one section of 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 placed a mole in one of America's medical schools
To preserve patient confidentiality, ages and other details are slightly altered. Students and teachers are also pseudonymous. Our story begins in the summer of 2016.
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.
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.
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.
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 touch 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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
"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.
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.
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.
"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.
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!