Second Year Physical Diagnosis

We had a bone path seminar this morning, and it was actually pretty good. I make my judgment based on the fact that I paid attention without having to really force myself for nearly the whole two hours. Usually, my attention span starts lagging a lot sooner....I haven't forgotten some of last year's painful histo sessions yet. :-P

This afternoon I had my first physical diagnosis class. It's done a little differently this year compared to last year. First of all, only half of us have it at a time instead of the whole class. Last year all 32 of us had PD every other Wednesday afternoon, but now only half of us do, and the other 16 go on Tuesdays. Today we had a communications session that was more or less the same as what we did last year. But the physical diagnosis part afterward was really awesome. There were four stations set up in the four PBL rooms. We went in groups of four from room to room every half an hour.

The first room my group went to covered the legs. The standardized patient was this really funny lady who kind of talked back to the doctor while he was demonstrating the exams, so it was fun for us. In the second room, some podiatrists showed us how to examine the foot. Feet are yucky. No thanks. The third room demo was about examining the shoulders and arms. That one was ok, a bit lecturish though. But the fourth room demo was by far the best. This was the one for the spine. The two docs in there were both orthopedic surgeons, and they were pimping us, but it was done in a gentle and fun way. I am not a huge fan of orthopedics in general, but I liked this one spine guy enough that I am thinking about emailing him to see if I can go work with him in his clinic one day. I think I will ask him, but not this semester. There's just too much going on right now, like my 7 AM MS class tomorrow....

Seminars, FCM, and Clinic

We had two seminars today on the endocrine control of bone metabolism. It was mostly review from last year, but these seminars weren't too bad. Our FCM session afterward was about medical malpractice. We went over a case where a patient sued a doctor over a delayed diagnosis of lung cancer. The doctor possibly did drop the ball a bit. It wasn't an open-and-shut case though, because the patient skipped several appointments, so he majorly contributed to the delay himself. It was based on a real case, and the jury ultimately decided in favor of the physician.

Today was a long day for me because I had clinic. It was a pretty interesting clinic day. The first patient I had was ridiculously rude. When I introduced myself and went to shake his hand, he just left me hanging there and didn't take it. OK....so I took him over to the scale to weigh him, and he ordered me to put down fresh paper towels so that he didn't have to step directly on the scale. OK....then we went into the room, and I was taking his blood pressure after getting his history. He said to me, "Is this your first day in clinic? Because you're obviously not very experienced." At that point, I decided that we were both sufficiently turned off by one another that any further physical exam would be pointless, so I told him that I would get my preceptor for him and left the room.

This is the first time I have ever had a patient behave like this toward me. When I talked to one of the nurses about it, she assured me that the patient was just like that, he would have treated her the exact same way, it wasn't me, and I shouldn't take it personally. I didn't take it too personally actually, but I viscerally disliked this patient to the point that I think it would have been difficult for me to care for him properly if I were his physician. I think that I managed to hide my feelings well enough that he didn't know what a jerk I thought he was. But it definitely got me to start thinking about what physicians should do when they really dislike a patient and the patient seems to dislike them as well.

My next patient was completely the opposite of the first one. She was really friendly and seemed to enjoy talking to me. She was also very nice about letting me examine her. In fact, at the end of her visit, this patient was assuring me that she was going to schedule her next appointment on a Tuesday afternoon so that she could see me again. Well, I may not be able to please everyone, but at least I can please someone!

I was finished seeing all four of my patients by 4:00, so I wrote up a SOAP note and a journal entry. These are two new requirements for clinic this year. SOAP stands for Subjective, Objective, Assessment, Plan. It is the general outline of how physicians write up reports to go in the patients' charts. Subjective is the patient's story. Objective is what I found during my exam. Assessment is what I think is wrong with the patient. Plan is what treatment I am suggesting. We are also expected to list the patients' medications and look up their uses and whether any can interact with one another. It's pretty time-consuming, but I can see that this is going to help me learn my pharm cold by the end of this year. The journal entry is a research question that I come up with from one of the cases I've seen. There are about a dozen different subject areas that we can research and write about. I did mine on behavioral medicine (psych) because I was interested in whether emotional stress could be causing or at least worsening one of my patient's problems. It turns out that it can.

First Day of NMS, Maltz Museum, and Dinner at Mrs. Lerner's House

Today was a very long first day back, and I am going to be sorry I stayed up so late tonight for the rest of this week. But it was a really eye-opening experience and totally worth it.

For all of second year, we have PBL first thing in the morning on Mondays, Wednesdays, and Fridays, followed by seminar afterward. (This is the opposite of our first year schedule.) Tuesdays we have seminar first, then FCM. This works out well for people who have clinic or physical diagnosis on Tuesdays, because we get out at 11:30 that day instead of 12:00 now. Thursdays are still a day off for most people except for those of us who are taking MS classes or have Thursday clinics.

We had a ton of reading for today about bone genetics and collagen. I had printed out all of the articles before break. So I was unpleasantly surprised to come back today to find that one of the seminar leaders had changed all of the readings at some point while we were gone, and no one had bothered to email us to let us know. I talked to him about it. He said that the articles I read were better ones anyway and I don't have to read the new ones, so that was plenty of consolation.

Our PBL case is really confusing and hard to follow. We weren't really sure about the timeline for a lot of the patient's symptoms or visits. My learning objective is about the effect of anticonvulsants on bone, and it's a really interesting topic. I also went to the lab for a while this afternoon to get some more data and talk to my preceptor about making my poster for the conference next month. I didn't get it all done, so I'm going to have to go back Thursday after class and finish the rest.

This evening, I went to the Maltz Museum. I had never even heard of this museum and knew nothing about it until fairly recently. But there is a new exhibit that just opened there called Deadly Medicine. It is about eugenics during the Nazi era. The exhibit is on loan from the United States Holocaust Museum in Washington, D.C. Most people have probably heard of Dr. Mengele and his infamous medical "experiments" on prisoners. But one of the more shocking parts of the exhibit to me was that thousands of German babies were killed for deformities as minor as a cleft palate. The worst part about it is that the physicians, who were highly educated people and who took an oath to do no harm, were among the leaders in the eugenics movement. Not only did they condone the killing of these children, but they were the ones providing the pseudoscientific justification for doing it.

Today was the opening day for the exhibit. Mrs. Lerner was one of the sponsors responsible for bringing it to Cleveland, and all of us who attended the exhibit opening went to her house for dinner afterward. Most of the other guests were not physicians or medical students, but we had some interesting discussions about the exhibit. For any of you readers who are in Cleveland, the exhibit is well worth seeing and will be open here until January 20th. It will then continue touring other cities around the country. I think it goes to Atlanta, GA next.

FAQ # 31: What Masters Programs Are Available for CCLCM and Case UP Students?

Here is a more detailed list of masters programs for people who are interested in getting an MD with a masters degree either through the Case UP or CCLCM. In each case, I have posted how many extra classes are required for CCLCM students. I'm not sure how many extra classes UP students have to take for most of these degrees. But it's probably safe to assume that they take at least as many classes as CCLCM students do, if not more. If any of the UP students who are doing an MS read this and can give me more info on how many extra classes you need to do for your MS, I'd be happy to add that.

Biomedical Investigation MD/MS Programs:

1) Clinical Scholars Research Program (CRSP) MS: This is the MS program that I am doing, and it's one of the more popular choice for CCLCM students. It requires three extra classes on top of the regular CCLCM curriculum, plus two semesters of attending seminar for one hour per week. The two tracks are in Clinical Trials or Disease Mechanisms.

2) Biochemistry MS: This program requires three extra courses (nine hours), a seminar course (1 hour), and an exam. There are no tracks.

3) Epidemiology MS: This program appears to require five extra courses (fifteen hours). There are no tracks.

4) Nutrition: This program requires three extra courses (nine hours), a seminar course (1 hour), and an exam. There are no tracks.

5) Pathology: This program requires three extra courses (nine hours), a seminar course (1 hour), and an exam. There are no tracks.

6) Physiology and Biotechnology: This program requires three extra courses (nine hours), a seminar course (1 hour), and an exam. There are no tracks.

Other Masters Programs at CWRU:

1) Masters of Public Health (MPH):This is a very work-intensive masters program that will require ten classes above the regular CCLCM curriculum. It is apparently possible to finish this degree in the five years if you plan carefully and double up on classes during some semesters. Tracks include Adolescent Health, Epidemiology, Health Care Policy and Administration, Health Promotion and Disease Prevention, International Health, Public Health Research, or Urban Health.

2) Bioethics MA: This is another work-intensive masters program. According to the information sheet, UP students will need to take an extra 24 credit hours on top of their normal med school curriculum, which comes out to be around eight classes. This is apparently possible to accomplish within the normal four-year curriculum. CCLCM students are required to take an additional 18 credit hours on top of our curriculum, assuming that their thesis is done on a bioethics topic. If it is not, then an additional six hours (two classes) of elective credit must be taken.

3) Other Programs: I couldn't find any information about these programs besides the contact information for the program directors. But for the sake of completeness, it is also possible to get an MD/MS with the MS in Applied Anatomy or in Biomedical Engineering. In addition, there is an option for an MD/MBA.

Heart Center Tour and Class Stuff

Thursday I went to take a tour of the new CCF heart center. It's going to be absolutely incredible: ten stories tall, of which eight floors are for patient care. The top floor will have an outdoor patio and banquet area that looks out over downtown Cleveland and Lake Erie. The view is gorgeous. The nineth floor houses all of the emergency generators for the heart center and the new urological building. There are four of them, and they're enormous. The fourth through eighth floors will have patient rooms, the third floor will be the ORs, and the second floor will have the cath labs. It's going to be absolutely state of the art, and the best part of the whole thing is that it should be opening next summer, just in time for my class to begin our rotations.

It turns out that now we will not be getting our epi assignment until after we get back from break. I'm not thrilled about that, but if they give it to us the first week, it's still early enough to get it done and out of the way before things start getting too crazy with NMS. On the bright side, I am done with my second stats assignment, so at least that's something. In addition, the school has finally begun posting our assignments for next block on the portal. So I guess I'll start doing my school reading over break instead so that I can do my epi assignment during the first week of next block.

In general, I am a very organized person. But I can already see that I will have to be even more organized than normal in order to survive these next three months. I guess if I can make it through my second year of med school, most other things I do in my life will seem pretty easy by comparison!

Finished with Clinical Research Block

Yesterday morning, we had our orientation for the rest of this year. It started at 8 AM with a one hour pathology session. This was followed by about three straight hours of FCM course information. If the goal was to overwhelm us and overload us, I would say that the FCM course directors have succeeded admirably. (In this context, when I say FCM, I'm not just talking about the Tuesday morning class on humanities in medicine that we take. Physical Diagnosis, Communications Skills, and Longitudinal Clinic are technically also included under the broad heading of FCM, although we don't usually refer to them that way.)

I am feeling relatively skeptical about some of the plans that are in store for us this year. For example, we have to tape an interview with a longitudinal clinic patient. This requires us to check out a video camera and operate it successfully on our own, as well as obtain a patient's signed informed consent. I am not good at operating video cameras or any other electronic equipment. I can already forsee spending a few hours wrestling with the stupid camera in my immediate future. To make matters worse, the first years are also apparently being required to do this, and all 64 of us will be competing for the same five video cameras.

In addition, we are supposed to be doing these research hypothesis generation projects four times this year during POD. The interesting part is that they will be having first year grad students from Lerner working with us. Ostensibly, this is supposed to allow us to learn basic science from them and them to learn clinical science from us. The fact that even the least experienced person in my class already has significantly more basic science background than a first-semester grad student strikes me as being a significant flaw in this plan. In addition, the grad students will presumably not be attending our PBL sessions, so I'm not quite sure how they are going to know what we're creating hypotheses about.

The biggest change, of course, is that we will have clinic and clinical skills twice a week now instead of just once. That, at least, is something that I knew was coming. My clinic and clinical skills days will be Tuesdays and Wednesdays. We are also apparently going to continue having FCM (the class) in future years, although we've been assured that it will be done differently now that CCLCM is creating its own FCM curriculum and not trying to coordinate with the Case UP's FCM curriculum. I'm trying to be open-minded about it, because I do believe that the faculty is sincerely trying to improve the class. One of our sessions is apparently going to involve a trip to the art museum. Well, it may not be the best possible use of my time, but at least it should be fun to do. I'm also glad that they are finally going to have us learn to use Epic, which is the Clinic's electronic charting system. There have already been several times within the last year when I wished I was able to use Epic on my own, and we'll definitely need to be able to use it next year when we hit the wards.

In the afternoon yesterday, our class went through the second set of summer research presentations, and the last third of them were today. One thing I forgot to mention is that my summer PSS tutor from last year came to all of my PSS group members' talks. The eight of us from last summer's PSS group were spread out all over the three days, but our tutor still came to see every one of us give our talks and find out how we were doing. This is the kind of thoughtfulness that reminds me about why I chose to come to this school in the first place. It was incredibly nice of her to come listen to talks for three straight days considering that she has basically not seen most of us for an entire year, and she has been working with a new group of first years doing PSS this summer. To my old PSS tutor: if you're reading this, thanks again for being so supportive. :-)

At this point, all I have left to do is to finish my second stats project and do the upcoming epi project. These are both for my MS classes--the people not getting grad credit are done for the block. I am getting close to finishing the stats project, and we're supposed to get the epi one this weekend. It sucks that I'll have to do it over break now, but I don't want to have to worry about it during our NMS block. So I'm going to have to just suck it up.

Clinical Research Talks

It was really nice not having class this morning, but I still got up early so that I could spend some time rehearsing my talk a few more times. This is the last week of the block--not that I'm counting or anything! Like last year, we each are giving a ten-minute presentation about our summer research protocol, followed by five minutes of questions from the audience. My talk was today. The other two thirds of my classmates will go tomorrow and Wednesday afternoons.

Now that I've given my presentation, I would be completely done with school for this block except that I still have to write about a hundred evaluations. (I'm exaggerating, but only very slightly!) I also have to finish my second stats project for credit and wrap up a few other small odds and ends. It turns out that we ARE going to be getting an additional epi assignment. I got a solemn promise from the prof to get it to us by this Friday so that I can do it over break. Well, I can't say that working on epi over break was really my plan, but if I can just get it done before we start up with neuro block the week after next, I'll be satisfied.

It looks like we're going to be in for some cooler weather for the rest of this week. Even though it's only September, the lows tomorrow and Wednesday are going to be in the 50s or maybe even the high 40s. I hope this doesn't mean that we are in for a really freezing winter....

End of Clinical Research Block and More on PD Article

Our research proposals and research talk slides were due today, and we had our last stats group project presentations yesterday, so this has been a crazy and hectic week. I got my proposal turned in yesterday and my slides done this morning--I was on version number five by the time I turned them in to the research office. The funniest part about this whole thing, once I got over feeling annoyed about having to redo my slides yet again, is that my preceptor has made so many corrections to my slides by this point that he is now correcting his own corrections!

We talked about Steve Nissen's controversial meta-analysis of rosiglitazone (Avandia) this morning during journal club. Coverage of his article was all over the news a few months ago, because he found that there was a 43% increase in the relative risk of heart attacks in diabetic people taking Avandia. It was an interesting article in its own right because we had a very good discussion about the strengths and weaknesses of meta-analyses in general. (A meta-analysis takes several articles and pools their results together to come up with an overall set of conclusions.) But of course this one was particularly interesting since Dr. Nissen is a very prominent person and works here at the Clinic.

The second article was interesting also, though not quite as political. In that one, the authors were trying to calculate whether it made sense to screen patients' genogypes before giving them a type of drug called an ACE inhibitor. (ACE inhibitors are used to decrease blood pressure and improve kidney function.) The authors did some calculations and found that it does make sense to screen patients....assuming, of course, that their assumptions were correct. ;-)

There isn't much new information for me to report concerning Wednesday's Plain Dealer article. Yesterday there was an editorial in the PD commenting on their own article from Wednesday. The Clinic also released a statement in response to the PD article:

Cleveland Clinic has had a longstanding, mutually beneficial relationship with Case Western Reserve University to advance research, medical education and other institutional projects. That relationship has not changed and we continue to work collaboratively with the University. Recently, Case announced a new, 50-year, primary affiliation with University Hospitals of Cleveland that strengthened the relationship between those two organizations. At this time, it is unclear how that relationship may impact the Clinic in the future. The Clinic has a number of relationships with colleges and universities across the country and will continue to explore other opportunities as they arise. We cannot comment on specific discussions with other universities. Cleveland Clinic is proud of the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University and is fully committed to excellence in medical education, research and other scientific programs.

Finishing Up Research Stuff and Plain Dealer Article

Yesterday wasn't a particularly exciting day except that we got free books from one of the CCF rheumatologists who is a block leader for our upcoming Neuromusculoskeletal (NMS) block. She was telling us how previous students and residents loved this book and had gotten really interested in rheumatology because of it. I'm not sure that I'd go so far as to say that any book will get me all that excited about rheumatology, because NMS was by far my least favorite block last year. But I sure gotta love anyone who gives me free books! I spent the entire afternoon going over my slides with my research preceptor--to make a long story short, I pretty much have to redo them all over again. Although I wasn't thrilled about that, I have to admit that his organization is a lot better than mine was. Presenting clinical research is sure not very much like presenting basic science research.

Today more than made up for the lack of excitement yesterday, however. There was an article in this morning's Cleveland Plain Dealer claiming that CCLCM was going to be switching its affiliation from Case School of Medicine to Columbia. Dean Fishleder met with the CCLCM students this afternoon to discuss the article. Basically he told us that the article's conclusions were premature. It is true that the Clinic is looking at its options with other schools, but a new affiliation with Columbia or any other school is certainly not the done deal that the Plain Dealer made it out to be.

Labor Day

This whole weekend has been just gorgeous: sunny, mid-seventies. Unfortunately, I was indoors chained to this laptop for most of it. But this morning I ran the Miles for Smiles 5K, which goes through Cleveland Heights (one of the neighborhoods near the Clinic) and raises money for Operation Smile. I used to run road races a lot in college, but I haven't been doing much running since I started med school. So today I was in the back of the group, just jogging along. There was a man with his elementary school-aged son right in front of me. About half a mile into the race, the boy was worn out and started walking. His dad repeatedly kept trying to make him run and go faster, when it was clear that the boy wasn't in good enough shape to keep up that kind of pace. Finally, the dad gave up and just walked with the boy. I felt really bad watching this, because I didn't feel like I could really intervene or do anything to help, and also because now this boy will probably hate running and will never do it again as soon as he moves out of his father's home.

People put way too much pressure on kids, and on themselves too, during races. That's the downside of running sometimes--runners can be competitive to the point where it's hard to even enjoy the run for what it is. I'm as guilty of this as anyone. When I got to the two mile point, the volunteer standing there told me my time. My initial reaction was to think, "wow, I used to finish the whole 5K in less time than that, and here I'm only 2/3 of the way through!" But I reminded myself that the run was supposed to be FUN, not stressful, and I cruised in very comfortably at the end.

They had a raffle afterward, and I continued my usual streak of winning nothing. I must be the most unlucky person on earth when it comes to raffles. If there were 50 prizes and 51 tickets, I'd be that 51st ticketholder. :-P

Journal Club and All Abstracts Submitted

Yesterday we had journal club. It has by far been my favorite class each week for the entire summer. This week's articles were one on whether Americans meet calcium requirements (the authors concluded that we don't) and a second one on whether treating people with prehypertension would help prevent them from progressing to full-blown hypertension (the authors concluded that it does). The first article on calcium requirements was particularly funny because there is no recommended daily allowance (RDA) for calcium. This is because we don't really know how much calcium people actually need. So it's kind of difficult to know whether the problem is really that people don't consume enough calcium, or just that the authors' admittedly arbitrary choice of a threshold was simply too high.

The second article was really interesting. I hadn't appreciated how progressive hypertension is. Normal blood pressure should be 120/80 or less. People who fall in the range above that but below full-blown hypertension, which starts at 140/90, are considered to be prehypertensive. The other sad thing is that most people become hypertensive eventually if they live long enough. So yet again, I am finding out that the key to good health is to stay young.

Yesterday afternoon, I finished my abstract for our school presentations, which will be the week after next, and submitted it. Today I got my abstract done for the conference I'm attending next month and submitted that too. I still have to make up my powerpoint slides for school and a poster for the conference, but things are finally winding down a little. We had a patient yesterday also, but it was another control.

Today is September 1, and a new, controversial CCF policy of refusing to hire smokers is going into effect. I've seen several people decrying it on the internet as discriminatory and overly invasive, so it will be interesting to see how things turn out. At this point, I'm not really sure how I feel about the policy. I can see some validity in the arguments for both sides. Plus, the arguments on both sides have been so extreme that it's hard to know what the actuality will really be like. I suspect the policy won't be as helpful in promoting health as the proponents claim, nor will it be as horrific a violation of privacy as the detractors are warning about.

Making Progress

Yesterday morning and today we had biostats, and the attendence was kind of slim. Some people have been kind of trickling in half an hour late or not coming at all for the whole summer. But it has gotten much worse more recently as our workload has really started piling up. I wound up skipping class myself this morning to finish analyzing the data from my summer research project. As it turns out, most of my classmates apparently decided not to go today either, and we finally got an email about it from the dean this afternoon.

I always feel bad about missing a class, especially considering how much Case charges for tuition. (We're up to $41,000 for this year....yikes.) But unfortunately there are only 24 hours in a day, and I had to get this work done so that I could submit my abstract with some results. It would be nice if the assignments could be better coordinated so that as our research requirements gear up at the end of the summer, we wouldn't have as much class work to balance with the research stuff.

Speaking of research, yesterday we had another patient, a case this time. I missed the OR part because I was in class, but I went to the ICU afterward to help monitor the patient there. It's a lot less hectic in the ICU than it is in the OR. On the other hand, the patients' families come in to see them in the ICU, which changes the dynamics considerably. It feels a little awkward, actually, because we wouldn't even need to be there at all if the patient hadn't joined our study. I kind of felt like we were intruding on the patient's family's time, which is a little silly considering that the patient hadn't woken up from the anesthesia yet.

I almost forgot to mention that yesterday, our extra biostats homework for grad credit was due. I was not terribly pleased to find out that we now have a SECOND assignment to do on top of it. The biostatistician was being cavalier about it, saying not to worry because it wouldn't be due until the end of fall semester in December. I asked him to please give it to us early, because I don't want to be working on biostats after this block is over. Things are going to get busier for us, not easier, once we start our regular classes! He did send out the assignment, and it's basically the same as what I just turned in yesterday, but on a different article. It's annoying and stupid that I have to do almost the exact same analysis over again for another article, but at least it will be relatively easy this time now that I know exactly how to do it. A while back, he told us that he wanted us to get really familiar with this software, and one thing I will say for him is that he's definitely accomplishing his goal. :-P

Classes, Proposal and Clinic

Today was a very long day, but I have gotten a lot done so far this week. Yesterday we had stats class, and in the afternoon I got my research proposal draft finished. It's due Friday, so I'm actually ahead with my work for once. This morning there were a couple of talks I was interested in attending, but I didn't make either one of them. We had epi this morning (about surveys, not the most interesting) and then I went to clinic.

Clinic was crazy busy. My preceptor didn't have a resident to train today. So I wound up seeing six patients, five on my own. Most were here for fairly mundane things. But there was one patient who had been barbecueing over the weekend and had somehow been splashed smack in the face with boiling hot marinade sauce. It is kind of a bizarre accident to have, but the poor man had serious enough burns on his face that he had gone to the ER to be treated. Fortunately his burns are healing well and they don't look infected. My preceptor described the shape as being "serpiginous." I had never heard that word before, but sure enough, it's a real word. Describing a skin lesion, it means that it has a wavy kind of margin, like the lesions on the foot in this picture. Think like a serpent.

Classes and Biostats Homework

Yesterday I had epi, and we spent more time going over diagnostic tests. There was one sentence in one of the articles we were asked to read that made absolutely no sense to me. I asked the instructor about it, and he started congratulating me for having caught that and said he had no idea where it came from either. I don't think it requires much to notice it, because it completely doesn't fit in with the rest of the paper. It's like the authors just lifted a sentence out of some other paper and dropped it into this one! In the afternoon, I was hoping to go consent more patients with the resident, but we didn't end up going. We had two study patients having their surgeries yesterday, but they were both controls.

Today we had journal club. I didn't enjoy this one as much, mainly because I was one of the student evaluators. It's a lot harder to follow the flow of conversation when you're busy taking notes and filling in all of those little boxes on the eval sheet. Plus, the internet kept going in and out, so I had to pay attention when I was trying to save to make sure I was connected at the time. The first paper was about using MRI as a screening method to detect breast cancer, and we had a really good discussion that unfortunately I could only partly participate in. The second paper was about the relationship between obesity and cancer. Some good issues came up during that discussion as well, mainly about whether the difference in mortality due to cancer was caused by obesity itself, or by the fact that it is harder to diagnose and treat tumors in people who are obese.

I spent most of this afternoon working on my biostats homework. I was trying to verify the sample size that the statistician had come up with, and I couldn't get it for several reasons. First, this trial is way more complicated than anything we've done in class. For example, there are three interim stopping points, and all of that has to be accounted for statistically. Second, the particular calculation the statistician used is not available on the software we are using, which is called PASS. In the end, I got close to the statistician's number, and I explained in my paper why I couldn't duplicate it exactly.

Right after I finished doing all of this, I received an email that had been sent out to our entire class. Some of my classmates had gone to speak to the dean with a petition concerning the workload we have been getting this summer. They got a few concessions, one of which was that the people who are not taking biostats for grad school credit don't have to do this homework assignment. Since I am taking biostats for credit, it doesn't affect me. It would have sucked though if I weren't taking it for credit, because I literally had just finished the assignment right before the email arrived! But the students did get one of our CAPPs for Week 6 taken away, and apparently our fourth biostats group project will be shorter now.

This block has been very intense. It was definitely a lot more work and harder than I had expected it to be. I think that probably all of us were expecting it to be more like last summer, which was relatively laid back. It has also been very difficult to balance our classwork with research. In spite of the onerousness of writing eight zillion essays, I have to admit that these homework assignments have taught me way more than any of the seminars or readings we've been asked to do have.

Classes, Biostats Projects, Research and Dean's Dinner

This week in epi we are covering diagnostic tests and what they mean. For example, if you go get screened for lung cancer, how do you know whether the screening is actually worthwhile in the sense that it is extending your life? It turns out that it probably isn't, in that case at least. Because of biases due to the length of time the tumor is known about or the greater likelihood of slow-growing tumors to be detected by screening, it often looks like screening is working even when it isn't. Finding the lung tumors earlier doesn't lead to decreased mortality in the studies that have been done so far. Apparently even small tumors can metastasize before symptoms develop.

I spent Tuesday afternoon in the OR helping with another surgery patient who was an interventional case. It went very smoothly. We have figured out how to more or less run the procedure like clockwork now. This patient was having a coronary artery bypass graft (CABG, pronounced "cabbage"), and I watched the surgeon remove some blood vessels from the patient's arms. That kind of surprised me, because I had thought they only used leg vessels for CABGs. Maybe there weren't any good vessels left in the patient's legs. I've already seen several patients this summer who are having a third or even fourth CABG, so that wouldn't surprise me.

This morning we had biostats again, and it was all right. We're covering regression, which is kind of anticlimactic considering that my partner and I were already doing that two weeks ago for our group project. Speaking of which, we presented our third group project this afternoon, and my partner and I didn't have much of anything to present. We basically already did everything we could do for the second project. On the bright side, it make the discussion much shorter, but I don't feel like I learned as much this time.

We had a Dean's Dinner this evening at the Foundation House, and the speaker was a molecular pathologist from the Clinic. We already knew him from our genetics seminars last year. This was a really good talk that was almost like hearing a medical mystery. The speaker had a young patient with a certain set of problems that no one could figure out the cause of, and it turned out that she had a brand new lysosomal storage disorder that had never been described before. Luckily for her, this particular deficiency doesn't affect the brain like most of them do, so she isn't retarded.

Pain Management Clinic

We actually had TWO patients for today, but I didn't help collect data on either one because I went to the Pain Management Clinic (PMC). It was a very eye-opening experience. My longitudinal preceptor sends patients to the PMC all the time, and I wanted to get a sense of what they do there. First of all, it's incredibly busy. One of the fellows told me that CCF's PMC is one of the largest and busiest in the entire country, and I believe it. I also got an appreciation for how much training it takes to become a pain management doctor. This particular fellow had gone through a year of internship, three years of anesthesiology residency, and is now doing the pain fellowship.

Mainly what they do is stick some really huge needles into people's backs, necks, and even heads. It's not acupuncture. They're injecting anesthetics like lidocaine directly into the spinal column or nerves of the scalp, which is called a nerve block. Some of the patients are addicted to narcotics, and the goal of giving them nerve blocks is to control their pain to the point where they can be weaned off the narcotics. The most fascinating patient I saw was one who gets constant headaches. The fellow injected anesthetic directly into the patient's scalp, and within 20 minutes, the headache was gone. The fellow said relief might last for several weeks or months, even though the anesthetic itself wears off after several hours. The doctors don't really know why these nerve blocks work, but I got the impression that it's sort of like rebooting a computer. Sometimes when the circuits are frozen and just not responding properly, you hit "restart," and suddenly it works fine.

FAQ #30: Do Other Schools Besides CCLCM Offer MD/MS Degrees?

Yes, there are at least a few other formal 5-year MD/MS programs that I know about. Here's my alphabetical list of formal 5-year MD/MS programs. If anyone knows of any others that I should add, hit the comment button, and I'll be happy to add the links. Keep in mind also that a lot of med schools offer informal options to take a fifth year and get an MS. So even if you go to a medical school that doesn't have a formal MD/MS program, you still may be able to get the MS.

1. Albert Einstein College of Medicine (AECOM) Clinical Research Training Program (CRTP). Gives an MD/MS in clinical research. Medical students apply during their third year and do research in their fourth year.

2. Cleveland Clinic Lerner College of Medicine (CCLCM) at Case Western Reserve University (CWRU). Options include an MD/MS in clinical research or one of several basic science MS degrees, or a 5-year MD with Distinction in Biomedical Research. Premedical students apply to the program separately from the main Case program. The last three years are flexible, and the research year can be done during the third or fourth years (or some mixture). There are several combined masters programs available through Case for both CCLCM and UP students. UP students will probably need to take a fifth year to complete most of these masters programs.

3. Harvard-MIT's Health Sciences and Technology (HST) Program. Offers an MD/MS or an MD/PhD. Premedical students apply to the program separately from the main Harvard program. It seems to be geared toward people who want to do engineering type of research.

4. UMDNJ-Robert Wood Johnson Medical School MD/MS in Biomedical Informatics. UMDNJ-RWJMS medical students begin the MS after their second year. Note that this program takes 5.5 years to complete. There is also an MD/MS in Jurisprudence, which seems to be geared toward people who are interested in health care regulation and policy. The MD/MSJ can be finished in five years.

5. University of Pittsburgh's Clinical Scientist Training Program (CSTP). Offers a clinical MD/MS or MD with Certificate in Clinical Research. U Pitt also offer a basic science MS option for people who want to do research in basic sciences. Premedical students apply to the program while applying to U Pitt. Students do research in their fourth year.

Research Is Picking Up

We had another patient yesterday morning, so I came in really early again. There was a talk I wanted to go to in the morning about translational research, but unfortunately it didn't work out. This patient got the interventional treatment, so we had a lot of work to do. One resident stayed with the patient, and the other resident and I went to consent another patient for today. The patient agreed to participate, so I had to come in really early today too. Today's patient was another control though, so again I had some extra time to read before class.

Yesterday's class was epi and covered more about clinical trials. Right afterward, I had to go back to the hospital for a research group meeting. It turned out that I was the only one there for my project, because both residents were still in the OR. So I was the one who gave the update on how our project was going. Then I ate lunch and went back to the OR too. This was a pretty long surgery. The patient got up to the ICU around 3:30 PM after a 7 AM start!

Our patient for today got a late start, so I left for class this morning without knowing whether he would be a control or an intervention. We had our normal Friday journal club, and it was good. One paper was about a drug that is used to prevent clotting by inhibiting platelet activity. The other described a really huge clinical trial where they screened older men for abdominal aortic aneurysms. The aorta is the huge artery that comes out of the heart. It travels down into the abdomen before branching and heading into the legs. Some men, especially if they smoke, can develop weak spots in the wall of the part of the aorta that is passing through the abdomen. Because it is under very high pressure, the weak spots can start to balloon out, and this is the aneurysm. Large abdominal aortic aneurysms are very dangerous. If an aneurysm bursts and the man isn't in a hospital (most of these abdominal aortic aneurysms are in men), he has a good chance of bleeding to death before help arrives. Anyway, it turns out that screening men who are in their late 60s with ultrasound does detect aneurysms and lead to lives being saved. There were over 60,000+ men in this study, so it's a pretty impressive trial! Men are being screened in the US now too.

After class, Dean Franco showed the same movie about the history of the Cleveland Clinic that I saw a few weeks ago. I went and saw it again even though I had already seen it once. Watching it this time with just the other medical students was a very different experience compared to watching it with the CCF employees. For example, the movie mentions that one of the founders of the Clinic graduated from the predecessor of Case's medical school in just nine months with highest honors. Naturally, that part was particularly amusing to all of us, considering that we will be taking 58 months to get through med school! The part near the end of the movie where they showed the first class of CCLCM medical students doing PBL got a bunch of laughs too.

I didn't have much to do this afternoon except that I went with one of the residents to consent two more patients for next week. One was there with his wife, and she was even more scared about his upcoming surgery than he was. It is going to be his first surgery, and of course heart surgery is a pretty major operation. So it's completely understandable to be frightened. Even though CCF is one of the best places in the world to get heart surgery done, they can't save everyone. As the resident was explaining the research project, all of a sudden, the wife pointed at me and right in front of me, blurted out to the resident that she and her husband didn't want me to be the one doing the procedure on her husband! I was trying so hard not to laugh that I couldn't even be insulted. She has no idea how many more years of training I have to get through before I'll be able to do anything to a patient without supervision! I'm just glad that I didn't laugh in front of them though, because I don't know how I would have been able to explain that I wasn't really laughing at THEM.

I am dead tired. There is a CCF cruise on the Cuyahoga River this weekend, but I'm not going to go. I have too much work to do. Plus, since it's on Sunday night, with my luck, I'll wind up having to get up at 5 AM on Monday for our next patient. It's bad enough to be this tired on Friday, but I don't really want to start out the whole week feeling like this.

Research, Class, and Literature in Medicine Seminar

We had a research patient today, so I had to come in really early again. When we did the randomization, this patient turned out to be a control. So we didn't have to do too much. Every patient gets randomized by a computer, so we never know until right before the surgery whether any particular patient will be a control versus in the interventional group. I haven't been in the OR for any other controls before today, but they basically just get the standard surgery procedures. I think the resident felt worse than I did about the fact that I had to get up at 5 AM and then there wasn't anything for me to do. But I understand that research is just like that sometimes, and it gave me time to do some reading. Not that I terribly love getting up at 5 AM if it's not absolutely necessary, mind you!

We had stats again today, and the statistician I like was leading the seminar. It was good because he made up some new examples and we went through them using JMP. I feel like I'm finally starting to get the hang of using that program. Do I dare say that it's almost fun?

I spent the afternoon working on my CAPPs for Friday and studying, and then there was an optional literature in medicine seminar in the evening. I had gotten the impression that the speaker was some kind of bigwig in the field of medical humanities, and it sounded like it would be a cool talk. So I signed up to go and did the reading assignments. Unfortunately, I was really disappointed with the seminar. I wound up leaving halfway through. As I think about it, I guess what disappointed me the most is that for a seminar which was billed to be something that would make us better doctors and help us empathize with patients more, it was just, so, well, sterile and academic. The guy was talking about different ways of viewing the aging process. Implicit in all of this was the idea that the medical view was not necessarily the most patient-centered view. That's probably true. But I can't help finding it ironic that the guy's analysis was itself not very patient-centered.

I think the seminar would have been a lot more meaningful if we had read a patient's account of the dying process. There is a hospice center right on the edge of campus, we have a geriatrics unit at the Clinic, and I have no doubt that the issue of dying is an important one for medical students to think about. I guess I just don't feel like this seminar gave me very much insight on dealing with aging and death: not my own, and certainly not anyone else's, either.

Classes, Research, and Clinic

This week we have two stats classes and two epi classes. Both stats seminars are being led by the guy who throws the silver dollars, but he didn't bring any in yesterday. He still had a good seminar though. I was supposed to go shadow a physician yesterday afternoon, but he thought I was coming next week instead of yesterday. I wound up spending the afternoon reading for my research instead.

We had a patient for our study this morning, so I had to come in at the crack of dawn again. We got everything ready and randomized the patient, and it turned out that she was a control. Since the controls just receive standard care (no intervention beyond what is normally done for them during surgery), that was basically the end of our involvement. Of course, it was kind of disappointing for us after we got all ready for a case, but at least it gave me time to finish reading the second chapter for class.

Today's epi class covered clinical trials, and it was very good. Afterward, I studied stats for a while and then went to clinic. Originally, I was planning to go to clinic next week, but I switched to today because of the shadowing snafu. I saw four patients: one with a sinus infection, one with back pain, and two who were just here for physicals. One of the people getting physicals also needed a Pap smear, but my preceptor did it since we were way behind schedule. I also found out that my favorite nurse is transferring to another department. Not that the other nurses aren't just as nice, but this particular one has always been especially cool about teaching me how to do things. It's obvious that she really likes to teach.

We have another set of epi CAPPs and SAQs due again this Friday. I have started working on them, but I didn't get as far with them as I would have liked. It's hard to do much in the evenings during the week because I basically feel completely exhausted every night when I get home. The days are all really full and long, and it doesn't help that surgeries start so ridiculously early....

Journal Club and More Time in the OR

Both of the journal club articles we discussed today were about genetics. When I first saw that last night, I did not feel terribly gung-ho about reading them, especially since one of them was about 17 pages long! But they both turned out to be pretty interesting after all. One article looked at several dozen genes that had been published in the literature as risk factors for cardiovascular disease. These authors did a much larger study on those genes, and they were not able to find that ANY of the genes increased people's risk of getting cardiovascular disease. The really long article considered genetic risk factors for several different diseases using a technique where they could look at the entire genome and not just certain genes. Interestingly, they found that certain loci on the genome were present more often in people with certain diseases, and that these loci don't necessarily correspond to genes! One of the things you learn pretty early on in a molecular bio class is how most of the human genome is "junk" DNA that doesn't code for anything. But obviously we ought to be more careful about writing it off as being useless. Just because we don't understand what it does doesn't mean that it must not do anything.

The resident I'm working with this summer paged me in the morning and told me to contact him if I wanted to come work in the OR with him after class. Luckily I had a pair of scrubs with me, so I went to the OR after lunch. It was kind of a comedy of errors. First I went to the cardiac ORs, because that's where we usually meet. But he was over in the general ORs, which are in a different building. So I went over there to the floor he told me, and he wasn't there. I ran into two other members of our research team and started working with them instead. In the meantime, the resident and I were sending one another a flurry of pages.

Him: Where are you? Come to the second floor OR.

Me: I'm already here on the second floor! I'm helping Allen and Seth (two other team members) collect data.

Him: I don't see you here anywhere.

Me: I'm with Allen's post-op patient in Bay 7.

Him: I can't find you. I'm starting to get worried.

Me: Allen and I walked around all of the bays and we didn't see you. I'm confused.

Finally, the resident showed up to where I was, and it turned out that he had told me the wrong OR. Evidently, there are two second floor ORs in this building. On the bright side, I am now very proficient with using the CCF intranet paging system. It's pretty cool. You can page people by phone from anywhere, but if you're on campus, you can also page them by intranet. I like that better, because then you can type an actual message to them like the resident and I were doing, and they'll get the message on their pager instead of just your phone number. I also have finally memorized both of my pager numbers. (Yes, I have not one, but TWO pagers, because I got a second one just for this summer.) Every time you send a page, you are supposed to put your name and beeper number at the end to make it easier for the recipient to get back to you. So now I have typed my own pager number enough times that I remember it without having to look it up.

Classes and Biostats Projects

Yesterday, we had biostats. The seminar leader was my favorite biostatistician. Reading that last sentence back to myself, I have to laugh. It sounds funny to say that I have a favorite biostatistician, but I do. He will be teaching the advanced stats class that I have to take for my MS, so I'll have another chance to work with him next year or whenever I get around to taking that class. One of the things that I like about this guy so much is that he's just an awesome presenter. He is very good at getting us involved and participating. And he does and says crazy things, so we never know what he'll do. Today he brought in a plastic baggie full of silver dollars, and he was throwing them to people who answered some of his questions. I ended up with two of them. He said he wasn't going to let us keep them unless we were able to catch them. Nobody dropped theirs, so I don't know if he was serious about taking them back if we had dropped them!

After class, my partner for the biostats group project and I finished up our presentation. The stats TA was there, so we were able to get some help to solve the problem of trying to eliminate confounding variables. The statistical solution the three of us came up with is way ahead of what we were supposed to do for tomorrow. But on the other hand, our project is a lot more interesting now than it would have been if we had just stuck to what we were asked to do. We ended up with at least one interesting result that we wouldn't have gotten otherwise.

This morning we had epi, and then I had to run for a research group meeting. During lunch, I was looking over our biostats presentation again, and I realized we had written one of our conclusions backward. I'm really glad that I reviewed the project early enough that I had time to fix it! The same biostats instructor that I like was the one in charge of our small group, and it was really fun. Since my partner and I had gone last two weeks ago, our classmates made us go first this time. This meant that our presentation wound up being the longest, because this biostatistician likes to interrupt and tell stories early on while there is still plenty of time. He told us that some of what we had done was "naive," but that the techniques we used are also what the stats faculty were planning to have us do for the fourth project at the end of the summer. Whoops!

Classes, Stats Project, and Clinic

Yesterday we had another stats seminar, and it was basically uneventful. Today we had epi, which was also fine. But this particular speaker has a tendency to get behind and go over time. Usually it doesn't bother me that much, but today I wound up walking out while he was still talking because I had to meet with my PA right at 11:00. I have finally filled out all of the forms to apply formally to the Clinical Research Scholars MS program, so I needed some papers signed. We also talked about the OSCE that I'm missing, and that I have been going to extra clinic sessions to keep practicing my physical diagnosis skills.

Afterward, my partner and I were working on our second statistics project, which we will be presenting on Thursday. It was kind of tough to decide what to do since we already answered most of these questions last week. We were trying to come up with a way to factor out some confounding variables so that we could figure out how much of the difference between our two groups was due to one single variable. But we had to call it quits before we figured it out because it was time for me to go to clinic.

I expected to get out of clinic early, but instead I wound up being there for longer than usual. The weather today in Cleveland was very bad, and I figured all of that rain and lightning would keep the patients home. Well, one did cancel, but all of the others came anyway. I saw one patient with an earache and another one with shingles on my own, and then I went with my preceptor to see two other patients who were getting full physicals performed.

My last patient was having dizzy spells, so I decided that I wanted to find out if she had orthostatic hypotension. A person who has this condition can get dizzy and faint if they get up too quickly, because their heart doesn't compensate fast enough to get the blood back up into their head from their legs. It is fairly common in older people, especially if they are taking certain medications. The test is simple: you take the patient's blood pressure once while she is lying down, and then again after she has been standing up for a few minutes. However, I wound up having to repeat the test, because my preceptor wanted me to take the patient's blood pressure three times while she was standing (after 2, 5, and 10 minutes) rather than only once. I also didn't know that I should get her pulse as well. It turns out that some patients might get a faster than normal pulse to try to compensate for having less blood returning to the heart. The problem with this is that if your heart starts pumping blood too fast, then there isn't enough time for the ventricles to fill up all the way before they pump the blood out.

All in all, it was a very tiring but good learning experience. I wound up staying afterward for about half an hour to talk to my preceptor about what I should be working on to improve my clinical skills for this year. The clinical faculty had already been discussing my progress anyway because I will be missing the fall OSCE, and apparently the physical diagnosis course director was very happy to find out that I took the initiative to set up these extra clinic days. My preceptor also offered to write an extra evaluation for me so that I can include it in my portfolio as evidence toward my clinical skills competency for this year. We agreed that I should start working on tailoring the history and physical exam to the patient's pathology, as opposed to trying to just get through a memorized list of skills and questions.

There is one downside to starting to learn clinical skills as early as we do, which is that a lot of times, you wind up memorizing questions and going through procedures without understanding exactly why you are doing certain things. Last year I got very frustrated with the physical diagnosis class at times for exactly that reason. I think that this year it will start coming together a lot better though, because we finally are reaching a point where we have enough background knowledge to understand what we're trying to do with various tests and questions.

Journal Club

I led my journal club session today, and it was a fun discussion. Both of the articles (mine and the other student presenter's) were really interesting. I think I've already said that my article was on drug eluting stents. I had some extra data from the Cleveland Clinic interventional cardiology labs that the director allowed me to use. We didn't have as much time to look at it during class as I would have liked, but it was still neat to see some in-house data anyway. (It appears that implantation of drug eluting stents does not increase people's risk of dying in procedures performed at the Clinic.) The other paper was looking for an association between sugary drinks, obesity, and type II diabetes. Not surprisingly, the association was very strong. What is even more interesting is that even diet soft drinks are associated with higher levels of obesity and diabetes. But this is probably because people don't change their eating habits even when they switch drinks. In other words, if I still go to McDonald's and get a Big Mac, fries, and an apple pie, I am eating so many calories that it doesn't matter very much if I got a diet Coke to go with it!

I've already mentioned that this year's journal club is much less formal and a lot more fun than last year's was. I think it's partly because of the different style of the discussions, and partly just because I find the material so much more interesting. Each presenter has a faculty "content expert" whose job is to help us analyze the paper. My content expert was an interventional cardiologist since the paper was about stents. He also happens to be the person in charge of my MS program (Clinical Trials), so I already knew him from before. I also got help with the stats from the TA, because we haven't covered most of the stats they used in the paper in class yet.

After class, I was talking to the other content expert about what it means for family history to be a risk factor for diabetes. People tend to want to write it off as just being genetics (i.e., if your parents had diabetes, you'll be at a higher risk to get it too), but you also have to take into account that families share many lifestyle habits and living conditions as well. So if a person's parents become diabetic because they have horrible diets and lifestyles and they are obese, but that person watches his diet and exercises regularly, it's hard to say how much risk of becoming diabetic he has. Even if he's more genetically predisposed to get diabetes in comparison to people with no family history, he can still alter his risk by removing himself from the kind of environment (low exercise, high calorie, high sugar) that would tend to trigger development of diabetes. The problem, of course, is that temporary fixes like going on a diet don't cut the muster. You have to make a lifestyle change (ex. stop eating at McDonald's altogether) and follow it for the rest of your life.

A False Alarm

Yesterday was a really long, tiring day. I got in at 7:15 to go to the O.R. because we were supposed to have another heart surgery patient for our study. But it turns out that we didn't have a case to do yesterday after all because no one had gotten the patient's consent. We are not able to get consent on the day of surgery, because otherwise patients do not have time to consider whether they want to participate. So unfortunately we had to let this patient go.

In the afternoon, one of my classmates wanted me to take her to the gym and show her how to lift weights, so I did. I haven't been going to the gym regularly myself though since I got back to school, and I tried not to do too much so I wouldn't be too sore. I don't know how she's feeling today, but I'm only a little sore. I've decided that I want to start working out regularly like I was before. I'll go again on Saturday.

We had epi this morning and some of the articles for today were pretty funny. My favorite was a study from several decades ago that was comparing the performance of surgery residents who had gotten grades in med school to other residents who went to pass/fail schools. The authors concluded that residents who had gotten medical school grades performed better in residency than residents who had gone to P/F med schools. But we spent quite a while ripping apart the authors' methodologies to the point where it was pretty clear that their results were not exactly convincing. For one thing, they had no way to evaluate the residents from P/F schools on the basis of what kind of grades they had gotten as medical students, which was how they determined the caliber of students the residents from graded schools had been. So it's completely impossible for them to even know whether their two groups of residents had equivalent characteristics as medical students. Then at the end, they bemoaned the decreasing standards in medical education due to social experiments. I bet if the authors are still alive today, they must really hate to see how many med schools are starting to move in the direction of P/F grading, at least for the first two years.

I am pretty much done with my journal club presentation for tomorrow. I met with my content advisor on Monday afternoon and the stats TA yesterday after class. There are some tough statistical concepts in this paper that we haven't covered in class yet (or maybe ever!), so I am only going to present a general overview about what they were doing.

Grand Rounds, Killer Biostats, and Clinic

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

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

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

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

Epidemiology, Stats Workshop and Journal Club

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

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

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

Epidemiology, Meetings, and CCF Movie

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

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

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

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

Much about Biostats

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

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

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

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

Clinical Research Journal Club, Consenting, and New Student Picnic

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

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

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

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

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

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

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

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

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