I’ve just had a fascinating look at the structure of medical school in Argentina, from a medical student who emailed me last week (the email follows). I think often we assume that teenagers in the US could never decide by 18 to pursue medicine for the rest of their lives, but starting medical school after high school is, I think, the norm in most other parts of the world. Although I definitely was leaning toward a career in medicine by the end of high school, by no means was it definitive. I definitely grew a lot during college and learned many things about myself that were important in strengthening my decision to apply to medical school. Clearly countries that structure their medical training more like Argentina have a longer medical school program, and it sounds like their curriculum is probably more extensive than ours; I imediately noticed several areas of traning that my friend has that I feel like I’m severely lacking, and some very different emphases.

Some of the highlights:

• Starting early with training physicians about mental health
• Multiple specific courses on Public Health and Bioethics
• Splitting up semiology (signs and symptoms, if I’m not mistaken) from diagnosis and treatment
• Required toxicology, trauma, legal medicine, and dermatology
• Separate full years of Internal Medicine (2y) and Surgery (1y)
• A seemingly different residency/fellowship program

Here, we finish High School when we are 18 years old., after that it depends in which University you will study the career, at UBA( wich is the very best here) we have to do the CBC,(common basic cycle) a whole year, then, if we can make it that, we start with:

First year :Anatomy , Histology, Embriology( i´ve been teaching it for 6 years) , Molecular biology and Genetics and Mental Health.

Second year: Phisiology and Biophisycs, and Human Biochemestry

Third year: Pharmacology I, Pathology I, and Microbiology
Plus Bioethics I , and Family Medicine( 1st or 2nd or 3rd year)

Fourth year: Internal Medicine I( Semiology) and Pathology II, Public Health I, Bioethics II

Fifth year:Internal Medicine II( diagnosis and treatmente, Nutrition, Radiology(Image diagnostic), Neurology,,Nuemonology, Pharmacology II( I ve been teaching it a year so far), Infectology,Public Health II, Toxicology. Psiquiatry, Dermatology

Sixth year:General Surgery, Ginecology, Pediatrics, Obstetrics, Traumathology,Oftalmology,ORL, Nuerosurgery, Legal Medicine, Urology

Our career is devided in to cycles, the first one: “Biomedico” I°, II°, III° year
The second, “Clinico” IV°, V°, VI°.

But there are exceptions, there are some Hospitals where you can finish before or even after.
And to finish, we have to do a whole year Internship( for free), in a Hospital from 8 AM to 17 PM.
We have a whole month from the ” Internado” to rotate where ever we want and in the subject we choose.

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I’m supposed to help lead a session today with some preclinical students and discuss the challenges of being on the wards as it relates to maintaining perspective and understanding patients outside of a strictly medical realm. I’m starting to posit that it’s almost a physician’s duty to be compassionate, if only for the fact that we contain knowledge about a person’s disease or medical state that most other people don’t. I think an example will highlight this:

I saw a patient yesterday in clinic who was on chronic high-dose steroids for rheumatoid arthritis. He was totally Cushingoid from his steroids–he had a big round face, major abdominal obesity, thin skin, extra hair growth, and had fractured multiple bones because of the osteoporosis from steroids. And I thought to myself, “You know, I bet when she walks around, or is pushed around in her wheelchair, most people just assume she’s obese, call her fat, and think she just has no control over the food she eats.” Most people wouldn’t necessarily recognize a person with these features–or even realize that these features together equal a medical syndrome. Because we understand her disease process, we absolutely must show compassion–if we don’t, and we supposedly understand her condition, how can we expect anyone else to? (I’m of course not assuming that I understand what it’s like to have a chronic disease, or live with any of these symptoms daily, but just that we understand the pathophysiology behind it, and realize the cause is not primarily a character flaw.)

Or the Middle Eastern man who took tiny steps, wincing with pain with each; no one else could tell he had an enormous, incredibly painful rectal cancer. Or the woman with throat cancer who had to have her neck opened up to remove the lymph nodes, and had her shoulder and neck nerve (Accessory Nerve, CN XI) cut on both sides? Unfortunately these people are probably just assumed by passers-by to be weirdos, freaks, geeks, mentally retarded–the epithets go on and on. But it’s the health professional, who understands the disease, prognosis (chronic pain for many years? 3 more weeks to live?), and challenges of patients that must show care.

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I’ve had an overwhelming response from everyone reading lately, and I just wanted to say thanks. I’ve heard from physicians, nurses, fellow medical students, and retirees in just a few days–from across the US and even around the world. Credit goes to Nick at blogborygmi for making it all possible, and for his fantastic interview questions. I wanted to include all his questions here, because he asked such great ones (and I gave such great answers). I kid, I kid! (I’ve gotten a lot of questions about how to get updates about this website. I offer an RSS feed, which you can subscribe to in My Yahoo or My MSN if you’d like. For email updates, enter your email address here:

1. You’re one of the few medical bloggers that started before med school. What was your site before, how did it change / how did you refocus? Obviously you’re writing more about medicine, but did you used to advocate for healthcare reform? Or did the techie stuff just get replaced?

   My previous site, which is, eerily, still available in the Internet Archive, was mostly just random rants about politics and health care. A few internet memes and links (similar to my “Goodies” links now) and a collection of quotations as well. Not much techie geek stuff. It was called the Glog (Graham + blog), and when I re-read it now, I’m not surprised no one ever commented. It was incredibly boring, and didn’t offer any interesting perspective or unique ideas. Mostly just related other people’s ideas and my take on them.

   I re-focused by deciding I would make my blog more focused, and only post about medical/health care stuff. I think it gives people a reason to read; they know they’ll find out something about health care or medicine, even if it’s just my personal perspective on it. There’s very few bloggers out there ( Mimi Smartypants is the only one I can think of) that can write about their daily lives and make it entertaining and fun enough to actually want to read it. Most people need to have a topic or subject they primarily cover.

2. Who is your audience? Do your classmates follow the blog? Is it mostly people who know you or complete strangers? Are you worried about having your name out there, now that you’re blogging about patient encounters?

   I don’t know who the hell reads this thing. My parents, some of my classmates and friends from college, and some pre-meds, physicians, bloggers, and other Internet strangers, mostly. I think I have a tiny (but loyal!) following, and the rest are people that Google “fetus in fetu,” “pee on me,” or “cranial nerve mnemonics” and find my page at the top of their search. Just yesterday I had a medicine resident at my medical school write saying that he enjoys reading it, and several other residents do too, which was quite surprising.

   I’m not particularly worried about having “my name out there” now that I’m seeing patients. (Maybe I should be?) I have to bite my tongue sometimes; I’d really like to rant about an attending or resident, but choose not to. Thumper’s mother’s rule is sometimes a guide: “If you don’t have anything nice to say, don’t say anything at all.”

   As far as patients go, I usually change the patient’s identity pretty substantially , and change the dates around that I saw the patient as well; different name, different gender, different hospital, etc. Will something I’ve posted come back to haunt me? I can’t say, but I want to be the kind of doctor whose patients realize that I try really hard, think about patients as people, not diseases, and try to educate and give perspective as much as I can. I think blogging shows them that I’m deeper than just my white coat, but also just as imperfect and human.

   (That being said, I’m considering going underground for residency. But who knows.)

3. Your single-payer flash, your recent Medicare walk-through, these are really great uses of computer- savvy to improve education on health care. Is this your passion? Would you do more of this if you had time? What else is in the works? Is the blog an end in itself, or just a framework for these projects?

   There’s probably some amount of cognitive dissonance in the computer/education stuff that I do, y’know? I want to feel like I’m somehow contributing something larger than just learning about medicine; I don’t think anyone should get to pass as a do-gooder or improver-of-health just by having an MD after his or her name. (Maybe an MPH, but I digress.) But yes, the computer geek in me is really passionate about this stuff. I love it. But I think that creates my biggest blindspot. *I’m* such a tech-oriented person (and, I should say fortunate enough to be able to afford the technology I love) that I get in the mindset that everyone is.

   I play mind games through my head where a tech utopia exists and everything just *works* right, but it probably won’t ever happen. Maybe more and more as the younger generation grows up, but for now, I think the fact that the education/websites/whathaveyou I come up with are computer-oriented severely limits their effectiveness.

   How many people are probably going to see the Medicare Part D Walkthru? Not many. But I keep doing it, hoping that it maybe helps a few people make sense of it. I think I have a particular talent with computers and technology where many of my classmates don’t, and I think it’d be a waste if I didn’t try to use them to improve medicine or healthcare, however that may be.

   If I had more time, I’d definitely try to do more; I’m considering taking a year off to do just that. If anyone has any stellar ideas, I’d love to hear them. I’m always coming up with ideas, but my brainstorm dies down to a light breeze when I’m busy in clinics.

4. You actually, you know, call bloggers out on some of their posts. Gruntdoc on the psych patient, Medpundit on her healthcare simplifications. I’ve been reluctant to do that because they’re attendings and I’m still new at this. Have you gotten any feedback, and responses or reactions from them? Any thoughts on the role of a student as a health care reform advocate?

   Come on. Everybody loves a controversy. *Especially* bloggers. It drives more people to read!

   GruntDoc and I had a great debate back and forth a couple years ago on Stanford’s new curriculum. Overall, I think if people aren’t watching who’s linking to them, they can totally miss out on someone else’s criticism of their post. I think Medpundit has no idea people criticize her or correct her incorrect statements on other weblogs; there’s no way to comment on hers. (I’ve rarely ever seen her respond to criticisms.) I’m of the mindset that just because I’m less experienced than an attending doesn’t make my opinion wrong. Now, if it’s a clinical matter or data-related bickering, it’s useless to call them out on it; they’re probably right, I’m probably wrong. But if it’s an opinion about a patient or a policy, I think it’s fair game.

   And look, this is not to say that I will not become jaded, that I will not use humor to cope, that I will never change my opinions. I think that the medical student can be one of the most important people on the team, reminding residents and attendings that the patient exists in a context outside of the medical realm. If my criticism causes someone to be reminded of that, great.

   Humor is totally, I mean totally, required for medicine. If you can’t laugh off some of the absolutely terrible, devastating things that you see and hear from patients every day, you’re a goner. I just think there’s a big difference between laughing off some frustration behind closed doors with other medical professionals and getting a laugh in a public forum–be it a blog, a bar, or a cocktail party.

5. What kind of doctor are you gonna be? You have 11 months to decide. Still thinking about EM? Can I talk you into it?

   Wait, *what*? No one ever said anything about *deciding*. Doesn’t someone just, like, *tell* me which one to pick?

   I’m all over the place. Probably not surgery, but maybe. Geriatrics is getting high points so far for its interdisciplinary approach and the fact that older people are just so gosh darn cute and tell great stories, but I love the atmosphere of the ED, too. People yelling, speaking 5 different languages, people from all walks of life.

6. Can you link to some of your favorite posts? Some things that were fun for you to write, or something you felt strongly about. Something that led to a lot of comments, a good discussion.

   The typical dissection post:
   http://www.grahamazon.com/2004/01/dissecting-the-brain/

   The breast exam post:
   http://www.grahamazon.com/2004/04/boobies/

   The health policy/advocate posts:
   http://www.grahamazon.com/2005/10/the-aarp-sells-out-again/
   http://www.grahamazon.com/2004/09/the-story-of-eflornithine/

   The more flighty/thinking about medicine and stuff posts:
   http://www.grahamazon.com/2005/07/attaching-to-patients/
   http://www.grahamazon.com/2005/01/protein-reincarnation/
   http://www.grahamazon.com/2004/05/see-one-say-one-teach-one/

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