Tonight:
Review Kidney First Aid
Tuesday:
Read Cardio Pharm
Wednesday:
Read Sacral OTM
Do OTM Qs
Thursday:
48/48 Qs
Review Psych Pharm
Review Cardio Pharm
Review Diabetes Pharm
Review Antibiotic Pharm
Genetics at tutoring
Home:
Cranial OTM
Review Sacral OTM
Redistribute:
Upper/Lower Limb Anatomy
Genetics
Monday, November 3, 2008
I want to go home
I never imagined this could ever be so hard. I want to pass this test so badly, but I feel like no matter what I do, I'm just treading water. I feel like I'm so close to breaking through, to getting on the other side of all of this, but now matter how hard I try I just can't break through. I want to more than just pass this test, I want to annihilate it. I want to prove that I AM stronger than this, and I will succeed at becoming a doctor. I want hope and change, hopefully when Obama wins tomorrow, I can feed off of that energy. I just want to move on, I can't get past this. I want it to end. I want to sit down, focus, not be nervous, think clearly and know the questions that I can get. I want to feel calm and confident going into the test, and know that I can do it. I want control and consistency with my scores. I want to look in the mirror and not feel defeated. I need to calm down, take things slowly and enjoy them, and know that I am just as good if not better than everyone else. I want to stop doubting myself all the time. I want to know that it's all going to be ok, and that soon we will have enough money and time to enjoy life. I want a baby, but I also want a little bit of time to enjoy just being successful before adding a baby into the mix. I'm not asking for things to be easy, I just want for them to be enjoyable again.
Thursday, April 10, 2008
Reflective Soapbox
So I'm here at the AACOM/AODME meeting in St Louis, and I'm brainstorming on how I'm going to start my own med school. And don't say I can't. That's the best way to make sure it'll happen. Stay tuned....
Monday, October 29, 2007
A Medical Divorce
Went to my first tumor board today. It was pretty cool, nice to finally see some real pathology from actual patients. One patient had Burkitt's Lymphoma with the classic starry sky appearance, that one was particularly interesting. They had her on some sort of a port through her head to give her intrathecal chemo, I need to look that one up and see why intrathecal rather than systemic. It was nice seeing actual doctors review cases together and ask each other questions about why they handled certain cases the way they had. Also need to look up EGFR.
There was one patient who had had 4 stereotypic screening biopsies in two regions of her left breast, and one from each region showed pretty severe calcifications. It was documented that all physicians involved independently recommended a mastectomy, and the patient refused. A girl from my class spoke up and said she'd seen her in primary care, and she was a very difficult patient. She's a smoker with emphysema and uncontrolled diabetes, and she also has temporal arteritis but refuses to get a biopsy done. Between that and the diabetes, it's only a (probably short) amount of time until she goes blind. My classmate said her rationale for refusing the mastectomy is that she saw a program on TV where a lady had a total mastectomy and then ended up being cancer free. She firmly believed that when the biopsies were done, the cancer was now gone and she was cured.
The oncologist in the room said that it was important for all docs involved not only to chart that she'd refused the mastectomy, but also have her sign a paper saying the same. He said that he'd divorced her. A ripple went through the crowd that each doc involved had done the same, and her primary care was getting ready to.
Such an interesting term to use for basically kicking a patient out, divorced. I've much more commonly heard it referred to as firing a patient, but that one doesn't make a whole hell of a lot of sense either. Where does the responsibility of the doctor end and the responsibility of the patient begin? And how is it helping the whole situation if the doctors involved switch from being primarily concerned about the patient's well-being to being concerned about not getting sued? I guess it makes them more aware that the patient understand exactly what she's turning down, but I feel like the system is forcing us to compromise our ethics at times. I mean, I know the responsibility of the doc can only go so far, but it seems wrong that good doctors need to "divorce" a patient when they realize that the patient is an idiot and their risk of getting sued is too high. I wonder if the older docs, or I guess the middle aged ones who've dealt with this longer even realize how fucked up it is anymore. I hope they do.
Addendum:
EGFR is "epidermal growth factor receptor (EGFR; ErbB-1; HER1 in humans) is the cell-surface receptor for members of the epidermal growth factor family (EGF-family) of extracellular protein ligands." Yeah Wikipedia. I thought it was some sort of growth factor.
And here it talks about why to use intrathecal chemo in Burkitt's, there's a high chance of meningeal involvement.
And bam I was right that the Burkitt's translocation is t(8;14).
There was one patient who had had 4 stereotypic screening biopsies in two regions of her left breast, and one from each region showed pretty severe calcifications. It was documented that all physicians involved independently recommended a mastectomy, and the patient refused. A girl from my class spoke up and said she'd seen her in primary care, and she was a very difficult patient. She's a smoker with emphysema and uncontrolled diabetes, and she also has temporal arteritis but refuses to get a biopsy done. Between that and the diabetes, it's only a (probably short) amount of time until she goes blind. My classmate said her rationale for refusing the mastectomy is that she saw a program on TV where a lady had a total mastectomy and then ended up being cancer free. She firmly believed that when the biopsies were done, the cancer was now gone and she was cured.
The oncologist in the room said that it was important for all docs involved not only to chart that she'd refused the mastectomy, but also have her sign a paper saying the same. He said that he'd divorced her. A ripple went through the crowd that each doc involved had done the same, and her primary care was getting ready to.
Such an interesting term to use for basically kicking a patient out, divorced. I've much more commonly heard it referred to as firing a patient, but that one doesn't make a whole hell of a lot of sense either. Where does the responsibility of the doctor end and the responsibility of the patient begin? And how is it helping the whole situation if the doctors involved switch from being primarily concerned about the patient's well-being to being concerned about not getting sued? I guess it makes them more aware that the patient understand exactly what she's turning down, but I feel like the system is forcing us to compromise our ethics at times. I mean, I know the responsibility of the doc can only go so far, but it seems wrong that good doctors need to "divorce" a patient when they realize that the patient is an idiot and their risk of getting sued is too high. I wonder if the older docs, or I guess the middle aged ones who've dealt with this longer even realize how fucked up it is anymore. I hope they do.
Addendum:
EGFR is "epidermal growth factor receptor (EGFR; ErbB-1; HER1 in humans) is the cell-surface receptor for members of the epidermal growth factor family (EGF-family) of extracellular protein ligands." Yeah Wikipedia. I thought it was some sort of growth factor.
And here it talks about why to use intrathecal chemo in Burkitt's, there's a high chance of meningeal involvement.
And bam I was right that the Burkitt's translocation is t(8;14).
Friday, October 26, 2007
What I Remember
Original post: Oct 23, 2007
I remember the look on her face, the pain, but the fear she wouldn't be able to breast feed after the surgery.
The teenage mother with no car who walked her baby's stroller to the office for every checkup. How she would never become the kind of mother that her mother or sister were. Knowing she meant it.
The cries of new babies. How wonderful and deliciously unfair it felt to be able to sit in the nursery and rock them while they weren't mine and their mothers didn't even know. The realization that all of them might not be perfect.
My hand on her chest, holding the retractor. Making it through the first sight of blood, the pus and infection, but having to leave the room to keep from passing out when I thought about her breathing beneath my hands.
The morning I first became a doctor. Being in the room with them when she had come in the day before, "dizzy," in the middle of a stroke. Watching silently, taking it all in, then going to get her son from the waiting room. That next morning in the hospital. Not even in med school yet, no clue what to say. Her thanking me for taking such good care of her the day before, for being such a good doctor, and being there when she needed it. The amazement and gratitude for this woman, so much older and wiser than me, looking up to me as her caretaker.
The rush, the intoxication of the first time in an OR. Playing the passive student, but internal monologue racing, telling the surgeon why she had lost her bearings on the camera. Confidence I had forgotten I possessed, confidence that used to define who I was. Flashing back to first grade, correcting the teacher who was teaching the other students how to read. Knowing I could have, would have been able to do the operation better. The thrill of rediscovering what it felt like to be me.
The fear of the first cut. The fear I wouldn't be able to handle it, that I would pass out or be sick. And once it started, never wanting it to end.
The Amish baby boy's steadfast, determined grip on my finger during his circumcision. The shock of his strong resilient personality showing itself only two weeks after birth.
When the pain stopped and osteopathy started.
The girl who said nothing. The teenager, impregnated by her uncle, hoping to deliver before the beginning of her freshman year of high school. The anger that she wasn't ever allowed to make the choice, regardless of what it would have been.
How he saw tonight. He saw right through me, grabbed the thought, and suddenly realized he was right. The split second look across the table, when everyone else disappeared, and seeing that he knew. Looking in through a window, seeing decisions I didn't know I had made. His excited smile of realization, I had already began to fall for it. Feeling that fraction of a second, shared only between us, being etched into my life.
Constant, nagging thoughts that I will never be good enough. Always trying to suppress it. The inequality of test scores and real life interactions. Knowing that not only am I equal to them, I am better. The hope that someday someone else will also see that.
I remember the look on her face, the pain, but the fear she wouldn't be able to breast feed after the surgery.
The teenage mother with no car who walked her baby's stroller to the office for every checkup. How she would never become the kind of mother that her mother or sister were. Knowing she meant it.
The cries of new babies. How wonderful and deliciously unfair it felt to be able to sit in the nursery and rock them while they weren't mine and their mothers didn't even know. The realization that all of them might not be perfect.
My hand on her chest, holding the retractor. Making it through the first sight of blood, the pus and infection, but having to leave the room to keep from passing out when I thought about her breathing beneath my hands.
The morning I first became a doctor. Being in the room with them when she had come in the day before, "dizzy," in the middle of a stroke. Watching silently, taking it all in, then going to get her son from the waiting room. That next morning in the hospital. Not even in med school yet, no clue what to say. Her thanking me for taking such good care of her the day before, for being such a good doctor, and being there when she needed it. The amazement and gratitude for this woman, so much older and wiser than me, looking up to me as her caretaker.
The rush, the intoxication of the first time in an OR. Playing the passive student, but internal monologue racing, telling the surgeon why she had lost her bearings on the camera. Confidence I had forgotten I possessed, confidence that used to define who I was. Flashing back to first grade, correcting the teacher who was teaching the other students how to read. Knowing I could have, would have been able to do the operation better. The thrill of rediscovering what it felt like to be me.
The fear of the first cut. The fear I wouldn't be able to handle it, that I would pass out or be sick. And once it started, never wanting it to end.
The Amish baby boy's steadfast, determined grip on my finger during his circumcision. The shock of his strong resilient personality showing itself only two weeks after birth.
When the pain stopped and osteopathy started.
The girl who said nothing. The teenager, impregnated by her uncle, hoping to deliver before the beginning of her freshman year of high school. The anger that she wasn't ever allowed to make the choice, regardless of what it would have been.
How he saw tonight. He saw right through me, grabbed the thought, and suddenly realized he was right. The split second look across the table, when everyone else disappeared, and seeing that he knew. Looking in through a window, seeing decisions I didn't know I had made. His excited smile of realization, I had already began to fall for it. Feeling that fraction of a second, shared only between us, being etched into my life.
Constant, nagging thoughts that I will never be good enough. Always trying to suppress it. The inequality of test scores and real life interactions. Knowing that not only am I equal to them, I am better. The hope that someday someone else will also see that.
Drooling on Command
Original post: August 2, 2007
I read a lot of other blogs, probably way too many. The good ones often leave me thinking about far more than I end up writing in comments, but us three Type B girls often get into good conversations about why these posts appeal to/disgust/inspire/amuse us. I've decided to do some posting on here about why it is that certain posts hit a nerve, and call these posts "Blog Rounds."
I caught this post tonight. It's over on a not uber-popular (read: Michelle Au..yeah you know who I'm talking about) but BEAUTIFULLY written blog, Nobody wears a white coat anymore... The writer is a resident at a hospital in Indiana (my home state!). She is amazingly clear and insightful about what is happening around her, I highly recommend it.
She was writing the other day about a patient of hers that she had just diagnosed with amyloidosis, and despite everyone saying what a "nice" woman this was, the unfairness that she will most likely die soon of this horrible disease.
Here's the excerpt that moved me the most out of all this, bold and italics added for emphasis:
"A has systemic AL-type amyloidosis. It's a horrible disease in which a particular line of cells in the bone marrow is overproduced, yielding an excess of a particular protein, which then simply silts out into the spaces between cells. The only good thing about this disease is that when you stain amyloid with Congo Red and light it up with a polarized microscope, it glows a bright shade of green and looks very pretty. The prognosis is poor, the progression is relentless, and most people who have it die within the year."
The post is much deeper and longer than this. But I think I've just figured out what it is that hit me so hard about it. We're taught in the first two years of med school how to make quick associations that lead us to develop differentials. Any med student entering their third year in the States will quickly, in true Pavlovian nature, shout out "Apple green with Congo Red stain!" if you so much as mutter the phrase amyloidosis anywhere near them. (Go ahead, try it sometime, I dare you. Even if they don't shout it, I can guarantee you that a picture somewhat like the one posted here popped into their minds.)
What is difficult for so many of us to deal with during these first two years, though, is that these aren't just diseases we're dealing with, they're PEOPLE with diseases. These people have lives. They have families. They have hopes and dreams. We came into med school saying that we were here to help PEOPLE, not learn how to knee-jerk diagnose a disease. But that knee-jerk association is necessary to even begin to be able to help them.
Somewhere between the beginning of med school and now, we've, I've, forgotten at times that the people are what matter. It isn't that I think they don't matter, but it's hard to not get caught up in the tornado of memorizing facts and spitting them back out that med school can be.
I'm glad to see it put into perspective that sometime down the line, a few years from the constant onslaught of Scantron tests and lab practicals, this information still came back to her in residency. But it was somehow separate and a tangent to what actually mattered, the patient.
I read a lot of other blogs, probably way too many. The good ones often leave me thinking about far more than I end up writing in comments, but us three Type B girls often get into good conversations about why these posts appeal to/disgust/inspire/amuse us. I've decided to do some posting on here about why it is that certain posts hit a nerve, and call these posts "Blog Rounds."
I caught this post tonight. It's over on a not uber-popular (read: Michelle Au..yeah you know who I'm talking about) but BEAUTIFULLY written blog, Nobody wears a white coat anymore... The writer is a resident at a hospital in Indiana (my home state!). She is amazingly clear and insightful about what is happening around her, I highly recommend it.
She was writing the other day about a patient of hers that she had just diagnosed with amyloidosis, and despite everyone saying what a "nice" woman this was, the unfairness that she will most likely die soon of this horrible disease.
Here's the excerpt that moved me the most out of all this, bold and italics added for emphasis:
"A has systemic AL-type amyloidosis. It's a horrible disease in which a particular line of cells in the bone marrow is overproduced, yielding an excess of a particular protein, which then simply silts out into the spaces between cells. The only good thing about this disease is that when you stain amyloid with Congo Red and light it up with a polarized microscope, it glows a bright shade of green and looks very pretty. The prognosis is poor, the progression is relentless, and most people who have it die within the year."
The post is much deeper and longer than this. But I think I've just figured out what it is that hit me so hard about it. We're taught in the first two years of med school how to make quick associations that lead us to develop differentials. Any med student entering their third year in the States will quickly, in true Pavlovian nature, shout out "Apple green with Congo Red stain!" if you so much as mutter the phrase amyloidosis anywhere near them. (Go ahead, try it sometime, I dare you. Even if they don't shout it, I can guarantee you that a picture somewhat like the one posted here popped into their minds.)
What is difficult for so many of us to deal with during these first two years, though, is that these aren't just diseases we're dealing with, they're PEOPLE with diseases. These people have lives. They have families. They have hopes and dreams. We came into med school saying that we were here to help PEOPLE, not learn how to knee-jerk diagnose a disease. But that knee-jerk association is necessary to even begin to be able to help them.
Somewhere between the beginning of med school and now, we've, I've, forgotten at times that the people are what matter. It isn't that I think they don't matter, but it's hard to not get caught up in the tornado of memorizing facts and spitting them back out that med school can be.
I'm glad to see it put into perspective that sometime down the line, a few years from the constant onslaught of Scantron tests and lab practicals, this information still came back to her in residency. But it was somehow separate and a tangent to what actually mattered, the patient.
Clinical Type B
Original post: 04-26-07
So my HPS with Stan the human patient stimulator…fuck, no, simulator… encounter was so good today that I thought it deserved a posting.
We always have no idea what we’re doing in these things. Standing around outside, waiting for them to take us back, one guy, let’s call him Todd for now, Todd starts talking about how awesome it is that we never have an OTM lab again, and now he can rejoice in the fact that OTM doesn’t matter anyway. I tell him I’m going to report him to the OTM police. Female student number 2 shows up, we’ll call her, um, Lucy. Todd pounces on her, because she has brought her reflex hammer to the HPS encounter. And while Stan has a lot of things, he doesn’t have reflexes.
I chime in about how I brought my Bakerman’s, the little blue book with all the lab values in it, because I’m sick and tired of them giving us a patient’s chart and it meaning absolutely nothing to me because I haven’t memorized a million different normals. David, the course coordinator, and an awesome person, coughs under his breath “BS”. He clarifies that whenever a student goes in a starts racking off what they interpret normals as, more likely than not, it’s BS. This makes me in my type-B-ness feel a little better, because I just thought I was the only stupid one not to know the values, turns out I’m just the only one with balls enough to admit I don’t know the values.
Then Todd starts calling Stan a robot, which is a major no-no (They’re patients, not mannequins). First year it would have gotten you asked to leave. But I guess Todd is man enough now and is so ridiculously cocky that they put up with it and ignore it. He then asks David if we get to kill the robot today. David says no, but he’s now questioning Todd’s career choice.
Anyway, they get ready for us to all go in to the room. I’m thinking “fuck, somehow I was the first one to walk in to the room, now I’m going to have to act like I know what I’m doing.” I’m going to spare you the details of the exact case, no one who isn’t a med student really cares and I probably don’t remember enough of it to write it all down. But it is at this point that our true med student-ness starts coming out.
The doctor running the case is a hypertension-nephrologist specialist. Kind of like a person who specializes in using a salad fork, but only when its warm outside, a little too specific. He starts asking a bunch of questions, and everyone’s trying as hard as they can to get a word in, so they won’t have to answer something we have no idea about. Todd tries to answer everything, he eventually ends up being told to be quiet, some of the other students might actually have a clue too. I get excited when I get one (”What’s the best way to evaluate his renal functioning?” “BUN/Cr”), but like most of these labs are, I get pissed off because I know the answers to far more of them than I answer, I just don’t trust myself enough to say it quickly enough.
Dr. asks a question about what would cause a 20 year old to have elevated upper extremity pulses, but normal to low lower extremity. At this point, random Indian boy chimes in. Random because I have been in class with him for almost 2 years and have no idea what his name is. And have probably never heard him talk before this either. “Renal artery stenosis?” random Indian boy says. Major mistake, never answer a question with a question mark at the end of your statement. Dr gives him a slightly weird look. “No” Oh well, good try random Indian boy. The correct answer was aortic coarctation, which I of course thought of but wasn’t brave enough to say out loud.
Dr goes on to ask what would cause the same symptoms, but in a 70 year old. Random Indian boy uses a classic med student strategy, that his answer has to be right sooner or later, and this doctor is a nephrologist after all. “Renal stenosis.” Dr gives him a total wtf-who-are-you look. “No….why would you think that? Anyone else?” Random Indian boy says nothing else for the rest of the 45 minute lab. Todd gets the answer, aortic dissection. I almost start laughing because I think of Michelle saying “aortic dick-suction.”
Todd recommends we do an opthalmic exam, and of course that is exactly the correct answer. They put up a picture of what it would look like, and I want to punch Todd because he shouts out “papilledema” before I get a chance to. But then, Dr asks why papilledema, and I am the quickest to say “because the margins of the optic disc are blurred,” trying as hard as I can to sound confident and like that is the most obvious answer in the world. I get a very approving nod and repeat of my answer by the Dr. Take that Todd.
A little later on, we start talking drugs. I am a drug retard. I’m offering absolutely nothing to this conversation, except repeating other people’s answers and trying to act like I knew if to begin with. “Oh yeah, alpha 1 antagonist” etc. I’m almost afraid that I’ll look like the worst person in our group, but then I remember random Indian boy, who is now basically hiding in a corner behind me.
We leave the room and Todd complains about how we didn’t get to kill the patient.
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