Cardiopulmonary Week

This week, we are covering pulmonary vascular disease. Our PBL case is a continuation of a case we had last year about a woman who got deep vein thrombosis (DVT), which is a blood clot in the large veins of the legs. You may have heard about DVT in the news. People who are immobilized (ex. bedridden or sitting for hours on an airplane) are at higher risk of getting them. The danger of DVTs is that pieces of the clot can break off and travel to the lungs (i.e., form a pulmonary embolism). Pulmonary embolisms can kill people if they're massive enough. This year, of course, our patient's problems are more complicated. But it's still cool to get a patient that we already "know" from before.

We had another pharm seminar yesterday, and today we had an anatomy session on the embryology of the heart. The actual lab part was mainly a review of the thorax anatomy that we learned last year, which was really helpful. This year I have a much better idea about what I am looking at in anatomy. I really like that we keep doing anatomy second year like this, because it helps to keep it fresh. For FCM, we had patient presentations again. One of my group members who was supposed to present was out sick, so we got out early.

I had clinic in the afternoon. The weather is still not so great, but most of the patients showed up anyway. There is this one older patient whom I've seen several times in clinic, and she came in today. She's always entertaining. Today she was telling me about how she is in such good shape for her age, and what she does to be in such good shape. Then she started telling me that if I follow her rules, I will be in just as good of shape when I get to be her age. She really is in pretty good shape, but it's still funny to hear her talk about it like that.

Kind of a Slow Week

I haven't had too much exciting going on this week since I didn't have any clinic on Wednesday after all. I was supposed to have had my first acute care session, but now I'm having it the Friday after next instead. That made this week pretty easy, which was nice, but it means that I'm going to have a three-clinic week in February now. Oh well. Not that I'm really complaining, of course, because I was very happy to have the extra time to study this week. Plus, it feels pretty luxurious to get home in the middle of the afternoon while it's still light out on a Wednesday!

We're still going through lung diseases. Wednesday's seminar was on chronic obstructive pulmonary disease, and today's was a pharm seminar on drugs for asthma. I really like the pharmacist who led today's seminar. She was the one that I worked with a while back when my longitudinal preceptor was away, and she is super nice and friendly. But this seminar just didn't seem to go well. I don't really even know why. I guess sometimes they just aren't a hit, and today was one of those times. Our POD seminar was on lung stuff too, and it was ok. Maybe it's just the time of year and the cruddy weather we're having, but eh, it's kind of tough to get too gung-ho about much of anything. Our PBL case had a happy ending this week at least, though.

Triple Clinics

This week, I have three clinics, but it isn't too bad since we didn't have classes yesterday for MLK day. I had the morning off and did my year 2 geriatrics clinic in the afternoon. It was a pretty easy clinic session. Basically I just had to do mini-mental exams and screen some patients for falling risk. We also had an audiologist in the rooms with us, so we did some hearing screens too. It was good that we had the audiologist, because I think every patient I saw was partially deaf. The geriatrician has this instrument that he can give to the patients to help them hear the conversation better. It looks kind of like a walkman. The patients put on the headphones, and it augments the conversation so that we don't have to shout at them. Apparently patients can also buy these instruments to use at home.

Since we didn't have class yesterday, we had two seminars today and no FCM. One seminar was on asthma/COPD, and the other was on pulmonary interstitial disease. It was nice having no FCM, but wow, four straight hours of pulmonary path was pretty intense. In the afternoon, I had longitudinal clinic like normal. The weather was pretty bad, so I thought some of the patients might not show, but most of them did.

Medical School Is Making Me Dumber

We finally got back our test results from the Comprehensive Basic Science Exam (CBSE) that a bunch of us took back in December. I'm pretty pleased with my score, especially considering that I've done no studying for the boards and still have 2/3 of the year to go. One thing that did kind of confuse me though was my subscores. Two of my best subjects were biochemistry and psychiatry, which didn't surprise me. The psych contains a lot of clinical research topics, and since I'm getting my MS in clinical research, all of those questions were pretty easy. I took biochem in college and then I studied it again the first summer in med school, so also no big surprise that I did well in that. But the third subject I did really well in was respiratory, which did surprise me because we haven't done respiratory pathology yet. Also, my worst subjects were neuro and musculoskeletal, which we had just finished covering a few weeks before I took the test. I was thinking, wow, I should stop going to medical school now and take the boards quickly, before all of my subscores in the rest of the subjects I haven't studied yet go down! Plus, I was a little bummed about the neuro subscore after I spent so much time studying neuro last summer.

I went to see Dr. Prayson about these results yesterday. Dr. Prayson is the pathologist who is now the Assistant Student Dean to help Dean Franco. (She's the Student Dean as well as the Admissions Dean.) He basically told me not to worry, because I could have missed or answered a few questions in some of these areas, and that's why my subscores are distributed so strangely. Also, he said that I'm starting from a very good place, and I should be pleased with my performance overall. It looks like I need to spend some more time studying neuro though, so I'm getting another book to do that for this spring.

Today was a pretty good day, even though Dean Franco totally busted me. Our PBL case had a relatively happy ending, and one of the pharmacists that I really like led today's seminar on antiarrhythmic drugs. Our POD talk was given by the infamous Steve Nissen, and it was phenomenal. I've gone to a few talks of his, and they've all been excellent. He's a great speaker, he does really cool research, and he's a maverick kind of guy who likes to stir things up. What more could you want in a speaker? After his talk, we were supposed to have a class meeting. I had to write an essay to get grad credit for the POD class, and it was due today at 5 PM, so I decided to skip the meeting and go to the library. I ran into Dean Franco later, and she commented about my not having been there. It turns out that the administration had passed out vouchers for us to take one of the online NBME exams (practice USMLE tests), and since the vouchers all had our names on them, she knew exactly who was and was not there. So I sheepishly apologized and told her why I didn't go. You have to understand, I almost never skip anything. Then the one time when I do skip, she busts me (though I don't think she was really mad at me). All I can say is that there is a very good reason why I don't ever play the lotto. :-P

If I Can't Be a Doctor, at Least I Can Try to Act Like One

I wound up getting the pharm learning objective for PBL again this week. It's about warfarin, and that is A-OK with me. Our seminar today was terrific. We went over to the anatomy lab and had a pathology session there. There were two pathologists. First, they gave us an intro in the classroom, and then we went into the lab and they showed us all kinds of hearts and parts of hearts. At one point, one of the pathologists took this bucket full of heart valves and just dumped them out all over the table for us to look through them. That was so cool. Most heart valves are supposed to have three cusps except for the mitral valve, which normally only has two. We saw some valves with one cusp, a bicuspid aortic valve (which should be tricuspid), and even one valve with four cusps. We also saw hearts that had hypertrophied. Some were big enough that they could have been cow hearts. There were also some hearts from young kids who had congenital heart defects and had died, which was kind of sad. But overall, this was a great session and it was awesome to see in person all the heart pathology I've been reading about in Robbins. I hope they'll do some more sessions like this.

I got a really nice compliment today from my standardized patient for communications. We were doing motivational interviewing. My actor was playing a patient who had an alcohol problem, and I was supposed to help him realize it. The story was that his wife had insisted he come in, but he didn't think anything was wrong. I wound up getting him to talk all about his family and work and how he'd been more stressed at work, and he hadn't been spending as much time with his daughters as he did before. He came to the conclusion himself that he should spend more time with his family, and that maybe drinking was getting in the way. My preceptors commented that I didn't push him as hard to get help as I could have, because he was clearly ready to stop drinking. Well, I didn't do that because he was supposed to be only pre-contemplative (not knowing he had a problem and not planning to change), not contemplative (knowing he had a problem and that he might want to change)!

When class was over, my group was heading out of the library. My "patient" was leaving at the same time, so I went over to him and thanked him for his help and told him that he was a very believable "patient." He told me that he had felt really comfortable talking to me and that he thought I was going to be a terrific doctor. I was surprised and also a little touched. He was only pretending to have a problem and I was only pretending to help him, but I had gotten deeply enough into playing my part that it had seemed real, and I tried to do and say what I really would have done and said if he'd been a real patient. I have to say that his compliment means way more to me than any positive feedback I've gotten from either of my preceptors.

It's a good thing that communications went well, because my cardiology exam practice session was rough. Since I didn't have time to review the cardiac exam video before class today, I was not well prepared, and I had the bad luck to wind up being in the first room by myself. The preceptor said, "Go ahead and do a cardiac exam like you normally would, and then I'll go through it with you." Oh boy, was I ever screwed. In clinic, I usually just take the patients' pulse and blood pressure, then auscultate (listen with a stethoscope) their hearts. But there are all kinds of other things that we're supposed to do for a full physical, most of which I only vaguely remembered. So I fumbled through the exam as best as I could, but it wasn't very good. I did remember to take the blood pressure by palpation first and do the exam from the right side, and the patient was super nice. But I definitely did not wow this preceptor with my cardiac exam skills. Fortunately, I had a couple of other students in the room with me for all the other stations, and I did a lot better once I had gotten my wits about me again. We spent time listening to murmurs in some of the other rooms, and that was really helpful. Again, the faculty had found some patients with overt, easily audible murmurs.

Deserted by My Preceptor?

This week we are learning about cardiac arrhythmias. Our PBL case is about a patient with an arrhythmia, and yesterday we had a seminar on the biochemistry of arrhythmias. That one wasn't the best seminar I've ever attended, but I really loved the one we had today. We went over to the EKG lab and had three stations. The first one was kind of repetitive from last year--we went into the electrophysiology lab and watched part of a procedure being performed. Then we had two stations about reading EKGs. One was by a physician who taught us about EKGs last year, and the other was with another physician who had made us a terrific booklet with explanations and examples of different arrhythmias and what they look like on EKG. I liked that third station the best, but we wound up having to leave before he was finished because we were already late for FCM. Two of my classmates did their patient and journal presentations like the one I did last week.

This afternoon I had clinic, and I got some bad news. My preceptor is planning to move out to one of the satellite campuses at the end of March. That will be in time for me to get my observed H & P done, but it will leave seven unfulfilled clinic sessions at the end of the year. I was planning to stop going to clinic in May anyway, because we are allowed to miss three clinic days and I haven't missed any yet. But missing all of my April clinics as well will be too many skipped days. I really don't want to have to go out to the satellite clinic, but it looks like I may need to go do a few sessions there.

Saved by Salt-Free French Fries

I had yesterday off, and I spent the entire day at home in my pajamas reading for school and watching the snow flurries falling softly outside my bedroom window. I have to say that when I don't have to go anywhere, I really like the snow. I got my learning objective done, and I even got all of the reading for today done too. I'm especially proud of that.

Our PBL case had a sort of happy ending--the patient survived, but she stopped at a fast food restaurant on the way home after being in the hospital for heart failure. It's pretty true to life, unfortunately. Patients don't even need to wait to be discharged to get their fill of grease, because there is actually a McDonald's in the Cleveland Clinic hospital cafeteria. I don't usually eat at the cafeteria, but whenever I have gone there, the line at the McDonald's stretches all across the room and around the walls. The interesting thing about this McDonald's is that they don't salt their french fries, as if a box of greasy, unsalted fries that don't taste good are somehow better for you than a box of greasy salted fries that do taste good.

The seminar was on endocarditis, which is an infection of heart valves. Pretty gross stuff, but interesting at the same time. Our POD talk was on the biochemistry of atherosclerosis, and it was decent. I'm glad that today is Friday though, because I'm ready for the weekend. The first week back is always a hard one.

PBL, Anatomy, and Echo Lab

Our PBL case this week is about congestive heart failure. I am doing the pharm learning objective, which no one else wanted to do. That's ok with me, because I like pharm. I have realized though that I suck at hearing heart murmurs. We had some heart sounds to listen to during the PBL case, and I really have a hard time hearing the diastolic murmurs. (Diastole is the point in the heart beat where the heart muscle is relaxing and the chambers are filling with blood.) Systolic sounds, which occur while the heart is contracting, are a lot easier.

Our anatomy session was really a body cavity embryology session. We didn't do much embryo last year, so we're doing it now. It's pretty complex, but kind of interesting how the embryo starts out as more or less a flat disk, and then it starts folding up in all different directions. I don't think I could explain the sequence of events from start to finish though. After Dr. Drake went over the embryo, we went through some prosections to review the chest anatomy. It was a really good review, and I understood a lot more this time around than I did a year ago.

We had a radiology station too just like we used to have last year. I don't know if I've ever mentioned our radiologist. He's awesome. First of all, radiology is just cool anyway. Plus, our radiologist is this really nice older man who has a British accent, so you have to imagine all of this being said with a British accent. He'll start out by showing us a CT of the chest and pointing to something really easy, like the aorta. And he'd say to me, "Can you recognize what this is?" Of course I would say, "The aorta." And he'll say, really enthusiastically, "That's right! It IS the aorta, isn't it! And look, here's the left ventricle attached to it!" I love the radiology station.

This afternoon, we went to the echo lab and listened to several patients who had heart murmurs. That actually really helped, because it's a lot easier to hear a murmur on a real person than it is on the computer, and most of these patients had really loud murmurs. But I still have a hard time making out the diastolic murmurs unless the murmur is practically audible without the stethoscope. I know it's shameful for a Cleveland Clinic medical student, but maybe I'm not cut out to be a cardiologist. ;-)

Back-to-Back Patient Presentations

We started our cardiopulmonary block this week, and so far it's been really good. Not that I'm surprised, because Cleveland Clinic is all about cardio everything. After I took the CBSE last month, I told Dean Franco that I didn't think I had done very well on the cardio path questions. She told me not to worry, because all of the CCLCM students come out of second year knowing cardio very well. Not that I'd ever doubt Dean Franco, but I'm glad to report that I can already see why that would be the case.

There are several things that I really like about cardio block. One, Dr. Stewart is in charge again. He ran our cardio block last year too, and all I can say is that he is a really cool guy. I didn't come here particularly gung ho about cardiology, but he makes it hard not to get excited about it. Next, there is only one seminar per day instead of two. Some of the speakers still go over the page limit for the assigned reading, but one person over-assigning work to us is nowhere near as bad as two of them doing it each day! Plus, we aren't crammed like sardines into the little conference rooms. Finally, the seminars we've had so far have been good, even the pharm one we had this morning. Yesterday's seminar was on hemodynamics, and it started out a little bit confusing, but it got better as it went on.

After seminar this morning, I presented my patient for FCM along with an article related to her disease. Two of us were presenting. I have to say that as annoying and unhelpful as FCM can be sometimes, today was a really terrific experience. I learned a lot by preparing my own presentation, of course, but I also learned a lot from my classmate's presentation. I wish we could do these presentations for FCM all the time.

This afternoon, I didn't have clinic like normal because we had the small group clinical reasoning skills class instead. I lucked out because none of my clinical reasoning group members were in my FCM group, so I presented the same patient a second time. Basically, after I presented the chief complaint, we went around the room coming up with hypotheses for what could be wrong with the patient. Then I presented the rest of the past medical history and the results of the physical exam. After I went, the other three students in my group did the same thing. It was really fun trying to figure out what could be causing the patients' symptoms, and I also felt like I was learning a lot too. I think a lot of my classmates liked it better than longitudinal clinic. I could go either way, but then, I really like my longitudinal clinic.