Histo Seminar, PBL, and Dean's Dinner

We had another histology seminar this morning with Dr. Prayson, the pathologist. He was going over the different types of cells (neurons and support cells) in the brain. My favorites are the astrocytes, which really are shaped like stars. Dr. Prayson, being the awesome guy that he is, printed out color copies of all of his slides for us. I wish he could do all of the histo seminars. Apparently next year when we do path, he'll be leading more seminars.

Our PBL case this week is kind of sparse. Again, we have the problem where there really isn't any case left for today, and so we basically have no learning objectives to do for Friday. Well, I take that back. Since the patient is an illegal immigrant and going on Medicaid, we are apparently supposed to be discussing the psychosocial aspects of the case. As if taking FCM weren't enough, now we should use our PBL time to talk about this stuff too? I'm not so happy about that. Plus, Medicaid rules are different in each state, and since I don't intend to ever practice in Ohio, it seems kind of pointless for me to spend a lot of time studying Ohio's specific Medicaid rules.

We had another Dean's Dinner this evening, and it was great as usual. The speaker was telling us about an unexpected side effect that resulted from the use of an experimental drug called natalizumab for multiple sclerosis patients. Multiple sclerosis (MS) is an autoimmune disorder that is caused by the body's immune system attacking the myelin covering of certain neurons. The drug apparently works very well for MS, but in a small number of patients, it resulted in a new illness called progressive multifocal leukoencephalopathy (PML). PML is caused by a viral infection in the brain. Unfortunately for the few people who developed the disease, PML is often fatal unless the person's immune system weakness can be reversed in time.

Not only was the talk really good, but the food was as well. I wish we could have Dean's Dinners more often.

FCM, Nerve Histology, and Clinic

Our FCM class today was about bioethics, and it was one of the better FCM sessions we've had. First we met in our small groups for about 45 minutes to discuss bioethics, and then we had a group lecture. I thought that the best insight from today's reading was that bioethics is really about not only how we treat individuals, but also what kind of a society we want to be in general. The faculty leader asked us if we thought bioethics was even necessary or important, and I guess I answered, "obviously!" kind of strongly, because he actually laughed that I take the importance of bioethics for granted. He said a lot of people don't. I learned another amazingly awesome thing this morning that has absolutely nothing to do with FCM: it turns out that this same faculty leader is related to Robert Boyle, the chemist who came up with Boyle's Law for gases. How cool is that?

The nerve histology seminars (there were two short ones back to back instead of one two hour long one) were pretty good. Our seminar leader did a really great thing and annotated her slides. This makes them actually useful to us for studying. I printed them out and plan to go over them again later when I have some time.

I had clinic this afternoon, and it was quite an interesting experience. We were finishing up with the neuro exams. You know how I told you that practicing these physical diagnosis exams on standardized patients is nothing like performing them on real patients? Ok, so today, I was trying to get this one patient to have a patellar tendon reflex. That's the stereotypical one that doctors do where they hit the patient's knee with the little reflex hammer and the patient kicks their leg. I tried it last week with the standardized patient, and I also spent some time practicing it on myself. No problems there. But today one of my patients was so obese that I couldn't even find the patella (kneecap), let alone the patellar tendon. You have to understand that on most people, the patella is pretty easy to find. Feel your own knee, and you can easily find your kneecap. The patellar tendon is right below the bone. But I couldn't find the patella on this patient to save my life. There was just too much fat covering it. So finally I took the reflex hammer and kind of hit where I thought the tendon should be. Not much happened. But the patient claimed to have felt it, so I decided to call it a positive patellar tendon reflex and move on.

Luckily my preceptor was understanding about it. We calculated the patient's body mass index (BMI), which measures whether your weight is appropriate for your height. A normal person's BMI is between 19-24. Someone who is slightly overweight will have a BMI from 25-29, and a BMI over 30 means that the person is obese. This patient's BMI was above 60.

Skull Anatomy and PBL

We started our neuro block today, and so far I have to say that it is way better than the past three weeks have been. Well, anatomy lab is always the best seminar every week anyway. Today we had one station that was for learning about the human skull. They were real skulls. I hadn't realized how many different holes, grooves, and ridges there are in a skull, and every one of them has a name. There were also two cadaver stations. One was for the spinal cord, and we saw the membranes around the cord and talked about the vertebrae. But the most riveting cadaver was the brain prosection. The resident had removed the top of the cadaver's skull and scooped out half of the brain so that he could show us the structures on the other half. Since our cadavers are not preserved, the brain winds up kind of collapsing under its own weight. I touched it, and it has the consistency of jello. The other impressive thing about the brain was the network of veins running all over the surface of it. We had a radiology station like normal, and a fifth station where we played with these rubber brain models that come apart. Those models are awesome. I wish I had one at home.

Our new PBL case is about the embryology and histology of the nervous system. These are not my favorite subjects, but I know they are important ones. My learning objective for Wednesday is about early embryology, pre-formation of the nervous system. That covers about the first three weeks of embryonic development. It amazes me that by the end of the first month of embryonic development, the rudimentary nervous system is already in place, and by the end of the third month, the nervous system is mainly established and thereafter is mostly getting pruned. It's like sculpting a topiary, the neurosurgeon said.

FAQ #24: How Does the CCLCM Evaluation System Work Exactly?

This is a pretty complicated topic, so I thought it deserves its own post. You probably already know that we don't have any tests or grades at CCLCM. But the Medical School Promotions and Review Committee (MSPRC), which is a group of faculty that evaluates whether we are ready to move on to the following year, needs to have some basis to make this decision. The MSPRC evaluates CCLCM students for promotion according to whether they have met nine competencies. These include 1) clinical and basic science research skills; 2) medical and biomedical science knowledge; 3) verbal and written communication skills; 4) clinical skills, including taking patient histories and physical examination; 5) clinical reasoning and diagnosis of patients; 6) professionalism, ethics, and personal responsibility; 7) personal and educational development; 8) knowledge of health care systems; and 9) reflective practice about learning needs and how to integrate knowledge. There are different expectations for students in each year of the curriculum.

Ok, so how do I go about proving that I have research skills and knowledge of health care systems and all the rest? This is why we have portfolios. We keep the portfolios on line in our CCLCM portal accounts. (If you want to see a sample CCLCM portal account, go to http://cclcm.ccf.org/ and login by typing "guest" as your userID and password. You won't be able to see a sample portfolio right now, unfortunately, but hopefully this will be a future addition to the portal guest account.) There are many types of evidence that go into the portfolios. Some evidence is collected there for us automatically. For example, we get regular evaluations from our our PBL groupmates, our PBL tutors, and our research and clinical preceptors. We also write self-evaluations each block. These evaluations largely comment about professionalism, but also cover research, medical knowledge, clinical skills, and communication. In addition, the faculty evaluations of the CAPP essays that we write each week can be used toward our medical knowledge competency. There is also a separate portfolio section for each student to add their own personal evidence that just pertains to that individual student. For example, I used writing this blog as evidence of my communications competency. Some of my classmates who are still doing research used that in their portfolios, but I didn't, because I haven't done any research since last summer. So our portfolios are not all identical.

Once per quarter (every three months), we write a formative portfolio essay. This was what I was describing earlier in the week. Writing the essay is a pretty big job with several parts. I always start by printing out all of my evidence, which comes out to be quite a stack of paper. Then I go through the evidence and look for the common themes. For example, both my clinical preceptor and my physical diagnosis preceptor said that I need to practice my clinical skills to become more comfortable with performing them. I also felt that I need to work on them more. So since this is a general theme, it's something that I addressed in my essay. The essay starts out with a paragraph about how much progress the student has made toward achieving their learning goals. Then there is a paragraph for each of the competencies. At the beginning of the first year, we were only expected to cover four of them. This essay, which was our second, covered seven of them. Our third formative essay next quarter will cover all nice competencies. The last part of the essay is a synthesis of your strengths and weaknesses, how this will affect your development and career as a physician, and our plan to improve our areas of weakness. At the end of the year, we write a summative portfolio based upon the three formative portfolios. It is the summative portfolio that is submitted for promotion consideration to the MSPRC.

This whole system sounds kind of complicated, and it probably would be pretty intimidating if we didn't have help. But we have our physician advisors (PAs), who are responsible for helping us assemble our portfolios and ensure that our learning plans will allow us to meet the competencies so that we will pass the MSPRC review. Contrary to popular belief, it IS possible for students to fail out of a pass/fail medical school! It doesn't happen very often though, because your PA is supposed to work with you to ensure that you'll be ready for review at the end of the year.

Intro to the Brain

Even though this week was supposed to be about skeletal muscles, I get the impression that it was really all a big lead-in for next week when we'll be starting the neuro unit. Our seminar this morning was an introduction to the anatomy of the central nervous system. It wasn't bad, but since I had finished all of the reading before class, and the seminar basically completely followed the reading, it wasn't the most exciting seminar.

Our PBL case this week was about a neuromuscular disorder, and we wound up making almost all of our learning objectives about the nervous system rather than the muscles. I think that everyone is feeling kind of anxious about the next four weeks because the difficulty of neuro has been hyped up so much. I guess I feel that way too. I wound up getting a neuroanatomy atlas that has some really nice pictures of the brain in it. Even better, every chapter has a section with USMLE practice questions. (Don't worry, agnathodemon, I'll post another list of books for you at the end of the block. :-) )

Our POD speaker today was talking about genes in muscle development. She was a good speaker, and my classmates who are really into molecular bio seemed to especially enjoy the talk. Her lab is interested in studying how alternative splicing of certain genes in muscle cells leads them to develop into muscle cells instead of some other type, as well as how their development allows them to function properly.

After POD, one of my classmates and I spent the rest of the afternoon in the library doing some cardiovascular anatomy and physiology practice questions. We were both lamenting how much cardio we've already managed to forget after only three months. Actually, though, doing the questions really helped us review a lot of these topics, and we're planning to do this again every month. I think maybe next time we'll go over the respiratory system.

Seminar, Clinical Research Class and Portfolio Essay

I came in early today to see a seminar being given by the director of the Framingham Heart Study. I almost didn't go because I still had so much work to do on my portfolio essay, but the talk was great, and I'm really glad that I went. It was worth losing an extra hour's sleep. The talk was mainly about hypertension (high blood pressure) as a risk factor for coronary artery disease. According to the Framingham results, there is a linear relationship between the two: if you lower your blood pressure more, your risk of CAD goes down proportionately.

We went over statistical tests and hypothesis generation in the clinical research class. These are important subjects, but wow, three hours of powerpoints by a statistician on this topic is a bit much, particularly when you've only had a few hours' sleep the night before. I had finished writing the draft of my portfolio essay by this point, but I still had to go back and put in my references, proofread it, and get it uploaded to the portal. Amazingly, I only had to get help from the tech support people once, and I got the finished essay uploaded by about 3 PM.

I forgot to mention that the cops were checking IDs all over Lerner today. Apparently there were some animal rights nutjobs protesting outside in the snow, but I didn't see them.

Another Way Long Wednesday

We started out today with a biochem seminar yet again, but it was a different biochemist than last time. This seminar was a lot better than the energy biochem one we had yesterday, although still not great. But to be fair, I guess it would be hard for anyone to turn purine biosynthesis into a fascinating subject. Then the biochemist from yesterday came back to give us the second half of the seminar, and I was resigning myself to another torturous hour. But this seminar was more clinical and a lot better than yesterday's. (It was on muscular dystrophy.) Maybe the speaker was less nervous or something, or maybe it was just a more familiar topic. I don't know what it was, but that has to be the biggest improvement in a 24-hour period that I've ever seen a speaker make.

I'm still the leader for PBL today. This week is supposed to be about muscles, but we're getting pretty heavy into neuro already. One of my group members knows a lot about neuro, and we had him give us a not-so-brief intro to the brain. I can already see that neuroanatomy is going to be very complicated, but I am still hopeful that it's going to be an interesting four weeks. I haven't really been enjoying the musculoskeletal stuff on the whole up to this point.

In the afternoon, we had clinical skills, and for the physical diagnosis part we finished off the rest of the neuro exams that we hadn't covered last time. Somehow the neuro tests we did today seem to be the easier ones--well, all except for testing people's reflexes. I managed to bang our standardized patient on the kneecap once while I was testing her patellar reflex, but only once. At the beginning, I was using my right hand to do the tendon reflex tests, but I got a lot better results when I used my left hand. So apparently I am a lefty when it comes to testing reflexes. Our communications skill for this week was on how to close the interview, which is kind of silly. I mean, we've been closing interviews for four months now! It's pretty easy: I just tell the patient that I'm going to go get the doctor now, and thanks a lot for letting me examine you. It's so easy to close the interview that I didn't even need to take this communications skills class to figure out how to close the interview. The best part of the class was when one of my classmates decided to pretend that he was the physician instead of a med student. He didn't give anyone any warning that he was going to do it, and he started making up a treatment plan on the fly. The rest of us were just cracking up throughout his entire interview, but he and the standardized patient both managed to keep a straight face.

Tonight I'm working on my portfolio essay. I won't be getting much sleep, I don't think. At least my paper for the clinical research class that's due tomorrow is already done.

Skeletal Muscle/Biochem Seminar, Clinical Research Grand Rounds, and Anatomy Office Hours

We had a ridiculous amount of reading for seminar today, and I didn't even come close to getting it all done. That seems to be a general pattern for this entire block. There is supposed to be a 30-page reading assignment limit per seminar, but someone forgot to tell these people about that. On the bright side, we did not have FCM this morning. There were actually three seminars. The first one was on the embryology of muscles, and it was fairly good. The second one was contrasting muscle contraction in skeletal muscles versus cardiac muscles. It was led by the same prof who taught us about muscles last fall in the cardio block, and she was awesome as usual. Her seminars are always really interactive and interesting.

The third seminar was by a biochemist, and it was quite possibly the most painful lecture I've ever sat through. You have to understand first of all that "lecture" is a four-letter word at CCLCM, and that's exactly what this was. It was the kind of thing that I'll laugh my rear off about later, but I didn't think it was very funny while I was sitting through it. ("This is the structure of ATP: it has phosphate groups on it," and "Now we will talk about the TCA cycle. It's called a cycle because it goes in a circle.") Even the course director walked out of the room about halfway through. But since there were no questions and the presenter could just keep zipping through that powerpoint, at least we got finished half an hour early.

We had a class meeting right afterward, but I wanted to go to the Clinical Research Grand Rounds, so I missed the class meeting. The seminar was about different kinds of clinical trials. It was a little over my head actually.

Afterward, I went back to Lerner and printed out all of my evaluations. I can't remember if I mentioned that our second formative portfolio essays are due on Thursday afternoon. I haven't started writing the essay yet, but I've been organizing my evidence for the past couple of weeks. So it shouldn't be too big of a job to actually write the thing, assuming that I don't have problems with getting the reference software to work. I don't know what it is about RefWorks, but I always have some kind of problem with it whenever I try to use it.

At the anatomy office hours, Dr. Drake reviewed the cadavers with a couple of other students and me. We're finishing up with the legs. It figures: just when I finally start learning all of the structures, we go on to something else and I don't know anything all over again. Next week we're starting on the head to go along with our neuro block. I keep telling myself that things will get better next week....

Anatomy of the Leg and PBL

We went over the anatomy of the leg today, and again, it was a lot less hectic in comparison to when we did the anatomy of the forearm and hand a couple of weeks ago. The good thing too is that we really don't need to know too much about the anatomy of the foot, so that eliminates a lot of tiny muscles and bones. It also makes it easier to learn about the leg if you do it by compartments instead of trying to memorize every individual muscle, nerve, and blood vessel. I'm a lousy memorizer anyway, so I would never dare try to just memorize everything without a context like that.

The POD coursemaster didn't know she wasn't supposed to tell us the answer to the PBL case last Friday when she talked to us about what we'd be doing this week. So it was a little anticlimactic to try to go through the case to "come up" with the diagnosis that we already knew. We still came up with some good learning objectives and had a good discussion about the science though. My learning objective is about the pharmacology of acetylcholinesterase inhibitors. I'm the group leader this week, and the job was much easier with this group than with my last group. Somehow, we were always rushing and pressed for time in my last group, and it was kind of stressful to be the leader and have to keep everyone on task. But this group is a lot more easygoing and relaxed, and we don't seem to have the same problem with finishing late. I don't know how much of that has to do with the different mix of people in the group versus the fact that my classmates and I are a lot more experienced now with doing PBL cases. Probably it's a mixture of both. Someone could do a research project about the improvement in functioning of PBL groups over time if it hasn't already been done.

I don't have anything that I have to do at school this afternoon, so I'm going home to work on my paper and try to get a little of tomorrow's reading done. We have a ridiculous amount of reading to do for tomorrow. I think it's close to 100 pages, although thankfully some of it is optional.

Cartilage Seminar, PBL, POD, and CHI

The speaker for today's seminar was another biomedical engineer, and he was really awesome. He started out by telling us that the purpose of the seminar leader was to amuse the students so that we could return to our books feeling refreshed. How can you not like a speaker like that? Plus, the course director brings us junkfood. We had blueberry muffins on Wednesday and chocolate chip cookies today. One of the most interesting things the speaker told us is that leather, like our bones, is mainly composed of Type I collagen.

Our PBL session today was really good. We didn't have any case to go over at all, and all eight of us had learning objectives, so we spent the whole time going over them and discussing the concepts. I think it was one of the better PBL sessions that we've had. I learned a lot. Our midblock evaluations for PBL have to be completed by Monday. I'm going to do mine over the weekend.

Today's POD speaker broke the general rule that MDs tend to be more interesting speakers than PhDs. He started out by telling us all about the people in his lab. He actually had made a color-coded flow chart to diagram how the chain of command in his lab is set up. Then he went through all of the grants he had gotten with us, too. At the end of nearly half an hour of this, he stopped to comment that he was getting concerned because none of us were asking questions! After that, he started telling us about his actual research, and that part of the talk was a lot better. He works on using stem cells to help heal serious bone fractures. Basically he is a tissue engineer.

All morning, it was snowing like crazy. I was supposed to work at CHI this afternoon, but the coordinators decided to cancel for today since the weather was so bad and the M2s had a class meeting anyway. I wound up going to the gym and actually got home nice and early, which was a welcome surprise.

Research Questions

I had class this morning, and we spent most of the time covering how to come up with a suitable research question. Two of the librarians came and reviewed how to do literature searches with us also. I don't think I've mentioned before that the CCF librarians will do our literature searches for us if we want. I haven't ever tried taking advantage of this service yet, but maybe I will at the end of the course just to make sure I haven't missed anything important before we start getting serious with implementing the experiment. In the afternoon, I met with my clinical research preceptor again. I have come up with my research question now, and I'm ready to write the first assignment for class, which is due next week. Basically we need to write a one page statement of the problem and a brief literature background for it.

Histology and Structure of Cartilage and PBL

We had a brief histology seminar this morning about cartilage. Again, the cartilage cells and extracellular matrix organization tends to parallel the organization for bone, so it's not terribly hard to understand the cartilage structures after having learned the bone ones last week. One difference though is that bone and cartilage contain different types of collagen in the extracellular matrix, and of course cartilage is not calcified (at least not normally!) like bone is. The second part of the seminar covered the structure of collagen molecules. Cartilage is almost all extracellular matrix, and a large portion of that extracellular matrix is collagen. It's a pretty interesting molecule. A collagen molecule gets synthesized inside a cell called a chondroblast as a precursor with extra pieces on the two ends. These pieces are needed to keep the collagen molecules from polymerizing inside the cell and to direct the assembly of the collagen, but they get cleaved off later.

Our PBL case isn't particularly interesting this week, but it has about a zillion parts. We also have a ton of learning objectives for Friday. That's ok though, because there really isn't any case left for Friday. We're making our presentations ten minutes this time instead of just five. My learning objective is on the anatomy of the knee. This will force me to finish reading the anatomy book section about the knees, so that's a good thing. I'm meeting with my preceptor for the clinical research project I'll be doing this summer in a little while, so I am off to finish reading the proposal draft.

Anatomy, Clinic, and Anatomy Office Hours

I wound up missing FCM this morning, but it was a really long day anyway. We're covering the hips and thighs now in anatomy lab. It is still ridiculously intense, but somehow it wasn't as bad today as last week. I think that part of it is that there are a lot of parallel structures in the arms and thighs. Not that they're identical, and there are a ton of new names of nerves, bones, muscles, and joints to learn. But at least now the organization of the limbs seems kind of familiar to me.

During lunch, I made myself a cheat sheet of all the tests for the cranial nerves. That was really helpful when I went into clinic. I only had two patients today, and I took the cheat sheet into the room with me so that I'd remember which test to use for which cranial nerve. I still missed a few, but it worked out pretty well overall. I got out of clinic really early, so I went to anatomy office hours. For a while, I was the only person there, and then one of my classmates came. I went over the cadavers with the anatomy assistant once, and then we went over them a second time with my classmate. I am feeling a lot more comfortable with thigh anatomy now, but I still have a hard time remembering which nerves innervate each muscle.

Geriatrics Clinic

Today was officially a day off from school for Martin Luther King's birthday, but I had geriatrics clinic this afternoon, so I still went in. The geriatrics clinic is on campus in the Crile building, and its function seems to primarily be to evaluate older people who are having memory problems. I was mainly shadowing today, and I saw four patients at various levels of orientation. The first one was very sharp and knew where she was, the day, date, who was president, etc. She even made a comment about how much she dislikes President Bush. This was in stark contrast to the last patient I saw, who had early-stage Alzheimer's Disease. That patient had fought in World War II, and he was telling me all about what he did and saw while he was in the service in the 1940s. But he had no idea what day today was, and he thought this month was October of 2003.

Overall I thought working with older patients was interesting but also kind of sad. All of the ones I saw today had lost their spouses, and they were relatively limited as to what they could do compared to how they were before. It's clear that they start losing their short-term memory way before their long-term memory. One funny thing that happened is that one of the patients got tired of waiting for the doctor and wanted to leave. There was a resident in the room with us who was examining her, and the patient told the resident that she had been here long enough and she was leaving right now. The resident was trying really hard to convince her to stay long enough for the attending to come see her. We finally had to get the attending out of another room with another patient before she would agree to stay.

I just finished my CAPPs for this week; we got an extra day to do them because of the holiday. This week, we have an unusual schedule. We only have two PBL sessions instead of three, and our anatomy lab is tomorrow after FCM. Tomorrow is going to be one hell of a day. I get to start it off with FCM. Then we're covering anatomy of the lower limb, which I haven't had a chance to do much reading for yet, and to top it all off, I have my normal clinic in the afternoon. I'm supposed to be practicing the neuro exams, which I am still not familiar with and don't feel comfortable performing. I am thinking that maybe I'm going to have to ask my preceptor to show me the tests again and watch me perform them, at least the first time. Sigh.

Bone Remodeling, PBL, and POD

Our seminar this morning was about bone remodeling. The first half was a general overview on the subject, and then the second half was a journal club. The articles for today were decent, and I think it's an interesting subject even if there is a little too much molecular bio for my taste. The seminar speaker was different than the one we had the last couple of times, but he was also good. I had no idea before this week just how complex bone biology really is. I think I had this impression that bone is mostly just some kind of scaffold to hang your muscles on so that you can move, but actually, bone is constantly changing and remodeling itself throughout your life.

The PBL case today was non-existent. It's like they gave us everything on Monday and then we had nothing left for the rest of the week. I was talking to our tutor afterward, and he was saying that we could have started next week's case today. Everyone's presentations were really good though. I enjoyed preparing my learning objective for today. Some of the nutrients required for bones are obvious ones that everyone knows, like calcium, vitamin D, and phosphorus. But it turns out that some other kind of bizarre things are needed too, including protein and silicon. People who eat Western diets primarily get silicon from grain products, and men have a higher dietary silicon intake than women do on average. Why? Well, apparently it's because men drink more beer than women do!

The POD talk was pretty interesting. Our speaker was a researcher in sports injuries, specifically the ligaments in the knee. He is studying how to prevent injuries in athletes who do a lot of turning and jumping, like basketball players or skiers. His research team does computer modeling of men and women making motions like they would make in sports, and seeing what variables lead to them injuring their knees. It has been known for a long time that women have more knee injuries than men do, but no one is sure why. People have all kinds of hypotheses about this, and it is probably a combination of things including different anatomy, different movement patterns, and different levels of strength and training. One really neat thing we found out about this speaker was that he won an Academy Award for his computer software, which was used to do the animation for Lord of the Rings.

Clinical Research Course

I had my first MS class today. The purpose of the class is to teach us how to write a clinical research proposal, which will come in very handy considering that we have to write one at the end of this summer anyway. There are six of us in the class: four medical students from CCLCM and two CCF residents. Today was an introduction. We went over the course syllabus and discussed the attributes of a good mentor. The presentation was a little long, but I think that this class will be really helpful, and I'm looking forward to it.

Bone Formation Seminar, PBL, and Clinical Skills

This morning's seminar was about how bone is formed from cartilage. It would have been helpful if we had learned about cartilage already, but the seminar was ok in spite of that. We'll be doing the cartilage next week. The faculty switched the order this year because MLK's birthday on Monday is an official CCLCM holiday. Today's material went more into inorganic chemistry (lattice energy, solution chemistry, crystallization) than physics. The seminar speaker was the same biomedical engineer who led yesterday's seminar, and he's a pretty good presenter. I have to say though that two hours of bone bioinorganic chemistry was way more than I ever wanted to know about the subject.

PBL today was short. I guess we went over the main part of the case last time, because there was basically nothing for us to go on today except a set of normal blood lab test results and a short paragraph about the patient's treatment. My learning objective for Friday is about the effect of diet on bone formation.

We had clinical skills class this afternoon, and it was kind of rough. There is always an introduction at the beginning where all of us are together in one room, and we get a brief overview of what we'll be doing that day. This week we were focusing on getting the patient's perspective about their problems and concerns for the communications portion of the class. The communications faculty showed us a brief video of someone doing this, and to their surprise, most of the students thought that the interviewer was condescending and otherwise not very effective. Apparently the video interviewer is supposed to be some kind of communications expert, so it's pretty funny that we all thought she was so awful. The communications session itself wasn't too bad, except that my standardized patient denied having any concerns at all about the lump in her breast. I tried several times to get her to talk about it with no luck. Not being concerned must have been in her script though, because she wouldn't talk about it to anyone else, either.

However, it was the physical diagnosis part of the class that was the most frustrating. For some reason that is unknown to me, we are doing the neurological exams now, even though we don't know anything about neuroanatomy yet. So the preceptor is asking us how to test the function of all of the cranial nerves (the nerves in the head), and I don't even know what all of them do or where they go. We won't start studying this stuff until next month after we finish the musculoskeletal unit. And the really senseless thing is that the physical diagnosis skills we'll be doing next month while we're studying neuroanatomy and neurophysiology are for the musculoskeletal system! I don't feel like I know very much about the neuro exams at all. I was basically just going through the motions of performing the exam without understanding everything I was doing. Well, I guess the one good thing is that at least we'll understand what we're doing during the musculoskeletal physical diagnosis session next month.

Histology of Bone, Bone Structure, Anatomy, and Career Development

Our seminar this morning had two parts: one hour of histology of bone and one hour about bone structure. Histology of bones is kind of neat. The osteons, which are the basic structural unit of bone, are quite pretty. Here is a picture of one. Plus, there are only four types of cells that we have to know, and they are fairly easy to distinguish from one another. Osteoclasts have several nuclei and are enormous compared to the other cell types. Osteocytes are in between layers of bone, have projections on them, and very little rough endoplasmic reticulum (RER) or Golgi apparatus. The osteocytes come from osteoblasts, which look similar but have a lot of RER and Golgi since they're still actively synthesizing protein. Osteoprogenitor cells are kind of flat-shaped (as opposed to the more cuboidal-shaped osteoblasts) and have a lot of mitochondria in them.

The bone structure seminar was given by a biomedical engineer. I hadn't appreciated before today how much analogy there is between bone and concrete. There are two components of bone: organic collagen fibers (which he said were like reinforcement bars), and the inorganic mineral hydroxyapatite (which is like the concrete itself). I don't have any prior experience with engineering, so it's a new way of approaching the subject conceptually. But it's pretty interesting. And for those of you who are pre-meds and wondering if you'll ever have to use all of that physics you're learning: you will. Today we discussed Young's modulus, density, moments of inertia, and torque in the span of one hour.

Anatomy lab today made yesterday look like a warm-up. Well, it didn't help that I haven't had a chance to read the sections of the book about the hands yet, but it also didn't help that I'd already sat through two hours of seminars before I got to anatomy, either. I came in kind of fried mentally. My classmates and I also couldn't help but notice how the cadavers' hands were all bloated and snow-white. Plus, the skin was peeling off their fingers where the cuts for the dissections had been made. It's really not very pleasant to see. Even so, I desparately need more review of the hands and arms, so I went back to anatomy office hours today, and I'm probably going to go on Thursday, too.

Besides going to office hours, I also did some of the reading for tomorrow this afternoon, and then I went to the Career Development seminar. This was put on by Dean Franco (she's the Dean of Students as well as the Dean of Admissions) and Wilma Doyle, our program administrator. The seminar itself was kind of silly, and I wasn't really in the mood to play the games. But we got access to an AAMC website that has tools to help us pick specialties, learn about the USMLE, and prepare for the residency match. I tried to log into it last weekend, but I couldn't get my access code to work. I'm going to contact the AAMC about getting it fixed. I'll let you know more about what's on the site once I manage to get access.

First Day of Musculoskeletal and Neuro Block

The upperclassmen had warned us before break that this was going to be a tough block, and they were right. The reading load for the next few weeks is absolutely insane. We're doing bones this week, cartilage next week, and muscles the week after. Then we have four weeks of neuro, followed by the gastrointestinal block, which is also four weeks. To add to the madness, we have two anatomy labs this week: one today and another tomorrow. Dr. Drake in particular just went crazy with assigning us chapters to read. On the bright side, we don't have any FCM this week. I'll happily take an extra anatomy lab over FCM. Speaking of FCM, the administration has apparently decided to stop having us go to Case and to give us more small group time during our FCM sessions. They sent out an email today telling us about these changes. The next FCM session is in a week, so we'll see how it goes.

In today's anatomy session, we covered the upper limb, which is a fancy way of saying the arm, along with the back. It's a lot to learn. I need to study which nerves innervate all of the muscles. Apparently this is an important topic for the Boards. One other nice thing is that we get an extra ten minutes now in anatomy lab. We used to end at 9:50 AM and then start PBL at 10:00, but now we end at 10:00 and start PBL at 10:15 on Mondays. I went back to the anatomy lab this afternoon for office hours, and since I was the only one there, Dr. Drake went through all of the cadavers with me again. Some of this stuff is finally starting to stick.

Our PBL case is about a patient with a sore back due to problems with her vertebrae. The session today was unusually long. Most of the time, the Monday sessions are pretty short, but we were kind of in a rush to finish today. This week I am the computer scribe. My last PBL group had two scribes, one for the board and one to take notes on the computer. This group only has a computer scribe. I don't have a learning objective for Wednesday, but I'm still going to be plenty busy these next couple of days. We have a ton of reading for our seminars tomorrow and Wednesday.

I registered to take one of my MS courses today also. Unfortunately it is being offered on Thursday mornings, so now I won't have my Thursdays off any more for the next few months. The other not so nice thing about it is that it's going to be graded. All of the CCLCM classes are pass/fail, but several of the MS classes are graded with the normal A/B/C/D/F scale. On the bright side, if it winds up being too much for me, I can drop the class with no penalty. I hope I won't have to do that though.