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.