More Cool Subspecialty Surgeries

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

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

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

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

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!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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)

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

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!

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???)