A Breath of Air

Stanford entering class of 2008

Well I made it through my first set of finals, and as far as I can figure, I passed them all.  I worried a little going into school that I may have forgotten how to study and that it would take a while to get back into it.  I think that really what happened is that being out of school for so long I forgot how not to study, a skill (or habit) that will no doubt come back.  With the amount of material we have though, and the unease I felt with taking tests again, I started studying for these tests weeks in advance.  Not a bad way to do it, I even got a full nights sleep before each final (though a "full night sleep" has been redefined since I have been here).  Hopefully I can keep it up.

Anyway, we finished our first mini-quarter of core course work on Friday and had the weekend to enjoy life outside of class.  And when I say outside of class, I mean the only class we had this weekend was a 5 hour CPR training.  Regardless, I enjoyed my weekend immensely.  Went to the grocery store, washed my car, (neglected my laundry again, I think I can hold out until next weekend . . . ) and just generally relaxed.  I even got to have dinner with some friends from off campus (thanks for coming down Carolyn and Eddie) and hosted a game night at my place with some fellow game lovers.  I also finally took some photos of my place here for anyone who is curious to see where I am living.  

Now we are back to it.  The weekend ended and we are starting into a new set of classes.  This quarter we are taking Developmental Bio, Genetics, continuing Anatomy, Ethics, Stats, and clinical skills.  I also have several elective courses that I am excited about and hopefully I will come up with something this quarter to start my research project.

Sorry for the boring blog today, I'm sure I'll have something much more engaging to share once we get into classes again.  I do have one piece of news though;  I got my feedback from my standardized patient today and it turns out that the hand washing mishap was not such a disaster.  Direct quote "I felt confident when you washed your hands when you left the room figuring you had done so before you shook my hand in the last encounter you might have had."  Awe, that was awfully kind of her to assume . . . :)

Stanford Quality

I really would like to update my blog right now, but I really have to study instead. Just thought I would share with you all a recent photo of a few friends (Ricki, Brian and Luz) testing out their new wheels on the way to class. Us med students do everything together. Really.

You should all know that I am absolutely happy here. Of course I miss everyone that I left in Seattle (and Homer, and anywhere else you may be), but I feel blessed every day to be here, at Stanford, with amazing professors and peers, studying something that is interesting and exciting and feels important. Medical school is a long road, but I am excited for every single day of it. And I appreciate every one of you for caring about what I am doing and allowing me to share it with you, thank you.

Just a quick note today, we have finals coming up next week and so far I am still not stressing out about it.  I would like to keep it that way so Ill be back to studying in a bit, but first let me offer a few random thoughts.

To start, an update on anatomy.  We have been through the complete Thorax (rib cage and everything contained within) and moved up towards the neck and the mess of veins, arteries and nerves that run through it (upon further examination it is not actually a "mess", thankfully for us it is all pretty well organized.  see drawing).  

So, having completed the section, today we had our first"walk-about".  

Here's how it works.  There are several dissected bodies set up in a room with a series 

of numbered pins labeling different vessels, muscles, nerves and bones in the body.  Starting at one number, we have 45 seconds to identify the marked feature before moving on to the next.  Organs are removed from the body for separate identification.  It was just a practice, self graded, for self-assessment purposes only so no big deal, we don't have a real test on anatomy until December.  Then it is all or nothing.  No pressure.

After the thorax is the back.  We flipped our cadaver and began to peel back the skin to reveal the musculature beneath.  One great thing about medical school is that everything is so directly interconnected.  As I pulled the skin back and cut away the fat connective tissues I thought about the cells that make up the different tissues and the developmental process that took them from an undifferentiated state (stem cell) and caused them to morph into chondrocytes and secrete matrix to build bone or merge and make myofibrils to become muscle.  And how the regulation of gene expression in each cell coordinated that process somehow.  It amazes me every day.  Life is amazing.

Anyway, tangent, sorry.  But if you are interested in more on what anatomy lab is like, here is an article about cadaver lab at Stanford.  It's not great, but if you are yearning for more . . . here it is).

Another thing that has been apparent to me recently is how quickly science is changing and advancing.  I guess I didn't really think of the consequences when I was doing research; that the results of that research would add to or change what we know, and that it would change what was taught.  In other fields things are more constant.  What was true in history college is, more or less, true today.  What I learned in calculus in high school is still what they are teaching today (I know you history and math buffs will probably challenge me in that).  But what I am learning in Molecular Biology today has changed since I took it 7 years ago.  Yes, the basics are the same.  We still believe that genes are coded into a double stranded double helix, transcribed to RNA and translated to make proteins which basically control what goes on in our bodies.  But how that all happens is still being picked apart.  and some of what we are learning was unknown up until five years ago.  One year ago.  Last month.  And somehow that connection was never so apparent; research findings change textbooks.  (Just another side note, it also seems that most important advances in science were accomplished by Stanford faculty . . . hmm, are they teaching selectively?  I wonder if Harvard kids are only learning what Harvard faculty are working on?  I don't remember that being the case at LC . . .)

Lastly, (me and my "quick note"s, if you believed me you should know better) for those of you that know this about me I thought I might just mention, I haven't slept through a class yet!  I know it is only four weeks in, but I'm optimistic, maybe I am turning over a new leaf.  

I have the stethoscope, I have the white coat, now bring on the patients

(by the way, I have scrubs as well which are quite nice, and I look especially sexy in the XL bottoms I was given last time I traded my pair at the laundry)

Today we saw our first patients. They weren't real patients, don't worry. They wouldn't subject real people to a first year medical students first attempt to take a history. No, they pay people good money to put up with that, and they do there job well.

All we were told to dress professionally (they men have to wear shirt and tie; us women had more choice in the matter) and to wear our white coats at all times. I guess that is what gives us authority. I mean, we are not hiding the fact that we are students, and we don't have a "Dr" in front of our names embroidered on our coats, but we do look pretty spiffy (I don't have a picture yet, but here is me with my stethoscope and my friend Sina). I think it will take some getting used to to not feel like an impostor in that getup, but it will come. Anyway, we were told that we need not worry about getting a real medical history from the patient, and we should not conduct a physical exam, but just to talk to the patients about why they were there, establish rapport, and do our best to make them feel comfortable while getting whatever information we could. We were to walk in, gel sanitize our hands, introduce ourselves, and then wing it.

The eight of us were led down a long hallway lined with numbered doors and told to stand in front of one of them. "The chart is on the door, you can look at that but don't go in until I tell you to, you will have 15 minutes". I felt like a bunch of horses at the gates. On your mark, get set, go. So I knocked on the door, walked in straight past the hand sanitizer and introduced myself to my first fake patient. In my defense, I had just washed my hands five minutes earlier, but I am sure that was check box number one left blank. So I made sure my patient was comfortable and then we got down to business. Her name was Pat Mitchelle (as was every other patient in the building it turns out), a 55 year old woman in for an employment physical. She was fairly healthy, had little family history of disease, and her only complaint was that she had been experiencing some shortness of breath in the past several months and had developed a small cough. OK. Where to go from there? With two weeks under my belt I still don't have the knowledge base to draw from to know what probing questions to ask. Do you exercise regularly? Does the shortness of breath affect your activities? Do you find that it goes away when you stop to rest or does it persist? Without any means to diagnose it was difficult to know where to go with it. She was in for a physical exam, and I wasn't qualified to do one so . . . so we talked a bit about her job change, about her family, about her dog. . . . finally, not knowing what else to say, I said "ok, I think I have enough information, I am going to talk to my attending and the doctor will be in shortly to give your physical". I stood up. "There is one more thing I was wondering about, I am a smoker and I am wondering if that might be connected to the cough". Oh, right, shortness of breath, developing cough, smoker. Another empty checkbox. Why didn't that cross my mind? So I sat back down. How long have you been a smoker? How many a day? Have you ever tried to quit? So we talked about the fact that the symptoms she was experiencing could very well be connected to the smoking and that we would check that out. We talked about her attempts to quit and that we could to connect her with a support group if she was interested or talk about a plan for quitting; that if she was ready to commit that we would encourage her to take the next step and that regardless of the connection to her current symptoms, quitting would be good for her health. Then the 15 minutes were up. I again stood up, told her it was nice to have met her and that I would be sending the doctor in, and left.

Of course once outside the door I was thinking of all the "should've"s and "could've"s for a patient interview. If I was given another one right then I have no doubt I would have done much better, but for my first try I don't think it was so bad. I guess I'll see though. We were all videotaped and the "patients" evaluated us which we will get to see at the end of the month. In any case, it will be very helpful to have experienced the "doctor-patient" interaction when we start learning the right way to do it; so we can look back and think, what was I thinking?

Just a side note, as far as I have gathered from the others that have done the patient encounter, very few of us thought to ask about smoking habits. I think that not having much direct experience with smokers and the health effects in my own life it is not yet an obvious connection to me. I am sure that once I start seeing patients it will become a common theme. And next time I will remember to sanitize my hands.

Abnormal Anatomy

Another day gone . . . I should be studying but I would rather write a quick update. We don't have a test until . . . midnight you say? oh, I better get on that . . .

Actually I did already complete the quiz due at midnight tonight, but only because I thought it was due at 5:00. The thing about med school is they expect you to be on top of things, and I think so far I am not. But then it seems like very few of us are, so I am not alone. Thank goodness for the few that are are super organized and prepared; that look up the syllabus weeks in advance, that study the lecture notes before the lecture, that obsessively check the student web portal for posted material. If not for them I would not know when Quizzes, Journal Clubs and Problem sets were due, because nobody tells us here. I guess they think we are all responsible adults . . . :) Honestly though, I am figuring out the system and soon I too will know what is going on.

As for classes, still loving it. Even the studying is not so bad because I actually do want to know the material. Granted years from now (or even months) I wont remember, or probably care, what the Wnt pathway is, but it will be there somewhere in the back of my brain. And the really cool thing is that all the molecular pathways that we are learning really do have huge effects in our own bodies, and the disruption of the activity of just one protein can be fatal. I wont go into detail (although I have considered using this blog as a form of review and subjecting you all to the material that we are learning) but just know, it is a miracle that your body is working.

My favorite is probably anatomy and cadaver lab. Even though it is a lot of memorizing terminology, it is really amazing to see first hand how everything works together. however, it has not been an easy road so far; our cadaver has been a bit challenging. We started at the skin on the chest and dissected through the muscles and ribs before removing the chest wall (rib cage) to expose the heart and Lungs. At this step we had our first problem. Normally there are two layers of tissue, one attached to the rib cage and one surrounding the lungs, that should slide past each other easily. However, damage to the lungs can sometimes result in adhesions where the sac around the lung actually attaches to the chest wall. Our cadaver, being a smoker (we assume, cause of death was lung cancer) had this problem, and not in a small way. The entire chest wall was adhered to the lung and Dr Gosling had to remove it by force (have I mentioned Dr Gosling's approach to dissection? He gets both hands in and pokes, pulls and tears, but I guess since he knows what he is digging for, it works out). Once we removed the rib cage we noticed something else strange. There was only one lung. Likely the lung was removed in an attempt to remove the cancer but the result was that the left lung was huge and the heart had been pushed over to the right side. OK, not quite a normal specimen, but at least one lung was intact and everything else was present. We thought. That was until today when we went to remove the pericardium (the sac surrounding the heart), which was already gone, and identify the veins and arteries on the surface of the heart, which were a bit confusing as the patient had had bypass surgery (adding an artery that was not naturally present) as well as all the connections to the right lung having been tied off during the removal of the lung. To top it all off, there were wires buried into the tissue surrounding the heart for which we could not distinguish the function. The really amazing thing about all of it is that the man lived well beyond the surgeries (evidenced by the extent of the tissues surrounding) despite having one lung, a heart that was fused to the back of the chest wall and a lung fused to the front his body was able to compensate and survive. Luckily though, there are 23 cadavers in the lab and plenty of classmates willing to share their organs in the interest of education.

They don't mess around here, when classes start, they start. Thursday and Friday were filled 9-5 with lecture and lab giving us enough material to keep us busy for the three day weekend. Of course no testing for another few weeks, but I think we are all still a little anxious about this medical school thing and, in these first days at least, everyone is going to class, and everyone is setting up study groups and review sessions.

Stanford Curriculum starts out with the basic foundations in science before moving into a systems based approach to education. We started off then with Foundations in Molecular Biology, Histology (Cells to Tissues) and Anatomy. First impressions - all of the lecturers are eloquent, excited about their subject and fairly good at communicating the information to the students. My only critiques, MoBio prof seems to think every question translates to "I don't get it" and starts over on his explanation. Not helpful to the questioner necessarily, but admittedly there is almost certainly someone in the class that doesn't get it. And secondly the Cells to Tissues lecturer could be watched at half speed and it would still be hard to get everything she covers. Thankfully we have all of our lectures videotaped and available online so it is indeed possible to watch histology lecture at half speed. In any case, I am so far impressed with the faculty here and hope it will continue this way as the year moves on.

Specifically, MoBio has been mostly a review. Thanks to my background in science and experience in Molecular Biology in the laboratory, I will have to relearn the details, but the basic concepts are all familiar. Histology however is completely new to me. Of course I have looked at stained onion cells and amoeba under the microscope and I know basic cell structure; that the Nucleus is where DNA replication and transcription takes place, the mitochondria are the power plants of the cell, lysosomes are in charge of waste disposal, but that is apparently not enough to qualify me as your doctor. Last week we delved into histology of the blood and all the cells that are found in both the peripheral blood and the bone marrow. I think the last time I used a microscope was at least 6 years ago, and this time we didn't spend our first day in lab passing a microscope certification test. Once I remembered how to work it though, I remembered something. Microscopes are cool. Everything under high magnification takes on a new life, Blood is no exception looking homogeneous at a macroscopic level, but beautiful and diverse under the microscope.

Lastly, but definitely not least, is Anatomy. I have never had an anatomy class beyond what is incorporated in general biology. Fetal Pigs have given me some introduction to dissection but is in no way sufficient preparation for the cadavers in our lab. It is a great privilege to have the opportunity to learn anatomy of the body first hand on bodies donated for our education. To feel and see the separation of skin, fascia and muscle, to observe the nerve bundles running from spinal cord along their path to the point of innervation, and to follow the muscle from bone to bone could not be replaced by book or even 3D model. There is something amazing too in learning about our own bodies. Like learning the chemistry of photosynthesis causes you to look at plants in a new light, learning the anatomy and histology of the human body will change the way I view and respect the physical us, as the complicated organisms that we are, forever.