Breaking the Silence

So it has been well over a fortnight since I last made a foray into the blogosphere to comment on the status of my life and studies.

I completed and passed (although with a less than comfortable cushion) Course Two prior to the Christmas Holidays. Having completed 1.5 weeks of Course Three I'm going to go out on a limb and say that MSK/Derm (Course Two) was my least favorite course. I found the organization lacking, the material not especially interesting (especially Rheumatology), and the course as a whole was rushed. Dermatology was quite interesting but I wouldn't have minded spending another week on Dermatology to cement some of the topics in my brain.

I was very ready for and enjoyed a restful and relaxing Christmas break with some of it spent in Southern Alberta and some of it spent in Northern Alberta. It was classic Canadian Christmas weather - decent amounts of snow and not too cold (other than the -36C at High Prairie) which made outside activities very enjoyable. Cross country skiing, tobogganing, snow mobiling, and sitting in front of crackling fires with large amounts of chocolate and other Christmas goodies were very much appreciated.

I was not ready to return to the information infusion that is Med School but I'm slowly getting into the swing of things again. Course Three is an eleven week course which is almost as large as Course 1 (12 weeks). The topics we are covering are the cardiovascular system (heart and blood vessels) and respirology (all about the lungs). Thus, I have christened it 'Beating and Breathing' to follow Blood and Guts, Skin and Bones, and now Beating and Breathing. We have begun with cardiology although there are components of respirology integrated as the two disciplines are very closely integrated - neither the heart nor lungs can fulfill their function without the other so it is a very logical integration. Tomorrow we will be heading to the hospital for a couple hours for our first cardiac clinical correlation session. This should be quite exciting because we may have another opportunity to use our stethoscopes for their original purpose - to listen to heart sounds. Beating and Breathing is one of the most crucial units simply because so many things that go wrong with its components cause death very rapidly. Thus, physicians in virtually any specialty need to be familiar with the various pathologies that can occur. Heart disease is still the number one killer in Canada so it is something that we need to learn about as future physicians.

One of the most complicated tasks we are coming up against so far is the interpretation of ECGs. An ECG aka EKG aka electrocardiogram is a recording of the electrical activity of the heart which gives the trained interpreter very large amounts of information...however, at this point in time I'm having a difficult time telling what a normal ECG looks like; it still primarily resembles a bunch of squiggles to me.

A while back a request was made for me to outline a 'normal' day at med school so I thought I'd give you an idea what a day at the UofC looks like. To give a bit of background first; med school for us here at UofC doesn't involve much 'assigned' work. We don't have worksheets, essays, quizzes, etc to complete for the most part. Our primary 'assignment' is to assimilate and integrate massive volumes of material that we will need to recall at some point in the future. Thus, we have scheduled 'Independent Study Time' for some of us this translates into 'time to deal with the necessities of life' i.e. catching up on sleep, getting groceries, and occasionally some studying. Thus, we usually have one morning and one or two afternoons a week that are not scheduled with lectures. Often we do Physical Exam sessions or Clinical Correlation sessions in this time. However, when nothing is scheduled they are ours to use as we please.

Monday

8:30-12:30 - Healthy Populations - 2, 3, or 4 lectures about topics in epidemiology, social determinants of health, understanding underserved populations, etc.

- This time block is sometimes used for other kinds of lectures such as course related material (Breathing and Beating) or other longitudinal courses such as Global Health.

1:30-3:30 - Main course material lectures - anatomy, physiology, pathology, treatments, disease processes, patient presentations, etc.

3:30 -5:30 - Case Studies

- We have case studies at various times but they are often in this time slot. Case Studies are almost always 2 hours long.

Friday

8:30- 12:30 - Main course material lectures - surgery, radiology, etc

- Anatomy small groups (time in the labs with cadavers, etc) are also slotted in at various times like this.

12:30 - 5:30 - Independent study time.

* This is just a sample but gives an idea of how our day goes.

To conclude this large post I thought I'd discuss History of Medicine. I choose in the late summer to sign up for an elective course called History of Medicine. For medical students this is an elective course that falls outside of regular lecture times (Monday 12:30-1:30, and Thursday 5:30-7:30). I'm not certain if I would sign up for this course if I were doing my first year again but there have been some interesting lectures. This past Monday I presented a 50 minute talk regarding Artistic Responses to the Black Death. I did some research and then prepared a presentation. Combined with a presentation I completed in December it fulfilled my requirements for the course and if all goes as planned there will be a letter in my official file that I completed this elective course and fulfilled the requirements. This information will be included in the file that is sent to Residency Directors when I'm applying for Residency and hopefully be a useful component in allowing me to settle and do my residency at my school of choice.

The time has come for me to return to the world of valves, bronchi, septa, percutaneous coronary interventions, ischemic cascades, and flash oedema, but hopefully my future posts will be more regular than they have been in the last month and a half.

Another Day, Another Lecture

I've now been in medical school for 3.5 months, learned a lot, sat in a lot of lectures, looked at a lot of pictures, and memorized (as well as forgot) a lot of material. We are almost wrapping up our focused anatomy section. Next Friday we have an exam worth 30% of our mark for Course 2. In the past four weeks we have covered an astonishing amount of anatomy as well as some clinical information. I've discovered that orthopedics can be both very exciting and very boring. When we have trauma surgeons talking about polytraumas coming in with multiple injuries from high energy incidents things get quite interesting. However, after a three hour discussion of osteoarthritis orthopedics/rheumatology is not nearly as exciting, in fact it is terribly boring. However the irony is that osteoarthritis and rheumatoid arthritis are much more common than exciting polytraumas.

Yesterday one of my group members and I had our Orthopedics Clinical Correlation at one of the Cast Clinics here in Calgary. We worked with a group composed of cast techs, us, a clinical clerk, a resident, a fellow, and the attending physician. In my limited previous experiences with the healthcare system I've wondered why there always seems to be random people standing around doing nothing - yesterday I found out why. When you are the clinical medical student (as opposed to a clinical clerk) you are pretty much at the very very bottom of the totem pole. However, even the resident (two or three steps up the totem pole) still had to wait for the attending physicians go ahead/ok on any diagnosis or advice. So for any of you frustrated by people standing around when you are waiting in the hospital it might simply reflect protocol as opposed to laziness.

The Cast Clinic was pretty cool. The cast techs who are amazing at their job showed us how to put casts on the resident who kindly volunteered his arm. My group member and myself successfully wrapped both his arms with cotton batting after pulling a sleeve on them and then applied the fibreglass casting material. We got lots of good advice and tips from the cast techs and fellow and did a decent job of it (although it took us much longer than the demonstration by the cast tech). After the casts were examined for flaws - they had a few - we got to cut them off with the cool cast cutting tool. It has a vibrating blade that can't cut through moveable material, i.e. skin and padding that you wrap the arm in before casting. Thus it won't cut through skin, unless it is stretched tightly over bone. When the cast tech demonstrated this for me by placing the rapidly vibrating serrated half moon on my palm I jumped and it didn't feel good but it certainly didn't cut me at all.

MSK has a ton of anatomy in it which I'm still attempting to learn (hopefully I'll have a good handle on it by next Friday). Anatomy is important for any medical specialty because it allows you to place things happening in the body in a physical context - where they are, what they are attached to. As part of this course we are also learning a large number of physical exam tests for a large number of things like anterior cruciate ligament tears (ACL), nerve root compression, damage to sensory nerves, reflexes, tears to the glenoid labrum, damage to the rotator cuff, just to name a few. These kind of tests are annoying to learn because most of them are named after some random doctor who lived more than 70 years ago and decided to name a kind of fracture after himself. However, they are tests that are relatively easy to perform and can be strongly diagnostic of given problem, without fancy diagnostic tools like CT scans.

In one month we will be done school for the Christmas break and also finished Course 2. This will mean that I'm done better than 2/7s of my theoretical medical training. However, in the meantime I'd better get learning that the fibula and tibia form a mortise joint that articulates with the talus allowing for plantar and dorsi flexion of the foot, as well as a whole bunch of other stuff.

I Passed!

Thank you all for your good thoughts and emails following my previous post. I received my results from my Course 1 final exam and I passed with flying colours. I was very happy with my result. It doesn't matter in the long run as all we will see on our transcript is a Pass or Fail but it was still nice to see that I had a solid margin above the minimum pass. With that I've put Course 1 to rest, but not fully. The topics we learned about - liver disease, blood, clotting problems are still relevant but they are just taking a backseat to our most recent course the Musculoskeletal System.

MSK is intense. This unit is likely to be our busiest in terms of anatomy memorization. In twelve hours we covered virtually all the muscles, bones, and ligaments of the hand, arm, shoulder, spine, pelvis, leg, and foot. Suffice to say, after three four hour sessions our brains were well and truly stuffed with information. This is the only formal instruction we are going to have specifically about the anatomy. The synthesis and further understanding of it we need to gain on our own through time spent with text books, in the lab with the cadavers, and optional sessions run by some fellow students and one of the anatomy instructors. The moral of this story is that I'm thinking about muscles and bones more than I ever have before. When I see people who are really thin and fit I'm tempted to stop and ask them if they could flex for me to see if I can identify the muscles I'm seeing.

The first week of this course was somewhat overwhelming and definitely different than Course 1. The course chairs and primary teachers are different and it shows. I suspect that I'm going to reflect on Course 1 with fondness for the rest of my education here at UofC. We are now getting into the clinical aspects of the muscle and bone. Today was all about trauma, Advanced Trauma Life Support (ATLS), fractures, and incident prevention. We also had a presentation from a patient who had been in a severe motor vehicle collision suffering multiple fractures and then had to go through five months of intense and painful rehab to regain function. It is days like this that make med school interesting. The orthopaedic surgeons are also doing their best to make Trauma and Orthopaedics sound like the best specialty. I'm not entirely convinced but they are definitely making a good effort. We've also had some incredibly painful lectures about topics like the physiology of bone growth and healing - not nearly so glamorous but just as relevant.

This afternoon was also super cool. We learned how to draw blood and insert IVs. While we understand that this is not necessarily something we will do a lot of (depending on location and specialty) it was still really cool to practice. We didn't have the opportunity to practice on each other but the stimulator arms we practiced on 'bled' when we poked them so it certainly felt real and we will be getting some real practice in the near future I believe. Being in the lab today playing with needles or 'sharps' definitely made me feel quite doctor like.

Anyways, it is Friday night and I'm off for the weekend...to the hot springs to study some anatomy.

Wish Me Luck

Good Evening from Calgary. This is just a very brief post to request your good vibes and happy thoughts tomorrow. Why you might ask? Well, tomorrow is my first certifying examination for which I feel quite under prepared. That begs the question of why I'm creating a blog posting instead of studying. At this point I'm wondering if perhaps good luck thoughts from around the globe might be more productive than further review of a multitude of acronyms. Probably not but that is what I'm telling you.

To give you a taste of the things I'm trying to keep sorted I'll give you a small list. However, I'll start with one key acronym - MPL. This refers to the minimum pass level. This is the mark (which will be determined after the test but is usually around 65%) that you have to achieve to be considered competent and not have to resit the examination next summer. So of all the acronmyms I care about at this point in time the MPL is the most important one.

Some other acronyms of note include: TTP, HUS, CML, CLL, ALL, AML, DIC, Plt, Hb, DDAVP, ET, PRV, PCR, HBA, HBV, HBC, antiHBs, HBsAg, IgG, IgM, IgE, HEELP, ALP, ALT, AST, MFD, MFS, DVT, PE, ALF, PJP, NHS, EtOH, MAHA, AIHA, CMV, HSV, HZ, HIV, RBC, WBC, A1AT, PK, G6PD, TPN, TPA, TIPS, ITP, and the list goes on.

However, I'd best continue studying. Tomorrow I write the first part of the exam (1pm-4pm MDT, worth 80%). Then on Friday from 12:30-1:50 I write the second part which is based in the lab and on identification of blood smears, pathological specimens, and anatomy based on cadavers which is worth 20%. With that I will wrap up the first course of medical school and be ready to move on to our next course which is the Musculoskeletal System and Skin.

A Break In the Silence

My apologies for the long silence. I've begun to get a few questions regarding the status of my blog and if you haven't found anything it is simply a reflection of my lack of writing as opposed to any technical difficulties that I am aware of. In my last blog I reflected on our first formative exam (which didn't count for anything). I got my results back and was pleasantly surprised with an overall satisfactory performance, even on the peripatetic component of the exam. There were some identified weaknesses but overall I was pleased. I have some room for improvement but that is the way with any assessment.

Medical school has settled into a routine which has reduced my number of 'exciting events' to tell you about. This is not to say that there are no longer exciting events but the novelty has worn off a little bit. For example two weeks ago we spent a whole week on diarrhoea. While this may not be particularly appetizing to many people I found it quite amusing and interesting. There are a number of causes, types, treatments, etc so I now know much more about diarrhoea than I used to.

Our first course is in its final stages. We have 8 more days of new material, a week of review, and then we write our summative exams (counting for 100% of Course 1) on October 22 and 23 which is coming right up. Thus, I have a lot of review to do in the next couple of weeks. By some rough figuring we have had 220 hours of lecture in this course with approximately 9000 powerpoint slides to review. While some of them are empty, introductions, charts, not important, there are still a lot of slides to click through...but I'll get through it and pass if all goes well because I certainly don't want to have to rewrite next summer.

We are almost finished our clinical correlation for this course. It has been interesting to see our skills improving. In terms of taking a history and performing a focused physical exam the difference between our first sessions in late August and now the difference is night and day. We still have a long way to go but we are definitely gaining skills and we have learned a lot. We will never be able to learn it all but the increase is phenomenal. During history of medicine last week one statistic that came up was 'medical students learn on average 20 000 new words in their first 2 years of medical school'. I'm not certain that it is actually this many words but at any rate we are learning a massive amount of information about a large variety of topics.

We've learned about a lot of different things but by far the most enjoyable part of medical school remains our small group and patient interaction learning situations. This past week we got to observe two gastroscopys - one showed a normal esophagus and duodenum while the other showed a Mallory-Weiss Tear (a tear resulting from retching at the gastric esophogeal junction). The Gastroenterologist put several little metal clips into the tear to hold it together and stop it from bleeding and that was that. Later we met a patient and practiced taking a history from him (as a small group of 5) and then I performed the abdominal exam - there were no visible scars, stigmata of liver disease, there was no bruising or significant superficial veins. There was mild edema in the ankles but no bulging flanks. Bowel sounds were heard on auscultation, there was no tenderness on light or deep palpation, Castel's Point was negative for splenomegaly and there was a palpable spleen edge just below the costal margin...so we are getting there.

Formative Exams and a Day in Strathmore

Another week has come and gone in the blink of an eye and I've now been in medical school for five whole weeks. I thought one way to reflect on my week would be in point form so I'll begin with a few things I've learned this week.

1. You feel very stupid when a doctor asks you a question in front of a patient and you don't know the answer. It doesn't matter that I've only been in medical school for five weeks, you still feel like you've seriously missed the boat.

2. I don't think I want to be an ER doctor. I've always thought ER sounded like an interesting specialty and it still is...but after a day at the ER in Strathmore, AB I think that I like the people interactions too much to be an ER doc. Interacting with the patients in that setting tends to be very brief, check them out, make sure they aren't dying, and send them on their way or admit them to the hospital - you don't have the time or need to form any real kind of relationship with them, you just address their immediat concern, and I think that I want a specialization where develop longer term relationships with your patients. That being said, watch this blog as I'm sure my ideas of what a 'good' speciality will change once or twice in the next year and a half.

3. I've decided that getting viral hepatitis is a bad idea whether A, B, C, D, or E I don't want it. Luckily I've been vaccinated against A and B but I have no plans in the immediate or distant future to share needles with IV drug users, or engage in other similar risky behaviours...I like my liver just fine the way it is and it can be damaged enough by fat let alone adding the risk of a viral infection on top of it all.

4. I'm realizing that in medicine when you have a bad day it has the potential to be a really bad day. Imagine establishing a relationship with a patient who is terminally ill that could be cured by an organ transplant of some sort but because they have too many risk factors against them and their illness isn't acute enough they won't be put on the list (or they'll be put too far down the list) to receive the organ that they need before they pass away...I think that passing that kind of news along would generally make you have a bad day, even though it is no fault of your own. The idea of being a 'healer' is something that I believe draws many of us medical students to pursue this career. However, I suspect that we are going to find that there are some days we feel like we are fighting a losing battle. We are going to face a combination of patients that don't care about their own health (or didn't care in the past and now face the consequences) and a system that is flawed - insufficient resources for growing needs. Organ transplants are a prime example. The number of people requiring transplants is going up, success rates for transplantation procedures have improved in the last 20 years (I believe) but the supply of available organs is decreasing or remaining constant. The same thing applies with screening and diagnostic techniques like colonoscopies. If I understand the science correctly many colorectal cancers could be caught by regular colonoscopies, in the same way that mammograms catch breast cancers. However, the resources are simply not available to meet the demand and so it forces medical professionals to rank patients according to immediate need, placing the priorities of one patient above those of another.

5. If I understood the doctor yet and I had to get a blood cancer I would rather get a faster growing one than a slow growing one. At first this seemed counter-intuitive however the explanation made sense. Fast growing cancers are dividing much more often than the normal healthy cells of your body. Chemotherapy can target dividing cells and you have a much better chance of eliminating the cancer that is dividing quickly because you can target it. Slow growing cancers that grow at similar rates to your normal cells are much more difficult to target and kill completely.

6. Mnemonics are very useful. Mnemonic is just the fancy name for a memorization technique and can be as simple as remembering something to the tune of a song, a phrase, or an acronym. The acronym I learned this week is VEAL to help me remember the complications of Portal Hypertension. V stands for varices (essentially varicose veins in your esophagus, they are bad). E stands for encephalopathy (this is essentially brain problems, also VERY bad). A stands for ascites (this is the accumulation of fluid in your peritoneum basically your abdominal cavity and increases your risk of dying quite significantly, thus it too is very bad). Finally L stands for liver cancer or hepatocellular carcinoma, as I'm sure you've guessed by this point liver cancer too is bad. In one simple sentance - Portal Hypertension is bad.

7. People are amazingly generous to medical students. On Saturday I did a day of shadowing at the Strathmore Emergency Room (which I found out is one of the busier ERs in the province). While there the doctor had me taking histories from the patients before he saw them. I introduced myself the men, women, and children who were clearly uncomfortable and had been waiting, possibly for hours and they allowed me to fumblingly work through a somewhat directed history to try and find out what the doctor needed to know to make a diagnosis. Some of them even allowed me to ask them questions that were clearly of no relevance to their complaint but allowed me to work on my history taking skills. We have been told in our Ethics class that doctors enjoy a unique place in society because people will tell us pretty much anything, even though we are complete strangers. Listening to the patients on Saturday made me realize that it is true, and with these stories comes a responsibility to respect the patients who are coming in their discomfort, pain, and need for assistance, to respect their privacy and to do everything you can to ease their pain. I don't know if my class will take the Hippocratic Oath upon graduation or not but there is a modernized version (at least modernized in 1964) that definitely has new found relevance after my day of dealing with 'real patients'.

I swear to fulfill, to the best of my ability and judgment, this covenant: I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow. I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism. I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug. I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery. I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God. I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick. I will prevent disease whenever I can, for prevention is preferable to cure. I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm. If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help. Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University.

8. I still don't really like to study. I'm not sure if I have ever actually enjoyed studying. I've always had this sense that studying is work and there is something, anything that I could be doing would be preferable. While I've certainly found activities that are less preferable than studying it is not my favorite activities. However, this coming Friday I have my first Formative Exam. At the UofC exams come in two flavours - formative and summative. Formative exams are worth 0 points. The come half way through each course and act as a check point to make sure you are on the right track, and you are learning what you ought to be learning. So, I've decided to try and treat this as a real test that does count for something in order to get the most out of it...so my 'day off' tomorrow is going to be largely studying but hopefully it will be a fine day and I'll get to enjoy some of it. One thing that is very nice about UofC and many other medical schools is that we are graded on a pass/fail system. While we will still find out what our actual score was (e.g. 37% or 93%) our transcripts will only record pass/fail. The pass/fail line is not set at 50% but is rather based on competency. Instructors sit down and create an examination. They then determine what percentage of questions a medical student at the examinee's level should get correctly to demonstrate competence. We are not being asked to know every single thing we have learned because that is impossible (although it would be nice). We are required to demonstrate competency as first year medical students, and this same philosphy will extend through the rest of our training...so hopefully on Friday I will demonstrate that I am competent. If not I guess I'm going to have to sort out how to become more competent at my study strategies. A friend of mine once described his overweight grandmother's attempt to lose weight by various diets - Cabbage, Atkins, Grapefruit, etc. His conclusion however was that she should try the 'less food diet'. I suspect that if my competency is found to be inadequate the best study techniqe for me to try would be the 'more studying technique'. However, Friday should give me a good indication where I'm sitting and if I need to change.

9. This 'point form' list has become rather long, however I will conclude with one final observation from the week - while it is possible for me to function on five hours of sleep I don't function an an optimal level and caffeine intake is insufficient to compensate for the lack of sleep cycles. Thus, my goal needs to be a minimum of six hours of sleep/night...so we'll see what this week holds.

Of Colonoscopies and Sleep Deficit

Another week of Medical School is done. In attempt to stay awake at some point this week I found a website that figured out how many weeks it is until I graduate, presuming I survive that long. It is almost a bit scary. Our course is 145 weeks long, the last 54 weeks are clerkship, we have 8 weeks of holidays and 83 weeks of instruction. Thus, having completed four weeks we have 79 weeks of instruction remaining to learn all that we need to know before we begin our clerkship. Time is such a precious commodity and it is slipping away so quickly. It feels like we just started class the other day but I've now been here for a month and I'm certain that the next 141 weeks are going to go at the same rate and I will be finished.

I've observed that I'm not a very good time manager and one of my biggest challenges is going to bed at night. This is partly a result of daytime procrastination and partly a result of the fact that I'm a night owl. The problem is that we had classes or activities of some description at 8:30 every day this week. That really cut down on my sleep in time and it made it a bit challenging to take anything away from lectures when I was functioning on not enough sleep. I'm quite fortunate though - almost all of the lectures in this course are podcast - they are recorded during the lecture and then uploaded to iTunes where we can download them. Thus, while I write this I am multi-tasking by listening to a lecture about alcoholic hepatitis and non-alcoholic fatty liver disease. This is the second time I've listened to it and hopefully by the time it is finished I'll have got the majority of important points from it.

There are two new words that I'm quite partial to. The first is asterixis - it is a symptom of hepatic encephalopathy and refers to a characteristic tremor of the hand when it is extended. The second is a phrase - scleral icterus and refers to yellow eyes (rather the 'white' of the eye) which is characteristic of jaundice.

Today we watched two colonoscopies. We were in a small theatre in the screening clinic and we watched the procedure via a live video feed. The colonoscopist was miked so she 'walked' us through the colon and a polypectomy. It was pretty cool! We've learned quite a bit about the large intestine but to see it in living colour with the healthy, vascularized, pink colon wall was fabulous. There was a small polyp we watched get burnt off as well so it was fascinating. It is amazing what you can do with technology today. It was also fascinating to see the variation between the lining of the terminal ileum which is lumpy from lymphoid tissue and has a carpet of columnar epithelium that looks like 'shag carpeting' compared to the smooth pink squamous epithelium of the large intestine. The border is very distinct. I've found it quite interesting how precise the borders in the body are. There are visible lines between different tissues at places like the gastro-esophogeal junction at the ileocecal junction and elsewhere. Another rather nifty thing was retroflexion. This is when the colonoscopist turns the tip of the colonoscope back 180 degrees on itself. This allowed the colonoscopist to view the rectal-anal junction (an important spot to check for pre-cancerous polyps) and you could see the scope being squeezed by the anal spincter. The same procedure can be performed during an endoscopy to examine the fundus or top of the stomach and the gastro-esophogeal junction where the esophagus and stomach join.

Anyways, I'm off to a bonfire and a nice sleep in tomorrow. I need to listen to some more lectures and by Monday morning I'm going to know a lot more about Hepatits, Gall Stones, and Liver tests but for now it is Friday night and I'm off.