Application of Knowledge

We had our first cardiovascular test right before Thanksgiving break. I found that the questions I enjoy most are the ones involving clinical scenarios. For example, the pathology questions involved an image of a gross specimen and asked which patient would exhibit this heart: a twenty year old male living in Africa, a forty-year old intravenous drug user, or an eighty year old man with diabetes and hypertension. Or a question would describe a clinical presentation of a patient and ask for the diagnosis: III/VI crescendo-decrescendo systolic murmur at the right upper sternal border. While there were the standard basic sciences questions, the very applied questions were most fun to do.

The Big Picture

During Organs, we've been introduced to biostatistics, epidemiology, and genomics. These represent more of a big-picture view of medicine. Biostatistics is critical in helping physicians understand and interpret papers. Furthermore, it's a fundamental basis for designing not only clinical but also laboratory experiments. Epidemiology studies the distribution and determinants of disease frequency. Genomics looks at genome-wide interactions and steps beyond single Mendelian mutations to examine humans as an integration of many genes and environmental factors. Thus, we move beyond the single gene and single patient to look at the complexity of nation-wide and genome-wide health and disease.

I was initially surprised that they introduced this to us during our cardiovascular block. At first, it didn't seem to fit. But we focus our attention on papers that are cardiovascular related, and it seems to work fine. We have to learn all of this sometime, and sooner is better than later.

Pharmacology

Organs block has a considerable amount of pharmacology. It's tough. We have to familiarize ourselves with drugs, many of which have random names (except the beta blockers). We have to know their indications, their contraindications, their mechanism of action, their duration of action, and their side-effects. It's a lot of memorization. It's not unimportant since we need to know these drugs at some point, but it's not easy as we haven't been immersed in clinical practice. I trust that in time, knowing the drugs will become very useful and rattling off their dosages will become second nature.

Thanksgiving

This year, more than ever, I find myself thankful to be in good health. Health is one of those things that we all take for granted until something goes wrong. Now that I am at the intersection between health and disease, I begin to appreciate the wonders of the human body and its operation. I hope everyone has a meaningful and memorable Thanksgiving.

Labs

We have several different kinds of labs this block. For anatomy, we only have two sessions, but they were fun. In the first, we took the heart out of the mediastinum and dissected out the chambers and coronary vessels. That was really neat. While I don't find most anatomy labs fascinating, I really did like following the flow of blood through the different chambers and tracing the coronaries (sites prone to heart attack) on the outside of the heart. I dissected a pig's heart at Stanford in an introductory seminar, and I was thoroughly confused then. Now, I have a much better idea of what an actual heart looks like and the importance of anatomy in determining physiology. In the other anatomy lab, we dissected out vessels in the neck. This one was much harder; the neck is a very complex area. But it was very educational.

We also have pathology labs. We look at diseased tissue under a microscope, very similar to histology, but there's a lot less. The more exciting part, though, is seeing actual specimens. We have been able to feel the thickness of hypertrophied hearts, poke our fingers through calcified valves, and look at scar tissue from a myocardial infarct. It's immensely interesting. One of the labs, they had specimens out and we had to try to guess the pathology from simply inspecting the hearts. That was difficult, but very fun.

Lastly, we have physiology labs. These labs mainly help us solidify material we learn in class. We have taken EKG's and PV-loops on each other, helping us learn how these tests work and how they help diagnose clinical condition. That's pretty fun, though it's extremely crowded.

Quote of the Day

We have these small group coaching sessions to improve our small group dynamics. Today, one of the questions was, "What role do you think you have in your small group?" Tim answered, "Well, I suppose, I guess I would say that my role in small group is...eye candy."

Education

Some students and I had lunch with Vice Dean of Education Irby. It was an informal discussion about how we felt about UCSF. In general, comments were very positive. One of the great things about this luncheon was that I realized how much import UCSF puts into education. The curriculum has changed dramatically over the past few years, and all their changes seem to be for the better. The curricular committees listen to feedback, think of ways to improve, and evaluate other medical schools to see what works best. We might have changes in the clinical core, which will be interesting. They're saying that instead of traditional separated rotations, we'll have a more integrated approach. Perhaps you will be on call in the Emergency Department one night and you get assigned a patient. If he goes to the ICU, you follow him. If he needs radiology tests, you work with the radiologists. If he needs a kidney transplant, you learn both nephrology and surgery. There is a core group of mentors that makes sure you're on track. It's a different kind of approach and incorporates more longitudinal experience rather than experiencing disciplines separately. I'm not sure whether or when this will happen, but it's certainly interesting. In any case, they're constantly trying to improve things around here, and that's what I love about it.

Learning Patient Care

Last Thursday, my Foundations of Patient Care group went to interview an inpatient at the hospital here. We had barely said, "We are first year medical students here to talk to you about your health," when he immediately replied, "Oh, the patient doctor relationship class!" He had a big smile on his face and was really welcoming in helping our education. It turns out his wife is a nurse, and he believes doctors need to learn to interact with their patients.

At preceptorship the other day, I asked an elderly lady whether it was okay for me to take her blood pressure and listen to her lung fields. She replied, "Whatever you say, you're the doctor." I quickly explained that I was hardly a doctor, but the message was clear. By virtue of wearing a stethoscope around my neck, I had privileged access to whatever I needed in order to understand her health and illness.

On the other hand, my FPC group went to interview an in-patient once, but we were late. The patient berated us for being tardy, rightfully saying that her time was equally important as our time. She then told us she didn't want us to interview her. It was a lesson learned for all of us. We owe patients the respect that we would give our grandparents and grandchildren.

This last Friday, we had a standardized patient presenting with a cardiac illness. With a partner, I took a history, trying to catch all the possible related factors: presentation of the pain, past medical issues, behavior, family history. We then did a focused physical exam on him, listening to his heart sounds and looking at his jugular venous pressure. It was a great learning experience in how to approach a real case as well as how to talk to a patient worried about his health.

Organic Chemistry

If you condense "alpha-methyl-phenyl-ethal-amine," you get "amphetamine," exactly what it is. Pretty cool.

Electrocardiogram

We started off the cardiovascular block with the electrical activity of the heart. EKGs are amazing diagnostic tools. They are also very fun to read. While at first, the twelve-lead EKG looks pretty intimidating, after a while, you get pretty quick at determining rate, rhythm, axis, etc. I was first introduced to EKGs in research a few years ago: we took them on mice. Since then, I've grown quite fond of the little P waves and QRS complexes and ST elevations. You can really tell a lot about a patient from simply looking at the EKG. We had a physiology lab which was quite fun in which we took an EKG on a student volunteer. We also had some small group sessions correlating EKGs to clinical diagnoses.

Leap of Faith

Reading X-rays takes a leap of faith. To distinguish some of the subtleties, you have to really convince yourself that you are seeing an anatomical structure and not a smudge. It's one of those things where you see what you're looking for. If you're hunting for it, you'll find it. Otherwise, it's a polar bear in a snowstorm.

Class Show

Traditionally, the second year students put on a show for the first year students. The show this year was "The Anatomy Awards," parodying the Academy Awards (complete with the Golden Femur award). It was great! Most of it was video skits making ridiculous puns on TV shows. My favorite was "Ocean Beach - the real UCSF," a parody of "Laguna Beach - the real O.C." The show centered around some students trying to find dates to the med school prom. At one point, one of the students, the nerd, tells his crush to check iRocket/WebCT - our online message board. There, under the message board "Critical Course Info," he posted a thread, "Will you go to prom with me?" His crush replied "Yes!!!!" The next scene cut to our course organizer last block Dr. Kruidering. She said, "Oh, those kids are hopeless," and replies with a message that said, "this message board isnot fordating purposes!!!!!!!" It was hilarious, because that was written exactly in her style.

We also had a live performance of "M&N" (metabolism and nutrition), which parodied Eminem's "Without Me." It was quite good, because you really are quite empty without your GI tract. It had such bad rhymes as ATP and energy and without me. The next skit was "America's Next Top Medic," quite entertaining. The radiologist had to have a photoshoot with a blood pressure cuff, but she had no idea what it was, saying "I haven't seen a patient in years." The MC's were very good too. The finale was "Les Med," a really hilarious and talented performance which touched upon many medical student experiences, from the exciting to the dreaded. We really do have a lot of talent here.

Organs Block

This next block, Organs, hits some of the fundamental systems of human biology: the heart, the lungs, and the kidneys. We have about 6 weeks of cardiovascular, 3 weeks of pulmonary, and 4 weeks of renal. It doesn't sound like a lot, but it is. In undergrad, I took human physiology and we spent about 3 weeks on each system, and class only met 3 times a week. Now, organs is all we're doing. We're going to get a lot of it, and by the end, we'll hopefully be somewhat comfortable and proficient with its related anatomy, physiology, pathology, and medicine.

In any case, I'm very excited about cardiology. I love the heart. It makes a lot of intuitive sense; the electrical activity and mechanical characteristics are very logical and straightforward. As an undergrad, I took a medical physiology seminar and the human physiology course, so much of this is review. My research focused a lot on adrenergic receptors, so I have some grasp of pharmacology. In my research, I took EKGs on mice, looked at PV-loops, and studied the molecular basis of cardiovascular physiology. This block will be fun. I will definitely keep cardiology a possibility in the future.

Change in Blog

I have been asked whether this blog can be linked to the website of Synapse, the UCSF student newspaper. That means this blog will shortly become publicly accessible. As such, I'm in the process of moving private posts (ie. those that reference people who don't want to be in a public forum and those that have very little to do with UCSF or medicine) to a different location. In any case, this blog will remain much the same, discussing issues that get raised during my time here as a medical student.

Not All That Glamorous

I've become very aware that doctors are called upon to see things society may not find palatable. From the loose, wrinkled, scarred skin of an eighty year old patient to the purulent bleeding eye of a victim of a dog bite, we deal with things that we might, under closed doors, consider to be gross. I admit it. I know it's wrong. But I recoil when I see the effects of gonorrhea-induced conjunctivitis in babies or hear about parasites burrowing into the skin and laying eggs. I mean, I haven't even been in this for ten weeks; I haven't changed the way I look at things. I still avoid bad smells and bodily fluids.

But I know that my visceral emotion will not prevent me from treating these patients. After you dig through the fat of the ischioanal fossae of a cadaver and dissect away the plantar aponeuroses, there's not much that will completely gross you out. And when you see these patients, you really understand that they need you, and you have the training to treat them. The visceral response may even help us as physicians empathize with the patients. No longer is it a clinical infectious disease or an avulsion or a third-degree burn. Now, this is something ruining the life of the person in front of you, something wrong with their body that they hate, something that the parents are terrified will scar the child forever. When we see such disgusting, revolting, blood-and-pus-spewing sights, we should be moved, not only by duty, but by some desire to restore humanity to an injured individual.

Physical Exam

One of the exciting things about UCSF is that we learn to do the physical exam early on. They frontload taking an H&P (history and physical) so that we can participate more in our preceptorships and at various other clinical opportunities. Last week, we had an observed physical exam where we performed the entire thing on a partner in a formal setting. We had a practice with some second-years and we were observed by a fourth year, which was very useful since everyone has their own method, and we could get tips and tricks from more experienced students. In any case, the whole physical takes a while and you would rarely actually do all the steps unless it was a new patient.

But it was fun: we started with vital signs and basic appearance. Then, we looked at the head, ears, eyes, nose, mouth, and neck. A lot of that was cursory since we haven't yet learned how to use our oto-ophthalmoscopes. After that, we did a back/pulmonary exam, a chest/cardiac exam, and an abdominal exam. Lastly, we finished with a musculoskeletal exam focusing on shoulders and knees. It was very useful, and I feel a lot more comfortable if I were asked to do parts of or an entire exam on a real patient.

Closure

We recently finished the first block Prologue. Unfortunately, I do not feel that all the loose ends were resolved; we got a bit of this and that, but they haven't fit together in a big picture yet. The purpose, I suppose, of Prologue is to set the stage for the rest of the blocks, and I think they did that fairly effectively. I have a good grasp of anatomy (and supposedly radiology), cell biology (including histo/path and immunology), and molecular biology/pharmacology to tackle the more complex issues of the subsequent Organs block. The exam was very fair; in the anatomy practical, they didn't test all the detailed muscles of the limbs, but rather key concepts like the innervation of a certain compartment or the dermatomes that can be tested by poking an area of skin. On the written test, only the immunology problems were a little far-fetched. Unfortunately, per exam policy, I can't give an example of such a question. I felt that we only touched the surface of the different subjects, leaving many complex issues up in the air, to be confronted as the year goes on.

Pun Demon

In one of my electives on pregnancy and childbirth, we had a guest speaker today who has three children, all delivered through different methods. Her first was a C-section, her second was with a doula, and her third occurred in her home. She was describing her third birth: she felt her water break and was hobbling out the door to get to the hospital when she realized that the baby was on its way. They didn't make it to the car, and she had her baby on the front porch. She and her husband sometimes refer to that kid as their "step-child."