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From our anonymous insider…

This week: White Coat ceremony; an exciting heart dissection lab; and our first real patient interactions.

In anatomy lab our goal was simple: remove the heart. Most textbooks depict the heart as a vertical organ, with the left and right atria lying on top of the muscular left and right ventricles. Our trauma surgeon described this as one of the greatest illusions of human anatomy. Instead, the ventricles are anterior to (in front of) the atria. We began by opening the pericardium, revealing the great vessels leaving and entering the heart. The aortic arch got several “oooh’s and aww’s” as we constricted this massive 1-2-inch-diameter thick-walled vessel. Once all the great vessels connecting the heart to the body were cut, the student would run around holding a human heart in the air, like Simba was held up in the Lion King.

Lectures detailed the embryological development of the lungs. Lungs begin developing at around 20 weeks gestation (18 weeks after fertilization; gestation is measured from the last menstruation). However, due to a lack of sufficient gas exchange sacs to sustain respiration, the lungs do not become pre-viable (sustainable out of the womb) until 23-24 weeks. Even after 24 weeks, a baby’s lungs are barely developed, and the most common cause of death is respiratory distress. The slightest complication, for example, a respiratory infection, could lead to death.

Our patient case was a baby born at 24 weeks, about 16 weeks before she should have been born. The mother detailed how she was having a healthy first pregnancy when she suddenly went into a rare form of premature labor. An emergency C-section saved the baby and herself. “Kate” was brought into the world at 1 pound, 6 ounces (normal baby weight is 6-8 pounds).

The family expressed pure love for the neonatologist who “gave life to” Kate in the Neonatal Intensive Care Unit (NICU). “You should all become neonatologists,” exclaimed the mother, “and if not neonatologists, then obstetricians!” The young couple had thought that the birth was the difficult part, but at 26 weeks Kate had a severe hemorrhage in the developing pulmonary vessels. As the neonatologist and nurses scrambled around the incubator, the parents were stunned. The neonatologist absently muttered, “This is not good.” As the mother recited this trauma, she paused and broke out in tears. The father continued, “We did not know what was happening. One moment it was fine, the next, lights were blinking everywhere, sounds going off, people running.” Blood vessels in the lung had ruptured. There were two serious concerns: first, the ventilator, which is breathing for the baby, gets clogged. The neonatologist and nurses frantically tried to vacuum blood out of the airways to prepare to insert another plastic trachea tube to ensure the airways remain open for respiration. After this was successful, the neonatologist knew the longer-term threat: stopping a massive bleed causes a sudden large volume return to the heart. When the heart pushes this additional blood into systemic circulation, immature blood vessels in the brain can rupture. If the baby does not die, this causes severe brain damage roughly half the time.

The neonatologist and family spent a nervous night waiting for to know if this cerebral hemorrhage had occurred. The family described their euphoria when the smiling and crying neonatologist came into the room with the test results: the blood vessels of the brain did not leak. The whole class crowded around as the family showed pictures of Kate today: a healthy, albeit slightly small, energetic toddler.

The White Coat Ceremony is a tradition dating back to 1993. Friends and family descend on the medical school to watch deans help each student into a white coat. The 1.5-hour ceremony was followed by a reception where parents snapped away with smartphones. The next day I would wear my white coat with my first patients, shadowing a Primary Care Provider who had trained in the Navy, but left after his four-year service obligation.

After the nurse took vitals, I introduced myself as a student, giving each patient the opportunity to demand a fully trained doctor (nobody did!). Then I interviewed the patient and performed any exams I felt pertinent, such as listening to the heart and lungs. I then reported back to the physician and we would return to the room together for discussion with the patient. It was empowering to walk into the patient room with my white coat on and a stethoscope around my neck!

Our first patient’s chart indicated an alcoholic smoker with Chronic Obstructive Pulmonary Disease (COPD). An episode of pneumonia had put him in the hospital for a week and he was here for a follow-up to confirm that his lung tissue had recovered. The lungs looked as good as they were going to get, so we sent him home. Next we treated a child’s ear infection, saw a type 2 diabetic, and checked on a hypertensive patient. Our last patient, in his mid-20s, had knee surgery nine months previously and was prescribed oxycodone for post-operative pain. He had been transitioned to tramadol, a less intense opioid, and, after reviewing the chart, the physician and I agreed he was likely asking for a refill, which should be denied. I asked if I should remain outside. My attending said, “No, you should see this. As a doctor you’ll deal with it too much.” After a brief exam of the knee, the conversation quickly turned to the subject of getting a tramadol refill. The doctor said that it is time to transition to a different pain-management strategy. The patient asked, aggressively, “Why? This is working. It’s the only thing that helps with the pain. How could you do this to me?” When the physician would not budge, he put his hands over his head in desperation.

The four-hour clinic taught me to make sure to get the full list of prescription drugs each patient is on. We had to consider four drug interactions when evaluating a switch to a new hypertension pill for our patient with high blood pressure, who was already on 12 different medications. None of my classmates were surprised by this story; one shadowing a neurologist said, “Two of my patients were on over 17 drugs.”

Statistics for the week… Study: 14 hours. Sleep: 6 hours/night; Fun: 1 outings, class halloween party! Medical school budgets bring out homemade costumes. My favorite was Ron Burgundy and Veronica Corningstone of Anchorman.

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

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Who else loved the Deepwater Horizon movie? Supposedly the filmmakers built an 85-percent scale model of the drilling rig and put it into a water tank. This helped push the budget to $156 million.

Personally I was happy to see the Bristow heliport and the Sikorsky S-92 helicopter. The aviation radio calls did not seem plausible and the bird strike 50 miles offshore was also odd. What would the bird have been doing out there anyway? Why couldn’t a bird see and hear a 56′-long helicopter? Then there was the fact that the pilots were prepared to take off again without shutting down and inspecting the bird damage.

The rest of the movie is apparently mostly accurate (TIME; Washington Post; History vs Hollywood), with the exception of it all being BP’s fault (funny how it works out that a movie made by Americans assigns 100 percent of the blame to a British company!).

Why was this amazing effort and achievement of moviemaking not rewarded at the box office? I appreciated being given the opportunity to experience life on the rig before and after the disaster. Critics on Rotten Tomatoes and audience members gave the movie a mid-80s rating. Why didn’t more people get off the couch and into the theater to learn about one of the worst examples of humans not being as clever as we thought we were?

Theories:

1. Americans don’t care about any story unless there is a hero who saves the day.
2. The movie was released shortly before a presidential election and Americans were preoccupied.

[Thinking back to the actual event, I remember that all of my friends without technical training said “If only there had been more government oversight the blowout wouldn’t have happened.” My friends with technical/scientific training said “What did you think the flip side of drilling the world’s deepest oil well would look like?”]

Related:

• The Deepwater Horizon accident, predicted in 1984

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According to Wikipedia, Barack Obama has handed out more Presidential Medals of Freedom per year in office than any other president. Does this reflect lower standards or simply a larger population?

There are five awards that fall into the “computing” category. Cerf and Kahn are there for developing the Internet protocols, but why not Bob Metcalfe for the underlying Ethernet hardware? Gordon Moore got an award, but not any of the folks listed as having been instrumental in developing microprocessors. Why not Jack Kilby instead, for developing the integrated circuit that made microprocessors inevitable? Why not the Bell Labs folks who built the first semiconductor transistor? The situation in software is curious. Grace Hopper (COBOL) and Margaret Hamilton (assembly language code for an obsolete-five-years-before-it-was-built NASA computer) won awards this year. Why not any of the Americans who’ve won the Turing Award? John Backus for getting most of the world (except for NASA!) out of the assembly language business. Ivan Sutherland for the computer graphics and virtual reality that makes sharing a small piece of land with 325 million other Americans bearable? Fernando Corbato for building the modern operating system on which we rely every day. The RSA inventors for enabling Internet to be used for commerce? What about my personal heroes, the folks who made the RDBMS? E.F. Codd, Michael Stonebraker, and perhaps Larry Ellison (not a Turing Award-winner, but maybe has a good shot next year due to being Trump’s kindred soul?).

[Bill Gates won an award this year, but not for computer nerdism. The White House says the following:

Bill and Melinda Gates established the Bill & Melinda Gates Foundation in 2000 to help all people lead healthy, productive lives. In developing countries, the foundation focuses on improving people’s health and giving them the chance to lift themselves out of hunger and extreme poverty. In the United States, the mission is to ensure that all people—especially those with the fewest resources—have access to the opportunities they need to succeed in school and life. The Gates Foundation has provided more than $36 billion in grants since its inception.

If most of the money spent by the foundation is for health care in foreign countries then essentially Bill Gates is getting an award for avoiding U.S. capital gains and estate taxes and sending a massive amount of capital out of the U.S. If the $36 billion had instead been passed down to his kids more than half of the money would have ended up in the hands of federal and perhaps state government (capital gains taxes, gift taxes, estate taxes, income tax on dividends received, sales and property taxes on items purchased with the money, etc.).]

Readers: Ideas for the next batch of computing-related awards? How about Steve Jobs (“Nerd Jesus”)?

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From our anonymous insider…

We started our exploration of the respiratory system in anatomy by using bone saws to remove the chest plate, thus opening the thoracic cavity. Half an hour after we started sawing, I was holding a human lung: heavy, fluffy, yet slippery to the touch. Unlike textbook depictions, they are asymmetric. The three-lobed right lung is larger while the the left lung has only two lobes. The aortic arch and descending aorta carve out a large groove in the posterior left lung. Comparing cadavers, it wasn’t hard to spot a smoker’s lung: copious amounts of black specs on the exterior plus one cadaver had burst alveoli. If you see a doctor smoking you’ll know that he or she really loves cigarettes.

My group finished early and snuck a peek by opening up the pericardium (membrane that covers the heart). The heart is surprisingly small, about the size of a clenched fist. We don’t have any information about how our cadaver donor died (aged 97), but we noticed a dark red spot on the left side of the heart, surrounded by firm white tissue. Our instructor explained that this indicated a left ventricular myocardial infarction (“heart attack”) and said that, if the patient had survived, the affected area would have remodeled into tough scar tissue. One small spec on a small organ is the difference between life and death.

We learned in lecture that the breathing system is like two springs: (1) the lung, which wants to collapse, and (2) the chest wall, which wants to expand. The lungs are stretchy, with a third of the elasticity from the tissue itself, and two-thirds from surface tension of the copious fluid coating the airways. They’re constantly being pulled open by the pleural membranes, connected to the chest wall. We disrupted the balance when we cut through a rib, which sprung outward, no longer constrained by the recoiling lung.

Our patient for the week had been morbidly obese, which led to sleep apnea, which led to pulmonary hypertension. Excess weight on her chest and neck obstructed airways and elevated thoracic pressure. Prescribed a CPAP oxygen machine, her compliance was haphazard, which is typical with this immensely uncomfortable contraption, despite the patient’s ability to choose her favorite mask color. Sleep apnea, with its intermittent decreased blood oxygen saturation, can lead to increased pulmonary artery pressure. This had caused her right heart to work harder pumping deoxygenated blood into her pulmonary arteries. Over the years this made it impossible for her to exercise. She felt continuously exhausted, unable to walk up a few stairs or stay awake during any prolonged meeting. She quickly used up all her vacation and sick days and had to quit her job, moving in with her sister 200 miles away. Her new doctor recommended she speak with a pulmonary hypertension (PH) specialist, a relatively new field spurred on by the rise of obesity and sleep apnea. The PH Doc described his reaction after the first visit: “I did not expect her to live for more than two-years. I thought her right heart would fail.” He continued by explaining the unfortunate truth for PH. “Pulmonary hypertension was an inescapable death sentence until the late 1990s. There is no surgical intervention and no drugs. Studies showed that over 50 percent of patients with severe PH die within two and a half years.” In the late 90s, pharmaceutical companies developed new classes of drugs to treat left heart failure and hypertension. Some of these turned out to temporarily reduce pulmonary hypertension, giving patients a brief window in which to lose weight. Our patient was able to complete an aggressive exercise and rehabilitation routine. Five years post-diagnosis, she is no longer morbidly obese, exercises daily, and has gone back to work part-time.

The PH Doc ended by reminding us not to be blinded by obesity in a patient: “Doctors too often blame all symptoms on obesity, even if there are other pathologies that can be treated.” For color he told us about the challenge of not offending a patient while saying “we need to send you to the zoo where there is a larger-sized scanner…”

Sunday evening a few students were invited to my favorite professor’s cabin. She is a never-married woman in her late 60s who has dedicated her life to the craft of trauma surgery. She entered medicine expecting to go into family practice. While a third year student, she requested to be sent for her family medicine rotation to a rural area. She drove into the mountains to a small mining town of 10,000 with two family physicians. Although regretting her decision at first, it was here that she learned to love emergency medicine. Sitting around the bonfire, she shared vivid memories of driving the ambulance up moonlit dirt roads to a mine and going down the shaft to retrieve injured miners.

What has changed in trauma surgery? “Well the cases have changed,” she answered. “I started out treating young males in high-velocity, multi-trauma injury cases: car accidents, gunshot wounds, stabbings. Now it is mostly low-velocity cases: an elderly patient who has fallen. The family feels terrible for not having been there when the trauma occurred. The family flies cross-country to say ‘Do everything you can to keep Grandpa alive,’ not understanding what this requires doctors to do. Too often they ignore palliative care.” She’d learned about hospital funding priorities: “It is easy to find donors for a state-of-the-art pediatrics wing; there is no money to remodel a decrepit geriatrics ward.” Her bonfire advice to us: (1) find a field where you will get more interested in it as you go on; (2) you can be happy in more than one residency field (i.e., don’t cry if you don’t get your first choice).

Statistics for the week… Study: 8 hours. Sleep: 6 hours/night; Fun: 2 outings. Example fun: Camping with Jane and Sunday BBQ at trauma surgeon’s cabin.

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

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Things I’m grateful for this year…

• the healthy and supportive family
• the scientists and engineers who pulled us out of the nosedive of human welfare purportedly initiated by the Agricultural Revolution (see No farms; plenty of food)
• the aviation friends who’ve helped to keep me alive by (a) fixing/maintaining aircraft properly, and (b) planning/copiloting
• the friends who’ve kept me entertained and educated
• the readers who have supplied more interesting comments than my original postings

Readers: What about you? What’s tops on your gratitude list?

[And my favorite exchange of Thanksgiving 2012:

• Mom: “I feel sleepy. What’s that ingredient in turkey that makes you sleepy?”
• 9-year-old son: “It’s called ‘wine’, Mom.”

]

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From our anonymous insider…

With the first exams finished, we are all more comfortable with our roles as medical students. My comfort level rose to the point that I ordered a stethoscope. I’ll be ready for next week’s “white coat” ceremony.

Anatomy this block will focus on the cardiopulmonary system. In preparation for removing the chest wall, we dissected the anterior neck. The carotid artery was huge, about the size of an adult’s thumb, and we could see the plaque that had built up during 97 years of living prior to becoming a cadaver. We got a beautiful view of where the common carotid artery bifurcates, forming an important structure called the carotid sinus. The carotid sinus contains nerves with specialized pressure sensors that regulate systemic blood pressure. A few decades ago, doctors investigating hypertension or shortness of breath would palpate and briefly constrict the carotid sinus to ensure blood pressure changes occurred. However, this can cause strokes from plaque rupture and we learned that therefore the practice has been discontinued, but we haven’t yet learned about modern diagnostics.

Lectures focused on embryology with a patient case of fetal alcohol syndrome. So many coordinated events occur within the first two weeks post-fertilization, it is remarkable how rare serious birth defects are. One fascinating process is how the embryo creates a left-right axis. A region of cells have a single cilium, a vibrating thread similar to the flagellum that propels sperm cells. Coordinated beating of these cilia produces a net leftward current and creates a concentration gradient of signaling molecules to turn on “lefty” genes. We learned about sinus invertis, in which the body is flipped left-right. The condition affects roughly 1 in 10,000 individuals, many of whom have no symptoms at all! We also learned about some more serious cases of birth defects, e.g., sirenomelia (“mermaid syndrome”) where the lower extremities are connected, and encephalocele, where the skull does not fuse correctly and the brain grows outside the skull.

Our patient case involved a teenager whose biological mother had used alcohol, cigarettes, marijuana, and cocaine while pregnant. “Greg” was born with fetal alcohol syndrome and addicted to cocaine. State social services agencies automatically investigate every case of fetal alcohol syndrome and, in this case, Greg was turned over to a foster mother, who was the primary speaker to our class. The foster mother, who quickly became the adoptive mother, told the story of how she came to love this child and the role of her Christian faith in the process. There was a lot of crying and the still-unanswered question of how the biological mother could have done this to Greg. Much to everyone’s later-expressed surprise, when Greg finally walked into the room he was articulate, though nervous, with none of the aggression common to patients with a history of fetal alcohol syndrome. Greg was aware of his history and challenges. He described being frustrated by his poor memory and difficulty learning abstract subjects such as mathematics. However, he enjoyed history and socializing with other students at his special-needs school. We were impressed by Greg’s determination and perseverance, but It seemed likely that he would require lifetime assistance from a responsible adult.

The case sparked a lively discussion on the legal ramifications of drug abuse while pregnant, a matter governed on a state-by-state basis. The spectrum of laws ranges from criminal prosecution if a child is born addicted to drugs or showing signs of fetal alcohol syndrome to no consequences beyond the potential for losing custody of the baby. Some midwestern states are in the middle of this spectrum, with a rehabilitation mandate for pregnant women who consciously abuse drugs and alcohol. Greg’s physician opined that the potential for criminal prosecution was counterproductive because it dissuades addicted mothers from continuing with prenatal care. Women who’d previously articulated feminist positions in the classroom immediately voiced their objections to sanctions against mothers on the grounds that this was a step on a slippery slope toward infringing on a woman’s abortion rights.

Later in the week, three primary care physicians led a discussion on how to approach patients about medications and drug usage. Doc 1 opened with a story about taking her 12-year-old daughter to a specialist. The nurse stared at the computer screen and read the questionnaire out loud without looking at the 12-year-old patient and mother seated nearby. “Do you drink?”, “Do you smoke?”, “Do you use illegal drugs?”, “Do you feel safe at home?” This tale of attempted human interaction in the age of electronic medical records prompted Doc 2 to chime in: “Never trust the medication list in Epic [‘MedRec’] as it is rarely up-to-date, and will certainly not include more sensitive drugs and behaviors.” Doc 3 seems to be a contributor to this phenomenon, saying that he is cautious about adding to a permanent electronic record that is accessible to the patient on request. “I never put a ‘suspected heroin use’ note in the chart,” he said, “I just keep a note on my desk.”

Doc 1 told us to remember that it is not just illegal drugs that are used illegally. She had prescribed a muscle relaxer and prescription-strength ibuprofen (NSAID) for a patient with a back injury. After three months, the patient said that she’d stopped taking the medications because her middle school daughter had been pressured into stealing them by her classmates. When the daughter began to refuse, her “friends” threatened the mother that they would “jump the house” (?) to steal them. Despite the limited potential for getting buzzed off a muscle relaxer, Docs 2 and 3 were not surprised. Lesson learned: lock the medicine cabinet.

Statistics for the week… Study: 10 hours (1-2 hours after class each day). It has been easier to study this block’s organ systems instead of the abstract biochemistry pathways that we were learning in the last block. Sleep: 6 hours/night; Fun: 2 outings. Example fun: drinks and music at Thursday downtown rooftop party and a class happy hour at a local pub.

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

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From Network Solutions:

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Because of this, renewal fees for certain domain extensions are increasing. Going forward the annual base price of your .com, .org, .net, .info, and/or .biz domain name(s) will be $39.99. This pricing will be effective upon your next renewal.

Related:

• Swiss pour cold water on our Internet dreams

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From our anonymous insider…

We have four straight days of exams, covering clinical exam skills, biochemistry, anatomy and cellular biology. Exams begin at 8:00 am, but on two days we were finished by noon. Our first, and main exam is a practice NBME Step 1 using prior, retired questions. The biochemistry and metabolism questions are quite similar to the MCAT. A classmate sent a message our GroupMe after he finished the exam: “There goes my Derm practice out the door.” Anita, and some of the other more sensitive, nervous individuals, did not find this funny. (Dermatology, along with orthopedics and surgery, are some of the most competitive residencies, requiring high Step 1 scores to get matched.)

Anatomy was a sore subject for many. The exam required detailed knowledge of discrete muscle group innervations. There was grumbling afterwards: “I couldn’t read the poor quality images”; “Who cares what the fascial layer is called?” I am grateful our medical school still purchases cadavers for us to learn anatomy; numerous schools are replacing cadavers with electronic images for anatomy education. There is no substitute for the real thing.

After our last exam, we were invited to a cocktail party by a wealthy local sponsor of the medical school. It was pouring rain, but they had a valet service working in their front yard–I’m not sure it was a big night for valet tips given the medical students’ typical debt load. The mayor and board members of the local health system were there to welcome our class to the city. The city symphony director played a few original jazz compositions on the piano. The class stayed late drinking martinis at the open bar and smoking free cigars.

I learned about tension among some physicians who teach us. Most of them love it. However, some are frustrated by the pressure from the health system to teach yet still are expected to have the same patient load. Instead of spending less time with their overbooked patients, they usually just stay later.

The celebration continued at our classmate’s apartment complex. Our whole class was there, including the few married couples. The diversity of ages and lifestyles was illustrated by someone doing the college-favorite “slap the bag” of disgusting Franzia wine next to the 27-year-old father of two.

Statistics for the week… Study: 35 hours; Sleep: 7 hours/night (more than previous weeks due to going to bed earlier); Fun: 1 night out at cocktail party after exams.

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

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A Facebook friend who was an ardent Obama and Hillary supporter posted the following comment over an article about Trump’s plans to deport up to three million illegal immigrants with criminal records:

The community I live in is 80% Hispanic and Latino. I can’t imagine what this is going to be like for undocumented family members. Neighbors, how can we help?

She didn’t appreciate the following suggestion:

Obama deported more than 2.5 million immigrants. So maybe you could go find some of those folks and help them return to the U.S.?

Folks: Now that the dust has settled on the election, what do we expect from the deportation bureaucracy?

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From our anonymous insider…

Exams begin next week. Type-A Anita is particularly nervous. Beginning last week she has refused to learn anything that is more in-depth than the NBME questions: “only high-yield.” She interrupts class once per day to complain when a professor gives more detail than the Step 1 exam books do. She also requests clarification about the number of questions per exam topic. She dropped her sweet Midwestern demeanor and submitted a formal complaint to the administration when an older physician said males have to work more to learn patient interviewing because women are more naturally caring.

Lectures focused on glycolysis and summarizing metabolic pathways. A rather plump gastroenterologist in his 50s gave an “energy” synopsis about different states of metabolism. These lectures were paired with our patient case, a young anorexic teenager. Anorexia fits with the metabolism unit because it forces the body to break down protein to use for gluconeogenesis. We heard from her doctor that the patient is on antidepressants and receiving psychotherapy, but didn’t get to meet the patient.

We finished dissecting the upper extremity with the elbow, forearm and the bewildering hand, whose muscles and vessels entail hours of dissection. I share my cadaver with three other students. Yet, with three hours of dissection time, we had explored only about 10 percent of the hand. Fortunately, the instructors convinced a chief surgery resident to spend his evenings dissecting a demo cadaver and then come in at 10:00 am to give us a guided tour of a perfectly dissected hand. We were doubly appreciative of his efforts after we heard about his 24-hour hospital shifts.

One of our most passionate and funny doctors spoke about using ultrasound to investigate the shoulder and upper arm. Ultrasound sends high frequency sound waves into the body and relies on differences in the ways that tissues reflect or absorb the sound. We broke up into groups of six, each provided with a donated battery-powered 10 lb. ultrasound machine. The expert (attending) arrived at each workstation to help us diagnose each other. We were able to see torn muscles, ligament damage, tendinitis, and bursitis. As with Week 6, a high percentage of our classmates were able to supply examples of musculoskeletal damage. I contributed a torn supraspinatous (rotator cuff) muscle torn in the college weight room.

In an after-workshop discussion, our professor described his frustration that the medical school accrediting body, Liaison Committee on Medical Education (LCME), limits the number of “formal instruction” hours. “I’m not exactly sure, but it is only about 25 hours per week,” he said. He recounted stories from his professors’ education in the 1920s. For example, a instructor asked a first year class if anyone was uncircumcised. Two students raised their hands. They were instructed to drop their trousers, and in the pursuit of education, were circumcised in front of the entire class, including the two female students. His own 1950s education did not include any in-class circumcisions, but they were at school for 12 hours each day, with some mandatory Saturday sessions. Anatomy lab dissection was 4 hours per day compared to our 4 hours per week. Our professor noted that passing the NBME exams requires more knowledge than for comparable tests in years past. Thus today’s medical student faces greater pressure to study independently.

Statistics for the week… Study: 35 hours (about 5 hours after class each weekday plus more on the Sunday); Sleep: 7 hours/night; Fun: 1 hiking excursion with Jane.

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

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