Ramblings on healthcare, medical education, and life with a spinal cord injury
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Category — Case Western

Just One Teensy Step

Two days ago, I took a huge step forward. No, not that kind of step this time. A metaphorical one. One of the major rites of passage in medical school is taking the first part of the US Medical Licensing Exam, or USMLE, as it’s cleverly known. The test is administered over the course of several years in three sittings, known sequentially as Step 1, Step 2 and Step 3, and taken after second year of medical school, during fourth year, and during the first year of residency, respectively. Medical students tend to refer to this first part as “Step 1,” or “boards” or “that $*#^% test.” I’ll just stick with “Step 1″ for now, this being a family kind of place and all.

One must pass all three in order to apply for a medical license in most states, I believe. Step 1 is an eight-hour marathon of questions. There are seven sections, each containing 46 multiple-choice questions and lasting one hour. You get 45 minutes of break time, plus a 15 minute tutorial that you can skip and add to your day, thus providing 60 minutes of break time to allot as one sees fit. And any time you have remaining when finishing each one-hour question block is also added to your break time. Take three sections back-to-back, then a full hour off, then four sections back-to-back if you like. Or take all seven straight through and be done in seven hours if it’s your preference. Based on solid advice from a good friend, I brought plenty of caffeinated beverages, fruit, snacks and a small lunch. Way too much, but better safe than sorry. Rather than one huge break, I took 5-10 minutes between every section with a bit longer for lunch and just tried to maintain a steady pace all day long.

It’s hard to overestimate the stress that this singular exam can put on students, and it’s important to keep one’s mental state in check. Yes, residency program directors do look at Step 1 scores as an initial guideline for who to invite for interviews. And it’s one of the biggest single components of a residency application. But of course, it’s not the only part. We were given eight weeks of time to prepare ourselves and even at the end, there’s always something more you could have studied. One more time to have gone over the microbio notes. One more time to review pharm. Just once more, I need to look at Wegener’s granulomatosis.

But it’s ok, because no matter how hard you study for this beast, there’s always just a little more that could be done. And what’s interesting is, I’m okay with that now. This is drastically different from when I took the MCAT five years ago. I left that test freaked out, thinking I should have cancelled my test right then and there because I was in such a daze that I was sure I’d bombed it. Well it turns out I didn’t bomb it, so I’m glad I didn’t cancel my score.

This time I didn’t even feel that urge to cancel it or feel overcome with concern. It was a test I’d known about as being a gargantuan stepping stone since long before I applied to medical school, and one which I’d been concerned I’d approach with great trepidation. But none of that was present. I just felt…relieved. Relieved to know I was done. Relieved to know that I’d spent as much time as my sanity would allow preparing. Relieved to know that I’d worked hard to get to that point. Relieved to know it was time to get my life back.

Phew.

June 26, 2011   No Comments

I Almost Cursed Out an Attending Physician

Hey there. Been a while, huh. Almost a year to the day. I’ve thought about writing more over the past year, as my goal was to document experiences I’ve had as a medical student living with a disability. And I’ve even got several drafts of things I’ve written over the past year that never got finished. It’s certainly been a busy year, but it hasn’t been without time to breathe.

In order for me to get things done, they have to make it to my massive task management list. It’s something I review regularly and it’s the only way I can get anything done. More about that at a later date, but the short of it is, I’ve decided to set a regular deadline for myself to write something here every few weeks. It’s something I really want to do, and that doesn’t seem an overly-impractical goal. Granted, who knows if I’ll be able to pull it off. But that’s the plan. So without further ado, here’s the first.

In late February 2011, I started my third year of med school (M3) with a couple months on neurology and psychiatry. One morning while writing a patient note during my psychiatry rotation, an internal med doc sat down next to me. He said, “Hello!” in a familiar way.  I had no idea who he was, but he sure seemed to know me. The man asked, “you don’t remember me, do you?”  I looked at him somewhat quizzically and shook my head. He said, “one morning, crossing the walkway…” And I knew exactly who he was.

I’ve written in the past about the strange interactions I’ve had with people – but that was mostly about people telling me I need a bell (I don’t), or that I should get a speeding ticket (I don’t go THAT fast), or that I’m quite adept at moving “that thing” (and you’re quite good at working those shoe “things” you have, thanks). One story always stuck with me, but I haven’t written about it before.

One morning I was hurriedly rushing to class at 7:50am, trying to be there by 8:00am. I took my normal route, which happens to pass through one of our teaching hospitals. As is the case for me, I was in my own world. I approached a walkway that had a slight incline, and started to go up it.  As I moved forward, someone asked if I wanted help.  I politely said, “no, thanks.” I wasn’t struggling, and it only takes 5-10 seconds to get up the full length of the incline.

The person again said, “here, let me help you.” And I again declined the offer, albeit not quite as politely as before. But the person persisted, and started to grab on to the back of my chair to push.

Now, imagine you’re walking up a ramp. Imagine someone asks if you need help, asks again after you decline, and then picks you up and starts to carry you. You’d be pretty ticked, right? You might even feel your personal space had been invaded.

I grabbed my wheels and squeezed my hands tightly to lock them in place before turning and angrily telling the person to stop, as I’d said several times I didn’t want help. I came very close to cursing at the guy, as this was very invasive on his part, but better judgment prevailed and I avoided it. Finally, he got the message.

And now, while entering my patient note into the computer two years later, here was the same person sitting right next to me. Wearing a white coat. Oops. Good thing I kept my tongue in check that morning.

We talked for a few minutes, and he told me how the brief, chance interaction early that morning, coupled with a story he saw on TV later that evening about an individual living with a disability, changed how he views and interacts with people living with a disability. He realized that, although well-intended, forcing assistance on people wasn’t the right idea. He realized that a big part of living with a disability is being able to retain control over the aspects of one’s life that one actually can still control. And that when people force help on you, it serves to take away certain parts of that.

He felt quite a bit of remorse for how he’d acted that morning, which was even evident two years later. And we ended up having a nice chat. We’ve since run into each other around the hospital any number of times, and it’s worked out to have been a positive experience for all parties. And every time I see him, I think how happy I am that one summer morning, I didn’t unleash a tirade that would have made a sailor blush.

You never know when you might cross someone’s path again.

Edit 2011-07-06: This post was recently selected by Doctor Fizzy for inclusion in Grand Rounds. To new readers, welcome! Have a look around and I hope you’ll come back and stick around for a while!

June 10, 2011   1 Comment

Is Medical Education Too Black and White?

Studying medicine while also living with a chronic medical condition provides somewhat of a unique perspective on how disease and various conditions are presented. And recent material we’ve covered has given me pause to consider how things are taught.

The curriculum at Case Med is based heavily on the concept of problem-based learning (PBL). Which means we do a lot of work in small groups (roughly eight students per group, with one faculty facilitator). On Monday morning, we receive two cases. Each provides a narrative describing a particular fictional patient, their signs and symptoms, some imaging and potentially a diagnosis. We spend about an hour per case in our small groups working through the details, discussing elements we need to learn more about and how we will focus our individual research about the cases in question. On Wednesday, we reconvene and discuss the first case, Friday the second case. Small group is augmented by lectures that serve to provide some formal guidance as to the physiology and pathology with which we are presented, a sort of springboard for our small group research.

I think this is an incredible way to study medicine, as it forces us to learn how to learn, which will be infinitely more essential in our future careers as physicians than having memorized the entire list of signs of interstitial lung disease. To be sure, the ability to recognize common conditions and their presentation will be necessary to do our jobs. However with collective medical knowledge expanding at a phenomenal pace, even more important is the ability to quickly and thoroughly assimilate details about something with which we are unfamiliar. But I digress.

Recently, we had a case that was intended to guide our learning of the diaphragm and the accessory muscles of breathing, as well as the various phases and intricacies of the process. Because the diaphragm is innervated by spinal nerves C3-C5 via the phrenic nerve, but the accessory muscles are variously innervated by nerves at the thoracic and lumbar levels, the case we were presented with involved a patient with a spinal cord injury around the level of C4-C5. The idea behind this being that the patient would have at least moderate function of the diaphragm, but no use at all of the accessory muscles. Being able to discuss the topic in depth requires an understanding of all of the various muscles, what they each contribute to the process of respiration, and how they are impacted by a neural deficit.

However, during the course of the case, no mention was made of the classification of the patient’s SCI: complete or incomplete, or what the ASIA level was. Unfortunately, without this information, it becomes a lot more difficult to fully ascertain how the patient would fully be affected. As the case was not intended to be a neuro case, going into great detail on the ASIA scale or all of the other items impacted would be inappropriate. But without understanding at least that there can be tremendous variance in how patients are impacted by spinal cord injuries, it becomes impossible to really know this patient’s situation.

Of course, I’m in a unique position and am acutely aware of these differences. I’ve had to learn it as I’ve lived it, and as someone living with an incomplete SCI, I’ve learned just how bafflingly variant such an injury can be. Some muscles may function perfectly fine, while others that are controlled by nerves higher up the spine are more poorly innervated than those further down. It’s impossible to predict the items that will be affected in an incomplete SCI, which is why patients comparing functionality between ourselves can be nigh on useless.

During the course of discussing this case, I tried to mention a few times the concept of complete versus incomplete, and reinforce the idea that incomplete can be a vastly inconsistent diagnosis. And people in my group seemed to either already be aware, or they came across it in their research for this case. But in talking to friends, it was clear that other groups didn’t seem to be aware of the concept and some students were under the impression that such an injury is simply binary: all or nothing. You’ve either got full functionality, or none.

Nothing could be further from the truth.

Which got me thinking. If the extreme variability that is central to even scratching the surface of an SCI wasn’t covered, what about other conditions? And as I began to focus more on how other conditions are presented to us, I started to realize that many cases are presented as “here is syndrome X, and here are the associated symptoms.” No mention is made of how variable something may be, or the depth of different manifestations.

I discussed these thoughts with some classmates, and many of them shared the feeling that it seems medical education may be a bit lacking in regard to the spectrum with which various ailments appear. Perhaps this is considered an implied undertone to everything we learn. Perhaps it’s something we’re assumed to pick up in third and fourth year, when we’re immersed in the clinical aspect of medicine every day. Perhaps it’s something we’re assumed to learn at some other point in time.

Whatever the case, my own experiences have made me more acutely aware of such variance than I otherwise would have been when considering anything that we study, as have those experiences done for several classmates of mine. Which in the end, I think, makes us all more versatile and adaptable as a result.

April 23, 2010   3 Comments

Hi from Cleveland

Well, I never thought it would take this long to resume writing here, but apparently it has. I’ve mentioned in the past the intention to somewhat transition the blog to a discussion of not only my recovery, but also life as a medical student. So this is the first step in that direction. In addition to progress updates on my recovery, I’ll discuss topics I find interesting or relevant that are related to healthcare, as well as certain experiences I’ve had as a medical student. Updates will be shorter, but hopefully more frequent than they used to be (the past six months excluded, of course). There have been plenty of topics as of late that I’ve wanted to write about, from healthcare reform to cancer to H1N1.

But first, a much-needed progress update.

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November 18, 2009   1 Comment

Cleveland and More Walking

Recently Kristina and I took a trip to Cleveland to meet with faculty at Case Med in preparation for my matriculation in July.  It was the first time I’d taken a plane since the injury, so it was a new experience.  But thanks to Sinai and the Internet, not anything I was apprehensive about.

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March 1, 2009   4 Comments

A Much Needed Update

Well, it’s been quite a long time since the last update.  Not for lack of activity, mind you.  Those of you who know me well know that I certainly don’t live a life of inactivity – wheelchair or not.  These past few months have been no exception.  So what follows is synopsis of what I’ve been up to, as well as the real important stuff: where I’m at with respect to recovery.

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February 12, 2009   6 Comments

Happy Thanksgiving!

I hope everybody, at least those of you in the US, had a wonderful Thanksgiving, replete with turkey, pie and all the trimmings.  And I hope you were able to celebrate it with those people who you are thankful to have in your life.  When I think back to last Thanksgiving, things are definitely vastly different for me than they were last year.  And while the events of the past year certainly could leave me with a laundry list of complaints, the things for which I am truly thankful far outweigh the meaning of any of the negative things.

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December 2, 2008   7 Comments

The Passing of Time

One thing that has truly struck me since being discharged from the hospital is just how quickly time passes.  And I’m not even talking about how quickly life flies by when we’re all busy living it, but how quickly it passes when you’re not busy living it.  Time seems to be passing me by much quicker now than when I was preoccupied with work and/or school.  I would have thought it to be the other way around.  But I guess when one doesn’t have a significant mental goal to reach for and focus on that there is no basis by which to judge how quickly time is passing.  Or at least, that’s how it is for me.

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September 8, 2008   4 Comments