Why Go to Medical School? Reason #2

There's been a fair amount written about the true cost of medical school. A quick survey includes:

1) quarter of a million dollars, down the crapper.
2) 4 years for the privilege of losing another 3-5 years
3) previous relationship
4) previous waist (3 and 4 may be related)
5) all previous hobbies and interests
6) ability to have non-medical conversations (throw this in with 3 and 4)

And we slug it out, each of us, for the dream of becoming competent. I find little solace living with the knowledge that everything I have learned I will likely forget, and that everything I really NEED to know I won't see until years 3, 4, or beyond. Ergo: nothing I am learning now is making me competent. Makes it hard to give a GODDAMN about osteomalacia.

So I'm fighting back. I'm going to save each and every person out there from doing this for the wrong reasons. How, you ask? I am going to start posting here all of the useful things that I am learning in medical school. Things that will change your life, every day. After reading these, the best medical gems, do you still want to come learn the boring stuff?

This is the first installment:

Working Title: Reason #2
Alternate Title: The Grace of Defecation.

First, let's start with a little Anatomy. You're a tube with limbs. You're mouth is connected directly to your anus. Along the way it bubbles and flares into your stomach, small intestine and large intestine. Your large intestine is also known as the "colon." I didn't know that before coming to med school, and thought the colon was it's own organ just like the mysterious "prostate," which I thought meant "lying down."

Everything you eat is slowly sucked dry of the nutrition and turned into waste. It's this sloppy green paste that's found in the small intestine. Then the colon takes over and the magic begins. The colon sucks the paste dry and ages it, like the worst wine imaginable, into a brown solid. The colon fills with this and stores it until it's convenient to void it, and aren't you glad for that small courtesy?



This is my drawing of the colon (Fig. 1). It bubbles and squeezes and pushes the waste through the Ascending Colon on the right, it travels along the upper deck of the Transverse Colon, and then it slides on down the Descending Colon. You'll notice that the Descending Colon is a little "off aim" from the rectum, that is, it isn't a straight shot. That connecting segment is the Sigmoid (S-shaped) Colon and its little kink is the life-saver. Without that, it would be much more difficult to restrain your bowel movement (BM). At last, we have the anal sphincters. You didn't know there were two, did you? Yup, the inner sphincter is under your body's control. Like any Control Tower, it doesn't let anything take off until it sees a need. The outer anal sphincter is under your conscious control and has to wait for ground clearance. Once that clearance is granted, it's the pilot's decision for go/no-go.

Now let's talk technique. The pressure of building feces is usually enough to have the BM. Untrained children know this. That's not why you're reading this. You're reading this because you are a professional, and professionals keep current with the latest journals. In the event that you have passed the golden two minutes and are losing hope for this BM, there are tricks both mechanical and chemical.

Mechanical: Remember Fig. 1? Like any hand-held maze with a single marble, the trick is to coax the feces down the chute. The order is crucial. First, lean hard to your left (Fig. 2). This ensures that any marbles in the upper deck are packed into the Descending Colon. Hold that position, shake a little, use your best judgment. When you are satisfied, bank a hard right (Fig. 3). This maneuver will hopefully un-kink and straighten the Sigmoid Colon, ensuring a straight shot and maximum pressure against the Control-Tower-Sphincter. Hopefully, you get clearance.





If this does not work, you have reserves. Your abdomen is filled with your guts and sits below your lungs and heart (Fig. 4). Your abdomen is also shrink-wrapped in muscles. Both can be used to advantage. Most everyone knows that crunching up your abs and leaning forward helps. Both moves compress the abdomen and build up pressure. But without incorporating the lungs, it's like throwing a fist flat-footed. You've GOT to put your weight behind that punch! You do this using the Valsalva maneuver. It was originally developed to help push pus out of the ear. We're going to modify it.



Because you're chest is next to your abdomen, building up pressure in one builds pressure in the other. That's why a punch in the stomach (increase in abdominal pressure) knocks the wind out of you. That's why building pressure in your chest is going to knock the poop out of you. To build up pressure in your chest, take a deep breath, close your throat (or pinch your mouth and nose), and SQUEEZE! Try to forcibly exhale against your closed throat, press your elbows against your sides, crunch your abs and lean to the right. If you'd rather use a more familiar tack: blow your nose (Fig 5). Hopefully, your best efforts will bear fruit.

That was graphic, right? Now that we're done with mechanical, let's talk chemical. Certain foods help us void. I remember the first time in my life when something was "stuck" in there. My father brought me a bowl of Cheerios. I was six years old and didn't know any better. While fiber and other ruffage (think leafy greens) helps keep us regular, it's more preventative than curative. For the right here and right now, you'll need some caffeine. Caffeine is a stimulant and a diuretic (makes our urine clear). Clears the mind; sharpens the senses. It also accelerates the colon's normal shuffling action. Unfortunately, our coffee mugs are usually out of reach, and it's a little embarassing to call a coworker or family member for a cup. I'll never forget the time I ran out of toilet paper at a friend's house. "There's more underneath the sink!," he yelled. I leaned over to throw the door open and there, next to a fresh role of Downy, was a single can of RedBull. This was a man who knew what he was doing. I've kept an emergency can by my thrown ever since.



So that's my advice. Rock left, then right. Blow your nose. Have an emergency can of Red Bull. I just saved you $45,000.

Having read this, I know that each of you is thinking: "What is wrong with this person? Who sits down to write a manifesto on the bowel? With pictures? I can't believe I just spent 5 minutes reading that." To which I respond, "Try, just try, to forget it. Also, you're welcome."

Disclaimer: I have not conducted barium studies to verify my shuffling bowel theory. I am not a nutritionist or a gastroenterologist.

Grand Rounds is Up

Grand Rounds is up at Kidney Notes. For those of you that haven't heard of it before, Grand Rounds is a collection of the best writing in the medical blogosphere hosted by different people each week. If you don't have the time to read everything out there, it's a great crib sheet.

Yellow Eye of Jealousy

In my life, I know that I want to have piles of money and work with complicated things. In highschool I thought computer programming was the answer. That was until we left the comfort of C++. In undergrad I thought Economics was the answer. That was until my love for Micro was stomped out by Macro, it being the bigger of the two. It's been a theme of mine to love something until it was hard, and then love it much less. Finally, in medical school, I'm starting to get a handle on it.

I can be a big-picture kind of guy, but mostly I like minutiae. If you want to write a test that I'll fail, don't ask me about the type of Reed-Sternberg cell seen in Lymphocyte-depleted Burkitt's lymphoma, because I know that one. Instead, ask me what lymphoma children get. In the tree of my mind, I'm leaves without branches and it's windy in here. It's why I do well against my roommates in Jeopardy. It's why I couldn't explain any of what I've learned to my parents. It's why, as a second year student having seen the material three different times, I can't explain the female menstrual cycle to anyone. I'm young: women and babies are too big-picture.

Everything endocrine is too big-picture, and every time I see the material coming at me in the syllabus, I make a promise that this time I will achieve deep understanding. I will come to knowledge, and I will own it. Never happens. I looked over my Histo notes from a year ago and saw to my horror that I had labeled the anterior pituitary as the hypothalamus and had kept that distinction throughout my notes. Those 10 pages of stupid stared at me; mocked me. "Remember in high-school computer class when you wanted to write programming code? Remember when you cried and quit over nested loops? I remember. I remember you're an idiot."

Economics is beautiful. Nested loops are beautiful. Endocrinology is beautiful. It's all about homeostasis and balance and listening and I suck at it. I think that the Liver and Biliary System is the most amazing thing in the body and I want to study it until I'm yellow in the face. I'd love to be some species of Endocrinologist but my M.O says that I'll shrink from that dream and instead become a surgeon. Those who know me say that I'm instead a surgeon with hormonal delusions. At 24, I'm still blaming puberty.

Next week will be my forth attempt. Every time I have failed has more firmly cemented my learning curve. And though I remain optimistic that this may be the effort that changes all of that, I cannot ignore the brutal truth of those two standard deviations in front of me.

I will probably fail at the academic side of medicine. I will instead marry an Endocrinogist, become a surgeon, and look with jealous eyes at the Anesthesiologist. He'll probably have his computer open. I'll lean over and see that he's writing a computer program for an economic pet project of his that he nursed through medschool, which came easily for him. And while he's kicking my dog and getting married to my first girlfriend, I hope I remember that I'm thankful for being good at anything.

So I'm not big-picture. The sooner I make peace with that, the sooner I can look at the glint from my shiny scalpel and forget about it. I'll sing the scalpel song that Todd from Scrubs taught me:

"Dum, did de dum, did de dum, did de SHINY SCALPEL!"
"Dum, did de dum, did de dum, did de GONNA CUT HIM UP!"

Jog-22

In medical school, I have options. I can do a few of the following:

1. Stay healthy.
2. Get As.
3. Have a healthy relationship.
4. Have a social life.
5. Do research.
6. Get tan.

The interplay is fascinating. When I go for As and Research papers, I gain weight and lose my social life. When I'm trying to be a good boyfriend, research and books go by the wayside. Also, if I'm happy in the relationship, I gain weight. I could get tan, but then I'd just be round and brown. Plus, being tan requires maintenance, and if I was capable of that then I wouldn't be round. Staying healthy was never really in the cards.

3rd term with all of its free time was my only real shot at nailing more than three items from that list. Funny then, that I remember so much of what I learned then as training for getting angry at ungrateful patients (that I haven't had) over not following my advice (which I haven't given). So what if a smoker comes in complaining of a cough for the last two years; I'll feel sorry for him. I'll bond with him over my obesity and diabetes. He has his 30yr pack history complicated by chronic pneumonia and I'll have a 20yr donut-breakfast history complicated by a double-chin.

Why the focus on my health? Today I sat at the computer and noticed that instead of the effortless inhale that I've been so used to, I had to fight against a roll of stomach squeezed against my belt buckle. "These pants must be too tight." In my empty apartment, I look left and right before opening the belt and letting loose the top button. I took a deep, satisfying breath. "That's better."

About five minutes passed before I had my running shorts on, house keys in hand. I went for a jog. I'll never again lie and say that I "ran from campus to the roundabout" or "went for a run." I've been friends with too many cross-country runners and track athletes to think that the way I lurch forward while shuffling my feet constitutes a "run." I know just as well as they do that I might travel faster if I was speed-walking.

I should be better at this. I used to jog in my previous life back home. It's harder (for me at least) without a running partner, and I tried to get my sister running with me. She, being a little overweight, would have none of it. "People will see me and think that I'm fat." Which is true. Most people love to take a cheap shot at a stranger. Before I had trouble breathing, I remember seeing an overweight person out jogging and thinking to myself, "Someone should tell her that it's not working." Not now though; not since having sisters. I see people jogging and think, "Good for them. Jogging sucks."

And I would never do it to stay healthy for health's sake. Instead, I subscribe to the Yo-yo plan of jogging:

1. Jog and be miserable until skinny
2. Stop running and begin slow descent into happy fatness
3. Become disgusted with fatness and buy a new pair of running shoes (and jog in them)

The problem with this plan of mine is that once my body adjusts by pumping more blood, burning more fat, and increasing my basal metabolic rate I've also developed a constant gnawing hunger that rears its head 20 minutes after any meal. And dammit, if I was strong enough to say 'no' to that stupid hunger in the first place I wouldn't have overeaten and I wouldn't have a few pounds to lose.

Frustrated with failure, I do the normal thing: run for a half hour, drink a beer in the shower, and call it a day.

Dear Fantastic Four

There are four people that have admitted to me that they read this thing, and I need their help. Thanks to some accidental work with the school's Orientation office in New York, I have the bent ear of the people that stock our bookstore. I mentioned to them that I wanted to buy some clothing that showed off SGUSOM back home but I didn't like what was available. So they called me out on it.

"You don't like it, well what should we have instead?" So I have suggestions of my own. But that's just going to fill the place with things that I like. So if you have an opinion, please post a comment and I'll make sure that it finds its way to some of the higher-up mucky-mucks.

Also, I'd love some t-shirt ideas. Here's the dumb stuff so far:
"Welcome to the Rock"
"Eat at patels"
"It's GrenEHda not GrenAHda"
"I (heart) GND"
"I (nutmeg) GND"

I also want to suggest shirts and hats like these:

A First Place Cheese Log

My sister is graduating this Sunday. She's the last in a long line of grey hairs for my folks and I'm so proud that she's leaving the state for Regis University. Get free, sis. Get free.

Speaking of freedom, the hog squeals again. I dumped $300 into my moped to get it running again and it feels great to be cheating death on a daily basis. Just yesterday I was trying to pass someone that decided to swerve violently in front of me and slam on the brakes in hopes of causing an accident. Thank you slackline; the balance you taught me saved my life. It was over before I knew what happened, but the students in the car behind me let me know:

"He tried to kill you. You tried to swerve out of the way and your bike went sideways and skid forward a yard without flipping on top of you, and then you went to the side of the road. He looked back at you and screamed something. It was definitely on purpose. Is your foot ok?"

I look down to see that two of my knuckles have been ripped from my foot and the holes are bleeding. Sandals are not protective. I thanked them for checking on me and continued driving towards the nearest bandaid. I think that when my life really is in danger I'm going to be robbed of the whole "life flashing before the eyes" bit since near as I can tell I just draw blanks. The bike is now for sale.

The exams I studied so much for went well and while Path still remains, Microbiology is over. I learned some amazing things in that course and am sad to see it go. A few of the gems:

Military officers do not contract gonorrhea, that's for enlisted men. Officers are afflicted with "bacterial urethritis."
I rarely spell "gonorrhea" correctly. In fact, all medical words that contain an "h" have to be preceded by "rr." Diarrhea, amenorrhea, rrhiccup, and so on.
Doctors are paid by the syllable and charged by the word. That's why you'll hear "Pyelonephritis by hematogenous spread" instead of "The bacteria got to your kidneys by your blood." If each word costs a dollar and each syllable pays a dollar, the first sentence pays $9, the second sentence pays $4. So as a physician, I can either be plain-spoken and poor or rich and confusing. I think I've found my calling.

I'm not ready to start studying again and am trying to stay distracted. This includes looking online for a tutorial on how to whistle with two fingers. I have technique but not power. I'll keep you posted on how it goes. I still say the alphabet backwards once a day, to stay sharp.

I finished the edit on my research paper and sent it back. Two days ago I received notice that it was accepted. I feel sorry for everyone with a birthday that's 4-6 months away, because you're getting a copy of the Annals of Thoracic Surgery that you DO NOT WANT and WILL NOT READ but are GETTING ANYWAY. I found out that I have one of the oral presentation slots for Congress this summer. The reserach congress is in Milwaukee. I feel like Wayne and Garth when "Delaware" came up on the blue screen.

I'm up against 14 other students, one of which won the prize last year. I have it on good authority that the boy whose voice cracks the most often will win this year. Should be fun. I'll bring back a cheese log. A first place cheese log.

So much depends upon...

William Carlos Williams once wrote that "so much depends upon a red wheelbarrow, glazed with rainwater, beside the white chickens." And he was an idiot. So much depends upon momentum, and every med school student knows this.

It usually happens two or three weeks before an exam, but you'll see every student stay later in the library, talk less, take shorter meals. They're switching into higher and higher gears of focus. It takes a while, but the hope is that the week before the test they'll be operating at their maximum, absorbing everything, learning like a machine. Once that test is over, they don't celebrate or take a day off. They hunker down for the next four days, never changing gears, in order to tackle the next exam. Momentum is so valuable and so hard to build that losing it over a celebratory beer seems irresponsible. And it is.

Once the week of tests is over, most will gather around a bar, drink the weekend away, and gladly lose all the ground that they've gained. Others will relax for a day, and then start on new material with the momentum that they refuse to lose. And this works, for a while.

But the thing that you learn afterwards is that so much depends upon balance. Studying straight, 14 hours a day, for five weeks and you start to burn up and burn out. You lose the joy of learning. You hear the stories of what you missed that weekend and soon enough you've lost your precious focus. It's times like these where you have to push the responsibilities away, go out, and remember how funny life is.

Tonight I went to Stewart's, a local bar on a floating dock. Students are buying 16 beers at a time because they hate waiting in line, a lot. The men's bathroom has two urinals, and I feel humiliated every time I have to use that one that is obviously for children because I'm not 6'10". At the end of the night a young couple knocks on my door asking for ice, and promises that they'll bring me some ice tomorrow. I try to explain to them that I can just grow some more but they insist. Fine, I'll take your ice cubes.

This recharges my batteries. This is what I'll laugh about when I'm locked in the library for the next three weeks rebuilding my momentum.

"So much depends upon a young couple, sloshed with warm liquor, begging for ice."

Take that, William Carlos Williams.

Hospitals For 3rd year Clinical

Approximate Spots in each hospital for students

Elmherst 24
Jamaica 18
LICH 24
Lutehrn 32
Maimo 32
NYM 50
Barnabas 28
Brookdale 16
Flushing 12
Highland 12
Jersey 8
San Joaquin 8
St. Francis 6-8
St. joseph’s Mercy 4

USMLE review

This is from a talk given by Dr. Moninger at St. Vincent's. It's rough and I'll add to it as I approach this hurdle myself.

Most important things

1. Good 3rd year grades
2. letters of recommendation
3. previous research
4. usmle step I score
5. 1st and 2nd year grades

-on test day, wear your least favorite long sleeves shirt
-you can’t mark on scratch paper, mark on plastic sheet (laminate a sheet of paper)
-cannot bring in baseball cap, electronic watch
-they videotape you while taking the test

passing is around 57%
avg is around 65%
best is about 80%, this is the best anyone ever does

-you will feel bad after exam even after you studied hard
mean is around 215-218
passing is 182

question types
-vignettes
-pictures
-charts
-calculations

60% of exam is new every year, but they compare everyone on the 40% of questions before
just to get any residency, you want to score above mean
if you get in top 75% of usmle, you can go almost anywhere (225 – 230)

-questions are written by a committee, all members of the committee must agree on each question

-questions based on core information, not research projects
-if there is a disagreement about the answer, the question is gone

question breakdown (approx)

70 - path
50 – phys, micro, pharm
40 – anatomy, behavioral science, biochemistry

-most medical students take 4 weeks to study for step I and take it right after you study, if taking review, take a 1 week to consolidate information
-gpa is more of how quickly you can stuff it in
-I recommend studying from 8 am to 5 pm

5 rules for doing well
1. know the material well that you study
2. keep it simple
3. know differences rather than similarities
4. do half hr of micro and pharm every day
5. rehearse out loud

do half an hour of micro and pharm each day
-med students want some sense of accomplishment
-just do 3 new drugs a day for 20 days will significantly improve your pharmacology score
-doing 15 new drugs a day for 5 days will not significantly improve your score

Rehearse out loud
-we tend to fool ourselves when we read quietly to ourselves
-the real test of knowledge is talking

Good news
-you can study the material you learned here and do very well
-if you created course notes or in some way condensed the material, this would be the best way to study from, sometimes the obsessive and organized people win

4th Term

Good luck with 4th term. Lot of work, lot of fun, lot of time in the library.

These courses are going to overlap a great deal, mainly with infectious agents, immunology, and diagnostic procedures. The review books that were the most helpful: First Aid for USMLE, Micro/Immuno BRS

MICRO (5cr):

The department does an excellent job on some sections and horrible on others. You really need another resource to handle and structure the information. I used the First Aid for USMLE step 1 book and the Micro/immuno BRS. I highly recommend each. I did not buy the Micro text. Too much information. Several times in the notes, a reference will be made to a table or figure. When it came time to prepare for the tests, I just checked it out of the library, found the figures and moved on. Save your money.

PATH (13cr):

Path is challenging because of the alien teaching style (group lab work) and the volume. Topics in Path are broken into Modules. You will have 6 before the first exam, 4 before the second, and the rest for the final. Each module consists of around 30 slides that are descriptive of different pathologies. Among your group, you will split up these slides, go to the library to prepare a presenation on whatever you were assigned, and then present to the group. For the first half hour of every lab you are free to say as many wrong things as you want, but then the tutors descend. Once present, they will listen like hawks for the first piece of stupid to fall from your mouth, and they will then punish you for saying it by asking you questions that you cannot answer and slowing down the group (your fault). Then, since no one could answer correctly, your tutor will explain the problem to you. Don't get hostile towards the tutor; it's only because you screwed up that they had to fix it. That said, some tutors will insert comments here and there and hijack the lab. If this isn't the way your group wants to work, all you have to do is say so and the tutor will stop. They're there to help you, I promise.

So if the members of your group take their responsibilities seriously and don't try to bullshit through an answer, things will run smoothly and you'll cover your slides in the time allotted. If not, then there is going to be some disappointment and hostility when a pattern emerges. You'll have to come in on days off to finish when you could be studying. For this reason, I beg you to pick a Path group full of people that you think will DO THE WORK. If one of your best friends is a lazy bastard, then she needs to be in a group with her kind. Don't feel bad about any of this: the less work they do, the more work you do, the harder path is for everyone. Groups on top of their game are having fun. Be that group.

The biggest problem that hits the Path student is Volume. VOLUME. There are going to be three and four and five good sources for information, and if you try to pull the best from each to make your notes then you can kiss the rest of your life goodbye. With all that volume comes the mistake of thinking that it is all important. It isn't. For example, when researching C.neoformans, you could either write a book or you could write:

"small cell, thick capsule, india ink, AIDS meningitis."

When the test comes, it's hard to memorize 300 books. One liners are just easier for this kind of volume. I'm sure you'll find your own happy middle.

As for books:

The Path manual with black and white pictures is available in color .pdf on angel. I never used the path manual that I bought and instead worked from my computer. So I wouldn't buy it a second time around. However, many people used it to write down their notes in lab, and then would also annotate with the lecture handouts. The great advantage of this is that ALL THEIR INFORMATION WAS IN ONE SPOT. Having three different books open along with dr.google can be a bit overwhelming, especially when it comes time to study.

Make sure you get the macdaddy. It has audio files (Sokumbi's Reviews). Indispensable. It also has every lecture slide completed in PowerPoint format from previous terms, so you can get an idea of what the hell you're supposed to be doing that first week. It's also the great equalizer if you're confused by something your tutor said that week.

Big Robbins: amazing text. Pocket Robbins: also amazing. Bought both, used both every day. I also bought the Pathology BRS but it was too much. I stuck with my Robbins books and the notes and did alright. DO NOT BUY THE ROBBINS REVIEW OF PATHOLOGY QUESTION BOOK. Look to links...

Now for the websites.
Pathguy: Path professor famous for his easy explanations. Architecture of the sight is a little odd.
WebPath: Website with quizes, timed quizes, quizes with slides, path case of the week. Amazing preparation for the tests. Has all the questions from Robbins Review of Pathology, so you don't have to buy it.
eMedicine: Went to this website almost every damn day.

Clinical Skills:

Yup, you get to hang out with your Path group one more time. All in all my favorite course of the term. I bought Pocket Bates' and a stethescope. The PD kit was a little too expensive for my tastes and I wasn't won over by the tourniquet and tongue depressors. And what use I'll ever have for a BP cuff, well, I may never know. Of course if everyone decided that then we'd all be screwed since I did rely on at least two people in my group of 6 to have the kit. My vote is that the CS program should supply the kit for labs and tests themselves. End rant.

The Powerpoints on angel are good review and a video is shown at the beginning of every lab. Channel your inner-trained monkey and you'll get through it. When you're examining your classmates make sure you go with confidence. The tutors can smell your fear and uncertainty.

Remember that the majority of your CS grade comes from Saint Vincent's, so it isn't the end of the world if you have to come unprepared every day in order to stay current in Path/Micro.

NUTRITION:
I have yet to begin Nutrition, but trust the people that told me to just buy the book.

Hope it helps, topher.