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

FAQ #29: What Books Do You Use for the ERB and HIM Blocks?

For the Endocrine and Reproductive Biology (ERB) block, you really don't need a supplemental book. Most of the assigned readings come from Boron. There are also optional readings that come from another book and that were posted on the portal as additional reading. I'm not sure what book those optional readings came from, but I liked that book's coverage of these topics WAY better than Boron. After the first week, I mainly read the additional readings instead of the Boron readings.

Hematology, Immunology, and Microbiology (HIM) block:

For immunology, you should get Immunobiology: The Immune System in Health and Disease. 6th ed. by Janeway, and also How the Immune System Works by Somparyac. Both of these books are recommended, and I liked them both a lot. It's best to read the Sompayrac book, which is very short and entertaining, early on in the block. Then you can focus on the denser Janeway book afterward. Just in case you're interested, Lippincott's Illustrated Reviews has also just put out an immunology book as of summer 2007. It didn't come out in time for me to make use of it during the class, unfortunately, but it might be a good alternative if you like Lippincott's books and don't like the Janeway book. If anyone reading this post has bought the Lippincott immunology book and is willing to tell me what you think of it, please leave a comment.

For hematology, no additional books are necessary. You might want to go ahead and get the Robbins path book for next year if you haven't already, because there are some very useful heme readings in there. Also, we weren't ever assigned any readings from the Hematology for the Medical Student book that we bought last fall, but I read several chapters out of it and found it to be a very helpful book for heme. Some of the heme articles we were assigned to read weren't as good as the readings from these two books.

For micro, I had bought a book from one of the upperclassmen as my main text called Sherris Medical Microbiology: An Introduction to Infectious Diseases. 4th ed. by Ryan. That was the book used by the first two CCLCM classes, and I just read the appropriate sections depending on what topics we were covering. The new required book for my class was Medical Microbiology by Murray, but you can use either that one or the Sherris book. Whichever text you buy, I recommend also getting Clinical Microbiology Made Ridiculously Simple by Gladwin. It's a much more digestible way to learn micro. Also, if you like the Lippincott's Illustrated Reviews series (pharm, biochem), you might want to also get their micro book. The pictures and diagrams are really awesome and helpful for conceptual learning, and the Lippincott micro book goes more into the clinical aspects of the lab tests than either of the other micro books I bought did.

Last Day of Year One and Promoted to Year Two!!!!!!!!!!!!

We had a second seminar this morning about anti-fungals, but as for the rest of this entire week, it was very hard to stay focused. I spent part of the time finishing up one more last-minute eval that somehow hadn't been in my account yesterday. I wrote to the secretary and swore on my life that last time I checked all of the evals were complete, and this eval hadn't been there! It turns out that it was a computer glitch and not my fault. But even so, I still had to get it done right away if I wanted my MSPRC letter today.

I think we spent about half an hour in PBL. My presentation was the shortest, least complete one I've ever done. When I first got there, I warned my group members that I had twenty slides and a quiz for them. They were starting to argue with me because they wanted to get out early, and finally I couldn't help it any more and I started cracking up. Somehow, no one ever knows when I'm joking! I really only had seven slides, and my presentation lasted about 5 minutes.

At noon, we got our letters. They're a page long, and each one is personalized for that student. The first paragraph of mine says:

"Dear CCLCMer,

The Medical School Promotion and Review Committee met on June 6, 2007 to review your Year 1 Summative Portfolio. Based on its deliberation, the Committee determined that you met the Year 1 standards for all nine competencies and will be promoted to Year 2."

This is followed by two paragraphs about my specific strengths and weaknesses based on what I presented to them, and then a generic paragraph that we seem to have all gotten commenting about the organization of our portfolios. Now it's official: I'm an M2.

We had our last POD session at 12:15 right after we got our letters. I couldn't believe that they scheduled POD on the last day, and I figured no one would show up once they got their letters, but actually most of us did. The speaker does basic science research on preventing rejection in kidney transplants. His work was pretty interesting, but he had way too much material to present. I mean, today of all days was NOT a time when we wanted the speaker to go all the way through to 1:15 PM, which he did. At the end, he asked if anyone had questions, and no one said a word!

So, that's it for year one. We have four weeks off, although I'm only getting three because of my fellowship. Still, I'm looking forward to having some time to chill. I'm going out of town on Monday. Before I leave, I'm going to do consults this weekend with Dr. Tomford, who is an incredibly funny and very knowledgeable infectious disease (ID) doctor here. I'm not really thinking that I want to do ID for a career necessarily, but I just want to see what it's like while I have the chance.

Tuesday and Wednesday Stuff

Yesterday was a really short day. We just had one seminar on HLA matching and blood typing. I think there was another optional micro review session before that, but I didn't go in early. Today we had an antibiotics pharm seminar and PBL in the morning. Then we had a mandatory FCM Course Evaluation in the afternoon. The course director wanted to get feedback from us about FCM, the physical diagnosis class, and the clinics. Several people in my class are unfortunate enough to have to drive long distances for their clinics, which is really going to be hard next year since we have clinic every week. That was the main thing that we talked about during the feedback session.

I don't really have much to suggest on how to make things easier for people who have to drive long distances, so I spent the time working on the eight zillion surveys we have to get done by Friday. We keep getting emails from the college staff to tell us that if we don't get the evals done by Friday, then we won't get our MSPRC letters. It's getting to be a pain to keep filling them out, because they're essays and not just multiple choice. But I can't really complain too much considering that one of my criticisms of some of the FCM faculty was that they didn't provide detailed enough comments so that I could use them as evidence for my portfolio!

Antibiotics Seminar and PBL

We've reached the last week of school! I feel like classes should have ended two weeks ago--I just don't feel very motivated to study at all. It kind of amazes me because this week is going to be all about drugs and bugs, which I like. But even so, I did basically no reading over the weekend aside from finishing "And the Band Played On" and doing my homework from last week. It's like my brain has decided to go on vacation already.

The classes themselves were good, but like I said, I am just not focused on them. One of the two pharmacists that I really like was leading our seminar. We went through several cases, and it was tough to concentrate. Even for PBL, people have not really been in the mood. We're doing our last case this week, and I think all of us just feel burned out and not in the mood for it. I still can't bring myself to go to the gym, so I'm going home instead. To do what, I don't know. Maybe I'll feel like doing the reading for tomorrow later tonight. Yeah, right.

Virology Seminar, PBL, POD, and CHI

I had a very busy day today. We started with a virology seminar on HIV that I think was a bit too elementary. It wasn't bad, but I had done some extra reading, so it was just kind of tedious. By the way, for anyone who is interested and has a copy of the big Robbins path book, there is a very nice section on the immunology of HIV in there. It's only about 10 pages. I just bought this book recently, and I've been reading random sections from the micro and immunology chapters here and there. So far I really like it, much better than I liked the Boron physiology book we used this year. Lately I've been reading sections of the Robbins book instead of some of the random readings we're assigned sometimes.

We were done early with the learning objectives in PBL, so we spent some time talking about the social issues of the case. I don't normally like to spend PBL time discussing these things, but I'll concede that it was pretty relevant to this case. Still, I would have rather gotten out of class earlier. I'm reaching a point of saturation where I'm really tired of sitting in classes and eager to be done with them altogether.

The POD talk was given by one of the same docs who spoke during our seminar this morning. It was about the history of HIV research. The talk was really interesting, especially because this speaker has been involved in HIV research for many years, and he knows many of the scientists whose work he was telling us about. He also mentioned a book I read several years ago in college called "And the Band Played On" by Randy Shilts. It's about the first several years of the HIV epidemic during the Reagan era. The focus is mostly on the U.S., but it talks a little bit about the spread of HIV in other countries too. I've started re-reading the book, and somehow the experience of reading it is very different now. I don't know if it's just that I'm older, or that I've been in medical school for a year already, or some combination of the two. But I really struggled to get through it the first time, whereas now I feel like I could stay up all night reading it.

I left POD a few minutes early so that I could meet with my PA briefly before I went to volunteer at CHI. We did our last CHI screenings for the year today. I was taking blood pressures. All of us were acting a little silly anyway, and since several of the patients brought their kids, we just got sillier while entertaining them. I took the blood pressure of a three-year-old after she saw me take her mom's blood pressure and wanted me to do hers. It was incredibly low, and I had to listen really hard to hear it. I also had to use the tiniest little peds cuff I have ever seen. As soon as I finished taking her blood pressure and removed the cuff, she solemnly held out her other arm. So I took her blood pressure again on that arm. I can't say that I ever see myself doing peds as a career, because being around screaming kids just makes me want to kill myself. But I have to admit that this one was really cute.

Two Seminars and PBL

I have nothing too exciting to report for today. We had two seminars, one on miscellaneous bacteria and one on platelets. We had kind of covered platelets a couple of weeks ago, so a lot of the material for today was review. My PBL group was right about the patient in our case. He did have a second diagnosis. My learning objective is on the pharmacology of anti-retroviral drugs.

I haven't been going to the gym at all for the past couple of weeks even though I have more than enough time to go now. I don't know if it's just that I'm exhausted or that the weather is so beautiful or what, but somehow I never feel like going. Every single day after class I struggle with myself about whether I'm going to go, and every single day I come up with some excuse not to go. At least I've been going for walks in the evenings though, so it's not like I'm not getting any exercise at all. As much as the weather here sucks in the winter, the summers are gorgeous. I guess that there are good seasons and bad ones pretty much everywhere.

Fungi and HIV/AIDS Talk

There was a morning review session for micro, but I decided not to go. I just don't feel like I get as much out of the seminars in comparison to reading the material myself, and it's not like I don't have enough reading to do without needing extra classroom sessions. Actually, this has been the first week where I've more or less been keeping up with all the reading. I have no Masters class, no FCM class, no portfolio, no other outside things to do at all besides the readings for school. I did go to the regular seminar at 10:00, which was about fungi. I don't think that microbiology is the kind of thing that you can really learn much about from a lecture though.

After class, the HIV/AIDS Interest Group had a speaker from Oberlin. She is a social scientist who studies how the media portrayals of the HIV epidemic and people who are HIV+ affect societal views about whose "fault" it is when people become HIV infected. The particular work she was telling us about is related to men on the "down low," which is kind of loosely defined as men who are heterosexual on the surface but secretly have sexual encounters with other men. The portrayals in the mainstream media tended to look at these men as bisexuals who are secretive or dishonest, and as people who spread disease to innocent heterosexuals, especially women. The portrayals in the black media also focused on increasing the visibility of men on the down low and protecting black women, but there was also more of an examination of the historical mistrust between the black community and the American public health system. It was an interesting talk, and it didn't hurt that that the lunch was catered by Cedarland (a really good Lebanese restaurant on campus) either!

Anatomy and PBL

I had a very pleasant, relaxing weekend. There were no portfolio essays to write--I only had to do the usual SAQs and CAPPs. Even our anatomy reading for today was pretty minor, just 8 pages. We did a review of the cranial nerves. It wasn't a bad idea to review them, but I wish we had done this about six months ago when we were struggling to learn the cranial nerve exams in Physical Diagnosis class. Now it's a little anti-climactic.

The new PBL case is pretty interesting so far. Some of the symptoms don't fit with the diagnosis though. I think that this will end up being another case where the patient has two different problems.

I met with my summer research preceptor after lunch to discuss what I'll be doing this summer. I'm going to be working on the same project that I wrote about in the protocol for my clinical research class. I'm really excited about doing this project. My preceptor gave me a copy of the final protocol to read over break, so I'm pretty much all set.

Blood Smears, PBL, POD, and Portfolio Done!

I am happy to report that I turned in the hard copy of my portfolio yesterday without a hitch. So that's it. I'm officially done with my first year of medical school now except for the last couple of weeks of class.

We were divided into four groups of eight for seminar. My group's seminar leader was the same hematologist who had been my communications preceptor. I really like him, and the workshop he conducted for us today was pretty good too. We worked our way through several cases of blood cell disorders and looked at slides of blood smears. As much as I usually hate histology stuff, these were interesting. I think I already mentioned that one of the pathologists promised me that I'd enjoy path way more than I like histo. So far at least, that seems to be true.

Yet another PBL patient survived her illness, thankfully. After having had two in a row die on us, now I'm a little paranoid about it. It sounds kind of silly on one hand, because of course we're not really seeing these patients. But the cases are based on real patients, and it's very real to me in that sense at least.

I really loved today's POD talk. It was about stress and its effect on the immune system. Dr. Moravec, who runs the POD sessions, gave part of the talk. But the main speaker was a CCF psychiatrist. He gave us some articles about things we could do to reduce stress. (Gee, I wonder why they thought we'd be feeling stressed the day after our portfolios were due???) The best part of the talk was toward the end, when he hooked up one of my classmates to his biofeedback machine so that we could see how someone's stress level could be measured. My poor classmate was kind of volunteered involuntarily, but was a very good sport about it. I think that this was one of the best, if not the best, POD talks that we've had all year.

Parasitology Seminar, PBL, and More Portfolios

I am ridiculously tired today, and I came into seminar having done basically none of the copious amount of assigned reading. I meant to do some of it last night. But one of the upcoming first year students is here visiting, and we went for dinner instead. (If you're reading this, and you know who you are, I swear I'm not blaming you!) On the bright side, I made the last set of corrections to my portfolio essay, and now all I have to do is print out the essay for my hard copy and upload the web version. I'm so happy about being done with my portfolio.

We have a short PBL case this week since there was no school Monday. The cases have been getting more complex all year, and now we're getting some where there is more than one thing wrong with the person, or where there is some set of symptoms that kind of leads us in the wrong direction for a while. It's good in a way, because we still get the learning experience of the wrong turns we take. It's probably also good to teach us not to immediately jump to conclusions about a patient's diagnosis! My learning objective this week is about the epidemiology and treatment of infection by Plasmodium parasites. They are the organisms that cause malaria.

I have this afternoon free, so I am going to finish off my portfolio, run some errands, and go to the gym. I would have tomorrow completely off, but I have to come in and meet with my PA at 4:30 to get my portfolio signed off before I actually turn it in.

Portfolio, Dermatopath, and Clinic

I got my PA's comments about my portfolio over the weekend, and I just finished making the changes. Most of them were pretty minor things, but I still had eight pages of them to go through. Unless I have to make any other last-minute changes, I'm pretty much finished. I came in over the weekend and printed out all of my evidence. Now I just have to number it all, print out the final copy of my essay, and upload the essay to the portal for the MSRPC to read. They'll start reviewing us on Monday, and we'll get our letters on the fifteenth.

We don't have FCM any more for the year, so we didn't have class until 10 A.M. today. It was a seminar on the histo and path of skin. Ok, I know everyone says that derm is such a great field and all because of the hours and the payments. But it's seriously incredibly disgusting. The blisters and acne and moles and cancer and ulcers....how do people stand looking at this stuff all day, every day? I'd rather not be a doctor at all than be a dermatologist.

It was a slow day during clinic today. I only had one patient, and then I saw a second patient with one of the residents. There weren't any other patients coming and it was pretty quiet in the whole unit, so I went back to the student lounge and started working on numbering my references. I wasn't even supposed to have clinic this week, but my preceptor is going to be out of town next week. So now I'm officially done with clinic for this year, and I'm pretty much done with my portfolio too. Yeah, well, maybe now I can start catching up with some of this week's reading....

Complement Workshop, PBL, CHI, and Hospital Update

We could have really skipped today's seminar. Not only did it basically just go over exactly what I was about to cover for my PBL learning objective, but it wasn't really adding that much new information to what we had learned about complement a few weeks ago. On the bright side, it did make my learning objective presentation more interactive since my group members already knew most of the stuff I was going over. Also, the seminar speaker tried to make his session fairly interactive.

We didn't have POD today because the speaker had cancelled, but I still didn't go home because I was signed up to volunteer for CHI. I used the time in between to run some errands, one of which was to go over to the billing office to pay off my debt from visiting the ER three and a half months ago. When I got my initial bill two months ago, I was charged about $250 after my insurance was billed for about $1250. There was a number on the bill to call to request bill forgiveness for financial hardship, so I called it. On one hand, $250 isn't an astronomical amount of money, but on the other hand, I AM a student, and I don't exactly have a good-paying job. So it really is kind of a hardship for me.

The lady in the billing office took down my name and address and mailed me a form to fill out to request bill forgiveness. I got the form about a week later, filled it out, and sent it back. Then I didn't hear anything for over a month, until just last week I got a letter back saying that I had qualified for 3/4 of the bill to be forgiven. So I still wound up having to pay $62 and change, but it's better than having to pay the full amount. I am kind of amazed that being a full-time medical student does not automatically qualify me as being too poor to pay, especially when you consider what it costs to go to school here. But I figured at this point it was easiest to just pay the balance and be done.

CHI was kind of slow today, and I only stayed until 4PM instead of 5PM like I usually do. I was weighing patients and measuring their body fat percentages and BMIs. One of my classmates wanted to do the cholesterol checks, and I didn't really care what I did, so I wound up doing something different this time.

This weekend I need to get my homework done (as usual) and make sure my final portfolio is ready. I am going to come in on Sunday to print out all of my evidence from the CCLCM portal. It's kind of silly, but we have to print out all of the evidence plus our essay and file everything into a 3-ring binder. This binder is then added to our permanent academic records in some CCLCM office somewhere. I don't think that the MSPRC uses the hard copy, because we also have to upload an electronic copy of the portfolio essay to the portal, complete with hyperlinks to our evidence. At least Monday we don't have class, but it's not going to be a very fun Memorial Day weekend.

Autoimmunity Seminar, PBL, and Subacute Session

Today was another crazy day. Next year we will be having two clinical days every week instead of just one. I had been thinking that I would like to do my two clinical days back-to-back on Tuesdays and Wednesdays, but now I'm not so sure. I am pretty exhausted from two straight days of clinic. Most of the upperclassmen either scheduled their clinical days on Monday-Wednesday or Tuesday-Thursday. I don't really want to have anything that I have to do on Thursday if I can help it, and I'd rather not start out the week on Monday with a crazy day either. Besides, my clinic day this year was Tuesday, and I don't know how my clinic preceptor would feel about changing it to Monday. I could ask, but it may not even be an option. Probably as long as I have my Thursdays off, Tuesday-Wednesday would be doable. The problem is that I don't know which day my next MS class is going to be scheduled for in the fall yet.

Our seminar this morning was on autoimmunity and tolerance, which is an interesting topic. There is a type of immune cell called a T cell that attacks foreign cells, as I've already explained previously. These T cells have to be "taught" not to attack your own cells though, and how this is done is a pretty hot area of research in immunology. If this doesn't happen, or if there is some kind of accidental recognition of self-tissues as being foreign, then an autoimmune disease like type I diabetes or rheumatoid arthritis can result. One of the most interesting things we learned is that there is some evidence that pieces of certain viral proteins called peptides can mimic self peptides. The T cells then get "confused" and attack body cells that express those peptides as well as cells that are infected with the virus. I read a paper about this that was linking viral peptides with type I diabetes. I don't think that this will ultimately be the cause of all or even most autoimmunity, but it's a really interesting phenomenon anyway because of how it affects our understanding of immune system regulation.

My learning objective for this week's PBL case is on the complement system and how it's related to autoimmune diseases like lupus. We went over the complement system a few weeks ago when we were studying the nonspecific immune response, but all of these concepts are still very important for the adaptive immune response because the adaptive immune response makes use of the components of the nonspecific immune system.

I had lunch with a friend and then I had to go to the subacute facility for another observed history and physical (H & P). We were supposed to conduct a full exam on a patient who was not ambulatory, again while being observed and evaluated. I had a patient whose surgical wound had become infected. He was a very pleasant guy and fun to talk with, but it wasn't very easy to keep the interview on track because he was wanting to tell me stories about things he had done when he was younger. It was hard to stop him not only because I didn't want to be rude, but also because his stories were actually really interesting. So I kept trying to steer him back toward health stories: his own health, his parents' health, and so on. I didn't even come close to finishing the entire H & P, but my observer passed me anyway based on what I had done and invited me to come shadow him. I am going to take him up on that this summer.

Coagulation Seminar, Clinical Research Grand Rounds, and Clinic

We were supposed to have FCM oral assessments this morning, but my group lucked out and our preceptor didn't make us come in. I had suggested to him a couple of weeks ago that he just give us written evaluations, though I don't know if that's why he decided not to make us come in. But these oral assessments really are pretty silly: each group member is supposed to come in to meet with the preceptor for ten minutes. Then we would get to hang around until seminar starts at ten, which really sucks if you're the person with the 8 AM time slot. Plus, since the assessment is oral and not written, you can't even put it into your portfolio. Whatever made him decide to let us off, I really appreciate it.

Today's seminar was about coagulation. We were broken up into four groups, and our leader was an MD hematologist. He was really good. We went through several cases and discussed them. One thing that was especially good about this seminar is that we went into more detail on vitamin K and its deficiency. The Hematology for Medical Students book, which I really like on the whole, doesn't cover that topic too much. I wound up printing out a copy of the vitamin K cycle and pasting it into my book.

Our seminar group ran a little late, which was unfortunate because the Clinical Research Grand Rounds were also today at noon. One of my classmates and I raced over to the Bunts Auditorium to hear it. (Bunts is all the way over in the hospital, so it's a pretty good hike from the LRI.) Today's speaker was the head of the Family Practice Department at CCF, and he was telling us about some of the research projects that are being conducted in the CCF satellite outpatient clinics. Having general practice physicians do this kind of work is a fairly new development at the Cleveland Clinic, but the patient volume at the satellite clinics is so large that it's a unique opportunity to conduct some of these studies. Plus, the patients and several of the physicians were really gung-ho about getting to participate in research. The talk was pretty interesting, but I had to leave a little early because I had clinic right at 1:00.

My regular clinic preceptor is still out, so I worked again with the same substitute who was helping me last week. Today we saw mostly mundane cases, except for one really cool patient who was very elderly. He was telling me stories about things he had done during World War II and how he had built up his business. His reason for coming to the clinic was that he had started taking naps every day, which he never used to do when he was younger, and now it was hard for him to play a full round of golf without having to take rests. All I can say is that I hope my biggest problem when I'm his age is that I can "only" play half a round of golf without taking a rest!

Anatomy, PBL, and Portfolio Draft Due

We're only having anatomy sessions every other week now instead of every week, and the topics we're covering have nothing to do with what we're studying this block. But since we didn't have enough time to cover this material during the neuro block last winter, we have to do it now. Our session today was about the eyes and included the normal prosections and radiology. This was the first time all year that we've actually seen the cadavers' faces. (It's kind of hard to see their eyes without seeing their faces!) Seeing their faces didn't bother me too much. The creepiest part was the prosection where the brain had been removed and we were looking down into the orbital cavity from the top. You could see the white part of the eyeballs in there, and they were all kind of wrinkly-looking like a ball that has started to deflate. I touched one, and I was able to press my finger right into it. The resident said that this happens because the fluid tends to come of people's eyes after they die.

I think a lot of my classmates didn't like today's anatomy session too much because the classroom part of it, which covered the ocular muscles and how to test them, was pretty confusing. But I had only finished half of the reading before class today anyway. So I came in already not understanding all of the ocular muscles and how to test them, and it didn't bother me that I still felt confused when I left. I plan to read about them tonight. Overall, I think that eyes are really neat and interesting to learn about. I still don't see myself being a surgeon, but I wouldn't mind considering ophthalmology. Too bad it's such a difficult word to spell. :-P

We started a new PBL case this week, and so far it has been a pretty good one. Part of what makes it interesting is that the patient has a lot of different symptoms, and she's also extremely obese. That makes it difficult to decide whether some of her symptoms are due to her having a disease versus just being problems from her obesity. (One could fairly argue, of course, that being this seriously obese is a disease in an of itself.)

Our portfolio final drafts are due to our PAs today at five. I'm completely done with the essay part unless my PA wants me to make any last minute changes. My essay is 18 total pages, 1.5 spacing, 1 inch margins, not including my 105 references. Now, I just have to go back and add in the links to all of the references before I submit it. (My PA is out of town this week, so we're just going to be emailing instead of meeting.) This is actually the worst part of the process as far as I'm concerned. I don't know if you've ever used RefWorks, which is a referencing software, but it is just awful. I never had used it before I came to medical school, but in my limited experience, it is not at ALL user-friendly. I've gotten a little better at it now that I've done this a few times, but it's still a pain. The good news is that so far it looks like I won't need to go hang out in the tech support office this afternoon!

Histology, PBL, POD, and Portfolio Stuff

Our seminar this morning was on the histology of the lymphatic system. It was ok. We also spent some time at the end going over flow cytometry and how it can be used to analyze white blood cells. It was kind of interesting but definitely a bit too long.

This is our first PBL case so far this block where the patient hasn't died on us. We had seven parts to the case today, including a bunch of blood smears and flow cytometry results to look at, so it was kind of rushed for a Friday. There was also an informed consent form included for the clinical trial that our patient was considering, but we basically didn't even get a chance to look at it because we were so rushed. The clinical trial treatment didn't work, but a second treatment did. I think this is my favorite PBL case. It has a little of everything in it, and the patient winds up being cured and going to medical school at CCLCM. What ending could possibly be better than that?

The POD talk was about circadian rhythms and how they are controlled. The speaker is studying circadian rhythms in mice, so of course you get the usual questions about how applicable any of it is to humans. Even though the topic is interesting, I'm not really clear on what this has to do with anything we are studying this block. Maybe there just wasn't room for it during last block.

Right after POD, the CCLCM Cardiology Interest Group had a speaker. There were only about half a dozen of us who went. I was hoping that the talk would be about research, but it was mainly clinical. It's tough to know these things ahead of time. I wanted to leave and go meet my PA early, but since there were so few of us and I had already gotten there late, I wound up staying until the end. The portfolio essays due yesterday were for Medical Knowledge and Clinical Reasoning, but I went ahead and turned in my Clinical Skills and Reflective Practice essays yesterday also. Now the final draft of the essays is due Monday, and the actual finished portfolio is due a week from Thursday. I can't believe how fast the time is just flying by....

Surgery Grand Rounds, Immune System Regulation, and PBL

This morning I went to Surgery Grand Rounds. The speaker is the director for the Center for Neurological Restoration at CCF and is working on neuromodulators. Neuromodulators are "brain pacemakers" that are implanted into the patient’s brain or chest. These brain pacemakers are being used to provide deep brain stimulation for movement disorders like Parkinson’s Disease already, and they are being studied for other disorders like epilepsy, depression, OCD, anxiety, and addictions. The surgery targets the subthalamic nucleus, which has abnormal electrical function in Parkinson’s Disease. Once implanted, the pacemaker sends calming signals to the brain, and the tremor stops immediately. The speaker showed us several patients with and without the pacemaker turned on. One patient was an amateur athlete, and he was able to compete in a triathlon a few months after his surgery!

His newer work is on using brain pacemakers to treat some of the other psychiatric diseases that I mentioned, but I didn't get to see all of those applications because I had to leave for seminar. It was an incredibly cool talk, and I didn't want to leave. The seminar was a workshop covering how the immune system was regulated. It wasn't bad, but in retrospect I wish I had stayed to hear the end of the grand rounds talk.

The diagnosis was given for our PBL case patient today, so now everyone in my group believes me! My learning objective for Friday is about immunoglobulin E and allergic reactions. The subject came up because we were talking about Portuguese men-of-war during the PBL session. Some people hadn't ever heard of them: they are a type of tropical jellyfish that can give a very painful sting and cause allergic reactions in some people.

End of FCM, MHC Seminar, and Makeup Clinic

This is turning into a pretty busy week so far. We had our last FCM session today, but it was just to present the projects we were supposed to be working on. I hadn't really done much of anything toward my group's project and I needed to finish the reading for seminar anyway, so I didn't go this time.

Our seminar was a workshop to go over how special antigen presenting cells (APCs) in the body can activate T cells. T cells are a very important component of the specific immune response. Some T cells can kill infected body cells, and others activate B cells to get them to make antibodies. The APCs present antigens to the T cells using special proteins called the major histocompatibility complex. These proteins are the ones that have to be matched if you want to try giving someone an organ transplant. Your T cells recognize MHC proteins from someone else as being foreign if their MHCs are different than yours. If someone gets an organ that doesn't match their MHCs, then their T cells will attack the new organ and kill it. This makes sense in terms of evolution, because we weren't made to get organs from other people transplanted into us. Of course, for people who need transplants to stay alive, this means that the logistics of transplantation are very difficult. Even when the MHCs of the transplanted organs and the recipients match each other perfectly, the recipients still have to take immunosuppressive drugs for the rest of their lives so that they don't reject the organ.

I wasn't supposed to have clinic today, but I had to make up the one that I missed last week. My regular preceptor is out of town, so I'm working with a substitute this month. My first patient today had a major complaint of being constipated. Since my second patient cancelled, I spent about an hour reading about the etiology and treatment of constipation. It is both disgusting and also kind of fascinating in that can't-look-away-from-the-train-wreck way. Basically, if the stool is hard enough and can't be softened, the doctor has to manually remove it. The only other somewhat exciting thing I did today was to perform a breast exam on a woman. Again, we aren't supposed to do this until next year, but I watched the doctor perform one, and then she told me in front of the patient to go ahead and repeat what she had done. You might be thinking that this would feel totally awkward to me, and you would be thinking right. I tried to just copy what the doctor had done and hoped hard that the patient didn't feel like I was groping her.

The more I learn about the fun in store for me over the next few years, the more I realize that it's a good thing I didn't totally know what I was getting myself into before I applied to medical school. I can tell you for sure though that I have zero interest in being a gynecologist.

Virology and PBL

We had our first virology seminar today. It didn't seem to be as hectic as the previous ones on bacteria were, even though it covered a ton of material. I think we didn't go into as much depth today as we did for the bacteria seminars. There are still tons of viral groups to learn. I haven't even been trying to memorize them all now. I already know for sure that I'll have to learn all of this stuff again next year for the boards. Micro is just one of those things you have to keep reviewing over and over.

I've been waiting for this PBL case all year, ever since I found out last fall that it is based upon the case of one of the current CCLCM students. I don't want to spoil the story for those of you who are going to be going through the case next year. But suffice it to say that the patient is very much alive and well and most of the way through medical school. Finally, we've gotten the first PBL case for this block that is going to have a happy ending! The funny thing about it was that apparently I was the only one in my group who knew the origin of the case. My classmates didn't believe me at first when I said what the diagnosis was, and I could have just kept quiet about how I knew and seemed House-like in my deductive skills. But I did tell them that the person the case was based on had told me, and that was how I knew. :-P

Tyrosine Kinase Disorder Seminar, PBL, and POD

Our seminar this morning was pretty good. We were divided up into four groups of eight, and the seminar was led by a hematologist along with an immunologist. He made the seminar a lot more clinically-oriented than most of them are. Plus, the hematologist my group got happens to have been one of my communications preceptors, and he's a pretty cool guy in general. He was discussing the clinical aspects of the disease that our PBL patient had, so it was really useful for PBL too.

Speaking of PBL, our patient died for the second week in a row. The stupid thing about it is that she died because she had an accident. While she was in the hospital for surgery, she ran out of her study medication from the clinical trial and somehow, no one noticed. The most aggravating part is that the medication she was getting was actually working too.

Our POD talk was about problems with macrophages in the alveoli of the lungs. It was ok, though it would have been better if the speaker had told us more about her career and showed us fewer slides of data. I met with my PA afterward to go over the portfolio essay drafts that were due yesterday. That's about it. I'm really tired and very glad it's the weekend!

Innate Immunity and PBL

Today was another kind of slow day. I'm not complaining about that, mind you. Our morning seminar was the third part of the innate immunity seminars we were doing last week. It was about the same as the first two parts: they gave us data from research articles, and we went over them in small groups. Our PBL patient is going to join a clinical trial. We were a little bit confused because the drug she's getting is already a drug on the market, but that's just because this case happened several years ago (obviously, before the drug got FDA approval). My learning objective is about neutrophils, which are white blood cells. It was originally supposed to be about neutropenia (shortage of neutrophils). But I made an executive decision to broaden the topic, because it wasn't very interesting all by itself.

Tomorrow, my personal development and communication competencies are due for my portfolio. I don't have to go in to school, so I can just email them to my PA from home. I haven't discussed my individual essays much, but they're each two pages, 1.5 spaced, Ariel 11 point font, 1 inch margins. (Yes, the MSPRC requires this.) I can already see that I am going to have a lot of evidence. Luckily, I've been keeping my evals and other evidence organized in my portal files as they come in. I started keeping up with filing my evidence after making the mistake of NOT doing that over the summer and suffering through trying to write my first formative portfolio with disorganized evidence. I'd give the same advice to those of you who will do this for the first time next year: keep your evidence organized from the beginning, and it will make writing the portfolio essays MUCH less painful.

FCM and Stem Cell/Bone Marrow Lab

Today was our last day of real FCM. We discussed the ethics of disconnecting the patient from last week's PBL case from life support. Basically we got into issues of informed consent, and what you do in a situation where the patient is unable to make his own decisions and it is not known what the patient would want. In the case of our PBL patient, he had not had any contact with his family in several decades. So the question then arises about whether it is reasonable to have his family members be his medical proxies and make his medical care decisions. Obviously this is a very difficult issue and underscores the importance of having a living will and designating someone to make decisions for you in case you become incapacitated. Not that I've done one for myself yet, mind you.

The stem cell seminar consisted of several cases. We were divided into small groups, and each group went through the cases individually. It was a pretty good seminar, and somehow the reading didn't seem so onerous even though it included a chapter out of the histo book. Maybe this is a sign that I should become a hematologist. There was some reading out of the path book we'll be using next year also, and I have to say that I actually like that path book, even if it IS over 1400 pages. Well, what's another 1400 pages? I can read it all, no problem!

I was supposed to have clinic this afternoon, but I'm going next week instead. So, that's it for me today. I need to go home and work on my portfolio anyway.

Ear Anatomy and PBL

I have a relatively easy week for once: no clinic, no research class. I'll be paying for this toward the end of the month though.

We studied the ear today in anatomy lab. There are actually two senses in the ear: hearing of course, and also the vestibular system. The vestibular system is a part of your sense of balance. And if you're like me, the vestibular system also is why you get motion sick if you go on a boat or try to read in a moving car. We didn't have any cadavers today, just a classroom discussion that was eerily similar to a lecture, and a lab section where we located structures on skulls and models.

The prognosis for the patient from the new PBL case is not looking too good either. Today's session ended with her being told to meet with the hospital social worker after she found out what her diagnosis was. We're getting into a lot more immunology and hematology stuff now compared to last week, which was more microbiology.

There is not much else exciting going on. I'm done for the day. I had a great weekend except for last night, when I was up a little too late getting my CAPPs and SAQs done. I always plan to finish them on Friday, but somehow I always wind up doing them on Sunday night....

More Innate Immunity, PBL, and POD

We had the second of three innate immunity workshops this morning. It was pretty much the same as last time: we were asked to look at data from research articles and answer questions about them. Then at the end, they gave us a little multiple choice "quiz" to do. I thought these workshops would be fun, but I'm kind of tired of them already. Maybe it's my short attention span. It's just hard to sit there and go through articles like that for two straight hours.

The end of our PBL case was kind of dramatic: this time the patient died. None of our other case patients ever died up to this point, and we were disappointed that this one did. It's easy to say, oh, well, it's just a PBL case. But these cases are actually based on real patients, so this is really how someone's illness ended.

Our POD talk today was about an antibiotic-resistant bacterium called Clostridium difficile that is commonly found in hospitals. C. difficile is an interesting organism. For one thing, it makes spores, so it's pretty hard to kill it all. For another, the best place to get sick with it is in a hospital. Patients who have C. difficile wind up having tons of diarrhea, and they still can shed the bacterium even if they're not actively sick. Many of us have small amounts of C. difficile in our colons, but it doesn't usually cause a problem as long as your normal bacterial flora is there. If you take a broad-spectrum antibiotic and wipe out all the normal flora, then you could have problems though.

My PA and I met briefly to go over my professionalism competency from yesterday, and I'm leaving for the airport to take a weekend trip now. Yay for Fridays!

Busy "Day Off"

Today was the last session of my clinical research class. I'm so glad it's over! The class session itself was fun though. We had each been assigned to read two other students' proposals. Then today, we had a mock NIH review session where each proposal had a primary reviewer and a secondary reviewer. Each of us was the primary reviewer for one proposal and the secondary reviewer for another. The way the reviews worked is that the primary reviewer would present the strengths and weaknesses of the proposal first, followed by the secondary reviewer. Then the rest of the "committee" could comment, with the exception of the person who had submitted that proposal. Normally, proposal authors are not permitted to sit in on the NIH deliberations, so here we were supposed to be "flies on the wall" while our own proposals were being deliberated.

Right afterward, I had a course review meeting for the Endo/Repro block that we just finished. I don't know how I keep getting invited to serve on these committees so often. Most of my classmates have only had two or three invites, but I've had five! This is the fourth time I've actually served. I had to say no to one because I had clinic that day. Anyway, I mainly wanted to reiterate the points I had been making all block, which were that the reading assignments were too long and the conference rooms are too small. Nothing new or exciting there.

The Professionalism competency for my portfolio was due at 5 PM, and I submitted it around 4:30. Then I went to a talk from the Department of Orthopedic Surgery that was cryptically entitled "The “Clinician Scientist” an Oxymoron?" The speaker is an orthopedic surgeon in Calgary. He explained that it is difficult to create and keep orthopedic clinician scientists. There aren’t enough of them, and it is not clear how to train, mentor and support them. It is very difficult to be a clinician scientist in orthopedics because they have so many clinical demands on their time. Surgeons are less than 1% of the MDs that have national grants in Canada. Very few surgeons are PIs on national peer reviewed grants. Orthopedic surgeons compose only a tiny percent of those surgeons, and the distribution in Canada is proportionately the same as in the US. Interestingly, orthopedic residents often come in having graduate degrees and wanting to do research. But somehow they change their minds during training, possibly because of lifestyle factors. Some of the challenges include finding and cultivating inquiring minds, training and mentoring people on collaborators, the clinical and surgical culture valuing clinical work more than research, and life balance.

I'm not particularly interested in orthopedics, but I think a lot of the problems apply to anyone trying to balance a procedural specialty with doing research.

Gram Negative Bacteria, PBL, and Career Development Seminar

Today's seminar was just as hectic and crazy as Monday's was. The main difference is that we went through all of the Gram-negative bacteria at lightning speed. If you don't know much about bacteria, the Gram stain is used to distinguish two of the main classes of them. Gram-positive bacteria have thick cell walls and stain purple (left side of the figure). Gram-negative bacteria have thin cell walls and a fatty outer membrane, so they stain pink with the saffronin counterstain (right side of the figure). The big gray thing sticking out of both sides of the figure is supposed to represent a flagellum, which the bacterium uses to swim.

Our PBL case patient is not doing very well. It's a really good case though. Apparently the guy who writes the cases for this block also writes fiction in his spare time. I can definitely see how the storyline of this case has a sort of extra flair to it.

I have a lot of homework for tomorrow: my professionalism competency is due for my portfolio, and I have to review two of my classmates' proposals and write brief essays about them for my Clinical Research class. But I stayed around to see a talk by a researcher who did one of our endocrine block seminars. He used to work for a pharmaceutical company before he came to CCF, so he was telling us about career opportunities in industry. The talk was sponsored by the Lerner Institute (I think the Cell Bio dept.), so everyone else who was there was a grad student or post doc except for me. I went up and spoke to the guy afterward about industry jobs for people with research MDs. Apparently the drug companies really want people with MDs, whereas they don't need that many biologists. I don't know if I want to go into industry, but I'm glad to know that it's an option.

FCM, Innate Immunity, and Class Meeting

The reading for today's FCM session was pretty interesting. It was about health care economics, and the role physicians can play in changing how health care costs get paid. The author argued, among other things, that if physicians don't increase value for patients and stop cost-shifting among payers, eventually the government or some other non-medical bureaucrats will step in and make medical care decisions. He also suggested that the way to decrease costs and increase patient value was through competition to provide the most value for patients. He used things like cable and telecommunications companies as examples. Considering how obnoxious and bad ALL of the service is by ALL of the cable and cell phone companies, I don't know convinced I am. We didn't get to discuss the article in our groups unfortunately, because we had a speaker come over from Case. He was pretty good as far as FCM speakers go, but I'd have rather had the group discussion. Most of my classmates seemed to really like him though.

The immunology seminars are all going to be problem sets that are based on data from research articles. These are not as popular with my classmates, because a lot of people would rather get a more general overview. I have mixed feelings about it. On one hand, it's better than just rehashing the reading we did for the seminar. I hate when seminar leaders go over exactly the same material that I just finished reading. But on the other hand, it gets kind of monotonous looking at graphs and gels for two straight hours.

We had a class meeting about the PBL process after seminar. I hadn't realized this, but apparently all of the other PBL groups besides mine didn't have student leaders last block. Some of the faculty were concerned about this. Dean Fishleder sent us an article to read about the PBL process. It was a good article, but it would have been a lot more helpful for us to have read it last fall instead of now though. Dean Franco talked to us about the goals of PBL and asked if we felt we were meeting them. Most of us do.

I don't think having no student leader is such a good idea. Granted, I've never been in a group that has tried it, so I'm not speaking from experience. And one of my previous groups had no board scribe, and that worked out ok. The board scribe and computer scribe roles are kind of redundant anyway. But no other role overlaps with that of the leader/timer. I think it's important to have someone who is "officially" responsible for keeping the group on track and making sure that we finish on time. Some groups are easier to run than others and don't require as much leadership, but I don't think I'd be comfortable having no leader at all.