Thursday, January 30, 2014

Vaccinate Your Kids!

Not much time for writing these days, but I've gotta get this out. In med school, we learn a LOT about vaccinations. How they work, what goes into them, what the risks are, and all the science-, tech-, and culture-related nuances of vaccination. And you know what?

It still FLOORS me that some people don't believe in vaccination.

For anyone who thinks along such lines, I think the below info is worth a gander:

One thing the above graphic doesn't show is the effect that parents' decisions to not vaccinate has had on the re-emergence of vaccine-preventable diseases worldwide in recent years. That's what this is for:

Not sure what Whooping Cough is like for a kid? Watch the below video.

Warning: if you are capable of empathy, this will make you uncomfortable.

If you want to learn more about vaccination in general, I recommend this as a reputable source of info:

Medscape on Vaccines:

So seriously.

Vaccinate your kids.

Sunday, January 12, 2014

The Patient Protection and Affordable Care Act

So, I'm a bit behind on my studying for the weekend, and my landlord is about to stop by and deliver a new refrigerator, which I'm going to need to help install. Thus, I'll keep this short.

In our second semester of Ethics, we've been talking a lot about health policy. Given the recent years' advances of Obamacare, the air is just ripe with political and ethical fruits to discuss. This week, we're talking about the Patient Protection and Affordable Care Act, known commonly as just the Affordable Care Act or ACA.

Everyone talks about it, but very VERY few people have read it. I'm not one of them, and I don't plan to be. Oh, I thought about it, but for a while I couldn't find a copy of the whole thing. Granted, "a while" in the era of Google constitutes the approximately six minutes before I found the copy online. To save you the time, here it is:

If you clicked that and glanced at the page count, you'll realize why I (and most other people who don't have endless time) haven't read the ACA. Including the table of contents, it's 906 pages long. That's about as long as the average epic fantasy novel. So, would I rather read 906 pages about Hobbits and Dragons, Aes Sedai and Trollocs, or Accountable Care Organizations and Allowable Variance in the Levels of Coverage? Yeah...

Anyway, if you're so inclined to read it, there you go. Let me know if you come to any earth-shattering conclusions about the future of our healthcare system. I'm going to try to understand more about nephrons. Out.

Saturday, January 11, 2014

The Male Genital and Rectal Exams

Update 3/30/14 - If you've found this page because you are nervous about going to see the doctor, please consider reading a patient's story who contacted me after reading this post. 

Click here to read Nervous About Going to the Doctor - A Patient's Story.

Image credit:

This week, I learned how to do the male genital and rectal exams. I then performed these exams on live patient volunteers. That's right - real humans. I don't know if they were truly volunteers or if they got paid, but I speak for all medical students when I say I hope they got paid and got paid a LOT. If they didn't get paid, then they have my utmost gratitude for volunteering for the sake of my education.

I went into the experience with significant uncertainty, as you can probably imagine. My emotions could probably be more aptly be described as an odd mixture of curiosity and trepidation. That's probably true of the majority of the new clinical exams that we learn, with this one weighted more heavily on the "trepidation" side of that balance...

If you have no clue why I'm saying this, you probably don't know what the exam entails. I'll help you out with a blunt description of each exam. I'll use common terms, but know that these are not the words that get used in the writeup. Please skip the rest of this if it makes you feel uncomfortable:

The Male Genital Exam:

The examiner first washes his or her hands and puts on gloves. The patient is asked to stand up and pull up his gown to the level of the belly button. The examiner sits in a stool in front of the patient and examines his genitals, noting things like skin lesions, uniformity of hair growth and skin pigmentation, and looking for any big signs of infection. The examiner explains what he's doing the whole time, both as a way to make the patient feel more comfortable and as a way to make sure to not skip any steps.

First, the shaft of the penis is examined for any changes in consistency, skin discoloration, lesions, discharge, and hypospadias (where the meatus exits the penis along the ventral side instead of the tip). If foreskin is present, the examiner must retract it to fully inspect all sides of the penis before replacing the foreskin. If the foreskin is left retracted, it can cause it to swell painfully around the head of the penis, potentially obstructing blood flow. It can be a big deal, apparently. Anyway, after inspecting the shaft, the scrotum must be inspected carefully, again looking for signs of inflammation, color change, or lesions. The testicles must both be felt at the same time to compare consistency and size between the left and right. The same goes for the epididymis on both sides, and the spermatic cords. The vas deferens must also be compared bilaterally, as well as the spermatic veins, looking for specific conditions.

A key part of the genital exam is to check for abdominal hernia. This is done by finding the inguinal canal, a structure just lateral to the pubic symphysis through which the spermatic cord runs on each side. Once it is located and a finger is placed in this canal, the patient is asked to either turn his head in that direction and cough, or to simply bear down. If a hernia were present, the examiner would be able to feel the intestine press against the tip of his or her finger. Once both sides are checked for hernia, the male genital exam is done.

The Male Rectal Exam:

The patient is asked to keep his gown at the level of the umbilicus. The exam can be done with the patient in the fetal position, or standing. We did the exam standing, but apparently it is mostly up to patient and examiner preference. With the patient standing, the patient is instructed to bend over and lean his elbows on the examining table. First, the examiner checks the skin of the buttocks and the perianal region, looking once more for skin color changes and lesions. One of my patients had a minor hemorrhoid, so I had to first check and make sure that it was non-tender before proceeding. The examiner applies some lubricating jelly to the tip of a gloved index finger and notifies the patient to be prepared for some cold pressure. At times, the external sphincter can be too tight, in which case the examiner applies anterior pressure to the inside margin of the external sphincter, causing it to loosen.

With the index finger inserted into the rectal vault, the examiner first checks to see if it is possible to palpate the far margin of the prostate. If the patient has an enlarged prostate, or if the examiner has very short fingers, this is not always possible. The examiner should also locate the central sulcus of the prostate, which is basically a sort of valley between the two lobes of the prostate. Our instructors told us that the prostate's consistency should feel like the tip of someone's nose, but that didn't really fit what I felt with my patient. It seemed more like if you took two miniature clementines and smushed them together, then wrapped them in a thin layer of plastic and ran a lubricated gloved finger over the whole thing. Firm, but not rock-hard.

We were also told that this portion of the exam can make the patient feel as though he needs to urinate. I forgot to mention this to my patient volunteer during the exam, but I'm sure he'd gone through enough exams by the other students that he was plenty used to it. After palpating and mentally comparing both sides of the prostate for consistency, nodularity, and size, the examiner sweeps the entire 360 degrees of the rectal vault, 180 degrees clockwise and counterclockwise, then removes the finger and offers the patient tissue with which to clean himself up. If any fecal matter is stuck to the gloved finger, the examiner uses it to do a hemoccult test, which checks for blood in the stool.

And those are the procedures for the male genital and rectal examinations! It went much smoother than I had anticipated, and I felt like I learned a TON. My patient volunteers were both very helpful and professional, and my physician preceptors both did a great job facilitating the experience. This was probably the best physical exam experience that I've had so far here at MSU CHM, though the female breast exam (which I don't think I wrote about due to being insanely busy at that time last semester) comes in at a close 2nd place in terms of the professionalism of both the patient volunteers and the physician preceptors. I learned a ton in that experience as well.

After the exam, the students have to write up the observation portion of the exam - basically, their clinical findings, described as concisely as possible. I realized later that I had forgotten to estimate the approximate size of his prostate, but oh well - guess that's what learning experiences are for! Below you'll find mine for one of my patient volunteers, with some defining physical characteristics removed:


Genital Exam:
Uncircumcised race male with calm demeanor, good apparent health and general appearance. Penile shaft absent of lesions, discharge, or discoloration. Prepuce retractable, no lesions noted. Light, large (XX cm), benign, specific skin abnormality noted over the left upper medial thigh, fading into the pubic hair. Scrotal pigmentation significantly relative darkness on left than right, but no scrotal swelling/lesions noted. Pubic hair symmetrical and of uniform density and color. Testes absent swelling, both smooth and descended with no masses. Epididymis nontender bilaterally. No varicocele of spermatic cord noted. No inguinal or femoral hernias detected, though the left inguinal ring noted to be larger than right.

Rectal & Prostate Exam:

External sphincter intact. Small (0.5cm), nontender, noninflamed hemorrhoid noted at the extreme anterior margin of the anus, otherwise no perirectal lesions or fissures noted. Rectal space and walls without masses or lesions to palpation. Nontender prostate bilaterally. Left lobe of prostate markedly firmer and more nodular than right, consistent with patient history of prostate reduction surgery. Median sulcus of prostate palpable and nontender. No stool present – Hemoccult test not attempted.


Experiences like this one definitely help make med school feel more real. I'm becoming much more confident in my interaction with patients. I've definitely begun to see how the transition from student doctor into doctor is possible, though it's still a long, looooong way off... All right, back to studying Urinary Tract pathology, the first domain of my 4th semester in medical school! Wish me luck.

Friday, January 3, 2014

Motivation for 2014

Right now, I'm straining something fierce for some motivation to kick this semester off hard on Monday. This break has been incredibly relaxing, more so than I could have imagined around Christmas time. We saw tons of family, had plenty of time at home sleeping, reading, watching movies, playing games, doing NOTHING. I'm well rested and everything... But I'm not quite ready to start working hard again. Here, let me provide some context:

Last year (the first year of med school) was the hardest in several ways - it was a huge shift in schooling style, it was scary because of thoughts like "what if I fail an exam" (or worse a CLASS) or "will second year be easier or harder than this?", and it was the first time in years that I'd been separated from Wife for extended periods of time. First year was the beginning of the unknown. Stress.

Happily, I've found 2nd year to be much easier emotionally, and the life- and study-styles are much more enjoyable, personally. This year is definitely easier, because it actually feels like I'm learning things that will help me be a doctor, not just things that will help me learn things that will help me be a doctor. Things about sickness, disease, malfunction, and how to fix it all. That's right in line with my personality; much to Wife's frequent frustration, it's instinctive and preferable for me to listen then FIX, rather than simply listen. So, I suppose it makes sense that I find this year an all-around better experience.

However, this year is also TERRIFYING in its own way. I now have six months, one week, and six days until I take the Step 1 exam. It feels like just yesterday it was a whole year away. Anyway, in these six months, I will hopefully pass through the Cardio, Pulmonary, Urinary, Digestive, and Metabolism/Endocrine/Reproductive Domains. I'll get 5 class-free weeks and 5 days to prep for Step 1. This test essentially determines what caliber of residency I will be able to aim for. It has the single largest say of what I do with my life. More than grades, more than recommendations or clinical year evaluations, the Step 1 is the deciding factor.

And that's terrifying. And just like that, I've found my motivation to study hard this semester - fear. I'd like say that it's excitement to discover my personal potential, passion for the material, and an overwhelming pride in the profession that I'm seeking. All of those things are definitely present, but at least right now, the biggest motivator of all is that smooth icy sphere of fear resting in my abdomen. And that's okay. It's just like the twenty minutes before I take any exam, just drawn out over almost six months. I always calm down the second I start the first question.

Come on, first question.

All right. Enough avoiding the next batch of practice problems. It's time to study.

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