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I have another big neurobiology exam behind me now. They are kind of like the anatomy exams. A lot of dense material, with a new language to learn, and they both give you the uncomfortable feeling that you just don’t have it all quite straight in your head no matter how much you study. We took the exam yesterday and I spent most of the week before and all weekend preparing. This class has me obsessing like anatomy did also. I even dream about the stuff. I have never had any problems sleeping before, but this course has me tossing and turning in bed at night. Even though I am quite sleepy, I’m unable to let it escape my mind long enough to nod off. The course is divided into three blocks and each exam is worth 30% of our final grade with the NBME board exam counting for the other 10%. Because each exam carries such a large weight I get more stressed over them than say physiology. In physiology we have nine unit exams plus a mid-term plus a final plus the board. Each unit exam ends up only counting for about 4-5% of our grade, so there is not nearly the pressure. In fact I have a GI exam in physiology this Friday and it almost seems like an easy week. Keys were posted after the neuro exam for both the practical and the written exam. I did just fine on the written but not so hot on the practical. I am not sure of the actual score on the practical, because I can never remember what I put down for each question. I might know that I had put down the right medial geniculate nucleus for one of my answers, but I don’t know if it was on number 32 or not. However I saw enough answers that I did not have anywhere on my answer sheet that I know that once again I have failed to beat my written component with a practical exam. We have had nine exams this year that had a practical portion, and I am 9 for 9. The format for this exam was a little different. We took the practical in the main lecture hall rather than the laboratory, and the exam items were slides shown on the screen. A professor would point to an area on the slide and ask us to either identify the area or describe what deficits a patient with a lesion in that area would experience. The images were actual stained brain cross-section specimens or MRIs or even drawings in some cases. We would have about one minute for each question. When a new image would go up, I would start thinking, “OK, that is a cross-section of the medulla. I can tell from the inferior olive that I am near the rostral portion. OK, what cranial nerve nuclei should I expect to find at this level? Would those be located medially or laterally?” Just as I would be about to hone in on an answer, my time would be up and I would have to frantically scribble down a possible answer, while never feeling really good about it. I felt like my problem was that I knew a lot of stuff and could think it out, but I hadn’t “memorized” the pictures in terms of seeing an image, immediately recognizing it and knowing where every tagged item in our atlas was. Oh well, only one more of these gut-wrenching tests this year.

Physiology is winding down with a whimper. Our GI exam is Friday, and then we just have two units on the nervous system. I have heard from the M2s that after having almost completed the full-blown neuro course, the material in physiology will seem like “Neuro for Dummies.” I think the class average for last year’s physiology nervous system exams were in the mid 90s. We do have a comprehensive final in that course which will require a good bit of review however.

Psychiatry is likewise just playing out the string. Most of the rest of the course is focusing on teaching us interviewing skills. We have divided the class up into groups of ten and each Wednesday we meet at the VA hospital, which is next door to University Hospital. These group sessions represent our first contact with real patients. These are psychiatric patients who are not necessarily veterans. I find it a little bit strange that our school uses this venue to begin teaching us about the patient interview. I know a lot of schools hire volunteer “actors” to present with certain stories and it is up to the students to try to figure out what role they are playing. Other schools use real patients but not generally psychiatric patients. I am not quite sure of the rationale, because it seems to me that we are “learning” in a more difficult venue for quality interviews than you would normally expect. My group’s first session was last Wednesday. We all trekked over to the VA together. We had been warned to not take our book bags as security is pretty tight and it would take quite awhile to run a hundred book bags through the X-ray machine. Right away, I knew it would be a different world. It turns out that just a few years ago, a disturbed patient came in with a gun and shot a doctor. Since then they have beefed up security and entering the hospital is a lot like to trying to get on a flight at Dulles International. A female psychiatrist and a female psychologist, who specializes in cognitive function testing, lead our group. They very briefly went over some interviewing techniques and then brought in our first patient. For this guy the psychiatrist conducted the interview so we could observe first hand, and then we got to ask questions. I would like to tell you a little about the guy, a young black male who had been admitted a few days previously for some psychotic episodes. However I have been made a little paranoid about discussing cases due to patient confidentiality concerns. We have been told that it is OK to discuss patients with colleagues but that we shouldn’t talk to family or friends or even to other doctors while we are in public places like the elevator. I understand the concern and the rights of confidentiality but I am kind of confused about the level of generality that can be used to tell about the experience. I notice that all of the writers on this site and in fact students everywhere talk about cases they have seen. Often specific symptoms and diseases are discussed and certain vital stats. Obviously names are not used, but it is certainly possible that someone who knows the patient could recognize them from a description given. I’d like to hear some of the other writer’s thoughts on this issue. Is it OK to say you saw a person with such-and-such diagnosis? What about revealing stuff like age, gender, and race? When does it quit being a matter of discussing things in an educational manner and begin to infringe on someone’s privacy? I don’t know. When we meet again tomorrow we will begin taking turns conducting the interviews ourselves. I am hoping to jump out and be one of the first in my group to go. I’ll report on that in my next entry.

To follow-up on the Question-of-the-Day for last week:
Which of the following occurs during exercise at aerobic levels?

The correct response (or at least what the professor was looking for) was:
3) Normal alveolar-arterial partial pressure of oxygen gradient

I answered: 2) Increased alveolar partial pressure of oxygen as did 42% of the respondents. It is true that even during exercise, arterial partial pressures of oxygen normally do not increase much. However oxygen consumption is up, so I would reason that the oxygen partial pressure on the venous side is down. Of course the systemic venous blood is the pulmonary arterial blood. The lower partial pressure in the pulmonary arteries should lead to an increased pressure gradient in the alveoli. That was what I figured anyway. If you can explain what is wrong with that reasoning, post a comment.