth dose was absolute agony. The woman giving me the test asked if I thought I could still hang on long enough to inhale and exhale into the machine. I felt like I was seeing stars a little, but I nodded and did what I could. She then gave me albuterol, which is a medication that opens the patient's airways again. If they have asthma, this should lead to a recovery of lung function to the level it was at before starting the methacholine challenge.

Inhaling that albuterol helped me tremendously. It also made my heart start pounding (side effect), but being able to move air in and out of my lungs freely was more than worth a few palpitations. When the entire test was over, the tech showed me the graph of my lung function test, which was textbook beautiful for asthma.

Now that I've been officially diagnosed with asthma, I have to start using an inhaled steroid and taking a pill, both for prophylaxis. In other words, these medications won't stop an asthma attack that is already taking place, but they will prevent future attacks. I'll still have the albuterol inhaler to use in case I have more attacks.

The most indelible impression that this test made on me is that I will never order a methacholine challenge for a patient unless I think it's absolutely necessary. Feeling like you can't breathe is extremely unpleasant.

Week 3 of Toxicology

2009-01-30T18:41:00.000-08:00

This week has gotten surprisingly busy. I've been reading for tox, working on my research protocol (though not as much as I would have liked), and finishing my research fellowship application. I'm still really enjoying tox. Wednesday we had a big snowstorm, and the resident and the other med student couldn't get over to Case. So I was the only one who made it in, and the attending and I went over that day's cases. We had a bunch of adult patients who tried to overdose on anti-psychotic drugs. I've gotten to know the psych drugs pretty well on this rotation, because they seem to be one of the more popular classes of drugs that people take when they try to commit suicide.

On Thursday, there was a mock LCME re-accreditation visit for Case. LCME is the organization that accredits medical schools, and Case is due for its re-accreditation visit in March. Most of the meetings are with faculty and administration, and then there are two meetings with students. The first one is for M1s and M2s, and the second one is for M3s through M5s. There were four of us, one M3 and one M4 each from the UP and CCLCM. We got asked about things that students had complained about in the survey last spring, like the OB/gyn rotation and student health services. Other questions were things like what we would do if we got stuck with a needle (call the exposure hotline) and what goes into our dean's letter if we have to remediate a competency (beats me, and I plan to never have to worry about this). I think now I am going to be asked to go to the real meeting too.

This afternoon I had my Friday research seminar at CCF on medical decision making. The first half on prediction tools was really interesting, and the second half on cost-analysis gave me a nice hour to daydream. At least I didn't fall asleep, which is more than I can say for a few of my classmates. ;-)

The Best of Toxicology

2009-01-23T19:18:00.000-08:00

I am now halfway through this toxicology rotation, and I really love it. It's mostly didactics and not very much clinical stuff, but the subject is really interesting, and the attending has all kinds of cool stories to tell. For example, he testified for a criminal trial where someone poisoned the defendant. That was definitely cool. He also gets to travel around a lot. Monday he'll be doing consults, so we're going to go with him. I'm looking forward to that. We're also each going to do a presentation at the end on some kind of tox topic. Mine will be on alcohol withdrawal.

We spent Monday morning in the attending's lead clinic. This is an outpatient clinic where he sees kids who have lead poisoning, usually due to ingesting or inhaling lead-based paints. If their lead levels are high enough, he chelates them. (Chelators are chemicals that bind to lead so that the body can excrete it.) Since a lot of the buildings in Cleveland are relatively old, especially in the poorer areas of town, there is still a lot of lead-based paint here. One family had three little girls, all with almost the same names. The nurse practitioner was having trouble remembering which one was which, but the funniest thing was that the girls' mother was having the same problem.

Today's afternoon seminar was on the art of physical diagnosis, or rather, how this art is being lost because of the dependence on technology. We didn't actually practice any physical diagnosis, mind you, just talked about how we don't really learn it. Again, it's an important topic to think about, but three hours of it is really not necessary.

Starting Clinical Pharmacology and Toxicology

2009-01-16T19:25:00.000-08:00

This was the first week of my clinical pharmacology and toxicology rotation. There are three of us on the rotation: an emergency medicine resident from Metro, a fourth year from the UP, and me. It was kind of a funny week, because the attending was out of town. He had left us a packet of questions to do, and he also wanted us to spend some time listening to the poison control nurses field calls. Other than that, we were pretty much on our own. We also took pictures to get University Hospital badges, which we still haven't gotten. The stupid part is that the badge expires at the end of the month, and I'm coming back to UH in March for my radiology rotation. But they said I'd just have to get another one then.

These questions are pretty hard. The poison control nurse I worked with commented that they were similar to the questions she had on her certification exam. I listened to calls with her for two days. Most of them were for pill checks, where people magically find some unlabeled pill and call the poison control center to get it identified. First of all, it would never occur to me to call the poison control center if I found a weird pill. Second of all, who just takes pills that random people give them? Most of the legitimate calls were either for toddlers who got into medications and household products, or for adolescents and adults who were trying to commit suicide. Amazingly, a lot of people try to commit suicide by overdosing on acetaminophen (Tylenol). That's an incredibly bad way to kill yourself. It takes three or four days for you to die of liver failure, and you feel really, really bad the whole time: excruciating stomach pain, nausea, vomiting.

Today's seminar was on meta-analysis. This one might have been the very worst of all, not the least of which because it went over time due to yet another ridiculous and pointless group activity. I hate to be rude, because I know these people are giving us their time. But there has to be some less painful way for us to learn this material.

Research Protocol and Funding

2009-01-09T19:33:00.000-08:00

This was my last week on research. I'm still not done writing my protocol, but at least I have a project more or less planned out. It's definitely going to be on trying to predict delirium in geriatric patients. I'm also working on my application for the medical student geriatrics research fellowship.

Yesterday, I met with one of the fellows about writing a protocol for a second project that sounds pretty cool. That would be a retrospective project, meaning that we'd be looking at data that have already been collected. He would use the results to support his application for funding to do a prospective trial, where new data would be collected. So it looks like I'm probably going to have two projects for my research year, which could be a good thing if I get two publications out of it. I don't know when I'm going to get around to writing that proposal though, because now I'll have to start doing work for my next rotation.

Other than that, it hasn't been a terribly exciting week. We've been trying to figure out where people are smoking that makes the cigarette smell drift into the med student office, but we haven't been able to find them so far. The funny thing is that apparently the people on the floor above us can smell it too, because someone who works up there came down to our floor to find out if it was one of us! I think whoever it is must be smoking outside next to a vent. There's no way anyone could smoke inside any of the CCF buildings without setting off the fire alarm. Believe me, people have tried!

Slow Week

2009-01-02T19:47:00.000-08:00

This has been another slow week as far as research goes. (Are you seeing a trend here?) We did have one patient to assess for delirium on Wednesday, but she was still intubated and sedated in the ICU today, which means that we basically didn't do the assessment at all. Next week I will be having a meeting to discuss the specifics of my project and hopefully get ready to apply for funding. The geriatrics grant that I want to apply for has a deadline in a month, so I need to get cracking on that. Nothing else exciting is going on except that I ordered my books for the rest of my rotations. I'm really looking forward to starting pediatric toxicology the week after next.

Research Training

2008-12-26T18:20:00.000-08:00

This has been another slow week. My PI and I have decided that I'm definitely going to do the delirium research. Coincidentally, my class got an email earlier in the week from the CCLCM research coordinator with a link to that same geriatric research fellowship for med students. Like I said, it's only for three months, but funding is funding, and I'll be applying for another fellowship anyway. Other than that, not much is going on. Most of the first and second years are gone on vacation, so it's pretty dead here. I finished my research training on Tuesday and ran some errands. I have also been going to do post-operative delirium assessments with one of the research fellows. These patients are not demented, so it's a lot easier running the mini-mental on them than it was on the demented patients I was seeing during my geriatrics rotation!

At least it is finally warming up. Last weekend we had an ice storm and temperatures in the single digits with a -25 degree windchill. Today it's like 60 degrees. Cleveland has the craziest weather. It's no wonder that everyone I know is sick.

First Week of Research

2008-12-19T19:10:00.000-08:00

This has been a very slow week. I've been working on writing a research proposal for my research year, which will be next year. I want to do a project on developing a screening tool that predicts which patients are at highest risk for developing post-operative delirium. If my PI goes for it, I'm also going to apply for a geriatrics research fellowship. It's only for three months, but hey, money is money. Fortunately my PI can afford to pay me even if I don't get it. A lot of people in the research group are out of town, including the person I need to talk with, so I have a lot of free time. I think I've watched about half a dozen movies this week, which is probably more than I've watched during the rest of the whole year put together!

It's snowing like crazy right now. Someone told me that this is going to be a bad winter, and so far, it looks like they're right.

End of Geriatrics

2008-12-12T19:09:00.000-08:00

I'm now officially done with geriatrics. This week was similar to the first week: seeing inpatients in the morning and outpatients in the afternoons. I did get to observe a driving test one morning, which was an interesting experience. A psychologist conducts the interview, and if the patient passes that portion of the exam, then they go out into the lot for a driving test.

The patient was a very sweet man who insisted that he could drive just fine, and he didn't understand what the fuss was all about. He seemed perfectly normal to me when we were chatting before the interview. The psychologist performed the mini-mental on him, and he got all of the questions right except for missing a couple of items on recall. Then the tests got harder. The psychologist asked him to name as many animals as he could, look at pictures, and answer other questions. As I watched and listened, it became apparent that this man really was mildly demented. The questions he was struggling with were mental tasks that no one should have had trouble doing.

In spite of performing poorly on several of the tests, the patients still insisted that he was fine to drive. This is an example of lack of insight, which is common in Alzheimer's patients. In other words, he did not recognize his own loss of memory and other cognitive abilities. Patients with some other forms of dementia (non-Alzheimer's) do sometimes retain insight and are aware that their thinking has declined.

Ultimately, the psychologist asked him about things like how many tickets he had gotten recently, and how many accidents he was in recently. It turns out that there were some of each. The patient's cognitive decline was apparent enough that no driving test was necessary. He was told that he had to give up his license, which unsurprisingly upset him. It was very sad.

The only other new thing I did this week was to go to UH to do some consults on inpatients. I hadn't ever rotated at UH before, and it was very trying. First of all, they don't have electronic charts. You wouldn't think that would matter very much, but it does when you're trying to read about a geriatric patient whose chart weighs more than you do! It didn't help that a bunch of papers were randomly stuffed in there every which way, and half the notes were scrawled in chicken scratch that I couldn't read. Making sense of it all was hard enough that I only saw two patients all afternoon, even with staying an extra hour. (The attending wanted me to stay even longer, but I had more than run out of patience by then.) All in all, this experience made me greatly appreciate how much nicer it is to use electronic medical records like they have at the VA and at CCF!

Elderhealth

2008-12-05T19:08:00.000-08:00

This week, I have been rounding at the VA in the mornings, and then going to Elderhealth in the afternoons. Elderhealth is a community center where UH has an outpatient facility for geriatrics patients. There is a general geriatrics clinic similar to the one at the VA, and also geriatrics subspecialty clinics.

Monday afternoon, I worked with a geriatric psychiatrist. Well, to be more exact, I shadowed a geriatric psychiatrist. This was my least favorite day. Not only did I not get to do anything, but some of the team members were kind of patronizing toward the patients. Tuesday, I worked with a geriatric neurologist. That was a lot more fun. The attending was cool, and he had me interview and examine a challenging patient who had several findings. He also had me write a note, which was less fun, because they don't use electronic medical records at Elderhealth. My patient's chart must have been at least two inches thick. I hadn't realized how spoiled I became at CCF (and even the VA), where we have electronic charts!

Wednesday, I worked with a general geriatrician who also goes out to nursing homes. She was great also, letting me see patients and teaching me a lot. Thursday I went with her to the nursing/retirement home. It was a lot nicer than I expected. If I had to be in a retirement or nursing home some day, I wouldn't mind living in this one. They had a computer room, a library, even a beauty shop, all on site. The patients all knew my attending and were excited about us coming to visit. I spent most of my time interviewing a couple of her patients who she thought would be interesting. One of them had no short term memory. It made having a conversation kind of frustrating, because she could tell me things from decades ago, but she couldn't remember what we had discussed a few minutes ago. I spent a lot of time telling her over and over again who I was and what medical school I attend.

Today I was at the VA all day. We have a new inpatient attending who is into teaching. He pimps us a lot, but it's mostly stuff we should know, like blood pressure drugs. Our patients were on two different floors, and he likes taking the stairs, so I got to spend some more time on the VA stairmaster. The other good thing about him is that he finishes rounds quickly.

I guess winter is here. It's been kind of flurrying every day, and now the snow is sticking. Definitely time to pull out my snow boots.

VA Stairmaster and Hospice Week

2008-11-28T18:52:00.000-08:00

This was a short week because of Thanksgiving, but a lot was packed into it. On Monday after geriatrics rounds, I went around with the chaplain and the Hospice nurse practitioner to visit the Hospice patients. Two of them wound up dying within half an hour of one another. Somehow, it didn't seem as bad as some of the other patient deaths I have seen. I think a lot of it was that they were comfortable and the families were there. Also, they all had time to prepare. It was sad, but not depressing.

Tuesday I had my own consult, and it was a tough one. The patient has stage 4 lung cancer with metastasis to the brain, which has caused seizures and dementia. So he really doesn't understand what is going on. But I did my best to explain what Hospice was to him, and he agreed to have a Hospice nurse come out to his home. Wednesday we had a patient who didn't speak much English, but fortunately his family was there to translate. They decided to take him home to his native country to die, which seemed sensible to me. Dying in a hospital is so undignified, especially if it's in the ICU.

The Hospice nurse wrote me an incredibly nice evaluation for my portfolio. She was really upset though when I told her that I didn't want to do medicine and was thinking of doing something with less patient contact. She told me it would be a waste of my talent at working with patients. Considering how much I hated my medicine rotation, it always surprises me when someone says this to me. It makes me doubt myself a little. But I keep thinking about how only five weeks of inpatient medicine made me so miserable, and how the residents were so miserable, and I just don't think I can do it for three years.

I was off on Thursday for Thanksgiving. Friday was a holiday for the UP students, but not for us. So I was the only student who showed up, and I was running around frantically trying to help the nurse practitioner cover the other students' patients. She wanted me to stay in the afternoon too. But I told her that I had to leave at lunchtime because we have classes on Friday afternoons. That is usually true, but we didn't actually have class today because it was our free Friday afternoon. (We get one free Friday afternoon each month.) I was annoyed that she expected me to stay in the afternoon. It made me feel like she was taking advantage of me. I had already come in for the morning even though I could have easily gotten away with not coming in at all. It was enough. I care deeply about doing the right thing, but that doesn't mean there are no limits to what people can ask of me.

I forgot to describe the VA "Stairmaster" last week. The hospital is six floors tall, and the Stairmaster is actually one of the stairwells. The walls in that stairwell have been painted with motivational exercise statements and pictures. There are also colorful charts telling you how many calories you burn doing various activities, depending on your weight. One of the UP fourth years who had rotated at the VA before had told me that they play music in this stairwell sometimes, but I hadn't heard it before. Well, on Monday, they had turned on the music. Since the Hospice patients are on more than one floor, I had several opportunities to go up and down the VA Stairmaster. They played all kinds of things, from country to pop to jazz. Every time I went into the stairwell it was a completely different genre. I was thinking last week that the VA Stairmaster was kind of silly, but now that I've been in there with the music playing, I like the idea. They should post a schedule for what they plan to play when, though. I have decided that I really don't like climbing stairs to jazz!

Geriatrics Patients

2008-11-21T18:38:00.000-08:00

As mentioned previously, I'm basically spending my days seeing geriatric inpatients in the mornings and outpatients in the afternoons. It still takes me at least an hour and a half to see each one. Since I'm on geriatrics, all of my patients were either in Korea or WWII. Most of them have multiple serious medical problems like heart failure and COPD, and they also have other issues like dementia, difficulty walking, or side effects due to polypharmacy (multiple drugs). The patients themselves can be quite the characters. One patient with moderate dementia wanted to tell me an off-color joke, and another had post-traumatic stress disorder. Many of them are depressed also, especially the inpatients. I am sure it doesn't help that we're getting close to the holidays.

This afternoon I had POD/ARM. It was on clinical trials. The talks were good, but since I have taken the MS course on clinical trials, I had already seen them all. After that, we had a class meeting on the research year and how to sign up for electives, advanced cores, and areas of concentration. Considering that I have done all of those things already (geriatrics is one of the advanced cores), it was pretty pointless for me to stay. But I had some time to kill anyway, because one of my surgery rotation patients was back in the hospital for another operation. I wanted to go see him after he got out of the PACU (post-anesthesia care unit). He was a bit groggy, but I think he was really surprised when I showed up. I probably won't get to see him again since I'll be at the VA all of next week, but at least I had the chance to stop by today.

Next week I am on Hospice. It is a palliative care service for people who are expected to die within the next six months. I'm interested in palliative care, so I'm looking forward to it.

Geriatrics at the VA

2008-11-18T16:46:00.000-08:00

I started my Geriatrics rotation at the Cleveland VA yesterday. This is the first time I have ever been inside the VA hospital, and it is surprisingly nice. The floors are all wooden, and there is a lot of cool, funky furniture and artwork in there. A lot of the rooms are single. The patients wear what I can only describe as pajamas with the VA logo on them. The funny part is that the logo says, "property of the government" right there on the patients' chests. There are five students on the rotation: me and four fourth years from the UP. The faculty always ask us what we want to go into here just like they did at CCF. I'm the only one who still doesn't know, because these fourth years I'm rotating with are all going on residency interviews already. So I always have to explain that I'm only a third year!

For this whole week, I will be spending my mornings on the GEM, which is the geriatrics inpatient floor. I've only been seeing one patient per day, mainly because these patients are incredibly complex. I was joking to a friend that they couldn't be much different than a lot of the patients I saw on General Inpatient Medicine at CCF. But actually, they are a lot more challenging because most of these patients have dementia, delirium, or both. The main difference between dementia and delirium is that dementia is a permanent state of altered cognition, while delirium is usually a temporary, fluctuating state. The reason why it matters is that delirium is sometimes curable if you treat the underlying cause, but dementia (like Alzheimer's disease) usually isn't curable.

So the schedule basically goes that I come in each morning around 7:30 AM and see my inpatient. He has moderate dementia and is also recovering from a post-surgery episode of delirium. What fascinates me the most about working with him is that he is actually capable of performing several activities of daily living like feeding or dressing himself, but he has to be coached. For example, he can use a knife and fork to cut his pancakes and eat them, but only if I tell him what to do, step by step. Otherwise, he picks the pancakes up with his fingers. I can understand why these patients are difficult to manage at home. He is just as docile as a young child, but also just as dependent. It would be impossible for someone to stay there and constantly coach him all day long.

We have team rounds at 8 AM on Mondays, Wednesdays, and Fridays, and a lecture at 8 AM on Tuesday and Thursdays. (We start rounds at 9:15 AM on Tuesdays and Thursdays.) I was a little worried about the rounds, but they've been surprisingly short and painless. This is mainly because we only have half a dozen patients on the team, as opposed to the two dozen we would have on Medicine at CCF. Today's lecture was on delirium. After rounds, we finish seeing our patients and writing notes if we haven't already. I've been getting in early enough to get everything done before rounds, so it gives me the rest of the morning off to get other things done.

In the afternoons, I go down to the outpatient clinic. Again, these are mainly patients with dementia. Conducting the interviews can be a huge challenge, because a lot of the patients aren't able to focus on the discussion very well. As you can imagine, it's pretty hard to perform a mini-mental exam on someone who constantly goes off on illogical tangents or confabulates (makes up stories to fill the gaps in his memory). The other thing about the mini-mental is that it's specific but not very sensitive. This means that there aren't very many false positives (i.e., most normal people will not come out with a score that suggests impairment), but there are a lot of false negatives (people who are demented but score high enough to suggest that they aren't). The reason why there are so many false negatives is that someone who is highly educated (beyond high school) can often compensate for their cognitive deficiencies. So basically, if you have a college education or beyond, you would probably be able to "beat" the mini-mental even if you were mildly or moderately demented.

Done with Micro

2008-11-14T16:33:00.000-08:00

This has been a very easy and relaxing week. I come in around 8 AM, hang out with the med techs for a few hours, go to a lunchtime talk, go on afternoon rounds, hang out and read for a few more hours (or maybe go to another talk), and I'm out of there around 4 PM. I went to the gym for the first time in about six months on Tuesday. I get a full eight hours of sleep every night. It's amazing. That being said, I'm ready to move on. I've covered most of the benches in the lab by this point, and I feel like another two weeks in here would probably be two weeks too many. There's a lot to be said for two week rotations. They're long enough to give you a taste of the subject, but not long enough to bore you.

I turned in my mini-clinical portfolio yesterday. This is a two page essay talking about what I did well and what I need to work on after my first block of rotations. It wasn't hard to write the essay at all. But putting in the citations was a huge job, because every eval from each attending has exactly the same title. So each time I wanted to cite someone who had written more than one eval for me, I had to open every single eval by that person in RefWorks until I found the one I wanted. I hate RefWorks more than I can possibly express in words. It's the most user-unfriendly program on the whole planet. I don't think the people who wrote it could possibly make it harder to use if they actively tried.

Today's FCM class was on dealing with difficult patients. It wasn't one of the better FCM classes we've had, but it was ok. They had standardized patients pretending to be the difficult patients, but they weren't very difficult. I've dealt with much more challenging real patients already. Plus, there wasn't enough info in the case scenarios, so it wasn't even clear what the problem was. Tonight I am having dinner with a couple of the UP students I rotated with last month, and then I am going to spend the rest of this weekend doing basically nothing.

Getting to Know the Bugs

2008-11-07T18:42:00.000-08:00

I'm continuing to work my way around the medical micro lab. So far I've done two days at the blood culture benches, one day at urine cultures, and then today was acid-fast bacteria (like tuberculosis). The labor-intensiveness of it all continues to amaze me, as does the ignorance of so many of the people who call down to the lab wanting answers, and wanting them yesterday. These are occasionally residents who are calling, and they are not stupid or uneducated people. A few of them just don't have any clue whatsoever about what goes on in the medical labs. Some doc who called for a stat culture is now a running joke among the med techs. (Stat means that the doctor wants something done right away. The joke is because the med techs can't force the bacteria to grow any faster just because some doctor ordered the culture stat!)

At this point, I've started getting pretty good at identifying gram stains of bacteria, and even some of the more common pathogens on agar plates based on how the colonies look. E. coli grows flat, pink colonies on a MacConkey plate. They look very different than the more spherical, slimier Pseudomonas colonies, which are also pink. Staph and Strep, two gram-positive cocci, both look like little purple balls under the microscope. But Staph forms clusters and tetrads, while Strep forms chains and pairs. Plus, the shapes of the cells are a little different. The Staph cells are more spherical compared to the almost teardrop-shaped Strep cells. The coolest thing I saw under the microscope this week was Candida yeast. I had never thought about this before because gram stains are mainly used to stain bacteria, but it turns out that yeasts stain gram-positive. What was cool is that I could see their pseudohyphae, and some of the yeasts were even budding.

I've been continuing reading a few hours each day. I wish I could have learned this much micro last year or the year before. You really don't get the same effect from looking at pictures in books or online that you get from viewing the slides with an experienced med tech who points out the relevant features for you.

This morning after hanging out at the acid-fast bacteria bench, I had my POD/ARM class. It was part II of the innovations session, and I was expecting it to be yet another exercise in pain. Instead, it turned out to be really interesting and useful. We learned about what kinds of things were patentable, how patents work, what criteria CCF uses to decide if a patent should be pursued, how spin-off companies get started, and more. If someone patents anything while they're at CCF, they would get 40% of the royalties. This is not as farfetched as it might sound. At least one of the CCLCM fifth years has a patent. My classmates and I had a lot of questions, and I didn't spend the whole time staring at the clock. Those are excellent signs that this was a good talk!

Medical Microbiology

2008-11-04T18:34:00.000-08:00

Yesterday I started my Medical Microbiology elective. Medical Micro is a department of Clinical Pathology. When we sent all of those blood and urine cultures off during my medicine rotation last month, this is where they wind up. It's not the most exciting rotation because I don't get to do very much in the lab, but it's interesting to see what's involved with processing the samples. I have a lot more appreciation now for how much time and work is involved. The other main thing we do is go on lab rounds each day to look at whatever interesting pathology has come up. That's pretty neat because you see all kinds of bizarre path at CCF. Yesterday we saw Strongyloides (parasitic worms) from brain tissue. Today we saw Yersinia enterocolitica (bacterium) from a blood culture, which is also unusual. I was at the bench where that was found, so for once I knew more about the case than any of the residents or fellows did. Ha!

I also learned that a medical technician is a two year degree, while a medical technologist is a four year degree. Medical technologists can get a job as soon as they get out of college, and it's a very high demand field with a shortage of workers. There is a training program for it here at CCF. It sounds like a pretty good deal for someone who doesn't want to be in school for eight years, only to follow up with a minimum 3-4 years of residency.

These past two days have been very chill and relaxed. Yesterday I came in at 9:00 and left at 3:30. Today was a "long day" because I came in at 7:30 and left at 5:30. Tomorrow I have to be in at 9:00 again. I have three or four hours every day to spend reading, which I absolutely love. Compared to medicine and surgery, this feels like some kind of vacation. Even the weather today was gorgeous. Just to reinforce that I made the right choice not to jump into Core II right after finishing Core I, this morning I ran into one of the UP students who was on Core I with me. I asked how OB/gyn was going, and the general gist is that it really sucks. Uh oh....

Tips for Doing Well in the Internal Medicine Rotation

2008-11-02T10:54:00.000-08:00

If you've been reading this far, you know I'm not a huge fan of internal medicine. But one thing about rotations you hate is that you don't want to take them twice. So, here are my thoughts on doing well on inpatient IM:

1) Don't complain. Everyone hates scut work, most people hate being on call, and a lot of people hate rounding for hours and hours. But no one likes hearing someone else gripe about it.

2) Do as many procedures as you can. Tell your intern that you want to learn to do procedures. Be around while the team is on call. I got to do a lot more at night when there were no attendings around.

3) Read about your patients. Medicine is a huge subject, and it can be overwhelming to figure out what to read. It's a good idea to get a general text to use (I liked Step Up to Medicine). But you should read in greater depth about the diseases your patients have from a more detailed and authoritative resource like Harrison's or UpToDate.

4) Offer to help your intern do their scut work. That way, you'll both get done sooner, and your intern will hopefully repay you by teaching you something (or even better, letting you go home early).

5) Participate in rounds. Insist on presenting your patients when the team gets to them. Join in on the team discussions as much as you can.

6) Fill out your patient logs DAILY. As painful as keeping up with logs on a daily basis can be, it will be a lot more painful if you try to enter them all at the end of the rotation, or even at the end of the week.

7) When you're preparing to present post-call, don't try to keep all of the info on each patient in your head. Write notes to yourself on an index card, or print out your note from Epic so that you can use it to jog your sleep-deprived memory. One great strategy is to print two pages of your note to one piece of paper. That way, you won't be constantly shuffling the pages while you present.

8) Check on your patients and make sure there isn't anything they need. A lot of patients are lonely in the hospital, especially on weekends and holidays. You're there anyway, so you might as well brighten someone else's day. Plus, you might learn something interesting that will help the team take better care of that patient.

9) Get to know the support staff. Tell them your name, and find out theirs. Ask your patient's nurse how the patient did overnight. Talk to the social worker and case manager about your patient's disposition.

10) When you're rotating at CCF, you will be wearing a long white coat, and people will mistake you for a resident. Always try to act like the future doctor you will become, but don't ever lie about your actual status as a student.

End of Block One

2008-10-31T18:28:00.000-07:00

I took the NBME (National Board of Medical Examiners) exam this morning. We had yesterday off from clinic to study, but I mainly spent the whole day in bed and just did a little reading. There is nothing that I'm going to learn in one day that I should have learned in the past four months. This NBME is a practice Step 2 test that is now optional for CCLCM students but still required for UP students. The good thing about the test being optional is that it is not at all stressful for us. The downside of it being optional is that it is now only offered at Case. I went over there with some of my friends from the UP, because I still get hopelessly lost every time I try to find my way around the Case medical school buildings. The test itself didn't seem too bad. I think I probably did better this time, even without specifically studying for it.

After the test, we had to go back to CCF to meet with the BAT (Block Assessment Team). This time they just had us all meet as a group and we went through to give our suggestions about each rotation. They also gave us a free lunch. We were supposed to have individual meetings with the BAT afterward, but fortunately the faculty decided that it wasn't necessary. I went and met with my PA and then went home.

I am incredibly grateful to be done with Medicine for good. If I were still on this rotation, I would have had another black weekend this weekend. My team was joking with me on Wednesday that I could still come in and take call with them if I wanted. I told them I'd try not to feel too bad for them while I was sleeping in tomorrow! Now that I think about it, they really got screwed, because this weekend is the end of Daylight Savings Time. So they are going to have an extra hour on call since they both will be on in the middle of the night when the clocks get switched back.

Some of my classmates are going to the Weatherheadless Ball at the business school tonight, but my exciting plans for Halloween include a fluffy pillow and a down comforter, both of which I have seen way too little of over the past few months.

Last Call

2008-10-29T19:52:00.000-07:00

We have a new attending this week, and I think it's fair to say that she doesn't like me very much. It probably didn't help that when she asked what specialty I want to go into, I was in a particularly foul mood and told her that I didn't want to do any of them. I'm so sick of internal medicine, and I'm REALLY sick of being asked what specialty I want to go into. My senior knew I was in the College program and helpfully piped up that I was going to be a researcher, not a clinician. That's not really true, but at least it ended the discussion.

At another point, the attending asked one of the other residents (not mine) why he had ordered a test that wasn't necessary to make the diagnosis. The resident said he had just wanted to see the results. I thought the attending would chew him out for ordering a purposeless test, but instead, she told him that if he had ordered it for educational purposes, that was fine with her. And people wonder why health care is so expensive! Our last attending had always emphasized how important it is to not order tests unless the results will change your management, and I agree with that philosophy.

Yesterday was my very last night of call. It wasn't a particularly good one. I guess all these long days and long nights were catching up with me, because last night I was really dragging. By 3 AM, I couldn't keep my eyes open any more and told my team I was going to bed for a few hours. I had just gotten all settled in the student call room when my pager went off. It was my senior wanting me to come down and see a patient in the ER. Swearing to myself, I got dressed again and went over there.

During the interim ten or fifteen minutes that it took me to do this, the patient was moved to one of the medicine floors in the H building. The senior told me to go to the H building and examine the patient. Now I was really pissed, because I had gone through the H building on my way to the ER from the call room. I went back to H, located the patient, woke her up again, examined her, and found nothing noteworthy. When I caught up with the senior, I told her that I wasn't sure what I was supposed to have found. She said she thought the patient might have had one eyelid drooping lower than the other, but it was very minor. I struggled to keep control of myself. Then she said with utter sincerity, "See, wasn't that worth getting up for? It's such an interesting case!" I contemplated strangling her to death with her own hair, but managed a weak smile. By that point, it was already 5:30, so I went to go preround on my patients.

Today was my last day on General Medicine, and I hope it wasn't too obvious when I dozed off during rounds this morning. We did have an interesting moment though when one of our patients wanted to check himself out AMA. It was freezing cold and snowing hard outside, so the attending asked the patient where he was going to go, how he would get home, and what would happen if he went outside with no coat on. The patient didn't have a good answer for any of those questions, and the attending decided he was delirious and wouldn't let him leave. We wound up pink slipping him. I got to go home at 1 PM since I was post call, and I have tomorrow off, ostensibly to study for the NBME on Friday. And that is the end of the General Medicine rotation.

Facing Fears of Contaminated Blood

2008-10-25T19:52:00.000-07:00

Yesterday morning, I did my second point/counterpoint. This debate was about how to counsel a woman who was BRCA-positive and had an extensive family history of breast and ovarian cancer. I was charged with arguing the pro-surgery viewpoint to prophylactically remove her ovaries and breasts. The opposing position was to monitor and screen her regularly. Since we don't have any way to biochemically or radiologically detect ovarian cancer until it is probably too late, screening women at high risk for ovarian cancer is really an untenable position. After the debate was over, I told the facilitator that the debate should really be about whether to use prophylactic surgical management versus medical management with an anti-estrogenic drug like raloxifene. At least that would be a real debate, because screening is known to be ineffective for preventing ovarian cancer, while prophylactic surgery is known to work in most cases. For those reasons, I thought only screening her for ovarian cancer was tantamount to malpractice. He agreed that the debate was too one-sided, so I think future students will have a medical versus surgical management debate instead.

In the afternoon, we had a POD session on innovations. It was awful. First, we got a one hour talk about the CCF Innovations office and how they would work with us if we had something we wanted to patent or whatever. I'm thinking, all I want to do is survive the next week of IM! Then, we had to break into small groups to work on projects. Our biomedical engineer facilitator gave us a problem and told us to innovate, as if you could order people to come up with creative ideas on the spot like that. The project was on designing a better artificial knee implant. I had been up late the night before preparing for P/CP and had a night of call ahead of me, so I wasn't in the mood for this nonsense. When the guy asked if I had any suggestions, I said no. Then he asked if I had any engineering background, and I said no. After that, he pretty much just ignored me, which was fine by me. I even managed to doze off a little. When it was over, I went to the cafeteria for dinner and then caught up with my team.

Last night wasn't too bad for a call night. I spent most of it with the intern, who, like I already said, is awesome. He let me do a bunch of procedures. First, we had to get an ABG (arterial blood gas) on one patient, so he asked me if I wanted to draw it. Well, I hadn't ever drawn one before, but I said I wanted to, and he walked me through it. Fortunately, things went well and I only had to stick the patient twice. Unfortunately, getting an ABG drawn is extremely painful for the patient. I don't know why drawing blood from an artery hurts so much worse than getting it from a vein, but it does. This patient was semi-comatose, but he could definitely withdraw to pain! I have no idea if he could hear me when I apologized for hurting him, but I hope so.

The intern and I took the ABG down to the lab ourselves instead of sending it through the pneumatic tube so that we could be sure it got done right away. However, we wound up neglecting to fill out some form that needed to go into the bag with the blood samples. So a few minutes after we left, the lab paged us, told the intern they couldn't run those samples, and asked us to bring over new ones with all the proper labels and paperwork. That was aggravating, because obtaining the blood for an ABG is very unpleasant for the patient, and the samples did have labels on the actual tubes of blood. But the lab was firm, insisting that the labels on the tubes had gotten smeared or could get smeared or would get smeared. Anyway, to make a long story short, I got the opportunity to draw a second ABG, and this time I hit it on the first try. But I felt really bad about having to do it at all, and we didn't tell the patient why we needed a second sample. Of course, I'm assuming he was even aware of what we were saying.

Later, we went to try to start an IV on a patient that the nurse hadn't been able to stick. I don't understand why the intern on call is expected to do sticks that the nurses can't get, when the nurses have way more experience starting IVs than the interns do. But we got called, so we went to try. The patient was really dehydrated and obese, which were major contributors to his being a hard stick. The intern tried first a few times but couldn't get it. Then he asked if I wanted to try, so I did. The patient was calmly lying in his bed and didn't jerk at all when I pierced his vein. I got a little flush of blood, but the needle came out again. After one more cautious attempt, I gave up. The patient's IV would just have to wait until a phlebotomist showed up in the morning. Normally I'm not the kind of person who has unsteady hands while performing procedures, but last night I did. Plus, I probably didn't try as vigorously as I could have, because that patient was known to be HIV+.

This was the first HIV+ patient I had ever knowingly encountered, and I was thinking later about how mindful I was about his HIV status the whole time I was poking around in his arm. Being stuck by an HIV-contaminated needle is every health care worker's nightmare. When the intern first asked me to try starting the IV, I had a fleeting thought of refusing. There would have been no repercussions if I had refused. I am only a medical student, and there was no inherent expectation that I would try to start that IV. But I tried anyway, even though I was afraid. I tried even though the entire time, the thought that this patient's blood contained the HIV virus was in my conscious awareness. But I managed not to be overwhelmed by that fear even though I was so aware of it.

As a preclinical med student, you tell yourself that your fear of contracting HIV would never interfere with your sense of duty to help patients. But somehow, the situation is a lot more ambiguous when you're poking an HIV+ person with a hollow needle, and the only thing preventing his blood from contacting your bare skin is a thin, latex-free glove.

My Last ICU Visit

2008-10-21T17:47:00.000-07:00

I met my new intern and resident yesterday. The new intern is really cool. He is going to be a neurologist, and he's another intern who loves teaching. Considering how bad my neurological exam is, I can use all the help I can get. Our first call together as a team last night was fairly uneventful, and we all got to go home early today since we are post call. But I only got a few hours of sleep last night, and overall I still feel pretty cranky and even a little bitter about the whole overnight call thing. Q4 call (every fourth night) sucks. You're always either on call, about to go on call, just getting off call. I have decided that I don't want to do any residency that requires Q4 call.

As promised, I stopped by the ICU on Monday last week to see my heart failure patient. I went into his room to find him intubated and sedated. Over the weekend, he had coded. When I went into the room, I pulled one of the chairs next to his bed and held his hand. I asked him to squeeze my finger if he could hear me, and he did. Then we just sat together like that for a while. For the rest of the week, I came in every day to sit with him for a few minutes, and every day he squeezed my finger when I asked him to let me know if he heard me. During one visit, his nurse saw me sitting there and asked if I was taking his pulse. “No,” I said. “I’m just holding his hand. He knows we’re here with him.”

Today, I got to his room just after a code was being called off. He had arrested again, and this time the code team hadn’t been able to revive him. Everyone had left except his son, who I had never met before. He asked me if I had brought the papers for him to sign. “No,” I said. “I’m a medical student. I came here to see your father. I’ve been coming to see him every day.” The son said something about how his dad didn’t want to be kept alive on a machine, and thanked me for taking such good care of his dad. Then he left me alone in the room with his dad's body to go searching for the paperwork.

At first, I was really put off by his seeming lack of emotion, as well as the fact that he had not ever come to visit his father in the hospital. But everyone deals with their grief differently, and maybe that was what he had to do to cope. At any rate, I am glad that I had the chance to know his dad, because he was a really great guy.

Drawing Boundaries

2008-10-17T19:50:00.000-07:00

I found another old friend (a patient) waiting for me when we went on rounds last Monday. Taking care of her was a challenge for any medical team. She had multiple major medical problems, both physical and psychiatric, that made her a difficult patient to manage. She found it difficult to be flexible. In particular, she was resistant to adapting to the frequent changes in the treatment plan or her daily routine that are the norm in any hospital. Whenever she got upset enough, she would sign herself out of the hospital AMA (against medical advice).

I had done her H & P when she came on the Cardiology service the first Friday I was there, and I spent a lot of time talking to her and her husband during my black weekend. My goal had been to keep her in the hospital all weekend so that we could cath her heart on Monday morning. Each time I left the room, I joked with her, "You'll still be here the next time I stop by, right?" She laughed and said she would. Even though there were some minor rough spots, we managed to get through the weekend without her demanding that someone bring her AMA papers. She had her cath, which turned out normal, and she was released from the hospital.

Now, one week later, she was back. Since I knew her, I asked my residents to let me follow her. They were more than happy to oblige, because she had done nothing but complain since landing on the General Medicine service. I checked on her several times during the day and encouraged her to have some patience with the doctors, who were doing their best to help her. Tuesday morning, I found multiple notes in her chart from the night nurse describing how she (the patient) had accused her (the nurse) of disliking her, and purposely avoiding helping her. I talked to the day nurse about my patient's psych history, and asked him to please keep an eye on her. The patient calmed down and was getting along fine with the day nurse.

One of the things that upset this patient the most was when she didn't get her breathing treatments on time. She really did have severe COPD (chronic obstructive pulmonary disease), but she would also work herself up whenever things weren't going according to schedule. I went home Tuesday afternoon after reminding the resident to put in orders for the patient to have her breathing treatments every four hours all night long. Wednesday morning, I came in to find her in the sorriest state I had ever seen. She could barely breathe, and she was very tachycardic. Somehow, the order for her breathing treatments had been discontinued, and she hadn't gotten any treatments all night long. No one had noticed her, because she had been given extra lorazepam in the evening to help her sleep and keep her calm. In her drugged state, she hadn't been able to complain, and the night nurse understandably hadn't gone out of her way to check on this patient in depth.

I listened to her heart and lungs, then went to get my senior. We got the respiratory therapist to come to her room stat to treat her. We also took her off the lorazepam. I spent a lot of time talking with her and her husband. She wanted to leave, but the residents and I convinced her to stay. So she did, and the next couple of days passed uneventfully. Yesterday evening when I was finished with my short call, I went by to tell her that I had didactics today and wouldn't see her in the morning. I promised that I would come by this afternoon before I went home. Her husband gave me their phone number and told me that I should come over for dinner some time. But at some point during the night, she got upset again, demanded that the resident on call bring her the AMA papers, signed herself out AMA, and left.

I was worried about her and even thought briefly about calling her at home, but I decided it was best if I didn't. Although she has a psychiatric disease, she is fully competent to decide that she wants to leave the hospital AMA. But I felt a little guilty when I heard that she left while I was gone. I was sure that if I had been in the hospital overnight, I could have again convinced her to stay. Maybe I could have, and maybe not. But it dawned on me that my approach to her was becoming personal as opposed to professional. I wanted her to stay in the interest of her own health, but I also wanted her to stay because I felt like it reflected badly on me as her health care provider if she left AMA. Of course, her leaving the hospital does not really reflect on me at all. I was the one who had been making her decision into some kind of referendum of my performance as a clinician.

General Medicine Service

2008-10-13T19:12:00.000-07:00

I came in this morning to be pleasantly surprised that I already know my senior resident. Last year, she worked with my longitudinal preceptor in the outpatient clinic sometimes, and that is where I met her. My new intern used to be a pharmacist before he went to med school, which is pretty cool. I am only working with the two of them for this week, because the residents change rotations on Monday of next week.

My new attending holds sit-down rounds instead of going room to room. Then he goes to see the patients on his own afterward, leaving us to do whatever scut needs to be done before the noon conference. I like this system a lot better than when we all had to go on bedside rounds with the attending! The team discussed all of the patients, and then my senior and intern, who were post-call, went home. I had gotten yesterday off, so I didn't get to go home. But there wasn't much to do this afternoon with all the team gone, so I had plenty of time to read. All in all, not too bad for a first day.

Heart Failure and EKGs

2008-10-09T18:52:00.000-07:00

This is my last week on Cards. I should have had to be on call again this weekend, but since I'm switching to a general Internal Medicine (IM) team next week, I lucked out and will get the whole weekend off. I'm grateful for that, because it's been a hectic past couple of weeks.

Yesterday and the day before, we had two EKG sessions led by one of the chief residents. They gave us sample EKGs and helped us go through them and practice interpreting them. Since my cardiology attending is the CCF guru of EKG and has been doing impromptu teaching sessions with my team over the past two weeks, I came in already feeling pretty well prepared. Then last night, my intern was going over EKGs with me in the ER while we were on call. Like I've said before, this intern really likes to teach, and I've learned a lot from him over the past two weeks.

I am still following one of the patients we were consulted to see in the ER a while ago. He had come in short of breath with a 25 pound weight gain due to an exacerbation of his congestive heart failure (CHF). Because of retaining so much fluid, he had the most impressive pitting edema (swollen legs due to excess fluid) that I had ever seen. Saying that his edema was pitting means that when I pressed on the swollen ankle with one finger and then let go, the pit made by my finger would stay visible on his ankle for a few minutes afterward. It's almost like how a piece of clay will still have an indentation after you push your finger in and then take it out.

Anyway, he had so much excess fluid in his body when he showed up to the ER that he couldn't even lie down--if he did, his lungs would fill up with fluid, and he wouldn't be able to breathe. He also couldn't walk because it made him too short of breath. So he had to stay sitting in a chair all the time. In spite of that, he was cheerful and joked around with me. We spent an hour in the ER going through his history and physical until my team came down. Then my intern admitted him to the floor.

The obvious solution was to give him an IV diuretic (similar to a water pill) to try to get some of that fluid off, which is exactly what we did. However, it created a real catch-22: every time we tried to increase his dose of diuretic, his kidneys would start to fail. But if we decreased the dose of diuretic to improve his kidney function, he would gain back a few pounds of fluid, negating the progress we had made in diuresing him. After several days of this stalemate, the team decided to transfer him down to the heart failure ICU. He still had so much fluid on him that he had to stay sitting up in his chair all the time, and he couldn't walk, talk or lie down without becoming severely short of breath.

Now that he's in the ICU, he isn't my patient any more. But he and I get along pretty well, so I have still been stopping by the ICU to check on him when I have some time. Today, he introduced me to some of his friends who were visiting him, and I told him that I'd come by again on Monday when I get back. Unfortunately, so far, the ICU team isn't having any more luck with diuresing him than we did.

Black Weekend

2008-10-05T14:47:00.000-07:00

It's entirely possible that this has been my worst week since starting medical school. Thursday was another full day of rounding and scut, so it wasn't any more boring or awful than any of my other days on IM so far. But on Friday, I found out that my last surgery patient had died. Even though I wasn't on the surgery team any more, I had been checking his electronic chart each day all week to see how he was doing. I knew he wasn't doing too well since he had been admitted to the ICU earlier in the week, but I kept hoping that he'd pull through. When I checked on Friday, I saw that he had been disconnected from all life support and had died soon after. That put me in an even worse mood to begin my black weekend.

A black weekend means that you get no day off for the entire weekend. In other words, you work for 12 straight days, from Monday of one week until Friday of the next week. Whenever you have a Saturday call, that's a black weekend because you come in Saturday morning at 7 AM and leave at 1 PM on Sunday. Then you still have to come in Monday morning at 6:30 AM like normal. I came in on Saturday already feeling cranky because I didn't find out that we had a 30 hour call until Friday afternoon. My confusion was because on surgery, weekend calls started at 6 PM and were over the following morning at 8 AM. So I blithely made plans for yesterday, only to be told by my intern the day before that no, I had to be here all day.

Being in the hospital on Saturdays is not much different than being in the hospital on weekdays. You still round on the patients, do scut, and write notes. The school gives us money for our call meals, which is a really nice perk. But as I found out, that call money can't be used at lunchtime, only for dinner and breakfast. So I still had to pay for my lunch even though I was on call, which annoyed me too. After lunch, I went back up to the floor and was standing right outside of a patient's door when a code was called. It wasn't one of the patients that I was following, so I didn't really know her. But I went into the room with everyone else.

Codes may look cool on TV, but they're pretty awful when you're there in the room for one. The code team members were compressing the patient's chest, and she was flopping around in the bed like a doll. I could hear her ribs cracking, and then the anesthesiologist intubated her. The team defibrillated her a few times and got her pulse and blood pressure back. The patient's family was outside the room, and her husband was crying. I went out to be with them just as the chaplain arrived. A few minutes later, one of the code team responders came out to tell the family that the patient had been resuscitated and they were moving her to the ICU. He said very matter-of-factly that the patient was in very bad shape and might die. The husband started sobbing even harder, and the responder just said, "sorry," turned, and walked away.

There have been plenty of times here and there when I have thought that I probably made the wrong decision to go to medical school, but that was one of the times it hit me the hardest. What really got to me was watching that responder's back as he walked off to go fill out his paperwork.

Inpatient Cardiology

2008-10-01T14:08:00.000-07:00

This is my first week of inpatient medicine/cardiology. I think it works a little differently at the other hospitals, but at CCF, we spend two weeks on inpatient cards and three weeks on inpatient general medicine (IM). Most people do IM first, but I have been scheduled to do cards first.

Monday was not the greatest start. I had paged my senior resident a few days earlier to find out when I should get to the hospital and where to meet, and he told me to be in the medicine residents' room at 8 AM. So I showed up on time, but then I sat around for the next hour and a half while he wrote his notes. Fortunately I had brought something to read, so it wasn't a total waste of time. At 9:30, we met with the attending and the rest of the team and started rounding. This made me realize two things: first, I really hate rounding for hours at a time. Second, it felt pretty weird to be wandering around the hospital floors all morning when I had always been in clinic or in the OR by 8 AM up until now. I think this has been the first time that I've been up on the floors while it was still light out!

After rounding for what seemed like an eternity but was actually only a couple of hours, we went to the IM noon conference. I had been to a few of these before, but not every day like now. They're not the most exciting things either, and I think the biggest reason people like to go to them is because we get free food. Then, we basically spent all afternoon doing scut. Scut consists of things like contacting outside hospitals to get medical records, sending faxes here and there, and making phone calls to various people. It's not very exciting, but it's still better than rounding because at least I'm doing something.

Monday night, I got to go home around 6 PM, but last night I was on call. That pretty much involves admitting people and answering pages from the nurses for this or that. The bad thing about call for the residents is that not only do we have our own team's patients to worry about, but we also cover the patients for three other teams as well. It's impossible to really know the details about 80 different patients, and the pages keep coming in nonstop all night long. The good thing is that seeing the patients is fun, and now I have two of my own patients to follow. They came into the ER and I did the H & Ps (histories and physicals) before we admitted them. After that, I got to sleep for a few hours.

This morning I saw my two patients again on my own before I met with the team for rounds and presented them to the attending. After my first kind of disastrous surgery call experience, I have gotten better about being more organized when I present. Right before rounds started, I printed out all the notes I had written so that I'd be able to remember the details and all the test results from the ER, along with the most recent lab values and vital signs. My patients are both very sick with multiple diseases, so there is a lot of information to collate. Since we were post-call, we got to leave at 1 PM after we signed out to the other team. 30 hours can seem like an eternity, especially when it's all you can do to keep from nodding off right in front of the patients and the attending while you round the morning after call.

Besides me, the attending, and the senior, there is also an intern on the team. He is really awesome. Since he wants to be a cardiologist, he is very enthusiastic about cards and has been going out of his way to teach me and help me with my notes. I've been doing extra scut for him in return, not only because he's nice and it gives me something to do, but also because I felt sorry for him. I think medicine interns must have the worst job of anyone with an MD. But when he found out that I had to take overnight Q4 call (every fourth night) with him and the senior for my whole rotation, he told me that he felt sorry for me! I hadn't realized that at a lot of other med schools, students aren't required to take overnight Q4 call. That does not thrill me, but at least I get the rest of today off. Tomorrow I will be back in at 7 AM to round on my patients.

Tips for Doing Well in the Surgery Rotation

2008-09-27T18:48:00.000-07:00

I think a lot of people are pretty intimidated by surgery, especially if you don't see yourself as the surgery type. But honestly, surgery is a lot of fun if you work hard and make an effort to learn how to be useful in the OR. Here are my tips for getting more out of your OR experience. Some are only applicable to Case students, but most are applicable to any med students.

1) Learn how to tie knots. I had a terrific attending who let me do a lot in the OR, and she let me do even more once she realized that I had learned how to tie knots. It was terrific. The best thing to do is to get one of the residents to show you and then practice on your own. You can probably get a few suture kits from the OR and use those to practice. Once you get the hang of it, practice using gloves. It's a lot harder tying knots with gloves on because the gloves are kind of slippery, and you can't feel the sutures as well.

2) Be assertive. Surgery is not going to be as much fun if you are more the quiet wallflower type. You have to tell residents and attendings that you want to scrub, suture, etc. and not wait around hoping for them to notice you. I don't consider myself to be particularly quiet, but my attending thought I was anyway because I'm not as forceful as she is. No other preceptor I've ever worked with has said that I need to be more aggressive. I really think it's a surgery thing!

3) Don't take being yelled at personally. It's not just you. Surgeons are tired, overworked, and a bit obsessive compulsive. They love efficiency, and third year med students are the wrench in their works. We're all a little clumsy, so we all get yelled at.

4) Don't fight with scrub nurses. No exceptions on that one. Just don't do it. You've already lost with the very first word out of your mouth. If a scrub nurse tells you that you've contaminated yourself, apologize and ask them what they want you to do. If they tell you to re-scrub, re-gown, and re-glove, do it without arguing. If you don't fight them, they won't make your life nearly as miserable. I had to change a few gloves and gowns, but I never had to re-scrub from scratch.

5) Try to read for half an hour every day. Surgery is one of those rotations that is more a 5-to-9 job than a 9-to-5 job. But you still need to read about your patients, log them, and complete your learning objectives. If you keep up with this regularly, you won't be swamped and panicky at the end of the rotation. I liked the NMS Surgery Casebook and did not use the Lawrence book that was recommended for the rotation at all. I also liked Cope's Early Diagnosis of the Acute Abdomen, which was one of the recommended supplements for the rotation. It's kind of quaintly written, but it's also written in a conversational style. Since most of us were on gen surg or colorectal teams, understanding indications for abdominal surgery is pretty important.

6) Don't be a martyr when preparing for the oral exam. When I first started the rotation, I wanted to prepare for all of the questions by myself. I quickly realized it would be impossible. There just aren't enough hours in a day when you're on surgery. Things went much better after I split the work up with one of the other students on the rotation with me.

7) Try to read about the surgeries before you scrub, including the anatomy you are going to see. This is good for two reasons: one, you will get more out of the surgery if you know what is going on, and two, you will be more prepared if you get pimped. I at least tried to read the appropriate chapter of Surgical Recall before scrubbing for my subspecialty surgeries. For those of you who are at CCF and don't want to buy your own copy, they have one in the library. I checked it out instead of buying it since I was pretty sure I wouldn't be going into surgery.

8) Eat breakfast every morning, especially on OR days. A lot of people try to eek out those last few minutes of sleep and skip breakfast. It's a bad idea. Really. Your chances of passing out will be seriously higher if you skip breakfast. Don't forget that if you're scrubbed in all day, you probably won't be eating lunch, and there's a very real chance you won't be eating dinner, either.

9) Make sure you keep tabs on your patients and know what's going on with them. Check their labs every day and pay attention to anything that is irregular. When you write up your notes, make suggestions for what you think might be wrong and what you think should be done about it. You'll be wrong at least half the time, but it's better to try to figure it out and be wrong than to not try and just look uninterested.

10) Don't despair when the going gets tough. Surgery is physically and mentally difficult, but it's doable. Thousands of other med students have made it though this rotation, and you will, too.

End of Surgery

2008-09-26T18:03:00.000-07:00

I can't believe that my entire surgery rotation is over already. It was way too short. Here I have finally reached the point where I was starting to get the hang of things and enjoy the rotation, and bam, that's it. Time to move on. Apparently I'm not the only one who feels this way, because the new clinical curriculum is going to have more time devoted to surgery.

The rest of this week has been kind of easy and relaxed. On Wednesday, I wanted to scrub in for a vascular surgery. But there were some bigwig visitors from another hospital there, so I got relegated to watching the screen in the control room. The surgery wasn't all that interesting anyway, at least not up until the point where they deployed the stent. That was really cool. The stents are self-expanding. I'm still not totally clear about what they do to get the stent to stay retracted while they're manuevering it, and then to expand once it is in place. But you can actually watch it spring open on the screen.

Afterward, I went to see what my team was doing and find out if my attending wanted me to scrub. They were running late in the OR, so I offered to go round on our patients myself and then present to them. The attending agreed, and I went to collect our patients' labs and check on their progress. This worked out tremendously well. Not only did I help get all of us out earlier by presenting to them in the OR, but she wrote a very good eval for me about the initiative and teamwork I had shown.

The attending has her outpatient surgery day at one of the satellite clinics on Thursdays, so I had a reading day to get ready for my presentation today. I presented on a woman who had a breast lump. There was a mammogram and an ultrasound available, but I couldn't figure out how to get them to open in Epic. It turns out that only some computers on campus have whatever karma is necessary to open those films, and the fellow on my team had one of them. So he helped me get the films open and copied into my presentation, and overall it went well.

Our didactic today was on bariatric surgery, which is cool. But we had already seen a lot of this stuff last year, so it wasn't the most exciting. The afternoon research seminar was even more painful. It was on how to make a good presentation. Why the research curriculum people thought we should cover this topic in our third year of med school is beyond me, since we've been doing research presentations for two years already. I also don't understand the need to beat the topic to death for three straight hours on a Friday afternoon. But no doubt this is why I am not designing medical school curriculums. To make matters even worse, we had a class meeting afterward to teach us how to sign up for electives and advanced rotations. I've already signed up for some of both with no instructions, and it is extremely simple. You go to the online elective catalog, pick out what rotations you want and when you want to take them, and email the list to the registrar. That's seriously all there is to it. (You may have noticed that I feel a bit cranky this afternoon!)

Oral Exam and a Lucky Break

2008-09-23T22:40:00.000-07:00

I spent the weekend studying for my oral exam, which was supposed to be this afternoon at 2:30. My attending let me out of evening rounds early yesterday so that I could study, and she told me not to scrub in this morning either. So I was feeling pretty relaxed because I had so much time, and I even slept in this morning. Then I got a page at 10:30 saying that my examiner wanted to move the oral three hours earlier, in one hour. Crap! That call made me finally start feeling a little stressed, because now I wouldn't be able to get through the whole review in time.

I was cursing myself for not getting up earlier, but it turned out ok. Even though I struggled a little with the first question, I got it in the end with some prompting. The second one I knew cold, and the doc couldn't find anything wrong with my answer to that one. It was kind of hard to concentrate during the exam because his telephone and pager kept going off every other minute. He is a transplant surgeon, and an organ (a liver) was possibly going to arrive this afternoon. First the organ was coming, then it wasn't, then it was again, and finally he told his assistant to contact the patient and get the team and OR set up. He made a comment about all the calls, and I felt bold enough after doing well on the second question to ask him if I could scrub in. He said it would be ok, and to page his assistant in a few hours to find out where and when the surgery would be. Then he said I had passed, and I left to go have lunch. The thought also occurred to me that I shouldn't have asked him to let me scrub for the transplant before checking with my attending. Fortunately, she was excited that I had passed the exam and enthusiastic about me getting the chance to see a transplant, so I didn't get into any trouble for not asking first.

The operation was long and laborious. This time, I was mostly watching and retracting (although I did get to do a little bovieing), but it was totally worth it. It took the team a few hours to remove the patient's old liver. That liver was shrunken, hard, a sort of sickly greenish color, and knobbly all over. (The patient had really bad cirrhosis.) In contrast, the new liver was large, brownish and glistening. Its surface was smooth, and it felt soft and spongy to the touch. Putting in the new liver took several hours also, because all of the hepatic blood vessels had to be anastomosed (connected). Once they were all connected, the surgeon opened the clamps, and blood began to perfuse the new liver. First, the tissue closest to the hepatic artery turned pinkish, and then slowly that pinkish color began to spread like a wave all throughout the organ until the whole thing turned pink. It was so amazingly alive compared to the old liver. Everything had gone well. We scrubbed out at 8:30 while the residents finished suturing.

Tonight I am on call, but I'm not doing too much. I'm tired and not really in the mood to stay up all night. Fortunately, I am here with the same cool resident again, and he didn't mind that I showed up three hours late for call. He also told me it's ok if I leave, and I think I will do that in another hour or two. All in all, this was a pretty awesome day. I don't want to live a surgeon's lifestyle, but I can definitely understand why surgery is so appealing to a lot of people.

More Cool Subspecialty Surgeries

2008-09-19T19:34:00.000-07:00

I've scrubbed in for a lot of cool surgeries in different subspecialties this week. Tuesday it was ortho, as I've already mentioned. Wednesday I scrubbed for a mastectomy. This was a lot more interesting than I expected it to be. The surgeon I scrubbed with does what is called a nipple-sparing mastectomy. Besides him, there is only one other surgeon in the entire country who does this particular procedure.

In a nipple-sparing mastectomy, the surgery team takes out all of the fat and glands from the breast, but they leave behind the skin and nipple. They also remove what are called the sentinel lymph nodes (lymph nodes closest to the breast) from the patient's armpit. This is done instead of taking out all of the lymph nodes in that area. The benefit of taking out fewer lymph nodes is that it decreases the chance that the patient will get really bad edema (swelling) in that arm. Edema can occur because with the armpit lymph nodes gone, fluid tends to back up in the arm with nowhere else to go. It's cool how they find the lymph nodes, too: they inject a blue dye (methylene blue) into the breast, and the dye gets carried out into the lymph nodes under the patient's arm. This dyes the lymph nodes that are closest to the breast a dark blue so that the surgeon can see them. The nodes are pretty small, about the size of a pencil eraser.

The woman can choose either to have implants placed in the breast during the surgery, or use temporary implants so that she can see what she'll look like before having permanent implants put in, or not have any implants at all. Some women choose not to have implants because of all the problems (leakage, immune reactions, more difficulty screening what is left of the breast tissue for cancer, etc.) that can happen with implants.

The main question that occurred to me while I was watching all of this was how they can keep the nipple and skin of the breast from dying. They are removing all of the tissues underneath, so how does the nipple get enough blood supply? Well, amazingly, it does.

Yesterday, I scrubbed for a nose septoplasty with an ENT (ear, nose and throat) attending and his resident. The surgery was cool to see, but I didn't get to do anything since it's all laparoscopic. It's also really tight to be in there around the patient's head with a few other people! ENT is cool, but as you can probably imagine, it's also pretty gross. The attending was surprised that I thought ENT was grosser than colorectal surgery, but I did. Somehow, sinuses full of snot and pus kind of get to me.

This morning, we had our normal surgery and medicine case presentations. I have to present again for surgery next week since there are only two of us in my group on surgery right now, so that kind of sucks. I'm getting a little tired of preparing these presentations. It's a lot of work, especially when you're on a time-intensive rotation like surgery. Afterward, we had a seminar on coughing and shortness of breath. That was pretty good. There were a bunch of cases, and an internist and surgeon went through them with us.

In the afternoon, we had an FCM session about apologizing to patients for medical mistakes. We had to do an exercise where one person pretended to be the doctor who had to explain about a mistake, and the other person pretended to be the patient. I was "lucky" enough to be selected to play the doctor, and I was doing my best to try to explain the mistake (the patient was given an antibiotic she was allergic to) the way I would have really done it. My partner kept laughing every time I looked her in the eye and started talking. After a few false starts like that, she started apologizing to me for not being a good actor, so by then, everyone was laughing. To add insult to injury, one of the faculty came in to tell us that we had standardized patients we could use instead of having a student pretend to be the patient. At that point, we were all hysterical. My classmate told me later that the reason she kept laughing is because I looked so serious. :-P

Next week is my last week on surgery. I just found out that my oral exam will be on Tuesday afternoon, so this is not going to be a weekend of fun and games. Tuesday night is also my last call. Yeah, I really know how to have a good time.

Drunk Driving Aftermath and Total Knee Replacement

2008-09-16T18:49:00.000-07:00

My Saturday call was pretty quiet, so I wound up leaving at 10 PM. I had the same cool senior as last time, and mainly I just ate dinner and hung out with him for a few hours. He had taken some time off before going to med school, and I found out that he had been a chaplain for a few years. That is probably the most interesting thing I have ever heard of someone doing before med school. It's especially interesting that he went from being a chaplain to being a surgeon! Sunday I mainly spent working on the questions for the oral exam. It's going faster now that I've been dividing up the questions with the other surgery students, but sadly I am still not done.

Yesterday, I was in clinic all day with my surgery attending. We spent a couple of hours with one patient who had a very sad story. He was a college kid who was driving drunk on the highway when he lost control of his car and hit a tree at high speed. The airbag deployed and saved his life, but his lower body was crushed. There was a girl riding with him who was killed. We were seeing him because he had become fecally incontinent since the accident. He had to have several tests to measure his anal sphincter function, and at the end, the attending told him that unfortunately, there wasn't anything she could do. The kid didn't say much, but his mom was sobbing. It was really awful on so many levels. Maybe the worst thing is that all of this tragedy was preventable. Now this guy will probably have to spend the rest of his life in a wheelchair, wearing diapers, and living with the knowledge that he killed his girlfriend, all because he made a really dumb decision to get behind the wheel that night.

Today I scrubbed in for an orthopedic surgery. It was a bilateral knee replacement, and it was really cool. The patient couldn't have general anesthesia, so he was awake and talking to the anesthesiologist the whole time. That was kind of weird. But I got to watch a spinal block, which I hadn't ever seen before. It's kind of like a spinal tap, except that instead of withdrawing spinal fluid, the anesthesiologist injected anesthetic. Then the patient was prepped like normal. I mostly watched for the first knee, but I got to do some drilling and cementing for the second knee. At the end, the attending left the intern and me to suture up the patient's knee. It took us a while since neither of us was very experienced, and the anesthesiologist and scrub nurse were kind of getting annoyed with how long we were taking, but we got it done in the end.

I don't really want to be an orthopod, but I can understand the appeal. You get to play with a lot of cool hardware and instruments that don't get used in other surgical fields. It's also very physical work and requires a pretty good understanding of geometry and biomechanics. For any of you readers who ever scrub into an orthopedic surgery, make sure you wear a face shield, because it's messy. Also, you might not want to make a knee replacement the first surgery you see, because it's a lot bloodier than the other surgeries I've scrubbed for. Fair warning!

Finishing My Second Week of Surgery

2008-09-12T19:52:00.000-07:00

The rest of this week has been a lot easier than last week was. Wednesday, I scrubbed into a pediatric hernia surgery. That was an incredibly pleasant experience compared to scrubbing into adult surgeries. The peds OR areas are decorated with cartoon characters and colors instead of being stark and white. The scrub nurses are really nice. (For anyone who has never done a surgery rotation, the phrase "nice scrub nurse" is almost an oxymoron.) I didn't get to do very much besides retract since the patient was a little kid, but it was still a good experience nonetheless.

Yesterday, I lucked out and got a study day because my attending was off doing surgeries at one of the satellite family centers. I'm still working on those surgery prompts for the oral exam, which I have to be ready to take in nine days. But I got a lot done yesterday, because the only clinical thing I had to do was go on rounds in the morning and evening.

I also had to present a patient at morning report today. Since I didn't have a really good surgery case, I decided to present the patient with abdominal pain who I saw on my first call night, the one who turned out not to have a surgical problem at all. The presentation went well, and the surgeon who was leading the discussion wrote me a very complimentary eval. Afterward, we had our medicine presentation, and then our seminar was on diabetes. That was a bit crazy, because the original seminar leader was sick or something and didn't show up. So the block leader led the seminar instead. To her credit, she did a pretty good job, especially considering that she didn't find out she was going to have to do this until the last minute.

This afternoon, we had a research seminar on designing questionnaires. I don't think I'd have liked it even if I wasn't sleep deprived and cranky from being on surgery, but that certainly didn't help. They also made us do this stupid group exercise. All in all, I am really starting to hate these Friday afternoon seminars. I understand that physician scientists need to know things like how to tell if a questionnaire is properly designed. But I still don't think it's necessary to make us sit through three hours of it on a Friday afternoon when it could have been covered in one hour. Plus, I still had to go on evening rounds afterward, so I didn't get much of a break.

Tomorrow night I am on call again with the same senior resident I had call with last time. Amazingly, I am actually looking forward to taking call this time. It doesn't hurt that I'll get to have Sunday off afterward, either. :-)

Dealing with Being Post-Call

2008-09-09T20:17:00.000-07:00

Saturday I came in to round on my patients in the morning, and then I spent most of the day working on my surgery questions for the oral exam. Sunday I did my laundry and all that kind of stuff that is hard to get done while you're on surgery. Later, I went in for my call night, which started at 6 PM. I had a different senior this time because the residents are on a new rotation month now. After we introduced ourselves, he told me that I could do whatever I wanted. I jokingly asked if I could just go home, and he told me, "Go ahead if you want." I have to admit that I was more than a little tempted, but I decided to stick around for a few hours at least. I mean, I was already there anyway, and the administration would probably not be too happy if they found out I had blown off my call completely.

The first page we got was for a patient who had just coded and died in the ICU. The senior had to pronounce him dead. So we went to the ICU, parted the curtains, and there was the patient, lying in bed like any other patient, except that the heart monitor and the respirator were eerily silent. My senior handed me a pair of gloves and told me to feel for a pulse at the patient's wrist. While I was doing that, the senior was feeling for a pulse on the man's other wrist. The patient had obviously just died, because he was still warm. I didn't really feel much of anything, but the senior told me to keep pressing on the man's wrist. He said, "If you wait long enough, you will start to feel a pulse." Sure enough, I did feel one after a minute or so. It was really freaky. He told me, "That's your own pulse you're feeling." Wow. We filled out the patient's paperwork and the senior signed the death certificate. I decided that I was going to hang around some more.

One of the interns was in the surgery resident office when we got back. She got paged a few minutes later, and I went with her to see the patient. This patient was a woman who was post-surgery for breast cancer (lumpectomy). We took her history and did an exam. All of her lymph nodes on that side had been removed, so she had really bad lymphedema (swelling because there are no lymphatic vessels to take the fluid from the tissues back to the blood vessels). Her arm and breast were swollen to the point that they were at least twice the size on that side versus the normal side. Unfortunately, there's not any surgical solution to lymphedema. We had her elevate the arm and told her to keep it elevated. Then we paged the senior to discuss whether the patient needed antibiotics, too. I wrote a note and the intern corrected it and gave me some feedback.

Things slowed down for a while, and I practiced tying knots a little, then just hung out with the senior in the resident office. Around 2 AM, I was getting pretty tired, so I decided to go to bed. I had to get up at 4 AM to pre-round, but at least I got a couple of hours of sleep. I wasn't feeling so hot though. My attending had clinic all day Monday, so I went in for the morning. It felt like the room was spinning, and I was pretty nauseated. I asked one of the nurses if I could lie down for a minute when things got slow, and I managed to doze off a little. My attending didn't realize that I had been on call the night before, so she thought I'd be there in the afternoon, too. I told her that I would stay if she wanted me to, but she said I should go to bed since I was post-call. I didn't need to be told twice.

This morning, I was supposed to scrub in for a vascular surgery, but it got cancelled. So I went and scrubbed in with my regular team, and it was a crazy day. We were in the OR for 12 hours, during which we did four surgeries with no meal breaks. I was really glad I had at least eaten breakfast. Today she let me suture, and I am getting pretty good at it. But now I feel too tired to eat and too hungry to sleep. The one good thing about missing so many meals on surgery is that you don't gain weight.

Here are the answers to a couple of surgery questions that I have been asked. First, yes, it really is possible to doze off in the middle of an operation. Assuming you are just standing there retracting and no one is pimping you, it's quite simple to close your eyes for a few minutes here and there. Second, needing to use the bathroom during the surgery has not been a problem for me so far. I go right before it's time to scrub in, and then since I'm often not eating or drinking anything all day anyway, it hasn't been an issue. I do come out of the OR feeling really parched though. When you first walk into the OR, it's freezing cold. But once you get gowned and gloved and those hot lights are beating down on you, it gets warm enough to make you start sweating. If the patient is being warmed by the anesthesiologist, oh wow, that really gets uncomfortable.

First Call

2008-09-05T21:40:00.000-07:00

I had my first call on Wednesday this week. It was kind of rough, mainly because I felt like a total jerk by the time it was all done. CCF has a night float system, which means that the residents who are here at night get to sleep during the day. However, the students do not get to sleep during the day. So I was in clinic in the morning, in the OR all afternoon, and then on call that night. The senior resident had me go see a consult in the ER who was having abdominal pain. My patient was an elderly man and kind of out of it because he had been given pain medication, but he was still in a lot of pain. I had no idea what was wrong with him based on the history and physical. Really the only thing I could find was that his stomach hurt any time he moved, and there was a huge bruise on the lower part of his stomach where he had been injecting himself with blood thinners.

When I went to present to the senior, I wasn't the most organized. Afterward, I realized that I should have taken notes while I was talking to the patient, because my memory was just shot by that point. Somehow, I muddled through with the resident correcting my presentation every few sentences, and then the resident asked me if I had done a rectal exam. Done a what?!?! He scolded me a little for not having done one. We went to see the patient and he did it himself. The poor patient was in pain every time he had to move, so rolling over for the rectal wasn't exactly a small ordeal. I had spent a couple of hours doing my history and physical, and then the resident poked and prodded the patient for another half hour or so. I still couldn't figure out what was wrong with the patient, so the resident finally told me that the patient had a rectus sheath hematoma. That's basically a fancy name for a big abdominal wall bruise. I found a review article about it, read it, and wrote up my patient log. At that point, it was 2:30 AM, and the resident told me to go to bed.

I was feeling pretty bad about having basically tortured this patient for a couple of hours for something that wasn't even a surgical problem. The building where the call rooms are was completely deserted except for a janitor who was mopping the floor. As I passed by him, he said, "Good night, Doc." That made me feel even worse.

Yesterday morning I was back in the OR with a different attending who was doing a laparoscopic repair of a hernia. The senior on this team was into teaching, and she let me do some suturing. Fortunately, I had been practicing while I was on call and at home. There are some really good websites that have instructions for suturing. My favorite is the site from Boston University. I also got to drive the camera for a while, which is a lot harder than it looks. It was a good experience, but I was feeling kind of sick because I had only gotten about two hours of sleep. But since I was post-call, I got off at noon and could go take a nap. At 5 PM, I met my team for evening rounds, which was incredibly stupid of me. We didn't get done until 9:30, plus my attending gave me three new learning objectives to do. That's what I get for trying to be responsible and part of the team. Sigh.

Today we had another point-counterpoint presentation, this time on the best way to treat atrial fibrillation (quivering of the upper chambers of the heart). I wasn't presenting this time, and it was a lot less fun being in the audience. Afterward, there was a seminar on treating blood clots. In the afternoon, we had another round of meetings with the Block Assessment Team. I can't even put into words how much I hate these stupid, pointless BAT meetings! I was so tired and cranky and not in the mood for this. It was hard to stay awake all morning in class, and then I was sitting around in the libary on my so-called afternoon off, waiting to have a five minute meeting so that the faculty can tell me I'm doing fine so far. Don't even get me going about how they assign the order for our meetings. After the block leader changed the order around for the third time today, we didn't wind up meeting with the BAT in our scheduled order anyway. Stupid, stupid, stupid.

Surgery is Awesome!

2008-09-02T20:28:00.000-07:00

My weekend wasn't very exciting, and I didn't get very many of the questions done. At first I wanted to try to do them all myself, but now I realize that it's impossible. Each question takes me like 3-4 hours, and there are 20 of them. So now the students are working on different questions and sharing our answers.

This morning I got up at 5 AM and went on rounds with the fellow at 6 AM. Then we went to the OR. Today was my first day scrubbing in, and it was just amazing. No one yelled at me for my scrubbing technique, and I muddled through getting gowned and gloved with the scrub nurse's help. Our first case was for a patient who needed part of his colon resected. The surgeon hands me the scalpel and tells me to go ahead and make the incision. After hearing stories from my friends at other schools about how all they did was just hold retractors and get pimped, I was not prepared for this. I didn't even know how to hold the thing! So she showed me, and I muddled through that too, albeit with some comments that I was not carving a turkey. I didn't mind her mocking me a little bit though, because it wasn't malicious. Then she hands me the bovie (an electrocautery instrument--see picture) and tells me to cut through the fascia (layers of connective tissue under the skin). So I did that too.

Next, she and the fellow started working on the colon, and she asked me to hold the small intestines out of the way. While I was doing that, I had some time to just observe everything that was going on in the surgical field. I was watching the arteries pulse all over this patient's abdomen. There were big ones and little ones, all pulsing in unison. It was awesome. Then I noticed that the patient's intestines were moving in my hands. I was watching as they were peristalsing (contracting by segments--this is how the intestines move food through down to the colon), and I could actually feel them moving. It was incredible. I don't think I'll ever forget that feeling for the rest of my life. We closed up the patient and I got to do the staples. That was surprisingly easy and fun to do. Using the surgical stapler is not so different from using a regular desk stapler.

By this point, it was 1 PM and I was so hungry that my stomach felt like it was eating itself. The surgeon turns to me and says that she and the fellow are going to start the next case. Was I doing ok? Of course, I wanted to scrub out and go eat lunch more than just about anything, but how could I do that while she and the fellow kept going? There's no crying in surgery! So I told her that oh, no, I was fine to go for another case. Fortunately, the second case went faster, and by 3 PM, the fellow and I had about 5 minutes to run downstairs to the cafeteria and wolf down a sandwich before we went back for the next case. We did four cases in all, and then we went on evening rounds. The surgeon didn't really pimp me in the OR, but she did pimp me a bit on rounds. It wasn't awful though. I knew some of the questions and didn't know some of them. Overall, this was a very long but good day, and surgery is much cooler than I could have possibly imagined.

Preparing for Inpatient Surgery

2008-08-29T19:29:00.000-07:00

I'm done now with all of the surgery subspecialty outpatient clinics. Since I'm going to be on the colorectal team, I had a half day of general surgery on Wednesday morning. I also had half days of urology, vascular surgery, and pediatric surgery. Most of the general surgery patients I saw were men who needed hernia repairs, really basic bread-and-butter stuff. My urology preceptor was a pediatric urologist, so I saw a bunch of kids with undescended testicles. Just in case any of you are new parents and worried, the testicle will usually come down in the first year or two of the kid's life without requiring surgery. Vascular surgery is really cool. The attending I worked with does 3D imaging of the patient's aorta and other vessels that have aneurysms. (Aneurysms are weaknesses in the blood vessel wall that lead to it expanding, kind of like a balloon. If they get too big, there is a danger that they could burst and quickly kill the patient.) Then he orders grafts that are made in Australia. It takes a few months for them to arrive since each graft is custom-made for that particular patient.

I have this weekend off and should be starting inpatient surgery on Monday. But I lucked out and got the day off for Labor Day since it's the first day for the two of us on this track. The other current surgery students who started the week before us did not get it off. (They are on a different track.) So needless to say, the two of us did not publicize this good fortune. It's not like I'm going to be spending the weekend doing anything fun anyway. We have 20 work-intensive surgery question prompts that we have to prepare for an oral exam at the end of the rotation, and that's what I'm going to spend this weekend doing. I know there won't be a lot of time to work on these prompts once things get going on Tuesday!

Outpatient Surgery and Orientation

2008-08-26T19:29:00.000-07:00

This is my first week of surgery, and I have outpatient subspecialty clinics all week. Starting next week, I will be on inpatient surgery. The rationale for having this outpatient week is that I am supposed to try to scrub in for a surgery in each surgical subspecialty. So far I have done one half day each of orthopedic surgery, breast surgery, and ENT (ear/nose/throat, also called otolaryngology). I also had orientation this morning along with one other student who is starting surgery this week with me.

The ortho clinic was really cool, and the attending spent a lot of time teaching. He had a whole collection of replacement joints. Some were modern, and others were the kind that got used a few decades ago. We also looked at several x-rays, and he showed me what to look for to identify osteoarthritis. I'm not very good at reading x-rays, but even I could see the jagged edges of the cartilage in a patient with severe osteoarthritis. The breast clinic wasn't as exciting. I've already done several breast exams, so there wasn't much new. I did get to see some mammograms. It's hard to see the calcifications if you don't know what you're looking for. ENT was pretty cool, but it's also kind of disgusting. One of the patients had an in-office nose procedure, which I got to watch. Another had a sinus infection. We put a scope up his nose into the infected sinus, and when I looked through it, I could see all the green, infected mucus up there. Wow, that was gross. No wonder that patient was in pain!

The orientation was this morning. It wasn't all that exciting. First, we saw a video that I swear was made in the 1970s based on the clothing and hair styles. It was describing sterile technique and the importance of sterility in the operating room (OR). Then we got a tour of the ORs, and there are lots of them. There is also a stairway I didn't know about until today that leads from outside the ORs straight down to the cafeteria. That's a useful stairway to know about! Then we were given scrubs and lockers up in the ORs. Unfortunately, we have to share them with other people. Seeing the ORs again has gotten me excited for next week. I'm a bit nervous too, because surgery is so different than anything else I've done since I started med school. But I think this is going to be a very interesting month.

End of Outpatient Medicine

2008-08-22T19:28:00.000-07:00

We had another P/CP today on gastroesophageal reflux disease (GERD). It's a lot easier participating in these talks as part of the audience instead of one of the speakers, but it's a lot less fun. Basically, this was another surgical treatment versus medical treatment case. After the debate, we had a seminar on dysphagia (difficulty swallowing) and hematemesis (throwing up blood). It's not the most appetizing discussion to have right before lunch, but it was a pretty good seminar. In the afternoon, we had an FCM session on empathy. We were asked to read a couple of articles about doctors who had become patients and found themselves treated without much empathy. We also had to write a brief essay about an example we saw from our rotations where a doctor did not treat the patient with empathy. I wrote about the GI doctor I worked with last week who wouldn't stop to answer any of the patient's husband's questions.

I'm done now with outpatient medicine. Cards was a lot better than GI, but I still am glad that this rotation is over and ready to start something new. Monday I start surgery. I will have a week of outpatient clinics, then four weeks of inpatient surgery on the colorectal team. This is with the same surgeon who evaluated my P/CP debate last week. The word is that she loves to teach, and the med students get to do a lot on her service. I hope that's true!

Outpatient Medicine and Cards

2008-08-19T18:20:00.000-07:00

This week is my last week of outpatient medicine. I still have general medicine clinic in the mornings, but now my afternoon specialty outpatient clinics are in cardiology. Many of the patients are here to follow up for pacemaker placements or MIs (heart attacks). But I had one patient whose cardiac problems were at least in part due to psychiatric problems. She told me that she measures her blood pressure every hour or two, at least a dozen times a day. She always brings her home cuff and the meds with her to work so she could take both all day long. She was worried because her pressure is always high, and she takes extra blood pressure meds whenever it's too high. The problem now is that sometimes she was getting dizzy and feeling like she might faint.

I wasn't quite sure what to do. Usually, we can't get patients with high blood pressure to take their blood pressures and meds consistently. This was the first time I had seen a patient who was massively overdoing the monitoring and taking too much medication! She had kept a thorough record of every reading from the past month, and not even one of her measurements was above normal (120/80). So I explained all of this to the attending, and then we went in to see the patient. The attending explained to her that she shouldn't take her blood pressure more than once or twice a day at most, because worrying so much about her blood pressure was probably making it higher. He also told her not to take more of the meds than had been prescribed. I could see that the patient was skeptical though. Now that I'm thinking about it, we should have probably referred her to psych, because she's obviously obsessive-compulsive enough that it's affecting her quality of life.

Surviving GI and Point/Counterpoint

2008-08-15T17:25:00.000-07:00

This has been a rough week. Wednesday afternoon, things started out well. I had a preceptor who seemed to really like teaching. He spent a lot of time with me going over the differential and treatment for my patient's disease. But then when we went into the room to talk to the patient, the doc started talking at her about treatment options and didn't bother answering any questions or explaining anything. She sat stolidly and said nothing, while her anxious husband looked at me and pantomimed what he thought the doctor was saying. I tried to pantomime back, but it was an awkward and embarrassing experience. After the doc and I left the room, he told me not to bother submitting an eval, because he wasn't going to fill it out anyway. Of course that annoyed me, but I felt a lot worse about what had happened in the exam room. When the doc dismissed me for the day, I left by a side entrance because I just didn't feel like I could face the patient and her husband.

As bad as that experience was, yesterday took the prize. It turns out that the doc I was supposed to work with had cancelled clinic for the day, but no one had bothered to tell me. While I was hanging out once again in the hallway, I struck up a conversation with a patient and his wife. This happened because I had gotten my white coat caught on the door as I was going out of the administrator's office, and this patient started laughing at me. I thanked him and offered to do an encore. The next thing I knew, I was sitting with him and his wife in the hallway, and the patient was telling me all about his GI issues. I figured since I had gotten his whole history anyway, I might as well get some credit for it. So I asked him who his doctor was, got his doc's permission to see him officially, and went on from there. That doc was really awesome. He went out of his way to make the patient feel comfortable, and he spent time teaching me as well.

Today we didn't have morning report because we had a surgery/medicine debate (called Point/Counterpoint or P/CP) about the best treatment for ulcerative colitis (UC). UC is an inflammatory bowel disease similar to Crohn's disease, but it mainly affects the colon. There were four of us who participated. We were given a patient scenario and then assigned to take sides. Two people discussed the basic science behind the medicine and surgery options, and the other two debated the actual treatment options. I was assigned to advocate for surgery to remove the patient's colon. Apparently most people in the past have debated with powerpoints, but I didn't want to do that. What kind of passion can you show with your audience staring at a powerpoint? So I decided to do my presentation with just a page of notes to jog my memory. The surgeon who was in charge of the debate snapped at us when she heard that my partner and I hadn't made powerpoints. But when I got up there, I really did my best to make the pro-surgery case. Out of the corner of my eye, I could see the surgeon furiously scribbling notes the whole time I was talking. When I was done, she didn't say a word to me. She just told the medicine people to come up there to present. That was how I knew she thought I had done a good job.

After P/CP, this same surgeon gave us a seminar on anal diseases. Some of the more interesting things I learned were that sitting too long on the toilet increases the chance of getting a rectal prolapse, and that hemorrhoids are only painful if they're external. That has to do with the nerve supply to the anus, which is different than the nerve supply to the rectum. I also learned that everyone has hemorrhoids, because hemorrhoids are just veins that drain the anus and rectum. The last thing I learned is kind of the stuff of nightmares, and that is about the existence of anal fissures. Wow, talk about a disease I hope I never see, let alone experience....

My last class today was POD, aka ARM. This class is incredibly painful. Picture this: it's Friday afternoon, you're exhausted from the whole week, and now you have to sit through a three hour seminar on how to write abstracts for scientific papers. The worst part was when they broke us up into groups, and we had to write an abstract on a project that we basically knew nothing about. All in all, it was the perfect rotten ending for a generally bad week.

Outpatient Medicine and GI

2008-08-12T17:57:00.000-07:00

The bronch I was supposed to see yesterday wound up getting cancelled, which was disappointing for me--I'm sure my patient was relieved though. This week, I still have general medicine clinics in the mornings and specialty clinics in the afternoons. General medicine clinic has been very slow so far. For some reason, a lot of the patients are no-showing. On the bright side, it gives me a lot of time to write my patient notes and get my logs done during clinic, and that means I have my lunch hours free (and sometimes even get to go to lunch early!).

I have GI clinic in the afternoons this week. So far that has not been the greatest experience. Yesterday, my preceptor showed up to clinic an hour and a half late. I only got to see one of his patients because after a while I got tired of waiting for him and just went to see the patient on my own. He showed up when I was done with the interview and about to start the exam, and he took over from there. After that I pretty much just shadowed him all afternoon. It's a good thing I went and saw the patient when I did, because otherwise I probably wouldn't have gotten to do anything on my own. I was also annoyed because he kept me until 6 PM for no good reason. One of his patients was late and showed up at 4:45 PM. It was only supposed to be a 15 minute appointment, so we should have been done on time or at most been 15 or 20 minutes late. Instead, he spent 45 minutes with that patient and then made me stay an extra half hour afterward so that he could tell me about how stressful his job was. I am supposed to work with him again on Thursday. Wow, can't wait.

My GI preceptor today was a little better, but I still had a kind of strange experience. He sent me in to see a patient with one of the fellows. The fellow was really nice and well-intentioned. He was demonstrating how he does the complete abdominal exam for me. Considering that I got no teaching yesterday, I was very appreciative that he was making this effort. But he was basically ignoring the patient. After some time, the patient made a kind of funny noise, and the fellow asked her if anything was wrong. The patient said, "I feel like I'm some kind of guinea pig." The fellow started stammering that I am a med student, and he was showing me how to do the exam so that I could learn, etc. etc. I turned to the patient, who was a graduate student, and introduced myself. Then I asked her what she was studying. After we chatted for a few minutes, she was fine, and the fellow and I continued with the exam. When we came out of the room, he kind of laughed and shrugged about what had just happened.

I was pretty surprised he still didn't seem to realize that the patient just wanted us to include her in the conversation. I guess his med school didn't make him take any classes to learn how to communicate with patients. Maybe all those communication classes that we had to take over the last two years weren't so stupid and pointless after all!

One Quarter Done with Block One

2008-08-08T17:44:00.000-07:00

I am officially 1/4 of the way done with this entire block as of today. It was a good week up until today. I spent the mornings in general IM clinic, which is pretty much like the longitudinal clinics we did last year. The main difference is that this year there is a lot more focus on differentials and treatment instead of physical diagnosis skills. I spent all of the afternoons in the pulm clinics and that was really cool. After two days of lung transplant clinic, I had one day of asthma clinic and then a patient yesterday who was just really cool and interesting. He needs a bronchoscopy on Monday morning, so I am going to go for that. The patient himself asked if I could come, which was a real compliment as far as I am concerned.

Today we had classes in the morning and then our first Block Assessment Team (BAT) meetings in the afternoon. The lecture was on wound healing and it was ok. It was nice not having class in the afternoon, but those BAT meetings are pretty ridiculous. We had to come up with a learning plan based on our evals so far by Wednesday, which seems like a sensible requirement. We were also required to fill out evals on the preceptors and on the rotations we've completed so far, which seems reasonable enough as well. Of course, the stupid eval system locked all of us out and there was a whole to-do for us to get the evals done by noon yesterday like we were supposed to. But in the end, I got them all done in time by working on them during clinic yesterday morning.

Next, some mysterious combination of the order we filled out the evals, where our last name falls in the alphabet, and the alignment of Venus with Mars was used to generate an order for when each of us would meet with the BAT. This order was guarded like Fort Knox and only revealed to us on the morning of the BAT meetings (this morning). The order was also changed at least two or three times during the course of the morning, thus making it impossible to plan anything for the entire afternoon. So basically, what we did all this afternoon is hang around in the library complaining about how stupid this system was while awaiting our turns to meet with the BAT.

The BAT has one family med doc, one internal med doc, and one surgeon on it, although my team's surgeon was in the OR and couldn't come. When you go in to meet with them, they have copies of your evals and your learning plan. The meeting lasts about five minutes, most of which is spent chatting about nothing in particular. Then they told me that it seems like everything is going well so far, and keep up the good work. I went out and told the next student it was his turn, and that was it. So much for my afternoon off.

Outpatient Medicine and Pulmonology

2008-08-05T18:08:00.000-07:00

For the next three weeks, I will be doing general outpatient medicine in the mornings, and then specialty clinics in the afternoons. The general medicine clinics are exactly like the longitudinal clinics that I was doing for the past two years on Tuesday afternoons. In fact, I even spent yesterday morning in the exact same clinic that I worked in first and second years (though not with the same preceptor, because my old preceptor is now out at one of the suburban satellite centers). The general medicine clinics seem downright slow after the hectic bustle of the family medicine clinics. I am only seeing two, maybe three patients each half day, and I never have trouble finishing my notes or logs before lunch. To be fair though, the IM department cuts back the schedule so that the preceptors have more time to teach us, and the patients tend to be older and have more complex problems compared to the typical family medicine patients.

My specialty clinics for this week are all with pulmonologists. These are lung specialists. It's a really cool and interesting specialty. I spent the past two afternoons working with people who evaluate patients for lung transplants. Most of the patients have chronic obstructive pulmonary disease (emphysema) due to having smoked for a few dozen pack-years. (A pack-year is equivalent to 365 packs of cigarettes, or one pack of cigarettes per day for a year. So someone who smokes two packs per day is actually accruing TWO pack-years in a year.) There are a lot of factors that go into deciding whether to list someone for a lung transplant. First of all, the patient has to be sick enough to need a new lung (or pair of lungs), but not too sick to perform the surgery. Second, there are many psychosocial factors that come into play. If the patient is still smoking or doesn't have enough psychiatric or social stability to comply with the demanding anti-rejection regimen that they will need to take for the rest of their life, they won't be eligible for the transplant.

I learned several interesting things from the past two days. One is that the Cleveland Clinic performs the second largest number of lung transplants in the country. (Interestingly, the preceptor wasn't sure who performs the most!) Another is that Cleveland Clinic operates on much sicker patients than most other centers do. For example, one of the restrictions for lung transplants is age, but some of the patients who have received lungs here are older than the upper limit. The last thing I took away from these past two days is a strong reminder of the importance of talking to patients who smoke about quitting in the general medicine clinics. The COPD patients have to have a really awful quality of life by the time they are sick enough to merit being listed for a transplant. They're in wheelchairs and have to be on oxygen all the time. They can barely speak one sentence without getting short of breath. And all of this suffering is for what, exactly? It is sickening to see teenagers or young adults smoking and know that in a few decades, they could end up in this exact same pulmonology office with a life-threatening illness that is entirely preventable.

Tips for Doing Well in the Family Medicine Rotation

2008-08-03T12:02:00.000-07:00

Here are my tips for doing well in Family Medicine.

1) Be enthusiastic. This is good advice for every rotation actually, but especially in the outpatient clinic. You might feel like you have no intention of going into family medicine (which I don't), but that doesn't mean you can't learn something from the experience or that it isn't important.

2) Read about your patients. Even though your contacts with most of the patients will be short-term (just one visit) because the rotation is so short, you should still read up on the patients and learn more about their diseases. Discuss what you read with your preceptors.

3) Be on time. This should be an obvious thing, so don't be "that student". You'll be fine if you always keep in mind that it is ok for you to wait half an hour for the attending to show up, but the opposite is not true! ;-)

4) Keep up with your logs. You should write your H & Ps and fill out your logs every day (every half day if possible). Yeah, it sucks spending your lunch hour writing logs and H & Ps. But you see so many patients in the family medicine clinic (I'd usually see about 8 per day on average) that there is just no possible way that you will remember what you saw or did if you don't write the notes as quickly as possible. Plus, if you get all of the notes done while you're in clinic, you won't have to write them at home.

5) Read a family medicine book. The book that was suggested for this rotation wasn't very helpful, in my opinion. It's too long to possibly get through during a three week rotation. Get Case Files: Family Medicine instead and read it cover to cover. That's definitely doable in three weeks.

6) Submit EVERY log for assessment. Some preceptors won't write you an eval. If you submit every log, you will have no problem getting enough evals for the rotation. Just be sure to batch them each half day so that the preceptor isn't getting like four different eval requests per day.

7) Any time a preceptor asks, "Hey, would you like to do....?" always say yes. Stay the extra half hour, do the extra Pap smear, interview the extra patient. The more interest you show in learning, the more willing the preceptor will be to teach you something interesting.

8) Be nice to the nurses and MAs. Yes, they have been in medicine way longer than you have. Yes, they do know more about clinical stuff than you do. Yes, they will talk about you behind your back if you're an arrogant idiot. I was hearing stories about previous med students who are long done with their residencies by now....assuming that they made it through the rest of their third years!

9) Work your way into the rooms one baby step at a time. Sometimes you may run into patients who don't want to see a med student. What you should do is ask them if you can just talk to them for a couple of minutes to get their meds or find out why they came in today. You can even point out that it will speed things up since you can put their info into the computer for the doctor. Once they have been talking to you for a while and you have had a chance to build up some rapport, you can then ask them to let you listen to their heart and lungs. While they're on the exam table, you can throw in an HEENT exam or an abdominal exam if appropriate. This strategy worked for me every single time. I never had a patient refuse to let me talk to them "just for a couple of minutes," and I never walked out of the room without doing a focused physical exam. The key is that you need to project an attitude of confidence and humility at the same time.

10) Even if you hate family medicine, look at the bright side. It's only a few weeks, and there are no weekends or calls. You're totally going to miss this rotation once you start slaving away 80 hours per week on one of the inpatient services!

First Presentation

2008-08-01T22:02:00.000-07:00

I did my first presentation today, and it went well. We wound up discussing the patient's psychosocial issues and how they could be contributing to her problems with headaches. It's interesting that so many people have these nonspecific complaints (headaches, stomach aches, muscle and joint aches). They go to multiple doctors and no one can figure out what is wrong with them. Maybe they have some random degenerative changes on an x-ray that are related to their pain, and maybe those changes are just coincidental. It's tough to know. But regardless, there are a lot of depressed, anxious, and stressed people out there, and it's important to ask people about their moods and stress levels. You cannot be in good physical health if you are not also in good psychological health.

First Rotation Done

2008-07-31T16:31:00.000-07:00

Today was my last day of Family Medicine. I can't believe how fast these three weeks have gone by. I went around to thank all of the doctors and staff and to say good-bye, and they were amazed at how fast the time went too. I am going to come back this winter for a physical, though. It turns out that the Cleveland Clinic doctors are on the new Student Health plan that we have through Case this year. (This is the third insurance company that I've had since starting medical school, which is a whole other nuisance, but I won't get into that now.)

Tomorrow we have didactics. I'll be presenting one of my patients for the IM/FM morning report, and the group will be going over the differential diagnosis for headaches. I chose this patient to present because we haven't gone over the differential for headaches yet, and I thought her case had some interesting psychosocial issues that could be contributing to the problem. After that we will have a clinical seminar about chest pain, and I have the POD research class (I still can't get used to calling it ARM) in the afternoon. So it's going to be a long day, because the third year POD/ARM class is three hours long and we have a class meeting after that. Yikes. 7AM to 5PM with an hour off for lunch is a lot of time to spend in the classroom. At a school like CCLCM, a full day of classes ought to just about qualify as treason. I mean, one of the reasons that I came to this school was so that I wouldn't have to spend all day in classes!

End of Second Week

2008-07-25T14:32:00.000-07:00

I'm done now with my second week of family med, and the time is really flying. I am still having a great time. You never know what you're going to see when you come into the clinic. Yesterday I got to observe and help a bit with a minor outpatient surgery. I also met a really fascinating patient who survived pancreatic cancer. The coolest part of his story is that the cancer was found incidentally when he participated in a research study that involved imaging his abdomen. He was extremely lucky that it was found so early, because pancreatic cancer is often too advanced to be cured by the time it becomes symptomatic.

Today we had classes. Like I said before, there is never clinic on Fridays unless you are unlucky enough to have call Friday night on one of the inpatient services. Again, we had a surgery patient presentation, then an IM patient presentation. For both cases, we went through the differential and talked about what studies to order to figure out how to narrow the differential. We never did figure out what was wrong with the IM patient, but that's ok. None of the docs who were caring for this patient figured it out either. After that we had a clinical rounds session on abdominal pain led by two surgeons. We didn't get through more than about half of the cases, but I can see now why the surgeon said that he likes abdominal pain so much. There is a huge differential, especially if the patient is female and of childbearing age. The surgeons ran over, but we had to stay afterward for a path presentation on appendicitis. I was having a very hard time concentrating by this point, and the UP students were upset because they had to get back to Case by noon for an orientation and it made them late. Somehow, we got this whole afternoon off, so I had plenty of time to run all of the errands that I needed to do.

Finally Got My Step 1 Score

2008-07-23T17:25:00.000-07:00

I didn't sleep very well at all last night. I kept waking up at least once every hour, and I was having these totally bizarre dreams. In one of them, I had gotten a 34 on the MCAT, but it was a 15 VR, 4 PS, and 7 BS. (Note: VR = verbal reasoning, PS = physical science, BS = biological science.) I was worried that I wouldn't get into medical school because of the 4 in PS. (For the record, I know that these subscores only add up to 26, but somehow they added up to 34 in my dream!) In another dream, I was washing my favorite pet cat, now deceased. I had to wash him a little at a time so that he wouldn't struggle while I was bathing him. Because of this, it took me several hours to wash the whole cat. When I was finally done, he was emanating a soft, whitish light. People were crowding around and commenting about how silky and shiny his coat was.

Once my alarm finally went off at 5:20 AM, I got up and went to the computer. I had left it on all night so that I could check for my score as soon as I woke up. My heart was pounding when I logged into the NBME website and saw that the score report was indeed there. I opened it up, and the first thing I saw was the word, "PASS." This caused an immediate resolution of my palpitations (pounding heart) and tachypnea (faster than normal breathing). Then I scrolled down a little farther and saw my actual scores. Total, utter relief. I have been trying so hard for the past three weeks not to think about the USMLE that I hadn't even realized how anxious I was about it subconsciously. I feel like such a huge weight has been lifted off me. I know that this one test score is not the end-all, be-all of residency applications. But I am just relieved to know that if I don't get the residency of my dreams, it won't be because I bombed Step 1.

The score report breaks down your performance by subject area, just like the practice tests I took did. Interestingly, my best subject on Step 1 was micro/immuno, of all things. My worst? Yeah, it was anatomy. No surprise there. :-P

Waiting on my Step 1 Score

2008-07-22T16:37:00.000-07:00

Today is Tuesday, and the next batch of Step 1 scores should be coming out tonight at midnight. It has been exactly three weeks since I took the test, so it's possible that mine will come out tonight. I'm hoping it will, but I'm also trying not to get my hopes up too much, if that makes sense. At this point, I really just want to know how I did so that I can make whatever plans I need to retake, or study my butt off for Step 2, or plan the celebration, or whatever.

Yesterday, I had clinic in the morning and then another anatomy session on the extremities and pelvis in the afternoon. I was kind of annoyed about having to come all the way downtown to Main Campus for a 1.5 hour anatomy session. But it was required, so I went. Actually, it was really good. These ortho residents were much nicer about pimping us gently than the thoracic surgery residents were last week. The only bad thing was that the cadaver with the arm dissection was kind of sick looking, mainly because of how the skin was peeling off. It made me feel a little nauseated, and I had to take a quick break.

The preceptor I was supposed to work with this morning isn't here this week, so I wound up spending the whole day working with my afternoon preceptor. I haven't worked with him before, but he's pretty cool too. All the family docs have been cool. I screwed up a Pap smear today, mainly because I still don't have the knack of using these plastic speculums. I always have a hard time finding the cervix with them. Plus, this patient had a lot of discharge, and it was hard for me to see what I was doing. On the bright side, it looks like I'll be getting plenty of practice. There is another Pap on the schedule for my morning preceptor tomorrow. I definitely need to work on the neuro and musculoskeletal exams some more also. The doc today loaned me a physical diagnosis book that goes over these exams and told me to practice at home. It's a good book, actually, because it takes you through the exams step by step. Maybe this weekend I will talk someone into letting me practice on them.

Friday Didactics

2008-07-18T14:38:00.000-07:00

The last couple of days have been pretty crazy, but I'm really enjoying my family med rotation. The preceptors are really into teaching, the nurses are encouraging, and the patients have been a varied and interesting bunch. They've also been super about letting me interview and examine them. I think the key is to start by first asking the patient if they mind talking to you for a few minutes. I've never had a patient tell me no. What better thing do they have to do while they wait on the doctor anyway? Asking if you can talk to them first gives you a chance to build up enough rapport with the person to then ask if they'd mind letting you examine them. I've never had a patient refuse the exam afterward either, even after I've been asking them detailed questions about their sex lives or drug use.

Today I had class all day instead of clinic, and this will be the schedule for every Friday throughout the block. We started at 7 AM with a surgery morning report. One of the students in my group who is doing his surgery rotation right now presented a patient, and the group went through a differential, talked about what tests we should order, and evaluated the results. I didn't really know what I was doing a lot of the time, but it was fun to try to come up with a diagnosis and plan anyway. Afterward, one of the students on internal med presented a patient, and we did the same thing for the IM patient. The IM morning report ended at 9 AM, and then we went through two hours of acute renal failure cases. This was a seminar led by one of the internists, and it was a really good review of the material that we had covered back in May.

There is a huge difference in how the surgeons run their morning report versus how the internists run theirs. Surgeons are much more formal and want everything done a certain way. The preceptor went around the table and asked everyone to answer a question. (I had to interpret the blood test results.) The internist, on the other hand, was much more laid back and informal. Unlike the surgery presentations, which have to be done with powerpoint, the internal med presentation was more like a group discussion. People could jump in and make comments or suggestions whenever they wanted instead of having to wait to be called on by the preceptor. I can see pros and cons to both methods. I like how organized and efficient the surgeons are, but at the same time, they don't seem to have as much room for individuality and creativity as the internists do.

This year, CCLCM has a new buddy program to pair up first years with upperclassmen. I went for lunch with my buddy, and we talked for about an hour until I had to go for my FCM class. Yes, FCM does continue on even after second year. The third year FCM class alternates with the third year POD class. (Note: POD is actually called ARM now.) We have all new groups for FCM that I think will stay together for the next two years. The groups are a mixture of third and fourth years. The thought had occurred to me last year that it would be interesting to have mixed-class PBL sessions. This isn't exactly the same thing, but now I'll have a chance to see what mixed groups are like. Most of the session was in a big group. We were asked to write a paragraph about one of our experiences at the end of it, and then several of us read our paragraphs out loud. I wrote mine about the last patient I saw at the end of second year. That was the one where I picked up an MI by going through the review of systems, which is the kind of experience that tends to make a lasting impression on you.

First Day of Family Medicine Rotation

2008-07-15T19:14:00.000-07:00

I had my first day of family medicine clinic today, and it was terrific. I'm at Beachwood Family Health Center, which is one of the CCF suburban family health centers. I did two half-days with two different preceptors: one from 8 AM-12 PM, and then again from 1 PM-5:30 PM. Unlike the IM clinic I worked in for the last two years, the family med docs don't cut back their patient schedule to accomodate the medical students. So there were at least a dozen patients on the schedule for each half day, which is twice as many as there are in the IM clinics. Today I saw seven patients on my own, presented them all to my preceptors, wrote SOAP notes on each one, and logged them all. I also went into the rooms with my preceptors for three or four other patients.

I had expected family med to be fairly monotonous after hearing some of my classmates' experiences with their suburban longitudinal clinics last year, but my patients were surprisingly diverse and interesting. The very first patient I saw had been diagnosed by a specialist with an extremely rare disease that the doc had never even heard of before. I knew what the disease was, but only because I just took Step 1 and it was one of those ostensibly pointless things to memorize in First Aid (the Step 1 review book). Now I'm glad that I learned that info! After that, we had to send the second patient for an immediate specialist consult due to concerns that what she thought was a minor problem might be a medical emergency. (This turned out to be a false alarm, fortunately.) The rest of the patients weren't quite as exciting as these two, but they were still a varied lot, from kids with sports injuries to elderly people with twelve different comorbidities and two pages worth of medications. All in all, it was a really good day, and I'm excited about going back tomorrow.

CCF Core I Orientation

2008-07-14T18:04:00.000-07:00

Today was technically the first day of my Core I rotation, but it was another orientation day. For some reason, we had to be at the Clinic at 7 AM. First, the faculty who are running Core I told us about each rotation in the block. These include family medicine, outpatient internal medicine (IM), surgery, and inpatient IM. I will be starting my actual rotation (family medicine) in the morning. Then the IT people taught the UP students how to use our portal, and one of the librarians told them about the CCF library resources.

We were finished around 10:30 AM, and then we had to wait until our anatomy session began at 3 PM. I spent the time working on my schedule for the winter block, which will begin in November. It's a good thing that I started planning my schedule this early, because it turns out that the block that runs during Christmas and New Years isn't a four week block for Case. So now I'm going to do my research month in December, after I do my geriatrics rotation in November. Have I mentioned lately how difficult this clinical block system makes scheduling electives and other rotations?

The anatomy session was really good. There were only 14 of us, so we were in really small groups for our prosection stations. This was like a normal anatomy seminar for us, but it was a new experience for the UP students. (They do traditional dissection of embalmed bodies.) The UP students in my group seemed to like the prosections. I had spent some time over the weekend reviewing the anatomy of the neck, thorax, and abdomen, but I still am going to need a lot more review before I'm surgery-ready. We have one more of these anatomy sessions next week to go over the limbs and pelvis.

My schedule for Core I is the following: three weeks of family medicine, then three weeks of outpatient IM, followed by five weeks of surgery, and ending with five weeks of inpatient IM. I will be out at Beachwood for my family medicine rotation. Then I come back to the main campus for my outpatient IM, which consists of general IM clinics in the morning and specialty clinics in the afternoon. My three specialty clinics are a week each of outpatient pulmonary medicine, gastroenterology, and cardiology. My first week of surgery will be outpatient specialty clinics as well, and then I have four weeks of inpatient surgery where I will be assigned to one of the surgery services. For inpatient IM, I will have two or three weeks of general inpatient IM followed by two or three weeks of inpatient cardiology. I'm really looking forward to that last bit, because cardiology at CCF is just awesome.

Bridge Week Day 4

2008-07-11T16:06:00.000-07:00

Today was the last day of Bridge Week. We had to come in at 7:30 AM to take a practice Step 2 test for five hours. Taking a practice Step 2 test a week and a half after I took Step 1 (and before I have even done a single rotation!) did not exactly thrill me, but I have to admit that I was curious about what the questions would be like. That's why I stayed the entire five hours and tried to do my best to answer the questions, even though the temptation to mark them all with "As" did cross my mind a few times. I was surprised to find that the test was remarkably doable. I knew the answers to quite a few questions. I'm not saying that I passed necessarily (we'll find out in a couple of months), but I don't think I totally embarrassed myself, either. We have to take three more of these exams: one after Core I, one after Core II, and then one more that we schedule on our own with the administration staff.

In the afternoon, I ordered some books for my rotations, and I registered for two of the electives that I'll be doing at CCF this winter. It turns out that we are allowed to do some of the advanced core rotations with only Core I as a pre-req after all. So I will be doing my geriatrics core rotation this winter. I wasn't expecting to be able to get it done before I take Step 2 for real, so this is a welcome surprise.

Bridge Week Day 3

2008-07-10T16:23:00.000-07:00

Today was a long day of hurry up and wait. We had to be at CCLCM by 7 AM, but it was mainly so that the UP students who are rotating at the Clinic could get their IDs, parking assignments, and white coats. I did get two sets of scrubs that I don't really need, and then three of my classmates and I went for breakfast. We spent the rest of the morning learning how to use EpicCare. This is the Clinic's electronic medical record, which we've been using for the past year in our longitudinal clinics. To be fair, I did learn how to do some things that I didn't already know how to do, but all in all, this morning left me feeling kind of grumpy about having to get up so early for not much value in return. At least the power was back on in the Education Building when we got there this morning.

The afternoon session was better. We got to skip the first hour, which was about the grading policy for the UP students. (The CCLCM students don't get graded, although we do get evaluations.) Afterward, we had a session to learn how to use the Clinical Assessment System (CAS) to log our patients during rotation and research blocks. I was playing around with it later, and amazingly, it's extremely easy to use. It will allow me to document all of my clinical experiences so that I can keep track of how many patients I see with various diseases, procedures I perform, and so on. We also use it to submit forms for the faculty and housestaff to evaluate us. The last event was a student panel with half a dozen fourth years from the UP. About the best advice that I heard today was to treat every rotation as if it were the specialty that I was planning to enter. I thought that was very good advice.

Bridge Week Day 2

2008-07-09T17:24:00.000-07:00

We had to go back to the Sim Center this morning for another four-hour session. Again, we were divided into four groups and we went to four different stations for an hour each. The first station was to practice presenting a patient to an attending. Of course, we all suck at it, but I got the message that we'll get very good at doing this in short order.

The second station was to start IVs and draw blood. It was run by the same anesthesiologist who taught us acid-base first and second year, the one who is really awesome. It was kind of a weird station because we had these rubber mannequin arms with veins, and we were supposed to put the venipuncture needles into the veins. When you got it in right, you would see a little bit of fake blood come up into the needle. What was funniest is how PC the whole thing was. There were some white (Caucasian) mannequin arms, and also some black arms.

The third station was to practice the female exam and deliver a baby. Again, this was all done with rubber bodies. Delivering the rubber baby from the rubber pelvis (complete with a rubber placenta that could be stuck to the inside of the uterus with velcro) was pretty bizarre! Then we had foam breasts with lumps in them, and we practiced doing the breast exam on those. I did a lot of breast exams in clinic with my preceptor, and these foam breasts aren't anything like real breasts! We also did a practice pelvic exam on, you guessed it, a rubber woman's pelvis. The os was amazingly easy to find, much easier than on a real woman. Each time I have done this exam for real, I have never been able to palpate the ovaries, and today was no different. But at least this time I had a good excuse, because the rubber pelvis didn't have any ovaries, just a uterus. :-P

The last station was for the male exam. We did practice rectals on rubber male rear ends. There were four of them set up, one with a normal prostate, one with benign prostatic hyperplasia, one with an early tumor (which I wouldn't have been able to palpate if I hadn't known it was there), and one with an advanced tumor (which was so obvious by palpation that the only way you could miss it was by not doing the rectal exam at all). Then we practiced catheterizing rubber male and female urethras. When you got the catheter in far enough, it would dribble fake urine. Since men have a long urethra, you really have to push the catheter a long way to get to the bladder. I went to catheterize the female model afterward, and got the catheter into the bladder immediately. This is the difference between having a 20 cm long urethra (men) versus a 4 cm long urethra (women).

This was the end of our session at the Sim Center. We went back to the Clinic, and a bunch of us had lunch with the new first years. The power was out in the Education building (I guess because of the storm last night), so it was really hot, humid, stinky, and dark inside. After the lunch, the first years went off to do whatever they had to do, and we had a class meeting about rotation and research requirements. I have already met with Dean Franco about how I want to schedule my last three years of med school, and she thought my plan was fine. My research PI was also ok with it. I'll mention more about it in another post, but briefly, I will be alternating back and forth between clinics and research over the next three years.

After the class meeting, we were done for the day. I went over to Case to get my PPD test done, then went home. I have to be back at 7 AM tomorrow morning, so this is going to be it for tonight.

Bridge Week Day 1

2008-07-08T17:17:00.001-07:00

Today was the first day of the clinical part of my third year. This week is Bridge Week for Case UP and CCLCM students who are doing clinical rotations this year. We only had a half-day of orientation today, although I went over to school early to do some required online modules and run other errands. Tomorrow I absolutely must get over to the Case student health center to get my PPD (tuberculosis skin test) done. I won't be allowed to start my rotation next week if I don't get this done.

Our orientation session today was fun. We went over to the Mt. Sinai Simulation Center on the Case campus. Probably about 50 or 60 students were there, mostly Case and CCLCM third years and some CCLCM fourth years who did research last year. There were four stations: one for reviewing how to read EKGs, one for tying surgical knots, one for reading chest x-rays, and one for stitching cuts. We were divided into four groups, and we spent about an hour at each station. The doc at the EKG station was the same one who taught us about EKGs during our cardio blocks at CCF. I had to be reminded how to tie the surgical knots at the second station, but after I did it once, it came back quickly. I am very glad that I went to that Surgery Interest Group knot-tying session last year. The chest x-ray station was run by an emeritus doctor who was absolutely hysterical. Now I will always remember that alveolar lung infiltrates are patchy, while interstitial lung infiltrates are grainy! The last station was fun too. First, we stitched a quilt, and then we stitched cuts that had been made into mannequin arms. That was pretty weird. The mannequins even had red interiors when the rubber skin on their arms was cut, although they didn't actually bleed!

I had a really good time today, and I am more excited than ever about starting my rotations.

CCLCM Step I Timeline

2008-07-07T18:58:00.000-07:00

This timeline will be most useful for CCLCM students, but some of it might be helpful for students from other schools too.

Late October to Early November 2007:
I registered for Step 1 at the NBME website. This is when the UP students register since they take the test in early March, so we have to register at this time too even though we'll be taking it at the end of June. Registrants pick a three month window, which for CCLCM students should be June-July-August. We are then able to register for any day within that three month period, assuming that there is an open slot at that test site. We paid $480 to register for the 2008 test, but they'll probably charge more in future years, so check on the NBME site.

Late November to Early December 2007:
Time to pick a test site and date on the Prometric website after you get permission to register from the NBME. Don't procrastinate on doing this, because the testing sites will fill up and you might not get the date and location that you want. There aren't any Prometric sites closer than a 45-minute drive away from CCLCM. Some of my classmates took the test in Strongsville or Mentor, which are the closest locations. But I am going to study here for five weeks and then go home to take the test. My date is July 1, which is the last Tuesday of our six weeks off. I think most people are taking it a week or two earlier than I am, but I'm waiting longer so that I can have the Memorial Day weekend off.

December 2007:
I took the NBME Comprehensive Basic Science Exam (CBSE) in mid-December. This exam lasts four hours and covers all of the basic medical sciences. It can only be taken through the school, and it is optional for CCLCM students. Some of my classmates took it last month with the Case students, but I couldn't take it that day. So I asked Wilma (the school administrator) about a makeup, and she was generous enough to arrange a second date just for CCLCM students.

Even though most CCLCM students will fail since we are so early in our second year, it's still worth taking the test. Med students at many other schools are required to take the CBSE as part of their normal curriculum in order to assess their preparation level in the basic medical sciences. The test is by the same people who write the real USMLE, and it gives you a valuable preview of what the real test is like, as well as feedback about your individual strengths and weaknesses. I would guess that about 3/4 of the people in my class took it. If you do sign up to take the test, don't back out later if you can help it. The school has to pay for each student who signs up to take it, including anyone who winds up not taking theirs.

March 2008:
I took my first NBME CBSSA (Comprehensive Basic Science Self-Assessment) over spring break just to get an idea of where I was at that point. This was the first time that I passed the test.

May 2008:
I began studying part time for Step 1 for the last few weeks of school, then full time afterward. Many of my classmates started studying much earlier than this. I took all five of the other NBME practice exams. The school gave us vouchers so that we didn't have to pay for Tests 3 and 5.

Late June to Early July 2008:
Usual time for CCLCM c/o 2011 students to take USMLE Step 1.

USMLE Step 1 Resources (Organized by Subject)

2008-07-06T19:07:00.000-07:00

General
-First Aid for the USMLE Step 1 (had a love/hate relationship with this book (mostly hate), but it is good as an outline and for tips and mnemonics)

Anatomy
High Yield Gross Anatomy (good for people like me who need extra review, but probably not a very high yield subject for most people)

Behavioral Science
-High Yield Behavioral Science (great, concise book and I highly recommend it)

Biochemistry
-Lippincott's Illustrated Reviews: Biochemistry (strong subject for me, so I only read the 40-page review at the back of this book)
-If I had more time, I would have read Rapid Review Biochemistry

Cell Biology/Molecular Biology
-Didn't study anything specific for this, mainly because I ran out of time and this was one of my stronger areas.
-A lot of people like to use High Yield Cell and Molecular Biology.

Embryology
-High Yield Embryology (cannot say enough about how much I loved this book. Finally felt like I understood embryo, and I wish I had used it during my embryo sessions last year)

Immunology
-Review of Medical Microbiology and Immunology (immuno section only, which I highly recommend)

Microbiology
-Clinical Microbiology Made Ridiculously Simple (good mnemonics and funny drawings to help you remember the bugs and drugs)
-Lippincott's Illustrated Reviews: Microbiology (mainly just read the earlier sections on lab tests for the pictures)

Neuroanatomy and Neurobiology
-Clinical Neuroanatomy Made Ridiculously Simple by Stephen Goldberg (short, easy to read review of neuroanatomy)
-Some of my classmates liked Roadmap Neuroscience, but I found it to be dense and too tough to get through during my study period.

Pathology
-Rapid Review Pathology by Goljan. (Got through this once and most of a second time. Best to use it along with his lectures, but start early if you're going to do this)

Pharmacology
-Lippincott's Illustrated Reviews: Pharmacology (intensive 500 page book with questions; start early if you're going to use this one!)
-High Yield Pharmacology (short, outline format, good later review)

Physiology
-BRS Physiology (looks long and hard, but it's a quick read, especially if you don't do the questions!)

Question Books
-Robbins Review of Pathology (great book for reviewing path, although the questions are easier than the real USMLE)
-Kaplan USMLE Step 1 Qbook (used this to review after I finished studying each subject)

Question Banks and Practice Tests
-Kaplan Step 1 Qbank (used about half of this earlier on in my studying)
-USMLE World Step 1 Qbank (used about half of this toward the end of my studying)
-NBME CBSSA Exams 1-6 (best way to monitor your studying progress. Test 5 was the most predictive for me. CCLCM students get two free tests paid for by the school.)

My General Advice for Step 1

2008-07-05T18:22:00.000-07:00

One thing I will warn you about ahead of time is that everyone you ask will tell you to do something different to ace the boards. I found this out for myself very quickly when I started asking some of the CCLCM upperclassmen what they did to study. Get two of them together in a room, ask them one question, and they'll give you three contradictory opinions. At some point, you need to think about what learning style works best for you, and just trust yourself. You didn't get halfway through med school without developing effective study habits. So use that knowledge to help you develop a plan that will be effective for you.

First, you should decide if you are a group studier or a self-studier. There are pros and cons to working with other students, and I think if you get the right partner or group, then studying with others can be extremely effective. That being said, I'm definitely a self-studier. A lot of my classmates worked together in groups, and I'm not inherently averse to doing that. But I have always been more of a self-studier. I studied on my own for the MCAT, and it worked out very well. So I decided early on not to study with other students. For me, the downside of being around other stressed people when I'm stressed myself far outweighs the benefit to be gained by bouncing ideas off other people.

Second, you need to decide what method helps you retain information best. A few people learn well just by reading, or by attending review sessions and having the info presented to them. Some people learn well using audio lectures. I think that many people learn well by doing a lot of practice questions, and that was the approach I took. I find that it is easy for me to kind of skim through stuff without really understanding it thoroughly if I just read it and don't try to apply what I've read to practice problems. I've always done well in math classes, but I have to work problems. I can't read a math book like it's a novel and hope to retain anything. Ditto for the USMLE.

Here's my general philosophical approach to studying for the boards (or any other exam): You start by figuring out what your weaknesses are, and you work on those first. That's how you get better and ultimately score higher. Plus, every school has certain subjects that are covered very well (cardio at CCLCM is, unsurprisingly, very thorough) and others that aren't as good. (I would say that our micro, pharm, and neuro are not as well-done.) You will need to put more time toward filling in the specific knowledge gaps that your school's curriculum has left. In my case, I needed a lot of work in neuro and micro, and I wasn't familiar with a lot of the drugs for pharm. In addition, since physiology and path are two of the highest yield subjects for the boards, I wanted to make sure I had them both down cold.

People often wonder how long to spend studying. Again, this is something that each person has to decide for themselves. Some of my classmates were already doing board review stuff during our first year. Others basically did nothing until spring of second year. I didn't start studying really hard until May of second year. It's hard to review path much earlier than that because you won't have covered the material in school yet. For CCLCM students, two really good subjects to start reviewing early on in second year are micro and immunology, because we cover those during first year but don't come back to them again second year. Neuro is also a good early subject because that's our first block during second year.

The final piece of advice that I have for you is not to go too crazy buying all kinds of resources. You won't have time to use them all. Pick a few good review books, and go with those (and your practice questions). Most importantly, don't give up. It's hell while you're going through it, but make sure that you work hard during your second year and study hard during your study break. If you do those things, everything will work out in the end.

Done with Step 1!

2008-07-01T19:16:00.000-07:00

I took Step 1 today, and I honestly have no idea how I did. I feel like I passed, but I'm not sure if I just barely passed or I totally killed it. I know there is at least one question that I definitely missed, and another one that I think I missed except that I can't remember the specifics any more to be sure. There are also a couple of questions I guessed on that I know I got right. I should be getting my scores in 3-6 weeks.

In the meantime, there's not much I can do but relax for the rest of this week and get ready to start my Bridge Week on Tuesday. I'm really looking forward to starting rotations, and also glad that I never have to read First Aid again. (Have I mentioned lately how much I hate that book???)

Feeling Good about Step 1 Next Week

2008-06-24T13:04:00.000-07:00

I have one more week to go until I take Step 1. Today I took the last practice NBME exam, and this is the best score that I have gotten yet. It's way higher than I needed or wanted to get. If I do this well on the real test, I am going to be super happy. I'm still not doing as well as I'd like to be in anatomy, embryo, and neuro. So those are going to be the subjects I focus on now, along with cramming all those last-minute stupid details that the NBME likes to ask about. I am too burned out to study any more today though. Also, I hate First Aid more than I can possibly express in words.

Core Rotations at Case

2008-06-20T16:14:00.000-07:00

I finally got my rotation schedule for next semester today. I'll be doing three weeks of family medicine, then three weeks of outpatient internal medicine, then five weeks of surgery, and finally five weeks of inpatient medicine. I start on July 14 and finish on October 31. (I also have a Bridge Week that starts on July 8.) I'm really excited about starting my rotations.

I am also starting to get sick of studying for Step 1. It was fun at first to sit around and study all day without having to get dressed or go anywhere if I didn't feel like it. But I am starting to reach a point now where I am getting sick at the very sight of my First Aid review book. I think this means that it's time for me to take the test already. I have a week and a half left to go, so it's getting close now.

Step 1 Study Update

2008-06-10T13:03:00.000-07:00

I just wanted to post a quick note to thank the people who are wishing me luck. Things are going well. I'm still studying full-time and taking full-length practice tests. (The NBMEs are not full-length, but I am doing an extra three sets of practice questions after I take them so that I complete the full length of the test.) It's a grueling schedule, but I'm still improving, which helps me feel more motivated. I'll post again soon.

My Next Practice Test

2008-05-27T13:01:00.000-07:00

It's finally getting nice in Cleveland. I swear the springs here are the coldest, grayest springs I have ever experienced! I've been studying part time for Step 1 for three weeks now, and my score has improved substantially since I took the last practice test. Today I took another practice test, and I have almost reached my target score. Now I will be studying full time for the next five weeks, so I won't be posting very much for a while.

Last Day of Year 2 and Promoted to Year 3!

2008-05-23T13:00:00.000-07:00

We had our last ever PBL session today followed by our last seminar. Then we all went to the office to get our letters. I am now officially an M3. The letter starts out like this:

Dear CCLCMer,

The Medical Student Promotion and and Review Committee met on May 16, 2008 to review your Year 2 Summative Portfolio. Based on its deliberation, the Committee determined that you met the Year 2 standards for all nine competencies and will be promoted to Year 3.

It then goes on to detail some of the specific evidence that the committee felt was particularly convincing. The last part says:

....your portfolio was well written, organized, and an excellent reflection of your performance. It was a pleasure to read. Congratulations on a strong performance and receive our best wishes for continued success in medical school next year.

So that's it. I now have 5.5 weeks to study for Step 1, followed by 1 week of vacation before I begin Bridge Week and my first block of rotations. (I still don't know what my rotation schedule is, which is kind of annoying. Hopefully I will find out soon.)

Lunch with My PBL Group

2008-05-21T13:58:00.000-07:00

My group's PBL tutor took us out for lunch today. We went to Cedarland, which is a really good Lebanese restaurant on campus. (For those of you who are visiting the Cleveland Clinic, you should definitely try it. It's on Euclid and 93rd by the Guesthouse, which is unfortunately the area that is under major construction right now.) After we were done eating, the tutor went around the table and predicted which field each of us would enter. I am apparently going to go into heme/onc. I actually wouldn't mind that choice, because I think hematology and oncology are both fascinating. But I'm not sure how I feel about having to do a three year medicine residency followed by a heme/onc fellowship in order to get there!

This Friday will be the end of the best PBL group I have had since I began medical school. Even though I started out as a doubter, this group really demonstrated how awesome of an experience PBL can be. Interestingly, several of my group members were also in my PSS group during our first summer of med school (summer 2006). That was a really great group too. Anyway, I won't miss going to classes next year, but this has been a great way to go out.

CCLCM Goes Tuition Free!

2008-05-15T19:15:00.000-07:00

Yesterday afternoon we had the most incredible thing happen. On Tuesday, an email was sent around to all of the students to tell us that an important announcement would be made the next day, and that we should try to be present for it if we could. We all suspected that it was either about changing our school affiliation or free tuition. The dean sent around an email saying that the announcement was NOT about our school affiliation. So then we all figured it would be for free tuition, and sure enough, that is what it was. Next year's first years will never pay a dime. The current students will also get free tuition from now on, as well as a refund on half of the tuition we have paid so far. So the people in my class will be getting back one year's worth of tuition, and the fourth years will be getting back two years' worth. What an incredibly awesome and amazing gift.

Here is the press release from the Cleveland Clinic:

I am pleased to announce that the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University is providing all its students with full tuition scholarships, beginning with this July’s incoming class.

Students currently enrolled in the Cleveland Clinic Lerner College of Medicine will receive additional scholarship funding to offset 50% of the difference between past tuition paid and the financial aid they’ve already received.

Cleveland Clinic will support the full tuition scholarships through existing endowment income and clinical operations. The long-term goal is to fund the scholarships entirely through endowment income.

Training the newest generation of physician scientists is an important aspect of Cleveland Clinic’s mission and enhances our long-term ability to provide patients with state-of-the-art healthcare.

By providing full tuition support, we will ensure that debt does not hinder the ability of bright and talented individuals to pursue a career in academic medicine. It is an investment in our future and the future of medicine.

Everyone was so excited! Dr. Cosgrove, the CEO of the Cleveland Clinic, was there to make the announcement, and I was able to thank him in person for doing this. After the announcement was over, all of the students poured out onto the deck and were calling their families on their cell phones. There were photographers taking pictures, Mrs. Lerner and the Board of Trustees were there, and people were laughing and crying all over the place. It was just incredible. What a feeling. I still can't believe that this has happened. I knew that the school was planning to go tuition-free eventually, but I never thought I'd be around to see it happen! Some of my classmates and I went out for dinner to celebrate.

The only downside to this whole thing is that unfortunately, the UP students are not getting the free tuition. I feel very bad about this, because our tuition for next year is up to $43,000. Hopefully Case will find a way to provide them with free tuition also.

Books for Second Year

2008-05-14T16:13:00.000-07:00

For the summer block, I suggest buying Epidemiology by Leon Gordis and reading it cover to cover. That's a really good book, and epi is a subject that is tested on the boards. I didn't like the stats book they assigned us, and I wound up getting a better book from the TA. I did buy the JMP Manual book, and that was useful for learning stats as well as for learning how to perform various statistical tests for the stats projects we had to do. So for the summer block, those are the only two books that I would recommend buying.

There really aren't too many new books that you need for second year beyond Robbins and Cotran Pathologic Basis of Disease, which is why I haven't been writing posts about second year books. Some of my classmates felt that Robbins was too dense, but I thought it was really good. I'm not going to get to a few of the chapters at the end like the eye chapter, but I've almost read the whole book cover to cover now. There is an atlas that goes along with the Robbins book that is really good. A lot of us bought it. You can also get the Robbins Review of Pathology, which is a path question book. I liked that book as well, although I think the questions in there are a lot easier than the practice Step 1 questions I've been doing. All of the other books we've used this year are the same as the ones we used last year: Katzung for pharm, Drake's book and modules for anatomy/embryo, etc. The only other books you will need are whatever you plan to use to study for Step 1. But you really can get away without buying too many Step 1 review books, because there is a whole collection of them in the library that you can use. They pretty much have all of the popular review books on reserve.

Acids, Bases, and ARBs

2008-05-09T19:57:00.000-07:00

We only have two more weeks of school left now. The time is really flying by. This week's theme was a whole hodgepodge of things: acute renal failure, renal clearance, electrolyte and acid base disorders. Wednesday was acid-base disorder day, and today we had a hypertension pharmacology seminar. They were both great seminars. I know I went on and on about how awesome the renal block was last year, and I am happy to say that this excellence has continued this year. Most of the renal seminars are in small groups of eight, and most of them are very interactive with good cases. I feel like I'm really getting a lot out of them. The other good thing is that since we have such a light schedule now, I even have time to do all of the reading for class along with spending a few hours each day studying for Step 1. Right now I am studying path and embryology. Embryo is not a very high-yield subject for Step 1, but I suck at it. Embryo and anatomy have been my worst subjects on all of my practice tests so far, so those are the subjects that I'm reviewing first. I'll need to go over them again at the end probably.

Intro to Step 1 of the USMLE

2008-05-06T18:13:00.000-07:00

I took my diagnostic practice test today, which is one of the NBME exams. (NBME is the National Board of Medical Examiners, the organization that adminsters the medical boards.) I am happy to report that I am already well above the passing mark at this point. Even if I didn't study at all between now and July 1, I'd almost certainly pass the test. Of course, I want to score higher than I am right now, but it's still a huge relief to know that I am starting from this point!

For those of you who are not familiar with the USMLE (United States Medical Licensing Exam), here's a brief primer on it. There are three parts of the USMLE, which are called Step 1, Step 2 and Step 3. (Step 2 actually has two parts, but we won't get into that right now.) Step 1 is usually taken after the second year of medical school, Step 2 is usually taken in the fourth year of medical school (or possibly the fifth year for CCLCM students), and Step 3 is taken after the first year of residency. I'm going to mainly talk about Step 1 since that's where I am in the process.

Step 1 is a test of basic science knowledge. Some of the most important subjects that are tested include pathology, pharmacology, microbiology, biochemistry, and physiology. Other subjects that can show up include anatomy, embryology, psychology, epidemiology, cell/molecular biology, and histology. The test is eight hours long, including one hour total for break time. It is taken on a computer, but it is not adaptive (every question counts the same as every other). There are seven sections of 48 questions each, and you are given one hour per section. Once you finish a section, you cannot go back to that section. A passing score on Step 1 is currently 185 on the three digit scale. The average score for allopathic medical students (people working toward an MD) is around 220. No one knows what the maximum score is.

Step 1 is important to medical students because many competitive residency programs use it to screen out applicants. The next obvious question you are probably wondering is what constitutes a "good" score on Step 1. The answer to this question is highly subjective, and it also depends on what field you are trying to enter. My personal opinion is that any score above the mean is a good score (220+), and any score above 230 is a highly competitive score for most specialties.

Done with My Summative Portfolio

2008-05-02T21:11:00.000-07:00

Our summative portfolios are due next week, but I wanted to get mine turned in early so that I could start studying for Step 1. I'm going to take my diagnostic exam on Tuesday since I don't have to go to clinic any more. (My advice to current and future second years: don't miss any longitudinal clinic days from September to April. That way, you can have no clinic afternoons for the entire month of May when you need that time the most.) The administration took pity on us and didn't require us to print out all the evidence and make those ridiculous binders like we had to do last year. One of my classmates came up with the idea of saving everything on a CD and turning that in. I thought it was a really good suggestion, but so far the powers that be haven't warmed up to the idea too much.

Not too much else exciting going on. The work load is starting to wind down so that we can have extra time to study. FCM ended back in March. We don't have any more Wednesday afternoon communication/physical diagnosis classes or Friday ARM/POD seminars. There was a meeting this afternoon about planning out the research year, but I didn't have to go since I'm only doing a month of research next year. I think this is the first time since I started medical school that I had every single afternoon off for the entire week. I've been using the extra time to work on pharm.

Clinical Reasoning and Communication

2008-04-29T17:33:00.000-07:00

Our communication class last week was about ending the doctor-patient relationship. It was insane. I was supposed to be a med student who had just finished my longitudinal clinic from first and second years, and I had to tell the patient that I was leaving to start my third year rotations. My actor was really over the top. He actually started crying with real tears when I told him that I'd be leaving! I wanted to laugh at the absurdity of it all, but I couldn't, because that would not be professional. Don't get me wrong. There are several patients whom I've seen multiple times, and we've built up some kind of relationship. But it's not like any of these people are going to throw a total hissy-fit like this guy did when I move on. Can we talk about dependence issues here? If this guy had been a real patient, I don't think I'd have worked nearly as hard to smooth things over. But when you're in a room with five people evaluating you, of course you have to see the whole thing through.

Friday was the last time we had to do one of those awful small group projects for ARM/POD. I was going out of town for the weekend, so I didn't even go to the presentation part. What a colossal waste these sessions have been. Even worse, what a missed opportunity to have made a series of small group sessions that could have been really interesting and useful. For example, it would have been great if the faculty had us actually go through the process of writing an NIH grant and taught us about different grant awards, how study sections work, etc.

We had another clinical reasoning session today. I had the same group and preceptor as last time, and it went about the same as before. First we each presented a patient and went through the differential as a group. Then we went over to the hospital to interview a real patient. This patient was a character. I'll just say that we heard about her sexual history in exquisite detail. And to think some people claim that you don't learn anything interesting in medical school!

Last week was our last week of GI (liver week), and now this week we have started with renal. Everything is going great. My PBL group still rocks. The renal seminars are as awesome this year as they were last year, interactive with lots of small group sessions. This week, we've been talking about glomeruli, which are the capillary beds that do the filtering in the kidneys. They're really beautiful. Here's a picture of one (the big thing in the middle). The smaller circular things surrounding the glomerulus are parts of the tubules of the nephrons, which are the urine concentrating units of the kidney.

My Last Patient

2008-04-22T18:31:00.000-07:00

This week has been much better. We're going over liver pathology. I like the liver because it has so many interesting functions, and it is also capable of regenerating itself. Those are just some of the reasons why it's my favorite GI organ, but I won't bore you by going on and on about how cool the liver is. Suffice it to say that yesterday we went over viral hepatitis, and today we did gall bladder diseases. (The gall bladder is the organ that stores the bile produced by the liver.)

Today was my last day in clinic. Wow, what a way to go out. My very last patient of the afternoon was a guy who came in because a box fell on his hand. His fingers were all black and blue, and he will probably lose some of his nails, but there didn't seem to be any major problems otherwise. I was going through the review of systems (ROS) with him, and when I asked him about chest pain, he said yes. I asked him more about it, and he said that it was a kind of tightness more than a pain. Did it radiate? Yeah, to his left arm. When did it start? About half an hour ago. Had this ever happened before? A few times within the past month. At this point, I excused myself and went to get my preceptor. We personally walked the patient over to the ED so that he could be worked up for an MI (myocardial infarction, popularly known as a heart attack).

I was most struck by the fact that if I had not asked this man about whether he had chest pain, he would not have ever told us about it. He didn’t fit the normal demographic for a patient with coronary artery disease (CAD) that I had learned about in school. He didn’t think his chest pain was important enough to mention to the doctor. I've gone through the ROS so many times over the past two years that it's practically perfunctory and mechanical by now. This experience re-emphasized to me how important it is to not take shortcuts, to ask every patient about life-threatening symptoms like chest pain. You will never have the opportunity to save a person’s life with one simple question unless you ask it.

Shifting Dullness

2008-04-16T18:30:00.000-07:00

This week we have been learning about the effects of radiation on the GI tract (not good) and congenital diseases of the GI tract. There are a surprisingly large number of babies who are born with some kind of GI malformation or malrotation. During embryology, the GI tract has to turn twice so that all of the intestines end up where they're supposed to be in the adult. If that doesn't happen correctly, it causes a malrotation. There can also be problems where the intestines don't return to the abdomen after they normally herniate out into the yolk sac during the second month of gestation, or where the neurons of the enteric nervous system don't migrate where they need to go. I hadn't realized that GI embryo was so complex.

Today I had my meeting with Dr. I about the OSCE. He had printed out all of my evals and read through them before I got there, and I got the impression he was kind of surprised that I had requested this meeting. I explained that I didn't feel I had done as well as I should have for the amount of time and effort that I spent preparing. He apparently didn't realize that my classmates and I were studying for the OSCE, because it was supposed to be something where you just kind of walked in and took it. He didn't think I had done badly at all, and he even wrote an email for me to put in my portfolio saying that I wasn't underperforming in clinical skills. Maybe part of the point of the exercise was to see how we'd adapt after we bumbled through the first station. But all I can say is that from a student perspective, it was a very frustrating experience.

My clinical correlation today was on performing abdominal exams. The GI fellow who was helping my group turned out to be one of my classmates from my Clinical Trials course last semester. We saw some interesting patients. One was so jaundiced that she was literally bright neon yellow. We also saw a patient who was positive for shifting dullness, which occurs when the patient has ascites (fluid in the abdomen). To test for shifting dullness, you percuss the patient's abdomen while he is lying on his back, then have him turn on his side and percuss his abdomen again. If the border between the dull and tympanic regions move, the test is positive. On an amusing side note, one of the attendings told us that when he was in med school, he and his classmates had to sit through boring lectures all day, five days per week. They used to call the lecturers "shifting dullness." :-D

Besieged by Reviews

2008-04-11T18:58:00.000-07:00

We had a couple of GI path seminars on Wednesday and a really cool pancreatic surgery seminar today. I think I am about the only sucker in my whole class who is still doing the assigned readings for seminars. I brought up something in PBL that I had read in the articles for today's seminar, and I swear the rest of my group was looking at me like I had two heads. It turned out to be good that I had read that article though, because it helped us understand the case. We also had a domestic violence screening communication class on Wednesday. It wasn't bad, but I thought they should have done it about a year ago. I've been doing domestic violence screening on my clinic preceptor's patients since about halfway through last year.

We were supposed to have a Dean's Dinner on Wednesday, but it got cancelled since most of my classmates couldn't go. The first years had their Dean's Dinner last week though, and I got permission to go. As it turns out, my research preceptor was the speaker, so I was glad that I got to be there. I had seen part of his talk before last fall at the conference, but some of it was new.

Today was also the first pathology review session for Step 1. I went to this one, but I don't think I am going to go to any more review sessions. I really didn't get very much out of it, mainly because I have not started studying at all for the boards yet. Being suddenly bombarded by so many review sessions is making me feel a little stressed out and overwhelmed. There are reviews being set up for everything: path, pharm, micro, anatomy, embryo. But right now, I am more worried about getting my summative portfolio done than I am about studying for Step 1. This is the portfolio that will be used by the promotions committee to decide if I am promoted to third year. I feel a little bad about not attending the review sessions, because the faculty are really going out of their way to try to help us prepare for Step 1. I don't want to seem ungrateful. It's just that I am not ready to start studying for Step 1 yet!

Observed H & P

2008-04-08T19:18:00.000-07:00

We had a really terrific pharm seminar on Friday about drugs for inflammatory bowel disease. The two pharmacists gave us some cases to work through and then went over them with us. Our POD/ARM seminar, on the other hand, was a disaster. I guess whoever was supposed to give the talk on diarrhea cancelled, because instead we wound up getting a talk by someone from the Innovations Center here at CCF. (They take care of patents for inventions made by people associated with the Cleveland Clinic.) What annoyed me the most about this talk was not that it was awful and had nothing to do with research. No, what really annoyed me is that the only reason I skipped the second look students' lunch and went to this talk at all is that Dean Franco asked me not to skip class when I told her about the schedule conflict. Once again, the faculty for the class didn't show up, and most of my classmates didn't, either. I think skipping it would have been completely justified, but I didn't feel right about leaving after I promised her that I would go. On a happier note, in the evening, one of my friends and I went for dinner at a Thai restaurant I had never been to before, and it was amazing. We are definitely going to go back.

This week seems to be a bit of a hodgepodge of different gastrointestinal (GI) problems. Yesterday we had a seminar on infections, and today we talked about diabetic neuropathy. You may not have known that the GI system has its own nervous system that functions semi-independently. This is one of those facts about the human body that I had no clue about before I began medical school, and that I find just fascinating.

My preceptor was back in clinic today, so I did my observed history and physical (H & P). It went really well. The patient was a very interesting woman who was involved in a variety of charities. I didn't do a Pap smear on her, but I did do a breast exam and instruct her about how to do them herself. I am amazed by how many women do not do breast self-exams. Whenever I ask them why, nearly all of them say that they know they should do self-exams, but that they have never been taught how to do them. This patient was no different. The good news is that patients seem to be getting the message about the importance of monthly breast self-exams. But of course, telling women to do these exams is not terribly helpful unless they also know when and how to do them! Instead of asking patients whether they do monthly self-exams, it is probably better to ask them if they know how to do monthly self-exams. Then if they say no, the provider can show them.

Spring OSCE

2008-04-02T19:16:00.000-07:00

On Monday, I participated in the feedback session for our Heme/Onc block. The students are supposedly asked randomly to participate in these feedback sessions, but somehow I sure seem to end up participating in an awful lot of them!

This week is the beginning of our GI block, and the seminars have been on the oh-so-appealing topic of diarrhea. I can't really complain, though. We've had a relatively light schedule so far because we're taking the spring OSCE this week. Yesterday, I had all day to study for the OSCE after the seminar was over at 10 AM, because we don't have clinic this week. Then I took the OSCE today.

It was worth spending the time to review all the exams, but in the end, it wasn't enough. This OSCE was much harder than the one we did last year, and I felt like I was really floundering around for a large portion of it. Like last year, we had to examine standardized patients, and there was a preceptor in the room with a checklist of skills we were supposed to demonstrate. But there were a bunch of new features as well. First, there were more stations (four in all), and they were much more ambiguous. We weren't told anything more than something along the lines that Mrs. Smith was here for a check-up. At the first station, I did a focused history and physical for a patient who had a sore shoulder. Afterward, I was getting feedback from the preceptor, who told me that I was supposed to do a complete history. He said that I did a good job on the parts of the history that I completed. But I still wound up flunking the station because I missed so many of the objectives.

Ok, well, now that I knew I was supposed to do a complete history, I could handle that. I went in to the second station, which involved counseling a patient on smoking cessation. That one went well and I got very good feedback from the preceptor. The next station was for an abdominal exam, and that one went well too. I had to write a SOAP note at the end, and I just barely got it done in time. But I totally missed the point of the last station. That patient had right sided abdominal pain and a cold, so I did the ENT (ear, nose, and throat) and abdominal exams on him. Then I gave an oral presentation to the preceptor. But it turns out that this patient's flank pain was supposed to be chest pain, and the preceptor said that I should have done a complete cardiac exam. I still don't really get how right flank pain was supposed to scream "cardiac problem!" at me. But I guess the lesson to take away from this is that anyone with pain below the neck and above the pubis is going to get a full cardiac exam AND a full abdominal exam from now on.

I am pretty disappointed about how I performed on this OSCE. Considering how much time I spent preparing, it's frustrating that I failed two out of the four stations. I have already emailed Dr. I, who runs our clinical course, to set up a meeting to discuss my performance. Don't get me wrong--I'm glad that I screwed up now and not on the clinical portion of Step 2 that I will be taking at the end of next year. But at the same time, this OSCE is supposed to be a demonstration of our current level of clinical and communication skills, and I know that my performance was not nearly up to the level of which I'm capable.

End of Heme/Onc

2008-03-28T16:48:00.000-07:00

Today was the last day of the Heme/Onc block, and I am going to miss it. Even though blood diseases and cancer (and blood cancers) aren't exactly the cheeriest subjects, they're still really interesting. Plus, this block was well-organized and most of the seminars were excellent. The PBL cases were depressing, but they were good also. Speaking of PBL, my group is still doing the discussions instead of formal learning objectives, and it's working really well. I'm glad now that I gave it a chance. We have a really good PBL tutor, too. He's a semi-retired surgeon, and he gives us great clinical pearls here and there. This is the best PBL group that I've had since I started med school. Our group is going to stay together until the end of the year, so I'm glad this group is such a good one.

We had a cultural sensitivity communications class on Wednesday. It was kind of silly. My standardized patient was playing a Jehovah's witness who might need surgery. Of course she didn't want to have a blood transfusion. So I had to tell her that I'd honor and respect her wishes, and that I would speak to the surgeon about it as well. I also asked her to tell me more about what things exactly were forbidden, and she told me about the religion a bit as well. It wasn't a bad class, but I don't think we really needed it at this point in our second year.

Our seminar today was on cancer drugs. The seminar leader was a new pharmacist that hadn't led any of my previous seminars, but he was very good. We were supposed to have a POD research seminar afterward, but it got cancelled. This whole POD course has been pretty haphazard. The fact that last year's POD course was so well-organized only emphasizes how bad it is this year. You know things aren't going well with the class when even the faculty stop showing up for it.

Blood Pimping

2008-03-25T18:08:00.000-07:00

Our seminars yesterday were kind of interesting. The first seminar leader didn't show up at all (apparently he thought he was supposed to come on Friday), while the second one did come, but he basically used a lot of the same slides that he showed us last year. All in all, yesterday was not the greatest of seminar days. But the afternoon session more than made up for it. I had my heme clinical correlation, and the first half of it was just amazing. For that part, we went to the heme path lab and looked at a bunch of slides of different red blood cell diseases. The doctor was pimping us pretty mercilessly, but it wasn't mean-spirited. I felt like I really learned a lot. After we were done looking at the slides, we went on the wards to see some patients. This wasn't quite as successful. Somehow, none of them were in their rooms, and we wound up having another pimp session instead where we had to come up with the differential diagnosis (possible causes) for splenomegaly (an enlarged spleen). After we had come up with all the easy and obvious causes, he was pushing us to come up with some more esoteric ones. I can see now why internal medicine rounds take as long as they do!

Today was a better seminar day. The regular scheduled seminar was about coagulation, and we were back to our small groups again. I know it's a lot more work for the faculty because they have to find four seminar leaders instead of just one, but small group seminars are so much better than large groups. Afterward, the seminar leader who missed class yesterday came and gave us his presentation on iron metabolism and overload. I was considering not staying for it, but I decided that I would, and I think it was worth getting that review. Iron metabolism is a pretty important and complex topic. I was supposed to have clinic this afternoon, but my preceptor is away on vacation. Since it was so crazy last week and I wanted to have some extra study time anyway, I decided not to go to clinic this week. (We are allowed to miss up to three days of clinic for the year.) It was really nice coming home early and having a chance to get somewhat caught up on my work.

Still Not a Budding Dermatologist

2008-03-21T16:22:00.000-07:00

I am really enjoying this heme block, even though it has been a lot of work, and even though it is really depressing. On Wednesday, we had another terrific discussion in PBL. I don't know what it is about this PBL group, but it is just gelling really well. The downside is that I knew this week's patient was going to die, and sure enough, she did. Afterward, we had another small group seminar on tumors of plasma cells. (Those are the B cells that make antibodies.) Then I had a few free hours to study, because for some reason we didn't have anything scheduled until the derm exam at 3 PM. I wasn't too excited about doing the derm exam, but it wound up being a pretty interesting, albeit disgusting, session. Now I know the difference between macules and papules and patches and plaques, but none of the above is very pretty to look at. Basically, if you were the kind of kid who was totally into scabs and scatology and anything else that was gross, you will totally love derm. To me, it was fun to do it for one afternoon, but I wouldn't want to make a career out of it.

Yesterday, we were supposed to have a class meeting and a portfolio meeting in the afternoon. But I was sick, so I didn't go. Today we had a seminar on anemias that was excellent, just like the others for this heme block have been. I was all excited about today's POD talk because it was supposed to be about cancer drug discovery, but it was pretty disappointing. The speaker mainly just went over general cancer principles, and I didn't really learn anything new. It wasn't a bad talk, actually. I think it was more that it just wasn't what I was expecting.