End of Heme/Onc

Today was the last day of the Heme/Onc block, and I am going to miss it. Even though blood diseases and cancer (and blood cancers) aren't exactly the cheeriest subjects, they're still really interesting. Plus, this block was well-organized and most of the seminars were excellent. The PBL cases were depressing, but they were good also. Speaking of PBL, my group is still doing the discussions instead of formal learning objectives, and it's working really well. I'm glad now that I gave it a chance. We have a really good PBL tutor, too. He's a semi-retired surgeon, and he gives us great clinical pearls here and there. This is the best PBL group that I've had since I started med school. Our group is going to stay together until the end of the year, so I'm glad this group is such a good one.

We had a cultural sensitivity communications class on Wednesday. It was kind of silly. My standardized patient was playing a Jehovah's witness who might need surgery. Of course she didn't want to have a blood transfusion. So I had to tell her that I'd honor and respect her wishes, and that I would speak to the surgeon about it as well. I also asked her to tell me more about what things exactly were forbidden, and she told me about the religion a bit as well. It wasn't a bad class, but I don't think we really needed it at this point in our second year.

Our seminar today was on cancer drugs. The seminar leader was a new pharmacist that hadn't led any of my previous seminars, but he was very good. We were supposed to have a POD research seminar afterward, but it got cancelled. This whole POD course has been pretty haphazard. The fact that last year's POD course was so well-organized only emphasizes how bad it is this year. You know things aren't going well with the class when even the faculty stop showing up for it.

Blood Pimping

Our seminars yesterday were kind of interesting. The first seminar leader didn't show up at all (apparently he thought he was supposed to come on Friday), while the second one did come, but he basically used a lot of the same slides that he showed us last year. All in all, yesterday was not the greatest of seminar days. But the afternoon session more than made up for it. I had my heme clinical correlation, and the first half of it was just amazing. For that part, we went to the heme path lab and looked at a bunch of slides of different red blood cell diseases. The doctor was pimping us pretty mercilessly, but it wasn't mean-spirited. I felt like I really learned a lot. After we were done looking at the slides, we went on the wards to see some patients. This wasn't quite as successful. Somehow, none of them were in their rooms, and we wound up having another pimp session instead where we had to come up with the differential diagnosis (possible causes) for splenomegaly (an enlarged spleen). After we had come up with all the easy and obvious causes, he was pushing us to come up with some more esoteric ones. I can see now why internal medicine rounds take as long as they do!

Today was a better seminar day. The regular scheduled seminar was about coagulation, and we were back to our small groups again. I know it's a lot more work for the faculty because they have to find four seminar leaders instead of just one, but small group seminars are so much better than large groups. Afterward, the seminar leader who missed class yesterday came and gave us his presentation on iron metabolism and overload. I was considering not staying for it, but I decided that I would, and I think it was worth getting that review. Iron metabolism is a pretty important and complex topic. I was supposed to have clinic this afternoon, but my preceptor is away on vacation. Since it was so crazy last week and I wanted to have some extra study time anyway, I decided not to go to clinic this week. (We are allowed to miss up to three days of clinic for the year.) It was really nice coming home early and having a chance to get somewhat caught up on my work.

Still Not a Budding Dermatologist

I am really enjoying this heme block, even though it has been a lot of work, and even though it is really depressing. On Wednesday, we had another terrific discussion in PBL. I don't know what it is about this PBL group, but it is just gelling really well. The downside is that I knew this week's patient was going to die, and sure enough, she did. Afterward, we had another small group seminar on tumors of plasma cells. (Those are the B cells that make antibodies.) Then I had a few free hours to study, because for some reason we didn't have anything scheduled until the derm exam at 3 PM. I wasn't too excited about doing the derm exam, but it wound up being a pretty interesting, albeit disgusting, session. Now I know the difference between macules and papules and patches and plaques, but none of the above is very pretty to look at. Basically, if you were the kind of kid who was totally into scabs and scatology and anything else that was gross, you will totally love derm. To me, it was fun to do it for one afternoon, but I wouldn't want to make a career out of it.

Yesterday, we were supposed to have a class meeting and a portfolio meeting in the afternoon. But I was sick, so I didn't go. Today we had a seminar on anemias that was excellent, just like the others for this heme block have been. I was all excited about today's POD talk because it was supposed to be about cancer drug discovery, but it was pretty disappointing. The speaker mainly just went over general cancer principles, and I didn't really learn anything new. It wasn't a bad talk, actually. I think it was more that it just wasn't what I was expecting.

Loving the Blood

We had a really great discussion in PBL again yesterday. I am the computer scribe this week, which is not a very tough job. It basically consists of sending out the discussion topics to the rest of the group at the end of the session. There was a small group seminar afterward on immunological diseases that affect the blood, which was really good. In the afternoon, I had my last acute care session on how to discharge a patient from the hospital. First, I had to read over the patient's chart. Then I went to interview the patient to see how he was doing, and discuss what other appointments and services he needed. Afterward, I briefly examined him and filled out a discharge form. I felt pretty bad for this patient--he is a young man and he has metastatic cancer. He had to have all kinds of surgeries and chemo, and I don't think his prognosis is very good. Not that you'd wish that on anyone, but I feel like it wouldn't seem quite as unfair if he were in his 80s. On the bright side, he is getting to go home at least for a while. Plus, I don't have to write up an H & P on him.

This morning, I had a small group seminar on lymphomas that was EXCELLENT. This guy is probably one of the best seminar leaders that we've had yet. I felt like he really cleared up a lot of things that I didn't understand. Afterward, I had a few hours to study (no FCM!!!), and then I went to clinic. I was supposed to do my H & P today, but my preceptor was out sick, so that didn't happen. As it turned out, one of the residents was also sick, and the place was just jammed. I think every sick person in the entire city of Cleveland was in our office today. I was working with a different preceptor, and I did another Pap smear with her help. This patient's os (the opening of the cervix) was off to the side instead of in the center, and I had some trouble finding it. But other than that, the whole thing went relatively smoothly. I don't know whether I should be glad or alarmed that I've done enough Paps that I'm actually starting to get the hang of doing them....

Stitches for Surgery

Yesterday, the CCLCM Surgery Interest Group hosted a practice session for learning to suture. I really hate going into school on Thursdays when I don't have to. But I'm doing Core I this summer, so I thought I probably should go. Core I, to remind you, includes the surgery, medicine, and family practice rotations. We had a couple of cadavers in the anatomy lab, and we cut their skin and then stitched them up again. After an hour at it, I was finally starting to feel semi-competent at doing the two-handed knot the resident showed me. He was showing some of the other people how to do one-handed knots, but I decided that it was better to stick to one kind of knot and do it well. At the end, there were a bunch of stitches all over the cadavers' arms and legs, like something out of Frankenstein. I don't know if they plan to use these cadavers again on Monday for the first years, but it's going to be hysterical if they do.

Today, we had PBL and then a pharm seminar. They were both excellent, although our PBL patient died. I knew that was going to happen because his prognostic factors from Wednesday were very poor, but it still sucks. Our POD talk was pretty good too. It was about how to improve the consenting process for clinical trials that involve children with cancer. After POD, I went to the OR to shadow one of the docs who had led one of our seminars last block. I had arranged to do this before the break. It was really interesting. I saw a couple of ENT (ear, nose, and throat) surgeries and helped a little bit with prepping one of the patients for surgery. The ENT residents had told us in anatomy last year that the thyroid bleeds a lot when it's cut, and I can now confirm that they were right. I felt a little nauseated at one point, but not bad enough that I had to leave the room.

Progress Notes

Today was a pretty good day. Our PBL group was finally at full strength, and the session went well. I haven't worked with several of the people in my group before, and there are a couple of others whom I haven't worked with since the beginning of last year. The people who were here on Monday decided that they wanted to try having discussions of learning topics rather than formal, presented learning objectives. I was a little skeptical about that, because one of my previous groups had tried it, and it wasn't very successful. We never got a good discussion going, and after a week or two, we went back to the formal presentations. But this group is different. I think it's in large part because most of us are talkers. Not only did we have an excellent discussion, but there were actually points where people were talking over one another. That's not ideal either, of course, but it's loads better than everyone sitting around staring at each other.

Our seminar was good too. We were divided into groups of eight for a tutorial on different kinds of diseases of blood cells. I thought our leader did a really good job. After the seminar, I was watching the physical diagnosis video because I thought I'd have to do another full H & P for my second acute care session, which was this afternoon. But I wound up spending most of the time learning how to read the patient's chart. Unlike the outpatient clinic patients, the hospitalized patients at the Cleveland Clinic still have paper charts. Part of their records are online in Epic as well. Epic is pretty cool once you get the hang of using it. My patient had some chest x-rays, and I could pull them up on Epic and take a look at them. His EKG was not online though, so I had to look in the paper chart for that. The other thing that my preceptor worked on with me was to write the assessment and plan portion of the progress notes. I have not really been doing too much of that in the outpatient clinic, so it's noticeably the weakest part of my SOAP notes.

My last acute care clinic session is on Monday. These sessions have really been super helpful. I am not sure how the faculty preceptors would feel about it, but it would be great if we could do even more of these hospital sessions, maybe in place of some of our outpatient clinic sessions. There are so many things to learn about in the hospital setting that any little bit extra would help us make the transition to the wards in July.

First Day of School Minus Me

I went away for spring break last week, and I was supposed to fly back to Cleveland on Saturday. Unfortunately, there was a huge blizzard in the whole Midwest that day, and the Cleveland airport was completely shut down on Saturday. So after I spent a few hours hanging out in the airport (thankfully they had wifi and I had my laptop with me!), my flight got cancelled, and I had to go wait for another hour at the ticket counter to get a new ticket for another flight. First the lady told me that the earliest they could get me back to Cleveland was Tuesday night. I started giving her this whole sob story about how I'm a medical student, that I'd be missing clinic, etc. etc. I guess it helped, because she did manage to find me a flight home for yesterday afternoon. So I only had to miss one day of school instead of two, and I was back in time to go to clinic today.

It's too bad I didn't originally schedule my flight for Sunday, because apparently Sunday was cold but sunny in Cleveland, and the airport was open. That's my reward for trying to get back early so that I'd have time to do laundry, get groceries, and chill out for a day before going back to school. But there wasn't anything I could do except email my new PBL group and the Monday seminar leader to let them know that I'd be out. It wasn't just me that had this problem--two of my other PBL group members who also had a Saturday flight home got stranded as well.

I finally made it back Monday night after a small detour to Detroit, and I basically just ate some dinner and went to bed. Today we had a seminar on drug discovery in colon cancer. There were five research articles we were supposed to read, and I started reading them yesterday on the plane. The first one was all about some molecular pathway that is involved with colon cancer cell death. Not too exciting. Then, the second paper talked about the same pathway, which is apparently involved in the mechanism of action of a certain drug. Ok, a little more interesting, and I noticed it was work done by the same group a few years later. The third paper talked about a phase I clinical trial, done by the same group and published a few years after the second paper.

Finally, I got the point of this seemingly endless barage of research papers describing these pathways--they are showing the development of this treatment based upon the molecular biology that this research group had been studying. In the seminar, the speaker noted that the drug regimen is now in Phase II trials. I think it would have been better if we'd been given a couple of review papers on the background pathways to prepare us, and then they could have told us the research "story" in class. But anyway, I eventually stumbled across a purpose for it in the end.

We don't have FCM any more for the rest of this year, so I had a couple of hours to study after class, and then I went to clinic. I was really dragging by then, but I got through the day, and I even finished my SOAP note for this week. My preceptor is going on vacation the week after next, so I am going to do my observed H & P next week.