Thursday, March 23, 2006

Spring Break? What Spring Break?

This week marked my first Spring Break since beginning medical school. Now, I have never been one to maximize my spring break opportunities--I've never gone to tropical locations to sip drinks on the beach, nor have I backpacked throughout Europe during my one week respite from school work. Honestly, during undergrad I would usually spend the time cleaning my neglected apartment, watching movie trilogies on a near daily basis, and hoping the weather would clear up enough to go outside and play some baseball with my buddies. Certainly not exciting enough to trade stories with my friends that did take full advantage of their vacation, but it was relaxing enough.

This break has been entirely different. First, our class got slammed with a mountain of material just prior to break. I had anticipated avoiding such a fate because we had just completed block exams a week and a half before break began. I thought there would be no way that they could swamp us with more material than I could handle in that time, provided that I kept up with my daily studying. Turns out I was wrong, and severely underestimated the evil that is our Neuroscience course. In that class alone we covered the majority of the motor pathways from the brain, as well as the vast majority of sensory pathways providing information to the brain from the rest of the body. It might not seem like it, but that is truly a gaggle of information, and the problem was only compounded by the mess that is our course syllabus for that class.

We also had the opportunity to cover one of the more time-intensive systems in our physiology course: the kidneys. I find this course to be by far the most interesting of our classes this semester, but this block seems to be a sharp departure from the conceptual understanding that has been required during the cardiovascular and muscle blocks that we have covered thus far. Renal physiology, as it turns out, consists almost entirely of memorizing the fluid levels that make up our bodily fluids and enter and leave our kidneys, the electrolytes that leave and enter the urinary tract within the kidney and how they are transported where they need to go, and how to inhibit renal function. Sure, I think the material is pretty interesting, but it certainly takes some time to nail it all down. All in all, these are some pretty hefty subjects to try to master, and as a result, I have spent at least the average amount of time I spend studying on a day with lectures, studying at home during break. Not exactly what I had planned.

So, you might ask, what have I actually done for fun? Well, aside from playing with our new computer, I installed and completed the E.R Computer Game (yes, a Sims-type game actually based on the TV-series). Playing a game like this on my spring break from medical school is the kind of confession that I will only make on a somewhat anonymous internet site. Asked about it in person, I would assuredly deny all knowledge of such a game.

But seriously, I have had a great time with a couple of clinical mentoring visits. My first visit of the week was to a cardiac cath lab. For those who have not heard of such a magical place, let me run it down for you (and please excuse me for any inaccuracies). Cardiac catheterization is a procedure in which a cardiologist gains access to the heart through peripheral veins and arteries in a minimally invasive manner. They simply thread a catheter (kind of like a tiny wire) through the vessel and into the heart and then are able to perform a variety of functional tests, take images of the coronary arteries to get an idea of their patency, take tissue sample, or even perform interventional procedures, like placing a stent to prevent closing off of coronary arteries that could lead to a heart attack. I'm very interested in cardiology as a whole, but really find the idea of aggressively treating heart disease through catheterization to be really exciting. Needless to say, I felt incredibly lucky to watch two such procedures from the cath lab control booth, and was talked through watching the procedure the whole way by some very knowledgeable nurses. The cardiologists that I shadowed is great too, and seems to really enjoy being able to teach a younger student about the physiology and pathology behind his decisions while planning the procedure. I was even lucky enough to spend time that morning with a 3rd year Internal Medicine resident who will be starting his Cardiology fellowship next fall, and he was really great about answering my questions and making sure I understood what was happening. Anyways, both catheterizations were non-interventional, and resulted in collecting information about the degree of coronary artery disease of the patients, the pressures in the four chambers of the heart (which can tell you a great deal about their cardiovascular health and can help in a differential diagnosis), and how effective the heart was functioning as a pump. I found the experience to be fascinating, and I felt like a complete medgeek when I felt excited as I recognized terms and concepts that were being discussed from my physiology class. After the procedures were done I was invited back anytime I found the time, and I definitely plan on taking the cardiologist up on his offer. I'll make sure to post those experiences when they happen.

My other clinical experience this break was visiting my clinical mentor for a couple afternoons as part of a Clinical Continuum class for the first year students. At the beginning of the year we are assigned a mentor who usually works in primary care to shadow for at least 6 afternoons before classes end. My mentor is a family practice doctor who works in private practice. I feel like I learn a lot from my visits to him because he is very candid about the field of medicine, including its political aspects and the future problems that I may face as I work within it. He also has very good patient communication skills, and really does a great job of reaching each patient he sees on the level at which they feel comfortable. Definitely a skill that I hope to develop over the course of my career. He's also very good about teaching me about the medical concepts that we encounter as he sees his patients, and really treats me more like a colleague than the underling that I truly am. Anyways, today when I visited him, he let me take out stitches on a man who had previously had a procedure done in his office to remove a sebaceous cyst from the back of his neck. I had shadowed him during that procedure as well, and the patient recognized me, so I think he felt comfortable letting me take the stitches out even though it was obvious with the instruction that my mentor was giving that I had never done it before. The stitches came out fine, and I once again felt excited at the prospect that in only a little over a year I will be doing hospital rotations and gaining more and more hands-on experience with patients and learning how to perform simple medical procedures. I'm sure for him and the patient it was no big deal, but for a rookie like me I felt like it was a big step!

So that's a not-so-succinct summary of my break so far. Tomorrow I visit my mentor for one more afternoon and then hopefully I'll be able to spend my last weekend of freedom catching up with my wife, who's been swamped herself by work lately. I certainly don't feel more rested coming out of break than I did coming in, but my "medical batteries" have really been recharged and I feel like I can face my coursework for the rest of the semester with a lot more enthusiasm than I could muster for it before break. If it gets me to the point that the doctors I worked with this week are, I say bring on that next Neuroscience exam!

Friday, March 17, 2006

What's that Lassie? You want your heart stopped?!

Spring semester drags on here, with spring break officially beginning today. However, as we might have expected, hordes of material has been dropped on us in the 8 days of class since the last block of exams, and many of us will likely spend a great deal of time trying to nail down the details of renal physiology or even trying to get the first clue what our profs are even talking about in neuroscience. Me, I'll be doing both of the above, as well as shadowing my mentor a couple of afternoons next week (part of a mentor experience class) and hopefully watching a cardiologist perform some catheterizations. Really excited about the latter experience, and my mentor is a really cool doc, so those should be fun. Hopefully they'll recharge the batteries a little bit, because I definitely feel like the monotonous material we've been covering this semester has taken its toll on my work ethic.

Anyways, let me explain the title of this entry. There seems to be a controversy brewing here at school about a physiology lab that we recently completed, which endeavored to teach us the cardiovascular system, as it might be found in a living dog. Put a little more simply, the faculty brought in about 50 dogs for our class of 200 students, and we placed catheters in their hearts, cut their chests open, and proceeded to conduct a variety of experiments, including nervous system stimulation of the heart and electrical excitation of the heart muscle. The experiment ended terminally, with us inducing ventricular fibrillation (the kind of heart (a)rhythm that is often behind sudden cardiac death in humans) and trying to "shock" it back into rhythm with defibrillator paddles. If the dog was able to survive that step, they were injected with potassium, which quickly ends their life.

Now, let me preface the following by saying that the lab was optional (as are all of our physiology labs). The faculty pointed out several times that they were not going to track who showed up and that they understood how some might have ethical objections to ending another living beings life for the sake of their education. HOWEVER, we were tested on the material presented in lab (which, to be fair, was covered in a follow-up lecture to the lab) and the professors stated over and over how valuable they thought this experience was going to be. As a result, there was a 90% attendance for the lab. I attribute this to two major factors: first, most medical students are intensely afraid of failure, and quite paranoid about making sure that they have the same resources and capacity to succeed as their classmates. Gunners or not, we all want to make sure that we are not disadvantaged when we enter a test. Many of us felt that we would be disadvantaged when tested on the "dog lab" if we were not in attendance. Secondly, most of us hold our professors up as authorities on learning. If they tell us that the dog lab is where cardiovascular physiology will truly come alive for us, and everything will finally "click" (which, interestingly enough, is a moment that all of my friends say comes at one point or another while studying exam material), then many of us will take them at their word and trust that this will be an educational experience not to be missed. I have to say that I fell prey to both of these errors in thought, and attended the lab despite my ethical misgivings. In retrospect, I think this was a mistake.

I should probably describe what I actually learned while in lab. I learned that arteries bleed ALOT. When nicked by a scalpel, they bleed fast, and they bleed a great amount. That was news to me. Next, I learned that making a simple incision down a dog's chest will sever many such minor arteries, and that without cauterization, it can be a big mess. Messes were made, classmates were drenched--lesson learned. I also learned what holding a beating heart and touching breathing lungs felt like. That was a really cool feeling for someone who has spent their whole academic life studying living systems without much exposure to the inner workings that make us "tick". Definitely one of those moments where you feel lucky to be a med student. Finally, I learned a little bit about suturing, which to me was completely foreign. Seemed pretty cool, if on the surface technically challenging. At the time, I felt very lucky to have a chance to get such hands-on experience, especially during first year where we plant our rear-ends in the lecture hall and library for hours daily.

Now let me tell you what I DIDN'T learn: cardiovascular physiology. Sure, we covered some real basics such as what epinephrine does to the heart, what happens to cardiac output when you completely block off venous return into the right atrium (doesn't take a brain surgeon to figure that one out), etc. But it seemed that whenever we injected a chemical agent that should change heart function, the response was depressed or otherwise abnormal. Sure, you might say that real biological systems do not respond in textbook fashion, and that's true, but how are we expected to be any more prepared for exams of our knowledge of physiological theory if none of the theories are demonstrated in a tangible sense. Seems to me that simply telling us these physiological principles don't always work the ways you expect them to could have saved us the trouble. So, when it came to advancing my knowledge of physiology, I felt that it was time better spent in the library with my textbook.

After the thrill of cutting stuff open wore off a few days down the road, I realized that I was left with an empty pit in my stomach. I reflected on why I felt guilt about this experience and realized that my biggest problem was compromising my ethics as a future physician who values life above needless suffering and death. The dog felt like my first patient while it was on the table and I monitored its heart rate, rhythm, and oxygenation--yet I was expected to just sit there and watch it die of ventricular fibrillation. I felt hopeless (which, I'm sure, will be a feeling that I experience more often on the wards come third and fourth year) and that I had made a conscious decision valuing my own education over the life of another living creature. Weeks later, I still feel guilt over this decision, and hope to take this experience with me by never placing priority of my own knowledge or idea of medical advancement over the life or suffering of another. Don't get me wrong, I stand in support of responsible, supervised use of animals in medical research that could save human lives, but at the end of the day I think that physicians are better served abstaining from conduct that harms another when it is not called for in medical treatment (I'm thinking chemotherapy here).

Call me old-fashioned if you like, but I guess I'm just one of those guys who still finds value in that whole "First, do no harm" thing.