One Year Anniversary

Well, the Swendiman Family traditions remain intact for one more year, although some have been modified as the years go on. Shelley and I still wake up early, jump on Mom and Dad's bed, and open our stockings. Now though, 9 AM is plenty early. Today, Shelley had to wake me up, and after finding the 'rents puttering around the kitchen, we sent them back to bed so they could pretend to slumber. Then, we burst into their bedroom screaming "Merry Christmas!" and the annual festivities commenced (Mom and Dad even acted surprised as convention dictates). Gone are the days of popping out of bed at seven, anxiously fidgeting by the tree waiting for our 8 AM start time (in those days, we genuinely did have to wake up Mom and Dad, no pretendsies). Now we can't start until we have all have coffee, from Starbucks of course. We go through our stockings, and after more coffee and quick showers all around, we head to the Christmas tree to see if Santa came. This year Santa arrived a bit early: sometime around five in the afternoon of Chrstimas Eve. (The excuse Santa gave was that the weather conditions were looking dicey, and this was a precaution. Also, Santa was tired this year and didn't want to stay up late.). Christmas pictures by the tree and then breakfast. The only omission in our December 25th traditions was visiting Grammy's house after lunch, but I know she is still with us this and every year.

It was a Christmas to remember, and a true joy to be with the fam again this year. I know it may not be long until December 25th is a work day for me. Unfortunately, people still get sick on Christmas day.

There are certain events in our lives that we remember distinctly. Everyone old enough remembers where they were when JFK was assassinated or when we put a man on the moon. I remember 9/11 like it was yesterday. I walked into 2nd period Religion with Father Eck, and the television was on in the east corner of the room. I watched in disbelief as the second plane crashed into the Twin Towers. I remember where I was when I heard I received a scholarship to UNC. It was Friday after swim practice senior year. I heard my Mom's message on my cell phone at the corner of Connecticut and Veirs Mill heading south (right lane, second in line at the light). And of course, I remember where I was (a year ago tomorrow!) when I first got my first acceptance to medical school. I was standing in my kitchen in Finley Forest, holding aloft that sheet of gold from Emory. I grew a couple inches as I read the letter, the weight falling off my shoulders.

A lot has changed in this past year. I've been an EMT, a barista, a world traveller, a pre-med, and now finally in medical school. As a student, I've passed Biochemistry and Anatomy, recorded a rap song about an upper extremity nerve plexus, started the brand new "Health Policy Interest Group" at UNC, and gotten over 1500 on the Helicopter game. But it has been a challenge, in different ways than I expected. Some people I've met have been inspiring, others disillusioning. I've met professors and physicians who are role models, and others who, in my mind, define what not to be as a future doctor. I've spent weeks not opening a book, and weeks where books were never closed. I've laughed, cried, work tirelessly, complained, achieved, failed, rinsed and repeated.

Finally, having a week off being truly free has given me some time to reflect. Having zero responsibilities is a fantastic feeling. It's given me time to smell the roses. When I visited medical schools last year, I observed students coming together and learning in groups, working with physicians in classrooms developing differentials for (made-up) cases. I even got the opportunity to participate in a few of those. I walked through hospitals and watched students interview pateints. On the tours I hearded beepers go off and doctors fly out of the room. These visions made me so ready for third year and beyond, that I forgot about the first two. I haven't stepped in the hospital yet, and the real patients in the clinic I've seen have had either running noses or the flu. I had built up medical school so much in my mind that my dreams could have only been let down. Time off has reminded me, hey, you gotta learn something first, Robby. I think the old addage "See One, Do One, Teach One" was wrong... you have to "Learn One" too. This is something I have vowed to keep in my mind as the year continues.

So I look forward to next semester. Block 3 begins with Physiology (now that I learned what everything is, what the heck does it do?) and Histology (upclose pictures that look like a creative kindergartener drew them - and then we pretend to call it a specific tissue). So let's get it on 2010, and I'm ready to make my New Year's resolutions next week.

Merry Christmas to all, and to all a good night!

One-Eighth MD

So at first I thought I had the "sleeping virus." No, that's not an actual disease, but if eventually it turns out to be real, I certainly won't be the first med student to have ever contracted it. The need for extra rest has gone on for about 10 days, maybe 2 weeks. This week especially; I slept in almost every day. I went to bed around 11 or midnight, and woke up at 9 am. Every day I went through my routine exhausted, and no amount of coffee could wake me up (in fact, it only made it harder to fall asleep later). I ruled out mono and swine flu since I've checked both of those off in college and this past fall, so what's the diagnosis, doctor?

Even though I've been sleeping 9-10 hours a night, it hasn't been good sleep. I wake up every hour or couple hours. But I'm not dreaming about relaxing on warm sand and feeling the cool breeze on a beach in the Caribbean. No, I'm waking up to thoughts of: "facial nerve cranial nerve seven pterygopalatine gland" or "buccinator mastoid stylo foramen alveolar confluence." Usually none of it makes sense. But now I dream anatomy, think anatomy, and wake up to anatomy. There's a pop song on the radio about how some girl is the last thing the singer thinks about at night when he goes to bed, and she's first thing he remembers in the morning. That's my relationship with cranial nerves and head and neck ontology. I think about anatomy all day and then again all night. So I've come up with the following diagnosis: I have "Tortuous Information Requires (too much) Energy Disease," also known by the acronym "TIRED." I am tired, and therefore I need Christmas Break.

It's been a long semester, and much has changed. We have been talking about this change in our Medicine in Society class. Since the middle of August, our family, friends, and even people we've never met, now view us differently. To most parents, we are no longer a son or daughter. We are their sons and daughters in medical school. And there's a difference. Since I've started school, the number of people who have sought my medical opinion has sky-rocketed. I've received texts and emails asking how to determine if someone has swine flu, whether a friend should go to a doctor, how a gun shot to the back can cause blindness, and "Do you think my hand is broken?" My two patients, whom I see through this class (Mr. and Mrs. Jones - Oct. 2nd post), even asked for my advice on how to talk to their physicians, and whether they should be more persistent about requesting more tests. A lot of the questions I get I wouldn't even direct to a resident, much less a 1st year medical student! But as we discussed this with our professor, we found this is par for the course from here on out. From the day we enter medical school until the day we die, we are now part of a different world.

Look at the things we've done. I've disemboweled, mutilated, cut, sawed, and hammered a dead body (illegal in all 50 states). I'm learning how to put in IVs, chest tubes, read radiographs, MRIs, and CTs. Patients tell me the most private information about themselves: their medical histories, their family histories, even their sexual histories. This is just the first four months of school. Imagine what I will have done and what I will learn in the next 7 semesters, and the years to come. It certainly has given me a lot to reflect on over the next two weeks of Christmas break. It is a power that is not to be taken for granted or taken lightly. I'm not a doctor; far, far from it actually. But the past few months have shed light on some of the responsibilities that come with that title. The question is, am I ready for it?

That's why I mean it when I say we are not half way through our first year of medical school. We are "one-eighth MD."

Getting on My (Cranial) Nerves

Next week is our final week of anatomy, and the course directors left the toughest part for last. Right now we are "appreciating" the Head and Neck. Even though this is physically the smallest anatomy in the course, apparently there is a lot of important stuff that goes on up there. I knew that there was the brain and a couple important glands hanging around in the head, but the level of detail is truly incredible, and also slightly stressful. Evolution biting me in the ass once again. In fact, there are 12 cranial nerves that we are committing to memory. Not just memorizing the names, however, we have to know their origin, insertion, what "foramina" (holes) they travel through, what they innervate, and every minute branch. This picture is an example of ONE of the nerves that we need to know. This is "Cranial Nerve VII - the Facial Nerve." Basically I have to imprint 12 of those diagrams into my brain (the actual mechanism of how I am able to "memorize" will be discussed in January).

In order to remember these cranial nerves in order, Wikipedia has supplied us with a number of mnemonics to help us on our journey. Here are a couple of my favorites:

• Oh, Oh, Oh, To Touch A Female Vagina Gives Virgins Amazing Happiness
• O! O! O! There's The Abercrombie and Fitch. Very Gorgeous and Very Adorable! Ha!
• Oh Once One Takes The Anatomy Final Very Good Vacations Are Heavenly
• OOO Truly There Are Five Very Gorgeous Vixens Awaiting Him

I think you get the picture. This stands for olfactory, optic, oculomotor, trochlear, trigeminal, abducens, facial, vestibulocochlear, glossopharyngeal, vagus, accessory, and hypoglossal nerve. Frankly, I think the mnemonic I came up with before I saw all of these wasn't too shabby either:

• Oh, Oh, Oh, Tom Tucker Ate Fried Vegetables Gladly and Vomited Against the House
  

Well, maybe it wasn't that good. But then we have mnemonics for whether these nerves have "sensory" innervation, "motor" innervation, or both (feeling vs. actually moving/doing something). Obviously S = sensory, M = motor, and B = both. Here's what I've got so far:

• Some Say Marry Money, But My Brother Says Big Boobs Matter More.
• Some Say Marry Money, But My Brother Says Big Brains Matter More.
• Small Ships Make Money, But My Brother Says Big Boats Make More.

These are some of the ways you get through medical school tests. By the way, it's that first one in this batch that I've committed to memory. Wikipedia gives such great advice.

The actual dissections have been for lack of a better word, cool. On Tuesday we removed the brain. Literally, we snipped away all the fascia, nerves, and vasculature that connects the brain to the skull, and pulled it out of a human head! In a mad scientist moment, each of us held it in our hands (mostly in disbelief). And it looks exactly like it does in cartoons. All the squiggles (sulci) and creases, they're really there. Pons, medulla oblongata, brainstem, cerebrum, cerebellum... words that come alive right there in your hands. I stood there cupping the squishy organ, staring. It's impossible to appreciate it: the memories, decisions, sensations... this was eighty years of life. Truly the most human part of the anatomy that I have experienced so far. More than the hands, heart, or even the face. It's just another amazing gift that our cadaver has given us...

The big test is next week, and then my first real break in med school. Two weeks back home in DC to read, relax, sleep, and reflect.

Group 4A and Rote Memorization

A couple weeks ago, I wrote about the Anatomy Practical Exam. We walked into the lab with all the bodies laid out in horseshoe around the room. Each had arteries, veins, nerves, or other structures with tiny strings tied around them; or perhaps we found them with a pin piercing through some muscle. We walked around the room silently with a clipboard, writing down the names of these body parts. There was a minute per "question," a total of 40 questions, and 40 loud beeps after time was up at each body.

Yada yada yada. That was nothing. The real fun began today.

This week our practical exam was a group presentation in front of a Professor. Old school European dissection style. Today, we presented the lower limb. There were five compartments: thigh, butt, lower leg, foot, and bones. The four of us (Kiri, Daniel, Eric, and me) pulled out a number from a cup, and we had to point out every single structure in that compartment. I went first, drawing out the number "2" (i.e. the butt, or "gluteal region" is it is more appropriately christened). I had three minutes to spit out all of this gibberish:

"First I want us to remember that we are working within this deep fascia called the fascia lata and you can appreciate the tensor fasciae latae muscle here most superiorly and laterally, then you can obviously see the gluteus maximus, and if you peel that back you see the gluteus medius, the gluteus minimus is just underneath this muscle, and between it and the piriformis you can find the superior gluteal nerves and vessels, putting a finger on the piriformis we can note several very important structures below it and between the super gemellus, most importantly we had the sciatic nerve which turns into the common fibular and tibial nerve as it passes inferior, then the pudendal nerve which passes in and out of the greater and lesser sciatic foramina (and note the sacrotuberous and sacrospinous ligaments, superficial and deep respectively), also we can see the posterior femoral cutaneous nerve and the inferior gluteal nerves and vessels between these two muscles, below the superior gemellus please appreciate the tendon of the obturator internus and then the inferior gemellus muscle below that and of course this flat muscle here is the quadratus femoris, then we need to take a look at the muscles of the hamstring: we have the semimembranosus most medial and then the semitendinosus, and then the biceps femoris with its long and short head, these all make the superior boundries of the popliteal fossa, also remember that these muscles are vascularized by the perforating branches of the deep femoral artery."

A perfect dissection and presentation. Well under 3 minutes. Kiri picked next, and recited the thigh (perfectly). Eric appreciated the foot (perfectly), and Dan got the anterior compartment of the lower leg (perfectly). Then we each grabbed a bone from the leg and presented them to Dr. Gilliland (again perfectly).

"On the foot we need to appreciate calcaneus or "heel" with its calcaneal tuberosity and sustentaculum tali, then see the talus and its trochlea, we have the navicular, the cuboid and the cuboid groove where the fibularis longus tendon passes through, and the 3 cuniforms, metatarsals, and especially note the tuberosity on the 5th metatarsal."

How did we know it so well? Yesterday we all studied individually, then came to the lab at 7pm. From 7 to 9:30pm we drilled and drilled and drilled these dialogues into our head. From there, Dan and Eric and I meandered over the the Health Science Library, where we drilled and recited and read and reviewed what we were going to say over and over and over again. Six pages of material we sat down and memorized, solely for the purpose of spitting it all right back out in the morning. We pointed on each others' legs and feet, and practiced on disarticulated bones. I even dreamed last night of the lower limb. (I'm not joking. I woke up three times last night wondering whether I had mentioned the sural nerve and plantaris - two structures that our body didn't have). And academically, this is the most fun I've had in medical school.

There is no such thing as "quads" or "calves" anymore to me. It's the "quadriceps femoris" and the "gastrocnemius and soleus that combine to inferiorly insert into the calcaneal (Achilles) tendon." Get it straight.

(The picture shows all of Group 4A pulling back an arrow and hitting an imaginary bullseye. That's because we scored a perfect 40/40 on our presentation. Right to left: Kiri Bagley, Eric Golike, Me, and Daniel McMillan.)

Things I'm Thankful For

I drove back to DC on Wednesday to celebrate Thanksgiving with the Fam. This was actually the first year I have even considered not coming home for a few days. It took me five hours to drive up (not bad for the day before a huge holiday, but I prefer the usual four), and if I left on Sunday, it would probably take me about six or seven hours to get back to Chapel Hill. This year I will leave on Saturday, trying to beat some of the traffic and save a couple hours for studying. Ah yes, studying. I went to Starbucks yesterday (Turkey Day), and they had to kick me out at 3 pm because they were closing the store. I have been trying to review the lectures from this week, I sent out my weekly Newsletter to the Health Policy Interest Group members, and I've attempted (to no avail), to find a summer job. To me, this is not an ideal Thanksgiving. However, there is a lot to be thankful for this year. And in the years to come, I probably will be working on Thanksgivings and Christmases. If only people could take the holidays off from getting sick. But here's my list:

• I'm thankful that Molecules to Cells is over. I think I've expressed that sentiment enough.
• I'm thankful that my Medicine in Society class does not argue whether it is derogotory to use the word "lame." Get over it, and stop being lame.
  
• I'm thankful that my roommate has yet to attempt to urinate on my television. I won't name names here, but you know who you are.
• I'm thankful that my Anatomy group is only slightly disgusted when I eat my peanut butter and jelly sandwich during lab.
• I'm thankful for Alice Cullen.
• I'm thankful for Phil the Rapper, who has made my childhood dream of being a hip-hop artist come true. It's a Five Star Nerve, what?
• I'm thankful that entering medical school has gotten me to over 900 friends on Facebook. Make sure to add me, Aunt JoAn... I'm going for a thousand.
• I'm thankful that I am the only one in my class whose laptop has yet to crash and see the blue screen of death (even though there have been a few close calls - oh, and knock on wood).
• I'm thankful for attaining over 1500 on "the helicopter game" during lecture.
• I'm thankful for not playing "the helicopter game" since.
• I'm certainly thankful for pass/fail.
• I'm thankful that now everyone in my class is absolutely sure that they can find the clitoris.
• I'm thankful for email reminders. Otherwise I would never remember to do anything.
• I'm thankful for the rubber duckies that my mother "secretly" puts in my bathroom everytime she comes down to Chapel Hill. Yesterday she found out that I've noticed.
• I'm thankful for Target grocery shopping. I hate you Harris Teeter. Go find some ziplock meat bags that won't break on me.
• I'm thankful for finally getting my first free coffee at Oasis Cafe. Only had to buy 15 regular coffees to get it.
• I'm thankful for Netter's Flashcards.
• I'm thankful for pink scrubs and hipster Thursdays.
  
• And I'm thankful that every time I lose my laptop charger, the ladies at the front desk of the Health Sciences Library don't recognize me, and are willing to search through the lost and found to find me a brand new one.
  

I'm also thankful for my family, friends, the ability to get together to eat in a warm house, and waking up every morning. I'm thankful for the opportunity to go to medical school and the generosity of our cadaver and his family. And I'm thankful for beginning a profession that gives me a chance to live a life of learning and service.

Happy Thanksgiving Y'all!

"All Day Gunner, No More Funner" Robby

Time seems to go by much more quickly these days. Between lectures, Grand Rounds, dissection in the cadaver lab, small group case conferences, extra courses like ICM and Medicine and Society, eating, sleeping, foosballing, going to the New Moon Premiere, going out, shopping for Halloween costumes, meeting people for coffee, shadowing in the OR, running a student organization, making YouTube music videos, Carolina basketball, V/House/The League/Big Bang Theory, watching the Redskins lose, and taking care of odds and ends around the house, there should be some study time somewhere in there. Our test this past Monday featured the Thorax and Abdomen, and unfortunately, I realized that I had just started studying the thorax 48 hours before the exam. The question was, is it possible to learn two weeks of anatomy in two days? The answer?

Epic fail.

The inevitable occurred: I failed an exam in medical school. In my defense, however, I only failed half of the exam. Indeed, I did extremely poorly on the AIMS online exam (under 2 standard deviations below the mean - so not cool), but I did do well on the practical exam. So what does that mean? That means I know the names of the structures, and I know where they are in the body. I just don't know anything important about them. This makes sense though. In the time I allotted to studying this past weekend, I only had enough time to learn the surface details. Luckily, with about 50% of the course complete, I am still well above passing, and am in no danger of potentially devastating consequences. BUT, that doesn't mean changes were not made...

My reaction has been to develop the "All Day Gunner, No More Funner" Robby for these next two weeks as a trial period. Before every class this week, I have gone through the PowerPoints for the next day and taken notes (on Tuesday I had 18 pages of notes before the Unit even began). I have attended the lectures the next day to fill in holes, and I listened to my first Embryology lecture (Zzzzzzzzz). I opened my Netter's textbook. I have memorized all the Netter's flashcards for this block, days and days before the weekend. I invented a way to describe what is beneath the inguinal ligament. I taught prosection. And I've acted like a douche bag know-it-all in the process. I only went to the studio to finish recording my rap because it was scheduled weeks ago. In short, I am an official gunner (for now), and I'm looking for no less than a 100 on the practical and over a 95 on the written exam this unit. Next thing you know I'll be sending out fake study guides to classmates with false information, ripping out pages of textbooks, and pouring coffee on my colleagues' computers.

We'll see how this trial goes. This is a short blog because it's time to get back to studying (obviously, weren't you paying attention?), but I will describe what it's like to be a gunner in more detail when I write over Thanksgiving, and I will undoubtedly share my remarkable exam improvement. Tootles.

The Real Reason I Stayed in Chapel Hill

I could lie. I could say that I chose UNC's School of Medicine for its reputation. I could say that I chose UNC for the balance: number 2 in the country in primary care and number 19 for research. I could say that I came because of the school's commitment to the underserved. It is a public university dedicated to the people of North Carolina. I could tell you that I came here because the tuition was a third of any other school I applied to. Three years in state would cost roughly the same as one year at a private institution. Frankly, it might have even been considered stupid for me to go anywhere else. I could say I stayed for the people, for the weather, for Southern atmosphere, or for any other reason, but all those would be lies.

Because honestly, I came back to UNC because it meant 4 more years of basketball tickets.

And do you blame me? My first UNC Basketball memory: I remember coming back after youth basketball games at the Boys and Girls club, and sitting down with Pops to watch the 1993 National Championship game. My dad had the game taped on VHS. We re-wound the tape all the way to the beginning, and picked out where Carolina played 2-3 zone or man to man, or where a fantastic pick and role was executed. The number of minutes and seconds into the tape were marked and labeled so I could come back to it before the next game and watch where I could improve.

I remember watching Antawn Jamison going up for a dunk, wide open, fast break untouched. And he show-boated and missed it off the back of the rim. I was sitting on my parents bed on a Saturday, and man I was angry. I wanted him benched immediately. It didn't matter that we were up by forty.

I even remember when Serge Zwikker made a three from the outside corner. Sheer ugliness.

I remember Dean, Brad, and of course Roy. I remember 8 and 20, and '93, '05, and '09. My living room is a shrine to the last two.

I remember the entire 2005 season. Coming back to beat Dook in the last 90 seconds of the game. I certainly remember the rebound Marvin Williams got and the And 1 to get us back in the game. Rashad's three. Then holding hands in the Dean Dome with John Sands watching the National Championship game. Winning the National Championship game. Rushing Franklin after the National Championship game, jumping over fires, people standing up and screaming through the moon roof of my sister's 25 year old Mercedes.

Oh, and then we won again last year. Sitting at Top of the Hill... amazing. Overlooking the thousands that celebrated on the street.

So how could I not come back for basketball tickets? Last night, however, was something special. As seen in the picture, Clodagh, Kristyn, Meg and I (left to right) sat in the front row of Section 127. I gave up my Phase I ticket so I could see the contours of Travis Wear's ass as he threw in the ball from out of bounds. Meg's extended family has had these tickets since the Dean Dome opened its doors in 1986. Everyone in the stadium and my phonebook was jealous (probably because I also texted and sent pictures of me on the court to at least 100 people in my phone). I told Will Graves when to shoot, and applauded Marcus Ginyard for his defensive efforts. We weren't even allowed to stand because we were front and center.

It is a totally different experience sitting in the front row. The atmosphere, even against NC-Central was spectacular. Final score by the way: 89-42. It was embarrassing... and I loved every minute of it. Thank you, Meg. That was a once in a lifetime moment for me. This is why I came back to Carolina.

I'm a Tar Heel born, and I'm a Tar Heel bred. And when I die, I'll be a Tar Heel dead.

Identify the Structure... Ready BEEEEP!

I can't remember the last exam that I've been excited for. A fourth of our class stood outside the doors to the Anatomy lab, apprehensive for our first "practical exam." Armed only with a pen and clipboard, this exam wouldn't be multiple choice. An anatomical structure would be "pinned," and you either knew it, or you didn't. Dr. Kernick and Dr. Gilliland split the class in half and led us into the room, single-file and in two lines. We walked next to our buddy, like elementary school children on a field trip. Through the double doors awaited 20 bodies arranged in a horseshoe, each tagged with different muscles, nerves, veins, arteries, or other anatomical structure. Stepping into the lab, we left our buddy and each found a station. 40 structures, 40 students. Each body had 2 structures to identify. I began in the middle of the room, on the superior medial interior aspect of the horseshoe (there's a little anatomy humor... in English, I was at the top of the horseshoe). We would have 60 seconds to identify the body part and write it down on our answer sheet before time was up. A countdown on a television ticked off the seconds before a piercing BEEEEP! From there we moved clockwise around the room, until we ended up where we began. Once that minute was up, we couldn't go back to look at the body. The exam would be over. I began at #26.

"Once you've identified the structure, legibly write your answer on the answer sheet. If you finish early, wait til the minute is over before moving to the next body."

I looked at #26 the moment I stopped next to the body. The man was lying on his back, with towels covering his arms legs and face. His chest was exposed. Earlier in the class, we had made an incision down his chest and abdomen, beginning at the sternal notch, down past the navel. From there, we made three horizontal cuts from the midline to the midaxillary line laterally: one near the sternal notch, one at the bottom, and one about halfway between. We slowly pealed the layers of skin, fat, and fascia laterally, exposing the thick muscles of the chest. Delicately we exposed the muscles of the scapula, anterior shoulder, and chest. The instructions for #26 simply read, "Identify the Structure." With the skin pealed back, I could see the large pectoralis major. But it too was reflected, and a smaller muscle just underneath lay atop the rib cage with a tiny little pin in it. I wrote the answer for #26 even before the exam began. Pectoralis minor.

"Remember, spelling doesn't count, but we aren't going to guess at your answer."

Good. I can't spell "zygapophysial joint" anyways. Actually I think it's an "e" at the end there, not an "i," but I had to look it up on wikipedia to correct myself.

"Any questions? No? Good. Let's start the countdown. 3, 2, 1, BEEEEEEP."

I used that first minute to take a deep breath. I took the paper exam about an hour earlier, and I thought it was actually pretty tough (it certainly wasn't as easy as the practice exam, surprise surprise). On the multiple choice test, it is not simply identification. A question might ask about what nerve innervates the muscle that allows the arm to abduct and extend from 90 degrees to 180 (serratus anterior). Or if the thumb can no longer oppose, but can still be involved in flexion, extension, and adduction, what muscle no longer has motor function? (Opponens pollicis). But there was no time limit per question, and I could always flip back to a question later, looking through the rest of the test for help. Not here. 60 seconds. That's all I get before I have to give up and move on. So I took another deep breath.

Looking around the room, most of my fellow classmates showed similar eagerness, first structure already identified. Others had their nose about an inch away from the flesh, making absolutely sure of their answer or looking for some insertion or origin. Some were trying to peer across the body to see which structure the classmate across the body had to identify. As the time ticked down, I looked up at the Amit across from me. BEEEP. With a quick wink we parted in opposite directions. #27. Easy. Radial nerve. BEEEP. #28. Cross-section. Serratus anterior. BEEEP. Rest stop. Another deep breath.

There were three stations around the room designated "rest stops." Here, you get a minute off to collect your thoughts, finish scribbling any notes you need to, and take a break. I would have rather had one of these towards the end (before the test, I was about as impatient as a ten year old Christmas morning). Slowly but surely I made it around the room in one full loop, with only one structure I had literally no idea what it was (Damn you Netter's flashcards for not identifying the inferior glenohumeral tuberosity!).

"Pens down and pass in your answers. Congratulations! You just finished your first anatomy practical."

And that's why I love Anatomy.

Med School Tomfoolery - "5 Star Nerve"

In an effort to lighten the medical school gloom and doom, I decided to write a "medical school rap." Yesterday while learning the brachial plexus, a complex bundle of nerves that split and merge and divide and rejoin multiple times in the shoulder and upper arm, I put together a little breakdown of each nerve and what it does. My glorificaiton of the brachial plexus is dubbed "5 Star Nerve," a parody of Yo Gotti's "5 Star Bitch." Go ahead and download the song if you'd like to follow along (you can also find it on YouTube), or just read it as a simple poem. One of my fellow first-years (Ronnie Milam) and I will lay down this track on mp3, hopefully sometime next week. There probably won't be a music video parody on YouTube for this one unfortunately, but no worries! The next rap remix we do (for next year's incoming class - Orientation 2010) will be video taped, edited, and special effected for your viewing pleasure. Until then you'll just have to do with this one. I'll post a link to our version on the song once it's recorded. DJ MS1 aka the White Lightning is back...


[Intro]
Yeeeeeah, yo I’m looking for a 5 star nerve you know, I’m talking about something I can break down for you real simple like, something like this…

[Chorus]
If you got that C-5,
In the arm and its high,
Innervatin up and down,
Plus other muscles on the side,
Then that’s a 5 star nerve,
Yeah it’s a 5 star nerve,
I need a 5 star nerve,
See this 5 star nerve…

[Verse 1]
Yo you gotta start with them roots, C-5 to T-1,
And you’ll end up with the branches when it’s all said and done,
Man it sounds really tough, why learn the brachial plexus?
So if you’re at the beach, spittin game, then you know the nerve to flex it!
So after these roots combine into three little chunks,
You got the superior, and the middle, and inferior trunks,
C-5 and 6 merged, so do T-1 and C-8,
But C7 stayed alone, not gonna to help them innervate,
Now the trunks split up, making 6 small divisions,
3 on the top and 3 more in the posterior positions.
The 2 anteriors all combine, and all the posteriors do too,
As they run down your arm, you can feel em coursin through you (YOU!)

[Chorus 2x]

[Verse 2]
We done roots, trunks, divisions, now we onto them cords,
Keep payin close attention, cuz you’ll find this on the Boards,
Look for the lateral on the outside, and the medial on the in,
The posterior’s in the back, and if you see it with a pin,
Then the axillary artery must be sitting in betweens,
Holdin on them cords like some Skinny tight jeans.
All three cords split in 2, then they branch into five,
Its musculocutaneous nerve that makes your upper arm thrive,
the axillary nerve hits the delts and teres minor,
while the radial helps extend your arms like a recliner,
Median gets forearm flexors and the muscles of the thumb,
And the intrinsic hand connects with C-8 and T-1 (ULNER!)

[Chorus 2x]

[Verse 3]
Now that’s the basic structure, but there’s more branching on the side,
Let’s start back at the top, and down the plexus we’ll slide,
Our first little break comes off the C-5 root,
The levator and the rhoms get that dorsal scap chute,
Then the long thoracic nerve roots from C-5, 6, and 7,
Breathing life in front serratus like the Spirit from Heaven,
The suprascapular nerve comes off the superior trunk,
and walks it out on both spinati like my boy DJ Unk,
The thoracodorsal nerve comes off the posterior cord,
So my lats extend my arms to 10 and 2 on my Ford,
Medial and lateral pectoral, you know what they serve,
And that’s five star rap, about some five star nerves!

[Chorus 3x]

[Outro]
Annnnnnnnd done.

The First Day of School... Again. (No, For Real This Time)

I swear to you, Monday was the first day of medical school. Maybe not really, but everything I dreamed medical school would be began this week. We delved into bodies, discussed real medical cases like House and his team, put on scrubs and wore rubber gloves, and got used to the smell of formaldehyde. Our first lecture was about the history of human dissection and the advancements of medicine through understanding the human form. We learned about embryology and the origin of life, as well as the anatomy of the back. After lunch we took our first steps into the anatomy lab to see our cadaver. On Tuesday, we cut.

During the lectures, I didn't think about what I was about to do. Not until I crossed the threshold into the lab did it hit me, literally. The wafting odor of formaldehyde and embalming fluid was my wake-up call. I'm going to actually cut into a human body! Someone who was alive, who was breathing and walking and talking not too long ago. A real person... As you walk through the double doors into the room, 20 blue cadaver bags lie in front of you, each entombing a different person with a different story. It's a sobering thought. All the hours I spent in the OR with living, sedated people were inadequate. There, I was working with surgeons to make someone whole or better: remove a tumor, gallbladder, or give someone a chance to walk again with a new knee. In anatomy, each person is going to be made unwhole: we will see every nerve, vessel, bone, and muscle. We will cut off skin, legs, and even make incisions through this person's face, skull, and brain. We will barely be able to piece the body back together by Thanksgiving. And yet this is the ultimate sacrifice given to the medical student. It is the only way to truly understand the human form.

Most groups give a name to their cadaver. We haven't yet, in part because we did not look at his face until today (yes "he" is a very elderly man). Some people took the towels covering the face off immediately on Monday, I'm not sure why. For us, not seeing the face made what we were doing more okay or less dirty, or perhaps we were just ashamed. I'm not sure. It's easier to cut into someone's chest wall if he isn’t staring right at you. If he can't see us, he doesn't know who's doing this to him. And we don't know who we're doing this to. But once I saw the face today, I was honestly on edge. Suddenly this body that we've been bluntly and shamelessly carving into for the past week was no longer a body, he was a person again, at least for me. Some medical schools wrap the face and hands until they are part of the dissection. The hands I don't have a problem with seeing, but the face... Whose husband was this? Whose father? Whose grandfather? Whose son??

We went too slow on the first day. We were too careful. Daniel M. and I made the first cuts. We had to turn the body over so it was lying in the prone position, and we cut across the back, all the way from the coccyx to the base of the skull, starting in the middle, moving in opposite directions. With no idea how deep to go, we barely broke the dermis on our first attempt. We were timid. We then made perpendicular incisions all the way to the sides, and peeled layers of skin, fat, and fascia back over the table. He was now exposed, and there was no turning back. Our hands were probing muscles and tissues that most people never see, that he himself never saw...

It was truly an honor. I only hope I can be so generous with my body.

Fart Noises and Gobbling Like a Turkey

Look to the left. This is what I’ve learned to do this past week: make little children giggle. The first patient I saw by myself saw me walk into the room, and ran screaming into his mother's arms. He was not happy at all to see me (I think it was the stethoscope and tie), but fortunately with a few high fives and a chance to let him look into my big ears to see if he could find my brain, he did let me listen to his heart and lungs. After this near disaster, I felt I needed to come up with a few new techniques to gain the trust of my little ones. The first technique I stumbled upon completely by accident. My second case was a two year old girl with MRSA. I had to put on gloves to examine her abscess, but there were only mediums in the room. So during my struggle to get the first too-small glove over my hand, I blew into it to help maneuver my hand into the individual fingers. I looked down, and my little two year old was beaming. Of course, there was only one possible course of action. I blew up the other glove all the way, held it on top of my head, and gobbled like a turkey. When I released the air, it made a fart noise and blew around the room. It was an instant hit with her and Grandma, both. "Dr. Robby likes to play!" Not a doctor yet, Grammy.

There are other things I learned this week. I now know how to make airplanes and helicopters out of tongue depressors. I can push a child's "starter button" (navel) to turn her on and off. I can look through a little boy's ear and see out the other side. I can turn an otoscope on and off simply by snapping my fingers, and I'm even working on my bird calls just in case I find any species of the avian variety flying around inside a four year old's eardrum.

On the other hand, I haven't learned much medicine. In fact, it was frustrating to realize how much I don't know, and need to know. I seemed to have found the one place in America where all the metabolic syndromes and hereditary disorders we learned in Molecules to Cells were discovered. I saw two babies with "floppy baby syndrome," a newborn with a heredity immunodeficiency disorder, a woman with tuberous sclerosis, and a patient who came in with pyruvate carboxylase deficiency which only occurs in 1 in 250,000 births worldwide! I realized that I learned much more than I thought in the first couple months, but I wish I had studied harder. It would have been nice to remember some of the details of these disorders that seemed so mundane and dry in class, but came to life (literally) here in Boone. My preceptor commiserated with my frustration, adding that it will all come with time and experience. I did get lucky with a phenomenal proctor. We spent from 8 AM to 7 or 8 PM in the clinic everyday, with patients waiting for hours and hours. But no one seemed to complain. They all came a long way to see my doctor specifically, and every patient and family member left with a smile (unless they left immediately after their immunizations; then you could hear them leave...).

I have also been surprised to discover I have picked up a significant Southern drawl when talking to patients. At least 90% of the people in the clinic have strong Western North Carolina/Appalachian accents, and quite of few of them are on Medicaid. As the conversations develop, my neutral half DC, half NC accent loses the DC part. Words become longer, and I don't think I've ever used "y'all" so many times in my entire life. I promised myself in high school that I would never succumb to using that ridiculous non-word, but Shelley will be proud of me. I guess that's what I get for living in the South for the past five years. Hey, I'd combine a few more words if I could stay away from city traffic for another few years.

Other tips and observations:

1. Get your kids vaccinated. It's not cool when you come to the office with meningitis. Vaccines are safe. There is no evidence they cause autism. None.

2. Use the European method of potty training. Look it up. The American way is crap (or at least you'll get more of it in diapers and less of it in the actual toilet).

3. Clear lung sounds with a nasty cough and fever means the flu. If I hear crackles in the backles, it’s something else. Don't ask me what though.

4. Nobody under thirteen years old actually likes shots, so let them get the flu-mist. It's better and they won't hate you for at least a day.

5. New mothers and fathers who write down their questions in a little book ahead of time are adorable.

Anyways, back to the classroom on Monday, but at least it's Anatomy. Time to cut. First though I'm heading down to Troutman, NC to spend a day or two on the lake with Brandon and some med school peeps.

Farewell, Molecules to Cells

Farewell, Molecules to Cells. I will not miss thee.

On Wednesday I took my final exam in biochemistry (and passed!). I have moved on emotionally, physically, and spiritually from (hopefully) the most boring topic in all of medical school. Frankly, I don't think anything can be more off-putting than RNA polymerase II (see left) and its transcription factors. After talking to some of the MS2s, apparently this is the worst block of our first year, and luckily we start Anatomy in just over a week. But first off to Boone, North Carolina for my first Community Week. Finally back to seeing real patients and human interaction instead of tyrosine kinase receptor / hormone interaction...

It was a fairly tumultuous week, beginning with the annual MS1/MS2 keg race. This past Saturday at 10 AM the kegs started flowing. 20 v. 20. Why we had to start so early I'm not sure (I guess a 9 AM wake-up is sleeping in for med students?), but the experience took me back to undergrad. We won (of course), but I think the best part about the morning was getting yelled at for drinking too slowly, being too social, and not being enough of a team player in my efforts. Apparently med students are like athletes: we like to win (or at least get an "A"). That even includes our "extra-curricular activities."

That time could have been better spent studying, however, duty called. Sunday through Tuesday was spent in the library gearing up for our final, and it was a relief to be free at noon. Ginny Moye and I then drove up to Blowing Rock, NC (right outside Boone) to spend some time at a mountain time-share that one of our classmates had for the weekend. About 20 of us made it up there, and we spend the time going for walks, seeing the bears, cougars, and bald eagles (all in captivity of course), "climbing" grandfather mountain, and debating whether Lawrence v. Texas negates the North Carolina anti-sodomy statute (this one is still up in the air; if you are an expert in NC Criminal Law please contact me immediately). This gave me the opportunity to really meet some of my fellow students. I met an MS2 named Shane who summited Kilimanjaro just a day before I did this past July. And one of my classmates, Ronnie Millingham, lives a block from Brandon Suddreth's house, and was in the same EMT-I class with me this Spring. Small world.

I recently posted on my Facebook status that I couldn't wait to start "real" medical school next week. I have a week of shadowing starting Monday, and then Anatomy begins 7 days later. I thought I would be nervous to start dissection, but I think I was so disillusioned by Molecules to Cells that I'm just plain excited. I see the relevance in this Block (obviously), and when you think about medical school, this is what comes to mind. Dead bodies, scalpels, tissue, cutting. I just can't wait to use my hands. And after reading Christine Montross' Body of Work, I'm very interested to see how I respond to the tense emotions and stresses of the Anatomy Lab, the real bodies, and my classmates. I think I have a good group of students I'm working with, but people deal with all this in many different ways. I certainly view the body with a ton of reverence after reading that book, and I hope my fellow group members do the same.

It looks like I have a good couple weeks ahead of me. Hopefully I won't make a little kid cry. I might not be able to post until Saturday if I don't have internet, but I should be able to write by Friday night and share some of my community week experiences.

What It's All About

Last week's frustration was mollified by the high emotions of the past few days. This picture of Pops and me outside the Old Well was taken immediately following our White Coat Ceremony. In the early 90s, medical schools started conducting these events to give the students a "modified" version of the white coat (not a "long coat" so we can be designated as the scrubs, lowest on the totem pole), to be worn during any clinical experience. For us, this comes just before our first "Community Week," where we spend 5 days shadowing a physician in some other part of North Carolina. On October 12th, I will be heading to Boone to shadow a pediatrician at his practice. Throughout our first two years, I will go back to Boone 4 more times, building on each with the clinical skills I learn in Introduction to Clinical Medicine (ICM). In this first week, I will mainly be a shadow, but will be able to conduct some patient interviews. By the second week I will be performing full physical exams.

The actual ceremony took place on a rainy Saturday morning. We all dressed up in our Sunday best and processed into the great Memorial Hall into the beaming smiles and gleaming (though sometimes watery) eyes of parents, loved ones, and faculty. They gave us a speech about giving money to the school (typical), not cheating (just plain odd), and about being caring doctors (trite), but it all seemed to mesh into nervous enthusiasm from the 160 of us. We were "coated," recited a modified version of the Hippocratic Oath, and processed out to the Tar Heel Fight Song for pictures. The Carolina grads walked briskly over the Old Well to get in line for some classic shots. Lauriane (Mercer '06) had to ask why we were going to take pictures next to "that column thing." They'll learn soon enough, but it gave Pops and me a laugh, taking us back to Searching for Bobby Fischer. Old school.

On Wednesday I went to see my first patient. In our Medicine and Society class, we have to meet with a pre-selected patient from UNC-Hospitals twice to learn first-hand about disease; it also gives them a chance to tell us how we should be good doctors, from the point of view of the person who is actually getting the treatment. Most medical students have never been ill (a point I argued two blogs ago), and this experience allows us to "get real" about disease. I can already tell you that I will not be seeing Mrs. Jones (a pseudonym) just one more time. I intend to be involved in her care, hopefully for years to come. She is an inspiration to anyone and everyone; and her outlook on life, disease, and death is unparalleled. Although I will tell you a little bit about her, for patient confidentiality I will have to change names and a few of the closer details.

Mrs. Jones and her husband are in their 80s. She's had a number of cancers, been through a dozen chemotherapy treatments, been poked and prodded by too many doctors here at UNC and Duke... but you could never tell. She is joyful, thankful, and bubbly. She is a full time volunteer, wife, great-grandmother, and child of Christ. She has lost her hair a number of times, but never her dignity. She is real about death and disease; she knows her time will come soon. She even joked that whoever "goes first" (her or her husband), the spouse will buy two dogs to keep them rolling. Doctors have made mistakes in her care, but she has never been angry. "Everyone is human; everyone makes mistakes." Her best advice was to listen, really listen to patients, because they know their bodies better than you do. We talked for over three hours, and I can't wait to go back. Being with her and her husband reminded me of Grammy, and how much I miss her perspective, wisdom, and guidance. It also was a serious reminder of why I want to be a doctor, and how I should go about it.

Many emotions and ideals this week: pride, joy, love, realism, sadness, inspiration. All good reminders about what it's all about.

Your Type A+ Premed Gunner

Urbandictionary.com, the premiere site for defining slang terminology, gives us the following:

gunner (n.) - a person who is competitive, overly-ambitious, and substantially exceeds requirements. A gunner will compromise his/her peer relationships and/or reputation among peers in order to obtain recognition and praise from superiors. Synonyms include: obnoxious premed, grade-grubber, over-achieving worry-wort, annoying type A+ personality hand-raiser, someone demonstrating "Dook-syndrome," person who openly complains about test questions to course instructors because they didn't get the answer right even though other people did and they dislike the "poor-wording" of said question.

Okay so I added the synonyms, but the sentiment rings true. The tipping point for me was Thursday morning in lecture hall. I overheard a girl complaining that highest grade given out by the course directors was a 4.7/5 on the latest group project. Now this project was worth 5% of our total grade. A 4.7 now means that 0.3% of our total grade has been lost. No longer can anyone get a 100% in the class. No, a 99.7% is now the highest possible grade. I had to listen to this person whine about how (even though their group got a 4.7) the grade wasn't high enough, and how the other people in her group must have been the causation for such an atrocious score. Luckily, I'm not prone to violence (and even more luckily, I'm not in her small group).

When I look back on my undergraduate career, I successfully managed to avoid these people. I knew they were there, and I even knew a few of them, but for the most part I stayed away. By junior and senior year, I was taking upper level Chem classes and Political Science seminars. Upper level Chemmies are more interested in PhDs, and the PoliSci people are simply happy. Oh, how I miss those people! So happy! (Unless they were applying to Law School of course...). But few and far between were the people whose lives revolved around getting into medical school.

Now the actual process of getting accepted will make you pull out your hair. The pressure of MCATs, applications, interviews, and the waiting will drive you crazy. But once you're in, it's smooth sailing. We're all here to become doctors, right? You have to study and work hard, but this over-competitive tomfoolery is so undergrad folks. Do your best, and it will all work out in the end. I guess the problem is the process. Ingrained within us is this need to be on top. In high school you had to be top of your class to get into a great college, then you had to be one of the best to go to a great med school. So now you have to graduate the top of THIS class to get the best residency. But we're at UNC guys everyone is going to get into a good residency program. And it's pass/fail too, these grades don't even count! Please be happy now and worry about this stuff in two years. At least then I can be prepared for the onslaught of whining. I can't handle it right now.

Once classes actually started, it was quite a shock to me. Many of the amazing people that I thought I met during orientation flip-flopped big time. It's like they're completely different people now. Cut-throat, gotta be the best. Don't study this stuff because you need to get an A (which by the way, there are no As, only Ps), study it because you love it. Study it because you are going to be a physician, and THAT'S exciting. Everyone just needs to chill out.

I hear being a "gunner" gets weeded out by the 3rd year, but I'm still skeptical. Until then I'll stick with my Patch Adams mentality and try to get a few of these people to "smile." For those who haven't done this before, this might help (courtesy of dictionary.com):

smile (v.) - to assume a facial expression indicating pleasure, favor, or amusement, characterized by an upturning of the corners of the mouth. Synonyms include: grin, beam, and look happy.

The Story Behind the Story

Last week we were assigned to write a "Personal Illness Narrative," describing a time we were sick. The point was to discuss what it means to be a patient, and to conjure up some future lessons for our future selves...

"Behind every affliction, illness, or malady, there is a story. Of course, there is the story of the affliction itself. That story tells the who, what, when, where, and how; but the story behind the story tells the why. The why is what determines whether you get sick or become ill. I will show you what I mean. First I will tell you my story; then I will tell you the story behind the story. First the what, then the why.

I have been sick before, obviously. I have had colds, coughs, runny noses, fevers, sinus infections, flus, and chicken pox, just to name a few ailments. I have been taken to the emergency room for choking on a peanut (if that counts). I have even gone under the knife for an inguinal hernia repair when I was ten. However, only one time have I actually been afraid. I had never dealt with uncertainty before in sickness, and a visit to the emergency department two years ago was my first encounter with fear.

I first started feeling poorly on a Tuesday. I felt fatigued walking around campus, my throat was scratchy, and I developed a cough and runny nose. It felt like the usual January cold-weather cold, so I did not think much of it until Wednesday morning when I began having trouble swallowing. I had the chills the night before, and by sunrise it was extremely painful to swallow anything, either saliva or food. So I skipped classes that morning and went over to Campus Student Health. After diagnosing a low grade fever and a general feeling of “crumminess,” I was given a rapid strep test. Strep throat was showing increased incidence on campus, and I was had all the symptoms. However, the test came back negative, so I was simply told to take an antipyretic and come back next week if the symptoms continued.

Two extra-strength acetaminophen tablets every six hours kept the fever low, just over 100 °F throughout Thursday night and Friday. I even got a call Friday morning saying the throat culture was negative. But just before ten at night, I woke up sweating through my sheets. My fever had spiked to 104.3 °F, much too high in my estimation. I had taken two pills a couple hours earlier, but I added an extra one for insurance. I stayed up for another half an hour, waiting for some relief. I got so hot that I took an ice cold shower to try to bring down my core temperature (I had seen House put a patient in an ice bath once and it brought down the fever, so why wouldn’t it work for me? Plus, one of my best friends was a fourth year med student and he confirmed Dr. House’s treatment.). About a quarter to eleven I took my temperature again, just after getting out of the freezing cold water, and this time it was 105.0 °F. At this point, I knew more than one thing was amiss. One, if your temperature gets too high, it can cause brain damage because of protein denaturation. Two, my fever was now running for over 24 hours. And three, I could not control the virus at home. It was time to head to the hospital since urgent care was closed at this hour.

My roommate drove me to the Emergency Department at UNC-Hospitals. I was scared, but I figured it would be faster to drive than call 911 since I was living on-campus. On the way I called my head swim coach’s wife, who was an ER physician at UNC. She told me I was doing the right thing, and that she would monitor my situation from home. Within minutes I was in triage. I was sweating so hard that I started taking off clothing; the lady sitting next to me in the waiting room told me she was hoping I’d go all the way. While being evaluated by the nurse, my hands and feet went numb. Apparently I was breathing so rapidly that the nurse had to tell me to calm down and breathe slower. Feeling came back quickly.

Soon, however, I was whisked over to “Minor Trauma,” an area for less serious sicknesses and injuries. I was seen by the resident within minutes and the attending no more than ten minutes later. Dr. Harrigan walked into the room, shook my hand, asked me how I was doing, and definitively asserted that I had strep throat. I recounted again, just as I had to the resident, the nurse, and everyone else, that both the rapid and the long strep tests had come back negative. Coolly, Dr. Harrigan told me that can happen, but he could smell the strep on my breath. He ordered a bunch of pills for me to take, slapped me on my shoulder, and sent me on my merry way. I was in and out in less than an hour, a miracle in itself. I felt better as I left, even before popping one pill. The uncertainty and fear slipped away…

Mundane and anticlimactic as this account may be, the story behind the story shows how lucky I was to be the right person in the right place at the right time. Implicit in my narrative are some important facts. First, I had ample access to health care. I went to my primary care physician immediately because I was not feeling well. I did not have to worry about the cost of the visit or the tests. It was all covered by my insurance plan through the University. I did not have to worry about the cost of missing work either; I simply emailed my professors. My life and my job did not depend going to work that day. And when all was said and done, after the hospital visit, tests, drug costs, and doctor’s fees, I owed less than $50 for everything. Insurance covered the rest.

Not only was I financially unburdened, but I had an incredible support structure. I was constantly on the phone with an experienced medical student while sick, receiving advice from someone inside the medical profession. My parents helped me decide when enough was enough and when it was time to drive to the hospital. An ER physician who worked at the hospital I was going to confirmed that I should go to the hospital. I even found out later that she called the Emergency Department to alert them of my imminent arrival, urging them to steer me toward Minor Trauma if possible. That way I would be in and out quickly and in a quieter environment. I also had a roommate and friend willing to drive me to the ER and wait with me. And once I was in a hospital bed, my head coach came to check up on me.

The moral of this story within the story is not that those who are financially and socially well off do not get ill. People of different socioeconomic backgrounds become very ill every day. My point is that, while sick, I was in the perfect position to get well. I did not have to worry about money, and I did not have to worry about making difficult choices. I had physicians, parents, and friends coaching me at every point, ready to spring into action if things got worse. The question is, what if things had been different? What if I did not think I could afford medical care? What if I thought I had to wait it out? Untreated strep throat can lead to very serious complications. What if I had to go at this alone? What if I had made all my health decisions by myself? In my case, the outcome may have been similar, but how much did that have to do with my education and family background? This story demonstrates the best possible health outcome in a crisis situation, but it is hard for me to imagine a similar chain of events for one of the 47 million Americans without health insurance, or one of the 3 billion in the world who live on less than $2.50 a day.

That is why this essay is not a personal “illness” narrative. I have never really been ill. I have been sick, but not ill. For me, illness implies something more serious; something life-threatening or something chronic and painful. Perhaps illness also encompasses the inability to afford to get well, or the lack of a friend to advise and help heal. Maybe we should take “illness” more seriously. I would argue that we can treat someone who is sick with a pill or a test or a procedure, but we cannot do the same for someone who is ill. The “me”s of this world get sick all the time, but rarely get ill.

This is why I came to medical school: to be the physician, advocate, and friend of the people who are not “me.” For the ill."

The Patient Interview

A 23 year old white male presents with flu-like symptoms. Headache, fever, cough, sore throat, runny nose, and fatigue began about 48 hours ago. No nausea, vomiting, or irregular bowel movements. The patient states that naproxen, water, and rest makes him feel better, and vigorous activity only makes him feel worse. The fever broke 24 hours ago, and the patient rates his pain at about a 5/10. Physical exam is unremarkable, except for a severely red and irritated throat. The patient denies any allergies to medications, and does not take any meds on a regular basis. The patient states that a few of his peers have had "swine flu" and he wanted to get checked out to confirm this diagnosis. Patient denies having the flu in years.

The patient also denies any chronic illnesses or pre-existing conditions, no admissions to the hospital, and has no pertinent surgical history. In his family there is a history of cardiovascular disease. The patient is a graduate student at UNC-Chapel Hill, denies tobacco and illict drug use, and denies significant alcohol consumption as of late. There is no pertinent sexual history relating to this case. The patient lives with his roommate, feels safe in his home, and states he eats 3-meals a day and exercises regularly. The patient has no religious beliefs that would affect care. This concluded the patient interview.

Diagnosis: he's got the swine flu, too.

I wish I could say that this was a made up case, but unfortunately, I have swine flu. Karma turned around and bit me in the ass. I have been mocking and taunting swine flu since it's conception. The world has gone crazy over a this pig flu, thanks to our 24 hour news networks. CNN has the latest H1N1 news, round the clock! Worldwide pandemic, everybody panic! Thank you, Wolf Blitzer. And so I said months ago, "Bring it on swine flu. You can't take me down." And you didn't take me down. I felt like crap for two days, and then got better. You couldn't even give me the runs? No puking? Just a fever that I broke with two pills? I laugh in your face swine flu. And when you come back bigger and badder than ever, ready to challenge the Great Influenza of the early 1900s, I'll be immune to you. You struck too early swine flu. You lose. Muhahahahahahaha.

Hopefully delirium isn't one of the symptoms.

Tonight's Top Ten - Ways Not to Study

#10 - Have dinner with your friends' parents. Saturday night I decided to skip the football game and head over to Klara's house to meet Dr. and Dr. Klein. After the initial meet and greet (and a few glasses of wine), we got into the serious issues of health care reform over steak and fish. The Kleins are much more skeptical of the new reforms, and are rightfully cynical of patients, doctors, and the system itself. I tried to do more listening than talking, as it's much more interesting hearing the stories of seasoned veterans. Their advice: work for awhile and then go change the world. The atmosphere became much lighter after dessert and Wii Sports.

#9 - Play tennis with your friends' boyfriends. Klara's boyfriend Evan and I set up weekly tennis outings to take our minds off of medical school (he's applying to matriculate next year). Every Sunday from here on out. First match was brutal; I got my ass handed to me.

#8 - Spend Labor Day in the sun, not the library. Lauren and Jennifer are nearby neighbors here in Finley Forest, and they held a wonderful Labor Day cookout. I didn't have anything to offer, so I brought leftover pasta for myself. Most people chipped in for burgers, macaroni salad, chips, and sodas to celebrate our first med school holiday. We sat on the deck for a few hours, stalling the inevitable.

#7 - Dress up as your favorite patient-type for dinner. After a spectacular meal prepared by our one and only Julia, a few of us dressed up as patients and conducted patient interviews (I know technically this is medical school related, but it doesn't really count because it's clinical. By "not studying" I mean totally avoiding Biochemistry, specifically glycolysis and pharmacogenetics). Lauriane dressed up as a crabby elderly lady, Julia was pregnant, Daniel was a happy go lucky drug dealer with a rash, and Natalie was the prom queen who was just wanted some damn Plan B but she was too young because she skipped three grades. I had just come from swim practice so I wasn't in costume, but I pretended to be a freshman laxer. What I lacked in appearance I made up for in attitude. Lax for life.

#6 - Sleep in. You will be happy and fully rested. Hey, that's what lecture capture is for right?

#5 - Write a constitution for your newly founded student group. That's right. The new Health Policy Interest Group (HPIG) was approved by UNC. We are now an official student group, pending the writing of a "constitution" that creates a written and binding agreement with the University. Sarah and I put a good hour into an outline today. Now we have to clean it up and have it "ratified" by our officers and faculty advisors. Most importantly, I now know what a "quorum" is, and we decided we need 60% of our "executive board" present in order to conduct business. So sophisticated.

#4 - Watch the President get yelled at by idiot Congress-people. Joe Wilson, really? You don't have to agree with the President but show some respect for the office, geeze. This outburst only adds to my sentiment that South Carolina is the outhouse of the United States (sorry Shelley, Furman can only pull the state up by so much). Great speech, although I think this is a perfect time for bipartisanship. Why not open up insurance across state lines and get some serious tort reform? I say add it all into the mix, baby (Duke Vitale, what? Yeah, I'm ready for basketball season already).

#3 - Meet with your advisor and talk about relationships. Not only is Dr. Dreesen the man (well, more like "the woman," but simply awesome), but she has promised to play matchmaker for me. Originally this started out only as helping me meet doctors and improve my resume for residencies, but she seemed genuinely perturbed by the fact that every female in our MS1 class is either married, engaged, or in a life-changing relationship. She's promised to keep her ear to the street and keep me apprised of any potential sugar-mamas out there. Thanks Dr. D. I also met with Dr. Kohn this week, and my name is on his latest paper!

#2 - Start working EMS (again). I interview next week with Parkwood in Durham County. Hopefully 36 hours a month with them will turn this frown upside down.

and...
#1 - Call your mom to vent about your classmates. I had a "why am I here?" moment earlier this week. It's tough when I am surrounded by people who are so excited about glycogen-storage diseases and renal drug elimination, and I'm just sitting here thinking, "Eh, it's okay." I'd rather read the New York Times and wax philosophical about our current reimbursement system. But that's what Moms are for. She told me I'm impatient and that I built up medical school so much that at some point, it's going to be a let-down. Personally I just think Biochemistry sucks. Bring it on Anatomy!

My Happy Place

They say you shouldn't get behind in medical school because it's very hard to catch up. Whoever "they" are, I now believe them. After finally figuring out what study strategies work best for me, I spent hours and hours and hours in the Health Sciences Library catching up. This is my happy place. Specifically, the second group study room on the left hand side of the first floor. That room (now designated "the spot" by Lauriane and me) is where I ate lunch and dinner for four straight days. In fact, on Sunday I could actually see what I ate on Friday night in the trash can, because they hadn't gotten around to cleaning that floor yet. And thus sadly last weekend I was in the HSL more than I was at home.

Lauriane and I are good study partners. For the most part, we study. But often we were dragging a bit, and then we played short games every hour on the hour, allowing a bit of tomfoolery to re-energize us briefly. Last Saturday was a particularly rough day, so we decided to talk about something that makes us very happy for a few minutes each hour (I like having my teeth cleaned and sweatpants with pockets, while Lauriane is a huge fan of vanilla scented candles and tomato juice). Later this week we tried things that piss us off, but that game didn't seem to have the same motivating effect. On Sunday evening right before the exam, we watched Cool Runnings and Lion King clips on YouTube to pump us up for the upcoming test (and we found them in both French and English of course...).

By the end of the week, I was losing my mind. Saturday night I locked my keys in my car, and it took me all the way until Sunday at 2 pm to fully catch up. I definitely wasn't as prepared for our exam as I should have been. 67 questions multiple choice on topics like RNA polymerase transcription factors, mitochondrial inheritance, and gene splicing. Yuck is right. Immediately after the exam, they posted the answers in the auditorium. 67 sheets of paper, each with the question, right answer, and explanation. Sarah and I refused to go. I narrowed so many questions down to two choices, that I couldn't even remember which one I finally chose. There was no point in even looking, so we had a dance party with Klara, Andie, Eric, Omid, and Perry outside of the cafeteria instead. Frankly that was a much better use of my time. And 24 hours later what did I find out, I passed! And I didn't even scrape by! P = MD, right? As a lot of my classmates like to say, "What do you call the person who graduates last in her class in medical school? A doctor." And many of us partied a little too hard on Monday night to celebrate that fact (but I won't mention any names out of respect for the party involved)...

However, I'm not looking to graduate last. So this week I've been good. As of today I'm only one day behind (and I'm looking forward to this 3 day weekend to catch up and study ahead of time - wait, what??). After class each day I head to the spot, study for a few hours, then head home for dinner and some shenanigans. This past week we got 14 guys to head over to Baileys and do a MS1 fantasy football draft over wings, Ryan Funderburk came over for dinner, I met with Dr. Kohn, and I played some basketball with the "med school ballers." So now that I'm starting to get in a rhythm, life is good. Tonight I'm heading to Raleigh for dinner, live music, and an art show. Who says med school can't be fun? Well, as long as you stay on top of it.

This week I'm looking forward to a three day weekend and dinner with the Kleins. Signing off.

RAS ,retired.

Eating to Ease Anxiety

The problem with constantly being around 160 other overachieving overachievers is the stress. Overachieving overachievers tend to stress other overachieving overachievers out. This begins an "enzymatic cascade" (sorry, too much biochemistry on the brain), leading to anxiety on top of stress on top of apprehension on top of worriment, with a little bit of nail-biting on the side. That's what happens in preparation before your first medical school exam, and it's something that I am determined to avoid. Fortunately, a good group of us here at the UNC School of Medicine have found a cure for this proliferating ailment. We eat!

Last Sunday night I hosted a meal at the Condo. On the menu was baja chipotle and herb and garlic grilled chicken, corn on the cob, fresh green salad, watermelon, wine, and an assortment of desserts. I manned the grill, and we were able to seat all eleven of us: Justin and co., the roomie and Laura, Andie and Robby 2.0, Klara and Evan, Lauriane, Sarah, and I all crammed onto the deck to enjoy a relaxing meal. We had table cloth ($4.95 a piece - thank you Target), candles, and lemon-scented mosquito repellent that I think actually included mosquito mating fragrances because they seemed only to make the situation worse. But we ate, the mosquitoes ate, and for a good three hours no one was studying. To continue our bad habits, Lauriane, Natalie, Julia and I had soup night the following evening over in Southern Village. I made chilled cucumber soup (it was a hit - thank you Mom), ate cheese and crackers, and found out what a "Rainbow Kiss" is (if you really want to know, ask Julia. I'm afraid 5th grade sex-education humor is not appropriate in this forum).

However, most of this week has indeed been devoted to studying. For a good four days of week #1, I tried to pretend I was still not in med school. I exercised 2-3 hours a day, caught up on my news, hung out with friends, etc. Apparently that doesn't work so well. So since last Thursday I have studied at least 4 hours a day, desperately trying to make up for lost time. What made it even worse was I tried to make notecards for all our material. About a sixth of the way through I gave up (I was estimating writing around 800 cards in all, so I called it a day around 162), and started a new study method: making electronic outlines. That, however, set me back another few days, and I've had to increase my study time to about 6 hours a day. Annnnnd we have a test on Monday.

The good news is I have found a study strategy that I like. Now whether it works is a totally different issue. I guess we'll see on Monday after Test #1, and then I can tweak it as needed. My goal is to improve my score on every test this block, fine tuning my technique for when it counts (anatomy starts mid-October). I do feel like I'm getting into the swing of things though, and putting in some good work everyday is starting to get pleasantly routine, and perhaps a little fun. Just a little though.

What I lack in Biochemistry I make up for in Introduction to Clinical Medicine (ICM) and Medicine in Society. These are my go-to courses. Clinical skills and medical philosophy are what's keeping me going this semester. I love patient interviewing (first standardized patient interview in a couple weeks!), and waxing philosophical about illness and disease. For the first time in my life I've actually done extra readings. This is more due to procrastination in lieu of learning biochem (sorry Mom I still haven't grown out of that skill yet), but it is much more interesting. Soon we'll have to write about our experience with personal illness, and I'll post that essay in the next few weeks. Premise: sure I've been sick, but I don't believe I've ever been ill.

Test #1 is t-minus 62 hours. Wish me luck!

Drinking Water from a Fire Hose

See this sweet little girl trying to drink some water? She's getting a bit more than she expected. This is medical school. It's not a difficult metaphor. There's a lot of information, and it's coming very quickly. We'll get there, but let's start off recapping this week at a happier place: Klara's house.

Sunday night was the calm before the storm. We capped off our orientation week by elegantly dining together. Andrea R., Sarah P. (+ husband, Michael), and I cooked homemade pizzas at Klara K.'s with her super significant other, Evan. We enjoyed some wine, salad, pizza, and dessert, bantering about annoying premed gunners and Jewish history/tradition. Oh, so grown up these days. We attempted to take advantage of each last moment of freedom before the real first week of medical school began. After day one there would be no turning back; it would be full steam ahead until graduation.

And so at 7:30 am I hopped on the S-bus with my fellow Finley Foresters, found seats in the front section of the auditorium, and primed my laptop for note taking, fully intending to catch every spoken word. I lasted two hours before my brain went into sleep mode. We sat in the lecture hall from 8 am to noon with minimal breaks, followed by another session from 1 to 2 pm. Then it was off to Introduction to Clinical Medicine, two and a half more hours of class. Medical school feels like middle school rather than "physician training:" too much time spent sitting in class, teachers shuffling in and out of prescribed lecture times, and a small, intimate group of students sitting among newly formed cliques. The only difference is we have high-powered laptops that allow us to G-chat and Facebook each other rather than pass tiny paper notes (and the material covered is slightly more advanced).

Thus the beginning of the week was characterized by massive anxiety. After Day #1 I had 55 pages of textbook style lecture material to master, only to be followed up by an additional 43 pages the next day. I was freaking out (just ask Klara K.). On Tuesday morning I heard of a fellow classmate who spent the previous night studying until 1 am... on the first day of school! It seemed that the "everyone should have a life and get along" philosophy was quickly swept underneath the carpet. It was back to our premed days: cut-throat, study-holics who have to have that "A." Boy am I glad it's pass/fail. If you get a 100 or a 70, everyone gets a "P" on that transcript. And rest assured, everyone will get a "P."

As I've gotten into the studying groove (a few hours a day after class), I've also decided that I'm not going to ruin my body, nor my intellectual curiosity in pursuit of a "P." I've gotten back into swimming these past couple weeks, getting in a good 3-4 times a week of enjoyable aerobic workout. I've lifted everyday this week, and played tennis on off days. I challenged Lauriane A. to a few points the other day and it ended in disaster. Hopefully soon we'll be able to trade tennis lessons for swim instruction. I think that's fair. But I've also started a Health Policy Interest Group here at UNC-SOM. Sarah P. and I submitted our proposal earlier this week and we can't wait to start leadership meetings. Our non-partisan group is organizing a lecture panel to inform ourselves and our classmates on the goings-on in today's health reform efforts. Have you read the Bill?

So that's life outside of studying. Looking to next week I'm hosting 12 or so of my friends for an evening at the Condo: baja chipotle grilled chicken with corn on the cob and wine. Then it's an all week event getting ready for our first exam the following Monday.

So grown up.