CAPSTONE

The "final course" of the first two years of medical school at Ohio State is called CAPSTONE, a class designed to put the finishing touches on pre-clinical medical learning and prepare the student for life in the trenches next year. Last Friday (2/23) was my class' first CAPSTONE meeting, and I left feeling absolutely stupid. The entirety of the first two years of medical school is spent learning physiology and disease states in a 'unidirectional' manner -- i.e., name of disease, etiology (aka "causative agent"), epidemiology ("who gets it?"), pathophysiology ("how does it work to cause disease?"), signs and symptoms, and treatment. I've trained my mind to work fairly well in this manner, as reading through a course packet or a fairly dense pathophysiology textbook is no longer the chore it once was.

But here's the thing about CAPSTONE -- now I have to "unlearn" everything I've learned about medicine and start applying it in reverse. Last Friday we were given six packets of patient cases; in each of these packets are summaries of four fictional patients with a wide variety of current medication lists, presenting symptoms, physical examination findings, and relevant histories. Our job now is to apply what we've learned since August 2005 and find out exactly what is causing the problem. Easy, you say? Think again.

The only analogy I can think of is this: imagine learning to play the piano without your hearing. Your ears have been plugged, and the only things you can rely on to play this instrument are (1) your manual dexterity, and (2) your sense of sight. You certainly would be able to read the music and process your visual sensations into specific finger movements after a good deal of training. That part is like being a Med-1/2 student.

Now imagine your ears have been unplugged for the first time since your piano training began -- except now your vision is taken away in return. Part of the skill set you used to learn the material in the first place is gone, and now you need to teach your ears what your eyes already knew using only the memory of movement and placement ingrained in your fingers. The only problem is that you need to do this quickly. And flawlessly. Why? Because your grade and subsequently your chance at a prestigious placement in postgraduate training depend on it. This is akin to being a beginning third-year medical student.

Ready for a breather yet?

Despite the overwhelming nature of the course, I think CAPSTONE will be of great benefit to those of us willing to take it seriously. The learning curve is steep, but in the wake of "solving" the first case (see below), I believe our group of six students has taken the first step in the process of transforming our thinking. And that is a very good thing.

Case 2a -- 3/2/2007

Middle-aged white paraplegic female with a history of breast cancer with spinal metastases presents with a 2-day history of progressive dyspnea (shortness of breath) and tachypnea (increased number of breaths per minute). Patient has difficulty completing a sentence without stopping to catch her breath and has difficulty eating and drinking. Patient denies chest pain but does have a dry cough.

Medications:

Naproxen 375 mg po BID
Percocet 5/325 mg po q6h
Duragesic patch 75 mcg q72h
Xeloda (dose unknown), per protocol

Physical Exam:

Temp. -- 100.4F (normal 98.6F)
Respirations -- 40 per minute (normal 12-20)
Heart Rate -- 149 per minute (normal 60-100)
BP -- 90/40 (normal 120/80)
Pulse oximetry on room air -- 89% (normal 99%)
Pulse oximetry on 100% oxygen -- 93%

Due to her immobility, history of malignant cancer, heart rate > 100 bpm, and increased respiratory rate, our group diagnosed this patient with a pulmonary embolism resulting from deep vein thrombosis (i.e., a clot resulting from stagnant blood in the deep veins of the patient's legs broke off from its site of formation and traveled through the venous system into the right side of her heart; since blood from the right side of the heart is pumped into the lungs for re-oxygenation, this clot became lodged in pulmonary vessels leading to the lungs and is causing her shortness of breath, increased rate of breathing, and decreased arterial oxygen content).

It seems easy in hindsight, but when first confronted with this illness script after learning about pulmonary emboli in the way described above, it was a bit daunting, to say the least. Several different diagnoses have to be considered and discarded before finally settling on the most correct one (the process of developing such a list of possible problems is called "formulating a differential diagnosis"), and eventually it will have to be done within a matter of seconds. All the possible disease states this patient could have -- pneumonia, pleural effusion, acute pulmonary edema, sudden inflammatory response syndrome, congestive heart failure, etc. -- have to be thought of, considered, and ruled out before the doctor can begin discussing treatment options with his/her patient.

I was lucky to be able to come to a conclusion after an hour of re-reading through textbooks and study guides. Your doctor is able to do this in less than 15 seconds.

I've got a long way to go ...