Bacteriology, PBL, and Lunch with Mrs. Lerner

Today was the first day of our Hematology/Immunology/Microbiology block. It's the last one. Seven more weeks until this year is over! The seminar this morning was on Gram-positive bacteria. (We didn't have anatomy this week.) I really like the seminar leader, but wow, does she ever go fast. You can't believe how much material she covered in just two hours.

The PBL case has been very entertaining so far. My new PBL group has a lot of very funny people in it. I think we are all a little silly by this point in the year anyway. I wound up with the same learning objective for Wednesday that I did once for GI, which is on normal body flora. Well, at least it will be relatively easy.

After PBL, a bunch of us went to Tommy's on Coventry to have lunch with Mrs. Lerner. (For those of you moving to Cleveland or visiting in the future, I highly recommend Tommy's.) Apparently the M1s do this every year. You may already know that CCLCM was started with a $100 million donation to the Cleveland Clinic by Al Lerner, the former chairman of MBNA. Unfortunately, Mr. Lerner died in 2002 and never saw the first class of students enroll at our school. But Mrs. Lerner told us that he wanted to start a medical school because he thought that saving someone's life was the greatest thing a person could do. She told us about her own life as well, and she gave all of the M1s Cleveland Browns baseball caps. (Her husband used to own the Browns, and now her son owns them.) All I can say is that she is one very cool lady.

Extreme Seminars, PBL, POD, and Meeting with My PA

Our first seminar this morning was pretty cool. It was on male erection and ejaculation, and really, how can any seminar leader go wrong with a topic like that? Unfortunately, the second seminar was led by the same pharmacist we all complain about continuously. This guy probably COULD actually make a seminar about erections and ejaculation boring. But he was lecturing to us on the pharmacology of bone agents, and that really IS a kind of boring topic. And to make matters worse, his answer for one of this week's SAQ questions is wrong. I double-checked it in the pharm book.

The PBL case ending was kind of anti-climactic. This is the end of the Endo/Repro block, and we are also starting new PBL groups on Monday along with the new block. This will be the Heme/Micro/Immunology block. I'm looking forward to that.

I thought our POD talk today was excellent. The speaker didn't go through tons of slides. He started out by telling us his life story, and it was pretty interesting. For one, he was just a really funny, deadpan kind of guy. You just didn't know what he was going to say next. And in addition, he had been diagnosed with a serious illness while he was in graduate school, which naturally affected the way his research went. He's actually a statistician, but he did his training in the business department of his school and only got into health science applications later. Basically he looks at how to decide on the most cost-effective and optimal health care decision, and he builds models to guide clinicians in deciding how to treat their patients. This same guy was supposed to give one of the talks for my Clinical Research class a week ago, but he was out of town. It's too bad, because he was awesome.

After class, I met with my PA to go over my first two summative portfolio essays. The time is really flying by. Only seven weeks to go.

Clinical Research and Portfolio

Today was one of those days where you ask yourself why A) you thought it was ever a good idea to come to medical school, and B) you thought it would be smart to take an extra class on top of the already intensive med school curriculum. Our clinical research protocols were due today at 5 PM, and so were our first two summative portfolio competency essays. I was mostly done with my protocol, but I still had some more work to do on the methods and abstract sections. Luckily I had already finished my portfolio essays a couple of days ago. We had our clinical research class this morning as usual. It was about statistical methods, and for the first time all semester I had not done the reading. So I was completely lost. But I spent most of the class working on my protocol anyway. Then in the afternoon, I was editing it and putting it all together, and I submitted the protocol and also the portfolio essays. We were supposed to do Research and Health Care Systems this week for our portfolios. But I wanted to hold off on Research until after this class is over so that I can include my protocol as evidence. So I did Personal Development instead.

Amazingly, I managed to get everything done by 4 PM. Don't ask me how. Then I went for dinner. Now I just feel incredibly brain dead and I'm so glad today is finally over.

Male Gonads, Spermatogenesis, and PBL

We had two seminars this morning. The first one was about the physiology of the male gonads, and the guy who was leading it was awesome. He was a urologist with a really wacky sense of humor, and throughout his presentation he had slides with rather colorful humor on them. It was fun. The second part on spermatogenesis wasn't nearly as entertaining, but I'm not sure how objective I can be. The first guy was a tough act to follow.

We're still doing the case about the patient with the small testicles. It turns out we were right about why he's having this problem, and it's not a very interesting reason. What IS interesting though is learning about all the things that can go wrong with male anatomy and physiology. Well, it's interesting and a little disturbing too.

Tomorrow is a day from hell for me. I have to turn in the first two competency essays for my portfolio and the entire protocol for my clinical research class. Then I have a dinner meeting in the evening. I will be so happy when this week is over....

FCM, Male Histo, Adrenals, Clinical Research Grand Rounds, and a First Pap Smear

Our FCM session today was about Medicare and Medicaid. It's incredibly boring, the rules are different in different states, and yet it's also incredibly important to learn about. Someone should come up with an entertaining cartoon book complete with mnemonics about health insurance like the ones they have for all of the science subjects. And by someone, I don't mean me!

We had two seminars today: one about male reproductive tract histology and one about the adrenal glands. What does one have to do with the other? Not much. I think the course directors just paired them this way because in females, the male hormones (androgens) are mainly produced in the adrenal glands.

The seminars were all kind of blah, and so was the Clinical Research Grand Rounds talk that I went to at lunchtime. (It was just about how the General Clinical Research Center operates, which is useful to know, but not the most exciting topic.) However, I had quite an interesting time in clinic today. My preceptor had to go to the hospital and make rounds. So I spent some time seeing patients with one of the IM residents. Then my preceptor came and got me, and we went to the hospital together. That was interesting too, except that we spent a lot of time searching for charts. I hadn't realized this, but CCF still uses paper charts for the hospital inpatients. In contrast, the outpatient clinic charts are completely computerized. In fact, outpatients' charts (complete with lab tests) can be released to the patients themselves on a website called My Chart. The patient logs in and can view all of their own info, make appointments, ask for prescriptions, etc. It's very cool. But the hospital hasn't gone computerized yet for inpatients.

After we saw several inpatients, we went back to the clinic to see another outpatient who had an appointment. This patient was here for a checkup, and it turned out that she needed a Pap smear. Now, keep in mind that we don't learn how to do Pap smears in school until next year. The three of us (me, my preceptor, and the patient) are all in the room together, and my preceptor says to me, "Do you want to do the Pap smear? You've done one of these before, right?"

Of course, I had not ever done any such thing. But I didn't want to say so in front of the patient and have her tell my preceptor to get this #*$#ing medical student away from her! So I said, "Yes, but only with your help. Would you walk me through it again?" My preceptor told me what to do step by step. I inserted the speculum, collected the cells, and removed the speculum. Then I inserted two fingers in the patient's vagina, palpated her cervix, and attempted to palpate her ovaries. Amazingly, her cervix felt just like the cadaver's cervix that I was palpating in anatomy lab yesterday, except that the patient's vaginal canal was plumper (she was pre-menopausal) and warmer (she was alive and she hadn't been in a refrigerator). We took a sample of the vaginal cells and looked at them under the microscope. The patient had a yeast infection, and I saw the yeast cells.

I've learned two very important lessons from this experience:

1) Yes, you should always take advantage of the opportunity to palpate the cadaver's cervix in anatomy lab. You never know when you'll need to do it on a living woman with no warning whatsoever. Plus, it's helpful to have paid attention in lab. That way, when your preceptor tells you to place the cell brush in the cervical os during the Pap smear, you know where the cervical os is. (It's the opening of the cervix.)

2) I wouldn't say that I am a particularly good liar in general. But evidently I can be a surprisingly convincing liar if I blurt the lie out before I have a chance to think about what I'm saying.

Anal Incontinence, PBL, and Diabetes Diet Seminar

There's nothing quite like having "anal incontinence" in your post title to grab someone's attention. Alas, I have nothing all that interesting to tell you about anal incontinence except that it was the subject of our anatomy lab case today. This is actually kind of gross, but the case was about a woman who has an episiotomy during childbirth. An episiotomy is a cut that the obstetrician makes in the woman's perineum if the baby's head is too big to fit through the vagina. The idea is that it will prevent the perineum from tearing with a ragged edge and being difficult to repair. As it turns out, performing episiotomies actually makes perineum tears MORE likely to happen, not less, so they aren't performed very often any more. The surgeon told us that sometimes the perineum tears all the way back to the anus like unzipping a zipper. Yuck. And then, you guessed it. The patient can have complications like anal incontinence if her anal sphincter is damaged.

Even after that rather unappealing beginning, anatomy lab was pretty interesting today. One of the stations was a female cadaver set up like she was having a Pap smear done again. The resident made all of us feel her cervix and try to feel her ovaries. Yes, you have to stick your fingers in the cadaver's vagina in order to feel her cervix. And if you were wondering, the cervix felt kind of hard and almost like rubber. I couldn't feel the ovaries at all, which isn't surprising since the cadaver was post-menopausal. The ovaries atrophy after the woman hits menopause.

Our new PBL case is really interesting too. The patient comes into his doctor's office complaining that his testicles have gotten smaller and softer. There are several other interesting symptoms too, but that's the most interesting one. My learning objective for Wednesday is to review the male gonadal histology and embryology, along with what happens when male genital development goes wrong.

After class, I went to a Wellness Grand Rounds seminar. This was the first time I had ever gone to one of these. The speaker was a physician from George Washington University who studies how to use diet to treat type II diabetes. It is a pretty extreme diet: you basically have to become a vegan, meaning that you eat no meat, no dairy, no eggs, no animal products whatsoever. In addition, you are also eating a lot of complex carbs. This diet is so low-fat and high-fiber that the patients can't help but lose a significant amount of weight, even without exercise. The results are unsurprisingly excellent. Some of the patients could reverse their diabetes altogether and stop taking their medications. Others were able to reduce the doses. I bought one of his books and got a few of his peer-reviewed studies. Really, the only downside of his research is that 99.999999999% of all human beings on this planet are not willing to spend the rest of their lives eating an extremely low-fat (less than 10% fat), high-fiber vegan diet. Bummer, huh?

Maternalistic Seminars, PBL, POD, and CHI

Today was another long and busy day, but it was a pretty good one. We had two seminars on maternal physiology this morning. One was about fertilization and conception, and the other was on pregnancy. The reading load was ridiculous like it has been this entire block. But since I gave up doing all of the reading a couple of weeks ago, I don't feel particularly stressed about it. The irony is that I am doing better than usual on my homework assignments. Go figure. Oh, and I learned a really cool new word: primigravida. It means a woman who is pregnant with her first child.

We had some good discussion today in PBL about the social implications of our patient's disease. Personally, I think the way the case ended was good. So far, pretty much all of our PBL cases have had happy endings. But the second years have told me that some of the cases next year won't.

I really liked today's POD speaker. She is an obesity psychologist. Basically, her job is to counsel patients who are coming to CCF for bariatric surgery. All of these patients have to attend a few hours of group therapy before having the surery. Of course there are a lot of psychological issues with having a major surgery like a gastric bypass. It turns out that maintaining the weight loss over the long term is not very easy. There are several reasons for this, some of which are physical (ex. the stomach pouch expands) and some of which are psychological. One fairly obvious thing I had never thought of before she mentioned it is that initially, patients have a lot of psychological reinforcement to lose the weight. The pounds comes flying off fast at first, people are telling them left and right how great they look, etc. But after a while, their weight loss slows down, they still aren't at the "ideal" body weight they would like to achieve, and the compliments dry up. Then it becomes easy for some of those pounds to creep back on.

I was scheduled to work at CHI today, and I was hoping to postpone and come next week instead because I have so much work to do. But they were short-handed, so I went for a couple of hours. I was doing the cholesterol testing again. One of the patients is a regular who has metabolic syndrome. The cholesterol test measures glucose levels as well as cholesterol, and both of them were sky high for this patient. That shouldn't be happening if the person is taking their medications correctly, so of course I started asking him about that. Many of our CHI patients have compliance issues and trouble getting their meds since they don't have insurance or visit a physician regularly. But the most frustrating thing in this patient's case is that financial issues are not the problem--the patient has insurance and can obtain meds, but he just doesn't take any of his conditions seriously. We measured his blood pressure too, and of course it was also high. I started asking him what he had eaten today, and he tells me that someone gave him cookies, but he only ate six of them. Only ate six of them! No wonder his sugar was so high.

So how do you deal with a patient like this who can comply, but won't? Fortunately or unfortunately, hypertension, diabetes, and hyperlipidemia are all painless diseases in the early stages. By the time symptoms start showing up, now you're looking at some major medical problems like heart disease, kidney disease, etc. I was discussing this with one of my classmates, and we thought it might be effective to show the patients pictures of people with foot ulcers, amputations, and other complications of diabetes. The best picture I found was of a diabetic man's necrotic testicles. If THAT doesn't grab a man's attention, nothing will.

Clinical Research Class and Summative Portfolio Workshop

I thought I had reached rock bottom with this research class already, but oh, was I wrong. This morning, I was incredibly tempted to skip class, but I decided I ought to go since I already had missed one session. I should have stayed home. The instructor was out sick, two of the other students in the class were out, and the speaker was the same person who had given one of our POD talks two months ago. It was the talk about making a website for people with MS, and it wasn't the greatest POD session we've ever had. But I can tell you that sitting through a second, longer version of the exact same talk (complete with the exact same slides) was definitely worse. If we weren't so close to the end already, I'd drop this class for sure. Only two weeks to go now though. On the not so good side, our protocols are due in a week, and we have to start working on our portfolios too....

Ok, so the portfolios. I had hoped to volunteer at the Minority Men's Health Fair, which was this afternoon. But I wound up not going because we had our Summative Portfolio workshop today. Writing the Summative is going to be a very long, drawn-out process that I imagine being somewhat analogous to a cross between writing a resume cover letter and keeping a personal diary. You have to bare your soul, which requires analyzing your strengths and weaknesses; providing adequate proof (complete with working hyperlinks, the bane of my computer-challenged existence); and adhering to a very picky set of formatting rules that I swear came straight out of a Dilbert cartoon. The other difference is that, unlike a real diary, this properly-formatted, proof-laden manifesto is going to be read by people who will evaluate whether you meet certain standards at a high enough level to merit being promoted to the second year of medical school. I don't keep a diary (unless you count this blog), so this should be an interesting experience.

Here's how it works: Each week, for the next five weeks, we will be submitting essays for one or two of the nine competencies to our PAs for review. The essays are due every Thursday at 5 PM. They should not exceed more than two pages in 11 point Arial font with 1.5 line spacing, and the standards for each competency should be bolded, not italicized. (Doh!) Your PA reviews the competency essays and makes "suggestions," which you should then incorporate in order to garner your PA's signature. (Your PA has to sign off on each competency.) Many people's PAs send them comments by email, but my PA is meeting with each of us for half an hour every Friday for the next five weeks. Sigh. The final copy of the Summative is due to the MSPRC on the 31st of May. We'll get our decision letters at high noon on the 15th of June, which also happens to be the last day of classes. That's assuming that the MSPRC doesn't decide to ask you for more info before they decide on your fate, and that you have correctly followed all of the directions. Curse those directions!

As wacky as this whole system is, all in all, it still beats having to take exams any day of the week and twice on Sundays. I make this feeble protest about writing it mainly in mirth, dear reader. More to come....

Surgery Grand Rounds, More Histo, PBL, and Dean's Dinner

Today was a long day, but I got a lot of things done. I went in early for the Surgery Grand Rounds. This was the first time a Surgery Grand Rounds talk has been kind of disappointing to me. The speaker began by describing a little about the FDA, and pointing out that in an ideal world, a regulatory body like the FDA wouldn’t be necessary. (Well, yeah, in an ideal world, no regulations of any kind would be necessary.) It then took him 20 minutes to go through all of these different parts of the FDA. Although it was not the most interesting talk I've ever attended, it definitely impressed upon me (if I had ever had any doubt!) that the FDA, like all governmental agencies, is ridiculously full of layer upon layer of bureaucracy. He was still droning on about some examples of devices that the FDA had approved when I had to leave for class.

My first seminar was yet more histo, this time of the female reproductive tract. There is a part II of it tomorrow. I'm still not all that gung ho about histology, but the speaker made us some fantastic review sheets. I have to say though that this block is ridiculously heavy in histo. It's like my worst M1 nightmare: hour after hour of sitting in the darkened library room (room 3-57, which you'll get to know well if you become a student here) looking at fuzzy slides that half the time won't load properly and that are barely distinguishable. It is looking more and more like a career in path is not in my future....

The second seminar was on oogenesis, and I really enjoyed that one. We went through several cases and discussed oocytes and their hormonal regulation. It's very complex and interesting. Girls are born with all of the oocytes they will ever have, and most of those oocytes die off without ever being ovulated. I also learned that menopause doesn't usually happen until a woman is around 50, which surprised me. I had thought it was more like early 40s, and apparently that does happen to some women, but the normal age is around 50.

I did my female urogenital system embryology learning objective in PBL today, and it basically built on the male urogenital system embryology learning objective that I did last week. Since we already knew a lot of the material, I focused more on comparing and contrasting the male and female development, and I made it into a quiz for review. Oh, and we were right about the diagnosis that we guessed for the patient last time.

I had the afternoon free, so I did some errands and reading and went to the gym. In the evening, we had a Dean's Dinner. The speaker was the same faculty member who helped me do my journal club presentation last summer. I thought her talk was really interesting; she is studying angiogenesis (growth of new blood vessels), and particularly as it relates to the eye. It may seem surprising, but too many blood vessels in the eye can actually lead to blindness or degeneration of the retina in the back of the eye. There were just four of us at my table for dinner, including the speaker, so we were able to ask her more questions about how she became a scientist. (She had started out as a physician and then went back to school to get her PhD.)

Now I am really exhausted, and I do not have the energy to do my reading for class tomorrow. I think I am going to have to just get up early and do it. There are only three more sessions left, including tomorrow. I can do this!

FCM, Female Histo, and Pediatric Clinic

Our FCM session today was about rationing health care. It was basically another rehashing of the same old stuff: health care is not equally accessible to everyone, and the poor get the short end of the stick. I'm still not too comfortable with this business of calling health care a "right." The problem is that healthcare doesn't grow on trees. I can't just go out and pick some when I want it, or buy it on sale at my local store. It's a service, and I have to get someone else to provide me with that service. Unsurprisingly, most people do not want to provide their time and services for free. But if I have a "right" to health care, then how can someone deny me that right by refusing to give me the service when I want it? Maybe it's a semantic issue, because we already have a system where people can get emergency service regardless of their ability to pay. Anyway, better minds than mine have failed to solve this problem. I skipped the big group lecture afterward so that I could work on the reading for peds clinic.

We had two seminars. My first one was on female reproductive tract histology. The seminar leader was pretty good. She had made a great review sheet for us. Also, we were up in the library and only half of us were in there at a time, so it wasn't too crowded. The other seminar was about hormonal regulation of the menstrual cycle, and I thought that one was pretty good too. We went through some cases and worked through what was going wrong with the woman's menstrual cycle. I like when we go through cases like that instead of just having lectures.

In the afternoon, I had my peds clinic. The preceptor was really young and nice. Basically I went with her into the rooms and repeated the exams after she did them. Most of her patients were teenagers except for one little girl who was about seven. That girl was really well-behaved and sweet, but unfortunately she had a serious illness that required surgery. Her parents had brought her in to get a checkup because she was having the surgery tomorrow. She had already been on all kinds of medications, but unfortunately, they hadn't controlled her illness.

The teenagers were a mixed bag. One had trouble concentrating and was on drugs for that. Not so interesting. Another had hurt her knee wrestling. Barely interesting. But the others were better. One was having problems with a medication she was taking, and I spent a lot of time talking to her and her mother about the symptoms she was having. The other was a boy who had come in for a physical. You wouldn't think that would be so exciting, but he refused to let the doctor perform the prostate and genital exam. She made his mother leave the room to see if that would make him feel better about it, but he still refused. Well, it probably didn't help that his mom commented as she walked out of the room that the doctor looks at little boys all day, so he should just let the doctor look at him!

More Female Anatomy and PBL

We continued with female anatomy today. One of the cadavers had her feet tied up like she was having a Pap smear done. This was to show us the external female genitalia. That station actually wound up being pretty interesting because the resident was showing us how to do pelvic exams. One of the pearls of wisdom she gave us was that we should never touch the woman's clitoris or urethra when inserting a speculum into the woman's vagina. Well, that is good information to know I suppose, although I really hope that giving tons of pelvic exams is not in my future.

The other cadavers were dissections of the internal genitalia and the nerves and blood vessels. There were only four groups today, so there were more of us in each group than normal. That would have been annoying, but the cadaver for the blood vessels and nerves smelled so strongly that I didn't have any trouble getting up to the front for as much of a look as I wanted. Plus, I went back later in the afternoon for office hours and went through both cadavers a second time. Lately no one else has been coming to office hours while I'm there, so one of the anatomy profs goes through all of the cadavers with me one on one.

Our new PBL case is a good one. I'm pretty sure that we already know what's wrong with the patient, although our tutor kept asking how we were so sure. This case has a lot of anatomy and embryology in it, so I volunteered to do the embryology learning objective for Wednesday. It's actually really interesting, which is not my normal feeling about embryology. All fetuses start out undifferentiated, meaning that they aren't obviously male or female. If they have a Y-chromosome, they start to develop into males, but it takes a couple of months for that to happen. The default sex for humans is female though. So if something goes wrong with a fetus's development, a boy could come out looking like a girl even if he's genetically a boy, or vice versa.

Interestingly, in other species (like birds), the opposite is true. They are males by default. And, unlike humans, they don't have X and Y sex chromosomes. Instead, male birds are ZZ and females are ZW. And then in some animals like turtles, sex determination for an embryo depends on environmental factors like where in the nest the egg is. The hottest eggs near the top become the females, while the eggs in the cooler part of the nest become the males. In alligators, the hotter eggs become males. Weird stuff, completely useless to know, and nonetheless fascinating.

Seminars, PBL, and POD

It's Friday the 13th, but today wasn't a bad day. We had two seminars again, and they were both fine except for too many of us still being crammed into the conference rooms. The first one was about anabolic and catabolic processes in energy metabolism. We went through several cases in small groups and then discussed them as a class. I really liked this seminar. The second one was on placenta histology. It wasn't too bad as far as histo seminars go. Dr. Prayson, the pathologist I like so much, was the one who taught it. He does a good job with leading seminars. I still don't feel like I have a very good grasp on the gross anatomy of the placenta though. I need to review this stuff some more.

We finished our PBL case. The ending was pretty anti-climactic (and of course, it was a happy ending). Because this patient had metabolic issues, we spent some time discussing biochemistry and nutrition requirements. We also talked about the cause of the patient's disease and how it should be treated.

Our POD talk today was on female urinary incontinence. Apparently giving birth to a child increases a woman's risk of having stress-induced urinary incontinence later in life. (That means urine can leak when she coughs or laughs.) The more children she has, the greater the increase in risk. The speaker studies incontinence after vaginal distention in rats. I can see a lot of problems with this, not the least of which is that female rats are anatomically very different than female humans! Older women also have a higher risk of urge incontinence, where they have bladders that contract too much and they feel like they need to go to the bathroom all the time. This is the kind of incontinence you see ads on TV for all the time.

My PA wanted to meet to discuss my portfolio, but I couldn't stay because I had to leave school a little early. So we just emailed about it instead. Most of the comments and suggestions I got were grammatical kinds of things anyway.

Research Class and Third Formative Portfolios

I'm very tired of going to my clinical research class. But I don't want to drop it, because now we're so close to the end. The last day is May 3, so are only a few more sessions. And the readings are actually helpful. I just can't stand sitting through the three hour power point talks. Today's session was about health economics. The readings weren't bad, and I wouldn't even have minded sitting through the class for an hour or so. But three hours of it is just too much. The basic gist of today's session is that it is difficult to decide between treatments when one gives a better survival but a worse quality of life than the other. Or, it's hard to decide if one has a certain set of bad side effects and the other has a different set. There is a calculation called QALY (quality adjusted life years) that takes these issues into consideration. Like I said, it's a good thing to know about, but wow, I couldn't wait for class to be over. It felt like noon would never come. I guess I am just feeling kind of all around burned out.

It doesn't help that our third formative portfolios were due today at 5 PM. We're up to seven of the nine competencies now, and they had us address each bullet point under each competency. I got mine done around 3:30, but now I feel too exhausted to do any of the reading for tomorrow. Thankfully, I don't have to do a learning objective tonight. I will just have to get up early and do some reading for seminar in the morning before school.

Two Seminars and PBL

We had a genetics of obesity seminar today by the same prof who taught us genetics over the summer. He's an amazingly nice guy, but his seminars still need some help. They always go over time, and they aren't interactive enough. But the thing that really annoyed me is that the assigned readings weren't on the portal until yesterday, which meant that I came to seminar today without having even looked at them. I had clinic yesterday afternoon, and I had to do my PBL learning objective, so I didn't even get the seminar readings printed out until this morning. Even though I probably wouldn't have been able to finish them all anyway, I don't understand why the assignments can't be posted at least a week in advance for every seminar. I plan to go back and read them later when I have time, because I'm very interested in this topic.

The second seminar was about renal hormones, mainly ADH. Apparently the person who was supposed to lead it couldn't come at the last minute, so we had a sub. She did her best under the circumstances, but it wasn't the best organized seminar I've ever attended. Overall, today was not the best seminar day we've ever had.

Our PBL case is taking some funny turns. The patient is not being compliant with her treatments and is doing things like missing appointments. It makes the case more like real life, but it also forces us to spend more time on SLEEP issues during PBL. I'm happy with how my learning objective turned out though. I didn't realize this, but apparently thyroid embryology is important to know for the Boards. Meh, just about everything seems to be important for the stupid Boards. I feel like I will never be able to retain it all.

FCM, Two Hormone Seminars, and Observed H & P

Today's FCM session was actually useful, although it wasn't particularly interesting. Our reading was about HMOs, PPOs, insurance, capitation, and other such topics that numb the mind of the average medical student, but are still incredibly important to understand. I won't bore you with explaining any of them. If you don't have to know what any of these things are, consider yourself lucky and never think of them again. If you're planning to go to med school, well, you'll have to learn about them once you get here. Sorry.

Our seminars were on the regulation of metabolism and appetite. I don't have any complaints about the seminars themselves. Both were case-based and fairly interactive. But at risk of repeating myself, we were once again crammed in like sardines in these stupid conference rooms that are way too small for half our class. Also, I wish the course directors would realize that just because we have double the number of seminars does not mean that we should have double the amount of reading to do. As it turns out, I have been invited to sit on the feedback meeting for this block on May 3, so I'll have a chance to tell them again. I've already been telling them every time I see them and every Friday on our weekly feedback forms. Hopefully it will help for next year.

This afternoon, I had my second clinical exam. (The first was the OSCE that we took before break.) All in all, it wasn't too bad, except that I had to rush right over to the clinic after seminar because my preceptor asked me to start at noon instead of 1 PM like usual. This meant that I didn't get a lunch break, but it was fine because I ate lunch during the second seminar. As it turned out, I was eating during the appetite regulation seminar, and the seminar leader used me to illustrate his learning objectives. I didn't tell him that the real reason I was eating during his seminar was because I had to go straight to clinic afterward. How could I tell him that after he had worked so hard to explain my early lunch time based upon my appetite hormone levels?

This exam was an observed history and physical (H & P) of an actual patient. We were basically supposed to do the entire H & P, everything that we've learned up to this point. Your preceptor is in the room with you during the exam to observe with a skills checklist, similar to the OSCE. This patient was just there for a checkup, and my preceptor wanted me to discuss smoking cessation with her. I did counsel her about it, and she agreed to work with the doctor to set up a plan to quit. We picked a quit date for her too. Hopefully she'll stick with it. The exam itself was pretty unremarkable other than being two hours long. It definitely wasn't very stressful. I had my list of systems review questions and exams, but my preceptor had me skip some of the exams in the interest of time. My feedback asked me to work on memorizing all of the exams and questions because this would help me speed up the exam. Well, I guess if the worst thing my preceptor can say is that I am too slow at performing the exam, that's not the end of the world. My preceptor is super nice and encouraging though. I am planning to keep coming to the clinic over the summer to get more experience with examining patients.

At the end of the two hours, we had another hour to prepare an oral presentation to give to our preceptors. We also have to turn in a written H & P. It isn't due until next week, but I figured I'd go ahead and do it now while I still remember everything. This H & P is much longer and more involved than the one we did on tape a few months ago. My preceptor made me re-write it a few times because I left some stuff out, but now it's done.

Anatomy, PBL, and a Trip to H & R Block

We're now moving on to the anatomy of the male, and it's an experience, to say the least. There were three cadavers today, one of which was set up to demonstrate penis and testicle anatomy. The resident had cut off about a third of the penis so that we could see the erectile tissues in cross section. You can just imagine the effect that this had on all of the guys! Well, next week we'll be looking at female anatomy again, so the girls will get their turn, I guess.

Our new PBL case seems pretty interesting so far. There is a lot of information in the case, so today wasn't as slow as most Mondays are. My learning objective for Wednesday is on the anatomy of the thyroid. I'm adding in some info about embryology too, since we aren't really going over that in seminar. Thyroid embryology is surprisingly complicated. Most of the thyroid comes from the first pharyngeal arch. But the C cells, which synthesize the hormone calcitonin, come from the fourth (or fifth) pharyngeal pouch. They just join together later in development. The weirdest thing about the thyroid is that most of it starts out by the back of your tongue, and then it travels down to its final position near the bottom of your neck. Feel your Adam's apple (thyroid cartilage), and your thyroid is below it. You probably won't be able to feel your thyroid though unless you have a goiter or something like that. One stupid thing is that your thyroid isn't actually over the thyroid cartilage. It's over the cricoid cartilage, which is right below the thyroid cartilage. And people wonder why anatomy is so ridiculously difficult to learn.

I tried to do my taxes over the weekend, but I couldn't do it. There are so many different rules in Ohio, and I have income from two different states for 2006. I had to finally give up and go to H & R Block. They charged me $132, but it was totally worth it. At least now I know how to do all of the local income taxes for next year, and I won't have to worry about figuring out local taxes from two different states again either.

FAQ #28: What Books Do You Use for the NMS and GI Blocks?

Before I start talking about books, just a word about the NMS block. You will have this ballbuster of a block right after you get back from winter break. The work load will be absolutely ridiculous and impossible to finish. Don't worry about it. None of us were able to finish all of that reading either. Probably not so coincidentally, this is also when Cleveland's weather takes a turn for the worse and makes you wish you had never come back from sunny California or sunny Arizona or sunny Mexico or anywhere else you went for break where the sun actually shines and you're not stuck scraping snow off your car every day. Hang in there, first years. This is the worst that things are going to get this entire year. Just take NMS one day at a time, and don't get too discouraged.

Cartilage, Bone, and Muscle:
You really don't need to buy any books for this part of NMS. It's only three weeks long, and the books they assign the readings from are available on reserve in the library. Unless you're sure you want to go into orthopedics, save your money. I'll warn you though that the books they assign are both abominable, especially the Buckwalter one. (The Favus book was bearable, but only relatively in comparison to the Buckwalter book.) I wound up not using either book too much. Instead, I read another book that I got out of the CCF library. It's called Musculoskeletal Medicine by Joseph Bernstein. Read the first 100 pages of that book during the first three weeks of this block, and that will cover your anatomy and physiology. Speaking of anatomy, the anatomy portion of this part of the block is especially ridiculous. We covered the arms and the legs in three weeks. It's not even close to being long enough to learn the subject, and there's no way you can keep up with all of the reading Dr. Drake is going to assign. Again, don't worry too much about it. None of us could keep up with it either. You'll be able to go back at other points on your own or in PBL and review some of these things.

Neuroscience:
Except for a few of my classmates who are really into neuro, most of us struggled a lot through this part of the NMS block too. Here are my book suggestions:

Neuroanatomy, A Programmed Text by Richard Sidman. This is not on the CCLCM book list, but it should be. It's a fill-in-the-blank kind of workbook. You finish one section, flip it over, and start on the next. I wish I had bought this book sooner. Get a copy during renal block and start working through it over winter break. It's actually fun to do, and it will really make your life a lot easier.

Neuroanatomy Through Clinical Cases by Hal Blumenfeld. This is the required neuroanatomy book. I actually really like this book. Unfortunately, the anatomy people start you out reading chapter 7, and that's not such a good place to start if you've never studied neuroanatomy before. It's super helpful to at least read chapters 1 and 2 before you tackle the anatomy reading assignments. Also, read chapter 3 and view the associated website videos before you do the neuro exams in your physical diagnosis class. And if you have time, chapter 4 covers the radiology.

Neuroanatomy: an Atlas of Structures, Sections, and Systems by Duane Haines. You could probably get by without buying this one. There are plenty of copies in the anatomy lab which you have access to 24-7. I did get a copy, but I didn't use it much. This was not because the atlas wasn't good. I just didn't have the time to read it.

Principles of Neuroscience by Eric Kandel. There is a new fifth edition coming out next year. If you want to go into neuroscience, Kandel's book is the neuroscience bible. But I would suggest waiting for the new edition to come out before you buy it. If you don't want to buy the book, you can definitely get by fine without it. Most of us just printed out the assigned chapters from the online version that we can access through the CCF library. I'm thinking I may buy the new edition once it comes out. I found this book to be pretty readable and interesting.

GI Block:
I didn't really use any special books for GI block except for a free GI atlas that I got from a drug company. You'll be fine with the regular anatomy, physiology, and histology books. GI block is a welcome respite from NMS. It's too bad though that they don't do GI first before NMS. We suggested that they switch the order in the future at the feedback meeting, so maybe you guys will luck out.

Lipid Seminars, PBL, and POD

The first half of the seminar was about intracellular receptors for steroid hormones. It was a good seminar except for the fact that once again we were stuffed into a too-small conference room. I really liked the second half of the seminar, but I think I'm the only one who did. The premise was that we were consultants for a company called Adipogone that is trying to identify novel targets for weight loss therapy. Of course, the strategy that the company wants to use to eliminate adipose tissue is bunk, and it's our job to tell them why it won't work. Not only had I done the assigned reading for this seminar, but I also did the extra reading. Between actually being prepared and also finding the topic interesting, I got a lot out of this seminar.

In PBL, I did my pharm presentation today, and it turned out to be one of the better learning objectives I have done so far. While I was researching the drugs, I was fortunate enough to come across a continuing medical education article for family physicians that went into all of the SLEEP aspects of using one category of drugs versus another. So I was able to add that info to my presentation too, and based upon all of these considerations (the patient's disease plus his social circumstances), I concluded that he had been prescribed the wrong kind of drug. The one he'd been given is cheap, but so is the one that I wanted to give him because it's available as a generic. I even checked, and you can get it at Walmart for $4 per month. (There is a program at Walmart where people can get a bunch of common generics from them for $4 per month.) Anyway, as much as I am not fond of SLEEP issues, it wound up being all right in this case.

The POD speaker today was a biomedical engineer who is working on foot biomechanics, particularly as it relates to patients with diabetes. Basically the diabetics lose sensation in their feet, and they can get these awful sores there because they also don't have very good blood flow to their extremities. If you like gross pictures, this was the POD session for you. It was definitely not MY favorite POD session. But since we have so many engineers in my class, they were loving it. Toward the end, the speaker said that he was going to put up a few slides of equations, and I swear, all of the engineering people got excited. :-P

Clinical Research and Anatomy Office Hours

We are getting close to the end of the clinical research class, which I'm glad about. Today's session was yet another three hour powerpoint fest, this time about designing clinical trials. I'm interested in the topic, but I don't have that kind of attention span. We had homework due today from our last class session before break, too. I had intended to get it done during break, but, well, you know how those things go. I wound up working on it last night instead. We had to do some calculations and draw graphs. My graphs were not coming out properly, and I was getting annoyed with the whole thing. So I stopped for a while and did something else, and then when I came back to it, I realized that I had forgotten to subtract the answers from 1. Such a simple thing, but the graphs looked much better once I had done that.

I went to the Internal Medicine lunchtime seminar today with a couple of my classmates because it was an endocrinology talk. Ironically, the speaker was the same physician who had led one of our seminar halves yesterday. (He's also one of our endocrinology block course directors.) Today he was talking about parathyroid and thyroid problems as they relate to levels of hormones and bone mineral density. I guess the most interesting thing that I learned is that the body will sacrifice the entire skeleton if there is a need for more calcium. It kind of made a funny picture in my head, imagining someone walking around with rubbery bones made only of collagen. But I suppose the person would have a lot worse problems before reaching the point where all of the mineralization was gone from their bones.

I worked on my learning objective for tomorrow, and then I went to anatomy office hours at about 3:30. I was the only one there again, and as tired as I am, I did not do so well with being pimped about levator ani muscles. Anyway, I got them all in the end. A couple of the urology residents were there dissecting the genitals of male cadavers for next week's anatomy session. I watched them work for a little while also. I'm sorry to say that male anatomy really is just as complex as female anatomy is.

It's snowing outside now. How sucky is that. Last weekend, Monday and Tuesday were all warm, sunny, and gorgeous. The temperature was like in the 70s. Yesterday it started raining and went down to the 50s. Today it's in the low 30s and the snow is actually starting to stick. I can't freaking believe it. I had put away my boots and parka, but I'm going to have to dig them out again, because tomorrow is going to be even colder. It's supposed to keep snowing all weekend. Some spring we're having here.

Hormone and Receptor Seminars, PBL, and Pediatrics Clinical Skills

Our seminar was divided into two halves again, as were we. My first seminar half was about hormone regulation, and the second part was about peptide hormone receptors. They were both pretty good seminars, especially the second one. But our new attendance policy went into effect this week, and it's totally miserable being crammed like sardines into these tiny conference rooms. I may be the only person in the entire class who dislikes the policy because it makes the seminar rooms too crowded. But I really do think that if they're going to require all of us to come, they need to find some larger rooms that fit us all comfortably.

This PBL case continues to be annoyingly SLEEP-intensive. (SLEEP = social, legal, ethical, economic, and psychological.) I'm glad that I didn't do a learning objective for today though, because we came up with a pharm one this time. I'll be doing it for Friday. Ironically, it turns out that even the pharm objective has quite a few SLEEP aspects to it, since the best medications for the patient's disease also tend to be the most expensive. Well, this should not be a big surprise to anyone: if you are wealthy, you get better health care than if you are poor.

Our regular physical diagnosis and communications class is over for the year, so we are doing some specialty physical diagnosis and communications sessions now. Today's was about pediatrics. One of the residents brought in his young son for us to examine. It was actually not a bad session, even though we are all exhausted and I didn't even come close to finishing the 70+ pages of pediatrics reading we were assigned for today. The boy was about three years old, and he was amazingly well-behaved. After his father demonstrated the exam techniques for us, we were practicing some of them. The father told the boy to pick who he wanted to examine him, and he picked all of the girls. Yeah, he may only be three, but he is definitely a boy!

FCM and Endocrine Histology

Our FCM session today was about the organization of health care. Naturally, of course, we heard a lot about how great the socialized systems of other countries are compared to our own. One of the articles was about the rise of in-store kiosks where you can go see a nurse practitioner for minor health concerns. I actually like that idea as a way to help pick up the slack of not having enough general practitioners. Even general specialties like family medicine, internal medicine, and pediatrics have become pretty specialized. These people still have to do a year of internship and three years of residency, only to go on to earn much less money than other physicians.

We went over the histology of all of the endocrine glands in seminar today. It wasn't a bad session as far as histology sessions go. The thyroid is particularly cool-looking and interesting. The principal thyroid cells change their shape from flat to columnar, depending on whether they're active. Plus, the thyroid actually stores hormone, unlike most other endocrine glands that just make it when they need it.

That's it for today, but I have a ton of reading to do. They're really loading us up this block. Sigh.

Reproductive Anatomy and PBL

We started our endocrinology and reproductive biology block today. It will be four weeks, and then we have seven weeks of hematology, microbiology, and immunology. That's the end of our entire first year. Time is really flying.

The gynecologic surgeon who did our intro talk today was really good. We had cadaver stations to go over female anatomy and the pelvic area in general. It was really interesting. One of the female cadavers was pre-menopausal, and we were able to see how much larger and better-developed her ovaries were compared with the other, more elderly cadavers. We also had a station about the pelvic bones, and we looked at pelvic ultrasounds in radiology.

Our new PBL case is a good one so far. It's making us review renal and biochem, and there are also some social issues. I'm the computer scribe. I wasn't scheduled to do it until next week, but the person who was supposed to be doing it today was having computer problems, so we swapped weeks. I don't have a learning objective for Wednesday other than to review the renal and biochem. That's ok with me, since I have a lot of other things that I need to do, like my taxes. In fact, I'm leaving for H & R Block right now.