The Haversian Canal

Interesting.

Better.

The central question every new medical student wants to know is "I know the exams are the measure by which I will be judged when it's time to apply for residencies. How should I prepare for exams?" It's difficult to answer this question when you're on the inside.After the first set of exams the good students will lie and say they could have done better. They know how hard they studied and don't want to be dragged down by poorer students seeking assistance. The students who find themselves struggling will lie and say it wasn't that bad. They know it's a dog-eat-dog world so they don't want to show any sign of weakness.

What really pisses me off is the professors. The professors will lie and tell you to learn the concepts, the big picture. This, as far as I can tell, came out of Bloom's Taxonomy of Educational Objectives, which identified six categories of testing, ranging from basic cognitive function, tested by knowledge questions that ask students to name, identify, or define things, to sixth level evaluation questions that ask students to appraise, judge, or critique. In observing that most test questions are knowledge or comprehension questions (levels one and two) most educators have assumed that these are easy questions to write, and therefore they are weak questions, and therefore such questions are beneath good teachers and students. Now it's easy to get confused about what the different levels of questions are, even if you have a comprehensive database of samples mined from every available internet source and have read both authorities on the subject. So virtually every professor just writes their damn tests and congratulate themselves when they finish with a stiff drink. "Bloom's taxsha wha? Ish that a ... Do 'hey shtuff deer?" At least, that's what I would do.

However, on close inspection, like when taking a test, if you've studied Bloom, you know what kind of question you're being asked. Because it is clearly relevant to your situation, which is figuring out the right answer. That's what I did to prepare for the MCAT, and it has stuck with me (I admittedly review now and again).

So here's the deal. The professors ask 80% to 90% knowledge and comprehension questions. And let's face it, you're in medical school. We know you can evaluate things and accomplish all those other higher level tasks. If for no other reason than the MCAT does test those higher order abilities. So is it all that bad that that you're supposed to know some actual facts? Who cares if you dump most of it over time. That's what happens in the real world. Dr Thomas Lee, an editor of the New England Journal of Medicine, recently wrote a Perspective article in in which he opined that doctors now don't need to know things. They need to learn how to learn. Preceding this observation was an article by the director and deputy director of the National Library of Medicine, who clearly laid out their expectation that the data rate will only continue to increase. These are the people that make funding decisions. That's what they're thinking. Pump the structures, doses, procedures into your head, and then use them. The amount of information required to diagnose and treat diseases today, when we know there are a zillion drug interactions and genetic disease and protein conformations, is stupendous. Learn it, use it. If it falls out after you're done you didn't use it much so it wasn't all that important. Hey, no use in crying over spilled milk.

Problem is the professors are ashamed to admit it. They still think they're supposed to be teaching and testing those higher order functions. So they lie to their students and say you don't need to recite the difference, per se, between heparin and heparan sulfate. We'll give you the structures on the test. Liar. At 1 am when they're writing the tests, they're in no condition to be coming up with deep questions that can actually test your ability to synthesize information.

You can use all that higher order problem-solving stuff later. Learn how to gorge on facts: structures, formulas, image patterns, diseases and their mechanisms. Actually, you'll use those higher order skills to organize the information and make connections so you can remember the facts more efficiently (only so much space in that noggin). But the central problem is learn the facts.

Flashcards are good for this. But don't buy them, except maybe for anatomy and histology, which are incredibly complex visually. Outside visually detailed subjects, make your own flashcards. Use white 3x5 cards. The ones with no lines on either side. Identify the facts you need to know. Use the learning objectives. Bottom line for the exam: fill your head with the facts.

I don't think that professors lie maliciously. I think they very, very often interpret the social context of student encounters (during lecture, before or after lecture, during office hours, chance meeting in the hall) in such a way that they believe their role is to 1) assure the weaker students that things will be okay, and 2) affirm their collegiality with the better students. I can understand why the students commit their deceits amongst each other, they're being ranked. But what motivation does a professor have to violate their basic responsibility to provide the students the objective information they need to maximize their performance? If the tests don't matter, then why test? Why not go to the Yale system?

There's a great little discussion going on about carnival moderation over at California Medicine Man. It's stimulated by the recent growth of Grand Rounds, the weekly collection of medical blogging.

I was going through my site stats for the month of February (today is 1 February; the report was relatively small), mainly to find out if my classmates are downloading more class lectures during test week, when I happened to read through the search keyphrases. These are the search strings people have entered in search engines that led them to my site. Somebody searched for "sinonasal undifferentiated cancer hope". Good luck, whoever you are.

According to the Medical Specialty Aptitude Test, I'm supposed to go into

What's a pulmonologist do?! (yeah, lungs, I got that, but really...)

Please read the addendum to My Current Thinking on Medical School Performance.

Where: Outside Charity Hospital

Why: The state and federal governments need to open the hospital doors and let the doctors, staff, and patients in. Charity Hospital is the regional trauma center for the state of Louisiana and southwestern Mississippi, but it has remained closed since Katrina. The facility belongs to the state, and the state has condemned it in the hopes of getting federal money for a new hospital. Their arguments look bleaker and bleaker as the other buildings in the medical district are being refurbished and reopened. The state refuses to budge, feeling they'd be folding under federal pressure, and the federal government has a pathological (and not entirely misplaced) distrust of Louisiana's state government. Meanwhile, the regional healthcare system, already straining, is one major problem away from failure. Charity Hospital is also the oldest hospital of its kind in the New World, and its relationship with the Tulane University School of Medicine has been an intergal part of Louisiana's medical infrastructure for over a hundred years, even meriting discussion by Abraham Flexner in his legendary 1910 report on American medical education.

Contact Marcia Glass, a third-year medicine resident, if you interested in flyer design or distribution or if you have experience with stage and sound setup. If you're alumni, I'm sure money would help. We are expecting several neighborhood activists and local politicians, but the key ingredient will be the medicine people. This is the hospital where thousands of Americans learned how to be doctors. Now the people they care for don't have anywhere to go. Maybe, as a program director I know quite well likes to say, the most important thing you can do is show up.

No, not the time, silly, the issue! Grand Rounds, volume 2, number 20 is up at Science & Politics.

Here's the op-ed piece from The Hill written by my Congressional Representative, U.S. Representative Bobby Jindal, on 1 February.

Now this is interesting:

Megite | What's Happening Right Now

This site has generated over 600 visits to my site since last night. It's obviously an aggregator, but what, exactly is it doing that beats Technorati by 100 fold? Who uses this? I've never even heard of it.

I just upgraded to Movable Type 3.2. That was scary. Now I have to set up the scode spamware.

For my classmates: if you're reading this, my hosting service, bluehost, is up. They have had a couple of outages today; I'm not sure why. They are actually well known for their reliability and that's why I chose them to begin with. Also, I added links to the audio at the top of the sidebar, on the right, and I missed the physiology lecture. Actually, the recorder was recording when the professor started the lecture, but it was on pause at the end of the lecture, having only recorded three minutes.

Does anybody have links to the stories I've been hearing about Harvard and Stanford's PR departments drumming up stories about how their medical school are brilliantly posting audio of their lectures online? I gotta get me a PR department....

If you walked into the operating room of a plastic surgeon repairing the nose of, say, a trauma victim, you might see this, a Gruber retractor. The weight is sculpted in such a way that it explains its own function, but that is secondary to its real purpose: it is sculpted to proper proportions. That is, the surgeon can grab the weight and hold it next to the patient's face to assess correctness of the repair comparitively before putting the skin back over the cartilage. It might seem gory, but it is a superb example of information at the point of need.

Happened across this on the web...

Does anyone know how to make InDesign create PDFs with a horizontal scroll bar that moves pages vertically?

Maria has first class Valentine's Day snark over at Inteuri: Grand Rounds 2:21. Be there or be square.

And tell her if she were a phaser, she'd be stuck on STUNNING.

We have an ethics class today on the physician's role in death and dying. Many of the articles we were assigned to read discuss these issues, but NPR brought it home this morning: New Orleans Hospital Staff Discussed Mercy Killings.

Sara Dwyer, a third year medical student, just won a runoff election for the presidency of the All Student Body governing council at Tulane. The ASB has a budget of over a million dollars and up till this year the graduate students hadn't even been allowed to vote! Undergrads were deciding the budget for medical students. Perhaps an accurate reflection of hospital administration, it still seems a bit out of whack. Thanks to Sara's previous role as the ASB secretary, she was able to ensure all the graduate schools were allowed to participate, although it took several days of voting before the programmers actually got us access. It's been a long road, and I hope the taste of her victory is thus especially sweet.

I'm going to start collecting good physio links here, feel free to submit yours in the comments. I'll move them up to the main entry as I get around to them.

My del.icio.us physiology bookmarks

Calcium pills may not be so helpful after all. Here's the New York Times summary of this recent finding of the Women's Health Initiative, a huge undertaking following almost 37,000 women since 1991. This is the same initiative that undermined a number of myths about hormone replacement therapy. So what helps keep bones strong? Well, I don't know all the factors involved, but I know the body remodels its bones in response to loading. For example, babies' legs don't straighten until they start walking. So weight-bearing exercise, if you can tolerate it (and most of us can), is probably the most sure-fire way to encourage the osteoblasts, bone-forming cells, to deposit more bone matrix, which, yes, happens to contain calcium.

My mother-in-law gave me a great gift for my birthday: a donation to Habitat for Humanity. If, like most Americans, your relatives aren't starving and seem to have a glut of personal possessions, maybe, just maybe, the best thing you can give them is an honest-to-goodness good, it's-the-thought-that-counts, thought-provoking, I-feel-good sort of gift.

March is colorectal cancer awareness month. So here are some fun facts from Cathy Eng, assistant professor of medical oncology at MD Anderson Cancer Center in Houston. Dr Eng is currently recruiting patients for a study and chairing the first annual 5k Sprint for Life on 26 March.
Colorectal cancer is the third-leading cause of cancer. It is highly preventable. It takes 7 years, on average, for a polyp to convert to a malignancy. 75% of cases are spontaneous, not related to family history. Here are some risk factors you can control:
Red meat: increased risk to distal colon and rectum.
Physical activy: occupational activity has no benefit to women. Vigorous activity is good.
BMI is directly proportional to colorectal cancer risk.
Alcohol is a moderate risk factor, most of the others in this list are bigger.
Tobacco contributes to a host of cancers, but rectal cancer is particularly increased, at least among various colorectal cancers.
Fiber: the academics are conflicted about whether or not fiber prevents cancer but there's more than one reason to eat salad.
Turmeric (curcumin): an ingredient in common Indian curry spice may reduce the risk. Studies are currently underway.
Colonoscopy is the gold standard for screening. 36% of colorectal cancers start in the cecum, the part of the colon furthest from the lower end. Gotta use the long scope to find 'em. Colonoscopy is recommended for everyone over fifty. People with normai findings should have another colonoscopy every ten years. Sigmoidoscopy (a shorter scope that doesn't see everything) is recommended at the five year midpoint.

Sunday march 26th 8 am.

Cathy Eng

For those in the Navy's Health Professions Scholarship Program, here's the customer satisfaction survey (right click and save to your computer) that was sent out in January's Fast Facts message. When you're done save it and, e-mail it to oh@nmetc.med.navy as an attachment.

And fill out the annual verification form for your AT while you're at it. More stuff to fill out here for orders.

I hope the nay-sayers take a moment to recognize this point of good news: Tulane had to separate 400 staff members, but the university has rehired 70 for different jobs and is trying to fill 175 vacancies with separated employees wherever possible. Bittersweet, no doubt, but a heck of a lot better headline than "Worst Natural Disaster in Nation's History Hits New Orleans". This is good news. Take it at face value.

Edward Tufte, my personal hero, is now taking orders for his new book Beautiful Evidence, for delivery in May. This represents the culmination of thirty years of thinking about analytic design, the presentation and consumption of quantitative information. His work is a must read, a visual Strunk and White, for any student or teacher of science, any engineer, anyone who plans to touch think about numbers. Appreciators of fine art and excellent writing will surely enjoy the book as well. Anyone who has actually made a book will find the construction of the books themselves exemplary. Much of the draft work has been published on the forum he maintains, Ask ET. Professor Tufte also teaches a one-day course that is absolutely cut rate for the value.

As an added treat, he is also publishing his mom's new book, Artful Sentences. Professor Virginia Tufte is a distinguished emerita at the University of Southern California. I have only one email from the author and two pages of the book to go on, but it seems to build on Strunk and White, sort of Strunk and White's Chapter 5—Style—expanded to provide a Strunkesque treatment of sentences within larger bodies of work. His father also earned a PhD. Regular Wyeth family, these Tuftes.

I've been teaching myself how to use Adobe's Creative Suite 2, the leading design software suite, by using InDesign (Creative Suite's layout program) and a Wacom tablet to take notes in medical school. It is entirely too time-consuming and I'm right back to pencil and paper. I compared a Wacom tablet with InDesign to a TabletPC with Onenote, and decided that of the two, the tablet was worse. I learned a skill with InDesign, but the overhead time cost was not sustainable because the work (getting the information into my head) flowrate plateaued at an unacceptably low level. In other words, as I got better with InDesign I realized even a skilled user can only produce at a certain rate, which I estimate to be five times slower than pencil and paper.

Paper and pencil also provides far richer tactile feedback as the pencil shears graphite onto the rough paper surface and the pressure and position of my fingers change over the paper and against the pencil. Using a Wacom tablet feels like drawing with a new felt-tip on the back of a photograph. Extremely smooth. Pencil on paper is also visually richer. A computer screen is 100 dpi at best, which the human eye can resolve probably 2400 dpi in the pencil strokes. I can also use a much larger visual space. In terms of satisfying my brain's craving for rich information, pencil and paper are literally orders of magnitude better.

We went to the Bacchus parade on St Charles Street on Sunday evening after having some excellent falafel from the Lebanese Cafe on South Carollton in Uptown. The theme was the Wizard of Oz. That was the most intense parade I have ever been too, in part due to some scary low standards of organization. The cops were coming through in between some of the floats, walking, driving, riding horses, but always physically pushing the crowd back, keeping the path clear. Why were there no baracades? Are there normally baracades? I can excuse this year, maybe, but I hope they normally use baracades for crowd control before relying on physical contact between officers and parade-goers. The people on the floats were basically bead dispensers, with thousands of strings of beads, each, to throw. And unlike the Macy's parade, the float riders weren't off-Broadway dancers showing some leg. These were were a mix of well-intentioned, macabre, and slothful babyboomers from around the country dressed in gowns and hoods, with masks. Hmmmmm, gowns and hoods, masks, in the South. Yeah, I'm thinking the proprieter of the Kool King Karwash* was on one of those floats. My daughter sat on my shoulders and for some reason didn't want to wear the beads, she just kept handing them down to my wife. This of course worked out fairly well, as the people on the floats would look down and see the cute little girl one her daddy's shoulders with no evidence of any beads, so the they'd throw more beads to her. She's slick for four-year-old.

The flashing lights, passing out drunks, and crush of thousands of bodies, however, got to her after about half an hour, so we left. An hour to find parking, twenty minutes to walk to the parade, 30 minutes at the parade, twenty minutes back to the car. I was never in the band, but I can't imagine being a kid in one of those marching bands, marching seven or eight miles over several hours, and then trying to get up for school the next day.

The walk itself was interesting. We walked down several blocks that still didn't have power, a music store that had been ransacked (because looting requires tunes?!), and through puddles of stuff I care not to describe. There was a burned out shell of a house, a building with a collapsed brick wall, which revealed the old wood exterior the brick had covered up, a wind-fallen tree with no remaining branches smaller than eight inches in diameter, and a pharmacy operating out of a trailer. Marked improvement over the last time I was here a month ago. All in all, the krewes put a lot of hard work into their floats and, with the city, put together a unique show. I saw the city's sordid past come to life and hope for the future.

We're going to a more family-oriented parade in Metarie tomorrow morning more on that later.

*The Kool King Karwash actually exists. It's on Route 90 between Houma and Lafayette. Many business owners in the KKK, a pathetic organization committed to a despicable cause, encorporate Ks into their business names and logos.
Edit, 7 March: In additional research since posting this I found that Elaine Frantz Parsons recently wrote about the connections of the KKK to Mardi Gras in the Journal of American History, Vol 92, No 3.

Here's the NOVA article I referred to earlier about the Tulane medical student, Andy Martin, who had sinonasal undifferentiated carcinoma. Whoever keeps hitting my site following search strings like sinonasal undifferentiated carcinoma hope and sinonasal undifferentiated carcinoma longest living survivor, e-mail me.