Saturday, August 29, 2009

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.

Friday, August 28, 2009

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.

Sunday, August 23, 2009

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.

Saturday, August 22, 2009

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.

Friday, August 21, 2009

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.

Monday, August 17, 2009

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.

Saturday, August 15, 2009

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.

Sunday, August 9, 2009

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).

Tuesday, August 4, 2009

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.