I didn't know then what I know now

I wanted to write a post reflecting on my experience and gleaning some insight, or something. Well, I can say I was so exhausted that it took a lot of effort to do any type of intellectual work (i.e. my paper and this blog) for over a week after finals. I also learned that medical school, at least term 1, is nearly pure memorization. I wish I knew how my brain memorized information before I started school, but luckily I quickly (re)discovered my visual learning style. The Netter Anatomy cards became a godsend.

Now it has been a few weeks since school and the next semester starts a week from Monday. I figured I would be posting about all the neat medical things I was reading over the break, but I got sidetracked everyday on random websites, going out to eat, walks around Boston with a slightly different perspective after being out of town, looking up computers, watching adult swim, etc. It was also freezing here and has been snowing most of the time, so it's been more of the coach activities than the walking ones. Some good material for facebook updates, but not this blog.

Perhaps the most rewarding part of the break was the applications of what I learned. A friend of mine mentioned how when he was diagnosed with cancer, the physicians said he had fluid around his heart and needed to go to the ER immediately. Ah, I thought in my head, Beck's Triad. It took some thinking/googling to figure out the items of the triad and the actual condition associated with it(not just the image of the ppt slide from lecture), but that was the nature of my training to that point: random associations would come back, sometimes out of context, and not always complete. But it was there. Watching medical programs with wikipedia became a combination quiz and review. As my awareness of my knowledge, and its limitations, grew, I began to get more excited about next semester and wanted to fast forward to clinical years when I could see my knowledge in action, just like on Discovery Health channel.

First Final Finished

Biochemistry is now over. Time to move on to first Histology and then Anatomy. I had a lukewarm relationship with biochem. There were parts of the class I found fascinating at first glance, such as discussions on obesity and metabolic syndrome, and others that after working really hard to understand I grew to appreciate, best example being lipid metabolism. Most frustrating was probably the endless amounts of coenzymes and cofactors that we had to simply memorize. A better organized list of what coenzymes went with what reactions could've been very helpful for the exam at least.

The best moment of the class probably came during the final, as I was reading through a question with blood test results of ALP, GGT, AST, ALT and Bilirubin and using information from the patient history (sick last week) and physical exam (yellow sclera) to come up with a diagnosis. Then actually creating a differential as I went through the question. That felt good, that felt like I am on my way to actually becoming a doctor.

Exercise May Slow Telomere Shortening, Aging (CME/CE)

Very interesting article... one of the first pieces of research I've noticed that delves into things that can reduce shortening our telomeres... a positive type of age research if you will - I'll be sure to check the references on this paper...

Exercise May Slow Telomere Shortening, Aging (CME/CE): "Endurance training appears to have anti-aging effects at the molecular level, researchers found."

In-Flight airway obstruction - what would you do?

Had an interesting discussion today in Anatomy dry lab. We were examining pictures of the larynx and describing how someone would do a crichothyrotomy. We discussed how that is done quickly on the street to open an emergency airway vs. the tracheotomy that is typically done in the hospital and can be a more time consuming procedure...
During this, one of the fellow students gave an anecdote (I couldn't find it online) about a physician on an in-flight airplane that performed a crichothyrotomy and saved the passenger's life. After this, the patient turned around and sued the physician for scarring their neck/larynx by doing the procedure that saved his/her life! The student then went on to say with the way malpractice suits are in the US, that he would not do the same thing.
I was shocked by this and argued that I would do the same thing and that it is our responsibility as physicians to help in an emergency. He said if he is not working in the hospital then he is not responsible for what happens. I countered that society has invested great resources to train us as physicians, to which he retorted that he is paying for his education and that he would not run the risk of being sued. As this was during lab, I only got partway through explaining that the government (society) sponsors our loans and didn't get to mention medicare funding for residency positions. Nevermind the ethical implications.

Now, both of our positions are based on our very limited understandings of lawsuits, mainly anecdotally or research, and our lack of having been in a similar situation with the ability to do something about it. But, it made me wonder: has the malpractice industry gotten that out of control - or at least the perception of it - that those with the power to save a life would just look the other way?

What would you do?

Mornings

I have been trying to stick to a morning schedule this semester, with spotty success. I've aimed to get up by 8 most days, only to roll out of bed in the 9-9:30 range most days. Lately, I've found that giving myself some deadline or something to do in the morning helps. Today that was getting my ID card at 8 (got there at 8:15 for it) and printing out a lecture to listen before histo lab.

As I was walking back after getting my ID I saw my first hummingbird in Grenada! I think it was a Copper-rumped hummingbird, looked like this guy. It flew around in its insect like manner and was off before I realized I brought my Nokia with its phone with me! A nice treat that may entice me to take some morning walks early in the morning...

Brainless

Just thinking about how it's been 2 weeks of head and neck and aside from cranial nerves and some vessels, we haven't really touched the brain. Just feels odd. I guess there is a lot of other stuff going on in your head and neck, like ear and eye and random ganglions and the nasal cavity and glands and muscles. So lot's of anatomy... but I feel that brain just sitting there. Waiting.

Toon Docs

Nice collection of cartoons from the Golden Age of Comic Book Stories via Neil Gaiman's journal. A few of the medical oriented ones are copied below, enjoy.

The Benefits of Cigarettes

The conversation began benignly enough: a discussion with my roommates of life cycle assessments (LCA) and how disposable coffee cups may or may not be better than re-usable mugs. It did not take long before the conversation went from the limitations of LCA to the much murkier territory of whether or not people will care enough to make changes before resource depletion forces us into a nasty evolutionary conundrum.

Why do so many conversations about environmental issues descend into philosophical arguments over human nature??

At that point it looked as if we were at an impasse - while I argued that people and society can make changes, I appeared outflanked by the cynical routine of "no way man, people just don't give a damn about anything except instant gratification". Mind you, this was a conversation among three medical students - so an interesting insight into potential predispositions towards patients. One (me) sucker thinking the reality TV junkies just might start exercising and the other thinking the lady with a sickle cell crisis is really looking for a morphine fix...

I thought about this for a moment and came up with a workable counter argument. I pointed out that smoking cigarettes was once commonplace: less than 30 years ago people smoked at work, in airplanes, at home in front of children - everyone smoked everywhere! If you had told people back then that there would be a time when you couldn't smoke inside buildings or even in bars(!) they would have thought you were crazy and that it would never happen... yet it did. And it happened because society as a whole recognized the inherit health risks from smoking and judged their lungs and wellbeing to be of greater value than convenience and gratification.

Unexpectedly, this point was granted and one more human realized that there is the possibility that things can change for the better...

Watching House as a med student

I watched my first episode of House (Season 5 - Episode 22 "House Divided") as a medical student. I think it was good timing being after midterms, because now I know just enough to catch some of the medical conversations, but not nearly enough to know what the hell is going on. It felt like trying to watch a film in a foreign language with only a year completed...The odd part was that there were two languages that I have very limited knowledge of presented in this episode: American Sign Language and, er, Medicalese...
In a way, it was more frustrating to watch the show because as the episode progressed I tried to figure out why the symptoms presented as they did:

Why can the deaf kid feel the boombox on his chest but not his arm? -- neuropathy is such a general answer!
They said Vagus and Phrenic nerve! And even mentioned hiccups with the phrenic! Yay thorax!
Eosinophilic something disease... I remember eosinophils...(meanwhile I miss 5 more lines of dialouge)

I soon realized there was no way I'd be able to do this.. this lead to my frustrated thoughts interfering with my ability to listen to the episode - which was a very good one... even the hallucination of dead cutthroat bitch was well done.
It was good to see myself progressing in my medicalese... and it gave me a bit of a better appreciation of the amount of work it will take to become truly fluent. Same goes for ASL.

Conserva-Care

Interesting reading from the LA Times - on four prominent conservatives opinion's of how to reform health care.

I find myself pretty much agreeing with Bill Frist - the only reasonable one in the article and the only MD... his proposition to focus on wellness - on preventing health not through screening for diseases (which is still needed and saves lives) but by actually addressing such as working with employers to get employees to eat better and exercise (umm, not just sit and eat Dunkins all day) and looking at how we build our communities to be better for health (increasing utilization exercise, reducing sprawl) his service on the board of the Robert Woods Johnson Foundation's Commission to Build a Healthier America is doing. That was a good start.

After that it went downhill. The most vexing was David Frum. Healthcare will NEVER work as a regular market such as how consumer products such as what does work with computers or say, shoes. I just don't see how you can incentivize health by making it monetarily penalizing people who utilize health care services more.... can someone please explain to me concretely how this would work?

I see health care costs as multi-factorial... the major factors driving up costs, I believe, our really outside the control of insurance/healthcare complex as it is currently in the debate going on right now. These are:

Habits/Behaviors - think smoking, exercise and food
Built and Work Environment (sedentary lifestyle + commuting)
Pollution (indoor + outdoor)

A lot of that has to do with how we've built our suburban dream... the long commutes, quick meals and need to drive EVERYWHERE leading to our current obesity and diabetes epidemics...

In terms of actual health-care system issues... a few come to mind:

The Fee for service of system of healthcare (hospitals/docs get more money for more tests, not for better care)
Malpractice Reform (one of the top issues eroding the salary of many physicians and leading to defensive medicine)
Uninsured Gap - it's unjust not to close this even it if costs a little bit of money.
Big Pharma (20% profit margin) and the device makers (16% profit margin) need to be reigned in
But, ultimately, Technology COSTS MONEY AND SAVES LIVES

In terms of the current bills going through Congress, it appears that the first point on "systemic" issues got watered down, that malpractice reform won't be touched and that we'll only get some - but not all - of the uninsured gap closed. And nobody has said much of anything about reigning in Big Pharma...those device makers also have excessive profit margins that insurance companies would kill for...

But the last point is really a take home from medical school. You know all those things that have extended lives (um, chemo) and made grandma be able to walk (hip replacement) and keep you alive while youre in a drug induced coma so you can survive that car accident caused by some idiot drunk drive (see the "non-systemic" section for that) - those things actually cost money. And they've gotten much better over the past few decades but also more expensive. I don't think it's the main factor, I think the "systemic" factors are all minor factors second to the "non-systemic" behavior/built environment. But it's good to have it in context of what you're paying for... which is your life. Not an iPod.

Relativity

When you are courting a nice girl an hour seems like a second. When you sit on a red-hot cinder a second seems like an hour. That's relativity.
-Albert Einstein

When you somehow manage to study glycolysis, PDH Complex, TCA Cycle, Beta-Oxidation, and Glycogenolysis all in one week - for just one class - then the amount of work feels like a month of undergrad. But throw an ever increasing histology study budget gap (well, I'm working on paying that down) and then the never-ending anatomy on top of it, and well, I can appreciate what relativity means a little better. The time has gone fast but I feel like I've been here for a long time even though I have felt there is never enough time. It's an odd feeling of going forward on a jet at hypersonic speed and the gravity pushes you back at 5g... you're making up a lot of ground but you feel slammed at the same time...

That's just a long way of saying working/studying 100 hours/week starts to wear on you. The key thing becomes time management of balancing pacing your studying, breaks, sleep and proper eating. Exercise has been helpful - I think the time sacrificed to it makes you feel better and at the same time improve concentration when you are studying.

At this level you become really conscious of your efficiency. Sitting down for 5 hours to study you want to make sure you set out reasonable goals and get them accomplished. It starts to get real obvious what reasonable study goals are for an evening or weekend are after a few times of over-reaching. Then once you find this average, the times when you don't get that much done you have to analyze why and see what is dragging you down.

For instance, I went full out last weekend and didn't take the usual Friday evening of only doing 2-3 hours of studying instead of the usual 5-6. I was able to plug through the weekend but once Monday night rolled around I really couldn't get much done. Nevermind Monday morning I couldn't wake up and so lost maybe 6 hours of work total because I didn't give myself a 3 hour break when I needed it. I think some of my classmates need to learn this... though others apply the breaks too well...

This is probably not very interesting.

I learned that hemorrhoids can be a sign of liver cirrhosis, and so possibly a sign of alcohol abuse... is that neat? I also was taught about the transverse colon - with a real one - and the hindgut, midgut boundaries - 2/3 through the transverse colon - while the professor picked up the colon to show me the spot. He got poo poo on his hands when he did that! The smell wasn't as bad as the look of it... am I getting warmer?

Future posts on healthcare coming soon.... found some interesting reading to share...

Pounds of Cure

I realized last night that I can probably already name a few dozen diseases and their causes (if not idiopathic) and some treatments for those diseases. We've learned about mutations, and improper structural formations, degenerative diseases and cancer. The information has been fascinating and is absolutely essential, but for all the diseases and treatments I've begun to notice two biases emerging - and this may have to do with the classes we're taking this semester.

First, almost all treatments we've learned about jump right into surgical treatments with barely any treatment of conservative options. This may be due to anatomy and the fact we're learning about structural defects... but still I feel as though its a bit biased regardless.
Second, though I can name many things that can make people sick and maybe a few drugs that can relieve or treat these diseases and their symptoms - sometimes removing the cause of the disease and other times just managing it, I've yet to learn much about anything that can actually improve health in patients. We KNOW about eating right and exercising, but there has been little discussion about the interaction of these factors - among others such as certain types of fruits or vegetables, or particular exercise regiments - with diseases either biochemically or anatomically.

I think this is from two main factors, among others - first that we need to know what can really kill people so that we can rule these nasty factors out when treating diseases (zebras) and two, already the allopathic model of treating disease rather than focusing on prevention, is showing its true form. It will be interesting to see how this plays out over the coming months and semesters of medical school.

On a somewhat related note - there was a Complimentary and Alternative Medicine course given as a selective this semester. I wanted to but couldn't find the time to go - but I see it (at this point) as a separate compartment and not really integrated into our overall education. In the end, this is less the fault of SGU and more the structure - I would assume - of the USMLE.

Of course, the whole prevention/cure thingy can be perverted a bit...

Dream Anatomy

This week, I finally learned how to learn in Anatomy. The class that was feeling overwhelming just became one that I can chart a course towards an A. I felt a wave of desperation on Tuesday, but remembered how I memorized things in the past - by just looking at it - and I sat down with my Netter's and was able to memorize all of the muscles of the forearm in one night. The following night I took care of all the features of the ulnar, radius, humerus, scapula, and clavicle as well as the nerves and arteries of the arm. When I went to lab this morning I knew what I was talking about and could understand even when I didn't get things right what was going on and why. Suddenly, the class transformed into one of going over notes and trying to apply hazy terms to traveling in an unfamiliar country with a handheld GPS loaded wtih ArcGIS desktop. I may not have known everything but I can figure it out.

This copperplate engraving, held by the National Library of Medicine and part of the online interactive Dream Anatomy gallery, show the posterior compartment muscles of the forearm which are innervated by the radial nerve and act on mainly extending the wrist, fingers and thumb. It marks the true beginning of my journey into Gross Anatomy.

A Clockwork Cervix

Last week was my first Anatomy lab, though I did go to lab the previous week to get study tips from honors students and check out the bodies.

It was an interesting experience and gave me that "I'm really in med school" feeling that apparently traveling 2,000 miles and attending lectures for the past two weeks coudn't quite do...

The anatomy lab is divided into 4 portions: Dry Lab, Wet Lab, Small Group Discussion and Physical Examination.

For me, first was dry lab. Ok, so it's 8AM and we're looking at X-Rays and going through some discussion questions in pairs. The guy with me knew what he was doing so that was good. I was still waiting for my coffee to kick in.

After going through a few pages of X-Rays the Prof's call attention to the front and begin to show slides on the TV screens hanging throughout the lab. Then they point to structures and begin to randomly call on people. OK, I think, I can handle a question... then, before I realize it I am one of the 5 people (out of like 50) that are called on. OK, it's a softball.... nice and easy "what is this structure here?" and she's pointing to the Cervicle Vertebrae.

I know this!

So I blab out "that's the cervix vertebrae"

Silence.

Professor: "Nooo... guess again"

I am stumped - didn't I just say what it was?

I can't remember if I say anything but before I know it she call's on someone else and they say "Cervicle Vertebrae" - Correct!

Dr. Brahim offers consolation since cervix does mean neck, just not in that part of the body... afterward he says my mind was in the right place. Cervix, of course, is in the uterus.

AAAH!

Things get better from there as wet lab went well. We go around in clockwork to different bodies which are arranged in stations showing different body parts. The spinal cord that was just on its own was neat. Random farm animals announce when it is time to switch stations, which is only after about 2 minutes.

Some people are a bit immature around the cadavers and show a lack of due respect by playing around and joking. Probably just their way of coping with the situation. At the other end of the spectrum are those who don't want to touch the body at all. I'm interested in figuring out what it is I need to know so I just jump right in and poke around. Most of my guesses are wrong but I learn so it's OK.

Then was off to small group discussion where we were admonished for not knowing the arteries of the vertebrae well enough but I ended up making up for my cervix obsession by giving a nice summary of the spinal stenosis clinical paper we had to read - and now don't have to give another summary all semester ;)

The physical exam was fun as we got to palpitate various parts of the back and find various vertebrae based on landmarks. I also showed people my scoliosis which they all remarked upon with interest... but for a bunch of future docs, only 1 actually showed sympathy and asked what the future complications are for me with this disease. To which I referred him to the spinal stenosis paper.

Overall, an interesting time and I look forward to more physical exam and wet lab... and hopefully the papers will stay interesting too.

Better than Ambien

Watch out big-pharma! A new sleep aid has been discovered here at SGU! Listen to this:

""I always thought I was a funny person, but when my sleeping problem got in the way, I wasn't myself anymore. I thought over-the-counter sleep aids would do the trick, but they only made me feel groggy the next day and didn't always keep me asleep. Then my doctor recommended BIOCHEM lectures at SGU. Now I stay asleep*, and can concentrate on the day ahead. I am back to my old self again. Heck, even Frank's jokes are funny now.""

-Brian: Year 1 SOM student at SGU

I know that if I ever have troulbe sleeping, a double shot of Dr. D and Dr. T will put me right to sleep.

Why do people have to read right off of slides in a monotone voice??!?!?

Crooked Timber

Excellent blog linked from the birdog: crookedtimber.org

I may not agree with everything on this article, but it makes a good read regarding the manipulation of evidence based medicine to get "policy-based evidence making", the discussion is good as well.

Another good article on Crookedtimber.org (via Boing Boing) dealt with the ongoing scandal at Elsevier... to summarize, basically Elsevier put together several psuedo-journals that were basically a collection of articles favoring pharma companies and given legitimate sounding titles such as "The Australasian Journal of Bone and Joint Medicine". More details at the Gaurdian. Are we surprised to see Merck involved with these schenanigans?

Oh yeah, first anatomy lab/full week of medical school posting coming sooon....

Nutmeg jam, peanut butter and banana sandwich.... mmmm

Attachment, actions and innervations of glenohumeral joint muscles... hmmm

Morning Lab Poll

Lots of sleepy faces at lab this morning, so I took a quick poll of my group:

"How many people got more than 6 hours of sleep last night?"

Nobody says anything, but the nice lady (can't remember name) across the table says "I think I got 6 and a half hours"

I can feel the envy around the table, but the general exhaustion prevents anyone from actually expressing it...

The lab TA (who is an MD) thinks in her head "sleep? hahaha"

Oh, and it's only week two!

Observations of a former cubicle dweller

Two weeks into med school and a few things have stuck out about how this land of palm trees and cadavers differs from that of the flourescent tinged cubes and long lunches.

First, the commute. I live on campus and have to, gasp, walk to my classes and labs. Tomorrow, for instance I have the extraordinary commute of 300 ft to my 8am histology lab. On those really tough days, I have to walk up a 100 ft hill to get to Anatomy Lab at 7:45 am... but it's still only a 7 minute walk. Yet, people complained about this.

Being a former cubicle dweller with a 30 minute commute to work and an undergrad that made his way through the juice to the blood (er, orange line to red line) and finally the awesome crystal transport buses to arrive at campus... well, I can appreciate the short commute.

Second, length of the day. Oh my gawd - It's 3pm and we're still in class. I can't believe we have to put up with almost 8 hours of lab and class on those really really long days. I can barely handle it. What? some people do this for the entire life?? They must be crazy!

Aren't we training to be doctors, people? And don't docs work like notoriously long hours? hmmm.... some people need more adjustment than others.

Ok, so it's a bit of a cranky post, but really I can appreciate being a student so much better after a few years in the work world. Yes, I did do less work when I had a 40hr work week, but campus life is so much easier in many ways. And, if I take the 'long' way home (10 minutes) I get to see some of the ocean as well...