Medical School Pre-Clinical Years: Twenty Questions (Part 2)

What About “Early Patient Contact?” Is It Important?

No. “Early Patient Contact,” like “All Natural” and “Holistic,” is a marketing phrase designed to entice earnest pre-meds into one medical school over another. Like “Problem Based Learning,” another slick marketing phrase, if I had my choice I’d flee as if from the Devil himself a school that touted this sort of thing. As if it’s not bad enough that on the first day of third year you have to march around the hospital like a big, fat, ignorant dork, at a school with “Early Patient Contact” you will not even have the benefit of a couple of years of medical knowledge crammed into your head when, like a cheap poseur, you will flit around in a sack-like short white coat, bestowed no doubt in some retarded White Coat Ceremony, trying not to spook the patients.

What’s the point? You will get, like God intended, plenty of patient contact during third and fourth year. The brief exposure to real patients in first and second year will be like studying during the summer before medical school, something anyone will tell you is a useless because even if you studied the right material, you will blow through your entire summer of effort in a few days once you start. In a similar manner, all of third and fourth year will be spent in contact with patients. The little bit of play-acting you do in your pre-clinical years will be a drop in the bucket and not worth the effort. Either that or they will give you a lot of Early Patient Contact and it will seriously intrude on your study time or anything else you wanted to do besides stutter your way through patient encounters with people who have diseases you have never heard of.

I would definitely run from a school that promised some sort of student-run clinic (usually for the indigent who are not particular about their food, sleeping arrangements, or doctors) during first and second year. Maybe I’m a purist but your first two years are best spent learning the theoretical basis of the medical profession, not playing doctor. I know that many of you feel that it is important to “keep your eye on the prize.” You believe that by seeing patients early you will stay motivated for the long struggle. For my part, I saw plenty of the motherfuckers hobbling into the building as I drove past them every morning on the way to the parking lot and that was enough. I like being a doctor but first and second year are probably the last time in your working life you will not spend your day listening and responding to someone’s complaints. Relish it.

Bottom Line? Early Patient Contact is unnecessary. At best it is an annoying distraction but if overdone, has the potential to really eat into your otherwise valuable time.

How Will I Handle Gross Anatomy Lab? Is It As Disturbing As I Imagine?

The hardest part about gross anatomy lab, at least from a psychological perspective, is maintaining the proper respect for your cadaver. Although the body you will be dissecting was once someone’s husband, wife, son or daughter, after a couple of days you will be so used to anatomy lab that the cadaver will begin to seem more like a piece of rancid meat than anything else. This is not to say that anyone is overtly disrespectful to the body. I believe that stories of medical students stealing body parts for use in elaborate practical jokes are mostly apocryphal and I never saw anything of the sort in my class. Rather, you will develop a casual relationship with your cadaver and you will find yourself leaning nonchalantly on the body, idly picking away at some scrap of flesh or another, as you daydream about what you’re going to do over the weekend or about the dinner party you are planning.

As for the initial weirdness of the situation, the sensation that you are doing something completely beyond the pale, that will last about five minutes as will any sensation of revulsion. Familiarity, after all, leads to acceptance and people have gotten used to and even grown comfortable with practices many times worse than dissecting a cadaver. You will, of course, dread your first encounter with the embalmed body of a real human being. Everybody does. It is often the biggest worry of new first year medical students and as you file into the lab for the first time, the tension, manifested by strained jokes and nervous laughter, will be obvious. It will quickly dissipate however as you expose your cadaver for the first time and get to work. To lay hands on the a cold, dead, naked body for the first time and to feel the rubbery texture of long dead muscle is the big hurdle. Once done their is nothing more to it. Certainly in the future you will step back from some particularly revolting procedure, sawing the head and neck in half and opening them like a book for example, to marvel at the creature that you are mutilating but it will be more appreciation than disgust.

As a precaution, you will probably not have eaten breakfast on your first day of gross lab. As the morning wears on you will forget that you were ever worried and look forward to lunch.

What’s Gross Lab Like?

At my school, the lab was in a large, bright, tiled room. There were about thirty “tanks” in the room, something like large stainless steel bathtubs on legs, that held the cadavers. The tanks had mechanisms to raise the cadaver out of the tank. At the end of the day the cadaver was lowered back into the pool of embalming fluid to keep it moist. A dried-out cadaver is hard to dissect and can still rot even though it is “preserved.” We had spray bottle of embalming fluid to periodically wet the areas we were dissecting. We kept the rest of the body covered with an embalming fluid-soaked sheet, not from any sense of propriety but to keep the cadaver, particularly the face and fingers, in good condition.

We had four students assigned to each cadaver. The cadavers themselves were mostly elderly people but there were a few relatively young bodies. Some were obese which makes for difficult and messy dissection as adipose tissue is greasy and difficult to dissect through or around. Some were better preserved than others. The tank next to mine opened their cadaver’s abdomen and were greeted with a flood of putrid goo, all that was left of the body’s internal organs.

Dissecting can be difficult and, particularly for delicate structures like nerves and small blood vessels, can also be extremely frustrating. Imagine trying to pick through a piece of chicken or roast beef looking for something the size of a thread. That’s what a lot of your time will be spent doing. Certainly you will easily appreciate large structures like internal organs and big muscles but the bulk of your time will be spent picking away at little things. You want to avoid using a scalpel for this as much as possible because it tends to cut across planes and distort anatomy. Blunt dissection with your fingers or a small instrument is the preferred method.

I was never very good at dissection. I don’t have the patience and I didn’t like anatomy lab very much so I spent as little time as possible there. In second year I skipped a lot of labs because, well, I was tired of picking at the damn things and smelling like embalming fluid. My wife refused to drive my car because even if you change scrubs, the smell gets into your pores and everything you touch is contaminated. My wife made me strip in the garage when I got home and proceed to the shower without touching anything.

Riding in an elevator with students just out of lab is unbearable and many people get one whiff when the doors open and decide to wait for the next one.

Anatomy lab was low-yield for me. I did very well on all the tests however because I had a good photographic atlas that showed perfectly dissected specimens. Gross Anatomy tests, you understand, are “practicals” where you circulate through the lab from tank to tank, identifying tagged structures on other people’s cadavers. The instructors looked for well-dissected structures that usually looked almost exactly like those in the atlas. If they couldn’t find a good example they dissected one themselves. So you see, my photographic atlas was like anatomy lab without the bad smell.

I did better on the practicals than many people who came in on their own time, after hours and on the weekends, to dissect. You are certainly allowed and even encouraged to spend as much time in lab as you want.

Get some cheap scrubs to wear in lab. We were not allowed to wear street clothes in our lab but even if you are resist the temptation unless you don’t mind throwing them away. I discarded all of my gross lab scrubs when I decided to stop going as well as my shoes.

Your group should get an anatomy atlas to keep in the lab as well as a “dissector,” the book that gives instructions for dissection. We kept ours in a plastic bag in the tank on top of the cadaver. The reason for this should be obvious. Do you really want to study on your kitchen table with a book that is soaked in corpse juice and may have small bits of human flesh stuck to it? Not to mention that it will stink up whatever library or Starbucks in which you decide to study.

Get a turkey baster. keep it in the tank. Trust me, there is nothing better for draining fluid out of body cavities and it beats rolling the body to drain it.


22 thoughts on “Medical School Pre-Clinical Years: Twenty Questions (Part 2)

  1. Ok, so I loathed anatomy (like you, too little patience) but I only had it for 10 weeks. And no yucky tanks. And the anatomy atlases were provided lab copies so we didn’t have to worry about getting it all disgusting. Once again, 2 hours of lecture a day and block scheduling, I feel like I dodged a bullet, reading your experiences.

  2. About “early” clinical experience, I have always had these thoughts and am glad that someone with first hand knowledge confirms them.

  3. Dissection was pretty low yield. I kept thinking of all the more productive uses of my time when going through layers of fat and fascia. I know it was the bees knees in the 18th century and all, but at this point it seems more like a rite of passage, and don’t we have enough of those already?

  4. I’m currently in Comparative Anatomy and the time spent with my cat and shark seems very similar to your time spent with your cadaver. But I enjoy lab a lot. I have the patience to meticulously go through my cat and find exactly what I’m looking for. (I hate the fucking shark. It’s impossible to separate anything) I get a great sense of achievement when I have clearly discernible body parts. And there is also something to be said about staying in the lab until 5AM with your classmates. If that doesn’t make good friendships, nothing will.

  5. How poignant, I just returned home from our mandatory weekly pre-clinical preceptorship in a busy outpatient peds dept. The early patient encounters are a mixed bag to me. On the plus side, not knowing anything keeps me pretty humble, taking histories is good practice, and I’m glad to know that most pediatricians are chill people. On the down side, I wasted like 6 hours of prime reading time this morning and I am starting to hate ear-aches, low grade fevers, sore throats, and inexplicable rashes.

    I actually miss the hell out of anatomy lab. I’d rather dissect the brachial plexus with my elbows than look at another histo slide. That tank sounds wicked gross though, we just drained a bucket every morning and I guess my wife won’t miss the fat globules in arm hair.

    Your previous post was right on, keep up the good work

  6. As an MSII, I actually like the (albeit minimal) patient contact that we have ~4 times a year or so. Of course, the actual amount of learning that these experiences offer is quite small – but it helps keep me focused on the big picture of why I am torturing myself with all this studying, and provides motivation to keep on the path.

  7. I’ve never dissected a cadaver, but then I’m not a med student. I did attend an autopsy, and it went swimmingly for me until they hit the bowel. Oh. My. Gosh. The smell. I am fine with all sorts of gross things, but bad stinky smells make me gag. I’d like to think that my kids have really loosened me up on the smells thing.

    I have dissected evrything from an ascaris to a turtle to a shark in my invert/vert anatomy class ages ago. It was so cool, and I loved it. I’ve even dissected a live cockroach, of course properly anesthetised as per regulations in case they can actually feel pain. I’m pretty certain that they don’t have enough neurons to process it. But just to be cautious. They did belive that infants couldn’t feel pain in the 60’s afterall.

    I think dissecting insects in my grad entomology class was the most rewarding because it was so damn hard to dissect under a scope, and when you fianlly got the structure, you felt golden.

  8. Dear Husband,

    Isn’t “early patient contact” that which made you into the sensitive, empathetic SOB that you really are? I know you cry inside for your patients.

    Mrs. Panda

    (Hey, Baby, when are you going to write that article you promised? -PB) 

  9. Ugh, anatomy lab. I was always the last one in, first one out. For me it wasn’t so much the smell or any sense of disgust, but mainly the low-yield factor. I had 2 lab-group-mates who loooved to dissect. The 3 of us who remained spent most of our time with either prosections, or the plastic, labeled, take-apart models in the auxilliary room (these were a lifesaver). When the 2 budding surgeons were done, they would come get us, and we would all look at stuff together. Sometimes it was hard to flag down a prof to answer questions – this was another thing I hated about lab. There was a faculty member from the physical therapy department who would often circulate – he had been teaching anatomy for 40+ years and was simply phenomenal.

    One of the other reasons that I hated anatomy lab was the fact that our entire class was in one room at the same time. While I love and respect my classmates, around exam time, the tension in the room was so thick you could cut it with a knife. For me, this was exactly the type of environment I needed to avoid. Even my lab group – composed of people whose company I normally enjoyed immensely – degenerated into bickering over stupid crap during these high-stress times (“That’s the lateral femoral!” “No, that’s the ilioinguinal!” “You’re both wrong, it’s the iliohypogastric”). The novelty had worn off by week 3.

    As for “early patient contact” – I believe that it is important as a reinforcement mechanism. Personally, I have a lot of trouble focusing on lecture material. I hate sitting in class, and I hate studying for the sake of passing exams. When I get to go to clinic and interview/examine patients – no matter how awkward or bumbling – I remember why I am putting myself through this torture in the first place. What I don’t like about “early patient contact” is the BUSYWORK. I understand the importance of write-ups, presentations, and communicating with other members of the team, but isn’t this stuff better learned during 3rd year? My school also likes to assign ridiculous “patient journals” and “diet logs,” and one course director in particular likes to emphasize the touchy-feely stuff. As if we don’t have enough to worry about in our regularly-scheduled classes, they have thrown together a course where we have lectures on “religious aspects of medicine,” “cultural competency,” and other such crap that you really can’t teach people. Those of us who choose not to attend these lectures have been both berated by said course director, and penalized on exams.

    The physical exam lectures are important, as is reading from Bates. But I could really do without the touchy-feely crap and the busywork assignments. Our school also needs to do a better job of integrating the physical exam & diagnosis stuff with the actual block schedule – for example, we had to learn HEENT/fundoscopy in the middle of our micro block. Most of us were completely lost and ended up doing poorly on the “physical exam” portion of our test (we have small written tests on PE skills).

    Early clinical exposure is thus important for me, because I need to be reminded why I am doing this. But it needs to interfere less with my actual coursework. Maybe if they made it optional, it would be a more positive, productive experience for those interested. Or, if it was to continue to be mandatory, plan a little better and take out the busywork.

  10. It sure would be nice if anatomy could be done on fresh bodies. I watched an autopsy today, and fascia quickly and easily released its grasp on nearly everything with minimal effort. Not only that, but everything actually had color to it, rather than mottled gray and brown.

  11. You are right on-it’s all coming back to me now. I loved picking at little things, though- it was like a treasure hunt. (I thought about becoming a pathologist but I kept getting migraines in histology lab.) If you like dissecting, make sure you’re not a “body hog” or your gross groupmates might get ticked.

  12. Is “problem based learning” euphemistic? At all?? Also, when it comes to patient contact, less is more. Efficiency. 8 minute appointment, or less if possible. Got places to go and people to see.

  13. we do a ton of pre-clinical patient contact-to the detriment of our other studies. The only reason it is even in the curriculum to such a high degree is because of so many people trying to make names for themselves as medical educators-despite the fact that they were never practicing physicians. It is to the detriment of our classroom learning. Hell even the family doc I have my preceptorship with has said they are wasting a lot of our time. If you can avoid it-do so-I also feel you don;t really get anything from it.

    I loved anatomy lab-would study what we were dissecting the night before in the atlas, dissect it out, then it was on to Netters flash cards-my group always took way less time in anat lab than the others-

  14. Much of medical training I felt was a “rite of passage”. The aspect of early clinical exposure is doubtful at best. Certainly as one said a “marketing tool”. Gross anatomy lab is one of those ‘rites’ Dissections are dicey at best and the information is quite variable from group to group. Modern computer simulations and plasticene models are much more beneficial. As one proceeds through clinical training and specialty training all of this anatomy stuff will be reviewed in a focused and meaningful way.
    Every year I receive my alumni news and requests for white coat funding, and how important it is for new “doctors in training”
    Balderdash!!! (that is my generation’s term for
    “it sucks”. I vote with my pocket book, I don’t give.

  15. I think some early clinical experience is useful just to get you very basic experience — the idea of entering your third year without having done an H&P on someone is absurd. Maybe one afternoon a week for a year is plenty, provided it’s focused on teaching you useful basic stuff. Any more than that is overkill.

  16. Agreed that ‘early clinical exposure’ is a big fat frustrating waste of time. It sounds like a good idea before you start doing it, but you quickly realize you won’t know enough for it to be useful for another couple of years, and you’ve got plenty of other stuff to spend your precious time with during the pre-clinical years.

    As far as anatomy is concerned, ours was an intensive course at the beginning of first year. It seemed difficult at the time but in retrospect was a cakewalk. I would actually like to do it over again because I think I could get a lot more out of it now that second year is just about over. Now that I have some understanding of the function of everything, I would like to more informed look at the structure.

    So yeah….no doubt about it, smelling like cadavers gets old fast, and there is nothing fun about scraping fat, but I would advise new students to resist the urge to skip labs or not be involved with the dissection since you might not ever get another chance to look at the stuff in that way again.

  17. I’ve always found the ceremonies for the donated bodies somewhat amusing. I understand it’s a show of respect and great for the donating families, but I wonder how many people would still donate their bodies if they had even a clue how much we disregard and mutilate them.

    They picture this noble endeavor where brilliant young scientists diligently take notes in little notebooks being careful with each little incision. When in reality you have a bunch of understandably whiny, semi-intelligent, tired students complaining about how fat their bodies are, how stanky the bowels are, the liquid that dribbled down their scrub pants, how much they hate lab, etc. They probably don’t realize how reckless and violently we pry the skin off of their fingers, mutilate their pudenda, probe into their orifices and saw through their skulls.

    I usually did about 20 minutes of dissecting, hacked my stuff up a bit and then went and told a professor “I can’t find blah”. Then I got to spend 30 min or more watching a pro dissect which was 10x more educational.

    That being said we did some amazing things and I learned a crapload in that class, which is still my favorite after 2 years. I am eternally grateful for their gift of ‘self’ but I would never allow anyone I actually cared about to donate their body for such a cause.

  18. Except for the odor, I think gross anatomy with lab would be an absolutely fascinating experience. I haven’t even made up my mind whether or not to go to medical school, to say nothing of having scrutinized different curricula, but if I do get to that point I would hope to end up with a traditional lab-based gross course.

    PBL sounds like one of those concepts that works better on paper than in practice.

    Early patient contact? Meh…I can see both sides of that one. Probably best kept to a minimum.

    Thanks for blogging, Dr. Bear. As a fellow nontrad, I really value your perspective.

  19. I came across your site quite by accident. I am in no way a health care provider, but we ‘civilians’ get a little curious about this stuff. After reading your post on gross anatomy, (actually, is it called that because it is gross..I wonder?)
    I digress…after reading this post, it suddenly hit me what the difference between Dr.’s and the rest of the population is! You have the ability to not scream, cry and say eeeeeeww when you’re cutting up a room full of dead people. OMG, cutting off their heads and sawing them in half??? No way…just couldn’t do it. Thank goodness some people can…I think…
    I’ll be back to read some more, but I misht have to skip some of it too, if you don’t mind. (very weak stomach)
    Take care

  20. I think you’re exaggerating a bit regarding the smell of medical students after dissection. Either that, or your anatomy lab wasn’t very well ventilated. I regularly wore street clothes, and although there was indeed a smell that clinged to my body and my clothes (until both were washed), the smell was never pungent or “unbearable”. Moreover, I am (and at the time I took gross anatomy, was) aware of the phenomenon called nose-deafness”.

  21. Okay I was really shocked reading this article. You mean people get into medical school without having seen or touched a cadaver? I’m a pre-med right now and I took Human Anatomy and Physiology, where we spent plenty of time in the cadaver lab. I’ve also taken Human Dissection (somebody is dissecting for those Anatomy students) where I’ve already had the experience of cutting open a cadaver. This is standard for every pre-med at my school, so it shocks me that people would not go through this experience and be able to know that they’re doctor material. Oh, and as for the smell, we had excellent vents, so the smell wasn’t bad AT ALL. Did I mention I was pregnant during the semester I took the dissection class? All my husband ever smelled was the soap I used to wash with. I’m sure as a doctor you’ve come across all sorts of nasty smells.

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