I can almost taste the freedom!

Last night was another one of those nights in which, despite all of my good intentions, I toss and turn for hours. I don't know if it's a stress thing or what, but it's gotten to the place where I'll just keep up the studies and hope that I'm not a zombie the next day. Fortunately, I maintained a modicum of focus - the big, final test on the island is tomorrow (and I really should be reviewing skin and kidney pathology instead of posting). I can't wait to be done with this place!

So I'd been TAing anatomy for a few semesters, and, lo and behold, they pay us. I mean, I knew that - I'd just never picked up my check (one per semester). I wanted to get it all as one big lump sum before I left the island - I figured it'd be like sticking my hand into the pocket of some shorts I hadn't worn in a while, and pulling out a few hundred. Here's the funny thing, though - my wages for slaving over dead bodies amounts to something on the order of 0.4% of my total current debt. How's that for perspective?

There's a lot to square away before I head home - I've got to fill a barrel with the books I'm going to use to study and I have tons of stuff to give away to some of the locals I've gotten to know. I have to close out my Dominica account because, let's face it - if I was going to have an offshore bank account, I don't think I'd choose this island. There's some packing to do (which I abhor), and then some relaxing to squeeze in.

While walking around with Nicole running errands yesterday, I snapped a few more shots, just to make sure I represent a well-rounded view of my little spot on the island. This one was taken just in front of one of the little grocery stores close by, and if you squint your eyes, you might be able to see the sea in the background.

That picture on the left was taken on my walk home - you can really see how the buildings butt right up against the jungle. It's like this island hasn't yet realized it's supposed to be civilized, and the mountains are keeping urban development in check like unruly toddlers around the knees of kindergarten teachers.

The one on the right is of the Cabrits - the little mountain peaks I'm sure I've shown numerous times, and which look nothing like that from the air. I only added it in here so you can see my view - I've taken to studying outside, and this might be one of the few things I miss about this island. I'm literally right on the sea, and even though I haven't been to the beach since our lectures about hookworms, it's nice to have it close-by.

Speaking of hookworms...here's another one of those pieces of information I referred to in my last post. Apparently, mice with more lice had fewer allergies. Essentially, they had more relaxed immune systems. You see, your immune system is like a hyperactive little kid - it needs something to do. Over the course of human history, it evolved to deal with a whole host of parasites - worms, protozoa, crustaceans, etc. But now, in this super-clean society, we've taken away the constructive outlets for our immune systems, and, like bored little kids, they turn on us and become destructive, hence peanut allergies and the like. Since the biggest threat to early man was starvation and not germs on a counter-top, there's no way anyone would have been allergic to food - if they were, by some random mutation, they probably wouldn't live too long. It all boils down to this: when our immune systems develop in infancy, it can take one of two paths - one of those paths develops cells that fight parasitic infections, and the other develops into cells that fight infection, but can have a more detrimental affect on body systems as a whole. The thing is, even though everyone has both systems, they're fairly mutually exclusive; if you grow up in a place in which it's necessary to fight off parasites and deal with lots of pathogens, you won't be allergic to anything, because your immune system'll be too busy. So, ideally, as much as I hate to say it, if you don't want your kids to be allergic, make sure they grow up with pets.

Before I get carried away by more witty metaphors, I probably oughta get back to the books.

Get me off the rock

I'm ready to be done. This was painfully apparent last night, when I was getting ready for the ICM shelf, and suddenly fell into that "I-just-don't-give-a-damn-about-this-exam" mentality I hadn't felt since undergrad (and is surely my reason for being here in the first place). The clouds eventually passed, though, I and got back to it. Luckily, it turned out to be the second easiest shelf I've ever taken - nothing makes me happy like seeing Kaiser Fleischer rings, and wondering what they could possibly ask me about Wilson's disease. You see, at this stage in the game, it's all still cluster bridges - I've realized that the NBME (who owns my soul as much as Sallie Mae, I now realize) merely wants to see if I can put 2 and 2 together. I'm sure I've said this before, but these are paper patients, and they're relatively easy.

Hold on there...I didn't say med school was easy. I said that paper patients can be simple - if you (1) can identify the organ system (2) have read about the cluster of disorders they're talking about and (3) have memorize some descriptor of each, it's really not that bad. They aren't like real patients - who don't always read the books, and who don't always realize that symptom A is supposed to belong to Disease 637. Paper patients are simple in that, when we make mistakes, it means a wrong answer - not a dead patient.

Perhaps it's the redundancy that's got me feeling this way. Our final test on the island is on Thursday, and I'm reviewing things for the third and fourth time now. I feel like King Solomon - "There's nothing new under the sun" - but without all the wisdom and women. And perhaps it's good that I'm feeling this way; it may mean that I've actually learned and understood something. It's gotten to the place where some "new" piece of medical evidence will be published, and my response is a very articulate "Duh...." coupled with an eye-roll, as I mentally run through the pathophysiological explanation why what they've said makes sense.

And somehow, I'm still aware that as far as the practice of medicine goes, I don't know squat.

Breather

I'm knee deep in the festering muck of shelf exams. I always approach them with a little bit of apprehension - they're supposed to be an external measure of (1) how well and comprehensively they're teaching us and (2) how diligently and aptly we're learning. That being the case, there tend to be a whole lot of things I've never heard of - not things I forgot to study, or just plain forgot - things I've never heard of. So, I split my studying between reviewing high-yield course information, and reviewing 1st Aid for the USMLE. Quite honestly, I haven't given that book enough credit - it wasn't particularly useful when I bought it first semester, but I've made some notes here and there. It was far more pertinent when we began looking at organ systems, and I wish I'd added more notes - it was invaluable for the microbiology review. Not so much for path.

Micro Shelf: The First One. I thought it went alright; one never can really tell with these things.
Pathology lab Final: I love these lab practicals - it's like playing a matching game, only with disease.
Pathology Shelf Exam: You know, as much as I enjoy pathology and as well as I tend to do, I wasn't overly thrilled walking into this one - maybe that's because it was only 19 hours after the last one.
Pharmacology Shelf: Even 1st Aid didn't help too much here; some things I knew without reading the rest of the stem, some things I had to sit and think through, and some things I'd never heard of. I wish I'd reviewed diabetic drugs a bit more, and I should have paid a bit more attention to antipsychotics, but oh well - what's done is done.

Next up we have the ICM (introduction to clinical medicine) shelf, and then MINI III (and then I'm leaving Dominica forever!).

The shelves this time around carried a bit more weight in my mind - whereas the shelf exams after the second semester (physiology, histology, anatomy, neuroscience, and biochemistry) felt somewhat arbitrary, this last round of NBME (National Board of Medical Examiners) Shelf exams is more geared to the the kinds of things we'll see on the USMLE Step 1. Sure, it'll all be covered, but there's a hell of a lot more path than histo - tons more pharmacology than biochem. That being the case, it really puts my learning thus far into perspective. Am I on the right track? Have I learned things well, or just "learned'n'purged"? There was definitely some of the latter, let me tell you - a month ago, I knew those diabetic drugs.


I guess we'll see. I'm anticipating 5th semester in Miami - whereas my colleagues are daydreaming about the reliability of hot water, and the complete absence of cows on the road, my thoughts are a bit more direct; since my building has a gym, I'll be able to work out every day - and I'll be able to do thousands of practice USMLE questions. In the words of one of the rednecks who lives in the backwoods of my mind, "I'm gonna whup that puppy."

Nothing left but hurdles

It's a little humbling to think that, since classes are over, I'm officially supposed to know everything I need to know for the USMLE STEP 1 - humbling and a little bit nerve-wracking. My last few days on this island will essentially suck big time, because they'll consist of an obscene information binge.

I realized some time ago that I'd gotten used to a certain amount of reliable transition in my life. I went to the same grade school for 6 years, but then all of my friends dispersed to different high-schools. After 2 years, I moved to Texas. After 2 years, I went off to college. Once there, I pro ceded to shuffle around my friend-group every year-and-a-half or so. There were of course some constants in there - some folks I'll do my best to stay in touch with - but the change was always welcome. After that I lived at home and worked for a year, and then the time came for that to end too. Now that I've been here on this island for almost 16 months, I think I'm getting ready for a change.

I was told that this wanderlust-like friendliness with change is something unique to military kids and other folks who've moved around quite a bit. The military really didn't shuffle us around too much - I moved when I was 2, 7, and 16 - but that last one was the most significant. All of the moves have been positive - but I find myself wondering what happens when I have to settle down and stick around for more than a few years at any given place. I bore easily and am in constant need of stimulation - I guess that means I'll have to (1) do my residency in a huge city, offering endless diversions, and (2) work as a wandering locum for the rest of my medical career.

There's still the possibility that I'll end up as a teleradiologist, reading scans at home on my giant, wall-sized plasma screen TV - in my underwear - but that still just one pipe-dream among many.

I digress. You know, just because someone teaches at a med school, it doesn't mean they can teach - not even if they've got all sorts of fancy letters after their name and are old enough to remember the Mayflower. Don't get me wrong, the vast majority of the professor here have me in complete awe of their ability to simplify and condense boatloads of information - but a few have me in just as much awe of their precise knack for doing the exact opposite. So now I have to read the kidneys all over again. Gee, thanks.

21 days and 7 tests left on this island. There is nothing left to do but study and pack.

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.