Thursday, November 30, 2006

Working on Homework

Nothing too exciting to report for today. I basically spent most of it at home studying, except that I did go to the gym over at Case. I'm really excited about my learning objective for tomorrow. I think that it might be the best one I've ever done in terms of how much clearer it has made a lot of the concepts we've been covering. I feel like I have a good understanding of the case, and I know now what the point was of the drug regimen the patient was given. I don't know if you ever have these moments where all of a sudden you feel like you are starting to get something, but that's how I feel. It's a great feeling.

Tomorrow is December already. The weather is starting to get really cold, like it knows that it's time for winter now. We're supposed to get snow this weekend, and this time it is going to stick. I hope it won't affect the turnout for Doc Opera. Anyway, I am not too worried about it snowing. I have some great boots, so whenever it comes, I'm ready.

Wednesday, November 29, 2006

Lipoprotein Seminar, PBL, and Clinical Skills

I was really dragging today, and I have to confess that I was basically counting down the time until I'd be able to go home. I'm just happier than I can say that I have tomorrow off and I can finally get some sleep. This morning, we had a lipoprotein seminar. It was pretty research-intensive and covered some material that the seminar leader thought was important but that was not really covered in the textbook yet. I thought it was a pretty good seminar, although a lot of people felt like maybe it was too specific. I don't know. It's hard to know when you're a first year what is going to be important to know about later on.

In PBL, we continued on with our case. I think that today's session went pretty well. Everyone did a good job with their presentations and we finished on time. Our patient is improving but is still not where he ideally should be. We got into a really interesting debate about whether we should treat him more aggressively with drugs or focus more on his lifestyle factors. The group was pretty much split half and half on that, with some people wanting to be conservative and give the medications more time to work, and others wanting to be more aggressive because they thought the patient's life would be in danger. I was on the side of wanting to wait until we were sure that he wasn't improving any more on his current dosage. It turns out that the doctor in the case did decide to up the patient's dose, and luckily the patient has not been experiencing any side effects. Anyway, it was really a good discussion, because sometimes there is not one easy answer to these kinds of questions. For Friday, I am going to be presenting about the drug regimen that the patient was put on, and what was the logic behind it.

After class, I went to a Pharm Free talk. This talk was given by the same pharmacist who is in charge of our pharmacology thread. Basically, it was about the dangers of physicians accepting free items and drug samples from pharmaceutical reps. CCF has a pretty strict policy about what drug reps are allowed and not allowed to do. They have to register, they can't see doctors unless they have appointments, and they are not allowed to provide food on campus. Personally, I do not view pharmaceutical companies as being all that evil. Yes, they do spend too much money trying to influence doctors and patients to buy their products. But a lot of good can also come out of their actions, especially when doctors give the free samples from drug companies to their low income patients or help such patients apply to the drug companies to get drugs for free or at reduced price. Anyway, the general point that you have to be careful when dealing with drug companies is a good one and well taken.

In the afternoon, we had our clinical skills class. Today was very enjoyable. We have a few different preceptors who have been teaching clinical skills to us, and the one we had today is my favorite. The other three students in my group and I have also figured out the best method for learning the skills. First we have the preceptor demonstrate one skill, and then all four of us try it. Then we go on to the next skill, and repeat all the way through the list. Our standardized patient today was a girl and she was really nice. We were doing the ears, nose, and throat exam, so I got to see her tonsils and her eardrums. Eardrums are very pretty, kind of pearly looking. For the communications portion of the class, we watched the videos we made four weeks ago with one of the communications preceptors. Watching my video, I thought I had done a good job with being empathetic, but I definitely need to work on the medical portion of the exam. Well, a big part of my problem there is the fact that I don't know very much medicine yet! But I'm getting better.

Tuesday, November 28, 2006

Long Day But Mostly a Good One

I woke up this morning not feeling very well, so I decided not to go to FCM. I feel kind of bad about having skipped it, because this is the first class I have ever missed since I got here. But I did the reading, and I guess maybe I just needed a little more sleep, because later on I felt better. So I did go to the 10:00 seminar, and it turned out to be really good. It was about how the body provides energy to the heart to use for contraction. You might think that a biochem seminar wouldn't be very interesting, but the seminar leader was really interactive and it was actually kind of fun. He gave us a brief packet of notes to read before we got to class today, and I thought the seminar itself did a good job of integrating a lot of the things we've been learning during this entire block.

After class, I went to a really awesome talk about facial transplants. I don't know if you've ever heard of this, but it's pretty incredible. Basically it is for people who have really severe disfigurement, like if they get most of their face burned away in an accident. They would be given a donor face (skin, nerves, blood vessels, etc.) from a cadaver. CCF is the first institution anywhere in the entire world to have an IRB approve a clinical trial to do facial transplants. They haven't done one yet on a human for various reasons, but they've been doing them successfully on rats for several years. The biggest issue is how to prevent the recipient's immune system from rejecting the transplant. You might already know that people who get organ transplants have to take immunosuppressant drugs to prevent their bodies from rejecting the donor organ, and the facial transplant researchers are hoping to avoid that problem. Apparently, if some of the deeper tissues like bones are transplanted along with the overlying skin, it helps prevent rejection. But this issue of immune system rejection is a much more complex problem with a facial transplant than it is with an organ transplant because there are so many different kinds of organs that are part of a person's face!

Right after the talk, I had clinic. Today is not my normal clinic day, but I missed clinic last week because of my preceptor being out of town for Thanksgiving. It was a really hectic day, and I was there until 6:00 because we were just so busy. Even then, we didn't get a chance to go over my patient logs, so we're going to have to do that next week. I saw four patients and did the chest and lung exams on them. A couple of my patients had some really sad personal issues they were dealing with. One actually started crying in the office, and basically all I could do was offer a tissue. I was warned before I started working in the clinic that patients will often tell students personal things like this, and it's definitely true. Anyway, it was a really tiring and trying day, but it was a good learning experience, too. You just never know what you're going to run into when you're dealing with patients.

Tomorrow is a long day for me too because we have clinical skills class. So I need to go to bed now.

Monday, November 27, 2006

Great First Day Back

Hope that you all had a great Thanksgiving. I definitely did. The weather here in Cleveland was astoundingly gorgeous all weekend: sunny, mid-sixties. I spent a lot of time sleeping, going for walks, and hanging out with my friends. Yeah, I did all of the things that you hardly ever have the time to do when you're a medical student. It was great. I just wish I could have had one more day off.

For some reason, we didn't have anatomy this morning. Instead, we had a seminar about lipid biochemistry. The seminar was ok, though I wish it had been more interactive and less like a lecture. We already covered some lipid biochemistry last summer, but now we are getting more into how lipids are used and transported in the body. You probably know that lipids, being fats, are not soluble in watery liquids like your blood. (Think of oil and vinegar salad dressing.) So the body has some pretty ingenious ways of getting around that problem so that the lipids don't all clump together in one big fatty mess. It's pretty neat to learn about, though also very complex and sometimes confusing. We're going to be learning about lipids and how they are transported this whole week. This is a very important topic for physicians, because problems with lipid metabolism cause a lot of common diseases like atherosclerosis and coronary artery disease.

We had PBL after seminar, and today we started our final case for this unit on heart and lungs. Our session went really well, and I think this is going to be a good PBL week. The case is about a "patient" with lipid problems, naturally, and it's a little different than the others we've done so far in that this patient came in to get a check-up and advice to improve his lipids, not because he was wanting to be treated per se. So we don't really have to come up with a diagnosis, at least not so far. (You can see that I've learned not to trust my Monday impressions at face value any more, because things are changing now on Wednesdays!) My learning objective is about interpreting lab lipid values, and I am very interested in learning to do this since I had my blood drawn last week for class and for a clinical trial.

That's about it for today, so I'm going to go to the gym and go home. Tomorrow and Wednesday are both going to be very busy days for me. I have to make up my missed clinic day tomorrow, and I have clinical skills class on Wednesday.

Wednesday, November 22, 2006

Kidney and Blood Pressure Seminar

Today was a very short day. We only had this one seminar, and that was it. Several people didn't show up. I really think we should have had this seminar tacked on yesterday afternoon, and then we could have had all of today off too.

Technically we are not into the kidneys yet, but we will be as of the beginning of December. This seminar was about the integration of the neural, renal, and cardiovascular systems in scenarios where fluid and salts in the body must be balanced. The reading was about experiments done on dogs here at Case several decades ago. Basically, the researchers used clamps to make the renal arteries narrower and block the flow of blood. This causes the kidneys to "think" that the body is hemorrhaging, and they respond by synthesizing hormones that lead to constriction of the arteries and a rise in blood pressure. Of course, these responses only make things worse. But as another speaker pointed out earlier in the week, our bodies didn't evolve to deal with being elderly and having cardiovascular disease. We would have been a lot likelier to have had to deal with massive losses of blood due to illness or injury.

Ok, I hope you readers have a great Thanksgiving, and I'll be back on Monday. We have class bright and early at 8 AM as usual. But the good news is that we are getting Friday off this week, and we do not have any homework (SAQs or CAPPs) either. :-)

Tuesday, November 21, 2006

FCM and Cardiovascular Homeostasis Seminar

I got to school early today to get my blood drawn so that my cholesterol levels could be measured for one of our seminars for next week. It wasn't too bad, except that I had to do it fasting, and it's not much fun to skip breakfast. I did have time to eat a quick breakfast before class started though.

Today's FCM session wasn't too bad. The presenter tried to make it interactive, and we actually had some time in our small groups to discuss the case that he had presented to us. It was about a school bus driver who had gotten hit by a train because she stopped the bus with the rear end reaching over the tracks. What does this have to do with medicine, you ask? Well, the focus of the seminar was about how to decrease medical errors and increase patient safety. Obviously this wasn't a medical case, but the same issues still apply: how could this accident have been prevented? It's not as simple as just firing the bus driver for being "careless." There are a lot of little things that each in and of themselves do not lead to accidents, but all of those little things in combination make accidents more likely to occur. The readings that we did focused on the airline industry, which, along with the nuclear industry, is one of the safest ones out there. Medicine has a much higher error rate. Within medicine, the best specialty in terms of avoiding preventable errors is anesthesiology.

The seminar was pretty good too. Basically, we went through how various cardiovascular and respiratory functions change in response to changes in demand. So, for example, if you're sitting on a couch and then you get up to go for a run, your heart rate, breathing rate, oxygen usage, etc. are all going to increase. We also discussed which types of fuel (ex. fatty acids versus sugars) were used for energy during different levels of activity.

I was supposed to have clinic this afternoon, but I didn't because my preceptor went out of town. I'll be making it up next Tuesday instead. That's going to make next week a monster week for me. I did stop by the anatomy lab briefly to review the prosections from yesterday. They had only taken out one cadaver, and we didn't have a list of structures we were supposed to identify. So one of my classmates and I got a copy of the anatomy book and went through them on our own quickly.

Monday, November 20, 2006

Anatomy, Neurohumoral Seminar, Thanksgiving Potluck, and Bone Marrow Drive Training

Our anatomy lab today was mainly a review. The case involved a man who was shot in the chest, and we went through all of the structures that could be injured. Obviously, there are quite a lot of important structures in the chest, like, oh, say, the heart and lungs, as well as the major blood vessels, various nerves, and so on. The cadavers were mainly review, and we also reviewed the radiology of the chest and the preserved lungs from a few weeks ago.

We do not have PBL this week because of the Thanksgiving holiday, but we did have a seminar on how the brain and hormones control blood levels and circulation. We were given a case to read about a smoker with shortness of breath who shows up at the ER because his symptoms are getting worse. We went through the case and also discussed how the body tries to compensate for problems with the circulation. (Even though the man in our case smoked heavily and had shortness of breath, it was due to a heart problem, not a lung problem.) The seminar was pretty good, and really the only complaint I have is that 16 of us were crammed into one of those conference rooms (it's right next to the one where you go when you come to interview here), and that's just a few too many people to fit in there comfortably.

After seminar, we had our Thanksgiving potluck. One of the upperclassmen had told me that this potluck is a CCLCM tradition, which made me laugh, because CCLCM is way too new to have any real traditions yet. But they want this to become a tradition, and as far as traditions go, it will be a nice one. Basically, the M2s organized a list of items we needed for a Thanksgiving meal and asked everyone to sign up to bring one of them. It was a lot of work and effort on my part, but somehow I managed the stress and avoided being overwhelmed by my task, which was to bring in three cans of cranberry sauce and a can opener. ;-) The school provided us with turkey and drinks, and all of the faculty were invited to come for lunch as well. We all ate too much, but everything was so good.

In the afternoon, I studied for a while and went to the gym before going to train for the bone marrow drive. I can't remember if I've told you about the Oncology Interest Group that we have at CCLCM, but they are one of the sponsors of the bone marrow drive along with the Asian medical student group over at Case. Any student will be welcome to register, but we are specifically targeting ethnic minority groups that have the most difficulty finding a match: Blacks, Asians, Hispanics, and Ashkenazi Jews. The drive is going to be held over at Case in a couple of weeks. It's really easy to register. You just have to swab the inside of your mouth a few times and fill out a form. Your DNA gets tested and put into a databank where it can be compared against people who have a disease like leukemia where they need a bone marrow transplant. If you come up as a match for someone, you are contacted and asked to donate your marrow. You are free to refuse to donate, but since it is expensive to register and test potential donors and we are not going to charge anyone to register, we are asking that people only register if they are serious about being willing to donate their marrow if they get asked.

Saturday, November 18, 2006

FAQ #18: How Much Clinical Experience Do You Get at CCLCM?

If you've been following my blog for the past five months, then you know that we are already getting quite a bit of clinical experience. We begin to see patients on our own starting in October of our first year. At the beginning, we didn't do very much because we hadn't learned too many skills yet, but over time, we've been gradually doing more. I think that the clinical exposure we get here is one of the greatest strengths of the CCLCM program. When I talk to my friends at other schools, I've spent way more time working one-on-one with actual patients than any of them have, no contest.

The way it works is that each week we have one afternoon of either clinical skills class or actual clinic. One week we learn a set of skills in our clinical skills class, and then the following week we practice those skills with actual patients in the clinic. When I say skills, I mean both clinical and interviewing skills. Our class lasts four hours, and we spend half of that time practicing clinical skills on standardized patients, and the other half interviewing standardized patients. A lot of medical schools use standardized patients to teach their medical students, so that is not something that is unique to CCLCM. Basically, these people are paid actors who allow us to examine them and interview them for practice. So far we've learned how to do things like take pulse and blood pressure, listen to heart and lung sounds, and take a patient history to find out why the patient came to the clinic that day. After Thanksgiving break, we'll be learning how to use the otoscope to examine the ears, nose, and mouth.

During the weeks that we have clinic, we usually see four patients. Again, these are real patients. We are supposed to see two of them on our own and two with our preceptor, but my preceptor is so busy that I usually wind up seeing three or even all four of my patients on my own. I get the patients from the waiting room, weigh them, take their blood pressure, ask them why they came to the clinic that day, find out about their medical history, listen to their hearts and lungs, and so on. Then I report what I found out to my preceptor, and we return to the room to see the patient together. Sometimes I perform that week's clinical skills in front of my preceptor, and sometimes I do them on my own and we just discuss my findings. Each week, the exam gets a little more complex, as does the interview. It is very challenging to work with patients, and you never know what you will find out when you shut the examining room door behind you. But it's also very exciting and interesting, especially when I see patients who have symptoms and illnesses that we've been learning about in class. I would say that the afternoons I've spent in the clinic have been one of the major highlights of my experience in medical school.

Friday, November 17, 2006

Histology of Blood Cells, PBL, POD, and CHI

Today was a pretty rough day, and not really because the classes themselves weren't good. I think a lot of it is that we are all getting tired and irritable now that we're nearing the end of the block, myself included. We started out this morning with a histology seminar, and I am just not gung-ho about histology. I know I haven't put as much time into learning it as I should have, and I would probably enjoy it more if I was more familiar with all of the different cell types. But somehow it is hard to get enthusiastic about hours of gazing at fuzzy pictures with arrows pointing at nebulous structures. I mean, cells are cells. Some have big nuclei, and some have small nuclei, but I still say that they all look more or less the same.

PBL today was kind of rough too. This was my last day as the group leader, and I think that we did all right with the session itself as far as getting through all of our work was concerned. Everyone did a good job with their presentations and we got done on time. But like I said, we are all very cranky, and we were arguing about stupid things and snapping at one another. I am sorry to say that I was one of the offenders.

The POD speaker was very good, and he didn't use PowerPoint at all, which I thought was great. Sometimes speakers will just present slide after slide of data, and those seminars are not the most fun for us to sit through. But this speaker didn't do that. Instead, he sat and talked with us about how he wound up where he was and the things that happened in his life to affect his current research work. It was really interesting to hear about. But some of the research he had done made me feel sick to my stomach, and I ended up walking out about two thirds of the way through because I just didn't want to hear any more about it. He had been doing physiology experiments on dogs that involved making their hearts fail, implanting sensors in their backs, and then driving up a hill with the dogs trying to run behind and keep up. I wouldn't normally consider myself to be some kind of animal rights activist or anything, and maybe I was just feeling sensitive because I was in a bad mood. But for whatever reason, it got to me.

In the afternoon, I volunteered at CHI again, and that was the best part of the day. You hopefully remember that CHI is our student-run free health clinic. I started out doing body fat percentage and BMI measurements for patients, and I counseled the ones whose body fat and BMI were too high about ideas to help them lose weight. We were giving out free flu shots today, so when things got slow at my station, the doctor who was running the flu shot station showed me how to give them, and I gave my first shots. It was surprisingly easy to do. She also showed me how to draw up the flu vaccine into the syringe to prepare the shots for patients. That's actually more tricky than giving the shot, because you have to make sure that there is no air in the syringe.

We have our normal SAQs and CAPPs to do this weekend, and I am not in the mood to do them. Not that I'll be in the mood to do them later either, probably, but I think I just need to take this evening off to relax and do something fun.

Thursday, November 16, 2006

Quiet Thursday

Ah, the best day of the week is here once again. No classes, so I mainly spent today getting caught up on my work and cleaning up this mess of an apartment. Amazingly, there is really a floor under these piles of papers and books. I went over to Case in the evening to be part of a medical student panel that was answering questions for undergrads in the pre-med club. It was kind of hard to get myself to go out because the weather today was absolutely nasty. I know I've complained about it constantly raining in Cleveland several times, but it actually doesn't rain here exactly. It kind of spits at you, making a fine mist that no umbrella or raincoat can keep out, and this literally goes on for days and days at a time. Everything is just cold and damp. The good news is that next week is supposed to be nice in time for Thanksgiving.

Wednesday, November 15, 2006

Surgery Grand Rounds, Pleural Fluid Seminar, PBL, and Clinical Skills

I think that today was my longest day yet, but overall it went well. I actually got here at 6:30 AM so that I could go to a Surgery Grand Rounds talk before class. That was a bit painful, but once I was up and awake, it was definitely worth going to it. The good part is that we got breakfast. Surprisingly, the auditorium was pretty full even at that time of the morning. I guess there are a lot of surgery residents here. Surgeons are very organized. The speaker is the director of the Bariatric and Metabolic Institute here at CCF, which has the appropriate acronym of BMI. He started out by reminding us of how many people in this country are obese (about 300 million overweight and obese people). He is specifically interested in treating metabolic syndrome (aka syndrome X), which describes a cluster of symptoms that tend to go together: hypertension (high blood pressure), hyperglycemia (high blood sugar), glucose intolerance (inability for cells to use insulin to take up blood sugar from the blood), elevated triglycerides (high blood fat levels), and low HDL cholesterol (that's the good kind, so you don't want it to be low). He is a surgeon, so of course his solution to the problem is to treat people by basically stapling their stomachs and re-routing their digestive tracts to bypass parts of their intestines. The results he showed look pretty good, but still, that is some pretty heavy-duty surgery (no pun intended!).

I was kind of sleepy during the seminar, but it was a pretty good one. We are still working on the lungs, and they are surrounded by two membranes called pleura. So the space between them is called the pleural space, and it has some liquid in it, which is the pleural fluid. See, I told you that medical school is not rocket science! Basically we spent most of the seminar discussing how and why this fluid forms, what it does, what happens when there are problems with it, etc. It's both fascinating and disgusting at the same time. Just so you know, you can get some really nasty stuff like pus in your pleural space (this is called empyema), and when that happens, the pleural fluid, which is normally whitish or clear, will turn yellow. This can happen if you have an infection. Sorry if I grossed you out, and hopefully you aren't eating while you read this.

PBL went a lot better today than it did on Monday. Everyone did a good job with their presentations, we got through the case on time, and we weren't as short with one another. My new learning objective is about the effects of carbon monoxide on the body. I'll be presenting that on Friday. I told you that the cases are getting more complex, and today we found out that even though Monday's problem was resolved, the patient has a new problem now. It's a lot more fun when the cases are harder. I think we still have a pretty good idea about what is wrong with the patient, but I like that the cases are getting more challenging.

In the afternoon, we did our clinical skills class, and it was really fun today. The skills we are working on are all related to the lungs and chest, so we practiced several techniques for the lung and chest exam. One thing we did was to check that the sound and vibration from our standardized patient's voice are transferred equally well on both sides of his chest. This entails getting the standardized patient to say "ninety-nine" multiple times. When you consider that these poor guys have to be examined by eight medical students each during the course of one afternoon, you have to admire their patience with us. We also percussed his chest and back. Here, you have you middle finger down firmly against the skin, and you tap it with the middle finger of your other hand. It sounds hollower over the lungs and duller over the liver or muscles. (You can try it yourself on the walls of your house if you want. If you do it right, you will hear that your percussion sounds hollower where there is no stud, and duller where there is a stud.) Finally, we listened to the man's lungs in several places using our stethoscopes. After the physical exams, we did practice interviews where we took the "patient's" medical history. So we had to ask them about what surgeries they have had, illnesses, medical problems, social and personal factors, etc.

Like I said, it was a good day, but I am exhausted and very happy to have tomorrow off.

Tuesday, November 14, 2006

FCM, Hemoglobin Seminar, Class Meeting, and Anatomy Office Hours

We had a joint FCM session with Case today. Since we had complained a lot about being segregated by program last month when we went over there, the good news is that the powers that be assigned us to mixed small groups so that we could interact with the UP students. However, these excellent intentions were thwarted by the speaker, who droned on for the entire hour and a half. So, although we were in small groups with the UP students and physically sat next to them for the hour and a half, we did not get to actually discuss anything with them. This is the usual FCM pattern. The subject is important, the reading was decent, and the class itself somehow just never quite works out the way it is supposed to.

The hemoglobin seminar we had afterward was pretty good. We talked about the structure and function of hemoglobin, as well as how the genes for hemoglobin turn on and off during development. The coolest part, of course, is discussing the things that can go wrong with hemoglobin, which are called hemoglobinopathies. Hemoglobin is the protein in the blood that carries oxygen from the lungs to the tissues. Some people don't make enough hemoglobin, and they have anemia due to a condition called thalessemia. Other people make normal amounts of hemoglobin, but their hemoglobin has too much affinity for oxygen or too little affinity for oxygen, and they either have problems with releasing oxygen to the tissues or loading oxygen in the lungs. The most famous hemoglobin problem is sickle-cell disease, which happens due to a mutation in the structure of the hemoglobin protein. The mutation changes the properties of the hemoglobin so that in situations where the affected person has low amounts of oxygen, the hemoglobins start polymerizing into long chains. When that happens, it warps the shape of the red blood cell. Normal red blood cells are round disks that have indentations on both sides, but sickle cells are long and thin to the point where they can get stuck in the tiny blood vessels of the body.

We had a class meeting after seminar. This was for all of the M1s. Dean Franco came to ask us what we could do to improve the seminars. Naturally, many of us wanted to talk about the problems we've been having with FCM, and we did for quite a while. But she really wanted to talk to us about the academic seminars, because some of my classmates have stopped attending them. This is kind of a sticky issue. On one hand, some of the seminars are kind of dry or otherwise not particularly helpful. But CCLCM is not like most medical schools where a lot of the students skip class, collect lecture packets, and read them at home to prepare for their exam. So I agree with Dean Franco that we all ought to attend the seminars. That being said, I also think that if some people want to skip them, they ought to be allowed to do that without getting emails sent to their PAs or otherwise being hassled for that choice. If we are adults, and we are, then we should be treated like adults. At the end of the class meeting, two of the M3s came and talked to us about applying for fellowships during our research years. We get stipends from CCF while we're doing our thesis year, but we can also apply for fellowships on top of that. I hadn't considered applying for a fellowship before this, but now I am planning to do it. So that was really useful.

In the afternoon, I went to the anatomy office hours. There was one other student there, and we went through all of the cadavers together with Dr. Drake. Even though we were doing early embryology this week, we are still working on the neck, so all of the prosections were of the neck. You wouldn't think that the neck would be so complicated because there aren't too many organs in the neck (just the thyroid mainly), but it actually is. There are really a lot of muscles, nerves, blood vessels, and connective tissues in there. I don't think I'll ever remember them all, but I'm still enjoying learning about them.

Monday, November 13, 2006

Anatomy, PBL, and Research Seminar

Today was a very long, busy day, but it was a good one. In the morning, we had anatomy lab. We are still working on the neck, but this is the last week of it. Next week we will be reviewing the chest, and then we will begin studying the abdomen in December. We have also begun doing some embryology. So far we have gone over the first three weeks of embryonic development. Dr. Drake has some online modules that cover embryology, and there is also an optional textbook. I wound up getting the book, and I've been reading that. I don't know---I just can't get into doing those online modules. A lot of my classmates really like them, but I don't somehow. Maybe I will try looking at them again at some point, but I think that I just don't learn very well by reading things over a computer compared to reading them from an actual book.

Our new PBL case is a good one. We actually don't know for sure what the problem that the patient has is, although we have some ideas. One thing that I've been noticing is that the cases are getting more complex. At the beginning of the block, they were all pretty easy, and we'd figure the diagnoses out pretty quickly. I think today was the first time where we still weren't sure by the end of the Monday session. I am the group leader this week, and it is not a fun job. We are getting close to the end of the block, and everyone is feeling kind of tired and cranky, including me. We spent too much time today arguing over stupid things like how many learning objectives we were going to have for Wednesday. On the bright side, we are doing a lot better with not talking over one another, and we did manage to get everything done on time. But all in all, this was not the best PBL day we've ever had.

In the afternoon, I went to a Clinical Grand Rounds seminar. The talk was about exercise in zero-gravity conditions, and it was pretty neat. The speaker was explaining how astronauts in space lose bone mass, and what NASA is trying to do to combat that. Unfortunately, NASA's exercise protocol is not working very well, so he is conducting experiments here at the Cleveland Clinic to try to combat this problem. The experiments involve having subjects stay in bed literally 24-7 for 84 straight days. They cannot even get up to go to the bathroom or shower. Everything has to be done while they are lying with their heads down at a 6-degree angle. The experimental group exercises horizontally on a special vertical treadmill, while the control group does not exercise. The research team monitors the forces on their legs along with how much bone mass they lose. At the end of the 84 days, the patients have to undergo mandatory rehabilitation so that they can walk again. It's kind of insane that anyone would even agree to participate in these experiments, but it is really neat, too.

Saturday, November 11, 2006

FAQ #17: Can You Explain What Exactly Is PBL?

This is an excellent question. I know that a lot of people argue about PBL and discuss it on SDN without really understanding what PBL actually is. For the uninitiated, PBL stands for problem-based learning. It is a student-centered way of learning, in contrast to lectures, which are faculty-centered. The two are complete opposites. Confused? Read on.

The typical class that you remember from college is a faculty-centered lecture. What this means is that you have a professor or instructor get up in front of a room (typically an auditorium if you went to a large state university like a lot of us did!), and talk to you for an hour or two. The instructor decides what to discuss, tells you what to read beforehand, and chooses what homework you will be assigned. The instructor also makes the tests and is the sole person who evaluates you. You, the student, sit passively and take notes on every word that the instructor says. About the most involved you get is when you ask the professor a question about something he said, or if the professor gives you one of those clickers so that you can respond to the polls on his Power Point.

PBL is completely at the opposite side of the spectrum. The faculty tutor who is assigned to our group speaks very little, and sometimes not at all. In our sessions, it is the students who are responsible for leading the group and setting the agenda. We have one student serve as the leader each time, and in my group, we swap leaders after each case (once per week). All students in the group are expected to participate equally, which means that we are all teachers and we are all students. As a group, we work through a medical case that has been assigned to us. Based on this case, we hypothesize about what problem the patient could have, and we make a list of what we know and what we don't know and would like to know. From the second list, we come up with a group of learning objectives. Each student takes a learning objective, reads about it, and prepares a brief (5-10 minute) presentation about it to share with the rest of the group during our next session. In a typical session, all of us present our learning objectives, and we then continue on with the case. As we add new information, we modify our hypotheses, come up with new learning objectives on things that we still don't know, and try to integrate what we are learning with what we already know. Periodically, we all evaluate ourselves and each other. Our faculty tutor also evaluates us, but his evaluation is one of many instead of the sole evaluation.

I will warn you up front that PBL does have a higher learning curve, and it takes some getting used to if you've never done it before, which most of us hadn't before coming to medical school. But I definitely feel that it is worth it. I have now had the opportunity to experience both PBL and lecture-style curricula, and I can tell you that PBL is WAY more fun than sitting through lectures all day. It is also a lot more work to set up a good PBL session than it is to just attend a lecture. But I am constantly amazed by how much I learn not only from preparing my own learning objectives, but also from the ones prepared by my classmates. PBL forces you to work with your classmates and adjust to everyone's unique background and learning style. It is impossible to be selfish in PBL, because you are responsible for everyone's learning and not just your own.

If you're interested in reading more about PBL, here are two great websites that talk about it quite a bit: and PBL is in use at many other medical schools besides ours, but CCLCM is one of the few schools that were designed from their very beginning to use PBL instead of lectures. I think that this is one of the reasons why PBL is so well-integrated into our curriculum instead of seeming like it was tacked on as an afterthought. If you think that you'd enjoy a PBL curriculum, you should definitely apply to schools and programs that use it. Some people might try to scare you and tell you that PBL won't teach you everything you need to know or won't prepare you for the medical boards, but the scientific literature doesn't support this conclusion. Actually, PBL-based curricula seem to prepare people equally well versus standard curricula, and again, the PBL is a lot more active and fun to do compared with sitting through yet another mind-numbing lecture. Here is one example of a paper on this issue.

Friday, November 10, 2006

Histology, PBL, and POD

We had a histology seminar this morning covering the lungs, and it was ok. The presenter was a pathologist, and she had us divide up into groups of three or four people. Each group was supposed to learn about a particular part of the histology of the airways, and then we had to present it to the rest of the class. These kinds of seminars are hard. We all feel like we get to understand the part that we are presenting ourselves well, but we don't get as much out of listening to other students present. Ten minutes really isn't enough time for us to truly learn enough about our topics that we can teach it well to others. Part of the problem too is that most of us don't know very much about histology in general. I say most of us, because one of my PhD classmates knew more about the assigned topic than the pathologist leading us did. All of the other groups, including mine, kind of gave a brief intro, and then the pathologist finished off the topic. She didn't say much of anything for that group, though, because my classmate was just that knowledgeable about those pathways. It reminds me yet again of how amazingly smart my classmates are.

After that, we finished our PBL case. I think that this was a pretty good case, and the concept map we made this week was our best one yet. I'm not just saying that because I was the one who was drawing it! I think it was so good because it was a lot more conceptual than a lot of the ones we have been making in the past. (It was also quite aesthetically symmetrical.) The presentations this week were also especially good. Not that we weren't all putting in the effort before, but we're doing a lot better now with not running over time and with relating our objectives to the case. We are also reaching the point where we usually have some time to discuss each presentation and hammer out concepts we still aren't sure about. I feel like I'm getting more out of PBL now than I was at the beginning of the block.

Our POD seminar today was about asthma. The speaker was an MD, and he spent some of the time telling us about how he got into a career in academic medicine along with telling us about the research he was doing. It was a pretty interesting seminar, and I think that most people liked it. Personally, I found the actual research he was doing to be less interesting versus hearing about his life story. I wish that other POD speakers would tell us more about how they got into their careers in academic medicine and not just about the research itself.

Thursday, November 09, 2006

Yay, It's Thursday!

I swear, Wednesday nights feel like Friday nights for me. There's something about getting home on a Wednesday night knowing that I don't have to get up early on Thursday morning that makes it feel like a weekend. The weather was gorgeous today too: sunny and in the high sixties. I did my laundry this morning, went to the gym, and then sat outside to study. It was actually pretty relaxing, and I got a lot of reading done. I'm finished with preparing my learning objective for tomorrow, too. I couldn't have asked for a better day in medical school than this.

Wednesday, November 08, 2006

Respiration Seminar and PBL

Today's seminar was really neat. We went over to the Crile building, which is one of the clinics on campus, and we got to see the effects of breathing a high concentration of carbon dioxide first hand. Three of my classmates and I volunteered to breathe a mixture of gases that contained a high concentration of carbon dioxide. There was plenty of oxygen in there also, but because there are chemical receptors in the brain that specifically detect carbon dioxide, it still makes you start breathing harder and faster when you breathe a gas mixture full of carbon dioxide. Of course, since you're breathing into a bag, that makes the carbon dioxide levels rise even more as you pant away, and things just keep getting worse. This experiment also simulates what it's like to be short of breath. I only did it for about three or four minutes, and it was kind of frightening. You're breathing hard, and it feels like you just can't get enough air. It definitely made a huge impression on all of us, and it also gives me some major sympathy for patients who feel like this all of the time.

We continued on with our PBL case today too. Because of the seminar that we had last Friday about acid/base chemistry, we pretty much figured out what the patient's problem was immediately. This case is also starting to get us into studying the kidneys quite a bit. My next learning objective involves figuring out what the creatinine levels in the blood mean. Our case patient had raised creatinine levels. From what I've read, it seems to mean that her kidneys are not functioning properly. Creatinine is the by-product of another chemical in your muscles called creatine. You make creatinine from creatine whenever you break down muscle mass. The raised creatinine level could happen for a lot of reasons, but I think it's because she's dehydrated. That would mean there would be a lower volume of blood going to the kidneys, and it would cause her creatinine to rise because her kidneys aren't filtering it.

After PBL, I had lunch and went to the gym, and now I'm home to do some studying.

Tuesday, November 07, 2006

Today Was a Crazy Tuesday....

And a really long one, but overall a good one. FCM was actually tolerable today. I won't come out and say it was great, because it wasn't. But it was tolerable, and that's a huge improvement. The reading for today's session was kind of dry and completely unrelated to the brief overview we had about the local men's shelter. I don't know why we had people talking to us about the men's shelter, because none of the FCM groups is assigned to work there. But the speakers were brief, and it was actually fairly interesting to hear about the programs they have going on. After the talks, we split up into our groups again to work on the projects. I told you already that my group is working with a women's shelter. I am happy to report that the size of this production has been greatly scaled down into something reasonable and manageable. We're now looking at doing a few drives to collect supplies for the women (books, clothes, toilet articles, etc.)

Next, my half of the class had our pharm seminar. Pharm seminars are always a little dry, and this one was too. But I happen to really be interested in pharm, so it doesn't bother me as much as it does some of my classmates. I think the worst part of the seminar actually is that we were stuffed like sardines into this tiny, hot conference room. Don't get me wrong: I like my classmates and all, but that doesn't mean I want them to be practically sitting in my lap for two straight hours. But we can't blame the bad room on the speaker. Our pharm seminars are taught by a pharmacist, and he's a pretty nice guy. I think it would help if he would make his seminars more interactive though.

At lunchtime, there was a meeting for a new interest group in cardiology. I couldn't stay for very long because I had clinic today. But I went for part of the time anyway, and the group has some very good activities planned, particularly the talks. I'm pretty sure that I won't wind up going into cardiology, but I like joining all of the interest groups anyway so that I can attend some of their events.

My clinic time today was hectic and awesome. The weather was good, and all four of my patients showed up. I can't tell you too much about the specifics of each case because it would violate HIPAA rules. HIPAA is the law that protects people's private medical information. But in general, what I did was go in to see each patient, interview them about why they were at the clinic, do some simple exams on them like taking their blood pressure and pulses, and then discuss their cases with my preceptor. After I finished presenting the patient, the two of us plus a resident who was also working in the clinic today would go back into the room and we would do a more involved exam. I got to practice some of the skills that we were learning in our diagnostic class last week. I was running non-stop for four straight hours, but I had a really good time, and I got to see some really interesting patients.

After I got out of clinic at 5:00, I stopped by the anatomy lab. Dr. Drake had waited for me like he promised, and one of my classmates was also there. The three of us went through all of the cadavers and reviewed the neck structures. It was a lot easier this time because I am starting to get familiar with the neck muscles, arteries, and nerves. I still need to finish reading the neck section of the book though. Now I am exhausted though, and I need to go to bed.

Monday, November 06, 2006

Anatomy Lab and PBL

We are still working on the neck in anatomy. Today we concentrated more on the thyroid gland. Besides the cadavers, there was also a plastinated half of a head and neck. I've never seen anything like that before. It's basically a real human head and neck cut in half and treated with some kind of chemical to make it like plastic. It's kind of eerie. I didn't think that the surgeon presenters were as good today as some of the previous ones we've had, but the fellows were fantastic. They were trying to talk us all into becoming surgeons. I'm still not convinced that I should become an ENT (ear, nose, and throat doctor), but I have to admire that these guys are so enthusiastic about what they do. Apparently ENT is a pretty competitive specialty.

This week I am the board scribe for PBL. That means that I am responsible for keeping track of our work on the marker board while we go through the case, and I also will draw our rough draft of the concept map on the board on Friday. The PBL case for this week is about a woman who was in the hospital for surgery and then stopped breathing. Again, we're pretty sure that we know why this happened. My learning objective is to find out what the normal dose of morphine is for patients being treated for pain, as well as how to treat morphine overdoses. We also spent some time talking about the evaluations as a group. Overall I think that everyone was pretty fair with their evaluations. Our group has really come together nicely. We have a lot of very strong personalities, but we've adjusted to working together, and I think that all eight of us will be sorry when we have to break up in a few more weeks.

I was going to go to anatomy office hours today, but Dr. Drake had to cancel them. So I talked to him about it, and he is going to stay after five tomorrow so that I can come by and review the cadavers after I finish with clinic. It's going to make tomorrow a very long day, but I get so much out of going to office hours that I really don't want to miss a week.

Saturday, November 04, 2006

FAQ #16: Why Is It Taking So Long for Me to Hear Back about My CCLCM Application?

I'm going to hazard a guess that you applied to both the Case UP and CCLCM. If you did, then that is a big part of the explanation. I think I've mentioned before that CCLCM has its own separate admissions office. It's not just down the hall from the UP admissions office, either. Our admissions office is physically located on the CCF campus, not at Case. So if you apply to both programs, your application basically has to undergo two separate reviews on two separate campuses here and at Case. The two admissions offices do talk to one another, and that adds to the time too. Although their admissions decisions are separate, they try to coordinate the applicants' interviews so that if you get invited to interview at both programs, you only have to come out here to Cleveland once. Unfortunately, this all means that it takes longer for your interview invites to get sent out, since both programs have to evaluate your application before either one or both will send you an invite.

In answer to your second question, yes, it is definitely possible to be invited to interview at one program and not the other. I am not really sure which program will give you a better chance of being invited. On one hand, we have a lot fewer interview slots versus the UP, but on the other hand, we also have fewer applicants. According to the Case admissions website statistics page, last year about 15.5% of applicants to the UP were interviewed, while about a third of applicants to CCLCM were interviewed. So when I applied, it looks like the UP interview was the harder one to get. But keep in mind that because CCLCM is such a new program, the numbers change a lot from year to year. Already, a lot more people have applied here this year compared to last year. Also, this year, CCLCM will be interviewing far fewer people compared to last year (closer to 250 versus 371 last year). So I'm not sure what the new numbers will be, but it's definitely going to be statistically tougher to get a CCLCM interview this year.

I feel for you current applicants. Every CCLCM application season so far has been more competitive than the one before it. The thought has definitely occurred to me on multiple occasions that if I had waited one or two years to apply to medical school, I might not have been able to get accepted here.

Friday, November 03, 2006

Acid Base Seminar, PBL, and POD

Today was a completely awesome day. Our seminar this morning was about acid-base chemistry, which could have been a little bit dry. But the speaker did a great job of making it interactive and fun. He gave us several sample cases to solve, and we went through them as a group to determine what each patient's problem was. The only thing I didn't like about the seminar is that I felt the speaker was too reliant on memorizing equations. It is definitely possible to solve the case problems with more of an intuitive approach, and since I don't like memorizing anything, I am happy to report that memorizing the acid-base equations appears to be unnecessary. You can see what we did on the website that he made to teach us about acid-base chemistry:

In PBL, we finished our case for this week. Since I was the computer scribe, I had to make the concept map for the group. We have the board scribe do a draft on the board first, and then I copied that and made it look prettier in Power Point. I think that this week's case was good and we were pretty much satisfied with how it was resolved. But I would have liked to have gotten a little bit more information about the patient's social history. Sometimes it's frustrating to not be able to actually ask the patients questions!

Our POD seminar today was about narcotics and respiratory depression, and it was fantastic. I think that it was one of the best research seminars we've ever had. The speaker was the same one who did our earlier seminar this morning, and he was just absolutely interesting, engaging, and hysterical. He has a very interesting background, too. He started out with getting his MD, then went to graduate school for a PhD, and along the way he has also picked up a few MS degrees. Talk about being a life-long learner! The great news is that he posted his entire talk on line. You can see it too if you want:

Well, I am going to go work on my CAPPs questions now. I didn't buy one of the books we were assigned to read yet, so I want to go use it in the library for one of the questions.

Thursday, November 02, 2006

Mid-block Evaluations and Sharp Talk

In the morning, I worked on writing mid-block evaluations for my PBL group because they are due Monday already. I have to do eight of them total: one for each of my seven PBL group members, and then a self-evaluation. For some reason that I don't understand, we never seem to do mid-block evaluations of our tutors. But we will evaluate them at the end of the block if this block works the same way that the summer block did.

There was no school today, but I did head over to campus for a little while in the afternoon to go to the gym and see a talk. The talk was by Phillip Sharp, who won the 1993 Nobel Prize in Medicine for his work on introns and splicing. He was telling us about small interfering RNAs. I thought that the first part of the talk, where he focused on therapeutic applications of siRNAs and the results of studies in primates, was the most interesting. I'm not really all that into molecular biology though, so when he started getting into the specifics of the mechanisms toward the end of the talk, some of it kind of lost me. But I think that it was a worthwhile talk to attend, and I saw several other CCLCM students there. Actually, the auditorium was completely full to the point where several people, including me, had to sit in the aisle. And there's one other thing that I'll warn you about going to talks here: people's beepers go off during the entire talk constantly. It's actually pretty annoying.

Wednesday, November 01, 2006

Respiratory Simulator, PBL, and Clinical Skills

Today was a really long day since we had clinical skills in the afternoon. We started out in the respiratory simulator lab, which is used to train anesthesiologists. Basically they have a dummy that can mimic a patient who is being put to sleep, given drugs, intubated, and other anesthesiological procedures. I had seen dummies like these when I visited some other schools last year while interviewing, but I didn't know that we had them here. They're pretty cool and kind of eerily life-like. They breathe, blink, have heart and lung sounds, and you can even feel their pulse. We were split into two groups. One group worked with the dummy first while the other group went over lung anatomy, and then we switched. The anesthesiologist who went over lung anatomy with us was really good also. There was apparently an optional pulmonary physiology book that covers the material in today's seminar, but somehow I missed seeing that on the portal. I am going to order the book and read it later though, because it seems like it will be really helpful.

We continued on with our PBL case from Monday. I don't think I mentioned before that I am the computer scribe this week. My job is to take the notes for the group and then send them out to everyone so that we know what was covered and what our learning objectives are. I'll also make the final concept map on Friday. We make concept maps every week at the end of each PBL case. Basically, they are diagrams that show how all of the concepts that we've covered that week are related to one another. We do a rough draft of the concept map on the board first, and then the computer scribe does the final copy. Next week I'll be the board scribe.

In the afternoon, we had clinical skills class. Today we learned how to take more pulses. I seriously never realized that there were that many pulses in the human body. Besides the ones that everyone is accustomed to taking, like in the wrists and neck, we also learned how to take the pulse in the jaw, arm, groin, back of the knee, and foot. After that, we learned how to see the jugular vein pulse using a pen light and to measure how high the waveform travels. What you do is get the patient to lie on his back with his head turned somewhat away from you, and you shine the pen light on his neck at an oblique angle. If you look on the pillow under his head, you will actually see the light move with the pulsation of the jugular vein. Kind of weird, but cool. The last thing we did was to listen to the heart sounds and to feel for the place where the maximum heart beat can be found. When you listen to heart sounds, you can listen for each individual valve in the heart, four in all. There are two kinds of valves in the heart, and they actually do sound different. After the physical diagnosis part, my group did mock interviews with standardized patients. We got taped doing them this week, and we'll be going over the tapes with one of the instructors at the end of the month.

I am really tired today, but I have to say that I really like clinical skills class. I feel like I'm learning a lot and starting to actually be able to do something useful. But of course this is just a drop in the bucket in the whole scheme of things.