Too many cytokines

It feels so good to be done with the first exam of our new block.  This one covered mostly biochem and immunology, but had some pathology thrown in with it.  It was pretty brutal, a lot of it.  I think one of the most frustrating things in studying the basic science behind medicine is the nomenclature, especially when we get talking about the most recently discovered, ultra-specific nomenclature.  Cytokines are the worst: you get IL-2 through IL-50 it seems with several of them doing the same thing, while others are doing more than one thing and totally different things.  There's no rhyme or reason to it really.  I guess it's just based on when it was discovered.  Mix that in with the coagulation cascade, where they decided to use Roman numerals, and the cascade doesn't fully go in numerical order, and some of the Roman numeral factors have different names.  Because we had biochem on this test to, we were studying signal transduction, so we got a bunch of different receptor tyrosine kinases with specific names and specific factors dancing around in the cell carrying on these messages, but some of these were given names with capitals, like GEF and GAP, and some with lower case, like ras and rho.
I have to say, I really love learning, and I really am interested in understanding the mechanism behind these disease processes, but I hate learning a lot of the acronym mumbo-jumbo names for what going on at the biochemical level.

Med school anatomy

The human body is messy.  Messy and complicated.  Doesn't seem like I should have had to spend thousands of dollars and hours of study to learn that, but I did. I may forget specifics like the relation of the lingual artery coursing posterior to the hyoglossus muscle while the hypoglossal nerve passed anteriorly, but I will never forget digging around in the mess of fascia and guts to find one tiny little nerve or artery (never knew it could be so tricky tell the difference between the two in the cadaver!).  The school (and I, for that matter) went to tremendous expense to teach me anatomy on an actual human body.  The return on that investment is an interesting sort of familiarity with the body that won't soon be forgotten.  Spending hours digging through tissue, discovering different parts, struggling to differentiate and identify has taught me more than I could ever learn from the prosected (already dissected to make it easier) bodies in my undergraduate anatomy class.  I feel honored to have taken that investment and to have others that invested in me to learn a bit more about the amazing wonders of the body.  I trust that the effort I made in my learning will pay off for the people that I treat down the road.
Although anatomy was only one small step in the right direction, working intimately with the body, more intimately than ever before, allowed me to get my hands dirty, literally and figuratively.  It was my initiation into the medical field.

A shot in the arm

This last week I had the opportunity to work with a family practice doctor in the northern part of the state. It's part of the med school's curriculum to give us an opportunity to get out into the thick of things. I have to say, it was exactly what I needed after being stuck in books for the last few months.

Dr. G was the doctor I followed, and he was not at all what I expected. In the first five minutes of talking to him, he decided that I should know how much he made, and that was the first shock of the experience. He made nearly double the median income for a primary care doctor. He also takes a ten-day vacation every month, has weekends off, and never takes call. I think he got that all out up front to counter everything that I've heard about primary care: that you're overworked and underpaid. I did quickly see, however, how he managed to do that. Dr. G saw about 40 patients in eight hours! He was a whirlwind that whole time, bouncing from room to room, glancing at charts for a few seconds and dashing off in another direction. This was the second shock for me. I've always heard that it is bad medicine to hurry through, that the patients become very dissatisfied. He got me to work immediately interviewing patients and reporting back to him. They had taught us to do a medical history in our class, but this was completely different. I realized that if I was to take a full medical history, I would be there forever! I just tried to get the history of present illness (HPI) portion down. After getting this part of the interview down, one patient remarked to me that I was very lucky to shadow Dr. G and that they loved how Dr. G always took his time with them and they never felt rushed. My jaw dropped. This doctor was seeing patients at more than double the speed of the other family doc I had shadowed, and still somehow the patients weren't feeling short-changed. I soon saw how this could be managed.

Dr. G had some killer people skills. He always came in with a huge smile and a joke on his lips. He often wrapped his arm around the patient and then immediately started with the person's complain that he had gotten off the chart previous to coming in. He sat close to them, listened intently for thirty seconds or so, and even started examining them while they were talking. He would throw in a comment here and there and carefully, yet effortlessly, guided the conversation to the end point of discussing treatment. He would always throw in a couple of compliments. The patients somehow felt comfortable enough to interrupt him with a concern, and he would interrupt them if they got too far off track. He would talk about his treatment plan for them with utmost confidence, joke around for a bit more with them, and walk out with them, and direct them to the desk to pick up their prescription that he would send over electronically. Then, he'd jump into the next room and repeat the same thing. He'd take breathers to chat with the staff and me, or run into the back room to dictate a stack of charts, but that's what he did the entire time. It was exhausting for me to try to keep up with him. He always kept at least 4 examining rooms filled with patients for the entire day.

I saw how crucial the nursing staff was to keeping up the pace. Dr. G's nurse always saw the patient first to get the stats and the chief complaint and kept up a steady stream of papers for Dr. G to sign. The nurse was extremely friendly with the patients and kept the steady stream of patients filing into the newly vacated exam rooms.

Overall, the experience was very enlightening. I feel like I got a small glimpse into the 'real world' of medicine, for better or for worse. I really doubt I could ever get Dr. G's speed or people skills, but I certainly began to see the truth of being able to practice as you see fit. There are different ways to doing this job, and each doctor brings his/her own unique style into the picture.