This has to be my favorite take on the state of health care in the U.S.

John Gary Maxwell: Health reform from my side of the surgery table

Someday I’d really like to get the time to write out a statement about my opinions on health care reform. Until then, just know that I think:

• Everyone needs access to quality health care. This includes financial access.
• Health care coverage shouldn’t be linked to jobs. People lose jobs (and therefore insurance).
• I like the idea of a single-payer system but admit the transition would be difficult.
• Americans think they deserve the best health care that someone else will pay for.

Don’t read too far into my political views based on what I just said. I assure you they are more complex than I can jot down in the five minutes I am taking to post this.

Too often people think that the government isn’t capable of running anything, let alone healthcare. So I was amused when I saw this comment on a website. I don’t know who wrote it, but it’s food for thought.

This morning I was awoken by my alarm clock powered by electricity generated by the public power monopoly regulated by the US Department of Energy.

I then took a shower in the clean water provided by the municipal water utility.

After that, I turned on the TV to one of the FCC regulated channels to see what the National Weather Service of the National Oceanographic and Atmospheric Administration determined the weather was going to be like using satellites designed, built, and launched by the National Aeronautics and Space Administration. I watched this while eating my breakfast of US Department of Agriculture inspected food and taking the drugs which have been determined as safe by the Food and Drug Administration.

At the appropriate time as regulated by the US Congress and kept accurate by the National Institute of Standards and Technology and the US Naval Observatory, I get into my National Highway Traffic Safety Administration approved automobile and set out to work on the roads built by the local, state, and federal Departments of Transportation, possibly stopping to purchase additional fuel of a quality level determined by the Environmental Protection Agency, using legal tender issued by the Federal Reserve Bank. On the way out the door I deposit any mail I have to be sent out via the US Postal Service and drop the kids off at the public school.

Then, after spending another day not being maimed or killed at work thanks to the workplace regulations imposed by the Department of Labor and the Occupational Safety and Health Administration, I drive back to my house which has not burned down in my absence because of the state and local building codes and the fire marshal’s inspection, and which has not been plundered of all its valuables thanks to the local police department.

I then log onto the Internet which was developed by the Defense Advanced Research Projects Administration and post on freerepublic and fox news forums about how SOCIALISM in medicine is BAD because the government can’t do anything right.

I was able to go to the American College of Osteopathic Surgeons conference this past weekend in Chicago. I treated it as a mini-vacation. I love Chicago.

FRIDAY: I went to class in Des Moines all morning and walked around in downtown Chicago all evening. How cool is that? I’m getting ahead of myself though. On the plane there I experienced the single biggest jolt I have ever felt on an aircraft. Sometimes in rough air you can look around and see everyone tensed up, but with this one single jolt the entire cabin actually audibly gasped (like a startled, hushed scream). It was really windy out but I think it also must have been new pilot training day because it was not smooth sailing. I got to the airport and took the subway into town – about a forty minute trip. Then I started walking east toward the hotel. After about twenty minutes of walking I snapped a nice picture of the sunset with my cell phone. Then it hit me – sun sets in the west. I had been going the wrong direction for a long distance. I finally made it to the hotel 2.5 hours after touching down. I was exausted but set back out on foot to find a decent place where a guy can eat by himself and not feel awkward about it. I passed a grocery store on the way back to the hotel and decided to check it out so as to experience what daily living in the heart of the city was really like. I returned to the hotel with a pop and a single beer. I enjoyed the beer and then decided to walk to Millennium Park. It was late on a Friday night and people were all dressed up for Halloween – I even saw a person in an all-out mascot suit (big stuffed head included) riding a bicycle down the street. While at Millennium I was lucky enough to see a firework show coming from Navy Pier. I went home and crashed.

SATURDAY: I got up and walked to the Field Museum. It was cold, I was under-dressed (insulation-wise), and the walk was LONG. Much longer than I thought. With blistered toes and a runny nose I made it to the museum. My legs were tired but just the thought of a museum to myself gave me an energy boost. It wasn’t busy at all. I’ve always wanted to go to the Field Museum by myself, just because I don’t think anyone else is as giddy as I am about that sort of thing. When my heart was content, I did the smart thing and took the cab to the hotel. There were some other DMU students coming to town and I was ready to emerge from my solitude. While waiting for them, I walked to the bar across the street to see if I could catch the ISU game (the bar advertised 42 TVs so I figured my odds were best there, but alas, no game). I got to do another thing I’ve always wanted to do – show up at a bar alone and see if I have what it takes to make some stranger-friends. The place was packed and I sat at one of the only open stools at the bar. These really drunk people started talking to me and long-story-short it turns out they were med students from Kansas City! I assumed they were also there for the conference but this was not the case – just a really strange coincidence! I also learned that a one-bedroom apartment downtown costs $2000/month! When the economy was better it was closer to $3000! And parking spots cost nearly as much per month as my share of my apartment in Des Moines! After a good time with those guys I finally got a call from my classmates who were two hours late because a car took semi truck’s mudflap to its radiator back around Davenport. Amy, Jimmy, and I walked around downtown to find a restaurant to eat at and finally settled at a brewery. Amy was dressed as Indiana Jones (complete with hat and whip) and Jimmy was a Boeing ground crew member (complete with yellow reflective coat and ear protection, but without the glowing orange sticks to direct planes around with). I was lame and dressed as myself. We then walked FOREVER to this strange bar to meet up with other med students from around the country. We thought someone had played a joke on us – the bar was really weird (it was named The Funky Buddha) and was full of men dressed as women and whatnot. Halloween, I guess. Or the regular crowd. Who knows? Mixed drinks were $10 so I got pretty drunk on water. There were VIP tables, but no one was at them, so we took one until we got booted to the dance floor with the other med students and all the, uh, uniquely-dressed people. We took a cab home and hit the sack.

SUNDAY – my reason for being in Chicago. The conference was interesting. We went to some good talks and some boring ones, but I learned some things. Probably my favorite tidbit: a neurosurgeon in Iraq gave a talk about the military surgery hospital there. During his time in Iraq two people came in with explosive devices implanted in their bodies. Really! It’s not just happening on Grey’s Anatomy. It was a good day, but there isn’t much that can be said that makes for a good story. I walked to the train station, rode it to the airport, and flew back to Des Moines. Back to reality.

A little medical humor for you.

Anonymous Philanthropist Donates 200 Human Kidneys To Hospital

Have some free time? Want to learn about an eccentric pioneering surgeon?

I knew it!

Here is a paper I wrote for a History of Surgery contest here at Des Moines University. I will post a link to the contest site on the DMU website as soon as it is updated.

Alexis Carrel by Adam Kapler DO13 (you might have to right click > save as…)

I don’t really want to toot my own horn here, but I do want to get this paper on the net and indexed. Maybe someday if you Google Alexis Carrel your search results will contain my paper! It’s not exactly primary-source-material but some high-schooler somewhere might find it helpful. One can dream…

I am now very indebted to this man (Carrel, below), Howard A. Graney, and the surgery department here at DMU! Thank you!

Text-only version below the fold… download the PDF for the full effect (pictures, additional tidbits, and looks better formatted).

AlexisCarrel

His vasculature repair method set the stage for organ transplants.

Lived 1873 – 1944; 1912 Nobel Laureate; French, but did much of research in America

In the summer of 1894, the President of France was making a visit to the city of Lyon. While riding through the city, an Italian man lept toward the carriage and stabbed the President in the chest. The President bled to death. In the assassin’s own words:

“…when the carriage was passing close by me, I sprang forward to the step, supported myself by resting my left hand on the carriage, and with my right hand buried the dagger in the President’s breast.”

He may have been aiming for the President’s chest, but it appears that the ultimate cause of death was lower – a severed portal vein. Surgeons at the time had no way to repair vessels without hemorrhage or thrombosis. Suturing was used with wounds but when it came to mending vasculature, the threads of sutures, which the body recognized as “foreign,” would cause clots to form. Those clots would later break off, causing pulmonary embolisms or even stroke.

A young surgeon-in-training at the University of Lyon, Alexis Carrel, was stunned. The assassination of the President had such a profound impact on Carrel that it directed his early surgical focus. He thought that there must be a way to successfully joining vessels – the act seemed so basic, in principle.

In retrospect, Alexis Carrel was seemingly destined to become known for his suturing prowess. His father was a textile manufacturer and his mother was an embroiderer – he grew up around stitches. Rather than turn to books and his faculty superiors, Carrel went to an embroidery shop. He was gifted with the needle. Time magazine reported in 1935 that he had “achieved the feat of sewing 500 stitches into a single sheet of cigaret [sic] paper.”  He learned to use tiny needles and fine stitches to sew seams with threads only visible from one side of the fabric. To Carrell, this may have been an epiphany – if vessels could somehow be sewn together with a similar method, there would be no threads exposed to blood. Ergo, no clotting!

Using animals, most often dogs, Carrel devised a new and successful method to connect a broken vessel without hemorrhage or thrombosis. The method involved using three sets of threads that, when pulled simultaneously, would hold the vessel open. This was especially helpful when it came to veins, whose thin walls made them prone to collapse and especially hard to work with. With the vessel open, the ends would be rolled back slightly, forming small cuffs which could then be sutured together. The beauty of this method was that no thread would be exposed to the inside of the vessel – to a platelet, the vessel wall would seem continuous.

Over the course of eight years he became very adept at successfully attaching arteries and veins. He became known for his strict adherence to aseptic technique, and was better than most at preventing infection. Carrel was a brilliant man but not without his quirks, some of which didn’t sit well with the faculty at Lyon. For example, Carrel insisted that doctors should study and give merit to the so-called miracles occurring at Lourdes, which Carrel himself was witness to. (Carrel made pilgrimages back to Lourdes most every August throughout his life.) Lourdes wasn’t his only mystic view that set him at odds with fellow faculty, and he was denied tenure. He moved to America and continued and expanded his research, first at the University of Chicago and later at the Rockefeller Institute.

The ability to either fix torn vessels or purposely sever and reattach them opened doors for the profession of surgery. The ideas of organ transplantation or limb reattachment had been around, but surgeons lacked a way to successfully reestablish blood supply. With enough practice of Carrel’s methods, these sorts of previously unthinkable operations could become routine. Carrel became so good at connecting severed vessels that, in his own words, “six months after the operation it was impossible to locate the place where the anastomosis had taken place.” It was then that he got imaginative and began performing what might be best-described as surgical oddities. He would sever the femoral artery and vein of a dog, and reattach them in their counterpart’s place, reversing the flow of blood. To some surprise, the veins did not succumb to arterial pressure and rupture. The limb seemed to function normally. Keeping things strange, he would later reverse the blood flow to a dog’s thyroid by cutting its artery and vein, crossing the vessels, and reattaching in the opposite configuration.

“Replantation” – the act of completely excising an organ or limb from an animal only to reattach it to that same individual – was Carrel’s next focus. It might seem pointless to, say, slice off a limb just to have it reattached, but there were doubts from some that the tissues of the limb would thrive post-op.  He generally chose to work on organs that had simple blood supplies – the fewer vessels to cut and reattach, the better the chances of a successful operation. Using animals, he “replanted” kidneys, limbs, thyroid glands, adrenal glands, ovaries, intestines, spleens, and even hearts. If these poor animals could have talked, they might have echoed the old adage “if it ain’t broke, don’t fix it.” The post-op conditions of most of these animals seem to be undocumented, but they probably didn’t fare well. Carrel would eventually admit that replantations are generally useless except as a fix for accidentally severed limbs.

Years later, during his Nobel lecture, Carrel told of the troubles he had with keeping dogs alive after limb replantation. Rather than master the simple before moving to the complex, he did the seemingly illogical – attempting transplantations before mastering replantations.” Said Carrel:

“The tissues and vessels healed by first intention, but we were unable to keep any animal alive longer than eleven days. I performed no more replantations and after this I proceeded to study the transplantation of limbs from one animal to another.”

Carrel had no better luck with dog-to-dog transplants. He recounts a number of dog limb transplants in his Nobel lecture. Time after time, things would look good: the circulation was good, the limb was normal in temperature and color, the pulse could be felt, there was little swelling, and little pain. But again and again, after a week or two the animals’ health would spiral downward until they either died or had to be euthanized. Since the dogs didn’t seem to have infections, Carrel was probably perplexed as to how his seemingly flawless transplants could be causing such complications. Keep in mind that to Carrel, a healthy blood supply was all that was needed to keep tissue alive, and he knew that he had mastered that. Why would perfectly perfused tissue always die, often killing the whole animal with it?

In one of his stranger transplants, he removed a kidney from a puppy, splicing the renal vein into the jugular and the renal artery into the carotid of an adult dog – he placed a puppy’s kidney in the neck of another dog. The kidney survived, and supposedly functioned, for several hours. Nearly as strange, Carrel also removed the ear and part of the scalp of one dog and transplanted it on another dog, successfully reestablishing circulation. At first thought successful, the tissue later necrosed and the dog eventually died. Initial positive outlook followed by the gradual decline to death was to become a reoccurring theme with Carrel’s surgeries. However, he persisted – it is hard to say how many dogs were chloroformed to death for kidney, thyroid, or limb harvest. His methods of research and risks that he took would probably be looked down upon or forbidden in modern-day research, but nearly a century ago, they were bold enough to win him the most coveted prize of scientists.

Carrel was awarded the Nobel Prize in 1912 for his work with vascular suturing and vascular/organ transplants. Knowing that he had trouble keeping dogs alive, he was cautiously optimistic about the success of transplants amongst humans, saying “it is not yet known whether surgeons will ever be able to perform a holoplastic transplantation with permanent success.”

Today, it is obvious that what kept Carrel from consistently having successful transplantation surgeries was tissue rejection. Though little was known about immunology at the turn of the twentieth century, it became clear to Carrel that some phenomena could cause an animal’s body to reject another animal’s tissue. From his Nobel lecture:

“It seems that this necrosis of the epithelium was not produced by the circulation but by a reaction of the organism against its new limb.”

It was clear that he understood the concept of tissue rejection but not the underlying mechanisms behind it:

“…it will be necessary to discover a means of recognizing the individuals, if such exist, between whom organs can be interchanged with impunity. “

“…the transplantation of organs has been solved from a surgical point of view…    …it will only be through a more fundamental study of the biological relationships existing between living tissues that the problems involved will come to be solved and thereby render possible the benefits to humanity which we hope to see accomplished in the future.”

He never lived to find out exactly why hosts rejected foreign tissues. Decades later, around World War Two, discoveries by Peter Medawar allowed for an understanding of tissue rejection that would lay the groundwork for consistently successful organ transplants and the development of immunosuppressive drugs.

Carrel’s single greatest achievement was also one of his earliest. His method of anastomosis was a needed precursor for the field of surgery to broaden its life-saving repertoire of operations. Today, we take for granted that vessels can be cut, spliced, and repaired. Imagine the worries going through the head of someone finally receiving a transplant they had waited for. “Will my body take to the organ? How long will this organ last? How bad will the side-effects of the immunosuppressive drugs be? Will I ever be the same?” Blood plumbing is very low on the list of concerns, and probably won’t cross the patient’s mind. The focus of a bypass operation is on getting the heart tissue the blood that it needs and rightfully so, but we forget how wonderful it is that vessels can be “cut and pasted” from one part of the body to another in the first place!

Aside from vessel anastomosis and transplantation, Carrel had a number of other accomplishments to his name. Most famously, he developed a precursor to modern day heart-lung machines with none other than the aviator Charles Lindbergh. Though an odd-couple of sorts, they had the utmost of respect for each other and became lifelong friends. Carrel also developed a novel method of wound antisepsis during World War One, but it was later made obsolete by effective antibiotics. He demonstrated that blood vessels could be kept in cold storage prior to being transplanted, and was even one of the first doctors to perform a successful heart valvotomy, an operation to fix an obstructed valve.

Carrel will be remembered as a pioneer in the field of surgery, obsessed with detachments and reattachments, and even more obsessed with the plumbing behind it all. However, as stated before, he was not without his quirks. His reputation will forever be scarred by his stances on political and humanitarian issues that he took later in life. He was a proponent of Eugenics,  thought society should be run by a group of “intellectual elite,” wrote about the need for “race betterment” and for “whiteness,” and sided with the Vichy government of France (which was a Nazi apologist).  To many, these flaws were unforgivable.

Flaws aside, it is clear that Carrel positively influenced the evolution of medicine and surgery. His work with vessel repair paved the way for new surgeries, bypasses, and eventually organ transplants, which he also had an intimate role in the development of. He even recognized tissue rejection. It can’t be stressed enough that modern human organ transplantation wouldn’t have been attainable without the work of Alexis Carrel.

His lifelong collection of work emphasized detaching organs, reattaching organs, relocating organs, growing tissues, and making a machine to replace a set of organs. With these interests in mind, one can imagine that Alexis Carrel had dreamed of one day growing an organ from scratch to have it transplanted into a human. An entire century later, many scientists are still working toward a similar goal with some success – a functioning rat heart has been grown in a University of Minnesota lab using an extracellular matrix of a deceased rat’s heart as a template.  Carrel was truly ahead of his time. If the field of immunology had been developed at the time Carrel was doing research at the Rockefeller Institute it is safe to say that successful human transplants would have been performed decades before they were.

SOURCES

Nobel Lectures, Physiology or Medicine 1901-1921. (1967). Elsevier Publishing Company, Amsterdam.

Alexis Carrel. The Nobel Prize in Physiology or Medicine 1912. (2009). Nobelprize.org. http://nobelprize.org/nobel_prizes/medicine/laureates/1912/carrel-bio.html

Burnie, David. (2000). Milestones of Medicine: the Eventful Century (20^th). Readers Digest: Pleasantville, NY.

Red Gold: the epic story of blood. Alexis Carrel. (2002). Educational Broadcast System. http://www.pbs.org/wnet/redgold/innovators/bio_carrel.html

Caserio at the Guillotine. New York Times. 16 August, 1894. http://query.nytimes.com/gst/abstract.html?res=9E06E4DC1730E033A25755C1A96E9C94659ED7CF

Researchers create a new heart in the lab. 14 January, 2008. University of Minnesota News.

http://www1.umn.edu/umnnews/Feature_Stories/Researchers_create_a_new_heart_in_the_lab.html#

Medicine: Carrel’s Man. 16 September, 1935. TIME magazine.

Alexis Carrel. Who named it? http://www.whonamedit.com/doctor.cfm/445.html

Alexis Carrel. NNDB. www.nndb.com/people/170/000125792/

Today is Columbus Day. It’s stupid. From my Facebook status:

Christopher Columbus shouldn’t be celebrated. The man raped, murdered, and converted his way through the Caribbean. It was genocide. Yet, revisionist history prevails.

I should add that all that raping, murdering, and conquering was done in god’s name. This guy was even a candidate for sainthood (Catholic) 1866. Ugh.

Try reading the first chapter of A People’s History of the United States (by H. Zinn) and tell me why this guy deserves celebration. Why insult the Native North Americans?

Don’t get me started on Thanksgiving…

I forgot to mention that we already had some patient contact. Well, sorta. We had to dress up in full physician garb (shirt, tie, slacks, and a fancy white coat) and meet with patients and extract information from them. They were actually actors. The woman patient/actor I had was convincing to say the least. I thought I would have trouble taking it 100% seriously, but nope. We get videotaped and are required to watch ourselves interact. I had to do the same thing while student teaching… and let me tell you… videotaping yourself and then watching critically is sheer agony. Everyone is hardest on themselves. It wasn’t so bad. Three more of those this year, and then eleven of them or so the second year. It will be more fun once we start physical diagnosis.

Anatomy! Anatomy lab is interesting to say the least. Gertrude, or Gertie, is our cadaver. What follows are answers to questions I anticipate people might ask….

• We know her age and cause of death, but that’s it.
• There are five people to a body. Two cutters per side of the table and a “navigator” that reads through the lab guide and displays diagrams and tells the others what to do. There is a big LCD TV monitor above each body. It displays the lab manual and anatomical diagrams. Works pretty slick – lab manuals don’t get gross.
• There are probably 30 cadavers in the lab, which means that there are 150 of us in lab at a time – med students and physical therapy students, mostly.
• The bodies are embalmed. So there is no blood and no decay. The lab is extremely well-ventilated, but the smell of embalming fluid can be a little strong.
• From what I’ve heard (lab rumors and insider info from Mr. R. J. Gunderson) the bodies might have been dead for nearly a year. Some definitely look fresher than others.
• We wear scrubs and lab coats. Our tools: scalpels, probes, tweezers, scissors (things you used in high school dissections pretty much)
• It’s harder to tell the sex of a person than you’d think. They are all naked and face down with shaved heads. On day one, we worked for a good twenty minutes on what we thought was a man, until a keen eye alerted us otherwise.
• Elderly people are not the best example of superb muscle anatomy.
• Anything we cut off (lots of loose tissue scraps and fat) gets put in a special bin. The remains of the body, and all the scraps in the bin, will be cremated and given to the family.

That’s about it for now. I have a History of Medicine exam first thing in the morning. Interesting stuff – I will miss that class. Bloodletting and mesmerism and trepanation… we’ve come a long way, baby.  (And yet, crazies still linger: homeopathy, faith-healing, most acupuncture, some chiropractors, GNC stores, magnetic bracelets, Carolyn Walker… don’t get me going…).

We have class/lab six to seven hours per day and then have lots of studying to do aside from that. And eat/sleep. I’m struggling to keep up. I don’t know how anyone could keep up. Maybe no one is.

One more thing: Cyclones will beat the Hawks, 20-17.

Interesting little article.

7 Phenomenal Wonders of the Natural World | WebEcoist | Green Living.

Gotta keep this quick. Need sleep.

Where did I last leave off?

Medical school started. That was almost a month ago. Wow.  My brain is now dead for the day, so here come random things to share:

• The courses that take up the majority of my time right now: biochemistry, anatomy, osteopathic manipulative medicine, behavioral medicine (a doctor-patient relationship course mixed with lots of psychology), and history of medicine.
• Time flies when Biochemistry takes over your life. I’ve already learned more in that course than I did in all of undergrad biochemistry. Too bad my exam scores don’t reflect that.
• Overall, we have already had three exams. The pace is fast. Too fast.
• Throw everything I learned in grad school (science education) about how people learn best out the window. Whereas the important thing used to be to get a good understanding of general processes and subject matter, now the intricate detail of what we are supposed to know is overwhelming. Sometimes it feels more like memorization and less like learning, if that makes any sense.
• We have these labs, which I will just call palpation labs for now, in which everyone is feeling and prodding everyone else, looking for landmarks that lie beneath the surface of the skin, checking alignments and asymmetries of bones and whatnot… well, as you can imagine, it was awkward at first. Feel your tailbone. We had to basically press on the underside of that. Now imagine locating a stranger’s pubic symphysis. Take a good guess where that is. We, the med students at DO schools do this, and the MD schools don’t (it might be an elective). It takes up a huge part of the curriculum for the first two years, and I was worried that I wouldn’t like it. However, the awkwardness wears off really fast and it is actually a pretty enjoyable learning experience. Now if only I were good at it.
• People are way too smart. Anyone who felt smart in high school got to college, where the “smart” kids go, and found the playing field leveled. Now, I find myself amongst the smartest of the college kids, and sometimes I wonder how I got in. Maybe someone made a mistake and accidentally sent an acceptance letter. I’m kidding, but I really envy how adept some people are at picking up this knowledge at the pace they are throwing it down.
• Thursday is the big day… I get a cadaver. I might have to dedicate a future post to this. Taking a scalpel to human flesh for the first time has got to be unforgettable. I mean, this is human dissection. Wow. I’m really hoping I get lucky: overweight people require lots more work and their tissues never, um, clean up as well; and elderly people tend to have atrophied muscles. A marathon runner on the slab would be nice.
• I think when I look back and wonder how I survived this first month, three things will come to mind: Ryan Adams, Gobstoppers, and this video:

• I’m tired. Enjoy some SMBC:

Things are changing fast. I worked my last day at the Science Center on Saturday and started orientation on Tuesday. Orientation has been about as dull as I expected. (Example, during computer training: “this is where you plug in the power cord.”) Part of me feels like I should be attending more events and trying to meet more people, and the other part of me is really glad I’m not giving in to forced socialization. There will be plenty of time for normal socialization.

It’s starting to feel real. We have a schedule now, I have a locker and mailbox, I got my picture taken in a lab coat for my ID badge, and they even already talked about how to deal with mild depression. Seriously. My assigned advisor was one of the doctors who interviewed me. Good story: on interview day the conversation somehow turned towards hobbies, and then motorcycles came up and, long story short, I walked out of there pretty sure that if I didn’t get in to DMU it would be because I didn’t always wear the motorcycle helmet. After all, how should I be expected to save lives when I show such casual disregard for my own? Anyways, I got in, and she remembered the motorcycle helmet conversation.

Tomorrow I should get loan money deposited into my bank account – so much money that I might be tempted to drop out of school, buy a new Corvette, and flee the country. If you don’t hear from me for a while, try Canada.

It have heard twice now that starting medical school is like trying to take a drink from a fire hydrant. Monday they turn on the water. I’m thirsty, but not that thirsty. Yikes.