Medical School 2020

a Fifth Chance Media book, ISBN 978-1-944861-02-5.

From the editor: Health care is nearly 20 percent of our GDP. The surest way to be a full participant in this massive and growing sector of the economy is to get an MD. But it is a substantial commitment for a young person to prepare for, enter, and complete medical school. What is it like day-to-day? To help young people (and old people advising young people) answer this question, I have placed a mole in one of America's medical schools. I'll be publishing his diary on a regular basis. Here's the first installment….

Year 1, Week 0

One week to go before entering medical school, Class of 2020, and I am two parts excited, one part anxious: excited about the first cadaver cut in Anatomy 101; anxious about aspiring to heal others, about having another trust me with vulnerabilities.  How must I change to uphold the physician’s charge?

 

Why this book: (1) as a reminder of the enthusiasm with which this long process was entered, (2) in case it is helpful to students considering premed.

Personal background: With the exception of a few years overseas, I grew up in a wealthy American suburb with two well-educated parents and academically successful older siblings. After enjoying an uneventful K-12 in public school, I majored in biomedical engineering (GPA 3.8) at one of America's better universities, scored 37 on the MCATs, and could have started medical school shortly after graduation in 2015. I spent a year working, however, so that medicine would be an affirmative choice rather than a default. I enjoyed the engineering job, but now that I've seen the opportunity cost of not pursuing medicine I won't have second thoughts after paying tuition bills.

Year 1, Week 1

Anatomy begins at 7:00 am sharp.  With the outside temperature well over 90 degrees Fahrenheit, we immediately know we are entering a different kind of learning experience kept at a chilling 55 degrees! Most of my classmates seem excited for a break from the 4-times a week, 2-3 hour morning lectures on cellular and molecular biology.  Not only can these lectures be somewhat tedious, especially for the abundant biology majors, but everyone seems eager for something different from the traditional undergraduate lecture format.  The class piles into the classroom and begins on time -- surgeons are punctual.

The trauma surgeon instructor briefly goes over dissection tool technique and we begin the exam of our “first patient”.  Our first dissection focuses on understanding the role of the “superficial back muscles” on shoulder support and joint motion.  The scapula, or shoulder blade, is an alien wing-like bone almost completely detached from the central skeletal system. Unlike most bones, the scapula is supported primarily by numerous muscle-tendon insertions with just a single bone-bone “pivot” at the lateral edge of the clavicle, or collarbone.  The fine-tuned muscle contractions slide the scapulae along the back for precise positioning of the shoulder joint.

As I look around at my new classmates, scalpels in hand, most sluggish from a night of getting to know each other over booze and late-night burgers, you see a few patterns.  Aspiring physicians include an abundance of type A personalities, which means that many clamor to be the primary dissector.  However, once the dissection begins you can quickly see the few who are captivated by anatomical exploration through slicing and dicing.  I would bet that those few pursue the cult of surgery, addicted to the “cut” as one of my surgical physician mentors put it.

 

Class ends at 12:30 pm and I grab lunch with my classmate who is a young father. It turns out that his wife is also starting a graduate program meaning their budding family is entirely supported by student loans.  They're expecting a second child soon. He jokes that he’ll just use all his vomit-stained clothes for anatomy lab.

Class begins every weekday either at 7:00 or 8:00 am.  Two days per week, classes, workshops, patient interviews, and other activities end before 1:00 pm.  On the other three days activities conclude around 4:00 pm. We have anatomy lab once per week. The rest of the week is centered on lectures about cell and molecular biology, including signalling pathways, molecular structure-function pairings and cell microenvironment. Much of the material is familiar from my undergraduate biomedical engineering studies. However, after a year in the working world, I am surprised by how much I have forgotten. I spent a total of 6 hours doing work this week. Dinners were off-campus with classmates. A typical weekend activity is a pick-up soccer game, getting drinks downtown, or a class hike.

Year 1, Week 2

This week I learned about the National Board of Medical Examiners (NBME) Step I board exam. Typically taken after the second year of medical school, just before clinical rotations commence, the score on this exam is the most important criterion for the residency application (the first year of a residency is technically the future specialist's "internship"). There is some bad news for nervous parents who worried about getting a child into the right preschool to ensure entrance to the right elementary school to ensure entrance to a prestigious high school to ensure entrance to a selective college to ensure admission to medical school: the real career-determining educational institution is the residency.

Our dean gave us some additional bad news this week: there is a worsening shortage of residency positions.  (See "Squeeze Looms for Doctors; More Medical Students Are In the Pipeline, but Too Few Residencies Await Them" (WSJ).) Medical students have responded to this situation by applying to 15-20 hospital residencies rather than the traditional 4-5. Residency admission committees have responded to this flood of applications by increasingly their reliance on Step I board scores. All of our tests for the first two years are in fact covering the same material as the Step I test.

In our morning cellular/molecular biology lecture series, doctors and researchers may preface a detailed explanation with "don't worry; you don't need to know all of this detail for the test." Nearly 20 percent of my classmates have at various points raised their hands to ask "is this going to be on The Test?" When the answer is "no," I wonder how many tune out the nitty gritty details of a cancer signaling pathway or the extracellular matrix remodeling in vasculogenesis.

Three days this week, including the weekend, I joined a group of 6 or 7 classmates at a local bar's happy hour for $2 beers and rail drinks. Roughly half of our class is female and one difference in conversation is that the men are less likely to talk about their romantic situation. Within the first 2-3 conversations with a woman, I've learned if she is single, dating, engaged, or married. About half of the women seem to be single, a fifth are engaged or married, and the rest are dating.

Though we have only recently met, it is already time for the class election. The positions up for grabs include president, vice-president, and a handful of Association of American Medical College student interest group representatives. Some eager beavers have been campaigning since the first week. There are three candidates for president and three for vice-president. All are male.

I did about six hours of homework total this week and went to bed every night before 11:00 pm.

Year 1, Week 3

Each week our class discusses a new patient that parallels the scientific theme(s) from lecture.  Most medical schools are pushing away from the conventional medical school format:  two years of basic science education followed by two years of clinical rotations in the hospital shadowing residents and attendings.  The newer approach is integrating clinical experiences and lectures during the first two years.

This week we reviewed a patient with a metabolic muscle disorder who became addicted to pain medications and heroin.  The case paralleled this week’s lecture topics of muscle structure, contraction and metabolism, including the dreaded Krebs cycle.  A public health official came in to discuss the country's opioid epidemic.  In 2014 the CDC recorded 28,647 deaths, triple the 2010 number, from opioid overdoses (prescriptions and heroin combined). We learned that "among new heroin users, three out of four report having abused prescription opioids prior to using heroin." (http://www.cdc.gov/drugoverdose/data/heroin.html) Most heroin comes from Mexico: “Researchers believe the border detection rate hovers around 1.5 percent — favorable odds for a smuggler.” (Washington Post).  Mexican heroin is unlike the “black tar” Southeast Asian variety of the 1970’s.  Mexican heroin is close to pure and frequently laced with potent fentanyl, a synthetic opioid over 100x as powerful as morphine manufactured in cartel labs.  (Prince overdosed on fentanyl.)  Overdoses rise when fentanyl is in the mix.

Week 3 went by fast because of a few firsts in anatomy. We continued dissection of the gluteal region and the posterior lower leg.   I saw a nerve for the first time -- it was huge!  The sciatic nerve runs through the thigh until it branches into the tibial and fibular nerve at the popliteal fossa (posterior knee joint).  The sciatic nerve is about the diameter of a large pen with translucent threads firm to the tough running along its axis.  This observation shattered the notion that nerves interact only at the microscopic level.  I can imagine how hypertrophy or herniation of nearby muscles could constrict the sciatic nerve causing radiating pain down the leg.  Interestingly, the tibial nerve lies superficial, above the arteries/veins, at the back of the knee.  You do not want to cut yourself here…  One of my teammates for our cadaver cut her hand with a scalpel, the fifth incident in three dissections.  She was trying to isolate semitendinosus, a muscle of the hamstrings, with a scalpel and her hand instead of a probe.

Statistics for the week… Study: 8 hours (5 hours devoted to anatomy); Sleep: 6 hours/night; Fun: 4 nights out. Example fun: A fellow classmate (let's call her "Jane") and I joined the Hawaiian-shirted locals at the weekly outdoor swing-dance downtown.  Dancing to the brass-heavy “beach music” band and wearing a thrift-store Hawaiian shirt, I would have fit in except for being 35 years younger than the average dancer.

Year 1, Week 4

In anatomy, we dissected the anterior thigh, lower leg and foot.  Before this week, I did not realize there were two bones between the knee and ankle: the tibia and fibula.  (To feel your fibula, locate the protrusion on the lateral side slightly below your knee and follow it down to a protrusion on the lateral side of the ankle.)  One of the most interesting parts of this three-hour dissection was the opening of the knee capsule, which requires ripping through tough layers of ligament on both lateral and medial sides to arrive at the treasures: the anterior and posterior cruciate ligament (ACL, PCL, respectively). These are named for the criss-cross structure they form in the interior knee.  Once we cut the ACL, a beautiful bundle of fibers from the anterior side of the tibia to the lateral condyle of the femur, it is amazing how much we could move the tibia in relation to the femur.

After the anatomy lab, orthopedic surgeons taught us how to conduct a lower leg exam.  We learned to isolate specific axes of rotation to evaluate ligament integrity and range of motion.  Tragically ironic, a classmate’s boyfriend injured his knee the next day.  She conducted the exam and felt an increase in medial rotation of the knee and offered the diagnosis of a loose lateral collateral ligament.  When asked what he should do, she responded, "I don’t know, ask me in three years.  Your LCL is messed up."

Our patient case had type 2 diabetes, which includes two distinct phases.  The first involves the desensitization of target cells to the action of insulin.  Insulin acts as a “signal of construction” by stimulating target cells to uptake available energy and molecular building blocks such as blood glucose.  As blood glucose remains high, pancreatic cells that secrete insulin become overworked and die.  As pancreatic islet function is degraded, the patient transitions to the second phase, a severe, irreversible form of type 2 diabetes that mirrors type 1 diabetes.  Importantly, patients who manage their diabetes before entering this second phase can reverse the entire disease.  The lecturers, an internist and a PhD researcher, agreed that determining the mechanism of insulin resistance would win a Nobel prize.

One common drug class used to manage type 2 diabetes and to depress blood glucose is sulfonylureas.  Sulfonylureas function by increasing beta-cell release of insulin.  One of my classmates asked, "Isn’t treating type 2 diabetes with these drugs accelerating the degradation of beta cell function?"  The internist responded "Yes, but sometimes we have to use them. When a patient’s glucose levels are off the chart, you have to use every option.  Second, sulfonylureas are much cheaper than alternatives such as insulin injections.  Many of my patients cannot afford anything else."

With exams in a month, a few classmates are already freaking out. We aren't being given the graded homework assignments to which they are accustomed and from which they could gauge their progress. We are supposed to determine what style of independent learning works for us. Instead of concentrating on learning, these classmates are worrying about exactly what is going to be on the Week 9 exam. Our drama for the week is that they apparently brought their uncertainty up with the Office of Student Affairs.  I would have hoped that they'd have more faith in the system with which they are entrusting four years and more than $300,000 (tuition, room, and board).

Statistics for the week… Study: 8 hours (6 hours devoted to anatomy); Sleep: 6 hours/night; Fun: 4 nights out. Example fun: Friday night about 15 of us had a “jam session” dinner party.  After spaghetti and homemade meatballs, we broke out the beer and instruments. The group included a classically trained cellist, two pianists who would have been welcome in most jazz clubs, and a harmonium(!) player. I was glad that I had brought my guitar, but I'm not sure that these real musicians were similarly glad.

Year 1, Week 5

Dissection investigated the shoulder joint.  Our upper limb is similar to our lower limb in bone and joint structure.  However, while most of our weight is translated through bone in our lower limbs, most upper limb weight is translated through muscles, the most fascinating of which is serratus anterior.  This muscle originates on the front of the upper ribs, wraps around the body, under the shoulder blade, to insert on the anterior side of the medial border of the scapula (shoulder blade).  This “boxer” muscle pulls the shoulder blade against the thorax ensuring it slides along the back when other muscles act upon it.

Lectures continued the discussion of metabolic processes, including the role of lysosomes, the recycling centers of the cell.  Extracellular debris, and cellular parts are trafficked to these small vesicles to be degraded by powerful enzymes. Our patient case was Hunter’s disease, a lysosomal storage disorder caused by a mutation or deletion in a lysosomal enzymes’ genetic code.  There are only about 500 Americans afflicted with Hunter’s, which affects nearly every organ system and can result in heart valve malformation, respiratory problems, liver/spleen enlargement and severe neurodegeneration.  Individuals suffering from Hunter’s, which typically manifests by age 2, frequently cannot speak or comprehend basic stimuli.  Life expectancy varies from 10-20 years.

A pediatric geneticist described treating Hunter's patients with Elaprase, a recombinant enzyme replacement therapy that replaces the mutated or absent lysosomal enzyme. This "orphan drug" costs over $300,000/year (see Forbes), but can't get through the blood-brain barrier to enter the nervous system and improve neural development. The geneticist explained that orphan drug prices are passed on to private insurance companies at an undisclosed negotiated price, paid in full by Medicaid without negotiation, or are paid for by the manufacturer when the patient has no insurance. Shire reported worldwide 2015 Elaprase sales of $552 million (press release).

We were done every day before 5:00 pm.  I studied 1.5-2 hours after class each day in preparation for the exams that are three weeks away.  There is a medical school test prep  industry that includes phone-based flashcard systems such as Anki and Firecracker ($300 for two years).  I haven't subscribed to any paid products yet because skimming through lecture slides and notes, then taking practice exam questions, is effective.

We got Labor Day off and our student affairs dean held a dinner party for those who stayed in town. We learned that for the past two years, approximately 20 percent of graduating students have gotten engaged to one another.

Statistics for the week… Study: 10-12 hours; Sleep: 6 hours/night; Fun: 3 nights out.  Example fun:  a Friday after-class soccer match followed by a BBQ with Jane’s family.

Year 1, Week 6

Two weeks before exams and the small library is packed in the evening. We have to review every topic since August while simultaneously being introduced to the complex biochemistry of the urea cycle, the process our body uses to eliminate ammonia freed from normal recycling and breakdown of protein and DNA.  Free ammonia is normally turned into urea by the liver for excretion in urine.

Our patient this week was a 20-year-old woman suffering from a Urea Cycle Disorder (UCD) since birth.  She had the cognitive function of a toddler.  A few of my classmates were left speechless after seeing the patient and hearing from the mother about her round-the-clock caregiver role. She described struggling against the adult strength of her daughter during basic tasks such as bathing and feeding.  UCDs are typically caused by a genetic mutation to an enzyme that catalyzes an intermediate product in the conversion from ammonia to urea.  If not detected early, excess blood ammonia (hyperammonemia) can alter blood pH enough to cause irreversible effect on the nervous system or death.  Most states' newborn screening programs now test for several UCDs.  Treatment typically is a combination of strict dietary restrictions and nitrogen scavenger drugs.  

We heard from a hospital Institutional Review Board (IRB) administrator in charge of approving clinical trial requests and access to patient data.   The IRB does not evaluate the value of the proposed research; instead, the IRB evaluates if the project can be conducted in a reasonable manner to benefit and to protect the research participants.  This process is historically a huge pain for physicians who want to conduct research.  The board can take months to review a simple clinical trial proposal or data analysis project of patient data.  She did not deny that the IRB process is cumbersome, but used the 1999 example of Jesse Gelsinger to explain why these protocols are followed. Gelsinger was a functioning teenager with a UCD that was so mild he should not have qualified for the trial to begin with.  Scientists attempted to use adenovirus (influenza) modified with a functioning form of the mutated urea cycle enzyme to cure the patient.  Potential dangers of the trial were not disclosed to the patient and his family. A principal investigator for this NIH trial had relationships with the pharmaceutical company providing the adenovirus vector.  Gelsinger died from a massive immune response and liver failure.  This tragedy triggered review of clinical trial procedures and halted many ongoing and future gene therapy trials.

After the 1.5-hour IRB presentation, an Emergency Room Physician talked about his experience with the IRB for a pain medication clinical trial.  He clearly was frustrated with the IRB, but diplomatically limited his criticisms to "there is plenty of room for improvement."

Anatomy lab continued with the previous week's dissection of the shoulder joint from the anterior side.  We saw the actions of the four rotator cuff muscles and observed the massive vessels and nerves near the clavicle.  Between the clavicle and the joint capsule lies a fascinating mesh of nerve fibers called the brachial plexus, by far the most complex nervous feature we've seen so far.   We learned how upper extremity range of motion is a function of three joints:  sternoclavicular (SC), acromioclavicular (AC) and glenohumeral (shoulder blade-humerus).  I never realized we have movement in the SC, the single point of contact between our upper extremity and our axial skeleton, when we raise or rotate an arm.  When orthopedic surgeons came in to demonstrate shoulder exam techniques, nearly 20 percent of our young class had bad enough shoulders to line up for a free exam.

Statistics for the week… Study: 16 hours; Sleep: 6 hours/night; Fun: 2 nights out. Example Fun:  Friday after-class soccer tradition followed by bowling night, in which we learned that one of our classmates is a former competitive bowler.

Year 1, Week 7

One week before exams; my classmates are nervous.  

Lectures introduced the immune system, both the innate and the marvelous adaptive immune system.  All of our immune cells start their lives as bone marrow stem cells.  These stem cells undergo education, either in the thymus or bone, to ensure they do not attack healthy cells yet can potentially attack foreign antigens. I had always thought during an infection our adaptive immune system would create a new immune cell against this foreign structure. Instead, the diversity of potential antigens to which our body can respond is determined within the first few years of life by a process of "student" immune cells randomly self-mutating their antigen receptors (see VDJ recombination). Only about 1-2 percent of the total cells graduate from self-mutation school; the remainder kill themselves. The textbook says that our immune system ends up with roughly 1,000 billion cells that can recognize 10 million different antigens. When an unknown invader arrives, if it is among the 10 million antigens that we've prepared to fight since early childhood, we're in great shape. Otherwise we will need antibiotics or a trip to the hospital.

A doctor from the world's only hospital that does thymus transplantation came in.  As mentioned above, the thymus is the schoolhouse of the immune system, educating immune cells to not attack self.  Transplanting a donor thymus, typically obtained from a young child whose thymus got in the way of cardiac surgery, could theoretically eliminate the issue of organ transplant rejection. If a diabetic needed a new kidney, immunosuppressors would be used to destroy the patient's immune system and then the donor kidney and a donor-matched thymus would be transplanted.  The regenerating immune system would be educated to not attack the patient nor the matched donor organ -- thymus education is additive!  The challenge is to generate a comprehensive thymus donor database or even engineer a biosynthetic thymus.

We dissected the arm from the shoulder to the elbow joint.  I was amazed by the vasculature (arteries and veins) as it branches from the major vessels in the thorax and the interweaving nerve structures (see brachial plexus).  We saw the funny bone, a.k.a. the ulnar nerve, as it passes between the medial epicondyle of the humerus and the olecranon, or elbow bump, of the ulna.  I also discovered my favorite joint:  the radiohumeral joint with the annular ligament of the radius.  The radial humeral joint allows rotation of the forearm (supination, palm up, and pronation, palm down).  The radial head, a spherical protrusion at the proximal end of the radius, is encapsulated in a sheath that allows it to rotate around a fixed point. Listening to the PhD medical researchers who come in as lecturers, I am coming to appreciate the amazing opportunity of anatomy lab. The researchers are experts on test tube experiments, but haven't had time to look at the circulatory system or liver anatomy, for example.

Statistics for the week… Study: 18 hours; Sleep: 6 hours/night; Fun: 2 nights out. Example Fun:  Friday after-class soccer followed by a repeat of the Week 4 jam session. More than half the class showed up and most of them sang along, despite any lack of formal musical training.

Year 1, Week 8

Exams begin next week. Type-A Anita is particularly nervous. Beginning last week she has refused to learn anything that is more in-depth than the NBME questions: "only high-yield." She interrupts class once per day to complain when a professor gives more detail than the Step 1 exam books do. She also requests clarification about the number of questions per exam topic. She dropped her sweet Midwestern demeanor and submitted a formal complaint to the administration when an older physician said males have to work more to learn patient interviewing because women are more naturally caring.

Lectures focused on glycolysis and summarizing metabolic pathways.  A rather plump gastroenterologist in his 50s gave an "energy" synopsis about different states of metabolism. These lectures were paired with our patient case, a young anorexic teenager. Anorexia fits with the metabolism unit because it forces the body to break down protein to use for gluconeogenesis. We heard from her doctor that the patient is on antidepressants and receiving psychotherapy, but didn't get to meet the patient.  

We finished dissecting the upper extremity with the elbow, forearm and the bewildering hand, whose muscles and vessels entail hours of dissection. I share my cadaver with three other students. Yet, with three hours of dissection time, we had explored only about 10 percent of the hand. Fortunately, the instructors convinced a chief surgery resident to spend his evenings dissecting a demo cadaver and then come in at 10:00 am to give us a guided tour of a perfectly dissected hand. We were doubly appreciative of his efforts after we heard about his 24-hour hospital shifts.

One of our most passionate and funny doctors spoke about using ultrasound to investigate the shoulder and upper arm.  Ultrasound sends high frequency sound waves into the body and relies on differences in the ways that tissues reflect or absorb the sound. We broke up into groups of six, each provided with a donated battery-powered 10 lb. ultrasound machine. The expert (attending) arrived at each workstation to help us diagnose each other. We were able to see torn muscles, ligament damage, tendinitis, and bursitis. As with Week 6, a high percentage of our classmates were able to supply examples of musculoskeletal damage. I contributed a torn supraspinatous (rotator cuff) muscle torn in the college weight room.

In an after-workshop discussion, our professor described his frustration that the medical school accrediting body, Liaison Committee on Medical Education (LCME), limits the number of "formal instruction" hours.  "I'm not exactly sure, but it is only about 25 hours per week," he said. He recounted stories from his professors' education in the 1920s.  For example, a instructor asked a first year class if anyone was uncircumcised.  Two students raised their hands.  They were instructed to drop their trousers, and in the pursuit of education, were circumcised in front of the entire class, including the two female students. His own 1950s education did not include any in-class circumcisions, but they were at school for 12 hours each day, with some mandatory Saturday sessions.  Anatomy lab dissection was 4 hours per day compared to our 4 hours per week. Our professor noted that passing the NBME exams requires more knowledge than for comparable tests in years past. Thus today's medical student faces greater pressure to study independently.

Statistics for the week… Study: 35 hours (about 5 hours after class each weekday plus more on the Sunday); Sleep: 7 hours/night; Fun: 1 hiking excursion with Jane.

Year 1, Week 9

We have four straight days of exams, covering clinical exam skills, biochemistry, anatomy and cellular biology.  Exams begin at 8:00 am, but on two days we were finished by noon.  Our first, and main exam is a practice NBME Step 1 using prior, retired questions. The biochemistry and metabolism questions are quite similar to the MCAT.  A classmate sent a message our GroupMe after he finished the exam: "There goes my Derm practice out the door."  Anita, and some of the other more sensitive, nervous individuals, did not find this funny. (Dermatology, along with orthopedics and surgery, are some of the most competitive residencies, requiring high Step 1 scores to get matched.)

Anatomy was a sore subject for many. The exam required detailed knowledge of discrete muscle group innervations. There was grumbling afterwards: "I couldn't read the poor quality images"; "Who cares what the fascial layer is called?" I am grateful our medical school still purchases cadavers for us to learn anatomy; numerous schools are replacing cadavers with electronic images for anatomy education. There is no substitute for the real thing.

After our last exam, we were invited to a cocktail party by a wealthy local sponsor of the medical school. It was pouring rain, but they had a valet service working in their front yard--I'm not sure it was a big night for valet tips given the medical students' typical debt load. The mayor and board members of the local health system were there to welcome our class to the city. The city symphony director played a few original jazz compositions on the piano.  The class stayed late drinking martinis at the open bar and smoking free cigars.

I learned about tension among some physicians who teach us.  Most of them love it.  However, some are frustrated by the pressure from the health system to teach yet still are expected to have the same patient load.  Instead of spending less time with their overbooked patients, they usually just stay later.

The celebration continued at our classmate's apartment complex.  Our whole class was there, including the few married couples.  The diversity of ages and lifestyles was illustrated by someone doing the college-favorite "slap the bag" of disgusting Franzia wine next to the 27-year-old father of two.

Statistics for the week… Study: 35 hours; Sleep: 7 hours/night (more than previous weeks due to going to bed earlier); Fun: 1 night out at cocktail party after exams.

Year 1, Week 10

With the first exams finished, we are all more comfortable with our roles as medical students. My comfort level rose to the point that I ordered a stethoscope. I'll be ready for next week's "white coat" ceremony.

Anatomy this block will focus on the cardiopulmonary system.  In preparation for removing the chest wall, we dissected the anterior neck. The carotid artery was huge, about the size of an adult's thumb, and we could see the plaque that had built up during 97 years of living prior to becoming a cadaver. We got a beautiful view of where the common carotid artery bifurcates, forming an important structure called the carotid sinus. The carotid sinus contains nerves with specialized pressure sensors that regulate systemic blood pressure. A few decades ago, doctors investigating hypertension or shortness of breath would palpate and briefly constrict the carotid sinus to ensure blood pressure changes occurred. However, this can cause strokes from plaque rupture and we learned that therefore the practice has been discontinued, but we haven't yet learned about modern diagnostics.

Lectures focused on embryology with a patient case of fetal alcohol syndrome. So many coordinated events occur within the first two weeks post-fertilization, it is remarkable how rare serious birth defects are. One fascinating process is how the embryo creates a left-right axis.  A region of cells have a single cilium, a vibrating thread similar to the flagellum that propels sperm cells.  Coordinated beating of these cilia produces a net leftward current and creates a concentration gradient of signaling molecules to turn on "lefty" genes.  We learned about sinus invertis, in which the body is flipped left-right. The condition affects roughly 1 in 10,000 individuals, many of whom have no symptoms at all!  We also learned about some more serious cases of birth defects, e.g., sirenomelia ("mermaid syndrome") where the lower extremities are connected, and encephalocele, where the skull does not fuse correctly and the brain grows outside the skull.

Our patient case involved a teenager whose biological mother had used alcohol, cigarettes, marijuana, and cocaine while pregnant.  "Greg" was born with fetal alcohol syndrome and addicted to cocaine. State social services agencies automatically investigate every case of fetal alcohol syndrome and, in this case, Greg was turned over to a foster mother, who was the primary speaker to our class. The foster mother, who quickly became the adoptive mother, told the story of how she came to love this child and the role of her Christian faith in the process. There was a lot of crying and the still-unanswered question of how the biological mother could have done this to Greg. Much to everyone's later-expressed surprise, when Greg finally walked into the room he was articulate, though nervous, with none of the aggression common to patients with a history of fetal alcohol syndrome. Greg was aware of his history and challenges.  He described being frustrated by his poor memory and difficulty learning abstract subjects such as mathematics. However, he enjoyed history and socializing with other students at his special-needs school. We were impressed by Greg's determination and perseverance, but It seemed likely that he would require lifetime assistance from a responsible adult.

The case sparked a lively discussion on the legal ramifications of drug abuse while pregnant, a matter governed on a state-by-state basis. The spectrum of laws ranges from criminal prosecution if a child is born addicted to drugs or showing signs of fetal alcohol syndrome to no consequences beyond the potential for losing custody of the baby. Some midwestern states are in the middle of this spectrum, with a rehabilitation mandate for pregnant women who consciously abuse drugs and alcohol. Greg's physician opined that the potential for criminal prosecution was counterproductive because it dissuades addicted mothers from continuing with prenatal care. Women who'd previously articulated feminist positions in the classroom immediately voiced their objections to sanctions against mothers on the grounds that this was a step on a slippery slope toward infringing on a woman's abortion rights.

Later in the week, three primary care physicians led a discussion on how to approach patients about medications and drug usage. Doc 1 opened with a story about taking her 12-year-old daughter to a specialist. The nurse stared at the computer screen and read the questionnaire out loud without looking at the 12-year-old patient and mother seated nearby. "Do you drink?", "Do you smoke?", "Do you use illegal drugs?", "Do you feel safe at home?" This tale of attempted human interaction in the age of electronic medical records prompted Doc 2 to chime in: "Never trust the medication list in Epic ['MedRec'] as it is rarely up-to-date, and will certainly not include more sensitive drugs and behaviors."  Doc 3 seems to be a contributor to this phenomenon, saying that he is cautious about adding to a permanent electronic record that is accessible to the patient on request. "I never put a 'suspected heroin use' note in the chart," he said, "I just keep a note on my desk."

Doc 1 told us to remember that it is not just illegal drugs that are used illegally. She had prescribed a muscle relaxer and prescription-strength ibuprofen (NSAID) for a patient with a back injury.  After three months, the patient said that she'd stopped taking the medications because her middle school daughter had been pressured into stealing them by her classmates.  When the daughter began to refuse, her "friends" threatened the mother that they would "jump the house" (?) to steal them.  Despite the limited potential for getting buzzed off a muscle relaxer, Docs 2 and 3 were not surprised. Lesson learned:  lock the medicine cabinet.  

Statistics for the week… Study: 10 hours (1-2 hours after class each day).  It has been easier to study this block's organ systems instead of the abstract biochemistry pathways that we were learning in the last block. Sleep: 6 hours/night; Fun: 2 outings. Example fun: drinks and music at Thursday downtown rooftop party and a class happy hour at a local pub.

Year 1, Week 11

We started our exploration of the respiratory system in anatomy by using bone saws to remove the chest plate, thus opening the thoracic cavity. Half an hour after we started sawing, I was holding a human lung: heavy, fluffy, yet slippery to the touch. Unlike textbook depictions, they are asymmetric. The three-lobed right lung is larger while the the left lung has only two lobes. The aortic arch and descending aorta carve out a large groove in the posterior left lung. Comparing cadavers, it wasn't hard to spot a smoker's lung: copious amounts of black specs on the exterior plus one cadaver had burst alveoli. If you see a doctor smoking you'll know that he or she really loves cigarettes.

My group finished early and snuck a peek by opening up the pericardium (membrane that covers the heart). The heart is surprisingly small, about the size of a clenched fist. We don't have any information about how our cadaver donor died (aged 97), but we noticed a dark red spot on the left side of the heart, surrounded by firm white tissue. Our instructor explained that this indicated a left ventricular myocardial infarction ("heart attack") and said that, if the patient had survived, the affected area would have remodeled into tough scar tissue. One small spec on a small organ is the difference between life and death.

We learned in lecture that the breathing system is like two springs: (1) the lung, which wants to collapse, and (2) the chest wall, which wants to expand. The lungs are stretchy, with a third of the elasticity from the tissue itself, and two-thirds from surface tension of the copious fluid coating the airways. They're constantly being pulled open by the pleural membranes, connected to the chest wall. We disrupted the balance when we cut through a rib, which sprung outward, no longer constrained by the recoiling lung.

Our patient for the week had been morbidly obese, which led to sleep apnea, which led to pulmonary hypertension. Excess weight on her chest and neck obstructed airways and elevated thoracic pressure. Prescribed a CPAP oxygen machine, her compliance was haphazard, which is typical with this immensely uncomfortable contraption, despite the patient's ability to choose her favorite mask color. Sleep apnea, with its intermittent decreased blood oxygen saturation, can lead to increased pulmonary artery pressure. This had caused her right heart to work harder pumping deoxygenated blood into her pulmonary arteries. Over the years this made it impossible for her to exercise. She felt continuously exhausted, unable to walk up a few stairs or stay awake during any prolonged meeting. She quickly used up all her vacation and sick days and had to quit her job, moving in with her sister 200 miles away. Her new doctor recommended she speak with a pulmonary hypertension (PH) specialist, a relatively new field spurred on by the rise of obesity and sleep apnea. The PH Doc described his reaction after the first visit: "I did not expect her to live for more than two-years. I thought her right heart would fail." He continued by explaining the unfortunate truth for PH. "Pulmonary hypertension was an inescapable death sentence until the late 1990s. There is no surgical intervention and no drugs. Studies showed that over 50 percent of patients with severe PH die within two and a half years." In the late 90s, pharmaceutical companies developed new classes of drugs to treat left heart failure and hypertension. Some of these turned out to temporarily reduce pulmonary hypertension, giving patients a brief window in which to lose weight. Our patient was able to complete an aggressive exercise and rehabilitation routine. Five years post-diagnosis, she is no longer morbidly obese, exercises daily, and has gone back to work part-time.

The PH Doc ended by reminding us not to be blinded by obesity in a patient: "Doctors too often blame all symptoms on obesity, even if there are other pathologies that can be treated." For color he told us about the challenge of not offending a patient while saying "we need to send you to the zoo where there is a larger-sized scanner…"

Sunday evening a few students were invited to my favorite professor's cabin. She is a never-married woman in her late 60s who has dedicated her life to the craft of trauma surgery. She entered medicine expecting to go into family practice. While a third year student, she requested to be sent for her family medicine rotation to a rural area. She drove into the mountains to a small mining town of 10,000 with two family physicians. Although regretting her decision at first, it was here that she learned to love emergency medicine. Sitting around the bonfire, she shared vivid memories of driving the ambulance up moonlit dirt roads to a mine and going down the shaft to retrieve injured miners.

What has changed in trauma surgery? "Well the cases have changed," she answered. "I started out treating young males in high-velocity, multi-trauma injury cases: car accidents, gunshot wounds, stabbings. Now it is mostly low-velocity cases: an elderly patient who has fallen. The family feels terrible for not having been there when the trauma occurred. The family flies cross-country to say 'Do everything you can to keep Grandpa alive,' not understanding what this requires doctors to do.  Too often they ignore palliative care." She'd learned about hospital funding priorities: "It is easy to find donors for a state-of-the-art pediatrics wing; there is no money to remodel a decrepit geriatrics ward." Her bonfire advice to us: (1) find a field where you will get more interested in it as you go on; (2) you can be happy in more than one residency field (i.e., don't cry if you don't get your first choice).

Statistics for the week… Study: 8 hours. Sleep: 6 hours/night; Fun: 2 outings. Example fun: Camping with Jane and Sunday BBQ at trauma surgeon's cabin.

Year 1, Week 12

This week: White Coat ceremony; an exciting heart dissection lab; and our first real patient interactions.

In anatomy lab our goal was simple: remove the heart. Most textbooks depict the heart as a vertical organ, with the left and right atria lying on top of the muscular left and right ventricles. Our trauma surgeon described this as one of the greatest illusions of human anatomy. Instead, the ventricles are anterior to (in front of) the atria. We began by opening the pericardium, revealing the great vessels leaving and entering the heart. The aortic arch got several "oooh's and aww's" as we constricted this massive 1-2-inch-diameter thick-walled vessel. Once all the great vessels connecting the heart to the body were cut, the student would run around holding a human heart in the air, like Simba was held up in the Lion King.

Lectures detailed the embryological development of the lungs. Lungs begin developing at around 20 weeks gestation (18 weeks after fertilization; gestation is measured from the last menstruation). However, due to a lack of sufficient gas exchange sacs to sustain respiration, the lungs do not become pre-viable (sustainable out of the womb) until 23-24 weeks. Even after 24 weeks, a baby's lungs are barely developed, and the most common cause of death is respiratory distress. The slightest complication, for example, a respiratory infection, could lead to death.

Our patient case was a baby born at 24 weeks, about 16 weeks before she should have been born. The mother detailed how she was having a healthy first pregnancy when she suddenly went into a rare form of premature labor. An emergency C-section saved the baby and herself. "Kate" was brought into the world at 1 pound, 6 ounces (normal baby weight is 6-8 pounds).

The family expressed pure love for the neonatologist who "gave life to" Kate in the Neonatal Intensive Care Unit (NICU). "You should all become neonatologists," exclaimed the mother, "and if not neonatologists, then obstetricians!" The young couple had thought that the birth was the difficult part, but at 26 weeks Kate had a severe hemorrhage in the developing pulmonary vessels. As the neonatologist and nurses scrambled around the incubator, the parents were stunned. The neonatologist absently muttered, "This is not good." As the mother recited this trauma, she paused and broke out in tears. The father continued, "We did not know what was happening. One moment it was fine, the next, lights were blinking everywhere, sounds going off, people running." Blood vessels in the lung had ruptured. There were two serious concerns: first, the ventilator, which is breathing for the baby, gets clogged. The neonatologist and nurses frantically tried to vacuum blood out of the airways to prepare to insert another plastic trachea tube to ensure the airways remain open for respiration. After this was successful, the neonatologist knew the longer-term threat: stopping a massive bleed causes a sudden large volume return to the heart. When the heart pushes this additional blood into systemic circulation, immature blood vessels in the brain can rupture. If the baby does not die, this causes severe brain damage roughly half the time.

The neonatologist and family spent a nervous night waiting for to know if this cerebral hemorrhage had occurred. The family described their euphoria when the smiling and crying neonatologist came into the room with the test results: the blood vessels of the brain did not leak. The whole class crowded around as the family showed pictures of Kate today: a healthy, albeit slightly small, energetic toddler.

The White Coat Ceremony is a tradition dating back to 1993. Friends and family descend on the medical school to watch deans help each student into a white coat. The 1.5-hour ceremony was followed by a reception where parents snapped away with smartphones. The next day I would wear my white coat with my first patients, shadowing a Primary Care Provider who had trained in the Navy, but left after his four-year service obligation.

After the nurse took vitals, I introduced myself as a student, giving each patient the opportunity to demand a fully trained doctor (nobody did!). Then I interviewed the patient and performed any exams I felt pertinent, such as listening to the heart and lungs. I then reported back to the physician and we would return to the room together for discussion with the patient. It was empowering to walk into the patient room with my white coat on and a stethoscope around my neck!

Our first patient's chart indicated an alcoholic smoker with Chronic Obstructive Pulmonary Disease (COPD). An episode of pneumonia had put him in the hospital for a week and he was here for a follow-up to confirm that his lung tissue had recovered. The lungs looked as good as they were going to get, so we sent him home. Next we treated a child's ear infection, saw a type 2 diabetic, and checked on a hypertensive patient. Our last patient, in his mid-20s, had knee surgery nine months previously and was prescribed oxycodone for post-operative pain. He had been transitioned to tramadol, a less intense opioid, and, after reviewing the chart, the physician and I agreed he was likely asking for a refill, which should be denied. I asked if I should remain outside. My attending said, "No, you should see this. As a doctor you'll deal with it too much." After a brief exam of the knee, the conversation quickly turned to the subject of getting a tramadol refill. The doctor said that it is time to transition to a different pain-management strategy. The patient asked, aggressively, "Why? This is working. It's the only thing that helps with the pain. How could you do this to me?" When the physician would not budge, he put his hands over his head in desperation.

The four-hour clinic taught me to make sure to get the full list of prescription drugs each patient is on. We had to consider four drug interactions when evaluating a switch to a new hypertension pill for our patient with high blood pressure, who was already on 12 different medications. None of my classmates were surprised by this story; one shadowing a neurologist said, "Two of my patients were on over 17 drugs."

Statistics for the week… Study: 14 hours. Sleep: 6 hours/night; Fun: 1 outings, class halloween party! Medical school budgets bring out homemade costumes. My favorite was Ron Burgundy and Veronica Corningstone of Anchorman.

Year 1, Week 13

We finished respiratory physiology with a lecture on arterial blood gases. Breathing allows the infusion of oxygen into the bloodstream and the removal of carbon dioxide produced by cellular metabolism. The respiratory rate is normally regulated by the amount of carbon dioxide in the blood, not by the amount of oxygen. CO2 is tightly regulated because carbon dioxide determines the pH of the blood. Remember that soda contains carbonic acid. When the can is cracked, carbonic acid is converted into CO2 and water, i.e., fizzy water. The reverse process, of CO2 in the blood turning into carbonic acid, results in acidic blood. The body tries to maintain a slightly basic blood pH of 7.4.

My favorite trauma surgeon used some of her patient experiences as case studies to describe the different permutations of arterial blood gas states. In one example, a drunk 18-year old falls three-stories. He is found unconscious, not breathing, with O2 saturation (sat) levels severely depressed at 60%, and CO2 levels severely elevated. The patient is suffering from respiratory acidosis. As the patient is transported to the hospital in an ambulance, his O2 sat rises to 80%, but CO2 has dropped below normal. The high-school-age EMT raised the patient's oxygen saturation levels with the breathing bag, but was squeezing it too quickly, causing increased expiration of CO2 and respiratory alkalosis.

The patient case was "John," a 40-year old male suffering from life-threatening asthma since the age of four. Growing up, his condition was successfully managed by the family pediatrician. John's father was a teacher and John emphasized how this doctor had tailored the treatment and medications to his family's modest budget, e.g., by finding low-cost alternative medications and free samples. In college, the asthma spiraled out of control. "I saw a PCP [primary care provider] at college once. The guy immediately insulted my pediatrician saying the way I was managing my asthma was terrible." The PCP scoffed when John said the treatments were working well for him. John never went back and lost touch with the medical system. As his uncontrolled asthma began to worsen (John now admits the college PCP might have been right), he used home remedies. When he was having an asthma attack at night, he would brew a large pot of coffee and sit outside on the porch in the middle of the freezing night drinking cups of coffee with his plump pug (caffeine would relax his bronchioles).  "I probably should have gone to the ED many times," John said, "but I would push the limits. Also, I knew how much it would cost me so I gulped that coffee."

John's asthma said that his asthma improved after he "moved and started a new job," enabling him to see the pulmonologist sitting next to him. It turned out that the "new job" was a cardiology fellowship and the pulmonologist was his attending. She joked that her fellow/patient was non-compliant and John admitted that it was difficult to find time to take care of himself. He sees patients as part of the fellowship, has two toddlers at home, and moonlights at the VA to support his family (a fellow earns about $60,000 per year). John noted some additional financial pressure from a recent regulation requiring eliminating Ozone-depleting chlorofluorocarbons from the inhalers' ejection mechanism. Although the drug itself was the same, this slight tweak to the mechanism allowed pharmaceutical companies to re-patent medications that formerly had generic competition. Prices soared from single digits to hundreds of dollars per inhaler. John said his insurance now covers most of it, but many patients have to pay out-of-pocket due to high deductibles. John noted that for some patients the inhalers can cost more than their mortgage payment, leading to abandonment of the optimal medications. John emphasized the need to listen to patients: "If they say something is working, don't brush it aside like the college PCP."

Anatomy lab was incredible, by far the most fascinating day thus far in medical school. After an early morning excursion with Jane to pick up pastries at our favorite breakfast place, we entered the cadaver lab where a fresh pig's heart from the local butcher awaited each student. The human hearts we removed last week were preserved for a later date once we can appreciate pathological conditions. We were quite timid at first. The surgeons and cardiologists went over and gave us a little instruction about where to make the first scalpel stroke, then said "just enjoy exploring wherever your heart desires." As soon as we opened the hearts, which we're told are almost identical to a human's, we saw an unfamiliar environment. Tendinous fibers, also known as heart strings, criss-crossed in the ventricular chambers connecting the atrioventricular valves to papillary muscles on the heart chamber wall. We rubbed the translucent leaflets of the heart valves in between our fingers. I saw and felt the beautiful tree-like muscular protrusions of the ventricular wall that help guide the flow to their destination, shattering my vision of the interior heart as a smooth surface.

Afterwards my favorite trauma surgeon gave a lecture on the aging heart. She described how the current generation of physicians were all trained on a younger population. Now, when physicians apply this standard of "normal" to older patients, many normal aging processes are diagnosed as pathological. For example, during aging the whole long axis of the heart begins to shorten. This is often misconstrued and overdiagnosed as a pathological state. She cautioned, "Get used to this. You are going to be dealing with an older population."

Last week's ear infection patient and I now share something: fleas. I have decamped to Jane's house until the fumigators can come. The physician with whom I saw the toddler calmly said, "It happens sometimes. Downside of seeing kids."

Statistics for the week… Study: 12 hours. Sleep: 7 hours/night, fleas kept me up one night; Fun: no downtown outings. Example fun: movie night with Jane bedtime 9:00 pm.

Year 1, Week 14

"I thought I was in a nightmare," one classmate wailed the day after election day. Every classmate seems to have voted, but none openly support Donald Trump. Type-A Anita held a class election party at her apartment with "I'm with Her" plastered on every wall. One classmate commented about the ease of registering to vote in a new state.  He used an out-of-state ID as proof of identity but never had to show any proof of residence: "I just typed my address into the online voter portal. They never requested a utility bill, or anything. The bouncer at Friday's bar looked at my ID more closely than the election volunteer." Jane and I left before the results were in, but the mood of our hostess gradually darkened.

On post-election Wednesday, our class president sent a GroupMe message to the class: "If anyone would like to talk about last night's election, please reach out to myself or the VP." I stopped to join a conversation among three students in the hall.  A proudly gay student said, "I always believed most people thought like me. I feel so alone. I don't feel safe. I never realized how many racists there are in America." I asked him what he thought about Peter Thiel's speech at the RNC? He had never heard of Peter Thiel. A rural West Virginian said that her entire family supports Trump, but she cannot. She described half of American voters as "brainwashed over guns," but said she still loves her family.

At our monthly journal club, where an instructor leads a six-person discussion of an academic paper, a student asked to be excused to make a phone call. The female biophysicist replied, "Well, apparently, anything goes now. Why not? Go ahead."  I chuckled, but Anita began to cry and excused herself.

Anatomy lab was not as exciting as last week: a short dissection, mostly identifying different structures that had not yet been removed from the thoracic cavity. We observed the descending aorta as it passes through the diaphragm into the abdominal cavity. One cadaver had an enlarged aorta, many had plaque build-ups. We observed the venous drainage system including the azygos and hemiazygos veins that drain the thoracic wall.  We compared this system among cadavers and noticed the immense amount of normal variation. Some cadavers have the hemiazygos system drain the entire left thorax into the azygos vein, a tributary to superior vena cava. Another variant had divided drainage basins with some going to the azygos system and some draining into the left subclavian vein. One cadaver had a visibly enlarged azygous vein. The trauma surgeon immediately started looking for deep venous thrombosis (DVT). If a large vein in the leg is occluded, the azygos vein acts as collateral circulation, partially bypassing the blockage. We could not find any blockage.

We also observed the paravertebral ganglia column, a fascinating bunch of neurons that run on either side of the vertebrae.  These sympathetic nerves have their cell body, e.g., nucleus, in the spinal cord but their axon exits the vertebrae and runs parallel alongside the vertebral column. It was small and easily mistaken for connective tissue. An instructor complimented our group for identifying this nerve!

Lectures featured a pediatric cardiologist. The whole class quickly fell in love with her three decades of stories about saving babies with congenital heart defects. Congenital heart defects, such as atrial septal defects (ASD), ventricular septal defects (VSD) and patent ductus arteriosus (PDA), are not uncommon. She explained these in the context of embryological heart development. Fetal circulation is quite different than after a child's first breath. The fetus uses hemoglobin with a higher oxygen affinity to steal oxygen bound to the mother's hemoglobin.

Most fetal blood bypasses the pulmonary circulation of the lung through the ductus arteriosus, a shunt between the pulmonary artery and aorta. The ductus arteriosus typically closes within a few hours to days after a baby's first breath. However, if the ductus arteriosus fails to close, the PDA could lead to severe hypoxia, heart development problems and death. Cardiothoracic surgeons can now close this using a catheter guidewire system instead of open heart surgery. Frequently the PDA patient has other heart defects that require more invasive surgery. Babies with an ASD, VSD, or PDA can live completely normal lives once this is fixed. She concluded by showing the class pictures of her "extended family".

The patient case followed the story of a baby with an exceedingly rare genetic disorder. Based on an ultrasound, physicians determined that "Kate" would never be able to talk, and would suffer from severe neurological impairment. Only fifty percent of babies with this disorder do not make it to birth, and a mere five percent make it to one year of age. Physicians advised her parents to terminate the pregnancy. The parents refused, "She deserved a fighting chance. Her fight was between herself and Him (pointing up to the sky)."

An early C-section saved Kate and the mother. Kate was then whisked off to the infant operating room to begin work on her full range of birth defects. These would include several life-threatening heart defects, respiratory distress and terrible GI troubles. She was placed on extracorporeal membrane oxygenation (ECMO) which functions as the baby's lungs and heart. The father broke down when he recounted his memory of this machine. Each ECMO machine has a lever attached. In the event the power goes out at the hospital, he would have to crank the lever to continue pumping oxygenated blood into Kate.

Now seven years old, Kate is fed using a G-tube and is unable to speak words. However, she can smile, laugh, and walk with assistance. Kate enjoys playing with her two younger, but already bigger, siblings. Medicaid pays for a daily caretaker to assist the parents. One classmate asked, "What are your hopes for Kate." The parents responded, "Kate has surpassed everything we hoped for. We were told she wouldn't survive the pregnancy. She did. We were told she wouldn't survive past the age of one. Every additional day is a blessing."

Statistics for the week… Study: 15 hours. Sleep: 7 hours/night, still staying at Jane's; Fun: 1 outings. Example fun: Dinner party with Jane's family.

Year 1, Week 15

Sonographers and clinicians demonstrated echocardiography.  The ultrasound radiologist said, "This will be the moment everyone is captivated by ultrasound." She was not wrong as we gazed at our hearts in action. Echos are a fantastic way to noninvasively get a snapshot of the heart.  My classmates loved using the "color doppler" feature to visualize the blood flow in and out of the different heart chambers. Due to Doppler effect, blood flowing towards the transducer compresses the sound waves and thus reflects sound at a higher frequency; blood flowing away from the transducer stretches the sound waves and thus reflects at a lower frequency.

Lectures continued on cardiac output and numerous regulatory mechanisms of the cardiovascular system. Cardiac output is governed by metabolic demands of the body. I was fascinated by the principle of "peripheral vessel capacitance".  Arterioles (small arteries) conduct rather than store blood. Arteriole smooth muscle tone determines the resistance of these rigid tubes by changing the diameter. Venules (small veins) are slack by comparison due to high levels of elastic fibers and the low amount of smooth muscle in their walls. Arterioles and venules behave as a combination of resistors and capacitors for blood. Venules collectively are a massive reservoir of blood. A sudden increase in cardiac output and increased blood pressure can be handled by charging the venule reservoir rather than by returning venous blood to the heart. In the event of a hemorrhage, the vessels will discharge to maintain arterial blood pressure. Smooth muscle contraction of the arteries increases resistance and thus decreases flow, whereas smooth muscle contraction of the venous system leads to a decrease in capacitance and increased flow. It seems to me most blood pressure research and pharmacological intervention is focused on manipulating arterial muscle tone. I wonder how venous tone may be dysregulated in pathologies such as hypertension? (see "How changes in venous capacitance modulate cardiac output", Tyberg 2002)

The patient case involved a late-50s male who suffered a heart attack. "Jack" was also a type 1 diabetic diagnosed at an early age. He lost his financial industry job in 2009, along with his insurance, then had a heart attack a month later. During his week in the hospital, physicians put him into a medically-induced coma, which the patient said saved his brain function (because an awake brain would place a greater demand on the injured heart?). He recovered well and is back to work in a "less-stressful" job. The enormous bill was paid in full by a charitable organization associated with the hospital.

Due to his chronic condition, type 1 diabetes, he deals with nearly a dozen specialists, including an internist, rheumatologist, cardiologist and endocrinologist. He prioritises his cardiologist's' recommendation over treating his joint pain from type 1 diabetes after his rhematologist recommended he switch to a drug which his cardiologist vehemently opposed putting him on. Jack complains that he does not know how his heart is doing now. He lives with perpetual uncertainty. He knows he should lose 15-20 pounds. The cardiologist said the tests that might shed light on the heart's condition are not economically justified. When Jack mentioned his concern, the cardiologist said, "the question for patients after the first heart attack is not if, it is when, the next heart attack will be."

A quirky neurosurgeon presented his research interests to the class. He opened with, "Fracking will save neurosurgery!" He explained that neurosurgery involves an astronomically expensive procedure that, even when successful, frequently results in disabled individuals who cannot support themselves. "If a bomb went off at the neurosurgery conference, public health would not be affected. Only rich economies can support such a field." His research dream is to find a neurosurgery procedure that has an actual economic benefit. This lecture was a good reminder that a country's GDP is not a great measure of a country's wealth; if everyone gets diabetes the GDP will go up from increased health care spending, but the average American will certainly not be better off.

Next, an ENT specialist described her interest in hearing loss. The ear is a masterful mechanical device that focuses sound waves and transmits it to a circular fluid drum called the cochlea. Sound energy hitting the ear vibrates the fluid inside the cochlea. Specialized nerve cells innervate the cochlea bearing tiny hair projections into the fluid that deform at pre-set frequencies. These nerve cells send this signal  this information to create the sense of sound. Medicine now has the ability to implant artificial cochleas. Our ENT lecturer was trying to determine at what age these prosthetics should be implanted to get the best hearing outcome. She presented a case in which one sibling got an implant at age 3 and is now more or less normal while the sibling who also lost hearing at age 2 but didn't get the implant until age 6 is struggling with both hearing and speech. She is able to surgically implant these devices without having done the grueling general surgery residency and also treats adults, thus breaking what we were told are the rules for choosing a specialty: (1) to cut or not to cut, and (2) do I like kids?

Statistics for the week… Study: 15 hours. Sleep: 7 hours/night; Fun: 1 night. Example fun: Double date with 24-year old classmate and his wife who is studying to become a physician's assistant, followed by drinks at the new taco/tequila bar.

Year 1, Week 16

A brilliant energetic attending, straight-out of fellowship and with bright red hair to go along with both her specialty and patient (see below), led the introduction to hematology. Blood plasma is almost all water with an amalgam of solutes such as protein, glucose, amino acids, hormones, cytokines and clotting factors. The cellular components suspended in this plasma include red blood cells (erythrocytes), white blood cells (lymphocytes), and platelets (thrombocytes). All of these cellular components are made in mesh-like inner bone structures, bone marrow, home to hematopoietic stem cells which can become any of the cell constituents of blood in response to growth and differentiation signals. For example, if oxygen content is low or an individual has been bleeding, the kidney secretes the hormone erythropoietin (EPO) into the bloodstream to increase differentiation towards the erythrocyte (red) lineage.

Red blood cells are an engineering marvel and a story of sacrifice for a single purpose: transporting oxygen and carbon dioxide through the vascular network.  Hematopoietic stem cells undergo a stunning transformation. The cell rearranges its membrane so the mature erythrocyte can survive intense deformations squeezing through capillary beds. The cell simultaneously begins to synthesize gobs of hemoglobin, which eventually will take up the entire intracellular volume of the cell. Hemoglobin is a marvelous contraption comprised of four oxygen-binding heme rings surrounded by four globin protein chains. Each of the four heme rings contains a reduced iron molecule at its center where oxygen binds. The globin chains are encoded in DNA and translated into an amino acid (protein) sequence. The protein scaffold modulates the oxygen-binding affinity to unload oxygen in metabolically active tissues. Genetic defects in globin genes can lead to hematological disorders such as sickle cell anemia. Lastly, red blood cells expel their nucleus and other internal organelles, such as mitochondria.  Once completed, the 7-9 micrometer biconcave cell has sacrificed its ability to replicate in exchange for a slow but inevitable death. The average circulating red blood cell lasts no more than 120 days.

Our patient case dealt with a form of hereditary spherocytosis that first manifested in a person who had seemed to be a perfectly healthy 18-year-old. "Jessica" was an A-student, high school homecoming queen, and cross-country athlete. Early in her first college semester, a flu put in her bed for several days. After an apparent recovering, she became even more ill, sleeping all day and unable to leave her dorm. She had piercing pain in her left abdomen, her eyes began to turn yellow, and then her whole body. She was stabilized by a hospital Emergency Department and the next day saw her pediatrician back home -- like most young adults had yet to find an internist. Her pediatrician referred her to our hematologist.

The mother interjected, "This was the scariest moment for me. [her pediatrician] would not tell us what it was, although he clearly had some idea. I called the referral office, and got put on hold.  I still remember the lady's recorded voice while on hold:  'You have reached the Hematology-Oncology office of ....'  I was speechless!  Oncology!  My 18-year-old has cancer!" Our hematologist instructor continued, "Hematologists treat both cancer patients and benign blood disorders. Cancer patients almost always have hematology issues from the cancer itself, or from the chemotherapy destroying their bone marrow. I wish we could have two offices."

Jessica recounted the first appointment. "The waiting room was scary. Almost everyone was old. It smelled of chemo and death. When the doctor spoke to us, everything settled down. She said, 'You most likely have some sort of anemia, not cancer.'" Blood tests showed severe anemia. The left-sided abdominal swelling and pain was caused by splenomegaly, or enlargement of the spleen. The spleen filters the blood where resident macrophages eat old or damaged red blood cells. The macrophages recycle heme rings by releasing iron and bilirubin into the bloodstream. The yellow discoloration of her eyes and skin were from an excess of toxic bilirubin in her blood, or jaundice, a common affliction for newborn babies.

A basic peripheral blood smear showed that Jessica had premature, sometimes even nucleated, red blood cells in circulation. If the signal for erythropoiesis (formation of new red blood cells) such as EPO levels is high enough, the bone marrow will release premature cells such as reticulocytes. Her symptoms immediately improved after supplements of iron and folate, required during red blood cell differentiation for synthesis of functioning hemoglobin. However, doctors and the family were still at a loss regarding the cause of this flare-up after 18 years of perfect health.

Genetic testing showed a defect in a membrane receptor that causes her macrophages to eat up healthy red blood cells prematurely. Her bone marrow, without any iron and folate, could not keep up with the destruction of red blood cells. The hematologist theorized that the flu virus triggered the immune system to increase erythrocyte destruction. Jessica is now a normal college student. She continues to take iron, folate and recombinant EPO supplements. She gets tired easily, especially around exam time. Her school has given her a single room to allow her to get more sleep. She sometimes has mild left-sided abdominal pain. Her two brothers and sister attended. They had both opted out of genetic testing. Jessica said she has two fears: "having my spleen removed and needing transfusions to live. I've spoken to a lot of anemic patients in the waiting room who all have had to do this. I fortunately have a less severe form of spherocytosis." The class laughed as she struggled to pronounce "spherocytosis"! She ended by saying how it is important for doctors to be cheerful and energetic. She jumped out of her seat, long red hair waving, and hugged our young hematologist. "We are best friends, redheads stick together!"

I shadowed my physician for the afternoon seeing six patients: two cases of Chronic Obstructive Pulmonary Disease (COPD, typically from smoking), a pneumonia case, a two-week follow-up after a car accident, a knee injury, and a fainting teenager. The pneumonia patient was a female in her late 60s with severe dementia and under the care of the state. A caretaker brought her in with a complaint of wheezing. She could no longer speak, but could make grunting sounds. While she tried to grab the physician's genitals, we listened to her lungs and noted pulmonary edema in her right upper lung. We prescribed antibiotics.

The physician and I read the car accident patient's chart. He said, "I do not know how this patient is alive." Crashing his Ford Fusion into a stopped car at 50 miles per hour did not result in a single broken bone. He had a neck brace and terrible lacerations over his face, chest and arm, a rare success story for airbag technology given that this 65-year-old gentleman had not been wearing a seatbelt. The chart showed a history of drug and alcohol abuse, but no evidence that either was involved in the accident.

The next patient was a mid-60s grandfather who hurt his knee while playing basketball with his grandson. "Little Johnny has gotten really good. I was defending with one leg planted, and twisted. I heard a snap. I cannot put any weight on it." I performed a knee exam and noted anterior displacement of the tibia (lower leg) with the femur (upper leg) under stress. X-rays showed no bones broken. Diagnosis: torn ACL, which unfortunately cannot heal once separated. We referred him to orthopedics for an MRI and refrained from making any Vito Corleone references.

A mature and articulate 13-year old teenager presented with recurrent episodes of fainting and dizziness. She has had these episodes for over a year, but got much worse last week and had to be taken home from school twice. I walked in first and conducted an interview and brief cardiopulmonary physical. I did not note any abnormal heart sounds upon auscultation. The mother explained her theory that the fainting was caused by beginning menstruation. During the family history, we learned that four of the mother's eleven uncles/aunts had a heart defect requiring open-heart surgery. The doctor joined me. He did not hear any abnormal heart sounds but was clearly concerned by the family history. He ordered several tests and sent the child home with a visibly upset mother. I'm impatient for a diagnosis but will have to follow up via email.

"Geriatricians are a dying breed," said our lecturer the next day. "No young doctors want to treat old people." Our class supports his theory; nobody has expressed a desire to become a geriatrician. The most challenging part of interviewing the elderly for him is breaking through their fear of losing independence. Many elderly individuals will not admit if they are struggling to perform certain instrumental activities, such as driving, cooking, taking medications and even walking. Our mid-40s geriatrician stressed, "This information is the most important. Frequently, I am able to prolong their independence but I cannot help them if they do not tell me." For example, simply using a walker could prevent an all-too-common fall resulting in a hip fracture: "A third of all patients with hip fractures die within one year."

The class segued into a discussion. Classmates opened up with memories of the last days of their grandparents. One classmate's grandparents committed joint suicide shortly after being admitted to a nursing home. The geriatrician offered, "I will tell you one thing: You never want to see another horrible death once you see one. I was in the army and saw a parachuter fall. That same feeling comes over me when I see patients suffer through decisions whose consequences they do not fully understand." He concluded, "Whatever speciality you go into, you need to define what the patient wants. Physicians too often conclude clinical decisions based upon their beliefs. Some of my patients may want to live to see their grandchildren graduate school. Some just want to be able to keep walking for another year. These desires change how I care for my patient."

Several of Jane's college girlfriends descended into town for her birthday weekend, arriving around 9:00 pm. At dinner we somehow got on the topic of unions. Jane's friend was passionate on the subject of the evils of right-to-work legislation and the need to force every worker to pay union dues. It turned out that she was an intern at the American Federation of Teachers (AFT). I'll probably share her passion for unionization once I work my first 100-hour week as a resident. Jane interjected, "Shut up... today is all about me!"

Statistics for the week… Study: 15 hours. Sleep: 7 hours/night; Fun: 1 night. Example fun: Movie night with Harry Potter fans to see Fantastic Beasts and Where to Find Them; Jane dragged me along.

Year 1, Week 17

"We live every second on the edge between bleeding to death and death by heart attack," exclaimed the young hematologist attending.  She introduced us to the coagulation pathway and the lucrative and life-sustaining hematological drugs. Numerous clotting factors (proteins) are produced in the liver and released into the bloodstream. My favorites were the actions of fibrin and plasmin. Vascular damage initiates a cascade of clotting factors to cleave the precursor fibrinogen into fibrin. Fibrin acts as a sticky filament that forms an intricate spider web, binding platelets together, creating a thrombus (blood clot). This nanoscopic mesh traps everything from red and white blood cells to the numerous clotting factors such as plasmin to plug the vessel breach. Vascular remodeling and wound repair signals activate the entrapped plasmin which degrade the fibrin web through fibrinolysis.

Simply resting one's arm on a table creates cuts in the microcirculation. Our finely-tuned coagulation system is able to plug these cuts to prevent severe bleeding, while not creating too many blood clots that would obstruct flow to tissues. The hematologist explained that mutations in clotting proteins lead to uncontrolled bleeding disorders such as hemophilia (factor VI, IX or XI) and von Willibrand Disease or uncontrolled thrombosis formation such as in Leiden Factor V. She finished by explaining that vitamin K is essential for the activity of a liver enzyme that is used in the production of several important clotting factors (Factors II, VII, IX, X, numbers that become ingrained into any medical student's mind for Step I). Drugs such as warfarin target the enzyme that catalyzes the reduction of oxidized vitamin K. Without this reduction process, fewer functioning clotting factors are synthesized. This results in decreased clotting function for a given signal, the costs and benefits of which were presented in this week's patient case.

"Gerry" is an eighty year old black male who suffers from congestive heart failure after three heart attacks. "I did not treat my body well for many years." Gerry became an alcoholic in his twenties, and smoked two packs a day from his late teens through his 60s. Vodka was his drink of choice.

Gerry grew up fatherless in a crime-ridden neighborhood. "Ma did her best to raise my two brothers and me. She would whip us if we did anything wrong. She'd grab us by a leg, hold us upside down and smack away. If none of my brothers would turn the culprit in, she would whip us all to ensure the guilty got punished," Gerry reflected. "Much of my neighborhood's problem was from the destruction of the family. No one has respect for authority. When I grew up, the cops were the good guys, Ma the bad one. We grew up wanting to be cops."

Gerry described the low point in his life as returning home to see his wife and children conducting an alcohol search. "They missed the bottle that I hid in the toilet cover." He claimed that he was able to "drink a bottle of vodka before work and no one would notice." His wife divorced him after catching him driving drunk with their two girls and then his unmanaged health conditions continued to deteriorate.

Gerry began to have congestive heart failure from combined systemic hypertension (high blood pressure everywhere) and pulmonary hypertension (high blood pressure in the lungs). His second heart attack in his sixties was a wake-up call. "My doctor said, 'If you do not make drastic changes, I do not expect you will live another year.' I went completely cold turkey. I moved back home at sixty and quit cigarettes and alcohol." Gerry now lives in a retirement home. "I was very anxious about death, so much so I would be afraid to sleep in my bed. I would try to stay awake in my recliner. Eventually I realized when I go, going in my sleep is the best way. Now I sleep like an angel."

Gerry's cardiologist explained that Gerry owes his life to advances in pacemakers and fibrinolytic pharmaceutical drugs. His weakened heart, after three separate heart attacks, has less contractility. Certain areas of the his heart, such as the atrial appendages and ventricular apexes, do not fully contract. This causes "pooling" of blood or hemostasis. Still blood is more likely to form a thrombus (or blood clot). These clots, unless broken down, can travel and obstruct vessels to vital organs causing a thromboembolism. A thromboembolism lodging in a coronary artery is the most common type of heart attack; a thromboembolism lodging in a vessel supplying the brain is called a stroke. Gerry is also at increased risk of Deep Vein Thrombosis, or DVT, due to sedentary lifestyle in advanced age and poor circulation from decreased cardiac output . If a DVT in a femoral vein gets dislodged it can lead to rapid death from a pulmonary embolism, blocking blood flow to the lungs (the cause of death in at least one of our cadaver).

"Even ten years ago, the general consensus was to avoid excess bleeding," explained the cardiologist. "This has shifted to prevention of clots. You can recover from excess bleeding by getting a transfusion or IV fluids. You will not recover from brain damage from a stroke, sudden death from a PE or heart damage from a MI." Gerry and the cardiologist discussed how warfarin and coumadin are difficult to take and to prescribe because their effect varies with vitamin K input. "If my patient eats a lot of spinach one meal, it could throw the whole clotting system out of whack with drastic consequences." A new age of fibrinolytic drugs are coming that are vitamin K-independent (see eliquis ads on TV). However, this new age would not alleviate a common concern for Gerry and other elderly people: "I sometimes have trouble remembering if I took my medications in the morning if I do not put them in the pillbox. If I took my meds again at night, could this kill me? This is something that gives me so much anxiety." The cardiologist added that one occasional double dose would not kill him, but emphasized these are powerful drugs.

Jane recounted a "Women in Surgery" interest meeting she attended with other interested female medical students. A young trauma surgeon who has been an attending for three years led the discussion on the life of surgery. "Go into something else if you could be happy there. Surgery is only for people for whom nothing else would satisfy." Jane recounted the surgeon's main point: "There is no such thing as work-life balance. Anything not work becomes a distraction against surgery... Getting married, distraction.  Having children, distraction. I was in surgery on my son's birthday. He waited until 10:00 pm to give me a slice of his birthday cake. His birthday was a distraction." The surgeon recounted a story of informing the parents their 17-year old child is dead. "Women cry a lot more than men. Men are usually silent. I woke up at 3:00 am for weeks thinking about that case, of what I could have done differently. Surgery never leaves you." The trauma surgeon said to wait for the surgery rotation (third or fourth year) before seeking to go into her specialty: "Most of you will be pulling your hair out on the first 24-hour shift, but a few of you will become captivated. Don't force it."

Our medical school requires students to do community service projects in six-person groups. My group chose to work with opioid addicts. The program was started by the local police department to try to fight the rise in opioid overdoses in the area. As long as there is no outstanding warrant, opioid users can bring in drugs and paraphernalia to the local police station, or a recently added clinic, and receive counseling and access to rehab programs. We met with the director, a middle-aged woman whose college son overdosed on heroin laced with fentanyl, and a nurse.

I asked how many addicts would willingly give up their drugs? The answer turned out to be three or four individuals per day. The nurse explained that based on an interview, a "program ambassador" customizes a recovery plan tapping into local, state, and federal programs: "The resources are there, just it is impossible for a non-expert to navigate them. One common complication is addicts having children. They are afraid of losing custody if they ask for help from healthcare professionals." Our group will able to serve as ambassadors once we complete an 8-hour training program.

Tuition is due this week. I have a Graduate Plus loan at 6.31 percent. There is no federal subsidy for this loan and the interest begins accruing immediately, but payments are deferred until after graduation. If I work in a non-profit health care system, i.e., most American hospitals, monthly payments are capped at a percentage of my salary. After ten years, the principal will be forgiven (paid by taxpayers!) if it hasn't been paid off. The program was designed for people who joined the Peace Corps, not for radiologists earning $350,000 per year, so there is some talk about the new Congress closing "the Doctor's Loophole.".

Statistics for the week… Study: 25 hours. With exams next week, I wish I was at this stage two weeks ago. Sleep: 7 hours/night; Fun: 1 night. Example fun: Evening watching Netflix's The Crown followed by Sunday brunch.

Year 1, Week 18

Exam week covered cardiopulmonary physiology, anatomy and clinical skills. Pharmacology remains the most dreaded topic. Despite this universal struggle, two-thirds of the class appear comfortable with the pace. We know what to expect. We realize that the exams are meant as a stop-safe. If one of us fails the exam, typically a score less than 60%, it is a wake-up call that we are not on-track for the final judgement: Step 1.

The other third of my classmates are nervous wrecks. They are so concerned about what they need to know that they forget about learning. Four percent of the class failed and will have to retake the exam next week. Most of these individuals had adhered to Anita's strategy of focusing on "High Yield" material, defined as material frequently included on the Step 1 exam and therefore in McGraw Hill's First Aid for the USMLE Step 1. The First Aid summary figures are worth reviewing the day before the exam, but it seems that "High Yield"-minded individuals quickly forget a substantial amount of the information. These individuals go blank during discussion of some aspect of the patient case that was in the previous block, for example, an enzyme involved in a urea cycle disorder.

As soon as the exams were done, classmates were able to reflect on their experience. We agree that the tested block was much more enjoyable than our first block, which was devoted to clinical applications of molecular pathways, many of which students were exposed to in pre-med required courses and MCAT studying. The tested block was our first foray into predominantly "clinical" material: physiology and pathophysiology. We also got to use our stethoscopes!

After my second exams, a few things I wished I knew on day one:

Most of the class reads the suggested Costanzo's Physiology ("I have a date with Costanzo tonight," is a common inside joke), but I preferred the more in-depth Medical Physiology (Boron and Boulpaep).

Twenty percent of the class no longer goes to lectures because they find it less efficient than independent study. I continue to go to hear the clinical vignettes. Some lecturers are down to an attendance rate of less than 30 percent. Maybe medical school costs could be cut considerably; Jane and and I agree that we could learn everything besides anatomy and clinical exam skills using Web-based and library resources.

The job of a medical student is to study. Many of us got through undergraduate exams by cramming the night before. This purge-in, purge-out mentality does not work in medical school. Curiosity becomes the most valuable asset in medical school. The depth and breadth of information requires constant dedication to translate understanding into retention. My search for immediate answers to questions is challenging for classmates because I don't have a smartphone right now. Jane suffers the most with my endless questions: "My ankle evertor muscles are sore. What muscles are those?" (Fibularis brevis and fibularis longus)

Statistics for the week… Study: 35 hours. The library was still packed when I left at 10:00 pm most nights this week. Sleep: 8 hours/night; Fun: Learning on Saturday that I'd passed!

Year 1 Week 19

We're back from our three-week Christmas and New Year's break. Our previous block was exclusively on the cardiopulmonary system. This seven-week block will cover the gastrointestinal (GI), endocrine, reproductive and renal systems.

Lectures introduced the components of the GI system, including the enteric nervous system (ENS), a network of 500 million neurons (as many as in the spinal cord!). In the 1900s anatomists dissected portions of the GI tract and tested responses to specific foods and distensions (see pioneering work by Bayliss and Starling, referred to as "The Law of the Gut").  The ENS contains afferent (sensory) neurons that possess mechano- and chemo-receptors that sense the lumen of the gut. These afferent neurons send their information to interneurons that synapse (connect) with efferent (response) neurons. Efferent neurons control smooth muscle tone and secretory gland cells. Drugs that affect neural synapse communication can affect GI function: I saw a patient abusing opioids hospitalized because he had not defecated in over three months.

The autonomic nervous system integrates with the enteric nervous system, relaying information from the central nervous system, which includes the brain, but the ENS can function independently.

We learned the embryological origin of GI organs: the liver, pancreas, spleen and lungs are all outgrowths of the same tissue! Classmates had a lot of questions and after-class discussions about the fetal twisting of the gut tube that produces these organs.

Lectures also covered the basics, e.g., peristalsis: when a bolus of food enters the lumen of what doctors call the gut, a continuous tube from esophagus to stomach to intestine to rectum. Sensory information is integrated in the myenteric plexus, a region of dense nerve activity that travels between the smooth muscle layers. Efferent neurons contract circular smooth muscle about two centimeters proximal to the distension. Simultaneously, efferent neurons relax distal circular smooth muscle. This ring of contraction propagates and moves the food about five centimeters before being succeeded by the next wave.

Anatomy lab kicked off with the dissection of the abdominal wall. We saw the numerous fascial layers that separate the abdominal muscles and the peritoneum. Every cadaver had six-pack abs once we removed the fat covering the rectus abdominus. Rectus abdominus is a superficial muscle that runs from the lower sternal border and ribs to the pubic tubercle (bony prominence in the front of hip). The muscle alternates between a muscle sheath and three or four horizontal tendinous lines creating six-pack or eight-pack abs.

We were told to concentrate on understanding the inguinal ligament, the division of abdomen from the legs, and inguinal canal. There are two routes for vessels to enter a lower extremity: under the inguinal ligament to the anterior leg or through the pelvic cavity into the posterior leg. Groups with male cadavers showed classmates dissecting female cadavers how the vas deferens takes sperm through the inguinal canal into the abdominal wall and down into the pelvic cavity to connect to the urethra. Sperm travel right next to the peritoneum membrane which encloses the intestines. My favorite trauma surgeon commented that interns and residents are selected to determine the hernia type by feeling up the patient's scrotum into the inguinal canal.

Three classmates and I stuck around through the lunch break to watch a GI surgeon attending dissect a "Fem-Fem". The cadaver had an obstructed left femoral artery. A tube was inserted into the left femoral artery distal (farther away from the origin) of the blockage and connected to the perfused (supplied with blood) right femoral artery. It felt like a hard rubber tube, not what I imagined for a biologically compatible material. I asked if this tube would cause stenosis (hardening) of the attached arteries. He said, "Eventually, but this man's comorbidities would likely kill him within two or three years, well before stenosis. This was a way for him to keep his leg for his last years."

Our patient case: "Jenny," a beautiful, intelligent 35-year-old female. After college she moved to start work at an advertising firm. She began to lose weight steadily despite a normal diet. She had regular diarrhea and terrible acne. "The acne was by far the most debilitating. It made me severely depressed," explained Jenny. "And the dermatologist was worthless." After the dermatologist's suggestions did not work, she proposed putting Jenny on Accutane. She declined because of the potential for depression due to interactions with her anti-anxiety medications. She lived with the acne and diarrhea for five years.

Seemingly overnight, everything changed. Jenny lost thirty pounds in a month. Her hair fell out. She developed painful bruises on her legs. "My coworkers thought I was crazy. I thought I was dying."

A new doctor tested her for celiac disease, and, after a positive result, referred Jenny to the Gastroenterologist who came to present her case. The physician, a woman in her 40s, explained, "Five years is quite typical for time until diagnosis following the onset of celiac symptoms. It wasn't on physicians' radar ten years ago." Celiac disease is an autoimmune disease triggered by gluten, an abundant protein in wheat. Gluten survives the acidic environment of the stomach and is phagocytosed by macrophages in the small intestine. In normal individuals, this elicits a small inflammatory response. Individuals with MHC gene variants may experience an aggressive immune response that destroys the gut epithelial lining. Due to the damage to the lining of her intestines, Jenny was unable to absorb essential vitamins and nutrients, which caused malnutrition and anemia.

Jenny worked to adjust her diet in the pre-gluten-free label age: "I called up every manufacturer and asked if the food contained gluten. Brand-loyalty was key." Adhering to a gluten-free diet, she is now the healthy mother of a healthy boy. "It is what it is. It is much easier now with labeling and I find my whole family eats healthier." A student asked the doctor, "What is the difference between celiac disease and gluten-sensitivity?" The doctor chuckled. "I have many patients who tell me they feel better when they do not eat gluten. I tell them good for you. It is not because of an immune response from gluten. It is probably because they just eat healthier food." Jenny chimed in, "I do not understand people who eat gluten-free foods that are 100-percent carbohydrates. How is that healthier?"

In lecture, a neurobiologist introduced the role of glial cells in regulating cerebral blood flow. Glial cells are the non-neuronal support network for neurons. Astrocytes, a type of glial cells, surround 98% of the surface area of the brain's capillary network forming the blood-brain barrier. They decide what gets in and out. We learned about current trends in astrocyte pathology. Glioblastoma, cancer of glial cells, is one of the most aggressive forms of cancer. The cancer cells migrate along blood vessels to expand to other areas of the brain making It incurable by surgery. While migrating, the cancer cells scrape off the adherent astrocytes giving the voracious cancer cells direct access to the leaky capillary and its nutrients. As it migrates along the vessel, astrocytes are unable to re-adhere to the vessel causing fluid to leak into the brain's microenvironment. This is theorized to be the cause of seizures in patients with glioblastoma.

Alzheimer's is another area he believes involves dysregulation of astrocytes. Unlike most tissues, brain blood flow is regulated both at arteriole and capillary levels. Evidence shows astrocytes are able to constrict capillary networks, but amyloid plaques lead to stiffening of the capillary, which interferes with this control mechanism.

I asked him about a recent 60 Minutes episode, "The Alzheimer's Laboratory", about families in Colombia with genetic early-onset Alzheimer's, based on church records going back to the 1800s. Children of an affected parent have a fifty percent chance of losing memory and independence in their thirties or forties. However, from this tragedy comes opportunity for researchers and future Alzheimer's patients. There is currently no effective treatment for Alzheimer's, which has thus become America's most expensive disease, about $240 billion in 2016 and set to grow as Americans age.

"This represents a critical juncture in Alzheimer's research," he explained. "Although amyloids are the only target of all drugs in the research pipeline, there is no evidence that amyloid plaques actually cause Alzheimer's. Some cases have tons of amyloid plaques, some none. Some people have tons of amyloid with no Alzheimer's." The 60 Minutes show described a clinical trial investigating whether a monoclonal antibody against amyloid can delay early-onset Alzheimer's. I was reminded of another neuroscientist's comment: "If a clinical trial fails they first blame the patient cohort, second the timing of therapy, and only then the science."

Statistics for the week… Study: 18 hours. Sleep: 7 hours/night; Fun: 1 night. Example fun: Dinner with Jane's visiting family before a Saturday morning 10K through 4 inches of snow.

30 classmates rented a ski lodge a two-hour drive away. Most did not go skiing but they still managed to have a grand-ole time, perhaps because they'd packed two car trunks full of peppermint schnapps.

Year 1, Week 20

Lectures detailed the absorption mechanisms of the gastrointestinal system. The sodium-potassium ATPase pump creates the electrochemical gradient that energizes transport of glucose and amino acids. (See next week for how the kidneys use almost the exact same proteins to get rid of waste.)

Stretch and presence of food causes G-cells in the Antrum of the stomach to secrete the peptide hormone gastrin. Gastrin acts directly on parietal cells to secrete hydrochloric acid into the stomach lumen. In case those cells don't respond adequately, gastrin also acts via intermediary enterochromaffin-like (ECL) cells that release histamine, which in turns activates parietal acid secretions. Eating complex macromolecules, rather than simple refined sugars, may activate more levels of regulation for processing.

Every day before anatomy lab, Jane and I watch the corresponding Acland videos, fascinating dissections by Robert Acland, the late surgeon and clinical anatomist who developed important microsurgery techniques. We get so enthralled by these that we have to stop ourselves from watching too far beyond the upcoming dissection.

This week we opened the peritoneal cavity, revealing the stomach, intestines, liver, pancreas, and spleen. Several cadavers, including mine, had appendectomies. My group's liver felt rock solid due to cirrhosis.  One cadaver had sigmoid colon volvulus: her sigmoid colon had twisted around itself, causing pressure to build up and stretching the typical 1.5-foot section to three times the normal diameter and twice the length. It looked like a massive caterpillar. One student stepped out due to nausea as her group accidentally sliced the colon, causing feces to ooze out. That's something we didn't see Robert Acland do.

A pediatric surgeon joined my anatomy group. She was was wonderfully helpful with a story to go along with every structure. She commented that our cadaver had been good for GI surgeons, with at least three abdominal surgeries: appendectomy, hysterectomy, bariatric surgery (stomach stapling). Darwin was interested in the origin of species; GI surgeons look at the "origin of appendixes." Surgeons look for an odd triangular fat fold at the ileocecal fold to locate the appendix during appendectomies.

I stayed late with the surgeon to dissect the vessels near the pancreas, which is nestled in among the stomach, spleen, and transverse colon. "Never touch the pancreas," she explained. "In surgery, all those pancreatic digestive enzymes can leak out and start digesting organs." I cut the pancreas to reveal the deep structures behind. I saw how the splenic artery runs with the pancreas to the spleen. The splenic vein then travels across the pancreas to fuse with the inferior and superior mesenteric veins to form the massive portal vein. Working in the cramped space gave me an appreciation for why pancreatic cancer is so difficult to remove surgically.

Our patient case: "George," a 55-year-old combat veteran with a history of alcohol abuse, pancreatitis (inflammation of the pancreas), and liver cirrhosis. He presented with jaundice, clay stool bowel movements and dark orange urine. These symptoms pointed to issues with the liver and pancreas for our differential diagnosis. Blood work showed vitamin deficiency and anemia. An x-ray revealed a pancreatic tumor mass obstructing the Ampulla of Vater. This prevented pancreatic enzymes and bile from being secreted into the duodenum of the small intestine. In a healthy person, bilirubin, the toxic product formed from recycling red blood cells' hemoglobin, is transferred into the duodenum with bile from the liver. Gut bacteria convert this into stercobilin which is excreted in feces giving it its characteristic dark color. George's obstruction caused a buildup of bilirubin in extracellular tissue, blood and urine. The tumor was inoperable and he was referred to hospice care, where he passed away after eight months.

George's wife came in to discuss her experience along with a nurse and a social worker who had managed George's "home-care hospice" case. The nurse manages 10-15 patients and makes up to 5 home visits per day. Many of these visits are pain management emergencies. A student asked if there was ever an issue with opioid abuse? She responded, "We err on the side of the patient. If the patient tells us there is an issue we listen. The prescriptions are for two-week periods." She explained that prescription is typically methadone, a slow-release opioid which has less addiction potential, but in the last year the hospice facility has tried to tighten control of opioids. "I dealt with one case this year where the family was stealing pain pills from granny."

"You are the gateway to hospice care," continued the nurse. "Saying there is nothing more I can do as a physician for a patient that you may have been caring for decades is heartbreaking. The patient transitioning from aggressive care with hope to comfort care is similarly heartbreaking for the family."

George's wife described how helpful hospice care was for her family. She described being crushed by the immense requirements for medical appointments and medications during chemotherapy. "We had no time to think about what comes next. We had no chance to enjoy the time he had left." George was able to live at home for his last eight months. The case manager described how hospice care allows families to plan and come together: "When the white flag goes up people have time to adjust. An estranged brother or daughter will travel to reconnect with the family." The nurse added, "People think someone in hospice care is going to die within a week. That is simply not the case. Most are there for several months to even one-and-a-half years."

The case manager added that hospice centers have coordinated care with other facilities to meet a patient's needs. "If a patient's last wish is to go to the beach, we'll coordinate care with a local facility." The team will typically attend a patient's funeral.

One student asked about assisted suicide. Although illegal in this state, the nurse believed it should be a terminally ill patient's choice. Some do ask about getting transported to Michigan or other states where it is legal. The nurse commented how one Huntington's patient made the decision to starve to death. George's wife commented how George considered assisted suicide. "He would never take his own life but he did ask about assisted suicide. If it wasn't for me and his son, I believe he would have done it." The panel concluded by stressing the need to have end-of-life discussions with patients early, before terminal disease states, and promoting patients to have an advanced directive (or living will).

At lunch our class discussed the cost and quality of end-of-life care. More than 80 percent of patients living with a chronic disease claim they want to avoid hospitalization and intensive care during the terminal portion of their illness. However, in 2005 the CDC estimates that only 25 percent of deceased died in their own home. In 2008, Medicare spent $55 billion for the last two months of patients' lives (CBS). One-quarter of Medicare expenditures are for care in a beneficiary's last year of life, an unchanged ratio from twenty years ago.

The next day, the state's chief medical examiner gave a lecture on opioid abuse. "Sherry" is a trained pathologist who conducts autopsies on suspect deaths and public health crises (at a much lower salary than if she were practicing).

According to Sherry, heroin use became widespread in the 1960s when addicted Vietnam veterans returned home. Poppies were cultivated in Vietnam. The 1980s cocaine boom caused a decline in heroin. "We have Kurt Cobain to thank for bringing back heroin with 90s Grunge."

"You will quickly realize that today's opioids are nothing like yesterday's heroin when you go on your ED [emergency department] clinical rotation," explained Sherry. "You'll see several ODs in a given night." In 2013, drug overdoses became the U.S.'s number one cause of unintentional death. Heroin is found in urban centers whereas pills are found in more rural and suburban areas.

"Street" heroin used to be cut to 6-7 percent purity, thus requiring intravenous injection to get high. This drove Hepatitis C infections, which Sherry said have declined due to access to clean insulin needles from Walmart and the increasing purity of heroin. Today's 20-percent-pure heroin can be snorted: "Without the needles there is no social stigma." Sherry said that students are trying heroin in the same way that older generations might have tried alcohol and marijuana. 1 in 13 high school students in our area admitted to using heroin.

"Do not touch any bag or foil you might find in the ED!" Sherry exclaimed. "If you touch it, you could overdose and die." Synthetic opioids are now so powerful that some act through absorption through the skin. Pure heroin is about twice as potent an agonist (binds to mu-receptor producing "high" response) as morphine. Fentanyl, quite widespread now, is 100 times as potent as morphine. "The new rave is carfentanil. Addicts are quite excited about this one, 10,000 times as potent as morphine and used to put elephants down. Drug labs and health workers are petitioning for access to the opioid-blocker Narcan in case of skin contact with carfentanil."

"Drug dealers are actually quite brilliant businessmen," Sherry explained. "They realized the demand does not go away after the prescriptions are cut off. Police try to suppress the names of individuals who overdose because users will look for his or her dealer. The overdose means that the product must have been good.Some dealers purposefully overdose a client because it boosts sales."

A student asked what she would recommend doing to prevent this epidemic. "Death penalty for heroin dealers," she laughed and continued, "Loved ones see the signs of drug abuse but they do not realize how serious they are. With the potency and variability of drugs these days, you can overdose on the first high, or the hundredth high." She also cautioned us that the gateway to addiction is frequently prescriptions from physicians. The individual who overdoses is on several prescriptions: antidepressants, anti-anxiety, sleep. "These are people connected to the healthcare system. These mental illnesses present as physical pain such as back pain. It takes one doctor to overlook the mental cause and prescribe painkillers for the physical pain."

Sherry said that prescription opioid abuse has been reduced by prescription monitoring networks. "A few years ago, drug addicts were able to state-hop because these monitoring networks would not talk across state lines."

Statistics for the week… Study: 18 hours. Sleep: 7 hours/night; Fun: 1 night. Example fun: drinks at classmate's apartment with about 10 other students, followed by the downtown bar scene (everyone else) and home (me and Jane).

Year 1, Week 21

Goodbye gastrointestinal system; hello renal system. I was only two-thirds of the way through the GI textbook chapter.

Lectures introduced how the kidneys regulate body fluid "compartments." The body contains about 42 liters of water: 28 liters intracellular (within cell membranes) and 14 liters extracellular (outside cell membranes). The extracellular fluid includes 11 liters of interstitial fluid (between cells) and 3 liters of blood plasma. These compartments are constantly changing their equilibrium with excretion of urine and intake of food with varying osmolarities (concentration of solution). Western diets high in salt increase the osmolarity of blood, causing a net increase in blood volume and increase in blood pressure for a given vascular tone, also known as volume-loading hypertension.

In Anatomy we continued dissection of the abdomen, removing the liver, spleen and kidneys. Liver removal required five scalpel cuts, each of which took about five minutes to prevent damage to surrounding tissue. The liver is anchored in the body by several strong ligaments: hepatogastric, hepatoduodenal, hepatodiaphragmatic and falciform. The falciform ligament connects the liver to the anterior abdominal wall including the belly button. Ligamentum teres, the remnant of the umbilical vein, runs through the falciform.

There are five regular Anatomy instructors, three of whom are surgeons and two are veterinary anatomists(!). However, our school also brings in three or four working surgeons. This week my favorite trauma surgeon noted how in some conditions the umbilical vein remnant can reopen! Two groups were scolded for ripping the hepatoduodenal ligament without dissecting the portal triad (portal vein, common bile duct and hepatic artery). Our cadaver had no gallbladder, so we worked with other groups to understand that region.

Next we removed the kidneys, slicing each into anterior and posterior sections. Most kidneys had large renal cysts, one the size of a golf ball embedded in the cortex (outer region), and some included stones ranging in size from sand grains that one could feel up to two centimeters in diameter.

Every day we bombard our body with a variety of food and water with different concentrations. It is up to our kidneys, the interface between the vascular system and the urinary tract, to maintain electrolyte and volume homeostasis (equilibrium).The urinary tract is a continuous, branching tubular network that extends from the urethra to the bladder to each kidney's ureter. The ureter branches into microscopic collecting ducts. Each collecting duct connects to hundreds of nephrons (specialized tubule segment). The nephron tubule segment ends at Bowman's capsule, a spherical bulge in the tubule and the glomerulus (specialized capillary network). Each kidney has about 1-1.5 million nephrons.

It is here at the glomerulus that blood plasma spills into the tubule system becoming filtrate. Under normal physiological conditions, the kidneys receive 20 percent of the cardiac output. Every day 180 liters of plasma is filtered by the tubule system. However, normal urine output is about 1.5 liters per day. That is an immense amount of reabsorption of solutes and water!

The glomerulus is the first step in deciding what becomes urine. The glomerulus supports the beautiful "foot processes" of podocytes, amazingly specialized epithelial cells (see the details in this Nature article).  During kidney development, the distal (far) end of the nephron tubule, which becomes Bowman's capsule, is penetrated by blood vessels, which become the glomerular capillaries. The glomerular endothelial cells begin to loosen their connection with each other to form fenestrated ("fenetre" meaning windows) capillaries. The tubule epithelial cells interacting with the capillary endothelial cells become these specialized podocytes. The cell body of a podocyte sends thousands of "foot processes" to wrap around the capillary cylinder. Proteins on the podocytes' cell membrane bring these foot processes together to create slit diaphragms, the final filter pore of 10-20 nanometers in diameter. For blood plasma to reach the urinary tract, it traverses through the fenestrated glomerular capillaries, a dense extracellular basement membrane and and the podocytes' slit diaphragms. This multi-layered biological nanofilter filter prevents large particles and negatively charged proteins from entering the tubule.

The plasma that is filtered becomes filtrate. Unlike the epithelial cells of the more distal urinary tract, the epithelial cells of the nephron are highly specialized in transport processes. Along the way the epithelial cells of the tubule reabsorb filtered solutes (e.g, sodium, glucose and amino acids), secrete waste products (e.g., protons and urea) and determine how much water should be reclaimed back into the vascular system. The kidney is under sensitive hormonal and nervous control to regulate plasma osmolarity and plasma volume. If blood volume decreases, baroreceptors in the carotid bodies signal the kidney to increase isosmotic absorption via aldosterone. If blood osmolarity is too high, the hypothalamus (part of the brain) signals the pituitary gland to release Antidiuretic Hormone thereby increasing free water reabsorption (urine concentration).

Sound complicated and failure-prone? It is. Most hypertension and other nominally vascular disorders start with dysregulation or degradation of the kidney. Our nephrologist professor: "The kidney allows terrestrial life."

Our patient case: "James," an 18-year-old freshman at the local community college. James presented to his primary care physician with fatigue, general weakness, and hepatosplenomegaly (enlarged spleen and liver). Lab tests revealed a low platelet and white blood cell count. He was prescribed antibiotics and referred to a hematologist: earliest appointment in two weeks.

His symptoms worsened with swelling in his feet and periorbital (around the eye) region. His mother took him to the ED, where a physician, suspecting a reaction to the antibiotics, swapped the antibiotics for an antihistamine to combat the inflammation. At the appointment the next day, the hematologist suspected mononucleosis (the kissing disease "Mono") but the test came back negative. He was referred to a nephrologist: earliest appointment in three weeks.

"The appointment made me put the symptoms to the back of my mind. I would deal with it at the appointment." James gained twenty pounds in water weight with swelling extending to his lower extremity and scrotum. The nephrologist ran tests that showed extremely low albumin levels in his blood plasma. Albumin is the most abundant plasma protein. Without this oncotic  (protein solute) pressure, there was a net movement of water out of James's plasma into the interstitial fluid. Why was his albumin so low? The nephrologist said, "You are either peeing out an unbelievable amount of albumin, or your liver is not able to produce it." He suspected Hepatitis C or HIV.

What would peeing gobs of albumin out look like? The nephrologist told James that it would look like frothy urine: "Imagine whisking egg whites with water." James responded, "I always thought frothy urine was normal. It's all I have known." He was sent straight to the ED.

James's kidneys were shutting down. While in the hospital, blood pressure spiked from 150/90 to 250/150. Doctors thought he might not make it. He underwent plasmapheresis (filtering of plasma through a machine) and plasma transfusions for two straight days. "I was really drugged up but I do remember seeing my blood being pumped through these tubes out of my body. That was the first time I was scared."

James stayed in the hospital for nine days.  "I did not sleep for two days straight. Every two hours a nurse would come in to check my blood pressure and take blood." He was most frustrated that he was not allowed to shave or shower: "My platelet count was so low they thought I might bleed to death if I cut myself." A kidney biopsy revealed inflammatory vascular deposits in his glomerular capillaries. He was diagnosed with Systemic Lupus Erythematosus, an autoimmune disease that causes destruction of various organs including the kidneys. He was put on short-term immune suppressors and glucocorticoids, which are anti-immune steroid hormones.

James's recovery was long and painful. He had 45 lbs of excess water weight. He would urinate clear fluid every 30 minutes. Water seeped out of a cut on his left leg. Three months after discharge he resumed classes. "I wrapped a washcloth around the cut to soak up the water that still seeped out." My legs were so swollen I could not bend them to walk up stairs. The severity of his disease did not hit him until after the critical episode.

The mother was thankful for his post-diagnosis medical care, but angry about the three-week wait between the hematologist and nephrologist. James's nephrologist said that if the appointment had been even one day later, James would have not recovered normal kidney function, if he even survived the severe electrolyte imbalance and hypertension.

James is now considered cured, though he remains on immune suppressors. His kidney function has returned to normal. James hopes to become a biochemist developing new drugs.

Later that day, the head of the ED introduced emergency medicine, the art of triaging undifferentiated patients and sending diagnosed patients to specialists for care. Straight out of a three-year residency, EM physicians make an average salary of more than $310,000. Salaries at academic institutions are lower, while salaries tend to be higher for more rural institutions. EM physicians work 30-32 hours a week with regular shifts. "Once I am off, I am off. I don't carry a pager. I do not have any patients once I am off my shift." A more rural and less busy ED will have 12- or 24-hour shifts; a busy urban ED will have 8-10 hour shifts. He loves going rock-climbing and skiing on weekdays: "The slopes are clear at 11:00 am on a Tuesday. Internists and surgeons claim they have hobbies, but if you ask them how long it has been since they did that activity, it is usually months. Ask an EM physician and the answer is 'Last week'."

The physician said that emergency medicine is the youngest speciality. In the 1940s, a critically ill patient would be brought to the family physician. Formal recognition of emergency medicine as a specialty came in the early 1970s.

Any downsides to the specialty? "Other specialists have no respect for EM physicians. We are a jack-of-all-trades, master of none." EM physicians are required by federal law to see all patients. "We do not get to pick our patients." EM physicians also get no appreciation from patients. "The patient sends the fruit basket to his cardiologist after a heart attack, even though it was the EM physician that saved his life. Instead, we get lawsuits. Patients don't sue their internist they have been seeing for a decade when their condition deteriorates into a heart attack. They sue the ED."

Our school's full-time chief diversity officer, a Ph.D. in psychology, hosted a lunchtime diversity discussion with catered Indian and Thai food. Sadly I was forced to miss this event due to shadowing a physician in the hospital. Classmates said the main topic was diversity in the classroom. Fortunately this was not my last chance. The chief diversity officer's assistant sent an email this week inviting students to a self-defense class:

Students who identify as female: Learn maneuvers to help you evade uncomfortable and/or dangerous situations. … Students who identify as male: Learn tips on how to engage in a situation and diffuse it without escalating it.

Statistics for the week… Study: 15 hours. Sleep: 8 hours/night; Fun: 1 night. Example fun: Medical school formal, also known as "MedProm" at a downtown ballroom. The medical school deans and instructors left around 10:00 pm, perhaps because the social chairs hired a DJ specializing in electronica and hip-hop. We danced to Lil Jon's "Get Low" and the pop hit "Closer". One of my favorite classmates and his wife brought hip flasks of liquor to spice up the cash bar concoctions.

Year 1, Week 22

In anatomy lab, we investigated abdominal blood vessels. The descending aorta pierces the diaphragm at the aortic hiatus to enter the abdomen where it is now called the abdominal aorta. (The external iliac artery becomes the femoral when it passes into the leg***. Being a medical student is like driving in Massachusetts where roads adopt new names every time they cross over a town border.) The abdominal aorta gives off numerous branches: the arteries of the gut (celiac, superior mesenteric and inferior mesenteric), the paired renal arteries and the gonadal arteries (testicular or ovarian). At the umbilicus (belly button) the abdominal aorta bifurcates into the right and left common iliac arteries. Each common iliac artery branches again into the internal and external iliac, which supply the pelvis and the leg, respectively. One group from last week thought they had an aortic aneurysm that was causing all the organs to be pushed forward in the abdomen. It turned out to be cancer (source unknown). They could not find any of the structures in our lab manual as the cancer mass had engulfed everything.

Our trauma surgeon, a woman in her 60s, described a frequent patient case involving the portal system (vessels that direct blood from the gut to the liver), which we dissected this week. An alcoholic presents to the ED for severe rectal bleeding or esophageal bleeding. A CT scan (Computed Tomography or 3D X-ray reconstruction) reveals liver cirrhosis, an enlarged portal vein, and tortuous blood vessels all through his GI tract.

Most blood supply to organs drains into the inferior/superior vena cava which drain into the right atrium of the heart. In a healthy person, blood supplying the GI tract (colon, intestines, spleen, pancreas, stomach and distal esophagus) drains into the portal vein. The portal vein drains into the liver for detoxification. Blood leaves the liver through the hepatic (liver) vein, which drains into the inferior vena cava to join the normal circulation.

The patient's liver cirrhosis (hardening of the liver) caused severe portal vein hypertension (high pressure). Blood seeking an outlet drains into the lumen of the gut tube instead of through the portal system. "Portal hypertension can cause bleeding worse than getting shot in the aorta," said the surgeon. "This is a life-or-death situation."

Lectures continued detailing transport processes of the renal system. We learned about several drugs to treat diabetes mellitus (not to be confused with diabetes insipidus, a hormonal disease preventing urine concentration). Diabetes is named for the accompanying diuresis (excessive urination). Diabetes mellitus (mellitus means honey-sweet) is named due to the high glucose levels present in the blood plasma and urine.The severity of diabetes can be categorized as "insulin-independent" and "insulin-dependent". Insulin-dependent diabetics require injected insulin to keep glucose levels down.

One of the most effective drugs for diabetes mellitus is metformin, which inhibits natural production of glucose from energy stores (gluconeogenesis). Metformin, derived from the French lilac (Galega officinalis), can prevent or at least delay type 2 diabetics transitioning to insulin dependence. Since at least the 1800s, this plant has been used to treat individuals with polyuria (frequent urination). By far the most common complaint is the terrible breath from metformin. The toxicologist brought a small dummy infused with metformin breath. Surgeon Sara, an aspiring general surgeon, was sitting next to the dummy and threw up after five minutes. "You try to go on a date with this breath," exclaimed the toxicologist. "Good luck!" Metformin has terrible compliance rates.

(A few hours later we were surprised when the conference room we'd planned to use was occupied by the apparently-forgotten dummy. We vacated the premises, with the smell chasing us down the hallway.)

Farxiga (Dapagliflozin), approved in 2014, is a fascinating drug for the treatment of diabetes. Farxiga inhibits SGLT, a glucose pump protein, used to reabsorb glucose in the kidney back into the blood. Patients just pee out glucose as blood plasma spills into the urinary tract. Unfortunately, this leads to unbearable urinary tract infections; bacteria love sugar.

The toxicologist brought in various insulin pens and even bought a bottle of insulin and needles. Apparently low dose insulin can be purchased over the counter although it is quite expensive. Insulin is measured in standard insulin "units". (One unit refers to the amount required to lower glucose a set amount.) $150 for a 10 mL bottle at 100 units/mL. This might last some patients a week, others a few days. "Some severe insulin resistant diabetics use 300 units a day."

Our patient case: "Sherry", a 50-year-old female who has had type 2 diabetes since her late twenties. Since childhood she has been overweight, but never obese. Her whole family had a history of type 2 diabetes.

Sherry's poor management of her diabetes led to kidney failure.(Diabetic nephropathy, degradation of the glomerulus caused by hyperglycemia, is the number one cause of kidney failure.) She joined the ranks on the dialysis wards. Dialysis filters a patient's blood by pumping the blood through a semipermeable membrane. On one side of the membrane is the patient's blood; on the other is a dialysis fluid (basically saline). Solutes such as glucose and electrolytes diffuse down their concentration gradient into the dilute dialysis fluid. Each dialysis session can use up to 30-50 liters of water!

Sherry described how close she got with her dialysis group. She elected to do overnight sessions. "It's hard to get much sleep with everyone chattering and all the noises from the machines. We had a good group." Sherry initially went only three times a week, thus requiring a large volume of blood plasma to be removed (some people go five times per week). This caused terrible cramps and muscle weakness. Fortunately, Sherry's federal employee insurance covered home dialysis treatment and she was able to switch to a five-times-a-week schedule in the comfort of her own home. An entire room in her house was dedicated to the fluid tanks, filled monthly by truck. Because most dialysis patients have a port (brachial artery-vein autogenous fistula) installed, at-home dialysis can be done without help from a technician, but the procedure is supposed to be done when someone else is in the house in case the patient passes out.

Sherry went through seven years of dialysis. "I was at the store when my doctor called me. 'Can you get to the hospital in 24 hours?'. 'Yes! Yes!' I screamed." Sherry matched. She had a kidney donor.

"You can only appreciate this gift once you have experienced dialysis for several years. I know several transplant recipients who quickly get their kidney and just throw it away after a year. They use their new life to drink, party and have sex. They end up back in the dialysis centers. No wonder why there is strong disapproval of kidney transplants at the dialysis centers." Sherry had retired from the federal government due to the time commitment of dialysis, but now she works part-time.

Shadowing my physician mentor this week, our first patient turned out to be a classmate. I excused myself. I also diagnosed my first patient! A 45-year-old male presented with right leg pain worsening with exertion. I asked him to lie on the examination chair and remove his pants. I then palpated his sciatic nerve, which caused a terrible radiating pain down his leg. Diagnosis: Piriformis syndrome. The sciatic nerve exits the pelvis into the thigh through a tight hole called the greater sciatic foramen. Piriformis, a muscle used for lateral rotation of the leg, can become inflamed and enlarged. This constricts the sciatic nerve causing radiating pain. He asked, "How do you make it stop?" I replied, "Let's ask the doctor when he comes in." Turns out there is not a great remedy. Medicine is better at labeling problems than treating them. Anti-inflammatory medications such as Tylenol and ibuprofen may help. The key is rest. Unfortunately, "George" is a construction worker without health insurance. He makes too much to be on Medicaid, but not enough to afford Obamacare premiums. I felt terrible sending him home knowing that he couldn't afford to rest and would soon be receiving a shocking bill from the clinic.

About 20 percent of the class, and some of the faculty, went to the local women's march, and Type-A Anita ventured to Washington, D.C. for the main event, explaining that she was demanding "equal rights for women."

At lunch after the march, there was what would have been a discussion among eight classmates about campus sexual violence (it fell slightly short of an actual "discussion" due to the lack of interest in hearing dissenting point of views or facts that didn't fit preconceived opinions). All supported the school-run administrative tribunals that have been expelling accused students since the 2011 "Dear Colleague" letter from the Obama Administration. Several students argued that by matriculating at school you agree to abide by the school's code of conduct. If the school's tribunal or committee deems an accused guilty of violating that code, that individual can be expelled without violating due process. Two classmates compared this to accusations of sexual harassment in the workplace. "A business can fire an employee if he or she is accused." Anita: "There are far more rape cases than false accusations. 1 in 5 female college students are sexually assaulted on campus. It would be unbearable for her to live in the same dorm and go to the same class as him."

Statistics for the week… Study: 20 hours. Sleep: 7 hours/night; Fun: 1 night. Example fun: Late night bar shenanigans on the pretext of a classmate's girlfriend arriving in town.

Year 1, Week 23

We began endocrinology, the study of hormones. Hormones are signaling molecules, namely peptides and cholesterol derivatives, that cause systemic changes in the body. The pea-sized pituitary gland sits in a small alcove at the base of the skull, right behind the nasal cavities near the optic nerve. This master regulator of hormones functions as the interface between the brain and the blood, secreting nine different hormones.

The pituitary is actually two separate organs. The posterior pituitary gland, more recently renamed the neurohypophysis, is a protrusion of neurons in the hypothalamus. These neurons release oxytocin and antidiuretic hormone (ADH) into systemic circulation (the blood). For example, ADH is released in response to an increase in the concentration of solutes in the blood, thus causing the kidneys to concentrate urine by reabsorbing free water into the blood.  Other neurohypophysis neurons release oxytocin (a.k.a. the love hormone) during labor causing uterine contractions and also while a baby nurses causing a "let down" (spray) of milk. (New mothers can have excruciating cramps from uterine contractions during nursing because of this oxytocin release).

The anterior pituitary or adenohypophysis is a broken-off extension of the mouth that wraps around the neurohypophysis. These cells also secrete hormones under the control of the hypothalamus. These hormones regulate everything from the thyroid and adrenal glands to the menstrual cycle and milk production. Thyroid issues are some of the most common adult ailments. The thyroid gland, located right under the "Adam's apple" secretes thyroxine. Thyroxine increases metabolism and "energy". Our endocrinologist says that many of her patient's request synthroid (synthetic thyroxine) to help lose weight. Low thyroxine levels can not only be caused by an issue in the thyroid but also by the pituitary. The pituitary secretes thyroid-stimulating hormone (TSH) which tells the thyroid to release thyroxine. Without TSH, there will be no thyroxine even if thyroxine levels are abnormally low.

Our patient case: "Susan", 22-year-old female presenting with fatigue, blurred vision, transient loss of vision, and a headache. Labs show abnormally low thyroid stimulating hormone (TSH) and low thyroxine and abnormally high prolactin levels for someone not breastfeeding. She was referred for a head MRI.

The MRI revealed a large mass in the pituitary. Susan had a prolactin-secreting adenoma of the adenohypophysis. The mass was squeezing her optic nerve causing the vision problems. She underwent transsphenoidal (through the nasal cavities) surgery to resect (remove) the pituitary gland. Her vision returned to normal, but she will require hormonal supplementation for life.

This presented an enormous challenge for Susan. Susan's husband was on SSDI. Her children had health insurance through Medicaid. Susan was the only one working and also the only one without health insurance because she didn't get it through her employer. Hormone supplements are expensive. Unless she withdraws from the workforce and qualifies for SSDI and/or Medicaid, she and her doctor will endure a lifelong struggle to decide what hormones to prioritize. Growth hormone? Synthroid? ADH?

An epidemiologist introduced clinical trial research. We investigated survival metrics and clinical trial studies on mesothelioma, a cancer of connective tissue, most commonly of the pleural membrane surrounding the lungs. Average survival is 12-20 months after diagnosis; five-year survival is less than 5 percent. The largest risk factor for mesothelioma is exposure to asbestos. Production of many industrial products such as paint, brake-pads and ships used to include asbestos fibers. "It isn't only males who get mesothelioma," explained the epidemiologist. "When Daddy got home from the shipyard, Mom and Daughter would run to the door and wring out Daddy's coat. Asbestos was on that coat."

We got on the subject of whether the National Institutes of Health (NIH) disproportionately funds cancer research. A traditional successful cancer drug trial finds a few months of additional life compared to the current standard of care, but if funded by a pharmaceutical company does not take into account quality of life.  For example, a clinical trial for a VEGF inhibitor in the treatment of renal cancer increases median overall survival (OS) from 21.3 to 23.3 months compared to IFN plus placebo. What if the quality of life for those 23.3 months is miserable compared to the quality of life for the 21.3 months under the current standard of care? "Patient-reported outcomes is the big buzz word in clinical trial research. Double-blind trials are essential for these subjective metrics."

The whole school is abuzz about Trump's seven-country immigration ban. Classmates post on Facebook about their immigrant roots (mostly grandparents or farther back in the family tree). One classmate posted a link instructing what to do if a "Customs" officer comes knocking on your door. The reply: "Did you mean immigration officer?"

Statistics for the week… Study: 25 hours. Sleep: 8 hours/night; Fun: 1 night. Example fun: class bbq followed by classmate's performance at local coffeeshop! They performed a now class-favorite Twistin and Groovin from Leon Bridge's Tiny Desk Concert.

Year 1, Week 24

Reproductive lectures start this week. "Males will finally understand how much harder females have it," joked a female classmate.

There are three main parts of the reproductive system: the internal genitals, external genitals and gonads (testis or ovary). A quick theme that emerges is female development is the default: unless some signal overrides this process, female parts will emerge.

Gonad (testes; ovaries): Primordial germ cells (PGCs) are some of the first cells that are formed after fertilization. PGCs have the potential to become any cell in the body including sperm and eggs. These cells end their migration at the genital ridge, a paired region in the right and left lower abdomen. Here, the PGCs interact with surrounding cells to form the gonad.

In females, each PGC differentiates into an oocyte (egg) that cannot replicate. The surrounding cells nurture each egg in a single follicle. These eggs lie dormant until puberty.

In males, the presence of a functional Y chromosome overrides ovary development. The SRY gene on the Y chromosome signals for the surrounding cells to form interweaving tubes of Leydig and Sertoli cells. Have you ever thought about why the testes are outside the body? Evidently, spermatogenesis (production of sperm) requires a lower temperature than body temperature. Thus production of testosterone by Leydig cells leads to the descent of the testes. My favorite embryology professor instructed, "Boys, don't drive with the seat warmer on for a long trip. It'll kill your sperm!" The testes are pulled out of the abdominal cavity through the inguinal canal (see prior chapter). This descent is typically complete a few weeks before birth, but may take as long as one year after birth. [At birth this canal is not sealed completely, which can cause an indirect hernia. Structures, typically small intestine, can squeeze through the inguinal canal and potentially into the scrotum! Infants are routinely checked for this disorder.]

Internal Genitalia (epididymis, vas deferens and prostate; uterus and fallopian tube): In females, an embryological remnant of the kidney forms the fallopian tubes, uterus and proximal (to cervix) vagina. These tubes must fuse together and the septum must be removed to form a normal uterus. Failure to remove the septum is not uncommon (~3%). A more serious defect is if the tubes fail to fuse completely resulting in a bicornuate uterus with two distinct cavities connected at the cervix. Both are still able to become pregnant but have a much higher risk for complications and miscarriages.

In males, a similar tube forms the epididymis, vas deferens and prostate. The vas deferens transports mature sperm from the testis through the inguinal canal into the abdomen. The vas deferens then descends into the pelvis to form an ejaculatory duct. The ejaculatory ducts open into the prostatic urethra (urethra section with the prostate surrounding it).

External genitalia (penis; vagina, labia minora, labia majora, clitoris, etc.): At six weeks post-fertilization, the undifferentiated external genitalia appear, namely the genital tubercle and genital swellings.  There is no way to differentiate male from female at this stage, just that normal development is occurring.This transformation all takes place in the perineum (square region formed from the pubis, ischial tuberosity (bone you sit on) and coccyx (pointy ). We quickly appreciate how crowded this area is -- the rectum, bladder and, in females, vagina/uterus all lie in this small volume. Initially, the urinary tract and anus share a common lumen. A septum forms to separate these into the anus and the urogenital openings.

My classmates and I learn this dense region differently. I have found focusing on embryology helps me. Each component of the undifferentiated external genitalia gives rise to the respective female and male reproductive parts (see Netter's, page 364). Therefore, each part has a homologue (typically with similar function) in the opposite sex. For example, the prostate in males which wraps around the urethra is analogous to the Gland of Skene in females (thought to be involved in female ejactulation). The genital tubercle will form into the glans of the penis or the glans of the clitoris. The glans is supported by erectile tissue and vascular tissue that engorges during sexual arousal.

Males fold each of these parts together as evidenced by the raphe, or ridge, noted on the ventral side of the penis all the way to the anus. Classmates laughed on learning that the anatomical terms for parts of the penis make sense only when the penis is erect: the ventral penis is the underside with the urethra; the dorsal penis faces up.

Looking at the above in real life: Anatomy lab was short. Most students left within an hour. We investigated the external structures of the male and female cadaver. One group found an undescended testicle that got stuck in the inguinal canal. It was far smaller than the descended testicle. The trauma surgeon did not notice any evidence of testicular cancer. She said, "He and his doctors most likely knew he only had one testicle. Today we would remove the undescended testicle at an early age.

In lecture, an internist introduced the male genitourinary (GU) exam before we practiced on dummies. He joked, "I still remember my introductory lecture on the GU exam. I remember the pictures. I was scarred by the pictures." He continued this tradition by showing us images of foreskin infections and noted that "the most common reason 20-year olds come in to the office is for penis problems."

The internist described a common reproductive defect: hypospadias is where the urethral meatus (opening of the urethra) in not at the tip of penis but along the shaft or even in the scrotum. He amplified on what we had seen in anatomy lab with 10 minutes on cryptorchidism, the failure of a testicle to descend into the scrotum at birth. An undescended testicle is infertile due to the higher temperature and carries an elevated risk of testicular cancer. If a testicle is not descended by age 1, the current standard of care is to remove it. The physician then asked the class, "What is the number one type of cancer in 20-year-old males?" Despite having been prompted by the lecture topic, nobody in the class was able to come up with the correct answer: testicular cancer.

We discussed 5-alpha reductase deficiency (5-ARD), a rare genetic disorder commonly referred to as güevedoce. The phallus of the penis forms under stimulation of 5-alpha dihydrotestosterone (DHT), a more activated form of testosterone (same compound that causes male baldness). DHT initiates enlargement of the paired vascular tissue (corpus cavernosum, crus of the penis) and the erectile tissue (bulb of the penis, corpus spongiosum). Females have analogous parts, just they have not folded onto each other, nor enlarged. 5-alpha reductase is the enzyme that converts testosterone into DHT. This prevents the enlargement of the phallus in utero. Las Salinas, Dominican Republic, is known for having a high prevalence of 5-ARD: 1 in 90 XY males are born with ambiguous genitals and raised as females. However, during puberty 5-ARD individuals have such high testosterone levels that the ambiguous clitoris enlarges into a penis. Hence güevedoce or "eggs at twelve". The community holds coming-of-age parties for these chosen individuals. 5-ARD individuals can be fertile propagating this genetic defect through generations in the isolated village. On the bright side, these individuals do not worry about male baldness.

The most dreaded part of the male GU exam for physician and patient is the digital rectal exam. The prostate can be palpated by pushing on the anterior rectum with two digits. Enlargement or masses can be felt. However, the internist emphasized that only the lower third of the prostate can be felt. "The digital rectal exam cannot rule much out." An ultrasound exam of the prostate can see much more without associated distress.

One student asked what the medical consensus is on circumcision. The internist replied, "There is no medical reason to get or not to get circumcision. The main medical argument is the increased risk of foreskin infection with poor hygiene. However, with good hygiene, there is no increased risk of infection." He ended by asking, "Why do doctors ask patients to turn their head and cough?" The cough increases intraabdominal pressure that accentuates any inguinal hernia. "We ask patients to turn their head cause we don't want to be coughed on…"

Statistics for the week… Study: 20 hours. Sleep: 8 hours/night; Fun: 1 night. Example fun: watched college basketball at the house of an M2 (second-year medical student). She is married to an engineer and they're debating when to have kids. The current plan is for her to give birth during the third year of medical school so that she isn't pregnant during residency.

Year 1, Week 25

Five hour-long lectures over three days on calcium regulation to control neuronal activity, coagulation, heart function, and bone structure. One challenge is that calcium is a cation (positively charged ion) that can come out of solution. Too much calcium will cause calcium precipitation with various anions (negatively charged ions) potentially causing thrombosis of vessels, kidney stones, and coma. Too little calcium will cause hyperexcitability of neurons with the classic Trousseau sign.

 

Calcium in your body is governed by mass balance: What comes in must come out to maintain equilibrium levels (flux in = flux out). Calcium intake varies, so calcium efflux adapts accordingly. Two hormones, parathyroid hormone (PTH) and 1,25 dihydroxycholecalciferol (vitamin D) regulate calcium homeostasis through the gut, the kidney and the massive calcium reservoir of bones. (Calcitonin used to be thought to play an important role, but, at least in adulthood, appears secondary to PTH and vitamin D.)

 

The parathyroid glands, four small tissue regions within the thyroid in the neck, release PTH in response to decreased extracellular calcium. PTH instructs the kidney to increase calcium reabsorption and decrease phosphate reabsorption. The decrease in phosphate is thought to prevent precipitation of calcium-phosphate crystals.  Further, PTH increases the kidney's conversion of inactive 25-hydroxycholecalciferol reserves into active vitamin D. Vitamin D primarily acts on the intestines to increase calcium and phosphate absorption. Both PTH and vitamin D act on bone cells to fine-tune bone maintenance.

 

Bone is an organized mesh of specialized bone cells, blood vessels, extracellular proteins and mineral crystals (primarily hydroxyapatite). There are three main types of bone cells: osteoblasts (bone-building cells), osteocytes (imprisoned osteoblasts), and osteoclasts (bone-destroying cells). Osteoblasts secrete various proteins, primarily collagen, into the extracellular environment that form osteons (nucleation site for mineral deposition). As the osteons become mineralized, the osteoblasts, now termed osteocytes, become imprisoned in this mineral matrix. Osteocytes communicate to each other with cellular foot processes, forming the elaborate osteocytic membrane.

The osteocytic membrane forms a cellular interface that separates the mineral deposits from the vascular network: bone on one side, blood vessels on the other. Therefore, the osteocytes can regulate the “bone fluid” to determine net bone resorption or deposition. If osteocytes pump calcium and phosphate from the blood into the bone fluid, net bone deposition occurs in this microenvironment; if the osteocyte membrane pumps calcium and phosphate out of the bone fluid into the blood, net bone resorption occurs in this microenvironment. Activated osteoclasts secrete enzymes and acid that degrade the osteon proteins and the mineral deposits, respectively. Although overactive osteoclasts lead to weakened bones, transient osteoclast activity is needed to make stronger bone by making room for more densely packed osteons. Perhaps next year I will understand enough to relate osteocyte and osteoclast activity.

 

Bone development and maintenance require adequate calcium input (1200mg/day), steady levels of vitamin D (greater than 30 IU/mL), and mechanical stress signals. One of the most overlooked bone health tools is weight-being exercise, the mechanical stress of which is sensed by the imprisoned osteocytes, inducing bone formation.

 

Our patient case: Lucy, 60-year old female artist with a history of kidney stones presents to the ED for a femur fracture after a fall. In addition to having broken the largest bone in her leg, a CT showed microfractures in several additional bones. Blood work showed extremely elevated PTH despite hypercalcemia  (high calcium levels in the blood). Presence of a parathyroid adenoma, a benign tumor that secretes PTH, is suspected. Physicians recommend the removal of Lucy's parathyroid glands, a parathyroidectomy.

 

Lucy suffered from several psychological diseases in childhood and had become a fervent believer in holistic medicine. Lucy's internist explained, "It's always a challenge to emphasize how these complementary approaches are complementary, not supplementary. The Internet has introduced patients to a lot of information. Some good, some bad." The internist explained that Lucy is one of her favorite patients despite the extra time required for each visit. "She would bring me stacks of articles on supplements I had never heard about. We would dig to find the active ingredient. I've learned a great deal from her." Lucy tried several herbal, yoga and acupuncture therapies for osteoporosis and joint pain. A student asked the internist, "When do you draw the line if a patient does not want to follow your recommendation?" She responded, "If a patient is not following my advice I don't boot them out. I ask myself, 'Would another physician have a better outcome?' The only patients I have kicked out were ones that forged my signature on prescriptions." After several months of holistic treatment, Lucy elected to get the parathyroidectomy. Her calcium levels have come down and osteoporosis, measured by bone mass density, has improved. Although this was a success for our healthcare system, Lucy was diagnosed with breast cancer six months ago.

 

Instead of dissection (anatomy lab), we went to a radiology workshop. My classmates describe radiologists as "antisocial people who sit in a dark reading room all day with $40,000 monitors." The consensus among our class is that this profession is at risk of being replaced by image-recognition algorithms. Only one of our classmates, a quiet Asian-American gentleman, admits he would like to be a radiologist. Our lecturer is a father of two whose phone repeatedly buzzed with a toddler's voice saying "dada" as the ringtone. "I teach one class a month, and this is the day imaging blows up," exclaimed the radiologist. The radiologist was quirky, but sociable and self-deprecating. He did mention his monitors at least twice: “they cost as much as your tuition!”

Although the software that can replace a radiologist with 12 years of training is purportedly around the corner, our workshop was derailed when we were not able to log into the Picture Archiving and Communication System (PACS) due to a recent software upgrade being incompatible with the browser. After the school's entire IT staff swarmed in to update the browser, we were up and running. I greatly enjoyed investigating abdominal and pelvic anatomy on de-identified patient CT and MRI scans.

 

The radiologist showed a CT angiogram (CT with contrast agent injected into arteries) of "nutcracker" syndrome, in which the left renal artery is compressed by the superior mesenteric artery and aorta due to a lack of retroperitoneal fat. It turns out too little fat can be a bad thing! Nutcracker syndrome is diagnosed by radiologists and fixed by surgeons. He spent ten minutes examining different imaging planes to convey the complex anatomical relationships.

 

Statistics for the week… Study: 16 hours. Sleep: 8 hours/night; Fun: 1 night. Early bedtime for Jane and me. We competed in a 5k. We both got first place in our age group, perhaps because the competitive runners elected to do the 10k. Drinks with our favorite couple (classmate and his PA-student wife) that evening.

Year 1, Week 26

"This is for 3,000 years of patriarchy!" exclaimed a female classmate as she slices off the penis. Today we are dissecting the external genitalia. We noted the three main regions of the penis: left corpus cavernosum, right corpus cavernosum, and corpus spongiosum.

Lectures introduced the female reproductive cycle, also known as the hypothalamus-pituitary-ovarian (HPO) axis.

This topic requires us to learn the derivatives of cholesterol and the enzymes that catalyze these conversions (graphic). Cholesterol is a 27-carbon structure that gives rise to numerous signaling molecules such as androgens, estrogens, progesterone, aldosterone (isoosmotic antidiuretic) and cortisol. When discussing cholesterol signaling, there are two questions: What enzymes are found in what cell? How much access does the given cell have to low-density lipoproteins (LDL) in circulation?

Two-thirds of the class is memorizing the names and important enzymes in First-Aid that will be tested on Step I. For example, they memorize 17-alpha hydroxylase deficiency will lead to increased aldosterone and cortisol levels with decreased sex hormones and ambiguous genitalia. They aren't trying to learn the structure of cholesterol. I am wishing them good luck in retaining that information for next year.

The cells of the body have an ability to make fine distinctions among these related cholesterol-derived compounds. For example, aldosterone is very similar in structure to glucocorticoids (e.g., cortisol). So similar that kidney cells' aldosterone receptors have an affinity to cortisol. However, the aldosterone receptor is typically near an enzyme that degrades cortisol into cortisone which has a lower affinity. In this clever way, the aldosterone receptor can maintain its high sensitivity (percent true positive) to aldosterone while increasing the specificity (percent true negative). [After you enjoy a bag of licorice, it is possible to have transient psuedohyperaldosteronism, including hypertension and hypokalemia from cortisol activating the aldosterone receptor; licorice inhibits the activity of the enzyme that degrades cortisol into cortisone.]

The menstrual cycle is divided into the ovarian cycle (follicular and luteal phase) and the uterine cycle (proliferative and secretory phase). Different regions in the hypothalamus release pulses of Gonadotropin-Releasing Hormone (GnRH) into the pituitary portal system. GnRH activates gonadotroph cells in the pituitary to release follicle-stimulating hormone (FSH) and luteinizing hormone (LH) into the systemic circulation. FSH and LH act on ovarian follicles.

Each follicle is surrounded by granulosa cells that nurture a single dormant egg. Outside the granulosa cells are connective tissue called theca cells. LH binding to theca cell receptors initiates a signaling cascade that increases cholesterol uptake into the cell and increases transcription of the enzymes required to convert cholesterol into androgens. These androgens diffuse out of the cell and suppress further development of the follicle.

FSH binding to granulosa cell receptors upregulate aromatase, the enzyme that converts androgens into estrogens. Granulosa cells do not have the enzymes to synthesize androgens (estrogen precursor) themselves. Follicles are selfish. Once FSH has selected a follicle it will suppress other follicles from maturing, thereby ensuring only one follicle ovulates each cycle.

As FSH increases aromatase activity in granulosa cells, estrogen levels rise throughout the follicular phase of the ovary. Estrogen has many effects including proliferation of the uterine lining (proliferative phase of the uterus). Estrogen also has negative feedback on the neurons in the hypothalamus controlling GnRH release and negative feedback on the gonadotropins in the pituitary. Every 26-32 days in a healthy female, estrogen levels reach such high levels that the negative feedback switches to positive feedback. (The mechanism of this about-face remains a mystery to medicine.) The positive feedback produces the LH surge, a massive release of LH and FSH from the pituitary, initiating ovulation.

Ovulation is the rupture of the follicle. The oocyte or egg is released into the peritoneal cavity (space between abdominal wall and visceral gut organs) where the fimbriae of the fallopian tube sweeps it into the fallopian tube. Fertilization typically occurs in the ampulla of the fallopian tube and is carried into the uterus for implantation. An ectopic pregnancy occurs when a fertilized egg implants anywhere outside the uterus, most commonly in the fallopian tube. However, our embryology professor mentioned it is possible to have implantation in the peritoneal cavity on the the connective tissue of the gut.

After ovulation, the follicle enters the luteal phase. The ruptured follicle becomes the corpus luteum, a highly vascularized endocrine structure. Before, only the theca cells had adequate access to cholesterol in the bloodstream. Now, the granulosa cells have abundant access to cholesterol from LDL in the blood. Granulosa cells lack the enzyme to convert cholesterol into androgens. They are able only to convert androgens into estrogens and cholesterol into an androgen precursor, progesterone. Thus, progesterone levels spike initiating the secretory phase of the uterus. The uterus is ready for implantation of a fertilized egg. If fertilization occurs, the placenta secretes HCG (a close analog of LH) which preserves the corpus luteum production of progesterone. If fertilization does not occur, the corpus luteum involutes (degrades) causing progesterone withdrawal. This sudden decrease in progesterone causes shedding of the uterine lining or menstruation. The decline in progesterone and estrogen disinhibits the GnRH pulsations initiating the whole cycle again.

Two-thirds of the males had at best a fuzzy knowledge of the menstrual cycle. For example, how long is it? When do menses takes place in relation to ovulation? About half of the women did not know how their birth control works. Classmates argued about whether males should be given a handicap for the reproductive block: "You females have it easy. We've never seen this stuff before."

Our patient case: Gina, 31-year-old overweight female presenting with amenorrhea (lack of periods) and hirsutism (hair growth on chin, armpits, etc.). A pregnancy test is negative. A hormone panel reveals high levels of estrogens, androgens and LH.

Gina suffers from Polycystic Ovarian Syndrome (PCOS). PCOS is named for the ultrasound appearance of small cysts in the ovary. Confusingly these fluid-filled sacs are not "ovarian cysts," but simply mature follicles that are unable to ovulate. The elevated levels of androgens inhibit further maturation of follicles and ovulation and cause hair growth. The endocrinologist explained that hair growth, especially on the chin and neck, is what brings women to her office: "The amenorrhea is alarming but it is not what typically brings them in."

PCOS affects about eight percent of reproductive age females, although there is not a standardized diagnostic criteria for PCOS and the causes are not fully understood. Diabetes and obesity are known risk factors: adipose (fat) tissue produces estrogens, which interfere with follicle maturation. The inability to menstruate is serious. The uterus is stuck in proliferation mode, which vastly increases the risk of endometrial (lining of the uterus that regenerates every cycle) cancer.

How do we get Gina to ovulate? The endocrinologist explained how every woman's HPO axis is different. "It's really trial and error." Gina, like many women with suspected PCOS or infertility issues, undergo a progesterone challenge. A high dose progesterone injection is given initiating the transition from the proliferative phase of the uterus (high estrogen, low progesterone) to the secretory phase of the uterus (high progesterone). Once progesterone is metabolised, progesterone withdrawal should initiate menses. This confirms that the problem is an inability to ovulate.

Gina is taking clomiphene, a drug also used to treat infertility. Clomiphene inhibits estrogen receptors in the hypothalamus to prevent estrogen negative feedback. Therefore, there continues to be release of GnRH and downstream release of FSH despite the presence of estrogen at levels which should cause negative-feedback . Clomiphene increases the risk of twins as multiple ovulations may occur. Gina also underwent what sounds like a barbaric procedure called ovarian drilling. A needle inserted laparoscopically destroys various follicles in a random array. Ovarian drilling is quite successful in decreasing androgen levels and inducing ovulation. Gina still is not on a normal cycle, but has been menstruating. She is trying to get pregnant with her husband.

[See also "Small-sample Behavioral Economics" for how clomiphene may be taken by women with normal fertility.]

Statistics for the week… Study: 20 hours. Sleep: 7 hours/night; Fun: 1 night. Example fun: One of our classmates recently moved in with two males in their 20s. Her new apartment is a bachelor pad equipped with a pool table, beer pong table, dart board and xbox. After two weeks of straight exam study, she was demonstrating her social skills by hosting a 26th birthday party for another classmate.

Year 1, Week 27

"Lactation: Use it, or lose it" is our theme for two days. A family physician brought in one of her patients, a 30-year-old mother of two. When four-month-old "Nora" got hungry, she whipped her breasts out in front of the whole class. The physician explained that the breasts are made of 4-18 glandular ducts with suspensory connective tissue and fat. The baby needs to be rotated using different positions (e.g., the football hold) to ensure each duct is used.

Two hormones are important for lactation. Prolactin, secreted by the anterior pituitary gland, signals the glandular ducts to produce milk. If the ducts begin to build up in pressure, prolactin secretion will be inhibited. Once this cascade has begun, it is almost impossible to reverse the spiral, which is why breastfeeding in the first days after delivery is critical. Although prolactin produces milk, oxytocin (the love hormone) causes the release of milk. When a baby is on the nipple, the ducts contract, producing a let down. Other signals, such as a baby crying,can cause oxytocin release. We were fortunate enough to see a let down: Milk shot out of the nipple for several inches and sprayed all over the baby's face and clothes. Nora was loving it.

"Breastfeeding should last for at least six months and up to one year plus/minus two months." The physician continued, "A child will let you know when he or she is ready to wean. The child will start grabbing solid foods and teething on the nipple." Current conventional wisdom, confirmed by the most heavily cited studies, is that breastfeeding for at least six months (1) builds mother-child bonds with oxytocin release, (2) decreases the child's risk of obesity, increases IQ, improves immune system function and improves social skills, and (3) decreases the mother's risk of breast and ovarian cancer.

The family physician noted that her specialty, increasingly rare in American cities, is the only one that follows both mother and child during pregnancy, labor, and after birth. "This allows a whole different perspective that used to be the norm. In most big city hospitals, the moment after delivery, the infant is whisked away by the pediatrician, while the mother is followed up by the Ob/Gyn. Family medicine bridges this patient divide by caring for both mother and child and sometimes grandmother too."

On the advice of yesterday's physicians, Americans abandoned breastfeeding in favor of formula. On the advice of today's physicians, Breastfeeding rates are back up to roughly 50 percent and are tracked by the CDC. The mother explained how difficult breastfeeding was for her first child. "If it was not for my physician, I would have quit after one month." She developed a severe case of mastitis (inflammation of the glandular ducts caused by an infection or obstruction). "Every time I breastfed, I would cry in pain." The worst thing to do for mastitis is to stop feeding. Instead, you should feed or pump in short pulses. The physician noted, "A big misconception about breastfeeding is that it should not hurt. It will hurt. A lot." In addition to the biting, oxytocin release in the first few weeks can cause painful uterine contractions similar to the experience of labor. The physician continued to explain the difficult decisions her patient's face without extended maternity leave. "They ask themselves, 'should I quit my job to breastfeed, pump, or switch to formula?' Each presents challenges especially if the pump is not covered by insurance, or if the family gets insurance through their job." (This seemed to support Ivanka Trump's observation that motherhood has become the primary obstacle to women's professional advancement, but Anita still isn't in a positive mood about any Trump family member.)

The physician noted how there exists a black market for milk, especially for colostrum. Colostrum is the milk produced in late pregnancy that is rich in antibodies and protein. Our modern range of reproductive technologies, including surrogacy, has produced the largest number of families in which an infant is present and yet no adult is capable of lactation. "Colostrum is worth more than gold!"

That evening I attended an optional workshop on women's health led by three female physicians, one of them an OB/GYN specialist. Fifteen students, including five men, from different years showed up. We practiced inserting different intrauterine devices (IUDs) in dummies. IUDs are shaped like a "T" with arms that spring out when deployed, thus anchoring the device in the uterine horns. The IUD is connected to two strings that exit the uterus through the cervix. A physician can pull on the strings to remove the IUD. The strings are trimmed during insertion so that they end just outside the cervix, which enables women with IUDs to check the strings every month to ensure the device has not been displaced. None of my classmates with IUDs knew that they were supposed to do this.

The first IUD marketed was Teva's Paragard. "Paragard is the most cost-effective contraceptive ever created," noted the gynecologist. Paragard uses copper to kill sperm before they can reach the egg for fertilization. It is is effective for ten years. Most women are choosing Skyla and Mirena, a progesterone IUD. These are more expensive but women like it because of the decreased bleeding. One family physician with experience with adolescents noted, "Paragard has this unfortunate misnomer that it causes heavy bleeding. It's just a woman's normal cycle. The progesterone IUDs give lighter bleeding. Some women on Skyla or Mirana stop having periods altogether." I asked if older or younger women are more receptive to IUDs versus normal birth control methods. She responded, "Younger women (under 25) are by far more resistant to IUDs. They don't want anything in their body but they want to have plenty of sex. I have to beg them to use some form of contraceptive."

A pediatric gynecologist gave two lectures on puberty. My favorite fact: fifty percent of healthy adult weight is added during puberty. Females begin puberty, on average, at age nine with the growth spurt, followed by thelarche (breast development) at age 10 and finally menarche at age 12.5. These ages are delayed in larger families, higher altitudes, and rural settings. Males begin puberty, on average, at age 11 with an increase in testicular volume. This is followed by pubic hair, the all-important growth spurt, voice changes, axillary hair, the ability to ejaculate, and fertility. The class chuckled when he commented, "Males are shooting blanks for a bit. Males can ejaculate before fertility."

In his practice, he evaluates "precocious puberty". He deems puberty premature if the child reaches a stage three or more years before normal. The most severe cases are generally due to a hormone-secreting pituitary adenoma. Some of his patients undergo the growth spurt and menarche at age six. Black children typically undergo puberty 1-1.5 years before risk-adjusted white children. "My colleagues in other countries have it easier. Race cohorts are not as meaningful in the US because of genetic and ethnic mixing. Other countries these 'normal' numbers are more relevant."

A week before exams and the library once again is crowded. Students stare at laptops (with peeks at an open Facebook window) or textbooks. The librarian brings her 12-cup coffee machine out for students to use during exam week. About half of us bring mugs while the rest walk across the street for Starbucks.

Pharmacology is a huge part of this exam and memorizing drug names is one of our toughest challenges to date. A friend's mother advises companies on drug names, which may reflect millions of dollars of analysis. Names that "flow" are easily remembered: gliflozin is a typical suffix for drugs that make glucose flow in the urine (SGLT2 inhibitor); glutides keep the GLT1 incretin tide coming on. Classmates say that they are enjoying TV drug ads a lot more than they used to.

Statistics for the week… Study: 20 hours. Sleep: 7 hours/night; Fun: 1 day. Example fun: Jane and I ran a 5k trail run.

Year 1, Week 28

Exam Week: physiology (including pharmacology), anatomy, and clinical (x2).  

Classmates are nervous about physiology due to range of systems covered in this block: endocrinology, reproductive, kidney, and gastrointestinal. From our class GroupMe chat: "I cannot believe they could not put one of these systems into the next block." (We can believe anything about the next block because we haven't experienced it!); "FML," [F… My Life] liked by 26 classmates.

Anatomy questions were easier than on the previous two exams. Every question was first order (e.g., What is this structure?), instead of a more challenging clinical scenario or applied reasoning (e.g., Which of the following structures would be used to access the posterior aspect of the stomach?). The most difficult question asked us to identify two arteries in the abdomen on a CT image slice. Classmates speculated that standards were lowered in response to complaints during the last block regarding the anatomy curriculum. I wasn't among the dissatisfied; if I get a well thought-out question wrong I tend to remember the material.

I spoke with an M4 (fourth-year medical student) after the anatomy exam. The school apparently used to conduct the anatomy exam in the lab on your individual cadaver. They stopped this because some students felt under too much pressure from being "pimped" by instructors and "it did not look good for the LCME [Liaison Committee on Medical Education]." I asked, "What does pimping mean?" The term refers to an attending bombarding a resident or medical student with questions. The M4 chuckled, "Hospitals have not succumbed to these restrictions so be prepared on your rotations. A good attending won't let his or her resident leave the day without feeling humbled or inadequate, depending on how you take the experience."

After exams we completed a Web-browser-based anonymous evaluation for every instructor. The "Learning Environment" section requires a response to "Were you required to perform any personal services?" and "Did you feel you were denied opportunities for training or subjected to offensive remarks because of gender, ethnicity, or sexual orientation?" We were informed via mass email to be careful with this section because every "yes" response causes an email marked "urgent" to be sent to each dean. Accidental "yes" responses at the end of the last block caused a bit of an inbox meltdown among the academic administrators.

The good news about "offensive remarks" is that LCME requires they be recorded, along with the rest of each lecture, on video. This way students who can't be bothered to attend still have access and anyone who enjoys being offended can repeat the experience. Over half the class uses this feature and our large IT staff are frequently called to help with issues. Before the weekend, a student asked a beloved instructor, "What is your favorite beer?" He responded, "The video is recording, I'll tell you afterwards."

Statistics for the week… Study: 25 hours. Sleep: 8 hours/night (I once again get more sleep during exam week?); Fun: 1 night. Example fun: Final exams ended at 12:00pm. Ten of us went to classmate's apartment for beer and mimosas, followed by an early happy hour excursion downtown and late night dancing. Jane and I slept until noon the next day.

Year I, Week 29

We had a week off. Several classmates visited girlfriends, boyfriends, and family. One went on a Caribbean cruise. A few stayed in town to recuperate and study this next block in advance ("gunners" is the class label for this behavior).

We'll study neurology for the next two months, but class began with two deans reprimanding us. "It has come to our attention that several doctors and professors think you need to work on professionalism. Several of you are on Facebook, browsing Amazon, and checking Instagram during lecture while you sit next to a physician. SnapChatting in class is inexcusable. These physicians frequently volunteer their time to come in and speak to you. Treat them with respect. Every class gets a reputation. Don't let this be yours."

For eight weeks we will be taught almost exclusively by a 74-year-old neuroanatomist, "Doctor J". He worked for several years as a physical therapist, then earned a Ph.D. in neuroscience. His first slide was a quote from Emerson Pugh: "'If the human brain were so simple that we could understand it, we would be so simple that we couldn't." "We will do our best," explained Doctor J. His second slide was a black and white photo of an old guy. "Neuroscientists bow before Cajal."  In the late 1800s there was no consensus on the anatomy of the nervous system. Two luminary anatomists, Camillo Golgi and Santiago Ramón y Cajal, supported opposing viewpoints. Golgi supported the reticular theory: nerves are a syncytium of several cells connected together. Cajal supported the neuron theory: each nerve is a single cell. Cajal used Golgi's own staining method to disprove the reticular theory. This history lesson gave a human spin to the evolution of knowledge. These men worked in shoddy laboratories with microscopes that we could build today out of paper and tape.

We had to purchase several tools for the neurological exam, including a reflex hammer, pen light, and eye chart. Our white coat is filling up with gadgets! We will practice the exam in several workshops. Students complained to the dean about Doctor J not posting answers to the workshop questions. The neuroanatomist responded during lecture, "This is your fault. The first few years we did give out answers for the lab book. I put a copy in the library. Within a week, someone had photocopied it and send it as PDF to the whole class. The value of the workshops went down, no one attended, so I no longer give the answers out." Apparently not all classmates were mollified by this explanation because enough students went back to the dean that he submitted a "formal grievance" against Doctor J.

Lecture began with an overview of the nervous system, divided into a central nervous system (CNS) and peripheral nervous system (PNS). The CNS is a tube with a hollow canal in the middle where cerebrospinal fluid flows. This tube is simple in the spinal cord but becomes suddenly more complicated at the top of the tube, which will become the brain. During fetal development (in utero), the cells of this part grow much faster than the surrounding skull causing bending and folding of the tube. The brain retains its lumen (inner membrane adjacent to canal) as the four ventricles of the brain that are continuous with the central canal of the spinal cord.

Unbeknownst to me, the spinal cord does not extend the whole length of the spine. Before birth, the spinal cord extends to each vertebrae. However, during childhood the vertebrae elongate faster than the the spinal cord, resulting in the spinal cord's termination at the first or second lumbar vertebrae (above the hip bones). A lumbar puncture ("spinal tap"), a common procedure to sample cerebrospinal fluid, leverages this anatomy by sampling the cerebrospinal fluid at L4 without the risk of puncturing the spinal cord.

There are about 860 billion cells in the brain, only 10 percent of which are neurons. Ninety percent are supporting cells called glia and microglia. These cells perform various functions: astrocytes (a type of glia) maintain the blood-brain barrier by wrapping foot processes around ninety-five percent of the capillary surface area (it reminds me of the scintillating podocytes in the glomerulus of the kidney); oligodendrocytes (a type of glia) insulate the axon cable (wire to the next neuron(s)) by wrapping sheaths of their cytoplasm around the cable; microglia are specialized resident macrophages that get in the central nervous system in utero before the blood brain barrier is formed.

Myelination is essential for neuron function. The conduction velocity of the action potential (the nerve signal) decreases as the resistance of the axon cable increases. Organisms such as the giant squid without myelinating cells achieve high transmission speeds by having huge axon diameters. Myelination decreases the effective membrane capacitance, which reduces the amount of potential needed to charge up the axon, and decreases potential leakage. Myelination enables the preservation of high speed as more neuron connections are packed into a small volume. This is important because intelligence is related to the connectivity (or synapse density) of each neuron. A human brain is estimated to contain more than 100 trillion synapses for roughly 86 billion neurons.

We learned how the number of cells change during human development. Between the third week and twenty-eighth week after fertilization, 250,000 brain cells are produced every minute! Many of these neurons undergo apoptosis (cell suicide) during training of the neural network. Despite this amazing proliferation, the brain is only twenty-five percent of its adult size at birth; the brain reaches seventy-five percent of its adult size at one-year of age.

In my small group we discussed foundational neuroanatomy structures. The corpus callosum is a bridge for nerve fibers to cross between cerebral hemispheres. Someone mentioned the corpus callosum is thicker in females. A question "Is this why women are more emotional?" yielded chuckles from several male students and glares from Type-A Anita and Straight-Shooter Sally. Anita replied, "Yes, that is exactly why. It's going to be a long two months with you guys."

Anatomy held a dry lab in which we felt bone vertebrae. Dry vertebrae (just the bones) have spinous processes which look like something out of a Game of Thrones episode. The spikes you can feel on your back are these spinous processes. The vertebral body, the main weight-bearing part, lies deep to this on the anterior (front) side. The spinal cord sits between the vertebral body and the spinous process inside the vertebral foramen (hole). The spinal cord gives off spinal nerves through the small bilateral intervertebral foramen.  We saw how the intervertebral facet joints differ among the cervical, thoracic, and lumbar (neck, chest, and lower back) regions. The cervical vertebrae have the joints in the axial (horizontal) plane facilitating rotation; the cervical have the joints in an oblique plane preventing significant movement here; and, the lumbar vertebrae have their joints in the sagittal (vertical side section) facilitating forward bending and extension.

Our patient case: Jonathan, 25-year-old male presents to the ED nine months ago for a three-minute seizure and worsening headaches in the morning for the past month. A neurological exam shows absence of venous pulsations, suggesting elevated intracranial pressure. Jonathan did not pay much attention to the headaches. He was busy at work, and his wife was due with a second child.

A CT ("CAT scan") revealed a 3x3x3 cm (a little more than a cubic inch) tumor in the right temporal lobe of the brain. Surgery was scheduled immediately. The neurosurgery team debated removing the entire temporal lobe or just a "lesionectomy" where they remove the tumor with as good margins as possible. A lesionectomy was performed and a pathology analysis of some of the tumor removed revealed a grade III glioma. Jonathan's neurosurgeon told us that "All grade III gliomas eventually become grade IV." A death sentence. Jonathan is still alive, nine months after his first ED visit, but was unable to attend due to worsening health.

According to the neurosurgeon, a patient presenting to the ED with a headache will always get a head CT. However, it is unlikely the same patient's primary care doctor will order a head CT for just a headache.

How many patients with advanced brain cancer elect not to get surgery? “Much more rare than you would expect," responded the neurosurgeon. "Everyone hopes they will be the exception, the extreme outcome. We hope for a cure, so our treatment plan is very aggressive.” He has operated on a 86-year-old with grade IV glioma (the patient died; Medicare paid the bill).  He recounted a troubling story of a 60-year-old late stage Huntington's patient with glioblastoma. “His wife had a very difficult time letting go. We said we could get him back to baseline, but that baseline was late stage Huntington's. They decided to not operate."

What’s more important for neurosurgery, dexterity or knowledge? “We can teach a monkey to do surgery in seven years. Passion is the most important quality. I see senior residents get angry at newer residents because they work shorter hours than they did. They are bitter, and remorseful. Unless you have the passion, you will burn out.” He joked that sometimes beginners can be too passionate. "One of my residents got so excited about a successful shunt [apparently, a common neurosurgery procedure] he performed. It's not that big a deal, we do shunts every damn day. I did not want to burst his bubble so I told him 'Great job!'... Don't tell him I said that!"

How did he cope with such depressing cases? "It is tough. I see cases like Jonathan's every month," he answered. "Everyone manages it differently. For me, as long as I feel like I treated my patient and their family like my family, I sleep fine. It is when I remember at night that I forgot to talk to that family member that it hits me."

A seventy-year-old dermatologist with a strong southern accent held a lunch session to explain why his field is the best: "I cannot think of a single reason why you would not want to do Derm. It pays well. It has unbeatable hours. The patient population is generally quite motivated to get better."  He was in private solo practice for much of his career. "Many of my patients, such as lawyers, paid cash." A classmate asked, "Did it get lonely working solo?" He responded, “No, we have nurses.” He described how there are just not many dermatologists, claiming this was the reason why there were so few dermatology residency slots. Dermatology is one of the most competitive residency programs.

Friday was Match Day, a slight misnomer because it is one day after fourth-year medical students hear where they will (or will not) be completing residency. Students and residency programs rank their top choices. Almost 36,000 domestic medical students and international doctors vied for about 29,000 residency slots. Fifty percent of applicants nationwide got their first choice.

The whole school attends the ceremony. Each student goes up to the podium and says something like "I will be will doing Internal Medicine at the University of Southern California." Fifteen percent of the class couples matched. Two individuals need not be married or in the same specialty to couples match. An orthopedic surgeon sent an email out congratulating the class on their impressive Match Day results, but reminded the first through third year students not to slack off. He ended with a quote from Will Rogers: " Even if you are on the right track, you will get run over if you just stand there."

Statistics for the week… Study: 10 hours. Sleep: 7 hours/night; Fun: 2 nights. Example fun: A good friend and former coworker visited for the weekend. We joined Match Day celebration at a pregame followed by a late bar night filled with plenty of Guinness for Saint Patrick's Day. Jane and I saw Beauty and the Beast on Sunday evening.

Year 1, Week 30

Anatomy lab was less than 30 minutes: we removed with blunt dissection the posterior muscles around the vertebral column to prepare for next week's laminectomy (removal of the vertebral laminae to expose the spinal cord)! We went over spine anatomy and common spine disorders such as a herniated ("slipped") disk (the gelatinous nucleus pulposus part of the intervertebral disk herniates through the outer fibrocartilage annulus fibrosus) and spondylolisthesis (anterior or posterior displacement of a vertebra). We discussed how aging causes loss of the elastic dampening capabilities of the nucleus pulposus.

Lectures detailed two sensory systems, the anterolateral and medial lemniscal tracts. The anterolateral tract conveys tissue damage (pain), whereas the medial lemniscal tract conveys fine touch and proprioception (vibration and positional awareness). Sensing vibration requires extremely responsive transducer elements in the skin to convert rapid changes in pressure into electrical signals. All these tracts end in the postcentral gyrus in the cerebrum, which forms the sensory homunculus. The medial part receives sensory input from the lower extremity. The genitalia neurons are adjacent to the foot neurons, a potential explanation for why some humans have a foot fetish. The lateral part of the brain receives sensory input from the upper extremities.

Doctor J called the tallest student up to the front. He grabbed a measuring tape and asked the student to step on one end of it. He then measured all the way up his back to the end of his neck -- 5'6. "This is the length of a single neuron in your body." The whole class was amazed. Neurons that sense fine touch and proprioception travel from the big toe up to the spinal cord, ascend the spinal cord in large bundles, and finally synapse in the medulla (part of the brainstem). One cell.

Our patient case: Sherry, a 50-year-old overweight female accountant with uncontrolled diabetes presents to her primary care physician with a foot ulcer. During tax season she is so busy that she forgets to take care of herself. She has not refilled her medications, including metformin, for several months. A neuromuscular exam, specifically using a 256 Hz tuning fork to test for vibration sensitivity, reveals diminished sensory ability in both extremities. She explains that her foot has felt numb for weeks. A cut on the foot went unnoticed, and got infected.

Sherry suffers from diabetic peripheral neuropathy. Uncontrolled glucose levels lead to non-enzymatic glycosylation (adding sugar groups) of proteins,lipids, and nucleic acids. These advanced-glycosylated products (AGEs) interfere with normal function and activate inflammatory pathways. A familiar complication of diabetes is vascular (arteries and veins) damage, which leads to increased risk of atherosclerosis, heart attack, and stroke. This inflammation also damages neurons and their companion Schwann cells (cells that myelinate peripheral nervous system axons). The longest axons are affected first. The neurological deficits such as numbness, loss of pain sensation and balance difficulty start in the foot and travel up the leg. By mid-calf, the sensation loss also begins in the hands. Fifty percent of diabetics have peripheral neuropathy (eighty percent after 15 years). Interestingly, the physician mentioned that twenty percent of prediabetics have some sign of developing nerve damage, suggesting that vibration tests should be used as a screening tool for diabetes.

Sherry had trouble simply walking. As is common among laypeople, classmates associate diabetes with laziness: failure to exercise, overeating. This case prompted us to ask "How could someone exercise if they cannot walk?" The physician concluded, "It is critical for diabetics to check their feet daily. They might not even realize they have a cut or foot ulcer. The infection can spread to the bone requiring hospitalization and, too commonly, amputation." He reminded us that diabetes is the leading cause of amputations [73,000 in 2010]. Sherry described her diabetic foot ulcer, now cured, as a wake-up call. She was discharged from the hospital three months ago and has been taking her medications regularly.

A diagnostic radiologist and an interventional radiologist led a lunch session about their respective specialities. Diagnostic radiologists complete 5 years of training: an internship year typically on general surgery followed by a 4-year radiology residency. Interventional radiologists conventionally would complete a separate 2-year interventional radiology (IR) fellowship, making for a total of 7 years of post-MD training. There are now direct IR residencies that take just 5-6 years.

IR is a subspecialty of radiology. Interventional Radiologists perform minimally-invasive procedures using imaging guidance such as x-ray and ultrasound. These procedures include: central line placement, endovascular (e.g., stents and thrombectomy of blood clots) procedures, radiation treatment, and bile duct obstruction procedures. Other specialities overlap with many of these. Indeed, there is sometimes tension what specialty group performs a given procedure at different health systems. For example, stents can be placed by IR or interventional cardiology; strokes can be treated by neurosurgery or IR.

The interventional radiologist explained why he chose IR: "I loved anatomy. And I like working with my hands doing procedures." The diagnostic radiologist explained why she choose radiology: "I had the worst internal medicine rotation fourth-year. Day after day, I would have a patient die on me. The worst was a 30-year-old cystic fibrosis patient, the exact same age I was. I was so miserable I considered quitting medical school or not completing a residency. A radiologist lived upstairs of me and noticed how miserable I was. He suggested I shadow radiology. Never looked back."

She described radiology as the "experts' expert." Clinicians increasingly rely on imaging procedures as opposed to physical examination skills. "Do not go into radiology if you cannot wield responsibility. You decide if someone in the ED goes to the OR or gets sent home." We learned that radiologists are highly compensated, but also have a higher liability profile: "Every radiologist will be sued several times."

What will the role of machine learning play in radiology? "Computers will not replace radiologists. They will just make radiologists much better at their jobs." The diagnostic radiologist elaborated, "Computer algorithms in some areas are just as good as radiologists in identifying if something is wrong with a patient [high sensitivity]. However, computers are terrible at ruling out issues [low specificity]." I attended a neurosurgery informal dinner where I asked a similar question about radiology. The neurosurgeon was shocked by the radiologist's response, and exclaimed, "Radiologists are terrible at ruling things out. Every report is littered with: 'cannot rule out x, y, or z'. Give me a break, they will be replaced." (See "A.I. Versus M.D.," New Yorker, April 3, 2017.)

I've been working on a personal project in the evenings. My favorite trauma surgeon comes in most Wednesdays at noon to evaluate my progress. She tidies up my dissection then sends me on another mission that our class did not have time to explore during formal anatomy lab. Examples: Find the annular ligament of the radius, the ulnar nerve, or the anterior humeral circumflex arteries. One thing that makes medical school different is that an after-hours project may involve a dead body. In this case, I have a whole cadaver to myself, unlike in anatomy lab where we switch bodies every few months. The cadaver was a black 60-year-old, mildly overweight female. I have developed a deep sense of appreciation for this woman who donated her body so that I could pursue this upper extremity (arms) project focused on nerve and blood vessel anatomy.

One evening around 9:30 pm there was a knock on the locked door. I took off my soaked gloves and opened the door to find the head dean escorting a fundraiser group of dressed-up bankers and business people. They wanted to see the wet lab. I forgot how quickly one adjusts to the sight of cadavers in a formaldehyde-scented room. As I was there by myself, the whole head was uncovered and several chunks of removed fat lay exposed. A few people approached the body, but most were hesitant and stayed at least several feet away.  I showed them the nerves and vessels of the arm.

A visitor asked about the purpose of cadavers. I explained that cadavers give unparalleled understanding of human anatomy. Textbooks cannot replicate this experience, especially the geometric relations of anatomical structures. An important part of the learning experience is discovering how the individual died and what diseases he or she lived with. I mentioned that one cadaver had a heart attack, prompting a question from a gentleman in his late 50s regarding what the heart looks like after a heart attack. I explained the cadaver suffered a heart attack in his left anterior descending (LAD) artery, as evidenced by a small, hardened discoloration on the surface of his left ventricle (see previous post). He did not die from the myocardial infarction because hardened scar tissue replaced the infarcted region. If he did die from the MI, the infarcted region would have the same firmness as the rest of the myocardium. The gentleman thanked me, took a peek at the cadaver and left. The next day the dean told me that the wet lab had been the guests' favorite part of the event.

Statistics for the week… Study: 8 hours. Sleep: 6 hours/night; Fun: 1 nights. Example fun: Two classmates and I attended this year's SonoSlam in Orlando, Florida. SonoSlam is an ultrasound competition among medical schools held on a Saturday by the American Institute of Ultrasound in Medicine (AIUM). My favorite part was using the most advanced ultrasound machines. Several of machines were controlled via iPads. One bluetooth-enabled ultrasound probe was only slightly larger than a smartphone and could be controlled via an iPhone app. The competition ended around 6:00 pm. As first-year students without the pathology training of the fourth years, we had low expectations for the competition and we did not exceed them. However, we celebrated our failure with post-competition drinks at a local brewery and "Cutthroat" at a nearby billiards parlor.

Year 1, Week 31

In anatomy, we performed a laminectomy. We removed the posterior vertebral structures to reveal the spinal cord, about the diameter of the thumb. We opened up the dura (outer meninges that forms a fibrous protective layer), a continuous white sheath that covers both spinal cord and brain. At each intervertebral level, four roots come off the spinal cord to form bilateral spinal nerves. The ventral root is where all the motor fibers exit the spinal cord to control muscles and glands. The dorsal root is where sensory fibers enter into the spinal cord. Several spinal nerves in the lumbar and cervical regions were surprisingly large, about the diameter of a pinky. How could something the size of a thumb contain nerves that occupied so many pinkies? The answer turns out to be that nerves within the spinal cord are highly myelinated, which maintains conduction speed without the need for a large diameter. Once the neurons fan out from the spinal cord, however, not all of these nerves are myelinated and therefore must be thicker. We also saw the aptly named cauda equina (horse's tail). The spinal cord stops at L4 but the spinal nerves must exit from the lower vertebrae. The spinal nerves flow down the vertebral foramen fibers forming a horse's tail!

This week in lecture we learned about the cerebellum (from the Latin for "little brain") and basal ganglia. The cerebellum is located in the posterior inferior (back/lower) portion of the skull under the occipital lobe and contains an estimated 50 billion neurons in the cerebellum—more than in the entire rest of the brain and spinal cord combined! These cells can be thought of as writing computer programs to determine muscle activity and timing. One program, for example, might determine the sequence of firing hand muscles to grasp a cup. "Anyone who has had one too many cold ones knows what happens when you lose cerebellum function," noted Doctor J. Alcohol affects the the purkinje neurons of the cerebellum first, causing the characteristic drunk stumble.

The cerebellum uses the same neural architecture to process different inputs. For example, whether information is coming from the vestibular (balance) apparatus, or coming from proprioceptive information of the big toe, the information ascends to the densely packed purkinje neurons. The purkinje cells form massive planar dendritic trees that stack together in parallel. Purkinje cells have the same branching pattern as fan coral. Information received from the nervous system is sent along parallel fibers that travel perpendicular to the purkinje dendritic trees, synapsing along the way. This allows an immense amount of connectivity.

 

Cerebellar lesions, for example from a stroke, are devastating. Simple tasks become near impossible as the victim has difficulty timing an action. We practiced various cerebellar tests including the finger-to-nose test where you ask patients to reach out to your finger and touch their noses. They will have an intention tremor as they near the end of the action. Doctor J commented, "Do not use their nose as the endpoint. A stroke patient will poke his/her eyes out. Use the chin."

We had two lectures on the basal ganglia, cell bodies deep in the brain that are involved in filtering information passing through the thalamus (relay station) to the cerebral cortex. While the cerebellum's outputs dictate the timing of muscle firings, the basal ganglia determine which muscles need to be activated. Lesions of the basal ganglia, for example Parkinson's disease, cause debilitating rest tremors (tremors while not performing an action). We learned that stripes of tape on the floor can help Parkinson's patients with stability. The visual cues of the tape are thought to override the abnormal baseline thalamic input. This simple addition has huge benefits for the patient and caretakers, for example, when the patient tries to get out of bed to the bathroom. "This is an easy way to help keep a Parkinson's patient out of the hospital."

Doctor J brought out a VHS cassette showing various tremors, reflexes, and symptoms of patients with neurological disorders. "It might be old, but it's the best display of these symptoms." It took two IT staff 15 minutes to get it playing. We saw symptoms and movements associated with Parkinson's disease and Huntington's disease. The video was apparently worthwhile; the next day, a classmate shadowing an internist diagnosed a 40-year-old patient with Parkinson's.

Our patient case: Martha, a 62-year-old female with Parkinson's disease accompanied by her daughter Janine. The class quickly fell in love with Martha. She was witty, humble, and kind. Martha was diagnosed about eleven years ago with Parkinson's after presenting with balance issues, difficulty writing, and a rest tremor in her hands. The neurologist explained there are two stages of Parkinson's. "The first stage involves movement and dexterity. Typically two decades after diagnosis, patients enter a second phase characterized by significant cognitive deterioration. There are drugs, for example carbamoyl-levodopa, that are effective at treating the tremor and movement disorders."

Martha explained that it took a while to find the right balance. Too much of these powerful drugs can also cause tremors. She takes her medications every four hours or as needed if the tremors get worse. "If I do not take my medications, I have this terrible slowness," explained Martha. "I want to walk but my feet do not move. They just twitch up and down with the rest of my fidgety body. My body does not respond to my mind."

Asked to describe her typical day and what she wanted others to know about Parkinson's, Martha responded, "Oh, I still do lots of stuff. I cannot drive, but I love to garden and cook. Everything just takes longer for me. Appreciate that it is difficult for me to get to an appointment or brunch at 10:00 am. It takes me several hours with the help of Janine to get ready."

What was her greatest concern? She immediately responded, "That I will become dependent on Janine." She explained that Janine was the only family member who was a significant help. A student asked Janine, "How has this changed your life?" Janine responded, "She is the center of my world. I wouldn't change it. I wish people understood that her disease has not destroyed everything of her. There is a whole life after diagnosis. It doesn't stop there."

Friday afternoon, we practiced motor and reflex tests on each other. Reflexes are elicited by sudden changes in muscle length. Swinging a reflex hammer at a tendon causes a sudden increase in the length of the tendon, which sends this stretch information to reflex centers in the spinal cord. Upper motor neurons communicate with these centers for a net inhibitory effect. Therefore, an upper motor neuron lesion may result in hyper-reflexia (e.g., doctor gets hit in the nose by the patient's foot). As we practiced on each other, two student-examinees shouted,  "I got the clonus!" Clonus is when a muscle undergoes a series of involuntary contraction-relaxation cycles after a sudden change in the fiber length. The hospitalist told them not to get too excited about a few beats of clonus: "Wait until you are on the hospital wards."

Seven students stuck around to speak to the physician. One of our classmates had suffered a stroke at age 10. He reluctantly volunteered to have his reflexes tested. We quickly identified hyper-reflexia in his left lower extremity (left leg below the knee). For the patellar reflex (knee), the leg straightened at the knee and then kept going up towards the ceiling. After that we saw more than 5 seconds of sustained clonus. This is entered on a chart as "Grade 4+" (2+ is normal). Further, the physician elicited the "Babinski sign" by moving a pen along the underside ("plantar" surface) of the classmate's foot. His toes fanned out, which is normal for a baby under six months old. After six months, this reflex is typically eliminated as upper motor neurons suppress the primitive response. We thanked our good friend and classmate.

The next day, Doctor J held a group "question and answer" session. The class gets into six-person groups to answer challenging questions. Each group is required to hold up an answer. Doctor J would then delve into why Group 1 picked "C" whereas Group 2 erroneously picked "D".  Type-A Anita did not attend stating, "I feel humiliated when I go to these question/answer sessions and he pimps me about why I got the question wrong."

Lunch outside with nine classmates: A woman checked CNN headlines about the missile strike on Syria on her phone and yelled that Trump was a warmonger. Type-A Anita added, "On top of this, Gorsuch was confirmed. We are going back to the Stone Ages." The topic somehow turned to race relations. A classmate chimed in, "Ben Carson got appointed only because he is black." A female classmate from a rural conservative family opined, "America has our class divisions but we are by far the most tolerant country compared to anywhere else." Immediate reactions stormed in. "This is because Western culture portrays whites as heros and blacks as criminals," a female Asian student asserted. "It is the West's fault that other countries are not tolerant because they watch our movies and pop culture." The discussion settled down after someone brought up the livestream of April the Giraffe (a pregnant resident of an animal park in New York).

Statistics for the week… Study: 8 hours. Sleep: 8 hours/night; Fun: 1 night. Example fun: After class, we played soccer with Ph.D. students in the rain followed by burgers and beers.

Year 1, Week 32

Eye week started off with a two-hour dissection of the orbit (cavity of the eyeball). We used bone chisels to open the orbit and remove an eyeball by cutting the various ligaments and nerves anchoring it to the skull and brain. A human eyeball feels squishy but not delicate.

The eye comprises several layers: eyelid, cornea/sclera, iris, lens, retina, sclera (again). The eye lids contain conjunctiva epithelia which is continuous with the white outer sclera of the eyeball. The sclera is a white, fibrous connective tissue. The sclera merges with the cornea, a thin transparent convex protrusion that provides much of the optic refractive index of the eye. Behind the cornea is a cavity filled with aqueous humor, a watery secretion. The iris (colored portion of eye) is actually a muscle with radial and circular fibers that control the size of the pupil. The pupil is literally a hole in front of the lens. Light hits the cornea, enters the anterior (front) chamber, traverses through the pupil into the posterior chamber, and hits the lens to be focused on the retina, which is at the back of the vitreous chamber. Classmates, including myself, tended to hear the term "posterior chamber" (in front of the lens) and erroneously identify the much larger vitreous chamber (behind the lens).

Most of my anatomy group left early, but one classmate and I stayed to open the eyeball. We cut open the sclera with a scalpel and held the lens in our hands. It felt like a marble with an opaque yellowish tint. Several cadavers had artificial lenses, which felt surprisingly similar. The vitreous humor, inside the vitreous chamber, felt gelatinous. The retina looked like a white transparent sheet, except for a small protrusion on the medial aspect (closer to the nose) of the retina. This was the optic disk, where nerve fibers merge to exit the eye and the retinal artery enters the eye to supply the retinal layers with blood. The retina peeled off with forceps. We put the eye back together and placed it back in the orbit.

The retina, except at the optic disk, contains photosensitive compounds that transduce light into electrical signals. Rods, cells with the pigment rhodopsin, are sensitive to small amounts of light (as small as a single photon) and line most of the retina. Cones, cells with different photopigments excite depending on the specific wavelength (color), require larger amounts of delivered energy to activate. The density of photosensitive cells increase in an area of the macula with the highest density of cones in the fovea. Rods are important for night vision, while cones enable us to see color and detail.

A student asked, "What is the resolution of the eye?" Doctor J said this is hard to define. Each eye has 150 million photosensitive cells (rods and cones) [compare to 100 megapixels for the highest-resolution cameras circa 2017]. These signals converge onto 1.2 million ganglion cells that transmit the information via the optic nerve to the brain. Most of these ganglion cells originate from the fovea, a region the size of 1.5 mm. Image details are integrated by the primary visual cortex and visual association cortex. If you're looking for something small at night, try scanning with your peripheral vision because the density of rods is higher outside of the fovea.

Our eyes have six extraocular muscles that provide the extraordinary range of motion of the eye. To support binocular vision and depth perception, the eyes have elaborate mechanisms to maintain foveation through the horizontal and vertical gaze centers in the brainstem. Strabismus ("cross eye") is a misalignment of each eye causing an image to hit different parts of each retina. Strabismus causes diplopia (seeing double). Compression of one of the nerves that innervates these extraocular muscles can lead to diplopia when they gaze a certain direction.

Our patient case: George, 74-year-old white male with hypertension and hypercholesterolemia presents for blurry vision. An eye exam reveals intact extraocular muscles with decreased visual acuity. Inspection of the macula with an ophthalmoscope reveals the characteristic geometry of drusen (lipid deposits in the choroid vascular region deep to the photopigment layer).He is immediately referred to an ophthalmologist for Age-associated Macular Degeneration (AMD).

[AMD is the leading cause of vision loss for individuals, with white Americans being at high risk starting around age 65. Fifteen percent of white Americans over age 80 have AMD (https://nei.nih.gov/eyedata/amd). Type-A Anita muttered "white privilege" when we went over a clinical trial of a drug to treat AMD. Reflecting the higher prevalence among whites, the study had 93-percent white enrollment.]

The ophthalmologist performed an Optical Coherence Tomography (OCT), shooting low energy light (infrared) into George's retina to create beautiful micron-resolution images of the retinal layers. The study revealed detachment of the macula due to wet AMD. The choroid plexus (blood vessels on the exterior of the retina that supplies the pigmented cells) began to grow into the photopigment layers causing microhemorrhages. George was fortunate to get this diagnosed before his whole macula became detached.

Every six weeks, George goes to his ophthalmologist for a shot of Bevacizumab (Avastin), which contains antibodies against vascular endothelial growth factor (VEGF). This drug is injected into his vitreous chamber to prevent the growth of the invading blood vessels. "These drugs have saved my vision. I am able to drive, read, really do everything I want to do." George was going in this week to get his shot before departing on a cruise next week.

"VEGF treatment has really been a godsend," explained the ophthalmologist. "It prolongs patients' vision for years. For the unfortunate few who do not respond, there are some other options." One was a telescope implant to replace the lens with a magnifying telescope that focuses an image on a different part of the macula that is healthy. Students dubbed this "going bionic". A more drastic treatment option is macular rotation. Surgeons detach the retina and rotate is to have a new, more healthy vascular choroid plexus.

A student asked about the difference between Avastin, originally developed as a treatment for colon cancer, and Lucentis. Lucentis, FDA-approved to treat wet AMD, is a cleaved form of the anti-VEGF monoclonal antibody Avastin, at roughly 1/40th of the dosage used for colon cancer patients. Lucentis may be able to penetrate deeper into the retinal layers because of the antibody's lower molecular weight. Lucentis costs $2,000 per dose, whereas the amount of Avastin necessary for wet AMD therapy costs $50. The ophthalmologist explained he always starts with off-label Avastin. "I have only anecdotal evidence that a few of my patients respond better to Lucentis." [This makes sense given that the drugs are essentially chemically identical.] Genentech makes both Avastin and Lucentis. "Why would the company fund a multi-million dollar trial to approve a drug that costs less?" If all Medicare patients were prescribed Avastin instead of Lucentis, Medicare Part B is estimated to save $18 billion and patients save nearly $5 billion over a 10-year period (http://content.healthaffairs.org/content/33/6/931.abstract).

That evening, I spoke with some fourth-year medical students going into surgery about the match process. I learned that many general surgery ("Gen Surg") residencies are trending towards the "5 + 2" option. Gen Surg residencies had typically been five years. After residency, you could then get a job, or apply to a 1-2 year fellowship (e.g., cardiothoracic, vascular, etc.). In order to make graduates more competitive when applying for fellowships, some prestigious surgery residencies are now requiring two years of research in the middle, hoping that the publication record will appeal to fellowship admissions committees. Thus what had been 4 years of medical school, plus 5 years of residency, plus up to 2 years of fellowship (11 years) might now turn into a 13-year training process.

An attending repeated his wish (see Week 8) that regulations would allow him to teach us more. "LCME caps the number of formal class hours at about 26-28. There just isn't enough time to do extra projects, especially if they do not advance LCME-designated areas." He told administration that he would even volunteer his time for optional events. "Administration responded by saying, 'Students would complain that they feel obligated to go…' Don't we have capitalism? Instead of stooping to the lowest denominator, you work harder, get better, and make more money."

At lunch, Type-A Anita lamented the loss of Obama. Several students agreed, but added, "Trump's election is actually a blessing. Now we have unprecedented activism against racism and sexism. In the long run this will be good." Type-A Anita agreed, "But honestly, if we blow up the world?" They ended by saying how much they missed Obama's dogs and looking at a Pinterest account of Merkel Faces.

Statistics for the week… Study: 10 hours. Sleep: 7 hours/night; Fun: 1 night. Example fun: Afternoon drinks at recently opened brewery. There must be six new breweries planning to open by the end of the year.

Year 1, Week 33

Auditory week began at 8:00 am with some classmates upset because the room was different than stated on the shared Google Calendar that is our primary source of scheduling information: "Ugh, now I have to pack all my things up." We moved across the hall and Doctor J tried to reassure the class by promising it wouldn't happen again.

The ear is involved in hearing and balance. The pinna (outer ear flap, also called auricle) funnels sound into the ear canal to strike the tympanic membrane. On the other side of the tympanic membrane is the middle ear, an air-filled cavity that is connected to the oral cavity through the eustachian tube. We practiced using otoscopes on each other in a clinical workshop led by a female otolaryngologist in her 40s. It hurt! Every few minutes we would hear a shrieking "ouch". The worst was when a student from one group hastily grabbed a new tip to practice the technique lurched over and hit another group's otoscope wielder. The otoscope twisted in the student's ear. Despite these mishaps, we learned a great deal. After you get past the ear wax and hair, the tympanic membrane comes into view. The malleus, one of the three ossicles (ear bones), is attached at the umbo, a small white spot near the center of the tympanic membrane. In a normal ear you can see the pale outline of the malleus through the transparent membrane.

The otolaryngologist went over some commonly diagnosed ailments using the otoscope. A more opaque tympanic membrane suggests fluid, instead of air, is behind the tympanic membrane in the middle-ear. The fluid is typically from a middle-ear infection, which can cause temporary hearing loss and pain. She explained that we can also diagnose pierced ear drums and grossly malformed ossicles. A student asked, "What are the common procedures you do?" The answer was removing the broken ends of Q-tips from the ear canal. He followed up with "Do ENTs promote the use of Q-tips for business reasons?" She laughed and responded, "Oh, God, no! Those visits are so boring." Her passion is performing cochlear implants to restore hearing in children (see below).

When a sound wave hits the tympanic membrane, the membrane transmits the vibration to the the ossicles. The malleus ("hammer") rotates the incus ("anvil"), which in turn displaces the stapes ("stirrup"). The stapes is the interface between the middle ear and the cochlea, a fluid-filled, snail-shaped bone of the inner ear. The stapes lies in the oval window, described as a "bony defect" of the inner ear, that interfaces the stapes with the encapsulated fluid (note that if you didn't have this "defect" you wouldn't be able to hear). The stapes transmits the mechanical energy to propagate a pressure wave through the tube to the exit at the round window (a "bony defect" of the inner ear interfacing with the air-filled middle ear). The cochlea is U-shaped, with the oval window opening into the scala vestibuli. The 360-degree turn is called the heliotrema, and the scala tympani ends at the round window.

The two divisions of the tube (scala tympani and scala vestibuli) are separated by a space, the scala media, another fluid-filled tube. This turns out to be the actual source of all hearing sensation. The scala media changes in thickness along the length of the tube, making it sensitive to different sound frequencies. For example, one frequency might lead to a high pressure in the scala vestibuli 1 mm from the oval window, and a low pressure in the scala tympani 1 mm from the round window. This signal would cause the scala media at this region to bend towards the scala tympani. Along the length of the scala media are hair cells, receptors that excite neurons when the scala media deforms as little as a few nanometers. The sensation of sound occurs when signals travel through the brain stem into the primary auditory cortex, part of the surface of the brain that happens to be near the ears. A cochlear implant works by turning the varying voltage from a microphone into nerve signals corresponding to what would have been the movements of the hair cells.

As will become important in the patient case below, the scala media is continuous with another fluid-filled bone, the vestibular apparatus, an accelerometer critical for balance. This tube is divided into three thin canals (sensing rotation) and two sacs (sensing linear acceleration). Due to inertia, the fluid inside the tube will tend to stay put as the head moves, enabling hair cells to sense a change in pressure within any of the five compartments.

I ate lunch outside with Straight-Shooter Sally. She is the first person in her family to go to college, let alone medical school. Her father is a mechanic. She worked for three years after college as a social worker with adolescent drug addicts in a poor urban neighborhood. "These kids quickly get involved with the drug scene," explained Sally, "Drugs are the easiest avenue to create friend groups and to avoid attack by the gangs. When kids get arrested they are given the option of going to juvy or rehab. Everyone choses rehab." Does rehab work? "Every summer I would come back and see the same kids. It was a revolving door and we did not have any tools to make a difference. The three-month rehab was nothing for them. Their father went to jail for three years—what's rehab speaking to a counselor for a few months?" She continued, "These kids go to failing schools, come home to disorganized families, and the only thing they aspire to is what they see in the community. The drug dealers are the ones who have the snazzy cars, women, and money." She concluded, "I don't know the answer, but these kids need help—education, role-models, jobs, anything. Counseling was not going to solve it. I had to get out of there." She switched jobs and became a health coordinator before starting medical school at age 28.

Our patient case: Giorgio, a 50-year-old salesman who developed right ear pressure and diminished hearing after an evening shower. When he woke up, his ear felt like it was about to "pop" and he had lost all hearing on that side. Two common tests with tuning forks, the Rhine and Weber tests, suggested that the hearing loss was due to a sensory-neuronal deficit rather than a conduction deficit. In other words, he had damage to the hair cells, cochlear nerve, or brain cortex, rather than a mechanical blocked ear or perforated tympanic membrane. An MRI revealed an acoustic schwannoma, a non-malignant tumor of the supporting Schwann cells of the vestibulocochlear nerve as it exits the internal acoustic meatus into the cranial cavity. The tumor had begun to squeeze the cochlear nerve. "Most acoustic schwannomas grow less than one millimeter per year," said the neurologist. "Some years they just lay dormant. For whatever reason, they might spike for a few months then go back into a dormant state." Georgio's tumor was removed by a surgical resection through a retrosigmoid craniotomy approach (incision behind the ear).

The neurosurgeon (not Giorgio's surgeon) explained the risks. "It all depends if the tumor has facial nerve involvement." The facial nerve exits the cranial cavity in the same hole, the internal acoustic meatus, as the vestibulocochlear nerve. If you touch these fibers, it can lead to ipsilateral facial paralysis." During the surgery they insert electrodes into the facial nerve to verify, after each layer of tumor is removed, normal conduction from the surgical site to the facial muscles. "There is not a consensus on whether the whole tumor should be removed if there is facial nerve involvement. If you can get, say, eighty percent of the tumor, you might be able to resolve the hearing deficients and decrease the risk of facial nerve damage. But, the tumor could slowly grow back." My classmates and I watched a Youtube video on the surgery (https://www.youtube.com/watch?v=PBE5rQ7B0Ls). "This is wild," exclaimed an aspiring female surgeon.

Giorgio underwent a full resection. He quickly regained most of his hearing. "I have worse hearing in my right ear, especially in the higher frequencies. For the most part, I hear fine." He does have persistent tinnitus (ear ringing). "Right now, focusing on it, I hear it, but I get used to it." He experienced terrible balance issues for months after the surgery. "I had to completely relearn how to walk. My whole balance seemed to have just reset to a new normal. I was completely dependent of my family for three months."  He also experienced a poorly healing wound on the skull behind the ear. "I was taking airline trips for my job with an open wound on my head. Not the most sanitary environment. One day in the car, my wife looked at my wound, and forced me to go see a plastic surgeon." The plastic surgeon performed a skin graft to revascularize the infected wound. The wound healed shortly thereafter. The neurosurgeon added, "I see these occasionally. It's not a petrid, ozzy infection. It's a lingering infection." Despite this complication, Giorgio was very satisfied with his care. He is slowly getting back into playing competitive tennis, although he still experiences balance issues.

We learned that Giorgio immigrated to the US as a student. He still maintains citizenship from his Scandinavian birthplace. A classmate asked what kind of treatment he would have received under the socialized medicine system of his birth country. "Completely differently," explained Giorgio. "I would not have been allowed to get operated on. If it is not considered life-threatening or malignant they would not pay for it." One classmate, a Canadian citizen and US green card holder joked, "I keep my Canadian citizenship for a Get Out of Jail Free card. If I get cancer, I'm packing my bags and heading to Canada."

I shadowed my physician mentor for an afternoon. It was a busy day so he saw some patients without my assistance. In 4 hours, I saw 7 of the 14 patients. The first patient was a 45-year-old gentleman, overweight but certainly not obese, presenting for follow-up after hospitalization with a transmetatarsal amputation (TMA). He was in disbelief after losing half of his left foot (including the toes) due to a foot ulcer. The physician delved into how he was managing his diabetes. His last sugar readings were off the chart and from over a year ago. He had not been taking his medications for several months. "It was too expensive," he explained. This was typical of our patients who make too much money to qualify for Medicaid, but not enough to afford Obamacare health insurance. Our patient's motivation: "I will do anything you tell me. Just let me have two legs when I see my thirteen-year-old son graduate college."

The next patient was a thirty-year-old mother presenting for follow-up for a prescription opioid refill indicated for joint pain. We informed her that the state has a new law requiring an annual recreational drug test for prescription opioid recipients. She responded, "Yeah, I smoke weed." She will come back in six weeks for her drug screen. The physician told me that this doesn't always work out: "One of my patients failed the drug test for marijuana. I gave him a second chance six weeks later. He remarkably tested clean for weed… but positive for cocaine." He did not get the refill. My attending also mentioned that these new rules will be costly for patients. "Insurance companies generally do not pay for drug screening. Patients have to pay $200 out-of-pocket unless they're on Medicaid."

The next two patients, a 40-year-old man and a 70-year-old woman, both presented for follow-up due to chronic obstructive pulmonary disease (COPD). Both smoked a pack a day. The doctor told each, "If you keep this up, you will eventually be on oxygen." Both had no desire to quit. COPD patients have this terrible sensation of not being able to get a full breath. Most of the COPD patients I have seen are 60 or older. They figure that they are beyond the point where quitting will help. But this forty-year-old male who could not even walk up his driveway without an inhaler! I remembered on the drive to the office I heard the daily radio ad for an oxygen machine cleaning apparatus.

A gentleman in his late fifties presented for follow-up after an ED visit. He was accompanied by his daughter. His whole face was bruised, with a large lesion on his brow. He had a stiff neck. I went in first to interview him. What happened to you, sir? "I asked my neighbor to get his dog under control. The crackhead punched me in the face. I punched him right back. He has it much worse than me." No charges were pressed. We changed his bandages, and refilled some of his prescriptions.

A female in her thirties presented for epigastric pain. I interviewed her first and performed an abdominal exam. Tenderness was noted in her mid-epigastric region (above the belly-button). She had been taking lots of advil (NSAID) for lower back pain. NSAIDs block production of prostaglandins, an inflammatory signaling molecule, which are needed  Prostaglandins are needed in the stomach to produce mucous. Prolonged use can lead to severe stomach ulcers as the acid and stomach enzymes interact with the epithelial lining of the stomach. I could not rule out pancreatitis. This was one of the first cases where I could imagine the flow of the interview. It was exciting asking questions to rule out various hypothesizes on the differential. The experience highlighted the differences between diagnosticians and procedural work. We prescribed her omeprazole and told her to use tylenol, if needed, instead of ibuprofen. "If the pain doesn't get better, we'll have to get an ultrasound or scope. I can't rule out pancreatitis but it is probably just gastric ulcers."

The next patient was a construction worker in his late thirties presenting for a painful bump on his thumb. "I can barely work." The physician thought it was a gangrene cyst. He usually would drain it himself, but it was on a precarious location of the interphalangeal joint. We referred him to a hand specialist. He was hopeful he would be able to get an appointment before he wielded another jack-hammer.

The last patient at 5:00 pm, a male patient in his thirties, had trouble hearing in one ear. Examination with the otoscope revealed a waxy ear canal. The nurse and I used used an ear lavage with warm water and hydrogen peroxide to remove large chunks of wax. It took about 30 minutes.

The next day, a classmate and I discussed the construction worker's prospects of getting an early appointment with the hand specialist. He described how the earliest appointment with his primary care doctor was in a week and half. At the appointment, despite having seen this classmate on three previous occasions, the doctor had no idea who he was. After shadowing physicians for a few months, we had no trouble understanding this interaction. Doctors have to see enough patients to generate target RVUs (relative value units) and at the same time have to grapple with clumsy electronic medical record (EMR) systems. The already-limited time between patients is spent at a PC documenting the encounter. There is no time to review the next patient's chart. My physician mentor (in his 40s) says "the medical system is failing your generation."

Is there hope on the horizon? My mentor is able to save some time with the EMR by using dictation software, which "has improved remarkably in just a few years." The classmate whose wife is in physician assistant (PA) school said, "People talk about there being a physician shortage. I disagree. I think there is a huge physician surplus and not enough ACPs."  [ACP is an "advanced care practitioner," e.g., a nurse-practitioner or physician assistant]. He continued, "Ninety-five percent of cases could be managed with training consistent with ACPs; when they do not have enough training, they bring in the supervising M.D.. M.D.s should become more research-focused. I hate research so I am not sure why I am doing the M.D. route." PAs do not complete a residency after school; instead, they get a job paid much more than a resident salary. Further, PAs are able to switch specialities whenever they want.

Statistics for the week… Study: 12 hours. Sleep: 7 hours/night; Fun: 1 night. Example fun: A classmate’s mid-20s roommate is an accountant for the hospital. He has become a regular at our class outings, although he has not become involved with any female classmate to my knowledge. We threw a party for the post-tax season celebration where several PA and nursing students attended.

Year 1, Week 34

One of the first slides for the three hour-long lectures on higher cortical function involved an updated Gallz’s phrenology for 21st century tasks (https://blakerivers.files.wordpress.com/2010/06/male-female-brain.jpg). Tattooed Talia, sitting next to me, expressed outrage: "Shopping! Jealousy!" During a break, Pinterest Penelope, a female classmate and social chair whose laptop screen is often filled by Amazon or Pinterest during lecture, said to Talia, “I love your boots! Where did you get them?” Talia and Penelope spent the rest of the break discussing the challenges of ordering the right shoe size online.

A psychiatrist in his 50s came in to present research on schizophrenia. Schizophrenia runs in families. According to the NIMH, "The illness occurs in less than 1 percent of the general population, but it occurs in 10 percent of people who have a first-degree relative with the disorder, such as a parent, brother, or sister." According to the latest research, a region of the prefrontal cortex (surface area of the brain) is less metabolically active in individuals with schizophrenia. Unfortunately, nobody knows whether this is a cause or effect of schizophrenia. Nonetheless, the psychiatrist suggested screening individuals at risk of schizophrenia with fMRI(functional Magnetic Resonance Imaging) to measure prefrontal cortex activity. If below normal, preventative interventions could be attempted.

After lecture, the psychiatrist talked about his interest in the mental health of incarcerated individuals. "Society is committing genocide against these prisoners, primarily blacks. They develop terrible mental illnesses in childhood. When they become incarcerated these illnesses spiral out of control. It is a sick cycle." He was lobbying state legislature for more extensive mental health programs in state jails. He also talked why he loves psychiatry. "It is a surreal experience to witness some of these disorders. Bipolar disorder causes patients to swing between fits of mania and extreme depression. We can predict these cycles with almost pinpoint accuracy."

We had two hour-long lectures on cerebral blood regulation. The brain always needs 750mL of oxygenated, glucose-rich blood per minute. That's 15 percent of resting cardiac output, which totals roughly 5L per minute. When you begin to exercise, stroke volume and heart rate increase causing a surge in cardiac output to about 12L per minute. How does the brain maintain constant perfusion (blood supply to tissues) while cardiac output varies? The increased pressure is sensed by stretch receptors in arteriole walls of the brain. The increased wall tension causes the arteriole smooth muscle to constrict to relieve this increased wall tension. This myogenic (muscle) response increases the vascular resistance of the brain tissue, thus maintaining the 750mL-per-minute perfusion, and diverting flow to other areas of lower resistance, for example, muscle. The opposite occurs when there is a decreased cardiac output from, from example, hypovolemic shock or cardiac insufficiency.

The two lectures that followed detailed anatomy of cerebral blood supply. The blood supply to the brain originates from the carotid arteries and the vertebral arteries. These form a miraculous structure at the base of the brain called the Circle of Willis. If one contributory artery is blocked, the brain will still get plenty of flow from the others. Doc J commented, “Evolution clearly valued ensuring the brain gets its oxygen and glucose.” The Circle of Willis feeds the six bilateral (left/right) arteries of the brain: left/right anterior cerebral artery (ACA), left/right middle cerebral artery (MCA) and left/right posterior cerebral arteries (PCA). The MCAs supply most of the brain. Unlike other tissues such as muscles, the brain does not have any energy reserves. Without a continuous supply of glucose (or ketones in the fasting state) and oxygen, brain tissue begins to die within minutes. A classmate and his girlfriend are passionate about fitness and supplements. They fast for three days every two months to "reset the system". He thinks a brain diet of ketones will help prevent Alzheimer's Disease.

Anatomy lab investigated the contours of the cranial cavity and the main blood structures. Due to time constraints, the instructors decided to perform the time-consuming removal of the brains from our cadavers' skulls. Next week we will explore "brains in buckets". Some students were disappointed. "I've been looking forward all year to removing the brain." One of our favorite labs was during the heart unit. We were simply asked to "remove the heart". A student commented how he found removing the structures that anchors the organ of interest helps build understanding of the anatomic relationships.

With the brains removed, we saw the holes (termed foramina and fissures) in the cranial cavity through which structures such as nerves and blood vessels pass. There are 12 holes per side that we need to know, e.g., foramen magnum (for the spinal cord), superior orbital fissure (optic nerve and ophthalmic artery), foramen rotundum (sensation of the face), and the hypoglossal foramen (nerve to tongue muscles). About half the cadavers still had their Circle of Willis. It looks more like a pentagon. You quickly appreciate how anatomic variations can lead to immense clinical differences for the exact same stroke. Some cadavers have more developed connections within the Circle of Willis (posterior communicating arteries and anterior communicating artery). These individuals would have a less severe stroke with an occluded carotid artery.

My favorite trauma surgeon discussed the two different types of strokes. An embolic stroke is caused by a decrease in blood perfusion to a part of the brain. This is commonly caused by a blood clot traveling up to an artery of the brain or from the slow accumulation of plaque causing stenosis (narrowing) of an artery that supplies the brain. A hemorrhagic stroke is caused by blood leaking out from a vessel, typically from a ruptured aneurysm or prolonged hypertension causing small tears in a capillary bed. We viewed different MRI and CT scans of strokes. She described the "Death-Star" sign. A subarachnoid hemorrhage ("sudden worst headache of your life") in the Circle of Willis leads to a five-pointed star on CT scan as the blood pools in the contours of the cranial cavity.

A first-year vascular surgeon fellow attended the dissection. He described the carotid endarterectomy, a procedure to treat Atherosclerosis (hardening and narrowing of arteries) and thereby reduce the risk of stroke. The common carotid artery bifurcates into an external and internal carotid artery typically a few centimeters above the thyroid cartilage at a bone called the hyoid bone. The turbulent flow at this bifurcation makes this a high risk site for plaque build-up and intimal (innermost layer of blood vessel) thickening causing stenosis (narrowing) of the internal carotid. The increased blood velocity and shear stress on the plaque wall increase the chance that a small calcium deposit will chip off. As this silent killer travels from the large diameter carotid to smaller arteries, the small deposit begins to enlarge as the body’s clotting system takes over. This blood clot can then get lodged in a small artery. If it gets lodged in the ophthalmic artery, for example, it would causing sudden “curtains to fall” as the retina becomes starved. If it occludes part of the middle cerebral artery, it might cause weakness of the upper extremity and face.

Carotid plaque can decrease overall perfusion pressure to the brain. The Circle of Willis can maintain normal cerebral perfusion pressure with 85 percent stenosis of single internal carotid artery. Above 85 percent, the brain tissue supplied by the end of the main arteries begin to get less flow, leading to a "watershed infarct" with slurred speech and poor comprehension of words.

The carotid endarterectomy is analogous to snaking out a slow bathtub drain. The vascular surgeon detailed the steps while making cuts into a cadaver. He made an incision along the neck exposing the sternocleidomastoid muscle (SCM). The SCM was retracted to reveal the carotid sheath. He opened the carotid sheath and retracted the internal jugular vein and vagus nerve before clamping the carotid arter. In a live patient, he would then have measured the back-flow pressure distal to the clamp. "I need to ensure there is enough perfusion from the Circle of Willis to maintain perfusion of the entire brain without one carotid artery. If the pressure is below about 40 mmHg, I need to create a shunt [install a bypass] of this clamped flow." He then opened the carotid artery and scraped away some plaque. He gave us the opportunity to feel the vessel. The cadaver's carotid artery had severe stenosis (greater than 85 percent). The plaque, hard due to the calcium deposits, comes off in sheets. Over half the thickness of the artery was plaque! He then sutured together the carotid vessel incision and closed the wound.

What's the biggest risk of this stroke-prevention surgery? Postoperative stroke. "It's impossible to get all the plaque because it goes all along the vessel. You have to decide where to stop." The surgeon described how he has to ensure that the interior of the artery is smooth. Otherwise these plaque edges will stick out and become dislodged from the shear stress of the blood flow.

The vascular surgeon urged us to follow our interests: "I am still in disbelief I get up every morning and get to perform what I love. It’s just crazy to think about. There is nothing like surgery. Don’t let the amount of time for training turn you off of surgery or any other speciality. Follow your passion." (Fortunately we're all in medical school, so the economic consequences of this advice are not as potentially disastrous as following our passion for painting or poetry.)

Our patient case: Jerry, a fit 42-year-old male presenting to the ED for upper extremity weakness and slurred speech. Jerry noticed he had trouble holding his toothbrush before bed. "When I grabbed the cup of mouthwash, I dropped it. I thought to myself, 'Huh? This is weird.'" I forgot about it and went to bed. When I woke up, my wife said that I was slurring my words. She rushed me to the hospital where everything went black.

Jerry was having a stroke in his MCA. His wife described how furious she was with the doctors. "It seemed like they were just sitting around twiddling their thumbs." The neurologist added, "Because we did not know when the stroke really set in, we could not use TPA. [Tissue plasminogen activator is a potent clot buster.] Guidelines state that unless you can identify the occlusion occurred within an hour, TPA administration could cause hemorrhagic stroke causing more harm than good." [A recent article in NEJM recently disputes this time restriction. (http://www.nejm.org/doi/full/10.1056/NEJM199512143332401#t=article).]

Jerry had a relatively minor stroke in a small branch of the left MCA. It still took months to recover from it. He had trouble with his right arms, swallowing and speaking. "I could barely speak for three weeks." He went to occupational therapy for two months. Most people would now have a hard time realizing Jerry had a stroke. "The main issue I have is that I cannot feel my entire right chest, shoulder and upper back. Some words seem to have just left me. I cannot seem to recall a lot of complicated words."

"What scares me the most is why this happened. I am a pretty fit person." The neurologist explained that the Jerry does not have the main risk factors for a stroke. "He does not smoke, does not have afib [atrial fibrillation]. We could not even find an ASD [atrial-septal defect]." He brought up the ASCVD risk estimator to show he was doing pretty well (http://tools.acc.org/ascvd-risk-estimator/). This nagged at Jerry. "I did not know what to tell my two kids." The neurologist recommended he join a clinical trial with a new drug to prevent strokes. "This clinical trial has given me confidence, even though I don't know if I am on the drug or the placebo. I just believe it is doing something." After one year, Jerry will know to which group he had been assigned and, regardless of his original group, will have the option to be on the new drug.

Type-A Anita is soliciting $12,000 in donations on KickStarter for a “historic photo book”. This will contain Anita's, and others', photos of protests over the first one hundred days of President Trump. Her Facebook post request contributions from friends and family: "Thank you & Keep Marching!" She has $2,200 pledged.

Statistics for the week… Study: 20 hours. Sleep: 7 hours/night; Fun: 1 night. Example fun: Jane and I took a break from studying and took a boat around a nearby lake with her family. George, a classmate in his late 20s, got engaged over the weekend during a beach getaway. I commented on their Facebook post: "Congrats, Julie, I cannot wait for you to move to here!" This created havoc. Julie, a marriage counselor, had not told her boss that she was moving. She frantically told George to delete the post.

Year 1 Week 35

Three hour-long lectures on child development. A student commented, "Who knew that children are blind as a bat when they are born. 20/300 vision!" Afterwards, several instructors brought in children aged one month to five years for a workshop. Each pediatrician noted specific tasks, behaviors and skills. Dorothy Disinterested was reprimanded for "not being interested in the subject material and being on her cellphone". Dorothy explained afterwards, "I am just not interested in children."

Also three hour-long lectures on cerebrospinal fluid (CSF) circulation. The brain is surrounded by an outer connective tissue called the meninges (meningitis is the inflammation of this connective tissue) composed of three layers (outer to inner): dura, arachnoid, and pia. The dura, a fibrous white sheet, is strongly adhered to the inside of the skull and, via dura folds, divides the cranial cavity into quadrants. The falx cerebri divides the brain into left and right hemispheres. The tentorium cerebelli is a horizontal sheet that separates the cerebrum (above) from the cerebellum (below).  These dural folds are tightly adhered to the arachnoid, named for its resemblance to a spider web, a clear membrane that wraps around the exterior surface of the brain. The innermost layer is the pia, another thin membrane, follows the contours of the brain into its crevices (sulci and fissures). The subarachnoid space, the space between the arachnoid covering and the tightly adhered pia, is filled with CSF.

CSF is produced in four connected brain cavities called ventricles. The left and right lateral ventricles connect to the third ventricle through a thin constriction called the interventricular foramen of Monro. The third ventricle drains through a narrow constriction called the Aqueduct of Sylvius into the fourth ventricle of the brainstem. CSF exits the fourth ventricle into the subarachnoid space through three foramina (the two lateral Foramina of Luschka and the medial foramen of Magendie). Students appreciated that the early 19th-century anatomists who discovered these respective structures have last names whose first letters correspond to the structures' anatomical positions: Francois Magendie for medial; Hubert von Luschka for lateral.

The CSF suspends the brain in fluid, thereby protecting the delicate tissue structure from small shocks and providing a buoyancy effect, which turns a 1500-gram brain into 25 grams. Without the buoyancy effect, the weight of the brain would crush itself. Each ventricle contains a choroid plexus where 500mL CSF, enough for four complete daily changes, is produced by ependymal cells. CSF circulates through the ventricles, draining metabolic waste products of neurological activity, such as glutamate (excitatory neurotransmitter) and potassium, into the subarachnoid space.

My favorite trauma surgeon explained the different types of hemorrhages. Blunt trauma can fracture the skull causing an epidural hemorrhage, rupture of the meningeal arteries that travel along the inside surface skull. After a car crash, the patient will go unconscious. They will then wake up for a "lucid interval" of roughly 30 minutes, then suddenly go unconscious again as the ruptured meningeal artery leaks into the brain. A subdural hemorrhage typically occurs in old age. The brain shrinks, which stretches the small veins that drain blood from the brain to the large venous sinuses in the dura. Slight trauma can then cause the veins to rupture, starting a slow bleed that brings the patient into the ED days or weeks later with headache and confusion. Both types of hemorrhages can result in sufficient elevation of pressure to cause herniation of the brain, in which parts of the cortex protrude through holes in the skull.

Our patient case: Greg, a 23-year-old male with Mike, his cardiologist father and Jennifer, his nurse mother. Jennifer's pregnancy was completely normal until a 30-week ultrasound. The obstetrician noted an enlarged skull with a protrusion on the right side. The mother explained, "My OB told me, 'Something came up on the ultrasound that we need to take another look at.' I knew something was wrong. Whenever a physician sees something bad that they have to refer you out to a specialist, they refuse to tell you a definitive answer.." Jennifer waited several hours in the waiting room until the specialist could see her. "I did not want to call Mike because he was dealing with a tough heart case."

Further ultrasound examination confirmed that Greg's Aqueduct of Sylvius had narrowed, causing hydrocephalus (abnormal accumulation of CSF). The choroid plexus continues to produce CSF despite the increasing ventricular pressure in his lateral and third ventricles. The increased ventricular pressure and size was damaging developing brain tissue and preventing the skull from closing. The physicians told Mike and Jennifer that Greg would unlikely be able to survive and that, if he did, he would have severe cognitive deficits.

"We knew this was bad," continued Jennifer. "We both have medical backgrounds so we were imagining the worse. Mike immediately became an expert on this condition. Keep in mind in those days Google was not around. Mike went to medical libraries to scour the limited literature on this condition and its outcomes. Our doctors recommended we terminate the pregnancy. But when I saw the ultrasound, I could not terminate. He was my boy." Jennifer was immediately scheduled for a cesarean section. Greg was whisked away to the NICU for intensive treatment. He had a ventriculoperitoneal shunt (tube inserted through brain tissue into a ventricle to drain CSF into the peritoneal cavity) and several cranial skull surgeries to release the increased intracranial pressure.

Greg is 5'5 with a cheerful smile. He speaks slowly but carefully. "More articulate than some of our classmates," commented one student afterwards. He chuckles after his jokes. He has terrible vision as a consequence of visual cortex damage.

Most of Greg's medical care occurred in his infancy. He had two additional surgeries to restructure his skull at age 8 and 14.  He lives with his parents and works part-time as a clerk at a local grocery store. His mother said that Greg's social life is more active than their own: "There are all these support groups for disabled people. I feel like every week I am ferrying him to an event downtown." He is intellectually disabled but has an encyclopedic knowledge of the Harry Potter books. Several female classmates tested his knowledge after the session.

One week before exams and Pinterest Penelope, our class social chair, released the results of "class superlatives", one per student. One student complained about the distraction from studying: "She is just trying to sabotage us." I received, “Most likely to ask Low Yield Questions in Lecture”. Type-A Anita got, “Most Likely to Complain About Said Low Yield Question Asker”. Our lone Canadian (we have no other foreign students) got "Most likely to curse in front of a patient." Our class president received, "Most likely to use 'I'm a Doctor' line at the bar". The shy Asian received, "Most likely to ruin his/her white coat and need to order another". Dorothy Disinterested apparently does have at least some interests. She received "Most likely to hook-up with a patient" (as the social chair is also female, this did not generate any complaints to the deans).

Statistics for the week… Study: 20 hours. Sleep: 7 hours/night; Fun: 1 day. Example fun: a "finisher prize" for the last day of class, beer and burgers with four classmates.

Year 1, Week 36

Exam week and most of us are feeling burned out. "I just want to get this over with," lamented one classmate. "Studying another few hours won't change anything."

We had four exams, three hours each, one per day, from Monday through Thursday, starting at 8:00 am or 9:00 am. All were computer-based.

The main NBME exam was challenging and surprisingly clinically-focused. Example: "Where is the lesion for someone who has right-sided intention tremor?" (Answer: right cerebellum; not everything in the brain is cross-wired.) Type-A Anita complained, "I thought it would be much more detailed and less big picture. I studied all the wrong things." There were numerous questions on peripheral nerve deficits as a result of disk herniation. Students complained that this subject was not covered in "significant detail" during lectures.

The anatomy exam, developed locally by Doctor J, was a blend of challenging second-order questions and basic identification questions, with both multiple-choice and short-answer styles. Students complained that the second-order questions as not testing only "anatomy material". For example, three students complained about questions asking to locate the lesion site for various visual field deficients. Several memorable questions started with a group of stroke symptoms and asked the student to identify the blood vessel most likely affected. Students were outraged at these applied questions. "I cannot believe Doctor J put that question in. He put that in just to screw us over."

Students were also frustrated by the locally-developed clinical exam covering the HEENT (head, ear, eye, nose, and throat) exam, the neurological exam, and child development. We looked at computer images of different retinas. Given a description of a patient's reflexes, we had to name the peripheral nerve or spinal nerve roots that might be damaged. We looked at a computer screen image of an ear canal that we would have seen through an otoscope. We were asked to identify the age of kids based on certain observable skills and behaviors. Type-A Anita complained to several classmates, "I don't need to know this for Step 1" (the board exam we will take at the end of our second year). The classmates echoed back, "I don't need to know this because I don't want to be a pediatrician." Students complained about the image quality of the ear canal, even though a higher quality image would not have helped them answer the question. Students complained, "This material overlapped with our other exams."

The patient case exam asked to propose hypotheses for various clinical scenarios. What tests would you order? What diseases should be on your differential for this given test result? What other information would you want to know? How would you manage this patient with Parkinson's? What other symptoms and test results would you expect from this patient? Most students do not study for this exam. Students complained about the drugs that were covered.

After our last exam, Jane and I went to a brewery. Students trickled in as people finished. "Cheers to another step to becoming a doctor!" Dorothy Disinterested responded, "I have lost so much faith in our medical system. It scares me to think that we are one-quarter of the way to doing stuff to patients."

Statistics for the week… Study: 15 hours. Sleep: 5 hours/night; Fun: 1 night. Example fun: We met at a classmate's apartment for pool and darts around 8:00 pm before heading downtown for an "End of M1" celebration. My classmate and I went to a less crowded part of the bar to get another beer. We were listening to a bartender's conversation with some of her friends. A friend asked the bartender, “What have you been up to since you graduated college?” She responded, “Working here pretty much.” My friend commented afterwards, "That's too bad she went to college with all that debt. She could have been the manager by now if she started after high school."

Year 1 Wrap-Up

Nearly every answer in medical school spurred another question until finally the answer wasn't known or wasn't answerable in the limited time for each subject. I eventually got used to the frustration that the system at-hand was too complex for a simple generalization. The every-two-month exam cycle gives students a sprint mentality, but I came to realize that it was okay to not know everything. Medical school is a marathon, not a sprint.

One year done and I'm more excited about working in healthcare, but disillusioned about the trajectory of American health. Diabetes, drug abuse, premature heart disease, psychosis. These are not typically driven by genetics, but rather symptoms of the society that we've built. Americans expect the healthcare system to clean up the mess, but seldom are doctors able to provide a complete cure for these ills of modern society.

I have also become disillusioned about our ability to formulate health care policy. We learned about ongoing clinical trials that pay diabetics to exercise and eat better, similar to the classic "A behavioral approach to achieving initial cocaine abstinence" (Higgins, et al. Am J Psychiatry, 1991), in which patients were given $1,000 to stay clean for 12 weeks rather than being put into rehab ($1,000 per day?). This could be much cheaper than Medicaid and Medicare paying to treat the inevitable complications. Politicians make beautiful speeches taking credit for providing insurance to millions of Americans, but where are these people who have purportedly been helped? Some of the hardest working people I met in the clinic made too much to qualify for Medicaid, but not enough to afford an Obamacare policy. They eventually have to stop work and show up in clinic with a far worse prognosis, e.g., half a foot that needs to be amputated, and the bill is paid by Medicaid or absorbed by the hospital's charity care fund.

At least in our university-run, mostly Medicaid/Medicare-funded, health care system, I didn't see obvious examples of what Jack Wennberg, the founder of clinical evaluative sciences, called "supplier-induced demand." However, my attendings would nearly always refer patients to specialists out of fear of "missing something," and every stubbed toe got an X-ray. Perhaps Wennberg's estimate that 30 percent of healthcare expenditures are unnecessary or harmful is correct, but it wasn't obvious which 30 percent we should have cut.

As a child I associated healthcare with doctors and nurses. One trip to the most popular restaurant across from the hospital campus and Jane and I realized that it was really more about administrators, lawyers, IT, and Human Resources staffers. I'm no longer surprised to see a hospital employee badge reading "business development officer" pinned to a business suit.

Classmates often wonder "Why does medical school cost so much?" Our conclusion is that the enemy may be us. Administrators and deans have proliferated along with LCME requirements in the name of creating an fair and equitable learning environment. Is it helpful to have lectures recorded? Yes, but it requires a huge IT department and expensive software. Our gym was just upgraded, which seems to have been a marketing decision because most classmates didn't know that we had an in-school gym within the school in addition to the membership at a comprehensive fitness center (with pool!) that is covered by our tuition. The Wellness Committee and the Office of Inclusion and Diversity, led by a Ph.D. psychologist, seem to have unlimited funding to hold seminars on self-defense and microaggressions (I try never to miss one due to the great catering from local restaurants); funding for student-organized events on medical topics, such as a suture workshop, is limited to $2.50 per attendee and can be challenging to obtain. Waste is noted, but seldom criticized, due to the free-flowing Federal spigot of student loan funds.

I conducted an informal survey of classmates towards the end of the year. Some of their responses are below.

What has surprised you?

"The amount of independence. You hear about all these learning environment resources, different subjects, supplemental materials for purchase like Anki and Firecracker. It is pretty overwhelming at first. I eventually realized that if I just study the exact the same way [as in undergraduate courses] then I do well. It is just school." [Jane]

"That I could actually be interested in surgery." [Disinterested Dorothy, originally planning to follow her father into internal medicine]

"People like talking about their health problems." [He obviously hadn't met my grandfather!]

Is it more or less studying than you expected? 

"Less overall but exam week is brutal. It's the way it is, not the way it should be.  I regret not being as organized and dedicated as some students. I would study more spread out instead of cramming before." [Jane]

What did you wish you knew about healthcare that you know now? 

"I always thought doctors were unquestionable. Doctors are human. Ask them questions. If they are not explaining the reason, they are not doing their job right. I now know there are good doctors and bad doctors." [let's hope that she doesn't practice these sorting skills at home; she's the daughter of a physician]

"Healthcare is challenging but it is more accessible than people would think. I approach healthcare as a field in which if you work hard enough or study long enough you can succeed. Compare this to, for example, computer programming or engineering. No matter how hard I worked at that, I just could not do it." [she majored in biology as an undergrad]

What do you like about the class and what do you not like about the class?  

"I like how our class is fun and likes to hang out with each other. We have a good sense of humor. What do I not like? Our class will complain about anything. They can also be quite disrespectful." [Jane]

Do you wish you took time off before medical school.  Gap year or no? 

"No stigma either way.  Straight in or five years out doesn't matter. Once you are here, you are here." [Youngest classmate]

"It took me three application cycles to get into a school." [Straight-Shooter Sally]

"I am glad I took a gap year. I don't think I was intellectually mature enough to go straight through. I think I would have fooled around with all the free time in medical school if I didn't learn some discipline working in the real world." [Male classmate who worked for pharmaceutical company]

"I am glad I am here, but certain specialities are off the table for me. I'm too old!" [Upperclassman who started medical school at 35]

What do you think about our teachers?  

"Passion is infectious.  When someone is passionate you can't help but listen to them. M.D.s are more fun than Ph.D.s. Teachers talk about what they know. They know their patients. That's why we are here." [undergraduate physicist major known as the class gunner]

"About a third of the instructors are great. I give an instructor one chance. If I don't like them, I no longer show up for lecture." [Classmate notoriously late for the few lectures he does attend. If the class gives him the heads up it was worthwhile, he might watch the recorded lecture online.]

What do you think about anatomy?

"I liked MSK (musculocutaneous) dissections. It was satisfying using your hands to isolate muscle and fascia layers. Reproductive was pretty cool too. I literally cut a penis in half and took the fascia layers apart. Not many people can say that! Oh, and that bone saw was sick!" [Disinterested Dorothy]

"I hate anatomy. You cannot see anything in a cadaver. So excited to be done with it." [Pinterest Penelope apparently has better things to do]

"Anatomy is the best part of medical school. It is the unique topic for medical school. All the other material a lot of us have have been to exposed to in various undergraduate majors. No one gets exposed to anatomy, at least at this level."

Anatomy Advice for M1?

"Get in there to get over. Thinking about it is bigger issue. I never had issue. Doesn't feel real because the cadavers are cold."

"It is pretty rare to have surgeons take time out of their day to spend two hours helping you dissect. Take advantage of it.  You get out what you put in. Be interested in what you are doing. It looks bad when half the class leaves early from lab." [Jane]

"Buy a pair of scrubs. You look badass and that way you won't get your normal clothes smelling like the lab." [Class Orthopod]

What are you excited about?

"Being a doctor allows you to make a decent living wherever you want to live. You don't have to live in a big city where all the jobs are for young people." [Classmate from Kansas]

"All my friends and family ask me about their health problems. It is fun to play doctor. We can now understand what is wrong with them. Ask us what to do about it? We are no better than the internet. Patient care comes from experience, not from education. I'm excited to eventually be able to answer their questions with action."

What is something you would change? 

"Administration treats us as kids, not adults. There is a resource for everything." [Classmate who juggles a newborn and toddler with medical school studies]

"The cost of tuition. The founding of for-profit medical schools tells you all you need to know." [Classmate with PA-student wife]

"Just tell me what is going to be on Step I. I do not have time nor the brain space for anything else." [Type-A Anita…]

"Residency match. If you want to do a speciality, it has become so competitive. The Match is in a death spiral." [Class Orthopod]

Following the curriculum isn't enough if you want to be a good doctor. Friends at other schools, a few classmates, and a physician mentor agree that the focus of medical school is ensuring that the lowest denominator passes, not challenging each student to reach his or her highest potential. The resources are there for anyone who wants to take the initiative, but peer pressure works in the opposite direction. The most vocal students echo each other's complaints that the curriculum isn't sufficiently test-focused.

First year for most students serves a reminder that not all of us are special. Most medical students were near the top of their undergraduate class, but that was partly because their fear of failure (failure = less than an A) was so great they didn't take challenging courses. Classmates' first reaction to getting a question wrong may be to assert that the question was unfair, poorly worded, or that the answer was not worth cramming into our already crammed brains. We expect to be the discoverer of a new drug or the manager of a big project. One of my bosses during my gap year said, "What we really need are great employees. Leadership comes afterwards." The more that I shed the entitlement mentality, the more I was able to focus on my strengths.

One thing that I learned is that medical students don't relax until a few months prior to graduation. Classmates traded their fear of not getting into their first-choice medical school for three years of anxiety of not doing well enough on Step I (end of second year) and in rotations (third year) to get into their first-choice residency. One of our clerkship directors sent us an article about the surgery residency match process: "This leaves the 163 orthopedic residencies that participate in the Match in the unenviable position of having to sort through 88,169 applications for 717 total positions from just over 1,000 total applicants." (Scott E. Porter, JAAOS, 2017)  I.e., a typical applicant applied to 88 programs, more than half of the total programs nationwide. Maybe the Web-based Match software will need to be updated with a Select All option…

Year 2, Week 1

We gathered at a Sunday barbecue before our first day of the second year. We won't expect to see too much of Awkward Allen because he married a business consultant who works two hours away and moved in with his wife. Although several students toiled away in our research labs over the break, most people took at least a short vacation. The young father whose wife is in law school jetted off to Europe: "our first vacation since the baby was born eight months ago." Baby was parked with the grandparents for two weeks. Two classmates coincidentally were both on separate vacations with parents and siblings to Peru. They took different approaches to anthropology. One camped in the mountains among the Inca ruins. The other reported, "the alcohol is so cheap there. Our family's whole tab for a week was seventy bucks!"

We're nervous about this block, covering clinical microbiology (everything that can cause an infection: bacteria, viruses, fungi, parasites, autoimmune disorders). All of last year's blocks were centered around a single physiology textbook. We'll be using a diversity of materials, many self-selected, for microbiology. About a fourth of students started researching textbooks and studying during the break. The general consensus of upperclassmen, based on the class Facebook and Group-Me chat, is to use Sketchy Micro. These are a video series of narrated progressive illustrations. For example, they will draw a cat for bacteria that are catalase-positive, or draw a van for bacteria that the recommended antibiotic treatment is vancomycin. In our new small-groups, some students close their eyes to imagine the illustration. It seems odd, but it works for them. So far I'm just using a textbook: Medical Microbiology by Murray.

Reflecting modern education's prioritization of bureaucracy over academics, M2 opened with an hour-long orientation led by two deans, experts on paperwork for the LCME. This year will be clinically-focused in comparison to last year's emphasis on basic science. This will prepare us for the rotations of M3 and M4, our "clerkship years." We need to be able to conduct a full history and targeted physical exam, then present this to our attending or resident with our differential diagnoses. Most lectures will be conducted by practicing clinicians, instead of PhDs, requiring scheduling flexibility on our part.

Our first lecture began on Monday at 9:00 am, right after the orientation. An Emergency Medicine physician in his mid-thirties specializing in the management of sepsis kicked off what promises to be a jam-packed two weeks of bacteriology. Our textbooks give the illusion that the moment you send a sample (e.g., blood, stool, urine, or sputum) off to the "Lab", the identity of the bacteria is immediately ascertained. "When I have a potential septic patient in the ED, I do not have two days to wait to grow a culture. Instead, I will get back a few key findings in maybe two hours before the full report. The prelim report will give me Gram-staining. If the identified bacteria is Gram-positive they will also run a quick catalase enzyme activity." I was excited to check the Google Calendar and see that he is returning for two more lecture this week. My female classmates were also excited, characterizing our lecturer as "dreamy."

 

Afterwards, a 45-year-old lab technician from Quest Diagnostics came in with three boxes of samples to lead a workshop. He explained how he runs 10 of the tests that we might order. He opened with a colony of methicillin-resistant staphylococcus aureus (MRSA), the bacteria that causes pneumonia, sepsis, endocarditis, and skin infections, and ran a quick catalase test. The petri dish had small transparencies in the agar gel demonstrating MRSA's ability to lyse red blood cells. He took a swab, swiped a colony on the petri dish and put some hydrogen peroxide on the swab. We saw it start bubbling up. "Now you know it is MRSA, and not Strep." He showed us two McConkey growth plates where a colony of pink lactose-fermenting, harmless E Coli contrasted with a dull-yellow strain of Salmonellae. Students afterwards commented, "He knew a lot, and this was a perfect complement to the theory, but I wish he would stop waving that swab around. I don't want to catch MRSA!"

Lectures afterwards delved into the main categories of bacteria defined by the Gram stain. Gram-positive bacteria have a thick outer peptidoglycan (sugars cross-linked with short peptide bridges) cell wall outside its cell membrane; Gram-negative bacteria have an additional outer lipid membrane covering its thinner cell wall. This key difference, specifically the presence or absence of a second cell membrane, will affect the virulence (ability to cause disease) and susceptibility to various antibiotics.

We learned that there is a fine line between hosting normal bacterial flora and being on the verge of death from infection. For example, Streptococcus pneumoniae, the most common cause of bacterial pneumonia, is a normal component of the oropharynx and throat. Pneumonia ensues when oropharynx secretions are aspirated (entry into larynx and respiratory tract) and the protective mucous lining of the upper respiratory tract is diminished by IgA protease secretion. The "flesh-eating" bacteria, Streptococcus pyogenes is also the culprit of the common strep throat in children. S. pyogenes produces many virulent proteins that enable its spread but induce a strong immune response. M-protein on its cell wall prevent phagocytosis, but elicits a strong antibody response. Sometimes, S. pyogenes release streptolysins and pyrogenic exotoxins that lead to Scarlet Fever or potentially Toxic Shock Syndrome from systemic activation of the immune system. The surge of antibodies produced during a S. pyogenes infection can lead to Rheumatic Fever (involving heart inflammation) and Post-Strep Glomeuruloar Nephritis (inflmmation of kidney from small immune deposits). According to the  American Academy of Family Physicians, "Although antibiotics have been shown to reduce the severity of acute symptoms and shorten the duration of the illness by about one day, more than 90 percent of treated and untreated patients with acute pharyngitis are symptom-free by day 7. Therefore, the primary reason for treating uncomplicated streptococcal pharyngitis is to markedly reduce the incidence of subsequent rheumatic fever" and other serious complications. Many people, especially if they work in healthcare, host Staphylococcus aureus in peaceful colonies on their skin. A small cut or abrasion in the skin can let Staph in where it will usually cause a benign skin infection, but sometimes can lead to release of Staphylococcal Toxic Shock Syndrome Toxin. This toxin, called a superantigen because it can lead to activation of twenty percent of T-cells, endothelial cell dysfunction, and shock. If the strain is methicillin-resistant (MRSA), treatment is vancomycin to kill the bacteria, and fluids, vasopressors, and blood transfusions to address the life-threatening symptoms of shock.

Our best defense against harmful bacteria seems to be other bacteria. Our body realized that we cannot beat them, so instead our immune system attempts to supervise the ecosystem. Numerous surfaces  skin, oral cavity, gut, urogenital canal  are colonized with competing bacteria that prevent any single one from domination (most antibiotics are copies of compounds secreted by one bacteria to inhibit the growth of another). Some of the worst infections occur when the entire ecosystem is wiped out after administration of a broad-spectrum antibiotic. Babies are vulnerable due to immature flora and immune systems, which is why women in the 35th week of pregnancy are screened for vaginal colonization of Streptococcal agalactiae (group B strep). If the baby picks up S. agalactiae during delivery, it could lead to bacteremia (bacteria in the blood), pneumonia, and meningitis.

The EM physician emphasized that the physiological response to an infection is not necessarily indicative of the degree of colonization. "Infection is just one component of septic shock." Septic shock occurs from the immune system's overreaction to an unwelcome guest. In fact, gastroenteritis can even be caused without eating a food infected with staphylococcus. If staphylococcus had ever been colonized in the food, it could deposit toxins that are resistant to heat and cold. "The bacteria could be long gone from a contained piece of food and cause severe gastroenteritis even if nothing is colonizing the gut. Simply the immune system reaction is enough." Antibiotics do not help against toxins.

 

Our patient case: Ellie, a 30-year-old female, was vacationing with a group in the Caribbean a year earlier. Ten group members got diarrhea after eating ice cream. After three days of symptoms, she and her husband went to a clinic where they waited briefly until the doctor showed up on a moped. The doctor explained that they didn't normally give meds for these symptoms, but the husband insisted and Ellie received a single dose of an unknown antibiotic. Her GI symptoms improved after three days, but four days later she developed general malaise, 102-degree fever, myalgia (muscle pain), petechiae (small diffuse red specks on the skin) and hemoptysis (coughing up blood). Ellie made it home, but these symptoms persisted for two weeks. Her primary care doctor referred her to an infectious disease (ID) specialist for further evaluation.

 

The ID physician, who did his residency in Ghana seeing nasty infections every day, explained, "This case really perplexed me. It was not a typical presentation nor clinical course." She was put on a seven-day course of levofloxacin for suspected Typhoid fever. A blood culture came back normal, but her stool sample revealed a non-typhoid fever strain of salmonella, a bacteria that infects the gut immune system. Typhoid-causing salmonella is distinguished by a short DNA piece. This gene island allows the bacteria to hitch a ride with macrophages to infect organs beyond the gut. Despite the antibiotic treatment covering salmonella, her symptoms did not improve. "I was convinced I had dengue fever. There was a CDC warning about it," explained Ellie. This fear was compounded because the ID doctor was uncertain about his diagnosis. "It can take up to a week after this treatment for symptoms to get better. Throughout the whole experience I was not sure her constitutional symptoms were due to the salmonella infection. Typically a non-typhoidal strain would be constrained to gastroenteritis which according to HPI [history of present illness] resolved quickly." On day seven, when he was going to re-evaluate her diagnosis and start her on another antibiotic treatment, her fever resolved. The ID physician hypothesized that the initial antibiotic dose may have caused Ellie's more serious problems by disrupting her ordinary bacterial flora.

The most surprising aspect of the case was that Ellie told us that she'd just returned from the same Caribbean island: "I did not go to the same ice-cream shop."

 

Statistics for the week… Study: 10 hours. Sleep: 8 hours/night; Fun: 2 days. Example fun: Jane and I joined Lanky Luke and his PA wife Sarcastic Samantha for a late afternoon beach-music concert followed by burgers at their pristine apartment. Samantha, in her final rotations at PA school, recently returned from her eight-week ED rotation in two nearby counties. "What shocked me about my ER rotation was that the docs are paid per patient and PAs are salaried. To maximize profit, all time-consuming procedures (e.g., central lines) are done by PAs. The result is that doctors tend to see the green triage patients [the least serious cases] while the PA is working with the yellow triage group. It just didn't make sense."

Year 2, Week 2

Three marathon 4-hour lecture sessions with infectious disease (ID) specialists. Some would cover over 10 different diseases caused by a specific bacterial strain in a mere hour time. Most of the information went in one ear and out the other, especially with the PhD microbiologists. About two-thirds of students stopped attending lecture after the first session. "I have to study this material on my own over several days to not suffer from information overload. I do not find getting bombarded at lecture is efficient use of my time." They missed a few clinical pearls from the more lively ID clinicians.

 

One ID doctor delved into the disease-filled, gram-positive, spore-forming, anaerobic genus Clostridium. Spores enable a bacterium to lay dormant, surviving external pressures such as extreme temperatures, pH, and sanitation chemicals. C. difficile is able to survive hand sanitizer and many hospital disinfectants. "Only thorough hand washing will get C diff off your hands. Hand sanitizer does nothing to it." C diff jumps from bed to bed in hospitals, causing terrible gastroenteritis. Although C. diff is not able to thrive against normal gut flora, after a broad-spectrum antibiotic that decimates the normal flora, C diff will overtake the gut leading to pseudomembranous colitis and the release of toxins that cause life-threatening rice-water diarrhea similar to cholera. The genus Clostridium also contains C. tetani and C. botulinum two related species that cause tetanus and botulism, respectively. C. tetani produces a neurotoxin that destroys inhibitory neuron activity producing a spastic paralysis, typified by lock-jaw. Why are rusty nails and dog bites associated with tetanus? The skin typically seals over a deep penetrating wound before it is fully repaired. Sealed off from the destructive power of oxygen, anaerobic bacteria such as Clostridium tetani thrive.  C. botulinum produces a similar neurotoxin, classified as a Tier I bioterrorism agent, that destroys neuromuscular junction activity, producing a flaccid paralysis. Otto Warmbier, the University of Virginia student imprisoned by North Korea, contracted botulism, which lead to respiratory arrest and coma. (The same Botulinum Toxin, "Botox," can be harnessed to extend the expiration date of the Hollywood elite.)

 

A 35-year-old overweight unkempt ID pharmacist and an internal medicine resident led a highly effective two-hour lecture and workshop. Unlike the pharmacist at your local Walgreens, pharmacists who work in hospitals must complete a residency. Our lecturer said that his job was to eliminate any bug that comes into his hospital. He went over the clinical impact of antibiotic resistance: "the never-ending arms race." "My job is to make you good stewards of antibiotics. Now, this can seem like a daunting task, especially when Cipro [broad-spectrum antibiotic] is OTC in Mexico, but let's give it a shot." The ID pharmacist added his opinion that there are few new antibiotic classes in the pharmaceutical pipeline because it is difficult to make a profit: "In addition to costing millions to bring a new drug to market, once it is in market, bacteria develop resistance so fast that it doesn’t have a long shelf-life. Further, the medical system reserves new antibiotics as a last line defense." A student shared a Harvard-Technion experiment on the class GroupMe illustrating the rapid generation of antibacterial resistant genes. Escherichia coli with a fluorescence probe was plated on one end of a giant agar plate with steps of increasing concentrations of the antibiotics trimethoprim (Bactrim) or ciprofloxacin A time-lapse video depicts bacterial colonies traversing onto each step and completely covering the sheet by 12 days.

The 27-year-old internal medicine resident, reminded us that Group A Strep (strepococcal pyogenes) is one-hundred percent sensitive to penicillin. "Don't be a jerk and give your poor patient a Z-pack," she cautioned. [Azithromycin is a broader-spectrum antibiotic.] We were also informed that hospitals in different regions have different antibiotic schedules: "MRSA is much more rare in rural Idaho than in NYC. I would be terrified to get hospitalized in NYC."

The workshop culminated in using iPads to play "Heads Up". One student would put the iPad on his or her head and, based on hints from other group members, try to guess the bacterium or antibiotic displayed on the screen, e.g., 1st-generation cephalosporin or Clostridium tetani.

My favorite lecture was by a 35-year-old emergency medicine physician on the management of sepsis, a systemic immune response to infection. The immune response causes blood vessels to dilate, thus reducing blood pressure (hypotension), leading to multiple organ failures ("septic shock"). Patients who show up in the ED with septic shock have a mortality rate of twenty-five percent. "I like how he made you feel like you were in the ED. He gave so many different clinical cases," commented a student after class.

The physician explained, "If a patient is in shock, I immediately conduct a RUSH (Rapid Ultrasound for Shock and Hypotension) exam. I am looking for what is causing the shock. Is it an internal bleed causing blood to pool in Morison's Pouch [between kidney and liver] or around the rectum?  Is it cardiac tamponade [fluid in the sac of the heart restricting its motion]?" Once he has determined septic shock, he starts the patient on antibiotics even without any confirmation of bacterial infection. He then determines if the patient is fluid-sensitive, i.e., if cardiac output would improve with IV saline. The Starling Curve describes cardiac output as a function of End Diastolic Volume (blood volume) for a given heart contractility and vascular tone. The physician continued, "We used to just give the standard 30mL/kg. [2 L for a 70 kg person.] Now electrical engineers have given us the NICOM [Non-invasive cardiac output monitoring] device to determine if someone is fluid-sensitive or insensitive." NICOM device uses two pairs of electrodes to measure the change in impedance across the chest to the abdomen as a bolus of fluid is injected into the patient. He concluded, "No idea how it works, but we use it everyday. It is pretty neat to see the Frank Starling Curve appear on the NICOM screen and watch the physiology we learn in medical school actually be applied."

Our patient case: A young ED physician describes his treatment of Abigail, a 26-year-old waitress attending community college for interior design. She presents to the ED for a worsening blood-tinged productive cough, fever, syncope (fainting episodes), and back pain. Over two months she has been to the ED twice and been prescribed different antibiotics for a productive cough and myalgia. With blood pressure of 80 over 55 and heart rate of 110, she is immediately recognized to be in shock and is transferred to the ICU. The RUSH exam reveals left ventricular dysfunction suggestive of distributive shock (leaky blood vessels from suspected sepsis infection decreasing blood volume). Even after a total of two liters of IV saline, she requires pressors (norepinephrine) to maintain a MAP (mean arterial pressure) above 65 mmHg.

"Her entire course changed from a simple question: 'Do you use drugs?'," explained the ED physician. Abigail confirmed she regularly injects oxycodone into her veins. "We immediately suspected septic shock with endocarditis [infection of heart tissue] likely from Staph aureus, which has a proclivity to infect the tricuspid valve after getting injected into the blood." Blood and sputum cultures grew methicillin-resistant Staphylococcus aureus (MRSA). She is immediately started on IV vancomycin (a non-penicillin-based antibiotic reserved for serious gram-positive hospital infections). Echocardiography reveals substantial vegetation on the tricuspid valve. The colonies were releasing small particles into her pulmonary circulation causing septic pulmonary emboli. In addition to heart and lung colonization, she developed osteomyelitis (bone infection) in her vertebrae. The immense immune response due to the bacteremia (infection in blood) and Staph aureus toxins caused glomerulonephritis (kidney inflammation) and hematuria (blood in urine).

"Although the bacteria is the cause of her sepsis, the infection was not the immediate concern," explained the EM physician. Intensive support therapy including blood/plasma transfusions, fluids, mechanical ventilation, and vasopressors were given throughout her two-week ICU stay. "I've rarely seen someone recover completely in medicine after septic shock with tricuspid valve endocarditis. It truly amazes me. Heart, lung, kidneyall fully recovered except for lower back pain." Abigail was transferred to a "step down" unit [in between the ICU and the general ward] and discharged to rehab.

When we returned to lecture, an ID physician introduced diseases of the spirochetes such as Syphilis and Lyme Disease. "Always note the presence of rash on the palms or soles." This can help narrow down a broad differential as not many diseases cause a rash there. Syphilis, caused by Treponema pallidum, begins with formation of a chancre, a characteristic painless ulcer, on the penis or in the vagina that lasts for four-six weeks. "I can never understand how some males do nothing about this quite obvious lesion." Patients then develop a generalized lymphadenopathy (enlarged or sensitive lymph nodes) with a  diffuse rash on the palms and soles that resolves. After a multi-year latency period (typically within 5 years of primary infection or 15-20 years after primary infection), some patients enter a serious tertiary phase that involve syphilitic aortitis (inflammation of the aorta potentially causing an aortic aneurysm ), neurosyphilis and gummas (red protrusions of the skin with a necrotic core).

Lyme disease, caused by Borrelia burgdorferi, requires an infected tick to be feeding on the human for at least 48 hours for the bacteria to change membrane proteins in preparation for human cell infection. The feeding ticks are typically less than two millimeters in size, so they are easier to miss than a syphilis chancre. Lyme-infected ticks and diseased humans are most common in the Northeast and upper Midwest, coinciding with large deer populations.

Statistics for the week… Study: 12 hours. Sleep: 8 hours/night; Fun: 2 days. Example fun: Our class held a Game-of-Thrones watch party. Straight-Shooter Sally: "Game of Thrones unites multiple generations under one roof. My parents love this show just as much as I do!"

Year 2, Week 3

Virus week. Long days of lectures followed by three hours of studying old material on infectious bacteria in the evenings.

"The more I study, the less I know," reflects Gigolo Giorgio, the class alcoholic frequently found on the dance floors of downtown clubs. One classmate asked Giorgio, "Is Campylobacter jejuni gram-positive or negative?" We were all impressed when Giorgio responded, "Gram-negative." We were stunned: "How did you know that!" He answered, "Well I haven't heard of it, and I've only studied gram-positives."

 

This block is particularly challenging because the material doesn't build on previous lessons. I feel more behind each day. "I'm still on gram-positive bacteria! I have not even started gram-negatives!" wails a classmate as we begin virology.

 

If you model a physician as an information processor, the result of this block is a database that is indexed in only one direction. For example, we study by investigating the properties of each pathogen one at a time. We can reliably regurgitate information from yesterday about a single bacterial species. However, when we attempt to develop a differential based upon symptoms, we have difficulty identifying potential culprits. For example, both S. pyogenes and an acute HIV infection can lead to sore throat. There were many blank faces when we were asked, "What are the common causes of sore throat?" Fortunately electronically implemented databases can be indexed in multiple ways. This is what gives clinical-assistance programs, e.g., UpToDate.com, their power to boost physician efficiency, especially in regions where ID doctors are scarce.

 

A 60-year-old internist who specializes in herpes and whose two children are also practicing physicians at the hospital introduces virology to us with four hour-long lectures. The Internist introduced infectious disease: "ID is not rocket science. It's an approachable field if you have the interest and dedication to learn a lot of diseases." Jane actually shadows the son and mistakenly thought he would be teaching us.

There are three types of viruses: RNA, DNA, and retrovirus. RNA and DNA viruses hijack host cell machinery to produce proteins of their own design. Retroviruses actually insert their own DNA into host cells.

 

A basic virus is a small particle containing genetic information (DNA or RNA) that encodes for its infective vector (the proteins that enable the virus to get into cells and reproduce). These proteins include the structural capsid protein(s), the polymerase(s) used to replicate the genome, and critical docking proteins to allow access into the host cell. The mode of transmission is restricted if the virus is enveloped in a lipid bilayer. "Enveloped viruses have an easier way to get into cells, but are much more susceptible to drying out on a surface. Non-enveloped viruses can last for days on a surface."

 

The internist asked the class, "What is the difference between herpes and love…? Herpes is forever." Herpesviridae is a large class of enveloped DNA viruses that include herpes simplex (genital warts and labial cold sores), varicella zoster (chickenpox and shingles), and the college-drag epstein-barr ("mono").  "Sixty to seventy percent of the population is infected with HSV1 [herpes simplex 1, mouth cold sores]," said our lecturer. "Most people do not have reactions, but some people have outbreaks, particularly under stressful conditions. Does anyone want to tell their story about cold sores?" Two students volunteered that they have outbreaks, particularly around exam week. They both have a prescription for the antiviral drug acyclovir, which can reduce symptoms if administered during the beginning of the outbreak (typically a tingling or burning sensation). Herpes viruses remain latent in sensory nerves until the immune system is weakened. Reactivated virus will travel to the skin to cause an outbreak.

Shingles, caused by the latent varicella, will typically infect only a single dermatome (region of skin innervated by a single spinal nerve). We also learned about flaviviridae, which causes several nasty tropical diseases, including Dengue, Zika, and Chikungunya. "Each of these is transmitted through the same Aedes mosquito, so it is possible to get multiple outbreaks simultaneously. I've had patients with two at once."

A number of students thought the viral lectures would have been more effective after a dermatology block (scheduled in two weeks). The early symptoms of viruses are typically nonspecific, with the exception of some characteristic rashes. For example, we looked at pictures for the common rash-causing diseases of childhood (measles, scarlet fever, rubella, slapped cheek and roseola) without having an understanding of what pathophysiological mechanism is causing these lesions.

The ID physician spent about 30 minutes on the hepatitis viruses. "There is now a ninety-five percent cure rate for all genotypes of Hep C. It's truly unbelievable the surge in drug innovation. Five years ago we had almost nothing. Now there are over 12 drugs." He commented how the first Hep C drug recently dropped in price to remain competitive as it only covers a few genotypes compared to the newer drugs.

 

Why are there are so many genotypes and viruses? Some viruses purposefully use an error-prone polymerase (enzyme used to replicate DNA/RNA) to accelerate their mutation rate. For example, influenza pandemics occur when a "genetic shift" arises that is sufficiently different from previous strains so that past exposure provides no immunity. This also means the influenza viruses make up to 10 percent null copies, incapable of infecting, but that is okay for an organism that is expending someone else's energy.

We also learned that many cancers are thought to be a result of past viral infections. For example, cervical and anorectal cancer are almost entirely attributed to sexually-transmitted human papillomavirus (HPV) infection. This is a DNA virus and the cancer-causing strains are primarily HPV 16,18,31, and 33, which are covered by the Gardasil 9 vaccine (ideally administered to both males and females at age 11-12). Viruses typically induce a cell growth state to increase DNA and RNA replication. Some viruses even encode proteins that suppress growth inhibitors such as tumor-suppressor gene p53.

 

Wednesday and Thursday featured lectures on HIV led by a quirky, cynical ID physician specializing in HIV patients and speaking in a voice that was a bit like Brian Boitano's. "Do you think he is gay?" a student asked after lecture. Type-A Anita quickly responded, "Of course he is gay. He treats HIV patients."

HIV is a retrovirus with machinery to integrate its viral genome into the host genome. HIV's genome encodes for (can produce) only nine proteins. Gp120 is a glycoprotein inserted into the cell membrane envelope that allows the virus to bind to CD4, a protein found on specific white blood cells. When bound, the hidden Gp41 aggregate to bring the viral envelope closer to the host membrane and eventually fuse allowing access to the host T cell. Other host proteins are necessary for viral fusion, including CCR5. One student sent a case report to the class GroupMe about an HIV-positive individual inadvertently cured of HIV when he received a transplant of bone marrow that lacked this protein. (http://www.nejm.org/doi/full/10.1056/NEJMoa0802905).

 

Two lectures were dedicated to managing HIV. The ID physician began: "My patient was diagnosed with HIV around age 40. She was confused until her husband admitted that for decades he would go on business trips and have unprotected sex with men. She got a divorce." A student whispered, "I wonder if health insurance survives after divorce?" (Answer: depends on the state; see Real World Divorce)

The ID physician continued, "You are now supposed to prescribe antiviral drugs to anyone with HIV as opposed to those below a CD4 count threshold. Europeans still wait for a low CD4 count to develop, probably because of the cost of these drugs." HIV antivirals, if taken regularly, are able to wipe out detectable virus particles in the blood and return CD4 count to normal. "There was a study conducted in West Africa where married individuals with one HIV-positive partner was treated. They evaluated how many HIV-negative partners contracted HIV over several years. Almost no one who adhered to the medication regiment passed the HIV to their partner. Some partners tested positive for HIV, but it turned out to be a different genetic strain. The partner had to have caught it from someone other than the spouse."

We also learned about HIV prophylaxis treatment. At-risk individuals, such as healthcare workers in a high-risk region, or high-risk sexually-active individual, are prescribed HIV antivirals to prevent transmission. "If you are stuck with a needle from an HIV-infected patient, TELL SOMEONE. If you get started on prophylaxis drugs within 48 hours, we can basically guarantee a zero percent transmission rate. You have to hit the virus before its genome is integrated into CD4 T-cells." One classmate asked, "Are there certain regions of the country where all gay people should be on prophylaxis?" The lecturer was slightly confused, but responded, "No. Assess the risk. If someone is having unprotected sex with two-three different partners a week, yes. If they are in a monogamous relationship, no. Also it depends on what insurance they have."

A few classmates discussed afterwards if medical education weights HIV too much compared to more common viral infections. Less than 1 percent of the world is infected with HIV. In the US, 1.1 million individuals are HIV-positive, about 0.3 percent of our 325 million population.

 

Our patient case: Taylor, a 41-year-old black female, presents to the ED in respiratory distress. She reports worsening shortness of breath and persistent cough over the past 4 weeks. Chest x-ray shows glassy white highlights on the normally black air-filled lungs. This suggests diffuse intralobular infiltrates (infection in numerous spots within the lungs; a typical pneumonia is just one big spot). She is admitted and placed on antibiotics. However, her pulmonary function continued to deteriorate and she is transferred to the ICU. Her CBC revealed elevated lymphocytes with a CD4 T cell count less than 100. She is immediately started on antifungal medication to address a suspected Pneumocystis jiroveci infection. HIV test is positive.

Her two-week hospital course is challenging. Because of her low immune function from the HIV, she arrived at the hospital coinfected with several viruses. Then once in the hospital she acquired a conventional pneumonia from intubation and urinary tract infection (UTI) from the foley catheter. She makes a full recovery and is discharged for outpatient follow-up.

Taylor, now 55, is energetic and recently became a grandmother. "At the time of the diagnosis, my three children were 14, 16, and 21. I was in complete denial. I went to four doctors in town to get another HIV test. I finally accepted it while talking on the phone with my internist. I dropped the phone and wept. My children came into the kitchen and asked what was wrong. It felt impossible bringing this up with them." Once Taylor acknowledged her HIV, she quickly began antiviral treatment without serious side effects. Her CD4 count has improved to normal, and she has not been hospitalized since the above episode.

How did your friends and family react? "I was severely depressed for several years. I've been on every single antidepressive that you can think of. You never know who will be there when you are most vulnerable. My best friends were the first to flee. Three of my siblings still do not speak with me. My sister will occasionally visit me, but she refuses to hug me, or let me see her children. People, especially in my community, remember the 1980s epidemic. They think if they touch, or even come near someone with HIV they will get infected."

"I told my oldest son a few months after my diagnosis. He asked, 'Do you know who did this to you?' I told him the truth. 'Yes. The man knew he had HIV, but still slept with me. When I found out and confronted him, he moved far away.' I was scared my son would search him out and attack him. I fortunately calmed him down."

How about coworkers? "I do not tell my coworkers about my health. I get my work done and get home for my kids. No socializing for me."

The last question asked by a student was, "If you could go back, would you not sleep with that man?" The whole class put their heads down in shame. Taylor seemed a little taken aback, but responded, "Yes, I regret getting HIV." Several students went up afterwards and gave her a group hug.

Back in lecture we were treated to three 2.5-hour sessions led by an experimental psychologist who studies human engineering in medicine: cognitive-biases, leadership and systems engineering in healthcare. She explained that she had worked at another institution on applying human engineering principles to the cardiac OR and had been recently hired into a newly created position at our hospital and school. "I am by no means an engineer. In fact, my former boss who was an engineer would always get frustrated when we had a meeting. We just think different." She now conducts studies evaluating the use of checklists, standardized communication protocols, team meetings before and after surgery, and sleep schedules.

"Healthcare systems are not engaging in improvement by pinpointing individuals anymore. Instead, they are trying to improve the system in which actors engage," she noted. "There were three occasions at the hospital where different nurses administered a full vial of insulin [about 300 cc; triple the correct dose]. The problem was that the nurses were used to getting insulin shots in a pre-formulated syringe with the dosage measured out instead of a whole vial. We implemented a standard insulin dispensary protocol."

Lanky Luke, a conservative-leaning 25-year-old, vented his spleen after the third session: "What a complete waste of our tuition dollars. We have already had that lecture about respecting other professions [working in the hospital, such as nurses and technicians]. I am all for sitting down and figuring out ways to minimize errors but you have to maintain individual responsibility or the whole system shuts down. I don’t need an overpaid psychologist who knows nothing about medicine to teach me that. Why don’t you just bring in an experienced PA or nurse who can tell what it is like getting talked down to by a PGY1 [intern year]." Another student added, "Why are we discussing how to improve team communication when we don't even know how to diagnose strep throat?"

Statistics for the week… Study: 10 hours. Sleep: 8 hours/night; Fun: 1 days. Example fun: Jane and I joined Luke and his wife Samantha for beers downtown followed by a space-themed Escape Room. Luke and Samantha had successfully completed one before. Three medical students and one PA student were not able to escape in the one-hour time slot. Let's hope that we do better when solving medical mysteries.

Year 2, Week 4

This week will cover mycology (study of fungi) and parasitology.

Our professor, a 70-year-old ID doctor with thick grey hair, used to go overseas six months of every year to treat rare disease outbreaks, including the 2014's Ebola outbreak in Sierra Leone. He is celebrating his forty-fifth year of teaching medical students! When he went to medical school, Latin was an admission requirement. This would have been quite helpful in memorizing the 70+ pathogens covered during the previous three weeks as well as in pronouncing medical terminology. Instead of using textbook images for these diseases, he uses pictures of his own patients. During an investigation, he goes to the patient's house and workplace to investigate potential exposures. One student's summary: "He's basically Dr. House!"

 

Dr. House likes to look at the big picture. "We think history is all about human actions. False. Two-thirds of the cells in our body are bacteria. We are the Uber for bacteria. Genghis Khan was about to conquer all of Europe. His army caught Yersinia pestis in Turkey. The Russians did not stop Napoleon's army. Napoleon caught dysentery from Shigella outbreaks." Several students are planning to read Guns, Germs and Steel on his recommendation.

 

Fungi are dimorphic organisms. At colder temperatures, fungi grow as the familiar mold, creating small inhalable spores. At body temperature, these spores convert into a circular yeast structure. Lectures detailed the three categories of fungi: dermatophytes (fungi that love keratinized tissue such as skin, nails and hair), systemic (fungi that can result in body-wide infections), and opportunistic (fungi that do not cause infections unless the patient is immunocompromised). Only dermatophytes are transmitted from person to person.

 

This block tends to evoke exotic diagnoses from students. "I'm going to get histoplasmosis [systemic fungal infection]!" exclaimed Straight-Shooter Sally after she removed an unwanted bird's nest from her potted plants. "As I was throwing it in the trash, the nest broke in half. I inhaled all the bird poop and dust!" After class it is not uncommon to hear, "Do I have a rash on my hand? Do I have syphilis?"  One student after class asked Dr. House to inspect his foot. Dr. House had commented, "People who get athlete's foot just on the nail, not the foot, are more likely to have diabetes." The student asked, "Do I have diabetes?" Dr. House replied, "You'll be fine. Remember to never treat your own children. I was convinced  my kids had meningitis when their first 103 degree fever occurred." He ended with a joke: "If athletes get athlete's foot, what do astronauts get…? Missile toe!"

 

Parasites are divided into protozoa (microscopic eukaryotic single-celled organisms) and helminths (macroscopic eukaryotic multicellular organisms). With only two days of lecture, we focused on the most common parasites, especially malaria. A common theme of this block is that many symptoms of disease are not caused by the pathogen-killing cells. For example, the watery diarrhea of Clostridium Difficile and Cholera are caused through a toxin-mediated mechanism releasing water into the lumen of the gut. The nonspecific flu-like symptoms of most viruses are not caused by cells dying but the systemic host immune interferon response. Malaria, caused by the protozoa Plasmodium, is an exception to this rule. Plasmodium infects and lyses (ruptures) red blood cells after replicating inside them. Different plasmodium species have different lysing rates giving a classical cyclical fever/anemia pattern ranging from 48 hours to months. Dr. House recounted how as late as the 1920s, syphilis was treated by giving the patient malaria (P. vivax)! The malaria would cause such a high fever it would kill Treponema pallidum. After the syphilis was cured, they would give chloroquinolone to cure the malaria.

 

We also learned about how the Rockefeller Foundation was founded to address the epidemic of Necator americanus (Hookworm) in the South (see http://www.pbs.org/wgbh/nova/next/nature/how-a-worm-gave-the-south-a-bad-name/).  Hookworm is a helminth that latches onto the gut lumen where it produces eggs that pass out in the feces. When a human walks barefoot through a field of fecal-contaminated soil, larvae penetrate into the foot. "Farmers would use human feces to fertilize the field where children would play barefoot." Once inside, the worm travels through the blood to the lungs, travels up the trachea to the pharynx, and finally is swallowed into the gut. Each hookworm drinks 0.3 mL of blood per day. "The problem is you are not infected with just one hookworm, but thousands. Losing 30 mL of blood per day will cause severe iron-deficiency microcytic anemia." Over time, this produces lethargy and mental retardation. It is estimated that 40 percent of school-aged children were infected with hookworm in the early 1900s. The Rockefeller Foundation led a massive public campaign that focused on schools to eradicate hookworm from the South.

 

Dr. House described the waterborne parasite called Cryptosporidium . "Crypto is all through the DC water system. It is resistant to chlorine treatment." The immune system is normally able to contain the infection. However, some of my AIDS patients before HIV antivirals would have 60 bowel movements a day due to cryptosporidium. These people would live on the toilet, and die from dehydration and malnutrition." Dr. House couldn't end lecture without showing us live video, captured during a colonoscopy, of Ascaris ("Giant Roundworm"), which can grow up to a length of more than a foot in the human gut (https://youtu.be/HOaZCkA8Zvk).

Classmates were particularly interested in another waterborne parasite Naegleria fowleri, the "brain-eating amoeba." Naegleria is found in warm lakes, including in the U.S. It is thought to gain access to the brain through the cribriform plate (thin bone separating the brain from nasal cavities) under barotrauma or a pressurized injection of infected water, e.g., falling during water skiing. I was conversing with a female hematologist in the hallway later than afternoon. She commented, "I will never swim in a lake out of fear of getting Naegleria."

Our patient case: Grandma Martha, a 68-year-old female accountant with degenerative disk disease in her lower back. Her daughter brought her to the ED for worsening back pain, neck stiffness, and headache over the course of weeks. On physical exam, she showed diminished lower extremity reflexes. Dr. House explained, "Before you can order a lumbar puncture ("LP" or "spinal tap"), you have to rule out increased intracranial pressure which could cause herniation of the brain." An MRI revealed several inflamed lesions of the meninges without evidence of increased intracranial pressure. LP results showed decreased protein, decreased glucose, and the presence of neutrophils in the CSF. Gram stain on the cerebrospinal fluid was negative (no bacteria observed). "The LP results were suggestive of a bacterial meningitis. However, her presentation did not fit. Bacterial meningitis is typically a very rapid onset of symptoms." She was started on empiric antibiotics until culture results could be obtained. "I was driving home that evening listening to the news on the radio. They were reporting about an outbreak of contaminated steroids. I turned the car around. Not everything on the news is Fake News." Several chuckles were heard in the audience.

 

Back in 2012, Martha had been getting regular epidural steroid injections for back pain. At least one was supplied by the New England Compounding Center (NECC) and, due to a profit-motivated sloppy approach to sterility, had been infected with the fungus Exserohilum rostratum. "We didn’t know how to treat it. No one had ever seen this before." Dr. House added, "It is extraordinary how quickly the local health departments and the CDC responded. Within 48 hours of the first diagnosis, the CDC was calling patients." (753 patients were injected with contaminated steroid; 234 developed fungal meningitis and 64 died. See https://www.cdc.gov/hai/outbreaks/meningitis.html.)

 

Martha was started on an aggressive antifungal regimen including amphotericin (known as "amphoterrible" due to its severe side effects including kidney failure) and voriconazole. "The challenge with fungi and parasites is that our immune system does not do a good job of killing it. Instead, they typically wall off the lesion to contain it. We did not know if our drugs could reach these lesions. We also did not know about the risk of recurrence. How long should we treat the patient?" Martha was in the hospital for 70 days, and continued treatment for another two months. She has fully recovered from the ordeal.

 

"I was fortunate compared to several other people who live with long term complications from the meningitis. Or who died. I know several people who have dealt with recurrent meningitis episodes," explained Martha. A student asked about the recent 9-year prison sentence for the NECC co-owner and pharmacist Barry Cadden. "What would you say to him?" "Well, I wouldn't say anything to him. I would punch him the face," chuckled Martha. Her daughter jumped in, "I would punch him too."

 

I had lunch outside with six classmates. One commented that "Medicine was really the Wild West a few decades ago. Could you imagine discovering these unknown disorders like hookworm?" Straight-Shooter Sally added, "The best part would be getting to name all these symptoms! How badass would it be to name Toxic Megacolon [severe, potentially lethal, distension of the colon that can occur when an antidiarrheal agent is administered during an active C diff infection.]"

 

Our group then walked over to the hospital's SimLab, which is led by a retired nurse and EM (emergency medicine) resident. We practiced running a Code Blue where a patient was in cardiac arrest. The main purpose of the simulation was to introduce us to standard communication skills such as "call-backs" (acknowledging an order with a clear read-back) and SBAR (situation, background, assessment, recommendation) hands off.  Lanky Luke had run EMS for all of his undergraduate career. The rest of us had no idea what we were doing. The first simulation round we were sent without any guidance to resuscitate a dummy. Over time we got the rhythm of running a code. Two people focus on chest compressions, one person performs breaths, one person runs the monitor and defibrillator, and one person records events. I learned that if you are performing chest compressions correctly you can actually feel a pulse from the compression in the femoral (leg) artery.

 

What do people who don't go to medical school do with $300,000 of college education and $300,000 of taxpayer-funded K-12? One of my undergraduate classmates on Facebook this week:

if you've been paying attention, you probably know I haven't been the same since November 9, 2016. things changed not only in this country but also in how I view myself within that context. i joked that if Trump won I would leave the country…

well, now it's time to follow-through on my promise. after weeks and weeks of trying to figure out what was next, I finally realized that I had no idea and couldn't figure it out while remaining in my last job and in my last city. so as many of you know, I left DC and my job [social media analyst for advertising agency] …

but now the time has come for me to say goodbye to what used to be my home and is now just the place I try to avoid claiming. i hope to find myself in the coming weeks and months and find what makes me truly happy, in both work and in my personal life.

to that end, I am saying goodbye to the US of A and hello to everywhere else! i do not know where I will end up and although it's a bit scary, I know I'll find my way by the grace of a god (and maybe just a little luck)! if you have an iPhone, nothing will change between us. if you don't, then you'll have to settle for Facebook Messenger if you'd like to keep in touch (starting tomorrow).

...

au revoir america, it was fun until it wasn't. for all those I'm leaving behind...fight the good fight, win back Congress and the WH, and maybe then I'll pay you all a visit in the future (!?)

until then, peace&love…

 

 

We had a 2.5-hour lecture from two physicians: "Motivational Interviewing: Eliciting Patients' Own Arguments for Change". A 2014 landmark study found that "Behavioral patterns contribute more to premature death than genetic predisposition, environmental exposures and health care errors" (Annals of Internal Medicine, March 18, 2014). The main message is that patients need to feel like they have autonomy. "Don’t give them orders, give them options." One internist described his patient who had been trying to quit cigarettes for a decade. "He told me, 'Hey Doc, I am down to five cigarettes a day from a pack-a-day.' I asked him, 'What's stopping you now?' He responded, 'If I give up now, my nagging wife will get all the credit.'."

On Friday, we were assigned our M1 mentees. A social committee of M2s, four women and one man, stalked the M1s for this entire week (online and offline) and concluded by matching the new M1s with M2s. The matches were announced using a "Tinder match" at the annual M1 welcome party, featuring a full keg and a SnapChat Geofilter. The M1s received folders with their mentors'' pictures and had to search for them in the house. Only one match was done with romantic hopes: Gigolo Giorgio and a cute sorority girl. Ten percent of the M1 class threw up during the party.

 

Statistics for the week… Study: 15 hours. Sleep: 6 hours/night; Fun: 1 night. Example fun:

Jane and I unfortunately missed the M1 keg/Tinder party to attend a surprise party for her sister, an advertising executive. Thirty family members crowded into a bar to watch the boyfriend, a pharmaceutical rep, propose marriage. Jane's sister said yes.

Year 2, Week 5

Hematology and immunology. Immunology is one of the class's least favorite topics. Gigolo Giorgio:  "I accept just taking a hit on the exam. It makes no sense to me."

An enthusiastic 44-year-old immunologist kicked off the lectures. She explained, "We need about 100 million unique antibodies to be immune competent. We have about 30 billion B cells in the blood.  That means we only have 300 potential B cells that need to become activated if we are to mount an antibody attack against a given antigen. This is the key dilemma in adaptive immunity: How do you find them!"

Our first-year perspective on the immune system was cell-centric. This week we learn that the story is more complex and includes smaller-scale proteins from the complement system and larger-scale tissues such as the spleen filtering blood-borne pathogens.

Our current understanding of a typical bacterial infection:

  1. The innate immune system recognizes common pathogens. Complement proteins (smaller than cells and made by the liver) mark bacteria for opsonization (trigger for phagocytosis or cellular ingestion).
  2. Resident macrophages (cells) phagocytose (ingest) marked intruders resulting in an inflammatory "cytokine storm". This causes systemic changes such as fever and increased production of immune cells in the bone marrow (lymphocytosis) and local changes such as blood vessel dilation to increase tissue perfusion and neutrophil infiltration into the tissue.
  3. Neutrophil infiltrate the inflamed tissue. Neutrophils, the most abundant leukocyte (white blood cell), are the immune system's pawns that kill bacteria by eating them and producing high concentrations of hydrogen peroxide in the phagosome (walled off vesicle containing the bacterial cell inside the neutrophil). After the neutrophil has worn itself out, it will explode in a process called netosis. The neutrophil's DNA acts like a spider web (called neutrophil extracellular traps) to prevent the bacteria from escaping the site of inflammation. Pus is dead bacteria and dead neutrophils.
  4. Adaptive immunity activated (if needed).
  5. If necessary, the spleen will filter bacteria in the blood (bacteremia) through small capillary beds called sinusoids.

The C3 protein is fundamental to the complement system and will bind to almost any biological molecule. How does the body avoid its own proteins being marked for phagocytosis? The liver releases anti-complement factors that bind to sialic acid, a component on human cell membranes. Streptococcus pyogenes, the bacterial strain causing strep throat and necrotizing fasciitis, expresses M protein to mimic sialic acid. The immunologist explained, "Although this molecular mimicry decreases the efficacy of the innate immune system, it is also Strep's greatest weakness." Our adaptive immune system readily produces antibodies that target M protein. The problem is that this antibody can cross-react with our own tissue causing a rare complication of sore throat: rheumatic fever (inflammatory disease that leads to skin rash, joint pain, and destruction of heart tissue).

If the innate immune system mechanisms are insufficient for clearance, the adaptive immune system will be activated. Resident macrophages will migrate to lymph nodes and present phagocytosed segments of foreign material on major histocompatibility complex (MHC) proteins to lymphocytes (T cells and B cells) that circulate among lymph nodes. Because the body can't anticipate all of the epitopes (protein shapes) we might encounter, we use a game of probability. The immunologist explained, "We are finally unlocking the adaptive immune system. When I was an undergraduate student in the late 80s, how our adaptive immune system generates this antibody diversity was still not accepted let alone in textbooks. MIT Professor Susumu Tonegawa won the Nobel Prize for discovering VDJ [variable, diversity, and joining] recombination. He showed that each B and T cell mutates its own DNA to rearrange the genes encoding the B cell's antibody or T-cell receptor. Each B and T cell clone has different DNA than your typical cell in your body! If this B cell antibody or T cell receptor recognizes a sequence presented on MHC, it will become activated. The activated cell will undergo clonal expansion [reproduction by division], and, in the case of B cells, will differentiate into a plasma cell secreting gobs of antibody against this specific antigen into the bloodstream."

Our patient case:  Georgia, a 46-year-old female presenting to her internist for a routine physical. Medical history is unremarkable except for well-controlled hypothyroidism. She has swollen lymph nodes (lymphadenopathy) in her neck. Routine blood tests reveal elevated protein. Serum protein electrophoresis, a technique that separates proteins based upon electric charge, reveals an "M-spike" in the immunoglobulin (antibody) zone, suggesting an increase in concentration of a single clonal variant of immunoglobulin. "Georgia had a rogue plasma cell producing gobs of a single type of antibody. It is essential you understand the significance of clonal expansion to her condition versus the antibody response to an infection. During an infection, several B clonal species will get activated, each with a different antibody that binds to different sites of a pathogen. Infection causes a general increase in globulin concentration but not a spike." The risk is as this single clonal variant continues to expand, it could push out the normal functioning bone marrow cells.

Georgia was referred to heme/onc (hematology/oncology) for further evaluation for this monogammopathy of unknown significance. One of my favorite lecturers, the young redheaded hematologist, followed Georgia for one year during which she began to have anemia, proteinuria (protein in urine), and bone lesions on routine tests. George was diagnosed with multiple myeloma (MM) at the age of 47 and, based upon her genetics and stage, given eight years to live. (Type-A Anita uses the helpful mnemonic "CRAB" to remember the classical signs of MM: hyperCalcemia, Renal impairment, Anemia, Bone lesions.) After her diagnosis, she quit her job as a secretary for a law firm and went on disability.

Georgia underwent several weeks of intense chemotherapy and a successful autologous hematopoietic stem cell transplant (HCT) over the course of a month-long hospital stay. She explained, "I never considered that I would die during the treatment." She is now two years into remission and maintains an active life.

The HCT given to Georgia is the gold standard for MM treatment. "Why do we even give bone marrow transplants to MM patients?" asked the hematologist. She answered her own question: "The purpose of a bone marrow transplant is to be able to give higher doses of chemotherapy that would otherwise be lethal. We nuke the patient." The hematologist recounted how bone marrow transplants were first investigated after the observation that individuals exposed to radiation from Hiroshima and Nagasaki developed pancytopenia (low blood cell counts). Bone marrow transplants were thought up as a way to reverse this aplastic crisis. "Leave it to the DoD to advance science. Pretty quickly oncologists applied the research to cancer treatment."  

"The scariest part of multiple myeloma is that you are never cured," explained Georgia, as she broke into tears. "It will come back every time. This tragic fact makes MM different from other cancers. I go to an MM support group every two months as opposed to a more general cancer group. It is such a different beast." Georgia grew up in a large mid-West family with five siblings. "My closest sister withdrew from me after the treatment. I think it is just hard for her to accept."

The hematologist added, "Plasma cells are the cockroaches of the immune system. They survive everything. The unfortunate truth is that the question is not if MM will relapse, but when. Further, the  traditional chemotherapy we use causes the plasma cells that do survive to have more mutations. Drug resistance develops after successive relapses." She gave an impassioned speech on the importance of research. "The life expectancy for MM has increased dramatically. Maybe ten years ago, Georgia would have had to be maintained on melphalan [nasty chemo agent that acts via a similar mechanism to mustard gas] to contain her MM." She turned to Georgia: "Could you imagine being on melphalan, the drug used during your bone marrow transplant experience, routinely?" "Oh, God, no. My hair, the diarrhea, the sheer pain. Mostly my hair though." The class chuckled, and the hematologist continued, "This is changing because of the extraordinary advancements in targeted therapeutics. I love this field because it changes so quickly. Cancer years are dog years. A five-year-old article or clinical trial is thirty-five years old by my standards. Even the current issues of journals are a year late; you have to go to conferences to learn about the latest breakthroughs. It is frankly hard to stay up to date on every neoplasm [cancer]. The result is that oncologists convey out of date survival expectancy to patients."

Jane had a slight hiccup with her mentee: the day after their first meeting, rumors surfaced that her mentee had disenrolled for personal reasons. The whole class joked that Jane made the helpless M1 quit. "What did you do to her!?!" We never learned the truth, but this classmate was quickly replaced by someone from the waitlist who became Jane's new mentee: "Rebecca," who had majored in electrical engineering at a large public university. Rebecca had spent a week at a DO (Doctor of Osteopathic Medicine) school: "I got a call from an unknown number. When I heard I got into this school, I almost fainted. My legs went weak. I packed everything back up and drove the next day eight hours. I really want to call my undergraduate prehealth advisor who told me I would never get into medical school because of my grades. Suck it!" An M1 told Jane, "I like your new mentee better than your last. Thanks!"

Statistics for the week… Study: 15 hours. Sleep: 8 hours/night; Fun: 1 day. Example fun: Dinner party with classmate and his wife, a marriage counselor. "My favorite patients at my old job were the couples with a schizophrenic." A classmate who worked on a psych ward before matriculating at medical schools said, "Wow! I was scared out of my mind. I had this one patient who would say, 'There is a woman standing behind you.' I believed her! I could never do psychiatry."

Year 2, Week 6

One week before exams.

"We are going back to preschool," said the young female dermatologist. "Dermatology is another language. We start with vocabulary." She spoke in a monotone voice and enjoyed sadistic humor. "It helps if you know Latin. How many of you took Latin?" Two students raised their hands. She chuckled, "Well... that is too bad." We went through several images, and described the lesion with the help of a handout with common terms: umbilicated nodule, erythematous maculopapular, scaly serpiginous plaque. The class was surprised to hear that erythroderma (diffuse erythema covering the body) is a "dermatological emergency". This massive inflammatory response can cause a drop in blood volume and hypotension.

A dermatologic pathologist gave two hour-long lectures on skin histology (study of the microscopic structure of tissues) with slides of normal and diseased skin. I enjoyed seeing how certain skin issues manifested themselves so clearly on histology compared to other organ systems where the pathological manifestation is more subtle. He ended: "Gastroenterologists and dermatologists always argue with each other about what is the largest organ. There is a huge amount of blood flow to the skin. Inflammation frequently leads to skin changes. Think of the skin as a window into the body."

"Dr. Joel", a brilliant pedantic rheumatologist in his late 30s with a heavy Jamaican accent, discussed infectious diseases of the skin and immune disorders that manifest with skin symptoms. Roseola ("Sixth Disease" or "three-day fever") is caused by human herpes virus 6 (HHV6). It is characterized by high fever, which can cause seizures in children, followed by a maculopapular (flat and raised erythematous dots) rash. Several of these childhood illnesses cause serious damage to a fetus if the mother becomes infected during pregnancy. A congenital rubella infection (German measles infection while pregnant) leads to the fetus having microcephaly and a patent ductus arteriosus (PDA). A male student commented, "Could you imagine living two hundred years ago before we understood the role of congenital infections? Your baby comes out as a dwarf or with microcephaly. Must be God's will."

These lectures should help us to answer multiple choice Board questions, but we are doubtful about being able to diagnose patients. Lanky Luke: "I feel much of medicine is getting the approval by society to witness disease. This ordained selection process entails paying it to the Man." Luke thinks that more of our medical training should be an apprenticeship rather than lecture-based.

He got his wish when we went in for an afternoon to the dermatology clinic. Four-person groups crowded into each small examination room to spend 15 minutes with a patient volunteer and a dermatology attending or resident. My group first saw a 30-year-old female who has suffered from neurofibromatosis since she was a teenager. Only when the patient took her gown off did we see the copious neurofibromas (benign tumor of nerve sheaths) covering her body with the peculiar exception of her head and distal extremities (arms and legs). She could walk around in a long-sleeve shirts and slacks without anyone noticing. The patient allowed each of us to palpate her skin. Neurofibromas are thimble-sized fleshy cylindrical nodules with a dark brown color that sag from the skin. They feel mushy, almost like a fluid-filled vesicle. The attending noted, "A lot of patients first try to scratch them off. They return much worse."

We rotated to the next room and a normal-appearing 50-year-old female. As we examined her more closely, we saw signs of scleroderma. She had sclerodactylyl (localized thickening of skin on fingers and toes) preventing full extension of her fingers. Her lips were permanently pursed with six or seven valley and ridges on the skin adjacent to her lips. "Before treatment with steroids, I could barely move any of my joints because the skin was so tight. I now live a normal life with my family." Our patient did not have any of the life-threatening manifestations of scleroderma, which can include pulmonary hypertension and pulmonary fibrosis.

We then rotated through a case of eczema and psoriasis. Eczema, also known as dermatitis,  is characterized by pruritic (itchy), erythematous (redness that blanches with touch), oozing vesicles (fluid-filled sac) with edema (swelling) typically occurring on flexor surfaces. It is commonly caused by an over-reaction to an exposure such as poison ivy or the metal nickel (e.g., touching dime). Interestingly, eczema is more common in asthmatics. Psoriasis is an inflammatory condition without a known trigger characterized by acanthosis (keratinocyte hyperplasia; thickening of the skin) leading to scaly plaques on the extensor surfaces (e.g., the outside of the elbow). The attending confirmed the psoriasis diagnosis by eliciting the Auspitz sign, bleeding after a pinprick.

Our patient case: Fiona, a 42-year-old female elementary school teacher, presenting for bilateral stiffness and pain in her wrists, fingers, and knees that is worse in the morning. She had her thyroid gland removed (thyroidectomy) in her 20s after diagnosis of Graves' disease: antibodies that bind to thyroid stimulation hormone receptor causing excessive thyroid hormone release. Her condition is now well-managed with synthroid.

She has been to her doctor several times over the past few years for joint pain in her hands. "I was originally diagnosed with arthritis. I got frustrated with my doctor. He would take an x-ray, prescribe physical therapy, and never follow up." Over the last two months she has been unable to do several daily activities at work and the pain has begun to interfere with her sex life with her husband. Her proximal interphalangeal joints (proximal knuckle) and wrists are swollen and warm to the touch.

Fiona has rheumatoid arthritis (RA) defined by synovitis (inflammation of the synovium or fluid within joint capsule). The pathogenesis of rheumatoid arthritis is unknown, but some people are predisposed genetically and there are environmental risk factors, e.g., smoking, which increases the risk of RA up to 40 times in individuals with Shared Epitopes (SE) gene variants of MHC proteins.

Fiona never smoked, although she had the positive ACP titer (measure of antibody concentration in serum) that is typical of smoking-induced RA. She also had other hallmarks of chronic inflammation such as elevated C-reactive peptide (protein produced by liver suggestive of systemic inflammation). The Rheumatologist explained, "The ACP is helpful to know what kind of rheumatoid arthritis I am dealing with. However, once it is present I no longer care about it -- think of ACP as a pregnancy test. You can't get more pregnant once you test positive. Instead, I listen to Fiona's symptoms and follow her C-reactive peptide levels."

She was initially prescribed naproxen (nonsteroidal anti-inflammatory marketed as "Aleve"; similar to Advil) without any symptom relief. She currently takes methotrexate, a folate synthesis inhibitor used to treat several cancers and inflammatory conditions. "I will still get flare-ups if I over-exert myself, but I am able to be active. I even exercise three times a week on the elliptical."

Describe the pain before your treatment? "My joint pain was unbearable before I was referred to Dr. Joel. Our family goes to the beach once a year... my one break from teaching. We always have a crab leg feast. I had to stop eating the crabs because my pain would be terrible for several days afterwards. I was bedridden. Perhaps it is punishment for the gluttony."

Does anyone else in your family have immune disorders? "I know my mother had joint problems. She was never diagnosed with rheumatoid arthritis though."

How does RA affect your family? "I've learned my limits now and my husband and kids are truly great about understanding. In the beginning they were a little confused. I still sometimes hear my kids half joke, 'Oh, Mom isn't cooking dinner? She is so lazy.' Even with treatment I still have to be careful how much strain I put on my joints. Scrubbing or cutting too much will cause a bad flare-up that lasts for a few days."

Dr. Stein, an internist who has been in practice for over 40 years, followed up on the "Motivational Interviewing: Eliciting Patients' Own Arguments for Change" lecture from two weeks ago. "There are 5 stages of change: precontemplation, contemplation, preparation, action, and maintenance. We also no longer use the word compliance to describe the degree of a patient following prescriptions and medical advice. We now use the term adherence because it suggests an active role and collaboration of the patient with the doctor and treatment process."  

After one hour and fifteen minutes of theory, Dr. Stein brought in one of his longstanding patients, an overweight female in her late 40s who quit smoking six months ago. She began smoking a pack a day when she was 14. "Smoking was a part of my life. I felt that I would not know what to do if I did not smoke. It helped keep peace in the house. It kept me calm during work." She described how Dr. Stein would bring up smoking "every single time" she went in. "He said all the right things, but I was just not ready up in the head. The key was I felt comfortable with Dr. Stein. He was not judging me, pointing a finger. When I finally was ready, Dr. Stein leveraged this motivation to help me." What made you quit smoking? "If you have a big enough why, you will figure out how to quit. I hated seeing my children grow up with me smoking. My father recently had a heart attack -- I am sure smoking all his life did not help. I had these two drivers in my mind and I just went cold turkey." We congratulated her for her smoke-free six months.

Afterwards we divided into four-person groups to present a patient from our clinical shadowing experience. We were fortunate to be presenting to Dr. Stein. Our goal was to practice how to present patients to attendings for Rounds next year and how to write a medical note. The general format of a note: chief complaint in the patient's own words, History of Present Illness (HPI), Past Medical History (PMH), Medications, Family History, Social History, Review of Systems (RoS), Physical Exam (PE), Assessment, and Plan. The transgender wave has reached daily Rounds: "Don't use male or female in HPI anymore," said Dr. Stein. "It's frowned upon." After Dr. Stein revealed his fondness for "complementary medicine" (accupuncture, yoga, etc.), Gigolo Giorgio said that Dr. Stein reminded him of someone who had a "midlife crisis and suddenly turned Zen."

We wrapped up the week by reflecting on a three-week prescription simulation. Students were divided into two groups: diabetics and HIV patients. The faculty gave us pill bottles filled with M&Ms. Our class president sent periodic GroupMe messages about various simulated issues. Example: "Update: your throat is burning and your chest is on fire! wait an additional 35 minutes after taking your pills before eating." Some students ate all the M&Ms the first day. Some abandoned the simulation. Everyone forgot to take at least one pill.

Straight-Shooter Sally recounted the awkward conversation after her new roommates, a nursing student and college-educated bartender, accidentally read a message: "You forgot to take your HIV antiretrovirals for today. Double up."

Mischievous Mary, a smart, petite jewish girl who dyed her hair pink last year because "it was the last time I could do something stupid before we start clerkships -- unlike a tattoo, this is reversible." She began school aspiring to follow in her father's footsteps as an internist, but is now determined to become a heart surgeon. Mary responded to Sally's story: "I realized this weekend that I have lost all sense of decency. I was in this quaint coffeeshop by my apartment studying STDs looking at pictures of penises on my computer, easily seen by the other patrons." Jane added, "I was walking with Giorgio on the Greenway. We somehow got on the topic of syphilis. It took us several minutes to understand why people were looking at us strangely."

Statistics for the week… Study: 20 hours. Sleep: 8 hours/night; Fun: none (one week before exams).

Year 2, Week 7

Exam week with three exams.

The main three-hour multiple-choice NBME exam consisted of 100 microbiology questions and 50 immunology and dermatology questions. Lanky Luke: "This was the hardest block since the beginning of medical school." Several students complained about the emphasis on tropical diseases. "There must have been 10 questions on leishmaniasis. Every time I saw that as an answer, I would choose it." Another student added, "I just felt it was not representative of what we will see on Step I. There were so few on hepatitis." Several students reflected that they will never understand immunology. Type-A Anita: "I knew going in that I would take a hit on immunology. Oh well."

The case-based exam asked about five hypothetical patients. It tested appropriate use of antibiotics, and classical "alarm" signs of serious imminent danger, for example, patient with sore throat who has difficulty swallowing and drooling may have epiglottitis with the potential to close off the airway. The clinical exam tested adult immunization schedules, screening guidelines, and dermatology pictures. Type-A Anita: "I know we need to know these, but I crammed the day before for immunizations and screening. I've already forgotten them!"

The clinical exam consisted of interviewing standardized patients (paid humans recruited from the community as actors) presenting for pneumonia. We used simulated stethoscopes to hear abnormal breath sounds. The clinical exam tested the same immunization schedules and screening guidelines as the case-based exam.

Recall that we meet three times per week for two-hour "case sessions." Our facilitator is the redheaded hematologist/oncologist. This is the first time that our six-student group met off campus, sharing margaritas as a Mexican restaurant with our facilitator. We were joined by another case session group and their young emergency medicine facilitator.

Our heme/onc attending described the abrupt shift between fellowship and attending. "Even as a fellow, you have someone to bounce ideas off of, to confirm a diagnosis or treatment plan. It takes a little while to get confidence in yourself as an attending." She had just returned from her first vacation since becoming an attending. "My husband forced me to go on the trip to the Dominican Republic. It was scary leaving my patients. I remember sitting on the beach with a mamajuana [local drink] and feeling completely relaxed. I realized that I had not felt relaxed since beginning my residency six years ago. And probably not since beginning medical school too!" [Hurricanes Irma and Maria passed through the D.R. a few weeks later.]

The other facilitator brought his wife, an Ob/Gyn, and their three children, the oldest aged eight. When should physicians have children? "We made an active decision not to have children during residency. My wife knows all too well that it is best to begin having children by age 35. This can be a serious constraint for women if they start medical school late. Residency is your training and you need to dedicate yourself to it." The EM physician said he enjoys shift work. He can dedicate everything when he is there, and upon leaving the ER, "I am clear-headed and can focus on my children and wife."

"A lot of my residents struggle if they have children," continued the EM attending. "You will have to sacrifice something. Most of the time it means you will miss soccer games and friends' birthdays. I find it is especially hard if their significant other is not in the medical world. Nonmedical spouses do not understand that once residents are off their 12-hour shifts, they are not done. After your shift, you hit the books. You study. The one exception is a resident I have now. He will not sacrifice his time with his children so after work he plays with his kids. When they go to bed, he hits the books. He just does not sleep and seems to functions fine thus far... I am not like that."

After the facilitators left, Jane, Mischievous Mary, Deeva Debbie and I walked over to our favorite burgers and beer spot to work on our 100-beer card. After drinking 100 different beers at this restaurant, you are awarded with an embroidered mechanic shirt. Debbie is a a young Indian-American who dominates the class SnapChat story and Instagram. She journeyed to Portugal over the most recent break for a trip with two high school friends.

The women continued the conversation of children over beers. Debbie lamented, "I have no idea when I will be able to have children." Mary reflected, "I now understand why my parents got divorced. My father was a internal medicine resident when they had two children. He was always gone. My mom had to everything: feed us, drive us, discipline us. She always felt like the bad guy. When my father was home, he would just want to play with us. There was just no time for my parents." It always surprises me how many male physician lecturers in their 40s are not wearing a wedding ring. [Editor's note: Our young medical student might want to read Real World Divorce and learn about the world of sexual and financial freedom opened up by no-fault divorce to any plaintiff suing a physician.]

After a well-deserved nap, Jane and I attended our classmate's housewarming party. He and his wife, a marriage counselor, recently moved into a spacious new downtown loft. While people danced in the center, I talked on the sidelines with a 25-year-old classmate whose parents are Iraqi Kurds. His last trip to Iraq was in 2010, his freshman year of college.

I asked for his perspective on Iraq and the Kurdish people. "It's hard for me to say. Everything I know is from my dad. My family was comfortably settled in the US when it happened. I just remember my father being glued to the TV during the Iraq invasion. He would cheer the U.S. army every step of the way. Saddam gassed my people." Why has it gone so wrong for both the U.S. and Iraq? "I don’t know. It comes down to the Iraqi people as a whole were not ready for democracy."

He is eligible to vote in the upcoming referendum on independence (held September 25, 2017; result: 93 percent in favor). "I think now is the best time for independence. We are ready. The state institutions are there and the Peshmerga will defend us against any invader -- Turkey, Iran's militias. It doesn’t matter that we are dispersed in Iraq, Syria, Turkey, and Iran. Everyone might invade us. I am concerned about the state of elections in Kurdistan. Unfortunately the only politicians come from just two families, but it is now or never. I'm voting yes for independence."

Year 2, Week 8

Our block coordinator, a PhD in physiology, is attempting to execute a flipped classroom for the six-week cardiopulmonary and hematology block. We have about 3 hours of online lectures recorded by various physicians to watch at home every week before synthesis sessions with physicians going over cases. The coordinator assured the class that she has set it up to be the same amount of total class and lecture hours, consistent with LCME guidelines.

The main textbook resource for this year is Robbins and Cotran's Pathological Basis of Disease. Upperclassmen recommended that we purchase a $95 subscription to Pathoma, an online organ-based video atlas covering high-yield pathologies. Many of us are watching the lectures at 1.5x speed, pausing to replay sections that are confusing or to check Wikipedia. Lanky Luke surmised, "This is the future of medical education. There are so many educational resources now. Most of our class would give up lectures if it saved $10,000 of tuition." The five classmates at lunch immediately agreed. Gigolo Giorgio: "Half the class does not even attend lectures." Straight-Shooter Sally: "I think it would allow medical schools to focus on emerging technologies and practical challenges in medicine. We could use that money to invest in ultrasound, EMR training, and memorable patient interactions."

An internist specializing in viruses lectures on upper and lower respiratory infections. "I know it may not be politically correct, but the most common cause of immunodeficiency is pregnancy. Every month we have a couple 20-something-year-old pregnant women admitted requiring mechanical ventilation. They have another child in daycare that brings home RSV [respiratory syncytial virus] or the flu." He explained how the emergence of new influenza strains commonly originate in regions of the world where there are close living situations between humans and animals hosts such as birds in Southeast Asia. Flu strains in birds produce new viral proteins that can infect human respiratory cells (genetic shift) and cause a pandemic.

A PhD respiratory physiologist from the hospital, in his late 30s, leads a workshop on mechanical ventilation with example patient cases for COPD (Chronic Obstructive Pulmonary Disease) exacerbation, pulmonary fibrosis, and asthma. Three respiratory therapists, the oldest in his mid-twenties, joined for the workshop. They were helpful in offering patient examples for our questions. A student commented, "How did they know about this career growing up in high school?" (BLS shows that respiratory therapists need an Associate's degree and, in 2016, earned median pay of $58,670 per year.)

During a break, a classmate asks why the asthma case had normal oxygen saturation despite poor ventilation. "Hold your breath... Please don't pass out though. [student holds breath for a few seconds.]  What is making your drive to breath is not your drop in PO2 [partial pressure of oxygen]. You have enough oxygen and a high enough pressure gradient in your alveoli to maintain your blood oxygen saturation for several minutes. It is the buildup of CO2. A patient even with status asthmaticus [severe exacerbation of asthma that no longer responds to brochodilators] should have normal oxygen saturation levels. If O2 levels drop, that patient is in really bad shape."

The respiratory physiologist explains why he got interested in physiology. "When I was a kid I had terrible uncontrolled asthma. I grew up on a farm in rural Iowa. My parents just took my occasional gasping for panic attacks. One time I had a really bad episode. Fortunately, we had come into town, and so they took me to the nearby family physician's office where I got an inhaler."

Before we arrived, he had connected mechanical ventilators to a dummy lung bag. In groups of three we learned about the different ventilator modes and settings. "When you place an order for mechanical ventilation, there are several things you need to include. The first step is specifying volume control or pressure control. For pressure control, you specify the peak inspiratory pressure, the rate, the fraction of inspired oxygen and the PEEP [positive end-expiratory pressure]." During inspiration from full exhalation, significant energy must be used to open compressed alveoli. Alveolar recruitment is maintained by holding the lungs at or above PEEP. "PEEP is your friend. Use it." He demonstrated PEEP by attaching a respiratory bag to the cut trachea of a fresh pig lung. "See how difficult it is to inflate the lung when it is collapsed. [5 cmH20 PEEP added.] Now try, much easier to inflate, right?"

We also learned about plateau pressure to ensure we don't "pop the lungs". Lung inflation requires overcoming the resistance of the airways and stretching the lung tissue (compliance of the lung comprised of the surface tension and lung tissue matrix). "It is okay to use high pressures to overcome obstructed airways. It is not okay to use high pressures to open alveoli. That will cause barotrauma of the lung." We learned how to measure the static lung compliance versus the airway resistance by measuring the pressure required to hold the lung at tidal volume at the end of inspiration. "If this pressure is close to the peak inspiratory pressure used to inflate the lung, most of the energy is being used to deform the lung tissue; whereas, if the plateau pressure is close to PEEP, most of the energy is consumed to drive flow through the airways."

The next day, the same respiratory physiologist gave a lecture on obstructive and restrictive lung disease. Obstructive diseases such as asthma and smoking-related chronic bronchitis and emphysema involve an increased resistance of the airways. Patients feel that air is trapped in their lungs. Obstructive disease can be treated with inhaled steroids and Beta-2 receptor agonists, e.g., albuterol, that cause bronchiole smooth muscle relaxation. Restrictive lung diseases are commonly caused by an occupational exposure such as to asbestos, silica, beryllium, or coal dust. These particles are inhaled into the lower airways where macrophages phagocytose the microscopic particles, but the macrophages are not equipped with enzymes to degrade these particles. Over decades, the inflammation leads to the deposition of extracellular matrix proteins that stiffen the lungs and make it harder to breathe in. The only effective treatment is lung transplant.

Our patient case: Nathaniel, a 68-year-old Air Force veteran, presents to his internist for an annual check up. He was diagnosed with emphysema following a 30-year history of smoking, and pulmonary fibrosis due to asbestos exposure working as a construction foreman after the Air Force. "My wife made me quit cigarettes 20 years ago, well before any of my lung issues. Beginning in my early 60s I started to develop difficulty breathing."

The pulmonologist explained, "Nate unfortunately has an obstructive and restrictive lung disease that combine to make his pulmonary function even worse." A normal individual is able to exhale at least 80 percent of his or her maximum inspired volume in the first second of expiration (typically 4 out of 5 liters of lung capacity). Nate is able to expire only 30 percent within the first second. Nate is treated with inhaled steroids, a long-acting Beta-2 agonist inhaler, and a rescue albuterol inhaler as needed. These medications alleviate symptoms. (The traditional age limit for a lung transplant is 65.)

"I get out of breath if I walk up half a flight of stairs. There are a lot of activities I am just no longer able to do," explained Nathaniel. "It makes me sad. I used to love to hunt and fish. I simply cannot do these any more. It is even difficult to take a walk with my wife."

This block we have weekly two-hour ethics lecture led by a psychologist, ethicist, or physician (frequently a geriatrician), followed by small group discussions led by a facilitator. This week: "Ethics in the Workplace," led by a female psychologist. When should a medical student speak up after noticing an error or unethical procedure? Should there be anonymous feedback in the medical field? The psychologist presented a peer-reviewed article that proposes a 5-step method by which a healthcare worker can determine whether to speak up:

  1. The nature and certainty of their judgment
  2. Their specific role in the situation
  3. The potential harm to patient
  4. The probable effectiveness of speaking up
  5. The likely cost to themselves if they speak up

The psychologist introduced the theory of "burdened courage" defined as a "system where there are rigid hierarchies, risky communications, and dysfunctional teams; and where unethical or unprofessional behaviors are ignored." The psychologist concluded: "We should design an ethical system such that individuals who speak up are not considered heroes. Courage should not be necessary for any health care professional to ask a question or make a suggestion regarding a patient’s care. It should be the norm."

Lanky Luke's summary: "Who gets paid for this? I want that job." Another student responded, "This field exists only because student loans subsidize these academics."

Statistics for the week… Study: 10 hours. Sleep: 7 hours/night; Fun: 2 nights. Example fun: Our class held a Floyd Mayweather and Conor McGregor Fight watch party. At least 25 students attended, including several M1s. "Much better fight than the Pacquiao fight. I think McGregor did really well. He got so tired at the end."

Year 2, Week 9

Classmates are enjoying the flipped classroom format, especially because class begins at 9:00 am instead of 8:00 am. Type-A Anita: "I do not even watch the online lectures. I prepare for lecture by watching the corresponding Pathoma videos. It solidifies the material when we go over cases in the workshops."

A tall Russian-immigrant pulmonologist in his late 50s introduces diseases of the pleura. Pleura is a thin membrane that runs along the inside border of the chest wall and outside border of the lung forming an air-sealed fluid sac called the pleural space. (Embryologically, the lung bud from the esophagus actually grows into this pleural sac like a fist going into a balloon). The pleural space links chest wall expansion to lung expansion. Chest wall expansion produces a negative pleural pressure that expands the lungs.

A pneumothorax occurs when air gets into the pleural space, thus destroying the negative pressure gradient that holds the lung expanded (-5 cmH20). This can occur spontaneously, typically in "long and thin" men, when a small section of lung parenchyma ruptures the visceral pleura, creating a connection between small airways and the pleural sac. It can also happen from trauma when the parietal pleural membrane is punctured. Tension pneumothorax, a life-threatening complication of a pneumothorax, occurs during trauma when the punctured pleura forms a one-way valve allowing air in on inspiration but not on expiration. The pleural pressure can get so high that it displaces the heart in the thorax.

A pleural effusion is a buildup of fluid in the pleural space. This causes increased intrapleural pressure and displacement of the lungs and potentially heart in the thorax. The fluid can be composed of plasma ultrafiltrate (transudate) suggested of inflammation or exudate ("a pus filled mess"). Pneumonia (infection of lung parenchyma) frequently leads to a harmless transudative pleural effusion, but the bacteria can migrate into the pleural space causing an exudative empyema. "Never let the sun set on an empyema. This is a medical emergency."

Mesothelioma, a rare complication of asbestos exposure, is cancer of the pleura. "Most of my asbestos-exposure patients were in the Navy, stationed either in shipyards or on ships. I ask them if they were exposed to asbestos. They respond, 'Oh yeah. I would go to the engine room and particles would be falling down.'"

"All of the data on the risks of asbestos exposure is from studying construction workers during the 1960s skyscraper boom in New York City." Asbestos exposure in the absence of smoking history is associated with a 6-fold increase in lung cancer. According to UpToDate, "asbestos exposure acts synergistically with cigarette smoking to increase the risk of developing lung cancer (not mesothelioma) 60 times over that of a similarly matched non-smoking, non-asbestos-exposed cohort." The pulmonologist: "The Board loves to test that mesothelioma is far less common than lung cancer or pulmonary fibrosis from asbestos exposure."

If lung cancer is a more common consequence of asbestos exposure, why so many commercials from plaintiffs' lawyers looking for mesothelioma patients? "Lawyers salivate over a mesothelioma case because it is no work. There is a one-one causal relationship between mesothelioma and asbestos exposure. Smoking is not a risk factor for developing mesothelioma. The defense cannot say it was lifestyle choices or smoking that led to the disease."

An invasive pulmonologist in her 50s discussed lung cancer for two hours. An invasive pulmonologist gets one to two years of training after a pulmonary fellowship and three-year internal medicine residency (i.e., there is no pulmonary residency, only the post-residency fellowship). With this additional training, an invasive pulmonologist can perform procedures such as a biopsy and bronchial thermoplasty (burning airway smooth muscle for non-responsive asthma). Symptoms of lung cancer are nonspecific. These include dyspnea, cough, cachexia (wasting, sudden weight loss), hemoptysis (coughing blood), and pleural effusion (from metastasis to pleura or to lymph nodes draining the pleura). "The most important aspect is to recognize the chronicity of the symptoms versus a more acute episode of pneumonia."

Smoking is the most important risk factor for lung cancer. She defines a non-smoker as "someone who has had fewer than 100 cigarettes in his or her lifetime." Smoking also causes the more aggressive forms of cancer: squamous cell carcinoma and small cell carcinoma (SCC). "SCC has a proclivity to metastasize to the brain. We treat SCC with prophylaxis brain radiation because by the time we can detect it in the brain it is too late."

She then went over the staging system for lung cancers. "Staging is important to be able to give the patient an estimate of his or her life expectancy. I would expect my fellows to be able to give an accurate stage. I just expect you to know the different components that go into staging." Staging incorporates the tumor size, nodal involvement, and presence of metastasis. "Lower stages are typically dealt with through surgical resection of a lung lobe and resection of any lymph nodes. Higher stages require chemotherapy."

Gigolo Giorgio asked the pulmonologist her thoughts on e-cigarettes. "E-cigs are such a new product. Each tobacco company uses a different formula. A new FDA regulation requires tobacco companies to release the full set of ingredients used in the vapor. I will withhold judgement until this information is analyzed." She did mention that she has noticed a rise in fungal pneumonia cases among e-cig smokers.

Gigolo Giorgio, true to his Los Angeles roots: What about pot? "That's also a tough question. There are no studies that show an increased risk of lung cancer that I know. When my patients tell me they smoke pot, I cannot tell them to stop for fear of getting lung cancer. Cancer patients? I say go for it."

She described how the second cause of lung cancer is radon exposure. Radon exposure increases the risk for adenocarcinoma, a less aggressive form of lung cancer compared to smoking-associated small cell and squamous cell carcinoma. "If you live in a high radon state, make sure you get a radon inspection. My house was off the charts. I had a radon mitigation system installed."

Our patient case: Beth, a 45-year-old spunky sarcastic mother of three, presents to her physician for worsening shortness of breath and joint pain. A chest x-ray reveals hilar infiltrates (enlarged lymph nodes of the lung). She was referred to a tertiary hospital for follow-up.

"I was diagnosed for three years with asthma. When I finally was referred to the university hospital for biopsy I was almost relieved." She drove three hours for her lung biopsy appointment. "When I was called back from the waiting room, the nurse grabbed my hand and started praying. I was like, 'Damn, Woman, what are you doing?' I did not realize I was in the OR. I did not sign up for this!" Her lung biopsy revealed non-caseating (no necrosis) granulomas diagnostic for sarcoidosis.

Sarcoidosis is a systemic inflammatory disorder that causes granulomas, a collection of immune cells formed in an attempt to wall off a substance. The soft-spoken Indian pulmonologist explained, "We have made incredible progress in understanding sarcoidosis. This mostly shows how little we knew ten years ago and how far we have to go. We still do not know what causes this immune response. It likely is an unknown substance that certain individual's macrophages cannot deal with." These granulomas can form anywhere in the body, but sarcoidosis almost always involves the lungs. "Patients are diagnosed due to shortness of breath from the pulmonary fibrosis or on incidental findings."

Beth has a lot to say about her physicians. "I cannot stand when the doctor comes in and says, 'So what brings you in today?' Look at my damn chart. Spend two seconds getting to know me. I once told a physician, 'Well I was learning to twerk on the kitchen table and fell. That's what causing my joint pain, not my sarcoidosis on my chart.'."

Beth is managed with glucocorticoids and methotrexate (folate synthesis inhibitor) to reduce her immune system response. These have greatly improved her joint pain and lung function, but have lead to significant weight gain. "Laugh all you want. Call me Fatso." She explained how frustrating it is that people around her, both strangers and close family members, attribute her weight gain to laziness. "It does not matter how much I eat or exercise. I will just keep putting on weight. It makes me depressed. I cope with it with humor, by poking fun at myself. I would not wish this even on my worst enemy... my ex-husband. And I hate him."

Beth has not had to increase her dosage for two years. Most patients will regress and require more intensive pharmacologic agents. "I am hopeful I can continue this lifestyle. I view my disease as that devil on your shoulder. He's always there, and I hope I can keep him silent for a little longer."

This week's ethics session: "Distributive Justice". Before the lecture and small group meeting, we read several papers and completed a quiz:

True or False: The Affordable Care Act can be viewed as an effort to mandate distributive justice in the United States? Lanky Luke had a field day: "I was going to put false. Then I remembered a liberal probably wrote it." [Editor: sometimes justice is not fully distributed; more than 30 million Americans were without health insurance in mid-2017, seven years after Obamacare was enacted.]

True or False: Distributive justice refers to the fair and equitable distribution of goods and services.

 

Which of the following strategies for eliminating healthcare disparities is the most difficult to implement? Answer: Collection of standardized data on patient and provider race and ethnicity.

One required paper was "Ushering In The New Era Of Health Equity" by Joseph R. Betancourt: (Health Affairs Blog, October 31, 2016):

 

several promising opportunities are on the horizon … activities focused on diversity and inclusion, and especially new conversations about racism, implicit bias, and stereotyping as root causes for disparities, are bubbling up now more than ever before. This is likely a direct consequence of the coverage of police violence against Black citizens, the Black Lives Matter movement, and the current and toxic political climate around race relations.

Luke: "My problem is not that they are making us read these articles. It is important to keep an open mind to new information. My problem is that they state their opinions as fact. Their job is not to indoctrinate us, but to provide the tools and resources for us to make our own opinions."

[Editor: Dr. Betancourt thought that the political climate was "toxic" in October 2016; imagine how he felt after Donald Trump was elected in November!]

Another article contained an interview with the physician president of a free clinic. He explained how they had planned to close down the clinic after the passage of the ACA. "Little did we know we would have more business than ever before from people with high-deductible plans not able to pay for small checkups and medications. Of the 4 million dollars in services we provide now, about 3 million go to the pharmacy."

An endowed university professor of ethics and member of the ethics committee at the hospital introduced the topic with a 1.5-hour lecture. He proposed that people agree on two principles:: (1) a decent minimum access for all, and (2) better or faster care for those who can afford it. [Editor's note: this is what most countries around the world, from Mexico to the U.K. to Russia, actually do provide. The public hospitals are free and can be reasonably good; private hospitals and doctors are available for the rich. They manage to do this while spending only a fraction of what U.S. society spends.]

He gave a personal story about Canada's attempt to provide gold-plated service for all: "I used to teach in Canada.  My daughter went to an ophthalmologist where she was told she may have brain cancer and needed an MRI to rule this out. She was given an urgent 3:00 am appointment… in 6 months. Instead of waiting, we went across the border to get a $500 MRI that was emailed to her Canadian doctor. It was quite the spectacle. There are these lots near the border where MRI and CT machines are set up in trailers. The whole parking lot was filled with cars with Canadian license plates."

After the lecture we broke into six-person groups with a facilitator. Our group's facilitator was a 35-year-old female professor of ethics from our affiliated university. She had completed a Science, Technology, and Society (STS) PhD dissertation on "kind of the intersection of technology and how knowledge is generated -- ethics is my passion." She disclaimed having better answers to ethical issues than others, but felt that her training enabled her "to ask the right questions about an ethical dilemma." Gigolo Giorgio scoffed. She began the discussion with "I do not want this discussion to be political. However, being engaged in politics is important, now more than ever with the ongoing 'medical apartheid' [instituted by Donald Trump]. I am not saying how you should feel about it. But be engaged, and always reframe to the cultural context."

We started by watching a clip from Dallas Buyers Club, a movie about getting ddC and peptide T at a time when neither drug was FDA-approved. [Today, drugs related to ddC are used in standard of care combination treatment and used while peptide T is not part of any recognized treatment.] One student whose internist father has practiced in India and England added, "My father told me how grateful he is to have the FDA. There are some whacky treatments and patient requests in medical systems without the FDA framework." Capturing the spirit of current discussions regarding inequality and race, the ethicist framed the FDA's 1980s approval process for AIDS drugs: "Although the AIDS epidemic was primarily impacting African Americans, it was wealthy white men with AIDS who had sufficient influence to expand treatment options for AIDS patients. This was fortunate, but it serves as an example of the challenges different groups face." She was confident in her race- and class-based analysis, but did not explain why the government would ignore wealthy white men with AIDS in the early years of the epidemic and then begin to listen to them in the late 1980s. Nor did she explain what the government could have done in the early years of the AIDS epidemic when there was no scientific basis for treatment.

We discussed Boston REACH, a community program to address modifiable risk factors, particularly obesity and smoking, among African Americans living in the Boston metro area. Straight-Shooter Sally said, "This program is great. There are whole communities that are alienated from the healthcare system. My concern is a growing culture that blocks candid conversations. Healthcare workers have to say you are beautiful no matter what. It's difficult to convey to an obese individual that, yes, you are beautiful but you are fat and you need to lose weight. I mean you are literally a walking poster child for risk factors."

Can future generations of doctors be reformed via ethics discussion? Lanky Luke: "I kept my mouth shut the whole time… Time to go shoot a gun!"

Statistics for the week… Study: 15 hours. Sleep: 7 hours/night; Fun: 1 nights. Example fun: Jane and I joined Luke, Samantha, and Mary for drinks at our favorite burgers and beer joint. Samantha will be finished with PA school in a few months. She is almost as excited as Luke. "I married you for the money," exclaims Luke. "In a few months I get the money." Samantha recounted her two-month psychiatry rotation: "We worked with foster youth. I never was exposed to this. Several kids were sexually abused by their parents and now sexually assault their new foster siblings. The older children are so mentally screwed up they are forever dependent on social services. The government pays for housing, food, and all the medical care."

Year 2, Week 10

Cardiology week begins with a one-hour lecture and two-hour workshop focusing on interpreting electrocardiograms (ECG or EKG). An electrophysiologist with a Southern accent who is celebrating his 40th year reading EKGs implored us to "develop a systematic way to read EKGS. Don't just jump into the details." He commented on 30 slides of pathological EKGs. Afterwards, we broke up into seven-person groups and went through 20 example EKGs with a fellow. Straight-Shooter Sally was unimpressed with our fellow: "When asked why this is a LBB [left bundle branch], all she would say is, 'That's what a LBB looks like. It's pattern recognition.' That does not help us. Connect the physiology to the EKG."

We next traveled to the clinical room to practice on Harvey, a cardiopulmonary patient simulator, with a soft-spoken retired Navy cardiologist who had become a class favorite last year. "Studies show that it requires hearing about 200 murmurs to get decent at identifying one on a patient." Jane put her stethoscope on Harvey's chest while the rest of the students listened to the simulated heart sounds on wireless stethoscopes. "Enter number 24". The heart sound changes from a crescendo-decrescendo systolic ejection murmur of aortic stenosis to the holosystolic murmur of mitral regurgitation. Jane found it challenging to determine whether a murmur is systolic or diastolic. "It was really helpful to listen on Harvey while feeling for the pulse. If the murmur happens with the carotid upstroke, it is a systolic murmur."

Each group also rotated through two patient volunteers. Patient #1: accommodating 40-year-old female recently diagnosed with pulmonary stenosis after an enlarged thymus was removed. We felt a thrill (vibration felt with hand) under her left clavicle and a loud systolic murmur that radiated to her back. Patient #2: genial 75-year-old male with mild mitral regurgitation, typically a benign finding due to the changes accompanying an aging heart. The murmur was barely audible after concentrating for 45 seconds. The cardiologist asked, "How could we bring out the murmur?" After several blank looks from the group, Gigolo Giorgio proposed, "Make him squat?" "Yes!!," exclaimed the cardiologist. "Squatting would certainly work, but we'll just ask him to flex his arms together." With an increased afterload (blood vessel resistance), the left ventricle pushes more blood backwards through the mitral valve orifice. This accentuates the mitral valve regurgitation murmur. We asked the patient to stand up. The decreased preload (the total amount of blood returning to the heart) completely eliminated the murmur.

A pediatric cardiologist, recently retired from clinical practice, introduced congenital heart defects. She emphasized the cyanotic ("blue baby") defects including Tetralogy of Fallot (four heart defects combined) , transposition of the great vessels (left/right reversal creating two nearly separate circuits), and tricuspid atresia (closure of the tricuspid valve orifice). She referred to current events while looking at the swirling color doppler field of flow through an obstructed aortic valve: "Looks like [Hurricane] Irma." Fortunately for her, she's already retired because Generation Politically Correct was gunning for her. Pinterest Penelope: "It is inappropriate to make light of the suffering of those who have gone through Harvey, Irma, and Maria." Two classmates piled on.

The pediatric cardiologist continued regarding the importance of the ductus arteriosus in these "duct-dependent disorders." The ductus arteriosus is a short connection (right to left) shunt between the left pulmonary artery (carrying deoxygenated blood from right ventricle to left lung) and descending aorta that allows oxygenated blood from the uterine vein (from the mother) to bypass the lungs and mix with the systemic circulation. Compared to normal oxygen saturation after birth, the fetus survives on a lower oxygen saturation in-utero.

When baby takes her first breaths, the pulmonary vasculature opens up. Usually the ductus arteriosus closes. However, if the ductus arteriosus fails to close (patent ductus arteriosus or PDA) the shunt reverses direction, causing oxygenated blood to overload the pulmonary circulation. A reverse-flowing shunt isn't bad for everyone. Patients with an obstructed right ventricular outflow tract, such as babies with Tetralogy of Fallot or tricuspid atresia, require the right-to-left shunt PDA to get blood into their lungs. "A patent ductus is the only thing keeping the baby with Tetralogy of Fallot alive. Pump those prostaglandins. Do NOT let it close."

Tetralogy of Fallot was a lethal disease until the 1940s when a surgical procedure was developed to connect the right subclavian vein (part of systemic circulation) to the right pulmonary artery for oxygenation. This procedure is front-and-center in the identity politics of medicine, having been developed by Alfred Blalock, a white male surgeon, Helen B. Taussig, a white female cardiologist, and Vivien Thomas, a black male lab technician. People fight about whether the procedure should be called "Blalock–Taussig" (BT) or Blalock–Thomas–Taussig (BTT) and also how much credit should be assigned to the three collaborators. The discussion regarding the race and gender identification of the creators has outlasted the original procedure. Today a synthetic dacron shunt is placed between the right subclavian vein and right pulmonary artery. "Eventually the child will grow out of the BT shunt," said our pediatric cardiologist, However, the heart has grown enough so surgeons can perform a more complicated fix."

Our patient case: Becca, a female neurotrauma nurse, age 27 at the time, returned to work two months after giving birth to her second child. "It was just a normal day. I had two great patients, which means it was somewhat boring -- not stressful at all. I was pushing some meds to my patient when I had this odd sensation in my neck. It wasn’t a sharp pain, but a strong tingling sensation. I went over to the charge nurse who sat me down." Becca's heart rate was in the 50s (bradycardia). She felt a searing pain in her chest and was sweating profusely. "It felt like someone was stabbing me through the front of my chest all the way out the back."

 

Becca recounted how she was hauled down to the ED in a gurney. "Let me tell you something: patients remember what they hear in the hospital. My scrubs were soaked with sweat by the time I got to the ED. I started taking off my scrubs and even sports bra. I am sure people saw me naked through the makeshift curtains in the ED. Some ED nurse blabbered, 'What's wrong with her?' It was just rude." Her cardiologist, the retired Navy doctor who taught our simulator session (above), commented, "A lot of residents make offhand jokes about patients. Try to do it in the resident lounge."

The ED physician performed an EKG. "I turned my head to look at the screen. Those Tombstone T waves are still seared into my head." [Tombstone T waves suggest a myocardial infarction ("heart attack").] "This is when I was called down to the ED," explained her cardiologist. She was taken to the Cath Lab while a nurse called her husband, at home with the 2-year-old and 2-month-old. Becca: "I've sent several patients to the Cath Lab, some don’t come back. I was freaking out all alone."

"We inserted a catheter through Becca's femoral artery up to her heart. Pretty quickly we realized we were not dealing with a typical MI caused by a thromboembolism," explained the cardiologist. He showed several images of the catheterization.  A student asked, "How could you tell this was not a thromboembolism?" The cardiologist responded, "This is why they pay me the big bucks." [Interventional cardiology is one of the highest paid specialties, if not the best with explanations.]

Becca had spontaneous coronary arterial dissection (SCAD) of her left anterior descending artery, the main artery that supplies both ventricles. From Wikipedia: "a dissection is a tear within the wall of a blood vessel, which allows blood to separate the wall layers. By separating a portion of the wall of the artery (a layer of the tunica intima or tunica media), a dissection creates two lumens or passages within the vessel, the native or true lumen, and the 'false lumen' created by the new space within the wall of the artery."

SCAD is a rare condition, accounting for fewer than 0.4 percent of heart attacks, but is more common during the postnatal period. This increased risk may be due to the the progesterone surge that weakens connective tissue to prepare for the baby traversing the vaginal canal. The progesterone also weakens connective tissue in blood vessels, thus enabling false lumens to develop.

Coronary dissections can be difficult to stent (putting a tube into the collapsed vessel, then inflating). "Sometimes it pays to be lucky instead of good." The cardiologist got the catheter through the true lumen instead of the false lumen. "I've only dealt with two coronary dissections in my lifetime. I knew I did not have my catheter through the false lumen because I did not have to put much force on the catheter to move it through the left coronary artery. If it had been the false lumen, I would eventually have gotten stuck where the lumen ended."

The cardiologist placed the first stent where the false lumen ended and worked his way back to where the dissection originated (working from distal to proximal). This required three stents total before perfusion normalized.

Becca's rehab included a psychology consult. "It was hard for me to not think about how close I was to dying. I would lie awake scared that this could happen again. I still see my psychologist periodically." The cardiologist: "Fifty percent of individuals experience depression during the first year post-MI." Becca returned to work at the neurotrauma ICU after 1.5 years and exercises regularly. She gets an annual echocardiogram. "One thing [the cardiologist] told me is that I cannot have another child."

During a brief intermission, our class joked about the weekly newsletter section on "How to Save Money". Recommendations submitted by former students included (1) Make your own laundry detergent pods, and (2) Take up offers for food from friends. The cardiologist chimed in, "Does anyone have a part-time job?" One of our classmates drove Uber five times per month during M1 year, but he has stopped this year. The cardiologist commented that one of his classmates paid for medical school by working as a cab driver while another worked as a part-time cop. "Getting shot at was his stress relief from studying. He is now a trauma surgeon." Classmates noted that tuition has gone up so much faster than wages that even paying for undergraduate tuition would be impossible today.

After the patient case concluded, the cardiologist summarized myocardial infarction complications. The danger of a MI does not end during the acute event. After the risk of cardiogenic shock or sudden cardiac death from an arrhythmia, there is significant remodeling of the necrotic tissue. Over the next few days, white blood cells infiltrate into the tissue to eat up the dead tissue. During this period there is a significant risk of ventricular wall rupture, in which blood flows from the heart into the pericardial sac. Blood filling the sac around the heart compresses the heart, preventing pumping (cardiac tamponade). "You die pretty quickly from a free wall rupture." Weakened tissue can also cause a papillary muscle ("heart strings") tear that holds the mitral valve from prolapsing during systolic contraction. Over months and years, remodeled scar tissue may develop arrhythmias and aneurysms. "An MI does not end after the two-week hospital stay. Patients need to be followed for life."

Our ethical group met for a 1.5-hour discussion on patient autonomy and veracity. Nervous Nancy, an attractive, intelligent female who asks great questions at the speed of sound, worked as a CNA and scribe for a large health system in the ED and orthopedic unit before medical school.  She recounted, "Patients would come in on lawyers' directions to get a payday because they knew the hospital would settle rather go to court. We had this one woman purposefully fall off a bed that did not have the railing up. She got one million dollars."

Lanky Luke continues to scoff: "I want a talk from a malpractice lawyer and from a physician reflecting on their experience about getting sued by a patient. Not from some overpaid ethics professor. Why do we as physicians get to decide what is or is not ethical. We should first be taught the Law. Yes, sometimes there will be grey areas. Those situations should be highlighted and settled through the legislative process." (Luke hopes to go into politics after graduation.)

Classmate political activism continues with a Facebook post from Type-A Anita regarding Trump's Department of Education relaxing requirements that universities run sexual assault tribunals:

I think that taking what [Education Secretary Betsy DeVos] says at face value is dangerous. This administration doesn't care about sexual assault victims.

Do you have any idea how hard it is to file a sexual assault claim on most campuses? Or how degrading [sic] victims are made to feel during this process? … The students Betsy is looking out for here are rapists, who already have the entire system at their backs. … Even if the school does something, it will take forever and their rapist will most likely be allowed to stay on campus, finish their degree, or be given a slap on the wrist. It's laughable if you seriously think rapists on campuses are actually punished - the vast majority aren't dismissed from school.

… I do not care if rapists feel their rights have been taken away from them under these university Title IX programs. University's [sic] have professional Title IX coordinators, larger universities have whole departments. It's not asking for the sun and the stars for schools to pay professionals to advocate for sexual assault victims on campuses. These programs force administrations to listen to victims over fucking rapists, and still so many victims don't get any semblance of justice.

… And this isn't just about rape, it's about all forms of sexual assault, which by the way isn't a fucking bipartisan issue. Conservatives literally voted for a man who bragged about assaulting women...

Nearly half of our class clicked "Like" on Anita's post, roughly one third of which is reproduced above.

Jane and I went to the mall. A 40-year-old sales clerk asked what we did and then told us about having dilated cardiomyopathy (enlarged heart). "If my meds don’t start working, I have to get a heart transplant." He recalls his doctor saying something about a viral infection. We spent the drive home pondering the possible causes. Dilated cardiomyopathy is typically familial, but we both thought of Coxsackie type B virus and Chagas Disease (prevalent in Central and South America, caused by the Trypanosoma cruzi).

Statistics for the week… Study: 14 hours. Sleep: 5 hours/night; Fun: 2 nights. Example fun: Jane and I went to a concert with Jane's sister, a nurse on the neurotrauma unit, and her two friends, a fellow female nurse on the unit and an autopsy assistant at the hospital who doubles as a part-time stand-up comedian: "If I were stranded on an island after a plane crash I would know exactly what cut to take out of the the dead bodies. Tenderloin dinner for me."

Year 2, Week 11

Heart failure week begins Sunday evening. Jane and I watch (at 1.75x speed) three hour-long lectures on hypertension and ischemic heart disease (due to obstructed arteries the heart is starved for oxygen causing chest pain d). The lecturer is a 35-year-old cardiologist who comes in Monday morning for a two-hour case workshop. "I get excited when I see 30-year-olds with hypertension. I can change their lives. When I see a 70-year-old patient with three decades of uncontrolled hypertension, the damage is already done."

Hypertension is categorized by disease acuity.  Malignant hypertension is a severe acute elevation of blood pressure that causes end organ damage, particularly in organs with dense capillaries, e.g., the kidneys and retina. Benign hypertension, over 95 percent of cases, is a progressive mild elevation of blood pressure. Our lecturer explained that Amazonian tribes with no exposure to Western diet typically show blood pressures of 80/50. Normal blood pressure for an occasional McDonald's customer is 120/80. Greater than 140/90 mmHg constitutes benign hypertension. Over 200/120 mmHg is malignant.

"The vast majority of benign hypertension is simply caused by chronic excess of salt intake," said the cardiologist. "Our bodies have evolved complex mechanisms to retain fluid by holding onto salt. Recommended salt intake is about 4 grams; most Americans consume about 10 grams per day." About 30 percent of the US adult population has hypertension compared to 45 percent of the Japanese adult population with their salt-heavy fish diet.

He explained that, although salt intake is a serious driver, "there are many risk factors that interplay with this volume overload state. It is well-established that African Americans have an increased risk of hypertension. The current theory is that there was an evolutionary adaptation to holding onto salt in Sub-Saharan Africa. These adaptations helped individuals survive as young children in a dry environment with little access to salt." He continued, "The unintended consequences of chronic hypertension that develop when you are 50 do not really matter from an evolutionary standpoint. Our genetics are most adapted to getting to reproductive age." There is nothing that humans can do after age 50 to increase their genetic success? "I would like to think there is some selection that occurs during your 50s as you take care of your child, perhaps even into grandchildren-rearing age."

Why is hypertension bad? "A misconception about hypertension is that the heart is at fault.  Hypertension is not a disease of the heart, but a disease of the vasculature and kidneys. Cardiologists get stuck dealing with many of the serious complications." The endothelial cells and smooth muscle cells of vessels do not respond well to chronically elevated hypertension. Over time, the increased pressure within the vessels hardens and narrows both large and small arteries (atherosclerosis and arteriosclerosis, respectively). The increased resistance decreases perfusion to tissues and increases the risk for thrombus (clot) formation leading to embolic events such as heart attack and stroke. Further, the left ventricle undergoes hypertrophy (thickening) as it struggles to pump against an increased total peripheral resistance.

 

"For most of my patients, losing weight is the most effective method," said the cardiologist. "Unfortunately, only six percent of patients told to lose weight actually keep weight off at one year. I give HTN medications first and tell them that they can get off them once they lose the weight." What about reducing salt? "Americans are so far to the extreme that taking away the salt shaker will do nothing. Shake away. Chronic benign hypertension needs antihypertensive medications."

Where is HTN treatment going? "We are in the dark ages of hypertensive treatment and pharmacology in general. Most of us hope that in twenty years we will have a renaissance in pharmacogenetics to personalize treatment. Right now it is just black or white." (White patients may respond to single drugs, but certain monotherapies are contraindicated in African Americans due to poor response rates. Black patients will be started on lisinopril in combination with a diuretic.)

The cardiologist concluded:  "On a brighter note, we are at a unique point in human history that we are no longer dying from microbes and predators. Instead, we are eating, drinking and smoking our way to death. Not bad."

The rest of the week was dedicated to the diagnosis and management of heart failure. First we learned multiple classifications:

Retired Navy Physician: "Cardiology is not rocket science. It is just common sense."

We were prepared for our patient case with a lecture on dilated cardiomyopathy, a systolic non-ischemic problem. The heart is enlarged due to growth of muscle cells, but the resulting thin-walled muscle is unable to pump enough blood. This can be caused by genetic defects, viruses (Coxsackie B), parasites (Trypanosoma cruzi causing Chagas disease), alcohol abuse, cocaine, and poorly understood autoimmune mechanisms.

For the most part, we're not working with cadavers this year, However, this week we go into the anatomy lab to dissect the preserved hearts that we removed from our cadavers last year. Several students expressed frustration that  they had to resurrect their anatomy outfits. Pinterest Penelope: "I thought we were done with anatomy lab. Another pair of scrubs will be tossed."  Our favorite trauma surgeon and an M4 helped with the dissection. We first weighed each heart and found that two-thirds weighed more than the normal 500 grams. The trauma surgeon attributed this to "pervasive hypertension".

We used a scalpel to open the right atrium. We used angled probes to identify the veins draining the body: inferior vena cava, superior vena cava, and the barely visible coronary sinus. We then opened the left atrium with its four pulmonary veins draining oxygenated blood from the lungs. One student found a patent foramen ovale (PFO) type of atrial septal defect (ASD). You could see a hole connecting the left atrium to the right atrium. (The trauma surgeon expected more: "I would expect to have several PFOs. It is expected to be present in 25 percent of the population. Look closer!" We then opened the left and right ventricles to observe the heart strings connecting to the valves. Afterwards we went over to the "Tray of Horrors," collected over multiple years. We looked at the severely dilated thin walls of dilated cardiomyopathy, a bicuspid aortic valve, and a heart with several stents in the left anterior descending coronary artery. "Good haul!, I am very impressed," said our trauma surgeon. She suggested that our class contribute to the school's archive: "Put the mechanical aortic valve and aortic dissection on the tray."

Our patient case: Jonathan, 53-year-old construction manager and father of two, presents to the ED for progressive shortness of breath and swelling in his legs associated with a 15-pound weight gain over two weeks. Lung auscultation (listening with a stethoscope) reveals bibasilar (base of both lungs) crackles. Heart auscultation reveals a S3 gallop, an extra heart sound that sounds like a horse's gallop, suggestive of rapid ventricular filling.

Feeling for the location of the heart under Jonathan's left nipple revealed a laterally displacement. Chest xrays showed an enlarged cardiac silhouette and bilateral infiltrates (pathy whiteness at the base of the lungs) with accentuated vasculature at the hilum (connective tissue where the pulmonary artery, pulmonary vein and bronchi pierce through the pleura). EKG shows sinus rhythm with a left bundle branch block, left ventricular hypertrophy, and biatrial enlargement. An echocardiogram (ultrasound of the heart) shows dilation with a 30 percent ejection fraction (normal > 55 percent). Jonathan is diagnosed with dilated cardiomyopathy secondary to viral myocarditis (infection of heart). ("Viral myocarditis and dilated cardiomyopathy," Kearney, et al. Post-Graduate Medical Journal, 2001 ).

Jonathan, his wife, and their 25-year-old son were joined by his cardiologist. Jonathan and the son rarely spoke; the wife, a middle school teacher, led the conversation. "We did not know what hit us. It came out of nowhere," explained the wife. "I did not know what to say to my children or husband for weeks." The son was clearly uncomfortable. When asked about his perspective on two separate occasions, he repeated: "I try to stay optimistic, and hope for the best. I just have to believe my father will pull through this."

Jonathan's symptoms rapidly deteriorated at the hospital to a point he underwent a LVAD (left ventricular assist device) implantation to improve his cardiac output while he waits for a heart transplant. "We would have liked to do the surgery at a larger hospital that does maybe 100 per year. There was just no time, he was on his deathbed," explained the wife. "The surgeon had done maybe two in his life. We put our faith in him, and it fortunately went great."

Jonathan has been on the heart transplant list for five years. He appears tired, worn out, although he still looks imposing in his burly 6'5" frame. "It is hard to find a heart that fits his size," added the cardiologist. His wife is convinced he will get one soon. She recounted the scariest day in her life: "I got a phone call from my husband telling me he got in a car accident. A truck veered into his lane, striking the car in front of him. He swerved off the road hitting a tree. "I believe God has a plan for him. He wouldn’t have come out of that car accident without any scars." Jonathan: "I am realistic. I have lowered my expectations." There is clearly a disconnect.

 Jonathan's symptoms have improved remarkably from his deathbed with the LVAD. His progress has pushed him down in the transplant list for more urgent cases. He is maintained on diuretics and antihypertensive medications. He quickly gets out of breath from walking. He has had to retire on disability, while his wife has picked up hours working at Starbucks after her job.

A student directly asked Jonathan, "Are you depressed?" "I feel like a failure. My whole life I provided for my family. Now I just sit and wait." Several students went up afterwards to thank the family and look at the numerous batteries and charging devices for the LVAD. Mary asked to listen to his LVAD. "It sounded like a fish-tank pump."

Our ethics lecturer and facilitator returned this week to introduce the topics of beneficence and nonmaleficence (do no harm). Lecture opened with the classic ethics train dilemma. "There are five people on the track who will die unless you pull the lever to divert it to the side track where one person will die. Would you pull the lever?" Most students responded via the iClickers, "Yes". "Now you have five patients that need a transplant and a healthy tourist comes to town? Should you harvest the tourist's organs to save your five patients?" The class responded "No". Asked to justify the different answers, one student responded "The guy on the track got into his unfortunate situation, the tourist did not." Lanky Luke: "Is that victim blaming?"

In our small groups, we went over the Jesica Santillan case. Jesica Santillan was treated for anemia in her hometown of Guadalajara, Mexico with iron supplements, but over the years her conditioned worsened and a heart murmur was found. She was diagnosed with restrictive cardiomyopathy, a genetic disorder requiring heart transplant. She crossed the border illegally to stay with a family member living in North Carolina and sought treatment at Duke. After she was denied Medicaid coverage, a local business owner and the community donated $500,000 to pay for a transplant. A heart and lung transplant was performed at Duke in February 2003. Unfortunately, she probably would have been better off getting the transplant in her native Mexico. The American transplant surgeon, James Jaggers, assumed that the organ program would not have contacted him unless the donor and Jesica were a match. Her body rejected the new heart and lungs, with incompatible blood types, resulting in brain damage. Duke found a second set of donor organs and transplanted them, but it was too late to save Jesica, who died a day later at age 17.

Our group discussed whether Jesica should have been able to receive the second heart transplant. "She was promised a heart. It was not her fault Duke messed up." Type-A Anita: "We should go to an opt-out organ donation system." Six of the seven students thought it was "immoral" that "insurance" (i.e., American taxpayers via Medicaid) did not automatically cover the foreigner's transplant operation.

According to the required reading, "The Jesica Santillan tragedy: lessons learned" (David Resnick, The Hastings Center Report, July 2003), physicians and our organ donation system should operate without regard to immigration status:

The fact that Duke did not deny Jesica an opportunity for a transplant based on her immigration status also reveals compassion. Some people criticized Duke for allowing an illegal alien, or undocumented immigrant, to have a chance at receiving an organ transplant. The organ allocation system, according to these critics, should serve citizens first, and illegal aliens should receive an organ only when no citizen requires that organ. Indeed, the reasoning goes, the fact that Medicaid does not extend benefits to illegal immigrants reflects this country's collective decision to take care of its own citizens first.

There are several problems with this reasoning. First, immigrants, including illegal aliens, donate organs in the United States. Indeed, some evidence suggests that they may give more organs than they receive. Second, immigrants, including illegal aliens, make important contributions to the United States economy. The Santillans had lived and worked in the United States for three years; they were not on welfare. Third, immigrants, including illegal aliens, pay taxes. As an employee of Louisburg College, Magdalena Santillan probably paid taxes to social security. Medicare, the state government, and the federal government. Both of the Santillans probably paid gasoline taxes and sales taxes. Although they did not qualify for Medicaid, they were not seeking a handout: they were industrious people who made sacrifices to try to save their daughter's life. Thus, there were sound moral and economic reasons to offer them medical care, including organ transplantation, notwithstanding their immigration status.

The author of the article has a law degree and hypothesized regarding the difficulty of recovering cash from Duke:

Although Jaggers has admitted his fault, since he is an independent contractor and not an employee or agent of Duke, his negligence would not implicate Duke under the doctrine of "vicarious liability." To go after Duke's deep pockets, Dixon will need to argue that Duke was negligent. So far. Duke has accepted responsibility in the mishap but has not admitted that it made an error. For the last few years. Duke has asked patients to sign mandatory arbitration agreements as a condition of providing care. These agreements require patients to submit their claims against the hospital to an arbitrator instead of taking them to court. As of this writing, information about any arbitration agreement between the Santillans and Duke was not publicly available. If the Santillans had signed such an agreement, they would need to show that the contract was invalid before they could pursue malpractice litigation.

That's where the matter stood in July 2003, apparently, and we the surgeon, James Jaggers, being thrown under the bus by Duke and becoming the primary defendant in any lawsuit filed by the patient's mother. Students expressed sympathy for Dr. Jaggers: "He made a mistake, but there should have been other checks. He made one error. Think of all that training he has put into becoming transplant surgeon."

[Subsequent news articles found via a Google search make it clear that Duke paid a settlement to the patient's mother in 2004. Apparently when someone is listed on your web site as being a professor of surgery it is tough to escape liability for his or her actions! Illustrating the asymmetry between the stakes that patients and physicians have in our system, Dr. Jaggers continued to be a professor of surgery and pediatrics with tenure at Duke through 2010, and Dr. Jaggers was on the faculty at the University of Colorado's School of Medicine in 2017.]

Type-A Anita was also thinking about immigration this week. Her Facebook post, "liked" by about 20 percent of our class:

DREAMer's parents were never 'criminals', but working people displaced by NAFTA and US economic and foreign policy. Their parents did not 'break the law', but obeyed the the law of supply and demand that were shaped according to the wishes of US corporations. US policy united economics, destroyed peasant economics in Mexico and Central America, attracted laborers to the US, then branded these same migrants 'criminals'. Rather than recognize this history or take responsibility, we now criminalize the children of people that we displaced, cheated and exploited. The real criminals in this equations are corporations who profited from migrant labor yet never fought for their legal rights, and politicians who decided demonize immigrants for political gain. There is the law, and there is morality, and these are at complete odds with regard to US immigration policy. We are not a 'nation of laws' but a nation of lies, a nation of greed, a nation of racism, and a nation of violence.

Our school holds two shows per year featuring local art. This semester's show is on the interplay between medicine, veterans, and the military. The 50 pieces in the hallways at our school include paintings of soldiers, photos of veterans, an American flag, and two essays, one on how a Health Professions Scholarship Program medical student puts on two coats (his uniform and his white coat) and another on the role art played in healing a Iraqi war veteran. A week after the show opened, the Dean emailed all students and faculty:

Some of you have brought up concerns that the display is militaristic and can seem counterintuitive to the type of learning environment we try to create at the school. I understand your concerns, especially without the context of the show. Our goal is to pay tribute to the sacrifice of veterans and their loved ones while also showcasing the power of art to promote healing and reintegration…

Please let us know if you have further concerns. We would like to continue the discussion.

Statistics for the week… Study: 15 hours. Sleep: 7 hours/night; Fun: 2 nights. Example fun: doubleheader Thursday night softball game before the playoffs followed by burgers and beers. Our school put together a softball team for a community recreational league. We play two or three games per week with five males and five females. Pinterest Penelope grumbled over the league rules: when a male is walked, he goes to second and the female on-deck has the option to take first, whereas when a female is walked, she goes only to first. Jane said: "I should identify as a male." Gigolo Giorgio: "I should just identify as a female so we have enough ladies every match."

We lost 35-3 the first game to the "Masterbatters", a team of plumbers. We spent 45 minutes in the field during one inning while the Masterbatters scored 28 runs. We won 9-8 the second game against "Pitch, Don't Steal my Vib", a local restaurant team. Jane, having never put a mitt on before, appeared several times at bat as the MVP in a school-sponsored video.

Year 2, Week 12

Hematology week. Our favorite redheaded hematologist/oncologist: "Heme is a free-for-all. Oncology is more by-the-book. Our whole practice has no idea what is causing one patient's hematological abnormalities. We've been following him for 3 years. This is what makes hematology so exciting."

Blood is composed of cells and plasma (water, electrolytes, and proteins). As introduced in the Year 1, Week 7 and Year 1, Week 16 chapters, all blood cells are derived from a single hematopoietic bone marrow stem cell that can produce either the myeloid lineage or the lymphoid lineage.  The myeloid lineage includes erythrocytes (red blood cells), platelets (for clotting), monocytes (white blood cells that consume particles), and neutrophils (the most abundant immune cell that responds to infections). The lymphoid lineage includes the immune system's T cells and B cells.

Platelets start as small cytoplasmic blebs (bulge in the cell) of megakaryocytes (large resident bone marrow cells) and eventually detach and drift away. Erythrocytes (red blood cells) mature in the bone marrow until they lose their nucleus. "If you see reticulocytes [immature red blood cells] in the blood, the bone marrow is working in overdrive producing red blood cells."

Our lecturer explained the complete blood count (CBC), the most common blood test. Normal CBC: 45 percent of blood volume is composed of red blood cells (hematocrit), 55 percent plasma (proteins, electrolytes, water), and less than 1 percent white blood cells and platelets. "Do not forget about the peripheral blood smear [looking at a drop of blood through a microscope]. It's vastly underutilized. You can catch iron deficiency before counts get low." The hematologist emphasized contextualizing a CBC: "Before you jump to pathological anemia, is this patient over-hydrated? If they are hooked up to IV saline, they are going to have lower counts even though the total rbc mass may be normal."

Anemia is divided into problems of underproduction or destruction. "Destruction anemias are caused by an intrinsic or extrinsic factor. Intrinsic anemia is caused by a defect in the red blood cell itself, such as the membranopathy hereditary spherocytosis or the oxidative damage from an enzyme defect such as glucose-6-phosphate dehydrogenase. Extrinsic anemia is due to destruction of the red blood cell from the outside." This can be due to an autoimmune reaction against red blood cell surface proteins or a platelet disorder causing small thrombi to form in the vasculature shearing normal red blood cells.

"Use the Coombs test to differentiate between intrinsic and extrinsic disorders." The Coombs test mixes the patient's blood with an antibody against human antibodies. If the immune system is attacking its own cells, the anti-Ig antibody will cause the red blood cells to precipitate out of solution.

When so many red blood cells are destroyed that the body demands more, immature red blood cells that still have nuclear material (reticulocytes) are released into circulation. "Always ask for the reticulocyte count if you suspect an anemia of destruction."

The next two lectures detailed hemostasis (clotting) disorders and the body's two systems for preventing bleeding. Primary hemostasis plugs the damaged blood vessel with platelets. Secondary hemostasis creates a more stable clot by using clotting factors, proteins released by the liver. Primary hemostasis disorders are associated with mucosal bleeding (gums, menorrhagia, epistaxis), whereas secondary disorders such as hemophilia lead to severe internal bleeding, especially in joints (hemarthrosis).

Our patient case: Gina, a 51-year-old secretary presented to her internist after gingival (gum) bleeding from a dental cleaning. She described bruising easily and itchiness after hot showers (aquatic pruritus). A CBC reveals an elevated hematocrit (extra hemoglobin) and a high platelet count. She was surprised to be diagnosed with polycythemia vera (PV): "I did not know I was sick until the doctor told me I was sick."

PV is a type of myelodysplastic disorder. A mutated myeloid stem cell, most commonly a JAK2 gain-of-function mutation, causes unchecked clonal proliferation of the myeloid lineage. This results in erythrocytosis (increased red blood cells), thrombocytosis (increased platelets), and leukocytosis (increased white blood cells, specifically of the the myeloid lineage).

Gina started with low-dose aspirin and biweekly phlebotomy (blood draws) to decrease her platelet function and hematocrit, respectively. Straight Shooter Sally: "Can she donate the removed blood?" The hematologist responded, "Great question, in many countries yes. In the US, the Red Cross will not accept anyone with an abnormal CBC. It is a shame because there is nothing abnormal about her denucleated red blood cells."

PV increases the risk of thrombotic events (clots, stroke, heart attack) due to the increased thickness of blood. According to UpToDate, the annual incidence of thrombosis in PV patients ranged from 2-5 percent depending on risk factors such as age and hematocrit management, which compares to annual stroke risk of 5.6 percent for a 75-year-old smoker with hypertension and diabetes.

PV patients have a 20-percent lifetime risk of their PV transforming into myelofibrosis and a 7-percent lifetime risk of acute myeloid leukemia. "PV overworks the bone marrow," explained the hematologist. "Myelofibrosis is what you get when you wear it out." Bone marrow becomes fibrotic with collagen (fibrous protein found in bone, tendons, and ligaments) deposition displacing the stem cells. This causes an abrupt aplastic anemia with extramedullary (outside the bone) hematopoiesis. PV turning into leukemia happens because rapid clonal proliferation increases the chance of an oncogenic mutation (cancer-producing mutation).

"When it rains it pours," recounted Gina. "I had left my husband. I was going through divorce, I had a new boss trying to cut costs at work, and my son was jobless after graduating from college. Now I have my doctor using all these fancy words and telling me I might have cancer. It was too much." A student asked: "Did you have any issues dealing with health insurance during the divorce."  "No, I was the primary insurer."  The heme/onc added, "I have issues with insurance and divorce all the time. Also, when the patient with insurance is diagnosed with leukemia and has to stop working. The family has trouble switching primary insurance to the other spouse."

[Editor: note Gina's description of being involved in a divorce lawsuit that she started as "going through a divorce." This is conventional for American plaintiffs, as though divorce litigation were a random weather phenomenon that they had stumbled into. See Real World Divorce.]

Could Gina describe the itchiness? "Every time I got out of a hot shower, I would have this uncontrollable itchiness for a few hours. It got so bad I would be afraid to shower!" The hematologist added, "There are a few theories out there to explain this phenomenon. One theory states the increased myeloid white blood cells cause increased histamine release. This doesn't make sense because patients can get the itchiness even without leukocytosis [high WBC]. The other theory is platelet aggregation after vascular constriction in the skin after a hot shower."

Gina, now 66, returned to her hematologist about a year ago due to acute left flank pain, fatigue, and poor appetite with a 15 pound weight loss over a two-month period.  Physical exam revealed a palpable mass on her left upper flank. CBC showed pancytopenia (low cell counts across the board). A bone marrow sampling revealed diffuse fibrosis.

The hematologist explained that bone marrow sampling has two steps: "First a needle is inserted into the bone. A vacuum is created to suck bone marrow aspirate into the syringe. Then, a small sample of bone is extracted for biopsy. I am told that the aspirate step is the excruciatingly painful part." Gina interjected, "It feels like a lightening bolt traveling through your bone." Her bone marrow cells have been expelled from the fibrosed marrow and now reside in her spleen, liver, pleural cavity and peritoneum. The enlarged spleen is compressing her stomach, which makes her easily satiated and explains the weight loss [Editor: when will be able to buy one of these spleens on Amazon?]. She was diagnosed with myelofibrosis and informed that her life expectancy was just seven years.

The only curative therapy for myelofibrosis is an allogeneic (from a different person) stem cell transplant to replace the defective myeloid clonal population. Gina was not a transplant candidate given her age. She was started on Jakafi (ruxolitinib), a small-molecule inhibitor of JAK2. Jakafi may relieve symptoms of myelofibrosis, but does not improve survival [Editor: except for the survival of Incyte Corporation, which collects roughly $1 billion per year from this "ophan drug"].

The hematologist recounted Gina's Jakafi-induced anemic crisis: "Jakafi is a double-edged sword. It can improve symptoms, but it also risks causing an anemic crisis. We followed the drug's guidelines but Jakafi was such a new drug. We took her off the drug, but then she had withdrawal requiring two transfusions. We titrated her down [with smaller doses of Jakafi]. She finally has great symptom control with this lower dose." Despite all these ups and downs, Gina is happy with her treatment. Her symptoms are managed well, and she enjoys vacationing at the beach in her retirement.

A student asked, "I apologize if this is blunt: do you struggle with the cost of Jakafi? Is making Medicare pay for such a costly medication that just improves symptoms worth it?"

"The medication makes me feel much better. I was barely eating before I started Jakafi. The pain in my stomach [spleen] got better, it allowed me to sleep. My blood tests have improved. Jakafi had a crazy price tag when I first started taking in 2012. I am fortunate that my doctor enrolled me in a charity program that pays my share." According to "U.S. Probe Sheds Light on Charities’ Role in Boosting Drug Sales," (Wall Street Journal, June 2017), pharma companies are the primary donors to these "charities" because "every $1 million donated to charities can lead to up to $21 million in sales for drug companies." In other words, patients are more likely to continue having their Medicare prescriptions filled if they don't have to pay anything out of pocket.

Friday afternoon concluded with a practice clinical exam session. We interviewed a standardized patient with simulated heart failure (bibasilar crackles with S3 gallop). After the 30-minute encounter, we analyzed a (fake) electrocardiogram and chest x-ray, and then we spent 45 minutes writing a H&P (history and physical exam) note.  Type-A Anita before the practice session: "I am so nervous. I do not know who we will have to write up. I don’t know if we should do vitals. I'm freaking out about having to read an EKG."

Students throughout the day were checking news about the Las Vegas shooting. Pinterest Penelope updated our small group from BuzzFeed: "Isn't that where Russian News propaganda is spread?" "Are you kidding, they have better live news updates than any other website."  "That's because they don’t fact check anything."

The weekly email from our director of academic counseling:

                        

... in this Wellness Weekly section, inclusive language will be highlighted. The following details were taken directly from the University of Massachusetts–Amherst transgender terminology guide [from The Stonewall Center, "A Lesbian, Gay, Bisexual, Trans, Queer, Intersex, and Asexual (LGBTQIA+) Resource Center"]

                                        

                                        

She promises more information on the topic of transgender vocabulary in future editions, includes a recipes for Zucchini Parmesan Crisps (preheat oven to 450 and bake for 30 minutes), and advertises a yoga session taught by a full-fledged MD.

                                

Statistics for the week… Study: 20 hours. Sleep: 8 hours/night; Fun: 1 nights. Example fun: Our social chair organized a 2:00 pm Saturday private wine tasting tour for $20 at a local winery attended by 15 students.

Year 2, Week 13

Leukemia/Lymphoma week. A spunky 40-year-old hematologist/oncologist hung up her phone as she arrived five minutes late for the first lecture. "Sorry! Sorry! My husband is incompetent at getting the children ready for school. I had to leave earlier than normal to get here. He can't find my son's shoes! The whole house is in chaos." (She rejected three additional calls from the husband during the lecture.)

Leukemia, a cancer of bone marrow blood cells, is classified according to (1) stem cell lineage (myeloid versus lymphoid), and (2) chronic versus acute. Disease severity is determined by symptoms and the percentage of immature cells (called blasts) in the marrow and blood.

She began the lecture with an impassioned speech on the advances in treatment of chronic myelogenous leukemia (CML). "This is the coolest story of the century! It is an amazing time to be in medicine. In the 1990s, CML had 100 percent mortality within five years." Dr. Brian Druker's lab linked CML to the Philadelphia Chromosome, a translocation between chromosome 9 and chromosome 22 resulting in the constitutively (constantly) active BCR-ABL fusion protein. Druker developed imatinib, a targeted therapeutic agent, that inhibits the function of BCR-ABL protein. "This is what bench to bedside medicine is all about. Imatinib was the first successful targeted therapeutic in cancer treatment. The trials of the drug that became Gleevec showed complete hematologic response in 94 percent of patients versus 55 percent for standard of care. We never see these numbers. The coolest thing is it is a small pill. This is Nobel Prize-worthy." The class, one week before exams and exhausted after three hours of lecture, showed little reaction. "Guys, come on, get excited!"

Imatinib is a nearly complete cure, with CML patients now as likely to live to a ripe old age as anyone else, but nobody wants to do a clinical trial investigating whether patients can stop taking Gleevec. "Would you sign up to be randomized to stop the drug that saved your life? Who is going to fund it? Not Novartis."

She continued with the childhood disease of acute lymphocytic leukemia: "ALL is a parent's worst nightmare. An 8-year-old falls on the playground and starts to complain of bone pain. When you go to the pediatrician, ALL is not on their radar. There is no fracture on x-ray, but the pain does not resolve." After several tests including an abnormal CBC, the child is referred to a pediatric oncologist who then performs a bone marrow biopsy to diagnose ALL.

Induction therapy (initial treatment) involves 30 days of intense chemotherapy (typically, methotrexate) to get the child into remission. Due to ALL's tendency to metastasize to the brain, chemo drugs are introduced via lumbar punctures every three days. "We fortunately have a fantastic prognosis for ALL. Children are resilient. We are able to use doses and treatment frequencies that are not achievable in adults."

Lectures conclude with an overview of common chemotherapy agents and a discussion of side effects: "An overlooked area of chemotherapy is managing nausea. I had a patient vomit when she saw me at the grocery store. These drugs cause such visceral reactions. We've developed much better antiemetics in the last few decades." She is a strong proponent of medical marijuana having trained in Seattle. "Even with the newer antiemetics, Marinol [synthetic THC] is one of the most effective agents I have seen to control nausea and appetite."

We need to memorize the major complications of several drugs. Doxorubicin has a 11 percent risk of developing acute dilated cardiomyopathy. This rises to 35 percent if higher doses are used. Vincristine, a microtubule inhibitor, can disrupt the highway system of the neuron. This can lead to peripheral neuropathy (sharp pain in the extremities), one of the most common side effects of chemo. Certain breast and ovarian cancers requires hormonal agents. "Some of the estrogen modulators and aromatase inhibitor makes the patient feel like he or she is going through menopause. Testosterone inhibitors for prostate cancer causes this similar menopause sensation with hot flashes and all." Straight-Shooter Sally: "All an oncologist does is hope the poison kills the cancer before the patient."

Our patient case: George, a 31-year-old owner of a small construction firm, presents for a painless mass on the right side of his neck he noticed showering a week earlier. He has lost 10 pounds over the last month, which he attributes due to training for an upcoming bike race. He reports occasionally waking up sweaty in the middle of the night, which he attributes to anxiety from his 100-hour work week. He has intermittent back pain, which worsens when he consumes two or three beers. Physical exam reveals a 4 cm x 3 cm mass in the right supraclavicular fossa (space just above the collarbone) and an unbeknownst 5 cm x 5 cm mass in the right axilla (armpit). George undergoes a lymph node resection (removal). Biopsy reveals pathognomonic binucleate Reed-Sternberg cells on histology. George is diagnosed with Hodgkin lymphoma (formerly "Hodgkin's lymphoma," but the trend is to get rid of the apostrophe S when a disease is named after a physician who discovered it, as opposed to being named after a patient).

Hodgkin lymphoma begins in a single lymph node and, unlike other cancers that can pop up in random locations around the body, spreads along continuous lymph drainage, spreading first to the spleen, then the liver and finally the bone marrow. Most lymphomas afflict the elderly, but Hodgkin patients have a bimodal age distribution, peaking around 25 and 65.

George is joined by his oncologist, a 60-year-old with a slight stutter. "Oncologists are stereotyped as two-faced. We are aggressive in attacking the cancer, but the moment we give up on beating the cancer, we switch to palliative care. It could be overnight the day after receiving chemo."

George: "I had chemo about once or twice a week for two months. Then I had a PET scan to re-evaluate." His oncologist commented: " George was a uniquely motivated patient. We discussed possible clinical trials. However, he wanted to preserve his lung function given his passion for biking. Clinical trials are not good for personalizing treatments. We customized a treatment regimen without standard-of-care Bleomycin." [Bleomycin causes pulmonary fibrosis in 10 percent of patients.]

George was asked to describe the chemo center. "Chemo centers are a depressing sight. You remember the faces of the person next to you. I would try to imagine the life of the person. You can tell who will not be there next month."

Mischievous Mary asked how George's family managed the diagnosis and treatment. "My wife was a rock," recounted a tearful George. "She would try to shield me. I remember one time I got up from the TV to do some task. My wife thought I would be away for 15 minutes. When I came back sooner, I found my wife and son scrubbing the whole room with bleach. I asked them, 'What is going on?' 'Oh, nothing…' they responded. I realized they were doing this out of fear I would get an infection." He continued:  "I kept working during the early chemo. After a few cycles it got unbearable to work immediately after a dose. I would take a few days off and lie in bed, then be back later in the week. My brother and his family moved into our house to help manage the business. I was upfront with my employees and clients. I am proud that not a single employee left."

Type-A Anita asked what motivated George through his treatment. "I grew up without a father and did not plan to have children because I thought I wouldn't make a good father. I am a Christian, but talk a lot with my neighbor who is a rabbi. One evening he told me, 'Look at what you have accomplished.' After that, I promised myself I would always be there for my children."

Friday afternoon concludes with an introduction to intravenous catheters (IVs), the first workshop in our clinical procedure series to prepare us for clerkships. "Think of this as a little treat before you start exams next week," explained the physician coordinating the series. Students have been eyeing each other's veins all week, especially Buff Brad's, a stereotypical class "orthopod" (aspiring orthopedist) who played baseball in college.

An ER nurse demonstrated IV insertion on a student. "The hardest part is getting the feel of advancing the catheter while retracting the needle. Access the vein by inserting the needle at 45 degrees. Once you see the flash [of blood], level out, inch forward with the needle and advance your catheter. If you lose the flash, pull the needle back and adjust."

Students paired up and began. We adjusted... a lot. Gigolo Giorgio practiced on Particular Patrick, a fastidious and fashionable student from California. Giorgio did not level out enough and punctured the vein. He was moving the needle around aimlessly with a grimacing Patrick shaking under his dyed blonde hair ("flow" in California parlance, apparently). The ER nurse told him to just practice advancing the catheter. Patrick was not happy. "You are just shoving the catheter into my connective tissue!" Jane and I partnered. Neither of us got it. When I retracted my needle, blood gushed out. She now has a 3 cm diameter bruise from my handiwork. I snagged two unused IV kits to practice on at home under the guidance of Jane's sister. Patrick: "We must look like heroin users."

Our director of academic counseling emails a recipe for Goji Berry Trail Mix, including an explicit "place all ingredients in bowl and mix together" instruction in case any aspiring interventional radiologists are in doubt. We also learned about seven ways to calm our minds, e.g., reduce caffeine.

Statistics for the week… Study: 20 hours. Sleep: 7 hours/night; Fun: none. Jane and I prepared for the weekend studying sprint by stopping at a craft beer and wine shop with a bar. We'll be concentrating on lymphoma histology and the endless list of cancer drugs.

Year 2, Week 14

Exam week: two standardized patient (SP) encounters, clinical multiple choice exam, NBME multiple choice exam, and case-based exam.

Interviews with "patients" are done solo with a faculty member observing and grading in real-time via video. My first "patient" presented for shortness of breath and 15 lb. weight gain over one month. I heard heard Bibasilar inspiratory crackles listening to the lungs, and an S3 gallop listening to the heart, suggestive of congestive heart failure. After the exam, I confirmed the diagnosis by reading a chest x-ray showing bibasilar infiltrates and congestion in the hilar vessels. The diagnosis was further confirmed by interpreting a difficult EKG with Q waves (prior MI), RVH (right ventricular hypertrophy), biatrial enlargement, and right axis deviation with potential hemiblock. Each of us then had 45 minutes to write a one-page H&P (history and physical) note. Nobody reported finishing the H&P note early and, in fact, some students said that they ran out of time.

The second patient presented for pneumonia with pleurisy (inflammation of the pleural membrane).  While listening to her lungs with the wireless simulated stethoscope, I heard the classic sound for pleurisy: "walking on fresh snow" on inspiration and expiration.

The 50-question clinical multiple choice exam included 35 questions on EKG interpretation and pediatric cardiology findings. For example:

"There were a few poorly worded questions," said Jane, "but nothing to get uptight about." As I walked out, a horde of students led by Type-A Anita were complaining to the clinical coordinator (administrative assistant to the physician-director) about the questions and the quality of the images.

The 3-hour 120-question NBME exam featured numerous questions on heart failure and chronic obstructive pulmonary disease (COPD). I should have studied the basic physiology from last year as there were several easy questions that I struggled with. I will study this for Step 1. The questions on cancer and hemostasis disorders were straightforward, e.g., a patient with sudden weight loss, night sweats, and an enlarged lymph node mass biopsy revealing Reed-Sternberg cells (diagnosis: Hodgkins lymphoma). The class agreed that this was easier than the last block. Straight-Shooter Sally: "Microbiology was the hardest."

On Thursday we started at 8:00 am with a case-based exam presenting H&P notes, test results, and images for four patients: COPD exacerbation, CHF, dilated cardiomyopathy, and an anemic elderly woman presenting to ED after she fell down. The elderly woman was the most challenging for the class.  Pinterest Penelope: "It caught me off guard. I was not thinking about MSK []musculoskeletal] material."

Most people finished the three-hour exam early, so eleven of us headed over to our favorite burger-and-beers spot for the 11:00 am opening. Composed Catherine, a short, intelligent Catholic with long black hair, was the center of attention showing off pictures of her new shepherd-mix puppy, who is being cared for by her new husband, a work-from-home engineer.

We spent the afternoon conducting a financial intervention with one of Jane's sisters. She takes home $2,500 after taxes each month working as a neurotrauma nurse. [Editor: she needs to come to Boston; nurses at Tufts went on strike in 2017 to protest wages that averaged, pre-strike, $114,500 per year and topped out at $152,000.] Although she graduated debt-free from a state university, she has accumulated $4,000 in credit card debt at 20 percent APR, a $15,000 car loan with a $350 monthly payment, and a $10,000 Lowes loan in her name for improvements of her ex-boyfriend's house. She has paid nearly $5,000 in interest payments over the past year towards the Lowes loan, but has not touched the principal. "I feel like I am struggling to stay afloat in a dark ocean. What do I do?"

Jane has been in the U.S. military's Health Professions Scholarship Program, which pays for all tuition, fees, and health insurance. Last year she got a $20,000 signing bonus and started receiving roughly $27,000 per year in cash. Jane agreed to dip into her "war chest" to loan her sister $4,000 interest-free to pay off the credit card debt. "You have to promise me that you will talk to [ex-boyfriend] about dealing with this Lowes loan."

Criticism of President Trump's condolence phone call to Myeshia Johnson, widow of fallen soldier La David Johnson, energizes several classmates. Type-A Anita wrote on the class GroupMe: "For anyone who has a military family, I am so sorry." Pinterest Penelope: "Such a sad time to be an American."

Grades are released on the school's Blackboard website on Friday at 11:00 am only if all class members have completed evaluations of the block and each lecturer (see Year 1, Week 28). This takes about an hour, especially if you're careful to avoid generating false alarms via the forced "inappropriate conduct" boxes (four for each lecturer). I've been careful with evaluations ever since the first exam week of M1 year, I awoke at 10:45 am on Friday morning after an evening of downtown bar hopping. My phone showed several emails from the examination coordinator reminding me to complete the evaluations. However, the power had failed in my apartment and I had to walk to the nearest Starbucks. I am waiting until graduation to admit to classmates that I was the reason they had to wait until 2:00 pm before leaving campus for their vacation (students who fail will stay an extra week and take an exam again).

Statistics for the week… Study: 20 hours. Sleep: 8 hours/night; Fun: 1 night. During drinks and dancing on Thursday night to celebrate completion of this block, I spoke with the Kurdish classmate who was excited about the independence vote (see Year 2, Week 7). What was his reaction to media reports of the Iraqi military re-taking Kurdish territory? "My family in Kurdistan and their neighbors don’t care about the prospect of war. They are used to it."

Year 2, Week 15

Those of us who passed the last block's exams on our first try are back from a week of vacation. Wildflower Willow, a free-spirited outdoors enthusiast from Oregon and founder of our school's wilderness club, went on a three-night solo backpacking trip. Pinterest Penelope spent the week in Banff with her family. Gigolo Giorgio crashed his parents' trip to Europe. "I was planning to go home, but my father had a last-minute business trip to London and Brussels. He called me up to cancel my trip. I asked if I could come along for the ride. He reluctantly agreed. I think he had been excited to spend quality time with my mother."

Jane and I skipped the Monday morning lecture, so our GI pathology week begins with a new 8-person "small group." "You look too happy to be medical students" remarked a gentleman in a wheelchair as Jane and I take the elevator to the third floor. The 57-year-old retired orthopedist is our facilitator. Five years ago he had a bike accident that left him paralyzed from the waist down. "I expect a comprehensive differential. Don’t just blurt out syndromes. Tell me why you are thinking that. Do not expect to be leaving early with me." Geezer George, a 32-year-old Boston native who is our oldest classmate, commented "It is refreshing to have someone hold us to high standards. Most of the facilitators have been more casual."

Our group discussed celiac disease and common GI pathogens. Celiac disease, an autoimmune disease due to hypersensitivity reaction against gliadin (component of gluten), is most associated with Northern European ancestry. Type-A Anita: "White people have to pay somehow." The immune reaction produces IgA that frequently cross-reacts with proteins in the dermal papillae (junction of dermis and epidermis) creating the characteristic dermatitis herpetiformis (grouped fluid-filled sacs, named after the similar appearance to a herpes outbreak). The IgA antibodies do not lead to GI pathology, but serve as a useful biomarker for diagnosis.

Geezer George brought up a norovirus outbreak while discussing common GI pathogens: "I was at ground zero in Boston. I lived across the street from the Chipotle where half our school got lunch." (the illness was traced to a sick employee and it was unrelated to an earlier E. coli outbreak at Chipotle) A student replied, "Chipotle gets a bad wrap... no pun intended. You do not have an increased risk of getting a GI bug at Chipotle compared to any other restaurant, just so many people get meals there. It's like the Toyota brake scandal." A student described getting a Staphylococcus aureus enteritis characterized by profuse vomiting and diarrhea: "It's like you don't know whether to sit on the toilet or to stand next to it."

 

A 45-year-old gastroenterologist specializing in hepatology (liver) gave Tuesday's lecture on GI pathology: gastroesophageal reflux disease (GERD), peptic ulcer disease, Boerhaave syndrome, and inflammatory bowel disease (IBD).

She explained that "36 - 77 percent of Americans experience GERD throughout their life. The severity of the symptoms do not correlate with the severity of GERD. Patients are not faking the pain. Some just have more sensitive mucosa than others. Avoid caffeine, smoking and late night meals." She detailed how the use of proton pump inhibitors (PPI), such as Prilosec (omeprazole) has gone through cycles. "Patients and providers have become skeptical about the use of PPI. The problem is that we overprescribed them for some time and they started to be linked to everything without evidence. I had a patient post-MI [heart attack] with a peptic ulcer. The CCU staff took him off the PPI out of fear of reinfarction. [Once off the PPI] The ulcer bled so much he required transfusion. The link has been proven false."

Peptic ulcer disease, ulcers that form in the stomach and duodenum (proximal small intestine), is associated with nonsteroidal anti-inflammatory (NSAID; aspirin and ibuprofen are examples) use and chronic Helicobacter pylori infection. "20 million people take NSAIDs daily including 70 percent of people over 65. As long as people use NSAIDs, I have a job." Why do doctors ask if the abdominal pain gets better or worse after eating?  "Gastric ulcers worsen after eating. Eating stimulates acid production in the stomach. Duodenal ulcers become better after eating. Eating causes release of bicarbonate in the duodenum that neutralizes irritants."

Boerhaave syndrome, a condition where intense vomiting leads to esophageal rupture, is caused by binge drinking. "Chronic vomiting such as in alcoholics and bulimics typically does not rupture through the esophagus," she explained. Boerhaave syndrome is associated with a 35 percent mortality, "the most of any GI perforation." Gigolo Giorgio: "I'm surprised that none of my college friends got Boerhaave syndrome."

"Do not get IBD [inflammatory bowel disease] confused with IBS [irritable bowel syndrome]. Much different. IBS comes and goes and is not as severe as IBD," she explained. The two most common IBD conditions are Crohn disease and ulcerative colitis (UC).

Nervous Nancy has Crohn disease. "My doctor is convinced I am Jewish. I keep telling him I am not. Infliximab [tnf-alpha inhibitor] has been a Godsend. I usually let my roommate inject it into me every three weeks. It's like ripping a band-aid - easier if someone else does it quickly. He was trying to impress his new female friend by winding up before stabbing me. He ejected prematurely, wasting half the dose. I am freaking out. That's like $4,000. My insurance won't give me another prescription so I am going to try to make the next few doses last longer. I can already feel my hands and legs swelling and getting hot."

Crohn disease, a transmural (entire thickness of gut tube) granulomatous inflammation of the GI system, usually occurs in the ileum [terminal small intestine]. Because Crohn Disease is transmural inflammation it can lead to performation and fistualization (connection between two tubes). If the colon ruptures it can create a connection to the bladder, called a colovesical fistula. Gigolo Giorgio: "Could you imagine peeing feces?"

Our patient case is Rebecca, a high-school swimmer who began seeing our gastroenterologist/hepatologist lecturer when she was 15. Rebecca presented for bloody diarrhea with mucous, fatigue, and a seven-month history of crampy abdominal pain. Over the preceding week she has experienced sharp right-upper quadrant (RUQ) pain. On physical exam, Rebecca appears pale with an enlarged liver palpable six centimeters below the costal margin and a palpable spleen. No scleral icterus (yellowing of the sclera) is noted. CBC shows pancytopenia (low red and white blood cell count) with a normocytic anemia (normal red blood cells, but not enough of them) and high reticulocyte count. Stool sample tests positive for white blood cells, red blood cells, but negative for pathogens. After a colonoscopy, Rebecca is diagnosed with ulcerative colitis.

What is causing her enlarged liver and spleen? Ten percent of patients with UC develop primary sclerosing cholangitis (PSC). PSC is an inflammatory reaction that causes fibrosis of the biliary tree connecting the liver to the duodenum. Over time this causes incurable cirrhosis (hardening of the liver), which clogs portal circulation of blood returning to the liver.

"The treatment of PSC is liver transplantation. That is how serious a disease it is. Liver transplant is not even a cure," explains her doctor (our lecturer). Rebecca is placed on the liver transplant list.

Patients on the liver transplant list are ranked according to the Model for End-Stage Liver Disease (MELD) score, which predicts three-month mortality among liver failure patients based on three lab values: creatinine (kidney function), bilirubin (liver's ability to breakdown and excrete heme), and the international normalized ratio (liver's ability to synthesize clotting factors). Rebecca was at 12 out of 40. "PSC patients are screwed over by the MELD score," explained our hepatologist. "Their lab values do not reflect their deterioration. I told Rebecca's family that she would not make it to the expected donation time." Her family and doctor petitioned the UNOS (United Network for Organ Sharing) to no avail. Pinterest Penelope whispered, "This story reminds me of Denny from Grey's Anatomy losing the heart transplant by 17 seconds."

Her mother described searching for a living donor. Live donor liver transplant (LDLT) is a procedure where a liver section from a living donor is removed for transplantation. The liver is able to regrow to normal function over time. LVLT has several ethical dilemmas. Who gives consent for a pediatric donor? A cousin or uncle who matches may experience immense family pressure to donate, compounded by the fact that many liver transplants require immediate decisions. Pinterest Penelope whispered again, "This is just like Grey's Anatomy! Remember that episode where the son of an abusive father has to decide to give him part of his liver?" Rebecca's real-life situation was more serious, but less dramatic. There was no abusive father and nobody in her immediate family was a match.

Rebecca waited three years for a liver while enduring serious complications such as hyperammonemia (high serum ammonia causing mental status changes). One evening she presented to the ED for severe hematemesis (vomiting blood). The dilated veins in her esophagus ruptured. (Esophageal hemorrhage is the most frequent cause of death in liver cirrhosis patients.) Rebecca underwent banding endoscopy (put rubber bands around the veins) to stop the bleeding. After these episodes, the family and doctor petitioned UNOS, who increased her MELD score.

Rebecca underwent a domino liver transplant the summer before her freshman year of college . The first domino was a cadaver (dead person) whose liver is transplanted into a patient with a genetic disease such as familial amyloidotic polyneuropathy (FAP) or Maple Syrup Urine Disease (MSUD). The second domino is the liver removed from that patient, which can be installed in Rebecca's body and then function normally. We saw a picture of the domino family smiling next to each other: the widowed wife of the cadaveric donor, the mother holding an 8-year-old daughter with MSUD, and Rebecca.

Rebecca's PSC returned three years later. Her mother said, "We knew the system better the second time around. We listed at a transplant center that did not have a national reputation and in a state with high donation rates."  Rebecca showed us her scars. The scar from the first transplant was roughly 4 inches long on her right side. The scar from the second liver transplant went across her entire abdomen. Her transplanted liver had enlarged to cover her spleen. The extensive fibrosis also adhered parts of her liver to the diaphragm making it difficult to remove. As a result, she experienced pain for several months requiring high dose IV opioid painkillers and neurontin. Two years out she is dealing with opioid tolerance and withdrawal symptoms as she tapers off. Rebecca, now a rising senior at college studying chemistry, plans to return to school after a semester break. "I hope to get back in the water next month. It symbolizes, sort of, returning to normalcy."

After Rebecca and her mother left, a student asked the hepatologist, "Given that there is such a long waiting list for transplants, what are your thoughts on a single patient receiving two livers?" She passionately responded: "Rebecca deserved this liver. I just came back from the AASLD [American Association for the Study of Liver Diseases] conference. UNOS just approved liver transplants for alcoholics who are three months sober [Hepatitis C from IV drug use is another common reason for requiring a transplant]. I have never met someone who is more motivated and wants to be a productive member of society. Throughout her first transplant recovery she kept going to college. Can you imagine the drive that requires? A lot of potential liver transplant patients just sit at home on disability. What do they do after the transplant. They continue to sit at home on disability. No, she deserved this second liver."

For each of the next six weeks we will write a two-page single-spaced ethics essay. "I am really excited about doing this ethics course with you," explained our former ethics facilitator, who is now the class lecturer. She explained that we would be preparing for 30-minute lectures by reading the same materials as her undergraduates, then break into 10-person groups for one hour.

This week's topic is pain and readings include essays by sociologists, peer-reviewed ethics journals, poems by Sylvia Plath and Elizabeth Dickenson, and three paintings. Jane had a higher pain tolerance than I did and got through all of them in two hours. We read a journal article on pain treatment differences between blacks and whites summarized in "U.Va. report: Med students believe black people feel less pain than whites" (USA Today):

The survey ... asked 222 white medical students and residents to rate on a scale of zero to 10 the pain levels they would associate with two mock medical cases — a kidney stone and a leg fracture — for both a white and a black patient, and “to recommend pain treatments based on the level of pain they thought the patients might be experiencing.”

The survey also asked them whether they believed certain statements about whites and blacks were true, e.g., black people age more slowly than whites, black people have less sensitive nerve endings and black people’s blood coagulates more quickly. Surprisingly, over 100 students believed these fallacies to be factual.

Those who believed that information to be true rated black patients’ pain lower than they did white patients’.

We read "Pain Sensitivity: An Unnatural History from 1800 to 1965" (Joanna Bourke, Journal of Medical Humanities, 2014):

In 1896, a second-year medical student simply known as “E. M. P.” was working in a surgical-dressing room at The London Hospital. … His account —which was published in The London Hospital Gazette, an in-house journal for hospital personnel— epitomized a particularly nasty strand in British chauvinism. Implicit in E.M.P.’s narrative was the belief that not every person-in-pain suffered to the same degree. While certain patients were regarded as “truly hurting,” other patients’ distress could be disparaged or not even registered as “real pain.” Such judgments had major effects on regimes of pain- alleviation. At the end of the nineteenth century, E.M.P.’s condescension (if not outright contempt) for destitute, “foreign,” and other minority patients was not aberrant.

[Wikipedia says that the author "describes herself as a 'socialist feminist'"]

Our group agreed that there is inequality in pain management for black and white patients, though it was difficult to separate socioeconomic factors. Geezer George wasn't persuaded by the study: "Who cares what medical students think. We know nothing. I have read other more reputable reports that link decreased opioid prescription rates for blacks versus whites with the same discharge diagnoses. I took a public health course that analyzed articles in USA Today and such. Journalists know less than nothing and are just trying to get clicks. Something like 9 out of 10 articles were simply inaccurate representations of the data in the report." Straight-Shooter Sally: "I agree. They should have presented us with better evidence." The ethics professor, overhearing, jumped in: "I'll try to send other articles, but it is well established that the perception of pain and pain treatment by medical professionals is impacted by race. Keep talking!"

Pinterest Penelope: "We all are racist. Some more than others. Everyone, at least, has implicit bias." Nervous Nancy: "Pain management happens a lot in the ED and ortho department. I do not think it is as simple as black and white. A lot of thought goes into writing an Oxy prescription. Does the patient have the support system and structure to handle a three-month prescription?" Straight-Shooter Sally: "I blame First-Aid [Cliff Notes for the first two years of medical school]. We are taught to use stereotypes to develop differential diagnoses. When I say sarcoidosis, you say?" "Black middle-aged female," responds the group. Sally continues: "The irony is that the overprescription of opioids to white-people pain has backfired. Whites are now disproportionately impacted by the opioid crisis."

 

Our class is registering for the USMLE Step 1 board exam, a one-day multiple-choice test that will be taken this summer. After collecting our names, medical school, addresses, and credit card numbers ($610!), the first question that we're asked by the registration system is about our race. Lanky Luke: "Should I identify as Black? No Derm for me otherwise." Particular Patrick added, "I wonder if selecting Asian will hurt my Match?"

The week wraps up with a workshop on catheters. An EM physician discussed NG (naso-gastric) tube and foley catheter insertion technique. The NG tube is inserted through the nose and advanced until the pharynx. He continued: "Once you are into the posterior pharynx, ask the patient to swallow some water. You should feel a yank [peristalsis of esophagus]. Keep advancing the catheter until you've advanced it to the predetermined length." You have to make sure you do not insert it into the trachea. "I have done maybe 1000 NG tube placements. Maybe 50 end up in the right lower bronchus instead. It is going to happen. If the patient is violently coughing and unable to speak, take it out. The tube is down the wrong pipe."

The EM physician asked for a volunteer. "This is the most malignant procedure we can do on students." After 20 seconds of silence, Wildflower Willow, a free-spirited outdoors enthusiast from Oregon who goes on weekend overnight solo hikes, volunteered. As the EM doctor advanced the NG catheter, he announced, "I am through the first turn. Drink some water." Willow was clearly uncomfortable, but signaled to keep going. She coughed once or twice. "Say something to me." Willow initially signaled she couldn't talk. Finally, she exclaimed, "Oh my." He continued to advance the NG tube until placed, and then quickly removed it. The class erupted in thunderous applause.

"You freaked me out when it seemed that you could not speak," said the EM physician. "My teaching days would have been over." William explained, "It was subconscious. I knew that the worst thing would be the tube going down the trachea. I just thought, of course this is going to happen to me of all people. You got that on video right?"

Her evening Facebook post:

Volunteered to have an NG tube placed on myself today!!! That's the like 2 foot tube used to remove stomach contents or feed patients. It was... unpleasant, but such a good experience to know what patients go through :)

On Thursday evening we attended a family medicine panel presented by five physicians. Family medicine physicians treat patients of all ages as a primary care physician.

Why is family medicine not in a lot of metropolitan areas? The family medicine chair explained: "You have specialist walls pop up. Large health systems make money on specialist referrals. Health systems are buying up practices for the referral population to specialist care. It is not as lucrative to have a family medicine physician manage a COPD or CHF exacerbation. They will get admitted to cardiology or pulmonary service instead of the family medicine service. We've really lost that continuity of care. I think it is slowly coming back from people realizing the value in it. I feel sorry for my patients when the bill comes back after a hospital visit."

The media frenzy around Harvey Weinstein apparently inspired part of the weekly email from our director of academic counseling:

When supporting a friend who has been a victim of sexual assault, it’s important to know your resources. RAINN (National Sexual Assault Hotline) staff recommend friends supporting victims keep the following in mind: (1) “I believe you. It took a lot of courage to tell me about this.”; (2) “It’s not your fault. You didn’t do anything to deserve this.”; (3) “You are not alone.”

It was unclear whether Mr. Weinstein endorsed the spaghetti squash lasagna or Dijon salmon recipes between which the sexual assault advice was sandwiched.

Statistics for the week… Study: 10 hours. Sleep: 8 hours/night; Fun: 1 night. Example fun: Halloween weekend! The social committee organized 9:00 pm private party at a downtown club with $5 cocktails and hors d'oeuvres. Faculty were not invited. Mischievous Mary hosted 30 students pre-game and photos. Most of our class dressed in costumes inspired by SketchyMicro pathogen characters, e.g., an Indian classmate shaved his head and dressed as Toxoplasmosis gondii (Gandhi).

Year 2, Week 16

Gastrointestinal topics began with four one-hour lectures on the liver. Jane and I did not attend. We took a morning trail run, then watched 65 minutes of liver lectures on Pathoma ("First-Aid of M2"). Jane: "I feel like I have accomplished so much."

We went to Dr. House’s Tuesday lecture on GI pathogens. "As medical students you will be a valuable member of the team performing digital rectal exams and fecal blood smears. It seems like grunt work, but it is essential to determine the course of diarrhea treatment. The fecal smear for leukocytes is a vastly underutilized, quick and dirty test." According to Dr. House, the most important step in managing diarrhea is to determine if a patient has invasive or toxigenic diarrhea. Invasive diarrhea is caused by a pathogen invading the mucosa (epithelial lining of the gut tube), which recruits leukocytes [white blood cells] to the infection. These white blood cells end up in the feces. Whereas, toxigenic diarrhea will not have any white blood cells in the stool sample. "Most diarrhea causes are treated with supportive care – hydration."

Vibrio cholerae causes profuse, toxigenic rice-water diarrhea.  "Does Haiti have cholera?" asked Dr. House. "Not before 2012. The earthquake hit in 2010. UN troops from Nepal, where Vibrio is endemic, brought in cholera. One in ten individuals exposed to cholera are asymptomatic carriers shedding it in stool. Without adequate filtration systems in earthquake-ravaged Haiti, cholera spread all over." How do you treat cholera? Hydration. "Cholera is a self-contained disease if you can survive the extreme dehydration from loss of water. Volume-in must equal volume-out. On the wards you will hear, 'hang the IV at 125 mL per hour.' 125 mL per hour is 3 liters over 24 hours or the amount of insensible water loss [sweat, metabolism, etc.]. So hydration would need to be greater than 125 mL/hr in a cholera patient."

"When I trained Clostridium difficile was segregated to antiquated case reports in journals that no one read." Dr. House continues, "C. diff is now a hospital’s bane of existence. Studies show that 13 percent of individuals have C. diff spores in the gut. They just lie dormant until a stress such as an antibiotic knocks out the normal gut flora. A severe C. diff patient can have 30 bowel movements per day with a high fever. Talk about dehydration. The best treatment is fecal transplant, ideally from a housemate, otherwise the new poop pill [OpenBiome's FMT G3 capsule]."

Dr. House cautioned to not jump to antibiotics for every patient with diarrhea. "Some toxigenic diarrhea cases are made worse by an antibiotic. For example, a patient with hemolytic uremic syndrome, a serious complication of shigella and E coli O157:H7, can be killed by toxins released from dead bacteria. I see this all the time: a patient with pneumonia or meningitis is given penicillin. The patient then crashes because of the sudden antigen [molecule to which immune system responds] release."

We ended a few minutes early so he asked some causal questions: "Has anyone heard of Saccharomyces cerevisiae?" A quite Asian volunteered: "It’s used in brewing beer." "Yes! Cerveza is beer in Spanish. This fungus is also implicated in exacerbating Crohn disease. Why? We do not know. But that’s the mystery of Infectious Disease medicine!"

Dr. House noticed Type-A Anita's MacBook Air decorated with five stickers: "I'm with Her", "Nevertheless, she persisted", "Nasty woman", "Change", etc. "Anita, how are you going to fit more stickers on the laptop next election?" Anita: "I don’t know, I never thought of that."

At 10:00 am, Dr. House left and we began learning about genetic diseases of the GI system. Our early-40s pediatrician-turned-geneticist explained that she is consulted whenever a genetic disorder is suspected, or "when physicians have no idea what is going on." She manages several families whose members share a rare genetic defect and also coordinates care for patients with complicated diseases such as Down syndrome, Prader-Willi syndrome, and Angelman syndrome.

She introduced two genetic GI diseases that we'll see on the Boards: Lynch syndrome and Familial Adenomatous Polyposis (FAP).

Lynch syndrome (also known as HNPCC for "hereditary nonpolyposis colorectal cancer") is an inherited defect in a DNA repair protein. Lynch syndrome is characterized by a high risk of cancer including colorectal, endometrial, gastric, and sebaceous carcinoma.

FAP results from a defect in the APC gene that is necessary for the transformation of normal colon tissue into a colonic polyp (adenoma-carcinoma sequelae). FAP is characterized by the formation of thousands of polyps in the GI tract. Patients have such a high risk of colorectal cancer that they undergo prophylactic colectomy in early adulthood.

She described some of her daily dilemmas. "Ten percent of patients do not have a paternal relationship to their believed father, don't rely on paternal medical history. We refrain from testing children for likely genetic disorders that won't result in symptoms until adulthood. If waiting will not compromise care, we want to maintain the patient's autonomy. I am also extremely careful with documentation for a potentially afflicted child. For example, what if a child eventually wants to join the military? If I document a 50-percent risk of having Lynch syndrome due to an afflicted father, lights out."

Our patient case: Jerry, a 50-year-old former truck driver on disability for liver cirrhosis due to chronic hepatitis C infection, presents to the ED for rectal bleeding and anemia. Twenty-five years earlier, te was in a motor vehicle accident ("MVA") requiring transfusions. A more recent MVA led to the diagnosis of hepatitis C, likely due to the transfusion in the 80s prior to hepatitis C screening for blood donations (1992). [Hepatitis C is transmitted via blood and sex.]

Physical exam shows a distended abdomen with ascites (fluid in abdomen), scleral icterus (yellowing of the eye), and several bruises over his arms and legs. His liver is enlarged, and the tip of the spleen is palpable. CBC and CMP reveal anemia, thrombocytopenia (low platelet count) and hypoalbuminemia (low serum albumin, a protein that creates osmotic gradient to keep fluid in the blood vessels). PCR testing shows an active Hep C viral load. Jerry tests positive for Hep C antibodies. Serum alpha-fetoprotein (AFP) levels are high, suggestive of hepatocellular carcinoma (liver cancer). An abdominal CT shows two liver nodules. Biopsy confirms hepatocellular carcinoma.

Jerry undergoes radiation therapy and surgical resection of the operable masses. Jerry died last year from rupture of esophageal varices while waiting for hepatitis C treatment and a liver transplant.

Our South American hepatologist went over Jerry's case and discussed the rise of hepatitis C infections in the United States driven by heroin use. Particular Patrick asked her opinion about needle exchange programs (popular in his home state of California). "Hep C rates are skyrocketing due to IV sharing. Every needle shared leads to nine Hep C infections. I cannot understand why needle exchange programs are resisted by conservative legislators. Yes, I understand the idea of traditional values and that drugs are bad. But you don't simply tell your child ‘NEVER have sex, period.’ No, you say, ‘Sex is bad… but if you are going to engage in it use a condom.’ Otherwise, you’ll get a pregnant child… with Hep C." Students chuckled. Lanky Luke: "I bet she does not want a needle exchange in her backyard." ["Do needle-exchange programs really work?" (Amy Norton, March 11, 2010, Reuters) summarizes research that casts doubt on a link between needle exchanges and preventing disease transmission.]

Drug treatment for Hep C costs roughly $90,000. "The first thing I ask my patients is if they have insurance," said our hepatologist. "If they are uninsured, I tell them, 'No problem. You will just have to pay maybe $30 for the blood tests. You'll get the pills free.' If they do have insurance, I tell them there is no guarantee. I say, ‘I will fight for you, but it will take time and there is no guarantee.’"

How does Hep C treatment compare in other countries? "Australia has a great coverage program. Every Australian gets the drug, no questions asked. Canada and most European countries have similarly good coverage." Does the drug cost as much? "No, America pays for the Hep C treatment of the world. One of my old patients pioneered going to Canada for treatment because it cost so much less there." She concluded: "I am hopeful coverage will increase as there are more and more competing drugs. It is truly amazing how science has advanced. A decade ago there was no cure, only poor management with short-lived transplants and drugs with severe side effects such as kidney damage. Now we have several options with over 90-percent cure rates for all genotypes [DNA sequence of the virus]."

This week included three afternoon workshops on nutrition and lifestyle medicine led by a fit 35-year-old internist specializing in weight loss, her blond hair tied in a ponytail ready for her next workout. She began by asking the class, "What percentage of the population does not smoke, has a BMI less than 25, eats 5 servings of fruits and vegetables daily, exercises 30 minutes five times per week? What we would consider healthy?" The class was silent. "Three percent," she answered. "Meanwhile, 35 percent of the US population is obese."

She was scornful of the government's nutrition advice. "Why is diary the only food required in a school lunch?... The milk lobby. Why are grains at the bottom of the food pyramid? The grain lobby. The original 1992 pyramid had grains third from the bottom. Imagine how many lives could have been changed if that guidance was not issued!" Lanky Luke: "Maybe times have changed and people have less faith in institutions, but does anyone really shape their diet based on the pyramid and now plate?"

Students were offered to get free DEXA [Dual-energy X-ray absorptiometry] scans in preparation for the next workshop. Over half the class volunteered for the 10-minute procedure after class. DEXA scan shoots two different energy x-ray photons at the entire body. In addition to providing a measurement of bone density, commonly used to diagnose osteoporosis before a fracture, DEXA scans also calculate percent body fat and fat distribution.

Pinterest Penelope: "I think the DEXA scans were wrong. I’ve been going to the gym everyday this year." Jane, as she squeezes her stomach into a mouth shape: "This is bad for my mental health, 26 percent fat." A retired Army physician told her that you do not want to be a fat doctor in the Army. Physical performance is evaluated in the military. "If you are fat, you do not get promoted, you do not get your preference on where you are stationed, and you do not get respected by peers."

"I never use the word ‘Diet’. Diet implies a temporary strategy. Long-term weight loss requires lifestyle changes. However, as a physician your patients will ask you about common diets. There are copious studies that try to evaluate Low fat versus Low Carb versus Mediterranean, etc. The key is to get them thinking about their intake and outtake." She cited, "The largest diet study found attendance at group sessions was the greatest predictor for weight loss and reduced cardiovascular events."

Students filled out a lifestyle goal on scratch paper. Most students promised to lose a few pounds, go to the gym, or make fruit/veggie smoothies daily. (Two weeks later Jane and I accompanied most of these people to Taco Bell and then the local ice cream shack.)

Thursday at lunch students discussed Harvey Weinstein and Kevin Spacey. Everyone had seen the headlines, but not everyone knew the details. What did Harvey Weinstein actually do? "He raped women. He attacked young actresses." Type-A Anita: "It's more like what hasn’t he done." Wildflower Willow: "I have become so disgusted by Hollywood. Power corrupts all men." What did Kevin Spacey do? "He attempted to molest young male actors. Now he cowardly comes out as Gay as if being homosexual makes you some predator."

Type-A Anita wasn't that interested in the question of criminal prosecution: "We are in the public-shaming part of punishment." What about the presumption of guilt based on unverifiable accusations? "So what if the pendulum swings a little bit in the favor of the accused. The rights of the women have been forgotten for so long. I don’t think people care about the wealthy assholes like Harvey Weinstein. Ladies, take it all!"

Jane: "Part of the divide here is that it is difficult for me to imagine what it would be like to be falsely accused of harassment. It is easy for me to imagine what it is like being the victim of harassment. I understand how one could say it is wrong to expel an accused student of rape or fire a physician for harassment of a nurse, but a suspension is not unreasonable while it is being investigated. That's not going to destroy his life."

Gigolo Giorgio: "I can see how this can be a slippery slope. Let's say a transplant surgeon, one of the best in the country, gets accused of sexual harassment to nurses when he was a resident twenty years ago. Let's just say we have objective proof -- a video -- of him doing it and evidence he cleaned himself up since then. Married with kids, upstanding citizen and all his coworkers love him. What should his punishment be? Should he be excommunicated and banned from surgery after society invested all those resources into him?" Straight-Shooter Sally: "Maybe he should be suspended for a few weeks. Just so there is some punishment and deterrence. I think he should still be able to practice eventually." [Editor: Hospitals are going to line up to hire this guy?]

What does $60,000 in tuition include? "An artistic space," as our visiting ethics professor explains the two-hour Friday afternoon session. We divide into groups of six to create a nine-panel cartoon with crayons. "Depict your experience with cancer," the professor says. What if we haven't had cancer? She says that it can be about a relative, a friend, or something we've read in a novel: "Enjoy this space, this is one of the only chances in medical school to express your artistic mind."

"My grandmother at age 78 underwent surgical resection for colon cancer," said a classmate on another team. "She ended up killing herself by pulling her feeding tubes out because of her terrible quality of life." One of my teammates: "My best friend was diagnosed with a brain tumor after a seizure. His doctors assured him it was benign, but took a biopsy. I was with him watching the [2016 Presidential] election results. As we were learning about Trump's victory he got a text that his cancer is invasive."

Friday evening, Jane and I drive 45-minutes out of the city to our favorite trauma surgeon's cabin. Twenty-six students (16 female/10 male) interested in surgery, or just intrigued by her stories, roast marshmallows and eat undercooked burgers around a campfire.

Straight-Shooter Sally asked How difficult is residency? Our hostess: "If you think you learn a lot in medical school, wait for residency. You end medical school knowing how to do a few procedures -- NG tube placement, IVs, suturing. You end surgical residency knowing how to reconstruct an aorta."

Gigolo Giorgio asked What is the progression of a resident? Our hostess: "I expect an intern to be able to navigate the hospital. You are primarily managing patients in the perioperative window—before and after surgery. Maybe at the end you are comfortable performing an appendectomy under guidance. A first-year resident should begin to have opinions and a sense of direction. Second- and third-year residents should be teaching interns. A fourth-year resident should be an equal. I ask for their input on cases. I listen to their thoughts. Attendings will go with the fourth-year resident's judgment, especially when there are several decent options and no clear winner."

The trauma surgeon emphasized: "When applying to residency programs, ask where their graduates end up. Do they feel comfortable performing surgeries on their own? A lot of prestigious residencies do not train surgeons to become independent. I see a lot of graduates taking fellowship positions not out of interest in the speciality, but because they do not feel ready to become an attending. You want to go to a program that offers both fellowship opportunities and job placement."

Students were particularly interested in the lifestyle of the surgeon. "Surgery culture is changing. There is no more God complex. Patient care is now a team effort," explained the trauma surgeon. "For most of my career, you would take your patients home after you left for the evening. If something happened, you would run back to the hospital. Now you have people on call who deal with it. You can always go above and beyond and follow up on a previous patient. Most physicians do that, but it is their prerogative, not the expectation." She concluded: "This change is a good step for lifestyle and overall well-being of surgeons, but there is less continuity of care."

What are some pitfalls? "The biggest issue I see with residents and attendings is ignoring home life. It is very easy to drown yourself in patient care as an excuse to ignore dealing with problems at home. They wonder why they end up divorced with broken lives and children they barely know. It's their own damn fault." [Editor: Read Real World Divorce to see which states give plaintiffs the largest financial incentives to pursue a divorce lawsuit; the biggest "fault" of these defendants may well be choosing to settle in a plaintiff-friendly jurisdiction.]

Can a medical trainee start a family? "Do not put your life on hold for residency. Residency is part of your life. If you want children, have children. It will be tough, but you will manage it. I’ve heard some residents say residency is a great time to have children because of the excellent health insurance."

Statistics for the week… Study: 14 hours. Sleep: 6 hours/night; Fun: 2 nights. Example fun: Jane and I joined Lanky Luke, Samantha, and Mischievous Mary for burgers and beers. Samantha works in a free clinic nearby for her final PA rotation. "I saw a 11-year-old child today. How much do you think she weighed?" Guesses: 150, 175, 210, 250. "She clocked in at 363. I mean that should be child abuse. You cannot recover from that." The mother, also obese, is on Medicaid. [Editor: therefore, by definition, taxpayers purchased most of the food via the USDA SNAP program ("food stamps").]

Year 2, Week 17

Monday morning begins with an introduction to gynecology from an energetic 36-year-old Ob/Gyn. She began at the end: menopause. "Menopause occurs between 45 and 55, with the average age at 51." She explains that hormone replacement therapy (HRT) is one of the most effective mechanisms to treat vasospasm (hot flashes) in postmenopausal women. "Estrogen is the fertilizer, progesterone is the lawn mower. Remember that. If the patient has a uterus, you must give combination [estrogen/progesterone] to thin the endometrium. If the patient underwent hysterectomy, she can just take estrogen. Nothing to grow!"

"Menopause symptoms typically last no more two years, but can last up to 13 years. Every three years we reevaluate the HRT and medications. Usually we take them off for a month and restart if needed. Some patients just feel better on HRT so they request to continue." Birth control pills contain the identical hormones. Straight-Shooter Sally, commenting on a controversy over requiring private employer-provided health insurance to offer zero co-pay contraception: "I wish people would recognize that birth control pills are used for a lot more than just birth control."

Particular Patrick asked why so many older women have hysterectomies [removal of the uterus]: "Hysterectomies have fallen out of favor in the past decade or so. The history of hysterectomies is fascinating, especially the regional variation. Where there were a lot of Ob/Gyns, there were a lot of hysterectomies. Same exact pattern for laminectomies [removal of part of the vertebrae to alleviate back pain]. Where there were a lot of neurosurgeons, there were a lot of laminectomies."

In our small groups, we discussed the costs and benefits to HRT in treating menopause symptoms. Laid-back Larry, a San Francisco native with a soothing voice, presented on a Women’s Health Initiative (WHI) study on the side effects of HRT in 160,000 postmenopausal women aged 50-79. In our age of identity politics, before talking about the medical conclusions of the study, Larry delivered an encomium about Dr. Bernadine Healy, the founder of WHI and one of ten women (out of 120 students total) in the Harvard Medical School Class of 1966 and later appointed by Ronald Reagan to be director of NIH.

After we finished celebrating women overcoming gender barriers, we returned to the study per se. WHI concluded that the lowest dose of combination HRT should be used to minimize the risk of coronary artery disease and breast cancer. Larry: "For anyone who says that investment in public health is not worth it, and that we need more military spending, look at this economic analysis. The study cost $625 million. That’s five F-35 fighters." Our facilitator asked, "So you do not think we should have the F-35 program?" Larry: "No, I do not think we should have the F-35 program or any military spending until we can get our domestic policies in order." Larry cited "Economic return from the Women's Health Initiative estrogen plus progestin clinical trial: a modeling study" (Annals of Internal Medicine, 2014), describing the results of an add-on $260 million study:

The WHI scenario resulted in 4.3 million fewer CHT users, 126,000 fewer breast cancer cases, 76,000 fewer cardiovascular disease cases, 263,000 more fractures [no free lunch, unfortunately], 145,000 more quality-adjusted life-years, and expenditure savings of $35.2 billion. The corresponding net economic return of the trial was $37.1 billion ($140 per dollar invested in the trial) at a willingness-to-pay level of $100,000 per quality-adjusted life-year.

The 95% CI [confidence interval] for the net economic return of the trial was $23.1 to $51.2 billion.

[Why did this cost nearly $1 billion? It is expensive to follow patients for years.]

Wednesday morning, a pathologist led a two-hour workshop on breast cancer, which 1 in 8 women will develop. Breast cancer prognosis depends on several factors:

The easiest breast cancer to treat is estrogen-positive and her2-positive (proto-oncogene receptor). We can inhibit the estrogen signal with endocrine therapy (e.g., aromatase inhibitor or estrogen-modulator tamoxifen) and the her2 growth signal can be inhibited with trastuzumab (Herceptin, antibody against her2).

Straight-Shooter Sally: "We’re getting all the low hanging fruit. All the cancer signal is going through this bad apple. I just cannot envision us ever getting ahead of cancer with multiple aberrant cross-talking pathways like in triple-negative breast cancer. Good luck!" (Triple-negative cancer does not express estrogen receptors, progesterone receptors, or her2 receptors.)

Our patient case: Kim, a 39-year-old nonsmoker premenopausal college professor, presents for a discrete hard mass in her left breast detected on self-examination. She undergoes ultrasound-guided needle biopsy which reveals a ER+/Her2- ductal carcinoma in situ with a high risk of recurrence. She undergoes radiation followed by a mastectomy and adjuvant chemo with tamoxifen (the estrogen modulator discussed above).

Kim, now 45, is in remission after five years of tamoxifen. She came in with her surgeon, a 40-year-old who specializes in breast reconstruction.

Type-A Anita asked How has this experience changed your perspective on life? "It has not really changed my perspective. I am not someone who creates a bucket list… The main thing this diagnosis did was prevent me from adopting a child. I knew before the cancer that I would not be able to have children so my husband and I began the adoption process. The agency requires both parents be home for a random drop-in session. My husband traveled a lot for his job so he quit, taking a large pay cut. By the time we were settled, I got this breast cancer diagnosis. I remember talking to a woman at the [government-licensed] adoption agency: ‘You think we would give you a child with this gravestone over your head?’" The surgeon answered: "It's somewhat dark and morbid, but dealing with patients has made me realize that we rarely recognize the hardships of people around us. I am not talking about just cancer, but any serious health complication."

Kim added: "There is always light in darkness. Chemotherapy is tough. I would get up at 6:00 am to go to the chemo center and get to work by 8:30 am. After a few weeks, I was just exhausted. My husband was gone many days. I remember getting home every weekday to find a fully prepared dinner in a basket delivered by some unknown mensch. To this day I do not know if it was my church, coworker, neighbor. That helped so much." [Kim was not Jewish, but apparently had picked up the Yiddish term mensch.]

Kim passed around her various accessories from her mastectomy. "I would wear a lot of scarves. My students must have thought I was a crazy scarf lady. I would wear scarves in the summertime to hide my mastectomy. One afternoon, my husband and I were doing yardwork and I was not wearing my special bra. The neighbors passing by would stare at me. I wanted to curl up into a ball."

Lanky Luke asked Why did Kim go on tamoxifen instead of an aromatase inhibitor? Kim's surgeon: "You are correct that tamoxifen has more significant side effects such as embolic events and risk of uterine cancer. However, AIs [aromatase inhibitor] are generally avoided in the premenopausal patient group because of the risk of ovarian activation [producing estrogen, which could stimulate proliferation of the breast cancer cells]."

Pinterest Penelope asked What would determine if you get a lumpectomy or radical mastectomy? "Well, radical mastectomy is a thing of the past," Kim's surgeon replied. "A true radical mastectomy included complete removal of the breast tissue, all axial lymph nodes, and pectoralis major muscle. What you mean is a modified radical [mastectomy] where we remove the entire breast tissue and all axial lymph nodes." She continued, "Only in advanced stage breast cancer would we perform this. We try to preserve as many lymph nodes as possible to prevent peripheral edema in the arm. We do a sentinel lymph node biopsy where we resect a single lymph node at a time to see if there are any cancer cells. If the pathologist does not see any, we can leave the distal lymph chains. I will add that most women these days elect for a mastectomy even when a lumpectomy would give clear margins. It is very difficult to match the lumpectomy breast to the other breast."

The surgeon explained that breast reconstruction is a two-part surgery. "The first surgery involves placing an expandable implant. We then go back a few months later to reconstruct the expanded space with a silicone implant or a saline bag. Silicone feels more realistic, but there are more side-effects compared to the saline bag. Autologous fat implants are very difficult due to preservation of the vasculature. This leads to sections of the fat graft to become necrotic, which has all sorts of complications such as infection."

[Lawsuits regarding silicone implants in the 1980s and 1990s resulted in nearly $10 billion in awards to women who thought that they had developed diseases such as lupus and rheumatoid arthritis from these devices. Dow Corning, founded in 1943, went bankrupt as a result of these lawsuits. No scientific link was ever established, however, and silicone implants are once again on the market. (See "Panel Confirms No Major Illness Tied to Implants," June 21, 1999, New York Times.)]

 

Our Ob/Gyn lecturer returned Friday for a talk on STDs, an evolving subject: "When I was in medical school, fluoroquinolones were the first line treatment for gonorrhea. When I started residency, fluoroquinolones were no longer acceptable, and we transitioned to ceftriaxone. Now we are seeing ceftriaxone is not adequate so we added azithromycin in combination with ceftriaxone. There are already macrolide-resistant [azithromycin] strains, we just hope they will not get together with ceftriaxone-resistant ones. Long term this is going to be a serious concern, especially with the rise in IUDs [because people aren't using condoms]." She continued: "Right now we can assume someone who is treated is cured. I see that paradigm shifting in 5 or 10 years. We will need to confirm successful treatment. That is a problem when our current tests require 4 weeks to confirm cure after treatment [PCR amplification will detect DNA of dead bacterial cells]. Asking a patient to not have sex for a month is a lot more difficult than asking a patient to not have sex during the one-week treatment window."

After learning about every kind of STD, it was time for lunch with Luke, Jane and Persevering Pete. Pete graduated college in three years and runs a small real-estate business "flipping houses" with his family who lives three hours away. He spent the last two weekends building a deck and painting the interior. He is in a long-term relationship with his college girlfriend who is an M3 at our school. Pete asks, "What is your biggest problem?" Jane responds: "Figuring out when I will do all my rotations with the Army's constraints." Luke: "Marriage and money." Pete chuckles: "Marriage for me too. My girlfriend wants to get married. What do you think about marriage at our age?" Luke: "Stay away." Pete: "I just do not think I should even consider marriage until I can envision where I will be in five years and until I am financially stable." Jane: "You’re confusing having children with getting married."

A handful of states had elections this week, in which Democrats generally prevailed. Students congratulated Anita on the outcome and she responded, "I feel like I can breath for the first time. Hope triumphed over fear."

Statistics for the week… Study: 14 hours. Sleep: 6 hours/night; Fun: 1 night. Example fun: Jane visited her alma mater to celebrate the return of one classmate who has been working as an Au Pair in New Zealand for 9 months. I played soccer with classmates followed by two beers with Lanky Luke and Mischievous Mary.

Year 2, Week 18

A suave 35-year-old male urologist introduces diseases of the external genitalia, testicles, and prostate. A urologist completes a four-year residency with a one-year internship year, typically in general surgery. "In medical school you are not going to get much exposure to urology because we are a surgical subspecialty. If you are at all interested, come shadow us for a day. You can shadow an academic urologist or a community urologist." Gigolo Giorgio: "That's quite exciting. You become a specialized surgeon in five years." (In a surgical field other than urology, six or seven years is more typical, plus, of course, four years of medical school.)

Cryptorchidism is failure of the testicle to descend from its embryological origin in the abdomen.  If the testicle is not descended, it will involute (curls up) because the warmer temperature is too high for spermatogenesis (production of sperm). "We wait until age two before we surgically descend the testicle. Most undescended testicles will descend on their own in the first year. If it doesn't, the child still won't remember anything if he gets surgery at two. The mother bears the brunt." Even if the testicle undergoes orchiopexy (peg it to the scrotum), there is still an increased risk of testicular cancer. "If you see cryptorchidism, immediately think testicular cancer on board questions."

 

After skin malignancies, testicular cancer is the most common malignancy in 15-35 year old males. "Testicular cancer is four times more prevalent in white than in African Americans. I have never seen a black male with testicular cancer." The mortality of testicular cancer has decreased substantially over the past two decades. "Testicular cancer is completely curable with less than a five-percent mortality rate. We hit it strong and fast, some of the highest levels of chemo, but we get it." (Younger patients can handle higher doses of chemo.) He emphasized how every testicular mass should be considered malignant as opposed to ovarian masses that are commonly benign. We learned a common board stumper: a 20-year-old male presents for a left testicular mass. After an ultrasound confirms a mass, what is the next step? Answer: orchiectomy (removal of the testicle). "Never biopsy a testicular mass," said our urologist. The testicles drain into a different lymph system than the scrotum. "If you shoot a needle through the scrotum, you can potentially seed a whole new lymph basin [with cancer]."

We spent the next two days focusing on the "controversial" prostate, a gland that wraps around the urethra and secretes the majority of the ejaculate fluid. Prostatitis is painful inflammation of the prostate, typically from an infection, but also from pressure. "Always ask the guy if he is a biker or motorcyclist."

The urologist continued: "Every guy over 50 will have BPH [benign prostate hypertrophy] with varying degrees of urinary symptoms. BPH is one of the most under recognized, easily treatable health issues."

Persevering Pete: "What could internists and family medicine Docs do better?" Our lecturer: "I think BPH screening should be part of the standard wellness check. So many 50-60 year olds have hesitancy, difficulty starting and inability to unload. Most men with BPH get accustomed to it as it is a slow decline in function, not abrupt. We have several lines of drug treatment. We used to have to perform surgery, which is now reserved for the severe refractory cases."

Our patient case: Robert, a comedic 5'4" 68-year-old recently retired Ob/Gyn, presents to the urology clinic after a routine wellness check discovers an elevated prostate specific antigen (PSA), a commonly used screening blood test for a protein secreted by the prostate. Robert denies dysuria, urgency, hesitancy, dribbling or erectile dysfunction. The internist was unable to palpate any prostate mass on DRE, but Robert is referred to a urologist who palpates a small nodule on the left lobule. Needle biopsy reveals an intermediate-grade prostate carcinoma. Contrast MRI of the abdomen and pelvis does not show any nodal involvement, and a PET-CT does not show any metastatic bone lesions. (First Aid: "Prostate Cancer loves the bone.") Robert underwent radical prostatectomy with clear margins.

Robert: "The diagnosis caught us completely off guard. My wife and I were preparing for our long-awaited retirement entertaining all sorts of crazy ideas. The Caribbean, Florida, Wyoming, who knows where we would have ended up." For 15 minutes, we discussed how he determined to get surgery. "I had fantastic doctors. I went into surgery knowing it was the right decision, even with the potential side effects. I had 2-3 years, now I am cured. I will die of my heart, not my prostate. I live a great life. I fish, enjoy walks with my wife, and celebrate being a grandfather."

Straight-Shooter Sally: "Are you able to have sex?" The nerves that control blood flow to the penis for an erection travel travel through the prostate into the penis. Invasive prostate adenocarcinoma can invade the nerve sheaths. The radical prostatectomy can damage these nerves as the cancer tissue is removed. Robert replied, "Oh, yes. Finally, someone asked. Last year it was the very first question from the class. My wife and I had sex last night! After surgery. I had urinary incontinence and erectile dysfunction. The erectile dysfunction improved over six to seven months. My urinary incontinence has still not returned to normal, but it is improving. I stopped wearing adult diapers about six months ago."

Gigolo Giorgio: "Does sex feel the same?" Robert replied, "Mostly. As you should know, I do not ejaculate. I still orgasm, but nothing comes out." Classmates turned to each other. The urologist, sensing the general ignorance and confusion, explained that radical prostatectomy removes of the prostate and seminal vesicles, and ties the vas deferens.

A discussion ensued regarding the new USPTF [US Preventive Services Task Force, government-funded panel of physicians] recommendation against PSA screening? Our urologist: "I still recommend males over 50 get annual screening involving a PSA blood test and DRE [digital rectal exam]. I understand that it is not a specific test, but I see so many patients diagnosed with prostate cancer prior to metastasis. The screening saves their lives. It is the best we have."

The urologist continued: "The challenge with prostate cancer is stratifying risk. 1 in 7 males will be diagnosed with prostate cancer… probably 75 percent of males by age 75 have prostate cancer. Most people will never be affected by their prostate cancer, but we do not have an effective screening method. Most patients present with metastatic disease when it is too late to treat. I am asking each and everyone of you to discover a better way to detect high-grade prostatic cancer. There is some hope with the new bound/unbound PSA ratio test. More and more doctor offices are offering this as a second test if an individual has an elevated PSA."

In the small group discussions Type-A Anita expressed her displeasure that we spent much of the week on prostate cancer and male reproductive system. "It is not that serious or complicated compared to other GU issues. Typical male-dominated field." A female group-member: "That is just because you hate men, Anita." Anita: "Just the bad ones."

After hours, Anita shared a "Showing Up For Racial Justice" Facebook group's post regarding Roy Moore's Alabama senatorial election loss:

@ white people: we need to get serious about changing minds and voting patterns. White people overwhelmingly made a disgusting choice in Alabama, and Jones' victory was because of black voters. How long is this party going to demand the absolute fucking most from people of color and not address the real fucking problem: white people.

Also @ white women what the actual fuck.

Our Dean lead a mandatory 45-minute session to review an LCME-required survey that our class completed back in May. Highlights of the survey: 15 percent fewer students in our class report they enjoy being a medical student compared to the class of 2010. Students are surprised that only 10 percent of the class felt there was unnecessary competition amongst students. The biggest issue continues to be "work/life balance" (but nobody has a job?). Our Dean: "We created an entire department [two years ago] to improve these issues. Stay tuned for more wellness events."

Most of the session regarded mistreatment among students and between faculty and students. The Dean just returned from the annual American Association of Medical Colleges [AAMC] meeting in Boston: "Three of the four lectures were on mistreatment in the learning environment." He shared a PowerPoint with the LCME's definition of mistreatment, which starts with "a behavior that shows disrespect for the dignity of others." Examples include language that "can be perceived as" rude, sarcastic, loud or offensive.                                

Our school has a committee composed of two student representatives from each grade, three deans and rotating faculty that meet monthly to respond to anonymous reports of mistreatment. The accuser need never be involved unless more information is needed. Following the committee's investigation, disciplinary action has included removal of a faculty member's appointment.

After class, Luke, Mischievous Mary, Persevering Pete, Jane, her trauma nurse sister and I go to our weekly Thursday beers-and-burgers spot. Lanky Luke: "A student could anonymously report a perceived insult from a resident or attending, which would immediately kick off a multi-month investigation. You don't see an issue when people feel entitled to not be offended?" After a 5-second silence, he added, "I am referring to mistreatment outside of sexual conduct. I agree you need a channel to address sexual harassment."

Jane's sister: "Almost every unmarried nurse on my floor is romantically engaged with another nurse or resident. Most of my coworkers who have gotten married found their spouse through work. There is nothing wrong with that. It just should not be someone you work directly with like your charge nurse, attending, subordinate, etc.."

Mary: "As a woman, I kind of take being flirted with as a norm. It's not good or bad. It's just life. And it serves a purpose. It lets you know who's interested in whom. Pretty quickly you can tell if someone is interested or not.

Jane's sister: "I flirt all the time with this Colombian critical care resident who passed through our floor. We went on a few casual dates. If you did not know him, some women would probably think what he is doing is inappropriate. His English is good, but he does not understand colloquial sayings and expressions. We tricked him to say dirty words to the new nurses. It was hilarious. In this day and age he could get fired for that. There needs to be a mechanism to report if something is inappropriate without that accused individual getting terminated. They should be given a warning."

Mary: "Sorry, but someone who cannot figure out how NOT to sexual harrass someone is an idiot and should be fired."

Jane's sister: "All I am saying is there are going to be a lot fewer happy couples because of this culture."

Pete changed the subject. Pete and girlfriend, an M3 who competes in bodybuilding competitions, co-signed an 18-month lease on an expensive apartment. She was unfaithful to him on an "away rotation" (extended interview at a different hospital system where one is interested in applying for residency). He broke up with her, but she will neither move out nor approve his removal from the lease. "I either have to move out and pay for two apartments, or stay living in misery. What do I do? Also, her brother is a lawyer and is not afraid to sue me." [Editor: Note that, as marriage rates decline, there is a trend to allow plaintiffs to sue in family court after living with someone for at least two years (e.g., in British Columbia and Scotland). Pete can think of the extra rent as alimony.]

Later that evening, Jane and I attend an optional heart workshop led by a 55-year-old cardiothoracic (CT) surgeon and his fellow. The surgeon was crude and direct, laying frequent F-bombs. Anita described him as a "Dick". Jane asked him about the lifestyle of a CT surgeon: "My residency is nothing like surgical residency is now. We would be 32 hours on, 8 hours off. while being on call every single evening -- that meant we were at the hospital every single day. I moved into the hospital for three months on one rotation. I did not see my wife for weeks on end. I learned many years later my wife went to therapy. We both did not think we would make it through my residency." She divorced him five years ago. He concluded: "There are many things I regret. I should have tried harder in my marriage. Despite this, I would do it all again." CT surgery plus divorce apparently does not yield financial security: he wasn't able to pay off his student loans until age 50. [Editor: She might not have divorced him if they'd lived in Nevada, Texas, or Germany, where the only reliable way to spend a surgeon's income is to stay married to the surgeon; see Real World Divorce.]

He is a vocal critic of the new CT residencies, which don't require starting in general surgery. "First, how do you know you want to be a CT surgeon in medical school? You don't know anything. I did not know I wanted to be a heart surgeon until my fourth-year in residency. Second, I do not trust the new graduates of these programs. We are hiring one now, and all my partners will treat him as a fellow. He will not be ready for the independence of an attending. He did not get a solid foundation in general surgery, or enough surgical hours."

 

Friday morning begins with a 40-year-old internist teaching how to conduct a sexual history. She starts with an explanation of the CDCs "6Ps": Partners, Practices, Protection against STDS, Prior history of STDs, and Protection against Pregnancy. "Patients now expect you to ask about sexual history. 20 years ago, it was a little offensive."

She had been to the same recent AAMC conference as our dean and attended a session specifically on the subject of how to teach taking a sexual history. She read aloud from a copied AAMC slide: "Cultural competency, the understanding of and respect for the cultures, traditions and practices of a community, requires cultural humility. To obtain cultural humility we must undergo self reflection and self-critique as lifelong learners and providers."

We learned about the difference between sexual behavior and sexual identity. "Sexual behavior does not always match up to sexual identity. You need to use the correct terminology to keep the dialogue going."  We also were instructed to use precise terminology when charting: not "patient is gay" [sexual identity], but "patient engages in sex with men" [practice or behavior].

Our lecturer cautions against stereotyping and racism: "There is a high risk of marginalization due to sexual history taking." Patients who feel marginalized by their healthcare workers experience increased risk of mental health issues, substance abuse, and unhealthy lifestyle. She explained that black males and males under 28 are the least likely groups to disclose to a healthcare provider they engage in same-sex sexual activities.

Surfer Saul, a laid-back Southern Californian, commented on his experience working in a free Los Angeles clinic. "I find it helpful to use terminology the patients use. For example, pussy for vagina, dick for penis, blowing for oral sex, rimming." The class went silent, while a favorite 45-year-old former Army doctor sitting in front of Saul slammed his head to the table trying to suppress his laughter. The female doctor acknowledged his comment, and said "Yes" but maybe put it in a clinical perspective.  After class, Gigolo Giorgio congratulated Saul on the number of profane words used.

 

At lunch, Lanky Luke objects to the standard of asking every patient where he or she falls on the LGBTQIA spectrum. "It seems offensive if the patient is an elderly woman. I would like to use my discretion." Jane  joked: "So you are confident enough in your Gadar?" Type-A Anita: "You need to ask every patient, period. You wouldn’t not ask about IV drug use… If only you knew what it was like to be in the minority for a second." [Anita herself is a white, native-born, and suburban-reared.]

The conversation is diffused when Wild Willow shares Ackanator, a phone app that asks questions until it can guess a user's chosen fictional character. "I stayed up all night trying to stump it. It's full proof." Students volunteered two characters: Porkins and a Dragon Ball Z character. We were unable to stump it. Jane: "I want to know its top pick at every question. What is its differential?" Another student added, "Stop doing that! You are making it smarter. It'll take our jobs."

I attend an optional evening workshop on opioid abuse led by two EM physicians in their mid-thirties. We had been cautioned by the CT surgeon that surgery was not a likely path to driving a sports car on three-day weekends; these two guys are both rumored to drive fancy sports cars. Physician A: "The CDC in 2002 issued guidance to err on the side of the patient. Treat pain. In 2012, the CDC released really a groundbreaking, earth-shattering statement to every physician in the country. It said, 'We messed up.' When does the government ever say that? Now the official doctrine is that every opioid prescription has the potential to be addictive." Physician B:  "This has completely changed our practice." (Nobody asked why doctors en masse were listening to the CDC to begin with.)

Physician A described how his brother-in-law is struggling with opioid addiction and has been in and out of rehab. "After rehab he was sober for three months. It really seemed he was turning his life around. He was bored one night, and called up an old friend to hang out. Another friend came over and asked if they wanted to shoot up. My brother-in-law was not seeking. You have to realize how difficult staying sober is. You have to give everything up, start fresh. Delete everyone's phone number because it has become so ingrained in the whole community. He ODed that evening, was saved by Narcan [naloxone], and now is back in rehab."

What can we do to help an addict in the ED? Both physicians chuckled. Physician B: "It depends how jaded you are. Frankly, not much." Physician A: "I agree. A patient has to hit rock bottom before waking up. That usually is losing a job, losing a family member, almost losing his or her life. Families blame themselves when in reality they are mostly helpless. This is a disease." Physician B: "You still have to try. I've had one patient come back after six months to explain that my talk in the ED behind curtains turned his life around. He went to rehab because of it. The patients that respond are never those you expect." We were trained and supplied with two uses of Narcan.

Facebook excerpt of the week: Anita shares TIME magazine's cover page of women who have accused various men of sexual misconduct. She adds "A fabulous way to highlight an awesome movement and the perfect antithesis to the sexual predator-in-chief’s tweet vomits. #MeToo"

Statistics for the week… Study: 14 hours. Sleep: 6 hours/night; Fun: 1 night. Example fun: we celebrate Jane's birthday at Luke and his wife Samantha's house. Luke and I drive to Lowes the previous weekend in his pick-up truck and built a fire pit. Sarcastic Samantha, finishing her Ob/Gyn PA rotation in a rough urban neighborhood, recounted her on-the-ground experience with the importance of conducting a thorough sexual history. Two days ago she saw a couple who came in due to infertility. "After ten minutes, my preceptor [also a PA] and I were concerned they were not having correct sexual intercourse. We had to explain to the couple that you do not get pregnant by swallowing. That's not how you do it." Luke: "I wonder if you should have told them." Jane: "That's eugenics!" Samantha described her disillusionment from the six week experience: "A mother of four from three different fathers came in for prenatal care of her soon to be fifth child. One child was born addicted to heroin. All she cared about was getting her government check in the mail for this additional child. It made me sick to my stomach imagining how these children are going to grow up. How does my preceptor deal with this everyday?" [Editor: If the patients are covered by Medicaid or Obamacare, the preceptor is also getting checks from the government!]

Year 2, Week 19

A reproductive endocrinologist begins Monday morning with a one-hour lecture on infertility. She explains that 15 percent of couples experience infertility, defined as more than one year of unprotected intercourse without conception. Fecundability, the probability of achieving pregnancy in a single menstrual cycle, should be about 25 percent. Infertility is on the rise in America: "More and more of my practice is managing PCOS [Polycystic Ovarian Syndrome, driven by obesity]."

An obstetrician finishes the day with three hours of lectures (four hours total for the day, so we were done at noon). "Spontaneous abortions occur in 20 percent of all pregnancies," she notes. "Most people do not even realize fertilization has occurred because the abortion occurs in the first trimester. At eight weeks of age with heart sounds, there is less than 5 percent risk of spontaneous abortion." The risk of miscarriage doubles every 5 years after the age of 35. (My female classmates, especially those who didn't come straight from college, have been talking about this since M1. They may be residents well into their 30s so when do they have children?)

The OB lecture covers the placenta, the organ that exchanges oxygen, nutrients and waste between the maternal and fetal circulation. "The placenta regulates all the blood flow to the baby. If you lined 100 placentas up, I could tell you exactly which mother was smoking or using cocaine. Preeclampsia, eclampsia and HELPP [Hemolysis, elevated liver enzymes, low platelet count syndrome] syndrome all involve issues with the placenta." We discussed placenta previa, where the placenta partially overlies the cervix. Cesarean section is performed at 39 weeks because of the increased risk of hemorrhage prior to delivery. "If a third trimester pregnant woman presents for painless vaginal bleeding, DO NOT perform a vaginal exam. During my residency, I saw another resident stick his finger right through the placenta causing hemorrhage." [Editor: maybe don't go to a teaching hospital?]

The rest of the week is devoted to three hours of daily lectures on nephrology. A 34-year-old soft-spoken nephrologist begins with a one-hour review of last year's kidney physiology. The block director, a PhD in molecular biology, is charged with ensuring we get our LCME-mandated 10-minute break after 50 minutes of class. During the break female classmates discuss how good-looking the lecturer is, emphasizing his fitness and broad shoulders.

Pinterest Penelope (recently broken up from her M3 boyfriend): "I love younger physicians. They understand what we are going through. Our fondness of First-Aid, our cluelessness about residency, our anxiety about Step I. Older physicians live in a different world."

Lecture continues with two hours on acute kidney injury (AKI). Every minute, 100 mL bleeds out of our capillaries through the glomerulus, a biological filter, into the kidney tubule system and finally the bladder. Over 99 percent of the filtered volume is reabsorbed through active transport of solutes creating an osmotic gradient for fluid reabsorption to maintain the body's electrolyte and fluid balance. Kidney aging, drugs (e.g., antibiotics, and NSAIDs), and autoimmune diseases decrease the summed rate of filtration, glomerular filtration rate (GFR), and the proportion of electrolyte reabsorption. The nephrologist explains: "You lose about ten milliliters GFR every ten years after the age of 30. As long as you do not have a comorbidity, you will never lose enough to confer disease. The problem is most Americans will develop a comorbidity."

Kidney injury is divided into several categories:

  1. Acute versus Chronic
  2. Location of insult: pre-renal (e.g., decreased blood flow), post-renal (e.g., ureter obstruction) or intra renal (e.g., inflammation of tubule system)
  3. Urine character: Nephrotic (protein wasting) versus Nephritic (red blood cell wasting)

Our patient case: 4-year old Baby Nora and her family hosted a family reunion cookout filled with beer, burgers and brats. Three days later, Nora develops a fever, abdominal pain, vomiting, and diarrhea. She is taken to the ED that evening, given IV fluids for dehydration and discharged home. The following day, Nora is brought back to the ED after her family notices bloody diarrhea.

On physical exam, Nora appears lethargic. She has tachycardia (high heart rate), tachypnea (fast breathing), a 101 degree fever, and hypotension (low blood pressure, 80/60). Given the bloody diarrhea and lack of symptom improvement, a "rainbow" is drawn. The tube for each test has a different color and when EM physicians are stumped, each tube is filled with blood. CMP (Complete Metabolic Panel) shows hyponatremia (decreased blood sodium) and uremia (elevated blood urea). ABG (arterial blood gas) reveals a primary anion-gap metabolic acidosis with respiratory compensation. CBC (complete blood count) shows leukocytosis (elevated white blood cells), thrombocytopenia (low platelets) and anemia (low red blood cells). Peripheral blood smear reveals the presence of schizoschites, suggestive of a vasculopathy. Urinalysis shows the abnormal presence of protein and red blood cells.

Her doctors are concerned about hemolytic uremic syndrome (HUS), the most common cause of acute kidney injury in children. The disease is caused by ingestion of Shiga toxin from E. coli O157H7, which typically accumulates in colonized food rather than being produced by bacteria that have colonized the gut. Also, if there is an infection, killing the bacteria all at once can release a flood of Shiga toxin. Thus antibiotics are not started and doctors will rely on the patient's immune system to kill any remaining bacteria. Shiga toxin damages small blood vessels and causes formation of small blood clots (microthrombi). These blood clots shear red blood cells creating the characteristic schiztoschites seen on a peripheral blood smear.

Nora's urine output continues to decline, and hemodialysis is started and continued for five days until her creatinine levels improve. Creatinine is a muscle protein product excreted by the kidneys at a constant rate used to measure kidney function. She requires one unit (300 mL) of packed red blood cells to maintain her hemoglobin above 7.5.

Nora gradually recovered during a 10-day hospital stay and, now age 9, does not remember the incident. Her parents reflected how scary the experience was. "I was furious at the doctor who sent us home when we brought her the first time. After the emotions simmered down, I have forgiven her. There wasn't any sign that it was more serious than just a typical food poisoning."

Nora's kidney function, as measured by GFR, is back to normal, placing her among the lucky 70 percent who recovery fully.

Our two hour ethics workshop focuses on disability. We read Enforcing Normalcy: Disability, Deafness, and the Body by Lennard Davis, "a nationally and internationally known American specialist in disability studies [an academic discipline]" and English professor at University of Illinois at Chicago (Wikipedia). Our ethics professor: "He uses the Marxist perspective. The disabled population is oppressed, and thus must be be given justice. Davis argues as long as society uses an ableist mentality, we will be unable to correct the injustice. He exaggerates slightly, but within the pieces are an immense amount of insight into the human experience." From the 1995 book:

When I talk about culturally engaged topics like the novel or the body I can count on a full house of spectators, but if I include the term disability in the title of my talk or a session the numbers drop radically. … our goal should be to help "normal" people to see the quotation marks around their assumed state. The fact is that disability as a topic is under-theorized -- a remarkable fact for this day when smoking, eating a peach, or using a bodily orifice are hyper-theorized.  Because of this under-theorization, which is largely a consequence of the heavy control of the subject by medical and psychosocial experts, the general population does not understand the connection between disability and the status quo in the way many people now understand the connection between race and/or gender and contemporary structures of power.

… The category itself is an extraordinarily unstable one. There is a way in which its existence is a product of the very forces that people with disabilities may wish to undo. As coded terms to signify skin color -- black, African-American, Negro, colorized -- are largely produced by a society that fails to characterize 'white" as a hue rather than an ideal, so too the categories "disabled", "handicapped" "impaired" are products of a society invested in denying the variability of the body.

In the process of disabling people with disabilities, ableist society creates the absolute category of disability. 'Normal' people tend to think of 'the disabled' as the deaf, the blind, the orthopedically impaired, the mentally retarded. But the fact is that disability includes, according to the Rehabilitation Act of 1973, those who are regarded as having a limitation or interference with daily life activities such as hearing, speaking, seeing, walking, moving, thinking, breathing, and learning. Under this definition, one now has to include people with invisible impairments such as arthritis, diabetes, epilepsy, muscular dystrophy, cystic fibrosis, multiple sclerosis, heart and respiratory problems, cancer, developmental disabilities, dyslexia, AIDS, and so on.

…  In 'talking' with Deaf colleges on e-mail particularly those whom I have never 'seen', I often 'forget' that my interlocular is deaf. Recently, in planning to attend a session at the Modern Language Association on disability, I received and sent a welter of messages on email to a number of people involved. I had no way of knowing which of these people was disabled, or in which way. When speaking on the telephone with a person who uses a wheelchair, I have no way of knowing if that person is unable to walk.

When the ethics professor was busy with another small group, Geezer Greg said, "I could have learned more by watching Curb Your Enthusiasm. Larry David calls a mechanic to bring his car in. When he brings his car in and meets the mechanic in person, Larry is surprised to find that the mechanic is black: 'You did not sound like it on the phone.'."

Persevering Pete: "I am not sure what Davis is arguing. On one hand he does not want people to consider disabled individuals as a separate group, but he wants more financial assistance for the disabled."

Luke: "Where does Davis draw the line on collecting disability checks? Am I on the spectrum?" Greg: "That's a Curb Your Enthusiasm episode also! The girlfriend claims her son is on the Asperger's spectrum, but Larry David thinks he is just a spoiled brat." (The wife sues for divorce during Season 8, taking the house and putting Larry back on the dating market.)

The ethics professor did not mention the financial aspects of being classified as disabled, nor that medical doctors are now the gatekeepers for whether or not an American can get aspect to disability payments (see "How Americans Game the $200 Billion-a-Year 'Disability-Industrial Complex'" (Forbes)), nor that some doctors earn 100 percent of their income as disability gatekeepers. This is something that Hippocrates probably could not have imagined.

Our week concludes with the Genital Teaching Assistants (GTA) teaching us how to perform the scrotal, penis, digital rectal exam, pelvic, and breast exams. The family medicine physician coordinating the workshop introduced this opportunity: "These are professionals that travel the country teaching these exam skills. Ask them any questions you have, this is their job. And let me tell you, they are good and they are very expensive -- largest item in our budget, I am talking thousands of dollars -- so we are partnering with internal medicine residents to bring them." Gigolo Giorgio learned that the female GTAs make $90 per student ($70 for vaginal exams, $20 for breast exam) or over $1,000 (3 groups of 4) in the afternoon workshop. The national standard seems to be that male GTAs are paid less, but so far there have been no demands for equal pay. Luke: "How much would you have to get paid to do that?" A few of the guys responded: "No questions asked, sign me up." No female classmates answered.

We are divided into teams of four and rotate through a male GTA for 1.5 hours and a female GTA for 2 hours. My group happens to be all male. The 35-year-old male GTA is a married family medicine resident with two sons who has been doing the GTA program as a side job for 3 years. Patricular Patrick leads the way beginning with the scrotal exam. We individually practice each step of the exam. The GTA is extremely helpful, drawing on his medical experience to emphasize certain pathologies to look out for at each step of the scrotal and penile exam. The digital rectal exam is last. As Particular Patrick is searching for the prostate, the GTA adds, "My right prostate lobe is slightly larger than the left." There is a 15-minute break before the female GTA session. Pinterest Penelope was enthusiastic about having felt a direct hernia in a "65-year-old geezer," but noted the "shriveled balls."

Our female session is with a 25-year-old GTA with two years of experience. She uses a mirror to help guide each of us through the exam as we struggle to handle the speculum to locate the cervix and to palpate the ovaries using the bimanual technique. She emphasizes, in an Eastern European accent, never to close the speculum until partially retracted to prevent closure on the sensitive cervix. We took longer than expected, so only one of us is allowed to perform the uterorectal exam. Ambitious Al quickly volunteers with no shame. Gigolo Giorgio was disappointed he could not practice it. This snafu apparently happened in other groups as well, and a few students (not Giorgio to my knowledge) complained how this asymmetric experience was unfair to those who did not get to perform the rectouterine exam. The family medicine physician apologized.

Jane: "This experience hit a lot of us. It seemed like everyone respects what happened, it's a kind of a milestone." (Jane might not have heard a few wags joking about the scrotal, bimanual, and uterorectal "shocker" exam.) The Family Medicine instructor comments, "I am glad no one fainted. One gentleman last year fainted while examining the male GTA."  Two (male) students became light-headed during both the rectal (male) and bimanual (female) exam, although no one fainted.

Jane and I ate dinner with her mother, learning that she loaned Jane's sister just under $10,000 to pay off a Lowe's loan for repairs on the ex-boyfriend's house (see Week 14). Solvent thanks to this and Jane's loan of $5,000 to pay off her credit card debt, the sister has recently gotten back together with the ex-boyfriend. "Well, I feel like an idiot!" said Jane's mom, not a fan of this boyfriend. "I keep thinking if she still had the 10k 'L' [for Loser] hanging over his head, they would never have gotten back together."

It is a week before Thanksgiving and Type-A Anita is hosting the class potluck Friendsgiving on Saturday afternoon.  Anita's board game collection includes The Cat Game and Trump: The Game, a gift during the election night party. "Still too soon to play it," said Anita. My favorite dishes: Straight-Shooter Sally's sweet potato casserole, Gigolo Giorgio's jalapeno guacamole, and Persevering Pete's homemade rolls. Most of us elected to bring wine or beer rather than expose our weak skills in the kitchen, resulting in 10 bottles of wine and 6 six-packs arranged on the serving table. At 9:00 pm on the dot, 20 classmates whip out their phones to play HQ, a streaming, single-elimination trivia app with a live host. None of us get to share in the $5,000 that is divided among contestants who correctly answer all 12 questions. Classmate Butch Brock and his girlfriend Annabelle the Beauty made it to questions 6 and 7. Annabelle recently moved in with Brock, studied communications at a state university, works as a hostess at a local restaurant, and has decided to apply to PA school. Lanky Luke: "Isn't there anything else people want to do besides medicine?" Jane and I left around 10:30 pm.

This Week in Facebook Activity: Type-A Anita shared Huffington Post's "Trump Official Blocked Immigrant Teen Rape Victim’s Abortion Because He Personally Opposed It" and added "Tw: rape [Trigger Warning] Hot Take: if you're a leaky pile of garbage concealed in human skin, you forfeit the ability to tell others what to do with their very real Human Bodies. no one can decide whether or not someone's reason for an abortion is "good enough". Anita shifted gears from attacking our weak commitment to advancing non-white causes to attack a non-white political candidate: "Anyone who invokes God as an unquestionable authority in a secular debate on REAL WORLD phenomena has no place in government. This woman, Angie Reed Phukan, is running for Comptroller of Maryland, and decided to let us all know what actual garbage she is ahead of time. (Anita has never lived in Maryland.) Later that evening, she shared an article on Viagra's patent expiration: "by all means let's help old dudes keep an erection but keep reducing people's access to contraceptives #godwantsyoutohavelimpdick" Pinterest Penelope shared that one on Facebook and messaged the class GroupMe: "The hashtag!!"

Statistics for the week… Study: 18 hours. Sleep: 7 hours/night; Fun: 1 night. Example fun: Jane and I join her college girlfriend who works as an au pair and bartender in Dunedin, New Zealand. In order to stay in New Zealand, she is signing up for a master's degree in international politics at a university there, using $17,000 in U.S. Federal student loans. (Editor: the U.S. welfare program for university bureaucrats now embraces the entire planet! Separately, if so many young people study international relations, why are there still wars?)

Year 2, Week 20

The Saturday Friendsgiving has thinned the ranks of Monday and Tuesday lecture attendees. At least five of us, including me, are down with an upper respiratory infection.

Instead of watching the recorded lectures, I watch Pathoma and read Robbins & Cotran. Chronic kidney disease (CKD) is an irreversible loss of kidney function defined by a GFR of less than 60 milliliters per minute for more than three months. Pathoma explains the process of hyperfiltration, where loss of one group of nephron units, from e.g., infection, inflammation, hypoperfusion (low blood flow), causes the remaining functioning nephron units to increase GFR.

I return Wednesday for two hours of CKD treatment strategies by the nephrologist from last week: "What I love about nephrology is there are only four diseases that I have to know: diabetes, hypertension, pyelonephritis (kidney infection), and hereditary kidney disease. 95 percent of all CKD is caused by one of these and they are all covered in First Aid."

He discussed some exceptions to this rule, starting with an unsolved mystery in Central America "Certain agricultural communities have up to 20 percent incidence of CKD. We do not know why." (see "Chronic Kidney Disease Epidemic in Central America: Urgent Public Health Action Is Needed amid Causal Uncertainty", Ordunez, et al., PLOS, 2014). He also described an outbreak of "Chinese herbal nephropathy" from a weight loss supplement that used aristolochia instead of stephania. This is the same compound that caused the 1965 Balkan Endemic Nephropathy in the Soviet Bloc. Aristolochia grows in wheat fields along Danube river Valley. This contaminated flour. "When I was in medical school, this was huge news. Now the region has 65 times the risk of getting uroepithelial cancer."

We learned about the various types of dialysis for end-stage renal disease. "We tell our patients it is fine to travel. One of the beauties of effective government regulation is that all dialysis machines are standardized. We use the same settings for each machine. Our patients travel all over the country, and we are able to handle dialysis for visitors from anywhere in the world."

The nephrologist concluded: "You will each briefly do a nephrology rotation. One of the things I wish you could see is the patients that are doing well. If patients do not take care of themselves there are serious consequences. You see these patients in the hospital. But if they do take care of themselves they can be healthy and productive members of society. You don't see the patients who have jobs, families, and a good quality of life. I wish we could show you what it is like on the outpatient side. Come join us for a day!"

Our patient case: Jenny, a recently married 24-year-old manager at a fashion designer store. She was fresh out of college, had moved with her husband for new jobs, and purchased a house, all within one year. Jenny presents for one month of joint pain and an expanding rash over her face and torso. She was worked up for Lyme Disease. "I got a call a few days later by the nurse who referred me to a rheumatologist." The earliest appointment was in two months.

"The next week I could not get out of bed because the pain was so bad.  I had to lie like a coffin. I thought I was dying. We had to cancel our honeymoon! That's when my husband realized that the problem was more than natural laziness." She chuckled, and continued: "I called my family friend who is a doctor. He gave me a list of tests to get. I called to get another appointment with my PCP, but I could only see a PA. I think she was insulted when I presented my long list of labs and tests." Her labs showed abnormal urinalysis including albuminuria and red blood cells in the urine. "They now wanted me to see a nephrologist instead of the rheumatologist! I saw the nephrologist the same day."

Her short, sarcastic 40-year-old nephrologist said that she had immediately suspected systemic lupus erythematosus (SLE or "lupus") given Jenny's age, sex, kidney function, and the expanding characteristic butterfly rash now covering her face. She started Jenny on several drugs, including an immunosuppressant, high dose NSAID, and steroids to bring her lupus into remission. Jenny has been in remission for almost three years since the initial flare up at age 24.

Jenny said, "My husband is a saint. Once I got the diagnosis, I immediately went to the Internet. WebMD is a dark hole of death. I thought every little ache or sniffle spelled death. After a week, My husband forbade me from looking up any information about lupus. If I was concerned about something, I told him, and he would search it."

After roughly six months, Jenny began tapering down the powerful immunosuppressants. Her lupus is controlled now only with high dose NSAIDs. "The drugs I was on had terrible side effects, but I was just as scared about relapse. Weaning off the drugs takes months. My husband was the only reason I was able to follow the strategy. He reminded me every day, and kept track of the dosing schedules." (Roughly half of individuals with chronic illnesses do not take their medications correctly.)

When would a nephrologist rather than a rheumatologist manage a patient with lupus? "It depends on what condition is the most urgent. If lupus is impacting the kidney, a nephrologist will manage the case until the kidneys are safe. The rheumatologist manages the day-to-day stuff, we get involved only to evaluate the kidney."

Straight-Shooter Sally asked Jenny to summarize her care. "To be honest, I was not impressed with my PCPs. I felt like they failed me. But, I love my specialists. They know so much. Any question or concern, they have seen before and know exactly what to do."

 

Surfer Saul asked Jenny if she is able to have children. Jenny's rheumatologist does not want her to get pregnant due to the risk of a flare up from the hormone surge. Her nephrologist: "I think it is okay. I've had a few SLE patients get pregnant." Mischievous Mary asked if pregnancy would stress Jenny's kidneys because of the sudden increase in blood volume and hyperfiltration? "Oh no, pregnancy is good for your body, good for the kidney. Pregnancy is a protective risk factor for lots of cancers. I tell Jenny she can get pregnant."

Gigolo Giorgio asked if Jenny, in light of her current knowledge of lupus, could remember pre-diagnosis flare-ups. "Yes, I got really sick in college once. Terrible. It had to be a flare up. I also remember being allergic to all these random things like yellow dye."

A student asked the nephrologist what her patients can you eat on a renal-restricted diet? "Wonder bread and lettuce. There are no good options. Every food has things the kidney struggles to excrete. I have patients come in to me complaining of having Wonder Bread stuck to the top of their mouth."

Our class discussed the proposed Republican tax plan at lunch. Students did not understand the changes to the mortgage interest deduction. One student believed that the new tax plan would increase the mortgage deduction limits "to benefit the wealthy in their McMansions." Luke attempted to correct the group by stating the new tax bill would restrict and cap the mortgage interest deduction at $10,000. (This was also incorrect; it was state and local taxes that were limited to $10,000 while mortgage interest would remain deductible on loans of up to $750,000.) Socialist Sam, a 23-year-old self-described "Democratic Socialist," responded: "Well, then, the deduction would distort the housing market. It would make it more expensive for people to move up in housing market, exacerbating racial housing discrimination." (Decades of government subsidies to homeowners via the mortgage interest deductions apparently did not constitute a "distortion" to the housing market!)

Curiously for someone whose future paychecks will be coming from insurance companies, Gigolo Giorgio supported getting rid of the Obamacare "individual mandate" requiring citizens to purchase health insurance. "A bunch of my college friends took the $2,000 hit instead of purchasing health insurance."

 

The argument continued on Facebook. Type-A Anita shared a Bustle article, "The GOP Senate Tax Bill Will Make It Much Harder To Be A Woman In America" underneath "hi warning friends only read this if ur ready to get good and depressed because IDK WHAT I EXPECTED FROM THE TITLE but wowie wow wow." The main point of the article is that people who don't currently pay taxes will be denied the opportunity to claim tax credits:

Millennial moms would also be impacted because the bill excludes 10 million low-income children from claiming tax credits. Because women still mainly shoulder the responsibility for child care, families in the lowest income bracket won't receive tax benefits for their children when they're the ones who need it the most.

[Editor: Let's see if single moms are so discouraged by this new tax law that they turn over custody, and the child support cash that comes with custody, to the respective fathers!]

Some of our female classmates thank her for educating them (8 angry faces; 14 likes). Sample comments:

My brain cannot even comprehend the sheer cruelty of this bill

I just...don't understand. I DON'T UNDERSTAND HOW ANYONE CAN DO THIS AND SLEEP AT NIGHT

 

Facebook also brought news from my college classmate who decided to leave the United States for enlightened Brussels due to Trump's election (see Year 2, Week 3). His coworker in Belgium has been "jokingly" calling him by a variety of anti-gay slurs:

        I refuse. I will not be defined by your words and I will not be forced to accept them as

“business as usual”.

His friends commented that Trump could be blamed for this outbreak of homophobia in Brussels.

Statistics for the week… Study: 25 hours. Sleep: 6 hours/night; Fun: none. We leave Wednesday after class for Thanksgiving break. Students complain that the administration scheduled exams for the week after Thanksgiving.

Year 2, Week 21

We return from Thanksgiving break for exam week: two standardized patient (SP) encounters, clinical multiple choice exam, NBME multiple choice exam, and case-based exam. Lanky Luke, Straight-Shooter Sally, and I were most concerned about failing the clinical exams.

My first "patient" is a 38-year-old female presenting for diffuse abdominal pain and a two-week history of bloody diarrhea ("tar colored") with no recent travel or sick contacts. She takes Aleve (naproxen) four to six times per week due to headaches and joint stiffness. After the 25-minute encounter, I left the room with no idea what the correct diagnosis should be. Peptic ulcer disease from NSAID use? Inflammatory bowel disease? Irritable bowel syndrome from low fiber diet. I forgot to ask so many basic questions. Several students commented how they similarly stared blankly at the computer screen writing up the H&P (history and physical note).

My second "patient" is a 26-year-old female presenting for a two-day history of a burning sensation on urination. She denies abnormal discharge or change in menstruation. I complete a full "5 P's" sexual history: partners, practices, protection against STDs, prior history of STDs, protection against pregnancy. She is in a two-year relationship with a female partner. One week ago, she had a few to many eggnogs at her store's christmas party. She had unprotected anal and vaginal intercourse with a male partner. She is now concerned that her partner will contract whatever she has, and she does not want to tell her. I diagnose her with cervicitis (inflamed cervix) due to chlamydia or gonorrhea. I recommend dual treatment of ceftriaxone/azithromycin with Hep B/C vaccine and HIV screening for risky behaviors

[Editor: One of my Manhattan friends, whenever a Ph.D. introduces himself as "Dr. …" at a party, takes the new acquaintance aside and says "Doctor: I have this burning sensation whenever I go to the bathroom. What do you think it could be?"]

The challenging clinical 60-question multiple choice exam covered nasogastric (NG) tubes, Foley catheters, nutrition, and sexual history. Questions included:

Pinterest Penelope was frustrated at the clinical coordinator for including two questions on immunizations and screening tests based on sexual history, relationships that were not explicitly covered in lecture. The clinical coordinator responded, "Do not blame the messenger. We always tell you that information from prelecture readings and recordings can be tested."

Pinterest Penelope after the NBME exam: "I knew everything, but a lot of the questions were poorly worded." Gigolo Giorgio: "What did you put for the question asking about a vaginal ulcer. HSV [genital herpes] or syphilis [chancre]? It did not say if it was painful or not." Penelope: "See poorly worded, there is a reason they are retired board question." Students continue to complain about the black-and-white histology slides. One classmate who is color-blind apparently asked if there are any accommodations for the colorblind because the real NBME exam includes color pictures [Editor: "Pictures of Color"?]. "The answer is no." One question asked about how to diagnose a penile ulcer due to syphilis. Straight-Shooter Sally: "I have no idea what is darkfield microscopy, but I think we've heard it before?" Jane: "Same! I just put it cause why not." I also chose this answer, which is fortunate because darkfield microscopy is actually used to identify the culprit bacteria,Treponema pallidum.

Wednesday evening, with one exam remaining, Jane lost her studying motivation and indulged in a three-hour Buzzfeed binge. I was under strict instructions not to disturb her while she laughed hard enough to cry at cat videos and tweet compilations.

The case-based exam covered five patients: breast cancer, alcoholic liver cirrhosis, testicular cancer, acute kidney failure, and Crohn disease. Each case had eight short-answer questions.

Example questions:

Describe the treatment considerations in breast cancer. Answer: premenopausal women with ER positive breast cancer should begin tamoxifen; postmenopausal women with ER positive breast cancer should be aromatase inhibitor.

What are the histological characteristics of Crohn disease versus Ulcerative Colitis? Answer: Crohn disease is characterized by inflammation of the entire gut wall potentially causing strictures and fistulas (connection between two parts of the gut tube, e.g., small intestine and large intestine); ulcerative colitis is characterized by pseudopolyps, loss of haustra (gut lumen foldings) and enlarged crypts with neutrophilic infiltrate.

What kind of acute kidney injury is this given the CMP with BUN:Creatinine ratio and urinalysis. Answer: BUN:Cr > 20 suggests prerenal causes, e.g., dehydration or hemorrhage; BUN:Cr < 15 with high urinary sodium excretion suggests acute tubular necrosis.

A patient with G6P deficiency gets a URI and develops colicky abdominal pain. What is happening? Answer: Red blood hemolysis is causing pigment (bilirubin) gallstone (cholelithiasis) formation.

An overweight, 40 year old female on birth control develops colicky abdominal pain. What is happening? Answer: Cholesterol cholelithiasis (gallstones)

A 30 year old male develops hypertension, hematuria and flank pain. Ultrasound reveals several dilated cysts on both kidneys. What other tests should be ordered? Answer: a patient with adult onset polycystic kidney disease (PCKD) should get regular MRIs and echocardiograms to evaluate berry aneurysms in the circle of Willis (cerebral vasculature) and mitral valve prolapse, respectively. What is the probability his child will have the same disease? Answer: Adult onset PCKD is an autosomal dominant trait, therefore 50 percent.

(On the liver case:) Explain eight etiologies of the disease shown in the above histology slides." Answer: Hep B, Hep C, Hep B/D coinfection, idiopathic/genetic, alcohol, obesity, biliary obstruction.

After exams, 15 students trickled into our favorite burgers-and-beers spot. Conversation shifted to the Republican tax proposal when Pinterest Penelope showed a BuzzFeed-produced video lobbying against the elimination of the student loan interest deduction. The video featured a Tufts University drama and communications graduate working as a "freelance production assistant" and receptionist struggling to pay over $118,000 in student loans ($118,000 is roughly 7 times the cost of in-state tuition and fees at Texas A&M medical school).

Lanky Luke: "Wouldn't the increased standard deduction cover the entire taxable income of a struggling, underemployed drama graduate? I feel like so much of the 'millennial' frustration is directed at the wrong people. How much were her drama professors making while she was paying sky-high tuition?" Straight-Shooter Sally: "What has changed to propel tuition so high? That is what I cannot understand. There were drama professors 10-20 years ago."

The topic turned to ongoing sexual harassment/assault charges and the #MeToo movement. Pinterest Penelope: "Can we just talk about sexual assault and how everyone is a terrible human being." Mischievous Mary: "Someone who cannot figure out how NOT to sexual harrass someone is an idiot and should be fired." Straight-Shooter Sally: "As a Democrat, I want Al Franken to resign. I know some of my friends who want him to stay to resist Trump, but that sets a terrible precedent."

Lanky Luke: "Mike Pence is looking pretty smug with his no dining alone with other women outside his wife."  Pinterest Penelope responded by referencing a Vox article, "Vice President Pence’s “never dine alone with a woman” rule isn’t honorable. It’s probably illegal" (sent in GroupMe chat). Luke: "So what are men supposed to do?" Three women all responded in unison: "Not sexually harass women."

Type-A Anita: "When a male assaults a female, the male does not need to add that he is attracted to women. No, Kevin Spacey did not need to add that he is gay. Thank you for setting gay rights back a decade. You are trash."

Friday evening, four female classmates independently shared Elizabeth Warren's Facebook post. Pinterest Penelope added "Marry Me" on top of the link:


You might have heard that Donald Trump likes to call me “Pocahontas.” …  today, he stooped to a disgusting low. This afternoon, in the Oval Office, Donald Trump was supposed to be honoring Navajo code talkers – American heroes who helped save the world from fascism and hate during World War II. Instead, Trump stood right next to those Native American war heroes and came after me with another racist slur.

[Editor: This is definitely an unfair comparison. Pocahontas died at 20 years of age, an attractive young woman whose cross-cultural marriage prevented a war. Elizabeth Warren is a divorced 68-year-old.]

After Type-A Anita and Pinterest Penelope, Lanky Luke played a Tucker Carlson segment on the TV in the small group room for Persevering Pete, the class Orthopod, Jane and myself. The segment interviewed a transgender activist who argues race and sex can be chosen. Lanky Luke: "This is fantastic. I am going to apply to residency as part Native American, part Black. Derm residency, here I come."

My small group went to our retired orthopedic surgeon facilitator's house on Friday for a dinner party. After a few glasses of wine, we discussed the opioid epidemic. Surfer Saul: "When it was minorities addicted to drugs, the state began the war on drugs. The war on drugs was a method to suppress and incarcerate minorities, primarily African Americans and Hispanics. Look at how we judge crack-cocaine versus opioids. The moment it is white youth struggling, the drug abuse becomes a public health emergency." [Editor: Actually if it is white youth who want heroin, the government will buy it for them! See "Who funded America’s opiate epidemic? You did."]

Statistics for the week… Study: 15 hours. Sleep: 8 hours/night; Fun: Saturday night dinner with Jane's sister (26 year old), newly back together with her boyfriend, a U.S. Navy special forces retiree. The apparently healthy 37-year-old, who teaches CrossFit classes, is applying for long-term disability, which will enable him to shift all of his daughter's college expenses onto the taxpayer. He is concerned he will not be approved before school starts this August.

Year 2, Week 22

We return for the New Year after a one-month break to study oral health. Exquisite Emily, a 26-year-old Iranian-American traveled to Thailand with her boyfriend, a Deloitte consultant. Type-A Anita and her boyfriend, a work-from-home web developer, took a 1.5-week trip to Japan. She sent a snapchat of the opening "In a galaxy far away" with Japanese subtitles on opening night of Star Wars: The Last Jedi in Japan. Most students flew home to visit family for this extended break.

A recently retired 65-year-old hospital dentist ("former section chief turned professional grandpa") leads a total of eight hours of lectures on head anatomy, the basic oral exam, and common oral pathologies. He described the various lesions of the oral cavity, such as leukoplakia (unscrapable white thickening of mucosa) and thrush (scrapable white plaque of fungus). "Whenever a patient comes in with an oral lesions that I am unsure about, I tell them, come back in two weeks. Most harmless things will go away on their own in two weeks as the mucosa is turned over. If I do nothing, it will disappear in two weeks. If I give you something, it will disappear in 14 days."

"The dentist is the last bulwark of arrogance. Dentists do not like to refer anything out. We are notoriously bad collaborators. Compare that to you guys [doctors]. You are completely dependent on radiologists, hold extended cancer panels, reach out to specialists, etc. This collaboration ensures the very best care for the patient." The dentists summarized why dentistry and medicine are separated. "There were two milestones in this divide. First, dentistry schools completely separated from medical schools. The second occured in 1965 when Medicare was begin created. The ADA [American Dentistry Association] lobbied to be excluded from Medicare. Dentists did not want to be involved with insurance." Lanky Luke whispered, "Dentists are looking pretty smug now that they are still in private practice without having to negotiate with government insurance." The internet at our school is quite slow as we attempt to play several linked videos in the slide. Gigolo Giorgio joked: "This must be the result of Net Neutrality being overturned. ISPs must be slowing our bandwidth because they think we are watching porn with all our anatomy searches."

Wednesday was led by the "Dane", a Danish-trained dentist and researcher. She was supposed to teach us oropharyngeal cancers but we never made it past the title slide as she answered questions. One student asked how is dental care different in Denmark than the United States. "Every child has free dental care. As an adult you pay for it, but it is much cheaper and we do not have such income inequality as you do. Only people with cavities are the immigrants. Our statistics are lower because of them." She continued, "It is truly amazing the income disparity in the United States. And mark my words. This is only made worse by this horrible tax plan that will just make the wealthy wealthier. And this idiot president."

[Editor: Denmark is not a paradise for everyone. An American child support plaintiff who collects $200,000 per year tax-free would be capped out at $8,000 per year per child in Denmark (see http://www.realworlddivorce.com/International ). The American who lives rent-free in means-tested public housing in an expensive neighborhood of Manhattan, San Francisco, or Cambridge would in Denmark wait many years for public housing in a dreary suburb.]

Lanky Luke: "If she thinks so little of our country, why doesn't she go back to Denmark?" Gigolo Giorgio to the GroupMe: "Will they post the title slide?" Lanky Luke: "If not, I will report this infraction to the LCME." Both got over 10 likes.

On Thursday we go over to the clinic to interview five patients with oral pathology. I started with a 70-year-old patient treated for squamous cell carcinoma of the oral cavity requiring surgical removal of most of his hard palate. He had a surgical obturator filling the space. He removed the obturator revealing a 3 cm diameter hole in the top of his mouth. Looking up into his mouth, we could see his maxillary sinus and nasal cavity, specifically the inferior turbinate! Gigolo Giorgio gasped. "What does it feel like to touch that with you finger?" "The gentleman responded, "Oh, nothing abnormal, it can be a little sensitive." He described his routine for cleaning the obturator and cavity every evening: "Just like brushing your teeth!" A dentist explained the anatomy of the teeth. "If a dentist is asking you to replace amalgam filling with a fancy composite, they are just trying to steal your money. It frustrates me so much. Amalgam works just as well and lasts a lot longer. Composite will need to be replaced within 10 years. These dentists figure, they can get more money by fixing that in a decade. Amalgam will last a lifetime." (This was in contrast to another patient we interviewed who had only a small indentation in his tongue remaining after recovering from a squamous cell carcinoma tumor that had spread all over his throat and oral cavity.)

At lunch, students debated if welfare benefits should include dental care when many Americans not on welfare cannot afford dental care. Students all agreed that dental health is an important part of people's overall health. Nervous Nancy: "This is clearly a good investment. Inexpensive procedures like cleanings prevent the more costly deterioration of health." We googled the dental care benefits for welfare and students were surprised to learn that states are required to provide dental care to children on Medicaid. Lanky Luke: "I do not see how our system is much different than Denmark's. Children are guaranteed dental care if they cannot afford it, if they are on Medicaid." Straight-Shooter Sally expressed concern for the working poor, potentially ineligible for Medicaid. Luke responded, "I wonder if the increased demand for dentistry from welfare participants might price out some of the working poor."

Mischievous Mary changed the subject: "Guys, I need your help. I am applying for a grant tailored to women in science. The essay asks: How do I promote other women in science? Any ideas?" Lanky Luke: "Tell them you empower students and patients to feel comfortable in their chosen identify." (Our Office of Student Affairs keeps us advised weekly regarding scholarships targeted to specific subgroups of Americans. This week's email mentioned the BuckFire Law Firm's Diversity & Disability Scholarships. A requirement is "a disability diagnosis from any person qualified to make a diagnosis," so perhaps medical students could diagnose each other?)

Our patient case: Harold, a 35-year-old grocery clerk with a history of alcoholism and tobacco use presents for worsening ear pain over the past two months. He reports a decrease in appetite, and denies fever. On physical exam, the external ear canal is not inflamed and the tympanic membranes are transparent. He has hard lymph nodes palpated on both sides of his neck. Erythroplakia (a nonscrapable white plaque with blood vessels) is noted on the posterior lateral border of the tongue. Smoking and alcohol use account for 80 percent of oral cancers and therefore squamous cell carcinoma is high on the differential. A biopsy reveals an invasive squamous cell carcinoma. He is referred to a oncology who initiates radiation therapy.

Harold described how he had to quit radiation therapy after 12 rounds. His ENT explained that Harold's gold fillings caused the radiation to unexpectedly scatter and deliver higher does to his oral mucosa and salivary glands." Harold: "I could barely drink, let alone eat, because it hurt so much. My mouth was so dry my tongue would get stuck to the top mouth, and I would have to take several painful sips of water to pry it down."

Two years after the radiation therapy, Harold presents for a sense of "fullness" in the back of his throat. Harold's cancer had returned. His ENT explained recurrence is not uncommon for oral cancer. "Field Effect" is the theory that a carcinogen, for example, smoking can cause mutations in a large area of tissue, but on different time tables. This time the cancer was far more advanced, spreading to his mandible.

Harold underwent a partial mandibular resection (jaw removal) with a fibular transplant and chemotherapy. A section of his mandible, from midline to the temporomandibular joint is removed, and replaced by a section of his fibula (a small bone in the lower leg not needed to support the body). "We preserved his temporomandibular joint so he still has some range of motion." Mischievous Mary: "Oh my god! I would never have known. We can do that?"

Harold has lost most of his teeth due to periodontal disease and removal of unhealthy teeth prior to radiation therapy. As he described: "More teeth, more problems." He eats mostly soft foods such as yogurt, fish, and smoothies.

At lunch students complete the 30-minute Y2Q medical school questionnaire conducted by the AAMC. Examples:

 

After classes end at 4:00 pm on Friday, we drive 3.5 hours through a snowstorm to a ski resort for the second annual ski weekend (Jane and I did not go last year). 32 students, 28 classmates and 4 significant others, cram into a four-bedroom ski lodge located in a prime location that is walking (shuffling?) distance from entering a Black Diamond slope. Jane and I drive up with Nervous Nancy, soon to be celebrating her 29th birthday. "I feel like everyone from my former life is getting older and moving on with their lives. My best friend bought a house. My other friend is pregnant. When I went back to school, I got younger." The car that booked the AirBNB had to drive down the other side of the mountain to pick up the rental keys. The rest of us sat in our heated cars for 1.5 hours drinking beer and wine until the keys arrived at 10:00 pm.

Once in the house, our class switched from drinking to drinking games, beginning with Kings. Tailgate Todd, a Clemson graduate with charming southern hospitality, suggests the game  Fishbowl. Every Fishbowl participant writes down two or three words on small pieces of paper. We then divided into two teams, male versus female. One participant from each team tries to act out the words while the remaining team attempts to guess correctly as many words in one minute. The women destroyed us. We settled the score by beating them at Flip Cup, four rounds to one.

Persevering Pete who has been a teetotaler, due to a history of alcoholism in his family, had his first alcoholic drink, a Tito's vodka cranberry with seltzer water. Around 1:00 am, students began to slumber off to bed for skiing tomorrow. The limited beds and bedroom floor space was settled according to who signed up and paid first. Jane and I were subjugated to the living room with Anita, her web-developer boyfriend and Nervous Nancy. Anita had brought a Queen size, self-inflating air mattress that took up most of the space. Nervous Nancy was relegated to the couch, while Jane and I inflated our twin air mattresses squeezed between the frigid sliding door and Anita's mattress. I did not sleep the entire night.

[Editor: I wonder if alcohol consumption and lack of sleep may explain why the U.S. healthcare system is in trouble.]

At 5:00 am, Stoner Suzy, a wealthy daughter from Southern California, and her (unbeknownst-to-me) boyfriend Gigolo Giorgio were moving around the house. Tonight she was experiencing chest pain, difficulty breathing, and peripheral angioedema (leaky blood vessels causing swelling). Her feet were swollen to the point that she couldn't put on shoes and her fingers were swollen enough to cause pain around a ring. A few students performed rapid exams, and the general consensus was a combination of anxiety and dehydration. Suzy was concerned that it was a heart attack. Giorgio wanted to take her to the hospital, at least a 30-minute drive in terrible conditions.

After waking up the owners of three cars that were blocking Giorgio's Subaru, he determined that it wasn't safe to drive down the steep driveway, slick with new snow and ice accumulation. They called an ambulance, which arrived in 20 minutes. Five paramedics came into the trashed house with mattresses strewn across the living room. They drove off around 7:00 am, as the remaining students were waking up for a day on the slopes. Due to lack of coverage, we didn't get any updates on Suzy's condition until the much-improved couple returned at 4:00 pm. Suzy's EKG was normal, which ruled out a myocardial infarction (heart attack). She was given IV fluids and worked up for a PE with a chest CT (negative as well). She had been upgraded from her usual dose of marijuana to fentanyl and discharged. (Tom Petty, Prince, Shiloh actor Blake Heron, and rapper Lil Peep all died from fentanyl overdoses.)

Jane and I return early from the bunny slopes and drink mimosas with the 10 non-skiers. Around 2:00 pm, a large group of students return from the slopes including Persevering Pete, Nervous Nancy, Tailgate Todd, and Steve. Following his pioneering sampling of alcohol the night before, this was Pete's first time on skis. By choosing a classmate as an instructor, Pete found himself on a black diamond slope with the experts. Thirty seconds later he was in a ditch. "We couldn't even see him there was so much snow thrown into the air," recalled Nancy. "We thought he was going to have to be carried off." After 60 seconds, Pete slowly rose, perhaps saved by the rented helmet, and walked the remaining half mile. "I lost vision for a few seconds, but I remember the whole experience." Pete decided to forgo drinking that evening.

 

Statistics for the week… Study: 8 hours. Sleep: 4 hours/night; Fun: 2 nights. We are all zombies.

Year 2, Week 23

Neurology week is shortened by two days of snow cancellations (the hospital and rotations for M3 and M4 students are on a normal schedule).

A 45-year-old neurologist with a British accent lectures on neuromuscular disorders such as Parkinson's disease, Huntington's disease, Amyotrophic Lateral Sclerosis (Lou Gehrig's Disease), and Multiple Sclerosis. Gigolo Giorgio asked about why deep brain stimulation (DBS) works for certain conditions? Neurologist response: "All of DBS is voodoo. There is not real science behind it, but it works. We just do not know why."

He teaches us about tardive dyskinesia, a permanent movement disorder after exposure to antipsychotics. In a healthy person, dopamine from the substantia nigra (black pigmented neurons in the midbrain) acts to facilitate muscle movement via stimulation of the basal ganglia, a network of neurons located deep in the brain ("deep nuclei"). Antipsychotics block dopamine signaling, an attempt at reducing the symptoms of bipolar disorder and schizophrenia. This can have the same effect as damaging the substantia nigra, as happens in Parkinson's disease. "Tardive dyskinesia happens after long-term use of the drug. We believe it is the brain trying to rewire around the drug. There are lawyers filling courtrooms around the nation suing doctors and pharmaceutical companies for this. There are more lawyers focusing on it than neurologists!"

He concluded: "The history and physical exam are are a dying artform. Some conditions, such as Guillain-Barré, you see nothing on imaging. Surgical residents, if they even have a stethoscope, put the diaphragm on the "Surgeon's triangle" -- where they can hear the abdomen, heart and lungs in one place. I ask what they got out of it and they respond, 'Umm, they are alive.' The answer is in the patient. You should know what is wrong with 95 percent of patients after taking the history. If you leave the room without knowing, DO NOT order tests. Go back in and take a good history, then do a good physical, and then order those unnecessary $5,000 imaging studies.

A 55-year-old neurologist reads through slides on seizure disorders. Several students doze off or check social media. She went five minutes over the 10:50 am official end time. The next lecturer, a 75-year-old neurologist, had snuck into the room five minutes early for the 11:00 am block and blurted out, "Are you done? I'll just do this another day." She then storms out. We have found a reason to have a PhD block facilitator in our lectures. She ran out of the third floor classroom and managed to corral the senior citizen on the first floor.

Despite a late start time due to the chase scene, the older neurologist did not disappoint. She lectured on myelopathies (disorders of the spinal cord). She ignored her uploaded powerpoint and used the chalkboard. We started with basic anatomy of the spinal cord and its blood supply. She asked, "Does anyone surf?" Buff Brad raises his hand. "How do you surf?" He slowly responds, "I wade out on my stomach, then pop up." She responds: "You are clearly a novice. First time surfers lay on their stomach and extend their back as they surf out to catch the next wave. This prolonged hyperextension of the spine causes compression of the anterior spinal artery in what is termed Surfer's myelopathy, potentially causing permanent paralysis." The class laughs. [Correct technique is a yoga-style pose on one's knees.] She concludes: "My husband died, so I have no one to not listen to me except medical students. It is such a pleasant surprise you are all listening to me." In the Age of Universal Offense, students were divided over her lecture. Everyone agreed they learned a great deal, but some were turned off by her sense of humor.

Wednesday morning, our chief of neurosurgery, a man in his 50s (see Year 1, Week 15), lectures for two hours on traumatic brain injury (TBI). The IT staff as usual comes in before the lecture to to ensure that the required-by-regulation PowerPoint slides were ready and that the video is recording. The Chief: "I don’t think I will be using it at all. PowerPoint is a way to present material you do not know." He made chalk drawings on the blackboard.

Any patient presenting for TBI will be scored using the Glasgow Coma Scale (GCS), which evaluates the patient's eye, verbal and motor responses to stimulus. "Glascow Coma Scale is like the SAT. You get a score for just showing up. Glascow Coma Scale starts at 3. Don’t say 2 to an attending. You'll sound like an idiot." Pinterest Penelope wrote this advice down. The Chief: "What are you doing? Pens down and listen." [Editor: Research shows that students who take notes learn more, even if they later discard those notes. See "The Pen Is Mightier Than the Keyboard: Advantages of Longhand Over Laptop Note Taking" (Mueller and Oppenheimer 2014, Psychological Science) and its references.]

Gigolo Giorgio was startled by the Kernohan's notch phenomenon. Kernohan's notch phenomenon typically occurs due to a hematoma (extravascular blood in the brain) causing the uncus, an inferior lobe of the brain, to herniate through the connective tissue floor of the brain into the brainstem canal. Nerves exiting the brainstem, namely CN III that innervates muscles of the eye, are compressed and lose function. "If the pupil is dilated on the left side, I go in on the left side, right?" However, occasionally the uncus can push the midbrain to constrict the contralateral CN III instead of the ipsilateral CN III. "I can operate on the wrong side of the brain because of this false localizing sign," he continued. "This was not unheard of before we had stat CTs commonplace in hospitals."

The Chief: "Medicine is a language. Isn't medical school so easy compared to crazy particle physics you did in undergrad. If you approach it just like a language it is not that difficult. Medicine is learning to convey complex data in succinct phrases. If a resident calls me and says there is 4mm midline shift after trauma I am going to run out of bed. If a resident says there is a 1mm midline shift with a small hematoma, I am going to say, 'Yep that's a old alcoholic brain that is compensating for a subdural swell. We can deal with it tomorrow.' I just downloaded a lot of information quickly. Practice presenting patients, that is what we will be evaluating you on in rotations."

Straight-Shooter Sally: "I don't think I learned much for Step 1 [the exam we're taking this summer]. He did not get past his 2nd PowerPoint slide, but who cares."

[The neurosurgeon's life was also educational for us. His wife loyally managed the home front, including two kids, through a 7-year residency. As soon as the surgeon began earning a surgeon's wage, she went down to the courthouse and shed the husband while keeping the kids and his income.]


Our patient case: Jimmy, a 69-year-old recently retired internist, was celebrating his 50th wedding anniversary with a trip to Scotland. "We were traveling with a group tour. I started to feel terrible. I was vomiting and felt weak. I was getting on the next train when I fainted. I initially attributed it to dehydration." He continued, "When we were walking on the cobblestone paths in one of the beautiful small towns, I started to see double. I did not know which of the two people in front of me was real. As physicians we know double vision under the context of systemic symptoms is a serious concern, but denial is powerful. Because I did not want to ruin our wedding anniversary, I tried to hide the symptoms from my wife. We had been waiting so long for this trip and my retirement."

His wife interjected, "I made us fly home early. He just looked weak. He was barely eating." Once back, their son, also an internist, realized something was amiss, and interrogated Jimmy. GI symptoms are rare for Lyme disease, but the presence of diplopia, malaise, and hiking in endemic areas prior to the overseas trip caused the son to immediately suspect disseminated Lyme disease. The family took him to the ED.

Lyme disease is a tick borne illness caused by the Borrelia burgdorferi that is easily treated with antibiotics. Lyme disease is divided into three phases: early localized, early disseminated, and late disseminated. Jimmy never had the classic early localized symptoms of the  "bull's-eye" rash (erythema migrans), present in 80 percent of patients. Early disseminated Lyme disease occurs weeks to months after the initial tick bite. Jimmy's double vision was caused by inflammation of peripheral nerves (peripheral neuropathy). He was also diagnosed with myocarditis (heart muscle inflammation) and atrioventricular ("AV") heart block, under-diagnosed complications of early disseminated Lyme disease.

Jimmy arrived at the ED and was worked up for Lyme disease only due to the persistence of the internist son. "They were trying to work him up for a MI [myocardial infarction] and PE [pulmonary embolism]. I kept saying, 'no, no get Lyme serology'." Once the test came back positive, he was started on doxycycline (antibiotic). His EKG showed mild AV block, and he was placed on cardiac monitoring. Over the course of five days, his symptoms improved remarkably, and he was discharged on day seven."

Gigolo Giorgio: "Why is there not a Lyme vaccine?" The internist son: "There was a Lyme vaccine. [FDA approved in 1998] GSK withdrew it after the early 2000s vogue for class action lawsuits against vaccine manufacturers. There is a new product in development using injected antibodies against burgdorferi bacterium that would protect for one season and then wear off. Has anyone gotten IVIGs [intravenous immunoglobulins] before traveling? They hurt! Great business model though. Europe is further in testing the vaccine now even though the US had it first." Another physician in the audience jumped in: "All my horses and dogs have the vaccine!"

[Editor: Mindy the Crippler, our Golden Retriever, got Lyme vaccines in 2014, 2015, and 2016. In 2017, less than a year after the most recent shot, she got... Lyme disease. This is in the tick-plagued hell of the western Boston suburbs ("woodsy").]


During lunch, we split into small groups in small groups to talk with M4s about Step 1 and the match process. My group was led by two women who are both applying to Ob/Gyn. Step 1 exam is an 8-hour exam with seven 1-hour, 40-question blocks and a 1 hour optional break split between each block. It costs $610 to register for the exam. "Do not study First Aid or any textbook," said the Florida native "Just do questions on UWorld, and go over each answer." She explained that she cried in the middle of Step I. "I had to call our school counselor for support."  The Bostonian, engaged to a recent graduate of the school visiting for support, described her Step 1 experience: "I had to get my fiancé to hold me [fortunately, he's one year ahead of her in his medical training]. I threw up the breakfast he made me. Fortunately, he packed me sandwiches and granola bars so I did not take the exam on an empty stomach."

After the M4s left, we stayed to consume the catered sandwiches and chat. Anita led the discussion: "Now no one can deny that our president is a racist pig." [Donald Trump had recently characterized Haiti as a "Shithole"] Anita explained that she preferred immigrants from unsuccessful countries: "We want immigrants who understand hardship. They will be grateful, educate us, and create jobs." Why not a merit-based system? Anita did not want immigrants taking the high-paying jobs. [Editor: like hers!]

Jane and I attend a late afternoon reception for applicants to our medical school who have come for final interviews. Most were fresh out of college and wanted to know about research opportunities at our school as well as nightlife (they don't seem to have an accurate estimate of how much time they'll have for partying). Some of the male applicants asked about the dating scene. The female applicants gathered around Southern Steve. We'd spread the (completely false) word that he had invented a successful medical device in between college and medical school and the women wanted to know more about him.Thursday night means Burgers and Beers. Tonight we celebrate Sarcastic Samantha graduating PA school and finishing her Board exam. She will not get her results for two weeks, but is already excited about starting work: "I am 27, and have never had a real job!" U.S. labor force participation will not be growing, however, because my college friend who works as a project manager at Amazon exiting to "travel and reflect," as soon as his stock options vest in March. "I do not respect or want to become any of my bosses," he explained, adding that eventually he wants to work in the nonprofit sphere.

[Editor: Nobody gave him the standard briefing "If you have a job without aggravations, you don't have a job." Even sadder, apparently nobody told him about SSDI!]

Samantha plans to search for puppies if she passes her exam. "It takes several months to get all the licences and paperwork processed to begin to practice." Luke wants to stick with their beloved cat. "I do not want a dog. Samantha wants a dog. So… we compromised and we're getting a dog."

[Editor: They're using the same "one-woman, one-vote" system that we have in our house!]

 

I ask Samantha and Luke, "When are you going to have kids?" My plan is to have kids after Luke gets into residency and I have a job there. I do not want to be moving and searching for a new job in a foreign city while pregnant." Luke: "I don't want kids soon. Samantha wants kids soon. So… we've compromised and will have kids soon."

Friday's 2.5-hour weekly ethics seminar is taught by the 55-year-old director of our Masters in Public Health program. The topic is "Social Determinants of Health." We had been assigned the first 30 minutes of the seven-part PBS documentary series Unnatural Causes: Is Inequality Making Us Sick? (2003). "Power, typically framed in political terms, is the ability to control an individual's destiny," she opens. "Power is used in public health as a goal because this is destroyed in a lot of communities and groups."

[Editor: The government spends $trillions on Medicaid and then spends $millions funding a documentary about how Medicaid doesn't work?]

MPH director: What did you take away from the video?

Orthopod Oliver: More money, less problems.

Pinterest Penelope: I was shocked by the discrepancy. CEO has 10 years longer to live than workers.

Straight-Shooter Sally: I was surprised that the discrepancy is not just low versus high income. Middle class is also on the scale.

MPH lecturer: "The video cited the famous Whitehall study of british civil servants in 1967 and 1985. People theorized that the CEO would die prematurely due to a heart attack from stress. What we found was the idea of a social gradient of health." The low-level workers were the ones to drop dead first. [Editor: Another great argument for collecting welfare rather than meekly taking one's place at the bottom of the bureaucratic pyramid!]

She emphasized that the term health disparity is out of fashion. "Health disparities is about what communities do not have. There is a certain victim-blaming mentality in this terminology. We now use the term health equity because everyone deserves the right to health. Health inequalities must be addressed to achieve health equity."

Donald Trump's proposed border wall might be the biggest public health improvement since the USDA stopped promoting carbohydrates via its food pyramid, according to our lecturer: "In public health there is something called the Latino paradox. As people settle in LA from Mexico and South America, they acclimate to US culture. We know their health declines. They no longer have the support system of, say, their small Guatemalan town. We think our lifestyle and communities are great, but in a lot of ways it is not. Our kids eat fast food, don’t exercise, don’t have strong community and family ties. They come from a good diet, strong ties, little screen time, etc. Their health declines as they try to live the American dream."

     

Empowered by Oprah's speech at the Golden Globes, Anita changed her cover photo to a Lord of the Rings frame reading "The Age of Men is Over." Her next post:

 

In response to the escalation of hateful incidents since the 2016 national election, the National Abortion and Reproductive Rights Action League is pleased to offer a Bystander Intervention Training. Join us to learn how to step up and be supportive when fellow community members are facing harassment and hate speech. This training will provide a grounding in the principles of nonviolence and de-escalation, followed by interactive scenarios where we practice our new skills. …

Statistics for the week… Study: 12 hours. Sleep: 8 hours/night; Fun: 1 night. Example fun: Winter formal begins at 8:00 pm, but our class, dressed in tuxedos and ballroom gowns, gets delayed at a pregame. While most play beer pong, Jane, Buff Brad, his girlfriend, and I play couples pool at the bachelor pad apartment. Faculty begin leaving when we arrive around when "Get Low" comes on. I never understand why they play hip hop music at this formal. Faculty might enjoy themselves more if they could partake in the dancing. No one threw up to my knowledge but several people fell down dancing and taking selfies in front of the photo backdrop.

Year 2, Week 24

Genetics week is taught by a 53-year-old pediatrician specializing in complex genetic diseases. Jane described her as "brilliant, but slightly awkward." She began: "You all know when you walk by someone, say at the grocery store, who just doesn’t look normal. We are going to develop a systematic exam and language to explain these features." We scrolled through slides of patients with various syndromes. "We'll start with severe dysmorphic characteristics, and then use the same analysis on less severe phenotypes." We look at kids with low set ears, flat nasal bridge, presence of epicanthal folds (skin flap covering lacrimal duct in lower nasal corner of the eye), smooth philtrum, and a high interpupillary distance. The geneticist: "You would be surprised how many terminologies in genetics have had to be changed over the years because they are no longer politically correct. We've changed simian crease to single palmar crease. We no longer use the term Mongoloid to describe upward-sloping eyes." (Most people have two palmar creases.)

After the 12 PowerPoint images, we play "Is it Normal?" in groups of six. Each group rotates through 15 stations, where we analyze an image and decide if it is normal or abnormal. The geneticist explained this is the same game they play at conferences: "Whenever we go to the annual genetic disease conference, the main lecture is preceded by a game where each geneticist in the audience tries to beat the computer in identifying genetic diseases from pictures. The computer gets better and better each year. Humans still win though." Straight-Shooter Sally: "I cannot wait until we have this technology in the office. I won't have to memorize this stuff."

[Editor: the Google AlphaGo team trained a computer to screen medical images. See "Development and Validation of a Deep Learning Algorithm for Detection of Diabetic Retinopathy in Retinal Fundus Photographs" (Gulshan, et al. 2016; JAMA). Maybe they will start selling ads for medical school loan refinancing next to the results?]

She concluded by explaining linkage analysis studies using VNTRs (variable number of tandem repeats). These regions exist on each chromosome and are passed through generations. "VNTRs provide a genetic fingerprint of each individual. I practiced in the age of patents on inheritance tests for specific genes. A family I worked with had autosomal dominant polycystic kidney disease (AD PCKD). The father needed a kidney, and his daughter wanted to donate. We needed to ensure the daughter did not have AD PCKD, but a patent troll had purchased the polycystin gene patent and raised the price to $10,000. Instead of paying the troll, we determined that she did not have the disease using an older technology linkage analysis of the family. We found a VNTR associated with the polycystin gene of the deceased father. We were able to clear the daughter based on her lack of this VNTR."

Gigolo Giorgio: "How do people think of this stuff?! Not many people can do what she does. She has a special skill." Lanky Luke: "I want each of my future children to go see her for a check-up. Make sure there is nothing wrong with them."

After lecture, we debate ethics cases in groups of 10 while a licensed genetic counselor and pediatrician rotate. For each case, we divided into 2 subgroups of 5 to take each side of the debate. Frustratingly, we never learned an authoritative resolution of any of these issue. [Editor: perhaps it varies by state?]

Case 1: Huntington's disease testing for a minor.  A mother wishes to test her 8-year-old child whose father died from Huntington's disease. Anticipation is a phenomenon in certain genetic diseases where the onset and severity of the disease increases as the disease is passed down through generations. For example, a grandfather may get Huntington's at age 45, the mother at age 40, and child at age 30. Straight-Shooter Sally: "The mother is violating the future autonomy of the child. We should wait until he is 18." The pediatrician added: "We also need to consider if this test is indicated. Would the answer change treatment?" Jane: "Does the mother have a right to know if her child has the disease? Perhaps she could get the test, and withhold the results from her child until he is ready to make a decision."

Case 2: Adoption of a child at risk for Fragile X syndrome, an inherited disease characterized by moderate mental retardation and dysmorphic features. Rebecca, a 14-year-old with Fragile X syndrome, is raped and becomes pregnant. The rapist is imprisoned. The family places the child on the adoption list, but declines amniocentesis testing for the child. The family requests you, the physician, withhold the 50 percent risk of the child having Fragile X syndrome from the adoption agency to improve chances the child gets placed into a "good" family.  Should the patient be required to get tested via an amniocentesis? Do you inform the adoption agency or withhold the information even if requested? Pinterest Penelope: "I don't think you can force a mother to get a test she does not want. Amniocentesis is not without complications." Straight-Shooter Sally: "I understand that, but an adoption agency should have the right to decline to list the child then." Lanky Luke: "It would violate the trust in the adoption system. Fewer families would be willing to adopt a child if they risk not knowing the health of the baby." Jane: "There are families that are actually seeking to adopt special needs children." Lanky Luke: "These are interesting dilemmas, but I do not believe it is doctor's role to decide what, from their perspective, is the right course of action. We should have started by studying the laws."

[Editor: The same-sex couple that ministers to the spiritual needs of the Millionaires for Obama in our Boston suburb has two special needs children, neither of whom has any genetic connection to either father. A handful of deeply closeted Deplorables in our town occasionally grumble about the cost to the school system of providing for these voluntarily adopted children of the pastor and his husband.]

Case 3: A pregnant alcoholic heroin user refuses to enter rehab and stop abusing these teratogenic compounds (those that can disturb the development of the embryo or fetus). My EM facilitator commented, "This happens much more than you can imagine." Can you force her to receive addiction treatment or counseling? Jane: "This is child abuse." Lanky Luke: "Is this not a double standard? If you assume the fetus has a right to not be harmed by teratogens, would not this argue against abortion after some age?" We discussed Wisconsin's 1997 Unborn Child Protection Act, whose constitutionality was still being argued 20 years later (see "Supreme Court allows Wisconsin to enforce ‘Unborn Child’ law" (Wisconsin Gazette, August 11, 2017). Type-A Anita became passionate on the subject of preserving abortion rights: "You need to educate the mother. I wouldn't consider [daily heroin consumption] child abuse." (The mom is unaware that heroin and alcohol are bad for kids?)

Breaking from the genetics theme, on Thursday we had three hours of lecture on back pain. A soft-spoken orthopedist with a Southern accent explained, "Doctors hate dealing with back pain. Ironically is is also the number one cause of office visits and 4 out of 5 malpractice lawsuits are related to back pain." His example of a typical case: "I fell while working at Walmart, and I want to sue Walmart for hurting my back. I want to get opioids and a check every month."

He continued: "Real back pain is debilitating though. Always ask the patient to show you where the pain is. A lot of people say back pain, but the issue is in the SI (sacroiliac) joint, the hip, or the kidney." How to tell the difference between real and malingering? Start with Waddell's sign: push on spine and ask to rotate hips. "My favorite is to ask patients who come in limping to limp backwards. No one ever practices limping backwards." He added, "Be cautious though. They will immediately know that you know they are FOS ["full of sh*t"]. Makes rest of the visit a little awkward. My advice is to refer any back pain patient to orthopedics. We are trained to handle the real ones, and the FOS ones. I always ask how patients make the pain less. Most people with real back pain have found a way to lessen the symptoms. The exception is a herniated disk. Someone with a herniated disk has trouble finding comfort anywhere."

"We're the Microwave generation," said our 45-year-old orthopedist. "Patients with a chronic condition expect immediate relief from one office visit. Our main cure is time, however. 8 out of 10 patients with back pain will be better in 3 months with none to limited therapy; 9 out of 10 people will be better in 6 months. It is tough to ask someone to be in this excruciating pain for three months though."

That afternoon, a geriatrician gave a lecture on dementia and then we broke into small groups to practice mental status exams, including the MoCA (Montreal Cognitive Assessment), recently taken by President Trump. Anita projected a picture of Rear Adm. Ronny Jackson, the physician who "stamped" Trump's exam. Anita: "There is no need to worry guys, our Commander in Chief is smart." The Hillary-supporting students proceeded to trash Dr. Jackson's credentials. Straight-Shooter Sally: "I am shocked that Trump scored 30/30." A handful within our group matched the President's score, but most of us lost 2-3 points on short term memory. Type-A Anita, looking at her near-the-bottom score, concluded: "Trump lied. Doesn't it amaze you how he can lie so easily and so much?"

Our patient case: Connor, a 6'4" 59-year-old CPA presents on his wife's urging for forgetfulness. Family history reveals his grandfather and father had dementia in his 60s. (Lifetime risk of developing Alzheimer's is 10 percent, but the risk is 25 percent when a first-degree relative has Alzheimer's and the correlation is stronger for early-onset dementia.) Connor: "My wife and I grew up together as neighborhood friends from kindergarten and started dating in high school. She saw my family deal with my father's dementia. He would walk out of our house and get lost for hours until the police picked him up. He got very aggressive in his 70s before he died." (Connor was speaking to us three years after his diagnosis, but he remained intelligent and articulate.)

Martha, who had been a stay-at-home wife, took over: "I started noticing things years before he was diagnosed. He would come home later and later from work. Things would take him longer. He was having to stay much later every day to finish the same amount of work, until 8:00 or 9:00 pm in the office. He lost his sense of time." Connor was diagnosed with early-onset Alzheimer's in 2014 and retired from his accounting job.

Martha: "One conflict was about our taxes. I know nothing about finances. He was adamant about continuing to do them. This became a crisis in 2016. He kept saying he would be able to do the taxes. The deadline was approaching and he still had barely started it." Connor was ashamed about having to file an extension and asking for help from a CPA friend: "I just couldn't get all the papers together."

Students asked Martha how her typical day had changed. "We talk about something, and ten minutes later he forgets. It can be infuriating. He'll forget where we are driving to; he'll forget to pick something at the store that I told him ten times. I try to be more patient. I pray every day for the strength to be patient."

What other changes had she noticed? "He has some balance issues. He used to love playing basketball with our grandchildren. He fell one time and has had to stop. He has the same preferences. He likes the same food." Ambitious Al asked about intimacy. Martha: "He looks the same, but I know he has become a different person. We do not sleep together. I have not slept with other people, but I have considered it." Connor was visible uncomfortable.

Mischievous Mary asked the geriatrician: "What are the guidelines to getting genetic testing for Alzheimer's?" "As of now, the guidelines do not support testing patients, early or late despite the genetic risks. This may change as the costs come down, but until there is some prevention therapy, the test will not change management of the disease."

Mischievous Mary: "Martha made the disease all about her. I wish we heard a little more from Connor." Pinterest Penelope: "That was 45 minutes of trashing poor Connor."

[Editor: Anyone who stays with an Alzheimer's-afflicted spouse in our age of no-fault, no-shame divorce, should be celebrated for heroism, not criticized for speaking frankly. Martha could walk down to the local family court at any time and get a warm reception by saying "Connor is annoying me with his illness so I'd like to take 50 percent of the cash and pension and move to a beach condo in Florida."]

Straight-Shooter Sally: "This was the most powerful patient case." Jane: "It gave me chills."

 

Rather than drive one hour to her rural home, Jane's sister used her key to move into our house for stomach flu recovery. We diagnosed her with norovirus based on profuse diarrhea, fever, and chills. The sister's nursing colleague bought over IV kits and saline bags, and we used the skills we learned in Year 2, Week 13 to hook her up to a saline drip. Rather that welcoming this this opportunity to practice her skills at establishing IVs, Jane was concerned about catching the bug.

Jane and her Health Professions Scholarship Program (HPSP) military comrades did not get paychecks on time due to a one-day government shutdown. "I only learned because the HPSP Facebook group is blowing up. People are yelling at each other about whom to blame -- Trump or the democrats."

 

Statistics for the week… Study: 14 hours. Sleep: 6 hours/night; Fun: 2 nights. Example fun: MedProm. Nervous Nancy hosted a pregame before the short walk over to the conference center ballroom. The rumors of Persevering Pete dating an M1 are true and his M3 ex departed shortly after the new couple arrived. Faculty exited en masse as students stormed the dancefloor to Justin Timberlake's Filthy.

Year 2, Week 25

Musculoskeletal week features 14 hours of lecture.

Monday morning, A nerdy early 40s orthopedic trauma surgeon discusses osteomyelitis (bone infections) and infectious arthritis (joint infections). An infected bone or joint requires surgical debridement to remove the infected tissue. "Antibiotics cannot penetrate this avascular infection. Ubi pus, ibi evacua. The age-old mantra. One of the most satisfying things is taking pus out. You go in and leave it better than they arrived, period." Students' favorite part of his lecture: "A classic case of chronic osteomyelitis is a WWII soldier who was shot. The bullet seeded bacteria that was walled off by his immune system from the healthy tissue. 45 years later in the soldier's old age with a depressed  immune system, the infection activates."

A lively 50-year-old pediatric orthopedist presents childhood muscle and bone disorders. Her practice involves improving gait and balance in movement disorders such as cerebral palsy. She does this by using braces, botox injection into certain muscle groups, and tendon release/transfer.

Cerebral palsy, present in about 2 per every 1000 live births, is a "non-progressive movement disorder caused by ischemia to the developing brain, typically in utero but also in early childhood. Example ischemic events include a cord wrapped around neck of baby in utero, stroke or a near drowning event. "When parents hear CP, they immediately picture a wheelchair bound, drooling, not functional child. If the anoxic event covers the entire motor cortex, then yes. But, more often CP deals with specific muscle groups. Some just have an issue with a few toes. CP is a spectrum." She explained how cerebral palsy a common malpractice suit. "If your baby has cerebral palsy, call us to sue your Ob/Gyn. It is not always the obstetrician's fault. 70 percent of events are thought to be prenatal." 50 percent of CP cases have a history of prematurity. "Interesting the advances in prenatal care have not improved the incidence of CP."

[John Edwards, the 2004 Democratic VP nominee, had a pre-Senate career as a plaintiffs' lawyer suing physicians in cerebral palsy cases, At trial he would channel the words of the unborn child for the jury's benefit. Expert witnesses hired by insurance companies defending these lawsuits would explain that there was no scientific basis for holding the obstetrician responsible, but the juries would often award millions in damages. Attempts to set up funds to compensate all cerebral palsy victims, not just the ones who sue, have been fought by trial lawyers. Edwards was a candidate for the 2008 Presidential election, but his campaign was impaired when a former campaign worker gave birth to his child and funds needed to be diverted to keep the new mother quiet. (She could have sued for child support in North Carolina, but the revenue obtainable through conventional family law is limited compared to in California or Massachusetts.) Edwards was criminally prosecuted by the U.S. Department of Justice for this diversion of funds to Rielle Hunter, but a month-long trial resulted in a mistrial on most counts.]

Our orthopedist lecturer showed a before-and-after video of her 10-year-old patient with cerebral palsy. The child initially had limited mobility, walking on his toes with a scissors gait. "Everything was tight. I was giving regular Botox injections, but those were having diminishing effects. I performed an adductor tendon release and transfer." After the surgical intervention and physical therapy, the class could not discern any gait abnormality. "This child will not be able to compete in sports, but he'll live a relatively normal life. Remember that cerebral palsy does not spread; we call it a static encephalopathy." Several classmates were astonished about the tendon transfer surgery. Jane: "We can do that?"

She concluded with some career advice: "Do not assume children with physical impairments have mental impairments. Just because their body is failing them does not mean their mind is failing them too. And when you choose a specialty, think whether you are improving the quality of your patient's life, or just prolonging their suffering."

Our third lecturer: a surgeon specializing in nerve reconstruction presents on upper extremity nerve injuries. Type-A Anita, an aspiring Ob/Gyn, exclaimed in horror about nerve injuries during delivery: "That happens? We are barbaric!" Erb's and Klumpke's palsies occur if the infant's head is placed in extension or if the infant's arm is placed into abduction (away from body), respectively. "If the kid regains elbow flexion in three months, there is a good prognosis that he or she will fully recover." The surgeon explained that it is possible to do nerve transfers. "We can get back elbow flexion and shoulder range of motion. Animation of the hand and wrist are still extremely difficult."

Gigolo Giorgio ask about the potential role for nerve scaffolds in the future. "It is here! We use it today, keratin scaffolds, pig submucosal, cadaver scaffolds. And some people are starting to use nanotechnology to implant growth factors and such. That's above me, I'm just the mechanic!"

Two sports medicine physicians held workshops on common musculoskeletal injuries using X-rays, CTs and MRIs. "Knee dislocations used to be caused only by severe trauma such as a football injury or car accident. We now are seeing low-velocity knee dislocations. An obese individual will step off a curb, and the momentum of the body on a fixed tibia will posteriorly dislocate the knee. Really no good surgical repairs for that so far."

After lecture I attend the weekly "quarterback" meeting where rotating students air concerns and complaints about the curriculum to the block director. Students complain that lecturers get off-topic following questions from unprepared students. Mischievous Mary and Geezer George cited infractions from students who did not know the anatomy of the brachial plexus (nerves innervating the upper extremity). "I do not go to lecture because of it. It is more effective for me to use that time studying in the library." George: "There is something wrong when some of the best-performing students do not go to lecture." Several students tried to show their maturity relative to others in the class. A student recommended that two or three lectures be highlighted each week that require preparation. Mischievous Mary and Geezer George lept on it saying "we are not kids, if you did not prepare just shut-up during lecture."

 

Wednesday morning, our sixth lecturer: a 50-year-old orthopedic surgeon lectures on bone diseases. Osteoporosis, and its precursor osteopenia, are diseases of disordered bone deposition resulting in decreased bone mass density [BMD]. "Your bone mass density peaks in your late 20s, and continues to decline thereafter. Moderate weight-bearing exercise is the most effective way of to raise your peak BMD, and to decrease the decline of BMD after your glory days. Moderately overweight individuals actually have stronger bones because they load their bones with more weight." (He may be taking his own advice here; Pinterest Penelope described him as "tubby.")

Why is osteoporosis bad? "The weak bone from osteoporosis is prone to fracture from normal weight-bearing activities and falls. People with osteoporosis can spontaneously fracture their vertebrae with no injury at all. Someone who falls on their butt or side should not get a fracture. One-year mortality after a hip fracture is 30 percent. This is not something you just put a screw in it and be done with. Yet, our medical system does not think about bone health. I see so many patients who have been on glucocorticoids on and off for asthma. [chronic steroid use causes osteoporosis.] They have terribly weak bones in their 50s. Frankly, there is nothing to do about it now."

 

Thursday morning the whole class turned out to hear the last orthopedist lecturer, Hot Shot, a spine surgeon known for being one of the most highly compensated surgeons at the university.

"When the spine is injured, it shuts down. This is called spinal shock. Reflexes will be absent, even if the connections are not broken. You cannot assess the spinal cord injury level until spinal shock is over [2-3 days]."

Hot Shot explained why he choose Ortho: "I never wanted to do a rectal exam again. Boy, was I wrong. As a junior resident -- that's the guy in ER -- my attending would tell me every single trauma case gets a rectal. If you do not do it on the patient, I will do a rectal exam on you." He explained that every trauma patient should have a bulbocavernosus reflex test to assess the spinal cord integrity. This reflex is elicited by applying pressure to the glan penis or clitoris (or tugging on a Foley catheter), and feeling for increased anal sphincter tone.

Gigolo Giorgio asked whether spinal shock could be shortened by steroids. "We do not know what causes spinal shock. Like most things in medicine, our understanding is observational." 

After lunch, two state health department epidemiologists lead a workshop on an example hepatitis C outbreak. The senior epidemiologist begins describing the case: "I got involved after two or three calls from EM physicians diagnosing acute hepatitis from a new hepatitis C infection." Hepatitis C is reportable disease in most state, meaning every physician must report the case to the health department. She scheduled a private meeting in a McDonald's parking lot with one patient, a 25-year-old male college student. "Fast food parking lots are a good meet-up location. People want to remain anonymous." (This is apparently an occupational hazard; the 55-year-old woman weighed at least 180 lbs.) The patient reluctantly explained that he visited a nearby college for an Ultimate Frisbee competition and "raging" party. Alcohol, cocaine, marijuana, IV drugs were all used. The patient explained, "There were a few tattoo artists hooking people up. I got a small one. I do not even remember it, I was so wasted."

The junior epidemiologist, a 40-year-old with pink and purple hair, interviewed two other patients, including a married graduate student who had sex with several partners at the party. This patient provided contact information for one of the tattoo artists. The tattoo artist was an herbal medicine enthusiast in her 40s who claimed to use a homemade needle-cleaning machine. After interviewing 10 people (providers and patients), the epidemiologists completed their case report, estimating that, between tattoos, sex, and IV drug use, 200 people were exposed to hepatitis C.

[If the Editor were qualified to work in a state health department, the report would read "People spent 85 percent of their time at the party having sex with strangers, getting tattoos while too drunk to remember, and injecting recreational drugs. They wasted the rest of their evening."]

We go to our small groups. Straight-Shooter Sally: "[The epidemiologists] seem so cynical." My facilitator, a 45-year-old EM physician who stopped practicing seven years ago after she gave birth to children, but is trying to study for her boards now: "Everyone who works in the ED becomes cynical. Part of it is your job training, you are supposed to see the worst in everyone to not miss anything. Part of it is just who you are dealing with. Some people just think different. No shame in taking advantage of the system. For example, I had a patient with a connective tissue disorder who would keep coming to the ED every few days. He would purposely dislocate his shoulder to get Dilaudid (hydromorphone). In residency we had this homeless couple who would come in once a week, matter of factly state they were contemplating suicide knowing they would have to be admitted. They would get 'two hots' [warm bed, warm meal]. The male was a registered sex-offender so he was not allowed to go to homeless shelters. Instead he was surrounded by children in the ED."

Straight-Shooter Sally gives a 20-minute presentation on tobacco cessation. She presents the findings of a "landmark study" ("A Randomized, Controlled Trial of Financial Incentives for Smoking Cessation", NEJM, 2009) in which people who could receive $750 over a one-year period were three times more likely to quit. All of us have seen COPD [chronic obstructive pulmonary disease] patients during our shadowing. They can barely walk, but they still smoke. Might they be more likely to quit if Medicare or Medicaid didn't pick up nearly all of the cost of their care? Type-A Anita shut the question down: "No, people would die."

I shadowed my family medicine physician mentor that afternoon. Regarding the first patient, a 54-year-old male with chronic hepatitis C infection, my attending says, "Ask him about his alcohol intake." I ask, "Sir, how much alcohol do you drink per week?" He responds, "A bit." "What do you mean by a bit?" Patient X: "Well it depends on the day. I have a few beers most days. If there is a football game on, at least a six pack. If there is a NASCAR race, then at least 12 beers." The attending came in, explaining"We cannot treat your Hep C until you quit drinking." Patient responds: "Doc, I cannot. NASCAR is coming up. I… I… I just can't. After NASCAR season we can talk."

Our patient case: Elizabeth, a 22-year-old female diagnosed with spinal muscle atrophy (SMA) at the age of 2, presents for excruciating hip pain and lower back pain not managed by her pain medications. She has had two spine surgeries for scoliosis and three hip surgeries to prevent hip subluxation (partial dislocation) that are common in SMA due to muscle deterioration.

SMA is a genetic disorder where a defect in the survival motor neuron 1 (SMN1) gene results in progressive loss of the anterior motor horn neurons in the spinal cord that innervate muscles.  These muscles begin to atrophy causing joint weakness, joint instability, and pain. Elizabeth's neurologist explained: "If you ever see these patients, your heart will break. They have full cognition, full sensation. Their minds are trapped in their bodies." (Don't go to North Dakota if your heart is easily broken; SMA prevalence there is 3-10X more common than in the rest of the U.S.)

Elizabeth: "I was quickly put in a wheelchair. I have a less severe form of SMA, but I still work hard on PT to maintain my function." Her 55-year-old mother added: "Elizabeth of course needs help going to the bathroom, putting clothes on. She cannot rotate herself from one shoulder to the other while she sleeps. You cannot imagine how difficult it is to try to help your child in the middle of the night while she screams out of pain from you touching her."

Elizabeth has minimal strength in her arms and legs. Her atrophied back muscles cause severe spine deformities. These have required three separate spine and hip surgeries within two years. She is unable to walk.

"I enjoy therapeutic horseback riding and training service dogs," continued Elizabeth, who had brought her enormous shaggy service dog. "Service dogs are not pets. They are medical equipment." The Bernese Mountain Dog helps pick up and carry items and also prevents depression. "Emotional support dogs are a fraud. I go shopping with my mother and one time a dog wearing a service vest started barking at my dog who was working on a task for me. The owner did not even apologize. It was fake. Emotional support dogs are ruining things for people who really need service dogs." (Type-A Anita blushed. She has been obtaining emotional support dog documentation to facilitate flying her black Labrador puppy to fly home during upcoming vacations. Nearly all of the couples in our class have been adopting puppies lately and getting together at a local dog park.)

[Editor's Christmas gift idea for Anita: "Black Labs Matter" poster, with optional yellow Lab holding an "All Labs Matter" sign.]

What did Elizabeth wish people knew about the disability community? "People with disabilities are not stupid. I still have a brain. When I am at the grocery store with my mom, people come up to us and ask: 'What is her name?' My mom just turns around and ignores it. I respond, 'I am right here!'"

Mischievous Mary asked the mother how she learned about the diagnosis. The mother, today in her late 50s explained, "I have two older children. I knew something was wrong with Elizabeth quickly. I kept bringing her to the pediatrician because she was missing her milestones. The pediatrician brushed them aside and said she would be fine. 'She'll be sitting up in no time.' I called a doctor who is a family-friend. He agreed that something was seriously wrong and scheduled an an appointment with a neurologist. The neurologist called with the rest results one evening while my husband was out with the kids. I was all alone as he said, matter of factly, 'Your daughter has spinal muscle atrophy and will not live for more than five years.' I do not remember what happened for three days after that. I had a nervous breakdown." (Straight-Shooter Sally afterward noted that it was possible that the doctor had good intentions, citing an HIV patient's doctor who called the patient at home so as to avoid a public scene in the medical office.)

"I hated people after that phone call," the mother continued. "I hated anyone who had a healthy child. 'Why me?' I would ask. When I went to my oldest son's basketball games, it would knock me down seeing these healthy kids and their happy parents in the stands. It sounds terrible to say, but when my sister had a healthy baby girl, I hated her too." She continued: "I dropped everything and devoted my whole life to my baby. This destroyed my marriage. I regret this, but my marriage was destroyed by my daughter."

There is some hope for SMA patients. Elizabeth's muscle movements improved dramatically after starting nusinersen (Spinraza), an orphan drug approved by the FDA in December 2016. "The new drug is amazing. I did not notice anything until my fourth dose. I used to have to use two hands and struggle with all my might to lift an object like a cup. One day I noticed I could pick up a cup with one hand!"

There may be even more hope for Biogen, the marketing partner for Spinraza. The list price is $125,000 per injection ($750,000 in the first year and $375,000 annually after that). The geneticist explained: "No one pays the sticker price. Most people are in a clinical trial, or the insurance company is negotiating behind closed doors to bring the price down. The only challenge I have faced is with the hospital pharmacy carrying these expensive orphan drugs. We have learned to never bill the patient. It just creates mayhem. Before we purchase the drug we get pre-approval from insurance or deal directly with the drug company."

Elizabeth concluded by saying, "Do not listen to what other people tell you. Everyone told me I would never be able to ride a horse. I can now trot a horse all by myself." Elizabeth goes on dates with other women and advocates for the local LGBQT community.

Friday concludes with a suture workshop. A plastic surgeon lectures on the types of sutures and various suturing techniques. Each student is gifted a basic suturing kit with forceps ("pickups"), needle drivers, and scissors. We practice on chicken breasts and a suturing model that incorporates synthetic material to mimic the epidermis, dermis, and subcutaneous fat. Mischievous Mary, an aspiring cardiothoracic surgeon, schmoozed with the general surgery clerkship director who helped with the workshop. Pinterest Penelope: "God, she was sucking up so much." Jane and I steal a few sutures to practice at home.

Statistics for the week… Study: 12 hours. Sleep: 7 hours/night; Fun: 1 night. Example fun: Jane's father, an internist, rents a three bedroom ski condo for a nearby medical conference. Jane, her sisters, and I join for a weekend getaway. I am falling behind in my studying for the upcoming block exam.

Year 2, Week 26

Psych week. Based upon my M3 mentor, I am using the DSM-5, also known as the "Holy Bible for Psych" and the First-Aid psychiatry chapter to study. Straight-Shooter Sally: "I'm surprised we have only one week of psychiatry. Mental health has become a prominent national issue." Lanky Luke: "Doesn't surprise me. Step 1 doesn't give much weight to psych."  

A quirky spaced-out 60-year-old psychiatrist introduces basic psych terminology and substance abuse disorders. He joked about the number of psych drugs. "There is a website that tests you on if a name is a drug or a Pokémon. Our former residency director is proud of getting 60 percent. Get ready ladies and gentleman for psych week!" The psychiatrist emphasized the diagnostic criteria for psychosis: presence of a delusion, hallucination, or disorganized thought. A delusion is a fixed, false belief. He gave several examples: "I've had patients who think they have Michael Jackson's baby or are the president. Somewhat more common is a referential delusion. While they drive, they believe a billboard is speaking about them, or a TV is speaking to them directly." Lanky Luke: "Is #NotMyPresident considered a psychosis?"

He began the substance-use disorder lecture by playing a BBC video of vervet monkeys getting drunk off stolen liquor from unsuspecting tourists on the beach in St. Kitts. "Among adults, 8.5 percent qualify as alcohol dependent or abusers. Think about that when you drive home tonight." He continued: "Why do we have 10 percent of our human population with [genetic] phenotypes that make them susceptible for this dependence?" Students responded: "Alcohol is important in certain cultures to build social interactions". Another student added, "Mating ritual." The psychiatrist added, "I do not think I would have met my wife without alcohol. I have terrible social anxiety meeting new people. Alcohol certainly helps!"

 

"What about heroin? Did the poppy seed hijack the reward pathway to disseminate its euphoric seeds around the world or was it coincidental? Cocaine, amphetamines, heroin, fentanyl, and coca leaves all activate the dopamine reward system. The Incas built an empire on drugs. Mail carriers chewed on coca leaves for more energy while traveling across the 1000-mile empire. Why did they not knock down and steal coca from ancient 7-11s?" Students responded: "They did not make coca illegal"; "It was not purified"; "It was chewed through saliva." He continued, "Right. Cocaine was purified in the 1880s. Sigmund Freud still has the best pharmacodynamics measurements for cocaine. When I was in medical school, they tried to replicate his experiments. They asked four volunteers to do cocaine and monitor blood levels for $500. Ninety-six people volunteered, but unfortunately I was not selected."

 

He digressed on the history of drug use in America. "In 1970s cocaine was $100 for a gram... so about $50 to get high. Then we developed crack in the early 1980s and a rock was about $5. This spread like wildfire among the urban poor. With good intentions we tried to stamp down on it, but the result was mass incarceration. It’s tough to get a job after incarceration, so these former inmates are on disability with psych issues now."

[Editor: Who has better mental health, the person who goes to school for 28 years and takes on $500,000 in debt in hopes of getting a job as a doctor, or the person who gets monthly SSDI checks without working?]

He continued, "We are seeing a similar transformation in opioids. You need poppies to make heroin so it gets expensive when the supply is reduced at the poppy farms. Fentanyl is completely synthetic; you can make it in your basement if you have basic understanding of chemistry for a lot cheaper. People are dying now from fentanyl, not heroin."

 

He continued: "When you come to my floor your job is to understand the mindset of an addict. Most of you guys plan about five years in advance. You imagine a family, a house with a picket fence. A heroin addict can plan only a week in advance. Someone on methamphetamine plans nine hours ahead. Good luck getting a meth addict to come for a follow-up appointment in two days."

He concluded, "We see that addiction spreads in culturally demoralized communities. I worked for two years on an Indian reservation, part of my penance for being an aging white male and therefore partly responsible for the introduction of alcohol in North America. What you quickly realize is the Navajo community has relatively low alcoholism compared to the Sioux because of their economic and cultural cohesion. With the decline of the coal industry, you see the same pattern in Appalachia versus the rest of the U.S."

[Editor: Appalachian coal shipments to China are up in 2017 and 2018, but Americans still love their opioids just as much!]

Straight-Shooter Sally: "I wish we had a Drug Use 101 lecture. Terminology, ways to use it, cost, demographics, etc.. This was close, but no cigar."

 

A tall 45-year-old child psychiatrist with a slight Eastern European accent briefly introduced Conduct Disorder. This is essentially the same as "sociopath" (also known as antisocial personality disorder), but the profession refuses to apply that label to anyone under 18. She spent the rest of the 100-minute lecture on attention-deficit hyperactivity disorder: "ADHD is a developmental disorder of inattention and impulsivity. They have task-irrelevant motor/verbal behaviors and delays in motor inhibition. A common observation from teachers is that the child will get derailed by any disturbance outside of the classroom, such as a squirrel climbing a tree or a cell phone ringing. Most kids will notice and get distracted, but they refocus on the task at hand." If teachers can pick the ADHD kids out of the class, what is the role of the psychiatrist? "My job is to look beyond the obvious. There are a lot of disorders that have attention deficits. Individuals with ADHD frequently have other development delays such as language and social interactions. Classic case is a patient with ADHD and oppositional defiant disorder [ODD, cognitively inflexible child that deliberately annoys others and cannot think of compromise out of dilemma]." Persevering Pete whispered, "ODD sounds like a fancy way to call a kid a brat."

She showed a slide with CDC data: 11 percent of school-age children and 20 percent of high school age boys have been diagnosed with ADHD.  This is a 16-percent increase since 2007, and a 41-percent rise in the past decade.

 

She briefly described an emerging theory about ADHD. "ADHD patients whose mother smoked have a tuned-down dopamine reward system. They are hardwired to search for new things because the world around them is not interesting to them. These were the explorers of new worlds in the era of cavemen. When we force the child with ADHD to listen to boring lectures all day, they find it impossible to focus. However, when they find a passion, they can focus without difficulty. Stimulants such as Adderall [amphetamines] and Ritalin increase dopamine signaling causing them to be more interested in the dull activities."

[Editor: Are there vats of Adderall and Ritalin sufficiently large to get Americans interested in computer programming? And maybe we all need Adderall and Ritalin during tax filing season.]

 

Once a patient has begun stimulant treatment for ADHD, they have regular check ups to assess attention, sleep, appetite, headaches, and mood changes. "We do drug holidays every two years. This usually happens when the child is learning to drive. When you ask children how they are doing, they will always say okay. Ask their parents how they are driving. People with ADHD [off the meds] have a much higher rate of car accidents."

 

Pinterest Penelope asked why the United States treats way more ADHD than any other country. "I'll try not to be too blunt. It’s several reasons. First, I think we have a greater demand for attention than we used to. I have parents and young adults come to me saying they need to pay attention for 16 hours per day [e.g., school plus music lessons then homework or a college student with an evening job]. It’s just not going to happen. Attention is a finite resource. Second, we do not train our children to delay any sort of gratification. The French use very strict schedules. Eat at this time with no snacks between. Third, other cultures are less willing to call this a disorder. The willingness of parents to give medications to young children astounds me."

( "The worldwide prevalence of ADHD: is it an American condition?" (Faraone, et al. 2003; World Psychiatry) concluded that ADHD symptoms are actually just as common among children in other countries, though diagnoses may differ.)

My small group waited 10 minutes for IT to come deal with our projection difficulties. Type-A Anita used the downtime to ask if we watched the State of the Union speech, which she characterized as "disgusting." Adrenaline Andrew, an aspiring EM physician whose family immigrated from Kurdistan: "I thought Trump was hypocritical. He was touting all these immigrants that he brought in, but he wants to keep them all out." Straight-Shooter Sally commented on the Arizona policeman and wife who adopted a child from a heroin-addicted mother. "Oh my God! You do not know if that baby will be f***ked up. I could never do that." Jane had watched some highlights on Facebook: "It was mostly a celebration of America, just a lot of patting ourselves on the back. I am not quite sure why we are celebrating so much."

 

We changed the subject when Fashionable Fiona walked in late, waving a beautiful diamond ring, to announce her engagement to an MBA two years her senior. We all congratulated her. Type-A Anita announced, "I have to be the primary breadwinner before I get married."

[Editor: Congratulating Fiona would have been considered a terrible faux pas in the 1950s; one congratulates the groom, not the bride, so as to avoid the implication that the woman was desperate to find a man. Separately, given that physicians have much longer careers than MBAs, let's hope that she reads Real World Divorce and settles in a state that won't offer her spouse the opportunity to tap her for a lifetime of alimony!]

Our small group facilitator is a brilliant personable EM physician married to a head and neck surgeon. She has been out of clinical practice for three years while taking care of two young children. "Don’t do the double doctor thing. It ends with one supporting the other." She has to recertify her boards two years from now, and enjoys facilitating to prepare for her studying. "It is amazing how much more you guys have to know. All these genes, drugs."

She recounted her medical school quest to get right-to-privacy rules altered in the state of New York. "When I was in residency in New York, we were not allowed to get a HIV or hepatitis test on a patient to see if we were exposed by a needle stick. We would have to weigh the risk of the patient to decide if we should go on these serious antiviral drugs. Imagine being on those drugs while doing residency. Fatigue. It was crazy. California and New York had these crazy antiquated laws. We lobbied [successfully] to get that changed. If you were exposed you could require a patient to get blood drawn to test for virus."

Thursday morning, our last lecturer for the week is a 65-year-old psychiatrist who became blind after medical school. "Most specialites have diagnostic imaging and tests. Psychiatry doesn’t, with the exception of some new expensive functional imaging. Think of psych disorders like trying to treat heart or kidney disorders 100 years ago. We barely understand them. We are in the Caveman age of psych drugs. We are just beginning to tap into the mechanisms of the brain disorders."

He described anxiety disorders: "The frontal cortex and amygdala are at war with each other. The amygdala is the old part of the brain, tens of millions of years old versus 1.5 million for the cortex. New always loses to the old. Our brain is wired to assess if something is trying to harm you. It's not wired to feel good about yourself. I have lots of patients that park their cars next to the ED when they're going to sleep because they are so afraid of these attacks." (Their treatment might stay within our lecturer's family: "I tried to be flexible with my son and let pursue his own dreams. I told him, 'You can do any psych residency that you want.' He ended up choosing EM. The problem is he now has more interesting stories that I do!")

Thursday afternoon, 16 of us visit the inpatient psychiatric wing of the hospital. "We did not have to prepare because we always have a few schizophrenics and bipolar patients admitted to our service," explains the attending as we arrive. The psych wing is in an old part of the hospital. My favorite retired trauma surgeon pointed out that the wealthy love to donate money to put their names on new pediatric wings, not for geriatrics and apparently not for psych. The hallways are a muted grey with occasional peeling chips of paint. Many of the sliding doors are glass so that staff can see inside. We divide further into groups of four to sequence through two or three patients, 5-10 minutes at a time, with a psych resident.

Our first patient has her face touching a wall of her room as she attempts to walk through it. The resident instructs Gigolo Giorgio to ask her something. "Hello, Meredith. Are you okay?" No response. She explains, "This patient has catatonic depression. Her neighbor brought her in yesterday. When she first came in she had her right arm raised above her head for two hours."

Our next patient is hospitalized for a hypomanic episode. "Just ask him what brought him here," chuckled our resident, "He'll do the rest." Ambitious Al: "What brought you here today, Gregory?" Gregory responds, "Well, let me tell you from the beginning. I've had bipolar disorder for seven years. I do not take any medications. I've been bounced around different hospitals, but this place is great. They got all my medications in order. I just want to be able to talk to my family. They are so sick of dealing with me. Every time they ask me something, they can't shut me up!" Students head home from the session at 7:00 pm.

Friday morning is our patient case: Sarah, a 25-year-old bank teller with a history of depression and anxiety since the age of 12. She presents to the ED for uncontrollable crying, a lack of energy, and a plan for suicide. The previous month, she felt "amazing," though she slept less than 3 hours per night for 3 weeks straight. Her boyfriend accompanied her to the ED and reports that she recently cleaned the house from top to bottom, and cooked tremendous amounts of food for her extended family and neighbors. She scores 20/30 on the MME (mini mental status exam; not the challenging Montreal Cognitive Assessment on which President Trump purportedly scored a perfect 30!). She is not oriented to place or time, is unable to subtract serial sevens, and can't recall three words from the beginning of the encounter. She agrees to be admitted to the psychiatric ward for Bipolar Type 1 disorder.

This turns out to have been a watershed moment for Sarah, who had previously been bounced around among multiple psychiatrists and multiple drugs, few of which were appropriate for bipolar disorder. Antidepressants can exacerbate the swings of mania and depression for patients with bipolar disorder and thus, during the seven-day admission, Sarah is taken off her antidepressant and started on a mood stabilizer.

Over the next two years, she tries 11 different medications to control her mood, finally settling on a three-drug cocktail. Sarah, now a skinny 29-year-old boasting long dyed red hair with streaks of purple, is well controlled. She told her own story: "My father committed suicide when I was 14. From what I remember, my depression started then." (She was hospitalized for an attempted suicide at age 14.)  Pinterest Penelope asked about other relatives with psychiatric disorders, such as depression, bipolar, or schizophrenia. Sarah responds, "Yes, my father, my cousin, and my aunt. All on my father's side."

The psychiatrist added, "You will quickly realize psych disorders run in families. We don’t know exact mechanisms, but it is both genetic and environmental exposure. How difficult is it for a mother or father to fear the child might suffer from their own disease?" Sarah's mother, a portly 58-year-old with a wide smile and gregarious laugh, nodded her head: "As a mother you want to see your children reach their potential. I have son who is a computer science professor at a university and a daughter who has bipolar disorder. I am proud of both of them. My daughter holds a job. My daughter is independent. My daughter has built meaningful relationships. She is a functioning member of society. My daughter recognizes the impact her choices have on others. You should have seen her growing up. The change is unbelievable. When she was in high school, I had to wrestle her to the ground with all my strength. She had cut herself horizontally with a knife, and was threatening to finish herself off with a vertical cut."

What advice did she have for us? Sarah: "Tell your patients they can get to normal if they really try with an invested psychiatrist. It might be different than other people's normal. But you do not always have to be a homeless alcoholic substance-abuser. You can have a job... and not be on disability."

Sarah continued, "From a young age, my dream was to be a mother. Dreams die. I have to respect myself, and respect those around me. If I were to have a baby, I would have to come off my drugs before and during pregnancy [her meds would interfere with a baby's brain development]. Also, after if I want to breastfeed. I do not know if the meds would work again because my hormones would be all whacky. I recognize that there is a high likelihood that my child would be taken care of by my mother, boyfriend, or husband. It has taken me a long time, but I cannot do that." Straight-Shooter Sally asked if Sarah had considered adoption. Sarah responded that she did not consider her condition sufficiently stable to take on the responsibility for a child, even without the pregnancy.

Type-A Anita asked for Sarah's view on abortion. Sarah paused, then answered, "I believe in God. But if I become pregnant I will not be having the child. I do not care what you believe about abortion, if I get pregnant, I will not keep the baby." (Sarah is unlikely to be a Planned Parenthood abortion customer due to the fact that she is currently "in a relationship" with another woman.)

Gigolo Giorgio ask Sarah's psychiatrist how he persuaded patients to continue taking their medications despite serious side-effects. "I tell them to treat their psych problems just like any other disease. Would you stop taking your blood pressure medications because they make you have orthostatic hypotension [lightheadedness when you stand up]?"

Afterwards at lunch in the common area, Gigolo Giorgio commented: "You can tell she is drugged up. She would pause for a long time responding to each question." The table agreed, and then moved on to an abortion debate. Jane: "Although Sarah is a unique case, and most women do not have similar reasons for why they can't be pregnant, this is a good argument for legal abortion." Type-A Anita: "To all those far-right deplorables, this is an example that disproves their anti-abortion views." Lanky Luke: "Look, I agree with you, but you don’t hear the pro-choice people agreeing to allow abortion for these cases and prior to say 25 weeks, but not after that." Straight-Shooter Sally: "Oh, please! 99 percent of abortions after the first trimester are for medical necessity. That's such a bogus argument."

After lunch a Step 1 panel was held with four M3s and four M4s. Next week will be our last week of lectures in M2. After that there will be a week for block exams and then a six-week individual study period before the Step 1 test. Lanky Luke whispered, "Our tuition is the same as last year even though we are not in school for six weeks?"

The eight panelists explained that most students used Pathoma, First Aid and a question bank to study for Step 1. Three of them had taken all eight of the NBME practice exams at a cost of $60 each. A fit M3 joked, "I've never been in better shape than studying for Step 1. I would get up in the morning, cook a luxurious breakfast of eggs or pancakes, then head off to the library from 9:00 am until 1:00 pm. I would get lunch then switch to Starbucks for another 4 hours." What is your advice about the day of the exam? "Bring lots of coffee. If you do not want to pee between breaks, bring 5-hour energy or caffeine pills." The panel explained that Step 1 is a one-day test with seven one-hour 40-question blocks. You can take a total of one hour of break in between the blocks, e.g., 30 minutes for lunch and a few 5-minute restroom breaks.

I spoke afterwards with two M4s, one applying to Gen Surg (general surgery) and one to Ob/Gyn. The aspiring Gen Surg resident is somewhat of an outlier in her class, enjoying hunting and skeet shooting. Any advice for rotations? The huntress responds: "Ob/gyn can be tense. The residents became cautious a few years ago when a  [female] medical student wrote up a [female] resident. The resident spent 30 minutes teaching the student how to do a fetal ultrasound, then asked the student to do the next one. The student freaked out, and the resident went off on her. Two weeks later, the resident was called into the Chief's office for a reprimand. You do have to demonstrate competence and then chill out. They do curse a lot in Ob/gyn, which is kind of surprising given their job of delivering cute babies. Just don't be offended."

The Ob/Gyn: "I loved Gen Surg. Internal medicine is a lot longer hours, it drains you. My best advice is to separate the people from the profession. You'll do some rotations with amazing attendings and residents, and you'll do some rotations with people that do not click with you. For example, I loved the people in Gen Surg, and they almost convinced me to become a surgeon." Why didn't she do it? "I realized that I don't want to do that stuff. The smell is terrible when you open the abdomen." The huntress giggled, "See I love that stuff."

Aziz Ansari's dating habits have been in the news and classmates are commenting. Type-A Anita posts the original Babe.net article featuring a description of a Manhattan date:

"It was white," she said. "I didn’t get to choose and I prefer red, but it was white wine."

Jane: "Well, that is just rude." [Editor: White wine? Ansari identifies as a woman?]

Jane and Pinterest Penelope thought that the article was positive for our culture and agreed that non-religious American women in this day and age would likely have had a similar experience while "hooking up with a guy".  Penelope elaborated, "You do not want to be mean or insult the other person, so you just freeze and go cold when you're not having any more of it. It's not realistic to justify this behavior and say, 'Well the woman should have just left.' It would have been even harder to leave a celebrity." Jane: "Whether or not it is true or justified, people will be more cognizant because of this article."

Type-A Anita's introduction to the article on Facebook:

TW [Trigger Warning]: sexual assault, rape

@ people who think I "hate all men," when I talk about how hard it is for me to trust men or add new men to my friend group:

It is so exhausting trying to figure out which men are "the good ones," and which will require a ton of energy on my part to discuss with them and educate them about how what they're saying/doing is sexist/misogynistic/reinforcing rape culture... Can men take a second to read this and appreciate that a lot of people, particularly survivors of sexual assault, looked up to Aziz as a guy who "gets it." It's a sad realization that so many survivors have had to experience over and over again in their own relationships and friendships, and I am tired tired tired.

Statistics for the week… Study: 18 hours. Sleep: 6 hours/night; Fun: 1 night. Example fun: Burgers and Beers with Mischievous Mary and Lanky Luke. Mary gleamed as she recounted her day. She scrubbed in on an open heart surgery in the morning and spent the afternoon in the cardiac care unit (ICU for heart patients). She heard a pericardial rub (inflammation of the heart lining that produces a "walking on fresh snow" sound) with her stethoscope.

Year 2, Week 27

Our last week of classes. Next week we take the block exam and after that we study independently for Step 1.

An endocrinologist specializing in thyroid disease leads 5 hours of lectures on the thyroid, the adrenal glands, and the gonads. She dedicated an additional 1.5 hours for the master pituitary gland, a pea-sized gland on the underside of the brain that regulates all the endocrine glands. "20 percent of normal individuals have a pituitary adenoma (benign tumor). Most are non-functional, and never will give the patient any issue. When I started teaching, there was a much lower threshold for removing these adenomas with transsphenoidal surgery [through the nose]. Now we typically wait and monitor."

She described how several types of pituitary adenomas can now be managed with drugs instead of surgery. For example, the most common functional pituitary adenoma, a prolactinoma, which secretes the breast milk-producing prolactin hormone, causes amenorrhea and breast formation in both males and females. It can be managed with bromocriptine, a dopamine agonist. "These are much more common in females, but I do not know if this is because they are diagnosed easier in females than in males. Males predominately get breast formation, but with all the obesity in this country, most people will attribute this to the obesity horse, not the tumor zebra."

What else is new in her practice? "Patients now have complete access to the same imaging reports we read. The patient reads her report and thinks, "Oh my God, cancer." We call these incidentalomas." She continued: "What do you do with this information? If we want to rule out a functional pituitary adenoma, we need to run another more expensive MRI study. It's hard to tell these patients to not worry about this small tumor in their skull. I mean, I would want to know. It will be up to your generation to decide the the right course. With great power comes great responsibility!"

A fertility endocrinologist leads 2-hours on hormonal pregnancy changes. She described Sheehan's syndrome, a emergent condition in which the pituitary gland infarcts (dies due to blood flow loss) because of loss of blood during delivery. "Throughout pregnancy, the blood volume expands considerably to supply the baby and all the demands on the mother's body. The pituitary gland enlarges to meet the hormonal demand. If you lose too much blood during delivery, you are at risk of causing ischemic necrosis of the pituitary from hypoperfusion." She concluded: "This is a terrific example of how medicine can improve lives. In the US, Sheehan's syndrome occurs 3 times in 1 million births, whereas in India it occurs 3 times in 100 births!"

A recently-retired, Russian-trained physician discussed acromegaly (enlarged skull and soft tissue structures) and gigantism (enlarged bones). He brought in his former patient and current friend Conan, a 45-year-old accountant with acromegaly due to a growth-hormone pituitary adenoma. "Look at his chin, look at his forehead," exclaimed the Russian. Mischievous Mary was a little taken aback by the physician's bluntness in front of his friend. "If the adenoma occurs in childhood before the growth plates fuse, the child gets gigantism. This creates the tallest people in the world. If the pituitary adenoma occurs in adulthood, it causes soft tissue swelling (e.g., heart, tongue, hands, feet) and facial bone protuberance (brows, chin)." Patients die of hypertrophic cardiomyopathy and associated-arrhythmias if left untreated.

Thursday morning features an applied workshop with five stations, each run by a physician covering a rare endocrine disease. "In all your future careers you might see one of these diseases," joked my first station internist. "The boards believe if you understand the pathology of the disease, though, you can understand more common issues."

We had a station on John F. Kennedy. Most people know that John F. Kennedy had Addison's disease (primary adrenal insufficiency) requiring cortisol shots. This is believed to have given him his characteristic bronze skin and round face. In addition to Addison's, a review of JFK's health records revealed a multi-endocrine autoimmune disease including hypothyroidism. We learned about other multi-endocrine organ disorders such as Multiple Endocrine Neoplasia 1 (parathyroid, pancreas, and pituitary adenomas; prevalence 1:100,000) and Multiple Endocrine Neoplasia 2 (pheochromocytoma, an adrenal tumor that secretes life-threatening levels epinephrine, and thyroid cancer; 1:50,000). The physician concluded: "both are highly testable on board examinations."

Endocrine disorders may impair kidney function because hormones can determine how much salt and fluid to absorb. A station on renal disorders is led by a 75-year-old physician. Straight-Shooter Sally: "He must have had had a mid-life crisis and turned Zen." My group struggled through the case on Conn's syndrome (primary hyperaldosteronism), an adrenal tumor that secretes too much aldosterone, which increases fluid reabsorption in the kidney. Patients with Conn's syndrome have hypertension (high blood pressure) due to increased blood volume. Most doctors work them up for idiopathic hypertension (unknown cause, as with 95 percent of U.S. cases). He continues: "Patients keep getting put on more and more anti-hypertensive drugs. This patient was taking 5 drugs at once. One simple lab test is all it takes." Patients with Conn's syndrome can be successfully managed with spironolactone ( aldosterone antagonist) or a curative surgical resection of the affected adrenal gland. "Listen up. If you want patients to love you, this is your chance. The patient that I diagnosed with Conn's syndrome gave me the 'World's Greatest Doctor' plaque that hangs in my office. I mean this is what it is all about."

Our patient case: Janet, a 26-year-old ED nurse presents with fatigue, cold-intolerance, and dry hands after delivering her second child Charlie nine months ago. She is frustrated that, despite eating a restricted diet, she has not been able to lose 25 pounds of her pregnancy weight.

"I was a healthy person up until this. When this happened, I realized I really never had a general practitioner. It took several weeks to get an appointment with a doctor accepting new patients."

[Editor: I wonder if Janet stuck around long enough to learn that her entire audience was seeking desperately to avoid becoming stuck in primary care.]

She continued, "My primary care physician's first thought was depression." (Postpartum depression afflicts 1 in 9, typically resolving within a year of giving birth.) Janet continues, "I was depressed because i was tired, not the other way around. Simple tasks were exhausting." On the second visit, the physician tested thyroid function, which showed low thyroxine levels despite normal thyroid-stimulating hormone response. Janet was diagnosed with primary hypothyroidism due to Hashimoto’s thyroiditis  (immune destruction of thyroid gland) and started on Synthroid, which she has been taking now for 30 years. Her aunt and sister are also on Synthroid for hypothyroidism.

Janet and her husband George are retired now and he joined her at the session. George said, "it is so clear in retrospect. Immediately after delivering Charlie, she lost all of her usual spunk and energy. I had just started a new job as a history professor when Charlie was born. I was working non-stop, but we hosted a family reunion. We were both so excited about the party when we planned it, but for most of the party she was sitting on the coach. When the party ended, she went straight to bed. Did not help clean up at all."

Janet describes her cold-intolerance: "I returned to work a few months after Charlie was born. It was a beautiful spring day, but I just felt freezing everywhere I went. I took out my packed winter clothes and put them on to get to work. I just could not put on enough layers." She added, "It did not stop there. I would get to work and go straight for the coffee machine. Not for the coffee, but to grab the pot to warm my hands. It was a physician co-worker in the ED who noticed that a crazy lady bundled up in winter jackets hogging the coffee pot should be seen."

Janet concludes: "You guys are all young and healthy but you still need to get a doctor. You'll need it when you least expect it. I truly believe this whole episode would have been resolved much sooner if I had a regular internist. You are not invincible!"

Fashionable Fiona, who has hypothyroidism as well asks, "Have you had any issues once you began Synthroid treatment? Have you switched doses?" Janet: "I have never had to adjust my dose. I once tried to switch to the generic version, but started to feel tired again, so my physician switched me back to the brand-name." Our professor added: "I hear that a lot. The generic is identical for most drugs, but I see variability in biologics. The patent describes the chemical formula of the drug, not the manufacturing process. So different companies may prepare the compound differently."

Despite Janet's positive response, our lecturer cautioned us to be careful in prescribing Synthroid. "Everyone hears about the energy-boosting, weight-busting miracle of thyroid hormone. There are serious health complications if you take too much, and long-term use can damage the health of the thyroid. Be conservative in diagnosing hypothyroidism."

I attend a conference for working orthopedic surgeons on Friday. An example hour-long lecture was on anterior lateral cruciate (ACL) ligament tears in female athletes, 4-6 times more common than among men playing the same high-risk sports. This is believed to be from several factors, including wider hips, decreased femoral notch width, and the impact of estrogen on connective tissue tensile strength. "Title IX is the gift that keeps on giving for orthopedic surgeons," said the lecturer, but researchers are looking at screening and training processes to reduce injuries. "Sports physicians may be able to screen for ACL tear risk by measuring the mechanical forces with various exercises. Individuals with high risk need to begin training before they jump straight into competition. Several companies are developing tests to monitor neuromuscular synchronization to strengthen muscle tone via biofeedback to minimize the ligament load."

Several classmates appear right before the free catered lunch. I overhear a few orthopedic surgeons discuss the impact of reimbursements being tied to outcomes and customer-reported feedback. "Medicine is now a product, health systems need good reputations, not just good care. In the past I might have told a patient that he didn't qualify for disability, but today I would not confront him. I will just refer him out."

An email titled "Self-Defense Class Sign-Up" from our Dean of Diversity and Inclusion: "This course is taught by [police officer] and [yoga instructor]. It is designed to help individuals who identify as female protect and defend against unwanted physical advances. Participants will learn general safety tips as well as defense techniques including kicks and strikes during the session. Every individual (faculty, student, physician, staff) who identifies as female is welcome to contact [yoga instructor] to participate."

We are done with classes for our second year of medical school.

Statistics for the week… Study: 20 hours until burn out. Sleep: 8 hours/night; Fun: 1 night. Example fun: After our last day of class, 25 students go downtown to our favorite burgers and beers joint. We discuss our most memorable moments so far. Our class VP: "This was Year 1, Month 2. I was working at the free clinic with Dr. House. He asked, 'The patient in Room 3 is having stomach pain, can you go in and report back your abdominal exam findings.' I come out after a few minutes, and say, 'Looks all good to me.' He had gone in beforehand and diagnosed her with metastatic ovarian carcinoma that had spread to her peritoneum (abdominal cavity). Dr. House said, 'Now you won't make that mistake again'." Lanky Luke: "I was waiting in the lab for a Path report for my research project. After 30 minutes, a freaking leg came through the door and the severed leg was just plopped on the pathologist's table."

Year 2, Week 28

Exam week: two one-hour clinical standardized patient (SP) encounters, a 4-hour NBME-style 200-question exam, a 2-hour case-based exam, and a 2-hour clinical multiple choice exam over four days.

 

My first SP is 50-year-old nonobese non-smoking female with a two-month history of radiating back pain. She describes pain beginning in her lower left back, traveling down her buttocks to her feet like a bolt of lightning. She denies urinary incontinence or retention, denies headaches or visual changes. She reports difficulty walking. Physical exam reveals weakness in plantar flexion of the right foot decrease in station over the lateral aspect of the foot. She is unable to walk on heels. She has 2+ pulses in distal extremity. Positive straight leg raise while supine. I diagnosed her with a disc herniation spinal stenosis causing a L5 or S1 radiculopathy. One mistake: I forgot to do sensation testing of the distal lower extremities (feet).

 

My second SP is a 40-year-old nonobese nonsmoking female presenting for right-side hearing loss and one-hour episodes of dizziness over the past several days. I conduct the Rinne test (tuning fork is placed next to the ear and then on the mastoid bone. If conduction loss, the patient can hear better when fork is placed on the bone) I then do the Weber test (tuning fork is placed on the midline skull, and localizes to the affected ear if conduction loss)

Good news: I have ruled out a problem with mechanical conduction and therefore her hearing issue is due to a sensorineural cause. Bad News: I did not read up on sensorineural hearing loss. Although we are not supposed to discuss the cases (others will see the same patients later in the week), Jane and I overhear the correct answer in the line at Starbucks: Ménière’s disease. Neither Jane nor I had ever heard of this, let alone how to diagnose or treat this disease.

 

The clinical multiple-choice exam tests ophthalmology, suture technique, lumbar puncture technique, and psychiatric cases. Several questions showed images where we had to identify the correct diagnosis: for example, a cherry red spot in the macula (pigmented area near the center of the retina) suggests a retinal artery occlusion or Tay-Sachs disease. How is it possible to test suture technique with multiple choices? Example: "What suture size and needle type should be used to close a face laceration? What technique is depicted with this diagram?"

Students led by Type-A Anita swarm the clinical director because one of the questions had the wrong units attached to an optic ultrasound measuring the optic sheath diameter. It had calipers measuring the optic nerve diameter at 3 mm distal to the retina. The multiple choice questions all were in cm instead of mm.

The case-based exam covers five patients, each starting with a two-paragraph description of a patient's presentation. We are then asked open-ended questions about what tests we would order and other symptoms to ask about. The exam for this block covers neurological diagnoses, endocrine diagnostic workups, musculoskeletal fractures, dislocations and malignancies. Neurology questions asked what other symptoms is most likely in a description of a Huntington's disease patient and localize the lesion for stroke symptoms (e.g,. right anterior cerebral artery for left-sided leg weakness). Endocrine questions dealt with determining if an endocrine pathology is primary (disorder of the endocrine gland itself) or secondary (exogenous or pathologic dysfunction of the pituitary). For example, a patient with low thyroxine hormone and high TSH suggests a primary thyroid disorder; a patient with low thyroxine hormone and low TSH suggests a secondary cause of hypothyroidism. Pinterest Penelope complained about a lifelong smoker with Cushing syndrome (excess cortisol) and high ACTH (adrenal corticotropin hormone, hormone released by the pituitary gland to stimulate the cortisol release from the adrenal cortex). We had to determine if this was a ACTH-secreting pituitary adenoma or paraneoplastic syndrome from an underlying small cell lung carcinoma. "How were we supposed to know what is more likely?"

Jane and I look at the sample question bank on UWorld the night before to prepare for our final NBME block exam. These will be retired Step 1 questions from the National Board of Medical Examiners. I ask Jane about drugs for the treatment of bipolar disorder. She responds, “First Aid says mood stabilizers. lithium and valproic acid.” I look at my own copy of this book: “On page 545, First Aid says you can also use antiepileptics like carbamazepine and lamotrigine.” Jane exclaims, “What!?! Those are sodium channel blockers for seizures.” I add, “I understand why doctors order psych consults and call it a day. We cannot go into psychiatry."

The Thursday NBME block exam was our toughest so far. Type-A Anita claims to have "blacked out" for the last 15 minutes: “I do not remember anything.” Pinterest Penelope: “Where was the biochem, where was the actual neuro on the test? There was nothing of yield." Mischievous Mary adds: "I am glad I do not go to lecture because I've heard not much was represented on the exam."

The renal questions required differentiating different types of chronic renal disease. Some questions you could answer using the patient demographics, e.g., African Americans are more likely to get focal segmental glomerulosclerosis (FSGS), whereas whites and hepatitis B/C patients get membranous nephropathy. Others started with black-and-white scanning electron microscopy images and asked about the immune complex deposition pattern. Anita was not happy: "There is nothing to memorize. It's like learning a new organ system every single question." Her mood was not lifted by a genetics counseling question concerning the probability that a couple's potential children will develop an autosomal recessive disorder. The husband has a sibling afflicted with the disease, which has a 1 in 40,000 prevalence in the general population. "I did not go to medical school to do math!" Anita exclaims. Answer: assuming Hardy-Weinberg equilibrium, 1 in 100 individuals are carriers of the disease. The husband's parents must both be carriers for a sibling to have inherited two affected genes and therefore the spouse has a 2/3rds chance of being a carrier (he doesn't have the disease so 1/4 of the sample space is removed). Thus the probability of an affected child is wife's risk of being a carrier times husband's risk times child's risk of receiving two carrier genes: 1/100 * 2/3 * 1/4 (1 in 600).

[Editor: In most states, any child born during a marriage will entitle the parent who can obtain custody to child support, regardless of actual paternity. So the wife could have sex with a genetically-clean neighbor and in the event that the husband ever does find out, she can still count on child support profits for 18-23 years (depending on the state).]

After exams, Jane, our class VP, and I help Lanky Luke and Sarcastic Samantha move into their new house. Luke and I rent a U-Haul trailer for his F-150 pickup. While driving, Luke informed us that his uncle has autosomal recessive polycystic kidney disease. "I thought the question Anita was complaining about was a great question. My father is an engineer, but has no idea about medicine. He told us he debated having children out of fear his children would inherit the disease." He continued, "Just like in that question, the doctor informed my parents it would be very unlikely." We googled ARPKD -- a prevalence of 1 in 20,000 puts the carrier frequency at about 1 in 70. Based on the uncle's phenotype, there is a 0.24 percent chance of his children getting the disease. Luke continued: "People overestimate certain risks. That's about the same likelihood as a typical couple having someone with Down syndrome. When you put it in that perspective, you wouldn't change your whole plans based upon that risk."

We drink some craft beer on their new porch overlooking a small creek as their dog and cat explore their new home. With exams over, campaigning for the six student admissions committee representatives (from M3 and M4) has begun. Geezer George sets off a firestorm by texting the class GroupMe:

Hey all, I know it’s a little early, but I’d like to throw my hat into the ring for the Medical school admissions committee. If you think I would be good for the job, and if one of your better friends isn’t running, I’d love your support!"

 

Buff Brad responds:

I would also like to throw my hat into the ring for a spot on the Medical School Admissions Committee. I have been working hard to promote the vision of our school to both incoming applicants and current undergrads. I believe that being elected as a committee member would allow me to really make an impact.

Type-A Anita grills the two men: "What are your strategies for getting more girls at our school?" Our class and M1 are both over 50 percent female, but nobody asks Anita to clarify her question with a target percentage. Instead, Fashionable Fiona announces her candidacy:

… Being a women (@Anita) I will ensure we will have equal representation of genders and as a minority I will ensure we have a diverse class. Let me know if you have any questions! I'd love your support!

 

Optho Annie, an aspiring opthamologist with a family heritage from the Indian subcontinent::

To piggyback off of Anita's question, I’m also interested in being on the Admissions Committee and have thought about increasing both female enrollment and enrollment of people of color and minorities, something we severely lack. I think the answer comes down to increasing visibility and outreach through different endeavors to show we host an environment where every student can flourish and feel safe. Happy to talk to anyone in person about my ideas, and would appreciate your support if you think I’d be a fair and just committee member!

Our school was awarded a diversity award by the LCME. What was lacking from Annie's point of view?

… In general, diversity to me means a community or group of people that are of different races, religions, cultures, which can all help expand their peers’ world views. However, that’s the more obvious form and not all of what diversity means to me. I also think people of different socioeconomic backgrounds, hailing from different geographic areas , and also people on different sides of the political spectrum can contribute to and enhance diversity. ...

… our class is pretty diverse when it comes to a lot of things like socioeconomic background, geographic background, and even culture and religion. However, I do think we are lacking in minority enrollment as well as female enrollment. We historically have had very few black, Hispanic, and Native American students. Also, over 50% of medical school students are now women but our class percentages do not always reflect this.

 

It turns out that one of Annie's prime motivations was hearing about a class several years ago that was 50/50 female/male rather than adhering to the national trend of majority female. Neither of the two closeted conservatives whom I know in our class offer to sit down with her and share their perspective from their Trump-tainted side of the political spectrum!

Adrenaline Andrew, an aspiring ED physician whose family is from Kurdistan:

I would also like to be considered! I think it’s important we present ourselves as inclusive and well-rounded. I really enjoy talking to future students and believe I can represent our school as such. I am huge advocate of diversity and ensuring minority students feel welcomed in our city (and increasing awareness within our school). This a very exciting position! I would love your support and welcome any advice you have for me.

 

After an extensive exchange of messages, it turns out that nobody wants to promote diversity of undergraduate majors, age, or any other characteristic other than gender and race ID. No white males come forward (Geezer George and Buff Brad can qualify as persons of color).

Sarcastic Samantha, who currently identifies as "white," cracks up as we read the texts aloud. "Why don't they just come out and say what they mean. They want more of everyone except white males." Our class VP, from a family of Vietnamese immigrants: "I've heard being Asian now hurts applying to colleges and medical school. It is not right to group all Asians together on the application box. Chinese and Indians are probably over-represented, whereas South-East Asians are probably underrepresented." He did not want race to be disregarded in admissions, but was lobbying for Vietnamese applicants to be given a higher priority.

Jane yelps as she gets an email that she was nominated to the position by Hardworking Harold. She does not post her position on diversity and inclusion to the GroupMe: "Best campaign is no campaign." On Friday we learn that she was right. The Google poll results are in. Jane, Adrenaline Andrew, Buff Brad, and Fashionable Fiona have been selected for the committee.

Facebook is quiet this week due to exams and GroupMe activity. Type-A Anita: "RELEVANT: Happy International Women's Day… except for the 53% of WHITE women who voted for trump"

Statistics for the week… Study: 18 hours. Sleep: 7 hours/night; Fun: 2 nights. Example fun: Annual "Champagne and Shackles" at Nervous Nancy's apartment with every class in our school. People are shackled together with zip ties. You are not allowed to cut this until you and your partner finish a bottle of "Champagne" each. Jane and I cheat by consuming only half to two-thirds. Several couples are typically formed at this annual event. Buff Brad, his girlfriend, Jane and myself struggle to play pool while zip tied. Several class pictures are taken. Luke promises to get a pool table for his new house. "It cannot be that difficult to find one on Craigslist. People give away that stuff if you can move it. I become the most popular person for the yearly moving season with my F-150."

End-of-Year-2 Study Period

We are finished with classroom education and now begin our Step 1 study period. Eight weeks from now we begin clinical rotations, also known as clerkships. Students may take the Step 1 exam, which determines the rest of our careers, at any time within this period. Mine is scheduled for six weeks in.

Unlike after most block exams, there is no mass exodus to exotic travel destinations or to visit family. The library is packed with M2 classmates as the M1s go on break.

Study resources are standardized across medical schools and were made available to use at the beginning of our M2 year. The most future minded among us began cramming for Step 1 back in August when our school's one-year group subscription to the Step 1 UWorld question bank began (the individual rate, with two practice tests, would have been $479). First Aid is the foundation and we also use Pathoma ($85) and SketchyMicro and SketchyPharm ($160 each). Several students have also been using Anki, a flashcard manager, to test themselves on First Aid information. We are told to focus on the four "High-Yield" subjects: neurology, cardiology, pulmonary, and gastrointestinal.

 

Mischievous Mary, driven by her desire to be a heart surgeon to extreme studying habits, gets up every morning at 5:30 am for a Orange Fitness class. "It's my guilty pleasure. I know we have gym membership through our tuition, but paying $100 a month gives me motivation to actually work out. When I wake up I think, I can't go back to sleep. I have to go, or I am wasting $100.". People respect her corner table in the library, where she leaves her books, and she arrives there by 8:00 am for a 12-hour shift. I've asked her several times to get lunch with me. She explains, "I don’t really eat meals. I just snack." She showed me her bag from the local health food store: kombucha, fruits, and nuts. The only chink in her discipline is Netflix on her Macbook's screen, visible through a window from outside the library.

Sarcastic Samantha drafted a Step 1 studying schedule for Lanky Luke. Samantha had taken her PA boards in January. "She killed her boards," said Luke. "She is smarter and frankly should be the doctor." Samantha responds: "I am so thankful that I didn't go to medical school." She now makes $115,000 a year as an inpatient hospitalist at a competitor's hospital. Luke took his exam three weeks in and has been relaxing all day while Samantha works 12-hour shifts, 7 days on/7 days off.

Gigolo Giorgio complains, "The stuff we're learning now is not useful in practice. For me to get those extra ten points, I have to study so many trivial details." He cited the different types of immune mediators (IL-6 versus IL-5), different RNA polymerases (Pol II synthesizes messenger RNA, whereas Pol I synthesizes ribosomal RNA), and preferred growth agar (media) for various bacteria (Chocolate agar versus Thayer Martin agar).

Jane scheduled her exam for four weeks into the period. Our typical day starts with the gym or a run, which should help Jane prepare for summer military boot camp, and we're ready to study by 10:00 am. Jane purchased a paper calendar and color-coded days for each subject. She watches Pathoma videos in the morning, then does 80 UWorld questions before lunch. She watches Sketchymicro videos when she is burnt out from questions or from First Aid. We're a little out of sync because I made the decision, later regretted, to spend two weeks shadowing a third-year Emergency Medicine (EM) resident and a ENT physician (see the next chapter).

Not everyone is as faithful to the library as Mischievous Mary. Gigolo Giorgio studies at Starbucks in the morning and expressed fear and anger regarding the company's plans to shut down for a day of diversity training. I saw six classmates working individually at a nearby county library. Through the school library's plate glass windows one can usually see two or three students taking a break on the patio. During my own breaks, the patio crowd would tend to gossip about study habits and travel plans after "Step": "How many UWorld questions have you done?" or "Are you finished with Pathoma yet?" Mischievous Mary: "Why do we put ourselves through this again?" My response: "Don't forget that we are paying three percent more tuition than last year, even though we are in school for twenty-five percent less time."

After two weeks, classmates lose some of their intensity. Pinterest Penelope sighs deeply and mutters "God Dammit" when she misses a UWorld question. Although the entire library can hear her, people no longer lift their heads in surprise. I can't resist checking Facebook or WSJ after finishing a Pathoma video or 10-question UWorld test.

Our school gives us vouchers for two practice tests and more can be purchased at $60 each. I take one about two weeks into studying and score 221: primary care. I take another 3 weeks before my exam and score 247: near-dermatology. Two days later, the Dean of Student Affairs stops me in the halls and says, "Good job on the practice test." I didn't realize that he had access to our our practice test scores.

Averaged over six weeks, I probably managed less than 8 hours per day of real study. I get to spend time with Jane. I've picked up some hobbies, such as gardening, woodwork, and biking. Lanky Luke, Sarcastic Samantha, Jane and I get together twice a week for our favorite burger-and-beers spot or for grilling at their new house. They just signed a two-year lease on a house as the apartment was not big enough for their adorable Great Pyrenees runt.

Jane's best friend from childhood comes to stay with us. She works nights as a certified nurse assistant (CNA) at a large academic health system specializing in neurological disorders. One of her recent patients, a 60-year-old veteran suffers from cauda equina syndrome ("horse's tail" syndrome, describing how the nerves of the lumbar and sacral region get pinched in the spine). The veteran had been going to the VA for several months complaining about leg numbness. "They just gave him lots of anti-inflammatories. When he came to our hospital, he was not able to walk. If he had been treated early on, he might still be able to walk."

Jane's friend described how her 25-year-old stepbrother has schizophrenia. "He needs to be committed. He is is starting to resist haloperidol injections. My father is concerned that if he is committed he will lose any future job opportunities when he gets better. My father and stepmother need to accept that he is not going to get better. Job opportunities should be the last thing on their mind. He could never hold a job in his present state. You should see some of the things he does. He goes off and buys hundreds of dollars of clothing, he moves around to new cities and lives homeless for several weeks at a time."

 

We start talking about marijuana. Jane's friend mentions that she noticed a lot of their high school friends who smoked pot early have mental illnesses. Jane, in full study mode, exclaims, "It's in our First Aid! Smoking pot early on is associated with schizophrenia." I add, "I do not understand why so little research funding is allocated to marijuana. States are legalizing. An entire generation is going to impacted with unknown complications." I leave Jane and her friend to reminisce while I walk her beagle-mix dog, a joint shelter adoption with a boyfriend. The boyfriend is gone, but the dog and his neurological disorder, which had discouraged anyone else from adopting him, remains. The animal freaks out whenever there is an unexpected noise.

I attend a Planned Parenthood event hosted by the women in medicine student group. A 27-year-old led the discussion. She graduated college and began as volunteer medical assistant and was then hired as an educator. She runs workshops at local high schools and middle schools "advocating for women's health and reproductive rights". The Our OB/Gyn clerkship director arrived late for questions.

Why would someone go to Planned Parenthood, instead of a typical gynecologist? Our OB/Gyn director: "The main reason is animonity. For example, a 30-year-old mother of four who wants birth control, but is uncomfortable telling her husband she does not want more children. The husband would see this visit and prescription bill from the insurance company. Planned parenthood can guarantee a greater level of anonymity. This is a common situation in my experience for my Muslim or immigrant patients."

 

A fourth-year student, interested in OB/Gyn: "How do residents get trained on performing abortions?" Clerkship director: "Great question. The ACGME requires that every Ob/Gyn residency program train their graduates to perform abortions. Most large health systems, such as training hospitals, will perform only medically-necessary abortions. For residents to get enough practice to meet the procedure requirements, each health system will have a connection with an abortion provider in the area for elective procedures." (Why won't big hospitals perform elective abortions? Our director attributed this to the complexity of ensuring that Federal funds weren't used to pay for the procedures, but did not explain why this was more challenging that the rest of the administrative and bureaucratic operations of a big hospital.)

Catholic-run hospitals generally do not perform abortions, except in emergencies. What about Catholic would-be Ob/Gyns? There may be an opt-out policy during residency. Thus not every Ob/Gyn will have training or experience in performing abortions.

Classmates have been more active lately on Facebook, perhaps because students are on their computers most of the day. Type-A Anita enjoys sharing "Sassy Socialist Memes" on Facebook.

"When America regularly overthrows democratically elected governments but suddenly needs someone to overthrow its own government like come on CIA where u hiding all of a sudden isn’t this ur “thing”

"Someone should probably tell the rich that workers banding together to present formal address of grievances is the alternative we worked out a long time ago to breaking down the factory owner's front door and beating him to death in front of his family? I fell [sic] like they forgot."

Anita is hoping that her Step 1 scores will be sufficient to get her into an Ob/Gyn residency. If she completes her training she will be able to bash "the rich" on Facebook while earning a salary over $200,000 per year and closer to $1 million per year if she decides to specialize in fertility.

Anita is also passionate about immigrants:

Keeping families together is reproductive justice.

Where all my PRO-LIFE and ALL LIVES MATTER people at? I can't hear y'all over the cries of immigrant children at the border...

These assholes who call parents “irresponsible” for trying to immigrate to America with their children to escape violence and create a better life for their families ARE THE SAME people who exult their own ancestors who “risked it all” to come to America on the Mayflower or some other shit … FUCK that racist bullshit

Pinterest Penelope:

If you had time to wish your dad a happy Father’s Day you had time to (depending on how tech savvy you are) google what’s happening at our border, email your state representatives about refusing to cooperate with ICE, email your federal representatives to demand they work to end this barbaric practice, and/or consider if you are able /willing to attend a protest against this injustice near you.

"This week has brought another wave of tragic news that has left me beyond repulsed and outraged. Thank you, Facebook, for reminding me 100x that my birthday is coming up and I should start a *birthday fundraiser*. I’m no Chrissy Teigen/John Legend, but I’d like to raise at least $280 to support RAICES (The Refugee and Immigrant Center for Education and Legal Services), the largest immigration legal services provider in Texas. After researching how I can help the humanitarian crisis, I found that RAICES is helping reunite immigrant parents with their children. Over $6 MILLION has been raised this week which is incredible and gives me some hope in Trump’s America. …  Oh, and 2 hours ago Trump announced he will be signing ‘something’ to keep families together... Still no plan of action on wtf will be done to reunite these families and fix this horrible, inhumane shitshow

[Editor: Penelope is from Massachusetts, whose winner-take-all family court system permanently separates more children from at least one parent in a typical week than ICE temporarily does in a typical year.]

Perhaps 10 percent of students delayed the exam by paying a $50 fee within one week of their original test date. Pinterest Penelope moved it back twice. Mischievous Mary before her exam: "I've become so frustrated, so numb from studying, that I am not even nervous. I am anxious to get it over with." Roughly as many students moved the exam up. Sometimes this was from study exhaustion. Jane moved it up four days to earn more free time before boot camp.

Statistics for a typical week Study: 50 hours. Sleep: 8 hours/night; Fun: 2 nights. Example fun: class winery tour and tasting set up by Pinterest Penelope attended by 15 students.

Year 2, Step 1 Exam

Jane takes Step 1 today. She was tossing and turning most of the night. I wake up at 4:45 am to make pancakes and pack her lunch. She departs at 6:15 am for the 30-minute drive to a Prometric test center for a 7:00 am start time. The average Step 1 score for 2017 was 229 out of 300, with a standard deviation of 20. You must score at least 194 to pass the exam, otherwise you have to take the exam again. If you do pass, however, you are unable to take the $600 exam again. Thus, you're better off getting a 193 and having the opportunity to retake than you are getting a 194 and being doomed to primary care.

[Editor: What do you call a guy who graduated last in his class at medical school? "Doctor."]

As was explained to us in Year 2, Week 26, during an eight-hour period there are seven one-hour sections, each with 40 questions. You can use the remaining hour however you like, divided up as breaks between sections. You can snack, look at First Aid, express righteous outrage regarding Donald Trump on Facebook, or call a friend. Out of the 280 questions that we've been torturing ourselves regarding, 40 of them don't count at all. These are experimental questions that might appear on a future exam. Test proctors can view students through a glass window and also through a webcam on every monitor.

Jane powers through four sections in a row, then takes a 30-minute snack-and-bathroom break, and finally chugs the last three sections. She finished before any other classmate I've talked to. "There were so many questions I had no idea about. I would look them up afterwards and still have no idea. They are not even on the internet." She adds: "Some questions have this essay long prompt, and I when I get to the end, I would literally mouth, 'What the hell?' The test proctor must have been laughing watching the webcam feed: 'Look at this girl. She is really struggling.'" Doctors need not be numerate: "I practiced so many statistics questions, but on the exam itself  I used the calculator only once."

We celebrate her finish by going downtown for $5 happy hour martinis at a fancy patio bar.. Asked how she thought she'd done, Jane stuck to "I plan to use the mature defense mechanism of suppression until my score comes. Nothing to do but wait." (She will get her score in three weeks.) Regarding the celebration: "This is such a finisher prize. I probably failed."

I slept well the night before my exam, two weeks later. Jane packs me a large lunch. Every computer is filled at the test center. Some of my classmates are taking a mock Step 1 exam in the test center for $80. The software format and some questions are nearly identical to UWorld's. Example: What part of the urethra gets injured in pelvic trauma? Membranous urethra.

I do three blocks with no break, then take a 30-minute break for lunch. I power through four in a row, with a 1-minute breather break in my computer chair in between blocks.

I nearly ran out of time on two blocks. Several questions have three-paragraph prompts even if the question only requires the last two sentences, e.g., What is the mechanism of a mentioned drug? I had to rush through perhaps ten questions total. Overall, I do not think studying more would have changed much. I should've completed more UWorld questions, but this might have affected only a few borderline questions. I did about 50-60 percent of the 2200 available questions. Advice: Start studying UWorld in September, reset it at the beginning of the study period, and try to get through all 2200 again.

I was surprised at the number of questions on the immune system. They asked about various inflammatory mediators: What causes swelling after a sprained joint? Histamine or C3a (complement factor). Which of the following growth factors stops proliferation? PDGF, TGF beta.

When I return, Jane has mojitos prepared from our organically grown mint plant. We went downtown and I avoided talking about the experience, use of the mature defense mechanism of suppression: consciously ignoring information. Jane: "Are you sure you're not repressing this information?" (a reference to the immature defense mechanism of unconsciously ignoring bad news.)

Jane gets her score back the next day. She scored 248. That should be one standard deviation above the mean or roughly the 85th percentile, a great achievement considering her four weeks of study. Wow!

Nobody expressed complete confidence in his or her performance. Mischievous Mary:  "I convinced myself every question that I got wrong is a mock test question." Geezer George: "Unbelievable, those questions. I had to take solemn walks after each section." Gigolo Giorgio: "I just had to laugh at some questions. It was a tragic comedy."

Jane and I relax before she departs for boot camp. We go on hikes, organize the house, and do yard-work before she departs. Although she will be required to do a residency at a military hospital, they are advertising residencies to her for specialities on which the military is current short. One powerpoint for a psych residency features beach-front facades of Hawaii and an ocean photo with a resident quoted as saying, "This is our view from our conference room, fyi."

Pinterest Penelope's two exam delays shortened the trip to Thailand with her M4 boyfriend to only one week. They post photos of themselves drinking oversized fruit-and-booze concoctions next to elephants on the beach. Type-A Anita, meanwhile, is more interested in the white elephants of Washington, D.C. On a resignation from the Supreme Court: "Fuck that cowardly limp dick Justice Kennedy." Later she shares a post regarding an ICE checkpoint on a Manhattan subway train. I didn't ask her how many of her Facebook friends she thinks might be undocumented immigrants and therefore able to use this information.

We'll all be back in July for M3 clerkships (informally known as "rotations").

Year 3, Week 0 (Orientation)

Students return for Year 3 of medical school. We've had a 2-4 week break depending on when we took our Step 1 exam. Most students, including me, are still waiting on their Step 1 scores. Lanky Luke surmises that we took a new test, which required aggregation of a few weeks of tests to normalize the scores to previous versions. Five classmates met up in Seattle for a road trip through San Francisco, San Diego, and the Grand Canyon. I visited family, and relaxed with Jane before she departed for boot camp. She returns next week.

"I am ready to learn some real skills," exclaims Lanky Luke. "When friends and family ask about their various medical issues, I realize how little I know." Hard Working Harold: "Give me a multiple choice question and I'll answer the shit out of it. Send me into a patient room, and I'll have no idea where to start."

Orientation begins at 7:00 am with an introduction from the clerkship director, a practicing psychiatrist. "When I went to medical school, we used to call you clerks. You are no longer a student. You no longer shadow." She lays out some basic principles for success:

 

  1. "If you meet with me, it's because you're in trouble. I will be following your progress from afar. I hope I never see you in my office until you apply for residency."
  2. "The focus is no longer on you. This can be hard for young people. If someone does not smile back at you or yells an expletive because they just lost a patient on the OR table, do not take it personally."
  3. Become part of the team. "The team will function with or without you. Don't get in the way. If there is a trauma that needs urgent resuscitation, this might not the best time to be asking questions or trying out new skills. You can impact patient care. Every block we get a report that a medical student discovered a complication. You will be able to know your patients at a much greater detail than residents or attendings because you have more time per patient."
  4. Duty hours. "Know your Duty Hours. It's your responsibility to not violate them. You cannot work more than 80 hours per week, averaged over four weeks. It is extremely hard to violate this. I've had students in the past complain to me that they are being forced to work more than duty ours when they are getting of at 5:30 pm when they just had radiology rotation last week. Come on… Also, don't complain on evaluations when you get out at 5:30 when they told you would get out at 5:00 pm. Things change. to get out to avoid this, I've stopped telling my students when I expect us."
  5. Be curious about everything. "Even if you are not interested in psychiatry, you need these skills for any specialty. We had a student deliver a baby on the psychiatry floor."
  6. "Check your email, not instagram. I make an effort to answer email until about 11:00 pm. That means if you believe it is necessary to send me an email at 10:30 pm and I respond, DON’T reply back in 5 days."
  7. Scrubs are not to pick up ladies. "Don’t steal scrubs. We watch. Scrubs Out must equal Scrubs In. An OR employee took a video that was sent to my desk showing a few medical students wearing their bloody scrubs at a local bar hitting on some women. I laugh when I get video of students walking out with scrubs on." [Gigolo Giorgio: "How do they catch us? They must be surveillance cameras on the exits!"]
  8. "Take evaluations seriously, especially learning environment violations [e.g., physical or mental harassment by attendings, inappropriate conduct towards students]. For God's sake, read the question. I have so many examples of someone checking "Yes" and putting "N/A" on the learning environment violation. If you have a reportable offense write it, but spend enough time reading it to know what you are answering. It matters. The LCME scrutinizes our reported rate. They are like the Supreme Court.  Five people came from LCME a few years ago. They analyze every detail. For example, they ask how many residents we have here. They then asked to see every resident's signature attesting they receive training about the learning environment. I know they cross referenced every one."

Our next presentation is by the Dean of Student Diversity. Her new assistant, the Inclusion Coordinator, joins her and helps pull up her PowerPoint. Title slide: "In pursuit of cultural sensitivity and awareness."

She begins by explaining her own implicit biases and insensitivities. "I want everyone to go home and take Harvard's implicit bias test. I learned a lot about myself. For example, I have an implicit bias that males are better leaders than females. I apparently have a bias that women are not as good at science. I didn’t even know that about myself."

 

The talk concluded with a request that students share microaggressions that they had suffered personally. Fashionable Fiona shared that one of her relatives told her, "You should go to nursing school instead of medical school. It's too hard. I was pleased to say, 'I already got into medical school.'" [She got an award for her year 2 block exam performance.] Several women shared that patients mistake them for nurses instead of medical students. One student shared an experience in pediatrics when a nurse asked who the mother for the name of the child's father. She replied that the kid has two mothers. The nurse replied, 'But who is the dad? I need to fill this in on Epic.'"

The Dean of Student Diversity concluded: "I hope everyone goes home and reflects about their own implicit biases. We each should strive to learn about a new community everyday. I will admit that I am ignorant about much of the transgender community. I am trying to learn about their language and customs. I don’t know much about them."

The next day we begin with a presentation from a Department of Health official about vaccination. "As you begin your rotations, you are going to interact with patients that do not believe in vaccines. As a healthcare worker you need to know about the misconceptions that are out there."

The biggest misconception is that vaccines cause Autism. She explained that this movement originated in Dr. Andrew Wakefield's study that found eight children who got MMR around the same time autism symptoms presented. This caused havoc in the UK. MMR vaccine rates plummeted, yet Autism rates persisted. The UK now has 80 percent MMR rates, well below the 95 percent required for herd immunity. Measles is now endemic in the UK.

"We find that physicians are a key communicator in the community to get vaccine rates up. Most of the time, the parents will change their mind if you delve into their thought process. That takes time that most physicians unfortunately don't have anymore."

Orientation concludes with a presentation on social media pitfalls and patient privacy. The Privacy Officer: "Long story short: don't snapchat or instagram. Talk about patients in the resident lounge not on elevators." [This advice was not heeded as Pinterest Penelope decided to snapchat a drug-screen result testing positive for benzos, cocaine, meth, heroin, and thc for a patient with the caption, "Must have been a crazy party."

Friday afternoon, I volunteer at the free clinic associated with our university. I interview the patient first, and then present the findings to an M4. We then interview the patient together and give a final report to the attending, typically an internist, family medicine physician or emergency medicine physician. The first patient: 56-year-old female with a history of depression and type 2 diabetes presents for a diabetes check up. She has been doing fantastic, losing 50 in one year while keeping her A1Cs in the 6 percent range. However, last year, she has gained 40 pounds and her A1C this visit has jumped to 7.5. As I do a medication overview, she says she has been taking depakote (valproic acid), a mood stabilizer for bipolar disorder. Why? She explains she was prescribed it when she was brought to the ED while using heroin. She lied to the physician who took her symptoms as a manic episode. She has not seen the prescription physician since her ED visit. I ask, "Do you have a history of bipolar disorder?" She responds, "No." She began the depakote around the time she began gaining weight. I speak with the M4 who recalls that depakote can cause a metabolic syndrome. We both go in an complete the exam. He quickly goes through a focused diabetes physical exam, complete with assessment of peripheral neuropathy and retinal exam. He fluidly asks questions focused on diabetes symptoms, e.g., polyuria, visual changes, numbness/tingling in the feet, shortness of breath. We propose our plan to the attending who decides to decrease her dose by half and have her follow up in a few weeks. Overall, I realize how out of practice I am with patient interview and physical exam skills. I recognize that I need to be able to do a diabetes exam, including retinal exam, peripheral neuropathy exam, like the back of my hand. It was exciting to see the M4 perform the exam with such fluidity.

Statistics for the week… Study: 0 hours. Sleep: 8 hours/night; Fun: 1 night. Example fun: Jane and I attend our class' July 4th BBQ on the weekend at a classmate's house. We had an excessive amount of food and beer featuring ribs, burgers, chicken thighs, and local craft beer for a cost of $4 per person paid via Venmo. We eight, including me, who are starting on surgery on Monday are the butt of jokes. Mischievous Mary: "Throwing you to the wolves." I talked with a refugee-status immigrant from Lebanon who attends the same church as a classmate. Straight-Shooter Sally overhears this and adds, "Oh, have you talked with Geezer George? His family is from Lebanon and he visits there regularly and is always talking about how great it is and encouraging us to come with him."

Year 3, Week 1

Eight of us arrive Monday at 6:00 am for surgery rotation orientation in a small conference room tucked away in the basement of the hospital. The surgery clerkship director introduces himself, and demonstrates suturing, hand ties, and laparotomy technique using a neat simulator device for 45 minutes.

He then leads a 45-minute discussion on postoperative care and complications. "Everyday the attending wants to hear the vitals, labs, and I/O [input/output]." The first two or three days after a surgery, the stressed body will hold onto water. Beginning Day 3 or 4, the body will begin to mobilize fluid. If you don't see this happen, you should start to worry." Does anyone know when is the highest risk for postoperative MI? [blank stares.] "It's day 3 or 4 if the patient does not mobilize fluid. The fluid overload basically causes congestive heart failure." We learn about the five most common causes of postoperative fever [5 W's pneumonic]: Wind (pneumonia/atelectasis), Water (UTI), Wound (infection), Walking (DVT), and Wonder Drugs.

General Surgery at our hospital is organized into four different services: (1) elective, (2) emergency, (3) trauma, and (4) pediatric. The speciality services, for example, cardiothoracic, urology, otolaryngology, orthopedics and vascular are seperate teams. If a trauma alert comes in from, e.g., a car accident, the trauma service responds by meeting EMS and patient in the trauma bay. If someone comes into the ED for an appendicitis, emergency will go to the consult and determine if they need emergent surgery or if they can wait for an elective surgery later in the week. Each team has one attending, one chief resident (PGY4 or PGY 5, postgraduate year 4, i.e., 4 years into residency), one mid-level (PGY 3 or 4), an intern with 1-3 medical students. The interns started only a month before us so they are also learning the ropes.

For the next three weeks I am assigned to the elective general surgery service along with classmate Christian Charlie. His fame among classmates was assured during the first year mock breast exam when he exclaimed, "Is this what breasts feel like?!?" During anatomy lab, he asked, "Is this where the clitoris is located?" (He was engaged when these questions were asked, then married at the end of Year 1.)

Orientation wraps up around 7:20 am for us to meet our team for a few minutes before the first case of the day. I meet my Chief as she downs one of her favorite La Colombe coffee cans in the Surgeons' Lounge. The PGY3, Quiet Quincy, and intern, Bumbling Brad, walk in shortly after me. Quincy is pretty open about his situation. He originally wanted to do orthopedic surgery, but did not get into a residency program. Having failed to match, he did two preliminary years in general surgery at two different institutions before finally getting a "categorical match" in general surgery (starting as a third year) at our institution. The intern couple matched with his girlfriend who is doing plastic surgery.

[I asked Brad about the couple match process. "It was terrible. We didn't get any of our top choices for her to do plastics while I did general surgery. Two spots makes up a large percentage of a residency's slots." He didn't have to be married to his match partner? "You can couple match with anyone. You don't even have to match to the same institution. You can couple match as friends, as same sex." He joked that if you really detest someone, you could couple match and rank hospitals at opposite sides of the country.]

Charlie and I are assigned by the Chief Resident to one of the two attendings operating today. The Chief joins one attending while the PGY3 and intern manage the floor of post-operative patients. The PGY3 may occasionally scrub in if the chief declines the case, if the attending requests him/her or if the PGY3 has been following the patient for a
takeback (additional surgery following a complication). The intern never scrubs in. Brad explains: "They want you to be begging for the OR." The intern, PGY3, and I head off to the floor to manage post-operative patients while the chief and Charlie head to the OR for the first case, a lap sig col (laparoscopic sigmoid colectomy).

Around 9:00 am, I head down for my first case, a
melanoma (skin cancer) excision from the left thigh. I introduce myself to the patient in the pre-op with the chief. I then go through the "OR tunnel," turning around once to grab a hairnet after a nurse yelled, "Where's your hair coverage?". I walk in and the four individuals in the room look up briefly as they continue their preparation. Fortunately, Quiet Quincy told me to always introduce myself when walking in: "Hi, I am a third-year medical student who will be scrubbing in." The circulator nurse responds, "Get your gloves." I don't know where they keep the gloves… I look around and see the cabinet. The goal to pick up two layers of gloves and get them on without anything non-sterile touching the outside of a glove. The packaging of the gloves is considered contaminated. Only what's inside the package is guaranteed to be sterile.

I grab "8.5 under, 8 over" gloves (two pair) and walk over to the sterile field. With my contaminated hands, I peel back the glove pack so that Loudmouth Lilly, the surgical technologist (surg tech, aka scrub tech) can grab the gloves without touching the outside contaminated plastic covering.  

Lilly enjoys poking fun at my surgical oncologist attending and, especially, medical students. She grins and asks, "So how many gowns will we need with you?" (Assuming that I will "break the field" and have to re-scrub.) I nervously smile, "Just in case, I'll grab another one."

The patient is rolled in by a nurse and the anesthesiologist begins propofol [Editor: Michael Jackson's first choice] and the inhaled anesthesia. I ask the circulator nurse to help me place the "foley" (foley catheter, a plastic tube placed into the urethra to empty the bladder). We both grab another pair of sterile gloves, just for this procedure, so that she can guide me through it. There are subtle tricks to make it easier, for example, pulling the plunger out of the lube syringe so you can anchor the foley tip. This stabilizes the foley so it stays in the sterile field until you are ready to insert it into the urethra. "Make sure you grasp the shaft firmly, once you place your hand down, it needs to stay there because it is no longer sterile." I advance it until I see the flash of urine, retract it a little bit and blow up the balloon to anchor it in the bladder.

Quincy and I then go to scrub in just as the attending arrives. He is a new attending in his 40s who completed a surgical oncology fellowship after completing a general surgery residency. I take the chlorhexidine sponge and scrub for 10 minutes. After I rinse off, I struggle for a few seconds to push the OR doors open (a practiced butt maneuver; everything below the elbows must remain sterile), upon which the circulator nurse opens them for me.

The surg tech hands me a towel to dry my dripping hands. Lilly then opens the gown as I spread my arms into it. "Keep you hands inside." The circulator nurse ties the gown from behind. I struggle to dip into my gloves as the surg tech opens them up. My fingers are in the wrong glove holes, but this can't be fixed with a non-gloved hand so I need to wait until the other hand is gloved to try to fix the situation. "These gloves are way too big. Get 7.5/7.5". Once the circulator nurse hands the new gloves to the surg tech, we reglove again. The surg tech whispers, "You'll get better." My second glove dive goes much more smoothly. I start walking towards the OR table. Lilly: "Hey, your card!" Oops. I need to finish gowning by wrapping the belt around. I hand the tech a card attached to one end of the belt. She holds it while I spin around thereby wrapping the belt around me. I then yank the belt end, detaching it from the card, and tie it in front. The nurses hoard these little cards. Why? "We write notes down on them. It's kind of a bragging right if you get a bunch of them." I take my place next to the PGY3 on the patient's right with the attending, surgical tech, and her Mayo stand (stand over patient with accessible instruments) on the opposite side.

The pimping starts immediately. What are the different types of melanoma? Easy. Sarcastic Samantha gave me her copy of
Surgical Recall. I keep this book in my white coat and reviewed the section and also UpToDate before the case. He realizes this, and changes the subject to soft tissue tumors. What is a sarcoma? I respond: "A neoplasm derived from mesoderm." What kind of animals are they classically found in? I'm stumped, and take a wild guess. "I'm going to guess dogs." He scolds me: "You need to answer confidently. It's okay to be wrong, but be confident. You know more than you think, and you must be confident with patients. I would rather you be confident and wrong than be right and timid. Now is the time to be wrong when you have attendings and residents to correct you… And by the way, dog is the right answer. We've learned most of what we know about sarcomas from studying them in dogs."

[Editor: A peek into the often-in-error-but-never-in-doubt factory!]

The pimping continues as we sterilize and drape the patient's left thigh and inguinal (groin) region. I am tasked with taping the scrotum up to prevent contamination. How large an incision do we want on this melanoma? I respond, "Margins are based on the depth of the lesion. His lesion is under 1 mm and not ulcerated, so we need 1 cm margins." He respond, "Okay, that's not answering the question. Quincy, how will you make your incision?" He turns his attention to Quincy but summarizes every step in a confirmation of my presence. Quincy uses a sterile ruler to draw a 1 cm margin around the 1 cm circular lesion. He then creates a 9:3 cm ellipse to get good closure." The attending asks me: "Do you know why we drew this ellipse?" "Is it easier to close? I mean, to make it easier to close." He responds, "Yes, but why?" I don't have a good explanation. "You need to stop us if you do not understand something. I assume you know it if you say nothing." He moves on to continue the case. The questions cease once he watches the PGY3 make the incision and inject "Local" (lidocaine with .25% epi mixture in a syringe). Once they removed the entire ellipse down to the rectus femoris fascia, the attending marks the superior and lateral margin of the specimen with a long and short suture that I get to cut with a suture scissors. I use Army/Navy retractors to retract the skin as they mobilize the skin around the thigh. The attending asks Quincy, "How would you close this?" The PGY3 responds, "I would do a deep dermal with 2-0 vicryl, then a running subcutaneous with 4-0 vicryl and dermabond." "Okay do that." He turns his attention to me while he watches Quincy's shaking hands at work.

He asks me, "How do we determine what lymph nodes to remove?" I respond, "We injected contrast for the PET/CT scan, and we inject dye that flows down the lymph node [I'm not sure when we injected the dye, perhaps with the local?]. "Yes, you must do a sentinel lymph node for any melanoma that is not in situ. Clearly this had 1 mm depth so we know it spread beyond the basement membrane. I'll look for the black dye we injected in our lymph dissection, and we'll use the scintillator to trace for nucleotide uptake. We're good once we get all the nodes with a hit less than 1000." We finish the lymph node dissection in about 30 minutes, and then the attending scrubs out while Quincy and I close -- Quincy sutures, while I cut the knots. The first few cuts I am freaked out that I will ruin the knot by cutting too close, but I quickly learn to slide the suture scissors until I hit the knot. I get out of the OR at 5:30 pm after two more melanoma cases, each requiring a lymph node biopsy. We never get a lunch break.

Our team meets with the night team in the OR lounge for the evening handoff. We also divide up responsibility for checking on ("rounding on") particular patients the next morning.

Tuesday is the first day that is typical of the rest of the rotation. The surgical oncologist (attending) starts his rounds at 6:30 am, requiring the Chief (resident) to start her rounds at 6:00 am. I have to see my patients before she starts and therefore wake up at 4:00 am, shower, and try to grab breakfast at Chick-Fil-A (discovery: they open at 6). I eat a few granola bars on the way to the OR locker rooms to change into hospital-provided scrubs. I arrive at the PCU (patient care unit) at 5:00 am and talk to the overnight nurse and night team intern about my two patients. No changes. I had not been present for either of my patients’ surgeries so I have to read the notes that are made confusing by Epic's auto-populated SmartText templates (two pages of insignificant labs before the assessment and plan sections).


I review the patient's overnight vitals, I/O (input/output), and labs (at a minimum, CBC and CMP (complete metabolic panel) every night). Being unfamiliar with the most efficient summary screens (e.g., the "Rounding" tab), how to customize Results Review, and how to read I/O, I don't get into the first patient's room until 5:30 am.

My first patient: "Greg", a 70-year-old s/p pancreaticoduodenectomy, commonly known as a Whipple procedure, for a biliary duct neoplasm on POD #6 (Postoperative Day 8, meaning he had the surgery on Wednesday of the preceding week). He has a pancreaticojejunal anastomosis leak, a common complication. This requires three peritoneal drains and NG tube decompression. The bilious drain output is increasing. His wife and two daughters are there (at 5:30!) and requesting a pathology report from the surgery. Is this a malignant tumor? I tell them the pathology report is still pending, but I will bring this up with the surgeon (same as this week's attending). After I examine the patient, I write a progress note on the patient using a student SmartText template on Epic. Medical student notes require a co-signature from a resident, so the result is that the resident spends more time than if he or she did it to begin with. My classmate and I keep getting kicked off the limited number of computers by nurses and residents from other teams. I finish his note around 5:50, leaving little time to interview and document the second patient.

When the Chief arrives with her La Colombe coffee, the intern, resident, Charlie and I sign off our computer and follow her lead. Our pack of five travel the hospital and stop outside each of the ten patients on our service. The resident, intern or med student assigned to the patient presents the case in a 30-second-maximum presentation: one-sentence description of procedure; any highlights for vitals, labs, or overnight events; I/O including drain output; medications (pain control, dvt ppx (deep vein thrombosis  prophylaxis); and plan (diet advancement, tube removal, imaging required, etc.).


We get back to the nurses' station a few minutes before the attending arrives at 6:30 am. We repeat the rounds with the attending. I mention the family requesting pathology results. He interrupts and instructs the whole team to never go over pathology reports with Whipple patients. "It is essential that I tell them what the pathology report says. We never discuss this while the patient is in the hospital. His goal right now is to get better, and only after will we begin that discussion." The pathology report is released that afternoon: Adenocarcinoma of the biliary tract. A death sentence. Even if he gets out of the hospital, he is going to have to get non-curative chemotherapy.

The Surgeons' Lounge is where surgeons get frustrations off their chest. I ask the Chief: Do you think my patient was a good candidate to get a Whipple? "Surgeons are by nature optimistic, especially <surgical oncologist>." One surgeon joked: "I do not know where he finds these patients. They're cockroaches, they just won't die." One attending chimed in: "One of his patients was so fat it took 160 Liters [of air] to insufflate. My god." [insufflation: before laparoscopic surgery, the abdomen is punctured with a needle and pushed full of air until 12 or 15 mmHg. This allows better visibility when the other laparoscopic ports are inserted. Normal insufflation volume is 5-10 Liters.]

Quincy and I step out to refill our water bottles and he offers advice about the surgery rotation: "Much different criteria than internal medicine. Internal medicine wants to see how smart you are. That’s the time to show your intellect, to pontificate about the nitty-gritty details. Surgeons want to see you’re willing to put in the time and effort. You need to be competent, but hard work is a lot of what it takes to become a good surgeon." He adds, "Also, make sure you know something about the patient before you go into the OR. You’ll get chewed out if you walk into a case and don’t know the patient name or HPI [History of Present Illness]."

After the nurse rolls Tuesday's second patient in for a cholecystectomy (gallbladder removal), around 9:00 am, the anesthesiologist begins Propofol in a peripheral IV. I learn that if I want to do procedures, get to the OR early and make friends with the anesthesiologist. She guides me through placing a radial arterial catheter line ("A-line"). It takes me three sticks. "Good job, those are some calcified arteries." (The Patient Care Unit (PCU) nurses that evening express concern about a large bruise on the wrist.)

The OR team can tell by the small details if you are competent or a newbie. Do you pull your arms all the way through when you spread your arms through the gown or stop at the white cuffs? Do you reflexively hand the belt card to spin around after your gown is on? Do you wait for the surg tech to acknowledge you or just open and hand your gloves to the surg tech? Do you grab the razor to shave the patient once he/she is under anesthesia? Do you get the Foley package or do you hover around the nurses until they grab it? The hardest part is learning the terms and abbreviations for different instruments and dressings. Once you master the smaller details, the surgeon will let you do more important things, such as closing the 5-port (smallest lap port incision) or suturing in a drainage tube.


The team discusses where to place the first port. Our attending: "What are the layers of the abdomen here, pointing to midline under the umbilicus [belly button]?" Me: "We are above the arcuate line, so from deep to superficial: Transversalis fascia, followed by the anterior and posterior aponeurosis." The surgeon interrupts: "We’re midline…" Me: "Sorry, sorry, we have the linea alba, and the transversalis fascia."

The Chief makes an incision and burrows down with her fingers. The attending watches and asks me, "What is the first step in this operation?" Me: "We need to insufflate the abdomen to 15 mmHg." Silence, indicating a correct answer. The surg tech hands the Chief a trochar (rigid hollow tube with valves) to penetrate the fascia and enter the peritoneal cavity. I see the pop, they blow the balloon up and begin insufflating the abdomen with air. As the belly rises, the Chief slaps it.

The Chief: "Why do we slap the abdomen?" My guess: "To make sure it’s all the way in?" She is too polite to point out my error: "Yeah, we want to make sure we are pumping air into the peritoneal cavity, and not into the colon or small bowel." Once insufflated to 15 mmHg, they remove the trochar, and place the laparoscope into the abdomen. I look on the television screen as the greater omentum appears followed by the small bowel and liver. They look down into the pelvis as they poke on the belly to place the next ports. They make two incisions and use blunt dissection (with their fingers or dissecting scissors) to create a path for the ports. The Chief hands me one of the port and trocars. "You do it." I apply pressure, but the fascia is not giving. "Rotate it, it’s more of twist and shove than just a shove." The transversalis fascia eventually gives and we have the ports placed.

Our overall goal: remove the gallbladder after gaining control of the cystic duct and artery. The attending grasps the gallbladder with "a Maryland" (forceps) while the Chief dissects the soft tissue attachments until the cystic artery and duct are two distinct structures. She applies 1 cm metal clips across the proximal and the distal end of what we believe is the artery (but was actually the duct). The Chief applies a clip to what we think is the duct and makes an incision with the scissors. The blood squirting into the abdomen tells us that we switched the artery and cystic duct. Attending: "Give me suction." Now that the blood is being vacuumed out we can see and apply two clips to stop the bleeding. Fortunately this artery won't be needed after the operation is complete. It takes the Chief six attempts to get a catheter into the duct so that we can inject contrast for an X-ray (fluoroscopy). The Chief and attending express frustration at the 5-minute wait for a tech. "They knew we would need them." Her results shows two stones in the common bile duct (CBD). We call in a gastroenterologist for an ERCP (endoscopic retrograde cholangiopancreaticography). I hold the port while he drives the scope. We get to the duodenum quickly, but it takes 10 minutes to locate and cannulate (push tube out from the center of the scope) the Ampulla of Vater. We are looking for a pyramidal projection of mucosa where the liver and pancreatic juices drain into the duodenum for digestion. He finally finds it and injects saline to dislodge the stones. After injecting more contrast to confirm there that we got all of the stones, the GI leaves while the surgical team begins again. The Chief uses the Mother of All Staples to place 200 staples along two inches of ligaments attached to the liver. This is a two-minute procedure with the Ethicon rep in the room available to answer stapler questions. We use an in-abdomen bag-and-seal device for the gallbladder and yank it through the large endoscope port. I remove it from the plastic and the walls are slimy. When compressed I feel about five hard rocks.

The attending scrubs out, and allows the Chief and me to close the fascia and ports. Three more operations, no lunch break, and I get home at 7:30 pm. Pass out at 9:00 pm. Wake up at 4:45 am and do it again.

Jane is on her psychiatry rotation. She goes in from 8:30 am to 4:00 pm. She loves her Chief resident and attending. They bonded over the Harry Potter pin on her white coat. She interviews admitted psych patients while the attending observes.

In addition to AM rounding and cases, we eight students on the surgery rotation attend two lectures/round-table-discussions per week. This week is on appendicitis and diverticulitis by the surgery chairman. He's a smiling portly fellow who wears bowties and pimps residents and students alike on the history  of surgery. Our class president, a huge suck-up, asks, "Isn't it tough for a surgeon to have so much pressure. How do you cope?" The Chair asks everyone to introduce themselves and say what their interests are. Everyone says they are interested in surgery. I know they are not.

Friday morning we round 30 minutes earlier so that we can get to the M&M [Morbidity and Mortality] conference and resident lecture. Med students sit in the front with residents behind and attendings in the back. After M&M, an attending lectures on a surgical topic focusing on Boards. The attending selects an intern to answer questions. If he/she is unable to, the attending goes back a row to a PGY2, etc. Medical students are never called on.

Statistics for the week… Study: 0 hours. Sleep: 5 hours/night; Fun: 1 night. Example fun: Burger and beers at 5:00 pm. Mischievous Mary is the first to complete her 100-beer list. We joined in for the celebration, but leave at 7:00 pm for my 8:30 pm bedtime. Year 3, Week 2

"The first week was pure adrenaline. I never felt tired. This week I'm crashing hard," comments Surgeon Sara, a classmate on the emergency surgery service, as we head up in our scrubs to the PCU at 4:45 am. I've learned that I need more time so I wake up 15 minutes earlier at 3:45 am. We both reminisce how we should have studied basic postoperative recovery timeline (e.g., Enhanced recovery after surgery (ERAS) protocol, pain medication regimens, anxiety meds, etc.).

Several of the attendings are on vacation so we have a light caseload for elective (non-orthopedic) surgery with the exception of the surgical oncologist's cases. The Chief is very excited about "her Whipple" on Thursday. I let my classmate Charlie scrub in on some more melanoma cases while I try to get in on some cases on other services. There are always ample orthopedic cases going on all hours of the day (including Saturdays), so my goal is to find a joint replacement.

The first step is to check Epic for the "Status Board" of scheduled surgeries. There are no private desks or offices. Using a personal device is challenging due to VPN requirements for accessing the hospital's Epic system. I take a rolling cart containing a Windows PC, which will connect via WiFi and Citrix, to the end of a deserted hallway. I find a shoulder replacement that looks interesting and watch a couple of videos in prep while consuming Cheez-Its and granola bars at 10:00 am.

 

Second step is locating the attending to ask if I can scrub in. Epic shows his name, but not a photo. His university profile page contains a photo, but these images are usually 10-20 years old. There are six attendings in the OR lounge, identified by badges, and I find him on my third attempt. "Of course, I’ll see you there in ten minutes."

 

We're doing a total shoulder replacement. I help retract as the surgeon hammers in the prosthetic joint parts. When finished, the surgeon steps out to begin another scheduled case and the PA allows me to close the incision sites under her guidance. I ask where I can get trauma shears, the most coveted item for medical students hoping to be useful during rounds and trauma alerts. They can be used for cutting clothes off a trauma patient, during dressing changes, and for chest tube removal."Stay here" She disappears for 30 seconds and returns with a brand new pair.

 

I get out of this case and a follow-on shoulder arthroscopy (minimally invasive procedure using endoscopy to evaluate and clean out a joint) at 12:30 pm and find my team in the OR lounge. The cases are finished, and they are planning to check in with the intern before the Chief heads out for the day. I check the status board and notice an organ procurement procedure is posted. I ask my Chief if I can see that. "Yeah, they might already be finished." As we are in the elevator, Christian Charlie mentions, "That’s awesome you’ll be watching an organ harvest. Good luck!" The Chief responds: "We don't use the term harvest; it's 'organ procurement'. But yeah, they are surprisingly quick, in and out in 30 minutes, but you can’t beat the anatomy experience." I head down to OR 10.

 

When I arrive, there are 10 people sitting on the floor outside the OR. The donor is 35 years old, suffered a car crash a week earlier, was declared brain-dead yesterday and had care withdrawn, thus initiating the donation cycle. Three different transplant programs have arrived -- a heart, a lung, and a liver/kidney team. They're waiting for final approval from the hospital's legal department while the donor is kept perfused by the anesthesiologist, the one remaining member of our hospital's team. The patient checked the organ donor box for his driver's license years earlier, but the organ donor program (typically a contracted company for the state) also sought and received written consent from his wife, which initiated the transplant program (the care team never brings up the possibility of organ donation with a family). Two hours, the wife withdrew her consent and requested a delay for reasons that are unknown to us.

The heart team includes an attending, a cardiothoracic surgery fellow, and resident. I take them to the cardiology reading room so they can review the TEE (transesophageal echocardiogram) images to confirm an acceptable heart. Everyone agrees it is a strong heart. When we return, there is no resolution on the consent issue. I check back in with my team still in the OR lounge. Christian Charlie went home around 2:00 pm, and the Chief is packing up. I head back to the OR and take a seat with the transplant teams.

The surg tech explains that he is on call for blocks up to 72 hours, and has to be at his local airport within one hour of a call to board a business jet.

[Editor: Our Boston-area organ program has a Cessna CJ4 and the pilots work week-on/week-off shifts.]

The state-authorized transplant coordinator finally gets an update. The wife wants to cancel the donation. This ignites a tense discussion among teams and four institutions legal teams (our hospital's, plus lawyers from each of the three hospitals that have sent transplant teams). The attending from the lung team wants to go ahead; the other two are leaning towards declining. A life-or-death situation calls for people to drawn on all of their philosophy, moral background, and legal training: "I'll decline, if you'll decline," says the liver/kidney attending to the heart surgeon.

The lung team calls home to see if they can use the other organs, but the transplant coordinator begins calling further down the list. "We have to continue going down the list as long as my program and legal say its a go."

"My responsibility is to my patients and their families back home," says the lung surgeon in an Old World accent and a tone that would earn him a role in the next sequel to Silence of the Lambs. The heart attending: "If the wife starts talking to the press, this will set back transplant medicine a decade. I know we might have legal ground, but as a doctor if you are not comfortable with something you always have the right to decline." The perfusionist on the lung team: "This doesn't seem right."

 

I leave at 7:00 pm and learn the next day that the organ procurement occurred at 3:00 am. Hannibal Lecter got his lung and two new teams jetted in overnight for the two two. Ultimately the widow had agreed to the procurement.

 

Thursday is the big day. The Whipple, a 6-11-hour procedure to remove a bile duct tumor (see Week 1). We are the first and only case scheduled for our OR. Only one student can be officially scrubbed in at once, so Christian Charlie and I agree to alternating two-hour shifts. We finish rounding at 6:45 am and head down to Pre-op to introduce ourselves to the patient. We help move the patient from her stretcher onto the OR bed, and the CRNA (Certified Registered Nurse Anesthetist) lets me intubate the patient!

Charlie scrubs in first. I'm not officially scrubbed in, but watch from a stack of three step stools behind the drapes at the head of the bed.

The chief begins with a large midline incision from one inch below the xiphoid  to one inch above the pubis. Christian Charlie helps suction and retract. Once the parietal peritoneum is opened, the Chief uses clips and the Bovie to dissect the lesser omentum of the stomach. The attending questions Charlie: "What vessels are we cutting?" (short gastrics) and "What space are going into when we cut this omentum?" (lesser sac). Charlie won't admit ignorance: "It's something in the abdomen." From my perch I ask, "Why don't we have to remove the fundus if we take the short gastrics [that are supplying the fundus with blood]?" The attending explains, "The stomach is one of the most collateralized organs in the body. You can take a few vessel groups and it will still be happy."

After about 30 minutes, they've gone too deep for me to see anything so I head off to my secret alcove and find the computer still there on its rolling cart. I watch YouTube videos of the Whipple procedure and read UpToDate as I eat Cheez-Its.

Charlie and I swap for the rest of the day. The most exciting part was when we were dissecting the common bile duct off from the portal vein. The tumor had spread into the adventitia of the portal vein requiring extreme care. "Careful, careful!" exclaimed the attending as he takes control from the Chief. The team will work until 11:30 pm, but Charlie and I have to leave for a required "learning environment" session at the medical school hosted by the Chief Diversity Officer. Charlie is unhappy about missing the rest of the operation and as we walk over, we encounter Ambitious Al, who had to scrub out of an exciting rib plating on a car accident victim ("MVC" for "motor vehicle crash"). "They might have let me do the chest tube."

We are 10 minutes late, but people are still filing in. We watch the same PowerPoint that we've seen four times previously in two years about types of reportable mistreatment. The Chief Diversity Office maintained an excited high-energy tone through slides defining harassment and avenues for reporting it, but many students took advantage of this break to check Facebook and Amazon from their laptops. Those on surgery rotations whispered about what they were missing. Last year's 45-minute lecture has been extended to 2 hours and 15 minutes total, including a 1.5-hour block for 8 students to go through scenarios with a dean.

We get a one-paragraph description of a case and each student is required to say something before we move on to the next one. A sample of the 11 cases...

Case 1: A surgeon hits a student's hand that is holding an instrument and yells, "Don't do that." The student begins to cry. Our Chief Diversity Officer opens: "The attending should never hit a student. Period." Lanky Luke: "We don't know the full story. Maybe the student was about to do something really bad on the patient, and it was a light tap, saying don't do that." Canadian Camy: "That is still inappropriate. It makes you feel very uncomfortable, especially if it is a male hitting a female."

Case 2: The chair of the department notices a female medical student studying in the library. The chair begins asking questions about the subject, which she can't answer. He continues to press, until she begins to cry. Class President: "There is a clear distinction between teaching versus emotional distress. There is no reason to push someone until embarrassment and mental distress." Type-A Anita: "Sounds like a douchebag old white male getting off on a powertrip." Chief Diversity Officer: "I love that! I'll have to use that with next year's group."

Case 3: Two males and two females are on an away rotation. The two males become good friends with the residents while playing basketball after work. They start to go on "boys night out". The two female feel like they are getting less OR time and less teaching time. Is this inappropriate? Type-A Anita: "Everyone should be given the same opportunities." Chief Diversity Officer: "I think there is a win-win scenario here. The women should ask to meet up with the team for drinks after basketball so everyone gets to know each other." [Editor: What if the two females are Muslim and don't drink?]

We get out at 7:30 pm and start at 4:30 am Friday morning for more of the same.

Christian Charlie and I begin a 24-hour call shift at 6:00 am on Saturday. We join the Chief, Quiet Quincy (PGY 3), and Prego Patricia (an intern who is 7 months pregnant) for a 45-minute morning report from the Friday night team on about 100 patients.

Patricia covers the entire floor while Quincy, Charlie and I cover only ED consults. The attending goes to his office and waits for any urgent calls. Our job is to determine if a patient has an urgent (requiring operation now), emergent (requiring within 72 hours), elective, or non-operative condition. Our home base is the trauma bay physician's lounge, a small alcove with comfortable seating for two and three computer terminals. Heat from the trauma bay, set to 80 degrees to prevent hypothermia, seeps into the alcove. The Chief hangs out in the trauma bay unless the intern (her career as a physician started three weeks ago!) needs assistance: "Interns are so cautious and self-doubting. Last week we had a patient who became hypotensive after surgery," she explained. "He called me up: 'I want to give a 200 mL bolus of LR [Lactated Ringers, similar to saline]. Is that okay?' 200 mL, come on!" [A typical fluid resuscitation protocol includes at least 1 L.]

Charlie and I interview patients as a team. I'll ask basic questions, and then he'll follow up with a clarification question. One of us will present the findings to Quiet Quincy.

We see a 25-year-old female with acute appendicitis. She came to visit a patient hospitalized after a car accident. "Her belly started hurting so we decided to come down two floors to the ER." As we go back to the trauma bay lounge to give report, the attending and chief spot us and whisper, "Hey come here. Go into this room, don’t look at anything in his chart before reporting back to us."

The 60-year-old university professor has been getting  progressively yellower for the past several months and now positively glows. Charlie and I look at each other. We go through the causes of jaundice. Any pain? No. Any exposure to transfusions or IV drug use? No. History of a blood disorder? We report back that he has painless jaundice, most likely due to a neoplasm (cancer). The Chief informs us that they had already discussed his CT finding of a pancreatic mass, a death sentence, with the patient. The chief explains, "We asked him if our medical students could interview him for learning." I exclaim: "What a nice guy! The attending responds: "It's always a nice guy. If it's a nice guy you know it'll be cancer."

Our next consult is a 45-year-old diabetic man suffering a perianal abscess. Weighing in at 450 lbs., he has not walked in several years, bed-bound in a nursing home. We roll him down to the OR in a special heavy-duty patient transporter. It takes the entire OR team with the special bean bag mover to get him onto the OR table. It takes about 30 minutes for us to get his legs in the lithotomy position to fully expose the anus. The attending exclaims: "Any other county this patient would be dead. Go USA!" Charlie attempt to insert a Foley, but as he is prepping the glans of the penis (head), urine shoots out and covers his pants and shoes. "Oh, God!" Charlie screams! The nurses laugh as they grab towels to stop the stream. Charlie repreps the patient and successfully inserts the Foley. Another 2 L pour out into the bag. "That's a neurogenic bladder," notes the attending as he watches from the computer in the corner. The Chief and I scrub in as the nurses prep the abcess site.

After we drape the patient, the Chief hands me the scalpel. "Do the honors." My eyes go wide -- first time I've held a loaded scalpel since anatomy lab. I cautiously make a 2 cm incision in the skin of the abcess. Pus and blood shoot out as the Chief dodges the jet. Some gets on my shoes and the smell makes us both choke. The Chief squeezes the skin to accelerate the drainage. The chief calls out: "Wintergreen! Wintergreen!" The nurse instructs Charlie to grab a small bottle in the cabinet. He breaks the seal and applies small dollops with a Q-tip to our masks. The pus-poop smell disappears as we breathe in the cool mint. The attending puts her fingers, then entire hand, into the abcess. She lets me insert my hand into the fist-sized cavity. We rinse the abcess out with saline, and leave a drain. The attending, watching, "He'll be back in a few months."

Afterward the perianal abscess, I scrub in on the 25-year-old's appendectomy, which is done laparoscopically and is done within 45 minutes by 1:30 am on Sunday. Things are quiet until 3:00 am when a 100-year-old patient presents for worsening abdominal pain. Charlie is in an appendectomy case, so I see her alone. She alert and oriented. The chart from from the ED  shows tachycardia and borderline hypotension that they treated with low-dose phenylephrine (to increase blood pressure) and fluids. A CT scan shows a massive amount of fluid in her abdomen, but no definitive source. She lived independently until two years ago, when she moved into a daughter's house. The attending discusses the case with the patient, daughter, and son-in-law, explaining that recovery is unlikely, though there is a small chance of a relatively benign cause of the fluid in her belly. The patient elects to have a exploratory laparotomy. The attending brings the family into the hallway and explains: "This will most likely be the last time you speak to her. I recommend that you say your farewells."

During our 30 minutes together in preop, the patient complimented my smile and explained how her daughter is the best person in the world. "She forced me to move into her house after I fell." She is unafraid of death, perhaps partly because it would reduce the burden on her favorite child. She described meeting her husband in church prior to World War II (he ended up stationed in Hawaii with the U.S. Navy). The daughter is trying to get her brother to come the hospital, but can't reach him. I allow the daughter to say farewell and come with us to the OR tunnel entrance.

The Chief makes a midline incision and we smell feces immediately. A gloom descends over the attending and Chief. The belly is tainted by a brownish red tinge covering every abdominal organ. They use their hands to feel around the belly and locate a 3 cm grey discoloration in the colon wall with a 5 mm perforation in the descending colon leaking brownish fecal material. "There is nothing we can do." The Chief and Attending continue looking and identify that the bladder and uterus are also perforated (by cancer?). "This is incredible," the attending exclaims. "She could have have been like this for months, and just recently perforated her colon. You can have urine in your belly and not be that symptomatic. " She scrubs out, and informs the Chief that she will explain to the family that there is nothing for us to do, we'll close her up and palliate her so she can be comfortable and alert for her last few hours. You teach until I get back to close." The Chief begins showing me various techniques. She shows me how to do perform a trauma evaluation on the mesentery for a "bucket-handle" injury (injury to the mesentery in a rapid deceleration injury). She hands me a segment of bowel and I feel along the mesentery and then pass the bowel to her with both my hands. She shows me the Ligament of Treitz. "Push down here, do you feel the SMA?" I move my hands along the superior portion of the bladder, feeling the too-small-to-see perforation leaking urine. The uterus perforation is large enough for an index finger. The attending: "Do you notice the adhesions?" "Yeah, the entire small bowel is adhered to everything. Itself, the large colon, the bladder."

I developed a much better understanding of the impact of cancer and the fragility of our organ systems. A barely visible hole in the colon can lead to devastation in the abdomen. The attending comes back, and reports the family agrees with our plan. We suction some of the feculent fluid out of her belly and close her up so that she can communicate with her son (he showed up just as my shift ended at 6:00 am) before dying.

 

Statistics for the week… Study: 0 hours. Sleep: 5 hours/night; Fun: none. My feet are killing me. I sleep all day Sunday.