Turns out the winter storm referenced in my previous post was simply a little foreplay from Mother Nature until she unleashed the full-on kama sutra of arctic chill on my little niche of the world (see right). As a result, I abandoned Siberia, I mean, my apartment, and have been sleeping on various couches of various houses I have broken into over the past 10 days. Having no internet access for nearly 2 weeks, being sans car, sans bed, and sans normalcy has been equal parts entertaining and maddening. The Great Thaw has finally come, and with it my migration home, just in time for me to hop on a plane tomorrow for Vegas and New Years. I don't really know what the point of this post is except to justify my hiatus. I was hoping to post some thoughts over break but that will have to come after my return from Sin City and the hangover subsides.
oh hai. Apologies for going on hiatus for two weeks. Haven't had much to post for the last while, but we've currently been slammed with a nice winter storm the past two days which has effectively put me on house arrest. For those of you who have no idea where I go to med school... that pinpoints my location down to pretty much 30 of the 50 states. For those of you who know where I go to med school... you know what I'm talking about. We actually got a snow day yesterday, which I never thought I'd see in med school.
You know, in med school we like to talk about all the things we gain in our training. Experience, knowledge, insight, competency, warm fuzzies, giant egos, all that shmooze. But I also have been reflecting lately on the things I've lost in med school. No, not my virginity, or my sense of humor (completely). But I have lost a great deal of patience (thankfully no patients yet). Not to toot my own flute, but I used to be a pretty darn patient person in my younger life. But one of the constants in medicine is the feeling that there is never enough hours in a day. And I've been deluged with that feeling every day for a while now. Between trying to keep up on studying, trying to maintain my sanity, trying to make it to meetings and talks I find interesting, and trying to maintain a semblance of a six pack, I find it amazing I have found time to even poop or sleep. Lately I've noticed myself become exasperated by activities, PBL sessions, and lectures which I feel like are a waste of time. I haven't developed overt road rage yet, but have formed a habit of yelling expletives at slow drivers (which breed like rabbits in this state) in front of me regularly when driving alone.
But it all came to a head this week. Now normally I have quite the active routine. I go to the gym, go study at different coffee shops, basically get away from my apartment, which is too close to campus and frankly claustrophobic.
Damn you freezing temperatures. I've been stuck at home for only 2 days now, and have already resorted to cleaning my apartment (!), organizing my DVDs, and even studying at home, a near impossibility for me normally. I am going insane.
Speaking of studying, we're currently mucking through endocrinology, which I have come to disdain nearly as much as the kidney. I do not state that lightly. But unlike the kidney, I actually somewhat enjoy the pathophysiology of the subject, I have just come to disdain the manner in which it is conveyed to us. For example, some of the bullshit lectures we have been fed in the past 3 weeks: 12/02 - Nutrition in Diabetes 12/05 - Nutrition Assesment 12/08 - Weight Loss 12/05 - Nutrition and Disease 12/06 - Women Nutrition 12/06 - Pediatric Nutrition
There are three main thoughts I have come to from our course direction. (1) Endocrinologists are glorified nutritionists. (2) Why am I spending $180,000 for this degree when I could get a bachelor's degree in nutrition for $60,000 (and its online!!!) (3) Why the **** are 20% of our endocrine lectures on nutrition?
Look, I know eating healthy is all puppy dogs and ice cream for your body. And the health care burden would be reduced substantially if people learned to eat better. But last I checked, med school was supposed to teach me what I needed to know to practice medicine. And there's only one thing you need to know about nutrition as a practicing physician. And that may or not begin with a "c" and end with an "-onsult nutritionist."
For comparison, we have spent 8% of our time on thyroid disorders. Ah, med school.
Man, time flies when you're having fun. And by having fun I mean really busy. But with four days off for turkey day I got to fit a little bit of fun in for good measure. Ok a lot of fun.
But as they say, all good things must come to an end and so this week we jump headfirst into our endocrinology block. It still feels like September to me, so the fact that we are barreling headfirst towards 2009 is equal parts disconcerting and exciting. Cardiovascular, renal, pulmonary, gastroenterology, the march through the body and everything that goes wrong in is continues. But a brief break also allowed for a bit of that "reflection" crap that I hear about all the time in our Principles of Clinical Medicine class.
MS2 is has turned out to be quite a comfortable year. You establish your system of studying during your first year, after a certain degree of flailing, and I've found I've been able to stick to that system with only some minor tweaks through my second year. I'm a tactile learner so I like to write a lot of information down, which has proven to be a larger pain in the ass this year with the larger volume of info that gets thrown our way, but it hasn't been enough of an annoyance to force me to change things up yet. The next step will come after the new year when I have to teach myself how to do worthwhile board prep in conjunction to my classes, but I'm sure I'll figure it out. Or I won't, and I'll fail Step 1 and end up in family practice. Either way, I'm sure it will be interesting. I was one of those douchebags that was able to skate through the majority of my academic career without too much effort, and that included the MCAT, so I'm curious to see how this next major standardized test will go when for all intents and purposes your score is an almost direct reflection on the effort you make into preparing.
But so far, MS2 has been a comfortable year. If MS1 is a futon, MS2 is a nice padded fabric couch (and MS3 is sleeping on a wood board over a ravine). Medical school is as much about learning the language of medicine as it is the facts that you cram down your throat, and its definitely the year when things begin to come into a more complete picture. The days tend to blend together the more comfortable you become, but I don't necessarily think that's a bad thing. In fact it may be a sign that I'm continuing to enjoy myself in this masochistic path to a career that I've chosen. I don't know if there's much more to say about it. After a while, the first two years of medical school become a certain form of Groundhog Day. Wake up, go to lecture, fit in some fitness, study. Wake up, go to lecture, fit in some fitness, study. It's like watching the proverbial lawn grow on your brain. It may be nice to host a block party on in the end, but no one is going to make any movies about how it got there. So I feel there isn't much to say about the second year of med school in regards to the academic side of it all. It's just more of the same. More learning. More growth. Of grass. On your frontal lobe.
Oh, and since this is MedZag's blog... go Zags. 5-0, with 3 impressive victories over Okie State, Maryland, and Tennessee over the break. #5 in the nation. Good time to be a Gonzaga fan. I'll be in Seattle for the UConn game the day after my next exam doing my best PremedZag impression. Which may or may not involve copious amounts of a liquid that affects your... endocrine system.
You spend $495 to go through the worst experience of your life.
Officially registered for Step I. It is now an inevitable Everest in my near future. Ok, maybe avoidable, but I can think of better ways to fart away 500 bills (translation: beer). I knew it was a bad sign when US Bank upgraded my Visa to a Platinum card last week.
If MS1 is treading water, MS2 is a water slide. You start to feel like your gaining competence of knowledge in important clinical disorders, then *whoosh* you move on to a new block and said knowledge goes sliding down the level III watery loop-dee-loop. You start to feel good about coming up with focused and pertinent differentials for patients then *whoosh* a patient comes along who you have no idea how to even begin to workup with nonexistent or contradictory clinical findings and a poor history. You start to feel competent at the lung, abdominal, or head and neck physical exam and *whoosh* a patient comes along with a vague shoulder complaint and you're left flapping the patients arm pathetically attempting to perform a musculoskeletal exam.
As I've stated before, MS2 is a lot more fun than MS1. The information is a lot more enjoyable and pertinent to your medical education, and the days and page upon page of syllabus tend to cruise by at a more enjoyable clip as a result. This definitely has its upsides, but also acts as a double edged sword, because it's info you feel like you should be holding onto but the pathetic biology of your brain and its synapses prevents you from doing so.
If I saw a patient with chest pain back in October, when we had just finished up our cardiovascular pathophys block, I was AWESOME at coming up with a differential diagnosis. Slap an EKG on that sucker and I could tell you exactly what was up, if anything. Fast forward to mid-November, with yours truly currently over a month removed from CV and slogging towards the end of our GI block, and my differential for chest pain would look something like: (1) GERD (2) Heart Stuff
In MS2, the blessing of your experience is that you're starting to gain some competency in your physical exam skills. Not to toot my own horn, but there's a fairly decent number of common complaints I've been seeing these days where I can come up pertinent PE findings and a decent treatment plan. Cold symptoms, abdominal symptoms, etc. But you start to pick up on your serious deficiencies also. Ask me to pick up on your heart murmur? Fat chance, it'll get figured out when you go into heart failure and present to the ER. Tell me there's a heart murmur and then ask me to listen for it? 90% chance I'll hear it. How I can get better at this besides making the patient lie there awkwardly in dead silence for 5 minutes while I listen to S1-S2-Between and the patient wonders why the "medical student" who looks old enough to be on their kid's t-ball team stares at their bare chest with a disconcerted look on their face... I have no idea.
The further I get into medical school, the further I seem to look forward. As an MS1, you're so far removed from your future self that to think of who you'll be as a clinician is something akin to the "what I want to be when I grow up" presentation in kindergarten. But the more experience I garner around patients and around various clinicians, the more I pick up on the do's and dont's I can see myself realistically integrating into my own practice in the future. As an MS1 I was content to trudge along in my BS classes, taking each block and exam in stride. And now, as much as I'm enjoying MS2, I was just want the year to be over so I can move on to my clinical rotations and actually learn on the fly. Only problem with that is that the Step I thundercloud has also crested the mountain and come into view. I've been pretty good at putting off thinking about boards but the thoughts of what it would actually mean if I fail or don't do as well as I need to are starting to creep into my consciousness. It still feels like September to me, time has flown by so quickly this year, so I know I'm going to blink and its going to be May.
And so the march goes on. 5 steps forward, 4 steps back.
Medicine is full of ridiculous moments. To me, and my extremely sarcastic sense of humor, its one of the many (or few) areas of medicine that remain dear to me.
Queue Situation #1: Patient Zzzz comes in for his routine physical (good for him!). He has had no significant medical issues, but his wife has a primary complaint, among many, that her husband snores so much that it seriously disturbs her sleep. The patient has gained 40 pounds in the past 2 years and is about 70 pounds overweight. He is pre-hypertensive. He complains of lethargy. He eats poorly and doesn't exercise.
Patient Zzzz: "So what can I do about the snoring? Isn't there some drug out there that can help me?" MedZag/Preceptor: "We can install a noisy machine in your bedroom to help you sleep better. But your wife will likely complain just as much, and counteract said effects of restful sleep. Try exercising and losing weight."
Patient Zzzz: "So what about feeling tired these days? Isn't there some drug that can boost my metabolism?" MedZag/Preceptor: "Well there's always methamphetamines. But if you're opposed to injecting your medications, or smoking them off of a knife, you can try exercising and losing weight."
Patient Zzzz: "My blood pressure has never been high. Why all of a sudden? Isn't there some drug you can give me to bring it down?" MedZag/Preceptor: "If it stays elevated or continues to climb up, yes. In the meantime, you can try exercising and losing weight."
Patient Zzzz: "Wow, I had no idea gaining weight was so bad for you." *MedZag smacks face with Phizer clipboard*
Queue Situation #2: It's 11:37am. MedZag is in one of those wonderful "small groups" that medical school curriculum directors have some strange fetish with these days. Topic of the day: reading radiological images of the chest. After slogging through your typical lobar pneumonia, bronchiolar pneumonia, and miliary cocciciomycosis pneumonia (ok, maybe not so typical), we reach the highlight image of the day. The small group facilitator clicks his snazzy InFocus clicker and a spiral CT chest image comes onto the screen. The group gets to work analyzing the image. Mediastinum... clear. Outside the lungs... clear. Lurking in the lower right lobe is a fascinating bright "opacity." The group diligently examines said "opacity," and discerns that it is a cavitary invasive lesion of the bronchus. It was invasive. It was big. And the local lymph nodes were enlarged and bright. Likely diagnosis: squamos cell carinoma of the lung, a nasty lung cancer highly associated with smoking. We discussed his prognosis, which was poor. We talked about how bronchus epithelial metaplasia from smoking insult can lead to the development of SQCC. The group excitedly gives its diagnosis to the facilitator.
Facilitator: "Well duh. You all forgot the most important finding on the CT scan. Can anyone tell me what it is?" Group: *best stoned pufferfish impression possible* Facilitator: "Look in the upper right corner of the image."
There, sitting on the upper right corner over the CT cross-sectional slice, was a section through the pack of cigarettes sitting in the patient's front left pocket. Yup, here we are reading this poor guy's catscan, talking about how screwed he was from years of smoking, and the dude went into the scanner with the smokes still in his front pocket.
I don't get the people that are predicting the "death of America" by an Obama presidency. Whether President Obama ends up being an FDR or a Hoover, a Reagan or a Nixon, an incredible president or a terrible one, our nation will continue just the same.
Like many other medical schools throughout the land, my medical school engages in the prestigious Exam Review after each one of our sodomizations, I mean, examinations.
Its supposed to be a time for the course director and instructors to garner useful feedback on the questions and learn where they need to clarify question wording, as well as an opportunity for students to learn what questions they got wrong and why. As I am sure you can imagine, this results in a very responsible and professional environment with each party, class and course director, exchanging meaningful ideas. For example:
Course Director: "And now question 23, on the West zones of the lung..." Class: "RABBLE RABBLE! RABBLE! RABBLE RABBLE RABBLE! RABBLE! RABBLE!"
I swear, Virchow himself could not write a sufficient test question for some members of the class. Of course, its not unexpected. Old habits die hard, and us hyper-type-A personalities have come from a long lineage of scrapping and clawing for every point back in our younger days. Most of the time you learn to let that go in medical school, but it comes out during things like... exam reviews.
I think some people are losing a good opportunity to modify there thinking process and understand WHY they came to the wrong answer. In medical school, a wrong answer is more rarely due to simply not knowing the information and much more often due to misunderstanding the information. And it would be prudent to identify what aspects of the material you misunderstanded (nuke-u-ler), and correct them before you misunderstand them in a patient. By fighting to justify your answer, you are reinforcing the information as correct in your brain.
Instead, the typical exchange goes something like this:
Instructor: "Well, B is the right answer because it is a true representation of the value of the pressures of the total respiratory system at FRC. D is wrong because it takes into account only the static dynamics of the lung." Student X: "But, if you rearrange the words of answer D backwards, and if the question is in reference to a 82 year old African American woman with toxoplasmosis, diphtheria, and a hangnail, and if you stand on your head when you read the question... isn't D technically correct?" Instructor: "..."
Now I can't complain too much, because my fellow classmates that smell blood on a question and really go after the course director are always successful (100% of the time, no joke) at netting me an extra couple of points on the exam. I'm more than happy to have others claw and scratch for me, because I'm a giant ball of apathy at these exam reviews.
Of course, the highlight of the exam reviews are when a certain select subset of question comes up. The Complete-and-Utter-Bullshit Question™ (CUBQ in dedication to the fact we are learning interstitial lung diseases right now). This is a question on a small minutiae of information that was either present in 2 point font at the bottom of some table somewhere in the syllabus, or the lecturer muttered the sentence under their breath during a sneeze at break, or the lecturer is playing the wonderful game of "guess what I'm thinking?" (I love that game!!!!!!!! HAHAHAHA!)
There's a certain percentage of students that will fight for every question they got wrong, but on a CUBQ its like a tsunami. It starts as a rumbling in the distance as the CUBQ is projected onto the screen. The rumbling gets louder as the course director reads the question. Then, as she unfortunately mutters the fateful phrase "Any questions?", the wave arises in front of her. Arms shoot up throughout the lecture hall, forming a wall which eventually crashes down and consumes the course director in a swirling turbine of indignation and outrage.
Ah, lecture hall. The closer I get to MS3, the more I look forward to leaving it all behind. But part of me will miss those little moments, where the "gravity" of the information being presented to us breaks way to reveal the absurdity underneath.
In dedication to the fact I sent in my ballot today for "the most important election in American history" ((dramatic music)) I figured I'd dedicate this moment with another ridiculous political motif.
Enjoy.
8 days to election day... Turn off the shitty television and walk down to your local voting center. It's exercise, it's good for you.
***I'm Almost-Dr. MedZag and I approved this message.
I am a big believer in karma. Y'know, the whole "the world comes back to treat you exactly how you treat the world" jazz. So I try to keep my divisive relationships in my life to a minimum. If only I had learned from the kidney.
As has been well documented in the past, I have a hate-hate relationship with the kidney that extends all the way back to high school. When we sludged through renal physiology last spring, it was hands down the worst 2 weeks of first year (well, besides my shotgun wedding with biochemistry). I celebrated being done with the kidney. Reveled in it. May or may not have even done a happy dance in front of the mirror in just my boxers as Rick Roll blasted in the background.
Cue 4 weeks ago. MedZag's cruising along in his MS2 corvette down I5 after finishing up the first exam of the year, conveniently on cardiovascular stuff (my favorite organ system). I'm getting ready for the coming week and glance at my syllabus and the lights go out and the clock flashes over to 3:33AM as my eyes fix on Wednesday's lecture: Review of Renal Physiology. The kidney... was back.
Since then, I've suffered through such wonderful subjects as ECF Content/Volume Disorders Part I & II, Total Body Fluid H2O/Osmolality Disorders, K+ Homeostasis, Pathophysiology of Hypertension, Syndromes of Renal Disease, Evaluation of Renal Function, Renal Stone Disease, Acute Kidney Injury, Tubulointerstitial Diseases, Pathophysiology of Chronic Kidney Disease, Glomerular Disease, Acid-Base Review, Metabolic Alkalosis, Renal Tubular Acidosis and Metabolic Acidosis, Proteinuria & Nephrotic Syndrome, and Diabetic Nephropathy. There's been PBL sessions. Pathology labs. Tears.
It's bad enough that I have had to study the kidney all day long for the past month, but the kidney is not content with that. No, the kidney wants to leave me huddled and whimpering in the corner, drooling all over my chest and referring to myself as George Costanza. Yes, the kidney has also successfully invaded my dreams.
I had a dream where I was examining a path slide trying to identify if it was IgA nephropathy. A dream where I was examining a patient for rear flank pain to rule out acute pyelonephritis. A dream where I was counseling a patient in the ED on how lupus can lead to a rapidly progressing glomerulonephritis. I had a dream where I was eating a burrito and all the pinto beans had pelvises and tiny ureters.
I think I can now empathize with the chick from Exorcist: The Beginning. I wonder if renal exorcism is something they teach you in nephrology fellowship.
So I always like to post whenever I come down with some kind of illness or other. It's really the only opportunity you get to being on the "other side of the fence" as a medical student... kind of like being a realtor selling your own house, or accountant filing your own taxes, or whatever.
So let's run through my latest bout with the big bad germs of the world. I'd had this nagging chest cough for about 2 weeks. On its onset, it started as a dry cough, and over the course of the first few days it moved "deeper" into my chest and I started to have laryngospasms when I coughed (the wonderfully coined 'croup' - no inspiratory stridor though). Overall it was a pretty subacute course. No fever, kinda rundown but not enough that I couldn't get through the days. No purulunt sputum, no involvement of the oropharnx or nasoparhynx. No earache, no headaches, no violent cough attacks. I just had this persistent deep-chested cough which sputtered out throughout the day and scared every healthy person 15 feet away from me for almost a month. Mild lymphadenopathy, no swollen tonsils or erythema of the throat.
So I thought it was viral at first, even though it seemed to be localized to my chest, generally by its pretty mild nature. So one week goes by, no improvement, no worsening. When the 2 week mark was hit I started being suspicious it was mycoplasma, since by that point I should have been on the upswing, and we saw a kid in clinic the day before I started to be sick who had it. Tough it out a couple more days before dragging myself into urgent care.
My plan was to play ignorant and just let the doc go through his exam, both because I was curious what sort of conclusion he'd reach and also because its kind of fun to play the patient. Y'know, I didn't have "lymphadenopathy," I had "some swollen lymph nodes." The illness wasn't "subacute," I "just never really felt that sick." "No green gunk when I cough." I know, I am so clever. My ruse was going perfectly as we went through the history until he asked me if I had had any fever, to which I replied "I haven't been measuring my temperature but I haven't really felt febrile."
Doc stops typing. Slowly turns and peers at me.
"You in medicine?" C'est la vie, I had been found out. Like every single physician when I first meet them, he wants to know what year I'm in, then subsequently looks disappointed when I tell him I'm a 2nd year. Yeah I know, I'm still stuck in the lame go-to-class study-all-day part of medical school.
Anyways, he finishes the exam and agrees with my diagnosis, even though he doesn't know it (Ed Note: Yes, I realize this sentence makes me sound like a total asshole), and hooks me up with a good old z-pack.
One day later. Cough dramatically improved. 5 days later, cough almost completely gone. The wonders of medicine.
Probably one of my favorite structures in the human body is the uvula. Maybe it comes from my childhood love of stalactites (nerd alert!), but there's something endearing about that little ball of mucosa hanging suspended from the back of your throat.
Little, that is, until it gets infected.
In one of the more bizarre medical presentations I have ever been around, a patient came in 3 days after having his uvula pierced. That's right, he pierced his uvula. Even more amazing, this sort of thing actually came up with a google image search.
Exhibit A: On examination, his uvula had swollen nearly to the size of a golf ball and was at risk of closing off his airway. And stuck in the middle of it, like a hula hoop around John Daly, was his newly acquired uvula bling.
We checked his epiglottis, and that seemed to be golden, so he wasn't at immediate risk of asphyxiation and this was almost certainly a case of a non-sterile piercing. The #1 etiology of bacterial uvulitis is group A strep, but since this was due to direct trauma by an instrument we weren't sure what it was, so we took a culture and put him on some amoxicillin and told him to follow up in 3 days. But as a parting gift, the PCP also gave him an epi pen and told him to inject his uvula if he felt like he could no longer breathe, and that should buy him time to get to an ED.
Yup. If he felt like he couldn't breathe, and was panicking, he was supposed to take this pen, put it him his mouth, and inject the back of his throat. His eyes got pretty big as the doc told him that one. If he was looking for a little "badass factor" with his new throat ornament, I think he got a little more than he bargained for. But hey, every guy on a certain level has to wish he could do his own little personal re-enactment of the scene in The Rock where Nicholas Cage injects himself to save his life. I should have given him some green flares for dramatic effect.
I'm used to being swamped in medical school, but the stakes are definitely raised in MS2. Blink and suddenly you are 8 lectures behind. It requires a higher degree of vigilance towards a continual level of effort than MS1.
It's like running on a treadmill. Or a rat wheel. Stop for a second and the ground goes out from under you, and I recently had a pretty dramatic faceplant to remind me of that fact. The days are definitely blending together. It's already October. Daylight is getting to be a more precious commodity.
The advantage of being in my second year is that I'm used to this. The feeling of the rat race is a familiar one. But it still feels like you're doing a whole lot of running and not getting anywhere.
It would be a disservice if I didn't mention that today, September 19th, is national Talk Like A Pirate Day.
Under the "Pirate Fun & Games" tab at TalkLikeAPirate.com you can print out your own Pirate Party Kit for your office, ward, classroom, construction site, clinic, wherever.
UPDATE: MedZag's Classmate YELLING at Last Lecturer Of Day (11:55PM): "Arrrrrrrr, good day to ye matey. I be havin a question for ye, what be the effects of me rum on me collecting tubules? Can it be causin' me hyponatremia-rrrrr?"
Another story from preceptorship. A patient came to clinic last year convinced he had lung cancer. He was a previous smoker (1 pack/day for 10 years), but had no symptoms, no family history, no other risk factors, in his 40s, nada, zip, zilch. So the doc ordered a blood panel, guy was healthy as a horse, and sent him on his way. He couldn't even elucidate why the patient was suddenly convinced he had cancer.
Got a call from radiology at the local community hospital this week. The guy had presented to the ED with acute chest pain. Chest xray revealed multiple metastases in his lungs.
Patient is a 12 year old boy with a sore throat. Neighbor boy had strep throat the week before and the patient was exposed at a birthday party. Mom brings him in wondering if he has strep.
History includes a 12 hour fever (no thermometer used) two days prior which disappeared overnight. No headaches, chills, or malaise. Chief complaint is odynophagia. No mucous drip, stuffy nose, ear pain, or cough. Patient is afebrile and on examination has no tonsillar exudate, no erythema of the posterior pharynx. Tympanic membranes clear bilaterally. Only remarkable finding was petechiae of the soft palate.
Preceptor: "Mr. MedZag, what would you say is the likelihood of this child having strep?"
MedZag: "I'd say 20-30%. The fever course was too short, currently afebrile, no tosillar exudate or enlarged lymph nodes."
Preceptor: "WRONG! With the presence of petechiae on the soft palate, I would place his likelihood at over 80%. I might make you print the antibiotics prescription."
Fast forward 15 minutes. Strep test comes back... negative. Score one for the medical student.
The CENTOR score is criteria used to evaulate the pre-test risk of GABHS phayngitis. The patient is given a point for filling any of the following criteria: :: Febrile (Temp >100F) :: No cough :: Swollen anterior lymph nodes :: Tonsillar exudate/swelling :: Age 3-14
Little Billy scored a 3 on the CENTOR score, which puts his pre-test probability at... drumroll please... 28-35%. Hey, 5% off ain't bad.
So the first week of MS2 is now officially down the tubes. I responded to the school year starting up again by putting off studying for as long as physically possible, but just as a crack addict needs his... crack, a medical student needs his studying, and the multicolor highlighters are now out in force. The first day of the year went pretty much exactly like I expected. After the fun of seeing everyone wore off (read: 30 minutes), the day felt just like any other day of medical school.
So, (I can see you pre-meds and MS1s rabidly foaming at the mouth) how is MS2 compared to MS1?
One of my more famous (or Follies infamous) posts was my ruminations on competitive eating. Yeah, MS1 is a lot like putting down a ton of hot dogs. After a while, you ask yourself why you ever liked hot dogs because, after all, its made of all the discarded parts of a cow. Who would ever want to eat that? But you eat and eat and eat, because there's nothing to do but eat. And summer break begins with you seriously overweight with a glossly flaccid stomach. But after a while you forget why you hated hot dogs, and are at a BBQ, and slowly creep towards that hot dog bun. Because part of you misses the hot dogs, as sick as the thought of eating one makes you.
Well, thankfully, MS2 is nothing like eating hot dogs. You're done with the days of all the leftover cow parts. Instead, MS2 is like a nice, juicy, delicious steak. The lecturers don't talk down to you (as much), the majority of the information thrown at your brain is rooted in some form of the actual clinical practice of medicine (aka the succulent hip, not the leftovers), and hell, you're a competitive hot dog eater, putting down a steak should be fun compared to hot dogs. After all, eating steak is an enjoyable experience.
Enjoyable at first, that is, until you realize the steak is 72oz. And steak sits in the stomach a lot heavier than hot dogs. And steak is all that is on the menu for the next 8 months. You're a competitive eater, so you know how to eat, but this is different. More tasty, but more challenging.
So yeah, MS2 is a lot more enjoyable than MS1. Instead of being forced to memorize a bunch of information a PhD would rarely find useful, the information is much more tailored and relevant to the practice of medicine. Instead of stumbling around in the dark looking for the fastest way to cram as many drug names, half-lives, metabolic pathways, and enzyme topographical maps into your brain, you're talking about how said drugs are actually being used to treat disease, how errant pathways manifest themselves symptomatically, and what current literature says about treatment strategies. But there's no getting around the fact that this is still medical school. And you're a MS2 now, the information comes faster. I already feel behind. We already have an exam in a week. My favorite neighborhood baristas already know that I am back at it. I already haven't talked to many of my friends since class started. It's still a crapload of information, and its still not going to be fun some of the time. But you can take heart in the fact that it is better information.
Ironically, as I stuffed myself with steak yesterday, cracking my syllabus for the first time this year to get my eat on, one of the first topics I had to study was... coronary artery disease. I think I feel heartburn coming on.
As an added note, Med11 (appropriately named the Pill Hill Pirates... arrrrrrgh) took the title in the first inaugural PA/MD kickball tournament yesterday, in an epic 14-13 title game which came down to a gut wrenching bottom of the 9th defensive slugfest. You have never seen a competitive kickball game until you throw a bunch of anal type A personalities together and tell them to go at it. Trust me.
The time honored tradition of walking the plank. Per wikipedia:
Walking the plank is a phrase that describes a form of murder or torture that was practiced by pirates, mutineers and other rogue seafarers. It involved the victim being forced to walk off the end of a wooden plank or beam extended over the side of a ship, thereby falling into the water to drown, often into the vicinity of sharks.
I'm standing on the plank right now. The sharks circle, they can smell blood. A stick pokes me in the back, spurring me to take a step further.
Yup, my times as a full-fledged (not just a fake) MS2 start up tomorrow. I am on the end of the proverbial summer plank and in 18 precious hours my life will once again consist of sink or swim time amongst the sharks.
The start of MS2 feels very different from MS1. There are some pluses. You know you can handle medical school just fine, you already feel like you're starting to establish a fund of knowledge, you have your study habits and know they work.
The drawback of knowing the ropes is that you... know the ropes. I know that my days will consist of endlessly staring at information. I know about all the work and time required. I know that the speed of information gets ramped up second year. I know there's this small little test looming in the distance called Hurricane USMLE. Surprisingly, these things do not make me anxious. Really, anxious would be one of the words farthest from how I would describe how I feel right now. Rather they just make me apathetic.
Waking up tomorrow and heading to class will feel just like another day of med school. All the wide eyed fluffy optimism of first year is gone, and now begins the trudge, through second year, through Step 1, through 3rd year, never ceasing.
Of course, part of me is still excited to get started again. My liver will appreciate the break. And, frankly, I really enjoyed my times as an MS1 and kind of went to medical school for the purpose of learning medicine, so it's my own damn fault that they expect you to learn stuff every once and a while.
But saying goodbye to the last summer break of your life is not easy. So goodbye, sleeping in 5 days a week. Goodbye, drinking on Wednesday-though-Saturdays. Goodbye, completely unregimented schedules. Goodbye, 2:00am bar close. Goodbye outdoor all day festivals.
As I said before, sorry for the lull in posting lately. My main blogging computer crunched its last bit of binary and croaked and the repair/upgrade process has been a bit time-consuming to say the least (that's the tough part about building your own computers... crap, think I just let a bit of the inner nerd slip out).
So things have been putzing along at a fairly uninteresting rate these days. I would say it's the "lull of summer" but frankly I love this lull and academics will have a difficult time wrenching it from my grasp 2 weeks from now when class starts up again. Ok, I'll probably end up giving it up right away while whimpering and screaming "please! no! somebody!" but such is the immovable march of time.
So I've been filling my time with what is turning out to be an entertaining pastime - selling all my old undergrad textbooks on half.com. 2 sales already in the past 12 hours, who would have known there'd be such a market for 2 edition/4 year old hardcovers? But the best part about it all hasn't been the money. I know, funny.
The best part has been the old papers I have found hastily folded and stuffed into the bindings, a relic of my past (lack of) study habits and aversion to binders and organizing. College (and alcohol) will do that to you. Here's some of my favorites:
My how far we've come. This was found in my old Biology 101 textbook. Yes, I was once tested on whether I knew and understood the terms "genetic variation" and "natural selection." There's two things that stuck out to me about the study guide.
One is just how much my scientific thinkbank has been expanded these past 5-6 years (despite my damnedest efforts to prevent it). There are thousands of words in my daily vocabulary now that were not there a couple years ago (or the gross majority a year ago). It reminds me of last summer. Last summer, I came into medical school missing a pre-req (*collective pre-med gasp*). Yup, apparently "statistics" isn't "math" enough for medical school, so at the last minute (1.5 months prior to matriculation) I had to pick up a science class at PSU to prove I was worthy of attending medical school. After talking to the dean's office, it turns out it could be any math class BUT statistics, so I flipped the course catalog to the MATH section and picked the closest freaking thing to the number 100. End result, MedZag, a cumme laude college graduate and accepted medical student, ends up enrolled in Math 107: Introduction to Algebra. With high school students. It actually turned out to be a lot of fun, since I hadn't taken algebra since I was 13 years old. Because algebra is one of the few classes growing up that I actually got a D on a test in. After many more years of math, geometry, pre-cal, calculus 1 & 2, statistics, to come back to that same subject I struggled with and to notice how easy, how fundamental it all seemed at that point of my academic career was really something. Call it "evolution." Now if only I could go back and retake BIO101 instead of having to look forward to "Circulation 201."
Second is that it's far too easy for us in medicine to assume our patients can understand what we are trying to educate them on when in actuality they may feel like we're speaking in a weird cross of latin and idiot. I've already been accused of speaking in "doctorese" when talking to my non-medicine friends about some of the crazy shit I see, but I cannot begin to fathom how you could explain to a newly-diagnosed cancer patient the difference between small cell and non-small cell lung cancer when they may barely understand what DNA is let alone mitosis, genetic variation, and natural selection/genetic evolution. These are words and understandings I gained with a college education, which seems so far in the past at this point of my training, but it is humbling to acknowledge that many patients I will see in the time of my practice who were never granted such an opportunity. The art of conveying "doctorese" in "crap-the-everyone-else-can-understandese" can take a career to perfect. And as not even in the "career" part of my life yet, I know I suck at it.
My how far we haven't come. If the previous page I found was a testament to how much you can learn over the years, this one is a testament to all the crap you forget. Little bugs like Rickettsia and Salmonella and "Stephylococcus" (yeah I noticed that) were words I crammed into my noggin back in the day... and then subsequently completely forgot about. When I came across this page, I was honestly surprised, because the information had completely and utterly slipped out of my brain, namely because I never had to use it again in the remainder of my college career. After a thorough spanking in micro my MS1, these words are now common parts of my daily vernacular, but it points to what you forget so readily, even after learning something, if you never use it or apply it to your knowledge the rest of your life.
That's the frustrating part about the first two years of medical school, especially first year. You pound all these useless facts into your brain, in order to pass your next test, and in sacrifice to the almighty Step I, only to know you will lose the majority of it in the remainder of your career unless you use it in your daily practice. It seems utterly inefficient, and for all intents and purposes, it is.
I leave you with a page that isn't my own, but is a piece of looseleaf left in my undergrad biochem book from the previous owner to myself:
Wellspring of life Superfluous as self I am none than a pH of 7.4 balanced (wow) by paying the bills and filling up the car with gas. Unleaded's already $2.09. We're drinking up commercialism in a tank of thick black wine. (wow) Drunk with the soldiers pressed in the huddle east where the sun rises to another lonely day. Seeing only the tops of our heads. No one basks in the sun. We bask in our lower office. No one looks up into the asky anymore, face greeting the rays. Only the very young and even their baby faces are turned to the luminescent screen. (They play virtual tag.)
Ah, undergrad bio majors. Gas for $2.09 a gallon? You got to be f*cking me. Black wine? More like black franzia.
I like to practice a little Patriot Act around here. My google counter tracks how everyone gets here. Which is always interesting (thank you SDN!), but tonight creeped into the weird zone.
First link to this site is from a person who did a google search for "medical student well endowed". I can only hypothesize what the motives are behind this sort of search.
The second link came 2 minutes later, from a google search for "MedZag genitals".
Every medical student has his or her own unique challenges as they progress through training. For some, its social anxieties fostered by years of seclusion in the library. Others its the constant berating by superiors. Fear of needles. Aversion to blood. Painful memories of gurneys. Dislike of the color white. Latex allergy. For me, I've had my own Everest I've had to climb.
I have a baby face.
Now I know. I'll be laughing when I'm 40. I'll miss the days when I get carded by Brutus on Monday $1 pint night (or carded for rated R movies... still happens!). But unfortunately I kind of need to learn this medicine thing now not later, and getting a 45 year old man to talk to me about his sexual history or confide possibly socially taboo behavior when I look like I should be playing on his 12 year old son's little league team just doesn't seem to fly.
There has been several (unsuccessful) attempts at growing a beard, but the battle against genetics has proven a futile one. Wearing glasses helps a little. Then patients just ask what college I go to instead of what high school (no exaggeration). White coat or not, patients are always observing "So you're following this doctor around today? How fun! Well do well in college and maybe you'll get into medical school!" Sorry lady. Jumped the gun on that one. Let me just put away your chart with your full medical history in it and go work on my English homework.
The best? A patient who told me I look just like Richie from Happy days (see above).
Maybe I should embrace it. It'll only take a couple months before I could grow a mean comb-over.
And change my name to Doogie.
Anyone got any good ideas on how to look older? That doesn't involve illicit drug use or alternative medicine?
Apologies for the lack of new posts in the past weeks. One dead computer and being out of town for a wedding both have kept me offline. New stuff coming soon.
Also, big thanks to other things amanzi for the shout out in last week's iteration of SurgeXperiences grand rounds. That was a pleasant surprise.
So after taking a couple weeks off from medicine completely, drinking my weight in beer, and catching up on all my trashy reality television (seriously, its the closest thing to crack you can dig up without having to talk to a large man named Bubba) I've finally started seeing patients again and dusting the cobwebs off the old hippocampus (see left). Medical school has taught me that its awe-inspiring how much you can learn in a couple weeks. Summer break has taught me that you can forget all that information plus tons more in a couple weeks more. But I'm starting to get back into the swing of things. This summer I am doing a preceptorship with a cardiothoracic surgeon (my 13 year old self would have wet himself at this sentence), and picking up a few shifts down at the free clinic. I'll muse on the deeper ruminations of each opportunity later, but for now I'll just present my top 3 experiences from each so far.
THE OR: || My First Cabbage || The coronary artery bypass graft (or CABG... or "cabbage") is the most common procedure in CT surgery. Layman's terms the "x bypass" surgery. For most CT surgeons, this procedure is as mundane as the morning coffee, but for a medical student seeing the procedure for the first time, it's pretty f'n cool. This one was cool because it was a throwback to my wide-eyed "this is super awesome" pre-med days. It was also cool because it really shows some of the ingenuity employed in surgical techniques. I've known that the internal thoracic artery (or internal mammary artery) is the most common graft harvested for use during the bypass due to the dual-circulatory blood supply to the anterior thoracic wall. But I always assumed you simply cut out a length of the artery necessary for the bypass and suture in one end to the appropriate coronary artery and the other end into the root of the aorta. In actuality, in most cases things are done slightly differently, with the surgeon dissecting the artery away from the sternal wall, ligating it at its distal point, and redirecting only the distal end to the point past the coronary artery stenosis. This allows the natural circulation of the IMA to supply blood to the coronary artery and has the advantage of removing the need to incise into the aorta, which is one of the most post-op complications-wrought steps of a CABG. Small difference technically which has big implications for post-op prognosis.
|| The Bi-Polar Heart || Saw an atrial septal defect (ASD) repair, a procedure that is common and straightforward in pediatric cardiac surgery. Most ASDs are found and repaired within the first few years of life. The difference in this case was that the patient was a 71 year old man, who has lived his entire life with a 3cm hole between the atria of his heart and a significant left-to-right shunt of his circulatory system. With so many years living with his condition, his right atrium had dilated to 60cm in circumference (when normal is under 20cm). Yeah, this guy's right atrium was almost as large as the rest of his heart. Besides making for one strange looking heart, the large floppy atrium allowed a big window to look into the heart during the ASD repair so I got a good look to see how the pericardium patch was applied to the atrial septum.
|| The "Holy Crap That's A Big Surgery" Woman || This one was a 5 hour surgery on a woman in severe end-stage heart failure. The patient underwent a two-vessel CABG followed by an atrial valve annuloplasty and a tricuspid valve annuloplasty. Layman's terms: a double-bypass heart surgery with two valve reconstructions. Essentially got to see three different surgeries all wrapped into a nice little wrapper. The most important thing I learned from it: I need more comfortable shoes. And never forget coffee is a diuretic.
THE CLINIC: || Love The Thyroid || Saw a patient with Graves' Disease who had been upping her carbimazole dose (an anti-TSH drug) to try to get her TSH levels back into normal range. She came in complaining of fatigue and irritability, two common symptoms of hypothyroidism, but also common symptoms of many other diseases. If it wasn't for her Grave's Disease I'd have had to idea to think "thyroid" in the diagnosis. This one stuck out to me because I have had a handout on hypothyroidism sitting on my coffee table for the past 8 months that I still have not gotten around to reading. And after a significantly humbling experience pow-wowing with the attending where I practiced my favorite "stoned pufferfish" expression as I had not a single answer to any of her questions, I found the patient had a laundry-list of all the other symptoms associated with hypothyroidism (hot/cold sensitivity, dry patches of skin, weight gain, depression, hair loss, constipation), which would have been readily available to me if I had had my coffee table with me in clinic. Note to self: coffee table fits in back seat of car.
|| I Do Not Speak Hausa || Second patient is a diabetic Nigerian who spoke minimal english, and to further compound issues, had significant hearing loss in his left ear. To further compound issues he came in reeking of alcohol, and had admitted to alcoholic habits in the past that would be characterized as addiction. To further compound issues I had a reasonable amount of clinical suspicion he was suffering from severe depression. So I had a drunk, depressed patient with wildly uncontrolled diabetes who I had to talk to through his one good ear while he comprehended maybe every 5th word out of my mouth. A complicated clinical situation in general, but especially difficult when you cannot express the nuances and expansiveness of the english language to the patient. A frustrating situation, because there was a great deal of good we could have done for this patient if not for the lost-in-translation issues. But we made sure he had access to his insulin and was scheduled for a follow-up, so there's always hope for the future.
|| Future Rap Video Girl || 15 year old girl comes in, leaving mom to wait in the hallway. Had started birth control a month ago in order to control her periods. Stopped after 3 weeks due to nausea. Only, after stopping birth control, the nausea continued. (*red lights and alarms* All hands to battle stations!) One pregnancy test later, I'm talking to a visibly shaking pregnant 15 year old girl. On counseling, found out she has had 12 sexual partners in the past year, and uses a condom "pretty much always." Hot damn, that's a more extensive resume than I have accumulated in the past 22 years of my life. Counsel her on the importance of ALWAYS using a condom, the dangers of the money-shot (ok, maybe not), and sent her on her way clutching a pamphlet with the phone numbers of various teen pregnancy resources in the area. On the way out, the mother comes up to me and talks to me about her daughter's nausea. Asks if her daughter should keep taking her vitamins. I tell her, yes, her daughter should take her multivitamin every day, to follow her weight at home, and to make sure she gets her protein. HEYO! I'm going to hell.
Ok, that's way too much writing for having to be up at 5am tomorrow. Ah, medicine.
So this arrived through my mail slot as part of a commercial ad packet the other day: Wow, all these years I thought it was the diabetes, the hypertension, and the cancer that was whacking off our population base. Little did I know it was actually colon gunk. What a waste of a $160,000 degree.
I could spend the next 500 words mocking the above ad, but that's just too easy. But it does offer an opportunity to talk about the supplements industry. I preface this rant by saying that I do not believe "organic" medicine to be completely ineffective, supplements to be completely useless, or that either do not serve a purpose in the medical world.
Herbal supplements irk almost all doctors. The general public loves them. This is a problem. Let me propose a scenario for you. You come in to visit your doctors office complaining of peripheral neuropathy, fatigue, etc. Blood tests reveal you have type II diabetes mellitus, and your doctor prescribes a medicine to get your blood sugar levels under control. Only thing is, when you fill your bottle of pills, every pill has a different dose of drug in it. Some have enough to keep your diabetes under control, others not enough so you feel symptoms again, others too much drug and you plunge into symptoms of hypoglycemia. Every time you pop a pill, you don't know if it will actually help, will harm, or do nothing.
This is the reality of herbal supplements. Herbal supplements work because they have ACTIVE DRUGS in them. It is the ACTIVE DRUGS which are helping you, not the fact that you just ate the pill form of a weed. But the reality is, the supplement industry is wholly and utterly unregulated. The amount of active ingredients within every pill is not checked (and studies have indeed shown levels of active ingredients to vary widely in supplements even within the same bottle of pills). Supplement companies can claim their product is capable of anything, and able to use any number of questionable characters to endorse it (You may see "Dr. Bumbleweed" in big letters on the screen but you miss the TINY asterisk in the lower left corner saying "*PhD in Ceramics"). And people eat it up.
I don't know where this public distrust of conventional medicine but patent obsession with "all natural" products came about. But I do know its incredibly dangerous. Every physician and medical student wishes they can go to town like a 5th grade teacher with a red pen and FDA-like force on the entire supplement industry. But the reason we feel this way isn't because we think supplements are useless. We feel this way because they are dangerous. The active ingredients in supplements are DRUGS. They interact with other DRUGS. Some of these interactions are dangerous and life threatening. Yet people blindly eat up the claims of "natural supplements" and pop these pills with blatant disregard for potential cross-reactions. We are fast approaching a nationwide need for supplement regulation and control.
And for the love of god, there is NOT a pill that can cause you to lose "excess body fat" on just you stomach, thighs, and ass. You lose it everywhere, or nowhere, so go stock up on those vegetables, put down the Big Mac, drink some water, and go for a nice long walk. Yes, with the simple GetYourAssOffTheCouch Regimen you too can watch fat MELT from your body and have unprecedented levels of energy. You'll feel great, look great, and all your friends will notice too! Hi, my name is Dr. MedZag* and I'm here to tell you the GetYourAssOffTheCouch Regimen has impacted thousands of lives as people were saved from their excess weight and low self-esteem. For 3 payments of $39.99 we'll send you the GetYourAssOffTheCouch Regimen Kit, including, a salad bowl, a water bottle, and a fanny pack. But if you order today, we'll throw in this placebo FatBuster pill for free. Call now! Don't miss out!
One of the main highlights of the short article is the following blurb:
"The man who died was aged 45 and had been under severe pressure as the lead engineer in developing a hybrid version of Toyota's blockbuster Camry line, said Mikio Mizuno, the lawyer representing his wife. The man's identity is being withheld at the request of his family, who continue to live in Toyota City where the company is based.
In the two months up to his death, the man averaged more than 80 hours of overtime per month, according to Mizuno."
This is not a unique occurrence in Japan. It happens with enough frequency that they actually have a term for it: Karōshi... occupational sudden death from overworking.
Now time for some basic arithmetic. Assuming they are talking about 80 hours of overtime a month in accordance with the Japanese work week (46 hours per week, thank you wikipedia), that means that the unfortunate Toyota employee from the article worked (46/7)*30 + 80 hours a month... ~277 hours.
Now take your average US resident. Under the new work week restrictions, US residents are "limited" to 80 hours per week (though many work more secretly to gain more experience or due to underlying program expectations... SSSSSHHHHHHH). (80/7)*30 hours a month... ~343 hours.
Note this post is in no way meant to belittle the unfortunate tragedy of this man's death. But it does offer a unique insight into the under-the-radar life that people in medicine live. Everyone I talk to outside of medicine understands and sympathizes on some level with the long hours of the field and realizes that a 36 hour shift is not good for the decision making processes. But if a resident were to die from overworking, I don't think it would illicit more than a curious yawn from the general public. Everyone I talk to outside of medicine also expects perfection from their doctors. At first glance these two things, sympathy to mistakes and expectations of perfection, seem utterly incompatible.
Of course the conundrum is that residents do not work so many hours simply as some form of primitive medicinal hazing ritual. Residents work so much because they have to. The Medical Knowledge Ocean is vast, and a single resident but a small speck upon a life raft on it (Wilson sometimes accompanying). Even cutting resident hours down to 80 hours per week, which some professions would be considered ridiculous, we have already seen a greater amount of graduating residents seeking fellowship feeling that they have not had enough training to enter individual practice on their own. With talk of a further reduced 56 hour work week for residents, the debate between the "enough hours to stay sane" vs. "enough hours to not become Dr. Death" debate has gained even further ammunition. The benefits of work hour restriction are obvious. More balanced and well adjusted residents. Less medical mistakes due to sleep deprivation. Candy canes and bubbles and rainbows and shit. The drawbacks are perhaps less obvious but just as important. Necessary longer periods of training on an already exhausting path. Losing the lessons learned from being in the hospital to follow patients from admission all the way through the course of treatment. More time with that "interest" ticker steadily clicking away on student loans.
Personally, since I am firmly plopped on the "baby" end of the medical student age spectrum, the idea of extending residency another 1-2 years in favor of more sane working hours appeals to a certain side of me. After all, whether I am 29 or 31 when I leave residency is apples and apples to me. But the path of medical training is a long and arduous path, and I can certainly sympathize with my older classmates who find the idea of even 12 more months of residency truly gross. And 56 hours doesn't seem like enough time a week to learn what you need to in medicine.
Of course, its easy to spin the wheels in the ol' noggin about this topic when my days still consist of a schedule largely under my own control. It will be interesting to see how my opinions change as I'm thrown into said Medical Knowledge Ocean and told to survive, with the nearest island far enough away it will take 80 hours of paddling a day to reach it in 5 years.
But the idea of residents dropping dead in the hallways, being picked off like flies, in an epidemic of karōshi is a funny image to think of. In a morbid, real kind of way.
It's often difficult to understand the culture of medicine unless you are in the middle of it. So when I talk to non-medical friends about my life and times in medical school, they draw upon the best thing they know about what I am going through.
Watching Grey's Anatomy.
Inevitably, if a story I am telling or an experience I am describing even vaguely resembles something from the television show, I get the line that makes all med students cringe: "Oh, you mean like on Grey's!" It makes sense of course. If I talked to a person who was in a traveling circus, most of my ability to relate to their life would come from watching Dumbo as a kid.
Now any med student/intern/resident/attending can tell you medicine is very much NOT like Grey's Anatomy. It's at very least half the boobs and half the libido. Which is why my interest was piqued when ABC showed trailers for their new show "Hopkins," which was billed as the "real life Grey's Anatomy."
You can watch the first episode here. I was understandably skeptical when I cracked a beer and went to watch it, since real medicine makes for horrible TV. It's a lot of boring, mundane, and paperwork, punctuated by rare moments of shit you just can't make up. Overall, I came away pleasantly surprised with the show so far. It's refreshing to see a show that humanizes doctors and the scenarios they crafted were very real. And anything that gives the general public a better view of how ridiculous physicians' lives can be sometimes is definitely a step in the right direction.
Of course, the show is partially, by its own nature, a visual and verbal fellating of the John Hopkins institution, but the Hopkins worship wasn't too bad.
Anyways, it's a 6 part series so we'll see by the end whether the show has degenerated into ER with bad actors, but so far, so good ABC. So far, so good.
I know this is supposed to be a blog about medical school. But, as is all too appropriate to medical school, sometimes its easy to get caught up in the drudgery and aggravations of our daily lives, and its great to see someone out who has a life that's just plain really cool.
So I was running on a nature trail by my place last week. About 1.5 miles in on a particularly brutal downhill stretch, I roll my left foot underneath me. I catch myself and stop, thinking "Oh. Man, that'd really suck to sprain an ankle out here." Run about 50 more feet, and sure enough, roll my RIGHT ankle underneath me, only this time its accompanied with a wonderful 'pop'. I hopped around in circles for a good minute or two and was able to walk it off, and ran the remainder of my 4 miles. Still, a pop is never good, so when I got home I crashed on the couch and kept my leg elevated. Sure enough, by that night it had tightened up considerably and by the next morning I couldn't put my full weight on it.
Of course, my natural curiosity gets the best of me. I hobble over to my bookshelf. Open up Netter's Plate 527. "Ligaments and Tendons of Ankle".
Looking at the mechanism of injury, my foot was plantarflexed and inverted at the time of the pop. Physical exam reveals mild non-pitting edema of the lateral side of the ankle. Palpation produces pain between the lateral maleolus and the calcaneous. No significant loss of range of motion or pain on dorsiflexion. No significant loss of range of motion but pain on plantarflexion. Pain on eversion and inversion of the foot with limited range of motion.
Diagnosis: Likely grade II strain of the calcaneofibular or anterior talofibular ligaments. The pop is worrisome and a less likely but more serious diagnosis of grade III strain is plausible. The fact I can still dorsi and plantarflex my foot and that I was able to continue running post-injury is a good indicator of a less severe injury.
Treatment: The RICE protocol. Rest, Ice, Compression, and Elevation.
... This is what happens when a medical student has nothing to do. I think I need help.
No med school blog would be complete without a requisite end-of-first-year sappy reflective post. Since I know my friends love reading my entries where I get all gushy and sentimental (Hi Kate!) I figured it would be a disservice to not add my 2 cents to the plethora of bad advice on the internet. With my final exam lurking in 5 days, I figured now would be a great opportunity to procrastinate, put on some Coldplay, mix up a cosmo, and look back at myself 10 months ago (and laugh).
1. You will fail. Maybe not literally, if you successfully claw above that 70% line every test, but you will fail. You will study your ass off for an exam and do significantly worse then you expected. You will make an idiot of yourself in front of a patient. You will inevitably do something that makes you turn a color of red so bright it has not existed in the world outside of a Crayola crayon box (see Torch Red).
But there is hope. Luckily, the admissions departments at medical schools do a superb job of selecting perfectionists with abnormally tight external rectal spincters and the moments of failure will become your moments of greatest insight and learning as you sadistically mull over your mess ups. Some of things that I will never forget from MS1 due to my own incompetence include how to feel for the PMI on a well endowed woman (BACK of the hand, do not cup the breast!), the many ways that steroids will destroy your body (that you don't hear about on ESPN), and the fact that the femoral nerve is lateral to the artery (stuttering is not a recommended method of answering a question when pimped). Love the failure, it's good for you.
2. You will have doubts. Everybody is a happy, fluffy cloud of optimism when they start medical school. Unfortunately, fluffy clouds can quickly become rain clouds (wow, did I really just type that?) There are times when medical school sucks. But it's important to realize that everything in life sucks sometimes and you are not experiencing a phenomenon unique to medical school. Everyone does it differently, but one of the most important things you can do in your medical career has absolutely nothing to do with studying tip & tricks or learning to differentiate rales and ronchi or buying out the pigs feet at Fred Meyer to practice your running line stitch. The most important thing you can do to get ahead is to find something that keeps you happy. Join a pottery group. Train for a half marathon. Go to a strip club. It is those things that will make you a better medical student, since no one likes interacting with a thorny burnt out wad of pessimism all the time.
Best advice I got from a physician this year: "Make sure at least one good thing happens to you every day."
3. You will complain. Unfortunately, medical students come off as very negative people at times to our friends and loved ones, since one of the most effective and easy ways to let out your stresses involving school is to bitch and complain. I was catching up with a friend the other day and explaining my 10 year roadmap, stating quite truthfully and rather sarcastically that I have 3 more years of medical school where I'm "everyone's bitch," following by 1 year of internship where I am "everyone's bitch... but the medical student," following by x years of residency where I am "everyone's bitch... but the medical student and intern." After finishing all he says to me is "so you wish you didn't go to medical school?" I've loved medical school so far, and don't regret my decision for a second, but can see how that can be lost on others behind the Wall of Bitch.
So, learn the art of complaining. Embrace it as a part of you. But remember when you're done complaining that you are going into a career thats pretty sweet too.
4. Make friends not enemies. Your classmates are pretty cool people. And thankfully we are kind of self-selecting to be generous and helpful. Same goes for most people you interact with in health care. Your life can either be miserable or awesome depending on how you choose to interact with others. Sure there are bitter and evil classmates, nurses, attendings, information desk receptionists, and patients lurking out there in the shadows, but if you let them make you miserable, they win. [Insert corny Star Wars analogy about the dark side here]. Be nice, it pays off way better then being an asshole.
5. You will love it. Medical school is really cool. You get to see and do things 95% of the population would never dream of. You get to visualize the human body in ways you never would think possible (tangent: people watching becomes really fascinating when you play the What Disease Do I Have? game). You will be continually challenged and rewarded for your efforts. Yup, most of that crap you rambled on about in your AMCAS personal statement is true.
As a result, I abandoned Siberia, I mean, my apartment, and have been sleeping on various couches of various houses I have broken into over the past 10 days. Having no internet access for nearly 2 weeks, being sans car, sans bed, and sans normalcy has been equal parts entertaining and maddening. The Great Thaw has finally come, and with it my migration home, just in time for me to hop on a plane tomorrow for Vegas and New Years. I don't really know what the point of this post is except to justify my hiatus. I was hoping to post some thoughts over break but that will have to come after my return from Sin City and the hangover subsides.
