Photo exposé

From here on in all photos posted will have true thumbnails and large viewable images. Enjoy.

A drop in the bucket…

And so, after much fret and fear, much sweat and anguish, and forlorn despondency I have emerged on the other side of the second year tunnel. I’m now, officially, 50% done. The final word came at an exam review session mere hours after having completed my last exam. The feeling of elation and relief was overwhelming. I may even have felt the cornea’s moisten slight – but only for mere seconds.

I look back at this insanity and wonder to myself, honestly and truthfully, what more can I give of myself to this undertaking? What more can I suck out of myself that hasn’t already been removed? What bloody tears do I have left to shed? What more can they possibly want from a simple man? How much more sacrifice will there have to be? With each passing year, I feel hollowed out that much further; each year bringing another ring of hollowing. All that remains is the ever growing shell of man living the life of some macabre tree.

I have made a pact with myself to really sit down and figure out if medicine is for me. It’s about bloody time. The work is becoming all encompassing, all embracing and I don’t think I can put any more soul into this endeavour whilst constantly wondering if this is really worth it. It’s time to make that choice and never look back at it. Deluding oneself no longer suffices.

On the horizon are very interesting developments. A lot has happened in the past few months, about which, of course, I haven’t had the chance to write. And so many more things will happen. Such whacking great things!

I’m off for paradise in a few days! I’m off for sunny weather, warm beaches, beautiful scenery and a Shangri-La on Earth. I’m off to cross another one of my “Life’s List” things-to-do off of my list. I’m off to learn some medicine and relax at the same time. I hope those two aren’t mutually exclusive!

Hibernation

I have, unfortunately, forced myself into self-mandated blogging exile; in fact, I can easily extend that to exile from the entire world of the living.

Finals are about me now. I live each day based on a schedule, timing myself to make progress through a given set of notes or material. My life revolves around “the schedule.”

I’ve already written one exam, an OSCE that went about as well as sandpaper on sandpaper. It wasn’t the most pleasant of experiences; I’ll write more about it later. I have another ten exams to write, covering all of last terms material. My mood is forlorn, punctuated by intervals of utter despondency and frustration, with paroxysmal highs of hope lasting mere seconds. In short, cyclothymic.

What a stunning change this entire experience is from undergrad when I could go into an exam knowing that I knew everything. I’ll be going into all of the coming exams rallying my feeble hope into believing that I know something.

I have some wonderful plans set aside for the summer, of which I hope to write as soon as I know that they are set and permanent. As of right now, everything is set in an ether of uncertainty; my future included. I hope this isn’t the last time that I’m writing as a medical student.

Best of luck to anyone else who happens to be going through a similar situation.

A Momentary Bliss

I’ve decided to use my time slightly more efficiently than through the art of staring out of my window and watching the traffic pass by. What better way then to sit down and pen a few more thoughts onto this blog. Time to dust off the ol’ typewriter, and get back onto the interweb.

Things have been steadily picking up pace at school and the work has been mounting to an unprecedented high. I’m trying to burrow back into things after a hiatus of many weeks brought on mainly by a cold and concomitant social responsibilities, namely, my responsibilities to my fellow thespians and to the great art that is theater [insert British enunciation]. Acting was always something that I had wanted to do and finally had the opportunity to do over the last few months. It was an amazing experience overall, despite coming at significant academic cost. But, as they say, the show must go on! The silver lining in all of it is that I set out this year to do things that I’ve always wanted to do, to be more bold and daring and to live life with more sparkle and less worry. I think I’ve made progress in this regard, though I’m still trying for that fabled balance that everyone speaks of. I don’t think that I’ll ever be able to attain it; it’s a mythical beast in my opinion, and I’ll always be feeling as if I’m not studying nearly enough.

Things are starting to shape up for the summer and the next few months will have some interesting decisions coming down the pipe-line from the administration. I’ve applied for a specialized elective program in the following year that will see me swept away to a community hospital, a ways out from the city for the majority of my third year clerkship. Inherent in that statement is the assumption that I’ll be able to continue onwards with my Meducation, though this isn’t looking particularly promising at the present time. I’ll find out inearly April, and since I just realized that we’re nearing the end of March, I feel it sneaking tantalizingly closer.

I’m rarely surprised by people in life. Now, you can take that to mean that either I’m not engaging in to many wild relationships or that I can generally get a pretty good read off of people. I tend to think the latter more true than the former. I’ve met my share of crazies in my time. So when a personal surprise befell me a few days ago, it really piqued my interest in humanity once again. Well, not in all of it, just in the better half. It’s amazing to me how beauty unexpected to the roving eye, suddenly befalls it, and manages, for those few seconds, to fill the soul with a fleeting radiance. It makes you realize that those moments when you look up and gaze at the night sky, a wonderful landscape or a woman, really make life special. The strength of these visions define those precious moments, ingrain them in the mind, and some how make the rest of the day or week that much better. They happen rarely, so if you catch yourself in one, as I did, savour it.

I feel as if the time has come to really start cranking things up academically and to hit the books all the harder. I’m slowly getting back into the swing of things and I’m sure that by mid-April everything will be sorted away just nicely.\However, it’ll require massive amounts of effort to get there.

Yet, despite all this work awaiting me, I am still left feeling a bit hollowed on the inside. Something is missing; I’m left with a gnawing feeling that tugs at my attention and drifts my thoughts away from tasks at hand. I’ve a shrewd suspicion of what it might be, though I won’t be sharing that yet. If I set to it I’d be able to find it; after all, it isn’t a case of “hunt the thimble.” A watched pot never boils, as they say, and I might have to sit back and take a more passive approach – at the very least mentally – to this hollow of mine. That’s demanding quite a bit when you’re an OCD, neurotic, medical student like myself. Instant gratification! Why should there be any other way?

ER!

What’s the best specialty out there? Well, if you ask me right now, it’s ER! I had my first shift in a community hospital ER this past Wednesday and it was awesome. The fast pace, the sheer number of patients, the wonderfully congenial atmosphere all made this experience really worthwhile.

It all started off a bit slow and it seemed to me like the shift would be disappointing. I had initially been placed with a Dr. Jekyll, a man of short stature and flat personality. His third year student, and one of my “colleagues” was equally cold and unfeeling. I didn’t get a good vibe off of the two of them. I had earlier been warned not to approach Dr. Kavorkian because he was stressed that day. Seizing a moment of boredom, I rushed over to his side of the ER. I asked one of the nurses, who this Dr. K was. He answered, standing right beside me. He had a shock of white hair, was tall and unwavering. His eyes radiant with laughter and good humor. I knew I was in for a good time. I introduced myself, and said that I’d just love to get to follow him around. The next few hours were fantastic.

We started with a few random cases. A congestive heart failure had come in. We walked over and took the history. Did we ask about orthopnea? No! I’ll do it. I ran back, saw the patient again. His pillow count had been increasing dramatically. CXR is on order. Blood work is drawn. Next patient. Elderly woman presenting with chest pain. Run troponins. Next patient. Woman with diffuse abdominal pain. She has ascites. I’m looking at her blood work. Could it be SBP I inquire? No, not based on the full picture. Abdominal x-ray shows diffuse scaring secondary to peritoneal dialysis. Her creatinine is 600+. Amazing. I’m running back and forth with him. I ask questions when I can, ask for explanations when he’s willing. We’re making a food run now – going to raid a conference room for some snacks. Students…always hungry. Back to the floor. New patient – developing stroke. STROKE! I’ve just been learning about stroke. We’re rushing over to the bed. The women isn’t in obvious distress but is presenting with left sided facial drooping. Her lips move asynchronously and her eye is watering on the ipsilateral side. What do we do now? The doc gets the patient to squeeze his hands, and close her eyes. “Don’t worry. You’ll be fine.” His assesment takes less than 15 seconds and he’s ruled out stroke. CT is ordered. “How did you rule that stroke out so fast?” He retorts with “Do you know what that was?” “No….” OK. I’ll tell you later. Radiology department now. I get to see my first CT machine, and watch our patient going through it. Even to my untrained eyes I can tell that her CT is normal. No obvious signs of bleeding. The radiologist doesn’t look worried.

Our putative “stroke” patient teaches me an extremely valuable lesson – that neuroanatomy actually does have a purpose, especially when it comes to cranial nerves. Know your cranial nerves! The patient had a Bell’s Palsy. Knowing the difference between UMN and LMN lesions of CN VII is essential to making the diagnosis, as is noting key negatives i.e. bilateral strength of arms and legs etc. Amazing. Medicine in application. It was really a phenomenal experience.

With the attention span of a rabid squirrel, and a real love of variety, I think that I’m an ER kind of guy. Screw Internal, I think Emergency is exactly what I’m looking for.

Hospital, Ho!

I’m back. Back to writing and back to doing some real life medicine. I think I’ll preface all of this with a vent. Drudgery and monotony prevail without respite; lectures are generally disorganized, filled with jargon, incomprehensible and generally overwhelming. I don’t feel like I’m learning anything, though I’m very sure that I’m supposed to be learning very much. It’s really quite humorous. Damn, how I hate the brain at this moment in time. How I revile those neural networks, those neurotransmitters, and all those neuroanatomical structures. I hate the grayness of it all, the lack of precise definability, and feel as if I’m perpetually floating in an ether of some sort. This is made worse by yet another dose of worthless PB-hell where I spend my mornings in philosophical discussion querying such topics as “why does the brain do this?”, “why does the brain remodel itself like this?” My answers to all those: I don’t care why. All I care about is what do I need to know, and why aren’t you telling me this right now. And, more importantly, why are we wasting time sitting here discussing this. I spent a joyous ten minutes in the bathroom this morning in respite from this insanity.

A faint glimmer on the horizon, however, was the time I’ve spent in the hospital over the last two weeks. It’s my first time on a real ward and in the real world of medicine. I’ve spent six hours over the last two weeks in hospitalist medicine. For the uninitiated, this is the family practitioners realm in the hospital. I got to see some real patients, and actually got to perform some basic clinical exams, after an embarrassingly long hiatus. I blundered through most of them, my histories were woefully imprecise at times, and I have no idea how to formulate even the most basic differential diagnosis. But, I did have a few successes. I heard my first flow murmur! I clinically diagnosed ascites! So, not all lost.

The last couple of weeks also reintroduced me to two dear friends in medicine: morbidity and mortality. Hospitalist medicine is rife with both. My patients are those dealing with the outcomes of strokes, or those dying of cancer. Palliation is common. It was difficult to deal with. What do I say to the husband who asks me “What can you do for her? What’s wrong with her?” I say what I’ve been taught, “I’m only a student” “I’ve never seen your wife’s chart before.” I say these things sincerely, because sadly, they are true. I feel helpless. These are the boundaries of medicine; oh, how helpless we are in the face of pathology.

However depressing these experiences were, I’m glad I’ve had them. I’m glad that I’ve enjoyed my time in the hospital; I take it as a semblance of hope that medicine might actually be for me. I’m hoping that next year, a year of solid clinical work, will crystallize that belief for me.

 

Humanity

The bone saws made a whirling noise. Fifty separate motors revved to life in anticipatory glee. The cutting started. As the first saws reached bone, there was a change in the noise, a jump, a new frequency, a sharp distinct whine. The noise fills the room; bone dust everywhere. Particles of osteoid matrix suspended gingerly in the still air. I look around the room, my vision distorted by the safety goggles. All around me people are sawing. Cutting. “Careful!” “You’re going to far!” “Easy….” Cutting and cutting. It continues, and then, as the first groups finish a silence begins to eek into the room. One saw goes silent, then another. Then a dozen. The whine ebbs away. A silent peace fills the void. A silence of wonder, a silence of admiration, a silence of looking at the very miracle of life bundled and cradled into its shell of safety.

With the cutting completed we lifted the skull cap off revealing that mass of brain covered in protective dura. The dura was removed from that entire mass of tissue. We cut the cord. My hands dove into the cavern, trying to loosen it from its surroundings. Slowly, and with most gentle effort, the cortex slipped out. Unfortunately, the cerebellum managed to stay stubbornly in its protective cavity.

Unlike the feather light lungs or banal heart, this organs intricacy, mystery and sheer complexity are reflected in its mass. Its heft was surprising; it must have weighed at least a couple of pounds. In my hands I hold the cradle of humanity. In my hands I hold thousands of memories long past, emotions of incredible breadth, thought, and intellect. I hold the essence of the person that lays there before me, I hold the organ of the soul.

Of all of the things that I’ve yet experienced in life, this dissection was one of the most unique and one of the most amazing. I can honestly say, that for the first time in a long while, I was dumbfounded, amazed and numbed by it all. It was, well, it was incredible. By far the most amazing experience of medical school to date!

Too Tired To Care

I’m tired. I wake up and I’m tired. I go to sleep, and I’m tired. I sit down at the books, and I’m tired. I drink coffee in lecture, and I’m tired. I am tired regardless of the circumstance, regardless of the day, regardless of the situation – save one, of course, I’m not tired when I’m downing a pint.

I do not understand why all of this has to be so exhausting. Why is medical school designed in such a way as to have to push this mammals body to the very bounds of psychological tolerance? Would it be so difficult to extend the semester by a couple of weeks, or by a month even, and give students well earned, and significant breaks away from school. I remember coming back after two weeks of vacation after my very first term of first year, and I felt just as I do now – exhausted. Two weeks is barely enough time to garner ones self together into a pile resembling a socially functioning human being, let alone to really decompress from school. I’d need two months to do that, at a minimum.

I don’t have any urge to study the material, the volume of which is building into wonderfully intimidating mounds. Our topic for the week was a haphazard and pathetic introduction to neuroanatomy. The faculty has, yet again, managed to teach absolutely nothing but disjointed mishmash over the course of the week. Is it too much to ask that lectures actually be related? We had one fellow explain the muscle spindle mechanism to us in such a way as to confuse all 224 people in that lecture hall. A colleague of mine remarked thereafter, “I didn’t know what was going on, and I have a degree in neuroscience.” Not exactly inspiring. I spent most of the week reading chapters out of Guyton’s “Medical Physiology” to try to bring myself up to speed. I highly recommend that book; it’s really quite straightforward, and if you want to learn all about muscle spindles, the topic is treated succinctly and clearly in that book. What a frustrating week.

To add to the frustration, I had a psychiatric clinical skills session to attend at the local puzzle factory. I volunteered [Lesson 1: never volunteer] to interview a psychiatric patient that day, after the psych doc demonstrated an interview for us. This interview would then be used as a writeup for an assignment. The interview went horribly. The “patient” managed to completely lead me astray, throwing me haphazardly around her insane little world. Trying to right her incoherent course was like trying to save the Titanic from sinking – futile secondary to inherent faults in design. I tried my best, but didn’t get much out of her. The doc then began chewing out my interviewing skills, stating simply, that my interview technique did not at all address the clinical issues, missed out key points [Lesson 2: always query suicide in psych cases], did not query the pathology correct, did not ask correct questions regarding psychosis and was, in one word, worthless. Have I been taught anything about DSM-IV? Do I know the features of common psychiatric disorders? No. Why would I. It is as if my tutor wanted a psychiatry residents competency in interviewing. The entire experience left me thoroughly dejected. I hate being made to look incompetent. It’s days like that that make me question my resolve and competency to be a physician. Do I really have what it takes?

I just hope things get better in the next few weeks. I’m looking forward to some time in sunny California, as I have the pleasure of flying down there in the next couple of weeks. It’ll be a welcome change from the dreary gray that seems to envelope this city for weeks on end.

Only Skin Deep

Reintroducing yourself to medical school after a couple of weeks of generalized drinking and revelry should be akin to slowly increasing the heat on a boiling pot. Go too quickly, and you’ll start losing frogs. In my particular case, it felt as if I was being dunked right into a roaring boil from the get go.

Crippled from insomnia, I wobbled my way into the first PB-hell of the year. As I stated before, my expectations were not high, yet surprisingly, they were disappointed nonetheless. Our tutor for the next five weeks is a PhD whose seen far too little sun, has absolutely zero clinical knowledge, and has never chaired one of these groups before. The perfect individual to guide future doctors through dermatology, neurology, psychiatry and neuroanatomy (all concepts on the chopping block for the next five weeks and beyond). Though rife for exploitation, he’s ponderous, slow and his inexperience necessitates the explanation of the most banal concepts. I would have thought that something like “Food on Friday’s” was pretty much self-explanatory and didn’t require an explanation. I hope he doesn’t quit his day job. In his defense, my opinion of him has improved slightly over the week, as he’s proven himself to be fairly non intrusive, and he satisfies: “Though will finish early…” We’ll see what happens in the future.

The week was ponderous, information heavy (even for medical school), and disturbing. We went on a whirlwind tour of the upholstery this week, or the skin as it is otherwise known. Apparently, aside from coming in different colors, there are a surprising number of different things that can be spilled, stained or grown on its surface. The wonderful bouquet of pathological pictures is enough to induce vomitus explosivus in any but the most hardened. I really thought that I was going to lose my lunch on a few occasions. A recent highlight of my life: seeing an obese, fifty year old white male, with a back resembling a finely encrusted ship’s hull. Quite wonderful. Now if actinic keratosis doesn’t get you out of bed, I don’t know what will.

Immersed in that boiling water, I’m contemplating more and more why the hell I’m doing this. Should I jump? A couple of friends of mine have recently started out on some decent careers, will be earning money, and living their lives. They’ll do the girlfriend, apartment, drunken party thing. I’ll do the study-in-the-library-till-midnight, sleep, eat and study thing. They’ll pay off their debt, I’ll accumulate it. They’ll sleep late on weekends. I won’t sleep at all. I’m not sure if not having anything else to do is really a good enough excuse to keep going with this. I’m tired of the work. It’s not particularly rewarding. Though I enjoy learning things, I’m not particularly fond of memorizing things and then forgetting them. I don’t feel like I’m learning at all. With each bloodied and sweat stained step forward, you’re hurled backward a couple hundred only to find that what you thought you knew you’ve forgotten, and what you did know has changed. That’s made all the better by having multiple contradictory opinions on every imaginable detail. It’s just so damn frustrating.

I hope my interest in medicine isn’t only skin deep. I hope that these feelings of mine will change in the coming weeks, and that the water will chill appropriately.

Back to it…

Well, the holiday is winding down. I hope I’m actually more rested then I feel. I really hope so. Another day and then back to school on Monday. Got a merciful email from the administration informing us that we’ll be starting at 0830 on Monday instead of 0800. But, this deal is only good for one day only – like those sales for cheap underwear at the Wal-K-mart. How incredibly kind of them.

Dribbling mylife away on every Monday, Wednesday and Friday morning is PBL. The acronym epitomizes all the inefficiency and incongruousness in medical education. The entire process of problem based learning is dependent on the knowledge of your peers (which is, in most cases, frightening) and that of the tutor directing the group. In the ideal setting a tutor would be a medical doctor specializing in the particular field of study being discussed, or else a generalist or family practitioner familiar with the clinical information, if not the explicit scientific nuances, of the subject.

In reality, were are usually graced by graduate students or PhD professors with no grounding in the subject, save for the manual they happen to be holding. Of the 11 groups I’ve had, ONLY 2 have been under the direction of MD’s. Moreover, in four of these, the tutor did not understand English. They could not follow our conversation, and their “guidance” consisted of looking blankly at the tutor guide, waiting for certain “buzz words” to be uttered before allowing the discussion to continue. That’s 16 weeks of time that I paid for, and utterly wasted. It is absolutely amazing to me that the university continues to hire and employ people to teach medical students who would be better suited sitting in the back row of an ESL class with a dunce cap on. Pathetic and utterly unacceptable. But, what can you expect when there’s such a dearth of people willing to work in the beaurocratic nightmare that is my universities administration?

Though lopsided toward the negative, I have had a single very positive PBL experience during my last block. Our tutor was an experienced internal medicine specialist. He was a fantastic tutor, recognizing the key commandments of PBL:

1. Though shall employ utmost expedition so as not to waste thy students’ time

2. Thou will ensure that students garner necessary knowledge i.e. students are explicitly (think XXX) aware of what is required of them

3. Thou will provide anecdotes from real life as to the clinical relevance of the material; thou will educate future doctors i.e. answer the most divine of questions: “Why the fuck am I learning/doing this?”

4. Thou will treat students as colleagues, in the most beautiful sense of the word, and allow them to treat you likewise

5. Thou will finish early (I tend to start quivering if more than 60 minutes has gone by and the end is not nigh)

During that entire block, even this not-so-chipper fox managed to crawl out of bed in a timely manner and, I daresay, actually looked forward to PB-hell on some days. It was a very welcome change from the routine. It felt as if we all got to know the tutor, and that, in a way, he befriended us. He was relaxed, congenial and wonderfully helpful. He always gave us relevant medical knowledge, told us about real patients, and provided us with real tangible career advice. I don’t think I’ve ever learned as much in PB-hell as I did in that block just passed.

Unfortunately, I’m not anticipating a similar performance in the next 15 weeks of hell. In order to best utilize those six mandatory hours of class attendance, I would recommend doing the following in order to make PB-hell more efficient and to fashion it into a personal education instrument. My two big recommendations are as follows:

1. Before a subject block begins pre-read all the required information. Say, for instance, you’re spending a week learning about cancers of the lung, spend time on the weekend reading the necessary chapters of relevant pathology (Robbins is fantastic for this) and clinical information i.e. differential diagnosis, diagnosis, presentation, management, treatment, prognosis etc. Good books for tackling those points are texts such as NMS Medicine and Step-Up to Medicine (my personal favorite).

2. With the above in mind, go into the case expecting to find one of the pathologies you read about. Help your group if the opportunity presents itself (but not to an obnoxious extent) and use every discussion as an opportunity to reinforce your recently acquired knowledge for yourself. Note things you’ve forgotten, and things you’re still confused about. Re-read that information in the future.

Though I don’t do this every weekend, I’m trying to incorporate into my schedule now. It takes six hours which were previously a colossal waste of time, and turns them into a personal review session, where I sometimes ask my group-mates to explain things to me that I’ve either forgotten or misread. In that way, everyone is learning, and most importantly, I’m not wasting my time.

For those of you questioning the veracity of all this, or wondering when I’ll get off of my pedestal, I gently extend my peripheral C7 dermatome in your direction.

But, realistically, if you happen to be crawling into PB-hell after having spent the night in revelry that overshadows even the orgies of Bacchus, then grab a coffee and imagine favorites from the Karma Sutra…