(A glimpse into my life as a Vanderbilt medical student)

Monday, October 04, 2004

Random Links and Renal Cell



Disclaimer: I write this in the throws of yet another caffeine high. For those who care, my radiology test went great (big shout out to my study partner Ashley Rowatt), so that’s one down three to go. In all reality, psych, path, and neuro make up the majority of my lectures so it’s more like “one down, nine to go” but semantics really aren’t my thing. Loyal readers of my blog will know my feelings about psych, thus right now my focus is squarely on the remaining two. Much like metastatic renal cell carcinoma, the multifocal nature of my study plan is causing some problems. I am now so hesitant to commit to either that I’m beginning to think I should run for office (give me the cheap shots, it’s late).

Time management is an important skill in medical school. It is also one that I don’t have. Thus the question “Is neuro more important than a new episode of Lost?” has an obvious, albeit inverted, answer. After finishing my show I am refreshed and ready to study. Why would anyone ask such an obviously rhetorical question?

Speaking of time management, I don’t have time for a witty rundown of all the happenings in the world of medicine, so here’s a list of some fun ones.

So there you go, click and learn. Impress your friends. You’ll be the better for it and I, having not had to tell you about it, will have more time throw my psych book over the fence in protest.

Wednesday, September 29, 2004

Caffeine Highs and Cerebellar Peduncles



They say to write what you know. So here goes nothing: squamous and small cell carcinomas are typically associated with smokers while adenocarcinoma has a higher incidence in women and nonsmokers. I could go on, but I’m guessing it wouldn’t be conducive to a high hit count. Blogroll me, the random pathology fact blog. I can see my counter spinning.

The truth is that my thoughts are consumed with random facts about lung cancer and the cerebellum. Midterm week is no time to consider trivial matters like food or friendships. There is minutia to cram and slides to study. Sleep? Sleep is for law students, I’ve got work to do. With hundreds of pages of path notes piling up around me I struggle to keep it all straight. Was it 11.p.13 that’s associated with Wilms’ tumor…or was that renal cell? My caffeine high is wearing off. Did Clarke’s nucleus project through the inferior cerebellar peduncle or was it the restiform body? I down my liquid legal stimulant and fight to stay conscious. Consciousness…from the reticular formation…uncal herniation….candy zebras….sadfasfalsk…zzzzzzzzz.

Monday, September 27, 2004

Virtual Reality and Basic Anatomy



The what goes to the what what? Words so often in uttered in desperation as my friends and I stared down at our cadaver in complete ignorance. Picking through the fat and fascia, it was sometimes hard to understand the rational for our (seemingly) trivial anatomic explorations. Was it really so important that I know where the anterior superior pancreaticoduodenal artery became the inferior pancreaticoduodenal artery? While honesty dictates that I answer a resounding retrospective “No,” this negativity is hardly the general attitude I hold toward my first year anatomy experience.

I view anatomy lab as one of the formative experiences of my first year in medicine. As a second year, I study the pathology of a particular organ system and I remember that organ in my cadaver. How it felt. Where it was. What it looked like. If these facts had been written on a sheet of paper or flashed on a screen, I could say that I had seen the material before, but therein lies the caveat. Seeing with the eyes is almost a passive process that can easily be set to auto; anatomy lab is unique in that it involves a multisensory approach to comprehension. Touch is key to medicine and starts with what our professors referred to as a student’s first patient: his cadaver. I remember cardiac anatomy because I have held a heart in my hand and dissected out its secrets. I know the functions of the extra-ocular muscles because I have explored their movements on an actual specimen. Would I be willing to give up these experiences for a couple of extra hours of study time? No. Would I have learned the same amount of information from a 3-D computer program? No.

I guess this discussion was spurred on by a recent article in the NEJM as well as tonight’s marathon path study session. I just realized how important that facet of my education was to me and can’t imagine a complete medical education without it. Don’t get me wrong, I’m the geek who would be first in line to try holographic dissection, but you gotta admit, there is nothing quite like a good old-fashioned fat pickin.

Sunday, September 26, 2004

Butt Sniffing and Bladder Cancer



Lassie, you’ve come a long way, baby. Although not too long ago the only thing a dog could do was rescue little Timmy from the well, times have changed. It seems that their noses are good for more than a friendly anal greeting and can be trained to detect bladder cancer from a simple urine sample. A new study in the British Medical Journal confirms that the canine’s chances of being correct are about 41%. Indeed, like the piss prophets of Olde England, there is nothing they can’t discern from a simple plate of pee.

You might be wondering what this has to do with anything. Sure it’s cool that you can pee in a dish and run to your oncologist if it scares your Chihuahua, but one wonders why such a prestigious journal would publish such findings. Initially, it’s obvious that these dogs weren’t just guessing. In order for this to occur, there must have been some kind of volatile (i.e. smell-able) organic compound in the urine that indicated the presence of cancer. In oncology, any compound that marks the presence of a tumor is known as (brace yourself) a tumor marker. Thus it is clear that the dogs had knowledge of some previously unknown volatile tumor marker and this in itself is exciting news. Unfortunately, the study was content to hypothesize the existence of such a marker, but offered no indication of it’s proposed identity.

Other problems with the study included the lack of breed normalization and questionable training practices, however for further discussion of the research, I suggest you reference this page where the BMJ allows people to comment on the study. It is amazing to me the different ideas that people come up with in the world of medical research. Now if only we could train a shih tzu to diagnose colon cancer, that would really be a trick.

Saturday, September 25, 2004

Backstabbing and Board Scores



According to the Wilson Phillips song (or Ecclesiastes, depending on your cultural background) there is "A time to love, a time to hate." This was definitely a time to hate. One of my good friends at Vandy had been humiliated and it infuriated me. The details aren’t important (if you are at Vandy, I’m sure you have already heard), but what was most surprising about the whole ordeal was how shocking it was that it happened at all. One hundred and four type-A overachievers used to being number one in everything: by all rights our class should be one giant ring of continual backstabbing. One would expect this undercurrent of undercutting to be med school status quo, but sometimes expectations and reality are two very different entities.

At Vanderbilt there is a community among the students. I have never felt a spirit of competition from my fellow classmates but rather one of mutual goals and purposes. We might have different backgrounds but we are all trying to tackle the same overwhelming amount of medical knowledge and this common cause unites us. I guess this idealization of our academic interaction was what made the aforementioned offense so egregious. Even if it was provoked (which I doubt) there was no justification for the action.

I guess it is some consolation that the rumor mill is already in full force and the offender will be identified and routinely vilified by our class. However, it’s hard to think that this is the action of a future MD. No doubt this person will have excellent board scores and most likely match highly, but if those are the qualities that ultimately define an excellent physician, I’m in the wrong business.

Thursday, September 23, 2004

Sickos and Socialized Medicine



Prepare yourself American healthcare, you have a new enemy. Villanous traitor to some, ultimate patriot to others, Michael Moore is on the war path again. This time, however, the fight is not on the front lines of Iraq but rather on the wards of the hospital. Inspired by three Canadian teenagers he met while filming Bowling for Columbine, Mr. Moore has decided that Canadians have it better when it comes to healthcare. Sensing controversy, the director has wasted no time getting the cameras rolling on his latest shock doc tentatively entitled Sicko.

While the film’s intentions are not yet clear, it is appropriate to assume (based on celluloid precedent) that they will lie diametrically opposed to the current state of affairs. Mr. Moore is a shrewd businessman who senses the dollar in every contentious statement and knows he can work the public like a cash machine if he pushes the right buttons. To be fair, his high profile arguments have ignited a newfound social interest in many important issues and will no doubt continue to do so regarding the state of healthcare presented in his new film.

Reactions to Mr. Moore’s creations tend to be divided strictly along party lines, but I am interested to see the divisions created by Sicko’s socialized premise. The majority of my friends at Vanderbilt could not praise Fahrenheit 9/11 enough, however I wonder if they will sing a different tune when Mr. Moore’s lens rests squarely on their way of life. Is socialized healthcare a feasible alternative? Do Canadians have it better? For an animated discussion of these issues look no further than the IMDB message board for the film. Just a few quotes from some of the posts:

“As an accident prone Canadian, who has used our healthcare services numerous times in the past few years, I feel lucky to have a socialized health care system.”

“Bush is an imperialistic idiot, but Kerry's running mate, John Edwards, was a malpractice attorney (and always fought on the side of the insurance companies) and made his millions off of doctors.”

And my personal favorite:

“Go drink a Molson and calm down.”

Apparently Mr. Moore is already inciting argument and he hasn’t even filmed a frame. Go dig in your closet and get out your dirtiest pair of scrubs; this is really going to get messy.

Wednesday, September 22, 2004

Potty Snakes and Policy Debates



Poisonous snakes in the toilet. Are you at risk? It was a slow day for news in Nashville. Today in our Media and Medicine elective, we took a field trip to a local news station and got to see the filming of, among other things, a follow up story to yesterday’s stunning toilet bowl serpent expose (nicknamed the “Potty Snake Story” at the station). What did all of this have to do with medicine you might ask. On Wednesdays, Channel 2 does their weekly health segment (today it concerned West Nile vaccines and herpes). After mentally commending the station for their contribution to West Nile hysteria, I proceeded to fix my attention on the woman crazily gesturing at a green wall. Turns out this was none other than Lisa Patton, storm tracker extraordinaire. Little inside weatherman tip: Penn State has a top notch meteorology program.

Although nothing was as cool as the green screen, we had a chance later to talk with a representative from the station’s parent company. It seems that the people with the money no longer want any “disease of the week” stories and are not planning on hiring dedicated medical reporters at any of their stations. “People go to cable or the internet for health news, it’s not worth our time.” He explained that there was not only a shift away from health news but also from any news at all. With the retirement of all three major anchors within the next five years, he predicted that news would be relegated to 24 hour cable channels in the near future.

When I asked how we as physicians could make our voices heard at a cable level, he explained that each news channel has its own criteria for story selection. The way he broke it down was you have to pitch to their focus. For example, Fox is all about issues so they would go for a policy debate story while CNN is more about scientific breakthroughs like a new vaccine trial. Overall it was an interesting experience but I can’t really write any more, I think I hear a water moccasin swimming in my toilet.

Tuesday, September 21, 2004

Boredom and Brain Tumors



Just give her an Advil and send her home, I thought. It was becoming all too clear that what was meant to be a quick day of clinic was going to take much longer than I thought. How many reflexes can this girl have. Dr. Huffman seemed determine to test then all and, as he poked and prodded, I became more and more restless. Great, she can follow your finger with her eye, so can my parakeet and you don’t see it wasting the doctor’s time. I shifted and waited.

To those readers horrified by the thought that a medical student might be this uninformed and downright uncaring, let me allay your fears. This didn’t happen today (or yesterday for that matter). Although I must truthfully claim these thoughts as my own, they occurred two years ago when I was shadowing a doctor in Kentucky as part of my pre-med acceptance checklist. As a second year student, I now look back at those feelings with a mixture of embarrassment and amazement. Didn’t I care about the patient? (Let's file that question under “rhetorical” so I can avoid an honest answer.) If I had done my homework I would have realized that a headache can be one sign of a life threatening lesion in the brain and that the “finger test” is very important in the assessment of nerve function. The doctor was not wasting my time, he was simply being an excellent physician.

I went into the office hoping to learn something about medicine. As I look back on the experience, however, I realize that I learned almost nothing about medical practice. Instead, I have retrospectively learned volumes about my personal biases and motivations. Did I care more about the patient or my time? Although it is easy to blame inexperience as the source of my frustration, aggravation is an ever-present emotion on the wards. Maybe next year when I am dealing with a patient who is really being a pain in the neck, I’ll remember that girl with the headache and how my impatience could have cost her everything.

Monday, September 20, 2004

Memory Loss and Anatomical Minutia



Is it bad to take pleasure in someone else’s pain? It’s not like I’m some sort of sadist, but today was the three hour review for the first year’s first anatomy exam and it made me extremely happy. Happy that I wasn’t sitting there terrified of tomorrow. Happy that I no longer care what arteries branch off of the thoracoacromial trunk. But most of all, happy that I don’t have an eight hour test on Thursday.

I know that this is gonna come full circle in a couple weeks with the arrival of our path midterm, but right now I am definitely reveling in my second year freedom. It was awesome to see just how far I have come since last year. I remember going through all of the rooms in awe of the vast knowledge of the second years and envious of their status. One vivid memory that pops into my mind was last year when I asked a second year how much she actually remembered from the lectures. She quickly responded that all the preparation she needed to teach the review session was a quick review of her notes. Bull crap. As an actual second year, I am now fully aware of just how much the omniscient second year class didn’t know as they pompously expounded on our notes. Granted, you don’t forget the important info, but really, who cares what constitutes the medial border of the quadrangular space (btw it’s the long head of the triceps for all you anatomy nerds).

I need all the encouragement I can get, and tonight was just a neat opportunity to see how far I have actually matured in my knowledge of medicine and (sometimes) life in general. It’s surprising what a little anatomy review can do for your mood. Who needs Prozac when you’ve got the axillary fossa?

Sunday, September 19, 2004

Viral Binding and Paris Hilton



I can’t tell which one looks more computer generated. While both images illustrate the effective application of modern chemistry, this article unfortunately concerns picture number two (me being a science nerd, it’s always a good bet to go with the most boring choice). Something you could ask about both pictures, however, might be “What the heck is it?” The answer, at least in the second case, would be virus but not much else. It seems that while modern science has been able to concoct plastic surgery out of food poisoning, they are at a loss to explain the actions of a little glob of protein. While it might be slightly unfair to blame the lack of knowledge on an academic shift from virus to Paris, the truth is that science knows relatively little about much of the pathogenesis of these organisms.

As we move into the future, however, a glimmer of hope has arisen from the ashes of despair. The source? None other than that tome of knowledge, the journal of Molecular and Cellular Proteomics. It seems that by taking a cell being attacked by a virus and blasting it with electrons, they have the first visual proof of a viral protease binding to DNA. By interacting with the genome the virus can alter the cellular protein machinery to do its will and thus rules forever as the supreme dictator of all things cellular!! Sorry, got a little carried away.

This news really is exciting, however, as it gives researchers the opportunity to make drugs tailored to attack the virus where it binds. These techniques can then be used to study the DNA binding habits of other viruses thus spawning additional meds. It’s like the circle of death (at least for the viruses). Now if you’ll excuse me, I have to go finish my research on the applications of modern science.

Thursday, September 16, 2004

Irrational Fears and Journal Articles



There was a time when I was afraid of the NEJM. The Journal and other medical sources only served to remind me of what I as a first year didn’t know and, more than likely, would never understand. It seems, however, that I am learning more than I think in my second year. Yesterday I encountered no less than five separate stories that not only directly applied to our classroom discussions but also concerned issues that I feel completely qualified to discuss. The debilitating pathologic course of Alzheimer’s disease, the debate concerning drug coated stents in PTCA, the clinical presentation of aortic dissection on an MRI, the mechanisms of ischemic heart disease, and the use of Peginterferon Alfa-2a Alone, Lamivudine Alone, and the Two in Combination in Patients with HBeAg-Negative Chronic Hepatitis B. (Ok, I lied about the last one, but you get the picture).

To be completely honest, my fear has its beginnings long before I started my first year at Vanderbilt. Unlike many pre-med students I was never one to religiously watch ER (in fact, I have never seen a complete episode), I didn’t really keep up with current medical research, and I was never heavily involved in the hospital system in high school or college. It wasn’t that these things didn’t interest me, they just served as reminders of the fact that I wasn’t going to get into medical school. You see, I had myself convinced that I was going to be the one who, no matter how hard he tried, could never make the jump from waiting list to acceptance. I would become the bitter grad student roaming the halls of academia mumbling obscenities at the MCAT and cursing passing med students.

Applying to medial school is an extremely public matter. Everyone you know knows. This knowledge hung over me like a thunderhead ready to strike me dead upon my final rejection letter. My technique of avoiding all that I am not good at has prevented me from publicly failing on numerous occasions (as well as completely stymieing my sports career). The application process, however, was unknown territory. There was no assurance of success, no preset way to win. My current status gives away the ending, but trust me, this was one heck of a step for me to take. The amazing year and half of classes have made it clear that my acceptance was worth the vulnerability it cost me to apply. However, I guess I should have known all along to go ahead with the Gamble; after all…that’s my middle name.

Wednesday, September 15, 2004

Divergent Strabismus and Artistic Genius



Your mother lied to you. Turns out, crossing your eyes isn’t bad for you; in fact, it may be one of the keys to unlocking your inner genius according to this new article in the NEJM (for access, see this website, keyword: www.nejm.com). In a stirring example of academic priorities, one researcher at Harvard spent her time examining the self-portraits of Rembrandt and came to the stunning conclusion that the master may have had a walleye.

This is actually not as trivial as it may seem. According to the article, congenital divergent strabismus can result in the brain shutting off the input from the offending eye thus allowing normal viewing of the world. The affected individual is thus actually only looking through a single eye and subsequently loses all depth perception. If you have ever tried to paint anything, you know that creating depth is a problem. Here’s a hint, close one eye and you lose all knowledge of depth and effectively see a flat image, perfect for painting (ergo baby van Rijn was predestined for artistic superstardom).

Just my luck, the secret to creativity is revealed and my artistic journey has already come to an end. Although retroactive eye crossing provides slight improvement to my current body of work, there is really no telling where my foray in ceramics would have taken me had I known the secret of the lazy-eye. That enormous glazed monkey would have only been the beginning.

Tuesday, September 14, 2004

Crickets and Olives



Chirp...Chirp....Chirp...I felt like I was at a campout. You know, the kind where you hike through beautiful mountains and spend the evening making smores around a blazing fire with the crickets gently lulling you to sleep. Except this wasn't the mountains, there was no fire, and I was not making smores. Instead, I was freezing in a smoreless lecture hall trying to distinguish a pyramid from an olive. Obviously for normal people this would not become a two hour ordeal, but (as you probably know) medical students are not normal people.

Let's get back to our insect friends. It seems that Nashville was feeling the effects of hurricane Frances and our second year classroom was flooded, thereby initiating a mini-Armageddon on our A/V equipment. One unforeseen consequence of this electronic holocaust was that the water puddles apparently created the ideal ecosystem to be colonized by Acheta Domesticus, and we are now serenaded by these arthropodal maestros throughout all of our medical lectures.

It is all I can do to keep from laughing when, at eight in the morning, our professor asks our class a question and the only answer is the faint chirp of crickets in the background. As sad as it may be, this has occasionally constituted the entirety of my attendance motivation on several predawn occasions. Currently, I am working on an EPA petition to declare the wet carpet at the front of our classroom an official wetlands. As long as there are olives and pyramids to find, so long shall the cricket sing.

Monday, September 13, 2004

Lifting Weights and Lung Cancer



I stereotype. I know it’s wrong, but come on, who really wants to interact with strangers on a personal level. Unfamiliar engagement is dangerous. I might be forced to confront something I hate about myself, or worse, make a friend. By cheap classification of unfamiliarity, I can safely float along in my bubble, oblivious to outside culture and society. Now that we have that justification out of the way, on to Exhibit A.

Mr. Smith is a 55 yo obese white male who is experiencing extreme dyspnea upon exertion. Upon closer examination (by me in the locker room of my gym), he is noted to reek of cigarette smoke. After stereotyping his case as a classic “what you smoke is what you get”, I went on with my happy healthy day, congratulating myself on a successful diagnosis.

It never occurred to me to consider the circumstances surrounding our meeting, namely, a health club. It wasn’t like the guy was sitting at home smoking camels and eating nachos on his couch. So what if his clothes smelled. He might have been smoking since the fourth grade and trying desperately to quit. In reality, this guy cares just as much about his current health as I do and deserves nothing but my respect for his efforts. So here’s to you Mr. Smith; without you, I’d have nothing to write about today.