Book Support Bizarreness

"I have never tried to convert medical students into textbooks. If we did, we would clearly be forced to lower tuition since the best composite of medical knowledge can be purchased for about $150." (Steadism #166, p.55)

I cannot believe what I just heard. The instructor, in a desperate attempt to justify this lousy course, used the textbook choice to justify it. The author himself says the text is geared for "resident physicians studying for post graduate boards." We are first year medical students.

That is, however, completely beside the point. This is the most ill conceived, poorly designed, busy work infested courses I have ever taken in my educational career. But arguing about it is absolutely futile. God, give me the strength to just get through this...please!

New Storm

Tropical depression could form near Cape Verde Islands

A low-pressure system in the Atlantic Ocean approaching the Cape Verde Islands could become a tropical depression before moving over cooler waters on Thursday, the US National Hurricane Center said Wednesday afternoon.

NOAA graphic - disturbed weather near to the Cape Verde Islands just off the coast of Africa

The system was moving to the northwest at 10 to 15 MPH and could cause heavy rain and gusty winds over the Cape Verde Islands later Wednesday and Thursday, the NHC said in its 2 p.m. EDT report. If the system strengthens into a tropical storm, with winds of 39 to 73 mph, the NHC will name it Edouard. The weather models showed the system would reach the middle of the Atlantic Ocean in about five days.

Hang Loose

There are qualities about island cultures that would best learned by medical students. We are thrust into a process of mind altering dimensions and told to relax. We are threatened with tests and future boards and told to chill out. We are constantly drilled on the need to learn every little detail or we may "kill the patient" but told that medical school is just medical school. The mixed messages aside, the environment can be stressful and some perspective is almost mandatory.

Such was a note I got today from a friend, physician, former physician assistant, and all around great guy. He said..."Guess what? It doesn't get a whole lot easier but don't get discouraged. Don't sweat the small stuff. It's all going to be worth it in the end. Keep pluggin' and remember why you are there.  Be cool."

When embroiled in the "stew", under the fire of learning the details, it is sometimes hard to see the "why" I am here. I know it's all worth it in the end. I've seen the end. I won't get discouraged. It'll only get more interesting and clinical. But, I really need a break.

Sunrise & Sunset

Each passing day, allows renewal and reflection. We live in a beautiful world, full of blessings, if we are willing to look for them, and see them for what they are. When we are consumed with finding the negative, what's wrong, faults of others...we'll find them. When looking for beauty, blessing, positives...we can find that too. A friend and colleague reminded me of that when she sent this photo, from her boat, of sunset in the Florida Keys.

Just finished 45 slides of head and neck content. Who knew there we so many holes, grooves, fosses, curves and angles in the base of the skull (I actually did, but forgot most of them). A neurosurgeon handed me a drill one day and let me start the craniotomy going after a subdural hematoma (likely middle meningeal artery disruption from a fall). I wish I remembered more about the anatomy of the skull, and less about the excitement of being able to participate in neurosurgery. Got some time today between classes to study the last 3 lectures. Noon conference is on evaluation of the cranial nerves. Looking forward to that.

Then Don't Ask!

I learned a lesson many years ago. As an instructor, if you really don't want to hear what is on the mind of students, don't ask! Once you ask, you invite commentary...and damn if that isn't exactly what they got today. The anger in this class is so palpable related to public health, with a strict division between those that performed well, and the many more that didn't on the last exam. And the latter let it rip today!

It is remarkable how everyone in the world knows what's on the boards, and uses that as justification for everything. The bottom line is that nobody has a clue what will be on their boards. I believe that I can rest comfortably knowing that I won't have to pick out the Pearson Correlation Coefficient formula from a list of formulas.

And using a book designed for public health resident MD's to study for their specialty boards for a first term public health course is total INSANITY. So don't justify the course by the book, or the bad questions used from the question bank that came with the book. What a crock!

P.S. I didn't open my mouth today. Everyone else did it for me.  I'm not justified by their comments. I am very sad that this is one of the worst classes I have ever taken post post high school...I actually like public health, and population healthcare. Worse, I am dismayed that many of my colleagues will view public health thru the discolored, distorted lens of this class.  It soon will be over, and not a moment too soon.

Ready, Set, Go

We are endowed by our creator with certain in alienable rights. Among there are life, liberty and the pursuit of being able to wear anything we want during Summerfest Carnivale. And so it was. Everyone brought out their most visual frockages for the last parade, marking the near end of this festival season on Statia. It was hot. It was loud. The beat was strictly for hip movement and "jumping". And now, it is OVER...at least for another year. I found it difficult to study in the silence, without the music in the background. One of the utility truck's carrying more speakers than band set up right outside my apartment. But study I must.

End of Summerfest brings the start of the last push for finals. Looks like histology is actually going to finish new content early and then actually do a final exam test prep for the last week or so. That is a great relief. Anatomy will consume most of my time between now and then with all of the pelvis, genitalia (male and female), and head and neck with all the intricacies. I am reminded of the 8 hour "face-ectomies" I first assisted in back in Daytona Beach, with all the nervous structures to preserve while dissecting out massive tumors in tobacco smokers and chewers. "Pinch and cut, pinch and cut"...long hours working in a 6 inch and 6 inch space. Dr. S was a great surgeon though. You'd think I'd remember all that anatomy then.

Yesterday I plotted my strategy and tried to find a psychological worm-hole to the end. Day by day...it'll be over very soon. Oh, did I fail to mention public health? Today was the review for the last exam. My only saving grace is that they noted that the performance on this exam was the worst they had ever seen on any previous exam in 6 years. I'm comforted. I've got my study-game-face on. Finals here we come!!

Last Block

The 5th term party was last night as well as a potluck dinner with a cross section of the classes. It was nice to see everyone in those non-school venues and relaxing together. Besides, the potluck food was great (I brought Macaroni salad). The 5th term party was a "send off" for those about to leave the island.  For the next several months those folks will study and take the USMLE part 1 and then begin rotations in the U.S. and the U.K. They all look relieved, happy and very excited about their futures. They should be. This last block of testing took the wind out a bit. This was recoup weekend with planning for how to get through the last part of the term. Feeling a bit more energized today as I begin to hit the new anatomy, contemplate the other. It is time for that final push toward finals and that is going to require attention to deliberate study on my part. I'm ready. "Do not dwell in the past; do not dream of the future, concentrate the mind on the present moment." -- Buddha

Dive Wonderful

To celebrate the end of the exam period and the five year anniversary of it's sinking, a GREAT dive today. It? The Charlie Brown...former ocean going cable laying ship, and one of the ten largest wrecks in the Caribbean. It is almost 350 ft long, and sits at about 100 feet underwater. It was a nice break from school reality to dive there this morning. Just 4 of us (one dive master) and all experienced divers (I think I was the least experienced)...great time.

It is truly an amazing experience to dive such a huge wreck.  After tying up to the buoy at the aft of the wreck, we suited up.  We then backward entered into the water from our Zodiac and moved quickly to deflate our vests and descend. The current was amazingly strong today and pulled hard to get us to move away from the buoy marking the wreck. The quicker you go down, the better...I did. I've learned that if you don't, the struggle to swim back "up current" is hard work. What I didn't know is that in our position, the current was the strongest as it moves toward, up and over the wreck...I vaguely remember the principle of flow over a surface.

We swam over to the buoy chain line, and began the descent into the deep, deep blue. Then, there it was...the propeller at the end of the buoy chain.

Imagine the view from the back....a full football field in front of you, the massive ship laying on it's right side on the sandy bottom. IMPRESSIVE. MASSIVE. And it was so quiet.  I could only hear my breathing (thank goodness) and the sounds of the occasional beep of my dive computer. I strained to hear other sounds like a far off humpback (wrong season) or creaks of the ship. I don't ever remember a silence like this, but my mind was pretty fixated on the ship.  Among the highlights: penetration of the ship in the large hallway called "The Highway", a face to face with a 5 ft. barracuda (mostly teeth), schools of Horse-Eyed Jacks, nudibranchs all  over the surface and a drive-by with a turtle who came up to me to check me out.  I never tire of the beauty of this part of the earth below the surface. I'm thrilled that my biology background has come to some usefulness.

To me the Charlie Brown is Statia wreck diving at it's best. She is a wonderful addition to the artificial reef program here, as well as to my dive log.  I am so blessed to have the opportunity to dive here and truly enjoy what it has to offer. Beyond the recreation of it, a chance to relax after a hard exam period, and relish in the beauty that is life of the seas.

300, Failures in Stats

I recently had a very short, yet interesting, and revealing discussion with the instructor of our stats class. Apologetic even for the exam and the annihilation of many students, but quick to point out that it "served those right" that never come to class (and I would agree). Unfortunately many did poorly that are there everyday, get extra help, attend the review and tutor sessions and work their assess off. What about them?

To have anyone with under 30 out of 100 would be tragic let alone statistically important. But to have as many as we did on this exam, it is truly problematic. But like the foe of Sparta, if you perceive yourself as a great, kind teacher, and God of knowledge, then there is only carnage and repeat of the gesture for future classes. There will be no learning here without intervention. I hope quickly for the sake of future classes, and our futures. And by the way, it shouldn't be those that scored well that are consulted about how the experience went. Administration would be best suited to ask all those that scored the average or worse, below the parametric low mean, in the left handed tail.  For in their descriptions will be the truth of what happened here (or what didn't happen), and what apparently has happened before in this class at the "Hot Gates" of Statia.  We brought many warriors. They only brought bad questions and a truly skewed perspective on what it is we are doing here.

Summer-Fest Carnival

Almost on cue after exams...It's a holiday on Statia...Summer-Fest.  I celebrated donation of my body parts to the exam process by going to the Summer-Fest parade today.  It started at the end of the airport runway, and wound it's way around the island "villages" and neighborhoods.  With 5 truck-pulled floats, 2 police trucks, 5 groups or troupes....it was considered a successfully, big turnout for Statia.  The Adventist weren't there though...it's Sabbath today. Did I mention one of the biggest populations here is 7th Day Adventists?

Carnival here is part religious, part cultural, part debauchery...a mix of fun, party, theater, folklore and a good excuse to close all the stores and leave work.  Hard to tell the origins but best I can tell it is a manifestation of the celebration before Lent, from the Catholic, 'carnevale'-which means "to put away meat." Somewhere along the way during the rape, pillage and conquest of the islands, Catholic Europeans involved in the slave trade brought carnevale here. Here it has almost become a celebration of emancipation and is celebrated with festivals year round.

Carnival, as it is called now, or Summer-Fest here on Statia, is celebrated on all the islands. Substance beyond the senses is not present, but not meant to be anything more than African rhythms, dancing, music, food, drinking, bands and parades.  Important to the Caribbean festival arts are the ancient African traditions of parading and moving in circles through villages in costumes and masks. The parade today was just that. As it wound through the streets of the island, it is meant to bring good fortune, to heal problems and chill out angry spirits.

There is an amazing amount of creativity that goes into the costumes and band floats. I've seen people working on them for weeks before today.  The "groups" walking behind a band float wear the same costumes. The band floats are mostly speakers and drown each other out as the parade passes by. Clearly the one with the most "amps" wins.

If you try to search for deeper meaning, you waste your time. That is not what Summer-Fest is about. It's about the joy of living.  Mostly what I saw was friendly, care-free street partying, where people smiled, joked and forgot the ills of living on Statia. In any event, it was a fun time away from the books for an hour or two and a wonderful celebration of the end of exams. Only 27 days left in the term.

What is it REALLY like

A former student of mine recently contacted me when she heard that I had gone back to medical school. I was thrilled to hear about her success in surgery and life with kids and husband (sounds remotely like a life I once knew). She asked me a simple question..."what is it really like?" She's been actually thinking about medical school for some time. I did my best to fill her in on the nuances of the learning, the process, the goals, my experience in school, the battle of memory and my choice. I think I was pretty honest about it, open about the pros and cons, balanced about the reality of this.

But then I got to think about what it's really like. It is, as I've heard before, like eating an elephant...it's a lot of material to digest, in a short amount of time, and after awhile, you'd like to have another dish or something sweet to eat. And while the class is supportive and we are all in it together, in the end this is a very individual experience predicated on personal tenacity, goal setting and resolve. This is not a group experience except as we attack the elephant to eat. And trust me, if anyone of us should go down, there would be about 1 second of grief and I would become that other dish or "something sweet" to eat. I have no delusions, at least about that.

Scream

I'm pretty sure Edvard Munch was thinking about public health statistics at Statia when he painted....

 

I believe those are the instructors walking behind on the bridge...actually they are running, chasing...

Rumination: n.

1. The act of pondering; meditation.

2. The act or process of chewing cud.

Both good qualities I think.

Purposeful Hurdles

After the tragedy that was the last block of medical stats, I searched for the "greater picture" so as not to get swallowed up by the "Dune"like sandstorm that it felt like.  I drifted into the thought of purpose and the hurdles that are important and those that are not so important. Important 1) the practice of ethical, safe, economical medicine, and 2) Pass USMLE Step 1, 2 (after clinicals) and 3 (after residency).

It's no secret that this exercise in study and intellectual basting has a purpose...USMLE Step 1. Sometime in about 20 months, it'll be our turn. The last term folks here are studying diligently for their go sometime this fall and I've learned some things over the past few days.

Passing score is a tightly held secret by the National Board of Medical Examiners but hovers around 185 each year.   The average score, estimated from the published distribution is about 214.  While not the only factor used in evaluation and purely speculation on my part, top internal medicine programs are looking for step 1 scores of 230 or better.  That would be a great goal.  215-230 would be a fine finish given the advanced plaque formation in my Circle of Willis.

The consensus seems to be, start studying now. I thought that was what I was doing. But, it's going to be more...questions everyday. I've got many resources and many have been recommended. The key is to do a little everyday and then after 20 months, I'll be ready for this first career hurdle. I appreciate the insight of the "last termers" here and their perspective on what it will take over the next two years. In all, I've got to keep the greater picture in mind else I will truly go mad. Or perhaps I'm already mad, and that is the reason I'm here?

Stats and Thou

I take full responsibility for the train wreck that just happened. I am fully to blame.  Over 20 hours of study (obviously the wrong things)...I'm really sorry I wasn't more prepared for the exam today, but I don't know what I could have done different.  I think I just passed it. What a miserable feeling.  Knowing what I know about USMLE and the use of statistics in medical practice, this class misses the mark so far afield that I probably psyched myself out. It was clearly the biggest challenge I've had since arriving here...one I hope to never repeat. I can see clearly that statistical research is not my forte'. Best to know what you can't do, than what you can do at this point, right? This class could be so good if the focus was actually clinical preventive, public health services. Ok, testing is over for this block. Finals looming in the not to distant future. I'm relieved, but so disgusted at the same time. Like someone said, "it's only medical school."

Just Wondering

Ever notice that "studying" is the contraction of student + dying? I love public health, I love public health, I love public health...it has been said that as you repeat the words, the actions will follow - NOT IN THIS LIFETIME! 4 p.m. cannot happen too fast today...

Various and Sundry Poisons

One absolutely wonderful aspect of living in a foreign country with lots of bugs is the availability of pesticides that are banned back home. I bought some stuff the other day that is banned in most developed and developing countries (Statia is in neither category). It not only kills bugs when you take the cap off, but it peels the paint off most surfaces. I can almost feel my laboratory mouse cancer cell titer going up and my bone marrow suppressing itself as I spray. Is this a great country or what? P.S. Got an A on my histology an hour ago...B on my combined Anatomy lab / lecture and have only Public Hell to go. I celebrated the end of today by taking a dip in the Caribbean. It was delightful.  I am confident that making it past tomorrow gets me over the hump and heading toward the end of the term....29 days to go, but who's counting? I am. Back to study so I can increase my confidence level to over 50%, one standard deviation from the mean, with an alpha=.50. Hopefully my sensitivity for detection of correct answers (positive outcome) will be greater than 80% and my false positive error rate will be low. Ahhhhh...save me from the stats monster!!

Anatomy and Rectums

Well I wasn't surprised by the lecture exam. It was as challenging and pedantic as the lab. In many ways, I am vindicated by the fact that no matter how hard I look at anatomy and study the infinite details, my clinical knowledge just gets in the way of sorting the important from the unimportant. I constantly get in the way of myself in the search for practice-based knowledge. Example, a question about the average locations of swollen rectal veins...nice to know, but in reality, you examine, locate and treat. If someone presented with complaints of hemorrhoids that didn't fall into the average location descriptions it would be inappropriate to say..." I'm sorry sir, I can't treat you because your problem falls outside of the description for the average location of this malady your are suffering from." Sometimes we are so consumed with the language and definitions in the practice of medicine that we miss the mark...those skills we need to practice. Another example...nice to know that a foreign body will likely fall to the superior segment of the upper lobe of the right lung when a patient aspirates laying down...but in practice, you go find it...WHEREVER it is! I get the "prediction" piece, but the practice of medicine is about taking care of the how things present, not falling into bad habits related to general rules and descriptions. I am overall pleased with my performance. I'm pretty sure I beat the class average and understand the material pretty well. I get where this is all leading and I'm sure that my core understanding is solid so I can transfer these skills to my history, physical examination and assessment skill set. It would be nice to be able to practice those skills at the same time.  Call me crazy, but laying a stethoscope on a chest when you are learning the locations of cardiac valve auscultation is a reinforcing and positively educational experience. It will only require many to go back and review what we just did when we get to that point in our education. Dr. Stead was right...this process has really degraded over time. Remember, medicine was an apprentice "sport" way back when...you learned by doing as well as reading.  Onward to Histology... As a parting thought, I wish other students would realize that if they would get out of the way, the process will reveal itself and that fighting it only ruins the process, and makes it bumpy at best. We have at least one person in the class who thinks he knows better than everyone else about everything. The fact that he is a total antisocial idiot and only gets in the way of our learning is my latest mental challenge. Ahhhh nammmmm....I can only hope that he is blessed with rotation attendings that not only aren't tolerant of his behavior, but publicly rebuke it. For if it continues, he will become one of those physicians who disrespects nurses, is in conflict with administrations and colleagues and treats patients as objects of his knowledge and skill. We don't need any more like him in medicine. Where do these people come from, and how do they end up in the healing arts in service to others?

Damn, Lab#3 Exam Done

There are good tests and bad tests, as defined by the testing experts. There are good questions and bad questions as well. When you merge good tests with good questions there is magic, and learning reinforcement. But it seems that all exams fall short in some way, mostly related to their construction of questions in a reactive manner to what has been presented and the dynamics of a given class. Exams should be proactively designed to the learning goals as established with the end in sight. If you want to train good doctors, the goals should address good doctoring skills. Then "test" what you need for students to know about those goals and skills.

I know how difficult it is to design good exams. I've tried and failed many times. I think overall this anatomy lab exam that I just oozed out of was a good one..challenging, educational, insightful. Everyone should not emerge from an exam thinking they did well. I don't think I did, and clearly I wasn't alone. But having said that, some of the questions outright sucked.

The sacral hiatus? C'mon, give me a break. An arrow pointed to a single lymph node on a chest xray instead of the hilum of the lung? You have got to be kidding me. We haven't even had radiology or clinical medicine yet. Laying a deflated, discolored, flat stomach on a table out of a cadaver (one we've never seen)? It looks like mesentary. Orienting a liver upside down for identification of specific left/right, up/down orientations? Nothing we would have to do in clinical practice. The logical question; why? For what purpose do these identifications feed our greater doctoring goals.

I would guess that out of the total about 15% of the questions were not only not emphasized on reviews, in lecture or in the book, but were clearly miniscule elements of knowledge that were way out of bounds of the knowledge necessary for the skills we will need in clinical practice. Not a single question about the lung segments we will soon auscultate.

I haven't a clue what grade I earned.  I studied my butt off for this one.  I hope I got my every loving B, but I do know that while overall a good exam, there were some horrible questions...and I don't think I'm alone in saying that.

P.S. (4 hours later) I love to read what I wrote after I find out my score. I did just fine, and beat the average enough to feel like my study and understanding it solid. But my gut feelings about the exam have not changed just because of my score. The more clinical the better IMHO.

Inspiring

"A master can tell you what he expects of you. A teacher, though, awakens your own expectations." -- Patricia Neal

I am continuously amazed at how good teachers inspire. Such is our anatomy instructor. There is little he doesn't  know...from memory. Truly amazing. Answers to questions, regardless of the depth or sophistication, from student are answered with nary a pause. Sometimes, he glances up or down, briefly pauses and then spews volumes of information and clinical relevancy about the topic at hand. Today, he conducted a complete review of the thorax and abdomen in the lab for nearly 2 hours, without break, breath or notes. AMAZING and inspiring. Regularly he awakens my own expectations and raises the bar higher for my own performance. Like the many I've had before him, I hope there are many more like him along the way. He makes me pay attention to the fine points of what is, the foundation of care. Dr. McKelvein, that crusty, chain-smoking, thoracic surgeon who taught me more about the human body in health and disease than most of my professors put together once said...with a complete understanding of normal anatomy and physiology, everything else in medicine is cake. I get that.

P.S. When did plastination (plastisized real bodies, like in the "Bodies" exhibit, become so integral in anatomy lab? I missed something of the technology in these past 25 years.

"The moment one gives close attention to anything, even a blade of grass, it becomes a mysterious, awesome, indescribably magnificent world in itself." — Henry Miller

Storm Dissipation

As of today, the new storm appears to be dissipating into the oblivion that is the waxing and waning of stormage. Of course, that could change in an instant, but complacency will likely find it's way back to the student body here in just a bit. For now, doesn't look like much more than a stiff breeze and some rain.

BTW, I went out to Fort DeWindt (Fort of the Wind) yesterday during a break (one of my favorite escapes)...just to reflect and dissipate some inner storm from "life". I stood on the wall surrounding the gun platform facing the Atlantic Ocean (where the Atlantic merges with the Caribbean). I closed my eyes and the 25 mph wind felt like it was going to blow me off. I hung suspended for a moment...almost like I was "taking off"...What a feeling! I think I heard Celine Dione singing something from Titanic in the background.