You know you're in med school when... (IV)

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.

You know you're in med school when... (III)

You look forward to Christmas not for the family or the time to relax or the weather or the music... but for the Starbucks gift cards.

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.

MSII in a nutshell.

Yes, med school is the equivalent of a sadistic 7 year old. And yes, I have a similar sort of grin on my face as med school gleefully tortures me.

New stuff coming soon. I promise. Until then, I'm focusing on keeping my humeruses (humeri?) from dislocating from their sockets.

"Wow, I had no idea med school was so bad for you."

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.


"Wow, I had no idea smoking was so bad for you."

Ah, medicine.

Your 44th President of the United States of America.

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.

But I think he is going to be an good one.

Constructive Feedback.

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.