At the end of block 6, I had set two goals for the break:

• Go through First Aid and review the “high yield” material we covered in the first year.
• Three-a-days at the gym to try to get back into before-medical-school-shape. Keep in mind that before this summer break, I hadn’t been to the gym since November 2009 (when my membership expired).

When it comes to classes, I’m probably a little too laid back. I distinctly remember one week in block 5 where I skipped most of the lectures (even “mandatory” case conferences ) and didn’t even go back to video stream them. That particular week, I spent more time playing computer games and basketball than sitting in a lecture/watching a recorded lecture/studying anything medical. Not too proud of it, but oh well… it’s in the past.

However, when it comes to preparing for the USMLE Step I, I’m a self-proclaimed gunner and proud of it. Judge me, label me, whatever… doesn’t make a bit of difference. In the end, that three digit score says a LOT about what kind of residency one is “competitive” for. The time I’ve spent reading First Aid has helped me remember a lot of the tiny details, provided useful mnemonics, and showed me what I can expect to learn as an MS2. Upperclassmen from other schools have also been generous enough to provide me with their insight on how to properly study for this monstrous exam.

I’ve also stayed honest with my workout routine having gone to the gym every single day multiple times and reclaimed much of the cardiovascular endurance and strength I had going into medical school. I really need to establish a proper workout routine during the next six months, so the regression I had as an MS1 doesn’t happen again.

Now I’m three days away from beginning my journey as an MS2. Speaking of which, I have a cheesy smile on my face as I write this, because it’s my first entry filed under the category “MS2.” If things like this excite me, you realize how boring my summer was.

• Lecturers say things like “I’m motivated by the fact that I’m hot, and I need to take off my clothes.”
• When in doubt, you know it’s vimentin positive.
• You’re taught ten things monocytes can become but are likely to get asked for fifteen things they can become on an exam.
• You would rather sell your first born rather than live a life of shame for missing a question on cilia.
• When leaving a block party, you calculate exactly how many days are left till the next one.
• “Positively elegant” is a complete sentence.
• The first thing you do after opening a PowerPoint file is look at the slide count… even before the title of the lecture.
• You live on a steady supply of candy for student affairs, coffee from the alumni office, and lunch from various meetings/seminars.

That’s all for now, but I’ll keep adding more content to this post in the future.

I learned about medicine.

This is medical school, after all. In the first six months, I probed human anatomy by studying my cadaver – an unfathomable vault of medical knowledge and consequently my “best teacher” (as the Baylor Med profs like to say). My donor’s body provided me with examples of structure-function evolution teetering along biological perfection each and every lab. From the squishy, air-filled sacs of the lungs to the muscle-tendon-bone connections responsible for our incredible range of motion, human gross anatomy was easily my favorite course in the first four blocks and a rare privilege I will never forget. (link to my anatomy posts)

We covered the enzyme-regulated reactions of metabolism and the mechanisms which drive our body towards homeostasis in a constantly changing environment. We covered cardio, respiratory, renal, GI, endocrine, and reproductive anatomy, physiology, histology… just about every “-ology” known to the biological sciences. We explored the incredible expanse of the nervous system, appreciated how different bacteria, viruses, protists, fungi, and parasites invade the body and precipitate disease, thanked evolution for the wonderful immunological response we’ve developed to combat the aforementioned infectious agents, and picked up a bit of pharmacology along the way.

Is medical school really like “trying to drink out of a fire hose?” Eh, sort of. But it’s always humbling to think that by the time I graduate, medical knowledge will have doubled. Medicine, therefore, can never be entirely “mastered”, but as healers trained in both learning and compassion, it’s a lifelong goal to keep up with the latest knowledge and treatments.

I learned about camaraderie.

Having come from a relatively small college, Baylor Med was my first experience with a class of more than thirty people. Way more. While I enjoyed the small-scale setting of undergrad, having ~180 incredibly intelligent, diverse classmates with an identical goal fosters a level of camaraderie unlike any other. Whose notes do I use for the upcoming exam? Do I play basketball this week with one group or go out to dinner with another group? Or both? On top of this, these are the same people who go out of their way to follow up on why you’ve been missing lecture, why you skipped that party, if you need any lab handouts, help moving, or offer to let you crash at their place rather than having to drive home after a late night of studying. I’ve learned that there are two constants in at Baylor Med – the feeling of belonging to a family and lots of opportunities for free food. And I’m not entirely sure about the latter.

I learned about patients.

To this day, I remember the first, middle, and last name of the first patient I encountered in my ob/gyn preceptorship. Her chief complaint, her appearance, her husband’s recent surgery, her grandchildren’s life goals, and most importantly, her advice going forward as a medical student are as plain to me today as they were nearly a year ago. It’s this intangible “human factor” which defines, in my opinion, the most rewarding part of being a physician and why I chose this profession over research/IT.

The first time I had my preceptorship at the Veterans Affairs (VA) Hospital, I made the mistake of putting on my white coat in the parking lot (so I could stuff my notepad, stethoscope, etc. in its pockets). Before I even got to the door of the hospital, I was stopped on three different occasions by VA-goers asking if I knew where the bus stop was and if I knew which floor so-and-so worked on. Each of these individuals had an identical greeting – “Doctor, do you know…?” In my infinite ignorance, I didn’t know the answer to any of their questions, but the fact that they even considered me a potential source of information was uplifting. “Doctor”… wow, that title is only three years away.

I learned about the human condition.

In block 4, I wrote about my experience in a clinical ethics round at the trauma center. Two and a half months later, the snapshot of that patient is a humbling reminder of what we fight to prevent. Is it ethical to pull the plug to salvage hospital resources given the patient’s terminal condition? Does the daughter have the right to keep her mom alive? What really is “dead” according to the state of Texas? It just baffles me… ten minutes away from the very lecture hall where I learned about ethical guidelines, doctors and patients alike are having to make difficult decisions on a daily basis.

As MS1s, we also touched on a number of “bad things” that can happen to the human body during development, age-related degeneration, and results of infection. It’s amazing how precious a healthy life really is. The fact that you’re reading this is a testament to a series of mechanisms being executed in a precise order during your development. Your immune system is constantly battling off foreign particles to keep you healthy. Your entire body is synchronized in a very narrow window of pH values, electrolyte concentrations, temperatures, etc. to ensure your survival. And all of this without you even thinking about it. Truly remarkable!

But disaster strikes when, for example, a normally healthy cell goes rogue and becomes cancerous. This is where death becomes a reality. Patients die… all the time. Sometimes when they come to the hospital, they’re already terminal and show few or no symptoms. How have I coped with the fact that, as a physician, I will fail from time to time? It’s because of a well known medical philosophy which I previously blogged about – “to cure sometimes, to relieve often, to comfort always.”

I learned about myself.

I learned that I’m lazy and have warm hands. Brevity is indeed the soul of wit. Nah, in reality, it’s hard to really gauge how I’ve changed since August 2009, but that’s the beauty of keeping a blog. I can go back anytime and appreciate how I’ve reacted to the medical environment over the last year.

In spite of the rigors, tribulations, successes, failures, friendships, and questionable situations I’ve been confronted with over the last year, there’s one inexorable truth – I’m really, really enjoying medical school. With clinicals starting in January, here’s hoping I finish the basic sciences on a strong note while trying to remain humble, helpful, and happy.

Yesterday, the board of trustees unanimously voted on Dr. Paul Klotman to serve as the next president and CEO of Baylor College of Medicine after months of searching and selecting from over fifty incredibly qualified candidates. Based on Dr. Klotman’s press conference, it seems that he wants to place more emphasis on research (always a good thing for those ranks ), so I’m looking forward to his agenda over the next few years.

Only three exams stand between me and claiming the title of “MS2.” Heh, better not fail.

We finished our cadaver-based anatomy course in the middle of February with head/neck anatomy, and then transitioned over to a neuroanatomy course. One would think that physically studying the brain would be of great interest considering my goal, but there’s something about it which just isn’t “exciting” like finding muscles, tendons, vessels, etc. Maybe it’s because the overwhelming majority of the brain’s elegance cannot be visualized? Maybe it’s because there aren’t any cool lever systems which attest to the body’s incredible mechanical design?

The infectious disease course has also spanned two blocks (four months), and just like anatomy, there’s a lot of memorization; however, unlike the former, there’s very little application until we get to clinicals. Initially, much of my time went into memorizing the Latin-root-heavy terms of anatomy, but I immediately applied that knowledge in locating structures during lab. Who cares if P. aeruginosa causes otitis externa or E. histolytica can cause bloody diarrhea? I won’t really remember any of this stuff until I see patients.

…but I guess that’s how medical school goes.

Earlier this afternoon, I completed the 90 minute exam (fifteen minutes for each of the six stations) and reflected on the feedback the standardized patients (SP) provided. All in all, everything went really well; however, there was an embarrassing slip up during the vital signs portion. After checking the SP’s pulse and respiratory rate, the blood pressure cuff just wouldn’t inflate. I tried several times by adjusting the knob (which I thought was fully closed so air couldn’t escape), but to no avail. Thinking there was a leak in the tubing, I proceeded to finish the other assigned tasks with the intention of coming back to the blood pressure if time permitted. During the fundoscopic exam, it dawned on me that I might have actually had the knob completely open instead of completely closed – this was precisely the case. Quite an embarrassing slip up (in retrospect, I still can’t believe I did that), but I pulled through just fine. The SP and I had a laugh afterwards.

Overall, with exams two weeks away, the OSCE feedback gave me reassurance that I’m doing at least something right in medical school. More than one of the patients commented on my calm, genuine demeanor and two specifically commented on my warm hands. Yeah, the latter never gets old. I was confident in my exam skills, thorough with my interview, and organized in my case presentation – probably a 9/10 for a self-assessment. There’s always room to improve.

One of last week’s behavioral science lecturers put forth a hypothetical scenario – when a patient sits in front of you, musters up his or her case, and tries to sway you to their end of the doctor-patient relationship, listen to your gut feeling. If your conscience tells you that “this isn’t right” or you’re just not comfortable with the situation, don’t continue to treat. Every patient deserves a physician who can adhere to the finest standard of healthcare, and if you can’t provide it, there’s nothing wrong in referring the patient elsewhere.

So what if this patient is a member of your family or a close friend? Are you obligated to treat, should you avoid the case entirely, or is it a toss-up?

I imagine most physicians prefer not to treat people they’re closely acquainted with for various reasons:

• Scared they might mess up and jeopardize the relationship.
• Might cause other family members to also seek help.
• Relationship might interfere with medical judgment and ethics due to inherent bias.

I’ve always been the other way. If I’m a specialist in some field ‘X’, and a loved one needs to see someone with ‘X’ training, I want to be the physician in the room. I really don’t intend to sound arrogant, but I just wouldn’t trust anyone else in this case. Yes, there’s the possibility that I could kill a loved one, but it’s a decision that, at the current time, I can see myself still making. Though this could change once I actually start practicing, I think that having a family member’s well being in the hands of another family member is the best situation… for both parties. Again, this is just my humble, first-year medical student opinion and by no means do I wish to sound arrogant.

We’re familiar with antibiotics working with the body’s immune system to destroy bacteria and resolve infections. In this case, antibiotics typically interact directly with the bacterial organism (halting protein synthesis, preventing cell wall formation, etc.) and the body has a chance to “catch up” with its immunological onslaught.

Disulfiram works in an interesting way. Since you can’t “target” chronic alcoholism, it’s mechanism is quite simple – if you’re caught drinking alcohol while on disulfiram, you’re going to regret it. Yes, it’s a drug therapy of intimidation.

Alcohol is metabolized by the liver to acetaldehyde (one of the main culprits of the “hangover”) which is subsequently metabolized to harmless acetic acid through acetaldehyde dehydrogenase. Disulfiram acts by inhibiting said enzyme and effectively raising the levels of acetaldehyde in the blood. The result? If you drink even a little alcohol, you’re going to have a miserably prolonged hangover – based on statistics, this has been a sufficient reason for chronic alcoholics to practice abstinence.

During the rapid-eye-movement (REM) stages of sleep, one’s brain activity skyrockets, dreaming occurs, and skeletal muscles (besides the diaphragm) are paralyzed to avoid acting out said dreams. In addition, the body’s temperature fluctuates drastically. Due to the increased brain metabolism, a lot of heat is generated which is dissipated by having our heads exposed to the cooler air. We cover the rest of our body to actually retain heat but only to a certain extent. Since we’re not blessed with fins, we find ourselves poking an arm or leg out from under the sheets to also help regulate our temperature. Admit it, you’re guilty of this.

Anyways, to sum things up – too much heat, and you’ll wake up sweating; too little, and you’ll wake up shivering.

On another note, we’ve all had dreams that we can remember and others which we can’t. What determines our ability to recall from the unconscious? Heh, it’s as simple as waking up – you can only remember the dreams that you wake up from since the sleep process is rather amnestic.

As with most neurological topics, the answer is “we don’t know for sure, but here’s our latest understanding.” When we make an observation, study, or just experience life in general, information bounces around in a “working memory” heavily regulated by the hippocampus for roughly fifteen minutes, and is then shipped off diffusely into the cortex. Long term memory is actually long term because the memory has structurally modified a neural network. The more we exercise said network, the more ingrained the memory becomes. What’s incredibly fascinating is that when we recall from our long term bank, the thought is placed back into working memory and risks being “knocked out” (theoretically) in the event of trauma.

Memory is a global process – there’s no single spot on the brain dedicated for remembering things, although they tend to be stored near their respective sensory origins. For example, things you’ve seen are stored more posteriorly towards the occipital lobe (primary visual cortex). Yet due to the brain’s amazing plasticity (especially early during infancy), in the event of a structural malformation or parenchymal damage, the already blurry distinction between structure and function is made even more obscure as neurons find a way to compensate for the defect.

So what modulates all of this activity? How do some people remember facts better than others? How do I find it easier to remember the lyrics to music from ten years ago but not the behavioral science lectures I covered yesterday evening? Well the real answer is no one really knows.

It’s just a testament to the tremendous complexity yet elegance of neuroscience.