Mountain Musings

On the way to an MD: The USMLE

Well, the first two years of medical school have been completed, as of this morning. I took my final in the "Practice of Medicine" class, covering Oncology, Endocrinology, Pediatrics, and Dermatology. This class is a little more clinically oriented than the others, but it's still no substitute for being on the wards. The only remaining barrier between me and my Pediatrics clerkship beginning June 26th, is the United States Medical Licensing Examination, known colloquially among med students as "boards," administered by the National Board of Medical Examiners. The exam I am taking is Step 1. I will take Steps 2 and 3 later (beginning of 4th year and following my intern year, respectively), and assuming graduation of medical school, passage of all 3 exams, and completion of an accredited residency, I will be eligible for a medical license and will become board eligible (BE) in whatever specialty I completed my training in. To become board certified (BC), I have to take another exam (I'm sensing a theme here!) specific to my specialty, following a couple of years in practice.

What does each of the exams test? According to the USMLE website, Step 1 assesses whether medical school students or graduates understand and can apply important concepts of the sciences basic to the practice of medicine. Step 2 assesses whether medical school students or graduates can apply medical knowledge, skills and understanding of clinical science essential for provision of patient care under supervision. Step 3 assesses whether medical school graduates can apply medical knowledge and understanding of biomedical and clinical science essential for the unsupervised practice of medicine.

I plan on studying ~14 hours/day for the next 2.5 weeks. My date for taking Step 1 is May 30th. The exam itself will take 8 hours, with an hour or so break for lunch. Thanks for your prayers for finals, here comes the biggie!

~Micah

V-I-N-D-I-C-A-T-E-S

How do doctors think? The answer to that question would fill quite a few blog posts, but we'll take one particular facet and examine it. When you come into the doctor's office with a fever, a cough, a headache, stomach pain, vomiting, or any other complaint, how does the doctor go about deciding what the cause of your illness is? Without knowing the cause, a correct decision regarding treatment is hard to come by, thus the underlying cause or etiology must be elucidated, or at least deciding in a general direction. One common way medical students are taught to think is by using the mnemonic in the title of this post. It is helpful for beginning students when looking at the presenting symptoms of a patient to be able to organize the differential diagnosis by etiology. As students grow more accustomed to seeing different constellations of symptoms and making diagnoses, the mnemonic becomes more cumbersome than helpful, but the basic process of elimination and prioritizing remains the same. The mnemonic stands for the following basic causes of disease:

Driving the Camera

No, it’s not some obscure scrapbook term used by my dear mom, nor is it anything like driving Miss Daisy. No, “driving the camera” refers to the duty given to medical students if they happen to be lucky enough to “scrub in” on a laparoscopic surgery. Usually this responsibility is only bestowed upon third and fourth- year students on their clinical rotations, but while tagging along on surgery rounds on Monday afternoon, the resident mentioned that the clinical students would be in a special lecture early Tuesday morning, and asked me if I wanted to come and “drive the camera.” Well, the choice was between 4 hours of pathology lecture (my normal second-year Tuesday schedule) or getting to experience my first operation (other than observing), on the right side of the table, so to speak. Needless to say, I jumped at the opportunity and spent Monday night studying up on “driving” technique and hoping I wouldn’t kill the poor patient by sticking the camera in some important vessel or structure.

Laparoscopic surgery carries an advantage over traditional “open” surgery in that the incisions are generally much smaller, the surgery is less traumatic to the patient, and the recovery time is shortened and less painful. The case is carried out by inserting a camera and 3-5 operating instruments through “ports” placed in small incisions in the body. The camera’s point of view is projected on the mobile plasma screens throughout the OR, and is relied upon by the 2-3 other surgeons as they maneuver their instruments in the body, through the small ports.

The surgery (a laparoscopic cholecystectomy, or gall bladder removal) went well, and I performed my duty by keeping the operating field in the center of the screen for the two surgeons involved in the case. I watched other cases during the day, but none of them was as exciting as the first one in which I actually took part! I’m definitely looking forward to next year, when “driving” will become second nature.

~Micah

Rabbit Surgery

While my family is having trouble with those flop-eared mammals over in the Valley, I'm putting them to good use in Charlottesville. My summer job in a surgery research lab involves performing a certain procedure on them to test the effects of various drugs on spinal cord function.

Here's a basic rundown: In humans, surgical repair of an Abdominal Aortic Aneurysm (AAA) involves clamping the aorta (the primary artery from the heart to the body) for a short amount of time. When the blood flow commences post-clamping, an inflammatory response in the spinal cord can cause nervous system damage. We're looking at potential interventions to prevent this initial inflammatory cascade.

I won't get into the details for those who might be squeamish, but the surgery involves two groups of rabbits: those treated with a drug prior to surgery and those without treatment. All rabbits then undergo a 30 minute aortic clamping, and the effects of the intervention is measured. Later, the spinal cord is harvested and examined microscopically to see the effects on the cellular level.

My primary project involves the same principle, but in the specific area of organ transplantation, specifically lungs. I will be performing lung isolation and transplantation on mice, rats, and rabbits. I'll let you know of progess as it occurs! So the next time you have furry garden intruders and wish they would just disappear, think of all the potential good they're doing you in other areas!

~Micah

Memorial Day Relaxation

The school year's over, as of this afternoon. I finished my last final, in Physiology, and heaved a sigh of relief as I turned in the bubble sheet. No studying to do until August! Now I just have to prepare for my summer research job in the UVA cardiac surgery lab reading various papers and protocols for the procedures I'll be performing.

Wednesday I'll be flying to Atlanta for a week and a half to be with Elizabeth and to enjoy our engagement party and then flying to Denver this weekend to be in a friend's wedding...so a little bit of vacation before the job starts.

So on this Memorial Day, as you remember the lives of the soldiers who have fought and fallen in battle defending your freedom, take time to remember all your future doctors, slaving away in the trenches of medical school, in preparation for the battle to defend your health! :)

~Micah

Doctor, Heal Thyself!

Monday evening I had the experience of being examined on my physical examination skills for my Practice of Medicine (POM) class final. The trick was maneuvering around in 4 different small exam rooms with crutches and the need to keep my right leg fairly straight. For the final, there were 8 potential different exams to perform. Each of us would randomly be assigned 3, plus the Neurological Exam for a total of 4. I started out with the Neuro and did just fine. Next, I drew Cardiac and Blood Vessels. Third was Musculoskeletal-Lower Extremity, and last was Ear, Nose, Throat. The 4th year students acting as patients (they were getting paid for their time...sounds like a 4th year elective to me!) were very accommodating of my situation and did their best to make me comfortable and to deal with my disability. All in all, not too bad. Now, I just have to concentrate on studying for my 4 other finals in a few weeks!

~Micah

DC Trip

Well, Elizabeth and I had a fun, long day yesterday in DC. We got all our must-see locations seen...the zoo, Union Station for lunch, the American History museum, the Holocaust museum, and the Washington and Lincoln monuments. It was a great day...we had great weather the whole day, and the crowds weren't too bad. We'll try to post some pictures later to share our day with you. Among items of interest in the day:

-I had the Great Steak Sub from "The Great Steak and Potato" in Union Station with onions, green peppers, cheese and mustard, plus half of Elizabeth's steak salad. I was hungry.

-A woman named Adele who gave some convoluted story and claimed to be a federal employee who had gotten into a car wreck tried to con us out of $40.

-Washington has a lot of big buildings.

-Hippos can hold their breath underwater for 6 minutes.

-It's a loooong walk from the Holocaust Museum to the Lincoln Memorial.

-I had a triple combo and a double combo at Wendy's when we left. I was hungry again.

-We arrived back at the house at 2 am, 21 hours after we had woken up. A full, fun day!

~Micah

Muser, M.D.

Just a few quickies on what's going on in the "body" of knowledge at UVA School of Medicine.

-Our lab group dissected our cadaver's brain on Monday...using a flat-bladed "brain knife," we sliced across the soft brain tissue in various sections, seeing structures such as the hypothalamus, hippocampus, and insula. It's one thing cutting out a bit of skin in the arm or leg...it wouldn't be that big of an effect on a living person. But even excising a tiny bit of brain tissue would have a large effect.

-Also on Monday, we had Standardized Patient Interviews. These are one-on-one interviews between student and patient (a volunteer who is role-playing) intended to develop comfort getting a history of present illness (HPI), past medical history (PMH) and other relevant issues. This round of interviews was a little more advanced than the interviews in the fall, with more complex issues in the history, like alcoholism, other substance abuse issues, and sexual issues, in additon to the regular "my leg/stomach/head hurts" complaints.

-Today was a half-day "preceptorship," spent shadowing a community physician. Three half-days this year are spent in this clinical experience...it's nice to get away from the basic science study and participate in something clinically relevant. Today I took histories from real patients, which was even more exciting. A little intimidating at first, but easy once you get used to it.

~Micah

Guest Muser

Guest Mountain Muser Micah here...I've done quite a bit of heavy "musing" the past week, with the first block of med school exams of the semester. I have 5 classes: Medical Genetics, Human Behavior, Practice of Medicine, Neuroscience, and Physiology. This semester is a bit heavier than last, and this past week was the hardest so far since August. But I've come out the other end just fine, albeit a little sleep-deprived. I've also noticed the mess in my apartment tends to pile up as tests draw closer; so last night I did a lot of dishwashing, vacuuming, and laundry.

So I thought I'd do a little education on medical education...a little breakdown of the many years between the end of undergrad and actually going into practice.

Medical school: 4 years after undergrad. There are about 140 medical schools between the US and Canada combined. The 4 years are generally split into 2 parts: 2 years of classroom learning, concentrating on the normal human body and processes in the first year, and transitioning to the disease processes and abnormal anatomy in the 2nd year. The 3rd and 4th years are much anticipated by students who have slaved away for 2 years of intense study. These years consist of several required and elective rotations among various specialties, such as Pediatrics, Ob-Gyn, Surgery, and many others.

Residency: After graduating from medical school, you are now offically an MD. To be officially licensed to practice however, you must complete a residency. Residencies are training programs that focus on the specialty you desire to practice in. These programs are applied for during the 4th year of medical school and last for a varying amount of time, depending on the specialty. For example, a Pediatrics residency lasts 3 years post-medical school, while surgery lasts 5. You receive intense training, often working long hours (officially limited by law to 80 hours/week) in the specialty of your choice. Residencies are paid positions and you function as an employee of the hospital during this time.

Fellowship: You are able to practice medicine following completion of your residency. However, many doctors choose to subspecialize in their specialty, and thus complete 1-3 additional years of training in the subspecialty. Fellows often complete research projects during this period as well.

Having completed this journey, you're now able to practice medicine, whether it be as a solo practioner (the popularity of this is fading in modern times with rising health care costs) private group practice, or academic medicine, where you are associated with a medical school/teaching hospital. All told, your time invested post-undergradute at minimum is 7 years (4 med, 3 residency) to as much as 12-14 years in some of the surgical subspecialties. It's a large price to pay, but most doctors see this investment as worth it in the long run.

I'm still deciding on a specialty--Surgery and Pediatrics are among my interests now, and who knows, they might change once I begin rotations.

Well, that's it from Medical Musings. Remember, an apple a day... :)

~Micah