Last Day of Fall Semester

Yesterday I took the Comprehensive Basic Science Exam (CBSE). This is an exam covering the first two years of medical school that is put out by the National Board of Medical Examiners (NBME). They're the same people who write and administer the medical boards. There were four sections (Step 1 has seven sections), each with fifty questions, and we had a total of four hours to complete the exam. The questions cover everything from first and second year, with a heavier emphasis on second year subjects like pathology and pharm. Suffice it to say that the test was really hard, especially since we haven't covered half the material yet! I would say in each section there were about 25% questions that I knew, 50% of questions where I could eliminate the answers down to two or three choices, and 25% where I had absolutely no clue whatsoever. The good part is that I had no trouble finishing in time. In fact, I went through the entire test three times and was still finished 45 minutes early.

It's unbelievable how fast the time has gone by. I'm now officially halfway through my second year of medical school. We finished the diabetes PBL case, and we had two seminars today, one on hypoglycemia and one on the complications of diabetes. They were both pretty good. The first seminar leader asked me to pretend to have hypoglycemia, so I was shaking, sweating, having a headache, and then I "fainted." After we talked about the symptoms of hypoglycemia, she gave me a little bag of Skittles. I guess that is supposed to be a glucose source to take care of my "hypoglycemia." The second seminar leader is the same endocrinologist that I had endocrine clinic with last week. It was funny, because he remembered me, but he clearly didn't remember my name and he didn't want to have to ask me what it was again.

In the afternoon, I did some errands and went to the gym. I don't normally go to the gym on Fridays, but they are closing all weekend for Christmas, so I can't go tomorrow like I usually do. Then I wrote evals for my PBL group and cleaned the lounge refrigerator and microwave. We have a signup sheet to clean out the fridge every couple of weeks, so that wasn't too bad. But the micro was absolutely disgusting. I don't know when it was cleaned last, but it probably was years ago.

Grades for my MS classes came out today from Case: two As in epidemiology and clinical trials, and a B in biostatistics. I was expecting the clinical trials and stats grades, but the A in epi came as a pleasant surprise. Looking back over the past year, I realize that although having to do the extra work for the MS was miserable sometimes, overall I'm glad that I stuck it out. It's one of those things that isn't always fun while you're going through it, but the short-term pain is worth the long-term gain. I guess that is true of medical school in general.

We have SAQs and CAPPs to do over break like normal. I am planning to do them this weekend and get them over with by Monday morning at the latest. I also have clinical homework to do for my first week back in January, which involves preparing patient presentations for my FCM group and my clinical reasoning group. The clinical reasoning class is something new, and we are doing that instead of longitudinal clinic the first week. I just realized that I will be doing BOTH presentations on Tuesday of my first week back. Well, at least I'll get it all over with early. It looks like we go back to clinic as usual after that first week.

I want to wish all of my blog readers a Merry Christmas and a Happy New Year. I'll see you all next year. :-)

Double Communications

Our PBL patient is not doing so well. This case has turned out to be a lot more interesting than we had expected, because we had a diabetes PBL case last year too. But this one focuses more on the long term complications for patients who do not have controlled diabetes. Unfortunately, the truism that being an interesting patient is a bad thing definitely holds true here. The seminars were on gestational diabetes (pregnant women become insulin resistant and can even become diabetic while pregnant) and nutrition.

This afternoon we had double communications for four straight hours, which would ordinarily have been fairly painful. But, one of my group members didn't show up at all and another didn't get a chance to video an interview with a patient, so we actually got out about an hour and a half early. The first part of the session was about how to deal with family members being in the room. I got a mother-teenage daughter duo where the mother kept trying to take control of the interview. These were standardized patients, and the two actors I had were terrific. I would have totally believed that they were a mother and daughter for real. I was able to tone the mom down a little by turning my chair so that my side was to her and I was directly facing the daughter. I even managed to get her to leave the room, though she really didn't want to, and at that point I stopped. I could have kept going and done a sexual history on the daughter at that point, but I figured we've already done that lesson, and I'd gone on long enough.

The video reviews took another hour. I had been counseling my patient (a real one this time, the same interview that I taped last week) about smoking cessation, and I could have definitely gone further with that. When we got done, there were big, fat snowflakes falling outside. It was beautiful to watch, though what it did to the afternoon traffic was not at all beautiful. We haven't been getting too much snow yet this winter, but today is more than making up for that.

Clinic Christmas Party

This week we are covering diabetes in excruciating detail. All four seminars from yesterday and today were about diabetes, and our PBL case is about the long-term complications of diabetes. So, it was only fitting that today was my clinic's annual office Christmas party. I got off easy with just bringing jello. Other people baked brownies, made homemade mashed potatoes, and someone even brought fried chicken. Oh, and I shouldn't forget about the macaroni and cheese. All of which, while completely delicious, are exactly the types of diabetogenic foods that are going to ensure that many of us partygoers will be the future diabetic and coronary artery disease patients who keep the Cleveland Clinic prospering for the next several decades.

The other nice thing about today is that I got about an hour and a half off between seminar this morning and the office party, so I got through with most of tomorrow's reading. Our FCM class today consisted of each of us meeting with the small group preceptor for about ten minutes. I got to go right at 10:00 as soon as the second seminar was over. Since my group's preceptor has been gone the last few weeks, I almost blew the meeting off altogether. But I decided I should probably stop by to see if he was there, and it's a good thing I did, because he did show up. These ten minute meetings are pretty pointless. They are supposed to be for us to get and receive feedback. But the feedback we get is useless because it's oral and can't be used for our portfolios. And giving too little feedback to the preceptor has never been a shortcoming of mine. He told me that I should try not to be so frustrated with the class. I wouldn't say I'm all that frustrated, but maybe I just expressed my feelings about these ten minute meetings a little more strongly than I intended. :-P

A few of our patients didn't show today, and the clinic was pretty quiet in general except that people kept coming by the break room to eat party leftovers. The nurses tried to get me to take some food home with me, but I didn't. I am sure the only reason I don't already weigh five thousand pounds is because I never bring any junk food home with me. That being said, I did manage to eat three brownies during the course of the afternoon.

Surviving My MS

Yesterday was kind of a hectic day, but I did get my paper done in time, and I gave my presentation for class. I got a few good suggestions as well as one softball question from someone who missed the first part where I explained the rationale. So that's it. I'm officially done with my second MS class. One more week to go until break!

Today's seminars were on thyroid disease and autoimmunity of the endocrine system. They were both good ones. The first one was taught by the doc who heads this block, and he's a really energetic and enthusiastic kind of guy. The second one was a really good review of the immunology we covered last spring, and it also specifically went into how the immune system interacts with the endocrine system.

For POD, we had the group presentations on the projects we came up with last week, and these were much smoother than the previous time we did this. Our group was the only one that came up with the stem cell idea, which is cool. Last time, it seemed like all four groups pretty much came up with the same project.

I am incredibly tired but oh so happy to be done with my MS class. It's not that any of it is hard. It's just a lot of work sometimes. On the good side, I registered for my courses for next semester today, and I just realized that I have basically finished the entire MS except for my advanced stats class and the research year/thesis. That's pretty incredible. No wonder I feel so tired. I basically did all of my MS coursework except one class in one year while being a full-time medical student! I could do the advanced stats class next semester, but I decided not to because I want to have some time to start studying pharm and micro before the final push to study for Step 1. This year is just going by so fast....

Endocrine Clinic

It's fortunate that I got that book about women's health on Monday when I had the chance, because my learning objective for Friday is about hormone replacement therapy (HRT). There are two chapters in there describing all of the HRT drugs, and it is even readable and informative. The seminar today was about puberty disorders. That is some weird stuff. I hadn't realized though how young normal girls are when they begin puberty. I would have guessed about age 12, but that's just the average age when girls start menstruation. Girls begin developing breasts and pubic hair a couple of years earlier, around age 10.

This afternoon, I had endocrine clinic. My classmates who went yesterday were complaining that all they saw were diabetes patients. But today my classmate and I saw all thyroid patients, except for one infertility patient. I think this doc we were with must be a thyroid specialist. It was so busy in the clinic though that we really didn't get a chance to discuss anything with him much. Plus, there was also a fourth year med student working with him. So my classmate and I didn't wind up getting to do very much except for once when the doc had to leave the room to answer a page. That patient had hyperthyroidism and was willing to let my classmate and me both examine his thyroid. I couldn't really notice too much difference from a normal thyroid. Maybe it felt a little softer and slightly enlarged, I guess.

When it was time for us to go, the doc offered to let us stay on and keep following him and the fourth year student around, but my classmate and I had both seen enough for one day. The endocrine clinic was more interesting than I had expected it to be, but I was disappointed about how little we got to do compared to some of the other students in my class.

Rants of a Crank

Our PBL case this week is about premature ovarian failure, and it's an interesting one so far. We had two seminars yesterday, one on deficiencies of adrenal enzymes and one on menopause, to go with it. The menopause seminar speaker has written a book on the topic, and she gave free copies to anyone who wanted one. Her powerpoint slides were disgustingly pink, the presentation made annoying little cutesy noises every time she changed slides, and her talk was half science and half soap box. But it's amazing how getting a free book can make all of these sins of powerpoint presentations forgivable.

In the evening, CCLCM was co-sponsoring an event at the Maltz Museum so that all the Case medical students could see the Deadly Medicine exhibit for free. It's the same exhibit that I went to a few months ago, only this time we didn't get to go to Mrs. Lerner's house afterward. Someone cancelled at the last minute, so there was an extra ticket, and I was able to go back to see the parts that I didn't make it to last time. I didn't stay too long though because I still had to do some more work on my paper for my MS class.

This morning, we had seminars on osteoporosis and thyroid pathology, and then for FCM we had a "field trip" to the art museum. I had been asked to participate in the NMS block evaluation session, scheduled for today at lunch. But I couldn't do it, because I had to videotape myself interviewing a patient in clinic. This is a ridiculous new requirement that all the first and second years have to do this year, where we check out a video camera, print out a consent form, and take them both to clinic to video an interview with a real patient. I wouldn't have minded as much if I could have scheduled the day myself, but the school decided to make me do it today, which is about the worst day they could have picked all block for me. They had also scheduled me to have a clinical correlation today, so I had to go see someone in administration to get it straightened out. I dare say that I'm a pretty decent multi-tasker, but even so, I readily confess that I'm not so good that I can be in two different clinics at the same time.

The actual patient interview taping went ok once I got everything set up. As it turns out, my first patient consented to be interviewed on tape, and he was some kind of video camera whiz, so he even set it all up for me. It was good that I did the videotaping early in the afternoon, because as usual we were double booked from 3-5 PM, and all four of those patients showed up today.

I was completely puzzled by one of my patients. She wanted to get pregnant but couldn't, so she was interested in infertility treatments. She said she'd been trying to get pregnant for several years. That definitely fits the definition of infertility, which is an inability to conceive after one year or more of trying. I asked her about the regularity of her menstrual cycles and age of menarche. Both were normal and she hadn't noticed any changes in her menstrual cycles. Did she take birth control? No. Was she using condoms? No, she was having regular, unprotected intercourse. Did she have a medical condition that could interfere with her fertility? None that either of us could think of. How about her husband? He didn't have any known infertility problems. At a complete loss, I started going through her medications on the computer, and what do you know, she had been getting intramuscular injections of Depo Provera for the past few years. At that point, I excused myself from the room and went to get my preceptor. I suppose I could have just told her myself. But I figure this is one of those things where it's better for the patient to hear it from the physician and not some second year medical student!

A Day Devoted to Research

I had thought up until about a week ago that the final paper was due for my clinical trials class yesterday because I wrote it down wrong in my calendar, but I got a reprieve. It's not due until next week. So, I am going to be spending this weekend working on it, but I'm very, very grateful for the extra week! The other nice thing is that after next week, there will be no more crack of dawn Thursdays for me for the rest of this year.

Today we finished our PBL case and had two seminars on pancreatic tumors and ectopic hormone production. ("Ectopic" means that the hormone is being produced by tissue somewhere in the body that isn't supposed to be producing it.) We also had another one of those small group research planning sessions instead of the normal POD/ARM seminar. I was initially wary after how badly the last one went, but this one was a lot better. A big part of it is that our PBL case this week had several engaging scientific and ethical issues (unlike the last one we had to use), and we came up with a research idea that is actually interesting. I'm not sure how feasible it is, but it would be cool if it could be done. Basically, we want to look at pancreatic tumor markers to differentiate tumors which secrete hormones that are normally produced by the pancreas (ex. insulin) versus tumors which secrete hormones not usually produced by the pancreas (ex. growth hormone). Our hypothesis is that the former come from differentiated pancreatic cells, while the latter come from from pancreatic stem cells. The existence of pancreatic stem cells was only discovered quite recently, so it's a hot field.

This afternoon, I met with a researcher who I am considering working with for my research year. We discussed some possible ideas. I wasn't particularly gung ho about any of them, but he was open to me coming up with something else. So I really need to spend some time thinking about exactly what project I want to work on this spring and summer. Then I will need to start working on convincing someone to fund me for it. :-P

A Good ERB Day

This week's PBL case has been really interesting. I don't know who is writing the ERB PBL cases, but they're much better than the ones we had last block for NMS. These cases cover more ground, and we can't always predict from the getgo what is going to happen. We have even been getting into ethical issues like the pros and cons of genetic testing for the patient's children. It seems like an obviously helpful thing to do, but things aren't always that simple. What happens if there's not a clear treatment that would benefit the child, but now the child has this known genetic defect and can't get insurance as a young adult because the insurance company says he or she has a pre-existing condition? That doesn't even address the psychological distress that people can have due to knowing their genetic status. It makes more sense to do the testing if there is preventive care or screening that can be done, and also if the exact mutations are well-established. That didn't turn out to be the case for our patient though.

Today's seminars were on hypocalcemia and pituitary disorders. I was not initially excited about the hypocalcemia seminar, because it feels like we've beaten this stuff to death already. But it wound up being more interesting than I had expected. The speaker was the same guy who is in charge of our Friday POD seminars and who gave the semi-painful seminar on parathyroid differentiation proteins last week. He had assigned us to read a book chapter he wrote himself on pseudohypoparathyroidism, and it always makes me suspicious when profs do that. But I am glad I took the time to read it, because it goes into a lot more detail than Robbins (our path book) does.

Your body secretes parathyroid hormone (PTH) to keep your blood levels of calcium high enough. Calcium is very important for things like muscle contractions and intracellular signaling. It is so important to keep your blood calcium level high enough that your body will degrade your skeleton if necessary to accomplish this goal. That's where PTH comes in. If your blood levels of calcium get too low, you secrete PTH, and that causes your blood calcium to get higher by various mechanisms. People who have pseudohypoparathyroidism have low calcium levels, but it's not because they don't make enough PTH (which is the problem in true hypoparathyroidism). It's because their PTH receptors can't signal properly when PTH binds to them, which makes their blood calcium levels chronically low. Some patients are resistant to other hormones too since those receptors share some of the intracellular signaling machinery with the PTH receptor.

This afternoon, we had a communications session on patient education. One of my group members was absent and we didn't have a clinical correlation afterward, which means that we got out super early (2:30). So now I have the rest of this afternoon off. The three of us who were there were joking that one of us ought to volunteer to be absent from communications every time from now on. Also, it was snowing earlier, but now that has stopped too. Even though I am not a huge fan of snow, it really is beautiful while it's falling and when everything has just gotten covered with a fresh coat of it. Of course, it doesn't take too long for this whole city to get disgustingly dirty and icy slick, and that's when I start wishing I was going to med school in the Caribbean somewhere.

Too Many Tumors

Yesterday's seminars were both about tumors of the female reproductive tract. Today's were about tumors of the pituitary and adrenal glands. Our PBL case patient has tumors too. It's nice to know that people can get tumors of parts of the body that I didn't even know existed a year ago. On a happier note, most of these malignant endocrine tumors are fairly rare.

Today's FCM session was on motivational health promotion. My small group preceptor still wasn't back, but we had a sub this time, so I didn't luck out like last week. She started out by asking us how we were liking the class. I suggested that we just answer the questions we were supposed to answer and not discuss how we felt about the class. Luckily she didn't push the issue too much. As far as I'm concerned, it's irrelevant whether we like the class, because attending FCM is mandatory. We're all feeling tired, cranky, stressed, overworked, and ready for winter break. Take it for granted that every person in the room would rather be doing something else, and let's just get on with it. I don't want to even think about how lousy I feel right now, let alone have a whole gripe session about it.

The weather is bad today, so several of my patients didn't show up to clinic. I only wound up seeing two people. Of course, the ones who didn't show up were the 1:oo people, while naturally both of the 4:00 people came. We gave some flu shots and did some follow-ups, but all in all it wasn't a terribly exciting clinic day. I was sitting down while my preceptor talked to the last person, and it was tough for me to keep my eyes open. The room was kind of warm, and I was definitely doing that head jerk thing, so I decided that I'd better get up before I embarrassed myself.

Even My Blog Is for Sale!

I randomly stumbled upon an absolutely hysterical website today called BlogShares. Apparently they assign "market values" to blogs based on numbers of links and allow users to buy and sell shares in the blogs. My blog has mysteriously been listed on their site, and at the moment, is valued at B$1,000.00. This page explains how it works. At first, I didn't know whether to find this site to be disturbing or amusing, but the more I think about it, the funnier it gets. According to the website, I could register on Blogshares and stake my claim to my own blog as the owner, but it doesn't seem worth the trouble. I'll have to check back at some point though and see if anyone buys shares of my blog. :-)

Doc Opera was awesome. It's too bad the revisiting students don't get to come any more now that the show is in December instead of March. But for those of you who will be attending any of the Case programs next year, you should definitely at least go, and consider being in the show.