never enough

See?  It's never enough.  Like this question.  Again, a supposedly "easy" one though only 28% got it right. 

      I correctly identified the disease - chronic bronchitis.  And I narrowed it down to two answer choices.  Then I made an educated guess that chronic bronchitis would probably have similarities with asthma.  Asthma involves eosinophils so I chose B.  WRONG.  Apparently, chronic bronchitis is not similar to asthma from a pathological point of view.  The correct answer is C.  Cram another thing into my already bursting at the seams memory tank.  And so I close my eyes and say it out loud.  "Chronic bronchitis differs from asthma in that the infiltrate are mostly CD8+ lymphocytes, NOT eosinophils like in asthma."

when is it enough?

     You can never be done studying.  The amount to learn is near infinite in its quality.  So for me, I study until I'm done.  There's no objective criteria.  I'm just done and that's when I stop.  And as I plow through thousands of questions for review, I wonder, if I were to pull 100 random docs, how many could answer some of these basic science questions?  Unless the doc is a pathologist or nephrologist, I wonder how many would know the answer to this question?

     In my question bank, I can select from Easy, Medium or Hard.  This falls under the Easy category.  And notice that only 48% of the respondents got the answer right.  Easy, right?  I knew it but that's just because I reviewed this subject for a brutal test yesterday written by a nephrologist. 
     And do you know how I remember it?  Let me walk you through it.  A kid comes in with dark urine.  A kid peeing coke would freak out most parents, right?  Through history, you find he had an infection a couple of weeks back.  That's a pretty easy reflexive association that I talked about in a previous post.  It's Post Infectious Glomerulonephritis (or post streptoccous GN).  Thankfully, some pathologist with common sense named the disease in a descriptive manner that tells you exactly what it is.  And what's the acronym of that?  PIGN.  Pigeon.  Pigeons leave lumps and bumps of shit all over my driveway when they eat my fallen mulberries on the ground.  The pathology looks like lumps, bumps or humps.  I can never remember if they're subepithelial or not but the answer choices only have one hump choice.  All that just to remember one disease.  And you don't even need treatment.  It resolves on its own.  Like I said, I just study until I'm done. 

reflex

     When faced with massive amounts of information, we docs-in-training learn to pick up on patterns pretty quickly.  Unless you're some kind of savant, it's impossible to remember every detail about every disease and therapy.  So you pick out little gems and regurgitate the answer before you even have time to think about it.  It's a reflex.  Like this question.

Any question, any time, any test, that has a question about an African American woman with some sort of funky lung issue ALWAYS has an answer related to sarcoid.  Period.  End of story.  I've yet to see one come up where it's atypical pneumonia or something.  Obviously, that's not going to be always be true in clinical practice and therein lies some of the difficulty in translating test taking knowledge with real world doc skills.

Waiting

I've reviewed so much information, I feel as if I have forgotten more than I've learned. Like a sponge that is too full, it begins to drip moisture back out. So I found a new place to hang out before the exams. Right near the med center is a large park. And in it is a Japanese zen garden that I had never seen before. If I'm going to forget stuff before the exam, this seems as nice a place to do it as any.

update

With all the exams, I don't really have time to post much of anything thoughtful about my dad.  So I figured I would just post the email I sent him a couple of days ago regarding his current back issues.  A lot of doctorese.

This is the summary report of the MRI:

RADIOLOGY/ECHO: MRI: Findings:
There is a wedge compression fracture of nearly every vertebral body, without evidence of underlying enhancement and T2 signal abnormality. Augmentation procedures have been performed at L1 and L2. Extensive degenerative changes are present. Grade II anterolisthesis of L5 on S1 is noted. Because of the anterolisthesis, there is severe left L5 neural exit foramen narrowing and mild right L5 neural exit foramen narrowing. There is also severe left L4 neural exit foramen narrowing.
The nerve roots of the cauda equina appear mildly thickened, but there is no abnormal enhancement.
The conus ends at L1-L2.
A broad-based disk osteophyte complex is seen at L2-L3. There is no significant central spinal canal stenosis or neural foraminal narrowing.
L3-L4: Broad-based disk bulge. Mild bilateral lateral recess stenosis. Mild bilateral facet joint hypertrophy.
L4-L5: No significant central spinal canal stenosis or neural foraminal narrowing.
L5-S1: Neural foraminal narrowing as described above. No central spinal canal stenosis.

JOHN DOE, M.D

And here it is with my comments inserted in parentheses:

RADIOLOGY/ECHO: MRI: Findings:
There is a wedge compression fracture of nearly every vertebral body, without evidence of underlying enhancement and T2 signal abnormality (this is very concerning. Definitely a consult with orthopedics is warranted. But I also think seeing the endocrinologist is a good idea. Perhaps pharmacological management is just as effective).

Augmentation procedures have been performed at L1 and L2. Extensive degenerative changes are present (have they degraded more since your last MRI? We need to get an orthopedic consult to evaluate if degenerative changes are ongoing that rapidly. If they are, it would seem an agent like Zometa or Denosumab to inhibit bone turnover are warranted).

Grade II anterolisthesis of L5 on S1 is noted. Because of the anterolisthesis, there is severe left L5 neural exit foramen narrowing and mild right L5 neural exit foramen narrowing. There is also severe left L4 neural exit foramen narrowing. (this is the one that may require surgery. This is the slipping that the neurologist talked about. It's NOT a slipped disk. It's a slipped vertebra. The vertebrae are out of alignment. He said it was a grade 2 and the scale is 1 through 4 with 4 being the most severe. This isn't simple kyphoplasty anymore. This is neurosurgery. There's one thing Dr. Numbnuts did right by bringing in a neurologist. But it's not an emergency as of yet. It still needs to be paid close attention, though. Any change in your leg function, leg sensation, bowels or bladder needs to be assessed IMMEDIATELY.)

The nerve roots of the cauda equina appear mildly thickened, but there is no abnormal enhancement. (this is good. If this gets messed up, you lose control of your bowels and bladder. Then it's absolutely a surgical emergency, SCT or not. If you notice any loss of feeling, loss of function, you need to go to the ER and request a neurologist IMMEDIATELY.)

The conus ends at L1-L2.
A broad-based disk osteophyte complex is seen at L2-L3. (these are changes indicative of osteoarthritis. This is a chronic process, not an acute one.)

There is no significant central spinal canal stenosis or neural foraminal narrowing. (a good thing)

L3-L4: Broad-based disk bulge. Mild bilateral lateral recess stenosis. Mild bilateral facet joint hypertrophy. (this is an example of a bulging disk that may start to slip. I'm not sure what the last sentence implies. Hypertrophy is a response to some sort of inflammation. As to what's causing the inflammation, I don't know. Cancer? Arthritis? Regardless, I don't see how this is an acute finding. This is something that's been chronic.)

L4-L5: No significant central spinal canal stenosis or neural foraminal narrowing. (a good thing)

L5-S1: Neural foraminal narrowing as described above. No central spinal canal stenosis. (already described)

uncertainty

     A phone ringing.  It's still dark.  It's too early for a phone to be ringing.  This can't be good.  It's never good.  "How are you?" I ask my dad.  "Not worth shit."
     To the ER.  Again.  Lower back pain.  BAD back pain.  Out of nowhere pain.  10 out 10 pain.  A long day with a test somewhere in the middle.  Conversations with a neurologist and the ER doc.  We don't agree with the ER doc.  My dad is discharged.  ER doc wanted to admit him.  He has several compression fractures in his lower spine.  And some narrowing of the holes where the nerve roots come out of the spine.  And a new rash.  Nothing to do with the pain.  Is it graft-vs-host?  ER doc pays it no mind.  Idiot.  Fool.  The spine just causes pain.  At least for now.  That's what opiates are for.  The GVH can kill him.  If it worsens.
     So my dad is home.  Taking opiates.  There will be many visits in the near future.  Starting with the SCT team tomorrow.

studying

2 down, 8 to go

During a routine doctor's visit, a 68-year old man is found to have an increased white blood cell count with normal RBC and platelet counts.  He reports to be in good health.  His peripheral blood smear is shown here. 

What is his most likely diagnosis?

1. Acute lymphoblastic leukemia
2. Chronic myelogenous leukemia
3. Chronic lymphocytic leukemia
4. Acute myelogenous leukemia
5. B12 deficiency

     I stared at this question for a long while, not because I didn't know the answer.  I definitely knew the answer.  I knew it all too well.  It was a textbook example of CLL.  And that was my problem.  How often do diseases follow the textbook?  I know from my research days that the lab animals rarely read the relevant literature and often didn't do what they were supposed to do.  And from my own personal family, 2 for 2 on completely non textbook diseases. 

     This has been a hard block for me.  Lots of cancer stuff and lots of emotions along with it.  And hard not to argue with the professors because I knew so well that cancer doesn't play by nice and tidy rules.  Intellectually I know we have to start with the basics and that "common stuff is common".  But when you learn a piece of information experientially and process it with intense emotions, logic doesn't really matter as much.  So I bubbled in the third answer choice and finished the 100 question pathology exam.  Went home, worked out and started studying for the next exam.  It's Fundamentals of Clinical Medicine.  Arthritis, anemia, and of course, cancers.

ageism

Ain't funny pickin' on the old students (yes, this was a real question).

A 45-yr old medical student, having failed year after year, was stressed out about the upcoming exam and developed scaly papules and vesicles only on the sides of the fingers.  A biopsy showed spongiosis and lymphocytes.  The most likely diagnosis is:

A. pemphigus
B. urticaria
C. dyshidrotic eczema
D. tinea versicolor
E. candidiasis

exam questions

I took my behavior exam on Friday.  91 questions of crazy goodness - OCD, sexual fetishes, heroin addicts, narcissists, drunks, narcoleptics.  As I took it, I couldn't help but think of this picture that was circulated around and grin during the otherwise taxing exam (oh crap! I forgot to submit my taxes!).

While F is definitely the real world picture of many, many, many med students (I'm not which is why I don't do as well on the exams as the other savants), the correct answer is probably C.

schedule

This is my schedule right now.  10 exams in 21 days.  And only half of them are finals cumulative over the entire year.  When I tell people that I'm training to be a doctor, their response is always something along the lines of "how fun!"  No, it's not.  It sucks right now.  Yes, it will be meaningful, worthwhile, etc. but by no stretch of the imagination is this fun.

“I’m Not Going to Treat Your Cancer” - Cancer Network

An interesting read by an oncologist.

“I’m Not Going to Treat Your Cancer” - Cancer Network

rest of the story

     Sharply dressed, standing erect, he strode quickly and purposefully with his IV pole in tow.  I leaned over to my mom and whispered, "you can always tell the people who haven't started the chemo or stem cell transplant yet."
    The woman was energetic, chatty and quite amicable.  Out of town, boredom was her biggest enemy at that point as she waited to start her process.  I saw her about a week later at the exercise class.  She had trouble walking and the cheerful demeanor was absent.  The chemo had started.
    I wish I could go back and know how these people fared.  Did they return to their pre-SCT transplant state?  Did they regain the spring in their step?  Did they at least make it home?