I thought it would be interesting to total the number of exams I will take prior to my first clerkship in medical school.
A 33yo woman comes to your clinic with bilateral cervical lymph node swelling and fatigue.
Examination: Afebrile. Several bilateral 1-2cm cervial lymph nodes that were soft, non-tender and freely movable. No other lymphadenopathy. Her chest was clear, heart sounds normal, but she had mild tenderness at the right costal margin on deep inspiration.
Lab studies: Hct 37% WBC 5,200/uL, ALT 75 units, AST 70 units, AlkPhos 140 units. UA nml.
What is the (infectious) differential? What testing do you want?
I have been cramming physiology, anatomy, histology, pathology, biochemistry and pharmacology into my head since August 4th 2008 and I am not one tangible iota closer to being able to effectively treat patients. It's not that I haven't learned anything, it's just that most of what I've learned is foundational. It's like building a house: when you drive by a newly laid foundation it doesn't look like much progress despite a terrific amount of work.
Yesterday I shadowed on the pediatric cardiology ward. This is a leading candidate for the kind of physician I want to be in the future and a field in which I have been published for clinical research. I didn't expect to keep up with the residents and fellows, but I thought I'd get some of it... maybe 10%?
Try less than 1%. About the best I could manage was knowing what the acronyms stood for. I knew why they wanted albumin levels and I correctly identified respiratory acidosis. But I couldn't tell you that the pleural effusion was protein or why, what the difference between a surgical and pigtail chest tube was, why you would withhold anti-fungals on the febrile baby with mediasteinitis, why a triple lumen catheter was better than a double, which port you put the guide wire through when changing a central line or what a 3/4 Fontan was. It was intense, thrilling and terrifying. How am I supposed to get from what I know now to being responsible for a pod full of patients like that?
Plenty of people dumber than me have become good physicians. I find myself repeating that a lot lately. I too will learn it and master it. But it was certainly a hip check to see just how long the road ahead is.
To end on a high note... I loved the day on the PTCU anyway. Despite feeling cluess most of the time, I loved it there. It's a great mix of medicine and procedures, acute care with repeat patients, interesting problems and enough good outcomes. One day my life is going to be amazing.
We recently had a lecture on bioterrorism within our infectious diseases sequence. One of the potential diseases that could be used as a weapon is Tularemia, a not-too-deadily infection caused by Francisella tularensis. It has a low infective dose, does not spread human-human, but you would feel like crap for a while. The Soviets were accused of using it and the US even researched its use as a weapon in the '50s.
Anyway, what I think is much more interesting is the outbreak that occurred in Martha's Vineyard in 2000. The CDC documented cases of people getting sick from lawn-mowing. Apparently, they mowed over nests of infected rabbits, aerosolizing the infected rabbits and inhaling the bug. That's right. The people of Martha's vineyard got sick from aerosolized bunnies.
It was then published in the Journal of Clinical Microbiology.
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1233993
My professor sang this to us in lab. Then he played a CD of his son's band performing it. It was originally printed in JAMA on Jan 31, 1942. Can you guess the disease?
There was a young man of Black Bay
Who thought syphilis just went away,
And felt that a chancre
Was merely a canker
Acquired in lascivious play.
Now first he got acne vulgaris,
The kind that is rampant in Paris,
It covered his skin
From forehead to shin,
And now people ask where his hair is.
With symptoms increasing in number,
His aorta's in need of a plumber,
His heart is cavorting,
His wife is aborting,
And now he's acquired a gumma.
Consider his terrible plight--
His eyes won't react to to the light
His hands are apraxic,
His gait is ataxic,
He's developing gun-barrel sight.
His passions are strong, as before,
But his penis is flaccid, and sore,
His wife now has tabes
And sabre-shinned babies--
She's really worse off than a whore.
He aches from his head to his toes,
His sphincters have gone where who knows,
Paroxysmal incontinence
With all its concomitants,
Brings forth unpredictable flows.
Though treated in every known way,
His spirochetes grow day by day,
He's developed paresis
Converses with Jesus
And thinks he's the Queen of the May.
One of the curricular elements here involves students visiting a family with a chronic illness several times over the course of two years. We then form small groups and create an interpretive multi-media project expressing common themes in chronic illness (as well as writing a series of reflective essays). While the visits are enjoyable and certainly lead to reflection on what it must be like to live with a chronic health issue, this is medical school not art school. During the most difficult sequence of the M1 year I am expected to come up with an interpretive art project?!
My two partners and I have decided to create artwork using the board game Life. We are going to remake the game board and glue it and other related game pieces to a giant posterboard. It's supposed to represent that illness is not really in one's control and that it affects all facets of life on a longitudinal scale. Or something like that.
When we proposed the idea to our class there was a certain amount of horror: you are going to make a game out of chronic illness? Crap. We hadn't really thought that through.
The best projects are then chosen to be displayed at a reception that all the families (and medical students) attend. I'll put up $20 that our remake of Life is not chosen.
We had our anatomy closing ceremony today. After seven months and 32 labs of dissection, we have completed the anatomy curriculum. The occasion was marked by a series of awards, given out by the legend himself, Dr. Burkel, for the best anatomy students. I received recognition for setting up the practice exams for every sequence (with my colleague Zach).
One of the body donors had written a letter to the students who would be dissecting him and it was read to the whole class. It was a poignant and appropriate moment, but it was nevertheless awkward. While I try to be respectful of the body I worked on (I never cut of random body parts for fun or put him in strange poses), I simply cannot think of him as a living, breathing man while I'm sawing off his cheekbone or cutting his genitals in half.
Anatomy was a rite of passage, but I'm not unhappy it's over. It's important and valuable material, but it's simply not my favorite subject. I will miss the anatomy faculty, they are truly great teachers and interesting people.
Histology is also over, but that seems less momentous. Onwards to histopath! Only two sequences left... infectious diseases and development (and some clinical weeks in between). Two more months, then I'm an M2!
Medicine is an interesting career in that it has very specific points at which you are forced to make a choice about what you want. The quintessential one is match day; there is a specific date on which everyone finds out what residency (and where) they will complete. For the current M4s, match day is this week. Medicine is also unique in that you are told where you will go - you don't get to weigh offers and choose one. You interview, you state your preference, and you hope to god you get what you want.
I have a lot of friends outside medicine right now trying to change jobs or get into graduate school and many of them have mentioned they envy the structure medicine provides. The next few years of my life are basically planned for me, but I find that terrifying. What if I can't make myself attractive to a residency program I want? What if I get stuck in a city I hate? What if I choose the wrong residency type (ie peds vs. surgery)?
I feel as if I have given up so much to do this, to be a doctor, and it doesn't end. I gave up a financially better career (banking) in a phenomenal city (NYC) to spend two years in night school just to apply to medical school. Now I'm living in a place I don't really like that's far from family and friends because it will give me the best chance at one of my top residency choices. I don't have the time (or energy) to play tennis or read books anymore and I can't keep a relationship together. I can't even make it to a friend's wedding or my 5-year college reunion. What do I have to give up next?
I know that what I'm doing is the best investment for my future and that I truly want to be a physician and yes, I am aware that eventually, when this is all done, I will have job security and a decent income (well... that depends a little on Obama...). I guess I just wish I was a little happier now. It's all well and good to plan for your future, but I seem to forget that I have to live in the present.
I know it's been a while since I've posted regularly. I can give you all kinds of excuses (medical school is a lot of work, I've been traveling a lot), but honestly it doesn't mean much unless you see me post regularly again... so let's see if I can manage that.
The first year of medical school (to date) has been a little different than expected - there is a lot less patient interaction than I was accustomed to while being in the hospital. It's a lot more social than you think - we work really hard but we go out a lot too. On the other hand, it's also cost me more than I expected and I don't likemy geography at all. I love my school and my classmates, but I don't like living in Michigan (too far from friends/family/big cities). Some notes:
1. I hate anatomy. It takes up a lot of time and it's not that interesting. Apparently this means I am unlikely to become a surgeon.
2. I love video-taped lectures and flex-time quizzes. It gives me autonomy and allows me to pursue activities outside of class.
3. I was in a swing dance performance
4. I am doing clinical research again (on HLHS). I didn't realise how much I would miss it, so it's really nice to be able to work that into my schedule.
5. I am a MedBuddy coordinator - we pair medical and nursing students with children in the hospital for extended stays. The students visit the kids 3-4 times a week. I also have a MedBuddy - cutest little girl ever!
6. Two of the papers I was co-author on have been published!
7. During an a series of alternative medicine lectures I received a massage and had an acupuncture needle put in my hand (it feels weird).
8. I went to the inauguration
9. I went to Rome, Florence and Paris for spring break
Ok - I think that covers some of the cooler tidbits. I will keep you updated!
I've finally put my finger on why dissection is making me feel a little hesitant and slightly uncomfortable. It's not cutting into a body per se; I was fine while watching surgeries. It's the fact that dissection is intentionally destructive. Surgery is about health and healing, about the best interest of the patient and their future functionality and quality of life. Dissection is about complete and total deconstruction with no consideration for the future. It feels like a violation because this is invasion with no intent to heal; it's taking apart a human lego set piece by piece knowing that not only can you not put it back together, you're not even going to try.
On the one hand I want to be respectful, this was a person and even in death they deserve to be treated well. On the other hand, I want complete detachment and dehumanization because otherwise, how do I (inexpertly) flay someone's father/brother and just go home and make dinner?
In some cases, the body donor willingly gave themselves, but the family did not. How do I look those family members in the eye, knowing that what I'm doing is against their wishes? I don't really want to meet the family (now); that will only make it harder to keep cutting. Do they really want to meet me? Do they really want to see who is doing this to their father/brother? Will I look undeserving to them? Not what they imagined a future doctor will look like?
I have successfully completed the first sequence in medical school: patients and populations. It was comprised of three threads: Medical decision making, pathology and genetics. If anyone ever told you there is no math in medical school, they were wrong. Bayesian probabilities anyone?
It was actually quite a nice starting sequence because we had no anatomy or histology
- giving us more time to get to know each other and the town. Once a week we had patient presentations, for example, the mother of a son with Down Syndrome, a woman who has tested positive for Huntington (but is still clinically asymptomatic) and a girl who was diagnosed with colon cancer at 22.
Speaking of extra-curriculars... the first football game was Saturday! You have definitely not seen a tailgate until you've seen a big 10 tailgate. Wow.
We have met our cadavers though and dissection begins Sept 2. Histology Sept 3. Next sequence: Cells & Tissues.
(one photo is from the tailgate, the other is karaoke night)
According to Dr. R, it is very important that we understand the concept of diapedesis; a phenomenon observed in the inflammatory response. So important, in fact, that he acted out the apparent struggle of a neutrophil trying to squeeze through an endothelial cell to attack a microbe (played by an M2). Popping across the stage in apparent success he yelled "I have diapedesed!" Later that night I felt the very same struggle when trying to cross a packed dance floor to get a glass of water. I couldn't help it, when we finally made it to the edge of the crowd, I turned to my roommate and said "I have diapedesed!"
Scientific definition: White blood cells migrating across the endothelium due to injury or trauma.
Real world analog: Crossing a packed dance floor due to thirst or heat.
