Tales of the Perineum

Pictured here is one of many different views of the Pelvic Floor and Perineum. This is the region of the body that has, well, all of those bits that you need to finagle around during your history and examination without *actually* talking about them.

At my medical school 'Abdomen, Pelvis, and Perineum' (APP) is the last large anatomical section covered before the comprehensive final exam. The faculty, wisely, threw us into Perineum first, as though to get out of the way.

You see, this section turns every driven, focused, sometimes married medical student into a Twelve-year old-- if only for a few minutes during a supplemental study group session.

My moment came this past Thursday when our Supplemental Instruction, an elective review group that meets twice a week to review lecture and lab concepts started reviewing the features of external genitalia. For the vast majority of the time, we sift through the slides, label diagrams, and look at Netter diagrams that are just contrived enough, without sacrificing accuracy, that one wouldn't feel uncomfortable.

Avoid eye contact, crack a little one liner, and keep labeling-- Rinse repeat.

Our group leader, Christine, thought we should go through and check our answers as a group. Usually this is a portion of the class where a few of the students, typically bright, type-A's tend to dominate the conversation and turn each question-answer session into a competition. I joined in at the beginning of the year, tasting the same prospect they must have to set themselves apart from a group; but I've since chilled out and filled the niche of "that guy who follows up what people say with some witty retort". I figure, let's save the frustration and stress of such competition for when we have to impress someone.

Christina pointed at a structure using her handy-dandy overhead and we mumbled out an answer (or sometimes a few different answers). We began on the external female genitalia: mons pubis, labia majora, etc.

Finally her pointer landed smack dab on the glans clitoris.

Well, in the rush to answer first my good, and married, friend Steve (one of the competitive types, but with a good sense of humor) blurted out, "External urinary meatus....uh..err." He strained, quickly realizing the gravity of his error.

I couldn't resist. Before Steve could correct himself I loudly responded, "So Steve, how's your marriage?"

The group erupted in laughter for a good moment, and a few people chimed in with various un-professional-but-hilarious comments they seemed to have bottled up. It was as though we performed some fasciotomy on the compartment syndrome-like tension.

After getting that out of our system we continued with the review series and went on learning.

The Medical School Interview: Some Advice

So, I haven't posted in a while and I thought I'd post some of my musings.

I work as an admissions ambassador at the medical school I attend. It's a nice extracurricular and gives me a chance to show off the school that I'm proud to be attending to prospective students. I also like helping applicants feel at ease through what is a very nerve-wracking experience.

My favorite part of the job is conducting the student interview. I really get excited when an applicant gives well-thought responses to the very ambiguous and often intellectually difficult questions that the admissions board dreams up. However, after conducting a bad interview or two, I thought I might post some suggestions for any pre-meds reading this.

What not to do during an interview:

1. Do not ask the interviewer what he or she thinks about the question.
I've thought about the question, I've probably answered it in my interview. The idea of the interview is for me to get a better idea of you as a candidate, not the other way around.

2. Name dropping isn't impressing anybody.
No, I'm not interested that you share Schopenhauer's opinion on the subject. That is, unless you explain what Schopenhauer's idea was and why you agree with it. Asking me if I've "read Schopenhauer" and stopping when I say that I have doesn't make you a better candidate.

3. Don't bring weaknesses up unless asked.
I make it a point to ask what applicants think their biggest strengths and weaknesses are. However, don't start the interview off by telling me why you got that "C" in Physics. I didn't even know you got a "C" in Physics until you told me. And now I have to listen to your awkward excuse. If you are going to say things without a prompt, make them positive things.

4. Speaking of weaknesses... be honest.
I wasn't the strongest candidate for medical school. I wasn't the 4.0, 15 extracurricular, 42 MCAT student either. But when I ask you a question that requires some honest introspection, don't give me a weak answer. For instance, if I ask, "How do you think you won't be a good fit for medicine as a career?" a bad response will be, "I care too much. I will have a hard time if I don't get the tests I need when I want them." Or when I ask what you think is a character weakness, don't reply, "I am too compassionate. I would spend all of my time on every patient so they receive the best care I can give, at the expense of my own time."

Give me a real weakness and a real solution. I will give you points for self-examination.

5. Don't ignore the strengths and weaknesses of each program

I chuckle when I read the U.S. News and World ranking of medical schools. You know how they make their lists? They rank schools based upon faculty bias, the credentials of entering students, and the number of applicants that the school rejects. I'm serious, check out their methodology.

The fact is: latissimus dorsi, glycolysis, Trisomy 21, dermatomes, H&Ps, and all of the details that a med student are expected to learn do not change from one medical school to another. Every student is expected to demonstrate the same proficiency on the USMLE and every school will likely prepare you.

So don't ask me about my schools rank.

Instead, tell me the aspects of the program you are applying for that you like or don't like (if you care to). For instance, my school puts an emphasis on developing globally minded physicians who have a concern for the underprivileged. My school also wants to create doctors that will stay in state. My school has one of the best Primary Care programs in the country.

Telling me you are a future Dr. Meredith Gray hoping to go into CT Surgery out in suburbia will not earn you points.

Yes, our students pass the USMLE at higher than the national average (which is already 90-ish percent). No, I don't know our exact score. Yes, you will likely place your first or second choice residency if you try hard enough. Yes, even programs like Mayo and Mass Gen. No, I'm not impressed that you went to Darthmouth.

6. Choose your examples wisely
One thing that impresses me is when an applicant supports his or her answer to my questions with an example from his/her clinical experience. I'm aware that not everyone has clinical experience, but I can guarantee it will make a much stronger applicant out of you if you do.

If you don't have clinical experience, talk about some sort of experience that might be equally significant, such as volunteering at a charity or following a family member through a medical problem.

The reason I say this is because I find it hard to believe that your experience at Best Buy working on the Geek Squad taught you as much in terms of interpersonal communication. I'm sure it was a difficult day for many of the people who came in with broken computers and software. But I doubt the experience was as life changing as you are describing it. Besides, I don't these people are having nearly the "bad day" that they could be having in, say, a cancer ward or emergency room.


Hope the advice helps. Or at the very least, amuses.

Did you know..

Did you know that water follows solute? Because if you didn't, I know a pom-pom equipped professor who will be happy to educate you.

Here’s a med school musing. We recently finished our Biochemistry final exam, which tested our accumulated knowledge of what is normally 2 semesters of biochemistry in undergrad crammed into 8 weeks in medical school. .. yeah…

I digress. One of the common questions found on our exam was regarding mitochondrial poisons. The question set up a patient vignette who is near death because of some unknown mitochondrial poison. Because each poison effects a different “Complex” in the chain we can ascertain the poison if we know the hypothetical levels of their intermediates (e.g. If there’s an abundance of QH2, what Complex I and II make; but an absence of reduced cytochrome c, what Complex III makes, then complex III is poisoned by Antimycin). ETC==> http://en.wikipedia.org/wiki/Electron_transport_chain

This is easy, binary style detective diagnosis in our biochemistry exam and usually freebie points.

Now, excepting for a moment that we can’t actually measure these mitochondrial concentrations at all, one of the steps in the diagnostic process is insane. The poison is Oligomycin. If you absorb it, it essentially plugs up the giant end machine at the electron transport chain called ATP Synthase. ATP Synthase looks like a big revolver, sans handle grip. It functions by using Oxygen, Hydrogen, and shuttling protons across this inner mitochondrial membrane. This whole reaction is energetic enough to make ATP and burns up Oxygen as a consequence (turning it into water, actually).

So if ATP Synthase is plugged by Oligomycin, no Oxygen is being consumed. Here’s how we theoretically find out how it’s oligomycin and not any of the other poisons further back the chain: we give our hypothetical patient another poison… 2,4, DNP (which interestlingly enough was used as a Phen-Phen-like weight loss 'cure').

This poison works by “uncoupling” the membrane, letting all the protons flow through without doing anything. If oxygen consumption resumes, it was Oligomycin all along. If oxygen consumption doesn’t resume, well, you’ve just poisoned your patient on top of the existing poison in his blood.

My question is: What if it is Oligomycin?

2,4 DNP doesn’t fix the problem, it just shows you what the poison is… and now you have to deal with counteracting 2 poisons instead of one. I’ve got to imagine this would ruin anyone’s day.

Moral of the story: If you do swallow a little bit of cyanide and somehow live, tell us what you took. You do not want us trying to figure out what you took.