(click on image for original source)

“…and I do declare that the sun is shining.”

When I last updated this blog in April 2010, I was fighting my way through Neural Science. Easy class for most of my classmates. Not for me. However, I not only passed, but ended the year on a very high note.

Since then I have:

• Found an advisor for my PhD
• Worked on a summer research project with my advisor
• Finished Foundations, i.e. finished all my basic science classes
• Begun helping out with the Care Net Pregnancy Center here in Burlington
• Been hospitalized and diagnosed with ulcerative colitis
• Worked to regain my strength, health and stamina  (see above)
• Taken two months off due to ulcerative colitis issues
• Completed my first rotation in the hospital: Internal Medicine
• Said goodbye to my med school classmates
• Begun my PhD
• Taken my boards
• Turned 26

I plan on doubling back to discuss most of these in depth. The ulcerative colitis in particular took a toll, and is a big part of the reason I haven’t blogged in so long. Let me assure you that not only am I back to normal and on minimal medications, but I can eat anything and am in better shape than I ever have been.

Now I am in grad school, doing a PhD in Bioengineering with Dr. Jason Bates, an Engineering professor tied to the Vermont Lung Center. What am I doing? For now, I can say that we are working on a computational model of what happens in the lung during an allergic asthma attack. More details in the future.

Doing this MD-PhD thing was one of the smartest decisions I’ve ever made.  After two years of the frenetic pace of medical school, the switch to grad school came at just the right time. It’s still busy in its own way, but it’s nowhere near as busy, affording me more free time. I know of one MD-PhD student at Johns Hopkins, Jimmy Lin, who’s using it to also get an MPH and a seminary degree. I’m nowhere near as ambitious, but I do have plans. Many, many, many plans.

Part of that plan involves The Meager Med Student. When I began it, I vowed I was going to walk my readers through all the details of med school life. But then I had to step away from blogging, and it gave me more time to reflect. I eventually realized that while the details of lectures and medical practice were interesting,  in the end I found my emotional journey through med school more fascinating.

So from now on, The Meager Med Student will switch back to a weekly post on med school life. There will still be details about classes and perhaps one or two funny stories. But now it will be more of my emotional responses to the events of med school and the issues of medicine. More fascinating. More insightful. And better written. Look for updates every Friday, the first being the Friday after next.

All that to say, this blog isn’t dead. It’s just begun. I’m back.

Josh Pothen (UVM’s Meager Med Student)

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(Jean-Martin Charcot. from en.wikipedia.org)

Today was…not the greatest day for lectures. Let’s just leave it at that. It doesn’t help that we have a readiness exam tomorrow morning.

***

Today we talk about how neurons and glial cells respond to injury, which gives us an idea of how the brain and the nervous systems respond to trauma. We also have a lecture on multiple sclerosis (MS), and we do an E-Learning Lab on neurohistology, which means we sit in the classroom and work through a powerpoint about how to read microscope slides of neurons. The TAs and lecturers stay around if we have any questions. (We can leave and do this on our own if we want.)

Among the tibdits we learn today:

• They Might Be Giants has a song called “Countrecoup”, which Dr. Jaworski plays for us. It refers to a term where a head injury occurs on the opposite site of where head trauma occurred. Not too surprisingly, the lyrics are scientifically correct.
• You cannot diagnose a concussion with an imaging study like an X-ray or CT scan. You can use them to find a contusion, however.
• Demyelinating diseases (i.e. diseases that cause neuronal degradation) are often caused by a viral infection, but they can also be caused by childbirth. “I’m not calling childbirth an infection.”
• The neurons of the central nervous system (i.e. brain and spinal cord) ARE in fact capable of regenerating. So why haven’t we found a cure for paralysis? Because the cellular environment of those neurons does not allow them to grow. If we were to give them the appropriate growth factors and remove the inhibiting factors, then maybe…
• According to Sigmund Freud, his mentor Dr. Jean-Martin Charcot kept a charlady who kept dropping plates and platters for several years. Why?  Apparently after she died, he autopsied her and to prove she had what we now know is MS.

***

Tuesdays mean MSLG. Today we had two patients with psychiatric conditions come in to tell us their stories. Wonderful timing considering we’re starting Neural Science.  

As I find myself writing so often, obviously I can’t divulge details. But what I can write is that in medicine right now, psychiatry gets a bad rap, due to notions that psychiatry is a “lesser” intellectual field and that people with mental conditions just need to fix themselves. As Dr. Forehand said yesterday, you don’t tell your pancreas to fix itself when there’s a problem. So why would you do that for your brain?

We asked the patients who visited us what advice they had for us. One noted that the best question her doctor ever asked her was, “What are you reading?” It turned out she was reading a book that was adding fuel to her depression, and so she was able to recognize that and stop reading it. But also, it indicated that her doctor had some interest in her whole life, not just for her condition. After all, people are more than the sum of their illnesses.

Josh Pothen (UVM’s Meager Med Student)

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(I will use this song to study. from www.amele.tv)

Spring break’s over. Neural Science begins. This 9 week course on the brain will be the last course in our first year of medical school.

***

Since today is the first day, it’s very basic. Dr. Forehand gives two lectures: one giving an overview of the central and peripheral nervous systems, and another describing the embryological development of the central nervous system.

At the beginning of the first lecture, she shows us this slide to indicate why understanding CNS diseases is so important.

The costs take into account both money spent on medication and money lost due to being unable to work.

Then she asks what one disease not shown on this table costs nearly the same as all of these combined. We all draw a blank.

“Substance abuse.” Again, we’re reminded that in medicine, cigarettes is a very common cause for diseases we study.

***

The other item on the agenda today is to go to the anatomy lab. Back in HSF, we removed the brains from our cadavers and put them away. Now we’ve brought them out to learn the anatomy of the brain.

Dr. Jean Szilva and Dr. Ellen Cornbrooks (i.e. Ellen the Magnificent) are back and help us with any questions we have. They’ve set up several lab stations, and so we start at one and rotate around. Today we’re studying brain sections and the different parts of the brain.  

Today I interact a lot with Jean. She reminds me a lot of Ms. Frizzle from those Magic School Bus books I read as a kid, in part because she’s always very peppy and gets particularly excited when you make a mental connection.

She also gives us a useful clinical vignette. Without going into too much detail, there are three layers that cover your brain: dura mater, arachnoid mater and pia mater, from outermost to innermost layer. Between the two hemispheres of your brain is a cavity (which we call a sinus) formed by the dura mater. Blood and cerebrospinal fluid (CSF)  goes through this space.

Where does the blood come from? Veins that run underneath the dura mater. If you have a head trauma, there’s a possibility you could damage these and get what’s called a epidural hematoma.

“This is what killed Natasha Richardson last year.”

What’s scary is that if you get one, you won’t notice that anything’s wrong for a while. It takes a little while for the fluid to build up pressure, but when it does, it will push on the brain, causing you to get a headache and then lapse into a coma.

We ask her what causes the symptoms. She explains that the pressure in the head pushes the brain down your skull.

Also, she tells us, this puts a strain on our oculomotor nerve, causing the pupils to dilate. This is why they shine a light in the eyes of an unconscious patient. They’re checking to see if the pupils are massively dilated, which would indicate that a subdural hematoma is present. 

Josh Pothen (UVM’s Meager Med Student)

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(from 123rf.com)

I wrote a guest post for jpothen.com today. Thankfully had the free time to do it now that I’m on spring break for the week. Check it out.

Josh Pothen (UVM’s Meager Med Student)

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Yes, my last post was an April Fool’s joke. I would have thought the idea of me wanting to become a clown was too ridiculous to believe. And while many people realized the truth, a few thought I was serious. I thought they were just trying to trick me, but no.

So below is the email I sent to my med school classmates the day after April Fool’s Day:

***

Just to clarify, yes, the email yesterday was just an April Fool’s joke, though I’m flattered if you thought I could be a clown. Med school’s always been my main dream.

And you all will still have me around next Monday and beyond. If I’d really been leaving, I’d have been upfront with all of you about why. 

The things I wrote in the shoutouts, however, are real. (Note: I wrote personalized messages to a couple of my classmates at the end, which I will not reprint here for privacy reasons.) And I’m touched by the lovely sentiments I received from many of you. I love you all.

Josh Pothen (UVM’s Meager still-Med Student)

(from www.torontoist.com)

I sent the following email to my classmates today, and I’m sharing it on this blog so you all also know what’s going on in my life.

***

Hi everyone,

Just wanted to give you the heads-up that I’m leaving med school.

I’ll be here the rest of the week to say goodbye to all of you and take care of some details, but next Monday, I’ll be home in Indiana.  

Don’t get worried. Nothing serious or bad has happened to me. In fact, quite the opposite. I’m super-stoked about what I’m about to tell you:

I’M GOING TO CLOWN SCHOOL!!!

Some of you may know this, but med school wasn’t my first career choice. I’m not one of those people who’s felt called to be a doctor ever since I could remember, or one of those people who had an intense surgical operation and decided to go into research to improve patient’s lives. 

No, I actually applied to clown school first. Didn’t get in anywhere. So I thought I’d give med school a shot. And while it’s been an honor and a privilege, let’s face it…is there anything better we can do than make people laugh?

I tried to suppress the image of me in the clown makeup, wacky hat, red rubber nose, striped shirts, giant shoes and baggy overalls, no matter how natural and obvious a fit it seemed. I tried say that was all in the past and that I’d chosen a better career.

But over winter break, I realized my true calling again when I was in Chicago and saw a clown in the street, bringing joy and happiness to everyone around him. All those secret longings to learn the ways of the random and wacky came rushing back stronger than ever.  So I tried again, and well, I made it!

The details: First, I’m going home to eat a lot of food and gain a lot of weight so I can look the part. Then I’m going to the New York Goofs Clown School, where I’ll participate in an intense two-week clowning class. From there, I’ll be heading to the University of Chicago, as part of a 3-year program through the 500 Clown Company to learn clown theater. This will enable me to work both on the stage, and off it at circuses or birthday parties. This should enable me to make a substantive (and lucrative!) living in Chicago for the rest of my life.  

Still, it’s not easy to say goodbye. Let’s enjoy the rest of the week we have together. Be sure you come and give me a goodbye hug.

And if you’re walking through downtown Chicago and you see someone in goofy clown makeup squirting people with water flowers and honking his red rubber nose, look carefully. It’ll probably be me.  

Josh aka “Jimbo Pantalone”

(HDL molecule. from www.lbl.gov)

Week 5 of NMGI. The day after Daylight Savings time ended. AND the Monday after the weekend when the UVM men and women’s basketball teams won their entries into the NCAA tournament.

So Dr. Tracy was pleasantly surprised when most of our class showed up for our 8 AM lecture. She told us she remembered having her kids wake up late for school on the day after we lost an hour, calling it the “worst day of the year”.

She also couldn’t hide her excitement for the upcoming sports events. “If any of you want to discuss March Madness, I am happy to do so.” Although, she later admitted, ”My favorite team is Syracuse.” I’m surprised she didn’t get booed.

***

Every year, the medical school measures the cholesterol of the current first-year class.  

We had our blood drawn for fasting lipid counts about two weeks ago. We were also interested in the results, because apparently each incoming class had better cholesterol measurements than the ones before them.

And yes, part of it is because we’ve been trying to outcompete the classes before us, whether it’s in test scores or on the field.

So in the afternoon, Dr. Martha Seagrave (of Family Medicine) presents our class results. They look good. Most of us have total cholesterol in the desirable range  (< 200 mg/dL), LDL in the optimal (<100 mg/dL) or near optimal range  (<130 mg/dL), and HDL (‘the good cholesterol”) higher than 60 mg/dL.

Then they compare us against the other classes with various graphs, with each class having a different color (except for 2008 to 2010, which are combined together).

And well, we don’t stand out. Don’t get me wrong. Most of us are obviously very healthy. But let’s just say 2011 had some amazingly healthy people, and a few outliers that have to be genetic.

So finally a student asks the question on everyone’s mind: “So did we win?”

You know you’re in trouble when this is your reply:

“Well, it depends on what we’re measuring. If we’re going by which of you has the prettiest color [on the graph], then I’d say you won, since you’re the orange.”

*** 

Another student asks the other obvious question: Do they measure the cholesterol level of each class when they’re 4th years, and compare it to the data from when they were 1st years?

No, Dr. Seagrave tells us, but she thinks it’s an excellent idea, and polls our class if we’d want to participate. Most of us do. That’ll depend on getting funding from Dean Jeffries, she tells us. Start petitioning…

***

Lectures today included Dr. Tracy’s talks on how cholesterol is synthesized and broken down, as well as dyslipidemias–diseases where there’s an error in the synthesis, processing or degradation of cholesterol.

You know all those pathways that we’ve learned in today’s first lecture? Basically, an error in any one of the step can give you a dyslipidemia. We’re guaranteed to see one of these in our medical careers, Dr. Tracy tells us.

We also learn about dietary management of cholesterol levels from Ms. Johansen. Obviously we learn about avoiding saturated fats and trans fats. I won’t dwell too much on the obvious.

But among the interesting tidbits: 

• Even if your total cholesterol is low, your risk of serious disease is still very high if your HDL level is also low.
• Nuts are great for lowering your risk of heart disease, although they’re high in calories.
• Apparently the jury’s out on the effectiveness of soy. We know certain parts of soy are linked to benefits, but we don’t know the correlation between the magnitude of the effect and the amount of soy eaten. Sorry, tofu lovers.
• Weight loss actually causes your HDL cholesterol levels to decrease at first, but if you sustain the weight loss, your HDL levels will increase. For every 7 pounds of weight you lose, you gain 1 mg/dL in HDL levels…as long as you maintain the loss.
• And in a very interesting experiment, people who drank half a bottle of wine every day for six months had their HDL levels increase by 7 mg/dL! Let’s see if our class we’ll try that one…

***

We also get a Heart Healthy lunch today! Not sure why today of all days, but it’s a nice little break. It’s about 90% heart healthy, according to Dr. Tracy: water, salad and whole grain rolls. The missing 10%? Cookies, some meat and probably the salad dressings. 

Hey, I’ll take it. But perhaps not everyone. This is the only time I’ve seen a faculty member walk back in the room and encourage people to take seconds.

Don’t worry. We cleaned it all off. Eventually. I think.

Josh Pothen (UVM’s Meager Med Student)

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(A Byzantine form of the Hippocratic Oath. from en.wikipedia.org)

Here is the oath we’ve sworn at our White Coat Ceremony. It is not the Hippocratic Oath, but an updated, modern version. (Who developed it, I don’t know.)

I swear to fulfill, to the best of my ability, this covenant:

I will respect the scientific gains of those physicians and scientists in whose steps I will walk, and gladly share such knowledge as is mine with those who are to follow.

I will remember that there is both art and science to medicine.

I  will pursue the expansion of my knowledge throughout my life for the benefit of my patients.

I will practice medicine with conscience and dignity.

I will respect the privacy of my patients and not judge them.

I will prevent disease whenever I can; for prevention is preferable to cure.

Most especially I will treat with care in matters of life and death. If it be merely within my abilities to help ease suffering at the end of a life, may I face this awesome responsibility with humility and awareness of my own frailty.

I vow always to act to preserve the finest traditions of my calling, and may I long experience the joy of healing those who seek my help.

Josh Pothen (UVM’s Meager Med Student)

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Friday. The day of the White Coat ceremony.

Yes, we had a few lectures in the day: one by Dr. Ciampa on Barrett’s and esophageal cancer, two mini-lectures by Dr. Lidofsky on Peptic Ulcer Disease and Upper GI bleeding and one by Dr. Rebecca Wilcox (a new UVM arrival) on Gastric and Small Bowel neoplasms.

But to be honest, those flew by. We knew what was coming. I had to get back home to drive my parents (who had flown in the night before) up to UVM for the ceremony. My housemates were coming to the ceremony as well. And then…

***

The ceremony was held in Ira Allen Chapel, the magnificent chapel here at UVM.

One of the many plusses to this chapel is a wide space between the main stage and the first set of pews. Today, they filled that space with enough folding chairs to seat our entire class. 

Even though it’s a big chapel, the place was PACKED with family members and friends. Slowly we worked our way towards the seats.

I look over the crowd. Everyone looks terrific. People always look better when they dress up for events, and today is no exception. I remember that a few months ago, I thought we looked too…young isn’t the right word. Inexperienced, perhaps.

But now, even though it’s only been six months since then, we look different to me. Perhaps it’s my perception. Perhaps it’s that we’ve dressed up a little. But now we look more mature. More experienced. We now look like medical students.

***

So the ceremony began.

The keynote address was given by Dr. Bob Macauley, who you may remember gave lectures in ICDM (and in A&D) about medical ethics and spirituality. (Appropriate since he’s an Episcopalean priest.)

I will transcribe and post his speech as soon as I can. He urged us to not let our idealism die, but to always wear the White Coat with reverance.

Then a surprise guest: US Senator Bernie Sanders took the stage.

He implored us to consider practicing medicine in underserved areas of the United States, assuring us he and other politicians wanted to pass a program for automatic debt forgiveness if we did so.  

***

And then the White Coats. Dr. Waterman and two other administrative faculty members remained on stage, one holding out the White Coat to us.

Our mission: Walk towards the faculty member, turn around, put our arms through the coat sleeves while they helped us wear the coat, and then shake the three faculty members’ hands. Then while the next person comes on stage, head to an area of the stage so the photographers can take pictures of you in your new coat.  Try not to trip.

The tall people had a bit of a disadvantage. While turned around, they had to crouch and try and fit into the coat, while trying to figure out where the coat sleeves should be. Sometimes it looked like awkward dancing. Barely noticeable, though, and I am proud to say that not one of the 114 people tripped.

We applaud as each person walks across. And as each person puts on their White Coat, each student goes from looking like a medical student to looking like a potential doctor. It’s like watching a hero don their uniform or costume for the first time. Each one is an inspiring transformation in my eyes.

***

And afterwards? Class photos. A reception, where I met many of my classmates’ parents and families. A scrumptious dinner at A Single Pebble (a fine Chinese restaurant here in Burlington) with my parents, my housemates and one of my classmates. A game of Apples to Apples. And an after-party with a few of my classmates in which good port and champagne was consumed.

In looking back,  I realize we didn’t really become heroes today. We already were, thanks to our education and training over the past six months. Today was a reminder of how far we’d come.  

Josh Pothen (UVM’s Meager Med Student)

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(Now we know why she's smiling? from en.wikipedia.org)

I haven’t felt this excited to write an entry in a while. Perhaps the last few entries show that.

Don’t get me wrong. I LOVED A&D. But it became harder to write blog posts that transcended the ordinary and conveyed information the lay public might be interested in.

Then our next course, NMGI began. 

NMGI stands for Nutrition, Metabolism and Gastrointestinal System. So even though our schedule over the past few days has been basic in terms of lectures, what we talk about is stuff I can talk about with my friends again. 

*** 

Take Dr. Toth, who for some reason does not have a website I can find. He’s a researcher studying physiology, and he gave us two lectures on energy metabolism and balance. 

Naturally, we discuss obesity. Everyone’s seen the charts. We know it’s an increasing problem. He asks us off the bat how many of us think the increase in American obesity is because of genetics, behavior or a combination of the two.

Only one person went for genetics. 60% of the class went for behavior, and the other 40% or so went for both.

According to him, the answer is…behavior alone! 

Because, you see, energy intake is the primary determinant of energy imbalance, which causes weight gain. It is true that the body expends energy, but the range of energy you can take in is MUCH greater. (There are other reasons, but it’s getting late and there’s more to write.)

Next question: Does merely eating more protein help you gain muscle? 

Answer: Surprisingly, no. Your body does have a nearly limitless store for fat, but it has a fixed store for protein and carbohydrates.

Simply eating more protein won’t cause your body to store more. Your body will store a little of it to replace the miniscule amounts of protein broken down in your body, but the rest of it will be oxidized and broken down. You’ll pee it out. 

So how do you get bigger? Exercise. That can increase your body’s storage capacity for protein. If you do that AND eat more, you’ll get those muscles you’ve dreamed of.

Third question: Is the reason you become fat when you eat too much junk food because your body makes more fat cells? 

No! In fact, the number of fat cells in your body remains the same. Your body simply stores more fat inside those cells, making them bigger. 

*** 

Interesting, no? But here’s what I think is the most interesting question: Is there a magic diet for losing weight?

For this, Dr. Toth referred us to a 2005 study by the Journal of the American Medical Association. In it, they compared patients on the Atkins, Ornish, Weight Watchers and Zone diets.

 It turns out that over a year, the average weight loss was the same for each of the diets! In other words, one diet didn’t work better than the other.

In fact, the people who lost the most weight were the ones who adhered to their diet throughout the year, regardless of what diet it was. “

I’m sure there may be issues with whether one diet is “healthier” than another. But in terms of weight loss, this seems pretty solid. At the end of the day, Dr. Toth says, it doesn’t matter whether you eat a higher percentage of carbohydrates, proteins or fat when it come to weight. It’s all about the calories. “A calorie is a calorie is a calorie,” he says.

Or, to put it another way, weight loss is simply a function of eating less calories and burning more of them. “You are in control of your weight.”

Incidentally, if you have an issue with anything I’ve written, take it up with Dr. Toth.

*** 

You may also remember Dr. Mawe and Haeberle from HSF. Back then, Mawe did several lectures on the GI system, while Dr. Haeberle did the infamous “barf cart“. 

Both returned to do lectures: Mawe on a review of the GI lectures from HSF, and Haeberle to discuss how different nutrients are absorbed. We also have lectures from Dr. Laurie Whittaker and Dr. Thomas Lahari on nutrition and treatment of cystic fibrosis patients.

One of them (I think it was Haeberle) showed us a picture of the Mona Lisa. About a month ago, the newspapers were running a story about a Sicilian anatomy and physiology professor who claims to have solved the mystery behind her smile.

According to him, the secret of the Mona Lisa is that she has high cholesterol. He noted signs of high cholesterol around her left eye and right hand. Amazing what you learn at school these days.

*** 

Tomorrow (Friday) is a big day for us. It’s our White Coat Ceremony–the day we get our precious white coats, which we’ll use when we work with doctors next month.   

Most schools do this ceremony at the beginning of the first year. Why UVM does it differently, I don’t know. Even my MSLG leader isn’t sure. 

But what I do know is that it feels like we’ve earned the Ceremony now. We’ve made it through HSF and A&D. We know how to do a basic head-to-toe physical exam and can begin to diagnose patients. 

I know some people don’t like the concept of a ceremony. We had a few readings in MSLG by authors who argued that the White Coat has come to symbolize elitism and detachment, since few doctors adhere to the ideals of humbly caring for patients.

For me, though, it is still an idealistic symbol. I hope that when I wear that coat, it reminds me of my responsibilities and inspires me to behave as an idealistic doctor, regardless of whether anyone else around me is. 

Tomorrow, I’ll see if it does…

Josh Pothen (UVM’s Meager Med Student)

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