Grand Rounds, Killer Biostats, and Clinic

Yesterday morning I went to the Neuroscience Grand Rounds. I don't normally go to that one, but this talk was being given by the same guy who did one of our Dean's Dinners last year, and I was hoping to hear more about a drug he told us about called natalizumab. Unfortunately, he spent most of the time talking about how the immune system surveys the central nervous system (brain and spinal cord), and he just gave a very brief mention at the end about natalizumab. I'd already heard it all, so I left for class feeling kind of disappointed.

Speaking of class, the last couple of days in biostats have just been insane. First of all, there is no way to really do more than just skim the reading. But this is medical school, and I'm already more or less used to that kind of insanity by now. The worst part is that the classes themselves feel like being in the Twilight Zone. I never thought two hours of my life could possibly go by this slowly. It has to be some kind of new warping of time and space.

This afternoon I went to longitudinal clinic. We don't normally have clinic over the summer, but I'm doing some extra sessions. I was going to do them anyway since I said I would in my portfolio last year. (That was my plan to try to improve my speed and comfort level with the clinical skills.) But now it's even more important that I'm doing it because I am going to miss the fall OSCE in October. (OSCEs are those clinical exams that we have to take to prepare us for Step II CS.)

My first two patients today were not terribly exciting, but the third one kind of got to me. She has a chronic, debilitating disease and she was feeling really depressed and worried about her finances. I was in the room with a resident and her, and the resident kind of moved on to other physical symptoms after the patient had said she was depressed. So while we were waiting for the doctor, I went back in and asked the patient whether she was thinking about hurting herself. She started just crying like crazy and telling me about how she was alienated from her family and didn't really have any friends in Cleveland even though she had lived here for a long time. I felt really bad and also totally powerless to do anything to help her. I also didn't know how to end the conversation, because it was obvious she wanted to keep talking to me about her problems. When my preceptor finally came in, we wound up spending like another 45 minutes with this patient trying to help her come up with a plan to improve her symptoms enough that she could go back to work and not have to worry about her finances. I don't know if we really did anything to help, but she seemed to feel better when she left. I am totally exhausted now though. I think emotional patients are even more exhausting than physically sick patients, and god help you if the person is both!

Epidemiology, Stats Workshop and Journal Club

Yesterday we had another epi class. I am starting to get the reading done, but I was still kind of lost from being behind. So far though I really like the epi book. It's pretty straightforward to read and the explanations are usually clear.

In the afternoon, my partner and I did our stats workshop presentation. It was just on descriptive statistics, which is kind of boring, so we decided to go ahead and do some t-tests to figure out whether the associations in our data set were significant. It turns out that most of them were, but of course that doesn't explain why they turned out that way. This is one of the weaknesses of association studies as opposed to randomized clinical trials. But that's a discussion for another day. I thought our presentation went well, and as it turns out, we've already done most of the work for the second project since we did the significance stats.

Today's journal club was also really good. One article was about Reye's Syndrome, which is a rare but serious illness that some children get if they have certain viral infections like chicken pox and then take aspirin. The other was about resistance to an antibiotic called ciprofloxacin in the bacteria that cause gonorrhea. That study was done here at CCF. Apparently this was one of the first locations where ciprofloxacin-resistant gonorrhea was detected anywhere in the country. Some claim to fame.

Epidemiology, Meetings, and CCF Movie

The last couple of days have been kind of rough. It didn't help that I stayed up all night Monday reading the last Harry Potter book and felt totally hung over all day yesterday. I am also really behind with my epidemiology reading, partly because I was too brain-dead to do it, and partly because there was so much of it. I felt really lost in class today though, so I need to get back on track with it.

I haven't had much to do for my research this week because we're waiting for an agreement to be signed for the equipment we're going to use. I went to two research meetings yesterday afternoon and it was really hard to stay conscious. Afterward, I went home and just crashed. I was still pretty tired this morning though. I guess it didn't help that I went to school early yesterday to see the Clinical Research Grand Rounds. It was about pain, which sounded really interesting. But the talk itself was kind of disappointing, and it would have been even if I hadn't been up most of the night.

Today after class I read two chapters of my epi book, so I'm feeling a little more like I have a clue. I also went to a movie about the Cleveland Clinic called "All for One." It was actually really interesting. One thing that is kind of disappointing about going to a brand new school like this is that you don't have that same sense of history and tradition that you get at schools where they have classes dating back to the early 1900s or even the 1800s. CCF was started in 1921, and the movie traced the history all the way from WWI to the present, including starting this med school. It's a good reminder that CCLCM didn't just spontaneously begin in a vacuum. Seeing the med school in the context of the Clinic's entire history gives a better sense of how we are part of the larger CCF tradition.

The only other exciting thing is that I found out I'd be missing the fall OSCE because I'll be away presenting my work at a national research meeting. It's pretty lousy timing, but I don't want to miss the meeting, even for an OSCE. I went to find out if there was something I could do to make it up, but there really isn't. So I'm just going to have one less OSCE and fewer clinical evals than everyone else.

Much about Biostats

We had absolutely perfect weather all weekend. It was sunny, maybe around 75 degrees for the high. Yesterday, I finally went to the Cleveland Botanical Gardens for the first time. I'm glad I waited until summer to go, because there are a bunch of outdoor gardens that are obviously only worth seeing during the summer. My favorites were the theme gardens (some of which incorporated waterfalls and musical instruments) and the children's garden. Indoors, there are two rain forest areas, one for Madagascar and one for the cloud forest in Monteverde, Costa Rica. There were chameleons and hissing cockroaches in the Madagascar section. The Costa Rica part was a butterfly garden, and they did a great job with it. I spent spent a few months in Monteverde during college and never saw a single blue morpho butterfly in the wild. But yesterday I saw dozens of them.

The reading load for this weekend was just ridiculous. We were supposed to go through six chapters of statistics for today. Needless to say, that did not happen in my case, although I did get through half of them. We spent the class time working on doing more analyses of data sets using the statistics program JMP (pronounced "jump") and discussing probability. Afterward, one of my classmates and I completed our group assignment for the Thursday afternoon stats workshop that we have this week. The assignment consisted of questions about a data set we had been given, and it required us to perform several statistical analyses using JMP. I'm getting better at using the program already. It isn't nearly as bad as I had thought it was going to be.

Later on, I went back to the hospital and sat in on a training session where the social worker was teaching two of the residents to consent patients. It was kind of an eye-opener for me, because I didn't know anything about this particular project, and some of their explanations majorly confused me. Considering that most of their study subjects won't have completed a year of med school and may not have any science education at all, I can definitely see why it's important to boil down the concepts so that laymen can understand them.

On a not-so-great side note, I found out that next semester, my MS class is being held from 7-10 AM on Thursday mornings. I don't think I even mind the earliness of it as much as I hate the idea of losing those Thursdays every week from now until Christmas vacation. :-(

Clinical Research Journal Club, Consenting, and New Student Picnic

We had our first clinical research journal club today. I was a little wary because last year's basic science journal club could be really frustrating. I often felt like the articles were kind of over my head. It was also very formal and sometimes kind of painful to sit through. On top of that, I couldn't help but notice that this year we have journal club for two hours per week instead of just 1.5 hours like we did before. (On a side note, I am still lamenting the loss of our free Thursdays. For the whole clinical summer block, we have two hours of class every single day. It sounds funny to complain about that when some med schools have class every day from 9-5, but it's all relative, isn't it? Luckily, we'll get our free Thursdays back once we start our next block in September.)

Anyway, today's journal club was pretty fun. First of all, we were sitting around a table where we could more or less have a group conversation instead of it being like a formal talk where one person was at the front lecturing. So it was much more informal, and that stimulated a lot more participation than last year's journal club did. Second, the papers were comprehensible and interesting, and I didn't have to google every other word to figure out what the heck they were talking about like I did last summer. And finally, our general research ethics focus for the week is the kind of topic that tends to stimulate discussion. I'm going to be leading my journal club discussion the week after next. My article is about drug-eluting stents, so I think it should be a good one because of how controversial these stents are.

This afternoon, I went with the social worker to consent another patient. She had met with seven patients yesterday while I was in the OR plus another one this morning, and all eight of them had agreed to join the study. But the one we spoke to this afternoon didn't want to participate because he didn't want to take the chance of winding up in the placebo group. He really liked the idea of getting the experimental treatment, but he said he'd only be willing to join the study if they'd guarantee that he'd be put in the experimental group. Well, that's not possible, because the trial is randomized, which means that a computer randomly picks which group each patient joins. If we started letting people join whatever group they wanted, then it wouldn't be very random! That's now three out of three patients who have turned down joing the study while I was there with the social worker to consent them. I'm already developing a reputation for jinxing her by my very presence.

This evening there was a picnic for the new first years at one of the Cleveland Metro Parks. I wasn't planning to go, but one of the first years talked me into it. I had already met several of them at school, and I met most of the rest of them at the picnic. The new class seems really diverse and cool, and it's fun having a bunch of new faces around. By the way, if any of you first years are reading this, in the near future you should definitely get your hands on a copy of the Costanzo physiology book they were raffling off at the picnic. Read the first chapter on cellular physiology now during summer block, because in October you are going to jump right into cardiopulmonary physiology without any general intro to physio whatsoever.

Classes, Mock IRB Session, Grand Rounds, and More Cardiac Surgery

Yesterday's biostats class was on how to build databases in a computer program called JMP. So far, the program hasn't been as scary as I was expecting it to be. After the class, we had a mock IRB session where several of the CCF IRB members discussed some real protocols that had been submitted to them from CCF researchers. We were able to also ask questions of the IRB members, and there were some interesting issues that came up. One was whether it is ethical to conduct a clinical trial with a placebo arm if there is a known treatment (the standard of care) that is already proven to be superior to placebo. In this specific case, there was one. So some of the IRB members (and I as well) had concerns about this.

The mock IRB session tied in well to today's epidemiology class, which was about clinical equipoise. Equipoise means that there is a real uncertainty about which of two treatments is superior to the other (including a treatment versus placebo if no treatment for that disease is currently known). We read an article for today where the researchers had performed a sham surgery in the placebo arm of the trial. In that case though, I think it was appropriate to do the sham surgery because the purpose of the study was to decide whether the standard treatment really was superior to placebo. It turned out that it wasn't.

Before class this morning, I went to the Internal Medicine Grand Rounds. It was about the General Clinical Research Center (GCRC) here at CCF. The speaker talked about some of the clinical experiments going on at CCF and the services that the GCRC provides. She was also talking about CCF setting up future clinical research collaboration with Case, University Hospital and Metro Hospital, including training opportunities in clinical research. It will be too late for me of course, but it sounds like there will be a lot of opportunities for clinical research training here in Cleveland in the future.

I spent all of this afternoon in the OR watching cardiac surgeries. One was being done because the outside covering (called the pericardium) of the patient's heart was sticking to the heart itself so that there wasn't enough room for his heart to contract and expand properly. Another surgery was for a patient whose aorta (the big artery coming out of the heart) was partially blocked. There was a third patient who was having a coronary artery bypass graft, but I had already been in the OR for five hours at this point, and I didn't want to stay longer just to see another bypass graft. It's really interesting to see all of these surgeries, but I have to say that I'm completely exhausted now.

First Epidemiology Class and Consenting Patients

The topic of our epidemiology class this morning was ethics of clinical research. It's very timely for what I've been doing in lab this past week and a half. We spent part of the class going over factors that are necessary to make clinical research ethical. But we spent a lot more time discussing something called the therapeutic misconception. This means that patients, when they sign up to join a clinical trial, often believe that they are signing up for therapeutic care that will benefit them personally as opposed to research where the benefits, if any, are unknown. It is a problem because studies show that many patients do not have a very good understanding of the level of personal risk or benefit they can be exposed to by participating in a clinical trial.

The social worker and I went to consent two patients this afternoon. We didn't even try to consent the first patient because apparently there was some kind of problem and the patient was meeting with the ombudsman. We had to wait for about an hour until the second patient was available. There were two other study coordinators who had already spoken to her. One of them had gotten her to sign up and the other had not. As soon as the social worker started speaking to her, it was obvious that she was not going to be a good candidate for any ethically-run clinical study. She was one of those people who pretends like she knows what is going on even when she doesn't. When the social worker asked her if she had ever heard of the procedure being tested in this clinical trial, she started rambling on about researches (sic) and expressed her concern that the residents might be terrorists since some of them are from other countries! So the social worker told her that probably she should just pass on this trial. The patient agreed, and we left empty-handed and disappointed. But I really think that the social worker absolutely did the correct thing by not enrolling this woman. Even though she didn't understand a thing, she continually tried to pretend that she did.

Another Surgery and First Biostats Class

Friday was a quiet day. I went to the uniform room to pick up my scrubs, did some more reading about research ethics, and had another orientation about consenting patients. In this research group, consenting is usually done either by a social worker or by one of the residents. I'm going to be allowed to do it also after the social worker trains me. I'll be shadowing her either this afternoon or tomorrow afternoon when she meets with a patient. Basically, the purpose of these consenting meetings is to explain the research and protocol to the patients so that they can make a decision about whether they want to participate. In order to join the study, the patient has to sign a document attesting that they understand the study and that they are willingly agreeing to participate. This is the informed consent document.

This morning, I saw my second surgery. I had to come in at the crack of dawn again, but it was really neat. The patient was having a coronary artery bypass graft. I was there while they prepped him and obtained the veins from his leg. (They use those to bypass the clogged coronary arteries.) But I couldn't stay for the rest because I had my biostats class at 9 AM.

It seems like the biostats class is going to be pretty intense. We're going to have 18 two-hour morning sessions this summer and some afternoon group presentations every other week. So far things haven't been too tough as far as the stats themselves go, but I'm still withholding judgment about the statistical program we're supposed to use. It's called JMP, and the instructor told us that it was very easy to use. I'll get back to you on that one after I finish downloading this enormous file that I need in order to install it....the good news is that we have a TA for the class. He's a biostats PhD student from Case.

I had some free time in the afternoon, so I was doing some of the reading for tomorrow's class. We were assigned to read two articles about research ethics. I had been thinking about doing a research ethics class for my MS elective. But amazingly, I'm starting to feel like I'll have gotten more than enough exposure to issues of research ethics after this summer!

More Clinical Research Training and Two Seminars

Today and yesterday weren't nearly as exciting as Tuesday was, but I still got a lot accomplished. Yesterday I was still so exhausted from the day before that it was difficult to drag myself out of bed in time to get here by 9 AM. Actually I was kind of dragging all day. But luckily I didn't have to do anything more active than read more of the clinical research training manual, pick up my scrubs from the uniform room, and go through an orientation about submitting institutional review board (IRB) forms. All of the IRB submissions occur completely electronically here at CCF, which is very cool. When you answer the initial questions the site asks you, it automatically generates forms for you and tells you what documents you need to upload for the IRB to review your research. (The IRB is a committee that is responsible for protecting the rights of human research subjects.)

One of the residents was making fun of me yesterday for actually reading through the research manual, because it's like 250 pages and kind of dry. But I was glad that I had read some of it, because otherwise I would have had no clue when the person giving me IRB training was talking about. She was asking me questions about things like investigator brochures that I hadn't even heard of before I started reading the manual. (Investigator brochures are for clinical trial drugs that haven't been approved by the FDA yet. They basically function like the little warning sheets that come inside the packaging of all marketed drugs and tell you what all the known side effects might be.)

Today I've continued reading the manual, and I'm finally done. I was determined to finish the whole thing by the end of today so that I can do something else from now on. I also had a second orientation about case report forms, which are the forms where the official data from the clinical trial are recorded. Again, I only knew anything about what the guy was talking about from reading the manual, because I didn't know about case report forms before I got here either.

I also went to two Grand Rounds today, one for internal medicine this morning and another one for wellness at lunchtime. The internal medicine one was about drug eluting stents. Stents are little metal mesh tubes that are used to hold the heart's arteries open in people whose arteries are clogged. Well, the drug eluting kinds prevent the arteries from re-clogging better than bare metal stents do, but they apparently increase the risk of getting a blood clot. The good news is that co-administering certain drugs seems to decrease the risk of getting blood clots in people who have drug eluting stents.

The wellness talk was about obesity in children and teens. Probably the most interesting thing that I learned is that Cleveland is the 12th fattest city in the country, with 30% of children under age 18 overweight. She also mentioned that about 80% of obesity is attributed to genetic causes, and her group is trying to work with the remaining 20% that can be affected by behavior and environmental modifications. The worst news is that in order to gain ten pounds in one year, you only need to consume an extra 100 calories per day. I have to say that I've become a lot more aware of my own lifestyle habits since starting medical school. Seeing pictures of atherosclerotic arteries from obese middle school-aged children will do that to you....

Starting My Clinical Summer Research

This week is officially our last week of break. But I'm already back in Cleveland to start my summer research because my fellowship is for ten weeks, while our summer block only lasts for nine weeks. So far it's going pretty well, even though yesterday morning when I showed up at 9 AM like my PI told me to, no one seemed to know that I was supposed to be there! It turns out that the med school had told them that I'd be starting next week instead of this week. The other not so good thing is that the department still hasn't received any money for my stipend, so it may be a while before I get paid. It's not the end of the world because I didn't expect to get paid until the end of the summer anyway. As long as I get paid eventually, I'll be happy. I didn't really do much interesting yesterday beyond meeting the other team members, reading the study protocols, and doing some of my online training.

I had the coolest experience today though--I saw an open heart bypass surgery. The surgeon cut open the patient's chest, and I was actually watching his ventricles contracting! It was so amazing. After they stopped his heart and started repairing the valves, it got kind of boring. Without the heart beating, watching the surgery didn't look much different than watching someone cutting up the inside of a cadaver. On the bright side, I'm super glad that we used fresh cadavers in anatomy last year, because I didn't get sick today at all. The OR staff kept telling me to let them know if I didn't feel good because they'd had some previous observer faint or something.

The study I'm working on is pretty labor intensive, and I had to get here at 6:45 AM because the surgery started at 7 AM. But I have to say that it was totally worth it, and I am really looking forward to observing some more surgeries. I still don't think that I would want to be a surgeon for the rest of my life, but I can definitely understand why a career in surgery would appeal to certain people. Not too many people can say that they've held a living man's beating heart in their hands.

Yesterday was also the first day of orientation for the new first years. I have to remember from now on to add a year to everyone's status, including my own. I caught myself a few times today telling people that I was a first year student....um, I mean that I just finished my first year and am starting my second year. :-P