Party in the (Questionable) USA

Today, I decided to take a break from my ED shift and eat dinner. Kind of an unorthodox move, but I figured that I owed it to myself to get some nutrition. That, and the ED attendings are really nice/don't seem to care. But I still felt a modicum of guilt as I chugged my TruMoo chocolate milk in the cafeteria, so I decided to cut dinner short and head back to the ED after 15 minutes.

As I came out of the staircase and walked past the first-floor elevators, I came across an elderly white gentleman and a younger woman. Naturally, I was in walk-really-fast-with-pseudopurpose-mode. As I buzzed into the ED and half-ran through the doors, I heard a doppler-effect-modified grumbling coming from the older man to his companion: "Are we in the United States anymore?"

Short answer: Yes. Welcome to the present and future.

Additional unnecessary questions:

• Surprised at seeing an Asian doctor? Please visit TMEC auditorium immediately. Or any hospital.
• First time at Cambridge Health Alliance?...
• Which skilled-nursing rock have you been hiding under for the past umpteen years?

Nerves.

Taking on some Victorian-frailty chic, I'm getting nervous about call tonight...

I don't really know what I'm getting into. I'm pretty sure that it will be a great learning experience. But goodness, this is intense.

In other news, my steamer has arrived, and I was able to steam out the wrinkles in a shirt pretty quickly. This device is going to change my life--for the better, hopefully.

Changing horses...

...with one hoof in the stream.

Without much explanation, I've been switched from pediatrics to medicine, which means that I start two weeks of inpatient medicine on Saturday night--my first night of call.

I have much fewer excuses not to know things about adult medicine, so it's time to do a lot of reading.

In other news, perhaps I should make it a goal to make this delight before the end of the summer.

Third Year Begins

Last Thursday was the first day of year three of my medical education. For the next year, I'll be working in the hospitals and clinics of the Cambridge Health Alliance. My experience will be a little different from the standard "clerkship" model of clinical medical education in which students rotate through discrete disciplines serially. This type of model is used at the other three major teaching affiliates of Harvard Medical School: Mass General, Brigham and Women's, and Beth Israel Deaconess. Instead, as part of the Cambridge Integrated Clerkship, I'll be following a panel of patients longitudinally, integrating the different specialties of medicine throughout the year.

So far, I'm both excited to be done with classroom-based learning and anxious to be on the wards. As with about every other part of my medical education, I've been told that I won't understand what I'm about to get into until I'm in the thick of it. While this description of self-realization during medical education has proven true in several cases over the past 1.5 years, knowing that I my uncertainty is intractable does not, in fact, allay of my immediate fears and concerns. Meanwhile, there's no guarantee that I will like what I find around the corner, making the potential for disillusionment very real.

My most acute concern has to do with "call." Generally, being "on call" as a medical student means that the student admits one or two patients to the hospital during the night service, serves as a point-person in presenting the patient's case to the medical team, and follows up with the patient until discharge. My first night of call will be this Sunday--in the pediatrics unit. I'll be the first to admit that I know nothing about caring for children. We barely covered pediatrics (for literally less than 1 day) during second year, and this trial-by-fire approach is anxiety-provoking, if anything.

Thus, my current priorities:

• Learn what a child is.
• Review the physical exam.
• Figure out what "call" actually means...
  

I may not know any embryology...

But I have managed to watch all three seasons of Arrested Development in 4 days. Check!

Similarities between medical education and the armed forces

The top-emailed piece on NYT.com explains how MS PowerPoint, not Al Qaeda, may be the military's chief foe in the War in Afghanistan. Apparently, the pretty transitions and graphics only "create the illusion of understanding and the illusion of control," according to Gen. James N. Mattis of the Marine Corps.

This is a lesson that medical students know all-too-well. Exhibits 1a and 1b: Compare the US Military's strategy in Afghanistan (1a) with metabolism (1b).

Also, personal experience has demonstrated that it is actually possible to sit through an entire attractively organized presentation on acute coronary syndromes without ever being taught that unstable angina means that a thrombus had formed. (This point may sound boring, but it's the main difference between stable and unstable angina when it comes to heart disease.)

But at the end of the day, all that this article does is confirm is that life remains about 70% presentation, 30% content. And PowerPoint 2007's templates are sure mesmerizing...

Amazon.com toys with my emotions

Amazon has been suggesting that I use one-click ordering for some time now. But it's already abundantly clear that three-click ordering is already far too dangerous for my credit rating. Hoping to catch my eye, the website has been tempting me with possible passphrases that I could use.

Today, here was Amazon.com's recommendation: "David's Passive Status"

Whatever, Amazon! I'm a go-getter, damn it!!11!

And now I'm going to mope about this in a corner.

At school...

I'm writing from the Peabody Skills Area. I had sworn off "school" after boards, but I needed to swing by campus and drop off a ton of paper weight (notebooks, books, etc.) that I didn't want to carry with me when I move next weekend. And now I have about 4 more minutes to write before I'm running to catch the M2C bus back to Coolidge Corner.

Here's the forecast for the next 1.5 weeks or so:

• Tomorrow, I'm headed home to Jo-Joah for a 5-ish day break. I plan on watching the entirety of Arrested Development (armed with Mayce's DVDs), and I'll also hopefully read 2 or 3 books.
• It's back to Beantown on Wednesday afternoon, when I plan to catch my last official Wine and Whine Wednesday with my current apartment-mates.
  
• Third year starts on Thursday--though it's unclear what that means as of yet since we have no schedules.
• On Saturday, I'm moving to Central Square. It's unclear how I'm doing this as of now, so I've got some planning to do...
  
• And then my experience on the wards starts for real on the following Monday.

And with that, off to the bus!

Update 13: None and Done.

Well, I'm done with USMLE Step 1.

Today in numbers:

• Hours spent testing: 8
• Questions completed: 336
• Cups of coffee consumed: 7
• Trips to the bathroom because of said coffee: 8

Boards prep in numbers:

• Days dedicated dedicated solely to USMLE: 20
• Practice questions completed on USMLE World: 1655*
• Practice questions completed on Kaplan: 1560**
• Pages of notes taken: 295
• Boards-focused books owned: 16+
• Boards-focused books used consistently: 3 (sigh)
• Boards-focused iPhone apps: 8
• Money spent on USMLE review: Shameful and repressed.

*Mostly completed during the last 3 weeks

**Mostly completed during the semester

So with this, I wrap up a rather rough 3-week patch of my life. Already, it seems surreal to look back and think how much effort I invested. I can proudly say that I studied harder than I thought that I was capable of doing. Regardless of outcome, I am happy with the effort that I was able to muster. I learned a large amount of information that I didn't know previously--whether or not I should have learned it already during medical school or not.

Now I just have to figure out what to do with myself...

Update 12: One.

And a partridge in a pear tree. Good thing we were able to avoid the milkmaids (though they're probably the only ones immune to smallpox these days, eh?).

I've decided to spend the day at home in my apartment. I was going to go to school to print something out, but I commandeered my roommate's printer instead because I couldn't stand the idea of going to campus. I also went to Trader Joe's this morning to buy food for tomorrow. On the menu: a BBQ beef sandwich with a small side salad. I intend to brew 2 Oxo mugs worth of coffee to carry in tow.

In other news, the Boston Marathon is happening to day. Having lived in the Law Library for the past 3 weeks, I was confused by the hubbub outside on Beacon St. But then I saw some people gathering around the street to watch the runners-by. I'd like to think that I'm in the midst of my own "marathon," but it feels more like a mad dash towards the "finish." I have to put quotation marks around "finish" because this is only Step 1 of three tests, and I'll have to recertify regularly throughout my career. Regardless, it'll be nice to jog by this milestone on the way to the next.

With that, it's time for some last-minute review.

Update:

• Well, it was inevitable, but I've started to worry about the test... a lot. I'm looking over some old notes, and I don't seem to remember anything... My find feels blank, heh.
• So it's almost 8:00 p.m., and I was going to stop studying at 5:00 p.m. But there's still so much to go over...

Update 11: Two

Two days left. There's still a lot of stuff that I don't know nearly well enough to be comfortable. But I'm ready for this process to be over. It has been rewarding to learn so much material in a very short time, and I'm proud of what I've accomplished.

This doesn't negate the fact, though, that I would have been happier to have at least 2 more weeks to study. But I need to take some time off to protect my sanity and accumulate enough sanity points to buffer what's to come. HMS could do its students a big favor and actually give us a reasonable amount of time to prepare for Boards Telling us that we have "4 weeks" in a zero-sum relationship with "vacation" is absurd when the next break is in July (one week... can't wait).

It's true that USMLE is a poor indicator of anything other than how hard someone has studied for this particular test. So it makes sense to some degree that HMS doesn't want to teach to an inane examination. Fine. But a board score is still a major determinant of what medical specialties are "within reach." This could mean that I could never become a dermatologist. OH NOES!!11! What's a shame is that the most important determinants about being a good doctor are not tested at all (nor taught in medical school, but that's another criticism). This is a weird profession--probably because it's filled with bizarre, sadomasochistic people who begin their training by loving punishment (hurts so good) and later torture the new generation of masochists (good to hurt).

On the agenda today:

• Lots of review. I'm going to read through a bunch of notes that I've taken.
• Lots of review. I'm going to finish First Aid for real (need to finish embryo and read some about genetic diseases).
  
• Some questions. I'm going to do some new questions and practice taking questions in blocks.

Update:

• "Bruce was nervous about Peyronie's until he took buspirone." (5-HT1A antagonist). (Warning: Link NSFW...)
  

Update 10: Stooges

Moments ago, I was freaking out because I left my headphones at home. The thought of not having access to any auditory entertainment for the entire day was almost too much to bear. Who wants to listen to the still, sad music of humanity when you could listen to this gem of 2002? (By the way, am I the only person who has to covert 200 km/hr into mph in order to appreciate what that number means?)

And after starting to write a blog post lamenting this sad state of my existence, I eventually remembered that I'd already used my headphones in listening to my iPhone on the bus this morning. So now instead of being sad that I don't have my headphones, I get to muse on my lack of short-term memory while listening to Oprah chanting "you-you-getta-getta-cah-cah-car."

On the slate for today: neuro and embryo. This is my penultimate full day of studying! Gotta get stuff done. Maybe I'll learn the pathways that are impaired in my poor brain while I'm at it.

Update 9: What's it good four?

Three days of studying left, and I have to hit up anti-microbials, embryology, and neurology. I also have to seriously review musculoskeletal. That's a lot of material, but I'll hopefully learn a good amount in these last few days.

Last night, I took a break from studying and went to the 2010 Ackerman Lecture on Medicine and Society on the 100th anniversary of the Flexner Report. Published in the early 1900s,* the Report is largely credited with standardizing medical education and giving the practice of medicine both scientific and (eventually) professional validity. The classic "2 + 2" model of education (2 years of pre-clinical science and 2 years of clinical training) was established by Flexner in order to combat the dearth of science training provided to medical students in his day. That model is still the gold standard across American medical schools.

It was very interesting to think about medical education in broader strokes. One thing that became more clear was that exercises like the USMLE exam are vestiges of the Flexnarian model--vestigial elements that are becoming obsolete. There's already talk about making USMLE Step 1 pass/fail only. (Currently, there is a pass/fail mark, but there is also a numerical element, much to my chagrin.)

For now, I have to set aside my intellectual gripes with Step 1 and be practical. In other words, I'm going to go study...

Update: Sit and Everybody Gets a Car

• * Thanks, Cat, for pointing out that 100 years have not passed since the early 1990s! But it sure feels as if it has been that long, sometimes, eh?
• The kid gyrated on the flo'(xacin) and pulled a tendon. Floor-oquinolones inhibit gyrase and end in -floxacin. Side effect of tendonitis and tendon rupture in kids.
• I was ticked off at the pipe's pseudomoaning in the psycho pantry. Ticarcillin, pipercillin as the penicillins used in the treatment of Pseudomonas infections.

Not comforting:

• Email from my hematology tutor to our small group: "I just wanted to wish you good luck. (If you know everything in First Aid, you'll be fine. Seriously)." I do not know everything in First Aid...

Update 8: Five...

We've officially moved to numbers easily communicable by one hand. Coincidentally, it's also National High Five Day and the Ides of April. So either it's a great day to exchange pathogens via hand-to-hand transmission or it's the one-month anniversary of getting stabbed in the back by your best-ie. You pick! (I'd go for the former with a nice dose of alcohol-based hand cleanser.)

I'm in a particularly sour mood right now because I just tried to schedule an appointment with a dermatologist. Earlier this semester, I jumped through several hoops (including a sit-down meeting) in order to get permission to schedule an appointment 3 months in advance. In medical school, it's not acceptable for students to have medical needs (only patients get that privilege), so it's particularly difficult to get people to accommodate "truancy." (As an aside, I find this kind of funny because what better way to learn the experience of a patient is there than being a patient yourself?!)

So a few weeks roll by, and I get a call saying that the doctor has to cancel my appointment. I explain that I can't simply reschedule myself and how difficult it was to get the first appointment scheduled in the first place. The person on the phone is very apologetic and gives me a list of available dates. I send this list to my site secretary to ask her to pick a "good" date for me to literally step out of the hospital for 2 hours. It takes her about a week to get back to me. Today, I call the office with that date, and--DUH--the time has been taken already. The receptionist suggests that I just pick a random time, and if I can't make it, I can just cancel the appointment. This kind of sounds like the problem rather than the solution, methinks. So I get impatient on the phone because she also refuses to let me know a few possible times so that I can get it cleared with my site director.

Also, get this: I'm being referred to another dermatologist because the one that I saw is leaving the practice. In the University Health Services' computer system, it's marked that I had a total body skin examination (TBSE). But since I'm going to a new physician, you'd figure that she'd actually look at my skin, right--especially since that's the only organ that she takes care of?

Nope. You only get one TBSE per year, apparently, and I've apparently already gotten mine. Except that I didn't. The last physician didn't even ask me to undress fully. It's hard to do a skin examination with a clothed patient. But what I find even more infuriating is that a dermatologist seeing a new patient would even consider not doing a physical examination of the only organ that s/he bothers to check. It's not as if I'm asking for an abdominal examination. I'm just asking that my new doctor, who only takes care of skin, check my skin.

This is only making me like dermatology even more. Life has a lot of variables, but one thing's for sure. Dermatologists need to work more and make less money.

Update 7: Six

Well, this is a nice switcheroo from yesterday, eh? (6:7; 7:6)

I'm writing to you live from Langdell, where it's another great day to cram information into my already-supersaturated head. If you ever took chemistry lab, you may remember that minor disturbances can cause dissolved substances to precipitate out of supersaturated solutions quickly (precipitously, if you will). True to the physical/chemical laws of this world, the large amount of useless associations that I've crammed into my short-term memory also tend to spill out of me given the slightest disturbance.

Two observations:

• While riding the bus to and from home to the main campus, my roommates and I often talk about random facts that we've learned. Loudly. I'm sure this is annoying for other people (no one else cares about neural crest cell migration?!). But I hope that it's a forgivable offense as it does often help me to remember things. We just let it all hang out.
  
• My roommate Katie agrees that these "flights of associations" (because we all know that they're not actually meaningful ideas) are helpful. The other day, she said that these "conversations" were useful but then had to make her compliment conditional--"if we can even call these conversations." Zing.

Regardless, this will all be over soon, and I will be reading short stories while watching the entirety of Arrested Development during 5 days. And considering how much I plan on doing in the next 5 days studying-wise, I'm going be doing a lot of arresting and not-developing once I'm in Georgia.

Update:

• I've hit the 50% mark on USMLE World, meaning that I've completed about 1000 questions since school ended. Gotta keep this momentum going...
• It's now time to try to learn all of microbiology and anti-microbial drugs in 1.5 days. And go...

Lessons of the Day:

• Don't eat poop:
  - Dog poop: Echinococcus all up in your liver (cysts--could cause allergic reaction)
  - Pig poop: Cystercicosis all up in your brain (cysts in your brain from tape worms, cause seizures)
• Don't breathe poop:
  - Bat poop: Histoplasma (fungus) all up in your lungs... or more
  - Pigeon poop: Cryptococcus infection
• Don't eat raw meat:
  - Raw pork: Tapeworm (T. solium) all up in your gut
  - Raw pork: Trichinosis (Trichinella) all up in your muscles (cysts)
  - Raw fish: Tapeworm (D. latum)
  

Update 6: Se7en

Whereupon which our anti-hero discovers Gwyneth Paltrow's face in an unexpected location.

I'm eating a brownie from Veggie Planet for breakfast. And then I'm going to scurry over to Langdell to take a practice test before lunch.

In other news, there is no other news.

Today's studying soundtrack selection of the day:

Update: Sit in Stupor
I've already decided to abandon my previous plans to take a practice test and have delayed it until Friday--at which point, I will have technically gone over all of pre-clinical medicine. Right.

• Cloudy weather (corneal cloudiness) makes me wanna hurl. (Hurler's syndrome, or mucopolysaccharidosis I)
• Clear weather (no corneal cloudiness) is huntin' weather. (Hunter's syndrome, or mucopolysaccharidosis II; time to get into a helicopter with Todd!)
• It's so gauche to have glucose in your cerebrum. (Gaucher's disease, from lack of a glucocerebrosidase.)
• Alternate: Fabrics and ceramics are things gals are into. (Fabry's disease, characterized by alpha-galactosidase deficiency and accumulation of ceramides.)
  

Udpate 5: Seven Ate Nine

Then what happened to eight? I bet eight was smart and escaped from Seven the numeric cannibal. About one week left. Officially one week left to study.

Today, I'd like to share one of my secrets for success: gum. Previously, I already told Helicobacter that it was decidedly unwelcome in my gastrointestinal system. But if I remember correctly, another way to help neutralize acid is through salivary secretions since they're basic (they're -OH-so-good).

Mentally, I'm in a rough shape. I'm studying biochemsitry now, and I don't remember a lot of the biochemical reactions. For instance, did you know that phenylalanine (essential) is processed into tyrosine (not-quite-essential) by phenylalanine hydroxylase? And if that doesn't quite work out, tyrosine becomes essential? And the result is phenylketonuria, which apparently makes people smell "musty." [Insert grimace here] Maybe Old Spice should start a targeted ad campaign (from the top of a horse).

Anyhow, back to it I go...

Update: Sit and Stagnate (in Langdell)

• No one noticed that in my original posting, I mixed up tryptophan and tyrosine. *caterwaul*

New memory aids that make no sense but will still be helpful:

• "Anne Fabryni likes ceramics." (There's a professor named F-a-b-i-n-y. That's close enough.) For Fabry's disease, which involves a mutation that leads to accumulation of ceramides.
  
• "Neiman's picked the sphinx." (In my head: Neiman Marcus for some reason decided to select the Egyptian Sphinx.) For Neimann-Pick diseases, which causes the accumulation of sphingomyelin.

Also:

• You, you get a, get a car. car.
• You, you get a, get a car, car, car

Update 4: Nein nein nein

I'm writing a morning post today, but consider this a valediction forbidding mourning. I'm pretty determined to crank out some results today. I'm equipped with a fresh notebook (I've already filled 3 spiral notebooks with notes in the past few weeks), bananas and granola bars, and a new addition to my studying soundtrack.

What I *wonk wonk wonk* is what you *wonk wonk wonk*.

Update: Sit and Wonder
Today's deep musings brought to you by aggravated studying

• Does "sinopulmonary" mean within the lungs of a Chinese person? China China China?
  
• His tone was loopy because of hydralazine and procainamide. (Anti-histone antibodies in drug-induced lupus)
• (Glucogenic) Arginine met his valentines, (Ketogenic) Leucy and Lysa. (Both) He said, "I-saw-Leucy (isoleucine); she's phenomenal." And then took three tryps to see her. (Essential amino acids--h/t to Chensi)

Update 3: Ten Daze

Heads-up-seven-up (what the heck did that ever mean, anyway?)!

I've been in the law school library since 10 am this morning. That makes almost 8 hours up in this joint. And I'll be here for 2 more hours before heading home at 9 pm. If I were a law student, I'd be annoyed at how many poorly dressed, on-edge med students there were in my library.

Aside from second-years studying for boards, there's also a tremendous number of first-year students in Langdell right now. I don't remember what I was doing on Saturdays during first-year, but rest-assured that it was not studying in the HLS library. Perhaps that's why I don't know anything now, come to think of it...

On a more concerning note, I'm about to drink my third Oxo mug of coffee, which basically means that I'm hopping over the 10-cup mark for today. But for now, it's either a power nap or this--and I figure that the diuretic effects will help keep me awake/alert, too. So here's my haiku to peptic ulcer disease:

Hey, H. pylori,
Heads up! You aren't welcome here.
Occult bleeding? Gross.

Update 2: Eleventh Day Trifling

Later tonight, I'm going to a potluck/mixer for first- and second-year students interested in primary care. I'll be carting along two things, well three, really:

1. My iPhone with apps on it to study for boards in between conversations (Ok, this is a joke, but maybe it shouldn't be.)

2. Some variation of this cranberry-broccoli salad

3. And some type of trifle so that I can use the extra whipping cream I have in the fridge

Until then, you can find me at my kitchen table, studying bizarre muscle and nerve injuries. If your knee ever opens like a drawer, please seek medical attention.