Saturday, September 30, 2006

In Loving Memory of our Cadavers

"My mother never liked to waste anything."

So, he told me, that's why his mother wanted medical students to be able to learn from her body.

"She never threw anything out, really. And even when she was dying, she didn't want to be buried or cremated. She thought that was a waste. And she never liked to waste anything."

I don't usually leave a memorial service really impacted by the things that were said.

Then again, I don't usually go to memorial services for people whose bodies I have seen fully exposed internally and externally, for people whose organs I have held in my hands, people who have taught me so much more than some teachers ever could. What a fascinating and unusual experience.

Among a couple choir songs, a piano performance and a candlelight procession, there were a few reflections and readings of poems. One of the student speakers talked about the courage that the body donors showed by giving their "most personal possession" to us. We med students often discuss whether or not we think we could donate our bodies, knowing what is done to them - even though they are treated with the utmost respect (as I
mentioned earlier), and what we do is done all the time in routine autopsies, it is still so generous of them to grant amateurs the opportunity to learn so much from them.

Another speaker said the following:

When I study their eyes, I wonder about the things they saw.
When I their arms, I wonder about the people whose lives they touched.
When I study their hearts, I wonder about the people they loved.

I can relate. I thought I'd get desensitized, and I have in a sense, it's not like the first day where I didn't know what to expect. But still, each week in anatomy lab I spend a good part of the time there overwhelmed by the fact that this isn't a "specimen" but a person.

I wish more of the students in our class showed up. Of a few hundred first- and second-year students, only about 30 showed up, and half of them were directly involved. Being there, and actually talking to the families was a great experience. It makes the donors more human. The only identifying characteristic to date is that my cadaver is the one on table 32.

Even before today I know I will never forget what I've already learned from my cadaver, which is already in a quanitity much greater than any anatomy book has ever taught me. By going to this service, I developed a whole new level of respect and gratitude for the body donors. Even though I knew they were people who lived lives and had loved ones cry at their deaths, I had never seen the people who they lived their lives with, nor watched their loved ones cry. Until today.

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"She was dying, and he didn't even look at her."

"I was watching my wife die over the course of those nine months. Our family doctor sent us to see a specialist. Without even doing a physical to see the her ribs jutting out of her back, he told me that 'women typically lose weight during their menstural period.' I was shocked. She was dying, she was as skinny as a corpse, her brain wasn't functioning properly, and he tried to tell me it was her menstrual period. He didn't even look at her."

That happened almost thirty years ago, and still, my patient's husband talks as if this happened last week. Today I had to go to the home of a patient who had volunteered to discuss their chronic condition, part of a rather interesting assignment meant to get me thinking about the impact of a chronic condition on a patient's life and family.

Unfortunately, the husband is still convinced that the only reason his wife was eventually diagnosed or received treatment is because he reamed out the doctor.

Not every story like that has a happy ending. But this one did. Once they diagnosed the disease, although that was a nine-month process, they gave her one injection and other than the low body weight, she was completely normal the next day. Today, one pill per day is all she needs to live a completely normal life, and if she didn't tell you about her disorder, you wouldn't even know it existed.

If only all diseases had outcomes like that...

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Wednesday, September 27, 2006

"Um, is this your first time examining a woman there?" "Hell no!"

I gave in.

I know I
said I was going to sit out the Maternity Hands-On night, but I didn't go just for the vaginal exams (and what if I did, anyways? I'm going to be a doctor, I need to get experience, nothing weird about that? right? why do I feel as though I have to justify this?) I went for two reasons: 1. I was there anyways for a meeting of the Emergency Medicine club, and 2. free pizza!

I'm glad I went, too. Not only did I get elected to a position in the ER club, but this was probably one of my most practical and interesting events since starting med school. Hopefully it's a taste of things to come in January when we stop the cirruculum of undergrad review and get into the doctory stuff.

I delivered a baby, determined how dilated a woman's cervix was, and felt for the position of a baby inside a woman's stomach!

Had I known the first two of those would be on fake silicone models, I wouldn't have been so shy about attending. Mind you, I was clearly not the only shy one. Even though there was a great turnout - almost a quarter of our class showed up - the men in the group were far fewer in number.

It was interesting, too, learning how much an experienced physician can tell from an exam; how the baby is lying / presenting, etc. Someday I'll be that good - someday at the end of my OB/GYN rotation, and it will probably all go downhill from there.

And the best part? If a woman ever asks me while I'm conducting the above procedures, "Is this the first time you've ever done this?", I can emphatically and truthfully say, "Hell, no!"

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Tuesday, September 26, 2006

The P=MD discussion, furthered

Before leaving the states, I wondered at all the rumors I heard coming from the Caribbean. Do they study on the beach? Do their professors sip cocktails with little umbrellas in them during the exams? Are they really learning medicine in a Third World Country?
Yes, the rumors were true.

That's a direct quote from the Rumours Were True blog. If I can't come up with anything interesting to post, why not post a reciprocal courtesy link to someone else? Especially if I apparently had something to do with their posts! In case that intro isn't interesting enough, Topher of
RWT was kind enough to further a discussion I initiated about pass/fail medical school marking.

Judging by the apparent popularity of this discussion, perhaps I'll muse about PBL (Problem-Based Learning or Case-Based Learning) here sometime in the near future.

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Extraeducational Patient Encounter

I felt like a real doctor today for a brief moment.

When I was switching buses on my daily commute home, I saw someone waiting for the bus whom I recognized - a woman who had been a patient of mine!

Okay, I'm not a doctor yet. Not even close. And in actuality, all my "patients" to date are either cadavers or fake - hired actors.

The one I fortuitously saw on the street today fell into the latter category, in case you were wondering.

Even though my feeling as though I am a doctor lasted for less than a measurable time quantity, it was kindof neat. I know that happens to doctors all the time, running into patients of theirs. My friend's dad is a GP in a small town, and it happens to him. It must be nice for doctors having these little reminders that they've made a difference in somebody's life, every time they bump into them. Or perhaps they're more like reminders of what a nightmare the patient was and how stressful the doctor's practice is.

Maybe I'm just stretching for ways to feel like I'm becoming a real doctor, since I don't get that feeling very much in class. All our classes so far are a repeat of fairly simple concepts we learned in undergrad, or even worse, high school. I've learned how cells divide about six or seven hundred times already, and that meiosis happens in the somatic cells and mitosis in the germ cells (don't freak out, I'm on it, that was a little joke for you science people out there). It seems like it's going to be like this for the rest of the first term, too, since it's designed to catch up the people who, unlike myself, do not come from a science background.

There's just enough new information that I have decided to heed the words of pretty much any second year I've talked to: "Don't get behind! Stay on top of the material." So my days of little to no homework are gone; I've started making work for myself, namely, reading and studying the notes, so that when study time for our midterm comes up in a few weeks I won't feel too pressured. But still, that midterm's only worth 5% of our how much pressure can that be?

That being said, you can probably understand how it's a relief to study things that are more clinically related, like our small group session on hypertension today. Though the second half of the first-year curriculum promises to be a lot more work, my friends in second year say it's a lot more clinically relevant and a lot more interesting. I think I'd rather have lots of interesting work to do than be bored reviewing things I've already gone over.

I have a feeling that I'm going to regret saying that someday.

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Friday, September 22, 2006

Did we mess up? Our cadaver's heart is on the RIGHT...

"Now that we've gotten past the superficial muscles, you're going to start seeing differences from one cadaver to the next," said our anatomy prof.

Boy was he right!!

Some of the crazy / cool stuff we've seen already:

  • Situs inversus with dextrocardia

This is a rare condition in which the person's heart was on the RIGHT hand side of their body, and all of their internal organs were reversed! (Liver on the left, spleen on the right, etc.) You gotta see it to believe it. Our anatomy profs hadn't seen this one in person before and they were so excited they were freaking out.

  • Pulmonary Atrophy

One of the cadavers had a left lung that was very tiny, and the right lung was MASSIVE

  • Pacemakers

Right after cutting back the skin of the chest, a few of the cadavers had stainless steel pacemaker implants

  • Sutured sternum

Those individuals who had cardiac surgery have their sternum sliced down the middle; following the surgery, the surgeon uses stainless steel sutures to bring the sternum halves back together.

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Tuesday, September 19, 2006

Vaginal Exam practice and Free Pizza!

I don't think that the upperclasspeople in my medical school realize that to us first years, it's still a bit odd getting an e-mail that juxtaposes "practice vaginal exams" and "come for the pizza" in the same sentence:

Come to the OB/GYN student interest group's Maternity Hands-On Night! Stations include abdominal palpation, finding the fetal heart beat, vaginal exams, and charting; pizza and beverages will be provided! First and second year students especially will find this to be a fun learning experience.

As "fun" as this promises to be, I think I'll skip this one out.

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P=M.D. ::: Does that worry you?

Q: What do you call someone who graduated at the bottom of their med school class?
A: Doctor.

Source: unknown. Some other med blog.

So much pressure is relieved by my knowing that I'll be graded on most classes as a Pass/Fail. Already, us med students are helping each other so much more than I ever saw in pre-med. Stress to get a top grade is at a minimum, and I no longer find myself giving much care when I get the page on the syllabus that tells me how much each assignment is worth. If I choose to spend my time studying for my midterm rather than agonizing over the finer details of my patient interview report assignment, I don't have to worry that my report is going to get an 78% instead of an 89%. Both get me a P, and that's all that counts.

As much as I love the H (Honours)/P/P-/F system, the more I thought about it, the more I honestly started getting nervous for my future patients and readers of this blog: how does the general public perceive a physician who could likely have gotten their medical diploma because they achieved the bare minimum (60% in most classes)? Should I really be gloating about that on my blog? "Hey, everyone, I only have to get a 60%! Guess what I'm aiming for!" This might be one of those posts that's more for myself than anyone reading, but hey, this is as much a journal of my education for myself as it is meant to be entertaining reading for you. So welcome to my thought process.

First of all, as Alice put it commenting on my last post, I still have the class rank to worry about. I won't be shooting for a 60% because I'd rather not end up at the 8th percentile. That's where the people who got in off the waitlist belong... and I must clearly be better than them. (Just kidding!! We don't judge each other that way! Besides, nobody who got in off the waitlist broadcasts that fact... I only know 1 person in my class who has confided that information in me). Besides, this is a really bright group. I'm pretty sure I will have enough trouble staying above the 50th percentile.

But secondly, since I've started thinking about the whole P/F system, two things have crossed my mind that make me less worried. Today we had a small group session where we learned how to take blood pressure and what a pulse is (yeah, pretty basic stuff, but they gotta teach it to us!) and one comment by the doctor teaching us really stood out. He was telling us about a patient he treated on a plane. He asked this patient a standard family history question: "Does this run in the family?" and the answer that the patient's wife gave him ("Yeah, for some reason our doctor wanted to talk to all his brothers!") immediately triggered in the doctor's mind what the disease was. The doctor's point for us: "If there's something important you need to know, trust me, it will get hammered into your head in medical school."

The other thing was this: Even if I try to cruise through school not knowing anything, there's still boards. I have to pass an exam when I graduate before I can practice. Anything I learn for good now is one less thing I have to cram for come boards.

Okay, now I'm not so worried about telling people about my P/F system and having them think I'm trying to cruise through my M.D. Cuz I don't think that anybody really can "cruise through" med school, and I hope it stays that way. I don't want an incompetent doctor, either!

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Saturday, September 16, 2006

Top 10 list: Things I love about med school so far (or, Med school is so...slack?!)

First an apology: I haven't posted in over a week because my computer died and I've been wrestling with the big box store for repairs. They gave me a replacement system...but they also 'accidentally' wiped out my hard drive too. Back up your stuff, people. Do it.

Okay, I know the title for this post is pretty much the exact opposite of everything that you have ever heard in your life about med school, even if you have never been a science student. And I know by reading that there are medical students and professionals who, upon reading that, will a) question the legitimacy of my medical education; b) rain down words of warning about how the first bit is no indication whatsoever of what is to come. To the medically unfamiliar, I will explain that the first term is designed to catch up people who didn't come from a science background and get everyone on an even playing field. And to the medically experienced, I will say I know very well what I'm in for as soon as first term is over, and that I am quite clear on the fact that it only gets worse from there (I need not even mention third year). No need to warn me.

That being said, I will now provide you with a list of things I love about med school so far:

1. It's so slack. So far. Yeah we're in class 8-5, so I'm pretty busy, but as far as work or memorization goes it's not bad at all and it's pretty interesting stuff. And yeah we have 20-60 mins of homework twice a week, but it involves looking up stuff I'm curious about anyways. I am enjoying this breeze of a workload while it lasts (because it will not be for long).

2. Pass/fail. No pressure. No competition. P=M.D. All I gotta do is pass. Trust me, I'll aim higher, but it takes a lot of stress away from having to freak out about doing really well and learning the extra, useless details.

3. My M.D.ID card. All of us got an ID card from our regional medical association today, which is affiliated with the national medical association. Best of all: instead of "Mr. Vitum Medicinus," my name is clearly indicated as "Dr. Vitum Medicinus." I'm going to let that 'accidentally' fall out of my wallet many a time when I'm around attractive women!!! My hospital id is pretty rad, too.

4 Free stuff. Free backpack embroidered with the logos of the above associations (a nice one, too!); free rubber tomahawk reflex hammer (awesome!), and lots of free food every so often.

5. Toys. Even though I'm paying a pretty penny for them, in about a month I'll get my brand new stethoscope and diagnostic set in the mail. My friend told me that she expects me to sleep with the stethoscope around my neck. She's right; I likely will.

6. The people. I did NOT think that a group of a couple hundred former pre-med students would be so fun! Everyone has such amazing, diverse backgrounds, stories, and they ALL love to partay. Thank God for the interview process. The geeks are weeded out! Well, 99.5% of them...which leads me to the next point:

7. Making fun of "that guy." As we expected there's a "that guy" who chooses to raise his hand every class and ask stupid questions, using the class as a forum for personal debate with the professor at the expense of class time. The entire class lets out a sigh when the hand goes up... I honestly wonder what his patients will think of him. Oh well, there's a reason he's here too.

8. The relevance of everything. Like I mentioned before, almost everything I'm learning I no longer have to ask, "when will I ever have to use this?" It's all applicable. It's awesome. It's nice being able to enjoy my classes.

9. Learning from cadavers. This week we turned our cadavers over onto their backs for the first time to dissect the chest and see the muscles. Some of them had pacemakers which was really cool to see. Our anatomy prof is amazing, and by only focusing on such a tiny part each lab, we're learning so much.

10. Working with professionals. They do a great job of making sure we have a few different ways to learn the information: lectures, organized workshops (go through questions in a small group with a tutor), courses structured entirely as small group learning, etc. Whenever we're in a small group, they pair us up with a professional. It is so much better discussing how to interview patients in a small group with your tutor who is a doctor who has experience, or working through genetics problems with a person who is not a genetics masters student but a clinical genetic counsellor with >25 yrs of experience. They just add so much more to the discussion and experience.

I'm having the time of my life so far. And again, for those of you veterans disgusted with my euphoric honeymoon stage, no need to warn me, I know this is NO indication what the rest of it will be like. Until that kicks in, though, I'll keep jumping out of bed in the mornings.

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Thursday, September 07, 2006

"The way the doctor talked to me made me want to kill myself."

Part of what I love about med school - even only a few days in - is that they're already teaching us how to be doctors.

It's a nice change from undergrad. When I studied science in my undergrad, we only really learned the science. Now, we have classes that teach us the scientific background, obviously, but they're much more applicable to the clinical setting - we learn about the pathology, the pharmacology, and so forth.

Better still, there are also a number of classes that could be summarized as belonging in the 'how to be a doctor' category. We have a course in clinical skills where we get the chance to learn how to take blood pressure, start IVs, stitch wounds (our school just started a new policy that the first time students practice suturing we are not allowed to do it on a patient), and practice injections on oranges. We'll be going into doctor's offices in just a couple of weeks to start interviewing patients and giving them injections. And we're taking classes on how to talk to patients, which will involve us not only learning the principles in lectures and small groups, but also being evaluated as we interview real and simulated patients (actors).

We had an excellent speaker today to open up our class on bedside manner / talking to patients. Even though he has five degrees, the one thing that is always highlighted when he is introduced to speak is that he has been on Oprah. He has interviewed thousands of patients for studies, and through that gained insight on iatrogenic suffering, meaning any sort of illness or suffering caused by the medical profession. "The way a doctor talks to a patient can cause more pain than the disease itself," he told us.

We were told a few examples of 'horror stories' of doctor/patient interaction, which most people hear about every once in a while. Here are a few of the ones he mentioned:

  • "They decided to remove the lump anyways, even though they told me months ago it wasn't cancerous. As I was just starting to wake up after the surgery, the doctor came to my room and told me from the doorway, 'We made a mistake, it's cancer.' I was horrified that he would tell me in that way."
  • "The doctor was talking outside the room and joking with someone else about a movie they'd just seen. Then, she came in and told us that our baby was dead. That's it. No intro or anything. Even though we were only 20 weeks along in the pregnancy, we had been trying for so long and were so excited. We knew it was a boy. We'll never go to this doctor again."
  • "The way the doctor talked to me made me want to kill myself." Or, "After the doctor talked to me that way, I left his office and tried to kill myself."

Scenarios like that are the justifications they use for teaching us how to talk to patients, and clearly a course of this nature can serve some very important functions and is well-warranted. I'm not sure how long such courses have been around, but according to some articles I've read they're pretty new. Obviously they'll teach us important things about bedside manner, which we'll begin to use right away.

The thing is, pretty much anyone reading the above scenarios - even medical students and practicing physicians - would be shocked at the blatant disregard for patient dignity that the doctors allegedly displayed in these instances. I'm sure that even the doctors who committed those actions would be shocked when it was put in a statement like that. As a result, the above can only be explained by some sort of a desensitization that occurs in physicians after they have seen hundreds of thousands of patients, a desensitization that causes doctors to do the above things without even being aware of it.

There are obviously clear benefits to holding these classes. However, I don't think we'll know the extent of how effective they are for a long time, becuase I guess the real test of these classes is to see if they are still influencing the way us future doctors practice medicine 20, 30, or 40 years from now. If, decades down the road, they have been and continue to be successful in preventing such scenarios, then they will have turned out to be a good idea. Until then, I suppose we won't know if doctors should be taught bedside manner in some other way.

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Friday, September 01, 2006

Cadavers Day 1, or, I Still Have The Smell Of Dead Person On My Hands

Mortui Vivis Docent
The Dead shall Teach the Living

Today was our first human dissection day. Though I’ve gotten a lot of dissecting experience starting with fetal pigs in high school to a number of different species in physiology and zoology courses, I’ve never had the chance to dissect human bodies before. It’s a rare privilege that a very small percentage of people ever get to do, as it should be; it’s not something to be taken lightly.

By no means did we take it lightly. Even before we were allowed near the bodies, the professors instilled in us a strong sense of respect for the body donors and their families. Though we're allowed to wear whatever we want into the lab (a set of scrubs used solely for this lab is recommended because the clothing 'picks up the scent'), we are required to wear a white lab coat over top, as a way to maintain professionalism out of respect for the body donors and their families.

This consideration of respect comes up in a few other ways as well. We don’t discard any portions of the body when we’re done with them; all of the remains go into a bag in a large bin under the body, which will get cremated with the body so the families can be given back the entirety of the ashes.There’s obviously an uneasy aspect to dealing with human bodies, and our faculty went to considerable lengths in an attempt to prep us for the event. Before we went into the football field-sized lab filled with body bags, the prof showed a short 360ยบ video of the room. They went over a few guidelines (for example, if we take photos or bring unauthorized people into the body lab, we could be expelled), and showed another brief video of unzipping the bags and spraying them to keep them moist.

They then talked a bit about the body donor program. Our school had been successful this year with the donation program, allowing us to keep the student-to-body ratio at about 6:1. While most of the specimens come from elderly people, the cut-off age is 35, and occasionally they will receive donations at that age. There are no specimens which died of infectious diseases, and none of children.

After answering some student questions about the embalming process, it was time to go downstairs to the body lab. They did a demonstration on one body that we all watched over the TV monitors above our stations. Even after all that prep, during the demonstration, right after the instructor folded back the flaps of back skin revealing the underlying muscle and fascia, one student - a big, buff Italian guy – passed out. And after, one of my small group members told me that even after all the preparation, he still wasn't sure what to expect when the bag was unzipped and the sheet came off; he was still a little flustered that there was a person in there.

In some ways, the bodies look very little like humans. When we unzipped the bag, the bodies were wrapped in a sheet and had a canvas bag over their heads. They have picked up a grayish hue, and many of them have large flat sections on their backs with pooled blood visible through the skin from the way they had been laying. Rigor mortis is obviously prevalent, and the skin has become tough and leathery, very much unlike the skin of anyone I know. If you really want to see what a cadaver looks like, the University of Michigan medical school has medical gross anatomy dissection videos online that anyone can access.

I had heard before that people often name their cadavers. I was very disappointed when I proposed this idea and it did not seem to go over well with the other people in my group…

Our dissection today was of the back. We peeled back the skin, revealing the muscle, and identified the trapezius, the levator scapulae, the neurovascular bundle supplying the trapezius, the rhomboid major and minor, and the latissimus dorsi. Over the next two years, we’ll spend a lot more time learning anatomy from cadavers.

I was once told by a doctor, “Becoming a physician is a privilege even more so than it is a profession.” It’s true. Society generally holds physicians in high regard, as valued members of communities, and as individuals in whom some people will confide their deepest and darkest secrets. The privilege of working with cadavers in our training is one more thing that I feel honoured to be a part of, and I’m grateful to my medical school, my body donor’s family, and my body donor for the gift of education in such a unique format.

Postscript ::: According to one medical student, the use of cadavers could eventually be a thing of the past. While I may not agree with his comments, his article in the Student BMJ presents the opinion of a student against the use of cadavers in training, but not using reasons of ethics or the gruesome nature of the procedure. He indicates that not a lot of anatomical detail is that effectively learned, the costs are fairly high, and while anatomy is important for surgeons, only 5% of medical graduates become surgeons and cadavers don’t feel anything like performing surgery on a living person.

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