My Next Practice Test

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

Last Day of Year 2 and Promoted to Year 3!

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

Dear CCLCMer,

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

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

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

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

Lunch with My PBL Group

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

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

CCLCM Goes Tuition Free!

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

Here is the press release from the Cleveland Clinic:

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

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

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

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

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

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

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

Books for Second Year

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

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

Acids, Bases, and ARBs

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

Intro to Step 1 of the USMLE

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

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

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

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

Done with My Summative Portfolio

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

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

Clinical Reasoning and Communication

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

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

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

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

My Last Patient

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

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

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

Shifting Dullness

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

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

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

Besieged by Reviews

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

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

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

Observed H & P

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

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

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

Spring OSCE

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

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

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

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

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

End of Heme/Onc

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

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

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

Blood Pimping

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

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

Still Not a Budding Dermatologist

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

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

Loving the Blood

We had a really great discussion in PBL again yesterday. I am the computer scribe this week, which is not a very tough job. It basically consists of sending out the discussion topics to the rest of the group at the end of the session. There was a small group seminar afterward on immunological diseases that affect the blood, which was really good. In the afternoon, I had my last acute care session on how to discharge a patient from the hospital. First, I had to read over the patient's chart. Then I went to interview the patient to see how he was doing, and discuss what other appointments and services he needed. Afterward, I briefly examined him and filled out a discharge form. I felt pretty bad for this patient--he is a young man and he has metastatic cancer. He had to have all kinds of surgeries and chemo, and I don't think his prognosis is very good. Not that you'd wish that on anyone, but I feel like it wouldn't seem quite as unfair if he were in his 80s. On the bright side, he is getting to go home at least for a while. Plus, I don't have to write up an H & P on him.

This morning, I had a small group seminar on lymphomas that was EXCELLENT. This guy is probably one of the best seminar leaders that we've had yet. I felt like he really cleared up a lot of things that I didn't understand. Afterward, I had a few hours to study (no FCM!!!), and then I went to clinic. I was supposed to do my H & P today, but my preceptor was out sick, so that didn't happen. As it turned out, one of the residents was also sick, and the place was just jammed. I think every sick person in the entire city of Cleveland was in our office today. I was working with a different preceptor, and I did another Pap smear with her help. This patient's os (the opening of the cervix) was off to the side instead of in the center, and I had some trouble finding it. But other than that, the whole thing went relatively smoothly. I don't know whether I should be glad or alarmed that I've done enough Paps that I'm actually starting to get the hang of doing them....

Stitches for Surgery

Yesterday, the CCLCM Surgery Interest Group hosted a practice session for learning to suture. I really hate going into school on Thursdays when I don't have to. But I'm doing Core I this summer, so I thought I probably should go. Core I, to remind you, includes the surgery, medicine, and family practice rotations. We had a couple of cadavers in the anatomy lab, and we cut their skin and then stitched them up again. After an hour at it, I was finally starting to feel semi-competent at doing the two-handed knot the resident showed me. He was showing some of the other people how to do one-handed knots, but I decided that it was better to stick to one kind of knot and do it well. At the end, there were a bunch of stitches all over the cadavers' arms and legs, like something out of Frankenstein. I don't know if they plan to use these cadavers again on Monday for the first years, but it's going to be hysterical if they do.

Today, we had PBL and then a pharm seminar. They were both excellent, although our PBL patient died. I knew that was going to happen because his prognostic factors from Wednesday were very poor, but it still sucks. Our POD talk was pretty good too. It was about how to improve the consenting process for clinical trials that involve children with cancer. After POD, I went to the OR to shadow one of the docs who had led one of our seminars last block. I had arranged to do this before the break. It was really interesting. I saw a couple of ENT (ear, nose, and throat) surgeries and helped a little bit with prepping one of the patients for surgery. The ENT residents had told us in anatomy last year that the thyroid bleeds a lot when it's cut, and I can now confirm that they were right. I felt a little nauseated at one point, but not bad enough that I had to leave the room.

Progress Notes

Today was a pretty good day. Our PBL group was finally at full strength, and the session went well. I haven't worked with several of the people in my group before, and there are a couple of others whom I haven't worked with since the beginning of last year. The people who were here on Monday decided that they wanted to try having discussions of learning topics rather than formal, presented learning objectives. I was a little skeptical about that, because one of my previous groups had tried it, and it wasn't very successful. We never got a good discussion going, and after a week or two, we went back to the formal presentations. But this group is different. I think it's in large part because most of us are talkers. Not only did we have an excellent discussion, but there were actually points where people were talking over one another. That's not ideal either, of course, but it's loads better than everyone sitting around staring at each other.

Our seminar was good too. We were divided into groups of eight for a tutorial on different kinds of diseases of blood cells. I thought our leader did a really good job. After the seminar, I was watching the physical diagnosis video because I thought I'd have to do another full H & P for my second acute care session, which was this afternoon. But I wound up spending most of the time learning how to read the patient's chart. Unlike the outpatient clinic patients, the hospitalized patients at the Cleveland Clinic still have paper charts. Part of their records are online in Epic as well. Epic is pretty cool once you get the hang of using it. My patient had some chest x-rays, and I could pull them up on Epic and take a look at them. His EKG was not online though, so I had to look in the paper chart for that. The other thing that my preceptor worked on with me was to write the assessment and plan portion of the progress notes. I have not really been doing too much of that in the outpatient clinic, so it's noticeably the weakest part of my SOAP notes.

My last acute care clinic session is on Monday. These sessions have really been super helpful. I am not sure how the faculty preceptors would feel about it, but it would be great if we could do even more of these hospital sessions, maybe in place of some of our outpatient clinic sessions. There are so many things to learn about in the hospital setting that any little bit extra would help us make the transition to the wards in July.

First Day of School Minus Me

I went away for spring break last week, and I was supposed to fly back to Cleveland on Saturday. Unfortunately, there was a huge blizzard in the whole Midwest that day, and the Cleveland airport was completely shut down on Saturday. So after I spent a few hours hanging out in the airport (thankfully they had wifi and I had my laptop with me!), my flight got cancelled, and I had to go wait for another hour at the ticket counter to get a new ticket for another flight. First the lady told me that the earliest they could get me back to Cleveland was Tuesday night. I started giving her this whole sob story about how I'm a medical student, that I'd be missing clinic, etc. etc. I guess it helped, because she did manage to find me a flight home for yesterday afternoon. So I only had to miss one day of school instead of two, and I was back in time to go to clinic today.

It's too bad I didn't originally schedule my flight for Sunday, because apparently Sunday was cold but sunny in Cleveland, and the airport was open. That's my reward for trying to get back early so that I'd have time to do laundry, get groceries, and chill out for a day before going back to school. But there wasn't anything I could do except email my new PBL group and the Monday seminar leader to let them know that I'd be out. It wasn't just me that had this problem--two of my other PBL group members who also had a Saturday flight home got stranded as well.

I finally made it back Monday night after a small detour to Detroit, and I basically just ate some dinner and went to bed. Today we had a seminar on drug discovery in colon cancer. There were five research articles we were supposed to read, and I started reading them yesterday on the plane. The first one was all about some molecular pathway that is involved with colon cancer cell death. Not too exciting. Then, the second paper talked about the same pathway, which is apparently involved in the mechanism of action of a certain drug. Ok, a little more interesting, and I noticed it was work done by the same group a few years later. The third paper talked about a phase I clinical trial, done by the same group and published a few years after the second paper.

Finally, I got the point of this seemingly endless barage of research papers describing these pathways--they are showing the development of this treatment based upon the molecular biology that this research group had been studying. In the seminar, the speaker noted that the drug regimen is now in Phase II trials. I think it would have been better if we'd been given a couple of review papers on the background pathways to prepare us, and then they could have told us the research "story" in class. But anyway, I eventually stumbled across a purpose for it in the end.

We don't have FCM any more for the rest of this year, so I had a couple of hours to study after class, and then I went to clinic. I was really dragging by then, but I got through the day, and I even finished my SOAP note for this week. My preceptor is going on vacation the week after next, so I am going to do my observed H & P next week.

Spring Break!

It's finally Friday, and I am going home for spring break. The rest of this week has been pretty slow. I usually have a clinical correlation or some other clinic thing on Wednesdays, but this week there wasn't one. Not that I could go home early, mind you, because I had to hang around until 4 PM to meet with my advisor about my portfolio. I had brought books with me to study, so it wasn't a waste of time, but I felt kind of grumpy about it anyway when everyone else took off on Wednesday afternoon and I couldn't. The actual meeting didn't make me feel much better, considering that the changes my advisor wants are pretty picky and don't really relate to the content of my essay. Even so, it will still take me a few hours to get them all done.

We got out extra early today because there was no POD, so that was a plus. The cardiac surgeon I shadowed last summer was supposed to lead one of our seminars today, but he wasn't able to get out of the OR. So the cardiologist who is in charge of this block did the best he could to lead the surgeon's seminar, but it was kind of rough going since a lot of the slides weren't labeled and he doesn't know all of that surgery stuff anyway.

I'm on vacation all next week, and I'll be back the second week of March.

YOU: The FCM Attendee

Finally, we have reached our last week before break. It felt like this week would never come, but it is a pretty easy week since we have seen most of the material before. We are covering hypertension and vascular disease. Yesterday, we had a seminar on metabolic syndrome that was really funny. We had been asked to read an article about metabolic syndrome that argues against the existence of metabolic syndrome. The doc who led the seminar is one of the endocrinology block leaders. He's really cool. Anyway, I'm not sure if I left this seminar having more understanding of metabolic syndrome or less, but it was an entertaining seminar anyway. The second seminar on hypertension wasn't bad, but there's just no competition with the first one in terms of the entertainment value.

This morning, we had anatomy lab to go over lung embryology and neck anatomy. I really like that we're doing these anatomy labs this year. Even going over all those stupid neck triangles wasn't so bad now that we've seen them once before. We didn't have any small groups for FCM today, just a speaker presenting, so about half of my classmates decided to bail. That was too bad for them, because the speaker was Dr. Roizen, who gave us all free copies of two of his books. Since there were so few of us there, most of us got a copy of both books. He signed them all for us, too. You can never have too many free books as far as I'm concerned. If you're not familiar with Dr. Roizen's "YOU" books, they're really cute cartoon books that explain medical concepts to laypeople. Even though I already know most of the info in them, they're still fun to read.

I had clinic this afternoon, but it was a slow day. I did see one of my regular patients, a diabetic who comes in for checkups every couple of months. The weather still sucks. It's amazing how many days we can go in a row without seeing the sun in Cleveland. I will never understand what made someone decide that this was a good place to build a city.

I Heart the Heart

I turned in my portfolio yesterday. This is the last formative portfolio that we have to do this year. We have the same nine competencies that we had last year, but there are new standards for each competency that are specific to second year. For example, in research one of the standards is "Applies principles and skills in medical biostatistics and clinical epidemiology to analysis of data." We weren't required to address the specific standards for each competency, but I did it anyway so that all I have to do in April is just update my evidence. If any of you first years are reading this blog entry, you should do the same thing for your last formative too. Trust me on this.

We're back to doing cardio this week, and the seminars have been much better than last week. On Tuesday, we went to the Vascular Lab, where there were four different stations. Two were demos of ultrasounds and the pulse volume recording of a patient whose leg vessels were mostly blocked. Those stations were ok. We also had a nutrition station that was just ridiculous. First we waited around for the doctor for that station to show up. Once he got there, he gave an introduction and then invited the nutritionist to speak, but she didn't get to say more than one or two sentences before we were told to rotate on to the next station. I was kind of annoyed, because nutrition is an important topic, and we got no coverage of it whatsoever. The last station was the best. There was a patient who had familial hypercholesterolemia, which is a disease where the person is missing the receptors for LDL (the bad cholesterol). She had xanthomas in her Achilles tendons due to cholesterol depositing there, so the tendons were incredibly thick. Even I could tell that those tendons weren't normal! I had clinic in the afternoon, and everyone was in a bad mood, including me. Fortunately, my preceptor and I got out early because the 4:00 patient no-showed.

On Wednesday, we went to the Cardiology Exercise Stress Lab, where we saw a patient undergoing a stress test. I took one of these stress tests last year, and it's really hard even when you're young and relatively healthy. This patient was neither of the above, and the test had to be stopped early because the patient started getting some angina (chest pain). We also went over echocardiography and angiograms. It was a pretty good seminar. In the afternoon, we had a really awesome Clinical Correlation, one of the best that we've had all year. First, the cardiology pharmacist came and gave us an hour-long talk about the cardio drugs that he wasn't going to have time to cover on Friday. He is one of the best pharm seminar leaders if not the best, and his talk was really good. Then we had a second talk about coronary catheters and invasive cardiac monitoring, which was also excellent. After that we went and saw a few patients in the coronary intensive care unit (CICU). Overall it was a really long day, and I was tired at the end, but it was a good day.

Today we had the rest of the cardio pharm and then another one of those pointless POD small group discussions. Last week's POD small group discussion was surprisingly pretty good. Only three of the eight of us showed up, and we worked on the project like we were supposed to and even came up with some good ideas. It was almost actually fun. In comparison, this week's session was pure torture. That's about all I can say about it.

Seminars in Solitude

Last Friday's seminar was on the cell biology of atherosclerosis, and only about six or eight of us showed up. I felt bad for the speaker, but the course leaders probably should replace this seminar with something else next year since we've covered this material several times already. At least the assigned reading was decent. Also, our PBL patient died again. I knew he was in trouble since we spent all of last week learning about things like ventilators and living wills, but I still hate it when they die. I can't even imagine how I'm going to feel the first time a real patient dies on my service next year.

Today's seminars were not much more cheerful. They were about end of life issues from a philosophical or social perspective, and it felt an awful lot like an extra FCM session. To say that these seminars did not go over well with my class is a huge understatement. Some people were actually walking out in the middle. Ouch. The atherosclerosis seminar last Friday might have been repetitive, but my feeling is that it never hurts to review important concepts like atherosclerosis. It wasn't very easy to find much redeeming in today's seminars though. Some of the readings were helpful, but the seminars themselves were pretty painful. Hopefully they will be cut out of the curriculum next year also.

This afternoon, I participated in a pharmacology thread focus group. This meeting was similar to the focus groups that are held for each of the organ blocks, only it was for the entire pharm thread for both first and second years. As much as I like pharmacology and most of the pharmacists who teach us, the pharm thread is definitely not the greatest strength of CCLCM's curriculum. I think we made some very good suggestions to the thread leader, and hopefully future classes will have a better pharm experience than we did.

Our second formative portfolios are due this Thursday, and I'm going to be spending the rest of this week finishing mine up. Other than that, there is not much excitement at the moment. The weather is still completely gross. I can't wait for spring break.

The Art of Breathing

Monday's seminar was about breathing control, and it was ok. Our seminar yesterday was a review of acid-base physiology by the same anesthesiologist who taught us acid-base last year. This guy is really cool, and his seminars are always good. I also had clinic yesterday afternoon, but nothing exciting happened this week. (Not that this is a bad thing!)

Today we had a communications class, which wound up being pretty funny. It was about establishing boundaries with patients. I went first in my group, and my standardized patient was asking me questions about another patient. Of course, I didn't know this person he was asking about, and I didn't realize that I was supposed to pretend to know the other patient but refuse to give out any info about him. So every time the patient asked me about the other guy, I kept responding that I didn't know the patient he was asking about. At the end, the preceptors told me that I was supposed to know the other patient. Oops. It didn't say anything about that in the write-up of the patient scenario that we read before seeing our "patients." Hopefully I didn't frustrate the standardized patient too much. :-P

Our communication session ran over time, which made my group late for our clinical correlation to learn about mechanical ventilators. This was kind of interesting, but I think it could have taken about half the time it took. They had us go to a few stations where we learned about the different modes of using ventilators to assist patient respiration. We also saw some patients on ventilators. I'm not sure I still really understand all of the breathing modes based on the wave forms (there are dozens, maybe hundreds of them in all), but the engineers in my group were sure loving this stuff. At one station, they had us try breathing using two of the different respirator modes (pressure versus volume) ourselves. It was surprisingly uncomfortable, as well as difficult, to time my own respirations with the machine's. Now I understand why patients on ventilators often have to be sedated.

Lung Cancer and Laryngitis

This has been a rough week, and I have really been dragging. It felt like Friday would never come. I still don't completely have my voice back even now, but the cough is a lot better. I can talk a little bit as long as I talk softly.

Wednesday was a really long day. I had PBL and a lung cancer path seminar in the morning, then a pulmonary hypertension clinic in the afternoon. That clinic wasn't as good as most of the other special clinics we have done. But I'm not sure how much of it was just that I wasn't feeling the greatest. I think maybe the engineer types liked it, because there was a lot of talk about the pumps used to treat people with chronic pulmonary hypertension. I have to admit that even when I'm feeling well, that kind of stuff really doesn't interest me. :-P In the evening, there was a Dean's Dinner at the Foundation House for my class. Only about half a dozen of my classmates showed up, which is pretty embarrassing. Plus, now the administration is probably going to cancel our spring Dean's Dinner due to lack of student interest, which kind of makes me mad. I really like going to the Dean's Dinners. Anyway, the talk and the dinner were both awesome, and I'm glad that I went.

This afternoon after POD, I had my first acute care clinic. I got lost in the hospital and ended up meeting my preceptor half an hour late. But he was cool about it, and the patient I had was really awesome. I did a complete history and physical on her and went through the steps of getting her admitted to the hospital. She was a woman who came from a rural area and did a lot of chores. When I asked her what the chief complaint was, she said that she was getting short of breath. Then I asked her what she had been doing at the time that she noticed the shortness of breath, and she said that she was chopping wood with an ax. I was thinking that I probably would get out of breath from chopping wood with an ax too, and I'm a lot younger than she is!

Later tonight, I am going to one of the first year's house for dinner. But I am going to take a nap for an hour first, because right now I am just drained.

Lung Infections

When I went to the doctor last Friday, part of the workup involved sticking a Q-tip up my nose to swab for influenza A. Sure enough, it came back positive--I really did get the flu. Talk about bad luck. On the bright side, I'm feeling a lot better now, and I don't have a fever any more. I just don't have any voice--none whatsoever. That made for a pretty hilarious PBL session yesterday. My group tends to be pretty rowdy, and sometimes it's hard to get a word in edgewise. Well, I was in no condition to duke it out with anyone, but my group members were awesome. Whenever I tried to whisper anything, the rest of the group would just stop talking. I don't think I've ever been this nicely accomodated in PBL when I wanted to say something! I had to leave a few times for uncontrollable coughing fits, but otherwise, the session was great. Ironically, the case this week is entitled, "Another Cough," and our seminars yesterday and today have been about lung infections. Here I am, continuing my class's pattern of someone coming down ill with the pathology of the week. I'm just glad that I didn't get sick at the end of the week, when we're going to be covering lung cancer. :-P

I went to clinic this afternoon, and my preceptor was sick too. The weather is still lousy, but all of the patients showed up except one of the 4 o' clocks. So we got done right at 5:00, and we mutually agreed to go home early and review my patient logs next week. I can't even imagine what the patients must have been thinking when we came into their rooms. First, I'd come in alone and get their histories in a whisper. I'd have to hold my own breath when I listened to their hearts so that I could actually hear anything. Then, my preceptor would come in with me, and the two of us would be examining the patient in between coughing fits. We were both way sicker than any of the patients we saw were. This just supports something I read once about how the worst place to be when you're sick is in the hospital. Why? Because that's where all the germs are.

Double Dose of Dentists and Doctors

I have had a pretty sucky past two days, maybe the worst since I started medical school. Where to start....Ok, about a week ago, I began having a toothache. Normally, I get my dental care when I go home to visit my parents during breaks. I've been going to that same dentist for a long time, and I only have to go once every six months, so why go try to find someone new in Cleveland? But this was an emergency, because we don't have another break until March, and I didn't think I could last for a month. I checked my health insurance plan, and it turns out that we do have dental coverage through the Case dental school. They'll even do regular cleanings for us every six months, and it's all covered. I managed to get myself an emergency appointment for yesterday morning.

The Case dental school is a pretty impressive setup. They've got a bunch of huge clinics in there, and the upperclassmen dental students work on patients with their preceptors. I wasn't 100% thrilled about being worked on by a student, but it's not like I can really complain. I mean, my patients let me poke and prod them in clinic all the time, so I'm really not in a position to say that I don't want to be a learning experience for a dental student. Plus, my tooth was really hurting, and I think I'd have just about let someone use rusty pliers on me by that point.

The student I got was very nice and obviously was trying her best. But she was slow, slow, slow, and she didn't do a very good job with freezing my mouth. She basically froze everywhere except the gum by the tooth she was drilling. So I had no feeling in my tongue, lips, or face on that whole side, but boy, I sure felt her drilling me! There was no way I was going to let her remove all of her torture contraptions, reinject me, and start over again though, so I told her to just keep going as fast as she could, and I'd do my best not to jump. I was pretty white-knuckled and had tears streaming out of my eyes, but we got through the drilling and she filled the tooth. So three hours later, the problem was solved, even if it wasn't the most pleasant experience during the actual procedure. (It took three hours because every time she did something, she had to get one of her preceptors to come take a look before she went on to the next part of the procedure. We also had to repeat the x-rays because the first set she got weren't right.) After that, I went home to chill a little.

I had woken up yesterday morning with a sore throat, but it was starting to get worse by last night. Then I started running a 102 degree temperature and coughing up a storm. So I emailed my learning objective to my PBL group and let them all know that I wouldn't be coming in today. I almost never stay home from school, and this is the first time I've ever missed a PBL session except for when I was away at that conference last fall. I didn't want to miss school today, but it turned out to be good that I did, because this morning I started vomiting too. In the afternoon, I got one of my classmates to drive me over to school, and I went to get checked by one of the docs in the clinic where I work on Tuesdays. My preceptor wasn't in today, but one of the other docs was. She told me that I probably had the flu. What!!! That is SO unfair! I got a vaccination last fall, and I still got the flu! It's actually possible for that to happen though, because the flu vaccine manufacturers have to guess which strains are going to be prevalent based on last year's strains, and sometimes they guess wrong. Lucky me.

On the bright side, the doc prescribed codeine to control my cough. I was a little nervous about taking it at first, because I still felt pretty nauseated, and nausea and vomiting are two side effects of narcotics. So I tried taking a half-dose, and it worked pretty well. I think I'll probably be ok with taking a full dose. Codeine is a highly effective cough suppressant. I was able to fall asleep for a few hours earlier this evening without hacking up half a lung. I still can't talk though without going into a coughing spasm, even with the codeine.

After the doc gave me the prescription, I went to get the codeine at one of the Cleveland Clinic pharmacies. While I was waiting for the pharmacists to make it up for me, I was sitting in a chair next to a large candy display. What a racket. I bet they sell way more candy than drugs in there. Every, and I do mean EVERY, kid who walked into that pharmacy with their parent made a beeline for that candy rack. It didn't matter if the kid was a toddler or a teenager. The same scenario then played out over and over again. First, the kid would ask for candy. The parent would say no. Then the kid would ask again, grab some candy, take it up to the line with the parent waiting. Nearly every parent eventually gave in and bought the candy for the kid after saying no multiple times. One guy who was there with his young son was the only parent who didn't cave in, not counting a second guy who carried his kicking, screaming daughter out of the pharmacy after refusing to buy her a piece of candy. All I could think was that if I had behaved like one of those kids, my parents sure wouldn't have rewarded me for being disobedient by buying me a piece of candy!

Cardiopulmonary Week

This week, we are covering pulmonary vascular disease. Our PBL case is a continuation of a case we had last year about a woman who got deep vein thrombosis (DVT), which is a blood clot in the large veins of the legs. You may have heard about DVT in the news. People who are immobilized (ex. bedridden or sitting for hours on an airplane) are at higher risk of getting them. The danger of DVTs is that pieces of the clot can break off and travel to the lungs (i.e., form a pulmonary embolism). Pulmonary embolisms can kill people if they're massive enough. This year, of course, our patient's problems are more complicated. But it's still cool to get a patient that we already "know" from before.

We had another pharm seminar yesterday, and today we had an anatomy session on the embryology of the heart. The actual lab part was mainly a review of the thorax anatomy that we learned last year, which was really helpful. This year I have a much better idea about what I am looking at in anatomy. I really like that we keep doing anatomy second year like this, because it helps to keep it fresh. For FCM, we had patient presentations again. One of my group members who was supposed to present was out sick, so we got out early.

I had clinic in the afternoon. The weather is still not so great, but most of the patients showed up anyway. There is this one older patient whom I've seen several times in clinic, and she came in today. She's always entertaining. Today she was telling me about how she is in such good shape for her age, and what she does to be in such good shape. Then she started telling me that if I follow her rules, I will be in just as good of shape when I get to be her age. She really is in pretty good shape, but it's still funny to hear her talk about it like that.

Kind of a Slow Week

I haven't had too much exciting going on this week since I didn't have any clinic on Wednesday after all. I was supposed to have had my first acute care session, but now I'm having it the Friday after next instead. That made this week pretty easy, which was nice, but it means that I'm going to have a three-clinic week in February now. Oh well. Not that I'm really complaining, of course, because I was very happy to have the extra time to study this week. Plus, it feels pretty luxurious to get home in the middle of the afternoon while it's still light out on a Wednesday!

We're still going through lung diseases. Wednesday's seminar was on chronic obstructive pulmonary disease, and today's was a pharm seminar on drugs for asthma. I really like the pharmacist who led today's seminar. She was the one that I worked with a while back when my longitudinal preceptor was away, and she is super nice and friendly. But this seminar just didn't seem to go well. I don't really even know why. I guess sometimes they just aren't a hit, and today was one of those times. Our POD seminar was on lung stuff too, and it was ok. Maybe it's just the time of year and the cruddy weather we're having, but eh, it's kind of tough to get too gung-ho about much of anything. Our PBL case had a happy ending this week at least, though.