31 January 2007

Choosing a Medical School

After I received my first acceptance, I knew that I was going to medical school but the question remained as to where I would be attending school. At that point, I had interviewed at three of my six schools and was holding one acceptance. It was late in December and I had interview invitations from three more schools. These interviews had been scheduled, two in January and one in early February. I had taken the August MCAT (MCAT was only offered in April and August in 1997) with my first interview invitation coming at the end of October. My interview season would run from early November to early February.

By my second medical school interview, I was well seasoned in the order of the day. There was always a meeting where someone from admissions/administration would speak with the group (8 to 20 people), then Financial Aid, then the scheduled interviews with lunch and a tour. Every school followed some version of this plan. Sometimes the tours would be after lunch and sometimes the tour would be first and interviews after lunch. In any event, there was a tour. (Even at the medical school where I taught, I elected to particpate in the tour much to the delight of my student tour guide).

By my third interview, I found that I was easily annoyed by the boastful pre-med. Every interview group has one or more persons who will brag about their publications, undergraduate GPA or MCAT score i.e. their general superiority. These folks will usually "scope out" one of the quieter folks in the group and proceed to attempt to "explain the ropes" to the quieter student. I observed one fellow brag about his undergraduate school and how everyone of his friends had been accepted to multiple medical schools and how his acceptances were likely in the mail. He also bragged about how he was going into Cardiothoracic Surgery and that the particular school that we were interviewing at was not particularly good for Cardiothoracic Surgery so he hoped that he didn't get in there. I often think of this guy today because I never encountered him later. I guess his hopes that he was not accepted at my medical school came to fruition. I wonder if he every got into medical school with his abrasive personality traits and booming voice.

By my last interview, I had five schools to choose from. My first criterion was location. All of the schools that I had applied to were located on the east coast (South Atlantic Region). I didn't want to attend medical school more than 200 miles from where I had grown up. The city, where I lived, had six medical schools within a 40-mile radius and eight medical schools within two hours drive. It was not difficult for me to apply to a variety of schools and still stay fairly close to home. Location was high on my list of priorties in choosing a medical school.

My next criterion was the "vibe" that I experienced during my interview day. I wanted to attend a medical school where I knew that I could be happy on a day-to-day basis. I was looking for a medical school that had a diverse student body (ages and ethnicities) because I thought that it would be fun to interact with many different people. i was also more intested in a medical school where the atmosphere was more cooperative than competitive. I also wanted a patient population that was fairly diverse too. Three out of my six medical schools met that criterion very nicely. The other three were acceptable. Generally, an urban medical school was going to suit me better than a medical school that was located in a rural area.

I didn't care so much about curriculum or USMLE pass rates. The one thing that graduate study taught me well was the my performance on any exam was based on my preparation and not on materials presented in lectures. If one person from a particular school had passed USMLE Step I, then the school was fine. USMLE Step I was not a significant factor in my choice of school nor was the match list as the matching process is self-selecting. As long as at least one person from any of my prospective schools had matched into the specialty of their choice, I knew I would be fine.

I did listen to my uncle's and father's friends when it came to medical school selection. At my top choices, I definitely knew that these schools provided an atmosphere that was condusive to an adult learning style. I also picked the brains of a couple of my cousins who had attended medical school. I wanted to know why they chose the schools that they chose and what was great about those schools. I was also fortunate to be a resident of a state that had three excellent medical schools that were reasonably priced.

By the time it came for me to make a selection, my number one and number two schools had offered me scholarship money. This money was based on my incoming GPA and MCAT scores. I carefully weighed my choices and was heavily leaning in the direction of my top choice when my number two school offered me a full-ride scholarship. Well, my choice was made and I was very happy to accept their offer. I am happy to admit that I could be bought by a good school offering a full-ride tuition scholarship. The conditions of my scholarship were that I would have to keep a high GPA in medical school which meant that I had to start strong and stay strong.

In the end, I chose well. I attended a medical school with an excellent faculty, cooperative student body and was exposed to some of the finest medical practice in the country. I am now quite happy to be an alum. When I started my intern year, I never appreciated my medical school more because I was a definite self-starter. I knew how to take very good care of patients and how to get things done. It was not much of a step to go from fourth year medical student to intern for me.

Things that I have realized now that I have been out of school. It is not the prestige of your medical school but your performance at said school. In the end, paying $250,000 for a medical education has to be worth every penny for you and you have to make the most of your education. I am happy not to have attended a school that cost $250,000 because that kind of debt would not be worth those enormous interest payments on loans. I am happiest with my total debt of $40,000 for four years.

Any medical school in this country, provided you do well, can prepare you for any career that you want. People who do not perform well in medical school can knock themselves out of competitive specialties and the prestige of their medical school will not overcome a poor performance.

Osteopathic versus allopathic medical school is a non-issue in today's world of medicine. Either type of school can provide the teaching that will enable you to become a physician. It is a myth that graduates of osteopathic medical school must go into primary care. I have worked with every type of specialist that were osteopaths from orthopedic surgeons to ENT surgeons to neurosurgeons. If you perform well in any medical school in this country, you can enter the specialty of your choice.

In the end, choose a medical school where you know that you can excell.

30 January 2007

Why Students Fail in Medical School.

One of the biggest myths in the medical school process is that once you get into medical school, it is relatively easy to STAY in medical school. Each year, approximately 5% of those who enter fail one or more courses or fail out of medical school entirely. Why does this happen after being subjected to a selection process that is very stringent?

The biggest reason for students failing a course or failing out of medical school is an inability to put in the study time that a very competitive medical school curriculum demands. A sizable proportion of freshman medical students may have been able to get through their undergraduate studies by the "last minute knowledge cram" method, only to find that they are in deep trouble fast.

Most of these students will adjust their time management skills and do well enough to pass their coursework but some are not able to make the transition from undergraduate to medical school. These folks find themselves behind their class very quickly and fail to catch up enough to pass. Courses like Gross Anatomy and Biochemistry quickly knock them out of the freshman class.

Another small proportion of students will have too many personal demands to keep up with their studies. They may be parents or spouses or they may have personal illness that actually prevent them from the mastery of their work. In these cases, a wise Dean of Students will offer a Leave of Absence before the student finds himself/herself in academic difficulty. It pays to alert your Dean of Students at the first sign of personal trouble. Often the Dean can alleviate the problem and get the student back on track. Again, sometimes the problem is so pervasive, that only a Leave of Absence will allow the student to take care of personal matters and return to academics without penalty.

Few medical students are intellectually unable to master the curriculum. While the amount of information to be mastered is massive, the difficulty of the material is fairly average. This means that the key to keeping yourself academically sound is disciplined study habits that enable you to digest this large body of information in a short period of time. Most students study daily and keep a rigorous study schedule even on weekends.

Many students will become caught in the "no one else is struggling so I must be stupid" trap. Every medical student from time to time will struggle with something. Most students figure out what they need, ask for help and get the task accomplished. Some students will become depressed and procrastinate. Procrastination is the enemy of good scholarship and leads to more depression. Again, chatting with a few classmates or the Dean of Students can often put your problems into perspective and give you new ides that get you on your way.

Here are a couple of examples that illustrate my points above:

Janet A. was newly married and entered medical school. Her husband worked as a high school teacher and had a eight-year-old daughter by his previous marrige. Two months into medical school, Janet discovered that she was pregnant. Her pregnancy zapped her energy level and made the demands of medical school more difficult. In addition, she was having difficulty getting along with her new step-daughter who was unhappy that they had moved from another state. She got behind in her studies, especially Gross Anatomy, and struggled with her other courses. She ended up failing both her Gross Anatomy lab and lecture exams and barely passed her Biochemistry exam. On top of her worsening academics, she miscarried and was absent from class for one week.

Solution: The Dean of Students recommended a medical Leave of Absence for Janet. She started with the next year's class and did very well. She was able to take the time for family counseling and was able to devote full time to her studies.

Chris P had eagerly awaited his medical school acceptance. He had been happy and enthusiastic during orientation week attending all of the social events and developed a lively group of friends and study mates. When classes started, he kept up but partied very hard on the weekends spending Saturday night in the clubs and Sundays recovering from his Saturday night partying. Few people were able to keep up with him. By the second block of exams, Chris found himself just barely passing his coursework yet he continued his active social life. He always said that he "needed to let off steam" in order to concentrate on his studies.

By the end of the first year, Chris found that he needed to take two courses in summer school in order to be promoted with his class. He was able to pass one summer course but failed the other summer course and was dismissed from his class.

Solution: Chris applied for readmission at the end of the summer and was denied. He applied for re-admission after sitting out for a year and was re-admitted. When he returned to school, his discipline and study skills were outstanding. He was able to finish medical school and enter residency.

James P had entered medical school witht he idea of becoming a child psychiatrist. He had extensive experience teaching inner city children (had been a high school teacher) and was the author of several books on innovative teaching methods for children at risk. He embraced his studies and did well on his first block of exams. About halfway through the material for the second block of exams, James decided that he was not interested in medicine at all. He went to the Dean of Students and withdrew from medical school. He later completed his Ph.D in clinical psychology and very happily practices his vocation.

The three medical students above, illustrate the most common reasons that medical students fail. It becomes very difficult to catch up with your studies if you get behind. Many people are overwhelmed with the sheer volume of material to be mastered but make the adjustments necessary to do what is needed. A small proportion of medical students do fail and fail out of school. An even smaller proportion decide that medicine is not what they thought it would be and elect to leave.

The bottom line is that medical school demands a student with good study skills and a strong work ethic. While having a photographic memory will help with pre-clinical materials, the strong work ethic will get the student through the clinical years and through residency.

29 January 2007

Why I went to medical school at a later age.

Back in 1995 when I was a busy graduate student, I was happily contemplating my future career as a college professor. Even as a child, I knew that I wanted to be a research scientist. I had excelled in math and science in the English school that my Mum had so carefully chosen for my education. My Mum was very pro-active when it came to the education and enrichment of her children. She was my first and best teacher. She had taught me the value of an education and the value of observation. While directing the growth of her children on a self-sustaining farm, she made our 90-acre horse farm, a living laboratory for our education. Armed with this background, we were expected to excell at all things academic. The "buzz" around our evening meal was not about sports but about Einstein's Theory of Relativity and higher mathmatics in addition to the fine reasoning of Immanel Kant.

Later, after I graduated from secondary school and entered university, I realized that I could trust my own observations and conclusions under the conditions of study. I approached every class with the vigor and demand for knowledge that my Mum had instilled in me (fostered with a healthy dose of curiosity on my part). I loved every second of my General Biology course and challenged myself to master every factoid that my professor presented. I never attended lab without careful preparation and continued with careful evaluation of every thing that I had observed. I was also very organized when it came to my coursework.

The first semester of my undergraduate freshman year, I took General Biology, General Chemistry and Differential Equations in addition to an English class on Critical Writing and review. I also played on the tennis team which required a fairly high demand on my time. Thus, I had to carefully set a study schedule and keep to my study schedule. When I started college, I knew that I was going to major in chemistry with an emphasis in the chemistry of the living.

I sailed through General Biology and General Chemistry with gleeful passion. I also loved my Differential Equations class as I explored the theories of solving these mathmatical equations. In addition, I honed my heavy flat serve and backhand volley that usually intimidated my opponents into submission. I had learned to play serve and volley with the boys so I generally dominated females who never came into the net. Most of the tennis games that I won were won on my fast, flat first service.

During my sophomore year, I took University Physics, Organic Chemistry and Histology. Again, my humanities courses consisted of a course on Early Puritain writers and History of American Thought. I had tested out of both classical and modern foreign languages haven taken classical Greek, Latin and Modern French while in secondary school. I also took a course in Applied Differential Equations (with the engineers). Physics became my favorite class and I loved Histology too. Histology provided a nice contrast from figuring out physics problems and mastering concepts.

During my junior year, I studied Analytical Chemistry, Advanced Inorganic Chemistry, Physical Chemistry, Advanced Analytical Chemistry (graduate-level mass spectromety and electro chemistry), Nuclear Physics and Atomic Physics. I spent most of my days in the laboratory and loved the precision of my coursework. I also began working on my honors project as an undergraduate researcher in the laboratory of one of the analytical chemists. Working in his lab honed my love of developing hypotheses and design of experiments. Most of all, I started to see the dawn of the use of mass spectrometry in the analysis of large biomolecules.

My senior year brought decision-making for me. I was torn between the graduate study of Analytical Chemistry and Biochemistry/Molecular Biology. My senior honors thesis had been on determining the detection limits and analysis of Snake Venoms by Matrix Assisted Laser Desorption Time of Flight Mass Spectrometry. By doing this project, I had learned much about biomolecules and the analysis of large biomolecules (proteins).

I decided to apply for graduate school in Biochemistry/Molecular Biology. I was accepted and received departmental funding to teach both undergraduates and perform my laboratory experiments. I was placed in the lab of a cardiologist who was working on oxidation-perfusion and low magnesium states. This lab was multi-disciplinary with immunologists, biochemists, biophysicists and chemists present. I thrived in this atmosphere. Here, I found a constant exchange of ideas and constant challenge to ask questions and research to find the answers to those questions.

My principal investigator requred his graduate students and reseach scientists to attend Cardiology grand rounds. It was during these sessions that my interest in the clinical applications of my research came to the forefront. I read as much as I could on cardiology, physiology and pharmacology. My PI loved my questions and one day suggested that I apply to medical school. "The worst thing that can happen is that you don't get in", he said. " If that happens, you continue your work here". He presented this as a "no-loss" proposition. This seemed reasonable to me at this point in my career. I could already see where the knowledge to be obtained in medical school would be useful for my research.

I took my comprehensive exams for my Ph.D in June, filled out my AMCAS and promptly took the MCAT that August. My MCAT study strategy was to study for my comprehensives (read, I didn't have much of a strategy). On MCAT day, I hopped on my bike and rode the six miles to my test site. I got in line for check in and listened to Aerosmith and Toni Braxton on my Walkman. I was seated in a room next to a window where I could look up and see a lovely blooming cherry tree with loads of fluffy pink blossoms.

The first exam section was Verbal Reasoning. I scanned all of the passages and chose to do the ones that didn't interest me first. I had little interest in psychology, history and sociology but loved science fiction and science. I scanned the questions and then read the passages underlining the key points that I needed for each question. I finished this section with time to spare so I just looked out of the window and enjoyed the view. I could totally let my mind wander far from this exam room and relax completely.

My next section was the Physical Sciences section. It was long but I had always worked these types of problems by using order of magnitude. I enjoyed the challenge of figuring out the hook for each question and supplying the answer. I found that I didn't need to do very many calculations as I could clearly figure what was being asked by underlying key words and working the problems using order of magnitude. This section was my favorite and I worked each problem as they came. About ten minutes into this section, three young men got up, turned in their test materials and left the room. My next question was, "Am I missing something here?" "This is really not THAT bad". Again, it was nice to be able to look outside for a mental break from the work.

The next phase was lunch time. I checked my bike and headed over to a small cafe where I knew the owners. After a light lunch of soup and tomato sandwich washed down with my favorite Diet Coke, I settled in the hallway ourside of the testing room with my Walkman and some Moody Blues. There is nothing like "A Question of Balance" to keep your head clear. I had chosen my music very carefully and made the right choices.

The afternoon session consisted of the Writing samples and Biological Sciences. I finished the tests, hopped on my bike and headed back home for a nap. Later that evening, I went to a disco with a couple of my mates and lost myself in the pounding music and Guiness stout. It had been a long day but it was over. No matter what, I was locked into whatever score I received and my application would be complete that October 15th.

My first interview invitation came on October 20th and my first interview was the last week in October. My last interview was in February. By my final interview, I was holding three acceptances and went on to acquire six out of six acceptances. To my astonishment, I had been hugely successful in application to medical school.

I don't know why I was accepted and two of my friends did not make it in that year. One of my friends was the president of the Pre-med honor society (I wasn't even a member) and the other had more publications that I and what I considered a better application. Both were also much younger that I. The only thing that I had beaten them in was MCAT score. Of the three of us, I had the highest MCAT score by far. My undergraduate GPA was strong (it had to be for graduate school) and I had held some interesting jobs (TV news producer, political campaign manager, environmental speech writer) in addition to my scientific work. I was also a pediatric, perinatal respiratory therapist (something that was hugely interesting to me at the time and easily obtained).

With that first acceptance letter, it hit me that my life was going to take a turn that I had not planned. I was going to add research physician-scientist to my career. I would teach, perform my clinical duties and research. To the delight of my uncle, I would follow in his footsteps.

I was never a "Pre-Med" student as an undergraduate. I certainly remember my classmates anguishing over receiving "Bs" in their science classes and grumbling about my performance since I really didn't care that much about the letter grade. I was in the class for the information. It was funny how my focus on mastery of course material (because I had to KNOW this material to be a good scientist) made getting the grade more easily than calculating what my score had to be to get an "A". My tests were my challenge to do better and better. If I destroyed a few curves along the way, it didn't matter much to me.

In the end, I carried a large body of knowledge and a solid background into medical school where I could build upon that background. Little did I know, until the second week of lectures, that I would be baraged with more information and a short time to assimulate it. My absolute curiosity about all things human would be satisfied many times over and continues to be satisfied to this day. For me, medical school was the ultimate mental exercise with a limitless supply of interesting experiencs and facts. I had the time of my life and learned to love the craft of medicine, not to mention, that I have met some of the most interesting people along the way.

28 January 2007

Pathology, the course that separates the physicians from the non-physicians

Our biggest and grandest course during my second year of medical school was Pathology. It was a year-long course that featured a mega-load of the things that physicians would spend the rest of their professional lives, dealing with. Our first semester consisted of Systemic Pathology and covered topics like Infection, Malignancy, Necrosis, Inflammation and Genetic Disorders. Our second semester covered all body systems and their pathology. This flagship course became my favorite because of the veritable "feast" of facts and tools that it would provide for my future practice.

Pathology was taught by a cadre of incredible professors, some of whom are internationally renowned. The single quality that all possessed was an ability to make the student as fascinated with their subject matter as they were. From our first lecture on Shock and Necrosis to our last lecture on The Pathology of the Male Reproductive System, our professors were just great. They came, armed with slides and the stories behind those slides. Many came with summary handouts that allowed review for USMLE (United States Medicial Licensure Exam) Step I, a breeze. I have every pathology handout and note sheet even today. If I need a quick review of every leukemia, they are literally at my fingertips thanks to my pathology professors.

To prepare for this class, I kept a very strict weekly schedule. We had a very thick syllabus that contained all lecture objectives and a very detailed textbook with readings for each lecture. By reviewing the syllabus and reading the test, I was able to sit in class and enjoy the explanations of every slide. I could take a note here and there which enabled me to remember the finer points of the pathology. My daily reading for this class was about 200 pages and my study for each lecture was about 250 pages. It was time-intensive but worth every second.

Along with lecture, we had pathology lab. These labs might be a conference (in the case of post mortem reviews) or might be our twice-weekly tutorial sessions. In our tutorial sessions, we were divided into three labs with each lab containing a pathology professor. The professors would shift but we would stay in our respective labs as assigned. We also had a wonderful gross pathology professor who provided a DVD video of every gross specimen presented for each exam. Those DVDs are golden because I can pop one in my computer and appreciate the fine points of a nutcracker esophagus or polycystic renal disease.

For each lab, we brought our slide boxes and microscopes so that we could follow along with the professor who was using the teaching microscope. These sessions taught us how to examine each pathological condition with the guidance of an excellent pathologist. Not only did we have the laboratory sessions but in between sessions, we could take our slide boxes home for review at home. Every Friday, I brought my microscope home for review of the previous weeks slides. I was also able to borrow additional slides from my professors in the pathology because I loved the study of pathology.

The other thing that I did that I believe made a huge difference in my approach to microscopic pathology, was develop a keen eye for the normal. During first year, I excelled in my histology class so that by second year, I was adept at surveying slides and identifying complex pathology. When I received a slide box, I took it home, got our a roll of lens paper and Windex. I cleaned every slide and arranged them according to lab and lecture. As each week went by, I had my slides clean and ready. I had also reviewed them carefully so that I knew what to look for in lab.

We were tested by microscopic and gross laboratory exam in addition to project and lecture exam. There were three exams for each exam period including the final exam period each semester. It is easy to see why Pathology took a major chunk of our attention during second year. I loved every second of these lectures, labs and conferences. To this end, the chairman of the department invited me (also based on my grades too) to apply for a well-paying Pathology fellowship that I would participate in during the summer between my second and third year.

The "catch" for participating in any second-year summer fellowship was that a student was required to take USMLE Step I, earlier than the rest of the class. I took my exam the second week of May after our classes had ended on April 28. Because I had excelled in Pathology, a solid review was all that I needed for this exam. I was very nicely suprised when I received my scores, at the end of June, that I had done quite well on this exam too. Pathology was indeed, a very good class to love and excell in.

My Pathology Fellowship allowed me to rotate as a medical student through two Offices of Medical Examiners. One of these offices was in a very large city and the other was quite suburban. I worked alongside the Medical Examiners (or a deputy) as we examined crime scenes and performed forensic post mortem exams. We were often asked to identify remains as human or non-human which was one of my favorite tasks.

I also worked the pathology end and performed Bone Marrow Transplants. This consisted of the harvest and infusion of stem cells. In addition I studied granulocyte transfusions and transfusion reactions. My pathologist mentor for Transfusion Medicine had a profound influence on the manner in which I practice medicine today. He was an excellent professor with a wonderful staff who was quite willing to show an eager medical student all aspects of Transfusion Medicine.

I was also required to attend all clinical conferences with the residents. These conferences generally entailed a discussion of the most complex cases that had come in for the week. A pathologist could call a conference within 24 hours if there was a great case. Our GI pathologist was trained at Massachusettes General Hospital and took great pains to make sure that the pathology residents (and me too) approached the complicated cases in a systemic manner. This was great teaching. At conference, we all sat around a table with microscopic viewers while the presentor "drove" the slides. At first, it was difficult to keep up but one of the residents spent an afternoon getting me up to speed. After his tutorial session, I could keep up with the slide driver and learn far more that I thought possible.

The best part of my experience during that summer was securing crime scenes with my mentors in the Medical Examiners office. I would hear news reports about the crime scenes that we had investigated and would often chuckle at how the news media would "get it wrong". I also went along with the deputy medical examiner had to provide court testimony. This was a good learning experience too. It wasn't like "Crossing Jordan" because the Medical Examiners office was not involved in the actual detective work. The M.E. provided as much information as could be gathered from the body and crime scene as it involved the body. I learned how these reports are put together and how important scientific observation and experiments are to solving a crime, not to mention, that I know how to "secure" a crime-scene so that valuable evidence is not lost.

As I entered third year, I was strongly considering becoming a pathologist. I certainly had a strong interest in the body of work and my graduate degree was an asset as I was well-versed in designing experiments and making observations. Even today, I always review my surgical pathology slides with the pathologist. All of the pathology residents and pathology attendings know me quite well and joke that I am a "closet" pathologist. I also include my surgical pathology slides in my presentations during Mortality and Morbidity conference (more about that in a later blog).

The study of medicine is unlike the study of any other body of knowledge. It requires an insatiable curiosity and anal perservance to "get it right" every time. There is a mountain of facts and experiences that a medical student must have to become a good physician. I was fortunate enough have some great professors who guided me through the learning process. I was also fortunate to have the energy to spend the hours needed to master my coursework. Pathology took many hours to master and pushed my discipline to the limits. In the end, it was worth every second because Pathology is the single most important pre-clinical course for any medical student. Pathology coupled with the rest of our pre-clinical studies made us physicians. In the end, it was great to see the transformation.

24 January 2007

Biochemistry, our first lecture as a medical student.

Orientation week was over and frankly, I was exhausted from a week of being hearded for ID photos, syllabi, microscopes and shots (Yes, we all had to roll up our sleeves for Hepatitis B vaccination). We had barbecues, lunches, mixers and drinking "fests" with the incoming dental and law students over the weekend. In addition, we had a great "White Coat Ceremony" featuring Ben Carson, M.D., chief of pediatric neurosurgery at Johns Hopkins University Hospital which was totally awesome (I will write more about that later).

On that Monday morning at 0800h, we all crawled (hungover and half-asleep), into our lecture hall for our first authentic medical school lecture. I had arrived early, thanks to nerves and good luck with the subway system, with plenty of time to do one more cursory pre-read of the material that was in our syllabus. The lecture would be a Review of Organic Chemistry by one of the Biochemistry professors that had been affectionately nicknamed "Rocket" by our upperclass advisors. I was feeling pretty confident since I had plenty of background in Biochemistry and had done extremely well in Organic chemistry. I had reviewed the syllabus and I was far ahead in my text reading. I sat in my seat (about 4 rows back from the front) with my multicolored pen poised (clicked to black) and ready for the lecture to begin.

Rocket came "out of the shute" with "guns blazing" and "white-lightening". I would never have believed any human being could cover an entire semester of Organic Chemistry in one hour (actually 50 minutes) but Rocket lived up to his name. Reactions rolled off his tongue like Eminem in 8-Mile. After two minutes, I just sat back and marveled. (Thank goodness for my little micro tape recorder). I just made a list of every topic that he mentioned and said a prayer of pity for the person who was assigned to cover this lecture for note service. The fee that I had paid for noteservice already seemed a bargin.

After 50 minutes, we were given a 10-minute break. I looked around the room which, was silent. All of us were sitting there in total terror. Rocket had taken us all out and we were too numb to even get up and mill around. After the break, he started up again, this time explaining the fine points of ph and Buffers. He finished the lecture with a problem sheet that he indicated would be due in two days. I looked at the sheet and shook my head. It was going to take a couple of hours but I would get these problems done.

My best friend looked at the problem sheet and pronounced it "extreme". I told her not to worry, I would get the problems done and I would write out an explanation of how I did them and share. Well, it turned out that I was the only person in class to finish all of the problems and my solutions went into noteservice for the class with much gratitude from my classmates.
Making buffers and solving buffer problems were pretty routine for me since I had been involved in research before starting medical school. I was happy to help.

During the semester, I would participate in many study sessions with my classmates. It was quite common for one or two of us to write up summary sheets or study sheets that would be shared with the class. I also became one of the primary notetakers for Biochemistry because of my familarity with the subject matter. We, as a class, tried to make sure that every person had the best shot of passing this difficult class. No matter what, there were some folks that just didn't get Biochemistry on the first try. They would be in summer school that year.

I have to say that I found Medical Biochemistry quite differerent from the graduate school Biochemistry course that I had been used to. Instead of chasing electrons and working on endless problems in enzyme kinetics, Medical Biochemistry had a distinct practical side. One needed to be able to use Biochemistry as a tool in the care of patients. To that end, we didn't chase electrons but spent some quality time chasing nutrition facts, hemoglobin disorders, molecular biology (theoretical and applied), pathways and numerous disorders such as diabetes, starvation and metabolic defects. It was all good learning and very detailed.

Biochemistry would be the second most demanding course of our first semester of our first year. Gross Anatomy took the top spot in terms of preparation time and study time. For me, since I had a strong background in Biochemistry, I was able to put in loads of extra time in Anatomy while holding my ground in Biochemistry with my usual pre-read, study lecture and repeat the schedule all over again the next day. I never attended lecture unprepared and I always stayed far ahead of the lecturer in case I became ill.

I kept very detailed notes and spent hours of time helping my classmates. They in turn, helped me to hone my teaching skills. When you attempt to explain something to another person, you hone your own learning. To my great pleasure, Biochemistry was a blessing in many ways. It was challenging but totally managable for me and it was my introduction into becoming a good colleague, something that I continue to work at today.

Rocket was our first introduction to the sheer volume-overload that was to come. He certainly received our rapt attention on that first day. We later learned that while he spoke rapidly, he made up the most awesome handouts. It was all good and we were on our way.

21 January 2007

Second Year of Medical School

The second year of medical school was, by far, the most interesting year for me. After learning all of the basic science of normal human processes in the first year, second year presented us with the abnormal. In other words, second year was the didactic exposure to all of the things that we would learn to "treat" and "fix" as physicians. It was also our first introduction to Physical Diagnosis and learning to examine living human beings.

Our major courses during the first semester of second year were Systemic Pathology, Microbiology (Virology) and Pharmacology. Our minor courses were Abnormal Psychiatry and Introduction to Medical Practice. Of these courses, Systemic Pathology was definitely the course that would absorb most of our time. This course was presented by lecture and then laboratory in the afternoon. We were given a huge syllabus, a box of slides (for home study) and a requirement that we attend at least one post-mortem examination. I was hooked on Pathology from the first lecture.

My strategy for Systemic Pathology was to be totally prepared for each lecture. I would read the objectives in the syllabus, read the syllabus and read the text looking very carefully at any of the photos. Next, I would attend lecture, taking notes on the Powerpoint slides as they were presented by the professors. At home, that evening, I would study my syllabus and lecture notes and then preview for the next day's lecture. I would also carefully review my slides from lab in addition to any notes that I had taken during the lab demonstrations by the professor. It was a totally awesome lab experience.

I observed a post-mortem examination of a young man who had died of testicular cancer. The pathologist performing this exam took great care to explain to me and two other students, why she performed the post morten in the manner that she did. She first examined the body from head to toe, carefully dictating detailed descriptions of any scars or marks that she found. She then, with the help of her assistant, a first-year pathology resident, rolled the body over and repeated the process.

After the external examination, she made a Y-incision where the Y ended at the symphysis pubis. The bones of the chest and abdominal organs were visible at this point. She made note of any fluid in the abdominal cavity and descriptions of the organs in situ. Following these descriptions, she and the assistant, used special cutters to separate the ribs from the sternum and open the chest. She noted a description of any fluid in the chest too.

One by one in a systemic fashion, she removed and weighed each organ while dictating a description of her findings. She also removed tissue samples from each organ that she examined. These tissue samples would be made into slides for the microscopic examination. She then turned her attention to the head, where she peeled back the scalp from the base of the skull and opened the cranial cavity.

With the aid of her assistant, she carefully removed, weighed and examined the brain. A sample of the medulla was taken for microscopic examination later. The brain was carefully placed in a preservative solution so that it could be sliced at a later date. The cranial cavity was closed and the skin sutured in back so that there was no visible appearance of the cranium being opened from the anterior view of the body.

While she finished her dictation, the assistant carefully placed all organs back into the body cavity and sutured it closed. The body was then returned to the morgue cart and morgue for release to the funeral home that had been designated by the young man's family. We then left the morgue as she explained that she would be reviewing the microscopic slides in 48 hours and that we were welcome to sit in on that review with the Pathology residents.

When we went to the conference, it was remarkable to see how this very invasive cancer had moved throughout the body and had caused death. My knowledge of pathology increased exponentially by attending this post mortum examination and conference. There are many things that can be learned that help in treating every patient, from attending an autopsy. It was far from being disgusting or demeaning to the body being examined. The pathologist and resident treated the patient's remains with great respect and care.

Microbiology involved learning how microbes participated in disease processes. We reviewed the pathology of every virus and and learned why viral illnesses are very difficult to treat and eradicate. This was quite a change from the Microbiology that we had during first-year where we learned to perform gram stains and identify bacteria from patient specimens. While there was no lab, the details of the replication schemes of every virus and how these led to the pathology of viral disease was very absorbing not to mention the huge volume of information that we were required to learn and assimulate.

Pharmacology was another huge course that demanded much of our time. We started with Autonomic pharmacology and moved to classes of pharmaceuticals. This course layered atop of Biochemistry, Neurophysiology and Physiology. Again, the material was very interesting and added to the tools that we would need to treat our future patients.

Our Psychiatry lectures presented the abnormal for us to examine. Since our Psychiatry professors were in clinical practice, they often brought patients who would explain how their illnesses had affected their lives. There is no experience that can compare to having a patient explain how a disease affects them or participating in an examination with the professor taking the lead. It was great. We also studied topics like sexuality and substance abuse. Needless to say, when the Human Sexuality tapes were broadcast, it was "standing room only" for a seat in the classroom. That was always a running joke with our class. (I will write more about this in a later blog).

Finally, during second semester, were were farmed out to the hospital to learn Physical Diagnosis. Many of us, had already learned to take a very detailed patient history from our first clinical rotations during first year, so our tasks were learning to examine living human beings. We were armed with tuning forks, stethoscopes, diagnostics kits and reflex hammers. It was great to actually learn how to use those tools.

My preceptor was an Endocrinologist. The first thing that you have to know about any Endocrinologist is that they are all very, very smart. My preceptor was able to teach me many fine points of performing a detailed physical exam. He required us to look at the optic fundi of every patient. At first, he said that we might only see the red reflex of the retina, then we would find a vessel. After that, we would learn to follow that vessel back to observe the discs. His motto was: "If you never use your opthalmoscope, you will never learn to use your opthalmoscope". The learning curve for this instrument is very steep.

Still today, as a surgeon, I am probably the only resident who will perform a optic fundal examination on my patients. In my opinion, I am able to judge the severity of the vascular damage by diabetes etc, in my patients with vascular disease. The retina is a direct observation of the central nervous system. By examining the retina and optic fundi of my patients, I can gather much clinical information. At this point in my career, I am a trained observer and my patients reap the benefits. Not to mention, I enjoy hanging out with my opthalmology friends.

Well, that's my snapshot of my second year. I will write about some of my specific experiences in later blogs.

15 January 2007

Summer between First and Second Year

I spent the summer between my first and second year of medical school teaching biochemistry in our pre-matriculation program. This program provided an opportunity for 25 students (20 who anticipated medical school and 5 that anticipated dental school) to experience three medical school classes. The classes presented were Gross Anatomy, Biochemistry and Microbiology. The program was six weeks long and pretty grueling for the students who participated. If a participant passed all three courses, they were automatically admitted to our medical or dental school that fall.

The pre-matriculation participants receive books, supplies, meals and housing during the six weeks of the program. They are expected to attend lectures and participate in dissections and study skills workshops. They learn to adjust their study skills to the heavy information load of medical school in addition to getting a huge "head start" in terms of two demanding classes of the freshman year.

As instructors, were were chosen because we had done very well in our first year coursework. We also went through a rigorous training session in order to handle all of the problems that might arise. We bonded as a group during these sessions and became pretty cohesive ourselves. In addition, we had an experienced faculty member who guided us through matters like lecture style, test making and course organization. Until you have to create an exam, you have no idea of how difficult this task can be. Questions that seem so clear to us (the instructors) could be confusing to the students who were being exposed to much of this material for the first time.

Our students were simply some of the most motivated and interesting people. There was an equal number of males and females. There was also a wide variety of ages from 21 to 49. Some were fresh from undergraduate and some had been out of school for awhile. There were mothers and fathers along with single folks. The diversity of the group was refreshing and wonderful. They all shared a dedication to mastery of learning that was great to see. It was six weeks of very difficult study but in the end, everyone did well.

Our faculty advisor was a great mentor. He coached us but allowed us to take the lead on preparing every lecture for these students. His wise counsel was one of the highlights of my medical school experience. This professor was an expert in the mechanisms of Diabetes Mellitus and was one of our most dynamic lecturers. He gave us just enough freedom to allow us to make our own mistakes but guided us in our development as new instructors.

Since Biochemistry is a very demanding course for most freshman medical students, my teaching partner and I vowed to make the course as useful as possible. One day when we were co-teaching, I caught a glimpse of the department chairman listening to our lectures and presentations. Later I heard that he was very impressed with how we presented the material. We spent countless hours coaching our students and encouraging them to not fear any learning opportunity. We taught them organization and mastery.

In addition to our teaching our students, we became the summer mentors for undergraduates and high school students who were visiting our medical school as part of a summer exposure to health professsions. We participated in a panel discussion with physican assistant students, nursing students, pharmacy students and medical technology students.

For some of the high schoolers, it was an awakening. When one of our orthopedic surgery residents (5'9" tall weighing 269 lbs bodybuilder) stood up and reminded them that the road to success in any of our professions is long and difficult. In addition, you needed to have something that would keep discipline in your life. For him, that "something" was bodybuilding. I could see the wide open eyes of several young men when this resident flexed his biceps. He explained how bodybuilding fit well with disciplined study and preparation. He also brought slides of some of his surgical cases which he described in great detail. I am sure that many of those young high school students left with new-found strategy to master their lessons too.

At the end of our program, we were happy to report a 100% pass rate for all 25 of our students. They had worked harder that summer and it was great to celebrate their success. I also saw a great transformation in these students because they would become the leaders in their classes in the fall. We had armed them with solid study skills and some great knowledge that would get them off to a strong start when classes got underway in the next few weeks.

The best part of spending the summer teaching in our pre-matriculation program was my interaction with the programs director. She was a Ph.D in psychology and brilliant. Her interests were in retention of every medical student. Through many of our discussions, we analyzed why students fail in medical school. The one recurring theme is that something prevents them from putting in the time necessary to master a challenging curriculum.

Common inteferences can be illness (personal or family), financial stress and emotional stress . In world of today's medical student, many have families that have needs which must be met. To go from being the person who was the main provider for the family to medical student where time is very limited is very difficult and requires a huge adjustment. Many times, the stress of providing support for family and the stress of mastery of coursework could take a huge toll on the emotions of a medical student with a family. It was a very difficult road that many navigated well. The one thing that was never the case was a student not being academically capable of mastery of them medical school course material.

My summer between my first and second year was a period of great enlightenment for me. I was selected as a peer tutor for students in the dental school as a second-year student. I learned to appreciate their labs and studies. I found that dentistry is as interesting as medicine and far more academically challenging. I loved watching the tooth-carving in the occlusion labs. For people who are interested in a very hands-on profession, dentistry is a wonderful option.

07 January 2007

First Year of Medical School

A short while back, some of my pre-med students asked me about memories of medical school. I thought it might be fun to write about some of those here as well as residency experience so here goes from the beginning...

My medical school had a classical curriculum with problem-based-learning intergrated. We had the typical first-year, second-year types of classes. Lectures went from 0800h to 1600h daily. We had some Tuesdays or Thursdays when we would be able to get out earlier but we spent loads of time in class (way more than students currently attending). Some of my classes had computer-based-learning exercises and some had laboratory projects that had to be completed. In short, school was the equivalent of a full-time job with much time spent on weekends reviewing and keeping up with the pace. The best thing was that all of my classes were very interesting.

My first lecture of medical school was in Biochemistry. The professor essentially covered an entire Organic Chemistry course in a 50-minute lecture. The material was extremely detailed and presented in volumes. This particular professor had a reputation for "rocket" lecture delivery and he got the job done. The great thing was that I understood everything well and could see that this was the basis of the next 50-minute lecture which started off with lipid biochemistry.

My next class was the first part of Gross Anatomy. Our lecture was on surface anatomy and types of neurons. Each lecture was 50 minutes followed by a 10-minute break. I think those 50-minute lectures were the beginning of my 50-minute attention span. After lunch, Gross Anatomy lab started with a brief introduction and then a long laboratory on the vertebral column. We were all given bone boxes (containing human bones) to take home for further study. Every bone was present except the skull bones. Needless to say, we were required to learn every bone and every part of every bone.

By the time the day was done, I had received the equivalent of about 3 weeks worth of undergraduate lectures on one day. Since I had my syllabi, I knew what would be covered in lecture and I knew what readings and material would have to be previewed for the next days lecture. After each lecture was completed, I would quickly fill in any gaps in my notes and briefly scan through my notes for completeness. Over lunch, I would start to memorize as much of my morning lecture as possible too. We had an hour for lunch so I would grab something quick and then spend the rest of the time pouring over my notes.

On the way home, I would study some more or just watch people. I took public transportation because I didn't want to worry about driving. My commute time was my time to relax and think about the day or plan my evening. When I got home, I would grab my gym bag so that I could get a quick swim in before dinner. I would dine with my fiance and then hit the books for a couple of hours. By that time, it would be around 8pm so I would go to bed. I would wake up at 2am and study until 6 am. I would then take a shower and get off to school.

When I was studying, I would finish studying the material that had been presented that day. I would then review the lectures for the day before and preview the materials for the next day's lecture. On the weekend, I would review the entire week's lectures in addition to reviewing an entire week's dissection in the Gross Anatomy lab.

I made study tapes to drill structures and notes so that I could listen to them while I was walking or running. I would also make concept maps and fill them in on large sheets of paper as I went through biochemistry. I always wanted to keep the "big" picture in mind as I studied.

We had an exam week about every five weeks during the semester. There would be two "reading" days (read catch up) and then exams would begin. For Gross Anatomy, we would have the lecture exam in the morning and the laboratory practical exam in the afternoon. Between the exams, I would go to the art museum and get completely away from campus. I couldn't stand to be around people who were so stressed about the exams.

In addition to Anatomy and Biochemistry, we had lectures in Psychiatry and Introduction to the Practice of Medicine. The Psychiatry lectures were always interesting and covered topics like development, personality disorders, sexuality, psychiatric drugs and the roles of various types of psychiatrists. Lectures in the practice of medicine covered topics like law and medicine, types of practices, alternative and complimentary medicine, history of medicine and medical education models. Psychiatry and Introduction to Medicine provided a bit of relief from the rigor of Biochemistry and Gross Anatomy but we were tested on these subjects so they required our attention too.

Our first semester ran from the middle of August to the second week of December. I can promise that the time goes by very quickly and soon Christmas vacation upon us. At the end of the first semester, we were done with Gross Anatomy and Biochemistry but still had more lectures in Psychiatry and Practice of Medicine. In addition, we had Histology, Microbiology/Immunology and Neuroscience lectures too. Second semester had a bit more material and more lectures. In addition, we had to dissect brains and spinal cords in Neuroanatomy. We were also given slide boxes with every type of tissue for histology. We would learn to recognize tissues and electron micrographs of every type of cell.

By the time second semester is over, we had learned a huge amount of material. Most people were happy to get exams done and get home for the summer. I was selected to become an instructor for the students who would be coming into our pre-matriculation program. I would be teaching Biochemistry primarily in addition to Gross Anatomy and Immunology. It was an honor to be asked to instruct in this program and I knew that I would enjoy working with these students.

The students who participated in the prematriculation program were medical and dental students with a conditional acceptance into medical or dental school. By successfully completing this program, these students are offered a seat in the school that they were conditionally admitted to. During this rigorous summer, we gave study tips, extensive reviews and got to know some very determined folks. In addition, these students have a huge head start when the actual courses start because they have been exposed to the material. It is a great program and I enjoyed the summer. In addition, we, the instructors are paid very nicely and can get some research done at the same time.

I finished my first year strong with honors and a much stronger interest in medicine than before I started school. When I looked back on all that I had learned, I was amazed. Little did I know that second year had even more to learn and would build upon my foundation of first year.

06 January 2007

Internship or PGY-1

After graduation was complete and I had finished filling out all of those thank-you notes for presents and good thoughts, I turned my attention to making preparations for my move to my residency location. Over my four years of medical school, I had accumulated loads of books and papers. The first thing that I did was toss out any papers that would not be helpful to my little sibs back at medical school. The next thing I did was get rid of the rest of my books and USMLE Prep materials. My little sibs split the lot of them.

We started packing on a small scale but quickly realized that we still had too much "junk". I even had boxes of things that I had accumulated and had left unpacked for my previous move that had taken place at the beginning of my third year of medical school. I had moved to be located closer to the clinical affiliated hospitals to shorten my commute. A forty-five minute commute was OK for medical school because I could study on the subway but I wanted to spend no more than 20 minutes if I was going to drive.

I made a couple of trips to the location of my residency. I took one of my best friends so that we could scout out some great places to live. She helped me pick out a wonderful three-bedroom home that was located in a wooded area with plenty of jogging and bike trails. Since I have a couple of dogs, I wanted a spot where they could get some exercise and I could get outside. I found the perfect place and I loved living about 1,000 feet from a beautiful lake with woods and streams all around.

After the move, I had one day to get to orientation. I was still in the midst to unpacking on orientation day. I had completed my criminal background check and drug testing. I had also finished completing the materials for my license and smooth move to the local medical society. Orientation started early with mugs of strong coffee and plenty of folks who looked as scared as I was. We received our pagers, our lab coats and our directories. The second day of orientation is where we received our departmental information including our rotation schedule.

I started with Vascular Surgery. These patients are among the sickest in the hospital. I quickly got into the routine of rounding in the early morning (0400h), getting my notes written and then getting ready for rounding with the team. The team, which consisted of the fellows, the surgical chief resident, a mid-level resident, two interns and four medical students would then round. It was the duty of the interns to write every order and plan after we presented our pre-round findings to the fellow and chief.

The residents and students would head off to the operating room while the interns would get orders and discharges done. We would follow up on all labs and studies and then get the discharges completed. I quickly learned to "pre-discharge", get the orders ready and then make one click to send them to the computer. The computer would print all instructions and prescriptions for me to sign. My dictations would be done at that time too.

Once the daily ward work was underway, one of us would try to get some OR cases while the other intern waited for new admissions and post-ops back from the OR. We would also follow up on all information that came from consultants and all studies as the patients returned. When the patients came back from the OR, it was my job to get them settled in and follow up on what had taken place during surgery. I would look at the OR reports, anesthesia notes and any history and physical information. I would also start a note sheet for tomorrow's note and check all orders.

By the evening, the fellow would leave and I would report all studies and findings to the chief resident. He or she would add orders or give me the plans for the next day. If anyone was headed for surgery, they would need to have preoperative orders placed for things like nothing by mouth after midnight. Periodically during the day, I would visit each room and find out how the patient was getting along. I would also do things like debride (clean off dead tissue) wounds and follow vital signs and labs. If I was not on call, I would leave the hospital around 6pm after reporting to the on-call intern. If I was on-call, I would receive report from the services that I covered.

I had the unique opportunity of covering cardiac, thoracic and vascular when I was on call. The other interns only covered one other service and their own. At first, the cardiac patients were scary but later, I fell into taking care of them just as I took care of my own vascular patients. My patients were the sickest patients on the three services and I knew them best.

After vascular, I rotated as intern through surgical oncology and colo-rectal surgery. My program director was very impressed with my work so he decided to change my schedule to include a month as Surgical Intensive Care Unit resident. Usually, this rotation would go to a second year resident but a couple of interns managed to get this rotation. I was fortunate because the other two residents on this rotation with me were second year anesthesia residents. They taught me how to place internal jugular central lines and to float Swan-Ganz catheters. The nephrology fellow taught me to place temporary hemodialysis catheters and how to calculate fluid balance. I already know loads about mechanical ventilation but I learned even more from the critical care specialists. It was a great month for me.

I was then invited to spend a couple of months at the Veterans hospital. This was an away rotation that was totally awesome because there was so much operative experience. I honed my surgical skills and could hold my own in the ICU. My chief resident was very comfortable with my work and left me in charge of the service (as an intern no less) when he needed to go out of town. At first, it was scary but I learned that I could trust my instincts. My attending physicians were great teachers and things hummed along for me.

I went through another rotation on Vascular and then Thoracic. I made a deal with the other interns in that I would do all of the dictations and discharges if they would pull chest tubes and work out discharge planning. They hated to dictate and I had become very efficient at getting these things taken care of thanks to the VA hospital. My fellows were great to work with also. I was very comfortable calling them at home and updating. One of the most demanding fellows turned out to be one of my best teachers. He showed me how to sew down grafts.

I finished my year as Night Float intern. I covered all of the General surgery patients. There was an intern for Trauma who took care of the Trauma patients and did all admissions. If he or she was busy, I would admit patients and follow up on studies. I learned to anticipate problems and get them taken care of. I also learned to do make things happen that needed to happen. I made great friends with the night radiography technicians who would get studies completed for me and placed in front of the radiologists before I could get down to the department. They were great folks to work with.

As I headed into second year, I knew that second year would be my worst year. As a more senior resident, I would expected to play bigger role in keeping the service running. Since I would still somewhat junior, I still had a huge learning curve too. All in all, my intern year was great. Some of my chief residents and fellows were very difficult to work with but I always stepped up to the plate and got the job done.

Being a good intern is being anal about every detail of your patient's care. It took a few months to learn the "ins and outs" of good patient care but I took careful notes and operated every chance that I could. The nursing staff also gave me high marks for getting things done and keeping the services under control. The hours are long and sometimes the work seemed endless but there was a learning point to every task. Intern year went quickly but I felt in control of my learning.