Classes, Stats Project, and Clinic

Yesterday we had another stats seminar, and it was basically uneventful. Today we had epi, which was also fine. But this particular speaker has a tendency to get behind and go over time. Usually it doesn't bother me that much, but today I wound up walking out while he was still talking because I had to meet with my PA right at 11:00. I have finally filled out all of the forms to apply formally to the Clinical Research Scholars MS program, so I needed some papers signed. We also talked about the OSCE that I'm missing, and that I have been going to extra clinic sessions to keep practicing my physical diagnosis skills.

Afterward, my partner and I were working on our second statistics project, which we will be presenting on Thursday. It was kind of tough to decide what to do since we already answered most of these questions last week. We were trying to come up with a way to factor out some confounding variables so that we could figure out how much of the difference between our two groups was due to one single variable. But we had to call it quits before we figured it out because it was time for me to go to clinic.

I expected to get out of clinic early, but instead I wound up being there for longer than usual. The weather today in Cleveland was very bad, and I figured all of that rain and lightning would keep the patients home. Well, one did cancel, but all of the others came anyway. I saw one patient with an earache and another one with shingles on my own, and then I went with my preceptor to see two other patients who were getting full physicals performed.

My last patient was having dizzy spells, so I decided that I wanted to find out if she had orthostatic hypotension. A person who has this condition can get dizzy and faint if they get up too quickly, because their heart doesn't compensate fast enough to get the blood back up into their head from their legs. It is fairly common in older people, especially if they are taking certain medications. The test is simple: you take the patient's blood pressure once while she is lying down, and then again after she has been standing up for a few minutes. However, I wound up having to repeat the test, because my preceptor wanted me to take the patient's blood pressure three times while she was standing (after 2, 5, and 10 minutes) rather than only once. I also didn't know that I should get her pulse as well. It turns out that some patients might get a faster than normal pulse to try to compensate for having less blood returning to the heart. The problem with this is that if your heart starts pumping blood too fast, then there isn't enough time for the ventricles to fill up all the way before they pump the blood out.

All in all, it was a very tiring but good learning experience. I wound up staying afterward for about half an hour to talk to my preceptor about what I should be working on to improve my clinical skills for this year. The clinical faculty had already been discussing my progress anyway because I will be missing the fall OSCE, and apparently the physical diagnosis course director was very happy to find out that I took the initiative to set up these extra clinic days. My preceptor also offered to write an extra evaluation for me so that I can include it in my portfolio as evidence toward my clinical skills competency for this year. We agreed that I should start working on tailoring the history and physical exam to the patient's pathology, as opposed to trying to just get through a memorized list of skills and questions.

There is one downside to starting to learn clinical skills as early as we do, which is that a lot of times, you wind up memorizing questions and going through procedures without understanding exactly why you are doing certain things. Last year I got very frustrated with the physical diagnosis class at times for exactly that reason. I think that this year it will start coming together a lot better though, because we finally are reaching a point where we have enough background knowledge to understand what we're trying to do with various tests and questions.

Journal Club

I led my journal club session today, and it was a fun discussion. Both of the articles (mine and the other student presenter's) were really interesting. I think I've already said that my article was on drug eluting stents. I had some extra data from the Cleveland Clinic interventional cardiology labs that the director allowed me to use. We didn't have as much time to look at it during class as I would have liked, but it was still neat to see some in-house data anyway. (It appears that implantation of drug eluting stents does not increase people's risk of dying in procedures performed at the Clinic.) The other paper was looking for an association between sugary drinks, obesity, and type II diabetes. Not surprisingly, the association was very strong. What is even more interesting is that even diet soft drinks are associated with higher levels of obesity and diabetes. But this is probably because people don't change their eating habits even when they switch drinks. In other words, if I still go to McDonald's and get a Big Mac, fries, and an apple pie, I am eating so many calories that it doesn't matter very much if I got a diet Coke to go with it!

I've already mentioned that this year's journal club is much less formal and a lot more fun than last year's was. I think it's partly because of the different style of the discussions, and partly just because I find the material so much more interesting. Each presenter has a faculty "content expert" whose job is to help us analyze the paper. My content expert was an interventional cardiologist since the paper was about stents. He also happens to be the person in charge of my MS program (Clinical Trials), so I already knew him from before. I also got help with the stats from the TA, because we haven't covered most of the stats they used in the paper in class yet.

After class, I was talking to the other content expert about what it means for family history to be a risk factor for diabetes. People tend to want to write it off as just being genetics (i.e., if your parents had diabetes, you'll be at a higher risk to get it too), but you also have to take into account that families share many lifestyle habits and living conditions as well. So if a person's parents become diabetic because they have horrible diets and lifestyles and they are obese, but that person watches his diet and exercises regularly, it's hard to say how much risk of becoming diabetic he has. Even if he's more genetically predisposed to get diabetes in comparison to people with no family history, he can still alter his risk by removing himself from the kind of environment (low exercise, high calorie, high sugar) that would tend to trigger development of diabetes. The problem, of course, is that temporary fixes like going on a diet don't cut the muster. You have to make a lifestyle change (ex. stop eating at McDonald's altogether) and follow it for the rest of your life.

A False Alarm

Yesterday was a really long, tiring day. I got in at 7:15 to go to the O.R. because we were supposed to have another heart surgery patient for our study. But it turns out that we didn't have a case to do yesterday after all because no one had gotten the patient's consent. We are not able to get consent on the day of surgery, because otherwise patients do not have time to consider whether they want to participate. So unfortunately we had to let this patient go.

In the afternoon, one of my classmates wanted me to take her to the gym and show her how to lift weights, so I did. I haven't been going to the gym regularly myself though since I got back to school, and I tried not to do too much so I wouldn't be too sore. I don't know how she's feeling today, but I'm only a little sore. I've decided that I want to start working out regularly like I was before. I'll go again on Saturday.

We had epi this morning and some of the articles for today were pretty funny. My favorite was a study from several decades ago that was comparing the performance of surgery residents who had gotten grades in med school to other residents who went to pass/fail schools. The authors concluded that residents who had gotten medical school grades performed better in residency than residents who had gone to P/F med schools. But we spent quite a while ripping apart the authors' methodologies to the point where it was pretty clear that their results were not exactly convincing. For one thing, they had no way to evaluate the residents from P/F schools on the basis of what kind of grades they had gotten as medical students, which was how they determined the caliber of students the residents from graded schools had been. So it's completely impossible for them to even know whether their two groups of residents had equivalent characteristics as medical students. Then at the end, they bemoaned the decreasing standards in medical education due to social experiments. I bet if the authors are still alive today, they must really hate to see how many med schools are starting to move in the direction of P/F grading, at least for the first two years.

I am pretty much done with my journal club presentation for tomorrow. I met with my content advisor on Monday afternoon and the stats TA yesterday after class. There are some tough statistical concepts in this paper that we haven't covered in class yet (or maybe ever!), so I am only going to present a general overview about what they were doing.

Grand Rounds, Killer Biostats, and Clinic

Yesterday morning I went to the Neuroscience Grand Rounds. I don't normally go to that one, but this talk was being given by the same guy who did one of our Dean's Dinners last year, and I was hoping to hear more about a drug he told us about called natalizumab. Unfortunately, he spent most of the time talking about how the immune system surveys the central nervous system (brain and spinal cord), and he just gave a very brief mention at the end about natalizumab. I'd already heard it all, so I left for class feeling kind of disappointed.

Speaking of class, the last couple of days in biostats have just been insane. First of all, there is no way to really do more than just skim the reading. But this is medical school, and I'm already more or less used to that kind of insanity by now. The worst part is that the classes themselves feel like being in the Twilight Zone. I never thought two hours of my life could possibly go by this slowly. It has to be some kind of new warping of time and space.

This afternoon I went to longitudinal clinic. We don't normally have clinic over the summer, but I'm doing some extra sessions. I was going to do them anyway since I said I would in my portfolio last year. (That was my plan to try to improve my speed and comfort level with the clinical skills.) But now it's even more important that I'm doing it because I am going to miss the fall OSCE in October. (OSCEs are those clinical exams that we have to take to prepare us for Step II CS.)

My first two patients today were not terribly exciting, but the third one kind of got to me. She has a chronic, debilitating disease and she was feeling really depressed and worried about her finances. I was in the room with a resident and her, and the resident kind of moved on to other physical symptoms after the patient had said she was depressed. So while we were waiting for the doctor, I went back in and asked the patient whether she was thinking about hurting herself. She started just crying like crazy and telling me about how she was alienated from her family and didn't really have any friends in Cleveland even though she had lived here for a long time. I felt really bad and also totally powerless to do anything to help her. I also didn't know how to end the conversation, because it was obvious she wanted to keep talking to me about her problems. When my preceptor finally came in, we wound up spending like another 45 minutes with this patient trying to help her come up with a plan to improve her symptoms enough that she could go back to work and not have to worry about her finances. I don't know if we really did anything to help, but she seemed to feel better when she left. I am totally exhausted now though. I think emotional patients are even more exhausting than physically sick patients, and god help you if the person is both!

Epidemiology, Stats Workshop and Journal Club

Yesterday we had another epi class. I am starting to get the reading done, but I was still kind of lost from being behind. So far though I really like the epi book. It's pretty straightforward to read and the explanations are usually clear.

In the afternoon, my partner and I did our stats workshop presentation. It was just on descriptive statistics, which is kind of boring, so we decided to go ahead and do some t-tests to figure out whether the associations in our data set were significant. It turns out that most of them were, but of course that doesn't explain why they turned out that way. This is one of the weaknesses of association studies as opposed to randomized clinical trials. But that's a discussion for another day. I thought our presentation went well, and as it turns out, we've already done most of the work for the second project since we did the significance stats.

Today's journal club was also really good. One article was about Reye's Syndrome, which is a rare but serious illness that some children get if they have certain viral infections like chicken pox and then take aspirin. The other was about resistance to an antibiotic called ciprofloxacin in the bacteria that cause gonorrhea. That study was done here at CCF. Apparently this was one of the first locations where ciprofloxacin-resistant gonorrhea was detected anywhere in the country. Some claim to fame.

Epidemiology, Meetings, and CCF Movie

The last couple of days have been kind of rough. It didn't help that I stayed up all night Monday reading the last Harry Potter book and felt totally hung over all day yesterday. I am also really behind with my epidemiology reading, partly because I was too brain-dead to do it, and partly because there was so much of it. I felt really lost in class today though, so I need to get back on track with it.

I haven't had much to do for my research this week because we're waiting for an agreement to be signed for the equipment we're going to use. I went to two research meetings yesterday afternoon and it was really hard to stay conscious. Afterward, I went home and just crashed. I was still pretty tired this morning though. I guess it didn't help that I went to school early yesterday to see the Clinical Research Grand Rounds. It was about pain, which sounded really interesting. But the talk itself was kind of disappointing, and it would have been even if I hadn't been up most of the night.

Today after class I read two chapters of my epi book, so I'm feeling a little more like I have a clue. I also went to a movie about the Cleveland Clinic called "All for One." It was actually really interesting. One thing that is kind of disappointing about going to a brand new school like this is that you don't have that same sense of history and tradition that you get at schools where they have classes dating back to the early 1900s or even the 1800s. CCF was started in 1921, and the movie traced the history all the way from WWI to the present, including starting this med school. It's a good reminder that CCLCM didn't just spontaneously begin in a vacuum. Seeing the med school in the context of the Clinic's entire history gives a better sense of how we are part of the larger CCF tradition.

The only other exciting thing is that I found out I'd be missing the fall OSCE because I'll be away presenting my work at a national research meeting. It's pretty lousy timing, but I don't want to miss the meeting, even for an OSCE. I went to find out if there was something I could do to make it up, but there really isn't. So I'm just going to have one less OSCE and fewer clinical evals than everyone else.

Much about Biostats

We had absolutely perfect weather all weekend. It was sunny, maybe around 75 degrees for the high. Yesterday, I finally went to the Cleveland Botanical Gardens for the first time. I'm glad I waited until summer to go, because there are a bunch of outdoor gardens that are obviously only worth seeing during the summer. My favorites were the theme gardens (some of which incorporated waterfalls and musical instruments) and the children's garden. Indoors, there are two rain forest areas, one for Madagascar and one for the cloud forest in Monteverde, Costa Rica. There were chameleons and hissing cockroaches in the Madagascar section. The Costa Rica part was a butterfly garden, and they did a great job with it. I spent spent a few months in Monteverde during college and never saw a single blue morpho butterfly in the wild. But yesterday I saw dozens of them.

The reading load for this weekend was just ridiculous. We were supposed to go through six chapters of statistics for today. Needless to say, that did not happen in my case, although I did get through half of them. We spent the class time working on doing more analyses of data sets using the statistics program JMP (pronounced "jump") and discussing probability. Afterward, one of my classmates and I completed our group assignment for the Thursday afternoon stats workshop that we have this week. The assignment consisted of questions about a data set we had been given, and it required us to perform several statistical analyses using JMP. I'm getting better at using the program already. It isn't nearly as bad as I had thought it was going to be.

Later on, I went back to the hospital and sat in on a training session where the social worker was teaching two of the residents to consent patients. It was kind of an eye-opener for me, because I didn't know anything about this particular project, and some of their explanations majorly confused me. Considering that most of their study subjects won't have completed a year of med school and may not have any science education at all, I can definitely see why it's important to boil down the concepts so that laymen can understand them.

On a not-so-great side note, I found out that next semester, my MS class is being held from 7-10 AM on Thursday mornings. I don't think I even mind the earliness of it as much as I hate the idea of losing those Thursdays every week from now until Christmas vacation. :-(

Clinical Research Journal Club, Consenting, and New Student Picnic

We had our first clinical research journal club today. I was a little wary because last year's basic science journal club could be really frustrating. I often felt like the articles were kind of over my head. It was also very formal and sometimes kind of painful to sit through. On top of that, I couldn't help but notice that this year we have journal club for two hours per week instead of just 1.5 hours like we did before. (On a side note, I am still lamenting the loss of our free Thursdays. For the whole clinical summer block, we have two hours of class every single day. It sounds funny to complain about that when some med schools have class every day from 9-5, but it's all relative, isn't it? Luckily, we'll get our free Thursdays back once we start our next block in September.)

Anyway, today's journal club was pretty fun. First of all, we were sitting around a table where we could more or less have a group conversation instead of it being like a formal talk where one person was at the front lecturing. So it was much more informal, and that stimulated a lot more participation than last year's journal club did. Second, the papers were comprehensible and interesting, and I didn't have to google every other word to figure out what the heck they were talking about like I did last summer. And finally, our general research ethics focus for the week is the kind of topic that tends to stimulate discussion. I'm going to be leading my journal club discussion the week after next. My article is about drug-eluting stents, so I think it should be a good one because of how controversial these stents are.

This afternoon, I went with the social worker to consent another patient. She had met with seven patients yesterday while I was in the OR plus another one this morning, and all eight of them had agreed to join the study. But the one we spoke to this afternoon didn't want to participate because he didn't want to take the chance of winding up in the placebo group. He really liked the idea of getting the experimental treatment, but he said he'd only be willing to join the study if they'd guarantee that he'd be put in the experimental group. Well, that's not possible, because the trial is randomized, which means that a computer randomly picks which group each patient joins. If we started letting people join whatever group they wanted, then it wouldn't be very random! That's now three out of three patients who have turned down joing the study while I was there with the social worker to consent them. I'm already developing a reputation for jinxing her by my very presence.

This evening there was a picnic for the new first years at one of the Cleveland Metro Parks. I wasn't planning to go, but one of the first years talked me into it. I had already met several of them at school, and I met most of the rest of them at the picnic. The new class seems really diverse and cool, and it's fun having a bunch of new faces around. By the way, if any of you first years are reading this, in the near future you should definitely get your hands on a copy of the Costanzo physiology book they were raffling off at the picnic. Read the first chapter on cellular physiology now during summer block, because in October you are going to jump right into cardiopulmonary physiology without any general intro to physio whatsoever.

Classes, Mock IRB Session, Grand Rounds, and More Cardiac Surgery

Yesterday's biostats class was on how to build databases in a computer program called JMP. So far, the program hasn't been as scary as I was expecting it to be. After the class, we had a mock IRB session where several of the CCF IRB members discussed some real protocols that had been submitted to them from CCF researchers. We were able to also ask questions of the IRB members, and there were some interesting issues that came up. One was whether it is ethical to conduct a clinical trial with a placebo arm if there is a known treatment (the standard of care) that is already proven to be superior to placebo. In this specific case, there was one. So some of the IRB members (and I as well) had concerns about this.

The mock IRB session tied in well to today's epidemiology class, which was about clinical equipoise. Equipoise means that there is a real uncertainty about which of two treatments is superior to the other (including a treatment versus placebo if no treatment for that disease is currently known). We read an article for today where the researchers had performed a sham surgery in the placebo arm of the trial. In that case though, I think it was appropriate to do the sham surgery because the purpose of the study was to decide whether the standard treatment really was superior to placebo. It turned out that it wasn't.

Before class this morning, I went to the Internal Medicine Grand Rounds. It was about the General Clinical Research Center (GCRC) here at CCF. The speaker talked about some of the clinical experiments going on at CCF and the services that the GCRC provides. She was also talking about CCF setting up future clinical research collaboration with Case, University Hospital and Metro Hospital, including training opportunities in clinical research. It will be too late for me of course, but it sounds like there will be a lot of opportunities for clinical research training here in Cleveland in the future.

I spent all of this afternoon in the OR watching cardiac surgeries. One was being done because the outside covering (called the pericardium) of the patient's heart was sticking to the heart itself so that there wasn't enough room for his heart to contract and expand properly. Another surgery was for a patient whose aorta (the big artery coming out of the heart) was partially blocked. There was a third patient who was having a coronary artery bypass graft, but I had already been in the OR for five hours at this point, and I didn't want to stay longer just to see another bypass graft. It's really interesting to see all of these surgeries, but I have to say that I'm completely exhausted now.

First Epidemiology Class and Consenting Patients

The topic of our epidemiology class this morning was ethics of clinical research. It's very timely for what I've been doing in lab this past week and a half. We spent part of the class going over factors that are necessary to make clinical research ethical. But we spent a lot more time discussing something called the therapeutic misconception. This means that patients, when they sign up to join a clinical trial, often believe that they are signing up for therapeutic care that will benefit them personally as opposed to research where the benefits, if any, are unknown. It is a problem because studies show that many patients do not have a very good understanding of the level of personal risk or benefit they can be exposed to by participating in a clinical trial.

The social worker and I went to consent two patients this afternoon. We didn't even try to consent the first patient because apparently there was some kind of problem and the patient was meeting with the ombudsman. We had to wait for about an hour until the second patient was available. There were two other study coordinators who had already spoken to her. One of them had gotten her to sign up and the other had not. As soon as the social worker started speaking to her, it was obvious that she was not going to be a good candidate for any ethically-run clinical study. She was one of those people who pretends like she knows what is going on even when she doesn't. When the social worker asked her if she had ever heard of the procedure being tested in this clinical trial, she started rambling on about researches (sic) and expressed her concern that the residents might be terrorists since some of them are from other countries! So the social worker told her that probably she should just pass on this trial. The patient agreed, and we left empty-handed and disappointed. But I really think that the social worker absolutely did the correct thing by not enrolling this woman. Even though she didn't understand a thing, she continually tried to pretend that she did.

Another Surgery and First Biostats Class

Friday was a quiet day. I went to the uniform room to pick up my scrubs, did some more reading about research ethics, and had another orientation about consenting patients. In this research group, consenting is usually done either by a social worker or by one of the residents. I'm going to be allowed to do it also after the social worker trains me. I'll be shadowing her either this afternoon or tomorrow afternoon when she meets with a patient. Basically, the purpose of these consenting meetings is to explain the research and protocol to the patients so that they can make a decision about whether they want to participate. In order to join the study, the patient has to sign a document attesting that they understand the study and that they are willingly agreeing to participate. This is the informed consent document.

This morning, I saw my second surgery. I had to come in at the crack of dawn again, but it was really neat. The patient was having a coronary artery bypass graft. I was there while they prepped him and obtained the veins from his leg. (They use those to bypass the clogged coronary arteries.) But I couldn't stay for the rest because I had my biostats class at 9 AM.

It seems like the biostats class is going to be pretty intense. We're going to have 18 two-hour morning sessions this summer and some afternoon group presentations every other week. So far things haven't been too tough as far as the stats themselves go, but I'm still withholding judgment about the statistical program we're supposed to use. It's called JMP, and the instructor told us that it was very easy to use. I'll get back to you on that one after I finish downloading this enormous file that I need in order to install it....the good news is that we have a TA for the class. He's a biostats PhD student from Case.

I had some free time in the afternoon, so I was doing some of the reading for tomorrow's class. We were assigned to read two articles about research ethics. I had been thinking about doing a research ethics class for my MS elective. But amazingly, I'm starting to feel like I'll have gotten more than enough exposure to issues of research ethics after this summer!

More Clinical Research Training and Two Seminars

Today and yesterday weren't nearly as exciting as Tuesday was, but I still got a lot accomplished. Yesterday I was still so exhausted from the day before that it was difficult to drag myself out of bed in time to get here by 9 AM. Actually I was kind of dragging all day. But luckily I didn't have to do anything more active than read more of the clinical research training manual, pick up my scrubs from the uniform room, and go through an orientation about submitting institutional review board (IRB) forms. All of the IRB submissions occur completely electronically here at CCF, which is very cool. When you answer the initial questions the site asks you, it automatically generates forms for you and tells you what documents you need to upload for the IRB to review your research. (The IRB is a committee that is responsible for protecting the rights of human research subjects.)

One of the residents was making fun of me yesterday for actually reading through the research manual, because it's like 250 pages and kind of dry. But I was glad that I had read some of it, because otherwise I would have had no clue when the person giving me IRB training was talking about. She was asking me questions about things like investigator brochures that I hadn't even heard of before I started reading the manual. (Investigator brochures are for clinical trial drugs that haven't been approved by the FDA yet. They basically function like the little warning sheets that come inside the packaging of all marketed drugs and tell you what all the known side effects might be.)

Today I've continued reading the manual, and I'm finally done. I was determined to finish the whole thing by the end of today so that I can do something else from now on. I also had a second orientation about case report forms, which are the forms where the official data from the clinical trial are recorded. Again, I only knew anything about what the guy was talking about from reading the manual, because I didn't know about case report forms before I got here either.

I also went to two Grand Rounds today, one for internal medicine this morning and another one for wellness at lunchtime. The internal medicine one was about drug eluting stents. Stents are little metal mesh tubes that are used to hold the heart's arteries open in people whose arteries are clogged. Well, the drug eluting kinds prevent the arteries from re-clogging better than bare metal stents do, but they apparently increase the risk of getting a blood clot. The good news is that co-administering certain drugs seems to decrease the risk of getting blood clots in people who have drug eluting stents.

The wellness talk was about obesity in children and teens. Probably the most interesting thing that I learned is that Cleveland is the 12th fattest city in the country, with 30% of children under age 18 overweight. She also mentioned that about 80% of obesity is attributed to genetic causes, and her group is trying to work with the remaining 20% that can be affected by behavior and environmental modifications. The worst news is that in order to gain ten pounds in one year, you only need to consume an extra 100 calories per day. I have to say that I've become a lot more aware of my own lifestyle habits since starting medical school. Seeing pictures of atherosclerotic arteries from obese middle school-aged children will do that to you....

Starting My Clinical Summer Research

This week is officially our last week of break. But I'm already back in Cleveland to start my summer research because my fellowship is for ten weeks, while our summer block only lasts for nine weeks. So far it's going pretty well, even though yesterday morning when I showed up at 9 AM like my PI told me to, no one seemed to know that I was supposed to be there! It turns out that the med school had told them that I'd be starting next week instead of this week. The other not so good thing is that the department still hasn't received any money for my stipend, so it may be a while before I get paid. It's not the end of the world because I didn't expect to get paid until the end of the summer anyway. As long as I get paid eventually, I'll be happy. I didn't really do much interesting yesterday beyond meeting the other team members, reading the study protocols, and doing some of my online training.

I had the coolest experience today though--I saw an open heart bypass surgery. The surgeon cut open the patient's chest, and I was actually watching his ventricles contracting! It was so amazing. After they stopped his heart and started repairing the valves, it got kind of boring. Without the heart beating, watching the surgery didn't look much different than watching someone cutting up the inside of a cadaver. On the bright side, I'm super glad that we used fresh cadavers in anatomy last year, because I didn't get sick today at all. The OR staff kept telling me to let them know if I didn't feel good because they'd had some previous observer faint or something.

The study I'm working on is pretty labor intensive, and I had to get here at 6:45 AM because the surgery started at 7 AM. But I have to say that it was totally worth it, and I am really looking forward to observing some more surgeries. I still don't think that I would want to be a surgeon for the rest of my life, but I can definitely understand why a career in surgery would appeal to certain people. Not too many people can say that they've held a living man's beating heart in their hands.

Yesterday was also the first day of orientation for the new first years. I have to remember from now on to add a year to everyone's status, including my own. I caught myself a few times today telling people that I was a first year student....um, I mean that I just finished my first year and am starting my second year. :-P

FAQ #29: What Books Do You Use for the ERB and HIM Blocks?

For the Endocrine and Reproductive Biology (ERB) block, you really don't need a supplemental book. Most of the assigned readings come from Boron. There are also optional readings that come from another book and that were posted on the portal as additional reading. I'm not sure what book those optional readings came from, but I liked that book's coverage of these topics WAY better than Boron. After the first week, I mainly read the additional readings instead of the Boron readings.

Hematology, Immunology, and Microbiology (HIM) block:

For immunology, you should get Immunobiology: The Immune System in Health and Disease. 6th ed. by Janeway, and also How the Immune System Works by Somparyac. Both of these books are recommended, and I liked them both a lot. It's best to read the Sompayrac book, which is very short and entertaining, early on in the block. Then you can focus on the denser Janeway book afterward. Just in case you're interested, Lippincott's Illustrated Reviews has also just put out an immunology book as of summer 2007. It didn't come out in time for me to make use of it during the class, unfortunately, but it might be a good alternative if you like Lippincott's books and don't like the Janeway book. If anyone reading this post has bought the Lippincott immunology book and is willing to tell me what you think of it, please leave a comment.

For hematology, no additional books are necessary. You might want to go ahead and get the Robbins path book for next year if you haven't already, because there are some very useful heme readings in there. Also, we weren't ever assigned any readings from the Hematology for the Medical Student book that we bought last fall, but I read several chapters out of it and found it to be a very helpful book for heme. Some of the heme articles we were assigned to read weren't as good as the readings from these two books.

For micro, I had bought a book from one of the upperclassmen as my main text called Sherris Medical Microbiology: An Introduction to Infectious Diseases. 4th ed. by Ryan. That was the book used by the first two CCLCM classes, and I just read the appropriate sections depending on what topics we were covering. The new required book for my class was Medical Microbiology by Murray, but you can use either that one or the Sherris book. Whichever text you buy, I recommend also getting Clinical Microbiology Made Ridiculously Simple by Gladwin. It's a much more digestible way to learn micro. Also, if you like the Lippincott's Illustrated Reviews series (pharm, biochem), you might want to also get their micro book. The pictures and diagrams are really awesome and helpful for conceptual learning, and the Lippincott micro book goes more into the clinical aspects of the lab tests than either of the other micro books I bought did.

Last Day of Year One and Promoted to Year Two!!!!!!!!!!!!

We had a second seminar this morning about anti-fungals, but as for the rest of this entire week, it was very hard to stay focused. I spent part of the time finishing up one more last-minute eval that somehow hadn't been in my account yesterday. I wrote to the secretary and swore on my life that last time I checked all of the evals were complete, and this eval hadn't been there! It turns out that it was a computer glitch and not my fault. But even so, I still had to get it done right away if I wanted my MSPRC letter today.

I think we spent about half an hour in PBL. My presentation was the shortest, least complete one I've ever done. When I first got there, I warned my group members that I had twenty slides and a quiz for them. They were starting to argue with me because they wanted to get out early, and finally I couldn't help it any more and I started cracking up. Somehow, no one ever knows when I'm joking! I really only had seven slides, and my presentation lasted about 5 minutes.

At noon, we got our letters. They're a page long, and each one is personalized for that student. The first paragraph of mine says:

"Dear CCLCMer,

The Medical School Promotion and Review Committee met on June 6, 2007 to review your Year 1 Summative Portfolio. Based on its deliberation, the Committee determined that you met the Year 1 standards for all nine competencies and will be promoted to Year 2."

This is followed by two paragraphs about my specific strengths and weaknesses based on what I presented to them, and then a generic paragraph that we seem to have all gotten commenting about the organization of our portfolios. Now it's official: I'm an M2.

We had our last POD session at 12:15 right after we got our letters. I couldn't believe that they scheduled POD on the last day, and I figured no one would show up once they got their letters, but actually most of us did. The speaker does basic science research on preventing rejection in kidney transplants. His work was pretty interesting, but he had way too much material to present. I mean, today of all days was NOT a time when we wanted the speaker to go all the way through to 1:15 PM, which he did. At the end, he asked if anyone had questions, and no one said a word!

So, that's it for year one. We have four weeks off, although I'm only getting three because of my fellowship. Still, I'm looking forward to having some time to chill. I'm going out of town on Monday. Before I leave, I'm going to do consults this weekend with Dr. Tomford, who is an incredibly funny and very knowledgeable infectious disease (ID) doctor here. I'm not really thinking that I want to do ID for a career necessarily, but I just want to see what it's like while I have the chance.

Tuesday and Wednesday Stuff

Yesterday was a really short day. We just had one seminar on HLA matching and blood typing. I think there was another optional micro review session before that, but I didn't go in early. Today we had an antibiotics pharm seminar and PBL in the morning. Then we had a mandatory FCM Course Evaluation in the afternoon. The course director wanted to get feedback from us about FCM, the physical diagnosis class, and the clinics. Several people in my class are unfortunate enough to have to drive long distances for their clinics, which is really going to be hard next year since we have clinic every week. That was the main thing that we talked about during the feedback session.

I don't really have much to suggest on how to make things easier for people who have to drive long distances, so I spent the time working on the eight zillion surveys we have to get done by Friday. We keep getting emails from the college staff to tell us that if we don't get the evals done by Friday, then we won't get our MSPRC letters. It's getting to be a pain to keep filling them out, because they're essays and not just multiple choice. But I can't really complain too much considering that one of my criticisms of some of the FCM faculty was that they didn't provide detailed enough comments so that I could use them as evidence for my portfolio!

Antibiotics Seminar and PBL

We've reached the last week of school! I feel like classes should have ended two weeks ago--I just don't feel very motivated to study at all. It kind of amazes me because this week is going to be all about drugs and bugs, which I like. But even so, I did basically no reading over the weekend aside from finishing "And the Band Played On" and doing my homework from last week. It's like my brain has decided to go on vacation already.

The classes themselves were good, but like I said, I am just not focused on them. One of the two pharmacists that I really like was leading our seminar. We went through several cases, and it was tough to concentrate. Even for PBL, people have not really been in the mood. We're doing our last case this week, and I think all of us just feel burned out and not in the mood for it. I still can't bring myself to go to the gym, so I'm going home instead. To do what, I don't know. Maybe I'll feel like doing the reading for tomorrow later tonight. Yeah, right.

Virology Seminar, PBL, POD, and CHI

I had a very busy day today. We started with a virology seminar on HIV that I think was a bit too elementary. It wasn't bad, but I had done some extra reading, so it was just kind of tedious. By the way, for anyone who is interested and has a copy of the big Robbins path book, there is a very nice section on the immunology of HIV in there. It's only about 10 pages. I just bought this book recently, and I've been reading random sections from the micro and immunology chapters here and there. So far I really like it, much better than I liked the Boron physiology book we used this year. Lately I've been reading sections of the Robbins book instead of some of the random readings we're assigned sometimes.

We were done early with the learning objectives in PBL, so we spent some time talking about the social issues of the case. I don't normally like to spend PBL time discussing these things, but I'll concede that it was pretty relevant to this case. Still, I would have rather gotten out of class earlier. I'm reaching a point of saturation where I'm really tired of sitting in classes and eager to be done with them altogether.

The POD talk was given by one of the same docs who spoke during our seminar this morning. It was about the history of HIV research. The talk was really interesting, especially because this speaker has been involved in HIV research for many years, and he knows many of the scientists whose work he was telling us about. He also mentioned a book I read several years ago in college called "And the Band Played On" by Randy Shilts. It's about the first several years of the HIV epidemic during the Reagan era. The focus is mostly on the U.S., but it talks a little bit about the spread of HIV in other countries too. I've started re-reading the book, and somehow the experience of reading it is very different now. I don't know if it's just that I'm older, or that I've been in medical school for a year already, or some combination of the two. But I really struggled to get through it the first time, whereas now I feel like I could stay up all night reading it.

I left POD a few minutes early so that I could meet with my PA briefly before I went to volunteer at CHI. We did our last CHI screenings for the year today. I was taking blood pressures. All of us were acting a little silly anyway, and since several of the patients brought their kids, we just got sillier while entertaining them. I took the blood pressure of a three-year-old after she saw me take her mom's blood pressure and wanted me to do hers. It was incredibly low, and I had to listen really hard to hear it. I also had to use the tiniest little peds cuff I have ever seen. As soon as I finished taking her blood pressure and removed the cuff, she solemnly held out her other arm. So I took her blood pressure again on that arm. I can't say that I ever see myself doing peds as a career, because being around screaming kids just makes me want to kill myself. But I have to admit that this one was really cute.

Two Seminars and PBL

I have nothing too exciting to report for today. We had two seminars, one on miscellaneous bacteria and one on platelets. We had kind of covered platelets a couple of weeks ago, so a lot of the material for today was review. My PBL group was right about the patient in our case. He did have a second diagnosis. My learning objective is on the pharmacology of anti-retroviral drugs.

I haven't been going to the gym at all for the past couple of weeks even though I have more than enough time to go now. I don't know if it's just that I'm exhausted or that the weather is so beautiful or what, but somehow I never feel like going. Every single day after class I struggle with myself about whether I'm going to go, and every single day I come up with some excuse not to go. At least I've been going for walks in the evenings though, so it's not like I'm not getting any exercise at all. As much as the weather here sucks in the winter, the summers are gorgeous. I guess that there are good seasons and bad ones pretty much everywhere.

Fungi and HIV/AIDS Talk

There was a morning review session for micro, but I decided not to go. I just don't feel like I get as much out of the seminars in comparison to reading the material myself, and it's not like I don't have enough reading to do without needing extra classroom sessions. Actually, this has been the first week where I've more or less been keeping up with all the reading. I have no Masters class, no FCM class, no portfolio, no other outside things to do at all besides the readings for school. I did go to the regular seminar at 10:00, which was about fungi. I don't think that microbiology is the kind of thing that you can really learn much about from a lecture though.

After class, the HIV/AIDS Interest Group had a speaker from Oberlin. She is a social scientist who studies how the media portrayals of the HIV epidemic and people who are HIV+ affect societal views about whose "fault" it is when people become HIV infected. The particular work she was telling us about is related to men on the "down low," which is kind of loosely defined as men who are heterosexual on the surface but secretly have sexual encounters with other men. The portrayals in the mainstream media tended to look at these men as bisexuals who are secretive or dishonest, and as people who spread disease to innocent heterosexuals, especially women. The portrayals in the black media also focused on increasing the visibility of men on the down low and protecting black women, but there was also more of an examination of the historical mistrust between the black community and the American public health system. It was an interesting talk, and it didn't hurt that that the lunch was catered by Cedarland (a really good Lebanese restaurant on campus) either!

Anatomy and PBL

I had a very pleasant, relaxing weekend. There were no portfolio essays to write--I only had to do the usual SAQs and CAPPs. Even our anatomy reading for today was pretty minor, just 8 pages. We did a review of the cranial nerves. It wasn't a bad idea to review them, but I wish we had done this about six months ago when we were struggling to learn the cranial nerve exams in Physical Diagnosis class. Now it's a little anti-climactic.

The new PBL case is pretty interesting so far. Some of the symptoms don't fit with the diagnosis though. I think that this will end up being another case where the patient has two different problems.

I met with my summer research preceptor after lunch to discuss what I'll be doing this summer. I'm going to be working on the same project that I wrote about in the protocol for my clinical research class. I'm really excited about doing this project. My preceptor gave me a copy of the final protocol to read over break, so I'm pretty much all set.

Blood Smears, PBL, POD, and Portfolio Done!

I am happy to report that I turned in the hard copy of my portfolio yesterday without a hitch. So that's it. I'm officially done with my first year of medical school now except for the last couple of weeks of class.

We were divided into four groups of eight for seminar. My group's seminar leader was the same hematologist who had been my communications preceptor. I really like him, and the workshop he conducted for us today was pretty good too. We worked our way through several cases of blood cell disorders and looked at slides of blood smears. As much as I usually hate histology stuff, these were interesting. I think I already mentioned that one of the pathologists promised me that I'd enjoy path way more than I like histo. So far at least, that seems to be true.

Yet another PBL patient survived her illness, thankfully. After having had two in a row die on us, now I'm a little paranoid about it. It sounds kind of silly on one hand, because of course we're not really seeing these patients. But the cases are based on real patients, and it's very real to me in that sense at least.

I really loved today's POD talk. It was about stress and its effect on the immune system. Dr. Moravec, who runs the POD sessions, gave part of the talk. But the main speaker was a CCF psychiatrist. He gave us some articles about things we could do to reduce stress. (Gee, I wonder why they thought we'd be feeling stressed the day after our portfolios were due???) The best part of the talk was toward the end, when he hooked up one of my classmates to his biofeedback machine so that we could see how someone's stress level could be measured. My poor classmate was kind of volunteered involuntarily, but was a very good sport about it. I think that this was one of the best, if not the best, POD talks that we've had all year.

Parasitology Seminar, PBL, and More Portfolios

I am ridiculously tired today, and I came into seminar having done basically none of the copious amount of assigned reading. I meant to do some of it last night. But one of the upcoming first year students is here visiting, and we went for dinner instead. (If you're reading this, and you know who you are, I swear I'm not blaming you!) On the bright side, I made the last set of corrections to my portfolio essay, and now all I have to do is print out the essay for my hard copy and upload the web version. I'm so happy about being done with my portfolio.

We have a short PBL case this week since there was no school Monday. The cases have been getting more complex all year, and now we're getting some where there is more than one thing wrong with the person, or where there is some set of symptoms that kind of leads us in the wrong direction for a while. It's good in a way, because we still get the learning experience of the wrong turns we take. It's probably also good to teach us not to immediately jump to conclusions about a patient's diagnosis! My learning objective this week is about the epidemiology and treatment of infection by Plasmodium parasites. They are the organisms that cause malaria.

I have this afternoon free, so I am going to finish off my portfolio, run some errands, and go to the gym. I would have tomorrow completely off, but I have to come in and meet with my PA at 4:30 to get my portfolio signed off before I actually turn it in.

Portfolio, Dermatopath, and Clinic

I got my PA's comments about my portfolio over the weekend, and I just finished making the changes. Most of them were pretty minor things, but I still had eight pages of them to go through. Unless I have to make any other last-minute changes, I'm pretty much finished. I came in over the weekend and printed out all of my evidence. Now I just have to number it all, print out the final copy of my essay, and upload the essay to the portal for the MSRPC to read. They'll start reviewing us on Monday, and we'll get our letters on the fifteenth.

We don't have FCM any more for the year, so we didn't have class until 10 A.M. today. It was a seminar on the histo and path of skin. Ok, I know everyone says that derm is such a great field and all because of the hours and the payments. But it's seriously incredibly disgusting. The blisters and acne and moles and cancer and ulcers....how do people stand looking at this stuff all day, every day? I'd rather not be a doctor at all than be a dermatologist.

It was a slow day during clinic today. I only had one patient, and then I saw a second patient with one of the residents. There weren't any other patients coming and it was pretty quiet in the whole unit, so I went back to the student lounge and started working on numbering my references. I wasn't even supposed to have clinic this week, but my preceptor is going to be out of town next week. So now I'm officially done with clinic for this year, and I'm pretty much done with my portfolio too. Yeah, well, maybe now I can start catching up with some of this week's reading....

Complement Workshop, PBL, CHI, and Hospital Update

We could have really skipped today's seminar. Not only did it basically just go over exactly what I was about to cover for my PBL learning objective, but it wasn't really adding that much new information to what we had learned about complement a few weeks ago. On the bright side, it did make my learning objective presentation more interactive since my group members already knew most of the stuff I was going over. Also, the seminar speaker tried to make his session fairly interactive.

We didn't have POD today because the speaker had cancelled, but I still didn't go home because I was signed up to volunteer for CHI. I used the time in between to run some errands, one of which was to go over to the billing office to pay off my debt from visiting the ER three and a half months ago. When I got my initial bill two months ago, I was charged about $250 after my insurance was billed for about $1250. There was a number on the bill to call to request bill forgiveness for financial hardship, so I called it. On one hand, $250 isn't an astronomical amount of money, but on the other hand, I AM a student, and I don't exactly have a good-paying job. So it really is kind of a hardship for me.

The lady in the billing office took down my name and address and mailed me a form to fill out to request bill forgiveness. I got the form about a week later, filled it out, and sent it back. Then I didn't hear anything for over a month, until just last week I got a letter back saying that I had qualified for 3/4 of the bill to be forgiven. So I still wound up having to pay $62 and change, but it's better than having to pay the full amount. I am kind of amazed that being a full-time medical student does not automatically qualify me as being too poor to pay, especially when you consider what it costs to go to school here. But I figured at this point it was easiest to just pay the balance and be done.

CHI was kind of slow today, and I only stayed until 4PM instead of 5PM like I usually do. I was weighing patients and measuring their body fat percentages and BMIs. One of my classmates wanted to do the cholesterol checks, and I didn't really care what I did, so I wound up doing something different this time.

This weekend I need to get my homework done (as usual) and make sure my final portfolio is ready. I am going to come in on Sunday to print out all of my evidence from the CCLCM portal. It's kind of silly, but we have to print out all of the evidence plus our essay and file everything into a 3-ring binder. This binder is then added to our permanent academic records in some CCLCM office somewhere. I don't think that the MSPRC uses the hard copy, because we also have to upload an electronic copy of the portfolio essay to the portal, complete with hyperlinks to our evidence. At least Monday we don't have class, but it's not going to be a very fun Memorial Day weekend.

Autoimmunity Seminar, PBL, and Subacute Session

Today was another crazy day. Next year we will be having two clinical days every week instead of just one. I had been thinking that I would like to do my two clinical days back-to-back on Tuesdays and Wednesdays, but now I'm not so sure. I am pretty exhausted from two straight days of clinic. Most of the upperclassmen either scheduled their clinical days on Monday-Wednesday or Tuesday-Thursday. I don't really want to have anything that I have to do on Thursday if I can help it, and I'd rather not start out the week on Monday with a crazy day either. Besides, my clinic day this year was Tuesday, and I don't know how my clinic preceptor would feel about changing it to Monday. I could ask, but it may not even be an option. Probably as long as I have my Thursdays off, Tuesday-Wednesday would be doable. The problem is that I don't know which day my next MS class is going to be scheduled for in the fall yet.

Our seminar this morning was on autoimmunity and tolerance, which is an interesting topic. There is a type of immune cell called a T cell that attacks foreign cells, as I've already explained previously. These T cells have to be "taught" not to attack your own cells though, and how this is done is a pretty hot area of research in immunology. If this doesn't happen, or if there is some kind of accidental recognition of self-tissues as being foreign, then an autoimmune disease like type I diabetes or rheumatoid arthritis can result. One of the most interesting things we learned is that there is some evidence that pieces of certain viral proteins called peptides can mimic self peptides. The T cells then get "confused" and attack body cells that express those peptides as well as cells that are infected with the virus. I read a paper about this that was linking viral peptides with type I diabetes. I don't think that this will ultimately be the cause of all or even most autoimmunity, but it's a really interesting phenomenon anyway because of how it affects our understanding of immune system regulation.

My learning objective for this week's PBL case is on the complement system and how it's related to autoimmune diseases like lupus. We went over the complement system a few weeks ago when we were studying the nonspecific immune response, but all of these concepts are still very important for the adaptive immune response because the adaptive immune response makes use of the components of the nonspecific immune system.

I had lunch with a friend and then I had to go to the subacute facility for another observed history and physical (H & P). We were supposed to conduct a full exam on a patient who was not ambulatory, again while being observed and evaluated. I had a patient whose surgical wound had become infected. He was a very pleasant guy and fun to talk with, but it wasn't very easy to keep the interview on track because he was wanting to tell me stories about things he had done when he was younger. It was hard to stop him not only because I didn't want to be rude, but also because his stories were actually really interesting. So I kept trying to steer him back toward health stories: his own health, his parents' health, and so on. I didn't even come close to finishing the entire H & P, but my observer passed me anyway based on what I had done and invited me to come shadow him. I am going to take him up on that this summer.

Coagulation Seminar, Clinical Research Grand Rounds, and Clinic

We were supposed to have FCM oral assessments this morning, but my group lucked out and our preceptor didn't make us come in. I had suggested to him a couple of weeks ago that he just give us written evaluations, though I don't know if that's why he decided not to make us come in. But these oral assessments really are pretty silly: each group member is supposed to come in to meet with the preceptor for ten minutes. Then we would get to hang around until seminar starts at ten, which really sucks if you're the person with the 8 AM time slot. Plus, since the assessment is oral and not written, you can't even put it into your portfolio. Whatever made him decide to let us off, I really appreciate it.

Today's seminar was about coagulation. We were broken up into four groups, and our leader was an MD hematologist. He was really good. We went through several cases and discussed them. One thing that was especially good about this seminar is that we went into more detail on vitamin K and its deficiency. The Hematology for Medical Students book, which I really like on the whole, doesn't cover that topic too much. I wound up printing out a copy of the vitamin K cycle and pasting it into my book.

Our seminar group ran a little late, which was unfortunate because the Clinical Research Grand Rounds were also today at noon. One of my classmates and I raced over to the Bunts Auditorium to hear it. (Bunts is all the way over in the hospital, so it's a pretty good hike from the LRI.) Today's speaker was the head of the Family Practice Department at CCF, and he was telling us about some of the research projects that are being conducted in the CCF satellite outpatient clinics. Having general practice physicians do this kind of work is a fairly new development at the Cleveland Clinic, but the patient volume at the satellite clinics is so large that it's a unique opportunity to conduct some of these studies. Plus, the patients and several of the physicians were really gung-ho about getting to participate in research. The talk was pretty interesting, but I had to leave a little early because I had clinic right at 1:00.

My regular clinic preceptor is still out, so I worked again with the same substitute who was helping me last week. Today we saw mostly mundane cases, except for one really cool patient who was very elderly. He was telling me stories about things he had done during World War II and how he had built up his business. His reason for coming to the clinic was that he had started taking naps every day, which he never used to do when he was younger, and now it was hard for him to play a full round of golf without having to take rests. All I can say is that I hope my biggest problem when I'm his age is that I can "only" play half a round of golf without taking a rest!

Anatomy, PBL, and Portfolio Draft Due

We're only having anatomy sessions every other week now instead of every week, and the topics we're covering have nothing to do with what we're studying this block. But since we didn't have enough time to cover this material during the neuro block last winter, we have to do it now. Our session today was about the eyes and included the normal prosections and radiology. This was the first time all year that we've actually seen the cadavers' faces. (It's kind of hard to see their eyes without seeing their faces!) Seeing their faces didn't bother me too much. The creepiest part was the prosection where the brain had been removed and we were looking down into the orbital cavity from the top. You could see the white part of the eyeballs in there, and they were all kind of wrinkly-looking like a ball that has started to deflate. I touched one, and I was able to press my finger right into it. The resident said that this happens because the fluid tends to come of people's eyes after they die.

I think a lot of my classmates didn't like today's anatomy session too much because the classroom part of it, which covered the ocular muscles and how to test them, was pretty confusing. But I had only finished half of the reading before class today anyway. So I came in already not understanding all of the ocular muscles and how to test them, and it didn't bother me that I still felt confused when I left. I plan to read about them tonight. Overall, I think that eyes are really neat and interesting to learn about. I still don't see myself being a surgeon, but I wouldn't mind considering ophthalmology. Too bad it's such a difficult word to spell. :-P

We started a new PBL case this week, and so far it has been a pretty good one. Part of what makes it interesting is that the patient has a lot of different symptoms, and she's also extremely obese. That makes it difficult to decide whether some of her symptoms are due to her having a disease versus just being problems from her obesity. (One could fairly argue, of course, that being this seriously obese is a disease in an of itself.)

Our portfolio final drafts are due to our PAs today at five. I'm completely done with the essay part unless my PA wants me to make any last minute changes. My essay is 18 total pages, 1.5 spacing, 1 inch margins, not including my 105 references. Now, I just have to go back and add in the links to all of the references before I submit it. (My PA is out of town this week, so we're just going to be emailing instead of meeting.) This is actually the worst part of the process as far as I'm concerned. I don't know if you've ever used RefWorks, which is a referencing software, but it is just awful. I never had used it before I came to medical school, but in my limited experience, it is not at ALL user-friendly. I've gotten a little better at it now that I've done this a few times, but it's still a pain. The good news is that so far it looks like I won't need to go hang out in the tech support office this afternoon!

Histology, PBL, POD, and Portfolio Stuff

Our seminar this morning was on the histology of the lymphatic system. It was ok. We also spent some time at the end going over flow cytometry and how it can be used to analyze white blood cells. It was kind of interesting but definitely a bit too long.

This is our first PBL case so far this block where the patient hasn't died on us. We had seven parts to the case today, including a bunch of blood smears and flow cytometry results to look at, so it was kind of rushed for a Friday. There was also an informed consent form included for the clinical trial that our patient was considering, but we basically didn't even get a chance to look at it because we were so rushed. The clinical trial treatment didn't work, but a second treatment did. I think this is my favorite PBL case. It has a little of everything in it, and the patient winds up being cured and going to medical school at CCLCM. What ending could possibly be better than that?

The POD talk was about circadian rhythms and how they are controlled. The speaker is studying circadian rhythms in mice, so of course you get the usual questions about how applicable any of it is to humans. Even though the topic is interesting, I'm not really clear on what this has to do with anything we are studying this block. Maybe there just wasn't room for it during last block.

Right after POD, the CCLCM Cardiology Interest Group had a speaker. There were only about half a dozen of us who went. I was hoping that the talk would be about research, but it was mainly clinical. It's tough to know these things ahead of time. I wanted to leave and go meet my PA early, but since there were so few of us and I had already gotten there late, I wound up staying until the end. The portfolio essays due yesterday were for Medical Knowledge and Clinical Reasoning, but I went ahead and turned in my Clinical Skills and Reflective Practice essays yesterday also. Now the final draft of the essays is due Monday, and the actual finished portfolio is due a week from Thursday. I can't believe how fast the time is just flying by....

Surgery Grand Rounds, Immune System Regulation, and PBL

This morning I went to Surgery Grand Rounds. The speaker is the director for the Center for Neurological Restoration at CCF and is working on neuromodulators. Neuromodulators are "brain pacemakers" that are implanted into the patient’s brain or chest. These brain pacemakers are being used to provide deep brain stimulation for movement disorders like Parkinson’s Disease already, and they are being studied for other disorders like epilepsy, depression, OCD, anxiety, and addictions. The surgery targets the subthalamic nucleus, which has abnormal electrical function in Parkinson’s Disease. Once implanted, the pacemaker sends calming signals to the brain, and the tremor stops immediately. The speaker showed us several patients with and without the pacemaker turned on. One patient was an amateur athlete, and he was able to compete in a triathlon a few months after his surgery!

His newer work is on using brain pacemakers to treat some of the other psychiatric diseases that I mentioned, but I didn't get to see all of those applications because I had to leave for seminar. It was an incredibly cool talk, and I didn't want to leave. The seminar was a workshop covering how the immune system was regulated. It wasn't bad, but in retrospect I wish I had stayed to hear the end of the grand rounds talk.

The diagnosis was given for our PBL case patient today, so now everyone in my group believes me! My learning objective for Friday is about immunoglobulin E and allergic reactions. The subject came up because we were talking about Portuguese men-of-war during the PBL session. Some people hadn't ever heard of them: they are a type of tropical jellyfish that can give a very painful sting and cause allergic reactions in some people.

End of FCM, MHC Seminar, and Makeup Clinic

This is turning into a pretty busy week so far. We had our last FCM session today, but it was just to present the projects we were supposed to be working on. I hadn't really done much of anything toward my group's project and I needed to finish the reading for seminar anyway, so I didn't go this time.

Our seminar was a workshop to go over how special antigen presenting cells (APCs) in the body can activate T cells. T cells are a very important component of the specific immune response. Some T cells can kill infected body cells, and others activate B cells to get them to make antibodies. The APCs present antigens to the T cells using special proteins called the major histocompatibility complex. These proteins are the ones that have to be matched if you want to try giving someone an organ transplant. Your T cells recognize MHC proteins from someone else as being foreign if their MHCs are different than yours. If someone gets an organ that doesn't match their MHCs, then their T cells will attack the new organ and kill it. This makes sense in terms of evolution, because we weren't made to get organs from other people transplanted into us. Of course, for people who need transplants to stay alive, this means that the logistics of transplantation are very difficult. Even when the MHCs of the transplanted organs and the recipients match each other perfectly, the recipients still have to take immunosuppressive drugs for the rest of their lives so that they don't reject the organ.

I wasn't supposed to have clinic today, but I had to make up the one that I missed last week. My regular preceptor is out of town, so I'm working with a substitute this month. My first patient today had a major complaint of being constipated. Since my second patient cancelled, I spent about an hour reading about the etiology and treatment of constipation. It is both disgusting and also kind of fascinating in that can't-look-away-from-the-train-wreck way. Basically, if the stool is hard enough and can't be softened, the doctor has to manually remove it. The only other somewhat exciting thing I did today was to perform a breast exam on a woman. Again, we aren't supposed to do this until next year, but I watched the doctor perform one, and then she told me in front of the patient to go ahead and repeat what she had done. You might be thinking that this would feel totally awkward to me, and you would be thinking right. I tried to just copy what the doctor had done and hoped hard that the patient didn't feel like I was groping her.

The more I learn about the fun in store for me over the next few years, the more I realize that it's a good thing I didn't totally know what I was getting myself into before I applied to medical school. I can tell you for sure though that I have zero interest in being a gynecologist.