FAQ #23: Is It Possible to Be a Surgeon if You Go to CCLCM?

Yes. I think that about half my class (not including myself!) wants to go into surgery of some type. I've mentioned before how many engineering majors we have, and a lot of them are planning to go into orthopedic surgery. I can also tell you that the Cleveland Clinic has many prominent surgeons working here, particularly in cardiac surgery. I think if you come here and want to be a surgeon that the school will be hoping to get you to become an academic surgeon as opposed to being a private practitioner. But there is definitely no expectation that anyone who goes to medical school at CCLCM must become a bench scientist. In fact, I'd say that the research emphasis here tends to be more on clinical science rather than bench science. From what I can tell, many of the MDs who do research here tend to do clinical research, and that is definitely something that is compatible with being a surgeon.

FAQ #22: What Books Do You Use for the Cardiopulmonary and Renal Blocks?

These are books that are specific for the individual organ blocks. The first three organs that you will cover once you get back from fall break are cardiovascular, pulmonary, and renal. After renal, which we are finishing now, you have two weeks of winter break before starting the next block in January. I'll post the other block books later.

Cardiovascular: The school suggested that we use Berne's Cardiovascular Physiology, which is part of the Mosby series. I like that series in general, so the book is probably decent. But I wound up buying Klabunde's Cardiovascular Physiology Concepts after we were assigned to read parts of that book that are posted online on his website. The Klabunde book is really good, and it comes with a DVD and extra info that was very useful for my PBL presentations. I don't think you need to buy both the Berne and the Klabunde books though, unless you you're planning to go into cardiology or just really like reading about it. We were also asked to buy Schmaier and Petruzzelli's Hematology for the Medical Student. You can get away without having this book during the cardiovascular block, but you'll need it in the spring for the heme block. So I think it's worth getting now. Another book that I found really useful was Dubin's Rapid Interpretation of EKGs. This book is written like a cartoon workbook, but you will learn a lot about EKGs from it, and you can get through it quickly. I don't think it's on the list of suggested books, but it seriously should be.

Respiratory: Definitely buy West's The Essentials: Respiratory Physiology. West is the pulmonary physio guru. His book is awesome.

Renal: You will need to buy Koeppen's Renal Physiology, which is also part of the Mosby series. It's a good book, and I thought it was easy to read. I also bought Rose and Post's Clinical Physiology of Acid-Base and Electrolyte Disorders. There is a renal physio section at the beginning, but this book is really helpful to have for PBL objectives because most of it covers renal pathology. You definitely don't need to have it though, and I think there's a copy available in the library.

Oh, and I'd suggest getting yourself a medical dictionary too. Learning medicine is seriously like learning a whole other language sometimes. I got Dorland's Medical Dictionary, which is pretty good.

Potassium Balance Seminar and PBL

Today was the last day of school for this block, and it was a short one since we didn't have POD. Our seminar was about potassium balance, and I had the same small group facilitator for my problem solving session that I worked with yesterday. Today's session went pretty well too, although potassium isn't as interesting as acid-base is. Again, we worked on several problems together as a group of eight, and the facilitator mostly let us work them out ourselves except for when we got stuck.

PBL probably should have been cancelled today, because we really didn't do much of anything. We just had the one learning objective presentation, and then we spent some time going through the parts of the nephron as a group and discussing how the week had gone. We also talked about how we were functioning as a group and what we wanted to do next block. Then we got out half an hour early, and that was it. We have the next two weeks off for winter break. I am now officially halfway through my first year of medical school, and 10% of the way through my MD degree. Pretty incredible. On a not so happy note, they actually gave us homework (SAQs and CAPPs) to do over break. I'm planning to do mine this weekend before I leave town. We also have a ton of anatomy reading to do for Jan. 8, which is our first day back. I don't think that I'll get through all of that. It's going to be a totally insane amount of work in anatomy next block. I wound up getting a book out of the library that has about 100 pages describing the anatomy and physiology of the musculoskeletal system, and that's what I'm planning to read for the first three weeks of next block.

I'll post a few times over the next two weeks, but it won't be regularly since we don't have classes. Merry Christmas and Happy New Year to everyone reading this.

Proximal Tubule Function Seminar and PBL

Things are finally starting to settle down for the holidays. We had a short day today with nothing planned in the afternoon, so I got to go home early. In the morning, we had a seminar about the proximal tubule, which is part of the filtering apparatus (nephron) of the kidney. It was another small-group problem-solving session, but with a different guy than the one I had last time. I really liked how this guy was less involved and gave us a chance to try to figure out the problems ourselves first, but he still helped us when we got stuck. I got a lot out of today's session, and I feel like I understand the concepts better. Ironically, I wasn't supposed to be in this group, but I remembered the room number wrong and some of my classmates who were supposed to be in that group had gone to different rooms also, so it all worked out.

I finally did figure out the answers for my PBL learning objective about what vomiting does to the patient's blood salt concentration. It turns out that hydrogen ions are not capable of drawing water after themselves when they cross membranes like sodium or potassium ions can, which was what I had thought. But, I was wrong about the idea that the salt concentration of the patient's plasma would change, because apparently along with losing the salt, the patient also loses a corresponding amount of water. Thus, the total salt concentration in his blood remains constant even though the composition of the blood (which salts are there and in what amounts) does change. Well, now we know.

I'm planning to spend this afternoon reading and taking advantage of my free afternoon. As it turns out, we only came up with one learning objective today, so I don't have a learning objective to prepare for Friday. That means tomorrow I can spend some much needed time catching up in anatomy.

FCM, Acid-Base Seminar, and Clinic

FCM this morning was more or less anti-climactic. We were each given a ten minute time slot when we were supposed to meet individually with our small group preceptors to get feedback. That's what we thought, anyway. I figured they'd talk to us about our participation and maybe comment on the essays, which were due yesterday. Instead, my preceptor asked each of us what we thought should be done to improve the course. I suggested continuing to have the small group meetings first before the lectures to prevent speakers from talking too long, and allowing people to choose which volunteer project they wanted to work on instead of assigning us to them. The preceptor agreed that those were reasonable changes to make and wrote them down. We'll see how things go starting in January, I guess.

The acid-base seminar was a problem solving session, and it went pretty well. There were five problems that we worked on as a group. We already covered acid-base chemistry a month ago during the respiratory block, but it makes a lot more sense now that we've gotten some background in renal physiology. You can't really talk about compensation for acid-base problems if you don't understand how the kidneys contribute to the body's acid-base balance. For those of you who are going through this next year, don't feel bad if you don't get all of the acid-base stuff the first time through, because it will all come together a lot better the second time.

I had clinic this afternoon, and I saw two patients. We didn't learn any new physical diagnosis skills, but we were supposed to take family histories. Ok, for those of you who are pre-meds, let me tell you right now that working with standardized patients is NOTHING like working with real patients. You will go on your medical school interviews and your second looks, and they will tell you how seeing standardized patients will prepare you for seeing real patients, but I'm telling you that it won't. It's like the difference between imagining in your mind about what it would be like to ask someone out versus doing it for real. You don't have any control over the outcome of these things when you do them for real. When I did the practice family history last week, it went like clockwork. The actress went through her pretend family members smoothly and efficiently. In contrast, with real patients, things are not nearly as efficient, and there is always some kind of unseen minefield waiting for you to step right into it.

In this case, I was going through the rather extended family history of a very nice but overly talkative older lady. She was telling me all about her multitude of family members. I was really having to work hard to keep her focused on the task at hand and not let her digress too much into stories from half a century ago. Then, with no warning, she tells me that one of her family members was murdered when she was a child and promptly bursts into tears. This is totally NOT part of the script, and nothing in our books explains how to deal with bawling patients whose family members have been murdered. I offered her a tissue along with my condolences and asked if she'd like to discontinue the interview, but she said she was fine with finishing. The one good thing was that she wasn't as talkative after this, and we were able to get through the rest of her family members relatively quickly. As it was, I spent about 45 minutes with her, and my preceptor was kind of annoyed with me about that. My second patient was much more reserved and did not have any murdered family members that she told me about. So we got through her family history in about 10 minutes, and I somewhat redeemed myself.

Christmas Caroling, Anatomy, PBL, and Cardiology Talk

Last night, I went Christmas caroling with some other medical students at the Hanna House over at Case. Hanna House is a residential rehabilitation center. We went from room to room singing whatever Christmas songs the residents requested. They were really glad to have us there. This one cute old lady was following us in her wheelchair so that she could hear the songs we were singing for the other people. In another room, the nurse asked the man who was staying there if he wanted to hear us sing. To her surprise, he said yes. (Apparently he is normally a big grump.) When we left the room, I heard her exclaim to him that she had seen him singing along with us. Going caroling like this was kind of spontaneous. We got together and practiced the songs for about an hour, and then we went to sing them at Hanna House for an hour afterward. I had never gone Christmas caroling before, but it was really fun, and I'm glad that I went. I would definitely do it again next year.

We had anatomy lab this morning, and the clinical case was mostly covering the embryology of the uritogenital system. We did some review of the abdomen and went over the ribs and vertebrae as well. But the really cool part about anatomy today is that we did a laparoscopic nephrectomy on a cadaver. That was seriously awesome. The urology fellows inserted a camera and two cutting instruments through small incisions in the cadaver's side, and all of us got to take a turn at operating the camera and the cutting instruments. You are watching a TV screen while you do this surgery, and it's just amazing. I still have zero interest in being any kind of surgeon whatsoever, but if I were going to do surgery, I think that laparoscopic techniques are definitely the way to go. Apparently patients recover from them faster too, and the surgeries can take less time since there's no need to sew the patient up afterward.

Our new PBL case is about a guy who has been vomiting for the past few days. Naturally, this has totally screwed up his electrolytes (sodium, acid-base chemistry, potassium, etc.). We had a long discussion today about whether vomiting would change the concentration of salts in his blood or not. The group was pretty much split half and half on it, and my learning objective now is to find out one way or the other for Wednesday.

In the afternoon, I went to the gym and stopped by the anatomy lab to look at the bones again. Then I went to the hospital to hear a cardiology talk. This research group figured out a way to miniaturize a cardiac ultrasound probe so that they could image atherosclerotic plaques in the arteries of living people's hearts. The transducer is 1 mm in diameter, and it rotates around inside the vessel, producing an ultrasound picture of the inside of the artery and showing the plaques. This technology allowed them to learn some important things. One is that with early atherosclerosis, a plaque develops in the artery wall, but the open part (called the lumen) is still ok. As the atheroma develops, the lumen didn’t really narrow in most cases. It is important to know this because if you did an angiogram, you won’t be able to see the plaques, so you wouldn’t know that there was any coronary artery disease (CAD). Young, healthy people (even teens) who eat Western diets have extensive CAD, particularly if they are obese. When the researchers examined multiple heart transplant donor hearts, 17% of teens, 37% of people in their twenties, 60% of people in their 30s, 71% of people in their 40s, and 85% of people over age 50 have plaques. The plaques are all over the body, not just in the heart. The research group also found that lower cholesterol leads to much lower risk of CAD, so now they are working on developing new drugs to lower patients' cholesterol levels.

FAQ #21: What Books Do You Use for the Clinical Threads?

I already posted the books we use for the summer block, but here is a list of books for the clinical threads in Year 1. The threads include anatomy, biochemistry, cell biology, embryology, genetics, histology, pharmacology, and physiology. There are also two books that you need for physical diagnosis and communication skills. You will use these books all year long, some of them over the summer as well. There is another list of books for the individual organ blocks that you will mainly only use while you study that organ system. I'll post the list of those next week, because I don't want this entry to get too long.

Anatomy: We use Dr. Drake's own book, which is called Anatomy for Students. It comes with online anatomy and embryology modules also. Apparently some people mainly use the modules and don't really read the text, but I do just the opposite. I've just never really gotten into the modules. I recommend buying the book, because you'll probably need it to do the SAQs. I also got a copy of Netter's Atlas of Human Anatomy, which is not required. You could definitely do without having an atlas, but I like looking through there every now and then. Dr. Drake is apparently going to be putting out his own atlas by the time you guys will be starting. So if you want to buy an atlas, you might want to take a look at his too before deciding which one to buy.

Biochemistry: See my previous post on summer books.

Cell and Molecular Biology: See my previous post on summer books.

Embryology: Our recommended text is Langman's Medical Embryology by Sadler. I bought it and feel that it was worth buying, but a lot of people just use the online embryology modules that come with Dr. Drake's book. If you like using the modules, you don't need to buy this book.

Genetics: See my previous post on summer books.

Histology: We use Kierszenbaum's Histology and Cell Biology along with Gartner's Color Atlas of Histology. I don't love the Kierszenbaum book, but it's ok. I think you could use a different histology book instead and it might be easier to read. The histo atlas is a good book, and it comes with a DVD showing slides along with practice USMLE questions. I recommend buying that one. I've also done some looking around the SIU histology website, which is really good.

Pharmacology: We use Katzung's Basic and Clinical Pharmacology. You don't have to buy this if you don't want to because it's available on line through the CCF library. You can print out the chapters or just read them on the computer. I did decide to buy it though because I hate reading books on line, and I'm very interested in pharmacology. Most people in my class, including me, bought Lippincott's Pharmacology by Howland and Mycek. It's good because there are short chapters in there (10-15 pages tops) about each of the drug classes, and it's helpful to read those as you go through your PBL cases so that you understand what drugs are being given to the patients and why. I would recommend that you definitely buy the Lippincott book.

Physiology: The school recommends that you buy Medical Physiology by Boron and Boulpaep. This book is very detailed, and if you've never studied physiology like many of us hadn't, you might want to also consider buying Costanzo's Physiology. Definitely buy the Boron book to use as a resource though, because some of the explanations in Costanzo are not detailed enough for answering SAQs and CAPPs. If you're going to buy Costanzo too, then I recommend buying it early, and read Chapter 1 on cellular physiology over the summer. Make sure you get the Costanzo physio textbook, not the board review book that she also wrote. Once you start the clinical blocks, read the appropriate Costanzo chapter first before attempting to read Boron. If you're coming in already having a strong physiology background, you probably don't need Costanzo.

Physical Diagnosis and Communication Skills: This is not really a thread. It's actually considered to be a block that you take all year long and all next year too. But it functions more like a thread in practice, so I'm including it here. There are two books that you need. One is Cole's The Medical Interview: The Three Functions Approach. To say that this book is pointless is an understatement, but you should probably still get a copy because they assign a lot of the communications readings to us from there. The other book we use is Schwartz's Textbook of Physical Diagnosis: History and Examination. This book is pretty good, and again, you really need to get it because you'll be assigned readings from it each week. One nice thing about the Schwartz book is that it comes with a DVD, and you can see the physical exams being given so that you aren't coming to class or going to the clinic totally cold.

Aquaporin Seminar, PBL, POD, and CHI

Today was a long, full day, but it was great. We started out with a seminar about kidney cell membrane channels called aquaporins. These are proteins that make little passages through the membranes of certain renal cells so that water can get through. It's a really neat system that allows the kidney to make your urine concentrated or dilute as needed. There is a hormone called ADH that is responsible for regulating the aquaporins. If you drink a bunch of water and want to get rid of it, then you don't produce much ADH, and the aquaporins aren't inserted into the renal cell membranes. That means the water can't get back into the cells. So it stays in the urinary system, and you wind up making a bunch of dilute urine and hitting the bathroom a lot. But if you're dehydrated and you need to retain more water, then the brain will release ADH into the blood. It goes to the kidneys and stimulates the cells to insert the aquaporins into their membranes. The water flows through the channels out of your urinary system and back into your blood, and you make concentrated urine. Cool!

We finished our PBL case today. Our regular tutor was back, so we were back to our normal rambunctious selves. The presentations were great as usual, and we did a half-hearted concept map in about five minutes. This led to a dicussion about whether we should even be doing concept maps. We decided that we didn't really want to do a concept map because we usually don't find it too useful. I am ok with that, but I was just worried that maybe the course director would not go for that. We were told that it is not actually a requirement for us to do concept maps, so we don't have to do them if we would rather not. On that happy note, we left it where we would do one if someone wanted to do it, and otherwise we'd skip them.

Our POD seminar today was really awesome. The speaker was a PhD who studies angiotensin converting enzyme, or ACE. If you've ever heard of ACE inhibitors, which are given to people with high blood pressure, this is the enzyme that they inhibit. It basically is involved in a pathway that causes the body to retain sodium and water and therefore increases blood volume and blood pressure. Anyway, this speaker was studying different forms of the enzyme. It turns out that for some unknown reason, men make a special form of ACE in their sperm cells and nowhere else. Women do not make the special form at all. So naturally, the question was what the special form in sperm does. It seems to be involved with sperm development. Mice who lacked it were infertile because their sperm were not able to penetrate an ovum. The subject itself wasn't what made the talk so good though. The speaker was just really dynamic and did a great job of getting us involved and talking about what hypotheses we would propose and how we would go about testing them. I wish that all seminars could be like this.

In the afternoon, I volunteered at CHI (the CCLCM student-run free clinic). Today was the last day of the semester for CHI, and it was absolutely insane. First of all, only about half of the normal number of student volunteers showed up, so we only had one person working per table instead of two. That meant we were working extra hard. I was doing the cholesterol and glucose tests, and about an hour into it I ran out of strips. (I had already started out not having any band-aids, but unlike the strips, those you can live without.) We have a second machine that can do glucose readouts only, so I started just doing those. But the people were pretty upset. They wanted their cholesterol read! I hadn't ever been in charge of doing cholesterol and glucose readings, so I tried it on myself first to make sure I could do it. The hardest part is getting enough blood out of some people's fingers. You have to kind of milk the finger, where you push the blood up from the bottom to the tip, and get a nice drop to come out. Then you can fill the capillary tube and add it to the strip in the machine. I got to where I could do it pretty quickly on most people. But whenever I'd get an older lady with skinny, cold fingers, I knew I was in for a workout to get any blood. On top of all that craziness, the CCF marketing people decided to show up today to film us for some promotion they're doing about people at CCF who volunteer in the community. They took footage of us doing all of the tests and also interviewed a few students about why we volunteer. So it was absolute pandemonium, but I had a fantastic time.

Now I am getting ready to go out with some friends for Indian food. Happy Hanukkah to my Jewish readers. :-)

Pharmacology, PBL, and Clinical Skills

We started out with a double pharm seminar this morning. You have to understand that I really, truly, honestly do love pharm. It's my favorite medical science, no question. I read pharm books on my own sometimes just because I'm interested in learning more about it. I even like pharm better than anatomy, and I know I've gone on and on about how much I love anatomy. But I have to say that the first part of today's pharm seminar was probably the most painful seminar that I have attended since I started medical school. On the bright side, the second half was much better. It was led by a different pharmacist, and actually, her part of the seminar was probably the best pharm seminar we've had so far. I hope that she will be coming back to lead some more seminars.

We are continuing on with the same case in PBL about the guy who drinks and urinates a lot. The presentations today went well, and we didn't come up with very many learning objectives, so I don't have one to prepare for Friday. That means that I can catch up and do some other reading I've been wanting to do tomorrow. Our PBL tutor was out of town today, so we had a sub. You wouldn't think that would be a big deal, but it actually does change the dynamics of the group. I think we were all on better behavior today.

In the afternoon, we had clinical skills class. We didn't learn any new skills today. Instead, we practiced the ones we've been learning up to this point. I really enjoyed the clinical part of it. First, my favorite preceptor was teaching us today. Then, one of the other preceptors didn't show up, so some of his students and their standardized patient joined my group. It made things very hectic and crowded, but it was really fun. One of the standardized patients had a bit of a cold, and when I was listening to his lungs, I could hear him wheezing on one side. I had been wanting to go over the lung exam again, and now that I did it again on both standardized patients, I feel a lot more confident about doing it.

For the communication skills part, we had to take a family history. That part wasn't as much fun as the clinical part, but it went ok. Basically, we had the standardized patient tell us about each of their family members and what illnesses they'd had. We had to make a family tree, kind of like a pedigree. Our preceptors had us change interviewers in the middle of the interview, and that was pretty awkward. We also tried doing the interview two different ways: once by family member, and once by disease. For the record, it's a lot easier to gather family history info in a systematic way if you go by family member and not by disease.

FCM, Renal Cell Seminar, Class Meeting, and Dean's Seminar

The FCM seminar today went fairly well. We were talking about medical errors and how (or whether) to communicate about them to the patients. The thing that was nice about today's session is that we met in our small groups first, and then we had a brief talk by a lawyer who works for CCF. So for one thing, we didn't have to worry about the speaker going over time. Plus, the lawyer did a nice job of making his presentation interactive. We went through some cases as a group and discussed what the patient should be told and how. It's kind of sad that we already are starting to consider what we have to do to avoid malpractice lawsuits, but it's obviously an important topic.

The renal cell seminar we had afterward was kind of a journal club. There were two articles that we had to read before class about how the cells of the kidney absorb water, and then two different people went over one article each with us in small groups of eight. The first guy we had was really great. He spent about 2/3 of the time going over the general concepts, and then he just talked about the paper for 15 or 20 minutes at the end. We all felt like we learned a lot from his part of the seminar. The second guy wasn't as good. He spent too much time going over the tiniest details from the paper he was covering and not enough time covering the basics. It seems like this is a fairly common problem whenever we have a PhD leading a seminar.

After seminar, we had a class meeting. Dean Fishleder came to talk to us about FCM, among other things. Several people were complaining to him about having to do the essay. I don't think we are going to get out of that one, and I'm not sure it's so terrible that we have to do it anyway. One of our competencies is knowledge of health care systems, and actually, this essay would be good evidence for that competency. Several students have also been talking with him and other members of the administration about how to fix FCM. The gist of his comments is that changes will be made to FCM, but no, they don't know exactly what will change yet. We'll find out in January. I'm not too sure that I like the sound of having FCM surprises in store for us next block....

In the afternoon, I read and went to the anatomy office hours with one of my classmates. We went through all of the cadavers again and practiced identifying the structures. Then in the evening, there was a talk by the Case SOM interim dean, Dr. Davis. She does research on cystic fibrosis over at Case, and she came to CCF to meet with the CCLCM students. Her talk was really good. Basically, she is working on coming up with drug delivery systems to deliver genes to treat people with cystic fibrosis. Since using viruses to deliver the genes causes an immune response, she is trying to use DNA nanoparticles. Right now her research team is working on getting FDA approval for a clinical trial. There was a reception after her talk, but I didn't stay for it because it was getting late and I still had to finish working on my learning objective for tomorrow.

Kidney Anatomy and PBL

Anatomy was really interesting today. We had one cadaver that showed all of the vasculature in the back part of the abdomen, two that showed the urogenital systems (one male, one female), and one station with embalmed kidneys. We also did radiology. The two cadavers showing the male and female urinary systems were really neat. The bladders had also been dissected open, so we were able to see what they look like from the inside. You can tell the male and female bodies apart just by looking in the abdomen if you look at the orientations of their gonadal blood vessels. Women's travel more toward the center, while men's travel toward the outside. One of the cadavers also had two ureters, which was pretty neat. The ureters are the tubes that carry urine from the kidneys to the bladder. Normally you only have one from each kidney, but apparently a minority of the population has an extra one, including this particular cadaver.

In PBL, our new case is about a guy who produces a large amount of dilute urine. We are studying water regulation by the kidneys this week. My learning objective is about the effects of antidiuretic hormone and how it causes the body to retain water. Water regulation is a pretty interesting and complicated topic. Well, I guess that "interesting and complicated" pretty much describes everything about the kidneys in general.

I don't have anything else that I have to do this afternoon, so I'm going to the gym and then going home.

FAQ #20: I've Been Put on Hold. What Does That Mean, and What Do I Do?

I've had a ton of people ask me about being on hold recently. I'm sorry to hear about those of you who were put on hold, but hold is unfortunately the most common outcome for people post-interview. My understanding is that there are three possibilities post-interview: you can be immediately accepted, immediately rejected, or put on hold. Most interviewees are put on hold. Hold means that no decision has been made about your app yet. It is NOT a waitlist. Basically, if you are on hold, the admissions committee wants to finish interviewing everyone first before making their decision. They will decide in the spring (April) to accept, waitlist, or reject you. So, for now you should expect to have to wait until the rest of the interviews are all finished to hear any more about your app.

Ok, so the other question I have been asked a lot is what to do to improve your chances of getting off hold and being accepted. I've asked around about that. Basically, you should update the admissions office with any new information you have (fall semester grades, new volunteer activities, awards, etc.). According to Dean Franco, letters of intent (where you promise to attend the school and withdraw all of your other apps if they accept you) are not really necessary, so you don't need to write one. Beyond updating your file with new info, I'm not really sure what else you can do to improve your chances of acceptance. I hope this info helps, and good luck to all of you.

Renal Clearance Seminar, PBL, and POD

We started out with a seminar this morning about how the kidneys are able to filter waste products out of the blood to be excreted. It's a pretty complex process. One important thing we learned is that the kidneys filter substances out of the blood based upon both size and charge. If the molecules are large like proteins, they won't get filtered. If they're very small like amino acids or glucose, they will get filtered. And if they're in the middle, they will get filtered more if they're positively charged and less if they're negatively charged. That is because the walls of the glomeruli (kidney capillaries) are negatively charged, so they repel negatively charged substances in the blood. Fortuitously, most of our blood proteins have negative charges on them. We also learned how to calculate the rate at which the kidneys are filtering the blood. This can be done by measuring the concentration of certain naturally occurring substances in the urine or by giving the patient certain drugs and measuring how fast they get filtered and show up in the urine. All good stuff.

In PBL, we finished our case today and kind of half-heartedly did a concept map. Most of us are not too gung-ho about doing concept maps, but our tutor did not seem very happy about the fact that we kind of blew it off. I hope that this is not going to make problems for us later. The presentations were good for the most part, and we had no problem finishing on time.

Our POD speaker was my group's seminar leader from Tuesday. His talk was good, although I think he could have been more interactive than he was. But he didn't go over time, and the work he is doing is very relevant to what we're studying since he's a nephrologist. One thing he is working on is preventing kidney disease in patients with diabetes. I hadn't realized before today that renal failure can be a complication of diabetes. Not all diabetics end up having a problem with their kidneys, but a significant minority of them do. Basically what happens is that those same negative charges in the glomeruli that I mentioned earlier wind up being lost, along with some other abnormalities like holes in the capillary walls. Those are both bad things, because together they allow proteins that should be retained in the blood to get filtered by the kidneys. These proteins can be detected in the urine, leading to a condition called proteinuria. This same guy is giving a talk in a couple of weeks for the internal medicine grand rounds, and I think that I'm going to go.

Home Studying and Avoiding the Snow

I was going to have to go in today for anatomy office hours, but now I don't have to since I had time to stop by the anatomy lab on Tuesday afternoon after I got out of clinic. So I get to stay home all day, and I'm currently sitting here still in my PJs, watching the snow blow by my bedroom window, and feeling very happy not to have to go anywhere! It wasn't supposed to snow today, but in case you hadn't noticed, meteorologists often get the weather forecasts wrong. I hope they're also wrong about tomorrow, because they're predicting that it WILL snow more tomorrow. Now that I have my unexpected free day, I'm going to spend some time reading and just kind of chill out. This week has been super intense so far. Today I've been spending quite a bit of time looking at histology and pathology slides of glomeruli, and it's going pretty well. I've gotten to the point where I can recognize most of the cells. The electron micrographs are still really hard to see, but at least now I have a clue about what the different kinds of cells look like on them.

Sodium/Volume Homeostasis Seminar, PBL, and HIV Documentary

Today was a pretty good day, except that I'm just so tired that I can hardly see straight. I think the lack of sleep is starting to catch up with me, or maybe I'm coming down with something. Our seminar this morning was about how the body keeps a constant volume of fluid and salt. This relatively simple concept (that you have to keep constant levels of things like salt and water if you want to stay alive) has the fancy name of homeostasis. I thought the seminar was ok, not the best I've ever attended but not the worst. Maybe it's just me, though, because everyone else was pretty gung-ho about how good it was. I still like kidneys, but I have to tell you that they are incredibly complicated.

PBL went relatively well. Even though we had talked last time about trying to make our objectives into discussions rather than presentations, I don't think that it's really turning out that way. Not that we didn't have some good discussions, but I just don't see a huge difference between how my last group did presentations and how my new group is doing them. I'm not complaining, because I thought we did a pretty good job with our presentations last block, and I'm glad to see that this is continuing with my new group. Our case is going well too. My next learning objective is about the histology of the glomeruli, which are the tiny blood vessels in the kidneys that do the actual filtering. I chose it on purpose because I know that I need more experience with histology. Speaking of which, I have made a promise to myself to start studying histo more. I've been reading my book and atlas, and also looking at the SIU website some. Unlike our own histo website, the SIU one has explanations so that I know what I'm looking at. Thank you again to those of you who wrote to me with suggestions for other websites. I'll be sure to check them out.

As I said on Monday, this is National AIDS week, and today the AIDS Awareness Group was showing a documentary about people with HIV. Of course, the main theme of the documentary was how evil the pharmaceutical companies are because all they care about is making profits off poor people living with HIV and no medications in third world countries. I'm not saying that pharmaceutical companies are Mother Theresa....far from it. But come on, let's have some balance here. That aside, the documentary was interesting, especially the part that talked about how Brazil made anti-retrovirals for HIV-positive patients available free of charge to all of its citizens who need them. Of course, to do that, they needed a supply of generics, and those come from India. Ironically, many of India's own HIV-positive citizens do not get the drugs they need, since the drugs produced in India are being exported to Brazil.

I don't have anything more to do at school today, so I'm going to the gym and then home to study and buy some groceries. The weather is still snowy and cold. And the streets are disgustingly slushy.

More FCM Woes, Renal Histology Seminar, Clinic, and Anatomy Office Hours

I don't think I could have possibly crammed any more into today than I did, but all in all, it was a good day. We had a joint FCM session over at Case, and they put us in mixed groups with the UP students like last month. This time, the speaker understood that he was not supposed to go on for the entire hour and a half, and we actually had some time to discuss the topic with our group members. We were talking about health care access, and specifically the fact that people with private insurance get the most access to care, people with no insurance get the least, and people on Medicaid have access somewhere in between. Ok, not too surprising, but still useful stuff for future physicians to know and think about, and my group had a pretty lively discussion going. So I would say that this FCM session went pretty well, as far as FCM goes.

When we got back to CCF, we had a renal histology seminar. It's really hard to intepret the slides, especially the electron micrographs. The speaker was good, and he was doing his best to help us, but it's still nearly impossible anyway. So, we were already feeling kind of lost and frustrated with trying to interpret these slides. And then in the middle of this, we get an email that we are now required to write an essay for FCM about health care access, due on the 18th to our FCM small group preceptors. This did not go over well with my classmates at all. Coincidentally, there was an FCM feedback meeting today after the histo seminar. I wasn't invited to participate, so I can't tell you much about the meeting. (They pick different people each time, and I participated in the summer block feedback meeting last month, so I won't get picked again for a while now.) Personally, the essay requirement doesn't bother me too much. I think that for the amount of time it will take to argue about it, it's easier to just write it and get on with more important things. I'm much more concerned about not letting the required community project become a huge time sink than I am about churning out a silly essay.

In the afternoon today I had clinic, and it was absolutely awesome. I only saw two patients. But they were both super nice, and because there were only two of them, I got to spend more time with each of them and do a really thorough ear, nose, and throat exam on each of them. (I was able to see their eardrums with no problem whatsoever.) One thing that really hit me today was how difficult it is sometimes to deal with a patient's cultural beliefs if they don't mesh with what modern science says. For example, one of the patients did not think that she needed to have a mammogram because she eats raw garlic. I am not sure how or why she got this idea that raw garlic would prevent breast cancer, but she was firmly convinced of this, and nothing that my preceptor or I could say would change her mind. In that kind of situation, the only thing you can do is to tell the person that this is your medical recommendation, and then document in their chart that they have refused to follow medical advice. My preceptor also wrote up my evaluation for this block, and it was mostly complimentary. I thought the few criticisms on there were pretty fair. Mainly, I need to work on improving my speed and facility with conducting the physical exams, and that is the kind of thing that will come with practice.

I still got out of clinic early since there were only two patients, and I actually had time to make it to anatomy office hours. I ran into two of my classmates who were on their way over, so I decided to go with them. Dr. Drake went through all four of the cadavers with us, and it was absolutely awesome. He is really good at explaining everything, and I feel like I got a ton out of it. The other good thing is that since I was able to go in today, now I won't have to come in on Thursday for anatomy office hours. Who can complain about having an unexpected day off, right? :-)

Anatomy, PBL, and a Visit to the Case Student Health Center

We had our first day of the renal block today, and so far I really like renal. I know it's heresy for me to like any other organ better than the heart, because CCF is the top cardiology hospital in this country. But I still like kidneys better than I like hearts and lungs. Sorry, but it's true.

In anatomy, we started looking at the abdomen today. Besides being much smellier than the thorax, the abdomen has many other notable features. One is that it is absolutely chock full of fat and intestines. I knew of course that our intestines are very long, but that kind of abstract knowledge still doesn't prepare you for when you look inside a cadaver for the first time and see loops upon loops of small intestine. The abdominal fat, as in the thorax, is bright yellow and kind of squishy. The women are a lot fattier than the men. We also saw the gall bladder in one cadaver, but not in another because the second one had apparently had his gall bladder taken out at some point. As I found out last summer when we visited the path lab, the gall bladder is bright green and full of none-too-appetizing bile. I also saw a stomach (larger than I expected it to be) and of course, our new friends the kidneys, which are much smaller than I would have expected. It's pretty impressive that such tiny organs can do so many different things. In the last cadaver, we saw a uterus and ovaries, which were impressive, and the pancreas and adrenal glands. Our prosections are now being prepared by urology residents, and they are pretty gung-ho about what they do just like the ENTs were last block. I have zero interest in being a urologist, but I could end up as a nephrologist one day, I guess.

My new PBL group is very different from the one I had last block. Two of my group members are the same, but the other five aren't, and it's amazing how different the sessions are based on who is in the group. I can already see that this group is going to be way more laid back than my last group was. We are doing several things differently than my old group did them, one of which is that we are going to try to make the learning objective presentations more into discussions rather than presentations. So even though we still have one person who will be in charge of leading the discussion, we are all going to read about every topic instead of just one person doing it. I am not sure yet about how well this will work, but I figure it's worth a try. If it doesn't work, we can always go back to making more formal presentations. My learning objective for Wednesday is about how the kidneys are able to filter out substances to start producing urine.

Right after lunch, I practiced the ear, nose, and throat exam with one of my classmates. We were both having some trouble seeing each other's eardrums, and a couple of the second years showed us how to do it again. Using their technique, it was really easy. For one thing, you have to pull on the patient's ear out, back, and up harder than we were. It also helps a lot if you hold the otoscope upside down and rest your hand against the person's head instead of holding it right side up. You have to hold it upside down when you examine children anyway, and there is no advantage to holding it right side up, so I plan to always hold it upside down from now on.

This is National AIDS Week, and there was an HIV+ speaker this evening. But I didn't go, because I had a doctor's appointment over at Case and I didn't feel like rushing back afterward. The Case student health center is right down the street from the Case medical school, so if I were on the Case campus, it would be super convenient. What impressed me the most was that the doctor was very thorough with getting my medical history. I don't know how much of this is that I'm more attuned to noticing how people take medical histories now, but I did feel like the people here were taking more time with me. The Case clinic is also pretty subsidized. At my old school, I would have had to pay a lot more for that same visit to student health compared to what I had to pay here. That was a very nice surprise.

It finally did start snowing yesterday, and it has continued snowing all day today. I got my new boots just in time.

FAQ#19: What is Doc Opera?

Ok, so I should have seen this one coming. ;-)

Doc Opera is the Case School of Medicine's fundraiser for the Cleveland Free Clinic. The show is entirely written, produced, and performed by medical students from all three Case programs (UP, CCLCM, and MSTP.) The songs are spoofs of real songs with the lyrics re-written to reflect medical school themes, and most of them also have dances that go with them. For example, "I'm Too Sexy" by Right Said Fred became "I'm Too Busy," and it was about a surgeon who didn't have time for anything or anyone else. "Still" by the Ghetto Boys became "Die Carcinoma." "Summer Nights" from Grease became "Med School Nights," and so on. There were also some medical school-themed skits that had been filmed ahead of time, and they were shown in between the live numbers. One of my favorite numbers was "Keeping Up is Hard to Do," which is a spoof of "Breaking Up is Hard to Do" by Neil Sedaka. Several of the Case SOM faculty were dancing in that one, and it was really cute. There was also one song performed by Docapella, which is the Case SOM acapella group, and they did "The Sound of Science" to Simon and Garfunkle's "Song of Silence." If you've never heard an acapella group perform, it's really neat. The singers make the harmony themselves as well as the melody, so the band didn't play during this song at all.

Most of the Doc Opera performers are UP students, but there were several MSTP students along with about half a dozen of us from CCLCM who were involved this year as singers, dancers, and members of the band. I think that next year we are going to try to have our own number like the MSTP students did this year. The MSTP students did a really cute spoof of Beck's "Loser." At one point, the lyrics say:

"And the clinic kids, as it has been said,
Hate us for our brains but want us in bed."

They are talking about CCLCM students when they say clinic kids. All I can say is that our supposed amorous intentions toward the MSTP students sure is news to me!

Anyway, Doc Opera is really fun, and it's for a really good cause. You can see some pictures by clicking on the link I included above. If you come to any of the Case programs, you should really think about performing or helping out behind the scenes. They used to hold the show in March, so last year we got to see it during the Case/CCLCM second look weekend. Unfortunately, you current applicants won't get to see it during your second look weekend because now the show date has been permanently moved to December. This had to be done because the second-year UP and MSTP students take the USMLE (step 1 of the medical boards) early starting with this year's class. Those of us in the CCLCM program still take Step 1 in June, but all of the other Case students are doing it in March.

Lipoprotein Seminar, PBL, and POD

Our seminar this morning had two parts. The first one was by a PhD, and it covered HDL production and transport. You may know that HDL is the so-called "good cholesterol" that helps prevent your arteries from being blocked up (a condition called atherosclerosis). It is not known for sure why high HDL levels can protect people and animals from getting atherosclerosis, but here is one idea that I thought was pretty compelling. When the arteries get blocked, what is happening is that there are plaques forming in there. These plaques are formed by, among other things, a type of cell called a macrophage. You can think of macrophages as being one of the garbagemen of the body. So if you have some cholesterol or other molecules in your blood that have been altered and aren't in good condition any more, the macrophages will take them up. Unfortunately, if this happens a lot, the macrophages get over-stuffed with altered cholesterol, and they turn into something called a foam cell. Foam cells are bad news for your arteries. Since they can't get rid of the altered cholesterol, they just deposit in the arteries and contribute to forming plaques. The thought is that having a high HDL level is good because HDL is responsible for bringing cholesterol from the body back to the liver for disposal, and specifically the cholesterol being brought from the foam cells could be what lowers the person's risk for atherosclerosis. I thought it was a really good and interesting seminar. I can also tell you that after this week of seeing all the bad things that a high-fat diet can do to you, my classmates and I were not too eager to eat donuts during PBL this morning!

The second half of the seminar was given by an MD, and it was kind of dry. She was mainly presenting about the Framingham risk scoring chart, which you can use to figure out what your risk of developing atherosclerosis is. I think it would have made the seminar better if we'd calculated our own risks instead of seeing slide after slide of hypothetical people's hypothetical risks. Be that as it may, I will tell you that the best thing you can do to avoid getting atherosclerosis isn't related to improving your diet, exercising more, losing weight, stopping smoking, or keeping your blood sugar and blood pressure levels controlled, although all of those things will certainly reduce your risk. No, the biggest thing you can do to keep your risk down is to not get old. Good luck with that one.

Today was our last day of PBL with our current groups, and it is also the last day of our cardiopulmonary block. We'll be starting the renal block on Monday. I thought our last session went well. Again, we did a good job with getting our presentations done on time, we had some good discussions about several of them, and we finished class on time too. It turns out that our patient from the case is doing very well, and his lipids are back to normal. Of course, he is unrealistically compliant with all of the recommendations he's been given. One thing you will find out when you start seeing patients is that most of them are not totally compliant, and a good percentage of them are not compliant at all.

Our POD talk today was by a biochemist who studies lipid metabolism. I thought his talk was pretty interesting, and he made it fairly interactive. Besides telling us about the work he is currently doing, he also told us about how he had ended up coming here to CCF and choosing his research interests. I like when the speakers do that, because it's not always straightforward to figure out how you're going to go from being a student in medical school to being a PI running a lab. One common theme that I have seen in various researchers' stories is how much timing and serendipity play a role in getting them to where they are now. It seems that the mentors I meet and work with now will play a big part in what I will wind up doing for my own career.

I have to go meet with my PA soon, and then I'm going to take off. It was supposed to snow tonight, but luckily now it looks like it's going to hold off until tomorrow night or Sunday. Tomorrow night is Doc Opera already, and it is going to be awesome.

Working on Homework

Nothing too exciting to report for today. I basically spent most of it at home studying, except that I did go to the gym over at Case. I'm really excited about my learning objective for tomorrow. I think that it might be the best one I've ever done in terms of how much clearer it has made a lot of the concepts we've been covering. I feel like I have a good understanding of the case, and I know now what the point was of the drug regimen the patient was given. I don't know if you ever have these moments where all of a sudden you feel like you are starting to get something, but that's how I feel. It's a great feeling.

Tomorrow is December already. The weather is starting to get really cold, like it knows that it's time for winter now. We're supposed to get snow this weekend, and this time it is going to stick. I hope it won't affect the turnout for Doc Opera. Anyway, I am not too worried about it snowing. I have some great boots, so whenever it comes, I'm ready.

Lipoprotein Seminar, PBL, and Clinical Skills

I was really dragging today, and I have to confess that I was basically counting down the time until I'd be able to go home. I'm just happier than I can say that I have tomorrow off and I can finally get some sleep. This morning, we had a lipoprotein seminar. It was pretty research-intensive and covered some material that the seminar leader thought was important but that was not really covered in the textbook yet. I thought it was a pretty good seminar, although a lot of people felt like maybe it was too specific. I don't know. It's hard to know when you're a first year what is going to be important to know about later on.

In PBL, we continued on with our case. I think that today's session went pretty well. Everyone did a good job with their presentations and we finished on time. Our patient is improving but is still not where he ideally should be. We got into a really interesting debate about whether we should treat him more aggressively with drugs or focus more on his lifestyle factors. The group was pretty much split half and half on that, with some people wanting to be conservative and give the medications more time to work, and others wanting to be more aggressive because they thought the patient's life would be in danger. I was on the side of wanting to wait until we were sure that he wasn't improving any more on his current dosage. It turns out that the doctor in the case did decide to up the patient's dose, and luckily the patient has not been experiencing any side effects. Anyway, it was really a good discussion, because sometimes there is not one easy answer to these kinds of questions. For Friday, I am going to be presenting about the drug regimen that the patient was put on, and what was the logic behind it.

After class, I went to a Pharm Free talk. This talk was given by the same pharmacist who is in charge of our pharmacology thread. Basically, it was about the dangers of physicians accepting free items and drug samples from pharmaceutical reps. CCF has a pretty strict policy about what drug reps are allowed and not allowed to do. They have to register, they can't see doctors unless they have appointments, and they are not allowed to provide food on campus. Personally, I do not view pharmaceutical companies as being all that evil. Yes, they do spend too much money trying to influence doctors and patients to buy their products. But a lot of good can also come out of their actions, especially when doctors give the free samples from drug companies to their low income patients or help such patients apply to the drug companies to get drugs for free or at reduced price. Anyway, the general point that you have to be careful when dealing with drug companies is a good one and well taken.

In the afternoon, we had our clinical skills class. Today was very enjoyable. We have a few different preceptors who have been teaching clinical skills to us, and the one we had today is my favorite. The other three students in my group and I have also figured out the best method for learning the skills. First we have the preceptor demonstrate one skill, and then all four of us try it. Then we go on to the next skill, and repeat all the way through the list. Our standardized patient today was a girl and she was really nice. We were doing the ears, nose, and throat exam, so I got to see her tonsils and her eardrums. Eardrums are very pretty, kind of pearly looking. For the communications portion of the class, we watched the videos we made four weeks ago with one of the communications preceptors. Watching my video, I thought I had done a good job with being empathetic, but I definitely need to work on the medical portion of the exam. Well, a big part of my problem there is the fact that I don't know very much medicine yet! But I'm getting better.

Long Day But Mostly a Good One

I woke up this morning not feeling very well, so I decided not to go to FCM. I feel kind of bad about having skipped it, because this is the first class I have ever missed since I got here. But I did the reading, and I guess maybe I just needed a little more sleep, because later on I felt better. So I did go to the 10:00 seminar, and it turned out to be really good. It was about how the body provides energy to the heart to use for contraction. You might think that a biochem seminar wouldn't be very interesting, but the seminar leader was really interactive and it was actually kind of fun. He gave us a brief packet of notes to read before we got to class today, and I thought the seminar itself did a good job of integrating a lot of the things we've been learning during this entire block.

After class, I went to a really awesome talk about facial transplants. I don't know if you've ever heard of this, but it's pretty incredible. Basically it is for people who have really severe disfigurement, like if they get most of their face burned away in an accident. They would be given a donor face (skin, nerves, blood vessels, etc.) from a cadaver. CCF is the first institution anywhere in the entire world to have an IRB approve a clinical trial to do facial transplants. They haven't done one yet on a human for various reasons, but they've been doing them successfully on rats for several years. The biggest issue is how to prevent the recipient's immune system from rejecting the transplant. You might already know that people who get organ transplants have to take immunosuppressant drugs to prevent their bodies from rejecting the donor organ, and the facial transplant researchers are hoping to avoid that problem. Apparently, if some of the deeper tissues like bones are transplanted along with the overlying skin, it helps prevent rejection. But this issue of immune system rejection is a much more complex problem with a facial transplant than it is with an organ transplant because there are so many different kinds of organs that are part of a person's face!

Right after the talk, I had clinic. Today is not my normal clinic day, but I missed clinic last week because of my preceptor being out of town for Thanksgiving. It was a really hectic day, and I was there until 6:00 because we were just so busy. Even then, we didn't get a chance to go over my patient logs, so we're going to have to do that next week. I saw four patients and did the chest and lung exams on them. A couple of my patients had some really sad personal issues they were dealing with. One actually started crying in the office, and basically all I could do was offer a tissue. I was warned before I started working in the clinic that patients will often tell students personal things like this, and it's definitely true. Anyway, it was a really tiring and trying day, but it was a good learning experience, too. You just never know what you're going to run into when you're dealing with patients.

Tomorrow is a long day for me too because we have clinical skills class. So I need to go to bed now.

Great First Day Back

Hope that you all had a great Thanksgiving. I definitely did. The weather here in Cleveland was astoundingly gorgeous all weekend: sunny, mid-sixties. I spent a lot of time sleeping, going for walks, and hanging out with my friends. Yeah, I did all of the things that you hardly ever have the time to do when you're a medical student. It was great. I just wish I could have had one more day off.

For some reason, we didn't have anatomy this morning. Instead, we had a seminar about lipid biochemistry. The seminar was ok, though I wish it had been more interactive and less like a lecture. We already covered some lipid biochemistry last summer, but now we are getting more into how lipids are used and transported in the body. You probably know that lipids, being fats, are not soluble in watery liquids like your blood. (Think of oil and vinegar salad dressing.) So the body has some pretty ingenious ways of getting around that problem so that the lipids don't all clump together in one big fatty mess. It's pretty neat to learn about, though also very complex and sometimes confusing. We're going to be learning about lipids and how they are transported this whole week. This is a very important topic for physicians, because problems with lipid metabolism cause a lot of common diseases like atherosclerosis and coronary artery disease.

We had PBL after seminar, and today we started our final case for this unit on heart and lungs. Our session went really well, and I think this is going to be a good PBL week. The case is about a "patient" with lipid problems, naturally, and it's a little different than the others we've done so far in that this patient came in to get a check-up and advice to improve his lipids, not because he was wanting to be treated per se. So we don't really have to come up with a diagnosis, at least not so far. (You can see that I've learned not to trust my Monday impressions at face value any more, because things are changing now on Wednesdays!) My learning objective is about interpreting lab lipid values, and I am very interested in learning to do this since I had my blood drawn last week for class and for a clinical trial.

That's about it for today, so I'm going to go to the gym and go home. Tomorrow and Wednesday are both going to be very busy days for me. I have to make up my missed clinic day tomorrow, and I have clinical skills class on Wednesday.

Kidney and Blood Pressure Seminar

Today was a very short day. We only had this one seminar, and that was it. Several people didn't show up. I really think we should have had this seminar tacked on yesterday afternoon, and then we could have had all of today off too.

Technically we are not into the kidneys yet, but we will be as of the beginning of December. This seminar was about the integration of the neural, renal, and cardiovascular systems in scenarios where fluid and salts in the body must be balanced. The reading was about experiments done on dogs here at Case several decades ago. Basically, the researchers used clamps to make the renal arteries narrower and block the flow of blood. This causes the kidneys to "think" that the body is hemorrhaging, and they respond by synthesizing hormones that lead to constriction of the arteries and a rise in blood pressure. Of course, these responses only make things worse. But as another speaker pointed out earlier in the week, our bodies didn't evolve to deal with being elderly and having cardiovascular disease. We would have been a lot likelier to have had to deal with massive losses of blood due to illness or injury.

Ok, I hope you readers have a great Thanksgiving, and I'll be back on Monday. We have class bright and early at 8 AM as usual. But the good news is that we are getting Friday off this week, and we do not have any homework (SAQs or CAPPs) either. :-)

FCM and Cardiovascular Homeostasis Seminar

I got to school early today to get my blood drawn so that my cholesterol levels could be measured for one of our seminars for next week. It wasn't too bad, except that I had to do it fasting, and it's not much fun to skip breakfast. I did have time to eat a quick breakfast before class started though.

Today's FCM session wasn't too bad. The presenter tried to make it interactive, and we actually had some time in our small groups to discuss the case that he had presented to us. It was about a school bus driver who had gotten hit by a train because she stopped the bus with the rear end reaching over the tracks. What does this have to do with medicine, you ask? Well, the focus of the seminar was about how to decrease medical errors and increase patient safety. Obviously this wasn't a medical case, but the same issues still apply: how could this accident have been prevented? It's not as simple as just firing the bus driver for being "careless." There are a lot of little things that each in and of themselves do not lead to accidents, but all of those little things in combination make accidents more likely to occur. The readings that we did focused on the airline industry, which, along with the nuclear industry, is one of the safest ones out there. Medicine has a much higher error rate. Within medicine, the best specialty in terms of avoiding preventable errors is anesthesiology.

The seminar was pretty good too. Basically, we went through how various cardiovascular and respiratory functions change in response to changes in demand. So, for example, if you're sitting on a couch and then you get up to go for a run, your heart rate, breathing rate, oxygen usage, etc. are all going to increase. We also discussed which types of fuel (ex. fatty acids versus sugars) were used for energy during different levels of activity.

I was supposed to have clinic this afternoon, but I didn't because my preceptor went out of town. I'll be making it up next Tuesday instead. That's going to make next week a monster week for me. I did stop by the anatomy lab briefly to review the prosections from yesterday. They had only taken out one cadaver, and we didn't have a list of structures we were supposed to identify. So one of my classmates and I got a copy of the anatomy book and went through them on our own quickly.

Anatomy, Neurohumoral Seminar, Thanksgiving Potluck, and Bone Marrow Drive Training

Our anatomy lab today was mainly a review. The case involved a man who was shot in the chest, and we went through all of the structures that could be injured. Obviously, there are quite a lot of important structures in the chest, like, oh, say, the heart and lungs, as well as the major blood vessels, various nerves, and so on. The cadavers were mainly review, and we also reviewed the radiology of the chest and the preserved lungs from a few weeks ago.

We do not have PBL this week because of the Thanksgiving holiday, but we did have a seminar on how the brain and hormones control blood levels and circulation. We were given a case to read about a smoker with shortness of breath who shows up at the ER because his symptoms are getting worse. We went through the case and also discussed how the body tries to compensate for problems with the circulation. (Even though the man in our case smoked heavily and had shortness of breath, it was due to a heart problem, not a lung problem.) The seminar was pretty good, and really the only complaint I have is that 16 of us were crammed into one of those conference rooms (it's right next to the one where you go when you come to interview here), and that's just a few too many people to fit in there comfortably.

After seminar, we had our Thanksgiving potluck. One of the upperclassmen had told me that this potluck is a CCLCM tradition, which made me laugh, because CCLCM is way too new to have any real traditions yet. But they want this to become a tradition, and as far as traditions go, it will be a nice one. Basically, the M2s organized a list of items we needed for a Thanksgiving meal and asked everyone to sign up to bring one of them. It was a lot of work and effort on my part, but somehow I managed the stress and avoided being overwhelmed by my task, which was to bring in three cans of cranberry sauce and a can opener. ;-) The school provided us with turkey and drinks, and all of the faculty were invited to come for lunch as well. We all ate too much, but everything was so good.

In the afternoon, I studied for a while and went to the gym before going to train for the bone marrow drive. I can't remember if I've told you about the Oncology Interest Group that we have at CCLCM, but they are one of the sponsors of the bone marrow drive along with the Asian medical student group over at Case. Any student will be welcome to register, but we are specifically targeting ethnic minority groups that have the most difficulty finding a match: Blacks, Asians, Hispanics, and Ashkenazi Jews. The drive is going to be held over at Case in a couple of weeks. It's really easy to register. You just have to swab the inside of your mouth a few times and fill out a form. Your DNA gets tested and put into a databank where it can be compared against people who have a disease like leukemia where they need a bone marrow transplant. If you come up as a match for someone, you are contacted and asked to donate your marrow. You are free to refuse to donate, but since it is expensive to register and test potential donors and we are not going to charge anyone to register, we are asking that people only register if they are serious about being willing to donate their marrow if they get asked.

FAQ #18: How Much Clinical Experience Do You Get at CCLCM?

If you've been following my blog for the past five months, then you know that we are already getting quite a bit of clinical experience. We begin to see patients on our own starting in October of our first year. At the beginning, we didn't do very much because we hadn't learned too many skills yet, but over time, we've been gradually doing more. I think that the clinical exposure we get here is one of the greatest strengths of the CCLCM program. When I talk to my friends at other schools, I've spent way more time working one-on-one with actual patients than any of them have, no contest.

The way it works is that each week we have one afternoon of either clinical skills class or actual clinic. One week we learn a set of skills in our clinical skills class, and then the following week we practice those skills with actual patients in the clinic. When I say skills, I mean both clinical and interviewing skills. Our class lasts four hours, and we spend half of that time practicing clinical skills on standardized patients, and the other half interviewing standardized patients. A lot of medical schools use standardized patients to teach their medical students, so that is not something that is unique to CCLCM. Basically, these people are paid actors who allow us to examine them and interview them for practice. So far we've learned how to do things like take pulse and blood pressure, listen to heart and lung sounds, and take a patient history to find out why the patient came to the clinic that day. After Thanksgiving break, we'll be learning how to use the otoscope to examine the ears, nose, and mouth.

During the weeks that we have clinic, we usually see four patients. Again, these are real patients. We are supposed to see two of them on our own and two with our preceptor, but my preceptor is so busy that I usually wind up seeing three or even all four of my patients on my own. I get the patients from the waiting room, weigh them, take their blood pressure, ask them why they came to the clinic that day, find out about their medical history, listen to their hearts and lungs, and so on. Then I report what I found out to my preceptor, and we return to the room to see the patient together. Sometimes I perform that week's clinical skills in front of my preceptor, and sometimes I do them on my own and we just discuss my findings. Each week, the exam gets a little more complex, as does the interview. It is very challenging to work with patients, and you never know what you will find out when you shut the examining room door behind you. But it's also very exciting and interesting, especially when I see patients who have symptoms and illnesses that we've been learning about in class. I would say that the afternoons I've spent in the clinic have been one of the major highlights of my experience in medical school.

Histology of Blood Cells, PBL, POD, and CHI

Today was a pretty rough day, and not really because the classes themselves weren't good. I think a lot of it is that we are all getting tired and irritable now that we're nearing the end of the block, myself included. We started out this morning with a histology seminar, and I am just not gung-ho about histology. I know I haven't put as much time into learning it as I should have, and I would probably enjoy it more if I was more familiar with all of the different cell types. But somehow it is hard to get enthusiastic about hours of gazing at fuzzy pictures with arrows pointing at nebulous structures. I mean, cells are cells. Some have big nuclei, and some have small nuclei, but I still say that they all look more or less the same.

PBL today was kind of rough too. This was my last day as the group leader, and I think that we did all right with the session itself as far as getting through all of our work was concerned. Everyone did a good job with their presentations and we got done on time. But like I said, we are all very cranky, and we were arguing about stupid things and snapping at one another. I am sorry to say that I was one of the offenders.

The POD speaker was very good, and he didn't use PowerPoint at all, which I thought was great. Sometimes speakers will just present slide after slide of data, and those seminars are not the most fun for us to sit through. But this speaker didn't do that. Instead, he sat and talked with us about how he wound up where he was and the things that happened in his life to affect his current research work. It was really interesting to hear about. But some of the research he had done made me feel sick to my stomach, and I ended up walking out about two thirds of the way through because I just didn't want to hear any more about it. He had been doing physiology experiments on dogs that involved making their hearts fail, implanting sensors in their backs, and then driving up a hill with the dogs trying to run behind and keep up. I wouldn't normally consider myself to be some kind of animal rights activist or anything, and maybe I was just feeling sensitive because I was in a bad mood. But for whatever reason, it got to me.

In the afternoon, I volunteered at CHI again, and that was the best part of the day. You hopefully remember that CHI is our student-run free health clinic. I started out doing body fat percentage and BMI measurements for patients, and I counseled the ones whose body fat and BMI were too high about ideas to help them lose weight. We were giving out free flu shots today, so when things got slow at my station, the doctor who was running the flu shot station showed me how to give them, and I gave my first shots. It was surprisingly easy to do. She also showed me how to draw up the flu vaccine into the syringe to prepare the shots for patients. That's actually more tricky than giving the shot, because you have to make sure that there is no air in the syringe.

We have our normal SAQs and CAPPs to do this weekend, and I am not in the mood to do them. Not that I'll be in the mood to do them later either, probably, but I think I just need to take this evening off to relax and do something fun.

Quiet Thursday

Ah, the best day of the week is here once again. No classes, so I mainly spent today getting caught up on my work and cleaning up this mess of an apartment. Amazingly, there is really a floor under these piles of papers and books. I went over to Case in the evening to be part of a medical student panel that was answering questions for undergrads in the pre-med club. It was kind of hard to get myself to go out because the weather today was absolutely nasty. I know I've complained about it constantly raining in Cleveland several times, but it actually doesn't rain here exactly. It kind of spits at you, making a fine mist that no umbrella or raincoat can keep out, and this literally goes on for days and days at a time. Everything is just cold and damp. The good news is that next week is supposed to be nice in time for Thanksgiving.

Surgery Grand Rounds, Pleural Fluid Seminar, PBL, and Clinical Skills

I think that today was my longest day yet, but overall it went well. I actually got here at 6:30 AM so that I could go to a Surgery Grand Rounds talk before class. That was a bit painful, but once I was up and awake, it was definitely worth going to it. The good part is that we got breakfast. Surprisingly, the auditorium was pretty full even at that time of the morning. I guess there are a lot of surgery residents here. Surgeons are very organized. The speaker is the director of the Bariatric and Metabolic Institute here at CCF, which has the appropriate acronym of BMI. He started out by reminding us of how many people in this country are obese (about 300 million overweight and obese people). He is specifically interested in treating metabolic syndrome (aka syndrome X), which describes a cluster of symptoms that tend to go together: hypertension (high blood pressure), hyperglycemia (high blood sugar), glucose intolerance (inability for cells to use insulin to take up blood sugar from the blood), elevated triglycerides (high blood fat levels), and low HDL cholesterol (that's the good kind, so you don't want it to be low). He is a surgeon, so of course his solution to the problem is to treat people by basically stapling their stomachs and re-routing their digestive tracts to bypass parts of their intestines. The results he showed look pretty good, but still, that is some pretty heavy-duty surgery (no pun intended!).

I was kind of sleepy during the seminar, but it was a pretty good one. We are still working on the lungs, and they are surrounded by two membranes called pleura. So the space between them is called the pleural space, and it has some liquid in it, which is the pleural fluid. See, I told you that medical school is not rocket science! Basically we spent most of the seminar discussing how and why this fluid forms, what it does, what happens when there are problems with it, etc. It's both fascinating and disgusting at the same time. Just so you know, you can get some really nasty stuff like pus in your pleural space (this is called empyema), and when that happens, the pleural fluid, which is normally whitish or clear, will turn yellow. This can happen if you have an infection. Sorry if I grossed you out, and hopefully you aren't eating while you read this.

PBL went a lot better today than it did on Monday. Everyone did a good job with their presentations, we got through the case on time, and we weren't as short with one another. My new learning objective is about the effects of carbon monoxide on the body. I'll be presenting that on Friday. I told you that the cases are getting more complex, and today we found out that even though Monday's problem was resolved, the patient has a new problem now. It's a lot more fun when the cases are harder. I think we still have a pretty good idea about what is wrong with the patient, but I like that the cases are getting more challenging.

In the afternoon, we did our clinical skills class, and it was really fun today. The skills we are working on are all related to the lungs and chest, so we practiced several techniques for the lung and chest exam. One thing we did was to check that the sound and vibration from our standardized patient's voice are transferred equally well on both sides of his chest. This entails getting the standardized patient to say "ninety-nine" multiple times. When you consider that these poor guys have to be examined by eight medical students each during the course of one afternoon, you have to admire their patience with us. We also percussed his chest and back. Here, you have you middle finger down firmly against the skin, and you tap it with the middle finger of your other hand. It sounds hollower over the lungs and duller over the liver or muscles. (You can try it yourself on the walls of your house if you want. If you do it right, you will hear that your percussion sounds hollower where there is no stud, and duller where there is a stud.) Finally, we listened to the man's lungs in several places using our stethoscopes. After the physical exams, we did practice interviews where we took the "patient's" medical history. So we had to ask them about what surgeries they have had, illnesses, medical problems, social and personal factors, etc.

Like I said, it was a good day, but I am exhausted and very happy to have tomorrow off.

FCM, Hemoglobin Seminar, Class Meeting, and Anatomy Office Hours

We had a joint FCM session with Case today. Since we had complained a lot about being segregated by program last month when we went over there, the good news is that the powers that be assigned us to mixed small groups so that we could interact with the UP students. However, these excellent intentions were thwarted by the speaker, who droned on for the entire hour and a half. So, although we were in small groups with the UP students and physically sat next to them for the hour and a half, we did not get to actually discuss anything with them. This is the usual FCM pattern. The subject is important, the reading was decent, and the class itself somehow just never quite works out the way it is supposed to.

The hemoglobin seminar we had afterward was pretty good. We talked about the structure and function of hemoglobin, as well as how the genes for hemoglobin turn on and off during development. The coolest part, of course, is discussing the things that can go wrong with hemoglobin, which are called hemoglobinopathies. Hemoglobin is the protein in the blood that carries oxygen from the lungs to the tissues. Some people don't make enough hemoglobin, and they have anemia due to a condition called thalessemia. Other people make normal amounts of hemoglobin, but their hemoglobin has too much affinity for oxygen or too little affinity for oxygen, and they either have problems with releasing oxygen to the tissues or loading oxygen in the lungs. The most famous hemoglobin problem is sickle-cell disease, which happens due to a mutation in the structure of the hemoglobin protein. The mutation changes the properties of the hemoglobin so that in situations where the affected person has low amounts of oxygen, the hemoglobins start polymerizing into long chains. When that happens, it warps the shape of the red blood cell. Normal red blood cells are round disks that have indentations on both sides, but sickle cells are long and thin to the point where they can get stuck in the tiny blood vessels of the body.

We had a class meeting after seminar. This was for all of the M1s. Dean Franco came to ask us what we could do to improve the seminars. Naturally, many of us wanted to talk about the problems we've been having with FCM, and we did for quite a while. But she really wanted to talk to us about the academic seminars, because some of my classmates have stopped attending them. This is kind of a sticky issue. On one hand, some of the seminars are kind of dry or otherwise not particularly helpful. But CCLCM is not like most medical schools where a lot of the students skip class, collect lecture packets, and read them at home to prepare for their exam. So I agree with Dean Franco that we all ought to attend the seminars. That being said, I also think that if some people want to skip them, they ought to be allowed to do that without getting emails sent to their PAs or otherwise being hassled for that choice. If we are adults, and we are, then we should be treated like adults. At the end of the class meeting, two of the M3s came and talked to us about applying for fellowships during our research years. We get stipends from CCF while we're doing our thesis year, but we can also apply for fellowships on top of that. I hadn't considered applying for a fellowship before this, but now I am planning to do it. So that was really useful.

In the afternoon, I went to the anatomy office hours. There was one other student there, and we went through all of the cadavers together with Dr. Drake. Even though we were doing early embryology this week, we are still working on the neck, so all of the prosections were of the neck. You wouldn't think that the neck would be so complicated because there aren't too many organs in the neck (just the thyroid mainly), but it actually is. There are really a lot of muscles, nerves, blood vessels, and connective tissues in there. I don't think I'll ever remember them all, but I'm still enjoying learning about them.

Anatomy, PBL, and Research Seminar

Today was a very long, busy day, but it was a good one. In the morning, we had anatomy lab. We are still working on the neck, but this is the last week of it. Next week we will be reviewing the chest, and then we will begin studying the abdomen in December. We have also begun doing some embryology. So far we have gone over the first three weeks of embryonic development. Dr. Drake has some online modules that cover embryology, and there is also an optional textbook. I wound up getting the book, and I've been reading that. I don't know---I just can't get into doing those online modules. A lot of my classmates really like them, but I don't somehow. Maybe I will try looking at them again at some point, but I think that I just don't learn very well by reading things over a computer compared to reading them from an actual book.

Our new PBL case is a good one. We actually don't know for sure what the problem that the patient has is, although we have some ideas. One thing that I've been noticing is that the cases are getting more complex. At the beginning of the block, they were all pretty easy, and we'd figure the diagnoses out pretty quickly. I think today was the first time where we still weren't sure by the end of the Monday session. I am the group leader this week, and it is not a fun job. We are getting close to the end of the block, and everyone is feeling kind of tired and cranky, including me. We spent too much time today arguing over stupid things like how many learning objectives we were going to have for Wednesday. On the bright side, we are doing a lot better with not talking over one another, and we did manage to get everything done on time. But all in all, this was not the best PBL day we've ever had.

In the afternoon, I went to a Clinical Grand Rounds seminar. The talk was about exercise in zero-gravity conditions, and it was pretty neat. The speaker was explaining how astronauts in space lose bone mass, and what NASA is trying to do to combat that. Unfortunately, NASA's exercise protocol is not working very well, so he is conducting experiments here at the Cleveland Clinic to try to combat this problem. The experiments involve having subjects stay in bed literally 24-7 for 84 straight days. They cannot even get up to go to the bathroom or shower. Everything has to be done while they are lying with their heads down at a 6-degree angle. The experimental group exercises horizontally on a special vertical treadmill, while the control group does not exercise. The research team monitors the forces on their legs along with how much bone mass they lose. At the end of the 84 days, the patients have to undergo mandatory rehabilitation so that they can walk again. It's kind of insane that anyone would even agree to participate in these experiments, but it is really neat, too.

FAQ #17: Can You Explain What Exactly Is PBL?

This is an excellent question. I know that a lot of people argue about PBL and discuss it on SDN without really understanding what PBL actually is. For the uninitiated, PBL stands for problem-based learning. It is a student-centered way of learning, in contrast to lectures, which are faculty-centered. The two are complete opposites. Confused? Read on.

The typical class that you remember from college is a faculty-centered lecture. What this means is that you have a professor or instructor get up in front of a room (typically an auditorium if you went to a large state university like a lot of us did!), and talk to you for an hour or two. The instructor decides what to discuss, tells you what to read beforehand, and chooses what homework you will be assigned. The instructor also makes the tests and is the sole person who evaluates you. You, the student, sit passively and take notes on every word that the instructor says. About the most involved you get is when you ask the professor a question about something he said, or if the professor gives you one of those clickers so that you can respond to the polls on his Power Point.

PBL is completely at the opposite side of the spectrum. The faculty tutor who is assigned to our group speaks very little, and sometimes not at all. In our sessions, it is the students who are responsible for leading the group and setting the agenda. We have one student serve as the leader each time, and in my group, we swap leaders after each case (once per week). All students in the group are expected to participate equally, which means that we are all teachers and we are all students. As a group, we work through a medical case that has been assigned to us. Based on this case, we hypothesize about what problem the patient could have, and we make a list of what we know and what we don't know and would like to know. From the second list, we come up with a group of learning objectives. Each student takes a learning objective, reads about it, and prepares a brief (5-10 minute) presentation about it to share with the rest of the group during our next session. In a typical session, all of us present our learning objectives, and we then continue on with the case. As we add new information, we modify our hypotheses, come up with new learning objectives on things that we still don't know, and try to integrate what we are learning with what we already know. Periodically, we all evaluate ourselves and each other. Our faculty tutor also evaluates us, but his evaluation is one of many instead of the sole evaluation.

I will warn you up front that PBL does have a higher learning curve, and it takes some getting used to if you've never done it before, which most of us hadn't before coming to medical school. But I definitely feel that it is worth it. I have now had the opportunity to experience both PBL and lecture-style curricula, and I can tell you that PBL is WAY more fun than sitting through lectures all day. It is also a lot more work to set up a good PBL session than it is to just attend a lecture. But I am constantly amazed by how much I learn not only from preparing my own learning objectives, but also from the ones prepared by my classmates. PBL forces you to work with your classmates and adjust to everyone's unique background and learning style. It is impossible to be selfish in PBL, because you are responsible for everyone's learning and not just your own.

If you're interested in reading more about PBL, here are two great websites that talk about it quite a bit: http://www.mcli.dist.maricopa.edu/pbl/info.html and http://www.pbli.org/pbl/pbl.htm PBL is in use at many other medical schools besides ours, but CCLCM is one of the few schools that were designed from their very beginning to use PBL instead of lectures. I think that this is one of the reasons why PBL is so well-integrated into our curriculum instead of seeming like it was tacked on as an afterthought. If you think that you'd enjoy a PBL curriculum, you should definitely apply to schools and programs that use it. Some people might try to scare you and tell you that PBL won't teach you everything you need to know or won't prepare you for the medical boards, but the scientific literature doesn't support this conclusion. Actually, PBL-based curricula seem to prepare people equally well versus standard curricula, and again, the PBL is a lot more active and fun to do compared with sitting through yet another mind-numbing lecture. Here is one example of a paper on this issue.

Histology, PBL, and POD

We had a histology seminar this morning covering the lungs, and it was ok. The presenter was a pathologist, and she had us divide up into groups of three or four people. Each group was supposed to learn about a particular part of the histology of the airways, and then we had to present it to the rest of the class. These kinds of seminars are hard. We all feel like we get to understand the part that we are presenting ourselves well, but we don't get as much out of listening to other students present. Ten minutes really isn't enough time for us to truly learn enough about our topics that we can teach it well to others. Part of the problem too is that most of us don't know very much about histology in general. I say most of us, because one of my PhD classmates knew more about the assigned topic than the pathologist leading us did. All of the other groups, including mine, kind of gave a brief intro, and then the pathologist finished off the topic. She didn't say much of anything for that group, though, because my classmate was just that knowledgeable about those pathways. It reminds me yet again of how amazingly smart my classmates are.

After that, we finished our PBL case. I think that this was a pretty good case, and the concept map we made this week was our best one yet. I'm not just saying that because I was the one who was drawing it! I think it was so good because it was a lot more conceptual than a lot of the ones we have been making in the past. (It was also quite aesthetically symmetrical.) The presentations this week were also especially good. Not that we weren't all putting in the effort before, but we're doing a lot better now with not running over time and with relating our objectives to the case. We are also reaching the point where we usually have some time to discuss each presentation and hammer out concepts we still aren't sure about. I feel like I'm getting more out of PBL now than I was at the beginning of the block.

Our POD seminar today was about asthma. The speaker was an MD, and he spent some of the time telling us about how he got into a career in academic medicine along with telling us about the research he was doing. It was a pretty interesting seminar, and I think that most people liked it. Personally, I found the actual research he was doing to be less interesting versus hearing about his life story. I wish that other POD speakers would tell us more about how they got into their careers in academic medicine and not just about the research itself.

Yay, It's Thursday!

I swear, Wednesday nights feel like Friday nights for me. There's something about getting home on a Wednesday night knowing that I don't have to get up early on Thursday morning that makes it feel like a weekend. The weather was gorgeous today too: sunny and in the high sixties. I did my laundry this morning, went to the gym, and then sat outside to study. It was actually pretty relaxing, and I got a lot of reading done. I'm finished with preparing my learning objective for tomorrow, too. I couldn't have asked for a better day in medical school than this.

Respiration Seminar and PBL

Today's seminar was really neat. We went over to the Crile building, which is one of the clinics on campus, and we got to see the effects of breathing a high concentration of carbon dioxide first hand. Three of my classmates and I volunteered to breathe a mixture of gases that contained a high concentration of carbon dioxide. There was plenty of oxygen in there also, but because there are chemical receptors in the brain that specifically detect carbon dioxide, it still makes you start breathing harder and faster when you breathe a gas mixture full of carbon dioxide. Of course, since you're breathing into a bag, that makes the carbon dioxide levels rise even more as you pant away, and things just keep getting worse. This experiment also simulates what it's like to be short of breath. I only did it for about three or four minutes, and it was kind of frightening. You're breathing hard, and it feels like you just can't get enough air. It definitely made a huge impression on all of us, and it also gives me some major sympathy for patients who feel like this all of the time.

We continued on with our PBL case today too. Because of the seminar that we had last Friday about acid/base chemistry, we pretty much figured out what the patient's problem was immediately. This case is also starting to get us into studying the kidneys quite a bit. My next learning objective involves figuring out what the creatinine levels in the blood mean. Our case patient had raised creatinine levels. From what I've read, it seems to mean that her kidneys are not functioning properly. Creatinine is the by-product of another chemical in your muscles called creatine. You make creatinine from creatine whenever you break down muscle mass. The raised creatinine level could happen for a lot of reasons, but I think it's because she's dehydrated. That would mean there would be a lower volume of blood going to the kidneys, and it would cause her creatinine to rise because her kidneys aren't filtering it.

After PBL, I had lunch and went to the gym, and now I'm home to do some studying.