Med School Confidential

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Med School Confidential Page 17

by Robert H Miller


  Your Physiology course will provide the critical functional context for the anatomy you’ve just started mastering. Here, you will study the complex and dynamic interplay among body systems that produces our biologic imperatives as living, growing, learning organisms. Again, the scope is, at first, bewildering. Hold on to your hat and, as always, begin by developing a macroscale blueprint for the information. Most of the anatomic systems you studied will directly translate into physiologic systems. Start with these concepts and extend your understanding to more complex physiology as you uncover functionality that spans multiple systems. The structural perspective in Physiology goes one level deeper than in Anatomy. Your Gross Anatomy class deals primarily with specific tangible structures and organs. Your study of physiology will extend all the way from an appreciation of cellular biology and biochemical signaling pathways up to integration of entire organ systems. The study skills and multidimensional thinking cultivated in Anatomy will serve you well here. Make sure you understand each level of the tree and can adequately define the cellular and anatomic entities involved as well as their contribution to the overall functional process.

  As with Anatomy, it is useful to organize the information along functional, anatomic, and systems perspectives so that you challenge your understanding and integration of the information. Diagram, discuss, rehearse, and test yourself independently and with your group.

  Biochemistry

  You were hoping that all that premed crap you slogged through would be a distant and disturbing memory, right?

  Well . . . not quite.

  Your Biochemistry class will reunite some uncomfortable points of Organic Chemistry with those dreaded metabolic reaction chains (the Krebs cycle and the like) from your Intro Bio class. On the one hand, this course can be onerous, since it proves to be yet another memorization marathon. On the other hand, most of your mentors recall this class as being one of the easier ones since they had previously seen much of the same information in their premed classes.

  If you take the time to integrate your Biochemistry studies with the structural and functional framework you’ve developed in Anatomy and Physiology, you will be impressed by the perspective it yields about the molecular underpinnings of who we are and how we work. As you will discover, our most complex thoughts and creative moves are, in fact, simply the end result of some insanely dynamic and well-orchestrated chemical reactions. As we’ve said before, getting this perspective on the knowledge you are acquiring is critical to your success in med school. You need to see and understand how everything fits together into the big picture.

  Remember—always—that it is first and foremost about learning.

  There are numerous approaches to studying biochemistry. Many students opt to list and diagram reactions. Search your med-school library for Jack G. Salway’s Metabolism at a Glance, an excellent text that beautifully diagrams entire reaction chains. The book takes the cascades of biochemical reactions and graphically orients them to the relevant cells and organelles, giving you a unified functional and anatomic view of the process. By studying these diagrams and recreating them in your own hand, you should be able to retrieve them reliably when test time comes.

  While you will be required to memorize these reaction chains for the tests, and a few of them for the boards, you will never see them again in your training or clinical practice. To this end, the most important concepts to take with you from your study of biochemistry are an appreciation for the fundamental molecular building blocks, an understanding of the different areas of metabolism, and an indepth knowledge and familiarity with the basic signaling pathways. While you may need the details for the tests, don’t worry so much about the details in the long run. Understanding the concepts and broad outlines of pathways in these areas will serve you well as you begin to study Physiology, Pharmacology, Genetics, and Nutrition.

  Biochemistry is another great subject to review in the USMLE Step 1 board review books as you go through the class. You may have access to old tests from your classes, but you’ll likely discover that many of the things your professor emphasizes may not be emphasized on the boards and, conversely, that there may be some material on the boards that your professor barely covered in your class. Take the time now to make your board-review flash cards, use them for your Biochem tests, then tuck them away until your second year when you can use them again to review for the Step 1 boards. Killing two birds with one stone in this fashion will make you a very, very happy med student down the line.

  Trust us.

  Cellular Biology

  Cellular Biology is essentially Anatomy and Physiology at the microscopic level. Here, you will begin to appreciate how and why tissues function harmoniously as organs and organ systems. You will come to understand the life cycles of different cells of the body, how we age, and how we renew ourselves when problems arise. You will investigate the body’s immune system and how we wage war on invaders—and sometimes on ourselves. You will see cancer in action and examine why it’s so hard to treat.

  Much of cellular biology hinges on how cells react to their local environment and communicate with each other. To this end, your studies should focus on these interactions and signaling pathways. There are numerous computer animations available online and at your medical school to help illustrate these concepts. It is worth your while to seek out, find, and use these animations. In many cases a single brief animation will literally be worth thousands of words in the textbook in terms of its value to your understanding of the concept.

  Like biochemistry, cellular biology is an area only lightly tested on the USMLE Step 1 Exam, so you should use your board review book contemporaneously with your course text and make sure you hit all the high points. Make your flash cards now, use them to prep for your classroom exams, and then put them away so you won’t have to reinvent the wheel come boards time.

  Neurobiology

  The brain and the nervous system are among the toughest challenges of first-year med school. Remember when we said that most of the challenge of med school was in volume, not complexity? Well, here you get volume and complexity.

  The course typically starts with the brain and its many subcomponents. You will learn the basic architecture, the functional units, and how they relate. You will probably also review the embryologic development of the nervous system again. Once you have a sense of which area does what and how they communicate, you will begin to investigate the major input and output tracts. How do the twelve cranial nerves control things like eyesight, hearing, taste, and smell? If you step on a nail, how does the sensory input in the skin on the sole of your foot travel from the cutaneous nerves to the large peripheral nerves to the ascending sensory tracts of the spinal cord and into the brain? In turn, how does this sensory stimulus generate both a feeling and location of pain in the brain as well as an immediate reflex that requires no thought control?

  Not only is Neurobio one of the most fascinating classes you’ll ever take, it’s also a crucial one. As such, be certain to take the time to get the anatomy memorized, then start to overlay your functional understanding on that. Draw diagram after diagram. Test yourself repeatedly. Test your friends. Make your friends test you. The only way to get good at these concepts is to test your understanding of them.

  You may never forget the weekly tests from your Neuroanatomy class that will have you tearing your hair out over the fine distinctions contained in A-through-K multiple-choice questions. Learned properly, however, the course material will provide you with an appreciation for and a fundamental understanding of the nervous system that will, on many occasions, guide your clinical practice.

  Embryology

  Embryology is, unfortunately, a class often given short shrift by medical students. Since you’ve already poured your heart and soul into mastering Anatomy and Physiology, mustering the strength to comprehend and memorize the embryologic evolution of each body tissue can feel like cruel and unusual punishment. Nonetheless, an appreciation for this critic
al process will enhance your understanding of disease later and give you further respect for how the human body functions.

  Start with the basic unicellular embryo and begin tracing each dermal layer’s development from there. Focus on how each layer of the evolving embryo differentiates into specific organ systems. There are some pretty good animated models available online and at most medical schools that can provide a more visual guide to the migration of cells and tissues. This is definitely a subject area where looking into a USMLE Step 1 board review book will ensure that you retain the critical information you will need later on the board tests. With the exception of genetics and some specific clinical specialties, though, you will probably seldom use your knowledge of embryology in day-to-day practice.

  Genetics

  You don’t have to be more than a casual observer of the popular media to realize that genetics is a hot topic both in medicine and in society more generally. Seemingly limitless in potential yet fraught with ethical controversy, this relatively new field continues to expand like a supernova. As we learn more and more about the human genome, we begin to see that almost every aspect of our anatomy, physiology, and pathophysiology is tied to our genes. Hope truly lies buried in that code.

  Your medical-school class on genetics will likely be somewhat more rudimentary. Most curricula are struggling to modernize and stay abreast of the staggeringly rapid developments in the field. Strive for an understanding of the fundamentals of Mendelian and nonMendelian inheritance, as well as the basic techniques used to determine and decipher a genetic sequence. You will take an in-depth look at cell division and genetic inheritance, which was first covered in your college Biology course. You will also begin to look at common dysmorphisms and understand their genetic basis. Again, it is important to review the relevant USMLE Step 1 material and make your flash cards so you don’t need to re-create these materials next year.

  Nutrition

  Yes, this course is more than just the same old food pyramid from your sixth-grade lunchroom wall. In fact, this class will provide you with a wealth of information on the fundamental energy and functional building blocks for healthy metabolism. The class will not only cover the basic dietary components but also make forays into metabolic deficiencies, homeopathic and alternative remedies, and clinical nutritional decision making. This class usually has a relatively light workload and is covered minimally on board tests. Use your board review book to identify and master the fundamentals.

  Ethics

  Many people consider their Ethics class to be an unnecessary distraction from classes like Anatomy. The truth is, the first-year Ethics course does two things for you. First, it offers you the chance to exercise the half of your brain that has been idling while the scientific/logical/memorize-the-entire-book side of your brain is beaten into submission. Not only does left-brain thinking play an important role in medicine, ethical issues are playing an increasingly significant role in the lives of today’s doctors.

  No matter what field you go into, as a physician you will often be forced to make choices between what is best for the patient, best for the hospital, and best for your practice. Hopefully your Ethics class will give you some tools to approaching these difficult issues.

  Most Ethics classes begin with a fairly dry litany of ethics principles before delving into their application with case-scenarios. With luck, you will have an engaging, small group that can bat these cases around. You will be surprised at how complex some of the seemingly straightforward cases can become and by how different your opinion of the right course may be from that of some of your colleagues. These real-life cases are guaranteed to stimulate good discussion. What you will find especially gratifying, however, is recognizing these same situations and scenarios in your clinical rotations and clinical practice and reflecting on how important many of these lessons truly are.

  Introduction to Clinical Medicine—your first patients

  Most med schools start you out in the first year with some form of “Introduction to Clinical Medicine.” This course is typically a combination of a regular didactic component coupled with weekly clinical exposure. The didactic component of this class will focus on teaching you the fundamental skills of taking patient histories and performing physical exams. While it may seem pretty straightforward, the truth is, it’s a very complex skill set that takes years to perfect.

  In addition to the basics of what’s in a good history and how you should listen to the heart and lungs, the class will also cover the importance of good communication styles, how to make patients feel like they’ve been heard, how to deal with difficult patients, and how to address communication barriers like language, culture, and disabilities. Many schools will test you on these skills through the use of Objective Structured Clinical Exams (OSCEs). On these tests, you will be expected to interview and examine a simulated patient (actually an actor). Your encounter will be captured on videotape, and you will be scored on the accuracy of the information you collected as well as the style with which you conducted yourself. You will review the tape with a mentor to discuss ways to improve.

  In the last few years, the OSCE has taken on a whole new level of importance. Starting in 2002, the USMLE Step 2 Exam began featuring an OSCE component. It is worth your while to pay attention to your OSCE training and develop your skills early in this area. If you practice and approach the simulated patient the same as you would an actual patient, you will do just fine.

  For your weekly clinical exposure, you will be assigned to a primary-care provider in the community, and you will spend one afternoon a week shadowing that person in his office or hospital practice. For most students, this is the most riveting, engaging, and gratifying part of their entire first year. In these precious few hours each week, you get to leave the books and tests and facts and figures behind and don the white coat.

  Yes, you will fumble and feel awkward and out of place.

  Yes, you will embarrass yourself.

  But at some point during this experience, a patient will turn to you and say, “So, Doctor, what do you think I should do?” And in that moment, you will realize the amazing gift you have been given by being accepted to medical school. Suddenly, those hours in the Anatomy Lab will begin to possess a poignant sense of urgency. It doesn’t make the studying any less hard, but it does give all that hard work unquestionable relevance.

  As a final note, we should mention the myriad additional extracurricular clinical opportunities available to you during your first two years. Most students feel that the few hours of time they get with their clinical preceptor each week are like gold. This needn’t be the end of your exposure. Most medical schools staff local free clinics for the homeless and underprivileged. They provide a great opportunity for you to volunteer your time, gain more clinical experience, and continue to build your resume as you look toward residency.

  A WELCOME SUMMER OFF

  In most programs, the summer between your first and second year of med school will be your last gasp of freedom. After the end of your second year, you will roll directly into third year, since the clinical academic calendar runs from June to June. Thus, the few weeks between your first and second year are the last serious block of time you will have to yourself for a long, long time—and possibly ever. Make good use of these precious weeks.

  What that means to us is relax and have some fun.

  You’ve worked your butt off to survive the first year, and you deserve some much-needed R & R. Plan a trip or adventure. You needn’t do anything medically related unless you want to. This time will not be closely scrutinized on your residency application, so if serving ice cream and traveling to Ottawa end up as your big achievements during this time, that’s okay.

  That said, there are a few things you could consider doing that may pay off for you later. First, many people have a lucrative skill set from prior jobs that they may be able to jump back into to make some money over the summer. Avoid burnout at all cost, though, so do not put yourself
in a high-pressure job all summer just to make money. On the other hand, a quick infusion of capital can make living expenses during the second year a bit easier to handle or may even allow you to reduce your debt load.

  If you’re interested in doing something medical, consider getting involved in research or a clinical or an academic project. Look for something that seems fun and interesting and may reflect a clinical direction you’re curious about pursuing. Maybe there’s a great lab project getting under way you want to help out with. Maybe there’s a medical relief trip being planned to some remote corner of the world that you can plug into. There’s no end to the options if you explore your resources. Talk to your favorite faculty members and peruse your med school’s Web site. Cold-call people affiliated with your school who are doing things you’re interested in. You’ll be surprised at how far the “I’m a first-year medical student” credential will take you. It opens more doors than you would think.

  Let us emphasize one more time, though—do not do something inherently stress-provoking, sleep-depriving, or emotionally tumultuous. The rigors of your medical education should already provide more than enough stimuli in those arenas. Do something fun and engaging and challenging that broadens your perspective and reminds you why you went to med school. Then tuck that inspiration away in your closet for the long, rainy days in the library when all you want is to stop studying.

  “We had a wonderful program at my medical school called the Pathway for the Underserved,” Pete recalls. “This included funding for language training and international experiences with a coordinator who possessed the most comprehensive folio of international medical programs, volunteer opportunities, and electives I have ever seen. As a result of this program I spent six weeks in Ecuador the summer after my first year, undergoing intensive language training and working in a clinic.”

 

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