Starting the Last Unit of MS2

Today we start the last unit of our pre-clinical years. Only 1 more exam stands between me and the end of my second year of med school! Then its one big board to pass before I start seeing patients in July; I am so excited! :)

This last unit of Organ Systems covers the Reproductive System, Skin & Connective Tissues, and a few miscellaneous lectures on things like aging, formulating new drugs, and clinical labs.

Yesterday, I completed my second-to-last exam of the year, which covered the GI system and the Endocrine System. I feel very confident on how I performed in regards to pathology and even pharmacology, but I am a little nervous about the physiology portions. Some of the questions  were tricky. For the physiology questions, I always have to go through all of the answer choices and literally decide which ones are obviously not true, which ones are sort of true, and finally choose the answer which is the most true (so-called "most correct answer"). That is to say that there can be, and often are, more than one correct answer; the tricky part is knowing which one is the most correct. For example, one of the simpler questions asked: which is most associated with cancer of the gallbladder? obesity, gallstones, male gender, ulcerative colitis, or old age. Of those choices, only 1 is truly false - male gender. All of the rest actually are risk factors: obesity, gallstones, old age, and even Ulcerative colitis - it has even been weakly-linked with gallbladder cancer, so technically that may be correct also. But the "most correct" answer is Gallstones, as they are the highest risk factor for GallBladder cancer. The silly thing is gallstones are really common, and gallbladder cancer is quite rare; that is to say, most people with gallstones won't develop cancer. And another thing, only about 75% of patients that have gallbladder cancer ever had gallstones. So I'm not sure how strong of a link there really is between the two.  Anyway, that's just a little taste of what the 108 question, two-and-a-half hour exam was like.

3 weeks left until Step 1 prep takes over my life! And only 3 weeks left of my pre-clinical years, wooooooohooooooo!! :)

Birthdayyy!

Yesterday was my fiancé's 24th birthday!!! I am so thankful to have him in my life; he is so understanding and kind-hearted, and he makes me try, every day, to be a better person. He believes in me even when I don't, he thinks I'm the smartest girl in the world, he tells me I'm beautiful even without any make-up on, he is always there as a shoulder to cry on, a best friend to lean on, an ear to listen to my frustrations, to lend a hand, to quiz me before exams, to celebrate with me after each step towards becoming a doctor, to cook me food when I forget I need to eat, to take a walk when I need to relieve stress, to watch a movie when I need to relax, to play games when I need to have fun, to drink a beer when I need to unwind...there are literally a million little reasons why I love him so much, but the one big reason I love him so much is because he makes my life complete, and without him, I know that I would get nowhere. It's only through his endless encouragement, patience, and understanding that I am able to be where I am right now, and I know that if it weren't for him, I would never be able to fulfill my lifelong dream of becoming a doctor. He believes in me unconditionally, and he makes me strive to be the very best person that I can be. He is truly an amazing man, and every day I thank my lucky stars that he came into my life and made me the happiest girl in the world. So my lovey, happy birthday to you. I promise when we're old and have money to throw about, your birthday presents will be top notch. But for now, I hope a whole lot of love will do. 

Lack of Lynch Info

As I am revising the GI system, I keep feeling a bit irritated by the lack of information we were given in regards to HNPCC, or Lynch Syndrome. Normally, the less info I need to shove into my brain, the happier I am, but we were literally only told to remember a few things about Lynch Syndrome. It's caused by a mismatch repair gene dysfunction, and it is associated with colon cancer. That's it. Having done my entire Senior Thesis project on HNPCC, I feel like the pathology associated with HNPCC should be presented more in depth. But I suppose I am a bit biased...

Lynch Syndrome is, in essence, the reason I decided to become a doctor. The kindest, most compassionate, and most giving person I had ever met passed away because of colon cancer. She was my aunt, and she was young. My grandmother passed on because of colon cancer the same year that my parents were married; my uncle has recovered from colon cancer, my 28-year old cousin is battling against colon cancer, and another aunt of mine is now battling this cancer for a third time. I've even had an 11-year old cousin diagnosed with Medulloblastoma (which can be associated with Lynch Syndrome). Clearly, colon cancer is strong in my family, and because of that (according to the Amsterdam criteria), we are categorized as a Lynch Family. As such, there are many cancers to which we are predisposed, including the obvious colon cancer, but also endometrial, ovary, stomach, small intestine, brain, urinary tract, and skin cancers. This also means that we need to visit several doctors annually to check for any possible malignancies...including annual colonoscopies starting at the age of 18. The frustrating part is the fact that there have been several doctors that I have come across that don't know much about Lynch Syndrome, and certainly don't know the associated increased cancer risks. In fact, my dad went to a dermatologist who knew nothing about what to look for in a Lynch patient. Hellooo, derm is one of the most difficult specialties to get into, and he doesn't even know that Lynch syndrome can predispose you to skin cancer!? There must be something wrong with our education...

So what are the things that I wish all doctors knew about HNPCC/Lynch Syndrome? Many doctors need to be able to assess these patients' risks, because there are many links to cancer, not just of the colon (Gastroenterologist), but also of the endometrium and ovary (OB-GYN), stomach and small intestine (Gastroenterologist), brain (neurologist), urinary tract (nephrologist), and skin (dermatologist). It's an autosomal dominant defect in mismatch repair, with a mechanism of action as a two-hit occurrence. In a patient with the Lynch genetic predisposition, there is a 90% chance that he/she will develop cancer during his/her lifetime, and it is likely to happen at an earlier age than the general population. They need to have annual screenings, and they need each of their doctors to know what to specifically screen for. If an OB-GYN, take an endometrial biopsy during each annual visit; as a dermatologist, specifically screen for skin cancer (and do a thorough check) and remind the patient to check his/her skin monthly; as a GP, get a urinalysis check for abnormal cytology that may indicate urinary tract cancer and also monitor for any neurologic changes which might suggest a malignancy in the brain.

I guess a big reason why I'm such an advocate on educating fellow future-physicians is because I had an adenomatous polyp removed during my last colonoscopy (in March), located in the right side of my colon. While I can't say conclusively that I have the defective mismatch repair gene, I do know that my risk of developing colon cancer is real. Adenomatous polyps are precancerous lesions. It was removed and biopsied, so it didn't have the chance to grow into a malignant lesion this time.

While you can't distinguish between an adenomatous (precancerous) polyp and a hyperplastic (noncancerous) polyp on gross visualization, this is what my little polyp looked like from the endoscope's point of view:
(The polyp is the little bump in the bottom right picture):

Nasty little shit, isn't it?! ;)

I hope you all learned a little bit more about HNPCC/Lynch Syndrome and how to better serve your future patients!