Education Beyond the Classroom

Learning the tricks of the medical trade comes from lots of exposure to lectures, books and hands-on experience. Initially we are expected to be attentive to professors who create a basic foundation and then pick up the rest on our own time through personal study and discussion with colleagues. When it comes to the clinical setting, the direct form of teaching dissipates and we carry more of the responsibility to be self taught. Yet there remains plenty of room for a student-teacher relationship. [Classroom at the Washington University School of Medicine 1943]

Learning Through Respect

In speaking with one of the residents at the program I am visiting, he reminded me that not all physicians remember what it is like to be a student. They have forgotten the basics and want to be identified as one who no longer has to be "at that level" of training. In doing so they often seem to have a chip on their shoulder, teach very little to students and ignore even the existence of students trying to be friendly. So doctor, my morning greeting was not an attempt to waste a breath of air, it was intended to be pleasant and acknowledge your existence in hopes that perhaps you would acknowledge mine. Little things like that are what really set a tone in my opinion. It standardizes a sense of mutual respect and understanding allowing for potential growth beyond that point. Maybe it is perceived as a "brown-nosing" tactic wherein I am gunning for a response. Whatever the case, I thought it was a simple common gesture in human interaction. What do I know, I am just a medical student.

Medical students just learn to grow thick skin. Patients give you grief because you are the first person willing to listen to their complaints and desires. After hearing out the patient, the student finally presents to the residents who are the first to think you have set them back because "you must have been delivering a baby in there." If you are not thinking what they are thinking, they will let you know without hesitation that you are wrong. But this mode of action comes from their superiors too. The attendings are looking at them in a similar light but may not always say so out loud. So it only makes sense that the residents become calloused and project their troubles onto the medical student who will smile, be pleasant and always take a verbal lashing for the ever coveted passing grade. All the while the student is thinking, "why do I pay good money to be demoralized in front of patients and coworkers?" We know our end goal and will walk through the gauntlet to get there, even if that means we will be red in the face a few times.

Once in a while, however, there are those who will remember the emotional strain medical students experience. In their wisdom, the residents will slow down and teach or maybe even learn something because we are all in this together. What one person may have recently studied, the other has not heard in a while. This resident remembers the efforts students are making to impress and succeed even if they fall short once in a while. The effects of the classroom extend beyond those four walls into the community and clinics. It has the potential to reside within each relationship we have for better or for worse. I refuse to let my education be compromised by those who have forgotten how a patient teacher can influence an eager student.

Question of the Week

A 24 year old medical student admires and begins to pattern her life after her surgical mentor. Which one of the following defense mechanisms does she exhibit?

A. Introjection
B. Projection
C. Rationalization
D. Identification
E. Conscious Control

Answer & Explanation

Things I Wish I Knew - Second Year

It's that time again to take a look at what I've learned from the last year and roll it into a bite-sized post. At first glance it may not seem much different than last year's report, but with a side-by-side comparison I'm surprised I am alive to tell the story.

Looking Back

Somewhere between peaked exam weeks and the troughs of vacation, I actually found time to breath. For what it is worth I have learned a few things along the way and would love to hear from others what you have gleaned from your experience. Without further ado, he is my small list of things I wish I knew before my second year of medical school.

1. Proper repose - Some people have a knack at getting sleep and lots of it. I have never been that fortunate, but learned that a regular sleep schedule was important to staying on task during the day. I must admit though, there were days when I just had to find a spot on the floor and take a quick nap. If only our brains could burn as much energy as a full workout, now then I would be set. Make sleep a habit and take short naps when needed.
2. Staying current - I am still convinced some professors do not communicate with the others and actually understand how much information is being thrown at us. Letting too many lectures and reading assignments go unattended can lead to undue stress before exams. Pacing is crucial to really understanding the concepts despite how well you "cram." It might be difficult, but getting things done now will save the pain of not having it done later.
3. Two heads are better than one - Normally, I am not one to study in groups, but I have found this to be fundamental to my success in medical school. Where I misunderstood a point or did not have the background knowledge to comprehend, my study partners were often able to fill in the blanks. And for all those times when the stress really got to me, a quick game of HORSE was sure to do some good. Study partners help you understand what you do and do not understand really fast, get some.
4. Practice makes perfect - After being in the classroom for so many hours, it is easy to lose sight of why we are there in the first place. For some of us, it really is about helping the patient. Be sure to take advantage of opportunities that permit exposure within the community. These help make the light at the end of the tunnel a little brighter along with gained experience in practices you may intend to be doing for the rest of your career. Be an active participant outside of the classroom.
5. Surmounting the challenge - Without hesitation, I can honestly say this is the hardest thing I have ever done. Having said that, it is also one of the most rewarding. High stress conditions, little sleep, poor exercise, sparse family time and a constant query of knowledge has kept me on my toes much longer than imagined. The best part is that it is fulfilling a goal that I have had for so long, which makes it all worthwhile. Take time to enjoy one of the more difficult hurdles life has to offer.

On another note, if you are interested in what other students are saying about their experiences, my Life as a Medical Student has been showcased along with theirs in this list of 42 Medical Blogs Written Entirely by Med Students.

Board Prep Question of the Week

A 3-year old child has dyspnea, severe cough, and a fever. A chest X-ray and laboratory tests lead to a diagnosis of Pneumocystis jirovecii pneumonia. Further laboratory tests indicate abnormally low levels of the IgG, IgA, and IgE immunoglobulins. However, levels of IgM are far above normal. This patient's immune deficiency is caused by a defect in which cell surface molecules?

A. CD40 ligand
B. CD86
C. Fas ligand
D. TCR
E. TNF receptor

Answer & Explanation

Second Exam Week Six

Now that our classroom career is over and the last set of exams are here, it is time to study. Fortunately for us, the first tests last week were in Osteopathic Manipulative Medicine. This meant one good corporal realignment before a week of uncomfortable postures and mental torture.

Final Adjustments

"...Take a deep breath." I then waited as my study partner dropped his weight on my upper body and we both felt the audible release of a vertebral segment that was misaligned. In no time the pain was gone and we moved on to continue our studies. As this was our last set of exams, we had the task of performing a full body evaluation and applying a specific treatment of our choice aimed to restore function. Since we were successful in treating each other in practice, our partners the next day had little to correct during the test. I think I am going to miss these little "corrective" sessions.

The thought of being finished with school is really exciting. It doesn't take long, however, to remind myself that as soon as this week is over, it will be time to dig deeper in preparation for board exams. (So much for having a vacation between school and rotations.) One thing is for sure, this experience has been so much better than I could have ever imagined. Sure, it has been difficult, but it continues to pique my interest and lift my thoughts to a better future.

Board Prep Question of the Week

A 13-year-old figure skater botches a quadruple lutz and falls on her right outstretched hand. Several weeks later a cast is removed for a healed scaphoid fracture. She begins having episodes of intense burning pain, sweating, swelling, and redness that begin in her right hand and moves up her forearm, sometimes up to her shoulder. These episodes often occur when she is angry or upset. On exam her arm shows no visible abnormalities. Which of the following nerve types are involved in the pathogenesis of her disorder?

A. General somatic afferent
B. General somatic efferent
C. General visceral afferent
D. Special somatic afferent
E. Special visceral afferent

Answer & Explanation

Medical Fraud

This posting comes as the 100th, marking almost 100 weeks since being accepted to medical school. Time has gone faster than I could have imagined. Thankfully it wasn't any slower!

Never Give Up

With Spring Break around the corner, professors have scheduled quizzes and midterms to query our knowledge. Normally this is not a problem, but with a block only four weeks long, there is a lot of information to cram in there. As a result, after last weeks barage of graded interrogations and late nights, I was flat out exhausted. Thinking I was the only one having difficulties focusing and reviewing materials, I didn't say much to my peers. A few days later I was surprised to learn that the majority of us have had similar experiences.

I have heard this called the impostor phenomenon. We feel as though we are the only ones who are not pulling our weight, making advances, or in plain terms...frauds. It is not until we see our achievements and learn that our peers are in the same position that we begin to feel a sense of belonging. Now that I know I am not alone, or at least the only fraud in the class, it's time to get ready for the exams next week. Medical school is relentless - if it's truly where your heart is, you have no reason to give up.

Board Prep Question of the Week

A 25 year old from Massachusetts complains of increasing fatigue and pre-syncope. Upon further questioning, he admits to having had a rash on his arm a couple of months ago. He denies joint pain, photophobia or a stiff neck.

An EKG is taken which shows 3rd degree heart block (complete heart block). His laboratory tests are within normal limits. Blood cultures are pending.

What is the most appropriate treatment?

A. Ceftriaxone
B. Doxycycline
C. Implantable defibrillator
D. Penicillin G
E. Rifampin

 Answer & Explanation

Cranial Osteopathy

A unique component of Osteopathic medicine, osteopathy in the cranial field, aims to treat the structural dysfunctions of the skull through manipulative techniques.

Osteopathy in the Cranial Field

Whether due to birth trauma, accidental injury, or abnormal strains, insults to the head can cause anyone distress. The cranium has numerous bones that move in an organized fashion to maintain optimal health. Like a dislocated joint, when one of these bones is forced out of alignment, somatic dysfunction ensues. This may present in the form of headaches, sinus congestion, neck pain, agitation, vertigo and a host of other complaints.

Initially difficult to comprehend and palpate, cranial alterations are smalll displacements of bones within the skull. Through diverse techniques the trained practitioner can treat everyone from neonates to elderly. As a student I am excited to be able to palpate the cranial rhythmic impulse (CRI). Apparently it can take hours and days before the CRI is appreciated. Despite making a step in the right direction, I find the cranial methods difficult to employ consistently as a beginner. Forty hour courses are available for extensive training, but the way tests keep coming my way, I don't think there will be much time to dedicate to this detailed study. For those who may be interested in learning more about this treatment The Cranial Academy has set up a website with course offerings and more.

Board Prep Question of the Week

A 50 year old woman with a history of headache presents with complaints of chest pain. She described the pain as pressure, and tightness in her chest. She said that the pain occured after taking a drug, the name of which she forgot. The most likely mechanism of this drug is:

A. Antagonist action at serotonin receptor
B. Agonist action at serotonin receptor
C. Release of nitric oxide
D. Inhibition of calcium channel opening
E. Decreased levels synaptic levels of catecholamines

Answer & Explanation

Second Exam Week Four

Thanks to the help of a few classmates, I came across an understandable metaphor for medical school. It might go down well, but the repercussions can be awful.

Pancakes

Eating pancakes is not normally considered a difficult task and may even be quite enjoyable. Equating five pancakes to a day in school does not seem like much to swallow. From day one you know that is all they ask you to do, eat your five pancakes a day. Things get tough when you decide to put off what you could have done today. As one of my classmates said while preparing for our exams last week, "Eating two weeks worth of pancakes in one night. Can't wait to regurgitate them tomorrow."

It is definitely a feasible task, but along comes all the distractions and enjoyments of life outside of school competing for that pancake eating time. Do we grab a fork or find that comfortable spot in front of the TV? Decisions, decisions... One thing I know for sure, this last week was one of the hardest yet and I couldn't be happier that it is behind me.


Board Prep Question of the Week

A 20-year-old female sees her physician for diarrhea and fatigue with a 20 pound weight loss over the past 6 months. On exam, she is afebrile and has mild muscle wasting, but her strength is normal. Stool studies do not reveal blood, ova, or parasites. A biopsy of the jejunum is taken and microscopically reviewed. The patient is placed on a special diet with no wheat or rye products. The change in diet produces a dramatic improvement. Which of the following microscopic features is most likely to be seen in the biopsy?

A. Crypt abscesses
B. Foamy macrophages within the lamina propria
C. Lymphatic obstruction
D. Noncaseating granulomas
E. Villous blunting and flattening

Answer & Explanation

Kidney Health

The latest installation of my Objective Structured Clinical Exams are now available. With practice, I felt much more comfortable and actually proved to be more efficient in my use of time. Although we will continue to have simulated patient encounters, our study of body systems is not yet complete and continues to flow...yes, cheesy pun intended.

Nephrology

It always seemed a bit confusing to have a urologist and a nephrologist until just recently. The former bases their practice on gross structures and specializes in surgical interventions while the later concentrates on the medical aspects of kidney disease. The smallest functioning unit of the kidney is called a nephron, to think there is a doctor who focuses a career around this structure is mind boggling.

When we started learning about the detailed pathology of nephrons and the kidneys it became clear why these specialized physicians exist. The kidneys are critical to our survival as they filter our blood. When malfunctioning, numerous other body systems are affected leading to a patient's compromised health status. The field of nephrology has not drawn great appeal from my side of the table, which is likely due to the fact that I have not yet come to a solid understanding of the material. Who knew such a small part could be so complex?

Board Prep Question of the Week

A 42 year old black woman presents to clinic complaining of swelling around both her eyes. The patient also adds that she recently has been only urinating twice a day which is much less than her usual. Further questioning reveals a few months history of subjective fevers, malaise, and non-focal arthralgias. Vital signs show a low-grade fever and a blood pressure of 155/90. Urine analysis reveals moderate proteinuria (3g/day) and RBC casts. Blood tests reveal a hemoglobin of 9.6g/dL, BUN of 29mg/dL, and a creatinine of 2mg/dL. What is the most likely cause of this patient’s symptoms?

A. Glomerulonephritis caused by anti-GBM antibodies
B. Congestive Heart Failure caused by uncontrolled hypertension
C. Glomerulonephritis caused by immunocomplex deposition
D. Glomerulonephritis caused by T-cell production of cytokines
E. Nephrotic syndrome caused by immunocomplex deposition

Answer & Explanation

Medical Diagnostic Lab

In an effort to broaden the scope of clinical understanding, each student provided urine specimens for gross and microscopic urinalysis. I felt rather fortunate to only find calcium oxalate crystals, a sign of dehydration. Considering the alternatives, it could have been worse.

Lab Diagnostics

The new, and last classroom, semester has begun and we are starting with an all encompassing look at the endocrine and renal systems. The two converge when considering the hormones involved, or the lack thereof. Our laboratory diagnostics course is intended to provide exposure to the procedures that are routinely performed when samples are needed (e.g. phlebotomy) or obtained. Despite knowing there will be staff who commonly accomplish these tasks, it is important for us to have an understanding of the protocols involved. Besides, how often do you get to analyze your body chemistry anyway?

The results of collecting various samples from wounds, vessels and orifices will be the determining factor in the care we provide as clinicians. Having a solid understanding of the results could very literally mean the difference between life and death. I will admit that there are so many values and tests that it can become overwhelming for the beginner, but in due time it will be second nature. Until that time, I intend to take a drink from the fountain at every opportunity, at the very least to protect my kidneys.

Board Prep Question of the Week

A 45 year old male presents to the Emergency Department of his local hospital coughing up blood. He reports a history of a dry cough for the past couple of months, but this is the first time that he has coughed up any blood. He denies any smoking history. On further questioning he notes that he has had episodes of blood in his urine recently.

A metabolic panel shows:
Na: 140
K: 4.9
Cl: 105
HCO3: 25
BUN: 30
Cr: 1.9

Urinalysis shows blood 2+, protein 1+, neg leukesterase, neg nitrites
Urine microscopy shows red blood cell casts

A kidney biopsy is taken and is stained (above). What is being stained in the slide?

A. Anti-glomerular basement membrane Ab
B. c-ANCA
C. C3
D. IgA
E. p-ANCA

Answer & Explanation

Objective Structured Clinical Exam

Despite the likelihood that I am actually making a fool of myself rather than providing a form of enlightenment, I have posted my personal OSCE experience for your viewing pleasure.

Medical Training

In preparing for the exam, I searched the internet for similar scenarios and was surprised that there are no amateur versions around. Perhaps that makes this the first student version available to be mocked, ridiculed and berated. It is in no way flawless, especially since it was our first OSCE experience. Nonetheless, I rather enjoyed the opportunity to "act" the part and play diagnostic detective if only for a few minutes.

For this exam, the patient was assigned to have strep throat, so it makes me chuckle in embarrassment that I submitted him to the Romberg test. In my defense, I was trying to stall with the last couple minutes to make sure there were no other exams I wanted to perform. Once we leave the room, early or not, we are not permitted to return. Fortunately, my assessment and plan were on target with the premeditated ailment.

Anxiety driven exams certainly test us under pressure, and we tend to make irrational decisions as a result. I did not have enough time to test for somatic dysfunctions as I ran out of time. If I was better prepared, I could have finished the physical early with a few less tests in order to leave time for the SOAP note. Not realizing how long the written portion would take, I learned the hard way that 9 minutes is not much time at all.

In time I have learned to hone in on the critical findings and tests to maximize the use of my time. The SOAP note information rolls out of my pen with greater fluidity and I now have a little more confidence than is portrayed above. At least this was an educational and preparatory experience, the real thing this early in the game could have been much worse.

Board Prep Question of the Week

A 48 year-old female presents with progressive shortness of breath and anxiety. She has no notable prior medical history, and on physical exam, auscultation reveals an opening snap over the cardiac apex followed by a mid-diastolic rumble. The most common cause of her disease process is which of the following?

A. chronic hypertension causing dilatation of the left ventricle
B. repeated attacks of Streptococci causing valvular lesions
C. primary pulmonary hypertension causing atrial dilatation
D. a congenital atrial-septal defect causing chronic hypoxemia
E. a congenital bicuspid valve causing increased afterload of the left ventricle

Answer & Explanation

Medical School Training

Fortunately, medical school is not solely based on bookwork. Labs are intended to solidify the knowledge we get in class and clinical experience are used to tie everything together. This last week we had our first patient encounter.

Objective Structured Clinical Examination

Also known as OSCE, this course provides patient encounters by local actors who give us an opportunity to experience patient clinical interaction. The session can be monitored and recorded by faculty to help the medical student hone in on the challenging aspects of their experience. The exam rooms are equipped with everything we would need to perform a basic exam and we are timed to simulate the practical exam two years from now.

I enjoyed my first OSCE experience as it took me back to my days as an EMT gathering a medical history and executing a physical exam. For the purposes of OSCE, we performed a brief history and physical in 12 minutes to be followed up with a 10 minute SOAP note documentation of the encounter. Overall, time went much faster than I expected, hence the reasoning behind preparing us well in advance for this important exam.

This unique part of the curriculum is used to help us develop an understanding of patient communication, the importance of a complete history, and proper clinical examination. All these points are reinforced by the documentation of our impressions and plan. It is essentially an "ice breaker" into the rest of our career. For now, I think I am still afloat.

Board Prep Question of the Week

A 72 year old woman presents to her physician with the complaint of loss of vision. Visual field examination reveals anopia of her right upper quadrant visual fields bilaterally. What is the most likely location of the lesion responsible for this defect?

A. Left optic nerve
B. Left parietal lobe
C. Left temporal lobe
D. Right optic tract
E. Right parietal lobe

Answer & Explanation

Medical Training

We are slowly making progress through the body systems and their related pathologies. Fortunately, the curriculum is set up to permit a significant overlap in material so that most courses are reinforcing concepts of an important nature. This repetitive exposure has been helpful to build working knowledge of how differing subjects can contribute to a comprehensive understanding.

Medical Program

All of our courses, during the second year, relate in some way to the health of the human organism. The learning process at Touro Nevada has been made simpler by combining topics from the multiple courses to coincide with one another to some degree. For example, this week in Pharmacology we covered Non-steroidal anti-inflammatory drugs (NSAIDs). At the same time in the Clinical Systems course we learned about various rheumatologic diseases that employ the use of NSAIDs to treat symptoms. Additionally, the Osteopathic Manipulative Medicine staff presented lymphatic treatments that could be used to aid in the recovery process.

The combined efforts of each course is to develop a well-rounded understanding of the approach to various body systems. So while studying for one class, I am equally reviewing material for another. The pieces of this "human puzzle" come together quite nicely to paint the whole picture.

Board Prep Question of the Week

A 40 year old female presents to her physician for worsening joint pain. She has had joint pain for many years in both wrists, MCP joints, and PIP joints. Her DIPs are spared. Her pain is always worse in the morning and improves as the day goes on. Lately she realizes both knees also hurt her and she is more tired than usual. Examination reveals her painful joints to be mildly warm and her PIPs are flexed, while her DIPs are extended. Laboratory testing reveals high titers of rheumatoid factor (RF), an elevated ESR and C-reactive protein, and a normocytic normochromatic anemia. Examination of the synovial fluid at the involved joints would most likely reveal which of the following?

A. Clear fluid; 125 WBC/mm3; 20% PMNs
B. Clear-yellow fluid; 1,800 WBC/mm3; 20% PMNs
C. Cloudy-yellow fluid; 6,000 WBC/mm3; 60% PMNs
D. Turbid, purulent fluid; 50,000 WBC/mm3; 80% PMNs
E. Reddish fluid; 1,500 WBC/mm3; 20% PMNs

Answer & Explanation

Pathology Education

The second year of medical school certainly has a lot of information compared to first year. Fortunately, it is focused on the pathological abnormalities, which make learning the material much more fascinating. [Image provided by the National Cancer Institute]

Pathology

This field of study often associated with autopsies and coroner's investigates both the abnormal macroscopic and microscopic findings in anatomical tissues. Learning a subject that takes years to master is quite a challenge for the novice pathologist.

It has been difficult to narrow my study of the subject as there are so many sources to pull from. The professor has his way of disseminating the information and pathology review books are quite different from that style. I have learned that with more exposure to the subject, the better it falls into place. As with anything, repetition is bound to make a connection sooner or later. Since there is a grade at the end of all this, in this case I am hoping for sooner.

We started the year with cellular pathologies and more specifically when cells get out of control. One of the leading concerns today is cancerous growth whether on the skin, in an organ or rampant throughout the body. Although I certainly do not have a cure for it, I am just starting to appreciate what causes cancer and how it is manifested. Often times it is the result of a genetic deviation from normal that no longer suppresses rapid cell growth. However, there are environmental factors that contribute to the development of cancer too.

Examples of carcinogens include UV light, occupational chemicals, and even hormones. We are exposed to them in various amounts depending on our habits, environments and genetic vulnerabilities. There is little that can replace healthy eating, regular exercise, and minimal carcinogenic exposure. So until next time, don't get too much sun and stay away from those asbestos infested workplaces; it could mean the difference between life and death.

Clinical Corner

Asbestos Exposure

Despite workplace safety measures, exposure to asbestos has been linked to mesothelioma, a malignant cancer affecting the lining of the lungs and/or abdomen. Where pleural mesothelioma can cause difficulty breathing due to fluid in the lungs, peritoneal mesothelioma affects the intestines causing weight loss, pain, and fluid accumulation in the abdomen. The latter is also associated with bowel obstructions, anemia, and fever.

It is most commonly seen in individuals who work closely with asbestos or their families, but may not be symptomatic for years. Mesothelioma is diagnosed by a pathologist who obtains a biopsy for histological examination. It is treated by surgical removal of the organ involved, radiation or chemotherapy. It is difficult to treat and therefore has a poor prognosis. For this reason there are clinical trials being performed in an effort to find better outcomes.

Neck Pain Treatment

One highlight for osteopathic medical students is obtaining hands-on training in Osteopathic Manipulative Medicine (OMM). Cervical spinal manipulations are among the most anticipated of techniques and thankfully have successful outcomes.

Neck Therapy

With the Hollywood stigma and the spine tingling sound of cracking, it is no wonder that we have had to wait this long to learn the mechanics associated with such treatments. As students we are just as nervous performing the technique as we are to be the patient on the table. The risk of severe damage is reported to be rather low, nevertheless, attention to properly performing these treatments is critical.

There are numerous resources available for learning the art of OMM and the American College of Osteopathic Family Physicians' website outlines a few of the more common treatments performed by osteopathic doctors. Although it is needless to say, there is more available than we students have time to consume. After learning it in the lab, we have to take it upon ourselves to make the time to practice our new skills.

In cases of somatic dysfunction, when a diagnosis is obtained, a trained DO can perform these treatments which relieve unnecessary pain and muscle imbalance. Because it is so sensitive, the neck can have a significant amount of dysfunction. Osteopathic cervical treatment is a quick way for the patient to find relief from their symptoms, and it is an enjoyably unique part of most osteopathic medical students' curriculum.

Bicycle Transportation

We've only had three days of class and I already feel behind in my work. Between previewing lecture notes, reviewing lecture notes and reading the texts, I seriously wonder if I will have enough time to do anything else. At least getting to and from school will now be beneficial in relieving some of that stress. Check out my new wheels!

Scheduling Overload

Somewhere between the end of first year and the start of second year I lost a lot of important information mentally. As we cover certain subjects again, I can feel that sense of lost recognition. The professors certainly did not wait to open the flood gates and started in full force. After pharmacology and pathology were introduced, I felt my time would be well occupied. But it didn't stop there, they tacked on behavioral medicine, medical microbiology/immunology, clinical systems, osteopathic manipulative medicine (OMM), and objective structured clinical exams (OSCE).

On top of all that, I plan to squeeze in time for work-study in the anatomy lab, tutoring, several interest groups of which I'm an officer for two, and act as a "big sib" to a couple of the first year students. I smell burnout in the near future.

Stress and Anxiety Relief

In an effort to reduce some stress and use my time efficiently, I purchased a great bike at a great price thanks to Craig's List. Last year, I was in the worst shape of my life due to classroom inactivity. I'm hoping this year will be different. Amid the busy schedule, I don't see a whole lot of time for exercise and plan to ride my new bike to school instead of taking the car. Surprisingly, it takes almost the same amount of time to travel due to an abundance of traffic lights. At least this way I will be getting some movement into my otherwise sweat-less chair routine and burning useless calories in the process.

Kidney Health

What do acids, bases, filtration, resorption, and secretion all have in common? If the title and image have not already given it away, they are crucial components of the kidney's functioning.

Renal Physiology

From that glass of lemonade to micturition, we have most recently explored the kidneys down to the smallest functional unit, the nephron. Understanding how it all works can be complicated and at times convoluted (pun intended...for those who are kidney junkies). Fortunately, the internet is full of wonderful teaching aides and notes on the subject.

• Kidney Function - Flash tutorial that shows the absorption and secretion of various substances
• Mechanical Nephron - A digital video approach from the University of Hawaii
• Drawn Physiology - A collection of visual mnemonics

Although they are somewhat daunting, kidneys make sense, if studied enough. "Where sodium goes, water follows," and with that little phrase you have a lot of the kidney solved. Just make sure there is enough water in the system to begin with.

Clinical Corner

Hydration

Our bodies are composed of a majority of water, yet we don't replenish it often enough. Drinking 2-3 liters of water each day is a difficult task, but when we lose so much throughout the day it is important to replace it in order for our bodies to function properly. "Pee pale" is a suggested line that implies getting enough clear fluids so that the urine is less concentrated. This ensures a well hydrated body that can filter waste products, run vital molecular reactions, and maintain optimal health. So the next time you are about to order a fountain drink, get a water instead, your body will thank you.

The Immune System

Perhaps the denouement is behind us and we are finally on the down turn of coursework for the year. Getting out while the sun is still in the sky and having understandable lectures is a nice change for the new spring season.

Immune System

We have started our coursework in Immunity which at first seems a rather simple subject. It's not until you learn about the variability and diversity that exists when it becomes very complex. Sometimes I wonder why my immune system is just not performing so well. Does anyone know how to treat chronic rhinorrhea? Perhaps when school is out it will cure itself.

The immune system has many components that together provide a healing response to invasions. Having a good knowledge of individual parts will simplify the learning process of understanding how they interact to function efficiently. Although it is good fun learning how it all works, experiencing this process is anything but fun. Fortunately, vaccinations are available to help ward off possible infections.

Resistant or mutant strains of viral and bacterial organisms can prove to be chaotic. The common cold and flu are results of this phenomenon as well as more serious illnesses. Despite our best efforts to enhance the immune system with pharmaceuticals and exercise, it will still have the occasional bout of weakness leaving us in the proverbial pits.

Creative minds have made a variety of infectious agents available for purchase with an added sense of comfort and wit. Check out these giant microbes.

Clinical Corner

Antibiotics

Physicians prescribe antibiotics to eliminate infection. A growing concern is the resistance that develops when patients do not finish their prescribed antibiotic regimen or take it as prescribed. (Some of the bacteria that is not killed may not be susceptible to the specific antibiotic.) This leaves a window of opportunity for bacteria to alter its response to drugs creating a new strain that is more resilient. If this continues to occur in the general population, antibiotics may not work on general infections causing severe complications in public health. The moral of the story, take your antibiotics the way your doctor prescribed them.

Starting Refreshed

The taxes are filed, financial aid has been requested and the groceries have been purchased. It sounds like spring break has been a success, not to mention sleeping in once or twice.

Back to School

It was hard to stay away from the books for a week knowing full well that the next six weeks will be building upon previous information. Gearing up for the last block of the first year of medical school has taken some effort as the tank of enthusiasm was reading empty.

Fortunately, the last set of exams went well and only one exam week remains. We are on the verge of starting two new subjects Renal Physiology and Immunology. From my understanding both are rather challenging subjects. I will take their word for it as I have learned professors know how to pack a lot of information into a few weeks of lecture.

Clinical Corner

Sleep

Sleep, it does a body good. Sleep disorders can make getting the rest you need very unpleasant. Circadian rhythms help to cycle our sleep patterns which induce relaxation and waking affects. No less than 7 hours of sleep are recommended to maintain optimum health and cognitive functioning. Thanks to spring break, I think I am back on schedule.

Technology and other methods are available to help individuals who suffer from the lack of a good night's sleep. If you are having trouble sleeping or getting your child to sleep, check out the Marpac SleepMate and the Conair Sound Therapy Clock.

Problem Based Learning

Like something out of an episode of "House MD", our first year medical class broke up into small groups to make our attempt at a clinical case.

Problem Based Learning

I was a little unprepared when I was chosen to be the group leader for our first case. We were asked to develop questions and an organized method of investigating a case to obtain a history and physical. Fortunately, we had a faculty physician to guide our steps in the right direction or it may have taken a lot longer to get to the treatment.

Although these are simulations, it is a great way to see how our knowledge base has advanced. The clinical skills may be lacking, but we can still apply diagnostic tests, reasoning, and questioning skills to build a case and develop a differential diagnosis.

Every couple weeks we gather again to work another case and hone the skills we will need next year when we have patient actors. Although House may be make-believe, the process of getting to a working diagnosis is still a matter of clinical processing. It is going to take a lot of practice before we feel comfortable in that position. If you have suggestions in collecting a patient history, SOAP notes or other case building ideas, please leave them in the comments below.

Clinical Corner

Hygiene

One of the easiest ways to avoid illness is to wash your hands often. It takes little time and avoids the frustration of becoming sick.

Powerful MRI

In conjunction with our Neuroscience coursework, we integrate the use of radiological imaging to visualize cranial structures as this is how we will see them most often. As seen in the image, technology is advancing quickly permitting greater medical flexibility.

Radiology

After spending the past few months learning the anatomy of the brain, we had guest lecturer Dr. William Orrison, Chief of Neuroradiology from the Nevada Imaging Center, present on neuro-imaging and research. He was the first individual to be scanned with Toshiba's 3T MRI and is currently researching the extent of its capabilities.

The 3.0 Tesla MRI detects 320 lines of data with one turn making it quicker than older devices. Imaging studies use less contrast and produce data that is more detailed than previous machines. With all the data this powerful machine collects, 3-D images can be produced as well as dynamic motion of anatomical structures, diffusion tensor imaging (shown above), and angiography. Shortening scan times from one hour to a matter of minutes and data interpretation to a few minutes time makes this machine the new standard of care.

Despite its arrival last year, this new MRI is being used around the world to change the way physicians use diagnostic imaging. It is an exciting time to be in medicine and especially as a student. The tools of our generation will be vastly different from those of former professionals and I am certain that within the next few years advances will continue to come about, ultimately revolutionizing the practice of medicine.

Clinical Corner

Cerebrovascular Accident

A CVA or stroke occurs when the brain tissue losses blood and nutrient supply. This is similar to a heart attack and is sometimes referred to as a brain attack. Commonly this occurs as a result of blood clots that block blood vessels to certain parts of the brain. Neurological deficits result that give an individual indications that medical care is needed. There is a small window of opportunity for physicians to medically intervene and such symptoms should be treated as emergent. Diagnosis includes the use of radiological imaging to confirm the presence of a stroke. Imaging techniques may also be used to treat or remove stenosed or blocked vessels.

The Brain

Did you get all that? I'm still working on it myself. Neuroscience is one of the dreaded courses in medical school for good reason. We are only beginning to scratch the surface.

Neuroscience

The brain is complex, period. Pinky and the Brain make it look so easy, but keeping all the information in my head is another story. For what it is worth, they are certainly keeping us busy memorizing structures and knowing how they function.

It is amazing to think that for most of us, during our developmental stages, all the nerve fibers make it to the right location to perform their proper functions. There are so many connections, tracts, and pathways that the brain is not completely understood.

Clinical Corner

Healthy Brain Development

Unfortunately, proper brain development is not always the case and severe deformities or neurological deficits may occur. Many factors contribute to poor fetal development such as maternal nutrition, infection, trauma, and genetics. One of the easiest ways to avoid these deficits is for women of child bearing age to maintain a healthy diet. Maternal nutrition often dictates the development of her unborn child and cannot be compensated for after birth in all cases.

The Mayo Clinic lists some foods that pregnant women should avoid while the government sponsored Department of Health and Human Services provides a great resource for nutritional recommendations. As for the rest of us, here are 7 tips for increasing your brain power. For more information on nutrition check out these books.