Blondes and Brunettes

I've been called a lot of things, but a pathologist is not one of them. So far in my medical career, I can think of very few things that have evoked an extreme, visceral reaction, but Thursday's pathology presentation got to me. Now, the first time I saw the face of my anatomy body I was a little uneasy. The smell during the disembowelment at my first autopsy was unpleasant, but nothing I couldn't push through. These things don't compare to the way the "teratoma" made me feel. How our professor went on about her "favorites" made me a little sick. I think I might have thrown up in my mouth a little bit. I have said before that the microscopic side of medicine is not nearly as interesting as gross pathology. Well, I'd probably like to ignore this part of the macroscopic as well.

A teratoma is the most common neoplasm of the ovary. It is usually benign, but only in terms of its possibility for cancer. Its morphology is by no means "benign." Not at all. It is called a teratoma because its growth is derived from multiple tissue types. Normally we define a neoplasm as either "benign" or "malignant," pertaining to its ability to metastasize and spread to other parts of the body. These tumors generally stem from an abnormal growth in tissue. Many times, if a neoplasm begins in a certain part of the body, the cells multiply from that single origin. If the tissue was of a glandular genesis, we use the term "adenocarcinoma." If it was derived from the melanocytes of the skin, it's call "melanoma." The teratoma, however, is derived from multiple tissue types. A mature teratoma is pictured above (but look at your own risk). It can grow gut tissue, respiratory tissue, teeth, hair, neuronal tissue... you name it, it's got it. Frankly, it's kind of gross.

Now from a professional standpoint, these feelings are irrelevant. I would never break poker face in the clinic, lab, or in front of a patient. The old EMS adage applies: no matter how gross it is, pretend that you've already seen it a thousand times. But sitting in the back of the MBRB lecture hall, I'm allowed to grimace a little. It looks painful, and it's hard to imagine teeth and colon growing in my ovaries (fortunately, I don't have ovaries). I also think it has something to do with the way it was described. Pathologists should avoid using food metaphors all together. Saying that a hydatidiform mole looks like a "cluster of grapes," or that endometriosis resembles little cysts of "chocolate" is not appealing, especially before lunch. I just want to eat in peace. Personifying teratomas should be banned as well.

This here is a brunette teratoma. You can see her molars and incisors, but it looks like she lost her front two teeth... Oh! Here's a blonde. She's obviously not as mature as her brunette sister. Pun intended!


No no no no no NO NO!  You know what?  Let's just ban medical metaphors in their entirely.  Thank you.  Genital warts don't look like cauliflower, and your birth mark doesn't look like Jesus!

Like I said, fortunately I don't have ovaries. This has been an important revelation over the past week (if you haven't figured it out yet, we're studying the female reproductive system). Men are simple. Your testes either descended or they didn't. There are only a few types of testicular tumors, and the most common has a good prognosis. In a women, everything can go wrong. You can have ovarian cancer, endometrial cancer, cervical cancer, vulvar cancer, ectopic cysts in your neck or stomach that menstruate each month (!!!!!), endometrium in the myometrium, and all this crazy stuff. And don't get me started on the menstrual cycle with all the hormones that are being secreted and fluctuated. In fact, "Dear Girlfriends of Past, Present, and Future... you win." Jamie Foxx can blame it on the alcohol, but sweetheart, just blame it on your period. I don't understand what's going on inside of you, but it's nuts and I want no part of it. So, women, you can have all the babies you want and enjoy that "special bond," because I don't want it. I don't need an estrogen/LH surge or menopause.

Kendall Marshall, if you're out there, then I'm sorry. I retract last week's blog post. Find your own baby daddy.

Ode to Neuroanatomy II

Damn you Neuroanatomy, you've come back to haunt me!
With your cross-sections and nuclei, you eagerly taunt me.
You want me to remember it all? That's absolutely redunkulous,
Even something as simple as the motor homunculus.
But nay! I must recall the pathways for somatosenation,
And lesions of the paramedian pontine ridiculous formation.
Then you add pathology (ugh!), now I'm filled with nostalgia,
For a Block that's far less painful than trigeminal neralgia.

First year was simple, just little axons and gliosis,
But now studying this path gives me hyperhidrosis,
This year it's ptosis, psychosis, and the nucleus pulposus,
Plus all the co-morbidities of tuberous sclerosis:
Okay, you've got seizures, ash spots, and angiomyolipomas,
Shagreen patches, hamartomas, and rhabdomyomas.
But this is just the beginning of the tumors and "-omas",
There's the meningioma, schwannomas, and medulloblastomas!

Wait! I failed to mention the pilocytic astrocytoma!
And its nasty adult partner, the grade IV glioblastoma.
These diseases are no joke, it's all serious business,
That's why when I'm wrong on a question I get hemiballismus,
Not because I've lost the ability to inhibit my thalamus,
Nothing's wrong with the stimulation of my trusty G pallidus,
If I'm wrong I throw a tantrum, develop chorea, and flail,
Because I know I must study even more! Else I'll surely fail.

But if I fail I'll defend my ego with conscious suppression,
And turn back the clock like maturational regression,
Forget med school, I'll drop out! See what else is in store,
Maybe make like an oligodendrocyte and turn into a whore,
Myelinate dozens axons and forget all of my scruples,
Although I'd rather not end up with Argyll-Robertson pupils.
That work would be easier, I could get help from Cialis,
But it's these kind of thoughts that get you tabes dorsalis.

Now it's one year later, and I still can't pay attention in class,
My right hemisphere has failed me (again!), there's no way I will pass.

(in case you missed the original from last year, check out Ode to Neuroanatomy)

Robert the... Gastroenterologist?

According to Geico Auto Insurance, I am a doctor. Apparently 15 minutes can do more than just save you 15% or more on your car insurance; it can buy you a degree. To my delight, I am now addressed on all Geico correspondences as "Robert Swendiman, MD" and I don't intend to correct them. They must have seen that I'm a medical student or something on the latest form. It really is a genius business move if you think about it. How can I switch to another auto insurer now? I'm not dropping coverage from a company that thinks I'm a physician! I certainly can't move over to State Farm where I haven't earned my degree yet; I would have to start over from scratch. Not likely now that I'm a Geico-er for life (or until I get a real MD in a few years). Geico should start assigning degrees to everyone: JD, MD, MPH, PhD. I bet fewer people would drop their coverage...

Almost exactly a year ago, I posted about my first (and only!) failing test in medical school (see: "All Day Gunner, No More Funner" Robby). Talking about grades is a bit taboo, but since I did talk about a low point in my academic testing career, it's only fair to note, just once, that some things have changed over the past year. Yesterday was actually a decent example of how much my study strategies have changed. I was sitting in Bean Traders coffee shop at around 10:30am, per usual, studying with my headphones on, drinking my liquid crack, when a gentleman approached me and asked,

"What are you studying there?"
"Ummm, just some physiology right now."
"Oh okay.  That looks like a kidney right there.  What class are you in?"
"It's renal pathophysiology."
"Are you in medical school?"
"Yes, sir."
"Oh yeah?  Second year, huh?  You're actually taking my course right now.  Hi, I'm Dr. Hladik, the course director for your Renal block."

I'm sure my face flushed, since I clearly should have been on campus sitting in class at the time, but he quickly interjected, "Don't worry. I don't care if people go to class, as long as they study in the best way they know how. I'm just glad you're studying; this is going to be a hard test on Monday." I stop coughing (time to drop the "I'm sick - cough - couldn't make it to class today - ugh, cough cough"). Yes, I was indeed studying, but it was in an entirely different way compared to a year ago.

I have always thought that learning solo was the way to go. It worked for me all undergrad, and group sessions tend to get silly, dissolve, and eventually prove group theory. This semester, however, Matt Forgues and I have found a synergy that has led to improve efficiency: better grades with fewer hours studying. I tend to blow through material, deeming everything unimportant, while Matt likes to go over every detail in the course notes and powerpoints. What ends up happening is we cover the most important material in appropriate depth, skimming (yet touching upon) the minutiae in a very efficient manner. Matt and I have found success with this balance. He watches lectures and pulls information from the lectures, course documents, and slides; I study directly from the Board review books and skim the lecture documents. Between the two of us, we capture almost all the information in the block, discuss it, and apply it pretty well on exams.

So now, I'm starting to think that the first two years of med school are really just about learning how to learn a massive amount of material very quickly. Much of what we learn in the pre-clinical years will change, some of it may even be wrong. However, the ability to acquire a ton of information in a short amount of time is an important skill, and I think our class has adapted quickly. Knowing what I know now, I bet I could cruise through Biochemistry, which was such a shock to my system over a year ago. Dare I say, I would be interested in taking it again just to fully experience the change (and then I slap myself, realizing I never want to touch that material again - wake up, Robert).

With fewer hours studying and improved results, my test average is up double digits from last year. It also especially paid off during this last block, Gastroenterology. I realize that second year grades mean next to nothing; learning the material well for Step 1 and life is much more important in the eyes of residency directors and patients, respectively. Rumor has it that residency programs actually have to call your school to find out what your grades even were during your second-year (something that happens rather infrequently, I hear). However, I wanted to do just a bit better in just one block this year, and maybe throw an "H" on the old transcript. Respiratory was the block I was hoping for (see Block III/IV: Breathing vs. Poop), but I just wasn't able to squeak out that top fifteenth percentile score. Needless to say, after ranting and raving about how much I detested poop and have no future in Gastroenterology, of course that was the block for which I was able to get a little bit of luck, and grab the elusive "H." Again, it is essentially meaningless, but it's nice to get the monkey off your back (or, prove to your Mother that it's okay to sell calendars for charity in the midst of school work!).

This, hopefully, will be the last time I talk about grades, but for my own retrospective purposes, it's nice to have a collection of high points and low points. The ups and downs in the roller coaster of life need to be documented so one can look back and see what worked and what didn't. And in a few years when I'm considering specialties, maybe I should consider GI, since that was one of my better blocks.

Or not.

Breathing vs. Poop

Right off the bat I'm going to have to ask those of you who love poop and just can't get enough of it to stop reading now (Clodagh, that is your cue to close your browser).  Now then.  I don't like it.  I don't like anything about it.  I don't like the way it's made, the way it smells, the ingredients... nothin'.  The only part about poop that I actually enjoy is what it came from, i.e. food.  But our Nutrition block isn't until spring time, and taste is covered in Neuro, so until then it's just poop.  Poop, poop, and poop.

Now I have to contrast that to Respiratory, because GI is the block that followed.  Oh, the beautiful lungs!  So rhythmic and mechanical.  Expand and contract, expand and contract.  Now here is an organ that makes sense!  You don't have to memorize silly enzymes and liver panels, or gastric juices and pH balances, and most importantly: no fecal matter.  I tried to think of anything in the lungs that was even closely related to POOP, and the only thing I could think of is BOOP (bronchiolitis obliterans organizing pneumonia).  These two subjects are on opposite ends of the spectrum for me, and I will be glad when Thanksgiving break relieves me of this crap.  Pun intended.

All whining aside, pulmonary medicine is actually the one internal med specialty that I could see myself doing.  I even went to the "Careers in Pulmonary Medicine" lunch talk to ask questions (look at me the active medical student!).  I'm in love with the lungs for 2 reasons.  First, they just make sense.  The reason I chose to be a chemistry major in college was because most of chem isn't memorization.  It's application.  Once you learn how things are supposed to work, you can figure out what is going wrong and apply that knowledge to new systems and pathologies.  The concepts build upon themselves.  Now it's fair to note that in the past I have loved anything that required the least amount of work (I was a sprinter, remember).  But it's nice to be able to attack new problems with applied knowledge.  The lungs are a lot like that.  Once you learn the anatomy and physiology of the trachea, bronchi, bronchioles, alveoli, blood flow, etc. (fairly easy concepts), understanding disease processes is simple(r).  And pulm physiology has a lot to do with physics, forces pulling in different directions and such.  The lungs are a good gig; I could see myself doing EM, then critical care, and then into pulm at some point.

The second reason the lungs are so great is that they are the "A" and "B" of the ABCs.  In EMS (and the rest of medicine for that matter), everyone's gotta know their ABCs.  Airway, Breathing, and Circulation.  This is what you're worried about when keeping a patient alive.  And since "A" and "B" come first, there's nothing more important than the lungs.  I've heard a lot of paramedics say that traumas are the easiest cases.  Why?  Establish a patent airway.  Are they breathing?  If not, breath for them.  Do they have good circulation?  If not, ratchet up that heart a little bit with drugs or just pumped it yourself.  Stop any major bleeding.  Maybe give them some fluids.  Boom, get them to the hospital.  Easy, manage the lungs because that's the key to life.  Why???  That's right you said, the rent is too damn high!  Sorry, I mean "that's right, the LUNGS are the most important organ!"  (Sorry, I guess we all got a little Jimmy McMillan in us after that election).  Seriously though, I believe the course directors in Respiratory are the only ones that can say their block is the most applicable to life.  I'm also clearly very biased.

Until Thanksgiving break, however, I will suffer though feces.  I'm going to have to try to own it though.  "People like studying what they like.  It makes them feel good." (courtesy Dr. Dent).  This summer I tried to start owning some Biochemistry, since that was my least favorite course as an MS1.  If I can nail Biochem and GI together, it's going to be some good prep for the Boards.  That's my goal.  FTS.

But until then, I leave you with a respiratory Haiku.

Breath in, out, repeat.
Life, a new baby is born.
Death, a final gasp.

Block III: Cardio and Community Week

Whew... and breathe. It's good to finally have a break. Block III: Cardiology ended Thursday, with a final exam average over 10 points higher than that of the HemOnc-ster. We literally went from the hardest block in the first two years to the easiest (as far as grades go). But as far as importance, this material was certainly the highest yield. Every patient we see in the clinic and hospital will receive a full cardiovascular (CV) exam; and since heart disease is the number 1 killer in the United States, all of us will see patients with CV pathophysiology: strokes, heart attacks, murmurs, palpitations, etc. Nothin' more important than the ole ticker.

Having Cardio right before Community Week #3 is going to turn out to be quite fortuitous. Last year I was frustrated with how little I brought to the table during these weeks here in Boone, NC. I could take a history, perform a focused physical, and I learned how to make helicopters out of Popsicle sticks. But I was annoyed with how little I actually knew. This time around, I feel like I now know at least a little bit about something. With Immunology/Microbiology under my belt, I have a better understanding of the diseases that most kids present with in clinic. Mycoplasma, Group A Streptococcus, otitis media: these are no longer abstract words associated with simple phenotypes. I have (at least basic) knowledge of the mechanisms of these diseases, and a bit of epidemiology behind them. That course allows me to develop more coherent differential diagnoses in clinic.

Cardiology will make the physical exam so much more meaningful. Last year I felt I was just going through the motions. I would listen to the heart in the aortic, pulmonic, tricuspid, and mitral areas over the chest and say, "Yup, there's a heart in there all right." But now I can listen to each beat and attempt to hear other sounds like murmurs, snaps, and thrills. I can ask a kid to take a deep breath and hold it, then listen to physiologic splitting of S2! (As the chest wall expands, a decrease of intrathoracic pressure during inspiration causes increased venous return and right heart volume, thus delaying the closure of the pulmonic valve, essentially... look at me with all this knowledge!). Pathologic splitting can be due to many things, including an atrial septal defect (ASD - fistula between the left and right atria), aortic stenosis, etc. These are the types of things I get to listen for this week!

So my goal for this Community Week is twofold. First, I am going to attempt to perform a full CV exam on as many patients as possible. That will include inspection (simply looking for pathological findings such as cyanosis or "clubbing"), palpation (touching the patient to identify the point of maximal impulse of the heart, i.e. is the heart oriented properly), and auscultation or "listening" with my trusty stethoscope. Hopefully by the end of this I will have that exam down cold. Secondly, I have to write two SOAP notes by week's end. SOAP stands for Subjective, Objective, Assessment, and Plan, and this is the type of note that I will be writing every day next year in the hospital to update a patient's status. Next week's blog will feature one of the SOAP notes I write this week (obviously with much of the information tweaked for patient privacy), and will essentially be my first attempt at documenting patient care. Hopefully in years to come I can look at how awful my first notes were and laugh.

This is nice. It is much easier this time around to focus on learning and preparing for third year. No more haphazard shadowing.

Upon return it's back to the grind with a three week Pulmonary unit, then GI, Thanksgiving, and the Urinary System. It will be Christmas before ya know it!

Block II: the HemOnc-ster

She is pictured left, the HemOnc-ster. Block II (out of eleven total) has the reputation of being one of the toughest in the second year. After the "wake-up, let's roll" introductory class (Block I: Tools for Diagnosis) where we were in lecture from 8am to 5pm almost every day, the more typical MS2 schedule began with Hematology-Oncology. Case discussions were every morning from 8-10, followed by two or three lectures through noon. The professors' PowerPoints were essentially 1 disease for each couple of slides (60 or so slides per lecture), and these pathologies would be the topic of case conferences the next morning. HemOnc is especially notorious for its amount of memorization and commitment to minutiae, and we weren't disappointed. The final exam average was around a 79 (the reason previous classes have dubbed this exam, "the HemOnc-ster"), which is the lowest average on a test that I can remember. I don't think the average has ever been below an 80 (and if I'm wrong, an angsty med student will surely correct me). The test questions were extremely detailed and a bit picky, so quite a few people I know thought they had a better grasp on the material than their performance gave them credit for (including myself). My least favorite question-types on these exams are, "Which is MOST CORRECT?" or "Which is the LEAST CORRECT answer choice?" All the answer choices my be right, but one of them is less right. Wonderful. I can't wait for my first patient to present to the emergency room with a multiple choice notecard on her forehead that says:

I am sick. I MOST CORRECTLY have:
a) TB
b) nodular-sclerosing Hodgkin's lymphoma
c) CHF
d) otitis media
e) all of the above
f) some of the above
g) none of the above - now i'm dead thanks to you...

But hey, moving on. There's no multiple choice in real life.

This year has certainly been a wake-up call. Ever once in a while, folks that I knew in my previous life (aka college) ask me how it's going. I usually say, "It's going, it's going. This year is a helluva lot tougher than last year. Way more studying." For some reason I expect a modicum of sympathy from this response, like I didn't choose this career path. Or perhaps I shouldn't have to put in all these hours in the coffee shops and library. I don't know why I am looking for sympathy. I know that this is a demanding career. I know that I didn't sign up for a nine-to-five or other normal job, and med school is supposed to be difficult. I guess I just simply wasn't ready for my free time to dwindle so rapidly. The pass/fail system made last year extremely easy (excluding biochemistry), and I had plenty of time to undertake many other endeavors. The material wasn't as important, and tests were biweekly. Now it feels like I'm studying for a test every few days. I told Mike Wilson that this would be a tough fall, and he said, "Good. I don't want my doctor to be an idiot."

Fair enough.

So, slowly I have settled in. Very slowly. I recognize now that I won't be able to do the same things as last year, and I'm going to have to put in a lot more work. Next year the days will be even longer (although I won't be sitting on my ass all day reading!), and residency will be the toughest. But mentally I've started to get my head around the fact that this is life. This is what I've gotten myself into. And maybe, just maybe, I'm ready.

So bring it on, Cardio.


(I was later corrected that the lowest average we've had on an exam was a 78. It was on the cardiovascular test during physiology this past spring... thank you angsty med students!)

Tools for Tools

It's hard to imagine that a week ago was the first day of class, and now Block I is already over and out. It was a whirlwind tour. Class from 8am to 5pm everyday, and then the pleasure of having Thursday afternoon off to study for our final exam at 1pm Friday. Certainly I am reminded that I do not miss middle or high school. All day in the classroom just isn't going to do it for me anymore. Somehow I had a better attention span as a 14 year old boy than I do today as a medical student, which is rather disheartening. And even though this was supposed to be an "introductory" block, focusing on tools for diagnosis such as radiology and pathology, it turned into a disorganized hodgepodgery of CSI forensic medicine mixed in with the histology of neoplasia (cancer), and a pinch of interventional radiology on top. In the spring I thought histology really looked like the work of a mentally challenged blind fingerpainter; but now I am certain that these cancer slides are masterpieces of the K through 5th special ed Sunday School class at University Presbyterian under the microscope. These professors have been messing with us all along.

Our second year is broken up into 11 blocks, 7 more than we had last year. First year was roughly divided up into quarters: Biochemistry, Anatomy, Physiology, and Microbiology/Immunology. This year we retake in detail all the organ systems we learned in phys, adding disease into the mix. For those of us who came to learn not about the normal human, but the abnormal human, we have arrived. We made it through the first year of hazing. I am hoping that this attitude will help me enjoy the extra hours of work in the upcoming year. Already I can see that most days will be consumed by small group, class, studying, studying, and studying, so I will cherish every moment of free time. For this first final in Tools for Diagnosis, I was more prepared for the exam than I was for any test last year. It was a good feeling having some real knowledge this time.

So this fall is going to be a doosy. Every day we have class from either 8am to noon, or 8am to 2pm. Small group is generally going to be from 8 to 10, followed by lectures. Monday afternoons I have Introduction to Clinical Medicine II from 3:30pm to 6pm, Tuesdays I have Health Policy (my elective) from 1pm to 2:50pm, and Wednesdays/Thursdays we all take Clinical Epidemeology from 2pm to 3:20pm. Add in studying, exercise, and errands, and you got yourself a nice little week there. Luckily the latter two courses disappear in the spring, allowing for more prep time for class and the looming Boards. Oh, and I some point during this debauchery I need to find some time to breathe, go watch Keith and Jon get married, and get away to Troutman a few times before the cold.

I called Block I "Tools for Tools" because we still really don't know anything yet. I feel like first year taught me nothing, except a few fancy words I can throw around at the dinner table to impress my parents (else they think all I do is make YouTube videos day in and day out). We're just tools. We start Hematology and Oncology this week, and it promises to be one of the best and hardest courses we will take in our first two years. Among us there is a real feeling that after this year we will have a wealth of knowledge: earnest, eager, and ready to hit the wards. That's momentarily a satisfying feeling, but then we will feel utterly helpless as attendings in the hospital stump us at every turn. And yet again we are tools! But soon thereafter we will graduate, feeling empowered and accomplished. Dr. Robert A. Swendiman, MD, yes sir! That day will come! And then we will move to new cities and towns to become interns, the ultimate tools. 80+ hours of week of being everyone's bitch (although at least we don't have to wear the short white coat anymore). The attending's bitch, the chief resident's bitch, all the other residents' bitch, the patient's bitch. Then we'll be tools as fellows, and tools as junior attendings. And by the time we have the seniority to no longer be a tool, I will be collecting Social Security and signing up for AARP magazine.

I guess we're just all destined to be tools for the rest of our lives.