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.