Prepare for the Boards in Six Weeks

All of this information is contained in the USMLE GUIDE.doc so that you can take it with you and not worry about your internet connection. I post all of it here for those that do not have Microsoft Word and so that people can find it through search engines. Hope it helps.

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A word on this guide:

I just finished my second year at St. George’s University School of Medicine. Figuring out what you are going to do for the Boards is a pain in the ass and gets people nervous that they do not have a plan. Many of them sign on to Kaplan or Falcon for this reason. I would like to prevent as many people as possible from signing up for those courses for those reasons, as they are expensive and you are poor. I want you to have a plan, an idea of what to expect, and all of that free. I hope this helps.

A word on advice:

I am wary of most advice. It is often unqualified, and by this I mean that I do not know why I should believe in your expertise. Did you score well and are you willing to tell me the score behind this advice? Are you like me in that we learn, memorize, and study alike? What works for Peter may fail for Paul and it is good to keep this in the back of your mind as everyone begins to tell you what you should and should not do. The other problem that I have with a lot of advice is that I am not told the reason behind the conclusion. It is easy to say, “Just do questions”, but it is much harder to give a well thought out argument to support your advice. There may be an excellent reason, but many people do not think to ask for it or to give it. Also, it takes a fair bit of time.

If someone says that there is a lot of Embryo on the test, please kick him in the face. That sort of advice (even if it ends up being true) is worthless for planning. The most frustrating part of this whole experience is that n=1 and it is hard to draw conclusions from a sample size that small. You will wonder if you did it correctly, how you would have scored if you changed blah blah, and so on. That leads us to why I am writing this:

Medical school is great because it is the end of decisions. Decide to go to medical school. Three and a half years later: decide what kind of doctor to be. Three to five years later: decide which job to take. That is three decisions over ten years and medicine is great that way. I was so tired of making decision about how to study that I wished someone had done it all for me. This guide is meant to be a turn-off-your-brain and do-as-I-say outline so that you can save yourself from all of that. It is the guide that I wish someone had made for me.

A word on irony:

I am aware of the irony that I am writing a little guide filled with advice while not offering my score, telling you about myself, etc. What I can give is my reasons for each decision so that even if you do not end up following it, you at least see the problem of planning and studying as manageable. If you are interested, when I get my score I will post it and at that point, you can decide to continue using this guide or decide to forget everything written here. Deal? Now on with the show…

THE SCHEDULE

I am assuming that you are taking six weeks to study for this test. If it is shorter or longer, I have structured this so that it is easy to change according to your unique schedule. This schedule is built using the newest edition of the First Aid for the USMLE Step 1 (Systems based) as I think it is the best game in town and damn near everyone seems to own it. We need a calendar, and we need to divide it into two main sections: cramming and pre-cramming.

CRAMMING

Cramming is undervalued. I took an incredibly long time to prepare (9 weeks) so that I would not have to cram because (cue lame music) I wanted to really understand the material. Fair enough, but the last two weeks are for cramming. You can realistically cover two topics each day. Anything more and you are skimming. I have good reasons for each of these choices, but first you should just take a look at what we will call “the cramming”.

The day before the test, you will be tired of studying (more so). This is when you are most vulnerable to total mental collapse. A friend described it to me: “I opened up Micro to look over viruses once more before the test and I realized that I had forgotten how to read. It was as if my head had exploded onto the table and I could not pick it back up again. I postponed the test a week after that.” To avoid this, I advocate taking a half-day and seeing a movie. It was one of the few things that I did that worked.

Before you start this final sprint, take a day off. You have earned it. I think you should begin with Biochemistry because the meat of this subject is in the underpinnings of other diseases. A good look in the beginning will help you interpret things later on and will reinforce the pathways that actually matter. By putting this first, you effectively study it all week. It is a big topic, so it gets two days. Molecular genetics and Immuno cover some similar ground (signaling) and this is a nice lead in to Micro. I will make the same argument about Micro, that putting it this early means that you study it with every system to come, reinforcing the pathogens. It is big, so also earns two days.

Cardio and Heme/Onc are thrown together because of the pathology. For similar reasons, I have placed them next to Musculoskeletal. As you will find, the vasculitides are covered in Musculo, not in Cardio or Heme/Onc, so these three topics are overlapping in the First Aid which is why I have grouped them. Cardio, Heme/Onc, Gastro, and Musculo are also grouped because chances are that one of these topics is a strength for you, so going through that subject quickly allows a weakness in the others to expand into that day.

Neurology and Psychiatry are next to each other for the association. Neuro, unfortunately, is just too big to group with a second large topic, so this is as good a place as any to split up Behavioral with Psych (they pair naturally) and Biostats with Neuro. Renal and Respiratory are not as big as the other sections and this should make for a somewhat easier day. These are grouped together in hopes that you finally sit down and learn Acid/Base compensation. After two years, it is time.

Embryology is tricky. Most of it belongs with Reproduction and Endocrine while the rest is spread out among all the systems. The best advice I have is that you study the Embryology for each system in the morning before getting into the thick of each subject and save the Repro/Endocrine stuff for the end. That it is a hodgepodge also makes it a natural move to group it with Basic Pharmacology and Basic Pathology. These sections are short and represent a little bit of everything. If you give it a good read, it can pull topics from earlier in the week together and is not too stressful to be studying up to test day.

And with that, use the last day before the test to print out your permit, print out the directions to your testing center, and look over some topics that you had to skip. Try to force yourself to stop studying by midday and do something non-medical that night like watching a new movie with a friend. The night before my test I caught 300, and it was great to think about something other than pathways for at least those two hours.

PRE-CRAMMING

That was cramming. Now, onto pre-cramming. Since we have six weeks and I just stole the last two weeks for cramming, that gives us exactly 30 days to prepare. Remember that you are not preparing for the test during this period; you are preparing for “the cramming”. If you do not cover everything in a section in the time allotted, it will not be the end of the world. You will get another crack at it, at which point not getting to it will be the end of the world. Ready for the suck? Seriously, stay optimistic.

If you are a numbers person, we have 30 days to cover 329 pages of the First Aid, which works out nicely to 11 pages a day. This is a lazy way to weight things, but who cares? I have gone to the trouble of counting each page per section for you, and arranged the following. Here is the first two weeks.

We start out with something general and familiar: the basics. Most of the connections in this section went over my head and I did not pull them together until the end, but it is nice to have the early exposure and to ease into this whole thing before the real subjects start. This brings us to Biochemistry. It is big and intimidating for a lot of students and three days does not seem like enough, but it has to be just three days. First, we give it two full days in the last two weeks of cramming. Second, the other subjects need to be given time and are likely higher-yield.

It does not let up as Biochemistry feeds into Immunology and Microbiology. Again, three days is not enough to cover Microbiology, but the other subjects need to be covered and we give Micro two full days during cram week. Behavioral science and Biostatistics are meant to be your first break. The ground of Behavioral science will be touched again during Psych, and Biostatistics is not that big. You can either take half the day off or use the extra time on Micro. As always, make sure you are not seeing anything for the first time during “the cramming”.

Embryology is just not big enough to get its own day and should be learned in pieces with each system that follows. What is important for now is the developmental aspect. You can combine it with the first day of Endocrine (as I have done) or group it with Reproduction, does not really matter so long as you get to it. I think these three topics together makes each of them stronger, and this might be the first time you really understand the menstrual cycle.

The second two weeks begin the systems. I was taught subject-based, but for the type of thinking that makes for good test scores, the integration that comes with doing Anatomy, Physiology, Pathology, and Pharmacology together just cannot be beat. If your school taught this way then this is old hat for you, but for me it was a shock to see all the new connections.

We begin with the Cardio/Heme/Onc/Musculoskeletal combination for the reason I described earlier. Cardio looks big in the First Aid and the pharmacology of Heme/Onc can be intimidating. Just remember that “screw it, I’m just not going to know that” is a perfectly good assessment for some of the material and if you can make peace with that, you will be less stressed. It probably will not be on your test anyway. Or you fly through these sections and earn a day off.

Gastrointestinal is there because where else would you put it? Renal and Respiratory go together with their acids and bases, and this brings us to the skull. Psychiatry is a new section with the First Aid and I think they have done a good job. It may bleed over into Neuro (as far as BRS and other review books go) but the two of them together get four days now and two more days during “the cramming”.

All together now:

If you are taking less time or more time, you simply shave or add a day here and there from one of the blocks in the first four weeks. I do not think it is a good idea to steal or add days from “the cramming” as this is a period favored by the gods. Why not add? “The cramming” is the period where you realize that everything you are reading is the last time you will get to see it before the test, and this is a shocker if you have not prepared for it. Cramming is also useful in the short term, and once you extend that period past two weeks, I think it is a hard argument that your short-term memory is still holding onto the lessons in the first days. Just my advice, but then again I could have done poorly and you should ignore all of this. You can access this calendar online. The dates used are from May 20^th, 2007 – June 30^th.

QUESTIONS

Which QBank is the best? USMLE WORLD. But that would be shitty advice, right? I could just cut and past the whole thing here, but I would like to keep this file manageable. Please read my evaluation of free questions and Qbanks available online.

BOOKS

Everyone is chasing after that magic bullet: the high-yield book. My experience was that few books can pull this off well and that most try to be miniature textbooks and are unmanageable in the time you have (HY Cell and Molecular by Dudek, HY Neuroanatomy by Fix) or are bare bones and do not help you make many connections (BRS Path). After spending a good chunk of change on these review books, I should have just covered the material in the First Aid using my own textbooks. Most of what you read you will not have to look up (because you learned it) and the things you do look up will be surrounded with full explanations. Anything less than a full answer is annoying and wastes time (if, like me, you tend to dwell). If you have played it correctly, you should also have old review notes from your courses and it is always easier to remember what you used to know instead of starting from scratch with everything. By the end, I was using Golan’s Principles of Pharmacology, Robbins’ Basic Pathology, and the Merck Manual. The Pathology BRS by Schneider and Szanto was useful as an outline (which I used to focus on Robbins) but the questions for each chapter are absolute crap. Costanza’s Physiology BRS was good in parts and her questions were reasonable, but there are a few uncovered topics.

FIRST AID

I tip my hat to Graham Azon of Over!My!Med!Body! for this piece of advice: put the First Aid in a binder. I took my copy to an Office Max, had the spine cut off and the book three-hole-punched, and put it into a 1.5” binder. Best move I ever made. I was able to take separate notes and include them exactly where I needed them and I was able to take my notes from previous courses and include them (my roommate expanded the book to fill two 1.5” binders). It is hard to overstate the advantage of having everything you need in one place.

THE EXAM ITSELF

It is hard to anticipate the pace of this test. When doing timed questions in preparation, there were instances where I would finish with 10 or 20 minutes left. I thought to myself, “Self, you’re going to have plenty of time to look over questions in each block”. I was wrong. On test day, I had around 10 questions marked per block that I wanted to give a second look and two minutes to do it. It was unexpected and unsettling, and for this reason I wished that I had taken the NBME practice test at the center. It is worth it just to remove the final few unknowns for test day.

The clock counts down for each block while you move up the list of questions. Unless you are willing to do the calculation (even subtraction can be stressful), it is hard to know how fast you need to move to finish. For pacing purposes, I ended up starting each block with question #50 and ending with #1. This way I knew exactly how many extra minutes I had to devote to problems as I went along and it helped me gauge whether I had to come up with an answer now (because I was falling behind) or could mark it for later (since I had a seven minute cushion). I would do this again.

I am thankful for the advice I received from a stranger: “You are going to walk out of the test with incredible relief that it is over. This will be mixed with some despair since you will think that you failed. It is over. You did not fail. Everyone feels that way.” He was right, and every one of my friends has echoed it. I went from relief, to defeat, to anger that I had not done better. A week later, I feel “okay”. When you go through it, remember that you are not the first, not the last, and it is normal.

Hope it helps, topher.

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The Old Man

He refused the joint. They were heading back from Prospect on Colin’s truck. He always sat on the edge of the bed, back curled forward so his hands could hold the frame and with his legs splayed for balance. It had rained earlier, and his plastic sandals weren’t much use to him against the metal. He kicked them off.

This was his third month with work. Yesterday he bought a wallet to hold his money since selling the last one some time ago. He felt worth something again to have so much. Colin and his brothers had started giving him lifts home since the second week. They were his new friends and this ride home was the highlight of his day. He knew its every inch.

He knew just where to lean. Past Git’s Supermarket there was a hard bend to the right with a pot hole. He would normally lean into the turn, but Colin had two beers tonight and would probably forget the dip. At the turn he leaned opposite as the wheel fell, dropping the weight of the car, and he kept his balance. Andrew didn’t know his brother as well and tumbled from his seat into the bed of the truck. He kept silent while the three others laughed. They teased him, “What matter wit you, boy? An’t you learn from d’old man? You don see him fall!” He had mastered these roads.

He knew the importance of details. Details mattered. He saw men with soiled clothes and recognized them. The lines of dirt on a man’s shirt shifted between begging and honest work, and he knew this. He saw it in his own sleeve slapping around his arm and he leaned his sholder forward against the wind, proud of the difference. Details mattered. His callouses were his proof.

He took the beer from Andrew. Colin was driving faster tonight and the smooth level spaces between bends and holes were shortening. He timed it to take a sip without knocking his teeth. He leaned to hand the beer back when Colin jerked the wheel. He had taken the last turn too quickly, too close to the center of the road, and swerved to avoid a car he should have seen.

He fell backwards. His bare feet lifted from the truck bed as he reached down for the lip. The beer still in his hand he didn’t think to drop it even as he balanced off the edge, half in and out of safety. Colin swerved back on course but into another hole. The dip and bounce of the bed sent him straight into the air. The truck kept moving forward while he hung there, still. He landed on the pavement flat on his back.

****************************

“Did you hear about the accident?”

“No, what happened?”

Med School Metaphor: Pancakes Every Morning

I have a lot to learn. By Friday, anyway. I have a Pharmacology exam followed by a Pathophysiology exam this coming Monday. Once again, I find myself behind. It’s the funny kind of behind where you look at the stack of notes on your desk (2″ of one, 3″ of the other) and sort of chuckle. “Ha. This is going to be funny.” Cue despair.

Looking at it now, I’m tempted to start the passive bragging of impossible odds. “You have no idea how hard it is,” I’d say. “Medical school is like trying to take a drink from a fire hose,” I’d brag.

And that’s total bullshit.

Nocebo

It just took me 15 minutes to outsmart a mosquito in my room. The bastard has been getting fat, happy, and maybe a little buzzed off me the last few nights. I lit a citronella candle in the room and discovered that the mosquito has a higher tolerance for that smog than I do. Mosquitos don’t wear belts nearly as well as I do, so it all balanced out.

It hasn’t been a productive day or week, so I might as well be the writing-kind of nonproductive. Some of my favorite lessons from the term:

If you ever take an oral estrogen pill, there’s a chance it contains equilin, which is obtained from a pregnant mare’s urine. Nocebo means ‘I will do harm’ and someone needs to name their next dog “nocebo”. Amaurosis Fugax is my new favorite term though I’ve forgotten what it means. Crazy people have hypomarble-emia (joke courtesy of roommate Kelly). The pharmacology course has taught me that a shot of expresso before a pot of coffee in an afternoon is properly termed a loading and maintenance dose of caffeine. It’s nice to have fancy words.

Severed Vacation

I do not enjoy vacation. Studying medicine makes me feel so useful that I go into withdrawal outside of it. Reading Atlas Shrugged with all my spare time doesn’t help matters any. I try everything I can. I cut my vacation short by starting a week late, electing to stay in Grenada to dissect cadavers for research. I cut another week by going to Milwaukee for the Annual Congress of Clinical Anatomists. I lose a week to a Michigan trip with my family, and I leave that early to spend a week at the University of Alabama at Birmingham (UAB). Why? To dissect for research, of course.

Working at UAB is my first time in the South and it’s everything with fresh eyes. Southerners chew gum lazily. Without wind, you’re under a heavy hot blanket. When walking for coffee in scrubs, everyone says, “Good morning, Doctor.” It’s pleasant.

I am at the UAB with other members of my group to finish dissecting projects in the hours between the classes of their first year students. We have complete access to 35 bodies and we all feel like kids in the dead people store. Each of us has come a long way from those first heady days of Anatomy Lab. After all, we have chosen to be here without threat of a grade.

We’re cutting into people? I don’t want to; I’ll just watch. I’m glad they put bags over their heads. Should we name her? That’s disrespectful! No it’s not. I’m naming her ‘mittens’. Should we say a prayer first? Oh, god. Give me the goddamn scalpel, Amen. How’s that?

For all the posturing, it was a special thing to watch my hand cut into someone for the first time. It was my hand that did it, by the way. I had nothing to do with it. After so many bodies, it losses its specialness. When it’s time to work, you approach, address the body, and then dive in for cleaning and measurement. A few minutes later you zip up your work and it’s time for the next axilla.

Most of us have been the ones quick through the door when it came to cutting, the ones that called for the scalpels. But here at UAB, it is a little different. Their cadavers are fresher, fixed with less formalin, smelling less, more robust. It feels like walking into a house so clean that you kick of your shoes even though that’s never been your custom.

Most of the students that flew down can give a few days or a week. We would stay longer but our classes are starting in a couple days, a few thousand miles away in the Caribbean.  A few students say, “screw it”  and decide to miss a few days of the first week, this being such a great opportunity for work.  It’s only because I decided to stay that I get this morning call,

“Marios, what am I dissecting this morning?”
“Severed head.”
Choking, “What was that?”
“Ask Vince to show you the severed head. Skeletonize the Facial nerve and clean away all fat and fascia.” Hearing my held breath, “Tophy, you okay?”
“Fine Marios. Just fine.”
“Congratulations. It’ll be fun. You’ll do fine.”

I find Vince. He takes me into the cooler where they keep the fresh cadavers. These people died a few days ago or a few weeks ago and have donated their bodies to the university. At UAB, there is abundance. I wheel a small bin into the prosection room and remove the lid. Thomas is staring straight at me.

I reach down to pick him up and can’t at first. Not expecting the extra weight, I give my arms a moment to recruit more fibers before he moves.  I hold him in the air while another student helps me clamp the vise grips into either side of his head. Of his head. I adjust the lights, pull up a stool, and grab my scalpel.

I can’t do it.

I push his cheek and it moves. I try to draw the backhand of the blade against his scalp to mark my incision and I scratch some of his skin. Before, I thought that cutting a fixed cadaver was the great big leap, and I was wrong. I stare at Thomas some more.

If you’re going to be a surgeon, you have to do this. How many people get to work on a fresh cadaver? What opportunity are you wasting?! Do it, topher. DO IT!

I let the blade sink in and I begin to draw the curve of his hairline down to the front of his ear, then drop to the bend of his jaw and forward to the point of his chin. I pull the line upwards and around the mouth, into the sweep of his cheek where tears would have slid and then around his socket and up, until I meet again at the widow’s peak. He’s bleeding, not in force, but in an ooze that marks each position of a superficial vessel. It’s creeping me out.

***********

His face flap is in the bucket. It took an hour to do, pulling up a corner and separating it from all the anchors of fascia. The beauty of dissecting is that you’re only as fast as your mind. I was trying to save every vessel and nerve fiber early on, terrified of doing harm, until I remembered that the Facial nerve has no cutaneous branches. At that point it became snip, snip. Finding the target nerves leaving the parotid gland was magic. Pulling against the fat to see all of the brilliant colors of muscle, nerve, artery and vein is something that my fixed cadavers could never do for me. I’m no longer bothered by how real this all is; I’m too busy being hypnotized. The nerves branch and split, branch and split until they are thinner than hairs and I can’t believe that I haven’t destroyed them yet. They’re so strong and wet and alive.

Gross, messy, scary, morbid.

Say what you want about dissecting the face of a man that died days ago. Just don’t leave these out:

Amazing, glistening, beautiful, perfect.

Cracked lips

If someone were to ask me, “What’s the stupidest thing you’ve ever done?”, I’d answer with this: trying to be in control.

Working on the terminal onc ward is pretty stressful if you’re emotive. People came to our floor because they were going to die. A lot of them were there for a week to receive the next chemo cycle before heading back home. Some of them stayed for longer, months even. But no one ever got so healthy that they left for good. Thankfully, I’m not as emotive as most.

You start to get a feel (or think that you do) for how people are doing. Some are feeling so well that they start thinking their cancer may be going away. Others are holding steady with their treatments, walking up the down-escalator. Some are doing horribly but are stably horrible. Those are the ones that are just agonizing to serve. I remember starting on the floor and taking care of the same women for three months. Every two hours, adjust position in bed. Clean as necessary. It was always necessary.

I remember a frail patient of mine that was in her seventies. Her family knew that things were worsening and that this weekend would be her last. Everyone from out of town was coming in and spending the full day with her. As a tech, it was always a strange experience entering the room to take vitals or perform a blood sugar test. The family members would watch me so intently and then each advance their chins to me, awaiting the result. “Her blood sugar is 136.” When there is no control, there must be control. Keeping track of BP, HR, and sugar are all our best attempts at control of some kind.

The family left for the night. I had ten patients for my census and checked in on her as much as possible. She was heading downhill and her breathing was becoming more and more labored until she started using her accessory muscles to pull in the air. They call this “agonal breathing” which just about hits it on the nose. I stood by her side and waited for the nurse to respond to my page. I didn’t see her do it, but the woman reached out and grabbed my wrist. It was unexpected and cold and it gave me a start. I reflexively pulled away and then felt a heavy embarrassment and sadness for her. I think I reached out to hold her hand. The nurse came in and the two made eye contact. She had such fear and the nurse looked at her and said that it was okay. You’re dying. It wasn’t cruel or improper, but somehow perfect for that moment. She relaxed.

There was nothing I could do for her. She was dying in front of me and I would be there for her final new and final final experience. I saw that her lips were cracked. I got some lip balm, held it out, and between gasping breaths she pursed her lips so that I could apply it. That was my stupid attempt at control. I can’t remember if I held her shoulder, or hand, or just stood there doing none of those things. She was staring straight ahead, bracing. And then she stopped.

We called the family. They came up the elevators crying at 4 in the morning. They stayed with her until 6 and, before my shift ended at 7:30, I walked into the room. After taking off her gown, I tied her feet together. I tied her wrists together. And just as I had turned her side to side so many times before, I managed her into the big white plastic bag. I wrote her name on a tag and looped it into the zipper. Security came and wheeled her away.

Alive, I could do something for this woman. Dead, I could do something for this woman. But dying? They didn’t cover that in training and it seems like something impossible to get entirely right. Even so, when the best you can do is stand in the room and treat cracked lips, it seems especially futile. A new patient with a new cancer and a new family was in the room within the hour.

Two years later and I still feel the pang of failing her that day with my stupid attempt at control. Worse, I know that it was one of her last memories.

Goodbye Grenada

I came home from my family reunion to books. For seven straight days I studied with breaks for food, completed hundreds of practice questions and made review sheets. And then review sheets of my review sheets. Monday was the Path final. Most people walked into this exam knowing exactly how many they could miss to save an A. I was no exception and after the exam finished and we were allowed to check our answer, you could hear people cursing under their breath as the first fifty questions sealed their fate before they could consult the other hundred.The toasts downstairs were split evenly between “Horray!” and “Path sucks!” My roommates still had some shopping to do. You see, Kelly is in charge of the Senior Slide Show and the refreshments. They have given him entirely too much money.

After getting alcohol and pizza, the roommates meet up to practice for the Advanced Clinical Skills final. Each of us takes two tests, learns them, and performs them on each other. I pulled Peripheral Nervous System and Abdomen. The exam is cumulative but we ignore the tests premidterm.

The next morning (9:00), we put on our Sunday best and grab our little kits. Here’s how it works: every imaginable test is laid out on a table face down. You stand at the top of the lecture hall until summoned to pick randomly. You then follow your tutor into a booth with a standard patient and begin. I picked up the Venous System. Lame. Because I haven’t studied this (premidterm material), I look at the checklist to jog my memory of the Trendelenburg test and Pratt’s test. The tutor yells at me, “You can’t look at that! Now follow me.” I play dumb, drop the test back into the pile face down and follow her. “Where’s the test?” “You told me that I shouldn’t look at it!” “Go back down and grab the test.” She shakes her head at my idiocy. I walk down and pull the Abdomen Exam. Perfect. 95 A.

So I’ve finished Path and the ACS lab. I’m feeling the euphoria of “finished.” We all sit around the apartment watching the World Cup and helping Kelly finish the slideshow. It’s going to be great. We set up at 6:00 the student bar which consists of several 5 gallon jugs of Hurricanes mixed by our own Louisiana natives. With the class appropriately loosened, the slideshow begins. It’s a riot with clapping and cheering along its entire length and Kelly is the true rockstar of the hour.

The next morning, instead of sleeping off a hangover with the rest of my class, I’m in the Anatomy lab with a bone saw, cutting some man’s hat off. I can sum up the entire experience with one word.

Dusty.

If you’d like to read the complete description, click here. The gist is that cutting into someone’s head, while gruesome, is also thrilling. To carry out the dissections that I want (on an intact jaw) I have to cut a circle around the top of this man’s head, cut out his brain, and then cut straight down the middle of his face. After all of this, you pull the two halves apart and you’re looking straight down at the target. My arm is sore and at least once I was shocked out of the moment by the absurdity of it: left hand clutching the lip of his skull, right hand punching the hacksaw down the center of his face and rattling of in my head the spaces in our skulls that I’m destroying. All of this and smiling, I could forgive someone for stumbling into the room and smartly assessing the situation before walking out slowly. And backwards.

What I’m doing know has nothing to do with collecting data and everything to do with a pretty picture. You see, whenever you carry out interesting anatomical research, you have to do a good job collecting data, but the pissing contest of “who is the best dissector” is far more important. That’s why I’ll spend two whole days on a jaw that would take two hours to dissect the ugly way. All that time in the lab, alone, was difficult, especially with everyone else out on the beach day after day.

Especially when all of the pacemakers go off at 9:15pm every night. They’re screaming at someone to change their batteries. I whisper back to them, “It doesn’t matter.”

So I end up spending a week dissecting a few jaws and sending off a case report to the Journal of something or other. I’d love to sit around and just be nostalgic about Grenada, but my time is tied up in boxes and small errands. I do make time for a few things. I ride to Grand Anse to eat at Nick’s for the last time. After that I see Mr. Green Jeans and ask for one last banana shake. I’m not even that hungry; I just want to hear him swing the mallet. I make it up the hill to Maurice Bishop highway. I wait my turn to pass a Red Reggae bus that opens up the rest of the straightaway. And with my shirt flapping up against my back and the Hero Panther Moped squealing for a fifth gear that isn’t there I’m reaching 80km/hr and flying. Tomorrow morning I’ll be calling a bus to take me to the airport, but that’s tomorrow. Right now I’m passing the wind, the sky is blue walls with a pink ceiling, and it’s beautiful.

Goodbye, Grenada.

Related Strangers

I have ants in my pants. I have them in my computer. And in the apartment. I’m trying to build up a head of steam in these last days in Grenada and it’s tough with all of these ants. I’ve discovered a lot about myself in the process. I am, if nothing else, an unflinching murderer of ants. I go to brush my teeth and they are swarming around the cap of my whitening toothpaste. They grin at me with teeth three shades whiter than before. I mash them.

By the time I’ve finished, I’m too worked up to sleep. The breast helps. I’ve learned that nothing is so boring as female pathology. If everything else fails, I read and write. I’ve read so much lately since discovering GoogleReader. I’ve discovered that an entire world of medical writers exists online. Students, residents, attendings and retired. They all have interesting things to say and many have published their work. I started reading one journal and lost a week of my life to depression. You see, his writing is much better than mine. Painfully so. I went back to his archives over the last three years and read it all. Exhausted, I decided I would could never write as well.

Or I could just copy him. So I started writing online as well, a second blog to the one that keeps the record of all of these emails. Sorry for cheating on all of you. The material is a little more stream-of-consciousness and a little less appropriate for mass emails. I write about wearing sheepskins and kicking wildly, you know: pagan things. I started writing a few medical essays and have submitted them to an online magazine of medical writing. I had two articles accepted and, feeling worth something again, have stopped writing so frequently.

I have a piece of software that tells me how people find my site. Search items include:

(1)the greatest pair of shoes
(2)inguinal hernia video exam
(3)coax feces from anus (Can’t. Stop. Laughing)
(4)yellow jealousy
(5)”why go to medical school?”
(6)reasons not to go to medical school
(7)shiny scalpel gonna cut you open
(8)where is the hanging statue of Lenin in Prague?

Back to the books. I have learned that in Rheumatoid arthritis a painful growth of the joint occurs and this is called a “pannus” which makes people want to walk less, become obese, and develop an apron of fat that hangs over their knees, called a “panus.” I have no idea how my dyslexic friend is cutting it here.

In Clinical Skills I keep getting the same tutor. Most students hate this guy because he’s unprofessional. He cracks jokes where every punch line is “that’s what SHE said!” He offers to meet all of us at Angie’s after class which, from what I’ve pieced together, is a whorehouse behind the Grand Anse Bank. He sits nervously, rocking back and forth always stealing peaks outside the curtain. Whether he’s checking out a student, watching the clock or high as a kite I don’t know. He describes a certain type of gait as “Clarke’s Ataxia,” after his favorite rum. In a previous life he inspired A Confederacy of Dunces.

Why don’t we complain? Why do we continue to let him be our tutor? Well, this is Clinical Skills after all and each of us thinks that he’s making us better at handling unprofessional people. We’re also trying to diagnose him. My money is on “Henry the VIII’s Affliction” otherwise known as alcoholism with a splash of tertiary syphilis.

Still in school, my family threw a reunion in the Poconos. I took the weekend off to meet related strangers. Off the plane and into the rented van, we quickly fall into our old roles: passive-aggressor, attention-seeker, policeman, frayed nerves, joker, instigator, smartass, complainer. I should give my family more slack since I’d forgotten how funny they all can be, when drunk. Two drinks in at dinner and we’re laughing about our own idiocy and the tiny miracles of iPod Jesus.

All’s well. I have my Path final in three days, so I’m wrapping this up. I’m embarrassed that my arm is sore from playing a video game where I had to hold a plastic gun at eye level for twenty minutes. I am not embarrassed that I spent twenty dollars to beat it (not an exaggeration). Of course, money was spent on dumber things.

The Larkin Clan was 6 tables strong in the banquet hall, and my brother and cousins were sitting at a table with a pitcher of beer to a man. Wasn’t too long before every other chair was in concentric circles around the booze and people were trying to eat seven saltines in a minute. I’ve never been to a race track, but this is what I imagine happens: Everyone sits around with money, someone emerges as an “expert” on how to pick a winner, and then people make twenty dollar bets while the horses choke on saltines. One horse can only finish two saltines and is put down while everyone mutters that, “it would have happened sooner or later.”

This was the same evening where I accused a relative of being too shy. Turns out her jaw was wired shut. In good company, My uncle wondered on a crowded elevator if this was some kind of “wheelchair convention.” Close, it was a retreat for people with Multiple Sclerosis. Yeesh.

By far the biggest event of the weekend was Karaoke. I cringe whenever I see that word but my family did a fine job. One of my related strangers is an actress getting her masters. She went up and brought the house down with “Material Girl” and “Genie in a Bottle.” My cousin Ryan took a different approach: gusto. 6’4″ monster that he is, it’s hard not to cheer.

Karaoke singer’s are fascinating and I’ve tried to classify them.

The singer: this person has some pipes. They can pick a song, do everything correctly, and walk off to applause.

The shower: this person is delusional about their pipes. With a singer’s swagger, they pick a song, match it note for note until you don’t, at which point it’s jarring and painful for everyone. They didn’t know this would happen since they usually have the backup singers inside the radio to carry them. You feel awful and pity clap.

Guy singer: rumored.

Average guy: plays his strengths and avoids the weakness. For most, this means picking a song were the singer “talks.” REM’s End of the World or Billy Joel’s We Didn’t Start the Fire fit the bill. You talk, louldly with gestures, and fool everyone. Don’t be fooled by Johnny Cash’s Ring of Fire. That’s a hard song.

The Calvin: you’re particularly awful at carrying a tune but by the grace of God you know this already. You pick a “talkie” and then butcher it, all in good humor. It’s better if everyone knows this song so that they become involved and share in the joke. You then sing Billy Joel’s Piano Man and manage to sing “La, did de da, did de da-ahhh!” off key. People laugh. People cry. You’re the hero of the night. Nice job, Cal.

That was the reunion. Cheers, topher.

Addendum:
(1) the journal that is hauntingly well-written: http://tomwaitsatemybaby.blogspot.com/
(2) the online medical magazine is Grand Rounds. The archives are here.
(3) My youngest sister just graduated from High School and received an iPod Nano. Supposed to hold 1000 songs, she was boasting that hers held 1050. I asked her how many of the songs were about Jesus (she’s very religious). “Around 400.” It’s a miracle.

Jog-22

In medical school, I have options. I can do a few of the following:

1. Stay healthy.
2. Get As.
3. Have a healthy relationship.
4. Have a social life.
5. Do research.
6. Get tan.

The interplay is fascinating. When I go for As and Research papers, I gain weight and lose my social life. When I’m trying to be a good boyfriend, research and books go by the wayside. Also, if I’m happy in the relationship, I gain weight. I could get tan, but then I’d just be round and brown. Plus, being tan requires maintenance, and if I was capable of that then I wouldn’t be round. Staying healthy was never really in the cards.

3rd term with all of its free time was my only real shot at nailing more than three items from that list. Funny then, that I remember so much of what I learned then as training for getting angry at ungrateful patients (that I haven’t had) over not following my advice (which I haven’t given). So what if a smoker comes in complaining of a cough for the last two years; I’ll feel sorry for him. I’ll bond with him over my obesity and diabetes. He has his 30yr pack history complicated by chronic pneumonia and I’ll have a 20yr donut-breakfast history complicated by a double-chin.

Why the focus on my health? Today I sat at the computer and noticed that instead of the effortless inhale that I’ve been so used to, I had to fight against a roll of stomach squeezed against my belt buckle. “These pants must be too tight.” In my empty apartment, I look left and right before opening the belt and letting loose the top button. I took a deep, satisfying breath. “That’s better.”

About five minutes passed before I had my running shorts on, house keys in hand. I went for a jog. I’ll never again lie and say that I “ran from campus to the roundabout” or “went for a run.” I’ve been friends with too many cross-country runners and track athletes to think that the way I lurch forward while shuffling my feet constitutes a “run.” I know just as well as they do that I might travel faster if I was speed-walking.

I should be better at this. I used to jog in my previous life back home. It’s harder (for me at least) without a running partner, and I tried to get my sister running with me. She, being a little overweight, would have none of it. “People will see me and think that I’m fat.” Which is true. Most people love to take a cheap shot at a stranger. Before I had trouble breathing, I remember seeing an overweight person out jogging and thinking to myself, “Someone should tell her that it’s not working.” Not now though; not since having sisters. I see people jogging and think, “Good for them. Jogging sucks.”

And I would never do it to stay healthy for health’s sake. Instead, I subscribe to the Yo-yo plan of jogging:

1. Jog and be miserable until skinny
2. Stop running and begin slow descent into happy fatness
3. Become disgusted with fatness and buy a new pair of running shoes (and jog in them)

The problem with this plan of mine is that once my body adjusts by pumping more blood, burning more fat, and increasing my basal metabolic rate I’ve also developed a constant gnawing hunger that rears its head 20 minutes after any meal. And dammit, if I was strong enough to say ‘no’ to that stupid hunger in the first place I wouldn’t have overeaten and I wouldn’t have a few pounds to lose.

Frustrated with failure, I do the normal thing: run for a half hour, drink a beer in the shower, and call it a day.

Commencement of Distraction

My sister, Honora, is graduating this Sunday. She’s the last in a long line of grey hairs for my folks and I’m so proud that she’s leaving the state for Regis University. Get free, Honora. Get free.

Speaking of freedom, the hog squeals again. I dumped $300 into my moped to get it running again and it feels great to be cheating death on a daily basis. Just yesterday I was trying to pass someone that decided to swerve violently in front of me and slam on the brakes in hopes of causing an accident. Thank you slackline; the balance you taught me saved my life. It was over before I knew what happened, but the students in the car behind me let me know:

“He tried to kill you. You tried to swerve out of the way and your bike went sideways and skid forward a yard without flipping on top of you, and then you got control and went to the side of the road. He looked back at you and screamed something. It was definitely on purpose. Is your foot ok?”

I look down to see that two of my proud climbing callouses have been ripped from my foot and the holes are bleeding. Sandals are not protective. I thanked them for checking on me and continued driving towards the nearest bandaid. I think that when my life really is in danger I’m going to be robbed of the whole “life flashing before the eyes” bit since near as I can tell I just draw blanks. The bike is now for sale.

For the first time since coming to Grenada a year and a half ago, I’m homesick. It doesn’t help matters that I am alone now since Sherin and I divorced. Sorry to dash so many hopes about torturing her in Michigan but it isn’t to be. No, I don’t want to talk about it. And instead of dealing with it in a mature way, I’ve elected for distraction.

This includes looking online for a tutorial on how to whistle with two fingers. I have technique but not power. I’ll keep you posted on how it goes. I still say the alphabet backwards once a day.

I edited the paper for the Annals and sent it back. Two days ago I received notice that it was accepted. I feel sorry for everyone with a birthday that’s 4-6 months away, because you’re getting a copy of the Annals of Thoracic Surgery that you DO NOT WANT and WILL NOT READ but are GETTING ANYWAY. I found out that I have one of the oral presentation slots for Congress this summer. I’m up against 14 other students, one of which won the prize last year. I have it on good authority that the boy whose voice cracks the most often will win this year. Fingers crossed.

The exams I studied so much for went well and while Path still remains, Microbiology is over. I learned some amazing things in that course and am sad to see it go. A few of the gems:

Military officers do not contract gonorrhea, that’s for enlisted men. Officers are afflicted with “bacterial urethritis.”
I rarely spell “gonorrhea” correctly. In fact, all medical words that contain an “h” have to be preceded by “rr.” Diarrhea, amenorrhea, rrhiccup, and so on.
Doctors are paid by the syllable and charged by the word. That’s why you’ll hear “Pyelonephritis by hematogenous spread” instead of “The bacteria got to your kidneys by your blood.” If each word costs a dollar and each syllable pays a dollar, the first sentence pays $9, the second sentence pays $4. So as a physician, I can either be plain-spoken and poor or rich and confusing. I think I’ve found my calling.

That’s all for now. CONGRATULATIONS HONORA!