Apres Mini 2, le deluge

I absolutely cannot concentrate on a single, important thing right now. It's always this way after a test, but that was weeks ago, and doing so well should have energized me. I'll get to that a bit later. Since I'm going to be leaving prematurely, I figured I throw in some extra pics of campus life, seeing as how I seem to snap the same sunset over and over.

Here's another view of my soon-to-be-former residence - I'm not kidding when I say that this island is the jungle. Annoyingly, when it rains, that little trail you see there becomes completely submerged, and I try not to think about what the cows have been doing as I slosh through in my flip-flops. We've already had enough parasite lectures to scare me away from walking barefoot on the beach for the rest of my life.

Here is perhaps a better view of the campus than I've ever posted before - it quite nicely captures the essence walking around down here. All of the buildings are covered by the same, white, hurricane-ready roofs, and none of them are more than three stories tall. Most of the student buildings are squat auditoriums, straining even now to contain the ever-swelling student body. The unspoiled beauty of this island is undeniable, but the greeness is almost oppressive at times - hulking, forested mountains loom everywhere. I'm glad I live on the sea.

This is the pathway to the Shacks - I don't know who this random guy is. Those taller white-roofed structures on the right shade a small eating area, and down those steps just above random guy's head can be found the aforementioned Shacks - the little eateries run by the locals. "Shack attacks" - our affectionate term for debilitating bouts of gastroenteritis - are probably just a myth; I've never gotten sick from eating here. Every single day I buy spiced chicken and rice with tomatoes and cucumbers from this gentleman named Nelson. I've gotten to know the guys who work for him, and I suppose I'll miss them when I'm gone. I also buy juice (mango, if I'm lucky) from Addison, down on the end.

Here's the view of the Shacks from the street - Addison's is that first one on the right. Some other shacks sell wraps, others fish dishes, others pizza - they try to cater to us. There's also one little lady - Mrs. Betsy, right next to Addison - who sells fresh fruits and veggies. It's nice to be able to get some shopping done right here on campus.

This sprawling piece of land here is where Ross holds their version of intramural football. I guess we all still need some semblance of normalcy this far from home, and so many of us turn to sports. Those two buildings on either side house classrooms for students, faculty offices, and the elementary school

This picture was taken just to the right of that last picture - it's the playground for all of the elementary school kids. Ross is fairly non-traditional -it's outside of the US, for profit, and has incoming classes of 500 students - so it attracts nontraditional students. Many of them are coming to medicine as a second career, and many of them come with their children. I don't know how the educational system is, but I don't think it's hurting anyone (I just know that the principal and I share a similar taste in heavy, slightly dark movies). This would be a great place for a kid to spend a couple months - ideally before they're 7 or 8, and after they can read - before returning to the states to get an education. I take my hat off to the folks who manage to be a full-time parent and full-time med student - I can barely take care of myself down here.

I cannot concentrate, and there are tons of things I should be doing - one of the most pressing being my second hospital interview write-up. (HPI) Last Tuesday, I went back to PMH for the second time, and I expected much better. Last time, I stood around waiting for the OBGYN to show us something interesting. This time it was more of the same, but with the orthopedic surgeon. I did get to see a gentleman who'd completely torn his quadriceps tendon - but it wasn't that interesting. Last time, I interviewed a patient who was in nearly perfect health, save for being smacked in the back of his head with a rock and losing his sense of smell - that made for an elegant, simple HPI. This time, however, I interviewed an 80 year old man who'd had scarlet fever and dengue fever, an appendectomy at the age of 13, 7 total hernia repairs, an open heart surgery, gall-bladder removal, and who now presented with arthritis in both knees. Everyone in his family has some cancer or other - and so I am not looking forward to writing this HPI. Perhaps it's a blessing that I'm getting sent to Miami - at least it'll be more interesting.

I cannot concentrate right now, and I don't know why - It's not like I've been doing nothing but working. I've just taken a step forward technologically, because I have the coolest thing ever - an Ipod touch. Sure, it's a touch screen Mp3. player, but it's sooo much more - you see, Amazon has released a Kindle application. Kindle is Amazon's wireless, electronic reader - you purchase a book and download it to your kindle. I drool at this idea. However, the Kindle is $350, and I'm years away from being able to justify that expense. However....with the addition of this Kindle app, I can now download and read any Kindle-ready book on my ipod touch! I'd known about this app for quite a while before I realized how cool it was.

I'm an absolutely voracious reader, but two things have kept me from indulging down here. Firstly, I am in medical school, and there just isn't the time or mental energy to put into pleasure reading. Second, Amazon doesn't like to ship down here. I've ordered a few online and had my family ship them down, but that's just not at all cost-effective. I've realized, though, that my escaping into some literary creation, my "getting out of my own head", is something that helps maintain my sanity. Just before the first semester final, I'd picked up an Alex Cross novel by James Patterson, and I couldn't study until I'd put it down. This hasn't been a problem here - reading doesn't get me in trouble - but it is something I feel I need to do to unwind. I scoured tattered paperbacks in the student activities center, only finding a few to my liking, but I also searched for free ebooks online (once again, not finding too many). With the advent of this Kindle thing, I can read almost whatever I want - it's like Christmas all over again! I've just finished Assassin's Apprentice by Robin Hobb. And you know what? It was a free download!

Speaking of staring at tiny screens, though, I think my vision is going. I noticed it a semester or two ago, and just figured it was my time for glasses. I paid attention to it for a while - things were suddenly fuzzier at certain distances than they'd ever been before - and realized that it was only after prolonged bouts of studying. I guess my aging lenses are becoming stiff, and aren't adjusting as easily as they used to. It's a little ironic - the ICM practical is coming up, and I'm practicing visual exams.

I can't concentrate, but not everything I've been doing has been frivolous - as I said, the ICM practical is upon, but it is also upon the 3rd semester folks. Last Friday, Nicole and I volunteered for an AMSA sponsored workshop over the physical exams. We had a small group, and just had them run through their stuff -BP assessment, precordial exam minus auscultation, respiratory exams, jugular venous pulse - etc. They were, for the most part, much more prepared than I was at their point in this game. That's why Nicole and I have started practicing earlier this time around; we have significantly more to review and learn. In addition to performing neurological examinations, we're also charged with diagnosing heart pathology from heart sounds on Harvey heart simulator - it's pretty cool, but I know that, when I'm under pressure of the examination, all of those murmurs will start to sound alike.

Yesterday, I held a TA session for more 3rd semester folks, this time reviewing the anatomy of the posterior abdominal wall. I truly enjoy these - I must be the only person on this island who becomes nostalgic at the smell of formaldehyde. It's different as a 4th semester, though - in addition to teaching the second semester kids, I'm helping out a 3rd semester TA I work with. They've changed some things around, but my advice on various classes and professors still holds water. I briefly considered working as an academic TA, but that would mean more weekly reviewing. Sure, it would have been a great way to brush up on old info for the shelves and even the step, but I've got cares enough of my own, and, since this is my second time TAing anatomy, I don't have to review as much.

Have I mentioned how swamped we are? It seems like the professors are trying to cram as much as possible into what little time we have left here. Generally, we'll move through powerpoint slides while the professors explain things - instead, they're sometimes reading through them as fast as they can. I'm getting tired of all of this - I'd gotten good at learning in class, but now, with the profs talking as fast as I can hi-lite, I really don't get much out of the lectures, and find myself tying to find time and plan when I'm going to teach everything to myself. There truly aren't enough hours in the day - I've got my physical exam practical on April 7th, and then a week after that begins my final onslaught of tests and examinations for my basic sciences years of medical school.

One thing I forgot to mention - a week ago yesterday we had our fourth semester banquet. It was held at the mansion of a man named Astaphan, an hour away from campus, and at the top of a mountain. Folks get all dolled up and go hob-nob with the professors as popularity-contest-obsessed student activities coordinators put together pat-ourselves-on-the-backs slideshows and superlatives. It was fun at first - Nicole and I got a nice bottle of wine and sat down quietly with another couple. A lot of the other students, though got smashed and proceeded to make asses of themselves. We left before the dancing started, but even then it was feeling way too "undergrad" for me. From what I heard later, folks behaved so badly that 6 professionalism cards were handed out (for what, I'm not entirely sure). Oddly enough, most of the folks there were probably the 1st, 2nd, and 3rd semester dates and friends of 4th semester students.

Extradition Repatriation

Things don't always work out as planned.

As the end of my second year of medical school hurtles imminently towards its electrifying conclusion (I say this only to stave off the dread of another firestorm of shelf exams), my placement for 5th semester has become increasingly pressing. I had three choices - stay here in Dominica and complete my 5th semester AICM (advanced introduction to clinical medicine) here at Princess Margaret Hospital in Roseau, Synergy somewhere in Michigan, or Miami - the ol' standby. Our choices were due sometime last week, and Nicole and I both chose to stay here. On my part, there were several reasons for this - perhaps the lion's share of which were summed up in the simple fact that I hate moving. Seriously...I think I have a type IV hypersensitivity reaction to placing things in boxes and bags only to remove them again in a few days or weeks. Another reason I wanted to stay was because it would give me more time to study for the comprehensive final exam, essentially the mother of all shelf exams, handed down by the NBME (National Board of Medical Examiners). It's supposed to give a fair estimate of performance on USMLE: Step 1 - perhaps the single most important test I'll ever take. Also, this is a third world country - I knew that I'd be allowed to partake in procedures that I'd only be able to watch on TV back in the states. Tied to that was my major reservation about staying down here - that I'd be learning third-world medicine and therefor be at a serious disadvantage when I went into clinicals, but that didn't really bother me; I can always look things up.

There was a little catch in the process, though - for those of us intent upon remaining in Dominica for the 5th semester, there was an option to do Peds and OB rotations down here. Now, these are rumored to be notoriously difficult to schedule in the states, and so the idea of getting them out of the way was quite appealing. However, Texas' requirements for FMGs (foreign medical grads - the term that applies to US citizens , such as myself who graduate from medical schools stationed outside of the US, used to differentiate from complete foreign IMGs - international medical grads) are strict indeed, and I wouldn't commit to doing rotations that may jeopardize my licensure in Texas. Thus, on my application, I told them that I'd like to if I could, but that I'd have to check with the Texas Medical Board to see if those rotations were approved. I haven't heard back from the yet, but I received an e-mail yesterday saying that preference for staying here would be given to those folks who committed to those extra rotations. Bummer, dude.

Or not - you see, that wasn't told to us. I thought it was based predominantly upon GPA - in which case, I'd have been able to go wherever I wanted. Something else they didn't tell us was that, if you committed to one of the special rotations and were chosen to remain in Dominica, and you changed your mind, you'd be subject to disciplinary action. Funny how they forgot to mention that little tidbit, isn't it? So I'm sure there were colleagues of mine thinking to themselves "I really want to stay, so I'll tell them whatever they need to hear - I'll just back out if I need to". Sucks for those folks. This is one of those things though that reminds me of one truth I've learned about Ross:

"If something looks like it harms students or doesn't make sense from an academic standpoint, it makes Ross more money." Let me add in this disclaimer, though - I do not lump together the faculty and the administration. I have the utmost respect for the basic sciences professors down here, and have been truly blown away by their intelligence and committment to the students.

I don't say this to be incendiary or bitter, but it is quite true. You see, this is a for-profit medical school that want to make money. Now, they make money by selling a product - medical degrees. If that product is faulty, the business fails, so it must be a fantastic product - Ross grads are just as good -if not better - than US grads. Some might say, then - if they were so good, why didn't they get into a US med school? Those of us who make it out of here are willing to fight and claw our way through all of the hoops before us; we all have chips on our shoulders - as the underdogs, we've got something to prove. We've had to fight every step of the way, and by the time we get to clinical rotations with our US peers, we're used to getting up earlier, staying up later, and working harder, because we're expected to not be as good, so we'll prove that we're better.

So Ross does provide a quality product. However, on the other hand, we have things that don't make sense. Why take people who, for whatever reason, didn't make it into a US med school, and give them shorter semesters and less time to learn the information? By doing so, Ross can squeeze in 3 semesters a year - adding millions to their bottom line.

There are more like this, but I only bring that up to make a point - why would Ross decide to surprise us with disciplinary action for backing out of doing rotations down here at PMH? Well, clinical rotations are difficult to come by for any medical school - it's not just us. However, the more rotations Ross can schedule down here, they fewer people they'll have to fill spots in the states. That means less overflow - fewer people complaining. If Ross can schedule more rotations down here, the shortage of clinical spots will not be as severe. And so, any student who increased the burden for clinical spots will be punished. Now we're all adults - we shouldn't commit to something we don't intend to complete, but the fact remains; I don't ever remember hearing about disciplinary action until after I'd submitted my application.

Nevertheless, I'm going to be back in the United States of America a few months earlier than I'd planned. I didn't want to go through the hassle of finding a car and housing, but it won't be that difficult to do - just a very small monkey-wrench in my plans. It'll get done, and I'll get to enjoy south Miami while I learn more about the practice of medicine - I'll get to go back to LA Fitness, the gym I fell in love with; Nicole and I will get to go back to Bacchus, the little jazz and wine-bar owned by the charming Columbian couple; and I'll get to see my family.

This is all for the best, I suppose - I've learned that if I ask God to give me His best, instead of what I want, things tend to work out better. So, I'm going to make the most of it.

Speaking of things working out, this past exam was the worst one I can remember, as far as the material is concerned. I can't remember being so stressed by the mountain of information - but in the end, it turned into my best exam ever. Let's hope I continue the trend.

Tonight, we've got the fourth semester banquet. It'll be nice to relax - kidney pathology is already too hectic. I spent the morning working out and teaching second semester kids about the abdominal organs and bloodflow. Pamplona has the running of the Bulls? Well, we've got the running of the bowel. Take your pick.

Wolves

We had our second exam of the semester this past Monday, and I think it went considerably better than I'd expected. This was the first test which had me feeling extremely overwhelmed (I've got more cluster bridges than I know what to do with), and I actually lost sleep before the night of the exam - something I haven't done since the MERP final. It was so frustrating to plan out my studies, get through most of it, leave enough time for an 8 hour sleep - only to toss and turn until 4:00 in the morning, be fully awake from then until 6:00, and only manage to get a scant hour of good sleep. Nevertheless, the epinephrine kept me going, and I think I did alright. My favorite professor is an old-school Italian pathologist (my panic was due almost entirely to the mountain of information he presented) who, around exam time, ends his e-mail responses to students with "In Bocc' al lupo", which is apparently a Roman (now-Rome, not ancient) student's exam-time wish that means something like "good luck". It literally means "In the mouth of the Wolf". This was the first time I've ever really felt that way.

I had to share another little piece of medical coolness. Here and here are the story of this little 7 year old girl who basically had her entire digestive tract taken out (with parts of it replaced) so that doctor's could resect a very rare tumor. It was tough to get a name, but it's called an Inflammatory Myofibroblastic Tumor. Here's what it looks like inside the body - it's basically composed of muscle-cell precursors gone wild. One of the hallmarks of cancer that distinguishes it from a benign tumor is the infiltration of other tissues with cancer cells - not quite metastasis; more invasion. With the aggressive surgery this little girl went through, the most likely clinico-pathology of her tumor is probably best explained by saying that those vicious little muscle cells you see below - with their big, ugly, purple nuclei - swarmed all over everything in her little tummy, taking over like a plague of locusts. That's why they had to take our everything in her abdomen, and put back what they could. That's why they couldn't save everything.

It's not common at all, and I'm still trying to figure out all of the nuances - you see, we're constantly studying cancer; true to its nature, it's infiltrated every aspect of medical learning. I guess it makes sense; people are living longer now, and basic pestilence and hunger are no longer the greatest threat to [most] people. In addition, we've got a plethora of designer chemical aimed at doing everything from making our food taste better to holding together the chairs you're sitting on - it makes sense that we'd miss something, and that there would be some untoward reactions with the very cells of our body. Granted, most cancers happen in much older people, due to the body's diminishing ability to keep up the myriad sub-cellular repairs necessary every second, but we've also got lists of chemicals that predispose to certain kinds of cancer. Sometimes, they just pop up and attack like packs of hungry wolves, tearing the body to shreds before the patient's eyes, and other times, they're far more insidious; more patient.. I can't help but think what a technological marvel it is that they've managed to save this little girl.

Checking in

I have nothing interesting to post - I am merely proving that I'm still here. Our next test is on Monday, so I will soon return to my cave and hunker down again, defying the oncoming storm with inumerable details. There's a hell of a lot of stuff to know this time, and while the last exam left me impressed at how much stuff I had in my head, this one makes me feel like I don't know anything yet. It's not that I don't get it - there's just so much to do, so much to learn. This time around, for pathology alone, we're covering GI path (gastric ulcers, liver cancer, pancreas, etc), male and female reproductive path, and endocrine path. I should get back to it.