What is personalized medicine?

A consistent theme that has been hammered into our heads throughout this Molecules to Medicine block is how personalized medicine is the future of medicine. By and large, the current approach to medicine is "one size fits all," which the professors always utter with a negative voice inflection so we medical students are sure to know that this is a bad thing. Personalized medicine, in contrast uses genetic or molecular analysis in order to predict who might respond well to a given therapy over another.

The most well known example of such personalized is in breast cancer. A quarter of all breast cancers are characterized as being caused by a mutation in HER2, human epidermal growth factor receptor (EGFR), which becomes overactive when it's mutated. This EGFR, as its name implies, normally activates signaling cascades that control cell adhesion, migration, and proliferation, cellular processes that are all important in the generation of a tumor. A HER2 mutation thus causes a particularly nasty type of breast cancer, but a drug called Herceptin has been developed that calms down the overactive EGFR by binding to and inactivating it. As you might expect, only patients who are positive for this HER2 mutation will benefit from Herceptin treatment.

Several weeks ago, we learned about Li-Fraumeni syndrome, which is a disease of increased susceptibility to developing cancer at an early age caused by mutation of a particular protein called p53 that is responsible for "proofreading" the genome as each cell is being replicated and fixing any mistakes. If this genome housekeeper gene is mutated, it's all of a sudden much easier to accumulate more and more mutations until, by chance, you get a cell that divides like crazy (in complete disregard of environmental signaling) and acquires other characteristics of a cancerous cell. So, radiation treatment is probably not such a good idea for patients who have a mutation in p53, because the radiation will likely just cause more mutation events that their dysfunctional housekeeping protein p53 is unable to fix.

During this morning's lung cancer clinical vignette, the lecturer again drove home the idea of personalized medicine by showing how one type of lung cancer is responsive to drug A while another type of lung cancer is unresponsive to drug A but more responsive to drug B. A molecular characterization of the exact kind of lung cancer starts to look like a necessary first step before deciding on any therapeutic intervention.

Indeed, for some diseases such as lung cancer, or when a patient's family history is highly suggestive of a mutation in one of those genome housekeeping genes, the standard of care is already trending toward a personalized approach to devising a treatment plan.

Last Warren Village night

My fourth and last Warren Village session was this past Wednesday night. I've enjoyed pediatrics much more than I thought I would. I'm sad, though, because I will not be doing Warren Village next semester. The number slots is very limited, and I know that many of my classmates also want the opportunity to do this elective.

All four of my attending physicians at Warren Village have been fantastic: happy with their jobs, low-key, and eager to educate. They have also been very understanding of the fact that, in terms of medicine, I'm basically starting from scratch.

One of my patients on Wednesday was a teenage boy who complained of severe acne, mostly localized to his forehead but also spreading through his scalp. His mother was a "well-informed medical consumer" and wanted to know about more aggressive treatments for acne. On examination, though, this boy's skin looked exceptionally clear for complaining of severe acne.

When I presented this case to my attending, I made the rookie mistake of neglecting to mention that this boy also likes to use hair gel (a fact that came out while questioning Mom) but that he wasn't wearing any today. So, when the attending physician came in, he started working under the assumption that, like many other kids his age, he was just extremely sensitive to the self-image issues that accompany acne. Once the attending uncovered this hair gel issue, though, he soon concluded that this boy was suffering from dermititis as a reaction to the hair gel.

I felt stupid for forgetting to mention such a relevant piece of information, especially since acne typically doesn't even extend much past the hairline. But, the attending physician turned the mistake into a great learning experience. First, he provided an example of the type of questioning and investigation necessary to move past distractors and mis-information to get to the bottom of a presentation of symptoms. Second, afterward, he owned his own mistake of too quickly buying into the acne story instead of starting the examination tabula rasa.

This is the sort of experience that (I hope) will help me become a better doctor.

Art class in medical school?

Yes, that's right: art class in medical school. And it was part of the required Foundations of Doctoring curriculum, not an elective. Needless to say, I was skeptical that spending three hours of my Tuesday afternoon in art class was a better use of my time than, say, studying for the cellular biology test coming up this Friday. Despite my skepticism (and borderline cynicism), I found this Art in Medicine class useful in helping me learn how to better make observations and report them.

We were given several artworks in small groups. Everyone turned away without looking except for a few people who tried to describe the work of art so that everyone else could visualize it. Then everyone turned around and talked about how their mental image of the painting was different from reality. One difficulty this exercise highlighted was the need for consistent reference points and language to communicate left versus right - which is apparently somewhat of an issue in medicine. Even though sidedness is always described with respect to the patient, people still get confused.

I enjoyed describing the paintings to my classmates, but no matter how thorough and systematic I tried to be, I inevitably left out some detail that greatly changed how my classmates drew their mental image.

Also relevant to the clinic, this exercise highlighted the difference between observation and interpretation. In everyday life, people tend to mix interpretation in with observation. When presenting a patient to an attending physician, though, the practice is to first present hard facts and observations then to use those observations to support an assessment or an interpretation. Take this painting, for example:


What observations can you make about this painting? What interpretations? If you were going to present this painting to an attending physician as you would a patient, what would it sound like? Click here for more information about this painting.

Homecoming

It feels good to be home for Thanksgiving, the first time back since I left for school. I have a lot to be thankful for, especially this year. I'm thankful for the opportunity to pursue my dream of becoming a doctor. But at the top of my list of thanks are my friends and family - particularly my mom and dad - who have been incredibly supportive of me.

Patient interview techniques: invite, listen, summarize

We had a Foundations of Doctoring session yesterday afternoon that focused on developing patient interview skills. The point of the session was to practice three specific interviewing techniques: inviting, listening, and summarizing. Then, in a group of four students and two facilitators, each of us took turns interviewing a standardized patient while the other three students watched and provided feedback.

Inviting refers to prompting the patient to talk by asking opened ended questions rather than yes/no questions:

"So, what can I do for you today?"
"How does that pain affect your daily life?"
"What do you think might be going on here?"

These types of open questions invite the patient to say what is on his or her mind rather than answering targeted questions that may or may not have anything to do with the real matter at hand. The idea is that this approach "humanizes" the patient rather than relating to the patient as a collection of symptoms to be solved. Also, the doctor may catch something that otherwise might have gone unnoticed. All of this may seem self-evident, but when I'm actually sitting in front of a patient, it's surprising how easily I can fall into the trap of peppering the patient with symptom-specific questions.

Listening refers to both verbal and non-verbal cues. Most of these are sub-conscious facial expressions (e.g. raising eyebrows, narrowing eyes) or body language (e.g. posture mirroring, nodding head), or simply keeping quiet.

I had the most trouble with summarizing because it felt so unnatural to constantly repeat what the patient had just said. For example, if the patient tells me that her foot started tingling two weeks ago and started hurting one week ago, the instructors would want me to say something like, "So, what I'm hearing is that your foot started tingling two weeks ago and started hurting one week ago." Then they would expect the patient to enthusiastically exclaim, "Yes, that's right, Doc!" I understand that the purpose of this is to make the patient feel like he or she is being heard correctly, but if done the wrong way, constantly repeating what the patient just said can make me look like a dufus. I did my best to make it work within my own personality and within the context of the conversation.

Overall, I found the patient interview training to be very helpful.

So, next time you're at the doctor's office, pay attention to how the doctor is communicating with you. I'm curious to hear people's real world experiences.

"Fake patients are just what the doctor ordered"

A classmate sent around this Denver Post article about standardized patients, and I want to share it here to give my readers a better idea of what standardized patients are all about:

By Jennifer Brown
Posted: 11/24/2009 01:00:00 AM MST

More than one nervous medical student has entered Robin Mulroney's hospital gown from the bottom to listen to her lungs.

Aspiring doctors also have been known to forget to release blood-pressure cuffs after taking the vitals of their "patient." And there was the time a student inserted a speculum upside-down during one of LoriLynne Lawson's many pelvic exams endured in the name of training future physicians.

The days when medical students learned how to examine patients just by watching real doctors in action and then trying it themselves are now supplemented by people such as Mulroney and Lawson: "standardized patients" who are paid $20 to $50 per hour to let students poke inside their ears and tap on their stomachs.

These fake patients, many of them professional actors looking for extra money, can cry on demand when they are "diagnosed" with cancer or Alzheimer's disease. Strong memorization skills are a must: Patients have to stick to a script saturated with family history of disease, medications, sexual history and surgeries.

Standardized patients are in higher demand than ever in Colorado with the opening of a second medical school in the state last year, Rocky Vista University in Parker. Rocky Vista, an osteopathic school, and the University of Colorado Denver School of Medicine each employs about 60 actor-patients, some of whom work for both schools.

The universities also have high-fidelity simulators — manikins ranging from $20,000 to $250,000 that take over where actors cannot: Give birth, have heart murmurs, bleed out, receive drug injections and require intubation.

Many actor-patients say they don't do it for the money but to help future doctors develop empathy, better listening skills and a gentler touch. After their exam, patients evaluate students as part of their grade.

"I want them all to succeed," said Rich Beall, who also has worked for the Denver Center for the Performing Arts and had a TV role on "Perry Mason." He doesn't hold back when it comes to constructive criticism.

"If someone comes in with a lab coat that's not clean, you note it," he said. "I had one gal come in all dressed for a Saturday night."

"Patient" doing her part

Mulroney, who has worked as a standardized patient for nine years and now trains others, believes she's doing her part to prevent that rare "doctor from hell" encounter. She recalled a real-life experience in which a specialist walked into the hospital room of one of her relatives, flopped into a lounge chair and without even introducing himself announced, "So you have lupus." The doctor kept talking "90 miles an hour" even after the woman burst into tears.

"His empathy, his patient care for the whole patient, the emotions of the patient, it was just tragic," Mulroney said.

Last week at Rocky Vista, 10 first-year medical students wearing white lab coats and clutching medical bags lined up outside their assigned exam rooms. One was so nervous beforehand that she put her fingers in a yoga pose and sighed, "Zen." With the sound of an alarm, each student knocked on an exam-room door and stepped inside to greet an actor-patient sitting on an table.

The students had 50 minutes to perform a routine physical examination, observed by faculty and recorded in a control room down the hall.

Meredith Kirtland, 26, sailed through the "patient encounter" after she had practiced on her fiance and some friends. "Just a couple questions about your sexual history," she told her male patient at one point. "Sorry, it's a little uncomfortable topic."

Her professor's one small critique: She should have lowered her patient's pants farther to feel his lower abdomen.

Kirtland was too busy running through a mental checklist to think about the fact that the patient was an actor. It was a lot easier to examine him than her friends, who are "kind of giggly and you know it's not real," she said. "Everything else in that room is so real. What better way to learn it?"

The highest-paid patients are gynecological and urological teaching associates who guide students through pelvic exams. Lawson, a 53-year-old with scars from a C-section and a breast lumpectomy, has had up to 14 gynecological exams in one day.

She had one student remove the speculum without closing it. And she chuckles remembering some of the clumsy statements students have made, as in, "Let's just take a feel now, shall we?"

Lawson doesn't tell everyone she knows about her job. "Some people say, 'Ewww, how do you do that?' Some people think you are prostituting yourself," she said.

But Lawson remembers holding her daughter's hand during her first pelvic exam. "I was glad they knew what they were doing and hadn't just practiced on a plastic doll," she said.

"Making a difference"

Gynecological teaching associates typically are feminists "who know their bodies like no other" and have a "real strong belief that they are making a difference in the world," said Gwyn Barley, director of UCD's Center for Advancing Professional Excellence, which employs the actor-patients. Men submit to urological exams, she said, because there are "so few opportunities of any sort for students to learn the male genital exam."

"There is so much kind of mystery," she said. "You can't just ignore the male reproductive system."

Chelsea Williamson, 25, became a standardized patient after she was laid off as a cabinet designer last spring. She has found that some medical students need to work on their listening and sensitivity.

While she was portraying a girl with severe psychological problems who cuts herself, one student kept saying, "Gotcha." Another said "Great!" after she informed him that her parents were dead.

The past few weeks: two tests, and a lot of clinical exposure

The past few weeks have been busy - the status quo in medical school. I got through two more Molecules to Medicine tests (biostatistics and genetics), but more significantly, I've gotten a lot of clinical exposure.

My very first patient ever was at Warren Village, a two year old boy whose mother was concerned about recurring ear infections. A classmate and I teamed up for the interview and physical exam, which worked out well considering how nervous I felt. But somehow I muddled my way through it, and now every patient encounter is easier and easier insofar as I have prior experience to draw on. I have gone into Warren Village two more times since then and will talk in more detail about those experiences in a later post.

I've also gained some clinical experience through my preceptor. This is a program that matches medical students with a community physician with the aim of setting up a long-term (2-3 years) mentoring relationship. There is a wide range of preceptorship experiences that depend on factors like the setting, specialty, and the individual who is doing the mentoring. Typically, preceptors are in some sort of general practice like family medicine, pediatrics, emergency medicine, or internal medicine. My preceptor is boarded in both family and emergency medicine but does occupational health at Kaiser. I'll talk more about that in a later post.

Two other clinical experiences that also deserve their own dedicated posts are: 1) shadowing a senior resident in the ER, and 2) Clinica Tepeyac.

So many of the older doctors reminiscing about their medical school experiences recount how they never even saw a patient until their third year when they started clinical rotations. I feel incredibly lucky to have these clinical opportunities now, during my first two years of medical school, which are traditionally reserved for cramming as much information as humanly possible into the heads of poor medical students. Pairing together the classroom and the clinic is, in my view, a positive evolution of medical education.

First Molecules to Medicine test

The first Molecules to Medicine test is tomorrow. I'm not nearly as scared about it as I was going into my first Human Body test, but that has both its upsides and downsides.

Pro: I'm no longer a Scary Medical Student whose temporary best friend is his cadaver and who has to take vitamin D supplements because he studies 16 hours a day and doesn't get any sunlight because of it. In fact, I now have meaningful non-medical-school-related conversations with my family/friends, I've renewed my Netflix account, and I've even gone out a few times. (Okay, I've gone out once since anatomy ended. After the last exam.)

Con: Motivation is a problem. Whereas all the anatomy material was brand new to me, I've had a lot of molecular and cellular biology before, both in undergrad and graduate school. That's not to say that this block will be a cake walk, by any means, just that my mind is primed to re-learn a good portion of this material and to place new information within a pre-existing framework of knowledge. But, it also means that I have to guard against boredom and procrastination.


The material being covered in this first test includes: bioenergetics, DNA structure, DNA replication, DNA repair, DNA transcription (process of converting DNA to RNA), RNA structure and post-transcriptional processing, gene expression, amino acids and proteins, translation (process of converting RNA to protein), the cell cycle, and various tools of molecular biology.

Also, one of the highlights of Molecules to Medicine so far has been clinical vignettes. These are lectures of specific diseases that tie into relevant material being covered in other lectures. For instance, we learned about prion disease after a lecture on protein folding. We are also responsible for knowing the molecular biology of Alzheimer's disease and Li-Fraumeni syndrome for tomorrow's test.


N.B. Yes, writing this post was indeed an exercise of procrastination. Back to studying.

Warren Village cancelled due to snowstorm

I'm very disappointed. But, I'm scheduled for next Wednesday, and I'll be able to make up the lost clinical time later on.

Warren Village orientation

Now that the Human Body block is over, the clinical fun begins! The orientation for Warren Village was yesterday. The elective has space for only six of us MS1's, so I feel lucky that I have this opportunity to participate.

MS4's are the leadership behind this elective, and they will serve as my managers and mentors. They first demonstrated how to do a pediatric exam. One of the mothers of Warren Village brought in her two little kids, one 6 months and the other a year and a half. I can only believe that most children who I'll be seeing in the coming weeks won't be nearly as well behaved as these two. We went through the exam from head to toe, quiet parts first and noisy parts last... except the little guy didn't even cry when a big scary something was stuck in his ears.

I have to admit that I'm more than a little nervous about beginning clinical work - and with babies and kids, no less. "Don't worry, you won't break them," one of my MS4 mentors joked, probably remembering how she felt when she started working at Warren Village three years ago. The anxiety will pass quickly after the first few patients.

The MS4's also taught us MS1's how to administer vaccination shots. We learned both intramuscular and subcutaneous, first watching a demonstration, and second practicing on an orange. Then, we practiced on each other! It wasn't difficult at all, surprisingly, and my classmate even gave me the thumbs up after I administered his IM and SQ saline injections.

I will be volunteering four Wednesday evenings this semester, one of which will be a vaccination night. I'll probably see about 2-3 patients per night on the other three evenings, while working together with one other MS1. My first day is tomorrow - how exciting!

A real change of pace

This transition from the Human Body block to the Molecules to Medicine block is a real change of pace. I actually spent the entire weekend relaxing and not studying! A large part of why I feel comfortable doing this is that I've already had a lot of the biochemistry and molecular biology material - it's not all new to me. Also, biochemistry is much more conceptual than the rote memorization of anatomy, which I think plays better to my learning style. Some second-years told me that after Molecules to Medicine the coursework returns to its previous memorize-as-much-as-you-can modus operandi.

So, I'll enjoy my luxuries while I can.

Foundations of Doctoring: SPETA evaluations

I had my very first CAPE exam on the 13th, the week before the Unit 3 written exam. The CAPE exam tested us on clinical skills that we were taught during our SPETA (standardized patient) sessions, six in total: 1) musculoskeletal upper extremities, 2) musculoskeletal lower extremities, 3) pulmonary, 4) cardiovascular, 5) abdominal, and 6) head and neck.

Three exams from these six were chosen at random, so we had to study them all. In the days leading up to the CAPE exam, an outside observer might have thought that we'd all cracked from the stresses of medical school. Walking by all of the study rooms, you'd see my classmates (myself included) mumbling to themselves and pantomiming the steps of a given exam. I also studied with my lab group. We got more than one weird look from people walking down the hall, as one of us was lying on a table playing "patient."

Really, the main purpose of these evaluations wasn't so much to make sure we'd memorized every item on the checklist for all six of these exams, though we were expected to know most or all of it. Instead, emphasis was placed on the clinical experience: Do I know how to interact effectively with my patients?

For example, it was drilled into our heads to always, always start by washing our hands in front of the patient then introducing ourselves by first and last name and title/position: "Hi, my name is Peter Griffin. I'm a first-year medical student, and I'll be doing your head and neck exam today." Coincidentally, just a few days before the CAPE exam, my mom was telling me about a recent experience when her doctor didn't introduce himself (or herself?) by name, which made my mom feel uncomfortable.

Another aspect of patient interaction is maintaining patient modesty. The pulmonary and cardiovascular exams in particular are very difficult to perform on women, for obvious reasons. So, we were taught how to properly drape patients and position them in order to preserve their modesty.

I was way more nervous for the CAPE exam than I should have been, but I excuse myself for this because it was a novel experience. My hands were shaking, even when I was palpating joints and such. It helped that my first exam was musculoskeletal upper extremities, which I felt fairly confident on. It didn't help that my first SPETA was in a grumpy mood and not very communicative. He was "in character." And to be fair, a lot of my future patients will be grumpy and non-communicative, so better learn how to deal with that now when it's all pretend.

Still, this CAPE exam wasn't meant to mimic a real patient interaction. For the purposes of these exams, we were told to verbalize everything that we did so that the instructors would know what we were doing (and that we knew what we were doing). I can't think of any appointment I had when the doctor explained everything he did step by step, but I do think that it's very important to be able to explain to my future patients in plain language what it is that I'm doing and why.

These exams serve a tangible purpose: to prepare us for our upcoming preceptorships, when we'll be mentored by a community physician and work directly with their patients. Every third- and fourth-year student who I've talked with has said that the CAPE and preceptorship experiences have been the highlights of their medical education. It's something to look forward to.

Anatomy is over! Anatomy is over!

Anatomy is over! I'm still pinching myself every now and then to make sure it's real. It's not that I didn't want to learn anatomy, or that I don't appreciate gaining this body of knowledge, just that the process of learning it was so grueling.

I consistently put in 14, 15, 16 hour days, which aside from lectures and studying included a lot of time in dissection lab. Not everyone in my class studied so intensely, but I felt that I had to in order to learn the material, especially since this was my first time taking any anatomy course. Earlier today, I talked with a second-year resident who didn't go to medical school here. She was shocked when I told her that I crammed 2000+ anatomical structures/terms into my brain during a short 9 week block. "Do you even remember any of it?" Yes, despite the stress and intensity, I learned a lot, and I walk away from the Human Body block very satisfied with my educational experience.

After handing in my Unit 3 (head and neck) written exam, I played a game of ultimate frisbee with my classmates and went out with them later that night to celebrate.

Next up: Molecules to Medicine, which is a course of clinically relevant biochemistry and molecular/cellular biology.

Emergency Medicine Interest Group (EMIG): Suture Night

I learned how to tie surgical sutures! The Emergency Medicine Interest Group recently held their "suture night" for the express purpose of teaching us lowly first- and second-years such skills that will probably give us a jump start in some of our third-year rotations. One surgeon worked with about 10 students, who each had a pig foot (the kind you buy at the grocery store or butcher shop), a pair of hemostats, and three suture packs.

By the end of the night, I felt fairly proficient at tying simple sutures but was still having some trouble with the mattress sutures, a type of suture used to make sure that the skin doesn't fold in on itself and thus prevent proper healing of the wound. I haven't practiced tying sutures since then and have probably lost most of what I picked up at suture night. This is definitely a skill that demands repeated practice to master. In fact, the surgeon who taught us even referenced The Tipping Point (excellent read!), in which Malcolm Gladwell discusses how a minimum of 10,000 hours of practice is required for a person to become an "expert" in anything.

I have a long way to go.

Alumni connection

Awhile back, I wrote a thank you note to the alumnus who donated the stethoscope that I received as a gift at the White Coat ceremony way back in August. I recently got a very nice hand-written note back from her saying how happy she is that the stethoscope made its way into good hands and how she's looking forward to following my progress through medical school.

From my experiences so far with both faculty and my fellow students, such kindness and geniality seem to be the rule rather than the exception, here.

Human Body block evaluations

With two units under my belt, I think it's time to describe the evaluation process. Evaluations for Unit 1 (back and extremities) and Unit 2 (thorax, abdomen, and pelvis) each consisted of 4 components: 1) Dissection quiz, 2) Dissection lab practical exam, 3) Clinical quiz, and 4) Written exam.

Dissection quiz (30 points)

The purpose of this is to see how good of a dissection job we did. Since the dissection was a group effort, each dissection group of 8 students receives a group grade. The instructor asks us to identify 15 structures, 2 points per structure. We must first correctly identify each structure. This usually isn't too difficult between the 8 of us. Then, we are evaluated on whether the structure is intact or not and whether we adequately cleaned it. The reality is that most groups do very well on the dissection quiz, which helps to boost our overall grade a bit.

Dissection lab practical exam (75 points)

On the morning of the dissection lab practical exam, the instructors wake up at an ungodly hour and "stage" the cadavers. What this means is that they pin certain structures that we will be asked to identify during the test and drape the cadaver with a sheet in such a way that exposes just enough of the cadaver to allow us to figure out what the structure is. Really, in this way, they're testing our knowledge of certain anatomical relationships.

There are 50 "stations" total, with one structure at each station (which means each station is worth 1.5 points). Some of the stations aren't at cadavers but instead present a painted bone and ask what muscle or ligament attaches to the painted surface. Other stations present a cross sectional image of the body with an arrow pointing to a particular structure and ask for its identification.

Before the test, we all line up outside in the hallway and nervously chat with each other while waiting for the instructors to invite us in. Then, we're each given a clipboard and an answer sheet with a number at the top of the page. That number is the station number where we start at (1-50). Only one student stands at each station at any given time.

The test starts with recorded instructions played over a loud speaker telling us that we'll have one minute to identify the structure at each station, that a tone indicates that our time is up and we have to move onto the next station, and that we may not touch or move any of the cadavers. The first tone starts us off, and we rotate through each of the 50 stations. After we've gone though all 50 stations, we're given 10 minutes during which we can hop around to any of the stations that we were unsure about to check our answers or change them.

My experience with the lab practical has been mixed. Sometimes I identify the structure right away and spend the rest of that minute collecting my thoughts, calming myself down, or trying to figure out a previous structure that I was unsure about. Other times, I have absolutely no idea and spend that minute looking at surrounding structures for a clue as to what it is.

The dissection lab practical exam is definitely the most difficult and stressful part of the evaluation process for me.

Clinical quiz (25 points)

The clinical quiz is a pretty straightforward multiple choice test taken and scored online. It's a "take home" quiz that becomes available 48 hours prior to and must be taken before the written exam. The material is pulled from a few clinical lectures that we get toward the end of the unit and also from the standardized patient sessions. Pneumothorax, inguinal hernias, and irregular heart sounds were all big topics on the Unit 2 clinical quiz.

Written exam (150 points)

Most of the points from the unit come from the written exam. It is also pretty straightforward, but there's much more variety in the types of questions asked.

One question type on the Unit 1 written exam asked you to match a given nerve with a list of bones to which the innervated target structures attach. So, for example, the inferior gluteal nerve innervates the gluteus maximus muscle, which attaches to the sacrum, inominate (hip), and femur. Another question type goes one logic step further, asking you to match a lesion in a given nerve with a functional deficit of movement. This deftly lumps together innervation, muscle attachments, and muscle actions all into one question.

Both exams had blood flow questions, which I actually enjoy. In these questions, you're asked to trace the blood flow from the aorta, through the capillary bed of a given target muscle, and back to the right atrium of the heart. The question and answer look something like this:

Question:
Trace the flow of blood from the arch of the aorta to the right atrium passing through a capillary bed in the right gluteus medius muscle.

Answer:
Arch of the aorta > Thoracic aorta > Abdominal aorta > R common iliac a. > R internal iliac a. > R superior gluteal a. > Capillary bed > R superior gluteal v. > R internal iliac v. > R common iliac v. > Inferior vena cava > Right atrium

To make things interesting, Dr. Carry will also throw in a few blockages, which forces us to take a slightly different route to the capillary bed through what are called anastomoses, or communications between two different arteries. These communications are the body's way of keeping itself alive in case something goes wrong, like a blocked artery.

Walking down the halls of Ed1 (the building where most of the first and second year classes are held) before the exams, you would see maps of arteries and veins scrawled all over the whiteboards in the study rooms. Committing these schematics to memory serves as a guide for learning which artery supplies which structures and as a jumping off point for understanding more anatomically relevant relationships.

A substantial portion of the questions are fill-in-the-blank, most of which test knowledge of anatomical relationships between structures. There are also a few multiple choice and true/false questions to round things out.

The written exam is loosely proctored, which means that we are given a firm 4 hours to complete the test but are allowed to take it outside the lecture hall anywhere on campus. I'm not sure if other medical schools operate this way, but here, the nature of our Honor Code affords us this privilege.

When will I start feeling like a doctor?

A friend wrote to me with a thought that I want to share:

It will be interesting to know at what point in your training you start feeling less like a civilian and more like a doc. Maybe when you start you start working with patients?

I can say with certainty that I have not yet reached that point and don't expect to until well after I'm wearing a long coat. It's safe to assume that most of my classmates probably haven't yet, either, but I'm curious to hear their perspectives.

We do start a preceptorship, after the Human Body block ends, when we will be working with real patients under the direction of a mentor. There's also a range of electives that provide us with the opportunity to work with underserved populations in a clinic setting: Warren Village (pediatrics), Stout Street (homeless), and Clinica Tepeyac (Spanish speaking immigrant population).

Another exam-relevant horoscope

Here's another horoscope forwarded to me that is particularly relevant to preparing for the Unit 2 tests and quizzes:

LEO (July 23-Aug. 22). Instead of wondering why you've been dealt a certain hand, you're figuring out how to play it. What you've learned pays off for you. You will respond to problems with an intelligent and precisely correct answer.

Dreaming about dissection

A few nights ago, I had a dream about dissection. When we first started the dissection, the cadaver's hands, feet, and head were all wrapped in cloth. We removed the cloth from the hands and feet to dissect those structures, but the cloth covering the head will not be removed until next week when we begin the Head and Neck unit.

In my dream, I was standing over Gloria (my dissection group named our cadaver), removing the cloth from around her head. I pulled away the last pieces of cloth and looked at her face for the first time. Except, the skin of her face, her hair, her eyes, they all looked alive! Her wrinkly skin was flushed rather than embalmed. She had a full head of thick, wavy, gray-blond hair. And her light blue eyes - she had her eyes open! - were looking up straight into mine. Her eyes seemed to have sadness in them.

This sight obviously freaked me out. I looked down at Gloria's dissected body, to make sure that she was actually dead, then back up at her face and into her eyes. I took control of the dream, at that point, observing within the dream that Gloria was in fact dead and that this was my subconscious mind's way of processing some anxiety that I have about seeing Gloria's face for the first time. The vivacity of her face faded to match the gray coldness of the rest of her dissected body, her eyes slowly closed, and the dream ended.

Honor Council class representative

I was recently elected Honor Council class representative! Eight people ran for the position, all of whom would have made an excellent HC representative. I'm very excited that my classmates gave me this opportunity.

Haverford College (where I went for undergraduate) has an honor code very similar to what we have here: one that is social as well as academic, and owned by the students. I served as an Honor Council class representative at Haverford, which is one reason why I ran for this position in the first place. I'm looking forward to seeing how the two experiences compare and what ideas from Haverford's Honor Council I might be able to translate here.

To give us a sense of ownership over the honor code, a group of a dozen or so classmates together wrote the class honor code, which is more of an "honor statement" that accompanies the medical school's honor code. This happened during orientation week, on the bus ride back from the retreat, and was supposed to have been included in the White Coat ceremony. Because of logistical problems, the class honor statement never made it into the program. Here it is below, unveiled for the first time:

Class of 2013 Honor Statement:

As future physicians, we hold ourselves accountable to develop a sustainable foundation of excellence, integrity, and compassion. We understand that, in order to be trusted, we must demonstrate that we are trustworthy. To best serve our patients, we endeavor to nurture the spirit of collaboration and mutual respect. We pledge to carry these ideals into our local and global communities and to be a force for positive change.

Time dilation: Unit 2 exams approach

Wow, it's hard to wrap my brain around the fact that I've been in medical school for just a little over a month. What's even crazier is that my first exam was less than 2 weeks ago, and the Unit 2 test is already this week. It feels like I've been at this for at least 6 months, already.

The evaluations for Unit 1 covered the back and upper and lower extremities. They consisted of a clinical correlates quiz (25 points), a group dissection quiz (30 points), an individual dissection laboratory exam (75 points), and a written exam (150 points). The evaluations for Unit 2 (which covers the thorax, abdomen, and perineum) will be very similar, with the group dissection quiz and individual dissection lab exam up to bat first on Thursday and Friday.

The lab practical was definitely my weak point in Unit 1, so I'm spending some late nights in lab this week, elbow deep in viscera and such. Going through the dissection guide and identifying structures is really the best way (for me) to prepare for the lab practical. But identifying a structure isn't just pointing to it and saying "That's the gastroduodenal artery." To actually help me learn the material, it sounds more like, "That's the gastroduodenal artery. It's coming off the common hepatic artery from the celiac trunk, bifurcates into the superior pancreaticoduodenal and right gastroepiploic arteries, and passes posterior to the duodenum." And we have to do that for every structure.

I actually just came from dissection lab just now, and it's a party up there: break dancing, Wayne's World impressions, "That's what she said" jokes. My classmates sure know how to make anatomy fun. Especially Anand, who apparently does and says crazy things in the hopes that he'll "make the Blog." Well congrats, buddy, you made it!


In a future post, I'll give a better idea of what these tests are like - examples of typical questions and a description of the lab practical test format.

So glad it's over

I feel like I've been lost to the world for the past week or so, as I've been putting in 15 hour days trying to cram every last bit of anatomy knowledge of the back and extremities. Has health care reform been passed, yet?

I'll write soon about the test format and my thoughts/feelings going into and coming out of the test. For now, though, I am enjoying what is left of my "vacation" before Unit 2 starts tomorrow morning.

Today's horoscope

Don't pay attention to the odds or the statistics. If you have faith in yourself and your dreams, with certainty you will succeed.

Much needed words of encouragement. Thank you!

Really absorbing the material

The past few nights, I dreamed very vivid dreams about anatomy. Interestingly, these dreams have been devoid of any emotion - positive or negative. I would have expected some sort of anxiety to have played out through my subconscious mind. Instead, I moved through anatomical structures, calmly and methodically identifying them. Last night, for instance, after studying the circulatory system, my dreams were filled with arteries and veins and anastomoses. This is either a good indication that I'm really absorbing the material, or an early sign of anatomy-induced insanity.

Mood swings and meditation

In one moment - usually after conquering a body of material - I am confident that, with another week of studying, I may in fact be able to do fairly well on the test. At pretty much all other times, though, I feel completely overwhelmed and paralyzed by the impossibility of knowing Everything. I need to chill out.

It may be time to start meditating. In the past, I have tried a breathing method of meditation: inhale for 5 seconds, exhale for 5 seconds, and continue that for a minute or however long. I've also talked with classmates who meditate using their stethoscope to listen to their own heart beat. My daily bike rides from school to home are also meditative - a physical release and mental break in cool evening air and under the clear Colorado night sky.

This past weekend, I decompressed by hiking in the Rockies - a major perk of going to school in Colorado. Would it be more beneficial to go on another mental health hike the weekend before my first test in medical school, or should I hole myself up and study the entire weekend?

First exam? Already?

I can't believe that my first exam is only a week and a half away. I'll be tested on the back, upper extremities, and lower extremities. This includes for these regions: arteries, veins, nerves, muscles, tendons, ligaments, fascia (meat and gristle), bones, and relationships between these structures. Am I missing anything?

The amount of information I have to learn is daunting, to say the least. From the very beginning, I have tried to be diligent and methodical - yet flexible - in my approach to studying these materials. Despite all my efforts, though, I still question whether I will be able to adequately prepare myself for the test in the limited amount of time left. I also wonder whether I have an efficiency problem in terms of how quickly I am able to learn and retain the material. It's only a small comfort that a good number of my classmates are in the same boat.

Rumors are that half the class will fail the first exam. Fortunately, no one is looking to thin out the Class of 2013, and the medical school will do what they can to make sure that everyone learns what they need to know and passes the course.

Standardized Physical Exam Teaching Associate (SPETA)

The Foundations of Doctoring curriculum here uses standardized physical exam teaching associates (SPETA) to teach basic clinical skills to medical students early in their medical education. While the use of SPETAs to teach clinical skills is by no means unique among medical schools, I believe that the extent to which SPETAs and simulated clinical settings are used in this curriculum is remarkable - especially in years 1 and 2.

Traditionally, the first two years of medical school are reserved almost exclusively for lecture-based torture of students. One professor recently recounted how he didn't see his first patient until his third year of medical school, and he wondered aloud to the class how learning about molecules and organ systems could have adequately prepared him for the real doctor-to-patient interaction. That concern was the driving force behind curriculum innovations that led to this Foundations of Doctoring course, which spans the first three years.

This curriculum innovation brings some much-appreciated balance to the life of a first-year medical student. Today, for instance, I spent the entire morning in the dissection lab, then in the afternoon, I learned how to give a musculoskeletal examination. Such juxtaposition of death and life 1) helps to ground me to the larger purpose of this masochistic exercise that we call medical school, to become a doctor with knowledge and compassion enough to effectively treat my patients, and 2) gives me a leg up on the USMLE Step 2 and residency applications, with early development of clinical skills.

I have actually never received a musculoskeletal examination in my adult life, so this was all new to me. It basically involves a head to toe check-up of all muscles, bones, and joints, including: visual observations of skin, posture, and gait; palpating (fancy-schmancy medical terminology for "feel over skin") muscles, bones, and joints; and range of motion tests on all the joints. Together with two of my classmates, the SPETA covered the entire musculoskeltal exam in a two hour session. She first gave an overview of the examination. Taking it in parts, she explained each step in detail then allowed my classmates and me to practice that step on her.

We have one of these sessions about once every week, coordinated with the course material for the Human Body (anatomy) block.

How I am studying the bones

Because this is the first time I have taken anatomy, I spent half of the first week of medical school just trying to figure out how I was going to learn some 2000+ anatomical structures, observing my classmates and playing around with different approaches. Everyone's learning style is different, and I knew that I had to tailor my study regimen to my own specific needs. I learn well by doing, creating, using. So, this is how I am studying the bones:

First, Dr. Carry created a study guide with all the bones and the bony landmarks that we are responsible for knowing. Bony landmarks are processes or cavities that are important because of their muscle or ligament connections. So, I use this study guide to type outline of all the structures.

Second, I sit down with my anatomy references: 1) an anatomy atlas, 2) the Visible Human Dissector (VHD) program, and 3) actual physical bones. My second-year buddy lent me a Rohen 6th edition atlas, but by far the most popular atlas among my classmates is Netter's because of the beautiful illustrations. The VHD program is a 3D rendering of a man who was photographed in cross-section from head to toe every 1 millimeter. Dr. Carry used this program to create flash images so that important structures become highlighted when you roll the mouse over the structure name. It's an especially useful study tool. Finally, I go up to the bone room to hold real bones, feel their structures, and visualize them in three dimensions. The bone room is located next to the anatomy lab where we do our dissections, and it offers medical students bins of all the bones in the body to hold and play around with, along with a showcase of bones with their landmarks labeled. I have found the bone room to be of most help in my studying.


So, with these three resources, I identify each structure listed in the study guide, describe its general appearance and specific location to myself in words, then type that out in my outline. I also add in any functions, articulations (where one bone abuts against another bone), or attachments to any muscles or ligaments that Dr. Carry included in his study guide. I have found that this helps me on multiple levels: 1) creating an outline shows me what I need to know and offers my first exposure to the material; 2) describing a structure in words helps me to visualize it and solidifies that structure in my mind; 3) describing one structure in relation to other structures forces me to review those other structures, further solidifying them in my mind.

The third step in my study pathway is to transfer this outline of anatomical structures and their definitions into an electronic flash card program. As I do this, I visualize each structure and review its description, location, and functions/attachments. There are several different flash card programs out there. One popular web-based program is iFlipr, but this past week I've been playing around with one called Anki, developed specifically to optimize memory formation and recall. So finally, in my protocol for studying bones and bony landmarks, I go through these flash cards.

I realize that I'm probably over-studying the bones, especially considering that most of the points on the first exam will not come directly from them. However, numerous people of authority told me that it's worth my while to learn the bones well, because muscles and ligaments are named for their attachments. I'm sure that I will have to modify my game plan slightly when I move into studying other areas such as arteries/veins, or nerves.

Human body dissection: The human component

I have to admit that I was nervous about anatomy lab. Dissecting a human cadaver is a big deal. Even the term "cadaver" is technical and dry, a euphemism to push from our minds that this body sitting in front of us used to have life. "It" wasn't just male or female, rather a man or a woman who experienced joy and sadness, love and heartbreak, just like I or anyone else have ever felt.

The person who I am dissecting during the next 9 weeks was a woman of short stature and light complexion. She was 80 years old when she passed away from "geriatric decline and dementia." Did she die alone in a nursing home, or is she survived by loved ones who are perhaps still mourning her passing? Why did this woman decide to donate her body for this purpose? Going into my first day of dissection, I refused to let go of these questions because I didn't want to see her as just a cadaver.

This anatomy dissection course is structured so that 8 medical students are assigned to one cadaver, with 4 students dissecting at one time. It happened that I was in the first group responsible for making the "first cut," which so far has been the most difficult moment for me. Until then, I had the luxury to hold onto my imaginings of the life of the woman lying before me, to preserve the human condition.

I was surprised, though, by how quickly that luxury evaporated once my lab mate made the first cut. Suddenly, the woman lying on the dissection table became an "other," an object that I could disassociate from my own personal human experience. That transformation itself was a little frightening to me. I want to stress that I didn't - and I haven't - lost the capacity to view the woman who I am dissecting as a human being; rather, I have gained the ability to partition those thoughts and to view her body as a tool for learning anatomy, in order that I may better tend the illnesses and injuries of those bodies that are still alive as I become a doctor.

Coincidentally, the woman who I am dissecting passed away on the same day that I was admitted to this program. That coincidence holds special meaning for me.

I survived my first week of medical school

Well I survived my first week of medical school. That sentiment seems to be the general consensus among my classmates. For me, it flew by so quickly that until now I've had little time for reflection. That's a good thing, in my opinion, because it speaks to the fact that I'm fully engaged both in learning the material and in the gestalt of the medical school experience.

To my pleasant surprise, lectures have for the most part been very interesting - at least, interesting enough to keep me awake from 8 in the morning until noon, then into the afternoon. The director of the Human Body block Dr. Michael Carry has given the majority of the lectures, and he's exceptionally good at what he does. There were a few lectures about medical imaging and the nervous system that I didn't necessarily need to attend, but I figured that it can't hurt to give myself a little refresher on the material.

In addition to lecture, we also had our first Foundations of Doctoring class. The purpose of this course is to teach clinical skills right from the beginning in an effort to tie in all the basic science and anatomy material during the first two years. We met one of our standardized patient instructors, who taught us how to do some of the basic components of the physical examination: making general observations, measuring waist circumference, taking blood pressure, and taking temperature. Even with something as simple as measuring waist circumference, I did feel like I was fumbling with my words and the tape measure a bit, but better to learn in this no-pressure environment rather than in the clinic with a real patient.

There have also been plenty of opportunities to get involved in interest groups, either medically related or not. I signed up with the CU Surgical Society, which is connecting me with a cardiothoracic surgeon for a one-day internship. I also signed up with the CU Emergency Medicine Interest Group (EMIG), which holds events throughout the semester that teaches real world skills: suturing, intubation, needle sticking, EKG, and ultrasound. Even if I don't end up going into either, it's still great exposure to these fields and helps me meet people and network.

Then, of course, surviving my first week of medical school also required getting through the first day of cadaver dissection. It went very well, but more than the previous four and a half days it thoroughly exhausted me. I'll talk more about it in another post.

Overall, the first week of medical school treated me better than I had hoped. I do feel overwhelmed by the volume of material I have to memorize, but I'm now confident that I can handle it. Getting over my anxiety (irrational, but real to me) that I wouldn't cut it was a very important achievement for me during this past week, along with establishing a pathway for studying, learning, and memorizing anatomical structures. Most importantly, I am very happy to be here: in Colorado, a first year medical student.

You know you're a medical student when...

... without realizing it, you're using the big toe of a skeleton foot to skim read an anatomy atlas.

First day of classes

First day of classes are over, and it wasn't nearly as exhausting as I expected. Maybe that's because I got a fairly good night's sleep. Or, maybe it wasn't so tiring because we get a 10 minute break every hour.

Classes started at 9, an hour later than they'll usually start. I arrived with about 10 minutes to spare after a brief scare with the chain of my bike falling off the grooves. Luckily, a man nearby offered to fix it for me. Something always has to go wrong on important days, and that was my something.

I brought my laptop to class, which is something I never did during either college or grad school. It's a mixed bag: on the one hand, I'm much better at typing quickly than writing quickly while still paying attention to the lecturer; on the other hand, wireless internet is a dangerous distractor. For me, the former outweighs the latter, which means that I have to be very disciplined in what internet surfing I allow for myself during class. My rule is only Blackboard (a course-related website) during class, along with any internet searches relevant to the topics being discussed. E-mail and all other internet surfing have to wait for a break. Many of my classmates aren't nearly as regimented as this, and others purposefully didn't bring their computers to class so they wouldn't be messing around on Facebook when they should be learning.

Speaking of regimented and structured (which I have to be if I'm going to survive medical school), a friend sitting behind me joked around with me about my mad typing skills, that she didn't even have to pay attention to the lecturer, just look over my shoulder to read the transcript. I may find out later that taking such detailed notes is unnecessary, but for now, I would rather have too much than too little. I have also devised a file naming system and directory tree that allows me to easily keep track of all the lecture notes I type up. The plan is (and we'll see how faithfully I stick to it) to review all of these notes that same evening.

One last thought before I go study bones: The curriculum here places an emphasis on "self-directed" learning. That means the lectures will not cover all of the material that I am responsible for on the tests. Having been a non-student for several years, I will need to quickly adjust to a mentality of proactively seeking out knowledge. I expect this adjustment to happen quickly, out of necessity.

Medical school orientation week: Overnight retreat in the mountains

We left early Tuesday morning in a caravan of coach buses to Winter Park, a mountain retreat where the next two days of orientation week were held. If the first day of orientation week felt like college, this was a full regression to the days of Summer camp, complete with horrible cafeteria food, nature hikes, and zip lining.

The purpose of this retreat was primarily group building. Our class of 160 was divided into 20 groups of 8, and in these groups we had to complete team building tasks:

1) While everyone is blindfolded, form a right triangle out of a piece of rope. It's harder than one might think!
2) Variations on a game where we have to keep a ball up in the air as long as possible.
3) "Chocolate Acid River." This was actually the most fun of them all. Two lines served as the banks of a river, and we had to safely get our group to the other side. Squares of carpet served as safe stepping stones, which we could move, but we only had 7 of them for our group of 8.
4) We put together a group art project that represented what we saw as the future of medicine and our medical careers. We came up with a giant dream catcher made out of rope and a hula hoop, representing the interconnectedness of everyone in the health professions and how we must all work together as a team (buzz word!) to fulfill the needs of society. It also represented how the personal career goals of everyone in the group were quite divergent (rural practice, focus on underserved communities, clinical research, etc...), yet as future doctors, we will all serve our role in serving society. It was a very touchy-feely exercise.

As cheesy as these activities were, I did have a lot of fun with them, and they actually served an important purpose. It turns out that the people who I got to know so well through these team building exercises are my problem based learning (PBL) group. In addition to lecture, the curriculum also includes a strong component of small group sessions that are, as you might guess from the name, problem-based. So, for instance, in our first "practice" PBL session on Thursday, we were presented with a scenario in which we witnessed a motorcycle accident and tasked to explore all medically related facets of the scenario. In contrast to lectures, these small group sessions are mandatory. Mandatory or not, I am looking forward to these small group sessions. I do better when the material I am learning is put into context.

We were broken up into different small groups, alphabetical by last name, to talk about the honor code. I will come to know the people in this group very well over the next nine weeks, as they will be my anatomy dissection group. Like in the PBL groups, there are 8 of us, but only 4 people will be working on the cadaver at one time. On any given day, 3 people will share the dissection duties while the fourth is responsible for reading the instructions and guiding the group. Then, the two groups of 4 switch turns.

My parents and little sister were waiting for me in Aurora when I returned from the retreat. I was exhausted.

Medical school orientation week: The first day of school

Before starting "real" medical school, my fellow classmates and I spent this past week going through a program designed to acclimate us to our new lives as medical students. As I rode my bike to school for the first time (it took 7 minutes), I reflected on my own excitement for what lay ahead. I have officially matriculated.

Monday, August 10th was dedicated to taking care of mundane but necessary details, like issuing ID badges, setting up e-mail accounts, and confirming immunizations and health insurance. Groups organized alphabetically by last name rotated from station to station, which made the experience feel very much like undergraduate orientation.

All of that waiting around gave us plenty of time for awkward conversations with a fairly predictable script. I complain just a little bit but know that such conversations are inescapable when trying to meet more than 160 people who I will be spending the next four years of my life learning alongside. And for all the repeatability of these conversations, I was wholly impressed by every single person I met: by their accomplishments, by their amicability, and by my eagerness to get to know them better.

The highlight of Monday was getting fitted for our white coats. Real doctors wear long white coats, while medical students are differentiated by wearing short white coats that cut off at the waist. The medical profession is very big on clearly demarcating the pecking order in visible and obvious ways. Some of my classmates said they felt like they were playing dress up, but trying on my short white coat for the first time, I could imagine getting used to it very quickly so that, over the next four years, it would come to feel like a second skin.


The rest of the day was spent meeting our deans and the director of the Human Body block, Dr. Michael Carry, who has been teaching this course for no less than 21 years. He is a phenomenal lecturer. Over the next 9 weeks, I will be memorizing 2038 anatomical structures, their functional relationships, and their clinical relevance. I can't pretend that that's not just a little daunting.


Here are some statistics of my class that Dr. Wagoner, dean of admissions, shared with us:

Of 3660 applications, 573 applicants were interviewed and 260 were given offers of acceptance. My final class size is 160: a quarter are straight out of undergraduate, a fifth are from out of state, and the gender ratio breaks down to 56% men and 44% women. I was also surprised that I fell in the age group with the most number of people.

Much-needed thank yous

I want to take the time now, the night before I start my medical school orientation, to thank those who have helped me get to this place in my life, on the eve of starting medical school. In particular, I am blessed with loving parents who have supported me at every step: morally, materially when needed, and otherwise. I also want to specifically thank my two sisters, my Nana, my best friend John, and my mentor Walt, who have all ushered me through the ups and downs of applying to medical school. Throughout this process, I have come to understand that the endeavor of becoming a doctor is truly a collaborative effort.

Settling into my new home

The day after arriving in Denver, my father and I unloaded the moving truck and started the process of unpacking boxes. We made a couple gargantuan trips to the Super Target, located just a 5-minute drive away, to stock my new home with the essentials for living.

We also explored my new neighborhood, which is a 1950's track home development that is blue collar and for the most part well maintained. Families sit in rockers and benches on the front porch in the evenings, and kids ride their bikes and play ball in the streets. There's a shopping center just a half-mile away, well within walking distance: King Soopers (super market), Ace Hardware, post office, a really good Mexican food restaurant, a thrift store, a liquor store, a carniceria (Mexican meat store), a Spanish language movie theater, and all other sorts of goodies.

My mom flew out the next day and helped my father and me with other aspects of settling in, like putting things away in the proper place and making the house feel more like a home. Most importantly, she brought my cat Ollie, who is essential for my survival of these next four years. I know that, if I had to, I could have moved in by myself, but having both my mom and dad helping me made both the logistics and the emotions of this transition that much easier.

As difficult as it was to leave San Diego, I can see a new life - a good life - taking root for me here in Denver (or, more specifically, Aurora).

Saying goodbye to San Diego, and the drive to Denver

Saying goodbye to San Diego was much more difficult than I expected. But I squeezed in as much as possible during the last few hectic weeks before moving: walking around Balboa Park, a play at the Old Globe, beach time at La Jolla Shores, a bonfire on Mission Bay, sharing a pie at Bronx Pizza with my wonderful friends who helped me pack up the truck, and lots of other fun stuff.

My father and I set out for Denver at 5 in the morning towing my car with a 16-foot Budget rental truck loaded with the majority of my worldly possessions. Most people wouldn't be able to sleep the night before such a voyage, and I was no exception. Throughout the day, as I ran my last-minute errands and tied up loose ends, I reflected that I had been working toward this move, directly, for over a year and a half, and indirectly ever since I was a little boy when I formed a vague notion in my mind that I wanted to become a doctor when I grew up. The whole day felt like that particular psychosomatic nervousness in the moments before a big race, combined with the jittery restlessness of too much caffeine. But I don't drink coffee (yet) and hadn't drank any tea or eaten any dark chocolate (my preferred source of caffeine). A monumental shift in my life lay waiting for me on the other side of midnight, but when midnight came and went, I wasn't yet ready to say goodbye. I forced myself to sleep in the early hours of the morning when common sense more than exhaustion overcame me.

Despite getting only 2 hours of sleep, I held up pretty well, driving my fair share of the marathon 21-hour trek from San Diego to Denver. Like my recent travels to Honduras on medical relief missions, I viewed this sleep deprivation as a challenge to prepare me for the exhaustion that lies ahead during medical school and residency. I now firmly believe what they say, that driving while tired is like driving drunk, and if that's true, it should make one question the presence of mind of medical interns and residents.


Next entry: settling into my new home.

Last day of work: the end of an era

My last day of work was on Friday. I've been so busy trying to wrap up the last remaining projects that there's hardly been time for me to notice that my time there was coming to a close. This past week has been full of goodbye lunches and dinners and co-workers dropping by my office in faux tears begging me not to go. It feels good to be leaving my job of 3.5 years on such great terms.

Yet I leave with mixed emotions:

sad to be leaving a mentor who has done so much to help me along in my career, and co-workers who have genuinely been a pleasure to work with, and a job that at once is intellectually challenging and provides a large measure of satisfaction that I'm doing something worthwhile;

but also excited for the adventures that lie ahead, in persevering through the trial-by-fire rites of a medical education, exploring a new city, and forging new friendships that will last a lifetime.

What I write sounds grandiose, but on the threshold of such grand changes in my life, I think it accurately and appropriately reflects how I feel right now.

Home Sweet Home

I finally found a place to live! I'll be sharing a 3br/2ba brick home with a guy named Josh, who is entering into a physiology Ph.D. program. The third bedroom will be used as a study, and the house is just a mile from campus, which is close enough for me to walk, run, or ride my bike to school on most days. Not knowing where I was going to live was a major stress for me, so I'm very relieved to have that item checked off my list.

Preliminary academic calendar

Finally, a preliminary academic calendar for the first semester has been posted. They have broken it up into two blocks:

1) Human Body: August 17 - October 19
2) Molecules to Medicine: October 20 - December 14

It's a relief to have concrete information so as to mentally prepare for what's in store, beyond the abstract "It's gonna be a lot of work."

Taking time for the self on the path to becoming a doctor

A friend forwarded me this NY Times article, "Taking Time for the Self on the Path to Becoming a Doctor," which addresses some very deep concerns that I have about how I will cope with the immense stresses of medical school, which another friend of mine aptly refers to as "dehumanizing." I think it's important to remember how vital it is that I have an anchor to reality, to sanity, throughout medical school and beyond.

By PAULINE W. CHEN, M.D.
Published: June 18, 2009

Over the next two weeks in hospitals and medical centers across the country, new medical school graduates will begin their internship. Among their many worries — moving to a new city, meeting new colleagues, adjusting to medical training — is a more profound, existential concern that had once plagued me.

Do I have to lose my self in order to become the doctor I want to be?

I learned the answer to that question partway through my internship. Not in the hospital but in the checkout line of a local grocery store.

The customer in front of me was an older woman — she wore a faux camel-hair coat and had hair dyed a matching color. I remember that she had wanted her groceries bagged in a particular fashion, but the sales clerk, a young woman with impossibly long pink acrylics, was perplexed by the woman’s demands.

I felt as if I had stepped into an avant-garde theatre production. Each time the young woman bagged the groceries, the older woman admonished her and asked her to go through the process yet again. The muscles of my jaw tightened with each round of bagging, and even though I was off for the day, all I could think was: I’ve got sick patients to take care of, I can’t wait for this!

Unable to bear it any longer, I stepped forward and bagged the woman’s groceries myself, shoving the plastic bags into her arms while resisting the urge to push her on her way. I imagined steam rising from my head as I ranted. But a part of me was as shocked as the people still standing in line. I had never lost my temper in a store, and I had never raised my voice in public. Now, a few months into internship and with a three-minute provocation, I had the capacity to act like a grizzly bear sprung loose from a trap.

I walked out of the store horrified. That night thinking back on the event, I grew more ashamed of my behavior. But I also realized that it was not the first time I had snapped. Over the previous months, I had thrown myself into my work and shunned everything I once enjoyed and nearly everyone I loved. I believed I needed to do so in order to become a surgeon.

But I had lost my self in the process, and the stress made me irritable. I was no longer the nonconfrontational person I once was.

I had, for example, raised my voice a couple of days earlier at a receptionist in the radiology department when she couldn’t schedule my patient for a CT scan. I had scolded a nurse who had had the misfortune of being the fifth person to page me as I scrambled to finish a procedure. And only a week prior, I had squabbled with my family after my mother innocently asked, "Why do you have to work so hard?"

According to a study from the Johns Hopkins University School of Medicine in Baltimore, I am far from the only doctor who has behaved this way. The researchers interviewed residents, or doctors in training, from seven different specialties and found that they set themselves up for burnout by accepting, even embracing, what they believed would be a temporary imbalance between the personal and professional aspects of their lives. While the young doctors interviewed defined well-being as a balance between all those parts, many felt that their medical training was so central to their ultimate sense of fulfillment that they were willing to live with whatever personal sacrifice was required, even if it meant a temporary loss of a sense of self.

I spoke to the lead author, Dr. Neda Ratanawongsa, who now practices general internal medicine at San Francisco General Hospital and is an assistant professor at the University of California, San Francisco.

“It’s partly a coping mechanism,” Dr. Ratanawongsa said. “We tell ourselves that we can do everything but not at the same time, so we are going to put off the thing that defines us as a person — time with children, running a marathon, painting, playing music — in order to get trained because being a doctor is also rewarding.”

That delayed gratification works well initially because residents believe it is only temporary. “A lot of what matters to residents at this time is the sense that they are learning to care for patients well and growing as doctors. They feel that what they are doing is going to be worth it.”

But when the imbalance persists for longer than initially expected, professional growth is not enough to sustain most young doctors. “The ones who are happier,” Dr. Ratanawongsa observed, "are the ones who have held on to one or two things and have said, ‘I’m not just another resident. I play the guitar, I run races, or I go home to family.’ They don’t do these things to the same extent as they did before residency, but they do them enough to maintain a sense of self.”

Residents who don’t find this balance are at risk of burnout, clinical depression or, more commonly, subtle forms of stress. “These residents may feel that even if they can give excellent care most of the time, there are times when they snap at a patient or don’t order a test fast enough because they are so burnt out."

Although her study focused on doctors in training, Dr. Ratanawongsa sees the same challenges among doctors who have finished and are currently practicing. “There is always this expectation that at some point things will turn around. The interns say, ‘When I finish internship and become a second-year resident, things will get better.’ The residents say, ‘When I finish training, I will finally have balance again.’ And doctors in practice may believe that they will find more balance once they have retired.”

The danger is that physicians may end up leaving the work force or will become less effective caregivers. Dr. Ratanawongsa suggests that doctors learn how to create a better sense of balance in their lives from the moment they begin training. “We are taught to put our patients before ourselves; it’s in our charter of professionalism. I agree with that, but I also think there has to be some sense that I matter, too, at some point. If something important is going on with our loved ones or with ourselves, we need to be able to advocate for ourselves. And we need time to reflect on who we are and where we are going.”

In the months after that incident at the grocery store, I continued to devote my life to my training — there was no other way to become the surgeon I wanted to be — but I also learned to find time for myself. Even 18 years later, I can still remember those moments away from work well — late morning breakfasts with the Sunday Times in hand at the greasy diner down the street from the hospital, glorious springtime drives in a friend’s used convertible, afternoons running on a boardwalk and walking along the beach. I lost a few extra hours of sleep each time I did something for myself; but in the end I, and my patients, would gain much more.

“My belief,” Dr. Ratanawongsa said, “is that doctors will have a greater capacity to know their patient as a person if they know themselves. That kind of knowledge requires a sense of balance and an understanding of why they chose to become a doctor. It comes down to their capacity to be an empathic, caring and compassionate provider; and it comes not from their medical knowledge but from their soul.”

“This is something we should never sacrifice, even temporarily.”

Financial Aid 2009-2010 Award Offer

I finally got my financial aid package, and man what a relief it was to know that my school is paid for. The package consists of a mix of Federal Subsidized Stafford, Unsubsidized Stafford, and Direct Grad PLUS (.PDF) loans.

None of these three loans require repayment while I am a student. Stafford loans subsidized by the government have a fixed interest rate at only 5.7% and do not start accruing interest until after graduation. Unsubsidized Stafford loans do not have this delayed interest accrual benefit, and their fixed interest rate is higher at 6.8%. Both Stafford loans have a 6 month grace period after graduation and before repayment starts. Direct Grad PLUS loans have the highest interest at 7.9%, also fixed, accrue interest immediately like the Unsubsidized Stafford loan, and its repayment grace period is only 2 months.

After my initial relief at knowing that the loans came through wore off, and after I took some time to crunch the numbers, the sheer magnitude of debt that I will be facing broadsided me. But my medical education is essentially a high stakes long-term investment in my future. I think it's important to keep that perspective, focus on my education, and not allow myself to get bogged down or stressed out by the numbers.

The orphanage and the dump

Today was a study in contrast.

La Casa Esperanza, The House of Hope

Our first stop was Casa Esperanza, an orphanage that lived up to its name. We drove down a winding dirt road to a hillside suburb of Tegucigalpa with Dr. Claudio, who helped found the orphanage and has been involved in Rescue Task Force and its new sister organization World Emergency Relief.

I asked Dr. Claudio more about the orphanage. There are currently 26 children living there. Casa Esperanza started some years ago with an initial investment of $320,000 and now costs about $3,000 per month to maintain. That covers all costs, including feeding the children and paying staff. It simply amazes me that more than two dozen orphaned children could be comfortably supported by such little money. The orphanage is currently at capacity, but Dr. Claudio wants to build another dormitory, which would raise capacity to about 50 children and operating costs to about $6,000.

The purpose of our visit, aside from playing with the children, was to survey damage to their dormitory from the recent earthquake. There were several large cracks in the building, but thankfully, the damage seemed to be relatively minor and the building still safe to use (not an expert´s assessment).


I was greeted with a BIG hug from a little boy even before I got out of the truck. We handed out candy and balloons, watched their grammar lessons, and took lots of photos. From that first little boy´s hug welcoming me, I was overwhelmed by the positive atmosphere. To be honest, this magnitude of positivity caught me by surprise since I typically think ¨Oliver Twist¨when I think of orphanages. But to these children, Casa Esperanza is a true home in all senses of the word. Though I know that they have already seen their fair share of hardship, it filled my heart with joy to watch these children enjoying the innocence of childhood, a rarity here in Honduras.

The Dump

Our second stop was the dump. I cannot adequately communicate the desperation and desolation of spirit that I saw there. People live there, they live at the dump: children, women, whole families. Some of them get paid 50 cents per day to sort and haul recyclable materials, while others fight over trash that they can sell or trade or eat.


A garbage truck arrived while we were there. When it dumped its load, a hoard of people descended onto the pile of trash like the hundreds of vultures circling overhead. At the top of the pile of trash was a little boy holding up a recyclable cardboard box for a toy scooter that he would never have, but he smiled with his spoils as if he were holding the actual scooter. Then I saw a little girl, who couldn´t have been much more than 8 years old, lugging a sack of trash larger than herself. It was only later, when I was looking at a close-up of a picture I took of her, that I noticed she only had one shoe and wore just a sandal on her other foot. Such is life for these children, robbed of their childhood and their humanity.

There were vultures everywhere, not just circling above. They hopped in and out of the crowd digging through the trash, and they lined the crest of the hillside overlooking the landfill like bandits waiting for an opportunity. As I was taking pictures, Richard (our Honduran guide who accompanied Andrea and me to the dump) abruptly said that it was time to go. Later, when we were back in the car, he told us that a couple men showed him knives and flashed gang signs at him. Esos no son solamente banditos, son malditos. They are not just thieves, he explained, they´re very bad men who are dangerous in their desperation, and they just wanted us to go away. So we went.

I never felt like I was in any immediate danger, but the atmosphere was unambiguously threatening and guarded: every person living at the dump literally fights each and every day for their life. Andrea showed me the dump because she wanted me to see for myself the base depths to which human existence can sink. ¨This is about as bad as I´ve seen it,¨she says. ¨People just don´t want to know, they don´t want to know that this is happening right now, but it is.¨ I don´t want to know, either, but I feel it is my responsibility to know. What can I do about this, though? What can anyone do about such an atrocity when it´s buried and forgotten as easily as tossing your leftovers from dinner in the trash?

Reflections: Honduras earthquake relief mission

We drove back from Puerto Cortez to Tegucigalpa all day yesterday. That 8 hour drive gave me some time to unpack my thoughts and feelings from my first experience in immediate disaster relief, responding to a 7.1 earthquake in Honduras.

We found a group of families whose homes were destroyed by the earthquake and gave them food and other supplies that would help them through the disaster. Rescue Task Force typically responds to bigger disasters, like the 2005 tsunami or Hurricane Katrina, where there's a great need for the immediate presence of doctors and medical supplies. We didn't really know what to expect, going in, and it turned out that no one - amazingly - was in need of medical attention.

These people were very poor to begin with, so losing their home was a catastrophe. I'm glad that we were able to help in what little way that we could, and knowing what I know now I would do it all over again. But I also recognize that the help we were able to give is only temporary, and that at the end of the day, these people still have no home to return to and no resources to rebuild.

Unfortunately, this represents deeply rooted sociological problems endemic to Honduras that a relatively small outfit like Rescue Task Force can't hope to tackle. I strongly believe in the service that RTF provides, acting as first-responders to natural and man-made disasters throughout the world (they say this somewhere on their website), and I will continue to do what I can to support them, including volunteering for future missions. Even so, it's still difficult for me to see these systemic problems and know that there's nothing that RTF can do about it despite its resources, both in the form of money and volunteers with the will to help.

I'll write more about my outside-the-box thoughts on how to address these systemic problems in a later post.

Today, we will visit the orphanage.

RTF #246: Mission Accomplished

Yesterday´s mission was a success. We first surveyed homes that were damaged or destroyed by the earthquake. Then, we talked to los bomberos (the firemen), who are the first-responders here in Honduras, to figure out how we could best help. They told us that 25 families whose homes were destroyed were temporarily relocated to a school not too far away, so we decided that our mission would be to give these families food and supplies. These are unfortunately people who didn´t have much to begin with, even before the earthquake. Thankfully, none of these people were in need of medical attention.

I don´t have time to go into a play-by-play of the day, because we´re heading back to Tegucigalpa momentarily, but I´ll write more when I get back home, and I´ll also post some pictures.

On Monday, we´ll be visiting the orphanage in Tegucigalpa that was described in the RTF newsletter. Then, we´ll be flying back to the States on Tuesday, a day earlier than expected. I will need some time for reflection to unpack all of my thoughts and impressions from this mission. It was such a gratifying experience overall.

Helping the earthquake victims

I am exhausted after a day full of helping people whose homes were destroyed by the earthquake.

We headed out first thing Saturday morning to meet with los bomberos (the firefighters), who are the real first-responders in emergencies like this, survey homes that were damaged by the earthquake, and to figure out what we could do to help. We sat down with el comandante of the firefighters, a stout man with a deep voice, thick Honduran accent, and intelligent black eyes, who carries an air of authority and respect due his position.


The most pressing need, he told us, was drinking water. The earthquake ruptured the pipeline that brings water to Puerto Cortez, leaving a large chunk of the city without potable water. To address this, the fire department has its only three tanker trucks filling up their tanks with water from the unaffected portion of town and distributing water to the city´s 120,000 inhabitants.


Indeed, as we were driving around town, we came across a crowd of women and children with water buckets surrounding one of the fire trucks. It was slowly making its way through the neighborhoods to distribute water. There wasn't any sense of panic, since plenty of water was to be had, but I did feel tension as people in the crowd made sure they got the water they needed. The air was heavy with smoke from fires lit to signal to the firefighters that water was needed. Women chased after our truck down a dusty road to ask us to tell los bomberos to stop by their neighborhood, too. Little children lugged 5 gallon buckets heavy with water from the main road arteries all the way back home.


El comandante told us about two dozen families whose homes were destroyed by the earthquake and were living temporarily at a local public school. It's amazing that there were so few injuries, for such a strong earthquake, and that there was no need for outside medical aid. But their homes were destroyed. Whole families were sleeping outside underneath blue tarps.


We toured the neighborhood where these families live. It was apparent that these people had so little even before the quake hit, but now, what had been modest houses before were definitely not livable. A major problem is that there is no drainage system, so rain water collects underneath the houses and rots the wood. The earthquake just sped up the inevitable. One family allowed us to tour their house, which should be condemned and demolished since the floor had caved in and stagnant water lay in the kitchen, bathroom, and bedroom. This poses obvious health concerns: respiratory ailments and skin conditions due to mildew and mold, not to mention an increased risk of mosquito-born illnesses.


I was agonized to see people living in such conditions and know that there wasn't anything I could do about it. Rescue Task Force is an organization with a modest budget; it's structured to deliver maximum impact with little money through targeted missions, usually in emergency conditions. Rebuilding homes was not in the scope of our mission.

Instead, we decided to help these 25 families whose homes were destroyed by giving them food and basic supplies like diapers. This sounds like a simple task, but it took a lot of coordination with two community organizers who were running the temporary shelter. With their help, we put together a grocery list and, a pack of kids in tow, walked to the local grocery store. Each family got a sack that included food basics such as eggs, milk, flour, rice, beans, and oatmeal, as well as other goodies.

Keeping track of what we purchased was a challenge, as was communicating to the sales clerks what we wanted. It was like playing a game of telephone: Andrea talked to me, I translated into Spanish to our Honduran guide Richard, who then made sure that the sales clerk got it.


I am so thankful for my Spanish because it allowed me to interact directly with the kids. I looked at them, happy and laughing in the grocery store. They were only allowed inside because we told the manager that they were with us, and we were spending big money. It occurred to me that maybe the kids didn't understand what we were doing for them and why. So I gathered them around me and explained to them that we were here to help them and their families because their homes were destroyed by the earthquake, that it's good to help people who are less fortunate. And I told them that I hoped that they would remember this day, what it feels like to be given help, and that maybe one day they could help someone else who needs it. In the middle of all the grocery store fun, it was a brief 30 seconds or so of seriousness. If what I said, or what we did together through Rescue Task Force, made an impression on even one of the kids, that is the real and lasting difference that I hope to have made in coming down to Honduras.