The Haversian Canal

December 16, 2006

USMLE Step 1 Advice from Robert Carruthers

Robert Carruthers is a third-year medical student at Tulane. He recently provided this advise to the second-year class. It is reposted here with permission.

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Hey 2009,

Step 1 is still pretty far away, but I thought I’d pass on some of my own and others’ advice. Write back if you want clarification.

Good Luck,

Rob

What you NEED to have:

1) QBank, 2) First Aid, 3) BRS or other relatively high yield review books for most, if not all subjects. 4) BRS Micro Flash Cards and Clinical Micro Made Ridiculously Simple

Advice:

“You spend 20% of your time learning 80% of the material.” - Dr. Wiese

Don’t get hung up on minutiae. Details will get you nowhere without the big picture.

“Do QBank and First Aid and you’ll be fine.” – Maya Jones T4

Getting ready is actually pretty easy. There are excellent resources at your disposal. Below, I have some suggestions to maximize your return on these investments.

According to Dr. Markert, students will burn out if they schedule their Step 1 more than 3 weeks after they finish their shelf exams.

Burnout is something that should be respected. Three weeks of prep time is optimal. Trust me. You’ll go crazy with any more. 3 WEEKS.

Be humble. Do the work now so you can relax when you take the test.

Medical students are neurotic messes about this Step 1 thing and it gets ugly. Good preparation will make this a considerably less-painful experience.

Micro was not the strongest subject last year. Learn it yourself. Use the Clinical Micro book with the flash cards and you’ll be very well prepared.

Timeline:

Already you should be using your First Aid to help review for your block exams.

Working on current material is very important. Don’t cheat yourself out of learning the material well the first time.

Get registered for the Step in January. Plan a 3-4 day break after your shelf exams in June. Schedule your test day to give you 3 weeks to prepare for the Step.

In February, you should put together a schedule, giving yourself enough time to blast through a BRS in a week or two. Getting up to study is the hardest thing here. Make sure you spend time on your weaknesses!!!

Studying with a friend helps a lot as other people will constantly throw you great material. Don’t study with anyone who is overtly competitive or negative.

In March or so, start using QBank. There are pitfalls you can avoid: 1) using the “tutorial mode,” 2) doing short tests and 3) not checking answers. You MUST do FULL-length tests of RANDOM questions at the correct pace to build your stamina. Tutor mode and short tests give you a false sense of security. Checking the answers is essential because QBank tests 2,000 important factoids/concepts/buzzwords.

By April, you should be getting better results on QBank as you develop your test taking strategy (ie. get questions by eliminating wrong answers instead of knowing the right answer). Finally, use your QBank Percentage Right as a monitor of your improving test-taking strategy and knowledge. That Average Percentage Right means nothing.

Before your shelf exams, use the BRS books, and First Aid for Path and Pharm. Condensed material will help get through everything (remember Dr. Wiese’s advice).

AFTER the Shelf exams, take three or four days off. That’s right Turkey. You will need some rest.

If you finish QBank and are dying for more computerized questions, try USMLEasy.com. QBank is better, but these will help you on your test stamina and technique.

After a day off, take the Kaplan Full Length exam TWO weeks before your test day.

After a day off, take another full length test ONE week before.

Then blast through first year stuff you haven’t gotten to. Get through Pharm and Path again. In the last few days cram any memorization intensive stuff.

Take a day off before test day. Relax. Drive to your test center. Watch a movie. Have a good dinner. Get some sleep.

TEST DAY!!!! Bring some sandwiches, coffee in a thermos, fruit etc. Avoid things that will provoke a huge insulin surge. I suggest bringing 2 bottles of Fresh Samantha (the green stuff). Don’t stress on the first section as it’s notoriously difficult.

Robert Carruthers

Posted by Niels Olson at 08:49 AM

December 15, 2006

Grand Rounds

Lawrence K Altman provides an excellent account of Grand Rounds in Socratic Dialogue Gives Way to PowerPpoint.

Posted by Niels Olson at 07:07 PM

December 04, 2006

What box?

Paraphrasing from a segment on NPR this morning, made by a Louisville, Kentucky public school principal:

. . . the ability to transfer is geat, because [example of one type of student, and then] there might be another student who would be removed[emphasis hers] because he would drive the teachers insane, because not only would he think outside the box, he wouldn't acknowledge that the box exists.

Thank goodness for that kid!

Indeed. Where, exactly, is this fabled box?

Posted by Niels Olson at 07:46 AM

October 26, 2006

What would you change about the first year of medical school?

There are a number of coincidental shifts in the faculty involved in the first-year curriculum, and I have been invited to participate in a committee that will be looking at some changes. I have a number of opinions on different issues, so I really want to hear what you have to say.

So, for anyone reading this, what have you liked and disliked about school in general?

If you're a medical student or doctor, what would did you like and dislike about your first year of medical school?

Posted by Niels Olson at 12:26 PM

October 02, 2006

Shop Class as Soulcraft

Matthew C Crawford's essay in The New Atlantis, Shop Class as Soulcraft, captures my view on a lot of issues. My dad's an engineer and my mom's a math teacher.

Anyone in the market for a good used machine tool should talk to Noel Dempsey, a dealer in Richmond, Virginia. Noel’s bustling warehouse is full of metal lathes, milling machines, and table saws, and it turns out that most of it is from schools. EBay is awash in such equipment, also from schools. It appears shop class is becoming a thing of the past, as educators prepare students to become “knowledge workers.”

We could hardly navigate the garage at times for all the tools, and we could hardly navigate our rooms at times for all the legos. Lego recently announced plans to lay off 1,200 workers and move production to Mexico. From one perspective, this indicates the upward growth of Mexico, and that's good, but it also concerns me that the people around me, Americans, are losing even more of this:

I never ceased to take pleasure in the moment, at the end of a job, when I would flip the switch. “And there was light.” It was an experience of agency and competence. The effects of my work were visible for all to see, so my competence was real for others as well; it had a social currency. The well-founded pride of the tradesman is far from the gratuitous “self-esteem” that educators would impart to students, as though by magic.

We know the effects of this self-esteem that educators impart are limited, but I know, from my own experience, that the satisfaction of proven agency and competence lasts far longer, almost as long as the effect of winning a race. And so it goes: the easier something is to come by, the less it is valued. An interesting sidenote, is that I have found statistical work to be relatively closer to craftsmanship than pure academic achievement or scholastic accolades. Finding definitive answers to interesting questions through the analysis of data changes the world. Much like craftsmanship, it has social currency. Similarly, leading a group to success in an interesting, significant problem, carries social currency.

In The Mind at Work, Mike Rose provides “cognitive biographies” of several trades, and depicts the learning process in a wood shop class. He writes that “our testaments to physical work are so often focused on the values such work exhibits rather than on the thought it requires. It is a subtle but pervasive omission.... It is as though in our cultural iconography we are given the muscled arm, sleeve rolled tight against biceps, but no thought bright behind the eye, no image that links hand and brain.”

So to, it has seemed to me that teachers are more interested in what the finished student looks like and what influence they perhaps had on the product, and little attention is paid to the vast majority of the work and thought that went into the product, that was mainly the student's effort and thinking. Who has measured what students do to make themselves? How do they make the decisions that lead them to certain methods and tools, and deter them from others? How does the student make himself into a craftsman?

Of course, surgery is perhaps the highest practical amalgem of study and apprenticeship,

Mike Rose writes that in the practice of surgery, “dichotomies such as concrete versus abstract and technique versus reflection break down in practice. The surgeon’s judgment is simultaneously technical and deliberative, and that mix is the source of its power.” This could be said of any manual skill that is diagnostic, including motorcycle repair. You come up with an imagined train of causes for manifest symptoms and judge their likelihood before tearing anything down. This imagining relies on a stock mental library, not of natural kinds or structures, like that of the surgeon, but rather the functional kinds of an internal combustion engine, their various interpretations by different manufacturers, and their proclivities for failure. You also develop a library of sounds and smells and feels. For example, the backfire of a too-lean fuel mixture is subtly different from an ignition backfire. If the motorcycle is thirty years old, from an obscure maker that went out of business twenty years ago, its proclivities are known mostly through lore. It would probably be impossible to do such work in isolation, without access to a collective historical memory; you have to be embedded in a community of mechanic-antiquarians. These relationships are maintained by telephone, in a network of reciprocal favors that spans the country. My most reliable source, Fred Cousins in Chicago, had such an encyclopedic knowledge of obscure European motorcycles that all I could offer him in exchange was regular shipments of obscure European beer.

And, finally, the guiding light:

So what advice should one give to a young person? By all means, go to college. In fact, approach college in the spirit of craftsmanship, going deep into liberal arts and sciences. In the summers, learn a manual trade. You’re likely to be less damaged, and quite possibly better paid, as an independent tradesman than as a cubicle-dwelling tender of information systems. To heed such advice would require a certain contrarian streak, as it entails rejecting a life course mapped out by others as obligatory and inevitable.

Posted by Niels Olson at 09:05 AM

October 01, 2006

What is the framework for USMLE Multiple Choice Questions?

Why, the National Board of Medical Examiners answered that question their spring newsletter. The rather drab article is about the flow of questions through the editorial process, but from a student's point of view, the real thing this article reveals is a hint at the general framework the editors use for questions. To explore this, examine the sample question at the bottom of the article and see what the editor does to it. What you see is the editors are *editing*. This may sound like a no-brainer, but it wasn't entirely obvious to me until after I found the article, read it, and asked the question. Editors everywhere, for Conde Nast, the Times of London, and Oxford Press, all baseline their work by seeking specificity (who's in the room, why are they there, what, when, where, how), consistent grammar and syntax (six year old becomes 6-year-old), and consistent presentation (age, sex, chief complaint, info from the intake, physical exam, follow-up tests), and, in the case of MCQs, specific diagnoses. Also,notice how some of the tip-off verbage that may have been au natural in the first draft (trident hand), has become, perhaps more generally correct use of language, but also has lost some of the visceral significance (tridentate appearance of fingers on extension).

The article also links to a prior article, Who Writes Those Questions, reveals another thing worth knowing. Try as they may, the professors just can't keep a hint of condescension out of their communications to students:

Many students and some faculty members at medical schools have the perception that the USMLE Step examinations are designed and constructed by a group of anonymous individuals who have little connection with medical schools or current medical school curricula.

If you're a medical student and thought that people with little connection with medical school wrote the USMLE questions, please raise your hand (preferably in the comments section). Notice the cherry-picked questions (how many times were these questions asked, out of how many total questions? Out of how many unique questions?)

Comments like the following reflect this point of view:

"What a stupid question!"
"We never were taught that!"
"Our curriculum doesn't require us to memorize facts!"
"They must have an army of trolls sitting in a cave writing these questions!!"

In fact, however, designing the Step examinations, developing the examination materials (including the determination of "the correct answer"), and setting the minimum passing scores are responsibilities of examination committees composed of medical educators and clinicians.

There is also a certain editorial lassitude in the writing that these folks don't use when writing for their colleagues: "In fact, however," emphasis-yours quotation marks around "the correct answer", and a weak introductory clause leading into the list. If these people can edit MCQs for medical licensing exams, they surely appreciate the value of introducing a list with an independent clause. I'm not saying they're aren't the sharpest blades, they quite probably *are* the sharpest blades. It is the lassitude of condescension that's coming out, not any lassitude in their peer-to-peer writing. What's it indicate? A glass ceiling. There's only so far a student is going to get with these people, and they'll actually be oblivious to the fact that you might be trying to get through to them. I have little doubt that the USMLE tests will prove to be some of the best, most challenging tests ever written, but I wouldn't waste to much effort on contacting the NBME about anything. Just do what they say and study.

Posted by Niels Olson at 08:21 PM

September 27, 2006

USMLE Step 1 Score Calculator

Here's the (in)famous score estimator. Reading around the site, I'm not sure how good it is. I'm just not sure. Using real-time regression modeling to determine the 'most appropriate' coefficients for the estimate is probably a good idea, but weighting of recency is an arbitrary weighting and it makes me wonder what the weighting factor is and why they added that. The other variables should not change much over time. And what, exactly, is 'recent'?

Posted by Niels Olson at 12:30 PM

September 26, 2006

Should Medical Students Take Performance Enhancing Drugs?

I've thought about writing about this before, and I wish I had, because Pin-Chieh Chiang did and now her comments section has become a world-wide confessional for medical students. 85, count-em, 85 comments, each with an illuminating story. From almost every continent. The value is fairly obvious; the side effects I've heard of are post-medication psychoses (716 hits in PubMed — once on Ritalin, always on Ritalin), loss of appetite, and cardiovascular risk (because Ritalin, speed, meth, etc, are sympathomimetics: they make your heart race). What do you think?

Would a shift of lectures away from PowerPoint factoids toward a focus on schema help?

Posted by Niels Olson at 08:31 AM

September 22, 2006

Get First Aid for USMLE Step 1

I recently got an e-mail that included this: "some students are questioning if and what is being addressed and how".

This is an issue of schema, and I empathize, to a point. The students with this concern want to know how this stuff should fit in the framework of knowledge, even as they are trying to build their own framework for the knowledge, their own schema. I recommend every first year medical student go get First Aid for USMLE Step 1 and start annotating their own copy with anything that isn't covered in class. Second year students who don't have this are likely behind the curve, or fall into the enviable group of people who don't have to study.

With an N of 1, a sample size of 1, the variance is infinite. You never get more variance reduction than when you go to N = 2. So maybe others had better think a bit about the audience, at least in some regards." - Edward Tufte, Technical Communication Quarterly, 13(4), 447–462

First Aid is written and edited by students and former students who have taken the test. So it's kind of like Wikipedia, in that it is a constantly improving resource, indeed, the kind of resource it is is a schema, which is improved by community feedback. A new edition is published every year, and I can attest to the fact that the current edition has new content every year. It the best possible ready-made schema simply because so many minds over so many years have worked on it. Perhaps you can develop a better schema all on your own, but First Aid has 400,000 customers, so the odds are against any given individual doing better. Peer-review from some subset of 400,000 recent test-takers, or one PhD, who never took the test. What do you think? A professor can certainly be relied on to get the solution right to the first approximation, and that's a big first step, huge, but First Aid has gone through new iterations of peer review every year and it is sensitized *to the test*, not to what one person or one school's department may have learned over the last year. It's not sensitized to what I think. First Aid is sensitized to the test.

Another interesting point about First Aid is who is investing their effort into it: all of the contributing authors for this year are from Yale. What, I thought the authors were from California? Well, Yale doesn't require their students to take tests, let alone go to class. You want to talk about some people who *need* to find their own schema, it's the Yale kids. Schema, schema, schema. See my blog's archives of medical education for copious detail on schema.

If you're a second year medical student, you've probably heard of Katzung's pharmacology books, but did you know he is one of First Aid's five faculty reviewers? Perhaps the most appropriate thing to do would be for medical school classes to buy their course coordinators their own personal copies of First Aid. At least then the maximum number of people would be singing from the same sheet of music.

Posted by Niels Olson at 03:43 PM

September 21, 2006

Why PowerPoint Is Bad and What to Do About It

PowerPoint is antithetical to the one thing students need from professors: schema. PowerPoint shatters the professor's schema that they are trying to present to the students. It causes students to tear down large amounts of knowledge and attempt to rebuild the information because the information is fragmented and it becomes exceedingly inefficient to try to rebuild whole from the pieces. This destruction of schema is very bad for education, but very good for advertizing.

PowerPoint breaks up the framework for knowledge. Diagrams, outlines, paragraphs, these are the shapes of knowledge and they rarely take the form a computer screen, and those subject-oriented shapes are usually too dense, require to much real estate to fit on a single PowerPoint slide that is readable from the back of the room. Indeed, there's a running recommendation that presenters and lecturers should plan about one slide every two minutes, or about 25 slides for a fifty minute lecture, and this is about what we see, at least at my school, but also in my past jobs, and other schools where I have sat in on classes. These frameworks for knowledge are called schemas. The physical representation of our knowledge is the architecture of the synapses between neurons, and the location of neurons, in the brain. So too, learning is the the formation of new synapses, and nueral pruning.

Not only does PowerPoint fragment the shema spatially and temporally, it can actually tear down the student's partially built schema, by undermining the confidence the student has in their sources. Loss of confidence is a terrible thing. To illustrate this, think about what the phrase 'loss of confidence' means to a military commander in the field. If a commander looses confidence in a subordinate commander, they have to relieve that subordinate of their duties! The commander will decapitate on of their own units to remove that one person who lost their confidence! Similarly, a student who looses confidence in an element of material may feel the need to tear down a whole wall of knowledge and rebuild it if they loose confidence in it. This becomes a wildly inefficient use of time. Its, its, disefficient.

How can PowerPoint cause loss of confidence? If the material is there, surely the student should understand it, right? It's coming in the ears and eyes at the same time, right? Saturation bombing the brain, right? That works. Right? Name a war where saturation bombing worked and I'll show you a war in which there was no fundamental misunderstanding to begin with.

Can the destruction of schema be useful? Perhaps in advertizing, in which the marketer wants to remove any barriers to the consumer's decision to buy. The marketer can make room for their own framework, their reasons for buying the product, by selectively destroying, or at least temporarily weakening, the consumer's schema, which is likely the product of a lifetime of hard knocks.

Avoid PowerPoint. If you lecturers use it, ask your teachers to not use it. If that doesn't work, avoid class. If you lecture, don't use it. If you are at a business meeting, decide before the first slide is shown whether you really want to allow this person to tear down your knowledge of the business you're in. This dichotomy of PowerPoint and good schema is realized implicitly by anyone who appreciates the irony of drug company education programs for doctors. We need to tell teach others about this. Schema, unfortunately, is Latin, which is very useful academically, because it's easily adopted by a mind interested in studying it and brings with it little to nothing in the way of background, but it's not a metaphor, which makes it ill-suited to widespread acceptance. We need a better word. Not just a word, a metaphor. Perhaps PowerPoint itself is the best metaphor available, but to appreciate it, we still need to introduce the concept that schema is the framework.

Posted by Niels Olson at 02:32 PM

September 15, 2006

Pedagogy, Policy, and Podcasting

There are a host of issues that people have brought up to me about, in my particular instance, podcasting, and that I have discovered in my research that would merit consideration in any policy document for the school, or the University, and professors. The issues break out roughly along the lines of pedagogy, that is, how teachers believe they do and should influence their students, three legalistic domains -- copyright, libel, and employer-employee relations, and, finally, technical issues.

Pedagogy

- "Students may face unforeseen circumstances, such as sickness, a meeting with a dean, or personal financial or housing affairs, that prohibit class attendence." This seems to be a prima facia good argument.

- "Students with learning disabilities may benefit to benefit greatly by having access to audio outside of a classroom setting." Again, this seems to be obviously good.

- "Professors must impose a schema, a framework for knowledge, on the lecture material." This ties in with the next statement.

- "Students need one schema in which to place the material they learn." The upshot of this is the students can't avoided the lecturer's schema. Many students don't attend class because they find that professors imposing their schema, however temporarily, destabilizes the fragile schema the student is trying to build using other sources. Too many schemas, too many frameworks, make a bush, instead of a building. A bush won't hold the first brick.

- "Even very bright students have a hard time parsing high level visual input (text-and-diagram slides) and audible input of the lecturer's voice, at the same time." This exists in parallel with the issues of schema, and it is almost totally unavoidable, unless one goes to lecture and covers their eyes. This also causes students to not go to class because their information transfer rate that asymptotically approaches 0. This is a matter of information overload. It is simply to much; people shut down.

- "I believe this offers another excuse for students to not go to class." Hopefully, but even still, we haven't seen a dramatic drop in class attendence simply because the audio is recorded. Indeed, popular lecturers get more attendance and more downloads.

- "I believe this will cause the class's USMLE board scores to go down." Maybe it will. Maybe they will go up. We don't know.

- "I believe more students will have consumed the lecture material before practicals and labs." No one but me has stated this, but it seems intuitively obvious.

- "I believe podcasting will lead to students who are less prepared for their clinical years." Again, we don't know one way or another.

- "I believe lecture is one of the more effective methods for learning the material." No one has actually said this. Quite the opposite, as a matter of fact.

- "I believe it is fair and reasonable to only allow the noteservice, a for-profit business to which not all students subscribe, to have exclusive access to recordings of my lectures." This was one professor's defacto position, but I think it was only a consequence of not having had the time to thoroughly think it through.

- "I believe that the presence of a digital recording will inhibit me from providing my students the best possible lecture performance." This has not proven to be the case. Ask me about Dr Jeter's joke.

- "I believe that the presence of a digital recording will challange me to provide my students the best possible lecture performance." I'm not sure this is the case either, but wouldn't it be nice if it were?

- "I don't want students to hear old material." This goes to the technology issues discussed below, but it certainly seems reasonable to dispose of the lectures after each class's preclinical years. That is, the first anatomy lecture should be up until the last student has finished USMLE Step 1.

- "I flat out don't want to be recorded." In so far as it is your performance, then that is your right to reserve.

Copyright

- "I can't trust every student to not unlawfully distribute my lecture, which I feel is my intellectual property protected by law." Copyright historically almost perfectly excludes educational material from copyright. It is the permanant, physical product which is protected. Copyright is a matter of commerce, not scientific knowledge.

- "I believe the possibility of a student distributing my lecture once he or she has possession of the digital recording provides unfair access to information to people other than my paying students." This goes to the technical issues below, as well as the legitimate desire to have everyone on the same page. It is not unreasonable, in my opinion, to ask students to sign an agreement acknowledging their responsibilities. It would be better, in my opinion, to have site protected with personally accountable university network passwords, instead of directory-local ht-access passwords.

- "I believe the possibility of a student distributing my lecture once he or she has possession of the digital recording provides people other than my paying students unfair access to my performance." This is, in theory, the copyrightable issue, the performance. The factual knowledge is not copyrightable. However, if anything, one would expect professors to endorse the widest scope of fair use possible as they and their students are the historical victims of copyright exclusivity. Nevertheless, it does seem reasonable to personalize the students' responsibility.

- "I believe the possibility of a student distributing my lecture once he or she has possession of the digital recording creates a risk of disclosing trade secrets that I share in my lectures, and that such action would jeopordize a business." This is an entirely different subject, and the professors are the ones assuming responsibility if they are disclosing trade secrets without pre-existing confidentiality agreements.

- "I would consent to podcasting of my lectures over a secure university .edu server if and only if the school of medicine or the university had a published policy on the matter." I suppose that's what this is about.

- "I would consent to podcasting of my lectures over a secure university .edu server if and only if the school of medicine or the university required all students to sign a statement of understanding that clearly defined their obligation to protect the digital recording of my lectures." As above, I suppose this is reasonable, though it seems to me there are other ways to raise the stakes without making people sign vaguely worded statements, and all such statements become vague in the end.

Libel

- "I may use offensive language in class which I do not want to be taken out of context." This is protected under current libel statutes, and, frankly, I think it is a relatively weak argument when compared to other arguments because the professors probably aren't to concerned about what could, in theory, be taken out of context. Professors are people who negotiate their lives with other people who are smart enough recognize something that doesn't fit the pattern and to then seek out contextual clues. And, even if the members of the professor's social circles don't seek out contextual clues, the victim is protected by libel laws, and the basic moral principles behind libel. Even this, however, is highly theoritical simply because we have no evidence of it happening in the context of podcasted lectures at Tulane. Admittedly, this is a relatively selective sample, but it's what I've got. I know professors have said things off-color in lecture before. I was there. It takes no podcast to propogate that fact. However, the possibility that the podcast itself would serve to bolster an act of libel assumes that anyone would pass the extraordinarily high barrier to access the material to begin with. Either the password has to be hacked by brute force, and then the person has to listen to a LOT of lecture, or the perpetrator would have to aquire the recording from someone who does have access, thus creating a trail of evidence, a high risk endeavor indeed. In either case, the perpetrator then has to lift the appropriate segment out of context and place it in a misleading context. This seems highly unlikely, when considered in the context of all the other things any given person might do in their day.

Employer-Employee Relations

- "A supervisor told me I had to allow podcasting lectures." This seems to be within the employer's perview, but I'm not sure how the delegation of authority works out amongst the faculty.

- "A supervisor told me I was to not allow podcasting of my lectures." Ditto.

- "I believe my usefulness to the organization will be jeapordized if my lectures are recorded even once, thus making them available to future classes." It seems fair and reasonable that the content should be taken down at the end of that year's pre-clinical years.

Technical

- "I am confident in the security of ht-access password protection." Well, ht-access is far from the gold standard of internet security. It relies on one login and one password for an entire group, so there is no personal accountability. It is also unencrypted, so packet-sniffers could get the information if they really wanted it. The gold standard is the SSH protocol. This is ripe for future implementation.

- "I find the technical aspects of recording the lectures, as handled by the students, to be cumbersome." This is what is addressed by having 'student-helpers' who deal with the wires and buttons.

For more, here's the Creative Commons Podcasting Legal Guide and Stanford's Copyright and Fair Use site.

Posted by Niels Olson at 02:04 PM | Comments (1)

September 10, 2006

Listening

I was in the middle of applying to medical schools and, coincidentally, I had to go to Bethesda's dermatology department where, as it happened, and a buddy of mine was applying for residency. He had even taken me to their Grand Rounds. But now I was the patient. And I'd been in the exam room nearly an hour.

“I don't need a graph. What's your issue?” Thus spoke the chief dermatology resident at Bethesda. I knew this “chief resident” guy was smart. And I needed his help to heal the skin on my fourth proximal interphalangeal joint. It looked like the skin had little holes in it, like I'd dropped concentrated hydrochloric acid on my finger in Organic Chemistry over a year ago. After months of visits to other providers, this was my second visit to the ivory tower. The inflammation was just a spot, a little bigger than a pencil eraser. Why wouldn't it heal?! I'd been prescribed anti-fungals, anti-bacterials, anti-histamines, steroids. In the mean time, I'd also gone mountain-biking, swimming in the ocean, and changed countless poopy diapers. Maybe the acid had only activated some dormant process that had been waiting for years. In recent years I'd been in the engineering department of a ship. My hands had been soaked in fuel oils, lubricating oils, and, treat of treats, bilge water: the collected putresense of a ship that collects in the bottom of the hull. The next ship I'd been on was nuclear-powered. I didn't know what was the causitive agent was, but I'd had a year to think of possibilities. The medical student who'd taken my history had worked very hard to smile, but I was clearly the nightmare patient—I knew just enough to be really annoying. “Some patients just know so much about their own diseases!” the fourth-year student had said, her smile revealing gritted teeth, as she'd extracted herself from the thirty-minute interview from hell to go brief the chief resident.

Was the chief being rude by not listening? Yes. Did he need to be rude? Probably not. Was it better to be rude? Quite possibily. In retrospect, they were asking about the forest and I was telling them about the trees. It really wasn't a profoundly difficult problem, merely one I didn't understand. And, nice as it may have been, I'm not sure either they or I had the time for a complete course in immunology and inflammation, which is probably what I would've wanted before I understood the issue to my own satisfaction.

So, back to our little dialogue. How did I, the patient, respond?

“I don't need a graph. What's your issue?”

“They...”

“Who? Who's 'they'?”

“At the Naval Academy clinic, the PA gave me Westcor ...”

“Butter. Westcort's butter. Then what?”

“I came here and you gave me Clobeta...”

“Clobetasol. Are you taking it?”

“No, not n...”

“Why not?”

“Goodman and Gilman's says...”

“It's strong shit. The best. Why aren't you taking it?”

“You told me to take it for ten days.”

“So why's it still there?”

“That was month ago.”

“Why'd you stop?”

“'Cause it's steroids. I didn't want my adrenal glands to shriv...”

“Was it getting better?”

“Ye...”

“Take the clobetasol. Here's another scrip, get some more. You'll be fine. You're not taking enough of this to have any systemic effects. If you were smearing this over your entire arm, I'd be concerned. Take the clobetasol till it goes away.”

Exeunt.

Posted by Niels Olson at 06:33 PM | Comments (1)

September 09, 2006

Complementary and Alternative Medicine (CAM) for your cat.

The patent (US5443036) for a novel method of exercising a cat. Trumped in pure audacity only be Dispair Inc's trademark of the frownie emoticon :-(

Posted by Niels Olson at 11:43 AM

September 06, 2006

Learning how to write

An anecdote from one former student. I graduated with a physics major in 1998. At the time, I wrote horridly, if at all. I can't say I ever learned anything about writing from writing a lab report, or even my capstone project. Several years later I did very well on the MCAT writing sample. What happened? In the intervening years I had four profound influences.

In 2002, I was standing in a very long line at a half-price book sale at a Border's Books in San Diego. After 20 minutes, out of pure boredom, I lifted a slim silver volume off a nearby shelf, thinking, based on the title, that it might have something to do with how to dress. Over the next 45 minutes Strunk and White's Elements of Style changed my life.

From 1998 to 2005 I had three consecutive jobs that required immense amounts of edited writing. Once you have the rule book, that is, Strunk and White, then the humility of being edited, and then the humiliation of further editing on resubmission, is profound. In the Navy, the junior officers write virtually every official document (letters, briefs, memos, instructions, manuals, guides, plans, radio messages, etc), but only senior officers, usually those who have had command, are authorized to release anything for distribution. Thus any given junior officer writes their draft, hand walks it to their department head, who chops the draft, while the JO stands there, then the JO goes back and makes those exact pen-and-ink editorial changes, prints it out, takes that to the executive officer for chop, until, finally, the Captain decides it's good enough. Needless to say, this creates a desperate desire, for the sake of not only efficiency but promotability, to improve one's writing. I probably got even more of this experience than most as my particular trajectory included stints as a ship's legal officer, an executive assistant to a senior officer, and then a staff officer at the Naval Academy. However, these almost daily treks between staterooms afloat and offices ashore did not improve my writing—perhaps I'm incorrigable—until I got my first copy of Strunk & White.

Heeding the advice that only the very brightest are cut out for a career in physics, when I got back to shore in 2003 I started taking med school pre-requisites. I found the biology and chemistry professors were using some strange software called PowerPoint. Perhaps you've heard of it. These biologists can go for years without touching chalk! I had no idea how to learn from this sort of lecture. I had to go learn about learning. Turns out very few people write about learning from a student's perspective. So I did what I'd done in intelligence work: I read what the enemies wrote to each other. I read about teaching. Which led me to Edward Tufte's books. After reading the Visual Display of Quantitative Information for about the third time, I was really starting to think in terms of crafting arguments in paragraphs on pages, and considering paragraphs within the scheme of the entire document, in the context of pages and figures and titles and notes.

Eventually, you find questions Strunk and White left unanswered, and that's what motivated me to find the Chicago Manual of Style. I have grown quite a reference shelf of style manuals, dictionaries, and assorted reference works. In some cases I bought duplicates for home and office. A gem that physicists may appreciate is S Katzoff's internal NASA booklet Clarity in Technical Reporting.

Nevertheless, in my humble opinion, Strunk and White should surely be a required text for any technical writing course, or any course in technical writing. If I were to conduct a writing workshop for undergrads, a daydream I entertain regularly, I would walk to the front and set down on a desk at the front of the room something simple, something that could be seen from the back of the room. A stick. A stone. A brick. I would tell them to write, for the rest of the hour, about that thing. I would take up their work at the end of the period, and work furiously to edit all their work, in red ink, by the next class session. I would return their writing samples and then I would tell a lie. I would tell them their entire grade for the course, A or F, hinged on returning, at the third class period, with a copy of Strunk and White, no matter how worn, and on the publishability of their corrections. I would answer no questions. At the third class period, I would account for their copies of Strunk and White, take up their writing samples, and again, dismiss them. Again I would have to work furiously to edit their writing samples. On the fourth session, I would again return the writing samples. No doubt most would still bear red ink. All Fs.

After a pregnant pause, I would say "That sucks, eh? Can't tell you how many times I've had that experience on the job. Turns out, the world really does have high standards. Makes you want to write well and never write again, all the same time, yeah? No worries, just an exercise for you all." Then I'd pass out the real syllabus.

I suppose if it was a physics class I might bring a meter stick to that first class, drop the brick from, oh, 0.73 meters, and tell them they'd get an extra chance at rewriting if they could, on a separate sheet of paper, predict the brick's velocity when it hit the ground and if it had been dropped from the same height on Phobos.

Posted by Niels Olson at 08:31 PM | Comments (1)

Learning

If you are at all interested in learning, subscribe to the PHYSLRNR listserv. It is mainly Physics educators, and that is the main resource for learning, IMHO: reading what the teachers write for themselves. It is the same thing intelligence agencies do to learn about the enemy: read what they write for each other.

Posted by Niels Olson at 06:09 PM

September 01, 2006

DCC

Here's the Wikipedia article I just started for DCC, a gene we're supposed to know about, but which I didn't find anything about in Robbins. I got almost everything from the OMIM article.

Posted by Niels Olson at 04:19 PM

August 26, 2006

Tsoni Peled's USMLE Step 1 Advice

Sanguine advise for Step 1 of the US Medical Licensing Exam. I haven't taken the boards, but I know a carnivore when I read one.

Also, interesting note in our Pathology syllabus: "This is not a lecture course. It is impossible to cover all of the textbook material in a classroom setting. You must read and learn from the book. It is recommended that you read the "Recommended" textbooks."

Here's the Kaplan Q-bank package that I think most people get.

Posted by Niels Olson at 06:56 PM

Downtown Student Health Center Hours

Downtown student health is currently open from 8:30AM-3PM M-F.
Beginning August 28th, the Student Health Centers on both campuses will be open from 8:30AM-4:30PM
Uptown Student Health Center will be open on Saturdays from 9AM-12PM.
Downtown phone number is 988-6929
Uptown phone number is 865-5255

Posted by Niels Olson at 12:00 PM

August 21, 2006

Anthracotic pigment

Fun fact about anthracotic pigment, carbon dust commonly found in the lungs and hilar lymph nodes: anthracite is a form of hard coal found in Pennsylvania mines.

Posted by Niels Olson at 09:49 PM

August 19, 2006

Dr Robichaux's Review

Here's a direct link to Dr Robichaux's comprehensive review pathology of infectious disease for the inflammation test.

Posted by Niels Olson at 10:21 AM

August 17, 2006

Diapedesis, Defined!

This company makes the best medical animations, bar none! Check out this white blood cell exiting the circulation!

Posted by Niels Olson at 11:36 PM

August 11, 2006

Prothrombin Time & International Standardized Ration

For those who went to Dr George's lecture today, the Wikipedia article on prothrombin time explains the INR.

Posted by Niels Olson at 12:49 PM

August 10, 2006

Owl Club Reps for Fall 2006

Path/MOD: Albert, Edward
Pharm: Alex, Amitabh
Immuno/Micro: Sara, Jacqueline
Clinical Diag: Kelli and Mithu
FIM: Whitney
Genetics/Human Behavior: Niels
T2 Coordinator: Jacqueline
T1 Liason: Kelli

Posted by Niels Olson at 10:01 AM

July 30, 2006

Is a course blog worth it?

Short answer: yes, an online database repository of questions and answers is worthwhile for the students. There are four basic flavors, in personal order of preference: OpenACS for the school, a forum for the class, a blog for the course, and, finally, Blackboard (which is like walking on nails, IMHO).

Whatever you decide to do, I'm strongly in favor of telling people in advance that their comments will be subject to moderation and placing heavy weight in your moderation decisions on whether commentors use their real names. Here's one of the best threads on the internet about comment moderation (full disclosure: I participate in aforementioned forum). I also recommend a soft, warm-to-neutral, near-white color palette and minimal use of lines in the design. Swaths of very mild color are better.

Long answer: Is a blog 'worth it'? For the students it would be better than Blackboard (the forum in Blackboard is the most horrid learning interface I have ever seen). A post-per-lecture is probably the best organization for a blog. If all the profs agreed on a forum, that would be even better for the students. The way most schools keep the students distributed among several different, exculsive feedback systems (their own little internet fiefdoms) is . . . less than ideal. Blog or forum, you could link to the audio and the slides in the post (blog) or first post of each thread (forum) and monitor comments by e-mail. Long answer: I think the OpenACS system is the best learning community system going, but it still requires a bright programmer. To the point, I taught myself photography and analytic design and web design on photo.net and Ask ET well enough to get paid, get repeat customers, and turn away work. I tried to get an OpenACS community for Tulane Med set up last year through Philip Greenspun's course at MIT (he developed ACS in the 90s, starting with Hurst Publishing's intranet and then photo.net), and he pushed his students to it take on after the storm (h), but they balked. Maybe I'll try again. The social bookmark site del.icio.us is also based on some ACS modules.

Posted by Niels Olson at 11:39 AM

July 21, 2006

What Computer Should I Buy for Medical School?

you all should be eligible for a Dell laptop at good discount as a medical student starting a new track. Go through their education store. You'll need to e-mail Dell Education an image (.pdf or .doc) of your acceptance letter (a web-based e-mail embedded in the ordering process). The authorization to order will take a few days to clear as a human has to look at your acceptance letter and the computer doesn't come with Microsoft Office, but who cares when OpenOffice 2.0 is free and better? I just got mine, loaded OpenOffice 2.0, gave it to my wife, who is very techno-phobic, and she uses it every day. Her MS Word documents opened just fine and her response after an hour with OpenOffice was "This is free?!" It's $1800 out the door and handles Windows XP .doc format just fine. The equivalent Dell on the open market is $2400 and has less storage (Tulane package has a 120GB hard drive; Dell's mass market max hard drive is 100GB). If you have a hunormous iTunes library, I recommend keeping it on an external hard drive.

I believe Apple offers a similar deal. If someone knows the scoop on that, please share. Update, here's a review of recent Apple notebooks from Zed Shaw. When I read it, it ranked number 12 on reddit (ie: good advice *and* a good read).

Another option, recommended by Wallace Wang of "Steal This Computer Book" fame, is to order a refurbished computer from a big seller, like Dell, Apple, Toshiba, whoever. Besides the discount these machines have a fairly quick turn-around, and often get better inspections before going out again because the company doesn't want to loose more money on them.

That said, it's not at all clear that using a computer in or out of class improves test performance or learning. I also came to medical school in the "I type faster than I write" crowd, and, if you peruse my blog's medical education category, you'll find I field-tested the available software options intensively. I don't recommend it. I personally recommend keeping your laptop tucked up on a bookshelf (out of sight, out of mind) and don't ever set it on the desk you study at. If you do use it, and you will have to check e-mail and download assignments, I recommend sitting on the couch with the laptop on your lap (it's comfortable until it gets really uncomfortable); not plugged into the wall (that's right, use the battery to rate-limit your usage). And that's coming from somebody who does web design and analytic design on the side and owns way more computers than necessary. If you want more on computers in medical school, and my personal thoughts on medical education in general, visit the medical education category.

I have a friend, about 50, who manages international financial IT projects. He carries a $15,000 fountain pen but doesn't wear a watch and doesn't employ a personal assistant. He carries a laptop on travel but I've never seen him use it. I asked him how he manages his schedule. He said it's actually quite interesting, it's an entirely different way of organizing one's life.

I think there's a tendency to overrate the value of computers in a formal educational setting. I could go into the tremendous value of the tactile and proprioceptive input of writing, and the synthetic learning value of having to choose which words to write instead of just typing them all, but I digress...

Posted by Niels Olson at 07:55 PM | Comments (2)

July 11, 2006

Advice From an Anonymous Rising Third-Year Medical Student

Unsolicited Advice for 2nd Year and Step 1,

I hate to break it to you, but 2nd year is tougher than 1st year, so relax and enjoy what’s left of summer. However, 2nd year is also much more clinically useful, so many people, myself included, did not find it as hard to force ourselves to study. Also, class material is the same stuff that is on the boards, so you’re killing 2 birds with 1 stone.

Immunology—You have to be ready to hit the ground running because you only have 2 exams and about 90 questions total for the class. The first test was about 55 questions, and second was about 35 questions. The remaining 10 points to were from small group sessions. This class was not as strenuous compared to Path, but I don’t know who the new course director is, so I can’t speak to the difficulty. However, if your brain is a few weeks late returning from summer vacation, you might have trouble on the first exam.

Path—This is by far the biggest course you have all year and also the most board relevant. I bought Baby Robbins and Big Robbins. I read all of Baby Robbins as we covered the material, and only used Big Robbins for reference and to look at pictures/figures. There is also a medium-sized Robbins that many of my classmates liked. Also, I used BRS Physiology(skimmed the relevant chapters at the start of each block to brush up on normal processes) and BRS Pathology throughout the year. The last book is the Robbins Review question book. Do these questions a few days before the exam. Some of the questions will find their way on the exams, and the others are good for distinguishing between features of similar diseases. You shouldn’t need any of the Atlas/Picture books…I don’t know anyone that used them, and they give you a CD representatives of all the pictures that are used on exams. Exam questions can be very frustrating because many of them are 2 jump questions (they describe a disease but don’t tell you what it is, and then the question asks you about another feature of the disease, so you have to be able to know what disease it is, and then pick out another aspect of it). The questions are good though in that they closely resemble what board questions are like. Doing practice questions is VERY important for success on both class exams and boards.

Pharm—The first test is one of the biggest so do well. Unlike Immuno this is a year-long class, so it is possible to come back from a less than stellar performance, but who likes playing catch up. They give you a great drug list, so study that primarily. Many people bought either Katzung or Katzung’s Board Review Book and used them mostly for reference. Seriously, the drug list is key.

Micro—This course was very inconsistent for us. Most people used Clinical Microbiology Made Ridiculously Simple as their main text and class handouts for professor specific details. I would recommend also reviewing what’s in First Aid before exams.

Behavioral Science—Read a board review book before the exam and you should do fine.

Boards—Most people that I know started studying somewhere between the end of Christmas break and mid- March. It all just depends on how competitive of a specialty you want to enter. The 2 main resources that most people used were First Aid and Q Bank. First Aid is more along the lines of bullet points than paragraphs of info. I spent a few months reading board review books and annotating First Aid with info that I thought was testable and missing in First Aid. I would recommend using the board review books along with the class schedule because this increases efficiency and lowers cramming in April/May/June. Then I just read First Aid multiple times, trying to extract new info each time. This was supplemented with Q bank questions. Q Bank can also be used as practice questions for class exams, but I would advise to set up most of your tests with all the possible subjects checked because the computer will create tests with a similar breakdown to the actual exam. A few important tips:
1. You’ve done well in school/exams thus far, don’t reinvent the wheel for this exam. Do what you know helps YOU learn.
2. It is a marathon, not a sprint. Don’t start studying too late, and don’t burn out early. Make a schedule with goals of what you want accomplished by when, and discipline yourself to stick to it.
3. It’s not how much you study or how many books you read, it’s what you remember from what you study that will help you on the exam. Pick a limited number of books to study from, and learn those well. Be realistic about how much info your brain can hold on test day, and know that info well.
4. Good luck.

Posted by Niels Olson at 02:51 PM

July 09, 2006

Thinking all the time

I use these Moleskine cashiers like they're going out of style. Best notebook I've found to carry in a shirt pocket. You can quickly, anywhere, jot down an idea or paragraph, or several paragraphs if you really want to. I wouldn't recommend them for a treatise, though.

Posted by Niels Olson at 02:34 PM

June 17, 2006

What do you get out of class?

Well? What do you get out of class?

I got of some interesting feedback from people on this last semester because I recorded audio of the lectures for my medical school class last semester. The feedback mainly came in the form of "Thanks Niels, I that was so helpful when I . . ." or ". . . because I . . .". Anyway, what I gathered was that there are six basic reasons to go to class:

1) Any handouts that the professor chooses to deliver in class and only in class.
2) Announcements that may not be recorded. Professors ought record these before-class and after-class announcements as part of their audio, but they often don't.
3) A sort of stamp—a certification—that you couldn't possibly have gotten more out of the course.
4) Reading the nuances of the professor's performance for clues on emphasis and organization. This is exactly the same content that that the intelligence community seeks through HUMINT—human intelligence. About 80% of this can be gotten through audio, but the 20% you miss, really sucks. The organizational framework for knowledge is most firm after going to class.
5) Socializing with your peers. This is an investment in the future, but there are other ways to socialize with peers, if you're the sort of person who doesn't mind losing their hearing to overamped static, I mean, music, or inhaling a pack's worth of second-hand smoke in a crowded bar. In fact, I think what you'll find is that the people who go to class end up consorting more with each other, and those who don't go to class end up consorting a lot with a few poeple and individually less with more people, but that's pure speculation.
6) Until the advent of slides posted on the Internet and podcasting, the final reason to go to class was the organizational framework, the schema, the professor provides, and this is, even with podcasting, still somewhat true, and it remains the fundamental thing the student needs from the professor. More about that in a previous post.

I've also heard that people who don't go to class spend more time studying directly.

Posted by Niels Olson at 11:46 PM

June 05, 2006

What to expect on an NBME shelf exam

The anatomy of questions is generally something like this:

Misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection. Misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection. _____question, _______, question, ________ which _______________ is most likely ___________ question, question ____________?

A. Distractor

B. Distractor

C. Answer

D. Distractor

E. Distractor

F. Distractor

G. Distractor

H. Distractor

I finished the Biochem shelf with about 10 minutes to go but they'd already frozen us in our seats (before the 10 minute warning anyone who finished could leave), so I thumbed back through looking for trends. That's the trend. I'd say 85 to 90% of questions is used the phrase which is most likely in a compound, complex, or compound-complex question.

Unlike the MCAT, which is easily parsed using Bloom's taxonomy, I'm not sure Bloom will be of much use on the USMLE. Perhaps, but I need to review it some more. Virtually all questions require the test-taker to walk one step beyond the information in the question. For example:

A thirty-year old man presents with dyspnea on exertion. Chest radiogram reveals an enlarged cardiac silouhette. If a viral cardiomyopathy is diagnosed, which hormone is most likely increased the least in the circulation of peripheral muscles on ELISA?

A. Renin

B. Angiotensinogen

C. Angiotensin II

D. Angiotensin I

E. Aldosterone

See, you really don't need to know, for the purpose of this question, what the symptoms of a viral cardiomyopathy are. That's misdirection. It might be helpful to appreciate that the heart is weaker, but, what you really need to understand is how the above hormones interact. Renin is likely to go up. Angiotensinogen production may go up, but there may not be an observable increase in concentration because the extra renin is converting it to Angiotensin II. I don't even know what Angiotensin I is off the top of my head. Aldosterone will go up if renin and ang II go up. Peripheral muscle, eh, not really useful. ELISA, eh, not really useful. But, also, do you see how this might really be the question you'd face in the clinic (okay, maybe not in the clinic, but maybe in a clinical trial)? Which enzymes might you test for to diagnose this patient? What results do you predict?

Also notice how a rather awkward reversal was introduced, which hormone is most likely increased the least, to preserve the is most likely to structure. It could have easily been rewritten as is least likely to, but that would mess with the QA people reviewing the questions.

Finally, don't bother copying somone else's answers. During my ten minutes of intel collection, I couldn't match any patterns from one answersheet to another. I mean, I was in the back of the room (Kaplan tactic) and stared quite conspicuously. I wasn't trying to change my answers, I was doing intel.

Also, why do you suppose the proctors give the tests to the students at their seats, rather than having the students come get the tests? Wouldn't that be more efficient? Well, think of all the times the proctors walked those aisles and rows, and looked at things. Casually. While all the students stayed still. Gives a good opportunity to catch conspicuous cheating, doesn't it?

Posted by Niels Olson at 10:46 PM | Comments (1)

May 25, 2006

On Lecturing, from a Student's Perspective

I've been writing about my thoughts on education from a student's perspective, and my thought for you is that the fundamental thing students need from teachers is through the levels of organization in the material, from the huge, grand thoughts, to the minute details, the schema. I came to this while considering what frame of mind a student should be in while studying outside of class. As I look back on my first year of medical education, it is fairly clear to me that some of our lecturers, though brilliant researchers and generally great people, were not good teachers, not because they didn't know the material, but because they did a terrible job of organizing their material and then putting their material in proper order. There are other ways to do a bad job of teaching, like interrupting natural trains of thought with 'clinical' pictures of terribly deformed children, or wasting the first ten minutes of lecture wrestling with the projector, but I want to focus on this large, conceptual, and it's-gotta-be-right-or-just-go-home issue of organization and sequencing.

Organization is somewhat at odds with sequencing. Time is a one-way arrow. Only one word can come out of one's mouth at a time. So how big a deal could organization be? Organization of a course is relatively straight forward: collect all the issues about the arm, break them up in reasonable bits, like, the superficial back, the shoulder, the brachial plexus, the arm, the forearm, the hand, et cetera, lecture for an hour on each of them, and then have a test. It's within a lecture where a lecturer's stock rises or falls. Most lecturers follow something along the lines of the classic "temple" model, where there's an introduction (the roof) three or four or five arguments or issues (the pillars), and a conclusion (the foundation, steps, whatever), and this is a good model. However, there is a challenge when the lecturer lecturer gets to those pillars and the logical organization no longer matches the sequential organization. This is where a lot of lecturers drop their students. Some get dropped as the lecturer dives into the first issue, but the real tragedy is when lecturers go to the second issue without transitioning. Another model for this is the GPG model - general - particular - general. You've got to come up out of the first particular and introduce the second, and when you're finished with the second, introduce the third. And the students need to know that you're doing this, because it's not obvious, particularly in the more abstract issues, like which cell types use which ion channels. If you talk about cell A using transporter A, then cell B using transporter A, then cell A using transporter C, where was the break? What exactly did you shift from and to? This is why I encourage profs to put as much information on one piece of paper as possible for each handout, so the students can anchor themselves in the lecture.

Ed (24 September 2006): There is a ready-made schema for the basic sciences years of medical education: First Aid for USMLE Step 1.

Posted by Niels Olson at 04:34 PM | Comments (1)

May 23, 2006

Frame of Mind for Studying

You need to learn what you don't know. Who's teaching you? You. As you study, you need to know what you know and what you don't know, so you can repeat the information you don't know to your future self. So you need to record what you don't know. You need to make a record. You need to produce a record. Making a product, in my case, notecards, is, in essence, you asking questions of your future self, and preparing answers in case your future self doesn't know the answer.

As you go through your notecards, if you know the answer, you can think it faster than you can read it or even say it, but it is still reinforced in your memory. The connection becomes stronger, more permanent. If you don't know, you need to hear the answer again to help the growing axonal processes weave their way through the jungle of connections to the other axonal process, dendritic process it needs to contact.

But that won't be learning for comprehension. Well, maybe, but I think it will, for two reasons. First, medicine is too complex to not be organized, and, secondly, the material is presented gradually, since well before you start medical school. The central piece of pedagogy that students need teachers for is the sequencing of information: general frames first, and proceeding to finer and finer details.

Notecards, in particular, are a conversation between you and your future self. Diagrams aren't particularly useful here, unless you need to see a picture to reinforce an idea for which you otherwise lack experience. The modern linguists seem to think that we simply have a very hard time talking about what we don't understand. That's why the leading edge folks are working in graphs and numbers and DNA sequences. They don't have all the information yet, so they're using the most basic tools to construct an accurate mental picture. Those more accurate mental pictures are what they pass on to the rest of us to learn. As science becomes more specialized, 'the rest of us' includes most of 'them', so don't worry to much about that. In any case, the idea is, you are having a conversation with your future self when you write notecards. Seeing a drawing made on a napkin can be revealing, as it happens, but the syntax, the order, of how that drawing came together is lost if it's completely written out. In fact, I think there may be a visuotemporographic syntax and grammar to drawing diagrams in conversation, but I'll have to look into that. One place a diagram is helpful, is in the question. Draw a diagram, of say, a sarcomere, label some proteins with letters, and then ask your future self to name those proteins. The answer, on the back, would have the letters with the associated protein names: A - Titin, B - Actin, C - tropomyosin, D - dystrophin, E - Z disk, etc.

Bottom line, write the clearest questions you can, leave no room for anything but the exact answer you're looking for, and then write that answer on the other side. Isn't that what you'd want a professor to do?

Posted by Niels Olson at 01:03 PM

May 05, 2006

How Hard is Medical School?

I found this question in my site statistics. Someone had typed that question into a search engine, and one of my pages came up. It's a tough question to answer, because it's relative. I mean, really, hard compare to what? Compared to qualifying as a tactical action officer in the Navy? Well, not really, but then, that didn't take four years. Harder than labor? My wife assures me med school isn't that bad, but that labor only lasts so long, though I'm sure it must seem like forever.

"Medical school isn't hard, there's just so much of it" is what all the docs told me before I started. I tend to agree there. My rule is there are only two things in life that are really hard, rocks and quantum mechanics. If you can wrap your head around quantum mechanics, the rest of your life will be a little different. Most people can't do it. 5000 people a year graduate with bachelors degrees in Physics from American universities, while the US produces 16000 MDs a year. So I'll agree, in that sense, medical school just isn't that hard. There's not a lot of conceptual 'wows', moments where you get all tingly because you just realized some deep truth that can only be spoken in the language of math.

Physics, however, is a very deep sort of learning. People talk about reaching up to the stars and diving down into the nucleus. Its a foot wide and a thousands of miles deep. I used to think of biology as a mile wide and a foot deep. It's got a limits. Biologists, biochemists, doctors, just don't care much about quarks, and the parking garage doesn't have many enzymes running around. It is, however, more like a 1000 miles wide and 1000 feet deep. Volume, volume, volume. The scope of medicine encompasses air quality in the parking garage and the quantum spin of hydrogen, the decay of which causes the electrons to emit photons that make magnetic resonance imaging possible. And everything in between.

I would caution those approaching medicine from business, the social sciences and humanities. Come on in, plenty of room, but the core skill developed in the training of business people, political analyists, and book critics—defending a position or selling an idea—isn't the ultimate yardstick in medicine. Rhetoric really is the ultimate yardstick in politics, fiction, and sales. It is. That's cool. Nothing wrong with that. But the body is only so amenable to pursuasion. Hey, don't get me wrong, persuasion works. . . . During Hurricane Rita I was at an emergency clinic with 185 patients in a school gymnasium when I was called out at three in the morning to a woman who was hyperventilating. I happened to know from earlier in the day that she was bipolar and asthmatic. Her breathing wasn't the sort of labored, panicked breathing of an asthma attack. Not knowing what else to do, with no doctor around and a dozen people huddled around, staring, in the dark, I put my hand on her shoulder. And she calmed down. Her breathing returned to normal. She stopped sweating. Turned out she just really wanted to go home. Yeah, so mind-body-soul, biopsychosocial, moral-mental-physical, whatever you want to call it, that's true. But everybody spends their lives on the mind and soul. Doctors earn their keep in society by knowing the body, the physical, the bio-. And that part isn't particularly amenable to persuasion. It comes down to actually knowing how the body works.

Which brings us back to medicine being 1000 miles wide and 1000 feet deep. It's an ocean. You don't have to know all of it. But you will be expected to understand how things work. That's the core skill in science: understanding how things work. The basic science professors, they kind of swim around in this big ocean. The molecular biologist will lecture about the neural plaques of Alzheimer's disease and everything they say, I mean, every word, is testable, but they don't have to know if a plaque in a particular location is going to cause a deficit in sensation in the foot or make the patient extremely irritable. The neuroscientist might know that, but isn't going to lecture the next day on the physiology of the gall bladder. Doctors are the ones that know about all the systems and how they all interact. At least, that's what Joe Q. Public is going to assume when he presents with pain in his belly every time he breathes in. As will the retired colonel, the state legislator, even the pharmacologist who teaches night classes.

It's great, it really is. Because you really can know a lot of it. And a lot of people without science backgrounds do better than the science majors. But I would suspect the biology majors, the neuroscience, physiology, and biochemistry majors probably get the best preparation for medical school. If you want a sense of the level of material you should be able to understand by the end of your first year without any look-ups, (well, maybe a couple), this review article on diabetes is representative. The contents of this article were dispatched in about five minutes of lecture, and the students were expected to know all the pathways discussed, all their enzymes, the structures of the substrates and products, and their consequences on the body.

So, how hard is medical school? Well, with all those caveats, you make it as hard as you want it to be. There are really bright folks with good intentions, research backgrounds and years under their belts who struggle. There are folks who are just back from England after finishing their Fulbright scholarships and work really hard and get really good grades but might actually tank their board exams and irritate their classmates. There are slackers who can't avoid As if they try, make friends with every patient, impress every attending, and are liked by everyone. The only thing I can caution you about the last group, is, if you're not one of them, don't take study advice from them. If they don't have to study, what would they know about studying?

Posted by Niels Olson at 04:11 PM

April 23, 2006

Temporary Trauma Center Opening

From the Times-Picayune: Charity to open interim trauma center

While this is certainly a sign of life, it is still disordered. My wife originally worked at the Elmwood facility's rehabilitation clinic. It's about fifteen or twenty minutes drive from downtown and nowhere near to be equiped as the long-term trauma service. There isn't enough parking and the facilities don't approach the capacity necessary to support the specialists a Level One Trauma Center has. As I recall it's a brick building about four stories tall and each floor is maybe the size of two or three three-bedroom ranch houses, so maybe 20,000 square feet. They don't even have the space for the imaging machines. If strokes and broken bones don't qualify, then this is surely not an emergency department. This is no joke trauma only.

The Elmwood site will not be the new Charity emergency department, Fontenot said, cautioning that the public should not consider it an option for routine injuries. The trauma center takes only seriously injured patients such as those with multiple fractures, gunshot wounds or heavy internal bleeding.

People with lesser trauma such as chest pain, strokes, broken limbs, cuts and other health concerns will still be directed to other local hospitals or Charity's temporary clinic at the former Lord & Taylor department store in the New Orleans Centre at 1400 Poydras St., Fontenot said.

Posted by Niels Olson at 02:50 PM

April 18, 2006

Taking Notes In Medical School Lectures

Medical school lectures can be fairly disorienting at times. A lecture may start as a broad overview of a system, and suddenly you find yourself trying to catch up because the lecturer is now talking about the second, no the third of three very important domains of a particular isoform of a particular membrane receptor found only in the first four inches of the duodonum. This is a consequence of the trophy model of presentation. There's an introduction, pillars of the discussion, and the conclusion. The pillars of the lecture, the tenents, the issues, the parts, whatever you want to call them, are logically equal, but must be addressed sequentially. As soon as the introduction is done, wham, you're in the details. Such is the limit of human intellect. Knowing, thankfully, goes a long way toward coping with it. This trophy model is taken to a bit of an extreme by some medical school lecturers because medical school lecturers don't usually lecture an entire course. They lecture anywhere from one lecture to half the class, usually between two and ten lectures. A new lecturer will typically start big and drill down to their area of expertise. So if you have three lectures from a physiologist who specializes in gut endocrinology, expect the first twenty to thirty minutes on the first day to be a general overview of the entire gastrointestinal system. While this is exceptionally repetitive, particularly if the last two lectures were on gut motility, the lecturer sees this as a very quick overview of terribly important material. Regardless, that's an issue to take up with the course coordinator. What you need to do is not start daydreaming about your hot date last night, foreign policy, your navel, or whatever it is you day dream about, and keep your Spidy-sense alert for that first pillar, the first details of the discussion.

Posted by Niels Olson at 12:16 AM

April 17, 2006

Productive Repetition

I've written before about hand-writing flashcards as a two-time-winner study method because they increase reptition and form a product you produce. Here are some ways that you can improve your notecards as you go through them:

• Complete both sides. I generally make the first draft of my flashcards during lecture. This is a good time to do it, because it keeps me engaged in the lecture, thinking critically, and offers many stimuli to associate to the information. However, I don't always get the question and the answer written. If I got most of it, I probably managed to write down the answer. If I didn't really get it, I try to at least write down a question. This can be a good thing. I can go back later and fill in the other half, which also makes the review a meaningful use of time.

• Annotate the bottom left corner with the subject, block, lecture number (or date) and page numbers of books and notes. The more of these you can fill in, the better. Particularly write in table and figure numbers if the lecturer indicates these during lecture. Understand these figures.

• Expand abbreviations and acronyms. This is particularly helpful if you have a helper (spouse, significant other, particularly smart pet, whatever), who can read the flashcards for you, but who may not actually understand the material.

• Write two to five questions and answers on each card. Write your flashcards in pencil and keep some of those white erasers handy. If you wrote multiple facts on the answer side, think of multiple questions to ask on the other side. This increases the number of associations you've made. Don't, however, make simple questions if you can make easy complex questions. "What's the difference between amylose and amylopectin" is a better than splitting the content into two questions "Describe amylose" and "Describe amylopectin".

• Underline keywords in the answer so your helper (if you have one) can know if your right even if you don't regurgitate the exact same sentence that you wrote in the answer. I use a red fountain pen for this. I find I can easily filter it out if I'm reading the gray pencil markings, it doesn't smear the pencil markings, like highlighter would, and, again in favor of red over highlighter, it doesn't affect the background of the words indicated.

• Rewrite questions and answers for natural language (e.g., use contractions) and active voice. There's a very simple formula for converting passive voice to active voice: "Hydrogen ions are produces by the parietal cells." is passive. Remove the linking verb, and by; then reorder the remaining components as subject, transitive verb, direct object: "Parietal cells produce hydrogen ions." Besides being shorter and more vigorous, it is more accurate, e.g., hydrogen ions may enter the stomach from sources other than parietal cells.

>

• Lay out all the handouts and lecture notes. Put the associated note cards on top of each set of handouts and notes. Look for glaring deficiencies in the piles, then go through each lecture and make sure your flash cards have all the right stuff.

• Put all the flashcards in order.

• Copy diagrams into your flashcards where you feel they add information. Keep in mind that the test will surely have more words than pictures.

• Identify the questions by placing an E, M, or H in the lower right corner of the question side, opposite the subject and lecture notes (see above), for easy, medium, and hard, respectively.

• As you get closer to the test, review all the flashcards and set aside the ones you obviously know. Just repeat the ones you don't know. This saves time and helps you organize your endgame as the test gets closer.

• Write comparitive questions. They are a more efficient use of mental space because they encourage you to form connections rather than just memorize more facts. A comparitive question, like "Does acetylcholine act faster or slower than serotonin?" requires you to know three things, while the two questions "Does acetylcholine act fast or slow" and "Does serotonin act quickly or slowly?" requires you to remember a total of four things, two of which, the rates of action, are actually quite vague standing on their own. Acetylcholine is quick compared to what?

Posted by Niels Olson at 11:25 PM | Comments (2)

April 05, 2006

You heard it here first

From a reliable source: contrary to a 1991 JAMA study published by a neurologist in New Jersey, there appears to be a looming shortage of neuro docs. In particular the VA is coming clean that they don't need more family practice physicians. They need more opthalmologists, neurologists, and neurosurgeons to cope with the aging population.

Posted by Niels Olson at 01:32 PM | Comments (1)

April 03, 2006

Gawande, again

Atul Gawande has a Perspective artice in the 23 March edition of the New England Journal of Medicine. This entry's a bit late, but I actually wrote it in my notebook first. And the blog is looking a bit sparce here. Gawande's article is about the Morales deathrow case in California. The ruling came on 14 February that Michael Morales could be executed only with the supervision of an anesthesiologist. 37 days later Gawande has 6000 words. That eight pages of ten point font. And you know he cut some out. If you write, you know somebody, even the author, did some editing. The article follows a clear progression, and is well-ordered, though the only demarcations are five horizontal rules: introduction with background—first vignette—second—third and fourth—fifth—conclusion or call to action (I'm not sure which). 6000 words.

About the same time Tulane's History of Medicine Society announced its annual essay contest. I'm going to interview Dr Weisberg on Wednesday. The essay is due on 1 May.

Posted by Niels Olson at 11:07 PM

March 31, 2006

Tulane Breaks into Top 50

U.S. News and World Report ranked Tulane's medical school 50th among the nation’s top research schools. There around 150 medical schools (MD and DO) in the US.

Personally, I don't put to much stock in the rankings, but a little competitive spirit is healthy.

Posted by Niels Olson at 11:22 AM | Comments (2)

March 20, 2006

Further Thinking about Medical Education

So, in my last post, I wrote gobs about what to do for each class. This will be more about how to plan and carry out the plan on a day to day basis. There's two schedules that you have to mesh: the class-centric schedule and the your-time-centric schedule. This is how I think of it: you've got a morning, afternoon and evening in each day. Some of those are weekday periods, some are weekend periods, some are at the beginning, some are in the middle, and some are just before the test. Within these blocks of time you have to take care of yourself (laundry, fitness, the bills, family, leisure, etc), class, and studying. Even though the topic of class is presumably the same as the topic of study time, it is inherently different in that you can't control it.



Let me take a moment about this 'fog of confusion' graph. What kind of goofball crap is that, Niels? Sounds like something out of a get-rich-quick-scheme book. Well, it's based on Clauswitz's fog of war. During war, and especially during an engagment, no one knows everything that's going on or everything that will happen. Uncertainty about the future is one thing, knowing that you don't know what you will soon need to know is something different. In war this is exemplified by time delays: a forward commander calls in an airstrike which is delivered on target, but the enemy got away under cover of darkness and no one knows it, and this will effect the projected number of bullets that need to be delivered through the supply chain, but the quartermaster already dispatched the projected number of bullets needed. Now resources have to be diverted to provide the bullets, the bullets are promised but redirected again in response to an even greater emergency so when contact with the enemy is made again, the promised bullets aren't on hand, grenades are used, which weren't budgeted for, and quickly no one really feels like they know what is going on.

Similarly, in learning, you're responsible for budgeting your time to learn the things you need to know, but sometimes it's not obvious what is going to require more time to learn. Worse, sometimes you underestimate the time required and spend it on something else, like writing a blog entry called "Further Thinking about Medical Education" and start falling behind, even though YOU THINK YOU'RE AHEAD OF THE GAME. Oh, Niels, this is simply poor planning on your part. I'm not talking about me. No one knows what the future holds, and when time is a scarce resource that must be allocated among competing interests, errors of allocation are bound to occur. The trick is to reduce them by as much as possible. And this why bosses are always 'looking for visibility' on something. They're trying to pull up and away enough to see the bigger picture, see where the resource could be best allocated. This is what schedules, budgets, and other planning documents are for. There are no consequences for violating what was written in the plan, per se. The planning documents are thought exercises to figure out how to allocate resources in response to various branches and sequels leading away from the current decision point. Planning documents are drawn up when things are safe and happy, with the expectation that when the time to make a decision comes, there will not be enough time then to work out the various planning alternatives.

If you want the luxury of considering alternatives, branches and sequels, you will have had to work them out in the plan ahead of time. A plan is not I will do A, B, and C. A plan is part descriptive and part proscriptive. Descriptive planning is budgetting: you assume you will earn so much money this year. Based on that, you allocate the fixed requirements, like rent, then set caps various other categories, like dining out, and minimums on others, like savings.Descriptive planning doesn't normally lead to back-up plans. Emergency plans are typically more proscriptive. If the mayor of New Orleans advises everyone to evacuate the city, then we will always, always, go to my parents house. Proscriptive plans are where you start getting into back-up plans: if my parents are out of town, we will visit some relatives in Tennessee.

Anyway, so how does this all relate to planning for the next block in medical school? Have a generic template plan, and fill it in each time as you go. I recommend the above as a good, generic form to customize during the first weekend before the beginning of a block. During that first weekend, you'll see it calls for a preview. As I've said before, produce something. So previewing doesn't just mean flipping through the book, it means laying out before you, within eyespan, what you need to do. In addition to my schedule, I also prepare these two column preview sheets, one sheet per class (don't worry, I'm taking more than two classes). The are the lectures, numbered, with the reading assignments in the margins. Every time I write a flashcard for that lecture, I will note the class, the block, lecture number, and page number in the lower left corner of the question side; if a figure needs to be referenced, I'll note it on the answer side. For example, the lower left corner of a block three physiology notecard from today lecture reads "P3-37-L22" P = physiology, 3 = block three, 37 = 37th lecture, L = Levitzky's textbook, 22 is the page number.



So how do these allow me to allocate time to favor the branches and sequels I prefer? Remember those three uses of time? Yourself, class, and studying? Well, what if my daughter falls out of a car, bounces her face off the curb, as happened earlier this year? Of course I'm going to go home if something like that happens, but for me, that means driving two hours each way, and probably staying the night. I'll need to leave the recording equipment at the apartment in Houston, and, while I'm in the car, I need to call someone to record the lectures. Using that time in the car and planning to spend some of my time later listening to the lectures I miss. Which lectures will I miss? How do I best decide when to go back? There will surely be earlier and later alternatives. If I'm missing five lectures the next day, as I would see on my schedule (not shown - I use Palm Desktop), maybe I'll try to get back earlier, even wake up the next morning at 4 am to get back. And when I review for the test, the absence of notecards for, say lecture 41, will remind me that I didn't go tot that lecture, so I need to allocate some time to go over that material in more detail.

Posted by Niels Olson at 05:40 PM

March 15, 2006

Recent Thoughts on Medical Education

I recently got an e-mail from a friend who was just accepted to medical school. Congratulations to him! In his e-mail he asked if I had any recommendations on what he could do before starting. Here's my answer, refined:

Yeah! Start producing study aids now that will help review the week, or weekend before the test. Don't, don't, don't take notes on a laptop. Use 8.5x11 or notecards. Preread means skim, and then, from the time you're in lecture on, all 'studying' should be focused on creating a product you will use to review for the week before the tests, like a big stack of notecards, diagrams, that sort of thing. Handwrite and draw it all. The tactile and visual feedback is rich input to your brain.

Physio and Biochem are straight notecard and diagram. Biochem, get Lehninger (all other biochem texts plagarize this guy) and start drawing glycolysis, kreb's cycle, electron transport chain, gluconeogenesis, glycogen synthesis, structures of the sugars (glucose, galactose, ribose, heparin, heparan sulfate, amylose, amylopectin, collagen, etc). Draw the twenty amino acids and the nucleic acids. Put all these on flashcards. If they're to big (glycolysis, Kreb's cycle, etc) draw them on 8.5x11. Over and over.

Physio: a big smludge of stuff. Kidney tubule. Learn the transporters inside and out. Same for myocardium. If you don't understand a synapse yet, that's about as priority one as it gets.

Neuroscience: Haines is the the textbook to get, but they all go into to much detail. You can start administering these quizzes to yourself (you have to click around a bit, but they're there). The site is awesome. Find the quizzes. Learn all the structures in the quizzes. Even if your prof swears you don't need to know it. If you try to not learn, you'll waste time and brain cells thinking "I don't need to know this that I'm not supposed to know. But I know it. Dammit". I found it a long time ago, then our neuro prof was using it independently for some of the videos. I suggested it to the students at A&M; now their prof is using it too. Also, Harvard Whole Brain Atlas.

Histology - too complex to draw. Find images on Google Images (you'll find the high-yield sites as you go) and compile them in powerpoint. Slide with the image, next slide has the same image, but with various structures identified. Every cell type you can imagine. Repitition, repitition, repitition.

For Anatomy, get Netter's Atlas of Human Anatomy, 3rd Ed, and quiz yourself by placing your hands over all the names of structures, and try to identify them. Every single one of them. They will all be on the test. You think I'm kidding or exaggerating, but I'm not. Don't worry though, there's a fair amount of repitition. You'll see how this works once you get the book. Don't get a textbook of anatomy until the prof tells you which one to get. They all suck. Bad. I own most of them. That's not a joke. I have been collecting, for years, virtually every anatomy text and atlas, every book on surgery. I've got first editions of Brodel illustrations. The textbooks are vacuous except maybe the highlighted 'clinical correlations' boxes, or whatever they call them in whatever text. You can be sure that stuff (torticollis, claw hand, whatever) will be on the test. Along those lines, don't get more books than necessary. You've got to much to learn to read anything twice. Make the study guides. If you run into something you need a second source on, go to Google. Repitition, repitition, repitition. If anything you're doing takes a lot of time, stop. Computer drawing programs (OneNote, Illustrator, etc) are a good example of this. I can draw a perfect circle in Illustrator faster than I can with a pencil. But I don't need a perfect circle. I only need a 80%, 90% circle. I can do that with a pencil in one stroke.

Most people in any organization pass on the same lore and legends one year to the next. It's all fluff. The smart ones lie because they don't want to spend time helping the people who are struggling. The strugglers lie because they don't want to let on they're sucking. The professors lie because they are taking gentle vengence on you for whatever they went through in graduate school. If you stop and listen you'll be amazed at how much fluff is presented as deep insight. It's really just the same lore and legend. They'll all talk about the ease of learning the brachial plexus once you figure it out. They'll all ask you five times about which nerve root is sensory, which is motor. They'll all tell you about freshman's nerve (a tendon), the rise of antibiotics, anesthesia, and how they revolutionized surgery. Blah, blah, blah. Learn what's going to be on the test. Cold. By repitition.

If you can, seriously consider just listening to the audio if they provide it. Listen to it at 1.5 times speed with the prof's powerpoint slides (most of them provide these through a website somewhere), at home. I'm the one that does the recording for our school, so I haven't tried this much. Because I always go to lecture, so I can record it. If this works, cool. Otherwise, go to lecture and don't take a laptop. At least, don't use a laptop while you're in lecture.

Read the medical education posts on this blog if you want some more stuff.

People will give you lots of study tips. Like this. If it doesn't match what you've been doing, be highly suspect. If you got As without group study, don't start now. If you got As without a computer, don't start now. If you eat seven pieces of Lindt chocolate when you study every night, don't stop.

For the non-traditional students: be especially suspect of advise from the professors. They spend most of their time advising the 80% who are between 22 and 24 years old. Nothing against 22. I was 22 once. I wish I was 22 when I went to medical school. I really do.

Posted by Niels Olson at 05:06 PM | Comments (2)

March 10, 2006

Bush & Clinton to Speak at Tulane Commencement

Dear Students:

I've always felt, in light of what we've experienced over the last few
months, that this year's commencement will be a special one. Just how
special was made plain this week when George H. W. Bush, 41st President
of the United States, and William J. Clinton, 42nd President of the
United States, agreed to be the keynote speakers at Commencement 2006.

As you know, Presidents Bush and Clinton first joined forces to raise
funds for the victims of the 2004 south Asian tsunami. Then, in the
aftermath of Hurricane Katrina, they formed the Bush-Clinton Katrina
Fund, which has raised more than $100 million to date, some $30 million
of which has been dedicated to 33 higher educational institutions in the
Gulf region, including Tulane.

The whole world has admired how these two leaders have risen above their
political differences, harnessed their formidable skills and galvanized
the generosity of the American people. Their partnership provides a
lesson for all of us.

Please join me as we welcome our two former presidents and salute the
graduates of this historic class, May 13 at 9:30 a.m. in the New Orleans
Arena. For a full schedule of Commencement 2006 events visit
http://www.grads.tulane.edu/.

Have a great weekend,

President Cowen


Posted by Niels Olson at 08:59 AM

March 09, 2006

Dr Donald Richardson

Fran Simon has an article in Tulane's New Wave rag about Dr Donal Ricardson's upcoming appearance on ABC's Miracle Workers: Calming a Storm in the Brain. The episode will air on 13 March at 9 pm Central time. He will be implanting a deep brain stimulator in Emily Bresler, who has Tourette syndrome. Since childhood she has "jerked and jumped with involuntary motion, making guttural noises and uttering curse words." Emedicine has an article about this that indicates the problem lies with dopaminergic cells in the ventral striatum, which is what we're studying right now, so this isn't complete procrastination. Yay, me.

Posted by Niels Olson at 11:22 AM

February 24, 2006

Wacom & Creative Suite for Medical School Notes

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.

Posted by Niels Olson at 12:22 AM | Comments (2)

February 22, 2006

Navy HPSP? Here's the Survey and AT Annual Verification

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.

Posted by Niels Olson at 06:30 PM

February 18, 2006

Physio Links

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

Posted by Niels Olson at 03:21 PM

February 17, 2006

Congratulations Sara!

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.

Posted by Niels Olson at 08:39 AM

Euthanasia Investigation

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.

Posted by Niels Olson at 07:55 AM

February 10, 2006

New Years Note From Dr Weise to Medical Residents

Happened across this on the web...

All,

Well, it's that time of year. Every year following the
holidays and new years there is a time of
reflection... and I suspect this year will match any
year of the past or for the forseeable future. The
difficult part is that it is always met with some
sadness and melancholy. Again, I would guess that this
year will match any year of the past or for the
forseeable future. Strange to me, however, that
reflection rarely dwells upon what has been gained...
and more importantly, what has been learned. And so I
pen this email to you to share some of my
reflections... both in the context of what I think
I've learned (or been reminded) and the various
emotions. As it was so adeptly pointed out earlier, I
am sure this email will be long... so as always, if
you are busy, feel free to skip it. As usual, it is
likely to have nothing of consequence.

I'll start my thoughts with Marx... so the next few
sentences will keep me out of public office (as if I
wasn't already out for other reasons, and as if I want
to associate with that crew). But I think it's a
useful starting point for this dot-to-dot puzzle of a
discourse. Well, Marx would tell you that there are
three classes in society, and each class is defined by
more than just its accumulated wealth. As opposed to
the Calvinist, Marx argued that after time, each class
was defined by an inherited (or via oppression)
attitude on life. It was not attitude that defined
possessions (or lack of it), it was possessions (or
lack of it) that defined attitude. The lower class
looks at life helplessly: life events happen to me and
I have no control whatsoever save to just try to stay
alive. From this perspective a life-event happens, and
a man responds like a stick in a river, being pushed
in the direction that the current takes him. The
middle class man sees life as under his control:
life-events happen, but for the most part, he sees
these life events as completely under his control. His
works define the moments... and the natural corollary
is that every life-event is under someone's control...
so everything in life is someone's responsibility (or
fault... i.e., lawsuit). And then there is the
upper-class man that looks at life as an exercise in
ultimate control- he completely controls life
events... largely because he completely controls the
lives of other people that make these events for him.
And his control is held tight because the people he
controls have one of the two earlier perspectives.
Now, I'm not advocating for the class distinctions,
nor am I saying that one life perspective is better or
worse than another... nor am I suggesting that these
classes should exist. It just is what it is. And as
Marx suggested, it would take a revolution to change
that.

I note this small watered-down piece of philosophy
because the issue at hand is all about perspecitve. So
here's some personal insight. I used to look at life
as a series of defining moments- put all of the
moments together and you have the outline of a life.
This outline is what you will someday look back on as
the definition of your life. But my perspective, as
Marx would predict, was that of the middle class- the
defining moments in my life were going to be regularly
scheduled events, well under my control and design:
high school graduation, college graduation, medical
school graduation, residency completion, marriage,
faculty appointments, etc. The common denominator of
all of my "planned" defining moments was that they
were all under my control, and while life existed
outside of my control, with enough effort, I could
define these moments, and these moments would in turn
define my life.

But it didn't take long to be shaken from my
perspective... I told you early on in this journey
that I had been through far worse life events than
this, and that is true. And after each of these life
events, I sought someone to blame.... thinking that
the bad things in my life were surely someone's
responsibility... but with no one discernable to
blame, I was left with only anger and frustration.
Anger that consumed me.....I would butt my head
against the brick wall of this lesson... only to find
greater and greater frustration that my "life"
philosophy did not fit very well with real life. All
the time failing to realize the lesson that was just
before me: Life is what happens to you while you are
making plans. And so it is with trying to put a
square-peg philosophy into a round-hole reality of
life... it just doesn't work, save to create more
frustration and angst.

But by the fourth major life lesson years ago, I had a
breakdown. A small, but necessary existential crisis.
And that crisis was not so much a function of the
event, but by the realization that my life philosophy
was wrong. Sufficient to say that the time was very
dark, and there was nothing nice about it... save the
special feature of all such emptiness and darkness.
In the dark and empty, you find great focus, as there
is absolutely nothing there to distract you. Just you
and your life thus far. And there is absolutely
nothing to do (or that you can do to change it). It is
like a mental straight jacket, and all you can do is
think. In that darkness, I realized my error... It was
not the wrong philosophy I had adopted, it was the
wrong perspective. True defining moments were life
events that were not defined by me... they were events
that happened to me. Now lest you think that I changed
from one social class perspective to another (the
lower class 'fatalism'), I didn't. But there is a
marriage between the two class perspectives (lower and
middle) that I think is probably right. (The upper
class perspective is ridiculous, obscene, and in the
best case, transitory). So here was the adjustment....

I still believe that there are defining moments in our
lives. And like a dot-to-dot puzzle (see attachment A)
the sequence of the dots defines the outline of our
lives. But the key piece is that we cannot control or
manufacture these moments. Not to say that graduating
high school wasn't important, but in the grand scheme
of my life, it didn't really change how I see myself
or my life. And that statement is very defensible when
you think back about the day before your graduated
high school and compare it with the day after. Not
much difference between those two days.

To the contrary, defining moments occur quite out of
our control. It was my dad leaving, my best friend
committing suicide in college, my first real love
leaving me stranded at an airport in a foreign
city....and many more (some of which were happy
moments, by the way)... and now, Katrina. Yes, all of
those were definitive defining moments because after
the moment, my life would never be the same again. And
that is the epitome of "defining." And none of them
were under my control... and certainly, none of them
were planned.

But I'm not a fatalist- I do believe we all have
control in our lives. For if there was no control,
then there could be no responsibility. No, all we have
to do in life is die, and since we always have a
choice, we always have responsibility for our actions.
But we do not have control over what happens external
to us, just control over what is internal in us- our
thoughts, words and deeds. And the essence of the
philosophy is this: You can't control (or predict) the
defining moments in your life... but you can control
how you respond to the moment. To use the dot-to-dot
analogy... you can't control the dots, but you can
control the direction your pencil moves once it hits
the next dot. And the beauty of the picture (your
life) is a direct product of how you respond to each
dot. Consider attachment B and C.... you be the judge
(Sorry about the armadillo thing... finding a dot to
dot on the internet is tougher than I thought). This
is not to say that the best life is one in which you
move directly from one dot to the next... first off,
it's impossible since you don't know when the next dot
will appear, and secondly, a rigid linear dot to dot
puzzle is rigid and boring. But it is to say that you
don't want to spin circles around one dot... the line
has to go on or the picture ends in an abstract piece
of crap. The art of life is not getting too bogged
down in any one moment, nor getting too far off course
as you ricochet off one dot so that your pencil leaves
the canvas (to mix art metaphores) such that you don't
stand a chance of seeing the next dot. And this last
point is important, because at the end of the day...
the worst thing you could do is to cower around one
dot such that your life's picture is composed of only
three or four dots.... because not many pictures can
be composed with only three or four dots. A line, a
triangle, a sqaure, a trapezoid... I guess, but not
much more than that. And that's a shitty life picture.

And the other curious feature of defining moments is
that they always seem to be uncomfortable... even if
they are good moments. Uncomfortable because you feel
the stretch of your life as it changes... but akin to
physical growing pains, the discomfort always
parallels expansion.... and deep inside, whether you
realize it or not during the moment... your life's
picture is expanding into something much more
interesting that it was even hours before. And with
each defining moment, as long as the pencil keeps
moving forward, the picture expands.


But now the reason for this email... I suspect you are
getting tired, and the strength you had in September
is beginning to wane. How could it not? Five months of
this is just an incredible strain. And like a long car
trip, the last 10 miles are always seemingly much
longer than the first 10. And like all great struggles
in life, that bastard of a question starts sneaking
in.... "is it worth it?" It's that same thought that
inspires Navy Seals to ring the bell. It's the same
thought that keeps a fighter down once knocked down.
And with fatigue at its maximum, you may begin to
revert to a survival mentality... "what's in it for
me?" Perhaps it is manifest in the thought of
leaving... or more likely just the fear and angst that
comes with prolonged uncertainty.... not knowing if
this lost time will affect the physician you will
become.

Well, know this. I've seen many great physicians in my
time... and I've seen many terrible ones, too
(remember, I used to remediate residents for a
living). And the one distinguishing feature between
the two was not the knowledge each held... not their
technical skill... not even their communciation or
interpersonal skills... it was the failure to live up
to the first fundamental lesson of this team:

"Requisite for being a great physician is being a
great person. If you are not a great person, you can
not be a great physician... for it is people that the
physician cares for, and if there is not goodness
within you, there cannot be goodness to come from
you."


So there has been medical knowledge lost in the past
few months no doubt... but there has been no character
lost. To the contrary, each life picture...predicated
on character... has expanded in proportions that would
take twenty years for the average physician to
accumulate. Each of you has kept the pencil moving
from dot to dot... even when things were very rough,
you didn't quit. And in doing so, you defined the
outline... the very character of your life thus far.
So come what may, I hope that in your contemplation
and reflection of what we have lost that you take a
moment to think about what you have gained.... and
think about how important that character is to the
life of the physican who lives at the bedside.

And all of this I thought of while spent a couple of
days by my grandmother's hospital bedside a couple of
weeks ago... And all I could think about is how much I
would want her doctor to be one of you. Any one of
you. Whether you knew the right medical knowledge was
quite immaterial at that momement... I just wanted
someone who wasn't going to give up on her. And in
those moments, it seemed to me, I just needed someone
of character to be her doctor.

So here is our defining moment... and like all
defining momements, either you will define the moment
by how you respond to it, or the moment will define
you... What will you do next? Will you keep the pencil
moving to see what comes next? Or will you pick the
pencil up?

Even with great sadness in my heart for what has
happened to you and what we have all lost... and with
great frustration in my soul at those whose actions,
inactions or incompetence have adversely affected our
lives and induced so much pain... my pencil stays on
the page, seeking that next dot in my life. No bravado
in this email this time... no admonishments about the
weakness of quitting. I just want you to know where I
stand. I'm just not going to quit. And I know that
that might mean going forward alone or with only a few
of you... but I just can't quit on this. I've
sacrificed too much... you have sacrificed too much...
I want too badly to be a part of what comes next,
because whatever it is, it's a hell of a lot better
than what came last. And you know the funny thing?
There is absolutely no doubt in my mind that our team
will be great again... it's just what happens when you
have truth on your side and good people at your
back... and when it is really great again... maybe
next month, maybe next year.... I don't want to be on
the outside looking in always regretting that I quit
too early and I didn't see it through... I just don't
want to wake up in the middle of the night for the
rest of my life thinking about how I didn't see it
through. I just want to see our greatness happen, and
I'll get up every morning when I don't want to, and
I'll work when I am too tired to, and I will drive to
wherever I have to. It just means that much to
me...just to see this happen.

Good night, all... you'll sleep well, I'm sure...
mostly because those 10 minutes won't bother you.

Wiese

Posted by Niels Olson at 12:10 AM

February 09, 2006

Class of 2009 Owl Club Class Reps Spring 2006

Foundations Niels Olson Lauren Eckert Physiology Whitney Stern Alex Newsom

Neuroscience Edward Pankey Biochemistry/Cell Biology Amitabh Pandey Kelli Wong Jacqueline Magne (coordinator)

Posted by Niels Olson at 11:39 PM

Information at the Point of Need

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.






Posted by Niels Olson at 10:09 PM

Host Outages

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....

Posted by Niels Olson at 07:26 PM

February 06, 2006

Rally for Charity Hospital, New Orleans, 2 pm, 25 March 2006

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.

Posted by Niels Olson at 08:29 PM | Comments (1)

February 02, 2006

Addendum to My Current Thinking on Medical School Performance

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

Posted by Niels Olson at 10:21 AM

February 01, 2006

The Next Red State Moron

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

Rank	Specialty	Score
1	obstetrics/gynecology	49
2	orthopaedic surgery	47
3	pulmonology	47
4	otolaryngology	45
5	physical med & rehabilitation	45
6	thoracic surgery	45
7	radiation oncology	45
8	general surgery	44
9	preventive med	44
10	hematology	44
11	infectious disease	43
12	occupational med	43
13	anesthesiology	42
14	neurosurgery	42
15	rheumatology	41
16	gastroenterology	41
17	emergency med	41
18	aerospace med	41
19	radiology	41
20	plastic surgery	40
21	urology	40
22	nuclear med	40
23	ophthalmology	39
24	pathology	39
25	med oncology	39
26	endocrinology	39
27	cardiology	38
28	nephrology	38
29	allergy & immunology	38
30	colon & rectal surgery	38
31	pediatrics	38
32	dermatology	37
33	general internal med	36
34	neurology	36
35	psychiatry	35
36	family practice	35

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

Posted by Niels Olson at 08:52 PM | Comments (1)

My Current Thinking on Medical School Performance

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.


——O——

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?

Posted by Niels Olson at 11:00 AM

January 30, 2006

Flexner on Tulane

From 1908 to 1910 Abraham Flexner, an informed layperson acting under the auspices of the Carnegie Foundation, reviewed virtually every medical school in the United States. Enticed by the (false) thought that the review would bring needed funds from the wealthy Carnegie Foundation, the schools gave Flexner access that was and remains unequaled. In reality, of 150 schools reviewed, fewer than 80 survived.² This is what he had to say about Tulane in his legendary Bulletin Number Four.

---

LOUISIANA
Population, 1,618,358. Number of physicians, 1798. Ratio, 1 : 900.
Number of medical schools, 2.
NEW ORLEANS: Population, 992,169.

(1)¹ MEDICAL DEPARTMENT OF THE TULANE UNIVERSITY OF LOUISIANA. Organized in 1834, the school affiliated with the University of Louisiana in 1845, and with Tulane in 1884, at which date the University of Louisiana became Tulane University. In 1902 it assumed its present status as an organic part of the university.

Entrance requirement: A four-year high school education or its equivalent, administered by the academic authorities. The actual standard is somewhat below the nominal standard, though gradually rising towards it.

Attendance: 489.

Teaching Staff: 75, of whom 17 are professors. The laboratory branches are in charge of five men, who give their entire time to teaching and investigation.

Resources available for maintenance: Endowment funds, aggregating about $900,000, yield an income of $26,000 annually; fees amount to $67,500. The budget of the department amounts to $101,781.

Laboratory facilities: New and excellent laboratories are provided for the work of the first and second years. The professors in charge represent modern ideals, and are enthusiastically engaged in reconstructing the entire school on progressive lines. The anatomical museum is one of the best in the country. The library is small.

Clinical facilities: The school enjoys unusual privileges and opportunities in the Charity Hospital, an institution of 1050 beds. Recently an additional ward for surgery and gynecology has been added, full control of the services being vested in the Tulane faculty by the terms of the gift. The abundant material is freely used by the medical faculty, though certain defects of organization, equipment, and relationship must be corrected in order to render the situation ideal. The main point, however, is secure, for the position of the medical school in the hospital is ensured through legislative enactment. The professorship in medicine has recently been filled by importation without any friction whatsoever.

The dispensary service is adequate.

Postgraduate instruction in specialties is offered by the New Orleans Polyclinic, affiliated with the Tulane University.


---

¹At the time there was a second medical school in New Orleans, the Flint Medical School, which had an attendance of 24 and access to a 20 bed hospital, which averaged 17 patients a month.


²Paul Starr, The Social Transformation of American Medicine. Basic Books; 1982.

Posted by Niels Olson at 06:47 PM

January 29, 2006

Feeling Useless...

"Sir, sir?" "He just collapsed." I'm a basic life support instructor, I figured I should probably see what had happened. Sitting in the bookstore cafe studying biochemistry for my exam tomorrow, a man had just collapsed at the entrance. He was wearing a plaid flannel shirt and jeans. Fifty, red beard turning white. Maybe overweight, but not obese. He had moderate convulsions, was lying on his left side, trying to right himself. Both arms were strong and he was grossly coordinated, though still convulsing and having difficulty getting traction with his feet. His cowboy boots were sliding on the tile floor. He didn't hit anything on the way down, except maybe breaking his fall with some boxed looks-like-a-book-but-it's-really-a-toy things, which had been stacked up by the door and had tumbled. He wanted to sit, so we held his shoulders while he braced himself with his arms behind him, legs sticking straight out in front. I was kneeling on his right side. I could feel the muscles of his upper back and shoulder convulsing under my hand. His pupils were equal and not dialated.

At least two store employees had said they were calling 911.

"Sir, what's your name?" "Sir, can you tell me your name?" "Sir..."

He turned to look at me. "Fred." He was either unsure about this or he was scared. My guess was scared. He can turn his head, presumably focus. I could see the whites of his eyes all the way around his irises. Not flushed, not sweating.

"Fred, has this happened before?"

"No..." Unsure. Eyes track together.

"Does anything hurt?"

"No..." Why does everyone keep asking if he has heart trouble? No expression of pain on his face, just fear. His speech seems clear, despite the limited vocabulary sample thus far.

"Do you feel any numbness?"

"No..." Convulsions were lessening. He could coordinate well enough to hold himself up.

"Can you feel your hands and feet?"

From above and behind me, "Is ya wife heah?"

"Yes..."

"Ah ya diabetic?" Ah, so this is hypoglycemia. The insightful Texan over my left shoulder was a man dressed about like Fred, of about the same age, clean shaven, glasses, a white straw hat, and a Santa Claus belly.

"Yes..."

"What's your wife's name?" I asked.

"Maurine. Baker." I could still feel the convulsions, but lessening.

An employee went to page his wife. She was well groomed in brushed camel and a white perm. She kept her composure. "He needs some sugar."

A couple of us went to the cafe. "Here, this doesn't have any added sugar." The sophmore juice expert was struggling with her own freshman 15. "You don't understand: it's the sugar he needs." The four dollar, 16 ounce bottle of juice still had 27 grams of sugar. That'd work. Everything was in glass bottles. Why can't they sell plastic? It's not like they're recycling the glass. "Here, this is banana..." but I was already walking back to Fred. I felt I had been short with the juice expert...

Fred seemed ok with the juice. So I asked the texan "How did you know what was going on?" "I was cop for thirty years. I seen this now and again."

EMS arrived. Blood glucose: 21 mg/dl (normal is between 75 and 115 mg/dl). They gave him oral glucose; I made small talk with his wife and the retired texan. They'd stayed in a motel and skipped breakfast. She and Fred were in town for the basketball game; their son was going to Texas A&M. I congratulated her on her son going to college as the techs helped Fred onto the stretcher. It was awkward. Maurine asked that they wait and observe for a bit before making any decision to transport him. I think she was thankful when they offered to load him in the truck to observe, the onlookers made her uncomfortable.

Posted by Niels Olson at 03:56 PM | Comments (2)

January 26, 2006

Study for Students

Cut to Cure summarizes an article every medical student should be interested in: digital rectal exams are not indicated in trauma patients. Probably want to make your attending aware of the study before being ordered to perform said examination....

Posted by Niels Olson at 10:03 AM

January 22, 2006

Boooooring........zzzzzzzzzzzzzzzzzz

I studied all weekend. That's it. Just studied. Wanna know about the anterolateral system? Sphingolipids? Calcium²⁺ regulation in the smooth muscle of your colon? Didn't think so.

I did scrub in for open heart surgery twice last week, though. Coronary artery bypasses on and off pump. Got to hold the heart. Beating and not beating. Oooooooooo. This week? Going around with an ENT (ear nose and throat doctor, aka, otolaryngologist). ENTs have a seriously split personality: most people know the half that it is sniffles and ear aches. The other half is surgery for seriously disfiguring and life-threatening trauma (claw-hammer-to-the-eye type stuff) and cancer (smoker cancers like tongue, vocal cords). We'll see.

Posted by Niels Olson at 10:59 PM

January 13, 2006

Tulane Opening 17 January

Tulane Reopens 17 January Expecting 88% Return.


Five months after Hurricane Katrina caused at least $200 million in damages and closed its doors for a semester, Tulane University gladly welcomed back first-year students yesterday (Jan. 12) for move-in to residence halls in preparation for the spring semester.

Tulane rolled out the red carpet with "Welcome Back" banners and flags on buildings and light poles, as well as numerous signs promoting its "Orientation Déjà Vu" activities for the entering class. While students and their parents moved boxes and luggage out of car trunks and down sidewalks, members of the news media photographed and videotaped the festivities.

On hand to report on Tulane's renewal were the Christian Science Monitor, the Chronicle of Higher Education, the Associated Press, NBC, National Public Radio, the Los Angeles Times and Fast Company magazine, in addition to local television stations.

Tulane will reopen for classes on Tuesday (Jan. 17). Approximately 88 percent of Tulane students are expected to return for the spring semester.

Posted by Niels Olson at 08:26 AM | Comments (1)

January 10, 2006

Bush & Clinton to Speak at Graduation

May 13th is the combined graduation for Tulane University. Presidents Bush (dad) and Clinton will both speak.

Posted by Niels Olson at 11:21 PM

January 03, 2006

Back in Your Hole!

First day of class; I'm already behind. Sweeeet....

Posted by Niels Olson at 10:14 PM

January 01, 2006

Choosing Residency

Hmmm... This may be helpful.



Drawn by Boris Veysman, resident, Yale School of Medicine, published in the British Medical Journal. Found via GruntDoc, Clinical Cases and Images and Dr. RW.

Posted by Niels Olson at 06:52 AM

December 30, 2005

Currently Reading

When the Air Hits Your Brain, Tales of Neurosurgery, by Dr Frank Vertosick. Gearing myself up for Neuroscience this semester.

Posted by Niels Olson at 10:17 PM

December 23, 2005

Professions

I don't know, but medical school without patients. Hmmm.... Probably evidence of my own short-sighted, selfish desire for some immediately gratifying reminder of why I'm doing this, but I went on rounds today at the rehab where my wife works, and man! That was helpful. I gotta do more of that.

Yeah, there's were sad stories, like the 27 year-old mother who didn't go to the dentist when her tooth hurt, got an abcess, the bacteria got in her blood, parked themselves in her heart, grew, and a chunk of the new colony broke off and took a quick trip to her brain, where it lodged in her middle cerebral artery, cut off the oxygen to that part of her brain, and now she can't move half her body. So now she's had a stroke, open heart surgery, and a titanium butterfly valve in place of of the custom, home-grown, miracle of nature she was born with. The new one, it clicks. And she got that root canal she needed. And blood thinners for the rest of her almost certainly shorter life.

And sad, yet satisfying stories, like the five discharges, one of whom, by surviving her injuries, finally lived to see her abusive husband in jail.

But the whole thing reminded me distinctly of the difference between shore duty and sea duty. Officers on shore duty ride desks and have no sailors or very few sailors working for them. Hours are good, but everybody is a little uptight. In the fleet, hours are horrible. Really. Medical hours just aren't that bad by comparison. That's a whole 'nother post. But at the same time, at sea, something is right. Palpably, leading-sailors-is-what-I'm-supposed-to-be-doing right. Some feel it more strongly than others. Admiral Leidig showed me that once when he was a captain: "Niels, I gotta get promoted to admiral so I can go back to sea." Uh, okay, boss. But that's it. Same thing for me at the rehab today: I gotta get this degree so I can be here with these people, doing these things. I gotta go learn how to do a neurologic exam. Right now.

I suppose this is all very quaint to anybody who actually works in healthcare for a living, but hey, I'm just a first-year medical student.

Posted by Niels Olson at 11:26 PM

December 20, 2005

Somebody I Want To Find

Dr Norman McSwain

Now there's somebody I want to study under.

Posted by Niels Olson at 03:35 PM

December 16, 2005

Starting Break

There's a block party to night to celebrate the end of gross anatomy and the first semester in general. Hope everyone has a good time. Make it safe. I'm on my way to College Station for the break. Going to San Antonio tomorrow for a day trip with the fam.

Posted by Niels Olson at 05:48 PM

December 15, 2005

Almost — There

Test — tomorrow. Must —— study —

Posted by Niels Olson at 04:23 PM

December 14, 2005

Meeting of the Deans

Dr Taylor resigned under pressure within himself. In his words "I had a conflict between my cerebral hemispheres and my heart. My heart won."
- fired clinicians he hired when he came in. Hired to grow.

Dr Paul Whelton: - 2500 beds to about 100. 40% clinic use, 25% inpatient use. 11 hospitals to 2. If we can't continue to be a school of excellence, we don't want to be there. Maintain ourselves as a "top ten" school. Trying to be in top fifty in research. Committed to pay faculty through June 2007. Committed to maintain direction Dr Taylor. We will be ready to return to New Orleans. Expect to have TUHC fully open by April. Working with VA to contract space and beds. They also have (VA) significant capacity to build.

Working to bring Charity with back. Leasing space in Elmwood to restart charity trauma unit.

University hospital also expected to come back, maybe above the first floor.

Dr Taylor is committed to continuing to help us. Advocacy?

Charity resident pay is a big if.

Question: we want a list of faculty. That is simply not possible. These people have careers that are not to be advertized.

We may be replacing the faculty that have left(?!)

You're asking us to commit to the institution. We came here because of the family. We have a sense that some members of the family have been kicked off the boat. We want to know what the core values are.

Clinical faculty were cut across the board.

From Dr Krane: there are real challenges to the nature of the education. We have kept small group sessions. We're going to pair 1st and 2nd years with 3rds and fourths to interview. We have gotten Houston physicians to start serving as preceptors.

From Dr Kahn: with regard to counseling and tutors. I'm here for you guys. We've got student tutors. Working on a website for local resources. AAMC site allows you to do career counseling.

Dr Whelton said that, contrary to the news reports, we actually separated about 140 faculty.

Orleans parish population went from 600,000 to 60,000 to 100,000, projected to go up to 250,000. 1.3 million antedeluvian. 1 million now, but many in St Tammeny and Jefferson parishes.

It is illegal for us to prevent people from transferring. We are not preventing people from transferring. I certainly do urge people to stay here because I believe it's important to keep the school together. When called by other deans about transfers, when they ask about you as a student.

Posted by Niels Olson at 01:28 PM

Late

I woke up late this morning and hurried out of the house so I could set up the recording equipment for lecture before it started. I ride my bicycle to school. While still in the driveway I realized I'd forgotten my helmet. Screw it. I'm late. Gotta go.

I took all the short-cuts. Little things that save time but I normally avoid because they're riskier. I was riding fast and it was wet when I came off the bayou trail onto the busy McGovern Avenue, just in front of the Texas Medical Center. That's where I slid out and got hit by the truck. My wife is typing this by my bed at Ben Taub General Hospital. They think the truck's bumper is what fractured my skull, which ruptured the middle meningeal artery, which caused an epidural hematoma, which is why I can only mumble.

Not really. But that's what I was thinking as I rode to school. Wear a helmet.

Posted by Niels Olson at 10:07 AM | Comments (2)

December 12, 2005

And Now for the Student Revolt

Oh hell, now a student's inciting a revolution. Great. There goes my tuesday evening. The Superintendent of the Naval Academy resigned while I was there, and the Commandant resigned before I got there. Another's promotion to the admiralty was held up over the 1993 cheating scandal. I wonder if they know this isn't the first time a leader has resigned?

Students of the Tulane Community,

The past four months have been very trying times for all of us. However, the full brunt of Katrina has not been felt by the medical school until the past week. After a unprecedented reorganization by the administration and faculty, we were the only Tulane school to continue regularly scheduled courses, only slightly interrupted, during the last semester. While the rest of the university has maintained a retention rate in the 85% range, we were able to retain 97% of our students.
What may ask is the reward to us for maintaining our faith in Tulane School of Medicine? Only the removal of 30% of our faculty who have worked so hard over the past four months to ensure the educational standards we are used to.
It is about time we get together and tell not only Scott Cowen, but the entire Tulane community that we are no longer okay with them compromising our education. We need to get together before Wednesday’s “meet and greet” to draft a letter that we’re not willing to have decisions be made without student representation. I urge you to meet with me and other leaders of the Medical School tomorrow afternoon at 5 pm. We have yet to acquire a room for this meeting, but you will receive an email tomorrow clarifying location. I understand that this is exam season, but due to the timing of the recent faculty changes, it is imperative that we come out with a statement immediately. If you are unable to meet then, however, you would like your name attached to any letter we compose, that can be accommodated, as you will receive a copy of our letter tomorrow.

I thank you for your time, and for your belief that Tulane medical school can once again become the beacon of education that it once was.




I've got a better idea, why don't we all get together and figure out what we can do to make it better. Ship, shipmate, self.

Posted by Niels Olson at 11:11 PM

Justin - Superb

Excellently said by the president of the Owl Club, the group that does most of what student governments do at other schools.

All-

I am assuming that many of you are as crestfallen as I am with the recent news of Dr Taylor's resignation and the mass layoffs of our faculty. Clearly we are all hungry for information as to the future of our school and the committment of Tulane University to the School of Medicine.

I had the opportunity to sit down and talk with Dr Taylor today about these recent unfortunate events. I think it is important for all of us to know that his first question for me was in regards to the status of the student body- "How are they holding up?"

This is the man that led a group of administrators, faculty and students to Houston and succeeded in reconstituting the medical school in a matter of weeks- in talking with him, he is now clearly saddened to see his medical school face yet another challenge. I think it is important for everyone to know that he has not "jumped ship" and abandoned us, and I hope most of you will be able to see his resignation in the context of the current situation.

I think it is also important for all of us to realize that everyone at the medical school is in the same boat- students, faculty & staff. We are all upset, concerned with the future of the school, and wanting answers to our questions.

I strongly encourage you all to attend the informational meeting to be held on Thursday (I do not know the time or place), and be prepared to ask the tough questions that are in all of our heads. Drs Taylor and Whelton will be present, as well as Kahn and Krane. We all have exams that we are worried about, but we are at a crossroads and need to speak up for the best interests of our school.

We as the student body should be organized and show up to have our questions answered and make it clear to the University that we are unsatisfied with the decisions that have been made. Your class may be interested in getting together beforehand and organizing your questions so that you can have a unified voice and have your various issues addressed. I suggest you contact your class officers if you are interested in doing so- the T3's have already initiated this process.
I would not expect to be given any miracle answers to our questions on Thursday. However I am expecting that you all will rise to the occasion and ask enough good questions that the University will have to respond.

I will not pretend to be unwaivering in my optimism, but I think it is important that we stand up together to speak out for the future of our school, faculty and administration.

Justin Lafreniere
President, Owl Club

Posted by Niels Olson at 11:10 PM

Dr Ian Taylor, Dean of Tulane School of Medicine, Resigns

This came as a surprise to me, and I think many of our classmates. Good luck Dr Taylor, and godspeed.

Dear Students of the School of Medicine,

I am writing to inform you that Dr. Ian Taylor has resigned his position as dean of the School of Medicine, effective immediately. I have asked Dr. Paul Whelton, senior vice president for health sciences, to also assume the role of dean for the foreseeable future.

Hurricane Katrina has clearly taken a toll on all of us, and I know that is especially true for all of you. With the announcement of our Renewal Plan on Thursday we have a clear pathway to a bright future for both the School of Medicine and the university, including reopening our educational programs at the medical school here in New Orleans on July 1, 2006.

On behalf of the entire Tulane University community, I want to thank Dr. Taylor for his four-plus years of service as dean. During that time period, he made many contributions to the school and university, including continued LCME accreditation, expansion of the faculty, and greater emphasis on research and the clinical enterprise. We are appreciative of his efforts.

I hope you will all join me in supporting Dr. Whelton and his senior team during this transition. Ever since Hurricane Katrina they have done a marvelous job of addressing and resolving every critical issue they have faced in a very difficult and complex environment. I am confident that same focus and determination will guide them in the future. I stand shoulder to shoulder with them to ensure the future success and vitality of the School of Medicine. We all look forward to welcoming you back in July.

President Cowen

This is from Dr Whelton:

Dear Colleagues,

By now you may have heard the news that Ian Taylor has decided to step down as dean of the School of Medicine. I want to take this opportunity to thank Ian for his many contributions to the school over the past four years. During his tenure as dean, the school experienced one of its most vibrant periods of growth; the school's educational programs were further strengthened; the track record for conduct of competitive research was greatly enhanced; and the capacity to offer high quality clinical services was substantially expanded. In addition, Ian provided the leadership for a new strategic plan and appointed many of the school's senior leadership team. He leaves a rich legacy of successful accomplishments. On a personal basis, I am grateful to Ian for his contributions as a valued member of the Health Sciences Center senior leadership team and for his friendship and support.

President Cowen has asked me to step in as dean and I have agreed to do so for the foreseeable future. Needless to say, the current circumstances require that we all focus on a common goal of recovery and renewal. Recognizing the challenges that confront us in the aftermath of Hurricane Katrina, I feel confident that the School of Medicine can thrive in the future. I will do everything possible to facilitate this and to encourage the continuation of excellence in each of the school's three mission areas. The Tulane University School of Medicine is a historic academic institution with a bright future. I look forward to working with each of you and to receiving your advice and support in the coming weeks and months.

Paul


Paul K. Whelton, M.D., M.Sc.
Professor of Epidemiology and Medicine
Senior Vice President for Health Sciences
Tulane University Health Sciences Center
1440 Canal Street, Suite 2400, TW-5
New Orleans, LA 70112-2709

The second-year class president, Scott Simpson, sent another e-mail "message from Dr Kahn". Dr Kahn is the dean for student affairs.

Students:

In regards to the recent developments, Dr. Kahn has asked me to inform you that the administration will address the students on Thursday 12/15/05. This will be an informative session with a question and answer portion. More specific details will be available soon.

While many details are forthcoming, there is indication that there will be no additional layoffs in the near future, hence Dean Taylor's statement "the University is guaranteeing the total salary of mission critical faculty through June 30, 2007" reference in his recent email. It is my understanding that this decision to leave was Dean Taylor’s choice and was not forced upon him.

Dr. Kahn is currently at a Hematology conference and will be back in Houston on Weds. Dr. Krane is in New Orleans and will be back in Houston for the meeting.

These have been exceedingly trying times for all of us. Please stay strong.

Scott Simpson
Class of 2008 President

Posted by Niels Olson at 01:03 PM

December 09, 2005

More on the Cut of 180 Faculty

The hard knocks keep coming to the medical school. In my last entry I quoted the University's article on the decision to cut 180 faculty. The dean names one of the consultants below.

December 9, 2005


The University has been proactive in developing a plan in response to Hurricane Katrina. A consultant firm with an international reputation was hired to work with the Health Sciences Center Leadership to develop a vision and plan for the future. This team was headed by Dr. David Chin, a Harvard M.D. and a Stanford MBA. In addition, several Presidents of Universities who oversee world renowned medical centers acted as consultants.

President Cowen has announced publicly that he wants our School to be in the upper echelons of Medical Schools. To achieve this goal we have had to define what is mission critical for our School so that we can develop a firm base on which to grow and expand in the future. A clear indication of the President’s commitment to this goal is the fact that the University is guaranteeing the total salary of mission critical faculty through June 30, 2007. This represents almost two years of post-Katrina support which will ensure the quality of our faculty and our educational programs. This will also ensure our educational mission continues to be central to everything we do. The educational experience for our students and residents this year has been of the highest quality thanks to the dedication of the Tulane faculty and the generosity of the South Texas Alliance. We are all committed to continuing to provide the highest quality education when our students and residents return to New Orleans for the next academic year.


Ian L. Taylor, M.D.
Associate Senior Vice President for the Health Sciences
Dean, Tulane University School of Medicine

More on Dr Chin here, a report on a project he did for the VA, an article about the project. He is on the advisory board for Harvard Med's Health Care Policy department. He works for PriceWaterhouseCoopers. Here he is on a video from PriceWaterhouseCoopers.

I've heard talk of people suing for damages that were caused in the immediate aftermath of the storm. Payroll cuts are THE sure sign that an organization is having a tough time. In light of payroll cuts, I don't think anyone with a vested interest in the school would be looking out for their own interests by trying to milk money from the school, whether to punish the school or because they need money. To the punishment argument: that's just not going accomplish a systemic effect without punitive damages, and, given the weakness of the case to begin with, I don't think punitive damages are reasonable goal. To the argument that a student needs the money: in the long run, and this may seem cold-hearted but read on, those scant posessions in a dorm are non-issue. Reading on, think about the conversations my wife and I must have had with a mortgage and a house full of possessions accumulated over ten years, toys for kids, etc. Thankfully we didn't get hit. Meanwhile we're paying a mortgage in a house we're not living in. Anything that fit in a dorm room is a rounding error in the life of a future physician. Get over it, the school is more important. Come meditate on the pull-out couch I'm sleeping on for nine months.

Also, by comparison, LSU Health Science Center laid off 430 without pay or benefits.

This post isn't in favor of the dean, the university's consultants, the faculty, the students or anyone else. I do believe the organization should be everyone's long term concern because it seems to be on shaky ground and we all signed on. Ship, shipmate, self.

Posted by Niels Olson at 05:42 PM

Tulane Downsizing

Cutting 180 faculty positions; fundamentally fewer hospitals and patients. Ouch... "Somebody has to make the move first"... I wonder if that means LSU hasn't decided to go back yet. Maybe they'll stay in Baton Rouge????

MEDICAL SCHOOL TO RE-FOCUS ON RESEARCH, EDUCATION

December 9, 2005

In a move to respond to a healthcare environment changed by Hurricane Katrina, Tulane University is restructuring both the focus and scope of its medical school. The Tulane Board of Administrators has announced that the Tulane School of Medicine will eliminate 180 faculty positions, downsize its clinical operations and re-focus its research areas.

“The fundamental fact is we don’t have as many hospitals and patients in the city of New Orleans,” said Martin D. Payson, who sat on the board’s medical subcommittee. “You have a large medical teaching operation that has to be brought back to the size of the constituency.”

Linda Wilson, chair of the board’s health sciences committee, said that in terms of research, the medical school will emphasize areas of strength: gene therapy, organ transplantation, cancer, infectious disease and cardiovascular diseases. “These are areas that are important to our population and where we are first class,” she said.

Payson and Wilson said that Tulane will recruit volunteer community physicians to supplement full–time clinical work and will reach out to other institutions to form partnerships to aid in developing residencies and clinical operations. “Tulane is saying that somebody has to make the first move, so we are making it with partnerships to the extent that they are ready to step up to the plate,” said Payson. Wilson added that HCA, Tulane’s partner in Tulane University Hospital and Clinic, was consulted in developing the current plan.

The medical school, which has been functioning at Baylor College of Medicine since the hurricane, is expected to return to its location in downtown New Orleans for the fall 2006 semester.

-- Nick Marinello

Posted by Niels Olson at 07:26 AM

December 04, 2005

IMGs

A short comparison: the AAMC's stance on international medical graduates, versus the writings of a couple of international medical students, Enrico, the Mexico Medical Student and the Carribean Medical Student. My wife swears the best allergist she ever went to was trained in Mexico.

Posted by Niels Olson at 09:38 PM | Comments (1)

November 27, 2005

Charity

One of the last antedeluvian pictures of Charity Hosptial



Posted by Niels Olson at 09:36 PM

November 01, 2005

What's Medical School

Ever wonder what criteria have to be met in order for something to be a medical school? Here they are, at least in the US: the Liason Committee on Medical Education's standards.

Posted by Niels Olson at 10:01 PM

October 26, 2005

Oh, yeah...

We're going to be in Houston through May. Needless to say a lot of people aren't happy with that. Apparently the cincher was the lack of clinical opportunities for third and fourth year students, which both the deans and the LCME agreed on. Could the first and second year students go back? Maybe, but that would stretch a thin administration even further. Personally, it's not that bad for me. If I'd stayed as a line officer in the Navy I'd be at sea all week every work week during the training cycle anyway, and if I wasn't in the training cycle I'd be on a six month deployment. My parents are helping my wife with the kids, my daughter is in school, my wife has a sense of occupation at her job, my mom could have kept up with her PhD program but was able to defer and wouldn't trade the time with her grandkids for anything. My dad has a full house to go home to, and my kids have lots of loving attention, far more than they probably got in New Orleans. They're not in daycare, which means we're saving on that, and we've been able to make our house in New Orleans available to some folks who lost everything. I've been told my living conditions are below what most of the other students came into, but it's still a lot better than I'll have on a ship (which may still be in my future once I graduate) and it's really close to school, so I can bike, which saves gas.

Posted by Niels Olson at 07:30 PM

October 24, 2005

Mr Lake

My first patient. My first standardized patient. My first standardized, scripted, done-this-chest-pain-script-so-many-times-he-can-improv, patient. Sweet. There's three of us students. Sure, I'll go first.

Hello, Mr Lake? [Mr Lake has his back to me... I'll walk around!]

Hello, Mr Lake? I'm Niels Olson, a medical student at Tulane. Do you mind if I ask you a few questions? [Do I ask if I can have a seat? Does my doctor ask that? It's not his hospital... Look at that, I'm sitting!]

So, what seems to be bothering you?

And how often do you have this chest pain?

It feels like pressure... And does it radiate? From you back to your stomach... [Why does he have an insulin pump? Is that part of the bit? Man, wouldn't that kind of complicate chest pain? We haven't even cracked the chest on the cadaver. It must not be part of the shtick, ignore the insulin pump.]

[Ignore the insulin pump]

[IGNORE THE INSULIN PUMP! THAT ONE! RIGHT THERE! THAT LOOKS LIKE MY OLD CELL PHONE! IGNORE IT!]

And how long does the pain last? Thirty or forty seconds, great. [It's not great! What the hell was that?! Great....]

You seem tense. [Note the lack of follow-up here...]

So, do you have any past hospitalizations? [My classmates are sitting there, so safe. I want to sit over there, watching the fool trying to interview the standardized patient...]

Blah

Blah

Blah

Okay, well that about raps it up, thanks for your time Mr Lake. I'll go brief your attending and we'll see what we can do to help.

———Next student———

Blah, blah, blah

Other student: "You seem tense. Would you like to talk about that? Is something troubling you, Mr Lake?"

Mr Lake: "Yes, yes, the stress is killing me! We just moved into this house, our dream house, that we built, and one night two weeks ago a thief came out of the bushes and beat me over the back and stole my wife's purse! And the economy's in a downturn and I've had to lay people off at my architectural firm, and my 18-year-old daughter stays out late, and I've got these skin cancers on my hands, ohhh, it's so horrible! I don't know what I'm going to do! I can't even sleep in my own home!"

[Hmmmmm..... should've followed up on that tense thing....]

Posted by Niels Olson at 06:23 PM

October 14, 2005

Observing

For whatever reason the Baylor students and Tulane students really haven't mingled that much yet, at least not in the first year class, despite occupying the same building, the same labs, and having two mixers already. I think this has to do with a few things, not the least of which is that the Astros are in the playoffs, so the Baylor folks are a little preoccupied during their free time right now. And the faculty worked really hard to make sure there was no overlap between the two classes. Their initially smooth two week schedule is on it's last lecture (shouldn't I be paying attention?) so we'll see if there's more overlap later.

Going in to New Orleans with, along with every other Tulane student this weekend. Hopefully I can get into the school to get my books out of my locker.

Posted by Niels Olson at 03:34 PM

October 02, 2005

Not Studying

I haven't studied the back or arm since we evacuated. I did the entire head and neck dissection at Texas A&M, but have done little more than a few flash cards and mental exercises on the arm and back. Now it's almost 9, I've got a few more things to do just to be ready to go to class tomorrow. Gotta go.

Posted by Niels Olson at 09:45 PM

June 29, 2005

Laptop for school

I bought a Dell 9300 before I got into Tulane on the assumption I might end up doing more of the analytic design work. Statistics and graphics are the two heavyweights in computing so I got the most of everything (processor speed, bus speed, RAM, hard drive space, screen size) that I could get. I'm a very visual learner and medicine has a lot of visuals, so I'm not sure I would change, even if I had the money, but I definitely would not get the 17" screen if I weren't a visual learner because it's quite heavy. I would consider a rolling suitcase or backpack made for laptops. I have found it very helpful for taking notes and I got a Wacom tablet to facilitate free-hand drawing in my notes, which I type in Adobe InDesign. I'm not sure Word supports Wacom tablets.

As for durability and service, you can't beat Dell. My wife's mom is still using the laptop I bought in a pawn shop in 1998 after it was already two years old. That nine-year old laptop has deployed on a warship and sustained an incredible amount of more conventional travel. As for service, my dad told me Dell worked with someone in his office for a year to fix a laptop and finally gave the researcher a new one.

Posted by Niels Olson at 04:34 PM

June 26, 2005

A Chiropractor's Son Sent Me to Medical School

DocSurg has an interesting post about chiropracty. My only encounter with a chiropractor was when I was riding my bike home from the pier where my ship was berthed in San Diego, and his kid hit me in a left turn right in front of his dad's office. When I came too in the middle of the intersection I pulled my left shoulder back into socket and hobbled over to the curb with my pretzel of a bicycle. Dad the Chiropractor came running out and told me he was a doctor. He asked me if I was okay; I said I thought I dislocated my shoulder. He assured me this was no big deal; then he put his hand on my head, rotated my head and neck and asked me if that hurt. When the ambulance came he assured me that I didn't need to bother them with the transport, that I would be fine. The first aid and lifeguard in me was screaming at this point, but I didn't know he was a chiropractor, he said he was a doctor. The upshot was that the Navy gave me a Bankart repair (four anchors and sutures in my scapula to pull the cartilage back onto the cup of the shoulder joint); my surgeon, Dr. Mologne, let me follow him during my convalesence and the money from the accident settlement basically financed my tuition, applications, interview travel, and the closing costs on my house in New Orleans.

Note: don't mobilize the c-spine of someone just hit by a car without their permission. The standard thing to do is immobilize the c-spine, with informed consent.

Posted by Niels Olson at 08:22 AM

June 17, 2005

Dr Mologne

I'm still thinking of people to send thank you notes to for helping me along the path to acceptance. One is Dr Mologne, who performed a Bankart repair on my left shoulder in 2001 at Naval Medical Center, San Diego, known simply to the locals as Balboa. Even before I'd been hit by a car, dislocated my shoulder, and Dr Mologne and his residents sewed the cartilage back onto my scapula, I'd wanted to be an orthopedic surgeon. He let me follow him around the clinic and OR for a week during my convalesence. Those memories have been some of my best motivators over the last three years.

He's gone into private practice in Wisconsin. If you've got an orthopedic problem in Wisconsin, well, my shoulder hasn't made any weird squishing sounds since the surgery, nor does it subluxate when I close a driver's side car door. I'd go back to him.

Posted by Niels Olson at 03:28 PM

June 15, 2005

Some down, more to go

There's a good article in Nature about visualizing networks. Interestingly, one of the graphics is horrid. It's the same problem as a New England Journal of Medicine graphic I cited in an earlier post on Edward Tufte's board. Actually, I'd cited the graphic on Tufte's board as an example of a mapped picture, but someone else pointed out that the authors had submitted it on a black background, because that's what's visually pleasing on a computer screen. On paper, white background is obviously preferred.

In any case, I got quite a bit done on all fronts today. I finally got my HPSP package to the Navy's local health professions recruiter. His goal is to sign 20 medical school students for HPSP this year. It's June and he's got one, my friend Mike. That's Iraq for you. Turns out most smart people don't want their kids to be associated with the military. Not to say that decision in and of itself is smart, more of a statement about the university system here in America. Anyway, I've got a couple of documents to the recruiter and we hope to have the package in by the end of the month.

I also contacted my financial aid advisor at Tulane. He's a retired chief, 20 years as a Navy corpsman. He said they had mailed me a financial aid package on the 11th. I haven't received it yet, but I found the forms online and filled the out so he gave me the fax number and I sent him everything. I still need to find out what lender I want to go with. That will take a bit of surfing.

Househunting is pressing forward also. I've got that for action while my wife looks for a job and applies for licensure. If you know anyone that's hiring occupational therapists in New Orleans, please let me know. Meanwhile, our bank's reccommended realtor contacted us and we've got more homework to do there.

My wife scheduled the cars to go in for repairs on Friday, one after the other. And I ran today. I didn't run until after dinner, but I ran.

For tomorrow:

· Get remaining HPSP documents (physical, transcripts, CO endorsement) to Chief Wright
· Stop all the automatic allotments based on my Navy pay
· Find out what physical, shots, etc, are required prior to admission.
· Review my separation how-to guide for upcoming requirements
· Contact Fort Meade about my DD214 (Ms Cann)
· Fix the muffler on the Honda
· Fix the rear-view mirror on the Chevy
· Check out houses, schools, etc on line.
· Determine which lender to use for financial aid
· Initial budget outline
· Get airline tickets
· Get BOQ reservations/Navy Lodge, Car rental

Posted by Niels Olson at 09:46 PM | Comments (1)

June 14, 2005

Good Problems

Ran for the second day in a row. Things are starting to settle out and I'm going to go to bed a bit earlier tonight, like 11 pm. I was on the highway today and almost fell asleep at the wheel. I haven't gotten more than about four hours of sleep since I got the phone call last Thursday. I was on the highway trying to deliver my Navy's Health Professional Scholarship Program (HPSP) application to the recruiter. Unfortunately he told me to go east when I needed to go west, so I'll be trying that again tomorrow. I did fill out the forms for Tulane financial aid. My FAFSA has been in since February, but these supplmental forms I just got. I'm supposed to be getting a package of additional information as well. So the HPSP application wasn't on the official to-do list, and the financial aid is nearing completion. I also got a pile of calls from the bank about starting the house-hunt, and they'll pay me to use their realtor. So I need to call them back as well. So,

· Drive HPSP application to recruiter
· Stop all the automatic allotments based on my Navy pay
· Contact Tulane Financial Aid and send the forms to them
· Find out what physical, shots, etc, are required prior to admission.
· Review my separation how-to guide for upcoming requirements
· Contact Fort Meade about my DD214.
· Fix the muffler on the Honda
· Fix the rear-view mirror on the Chevy
· Call NFCU about a realtor

On the whole, still good problems to have.

Posted by Niels Olson at 10:03 PM

June 13, 2005

Follow-through

I ran this morning, and I did do quite a bit of house-buying research (pre-approved, contacting a realtor, and my parents and in-laws taught me all about the home-buying process). My wife found out about health insurance: $6500/yr, but we can opt out if we prefer what is availabe through her job. I got clobbered this morning at work with several to-dos so the rest of it will have to be done tomorrow. ET outed me on his forum, which is a good thing.

So, tomorrow, I need to:

· Stop all the automatic allotments based on my Navy pay
· Contact Tulane Financial Aid
· Find out what physical, shots, etc, are required prior to admission.
· Review my separation how-to guide for upcoming requirements
· Contact Fort Meade about my DD214.

Tracie said when she moves to Europe I can dissect all her African river fish!

Posted by Niels Olson at 10:01 AM

June 12, 2005

Weekend Wrap-up

Rest and digest is the order of the day here. The entire family arrived yesterday for Ben's christening today. Our neighbor, 'Fro, invited us to a pool party for her younger daughter yesterday night, so the whole clan went down to the pool and we were there until about 9 pm. It' nice because the pool (actually three pools) is literally down the hill from our apartment: we can see it from our door. A number of people were still catching up afterwards in the apartment and I got to bed about 1 am. Today we got up early to make all the food for our party after the christening today, went to the Naval Academy Chapel for the christening, and had the party. We just finished clean-up. Uncle D and Aunt J have left for Tennessee and just about everyone else is asleep. Mike, who carpooled with me to Organic Chemistry at the University of Maryland, came for a while and regaled us with stories from his job at Ethicon Endosurgery. He'll going to the University of Maryland for medical school at the same time I'll be going to Tulane.

I worked out for the first time in a long time this morning, which felt great. Part of the reason I'm keeping this blog is to force some public accountability on myself, so here goes: I need to get back in the swing of working out; I'm not going to sleep Monday unless I run an the Academy's inner perimeter (three miles).

Tomorrow I need to
· Stop all the automatic allotments based on my Navy pay
· Check in with Carole Woodward
· Contact Tulane Financial Aid
· Get more information about the Tulane's health insurance, and
· Find out what physical, shots, etc, are required prior to admission.
· Review my separation how-to guide for upcoming requirements
· Contact Fort Meade about my DD214.

Posted by Niels Olson at 04:43 PM

June 11, 2005

Priorities

Where are we going to live? I e-mailed a real estate agent, Carole Woodward, recommended by a friend. Do mortgage companies frown on students or is income is income is income? How much can we afford? I think our cost of education will be something around $45,000, but that's plus or minus $10,000. We've got 54 days before class starts. It takes 30 days to close on a house, so we need to make an offer by 4 July, which is a Monday, and we're in the United States, so the last day to make an offer is really 1 July, 19 days from now, a Saturday. What we've really got is three work weeks. Figure this week ain't gonna work, so we need to be targetting the next week, 20-24 June, and that leaves 27 June to 1 July as a back-up week. Right?

Posted by Niels Olson at 05:01 PM

June 10, 2005

After 24 Hours

So we were going to move to Arlington, Texas if we didn't get in so I could go to school full time. I had just gotten the pick-up date for the movers, 13 July. So I turned that off today, New Orleans move date TBD. Late July, early August. First day is 5 August. Here's the schedule so far.

We're trying to figure out housing. Ideally, we'd like to buy, but we have to get a loan and make an offer quick, like 1 July. We may need to fly down next week.

I touched up the blog layout to correspond to Tulane's web green and the health science center's blue for in the banner. Here's the Tulane University style guide. The colors page is hard to open in Mozilla's tabbed environment because the source page buries the link in javascript myOpen command.

Finally, I got the official letter today, so I need to drive my Health Professional Scholarship Program (HPSP) package up to Chief Wright at the Navy recruiting station on Monday morning. Which means we can't fly to New Orleans until some time after that. Of course, we'll have company here from the christening until at least Tuesday.

Oh, and I sent the $500 deposit UPS, garunteed to arrive Monday before 1030, which cost $21.83.

Posted by Niels Olson at 11:59 PM

June 09, 2005

I'm IN!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

After I interviewed at Tulane on March 31st, I sent a letter every week. Actually, I sent two letters, one to one of my interviewers, Father Don Owens, and another to Dr. Beckman, Dean of Admissions. As I was writing the tenth letter to Father Don I checked to make sure the address was correct. I had it going to the wrong office! Ahhh! So I called him to make sure he had gotten the previous nine letters. He wasn't in; I left a message. He called me back from home. He said yes, he had, and I'd done a good job. Had I checked the mail? Pause. My heart rate went from 50 to 200 in the course of one beat. No, I hadn't, although I will shortly. Very shortly. Well, he couldn't be absolutely sure, but he thought he remembered seeing my name in the right stack. Holy crap, nice cliff-hanger! After a brief discussion on housing I had to go to a meeting. I gave my wife the preliminary word by phone before going to the meeting. Where I couldn't focus for more than 10 seconds. After the meeting I called Karen Joia in the Admissions Office and she confirmed it. I went home to help my wife get ready for our son's baptism. The entire extended family will be arriving within 48 hours.

After much rejoicing and everyone went to bed I decided I'd set up a weblog to chronicle my journey for the next four years and beyond. So I spent a couple hours setting up Movable Type and now it's 1 am on the 10th, and time for me to go to bed.

Posted by Niels Olson at 11:59 PM