On the road again

So I have to say, hindsight being 20/10, I ended up enjoying my psych rotation a lot more then I expected. I'll readily admit my preconceptions of patients with mental illness were too skewed by popular culture; I think I was expecting more of a Hannibal Lecter flavor. A "What are the voices in your head telling you Mr. Williams?" "TO KILL YOU!!!" sort of thing. But, fortunately, I found my interactions with patients to be generally pretty interesting and much more pleasant on the whole (exempting one interview with a drunk patient with narcissistic personality disorder). Especially gotta love the schizophrenic patients. Such a sad disease, but a rich source of some purely AWESOME conversations.

Anyways, like it happens time and time again during third year, just when you get comfortable in a rotation, the dean's office picks you up and plops you down in another unfamiliar location. For me, for the next 5 weeks, into a low income family practice clinic on the southeast side. It's been a tough adjustment coming from a rotation where I was afforded a great deal of autonomy and input into patient care, namely because the physician I'm working with has somehow come under the assumption I have the IQ of a sheet of dry wall. Cue one interaction I had today in clinic:
*MedZag, presenting patient to attending while in patient room (I know, awkward.)*
MedZag: Ms. Rogers is here today complaining of persistent worsening of allergies of the past 8 months. She states her main symptoms have been rhinorrhea, nasal stuffiness and sneezing, sore throat, and some intermittent wheezing. No sinus pain or pressure, no cough, no shortness of breath. She tried a trial of Claritin for 2 week...
Attending: So what brings you in today Ms. Rogers?
*Physician and patient proceed to start talking and cover all pertinent points I was about to distill in my presentation*
*Attending begins physical exam*
Attending: Now, if you see here MedZag, if you look up her nose you can see fluid.
*biting tongue*
Attending: You can also see swelling. This is very characteristic of allergies.
MedZag: Hmmm, yes, interesting. I also noticed that when I performed a physical exam (not so subtle hint). I had some ideas of an assessment and plan, would you like me to continue?
Attending: Oh no, that's ok. We'll just give her some Allegra.

This is going to be an interesting 5 weeks.

Dear kidney, I love you.

The following words were uttered from my mouth this past Thursday:

"I hate this so much it makes me miss 'renal'."

Yes, neuroscience, neuroanatomy, neuropilates, all that neuro- junk has officially crawled itself to the top of the Super Aggro Crag that is my 'Most Hated' list. Maybe that's because I've spent the past 3 days straight cramming for an exam I spent the previous week and a half being a piece of crap preparing for. But I'd rather pawn off my irresponsibility on the subject matter. I was at Macaroni Grill last night and all I could think to draw on my paper tablecloth with my Roasted Pepper Red crayon was a f#@cking diagram of the cerebral cortex (complete with labels!). I am so much better then that.

Exam tomorrow. I will feel so much better when I purge myself of this information all over that scantron sheet.

Until then, I defer to Bobby Boucher.
Mama says that alligators are ornery 'cause they got all them teeth but no toothbrush.
...
Somethin's wrong with his medulla oblongata.

Splash.

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.

Fievel Goes to Medical School.

Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday. Study, study, study, study, study, study, study.

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 even has my skin tone.

I am a medical student. A big, bad learning machine. Well adapted to its environment, with skills honed at survival. That is, until the end of the year workload comes, and bites my fucking head off.

***This post in tribute to the infectious disease block we are currently slogging through, aka "101 things you do not want growing in your body" aka "I am never traveling to anywhere outside of my apartment again"

***This post also in tribute to the 5000 visitor milestone I just passed. That's cool. So are people who visit this lame blog.

***This post also in tribute to the 4 other posts I have started but not finished. I look forward to the day when I have sufficient motivation to finish them. That day is June 14th, or the mythical "summer vacation" I have heard about but lost hope in long ago.

Super Hyphy

So we just started our micro/infectious disease block, and blew through all the fungal infections in 3 lecture hours. Which included such vividly lovely descriptors such as "grainy exudate," "cauliflower-like," and "versicolor lesions."

These lectures are mind-numbingly boring, especially right after an exam. Yet, even in my fungally induced coma, I noticed there seemed to be an unwritten law amongst mycologists. For every disease of the fungus, thou must havest four slides:

Firsteth, thou must haveth a slide that talks about how common this fungal infection is and how important it is that you learn it. (BS)

Secondly, thou must haveth a slide showing a highly advanced form of the fungal infection in attempts to gross out the students. (BS)

Thirdly, thou must haveth a slide talking about Amphotericin B. Complete with requisite "Amphoterrible" joke. And a tiny aside about the azoles and how they are actually the mainstay of treatment. (Not really BS, but redundant)

And fourthly, thou must haveth a slide showing a KOH prep or biopsy slide. (see right)

Now along with every microscopy slide must come the following remark: "If you were a good mycologist, you could differentiate the species based on this slide." There are two things wrong with this statement (I'm big into lists today). One, I am not a good mycologist. Two, I have no desire to ever become a good mycologist. In fact, the odds of even one person from our class of 126 becoming a "good mycologist" are well below .500.

But I digress. Maybe we should be more appreciative of our mycologists. After all, when it comes to deadly systemic fungal infections, there isn't mushroom for error

...

I'm sorry that was in spore taste.

Venti Coffe, No Cream, Hold the Sympathy

Good news for me: Goodbye kidney. I have now put in my requisite time for the year learning about pee. Yippee.

Leading up to this last exam, I've noticed a trend that's been developing over the last few months. See graph:


The funny thing about burnout is how it sneaks up on you. Time starts to slip away from you, the days start to blend together, and before you know it you're sitting in starbucks with 3 empty venti cups strewn about you staring bleary eyed at the same page of notes you've been looking at for the last 1/2 hour, listening to the crazy woman in the corner talk on her corded phone thats not hooked up to anything, then getting a free 4th coffee from the barista who looks at you with a sad sympathetic look in her eyes as she says "you're always here."

Thanks for the free coffee.

Luckily, I have two of the most potent drugs possible for combating the dreaded burnoutosis (its not quite developed into a full blown -itis yet). The two magical medicines are:

-SevenDaysOfDrunkenessonix (generic name: spingbreakatol)

-Guinnessium (generic name: stpatraxia)

Applying my mad pharmacokinetics skillz obtained over this last block, I had my proper loading dose of stpatraxia on Saturday and now plan to work my way into therapeutic levels tomorrow, March 17th, the greatest day of the year. Hopefully this can help keep off some of the more severe symptoms of burnoutosis until I had get onto a steady regimen of sprinbreakatol on Friday. And yes, my life has now degenerated to the point where making lame jokes turning fun things in my life into fake drugs is highly amusing to me.

I have a couple cool stories from clinic to share sometime soon (one thing I've learned about pediatric oncology - there's always stories), but given my current level of motivation (read: none) it will have to wait. Maybe when I'm sufficiently medicated with springbreakatol (I'm so funny!)

Any Given Sunday

Being a former football player, I am well familiar with the saying that football is a "game of inches." Well, so is medical school.

Yes, my enjoyment in life is directly proportional how many inches thick my syllabus is for that given block.

To keep my football analogy going (you know how much I love analogies), I have established the "how much my life sucks at any given moment" scale - complete with football comparisons.

Syllabus is 1" Thick
Football Analogy: This is like having a three touchdown lead in the forth quarter. You're calling a running play every time just to chew up the clock, the other team knows you're calling a running play every time, and you're still averaging 5 yards a play and the game in totally in the bag. No anxiety, the fans are cheering their heads off, you're sipping some mighty fine gatorade on the sideline, just soaking in the scene.

Medical School Translation: Yeah, I love when my syllabus is this skinny. This is when I truly love medical school. The amount of material is manageable enough you can take a good number of days off from studying. I can find time to do more actually medically related things like scrubbing in on surgeries or reading the new england journal of medicine. But mostly I am finding time to go to the gym, go on runs, frequent bars, drink beer, and watch sports. Ah, life is good at 1" (that's what she said).

Syllabus is 2" Thick
Football Analogy: This is like having a one touchdown lead going into halftime against a team that on paper you should beat but is putting up a good fight. The other team is good enough you can't coast and the game isn't nearly in the bag yet. But at the same time, you got the lead and you got the better team. You should win, but there's just enough of a question mark about the outcome you got to be on your game.

Medical School Translation: This is status quo for medical school. Everyone should theoretically be able to handle the amount of material just fine, but at the same time, its just enough to strike a small bit of fear into you. You can't coast on two inches, but at the same time, you can handle it just fine. If you stay on top of your shit.

Syllabus is 3-4" Thick
Football Analogy: This is being down by two with two minutes left and you just received a punt on your opponents 40 yard line. You got a proven clutch time quarterback and all the pieces to drive within range to kick the field goal for the win. But you're down. And time is your enemy. Will you be the hero or the goat?

Medical School Translation: This is where you start to go "oh shit." It seems like a LOT of material and you wonder if you have enough time to get all your studying done. But at the same time, you have a proven clutch time quarterback (your brain). This is make or break time in medical school, when you need to start giving up an inordinate time with things you enjoy (beer and sleep) for time with the books (lame). But when you kick that field goal for the win (pass the exam), damn, it almost makes it all worth it. This is where legends are made. At least thats what I tell myself. Wow, I'm lame.

Syllabus is 5"+ Thick
Football Analogy: This is where you're out of timeouts and down by a touchdown with 45 seconds left and attempt an on side kick to get to ball back to try and tie the game. Only the other team recovers the on side kick and just has to kneel to run out the clock. Game over. You lose.

Medical School Translation: Thankfully, I have yet to experience a syllabus of 5 inches. And hopefully I won't have to anytime soon. But I know I will have to at least once in my medical career. One word: Boards.

So where am I right now? Squarely at 3.5":


By my very definition, I should be giving up things I enjoy right now, so why the hell am I posting a new blog? Well, I might just have to chalk that one up to ego. Or being an idiot.

Death.

Every medical student knows this image.
Every medical student fears this image.
Every medical student hates this image.

Yes, it's reached that time of the year when we have the privilege and honor of studying... metabolism! Of course, this is only our first romp with it, we'll get it again next year. And that's what so great about metabolism - it sucks so bad that they give it to us twice!

What's that you say? If I had a dollar for every disease that somehow involved the metabolic pathway I could likely pay off all my med school debt? Ok, so I guess its important. But you try learning it all in 12 days. Yes, if there's one thing I've gotten good at lately its complaining. And all of this ridiculous information will be purged from my brain within minutes of taking the final. But still, you try learning it all in 12 days.

I Enjoy VH1 Celebreality TV.

There's different types of tired. There's just-had-a-crazy-intense-workout tired (which I actually enjoy). There's running-on-too-little-sleep tired (which I definitely don't enjoy). There's an emotionally drained tired. There's a been-running-around-all-day tired.

Right now I'm feeling a wholly different kind of tired. My brain is tired.

I am currently about to start the second week of a three week gauntlet where we have an exam each week. As I have already covered, preparing for a medical school exam is like preparing for 4 college exams in the same day - it's a week long process that requires a great deal of time and energy investment.

My previous strategy for surviving these draining cram-and-purge periods was by mailing in the week of school after the test. Not studying much (ok, at all). Maybe catching up on study objectives for a couple hours max on saturday. It worked well, gave my brain a nice break, gave me a chance to hit the gym, and when it came time to get back to work I was more than happy to jump right in. I really liked mailing it in.

I took my final GIE exam last week, a grueling exam on 3 weeks of material that was easily our most difficult challenge yet. This week I have a cumulative exam for our Principles of Clinical Medicine class. Next week is our first exam for our new Cell Structure and Function curriculum. Basically this requires me to be in full balls-to-the-wall study mode for 4 weeks straight. I can now understand why Pheidippides fell over dead after his sprint from Marathon to Athens.

So what's it like to be brain tired? Pretty easy to describe actually. Motivation? You lack any of it. Sense of humor? Well lets just say I have no problem perpetuating my blonde hair stereotype at the moment. A little slow on the uptake. Energy? Good luck, even on the back end of halloween and its copious amounts of candy lying about - no sugar high can touch my fatigue. Quad venti caramel low fat peppermint mocha latte extra hot? Please, I'm not even sure a line of coke could move my flatline.

Thankfully, at the end of the tunnel is a four day break for thanksgiving where I get to mail it in and not feel guilty about it. I think someone on our med school curriculum board has a soul. And if there's one undeniable truth, its that I will eat my weight in stuffing, park my butt on the couch, and have the most amazing nap of my life. Just got to get there first. Anyone got any coke?

Private Snowflake.

I've never really had a problem with tests in my life. Not because they haven't been difficult, I've had my fair share of those. But I've never been the type to stress out before tests (or study for them). Get in, get out, quick f*ckin' about.

Enter medical school. Our first exam of the year looms at the end of the weekend, a 4 hour behemoth called "GIE Exam 1." I just battled my way through the first level of medical school, now I gotta beat the boss. And you know the funny thing? I'm not stressing too much. Oh, I have enough of apprehension in me to keep me in the library all weekend, but (and I can't believe I'm saying this), the material doesn't seem "that bad." Just 3 weeks ago, I got my 2 inch syllabus, and my jaw dropped 20 inches. Now, it all seems damn reasonable. A continual evolution of me, I guess. That being said...

Preparing for an exam in medical school is like preparing for war.

Studying for it is an intensive endeavor. Packing my bag in the morning is like preparing to go on a week long recon mission. I need my manuals (books), water to stay hydrated, source of energy, source of caffeine, radio (ipod). Throw it all on your back and trudge off for 12 hours.

The exam is close to 4 hours long. For comparison, the LSAT is close to four hours long. I am taking an LSAT I only had 2 1/2 weeks to prepare for.

The exam is split into two parts. The first half is multiple choice based on lecture material and the questions are framed to be like what we'll see when we take the United States Medical Licensing Exam (USMLE) Step 1 following our second year. I haven't taken a multiple choice test since my lower division sociology class at Gonzaga (upper division profs considered them "too easy"), but wouldn't you know, I'm taking them in medical school. The second half of the exam is the lab practical. The day before the exam, the lab professors and 4th year students go through each of our dissections. They grade the dissections, and choose structures from each group's cadaver that are good representations of what things SHOULD look like (or, as our course director says, "we're really superficial, we choose things that look pretty"). For the lab practical, you enter the lab and start at a station. In front of you is a cadaver, and in this cadaver are tiny metal pins. At the tip of these pins could be a variety of structures. The filum terminale of the spinal cord, the recurrent branch of the median nerve, the extensor carpi radialis brevis muscle, the thoracolumbar fascia. If its a muscle, you might not be asked the name, but will be asked where it originates, or where it inserts, or what it does, or what nerve innervates it. Obviously, this is a very daunting task with no Word Bank to help you out. You have 60 seconds to identify the pins, pick their names out of thin air, and move on to the next station, where a whole new set of pins await you. At least we get to stand.

Obviously, this sounds like a really fun way to spend a Monday (sarcasm). I've been trying to put my finger on why I'm not FLIPPING SH*T about this exam, and I've yet to find a good reason why not. Maybe its because I'm a person the world needs most (thank you Gonzaga). Maybe it's my ego. Or maybe my brain is really just running that well after years of lack of use (and abuse, likely). I think above all the main emotion I'm feeling going into the exam is simply... curiosity. These will be the things that judge my progress for the next two years, and I just want to get the first one out of the way to see whether my study strategies have been working so far.

So, we'll see how it goes. The class is going out to happy hour after the exam, and I'll either be celebrating or drowning my sorrows. The nice thing is all you need to do is pass. As they say, "P's get MDs."