How I study

One thing that really differentiates medical school from undergrad is that as an undergraduate, you have a set of textbooks and assigned readings or sections that are common to the whole class. Everyone reads and studies from the same resource. In medical school, you can buy whatever books will help you the most. Some books are better than others, but if you make friends with someone who has a differnet book, the weaknesses usually balance out. Netter’s Anatomy Atlas for instance, has great pictures but too many labels. There are so many lines coming off the pictures that you have a hard time figuring out what you’re looking for. Grant’s Atlas is good, the pictures are simpler, but sometims there isn’t enough detail. If you want supplemental clarification, you’d better get a Moore’s Clinically Oriented Anatomy, because the previously mentioned atlases only have pictures, but no explanatory text. BUT, Moore’s alone will not suffice because the text can be too much and sometimes you just need pictures.
It is no accident that there are no required texts. The administrators in charge of curriculum explicitly told us that they set it up this way to begin encouraging us to be self-teachers. Most of the learning doesn’t happen in the lecture hall. I always go, but the pace is so fast there that you only have time to jot down a few key words that might not be covered in depth in the syllabus but might come in handy. The real learning happens after class when we get together for 6 hours and teach each other the material. The first step is usually a re-read of the syllabus with Q& A with one another to either clarify or to quiz each other. For me I study most effectively when I’m working with two other people, three tops. A group of five has a tendency to degenerate into social time and if it is work focused, then people are split into a group of three and a pair, so why bother with five in the first place. We study together for the afternoon until 5, though usually one of the regular group is dissecting, sometimes two. After 5, we head home, and I begin studying again at seven, and go until ten. The great thing about studying in a group is that you can teach the other guys and that really shows where the gaps in your own knowledge are. I’m very fortunate in that I have three extremely bright guys with whom I study regularly.

Tools and Dorks

So, I wrote of the first week that there were no morons in medical school. I now ammend that statement. They aren't necessarily dumb, obviously they aren't since they got in. They are just lacking in common sense.

Example: If you are a VERY hirsute man, please, don't assume that you are Adonis incarnate. We don't really want to see your furry body as you change into scrubs in lab. We have a locker room or a bathroom that are perfectly suitable to this purpose.

Example 2: If the dissection instructions contain a list of structures to be exposed during the dissection, you can safely assume that those are the things to look for. Don't just skin the cadaver and call it good. The rat's nest of nerves underneath is what we're looking for. See, when the instructions want you to expose the internal jugular vein, it's really helpful for the labmates who aren't dissecting that day if you actually do it, so that we can see the adjacent structures.

Example 3: Cadavers that dry out are like jerky. Please spray them down!

Another week come and gone.

Another week come and gone.
This week was a lot better than last, in short. We had two embyro lectures and a lot of PPS which reduced the amount of new anatomy I had to learn. PPS is Patient Physican and Society, which the clinical bone they throw us in the pre-clinical years. This week we had a lecture on pain, the only formal didactic session on chronic pain that we’ll recieve. The professor alleged that 80% of office visits pertain to chronic pain of some kind. If this is in fact true, you would think that we would have more instruction. There was a gentleman with chronic back pain secondary to a workplace injury who talked at length with how he came to grips mentally and emotionally with his intractable back pain. We then practiced interviewing a standardized patient about chronic pain issues. We haven’t gotten to do this 1:1 yet, but we have a small group and one of the group interviews while the rest of us watch. The guy who was interviewing was pretty choppy and stilted in his interview style. As several of my LDS friends who were in different groups and I debriefed the PPS session together, we all talked about how serving a mission helped us a lot to easily talk to strangers about intimate subjects.
Anatomy: this week we learned the following:
Posterior triangle of the neck: This region is defined basically as the area in front (anterior) of your trapezius and behind the platysma muscle. If you exaggerate a frown and push your face forward, the muscle that bulges out on your neck is the platysma (roughly speaking). The superior (upper) border is the matoid process which is the bony protusion behind your ear. In this little space we have the cervical plexus, the brachial plexus, and some small muscles that help to hold your head up. There are a host of blood vessels which are very difficult to remember. The brachial plexus is especially hard to remember, this innervates the arm and hand, as well as some of the pec muscles and the muslces of the shoulder. It’s easy to draw on paper, but tracing the actual nerves through the arm and shoulder is pretty tough, at least on my cadaver.
The Axilla: Simply put, this is the armpit. It contains the brachial plexus, and some major vessels, including the axillary artery and vein, a lot of fat, and a whole lot of lymph nodes. Human anatomy is a lot like street naming in a big city. Streets will change names for no good reason, same thing applies in anatomy. The brachial artery is also the axillary artery is also the subclavian artery is also mostly the brachio cephalic vein, depending on where you are.
Posterior Mediastinum, the junk behind the heart and lung.

We had another practice practical in lab on saturday which was extremely frustrating. They pinned the same structures several time in different areas so you would be tricked. I realized after taking the practical that I need to spend a lot more time with the actual body so I can get a subconcious understanding of where things ‘ought’ to be in relation to other things. You can learn so much faster by seeing the real article than by studying the abstract version, it’s just a lot harder to study the body because it’s not clean and well colored. The majority of the contents of a cadaver are white, brown or yellow. Veins are sometimes blue, but lymph ducts can look a lot like a blood vessel too.

Saturday

Medical school is not a 9-5 affair, nor is it mon-fri. This is a truism to anyone who has been in school. Duhh! you say. I know. It's just a lot busier than I had imagined. Saturday is a perfect example. As an undergrad, you might write a paper for a few hours on saturday or do a little studying, but you generally had a good chunk of the day freee. Yesterday Aaron, Dan and I studied in the morning for nearly 5 hours. Our anatomy professor had compiled a review sheet with the weeks material in brief, and a list of review questions. We spent 4 1/2 hours going over it and we still hadnt' touched the last day's lecture by the end. I had promised mindy we would go and do something in the afternoon, so at 1330 we stopped and agreed to reconvene at 10pm in the anatomy lab. Mindy and I went to the world market to get some exotic cookies as a treat. This took far longer than we had anticipated because the highway is under construction. By 7pm I was back reading my old friends Netter and Moore. At 10, in the midst of a towering thunderstorm, Aaron, Dan, and I left to go take a practice practical exam in the lab. A lab practical is when there are different tags placed on the cadaver with a number and you have answer the questions regarding the tagged part. If it's a muscle, you might only have to ID the muscle, or just give the innervations, or the actions etc.. If it's a nerve, you might have to indicate what level of the spinal column it arises from and what kind of nerve fibers it contains. The ID"s are pretty straightforward, unless the cadaver looks like beef jerky, which was how we found them that evening. I did pretty well, I just made a lot of stupid mistakes which is usually the bane of my test taking. Got home at 1210, and went to bed.

The Best of Times, the Blurst of Times

The coinnoisseurs of the Simpson's will recognize the title. Mr. Burns has a thousand smoking monkeys writing novels on typewriters and this is what they wrote. In the interest of not being a snivelling sort of blogger, I thought I'd make a list of the best and worst things that I have seen in the first week:
Best:
- They treat you like adults. Nothing is babied or dumbed down for you. You are expected to study hard .
- You have smart classmates. Nobody in the class is an utter moron.

Worst:
-The workload never decreases, and the pace doesn't slow.
- You can never know the material well enough. There is always some minute detail that you forgot in your studies. Ergo, there is no real sense of mastery or completion.

Mediastinum and a long day

Yesterday we had our first embryology lecture. Here, embryology is taught once a week concurrent with the gross anatomy course. That means we have ten embryology classes, and one pass/fail final. Since we didn’t have gross yesterday, that meant no dissection and a little more time to study the dissections from the previous two days. Since the first lecture was pretty superficial and ‘big picture’, the locker room consensus was that it wasn’t worth our time to study embryology until we got some more detail. I’m inclined to agree with this assesment, since time is precious and embryology isn’t a big portion of the course. “ But you’re in medical school to learn all you can!” I hear you cry. So I am, but I study between 6-10 hours a day just trying to master gross anatomy without tossing embrology into the mix. If I had the time, I would study it every week, since it would actually facitlate the understanding of why certain structures are posistioned where they are in the body.
Regarding pace: We have about 90-120 minutes of lecture a day for gross anatomy. I asked my friends who took gross as undergrads what the pace was like with respect to their previous experience. It turns out we cover in one lecture what took them a week to cover before. That means we’re going about 5 times as fast as an undergrad. This is why I study so long. It’s exhilirating in a way, but I also know that it’s like riding a bike at 20 miles an hour along the top of a median barrier. It’s a rush, but there isn’t a lot of margin for error. If I miss just a little, the consequences are dire. THe material is pretty cumulative, so you need the previous day’s lecture to understand today’s lecture.
Today was just such a day. It wasn’t my turn to dissect (we rotate dissectors every day), so I studied for a few hours after lecture until the lab opened up to the rest of us. Our dissection for the day was the mediastinum and the pleural cavity. These lie directly below the ribcage, and include the heart, lungs and associated structures between the diaphragm and the clavicle. Our individual is rich in adipose tissue which really slows down a dissection because it has to be removed before you can actually see anything. The lungs weren’t in very good shape at the time of death, and the dissection process hadn’t aided matters. Everything was still really jumbled together when I got to the lab, so it was pretty tough to learn from the cadaver. The fact that I couldn’t see firsthand what I had been studying for a few hours set me back in my schedule quite a ways. I felt pretty panicky and behind as I left the lab frustrated and annoyed. A friend of mine who is a pretty talented dissector and has been helping me through anatomy offered to come in early before class and help me to see everything on his cadaver. Tomorrow morning at 6:45 we’re going to go over the mediastinum and everything else in there before lecture....

Spinous Process

Spinous Process
So we dissected yesterday. It was not a shocking as I thought it would be. Currently we are covering the back muscles, spinal cord, nerves, etc... Monday morning we were introduced to our cadavers prior to the first anatomy lecture. They were in blue tarpaulin bags with a zipper up the top. We unzipped our bags to inspect the cadaver itself for any scars, tattoos, missing parts (e.g. fingers). The faces are covered with a rag, they’ll be uncovered later. The body itself was pale yellow-white with gray parts too. I found that the hardest thing to look at were the hands, actually; I don’t know why. After lecture 3 of the 7 of us returned to the lab to dissect. The bodies were prone and propped on blocks to facilitate the dissection.
Our first task was to skin the back so we could probe deep into the muscles. Human skin is much tougher than I realized, it took much more force to pierce it with a scalpel than I had imagined. In life our cadaver was a hefty individual, lots of fat to pick away. Fat really blunts your scalpel blades, since you have to cut a lot of it away to reach muscle. The muscle itself of course did not look like it does in Netter’s Anatomy. It’s dark brown, kind of grayish too. The fascia that invests (covers and surrounds) the superficial and deep muscles of the back is a lot like strapping tape. It’s thin and extremely tough with whitish striations running longitudinally down it. We were able to distinguish and expose most of the muscles of the back, with the exception of much of the levator scapulae (raises the shoulder, kind of on the side and back of your neck), and some of the smaller muscles that turn the head. They overlap and aren’t clearly delineated in the body so distinguishing between the different muscles took professional assistance.
I think that studying for this class is going to mean a lot of time in the lab. The atlases are ok for getting a rough idea of what to look for and they’re invaluable in identifying stuff in the lab itself, but it’s hard to get a 3D mental image from book study alone. The most difficult thing about anatomy so far has been learning the innervation of the back muscles. The pace is really fast, I imagine that in the last two days, we’ve covered what would take a week at an undergrad school. At times the fast pace is terrifying, because I know that if I fall behind, I’ll never catch up. Since I’ve never studied innervation or anything remotely close, I have to teach myself the language in order to understand the texts and atlases. Yesterday I was in school or studying from 6am until 10 pm, with about a 90 minute dinner break. Long Day!

Poised on the Verge

So, I write this on the eve of my first day of medical school. On thursday we received our syllabuses for gross anatomy. The syllabus itself is a packet nearly two inches thick with outlines for every lecture. There was an accompanying packet filled with cross-sectional diagrams of each unit we’re covering. The first unit is the back, from the nape of the neck to the iliac crest.
Friday I bought my Netter’s Anatomy Atlas which is filled with pictures and labels, but no other text. I have an old edition of Moore’s Clinical Anatomy to supplement. Hopefully between the two of these I can make some sense of gross anatomy. Netter’s set me back $75, but at least it’s a nice book. The biochem book I bought during under grad was $130, and I only used it twice, which is why I still have it. Perhaps Voet and Voet will be more helpful in medical school than they were in under grad.
Friday and Saturday I studied the first unit, trying to get a handle on the language of anatomy and at least a superficial understanding of where the various muscles of the back are located. Moore’s is hard to read because it uses words like “inferolateral”, which I think to the layman would mean “down low and to the side.”
I’m pretty worried about the workload that I’m getting myself into with school. It’s been over a year since I’ve had to study every day, and that was for organic chemistry. With o-chem, I knew that if I put in about 2-3 hours a day I would be ok. For anatomy, I think, at least judging by my preliminary attempts to learn the back, the time investment will be something more on the order of 5-6 hours. The last time I had a workload that was similar was during the e term I was writing my thesis for history. During that quarter, I remember that pretty much every free minute was spent in the library writing or doing research. There were many times that I felt that I didn’t have time to go to class because I was too busy studying. Since I was pretty depressed during that time, I’m more than a little concerned about what is going to happen during medical school.
Being on the edge of this impending besogne I am reminded a little of the feelings I would have in high school when I was rowing. Every afternoon during the winter months I would get nauseous with anxiety when I thought about the upcoming erg workout. I couldn’t think about anything but how much it was going to hurt and how badly I wanted to do anything but row, a fear which was exacerbated by the knowledge I couldn’t get out of it. I know intellectually that medical school is going to be hard, but like when I was rowing, I also know that I can’t realistically get out of it, nor, deep down, do I want to. It’s going to be important to remember that there will occasionally be fun times and rewarding times interspersed with the hours of studying.
A vaincre sans périle, on triomphe sans gloire-Corneille. He did actually write something worthwhile!

Recap

Here is a brief recapitulation of our lives since we left Eugene.
-Spent 3 weeks at camp: wonderful time kayaking, reading and just hanging out.
Arrived in St Louis 2 weeks ago. We arrived at about 1130 in the morning, left our stuff at my grandma Flatley's in Kirkwood, and left to visit apartments at the Hampton Gardens. These apartments are in "The Hill", which is a heavily Italian neighborhood in west St. Louis. They were close to a heavily trafficked road which didn't really appeal. The price was about right, however. The primary downsides were: small kitchen (comically small stoves), smallish floorplan, and inability to place a piano on the premises. There was a basement which we could store things in, however.
After Hampton Gardens, we saw some rather seedy places in teh Central West End, which is close to Washington University, which is a few miles due north of the Hill. From there we went a little further into the Central West End, visiting Forest Station Ap'ts. These were ok, in old buildings that could have been nice. The problem was that, rather than preserving the oldness and capitalizing on it, the managers were trying to modernize the place on the cheap. The end result was an odd mixture of inexpensive low quality modern fixtures and carpet in old high ceiling rooms. The mélange of the two was poorly executed. We spent the next two days looking at more of same, growing increasingly frustrated. Everywhere was either nice but too expensive, or affordable but crummy.
Finally we decided to drive around Tower Grove Park, which is just southwest of the medical school and look for 'For Rent' signs. Along Arsenal, the southern border of the Park, we found a lot of rentals available. We finally got in one to look around and fell in love with it. Our current abode has pale green walls with white trim, wood floors, and old ceramic fireplace, built in bookshelves, a big kitchen with pantry, a bathroom where the tub has little legs, and a huge bedroom. The price tag was well within our range and best of all, the place was available!
To abreviate the narrative, we obtained parking permits from the police, had the truck delivered, and unloaded it with the assistance of the young men in our ward. 3 days later, we were pretty much unpacked and situated, with only the pictures and some other odds and ends left unplaced. The only casualties of the move were our kitchen table which was wounded in action (a minor gouge on the surface), and the box with our posters which disappeared entirely. I guess some thief somewhere is enjoying a collection of obscure prints from the Louvre. I hope he likes pictures of Egyptian artifacts and Spanish naval vessels.
All of these events bring us to the beginning of Orientation which will be sumarized in the next post.