Running into St. George's University students at the airport

In the airport on my way back to Denver, I talked with a couple students from St. George's University Medical School in Grenada. They saw me reading BRS Pathology, recognized its distinctive formatting, and struck up a conversation.

I was very curious to hear a first-hand perspective about SGU because I had seriously considered applying there. For Americans it's usually highly preferable to go to medical school in the States, but in recent years, many medical schools have been founded that cater mostly to people who for one reason or another were not able to attend an American medical school. St. George's University is the first and most reputable of the "Caribbean medical schools."

There's a certain stigma attached with going to a Caribbean medical school. The assumptions, I think, are that students are of a lower caliber and that the curricula at Caribbean medical schools are "inferior" to those of American schools. The reality is that 1) every year hundreds or thousands of deserving applicants are denied entry into an American medical school, 2) Caribbean medical schools must meet the same curriculum standards as American schools, and 3) students attending Caribbean medical schools must pass the same standardized exams as everyone else.

I was most curious to learn whether my new friends had encountered any prejudice against their school; they had not, yet, but they were in their first and second years and had not yet gone back to the States to do their clinical rotations. "It's all about going out there and making a name for yourself; you have to do that regardless of where you go to school."

That was something of which I was unaware: that SGU students do their clinical rotations at hospitals in either the New York or Los Angeles metro areas. It makes sense. Moreover, like the Sackler School of Medicine at Tel Aviv University (which I did apply to), the residency match program is run through New York State.

I also had an image in my mind of SGU students SCUBA diving before class, sailing on the weekends, etc... According to my friends, that's not they way it is down there at all. Most everyone, they say, is very serious about studying.

One major difference about their program is that they are much more strict about failing a class or the Step 1. Apparently, at SGU, you can be kicked out for failing one class. Here at Colorado, a student who fails a class is offered a chance to remediate that class. It still goes on the transcript, which will make residency applications that much more difficult, but at least it doesn't torpedo a fledgling career.

Even though their school is in the Caribbean, and despite the slight curriculum differences between their school and mine, their experiences in their path to becoming a doctor are not so very different from my own. There's something comforting about that.

Free time

The semester ended yesterday, and I'm left with the strange feeling of not quite knowing what to do with all of this free time on my hands. Love it.

Computer horror story with a happy ending

I've heard horror stories through the years of computers crashing on people right before an exam, or before a term paper was due, but I never thought it would happen to me. This evening, it did.

After studying at school all afternoon, I grabbed some dinner and came home to do some more studying. Except, my Macbook Pro decided that it did not want to turn on. There's really no opportune time for something like this to happen, but I got a sinking feeling in my stomach because the last exam in the DEMS block was just three days away. Is this a hard drive or software issue? When was the last time I backed up my computer? Good thing I got the AppleCare extended warranty.

The tech support guy at AppleCare told me that there was nothing he could do over the phone and immediately booked an appointment for me at the Apple Store in Cherry Creek. Forty-five minutes later, I was greeted by Mark, a guy in his mid-20's, short, ruffled hair, scrappy beard, and black-rim glasses: "Welcome to the computer doctor's office!"

Indeed, he approached this appointment much like a good doctor treats a patient. When he connected an external hard drive to my computer, he explained in non-computer science terms that he was using it to try to gain access to my hard drive. Mark did this at every step along the way, just as I might say to a patient, "Now I'm going to listen to your lungs to make sure they sound clear." This progressed naturally to the point when he broke the news: "I think we're going to have to replace your hard drive." Despite wanting to deny that this was happening, I saw that it was coming. And he immediately followed that up with the practical question, "When was the last time you backed up your computer?" A few days ago, maybe a week.

So, I signed some papers, and he took my computer in the back to operate. I felt like a family member waiting while a loved one was in surgery (this would be analogous to.... brain replacement?). Mark came out after 15 minutes to tell me that the procedure was going well and that I'd get to see my Macbook Pro in about 5-10 minutes.

I was home by 9pm, and thanks to the wonders of Time Machine, my computer was completely restored by 10pm - applications and everything - to its last backup point about 5 days prior. Amazing. It could have been so much worse.

Moral of the story #1: Back up your data regularly!!!
Moral of the story #2: Buy the extended warranty for your computer!!!

Step 1: Booked.

I have officially booked my USMLE Step 1 exam. I'm scheduled for 08:00 on Monday, April 11th at the Prometric testing center in southwest Denver. Ideally, I would have liked to take the test on Tuesday the 12th or Wednesday the 13th, but that was actually the only date available during that week at any testing location in the Denver-metro area. I would have had to go down to Colorado Springs (an hour-plus drive) in order to take the test on that Tuesday or Wednesday. Ultimately I decided that test-day convenience was worth more to me than an extra day or two of studying.

Some thoughts on specialties

Over Thanksgiving break, a number of people asked me what kind of specialties I'm interested in and whether I know yet what I want to be when I grow up. Although some enter medical school knowing exactly what they want to do - and end up doing it - a sizable majority of medical students have absolutely no idea until they're practically forced to make a decision at the beginning of fourth-year.

"That's what third-year clinical rotations are for," is my short answer when people ask me about specialties. I want to keep an open mind and not close any doors until I have experience-based reasons to do so. That said, there's also a long answer; but it should be kept in mind that this long answer is time-sensitive as it will necessarily change as I'm exposed to new material and new experiences.

So, without further ado, here is my specialty differential (at this moment, in no particular order):

1) Neurology: I have a background in neuroscience, so I obviously find the brain a fascinating subject intellectually. How that translates into day-to-day clinical practice, I'm not yet sure. I have shadowed several neurologists, including my Mentored Scholarly Activity adviser, but I won't get a full picture until my third-year neurology clinical rotation. I am interested in movement disorders, seizure disorders, and perhaps interventional or pediatric sub-specialties.

2) Emergency Medicine: I have been working for the past year in the Emergency Department with my Foundations of Doctoring preceptor. I like the pace of the job. I like that I'm (usually) presented with an acute problem that needs to be fixed immediately. I like the fact that I'd be doing procedures (e.g. lumbar puncture, joint aspirations) in addition to medicine. I like that I'm helping people who typically do not otherwise have access to medical care. I like that I would be working shifts and could leave my work at the hospital. That's especially important to me as I'd like to eventually have a family and be more than a nominal presence at home. I also like that my skill set could be put to good use in volunteering for organizations that provide medical care abroad.

3) Surgery: I like doing things with my hands - I have good manual dexterity from all those years of playing video games, and I'm good visuospatially. But, I know nothing of what surgery is actually like and how good I actually am with my hands. I'm also skeptical about the surgery lifestyle. My interest in surgery will come down to my third-year rotation experience.

4) Nutrition/Metabolism: It turns out that I really enjoyed the nutrition/metabolism unit that we just finished. I found it surprisingly interesting and applicable to everyday health. I'm a strong believer in preventative medicine, and specializing in nutrition or metabolism would be consistent with that value. Plus, with the obesity epidemic, the need for such physicians will only increase. I worked for four years in an eating disorder clinic, and my very first job in high school and college was chart review and data entry for a bariatric surgeon who performed laparoscopic gastric bypass surgeries. A career path in nutrition/metabolism would be consistent with what I've done in the past; still, I know very little about it in terms of clinical practice options and need to do some homework.

Step 1: Anxiety dream

I'm already having anxiety dreams about the USMLE Step 1.

Last night, after having taken the dreaded test, I opened up the envelope with my score and saw "188" staring back at me. 188 is on the border of passing and failing, depending on the national performance for that test and recent tests. The national mean is somewhere around 222, one standard deviation above the mean is somewhere around 140-145, and a top score is 270.

Needless to say, I was horrified. In my dream, I was trying to assimilate the fact that I would not have the residency of my choice and would not even be able to go into the specialty of my choice. It was very traumatic.

I accurately predicted my MCAT score in a dream a week prior to the exam, but the Step 1 is still 4.5 months away. Maybe 188 is what I'd get if I took the exam a week from now - that wouldn't be so bad. An astute classmate friend noted that the dream can't be true because we get our scores by e-mail, not snail-mail. As silly as that sounds, it makes me feel better.

The USMLE Step 1 is a stressful exam - there's a lot riding on it. It's perfectly natural to have feelings of anxiety about it, even this early. What's most important, though, is that this anxiety is handled in a healthy manner.

Registering for the USMLE Step 1

Medical students must sit for Step 1 of the United States Medical Licensing Exam (USMLE) after they have completed their first two years of didactic learning and before they can enter into clinical rotations. Students at the University of Colorado School of Medicine take the exam a bit earlier than most other students around the country because the Powers that Be decided to shorten Year 2 in order to lengthen Year 3 - a decision for which I'm grateful.

So, while most medical students take the USMLE Step 1 around June or July, I will be sitting for mine in April.

The registration process is quite involved. First, I had to go to the National Board of Medical Examiners (NBME) website, create a username and password, and enter in my basic information. This allowed me to print out a "Certification of Identification and Authorization" form (complete with a 2"x2" picture of myself reminiscent of medical school applications), which had to be signed by the Dean's office and mailed into NBME. I just recently received an e-mail from NBME:

Your USMLE Step 1 Certification of ID/Applicant Authorization has been received.
Your registration is complete.
Your eligibility period is Mar 1 - May 31, 2011.

Next, I will be getting something in the mail from NBME that will allow me to schedule my Step 1 exam within that eligibility period.

This whole rigamarole is much more involved than what I remember going through to sign up for the MCATs. Jumping through these hoops has had the effect of making the looming threat of the USMLE Step 1 exam that much more real. It's coming up soon.

Thanksgiving

I took my metabolism exam a day early and flew home for Thanksgiving. The exam was originally scheduled for Wednesday morning at 8:00 am, but Dr. Michaels kindly allowed students to take it at two other times to accommodate travel plans. I'm curious about how common this is at other medical schools, having students take an exam at different times and un-proctored. Regardless, I am very thankful that the administration places such trust in us students.


It feels good to free from medical-school-related-responsibility, even if it is just for 5 days. I don't realize how stressed and focused I am on my studies until I'm not studying anymore.

Metabolism + Psychiatry = Eating Disorders

The metabolism and psychiatry curricula converged last week with a discussion on eating disorders. Having spent 4 years studying the neurobiology of anorexia and bulimia nervosa with Dr. Walter Kaye at the UCSD Eating Disorders Treatment and Research Program, I was naturally curious as to how the topic would be presented.

Dr. Kenneth Weiner (who heads the Eating Recovery Center here in Denver) gave a one-hour lecture during which he commented that this one-hour lecture is the extent of our contact hours throughout medical school touching on eating disorders. Further, according to Dr. Weiner, internal medicine residents get a grand total of 8 hours of lecture on eating disorders. Perhaps I shouldn't be shocked by those figures, given how much material there is to cover and the limited space in the curriculum. The lecture itself is one I've heard dozens of times before - still very interesting given that Dr. Weiner has his own style of presentation and his own vantage point of eating disorders quite distinct from Dr. Kaye's.

The lecture was followed by an interview (in our regular psychiatry small groups) with a patient recovering from an eating disorder.

Is high-fructose corn syrup really all that bad for you?

Having just finished the digestive organs unit (covering the gastrointestinal tract from mouth to anus including the liver, pancreas, and gall bladder), we're now learning how those nutrients are metabolized after they're taken up into the body. It's actually very interesting material because it is applicable to everyday life. Our metabolism professor Dr. Besseson says that "Nutrition is just applied biochemistry."

One nutritional controversy that has been in the news for the past few years (and has spawned new marketing campaigns from various food companies) is whether or not high-fructose corn syrup is bad for you - or in more apocalyptic terms, one of the underlying causes of America's obesity epidemic. Here is my attempt at an explanation that is accessible to the lay person.

First, some background. Common table sugar (sucrose) is a disaccharide (two sugar subunits stuck together); specifically, it is one glucose and one fructose molecule stuck together. They are broken apart by enzymes and absorbed in the small intestine before they can be broken down for energy.

There are two key points to consider. The first is how glucose and fructose are absorbed by the small intestine. The absorption mechanism for glucose is tightly regulated by insulin, whereas the absorption mechanism for fructose is not. What that means is that the presence of insulin allows for more glucose uptake, but fructose uptake will keep going regardless of whether insulin is present or not.

The second key point to consider is how glucose and fructose are biochemically broken down to make energy. Glucose enters the glycolysis pathway (i.e. the breakdown of glucose into energy), the activity of which is tightly regulated by.... you guessed it, insulin. In contrast, fructose by and large enters an alternate pathway that allows it to avoid a key regulatory step of glycolysis and produce energy regardless of whether the body is signaling a need for that energy.

As you might imagine, this might be problematic. First, you have fructose absorption even if you don't really need it; second, you have fructose breakdown into energy even if you already have all the energy you need. Then, why don't you get fat when you eat fruit? I asked this question in class, and the answer is simple: quantity. A person eating fruit will feel full and stop eating the fruit, making it less likely that he or she will over-eat.

Here's the crux of the issue: a person eating high-fructose corn syrup is able to eat large quantities of concentrated fructose before feeling full. So, it's not necessarily that high-fructose corn syrup per se is bad for you, just that it's much more likely that a person will eat more of it than he or she really needs, which in turn leads to obesity and all of its adverse health problems.

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I hope that was clear enough for everyone. Also, I'd appreciate hearing from anyone who can add anything to my understanding of the metabolic consequences of high-fructose corn syrup.