5th Semester: Check!
January 21, 2015 § 8 Comments
I usually only write in moments of reflection. I find it is easier and faster when I am feeling inspired and when my thoughts sort of line themselves up without me forcing them to. I’ve been done for a week now and still haven’t found myself in a reflective state. It’s been on my mind that I need to write something soon; this is, after all, a chronicle of my time in medical school. Still, I’ve been putting it off and avoiding doing anything that feels forced. Exam period sucks you dry of any and every drop of motivation, strength, willpower, you name it. It takes days, possibly even weeks, to refill the stores when you’re finally done. Charlotte gifted me with a journal for my birthday last August and I have recently been consumed with the idea of finally starting to write in it. This blog has really been a journal for these past (almost) three years, but I need a place to process my more irrational and transient thoughts.
Last night I stumbled across my old journals. I haven’t really been consistent over the years, but I have kept everything I have written. When I moved to Norway, I couldn’t bring all the individual books with me, so I ripped out the pages I’d written on and placed the loose memories into the pocket of a larger, almost-finished one. I went to lunch with Charlotte this past Saturday and in the midst of a discussion on journaling, I joked that my journal entries from my grade school years would probably bring me to laughter now. And that they did! I didn’t read through everything; it was too embarrassing to read anything I wrote during my teenage years. I do think that it might be nice to one day “go on a date” with my past self, to grab a glass of wine (my current favorite is the Hungarian Egri Bikavér, meaning Bull’s Blood of Eger) and read through my past reflections. The earliest dates back to 1997, when I was 10 years old and friendship was my biggest worry (that and a subconscious fear of someone stealing our dog).
I also found some unfinished art pieces in a sketchbook I’d stored among my journals. I haven’t done a piece since I moved to Budapest, so I’m quite overdue. There are two pieces I would like to do before school starts, one for Skjalg’s grandmother and another for my mom.
Now, about those exams!
Pathophysiology – the last “big one”
After my last post, I had my exam in pathophysiology. The exam consists of 3 parts: (1) EKG analysis, (2) Case with diagnosis, (3) Two topics from the topic list. I had been feeling hopeless before my exam (again, as I always do) but pushed through it anyway.
We met up for our exam at 8:00. I was to be examined by the same examiner I’d had for my midterm. He took the 5 of us to the lab room outside of his office and we were each given an EKG and case and then allowed to draw two topic cards. I don’t think I had my exam until around 11:00, which meant I had 3 hours to sit there with my nerves and my exam topics. I was the last one to be examined and I was grateful that there wouldn’t be anyone there to overhear my exam.
(1) EKG – Diagnosis: Lenegré syndrome: right bundle branch block with left anterior hemiblock. When I started, I asked if he preferred the diagnosis right away or if he would rather me walk him through my analysis. He preferred the latter and while I did as such, he flipped through every page of my index book, examining every grade I’ve gotten in medical school. Talk about feeling vulnerable! When I finally said the diagnosis, I did my best pronunciation of “Lenegré”, laughed a little and then asked to be corrected. He smiled, tried out a few pronunciations himself, said that he didn’t speak French and then asked with genuine interest which languages I speak. There were absolutely no questions about the EKG. The same thing happened when I had my midterm with him during the semester.
(2) Case: Cushing’s Disease. There were about 50 or so cases that we analyzed during the semester in our practicals and we could get any one of them for our exam. Rather than memorize the diagnosis of each, I made sure to really process the cases and understand them so that I would have the tools and experience to diagnosis it during the exam. I ended up getting a case concerning a topic that Skjalg and I had spent a long time one. I drew out the diagnostic algorithm shown below and that aided in my answering most of my questions (i.e. What is the role of dexamethasone? Why are there two different doses? What does the first dose show? What are the different causes of Cushing’s syndrome? Describe ectopic Cushing’s.). To start my presentation of the case, I made sure to describe the difference between Cushing’s disease and Cushing’s syndrome and then stated my diagnosis along with a short explanation of why.
(3) Topics. I ended up getting two topics that I hadn’t had time to review before the exam. However, I learned that not reviewing them before the exam does not mean that I know nothing about them. This was a big lesson for me because I’ve always felt that, unless I’ve reviewed it specifically for the exam, that I don’t know it at all. Each of the topics consisted of a series of different points. I filled up about 2-3 pages of notes with information, but in the end, he only wanted details for one point from each of the topics (see the highlighted points):
I messed up some details with Helicobacter pylori (which we covered extensively in microbio) and that resulted in my getting a 4 for the exam. It was a very friendly exam and felt more like a conversation. I got a little embarrassed at one point when he said, “I saw you weren’t so strong in biochemistry and there are parts of biochemistry that are very useful to know.” (I got a 2 first semester, 4 second semester and a 3 in the final exam.) I was able to laugh it off and not take it too personally and wasn’t afraid to tell him that I was embarrassed and a little thrown off by his little stab at my past grades. We talked a lot about Helicobacter and somehow got onto the subject of lactose intolerance (since I am lactose intolerant). He asked me if it was a disease (which I replied that it isn’t) and he shared that when he attended medical school, it was actually considered one. Apparently it was a point of huge interest for him and he ended up sharing the entire history of lactose intolerance. I learned that I, being lactose intolerant, am normal whereas those that tolerate lactose have mutated genes. “So you’re actually the normal one and I’m the mutant,” he’d said with a smile, hidden under his giant mustache.
For my second topic, I pulled knowledge I’d obtained whilst studying for my immuno midterm. I mentioned chronic granulomatous disease (resulting from deficiency of certain enzymes needed for oxygen dependent killing) and leukocyte adhesion deficiency. He seemed happy with that, though mentioned that he would have liked me to include Chédiak-Higashi syndrome.
In the end, I was pleased with my grade, especially considering that before the exam I’d believed that I wasn’t going to make it at all. I need to work on how I evaluate my knowledge…
We’ve had 5 semesters of Hungarian and with this exam behind us – we are finally done! The exam is split into two parts, the first is written and the second oral.
Here is an example of one of the exams given to us by our teacher. Sorry for the poor quality! Photos were taken with my iPad and notes written in Notability.
If we passed the written, we were free to go on to the oral exam. It consisted of 3 parts: (1) Introduction about yourself (where you are from, languages you speak, where you want to live after school, what kind of doctor you want to be), (2) Case – the examiner is a patient and you have to ask them questions about their symptoms and come with a possible diagnosis, (3) Describe a medically related photo. They are quite nice in this exam and really don’t demand too much. I did a poor job presenting my Hungarian knowledge and I still ended up with a 5. For my case, the examiner complained only of itchy skin, so I didn’t have a lot to go on. For the photo part, this is an idea of what we needed to know. These are my notes from class and an example of what I said for a photo.
This was my last exam and I was seriously lacking motivation to study for it. I had four days to prepare and for the first three, I only read two chapters about history taking. On Day Four, the motivation kicked in!
The problem with internal is that we are assigned to about 20 different doctors, all of whom have different specialties, number of years of experience, techniques, etc. Sometimes it feels kind of like a free-for-all when it comes to what we are learning and how we are learning it. I haven’t heard of two teachers who do anything the same way! Our teacher is really strict and expects us to be fluent in Hungarian, at least medically. He also expects us to fill out a medical chart perfectly. If you can’t do that, you fail with him. Other teachers? May translate for you, may allow you to use Hungarian notes, or maybe don’t even expect you to be able to communicate with the patient more than a few sentences. Our teacher is the only one I know who has us filling out the medical chart. (Here’s an example from one of my previous posts.) The variation in teaching styles also manifested as a huge variation in the exam styles. In the beginning, most people were saying that it was such an easy 5 and that no one fails. Some people showed up without having studied, were asked one question and then sent home with a perfect score. Others, didn’t have it so easy. Ours was the latter…
We had an older cardiologist with glasses who seemed friendly at first. Well, he was friendly, but he was also particular. We were each assigned a patient and asked to conduct a full physical exam and take as much of a history as we could (he didn’t expect that we knew much Hungarian). I took my time with my patient, making sure to get a full history and hit every point of the physical exam. He was really friendly and I was able to communicate with him quite well.
After we had finished with our patients, we waited out in the hall for our examiner to return. One girl had her Hungarian exam scheduled at noon that same day and asked that she be examined first so she could leave. She went in with the examiner and closed the door. I sat down to write out my notes from my patient. Within seconds, she was at the door and told us that the examiner wanted us all to join. We soon realized that our individual exams had all started – at the same time. Each of us were asked to present our patient, were asked a slew of theory questions and then asked to perform a specific part of the physical examination. If we couldn’t answer a question, one of the others was asked. Some of our answers were challenged; he would ask us a question and then upon hearing our answer, he would ask if the others agreed with our answer. With the first girl’s exam, the rest of us (3 total) got very nervous. When she asked if she could have her grade and leave, he said he preferred to compare us all with each other at the end, but that he would make an exception.
My patient was out when it was my turn (I was the second), so we sat out in the hall and went through a round of theory. This went exactly the way I’d feared it would. My teacher is an endocrinologist and we have therefore not spent nearly enough time when it comes to heart examination. We do it, of course, but it is more thorough for those in the cardiovascular departments. We’ve heard one murmur this semester whereas they may have heard one every practice. When it came to covering theory for this part of the exam, I learned the classification of murmurs and the four main murmurs our teacher told us we should know (aortic stenosis and insufficiency and mitral stenosis and insufficiency). I’d read through the chapter in the book and covered the lectures, so I had a general understanding, but I didn’t intensely memorize all the points. It seemed outside the scope of what we were to learn this exam period: physical examination. (I’ll add that we had no topic list for this exam.)
He asked me maybe 20 or so theory questions, while sitting around a table with the other two examinees. I was able to answer a good number of them, but then we starting going deep enough that I had to admit to him that these were things that I had not been taught nor covered on my own and would have to logically guess the answer. I can’t remember all of the questions, but here are those I can:
- Can different pulse rates be measured at different points in the body? (He said it is impossible if you can feel the pulse)
- What are the possible causes behind different blood pressure values? (My patient’s blood pressure measured different in his right arm and his left) (1) Supravalular aortic stenosis (increased BP measure in the right arm), (2) Takayashi syndrome, (3) Aortic dissection
- How do heart sounds change in heart failure? (1) S1 – diminished intensity, (2) S3 – normally not heard, but heard in HF, (3) Mitral regurgitation
- What type of murmur is mitral regurgitation/insufficiency?
- What type of murmur is tricuspidal regurgitation/insufficiency?
It was a little hard to communicate with my examiner. I’m not sure if he didn’t understand English well enough to hear our answers or if he was just a little strange. There were several times I had to repeat myself and that seemed to count against me. At one point, he corrected me by saying that the patient had had two heart attacks this year (I had said last year) and went to check in the patient’s history, “Yes, March of this year”, he’d said… It was only Jan 13th at this point, but still!
When my patient returned, my task was to examine the peripheral cardiovascular system. Luckily, this was one of the tasks I knew well. I had a little bit of a problem with the examiner when it came to feeling the peripheral pulses. There were at least 3 or 4 that he couldn’t feel that I could. I didn’t back down though. I didn’t want to change my answer to please him. I tried showing him where I felt it and yet he still didn’t feel it. I continued the exam as if I too hadn’t felt the pulse, so as to demonstrate that I knew what to do. There were a few hold ups where I didn’t really understand what he was asking me or where he was asking me something I had already answered. Also, when examining the carotid artery, I’d told the patient to stop breathing (in Hungarian) and the examiner thought I’d told him to stop talking. I repeated what I’d told to the patient and the reason for doing so (to hear for any turbulent flow without distortion by breathing sounds) and that seemed to appease him. He smiled constantly for almost the entire exam, which meant that you never knew if he was pleased or mentally noting a failure.
The whole process lasted for almost 4 hours. Once I was done with my physical exam, we moved on to the two others. I was feeling relieved that mine was over, but it really wasn’t. The questions were hard. At times, it felt like he thought we were fourth year students and not third year…
These were questions that I wrote down:
- Tops two cases in which pacemakers are implanted.
- How do the heart sounds change in heart failure and hypertension? What are the physical manifestations of these diseases?
- How does the apical beat change in the case of hypertension? (1) Prolonged, (2) Circumscribed, (3) Increased intensity
- What is the old term for late fine crackles? Crepitations
- What are the causes of increased intensity of the second heart sound? How can you determine whether it is the pulmonic or aortic component responsible? What are the cases in which these components would result in increased intensity of the second heart sound?
- What are the 5 causes of infiltration syndrome? (1) Tumor, (2) TB, (3) Pneumonia, (4) Pulmonary edema, (5) Pulmonary infarction
- In what cases do we have non-pitting edema? Hypothyroidism (myxedema)
- What are causes of non-productive, dry cough? (1) Left ventricular heart failure, (2) Drugs – ACE inhibitor
- How do the bowel sounds change in the case of acute peritonitis and why? Decrease due to rigidity.
Afterwards, we gathered around the table in the hallway for our grades. He assigned a grade 3 to one of us, then looked at the other in the group and told her that she had the best individual exam and was barely a 5, but that he would give her a 5. He then looked at me and I flashed my biggest smile. I wanted a 5 so, so badly in this exam. At 7 credits, the effect on our GPA is quite significant. He told me that I struggled a bit in my individual exam, but that I rectified myself with answers I gave to questions during the exams of the other two. With that, I got a 5. Probably the hardest 5 I’ve had to work for, or at least it felt like it!
That rounds up what feels like the toughest semester yet. I’m generally happy with the results, though bummed about my performance in pathology. I feel like I spent a lot of time this exam period learning exactly how to study for each of these subjects. At the start of third year, we began with a completely new load of classes – all of which required their own study technique. Before this next semester starts, I will lay out my “plan of attack” for this next semester. It is only going to get harder from here: next exam period we will be double what we had for this one. We will have our final exams in Pathology, Pathophysiology, Microbiology, plus smaller finals/semi-finals in Internal Medicine, Genetics, Medical Psychology, Medical Imaging and Basics of Surgery.