Guadalaharvard

Here I come full circle with this blog, posting once and for all about the conditions at my medical school.  While this blog started before I got here, it did carry the hope of what I thought would be an education that, albeit academically lacking at times, would be made up for in other cultural, non-academic ways. *coughing*  For all you people considering a foreign medical school, know this: you better be rock solid with your self esteem, your goals, and your ability to nod appreciatively while inside you may be thinking, “You bass-ackwards !@#@!”  You need to find the silver lining in everything, and appreciate each good moment to its fullest extent because you don’t know when the next one will come (they do happen, just not often enough).

Here is the template: take a Mexican medical school, carve out a portion of the campus for international students (60% US students, 39% Puerto Rican, 1% Other) complete w/separate administrative offices and the like–a school within a school.  The rest of the campus and students are Mexican nationals (the “Latino” program), choosing the private education here over the big, public  Univ. de Guadalajara to study medicine. There are some dental and nursing students here as well, but you can’t tell by looking at them for the most part.  Almost all of the Latino students start at 18, fresh out of high school.  While they might have gone to a specialty/magnet school, they haven’t had university level calculus, organic chemistry, physics, etc. — all the things that make a pre-med education prepare you 100% to begin your training as a doctor (*laughing*).  Imagine what you were like as an 18-year-old, then imagine you’re in a lecture hall with your friends and suddenly there is a 6 foot penis on the projector screen behind the professor as you begin to discuss male pelvic anatomy.  Hilarity ensues. Repeat for female genitalia, breasts, and ano-rectal lectures.

I mention all this not because it has anything to do with us directly, but in spite of the international program having its own cadre of professors, they were brought up in the system–perhaps were teaching in it as recently as a few years ago or even currently.  The average demographics of our program consists of an older student, perhaps choosing a 2nd or 3rd career or a college grad who took a little more time deciding what they wanted, 1-2 years older than the standard US “5th year” MS1.  A lot higher proportion are therefore married and/or have children, were professionals in their own right–some with advanced degrees already, etc.  Now imagine said professor laughing with the penis or breast slides like an immature child, because he’s so used to having to deal with teenagers.  He doesn’t get the funny response he hoped for, so he extends the joke further.  People walk out.  He doesn’t really teach as much as point and explain the labels on what amounts to a Netter slide.  Repeat most of the semester.

Said professor says, “This will/won’t be be on your exam,” only to find out when the exam comes, it’s 180 degrees different than what he told us in class.  Why?  He didn’t make the exam. He never had any input in the exam. The exam actually comes from a “bank” full of asinine questions that should have died 100 deaths the minute they first soiled the page with their ink.  Professors long gone have deposited their detritus into this “bank” to be used by current professors who also deposit their questions but have no input on whether or not which questions get included on their exam.  They get no ‘veto’ power for any given question to choose another (although they can throw it out come test-time, of course), but they also don’t have freedom to proofread it themselves. Why?  Because the university doesn’t trust them, either. Too many exams have been sold by either corrupt professors or opportunistic secretaries. So not even the professors get to see the exam before its given.

Or so we’re told.  Because no matter what semester, there is always at least one professor who seems to know exactly what will be on an exam.  Why are they so special?  But this is just the idiosyncrasies of my medical school and its never ending quest to exert micro-managerial control to a pathological level. The real crime are the professors who don’t even make their own exams or submit their own questions.  They simply cut and paste from other universities web sites without warning. These public websites have questions for their own students and the Internet at large for educational purposes. But you can’t escape the fact that questions from any outside source exhibit a type of professor bias that is impossible to know if you weren’t in that class, such as specific incidence rates, a hyperspecific question that the prof really wanted you to know, etc. As an outsider, you scratch your head with a question like that and say, “Huh?”

Any monkey can cut and paste questions from a web page or copy straight out of a review book or use another (better) professor’s exam questions and rightfully point to them and say, “Those are good USMLE-style questions.” It’s not about whether the professors know the material they’re teaching, it’s whether or not the instruction and academic support sets us up to succeed at that level, whether they are actively helping us along, pointing out pitfalls and explaining difficult concepts or simply putting in their lecture time and that’s it.

But in class–and here is where the problem lies–classes are mostly not helpful, to be kind. We are in lecture 2 hours per class, often with 3 classes (with a lunch break) and sometimes a clinical course elsewhere. When you are in class–mandatorily because attendance will affect your grade outcome–for 6+ hours a day, sitting in a rinky-dink hard-as-a-board auditorium desk that isn’t big enough to effectively study if you wanted to do something else, etc. you are TIRED when you get home. You need to do something just to get the blood flowing again. There are no problem solving sessions, no academic labs, no case discussions, or anything that supplements the book/lecture/etc. The lectures consist of being read to by professors, many of whom have a barely working knowledge of English. Most literally read, word for word, from PowerPoint slides we already have. The slide will have something as ridiculously simple as “Blahblahvirus recognizes glycoprotein moeties in the host cell’s membrane,” but the test question will be “Host cell-Blahblahvirus attachment is mediated by a) virus encoded VP6, b) CD28 c) CD3 d) B7 ” or whatever–you get the picture. It’s an aereal view from a plane followed by a scanning electron microscope of specificity.

To add the icing to this bitter cake, many professors simply feel that you owe them an inordinate degree of respect, as if they were renowned physician-scientists from Harvard (hence the title of this post). In fact, they might be succesful doctors who come to teach a class or two, who are used to patients and secretaries fawning over them, then they get to a group of students from the US who have a slightly higher threshold of “absolute” respect, and then we get attitude back for being “ungrateful.” Of what? Why the fact that they deigned to take time out of their busy schedule to teach the likes of us, of course. One professor in particular started every lecture (late, which is important to explain later), with a diatribe about the people who were not there, on time or otherwise, that they complain they don’t understand something and he doesn’t have sympathy for them, that they are disgraceful students, an embarassment.

“Do you know what I tell a student or resident that comes into the OR five minutes late? ‘Buenos dias, que bien que levantaste. Ya, regresate a tu cama. Peridiste la oportunidad para operar con migo. Vete.’ [laughs, proud of himself] This is what I say. And it never happens again.” (translation: “Good morning, how nice of you to have finally gotten up. Go back to bed. You lost the chance to operate with me. Get out.”

Ok, this isn’t Michael DeBakey, this is just a run-of-the-mill GI surgeon. But he likes his little pedestal of power, and unforunately, this adversarial relationship pervades almost all of Mexican medical education. It is especially frustrating for someone like me who is older, wiser, and less tolerant of bullshit. There is another older student in the class in his 40s who was a PA for 20+ years. I can’t imagine his frustration, but then again, he’s probably seen it all in terms of abuse having worked for at least a few physicians who saw a PA as their whipping boy when a nurse wasn’t around. Assholes. I’d hate to say this is the attitude of the typical surgeons we get (including our surgery classes), but it’s true. Generalizations come from somewhere.

The whole useless lecture thing reminds me of the famous quote from Shakespeare’s Macbeth. I’ll let you substitute for your own analogies, but you’ll get the picture:

Life is but a walking shadow, a poor player
That struts and frets his hour upon the stage
And then is heard no more: it is a tale
Told by an idiot, full of sound and fury,
Signifying nothing.

It’s all up to us and our textbooks in the end for these first two years. I wish I would have known sooner; it would have saved me a lot of frustration and disappointment over the last year+. You’d think that medical school, paying 20k a year for tuition, etc. you’d feel that you were shephereded along the enlightened path, not herded like cattle en masse. Oh well.

Moo.

Marriage and Relationships: Advice(?) for future and current med students

Relationship self-help/advice books, CDs, TV shows, etc. are a dime-a-dozen, and this post is NOT about “how to make relationships work while in medical school.” If I knew that secret, I would have written that book instead of this stupid blog and not have to take out any loans to go to school as I double park my Bentley in the faculty lot because I can. No, I can’t tell you how to make it work, but I can definitely tell you what to watch out for, what hasn’t worked for me, and give you a wider perspective on what is usually a hyper-myopic medschool life.

A few bullet points first, then I’ll expand on them:

• Medical school does not break people up in and of itself; it places strain (sometimes severe) on a relationship whereby a weak relationship can not endure it and a strong one can.
• There is far more to life than medical school, even (and sometimes especially) while in medical school.
• Medical school by definition is temporary. Try to make as few “permanent” decisions as possible (such as divorce, breaking up with a potential spouse, making irreparably bad financial decisions, etc.) using medical school as the driving reason.
• Your spouse/partner will never understand what you are going through. They can try and have the biggest heart about it, but you should save the true vitriolic dumping for those in your medical peer group who can understand and appreciate the context (and language) of your rant rather than set impossible expectations for your significant other who will probably always fall short. (all of this, of course, assumes your partner is not of the medical persuasion)

I especially want to expand on the last point: anybody on the “outside” will never fully understand what you’re going through. People who have gone to law school or a particularly rigorous graduate program may have a 1:1 comparison for the pre-clinical years when it’s almost all classroom, but especially when you get to your clerkships and you are dealing with sick people, real human suffering (or like here in Mexico, when we do have to deal with real patients to a limited extent our first two years), the analogy stops, because as we’re reminded all the time, this is about life and death, or at the very least, affecting people’s lives in a seriously direct way where any little mistake can have disastrous consequences. And that’s for EVERY patient you see, a situation you’re faced with multiple times a day, not just an occasional job hazard.

Everything I wrote above applies to me and my marriage too, except when it’s yourself, you lose judgment and sometimes emotions get the best of you. I am actually not a fighter; I’m a debater. I can calmly pick at arguments/points-of-view all from a perspective of logic, whereas Claudia, being raised with 8 siblings is quick to fight and lets her emotions get the best of her in a way that is frustrating for me. However, she’s able to let things go and slide off her back (for a lot of the same reasons) in a way that I can’t. So while she’s over everything, I’ll come up later and say, “Ok, I’m still having a problem with this…” to which she replies “are you still on that?!” This renders me feeling like I’m not being listened to while she feels like nothing ever gets put behind us. Neither of us is wrong, yet both of us could be more tolerant of the other’s needs.

This semester has been hellish, scholastically. Everyone’s grades are down, and students’ morale is even lower (more on that in the next post). If you’re by yourself, you don’t really have anyone else to turn to and you are necessarily more self-reliant. If you are with someone else, you naturally expect to reap one of the benefits of the relationship and want a soft place to fall when things are going tough. But what happens when you feel like you’re falling all the time and instead of the occasional complaint of “Man, what a shitty day” it’s turned into a daily litany of complaints as soon as you walk in the door? What happens when you’ve burned out your partner and that soft place to fall is the same concrete pavement it was had no one ever been there, except now, it’s complicated with them getting after you for being so negative? These are expected situations, people.

There are those who embark on relationships while in school (or came in with one) and have the attitude that they’re going to tough it out and hope for the best, and if it’s meant to be, it will work out in its own time, but priority is given to a fuller, more complete life outside the classroom/hospital, not waiting for a “right time” to satisfy the basic need of wanting to be with somebody. Another is popular among the early/mid-20s crowd, taking the opposite view of “I don’t have time for a relationship right now; I am going to completely focus on my studies.” I think that’s a luxury of youth, personally, or at the very least, a luxury of those who don’t feel that being with someone makes them a better, more complete person.

I don’t wish I could be that way, specifically, but I do wish I could let more things slide off my back, more things not seem so dramatically important at that moment, like I could have the benefit of “sleeping on it,” without having to lose the time to do so. I wish I could compartmentalize my feelings in a box and just say, “I’ll deal with this later; I have a pharmacology exam on Monday I need to prep for.” As physicians, we have to necessarily have some kind of barrier with our patients, or we’ll burn out, get into legal trouble or both. I like to think of it (computer geek that I am) as a firewall, inspecting each “packet” of interpersonal data and determining if it’s kosher to discuss, reveal, touch, hug, give a cell phone number to a patient with a special case, etc. rather than an impenetrable wall that keeps a patient at a distance that is not always therapeutically necessary. I wish I could do the same for relationships, allowing some amount of feelings to leak through, to deal with, etc. but not have it flood the dam and render me incapable of concentrating.

I say “relationships” (plural) in the 1st person because I include friendships in this as well; it’s not all about burning out/fighting with your spouse, but you can tap out a friend too. It’s gets harder to manage your feelings with friends in class, because while you get the supreme benefit of someone knowing EXACTLY what you are going through without the need to explain or justify, they too are usually in the EXACT same predicament and can be the last person to turn to for emotional support. Imagine the conflict where your spouse/significant other doesn’t understand, you turn to a classmate who is emotionally unavailable or at the very least, you have to think about what problems you’re bringing to them the night before an exam (as you try to seek help calming yourself for the exact same reason), and you see where it gets complicated yet again. Of course, all this is made tons easier if, as I stated above, you can effectively compartmentalize and deal with things later (or you are a simpleton; either is good for this). It’s part discipline, yes, but it’s also a good part personality.

Well, this is getting away from the main purpose which was “advice,” but like I said in the beginning, I don’t have all that much. I have my own major problems, thank you very much. But in sharing some of the basics of what I’ve learned so far, perhaps it helps guide you in keeping you aware as you go along to not fall into obvious traps or realize sooner rather than later that something isn’t working for you. Be as self-reliant as you can, above all else. It’s not that you can’t count on others because they’re unreliable, but you really can’t count on others the way you’d think because of specific reasons that are not their fault. And while we’re all trying to be the best doctors we can be, remember that there’s a lot more to being a good doctor than memorizing textbooks or doing whatever it takes, bar none, to impress the holy hell out of the attending in a clinical rotation. I think a big part of my problem is that I go to school with so many people who haven’t figured that out yet; they either don’t get it at all, seeing such statements as evidence of my academic shortcomings, or they haven’t grown up enough to care or even think about such things. I’ll give them one thing: if I were freed up from myself to not think about just a fraction of the things I think about, I’d sure have a lot more time on my hands.

Maybe they were right all along…

Microbiology final, always good for the appetite

I have my microbiology final today, so the posts with be coming afterwards, a couple are drafts nearly finished. Until then, I leave you with this wonderful, wholesome clinical case presented here from Bugcards, a flash card set I have:

An 18 y.o. female is your first patient on your Ob/Gyn clerkship. She states that she has had vaginal itching and discharge for approximately 1 week, and says she has been sexually active with “several” partners. A speculum exam reveals copious, frothy, greenish discharge, and a wet mount shows numerous organisms quickly swimming about on the slide. What is your diagnosis and treatment?

I swear I was eating dinner last night when I read that card. My initial diagnosis: depends on whether “several” (their quotes, not mine) meant total number or simultaneous partners; my initial treatment: exorcism.

(The real answers are Dx: Trichonomas vaginalis and Tx: metronidazole)

More later tonight once my appetite returns…