Splash.

If MS1 is treading water, MS2 is a water slide. You start to feel like your gaining competence of knowledge in important clinical disorders, then *whoosh* you move on to a new block and said knowledge goes sliding down the level III watery loop-dee-loop. You start to feel good about coming up with focused and pertinent differentials for patients then *whoosh* a patient comes along who you have no idea how to even begin to workup with nonexistent or contradictory clinical findings and a poor history. You start to feel competent at the lung, abdominal, or head and neck physical exam and *whoosh* a patient comes along with a vague shoulder complaint and you're left flapping the patients arm pathetically attempting to perform a musculoskeletal exam.

As I've stated before, MS2 is a lot more fun than MS1. The information is a lot more enjoyable and pertinent to your medical education, and the days and page upon page of syllabus tend to cruise by at a more enjoyable clip as a result. This definitely has its upsides, but also acts as a double edged sword, because it's info you feel like you should be holding onto but the pathetic biology of your brain and its synapses prevents you from doing so.

If I saw a patient with chest pain back in October, when we had just finished up our cardiovascular pathophys block, I was AWESOME at coming up with a differential diagnosis. Slap an EKG on that sucker and I could tell you exactly what was up, if anything. Fast forward to mid-November, with yours truly currently over a month removed from CV and slogging towards the end of our GI block, and my differential for chest pain would look something like:
(1) GERD
(2) Heart Stuff

In MS2, the blessing of your experience is that you're starting to gain some competency in your physical exam skills. Not to toot my own horn, but there's a fairly decent number of common complaints I've been seeing these days where I can come up pertinent PE findings and a decent treatment plan. Cold symptoms, abdominal symptoms, etc. But you start to pick up on your serious deficiencies also. Ask me to pick up on your heart murmur? Fat chance, it'll get figured out when you go into heart failure and present to the ER. Tell me there's a heart murmur and then ask me to listen for it? 90% chance I'll hear it. How I can get better at this besides making the patient lie there awkwardly in dead silence for 5 minutes while I listen to S1-S2-Between and the patient wonders why the "medical student" who looks old enough to be on their kid's t-ball team stares at their bare chest with a disconcerted look on their face... I have no idea.

​The further I get into medical school, the further I seem to look forward. As an MS1, you're so far removed from your future self that to think of who you'll be as a clinician is something akin to the "what I want to be when I grow up" presentation in kindergarten. But the more experience I garner around patients and around various clinicians, the more I pick up on the do's and dont's I can see myself realistically integrating into my own practice in the future. As an MS1 I was content to trudge along in my BS classes, taking each block and exam in stride. And now, as much as I'm enjoying MS2, I was just want the year to be over so I can move on to my clinical rotations and actually learn on the fly. Only problem with that is that the Step I thundercloud has also crested the mountain and come into view. I've been pretty good at putting off thinking about boards but the thoughts of what it would actually mean if I fail or don't do as well as I need to are starting to creep into my consciousness. It still feels like September to me, time has flown by so quickly this year, so I know I'm going to blink and its going to be May.

And so the march goes on. 5 steps forward, 4 steps back.

Constructive Feedback.

Like many other medical schools throughout the land, my medical school engages in the prestigious Exam Review after each one of our sodomizations, I mean, examinations.

Its supposed to be a time for the course director and instructors to garner useful feedback on the questions and learn where they need to clarify question wording, as well as an opportunity for students to learn what questions they got wrong and why. As I am sure you can imagine, this results in a very responsible and professional environment with each party, class and course director, exchanging meaningful ideas. For example:

Course Director: "And now question 23, on the West zones of the lung..."
Class: "RABBLE RABBLE! RABBLE! RABBLE RABBLE RABBLE! RABBLE! RABBLE!"

I swear, Virchow himself could not write a sufficient test question for some members of the class. Of course, its not unexpected. Old habits die hard, and us hyper-type-A personalities have come from a long lineage of scrapping and clawing for every point back in our younger days. Most of the time you learn to let that go in medical school, but it comes out during things like... exam reviews.

I think some people are losing a good opportunity to modify there thinking process and understand WHY they came to the wrong answer. In medical school, a wrong answer is more rarely due to simply not knowing the information and much more often due to misunderstanding the information. And it would be prudent to identify what aspects of the material you misunderstanded (nuke-u-ler), and correct them before you misunderstand them in a patient. By fighting to justify your answer, you are reinforcing the information as correct in your brain.

Instead, the typical exchange goes something like this:

Instructor: "Well, B is the right answer because it is a true representation of the value of the pressures of the total respiratory system at FRC. D is wrong because it takes into account only the static dynamics of the lung."
Student X: "But, if you rearrange the words of answer D backwards, and if the question is in reference to a 82 year old African American woman with toxoplasmosis, diphtheria, and a hangnail, and if you stand on your head when you read the question... isn't D technically correct?"
Instructor: "..."

Now I can't complain too much, because my fellow classmates that smell blood on a question and really go after the course director are always successful (100% of the time, no joke) at netting me an extra couple of points on the exam. I'm more than happy to have others claw and scratch for me, because I'm a giant ball of apathy at these exam reviews.

Of course, the highlight of the exam reviews are when a certain select subset of question comes up. The Complete-and-Utter-Bullshit Question™ (CUBQ in dedication to the fact we are learning interstitial lung diseases right now). This is a question on a small minutiae of information that was either present in 2 point font at the bottom of some table somewhere in the syllabus, or the lecturer muttered the sentence under their breath during a sneeze at break, or the lecturer is playing the wonderful game of "guess what I'm thinking?" (I love that game!!!!!!!! HAHAHAHA!)

There's a certain percentage of students that will fight for every question they got wrong, but on a CUBQ its like a tsunami. It starts as a rumbling in the distance as the CUBQ is projected onto the screen. The rumbling gets louder as the course director reads the question. Then, as she unfortunately mutters the fateful phrase "Any questions?", the wave arises in front of her. Arms shoot up throughout the lecture hall, forming a wall which eventually crashes down and consumes the course director in a swirling turbine of indignation and outrage.  

Ah, lecture hall. The closer I get to MS3, the more I look forward to leaving it all behind. But part of me will miss those little moments, where the "gravity" of the information being presented to us breaks way to reveal the absurdity underneath.

Revenge of the Kidney

I am a big believer in karma. Y'know, the whole "the world comes back to treat you exactly how you treat the world" jazz. So I try to keep my divisive relationships in my life to a minimum. If only I had learned from the kidney.

As has been well documented in the past, I have a hate-hate relationship with the kidney that extends all the way back to high school. When we sludged through renal physiology last spring, it was hands down the worst 2 weeks of first year (well, besides my shotgun wedding with biochemistry). I celebrated being done with the kidney. Reveled in it. May or may not have even done a happy dance in front of the mirror in just my boxers as Rick Roll blasted in the background.

Cue 4 weeks ago. MedZag's cruising along in his MS2 corvette down I5 after finishing up the first exam of the year, conveniently on cardiovascular stuff (my favorite organ system). I'm getting ready for the coming week and glance at my syllabus and the lights go out and the clock flashes over to 3:33AM as my eyes fix on Wednesday's lecture: Review of Renal Physiology. The kidney... was back.
 

Since then, I've suffered through such wonderful subjects as ECF Content/Volume Disorders Part I & II, Total Body Fluid H2O/Osmolality Disorders, K+ Homeostasis, Pathophysiology of Hypertension, Syndromes of Renal Disease, Evaluation of Renal Function, Renal Stone Disease, Acute Kidney Injury, Tubulointerstitial Diseases, Pathophysiology of Chronic Kidney Disease, Glomerular Disease, Acid-Base Review, Metabolic Alkalosis, Renal Tubular Acidosis and Metabolic Acidosis, Proteinuria & Nephrotic Syndrome, and Diabetic Nephropathy. There's been PBL sessions. Pathology labs. Tears.
 

It's bad enough that I have had to study the kidney all day long for the past month, but the kidney is not content with that. No, the kidney wants to leave me huddled and whimpering in the corner, drooling all over my chest and referring to myself as George Costanza. Yes, the kidney has also successfully invaded my dreams.
 

I had a dream where I was examining a path slide trying to identify if it was IgA nephropathy. A dream where I was examining a patient for rear flank pain to rule out acute pyelonephritis. A dream where I was counseling a patient in the ED on how lupus can lead to a rapidly progressing glomerulonephritis. I had a dream where I was eating a burrito and all the pinto beans had pelvises and tiny ureters.

I think I can now empathize with the chick from Exorcist: The Beginning. I wonder if renal exorcism is something they teach you in nephrology fellowship.

MedZag diagnoses himself (again)

So I always like to post whenever I come down with some kind of illness or other. It's really the only opportunity you get to being on the "other side of the fence" as a medical student... kind of like being a realtor selling your own house, or accountant filing your own taxes, or whatever.

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So let's run through my latest bout with the big bad germs of the world. I'd had this nagging chest cough for about 2 weeks. On its onset, it started as a dry cough, and over the course of the first few days it moved "deeper" into my chest and I started to have laryngospasms when I coughed (the wonderfully coined 'croup' - no inspiratory stridor though). Overall it was a pretty subacute course. No fever, kinda rundown but not enough that I couldn't get through the days. No purulunt sputum, no involvement of the oropharnx or nasoparhynx. No earache, no headaches, no violent cough attacks. I just had this persistent deep-chested cough which sputtered out throughout the day and scared every healthy person 15 feet away from me for almost a month. Mild lymphadenopathy, no swollen tonsils or erythema of the throat.

So I thought it was viral at first, even though it seemed to be localized to my chest, generally by its pretty mild nature. So one week goes by, no improvement, no worsening. When the 2 week mark was hit I started being suspicious it was mycoplasma, since by that point I should have been on the upswing, and we saw a kid in clinic the day before I started to be sick who had it. Tough it out a couple more days before dragging myself into urgent care.

My plan was to play ignorant and just let the doc go through his exam, both because I was curious what sort of conclusion he'd reach and also because its kind of fun to play the patient. Y'know, I didn't have "lymphadenopathy," I had "some swollen lymph nodes." The illness wasn't "subacute," I "just never really felt that sick." "No green gunk when I cough." I know, I am so clever. My ruse was going perfectly as we went through the history until he asked me if I had had any fever, to which I replied "I haven't been measuring my temperature but I haven't really felt febrile."

Doc stops typing. Slowly turns and peers at me.

"You in medicine?" C'est la vie, I had been found out. Like every single physician when I first meet them, he wants to know what year I'm in, then subsequently looks disappointed when I tell him I'm a 2nd year. Yeah I know, I'm still stuck in the lame go-to-class study-all-day part of medical school.

Anyways, he finishes the exam and agrees with my diagnosis, even though he doesn't know it (Ed Note: Yes, I realize this sentence makes me sound like a total asshole), and hooks me up with a good old z-pack.

One day later. Cough dramatically improved. 5 days later, cough almost completely gone. The wonders of medicine.