Medical School 2020, Year 1, Week 4

From our anonymous insider…

In anatomy, we dissected the anterior thigh, lower leg and foot. Before this week, I did not realize there were two bones between the knee and ankle: the tibia and fibula. (To feel your fibula, locate the protrusion on the lateral side slightly below your knee and follow it down to a protrusion on the lateral side of the ankle.) One of the most interesting parts of this three-hour dissection was the opening of the knee capsule, which requires ripping through tough layers of ligament on both lateral and medial sides to arrive at the treasures: the anterior and posterior cruciate ligament (ACL, PCL, respectively). These are named for the criss-cross structure they form in the interior knee. Once we cut the ACL, a beautiful bundle of fibers from the anterior side of the tibia to the lateral condyle of the femur, it is amazing how much we could move the tibia in relation to the femur.

After the anatomy lab, orthopedic surgeons taught us how to conduct a lower leg exam. We learned to isolate specific axes of rotation to evaluate ligament integrity and range of motion. Tragically ironic, a classmate’s boyfriend injured his knee the next day. She conducted the exam and felt an increase in medial rotation of the knee and offered the diagnosis of a loose lateral collateral ligament. When asked what he should do, she responded, “I don’t know, ask me in three years. Your LCL is messed up.”

Our patient case had type 2 diabetes, which includes two distinct phases. The first involves the desensitization of target cells to the action of insulin. Insulin acts as a “signal of construction” by stimulating target cells to uptake available energy and molecular building blocks such as blood glucose. As blood glucose remains high, pancreatic cells that secrete insulin become overworked and die. As pancreatic islet function is degraded, the patient transitions to the second phase, a severe, irreversible form of type 2 diabetes that mirrors type 1 diabetes. Importantly, patients who manage their diabetes before entering this second phase can reverse the entire disease. The lecturers, an internist and a PhD researcher, agreed that determining the mechanism of insulin resistance would win a Nobel prize.

One common drug class used to manage type 2 diabetes and to depress blood glucose is sulfonylureas. Sulfonylureas function by increasing beta-cell release of insulin. One of my classmates asked, “Isn’t treating type 2 diabetes with these drugs accelerating the degradation of beta cell function?” The internist responded “Yes, but sometimes we have to use them. When a patient’s glucose levels are off the chart, you have to use every option. Second, sulfonylureas are much cheaper than alternatives such as insulin injections. Many of my patients cannot afford anything else.”

With exams in a month, a few classmates are already freaking out. We aren’t being given the graded homework assignments to which they are accustomed and from which they could gauge their progress. We are supposed to determine what style of independent learning works for us. Instead of concentrating on learning, these classmates are worrying about exactly what is going to be on the Week 9 exam. Our drama for the week is that they apparently brought their uncertainty up with the Office of Student Affairs. I would have hoped that they’d have more faith in the system with which they are entrusting four years and more than $300,000 (tuition, room, and board).

Statistics for the week… Study: 8 hours (6 hours devoted to anatomy); Sleep: 6 hours/night; Fun: 4 nights out. Example fun: Friday night about 15 of us had a “jam session” dinner party. After spaghetti and homemade meatballs, we broke out the beer and instruments. The group included a classically trained cellist, two pianists who would have been welcome in most jazz clubs, and a harmonium(!) player. I was glad that I had brought my guitar, but I’m not sure that these real musicians were similarly glad.

The Whole Book: http://tinyurl.com/MedicalSchool2020