Crusty And The First Internal Inquisition The practice of medicine is an art. Someone told me that once. It takes a lot of studying to become proficient at it. The funny thing is that it's rare to see someone who was efficiently proficient in the discipline . One thing I've always understood is that doctors are not infallible. Shit happens. But to think of the amount of studying required to become imperfect, it always made me wonder about the cost-benefit ratio of attending such an establishment. Maybe I'm making a mistake equating proficiency with excellence. Either way, the gauntlet had various encumbrances to measure our progress at one day being imperfect. One such minor hindrance was the dreaded "internal exam". These little bastards were the equivalent of midterms. Passing a subject required the aptitude to score enough "marks" (fobspeak for points on an exam) on three different disciplines: theory (written) exams, practical exams, and internal assessment. Theory was worth 100 marks, practical was worth 40 marks, and internal assessment was worth 60 marks. In order to pass a subject, one needed to score at least 45 out of 100 on theory, 18 out of 40 on practicals, and whatever balance was required on internals to get 100 out of 200 total possible marks. This system presented a delicate conundrum. It was theoretically possible to score the requisite 100 out of 200 on the entire exam. But if you didn't get the minimum passing marks in EACH section, you would fail the ENTIRE EXAM and have to take it over 6 months later. On the other side of the coin was passing each individual section but coming up short in the total required to pass. Yeah they liked to fuck you in multiple ways. Internal assessment encompassed the evaluation of such trivial things as attendance, behavior, and your scores on various "internal exams", the most important of which were "model examinations" which I will get to later. The marks that were appraised for your (sarcastically making quotation marks with my hands) assessment were pretty subjective. If CDS didn't like you, you were pretty much fucked. There were other teachers/professors who could give you a poor mark too. In physiology, it was the Head of the Department, a man we dubbed "Aquaman" because he looked like he had gills on the side of his face. In biochemistry, it was the illustrious Kartha whose passion for idli (steamed indian bread made with rice flour) was surpassed only by his passion for the Hexose-Monophosphate Shunt. In India, he who had the gold made the rules. The key was to score higher in other portions to make up for their lack of vision. But first things first. Our very first internal exam in anatomy encompassed the upper and lower limbs. It was only a written exam which consisted of 2 essays, 8 short answer questions, and 30 multiple choice. Essays in anatomy included structures like the elbow joint, important nerves and vessels, intrinsic muscles of the hand, etc. Short answers included the flexor retinaculum, a muscle, or an insertion of a muscle etc. Multiple choice could be anything. Our first one was scheduled for sometime in November. People started studying pretty hard for them. I noticed one thing right off the bat. The studying methods were different over there. I'm the type of person who grasps concepts and applies the new information I have gathered to create a new cogent process. In India, a lot of students used a process called "mugging". No, they didn't beat their other classmates for information. They memorized. And memorized. And memorized some more. Then they took a tea break. And then they memorized some more. I found it fascinating because I could pick a local classmate out of a line-up, ask them what it said on page 159 of Chaurasia's Anatomy (text of choice in hell), and they could recite it word for word without looking it up. These people had freakish recall abilities. When I crammed, I could do that as well, but not to the extent the locals took it. To be honest, most of my time was not filled with studying. It was filled with reading novels, talking with my boys, playing basketball, and eating pakora when the opportunity arose. I was like Matthew Modine's character in the movie "Gross Anatomy". I studied when I needed to. And I soon needed to start studying for these first exams. Seeing as how I wasn't very interested in anatomy, I asked some NRI seniors for some suggestions on essay topics and short answer possibilities. Logic dictated that picking the brains of intelligent people would be the way to go. But since the Indian experience was proving to be maddeningly illogical, I figured I'd just ask everyone I could for predictions of what could come on the exam and then make a list of stuff to study. King Surej told me about the brachial plexus. Sounded legit. Sushil suggested the great saphenous vein, the longest and largest superficial vein of the body. Something told me it had a shot. Anil The Long-Limbed suggested the median nerve. I didn't ask the 93 batch NRI's what to study because well, I hated them. So, with a sprinkling of predictions at my disposal, I set about to prepare for the first test. It was hard going in the beginning. I had no idea what to write for essays or short answers. I mean, in English class if the teacher needed an essay on the significance and use of foreshadowing and dramatic irony in Daphne Du Maurier's Rebecca, I most certainly could oblige. But something gave me the sense that essay questions in medical school were a tad bit different. Since I had no idea what to prepare for, I decided to use the first internal exam as an impromptu litmus test so I would at least be better prepared for the first one. Since our marks were so subjective anyway, I just considered them practice for the big dance that was coming in April. Before you could say supercalifragilisticexpialidocious, the first set of exams were upon us. The penultimate night had arrived and Mike, Ajit, and Abi were shitting bricks. Apparently there were probably 10 or more essay topics to cover as well as dozens of short answer possibilities. I wasn't in the mood to pull an all nighter, so I just studied one thing: the median nerve.The other three guys had no idea what to study the night before the first test. Mike was studying the elbow joint. Abi was studying the breast (made total sense if you ask me). Ajit was studying the femoral vein. I walked into Mike's room at around midnight to assess the preparations of our party. "Hey Mike, what did you study?" "Oh man, Bobby, I studied as much as I could. I finished about 5 of the essay topics and 10 of the short answers. What did you read?" "Eh, I read about the median nerve." "And what else?" "That's it." "That's it?" "Yeah." "So out of 10 to 15 possible essays you've read ONE." "Your estimate sounds correct." Mike gave me an aporetic look that counted as a smirk in my book. He shook his head from side to side, rolled his eyes, and dropped his nose back on page 159 of Chaurasia. Ajit was having an even worse time of it studying for the exam. He read about half as many essays and short notes as Mike had. I wasn't particularly inclined to study all that stuff when we would be tested on it again anyway. I left my friends to their devices and went to sleep. I like to think that I had dreams of a better place. At 7 am, my wind-up alarm clock went off (concession to the frequent power outages in the area). As per my usual daily ritual, I turned it off, got out of bed, scratched my balls, applied toothpaste to my Oral-B, and corralled my red bathroom mug. The rim and upper portion of the mug had been baptized by a grimy rim of salts and deposits that were present in the bathing water. I strolled on down to the bathroom to go about my business. The best part about the bathroom I used in the morning (along with several other guys I might add) was that the toilet was top-notch, even though it was a commode in the ground. One's rectum could expel a turd the size of the Titanic and not worry about it getting clogged. I sometimes noticed, rather unfortunately I might add, that toilets got clogged. The surest sign of a clogged toilet was to assess the degree of closure of the bathroom door. If the door was fully closed, odds were that there was someone using it at the moment. Confirmation came by observing a lungi draped over the door frame. If the door was partly open, leaving a sinister gap in between, chances were that that toilet was now clogged. Of course, the only way to assess the degree of outlet obstruction was to open the door and check. More often than not, if I came across a partly open bathroom door, I expected the worst. The worst comprised of turds floating out of the toilet and onto the bathroom floor, with the water level rising each time one tried to flush it. But on this morning, there were no surprises of that variety. As I pulled down my boxers and assumed the position, I thought about any other important things I should know about the median nerve. I came up with mnemonics for the relations, the course, and the muscles supplied by said nerve. As I was pondering the multitude of ways to answer, I reached over to the tap to turn on the water for my filthy mug. Consternation took a hold of my muscles of facial expression. There was no Adam's ale being expressed from the faucet. I now had no real way to clean my ass. And the worst part about it was that I had diarrhea. This was not your garden variety intestinal infection. I was genuinely a bit nervous about my first exam and had a bowel movement that has since been dubbed by medical students in India as the so-called "nervous diarrhea". The stress and anxiety causes your shit to somehow liquefy and come out in a semi-powerful stream with one or two squirts thrown in for good measure. For a minute, I supposed that I could have just tried the next stall over. I half squatted and half scurried to the next available water source in the bathroom, clenching my cheeks to make sure no gooey brown paste would be dripping down my legs. The faucet didn't work. Now was the time to panic. I didn't have any more toilet paper from my stash of survival necessities because Anil The Crazed confiscated and burned them. The next possible solution to enter my problem-solving center was to use my boxer shorts as toilet paper for 1 quick wipe. I pondered it for a second or two or three and decided against it. The final analysis of the situation provided a dastardly resolution. I pulled up my boxers and stood up. I clenched my cheeks as hard as I could and ran to the next bathroom, 6 doors down the corridor. I pulled down my boxers, squatted, made the sign of the cross, and turned on the faucet. Eureka! It was not my destiny to have a pasty, crusty ass for the rest of the day. I happily cleaned my anal verge, including the taint (movement and friction might have dislodged some doodie) and washed myself thoroughly afterwards. I went back to my room, took off the now tainted boxers and threw them out my barred window. With enough adventure for one morning, I proceeded next door to Ajit's room. Mike and Ajit were sitting at his desk doing some last minute ruminations. "Hey, Bobby," Ajit said, "Are you ready?" "Yeah I think so. You guys ever had one of those nervous shits that come out all diarrhea-like?" Both of them dropped their books and looked intently at me with glances of bewilderment. "What the hell are you talking about?" said Mike. "Man, I just had to go for my morning shit and it all came out like diarrhea." "Yeah welcome to India," Ajit said. "Well, that's not even the worst of it." "What do you mean?" "When I was done with the poo part, I turned on the faucet and no water came out." "WHAT?" cried Ajit as he scrunched his face up like he just took a bite out of the world's largest lemon, "Oh man, that's CRUSTY!" And with those four words, I was now dubbed "Crusty, Centurion of the Ivory Throne That Must Be Squatted Upon". In a place where Murphy's Law was omnipresent, it figured that on the morning of our first exam I would have excrement issues. Mike and Ajit had a big, bellowing laugh at my expense for yet another time and we continued to small-talk, nervously watching the clock to strike 8 am, the start of the exam. At a quarter to 8, we got dressed in our prison issues and collected our books and writing instruments. I mentioned before that Ajit was a big "Top Gun" fan. He decided we needed some "mood music" to inspire us or some shit like that. He painstakingly selected a tape from his vast collection and put it in his boom box. Suddenly, the theme to the movie by Steve Stevens and Harold Faltermeyer started playing. If you've seen "Top Gun" you know the music I'm talking about. It's the music that's used in the slow motion scenes whenever they're walking towards or away from their F-14 Tomcats. Listening this brought on a new wave of apprehension and nausea that I never knew I had. It felt like we were going into the final battle and we were totally underprepared. I looked at Mike and breathlessly pleaded, "We studied, right? Are we ready? What are we gonna do?" Mike slapped me upside the head and told me to calm myself. It was just the first internal. He rationalized that as long as we showed improvement over the course of the year, we'd be alright. For us bloody Americans, it was a rite of passage to fail the first internal exam. It just meant we weren't abnormal or anything. The song finally ended and we departed the hostel. On the way to the academic block, we crossed paths with a senior NRI named Pragie. Pragie was from Australia. He's the closest thing I've ever met to an Indian surfer dude. He saw us approaching and stopped. "Hey guys, I know you've got your internal exams today. Just know that you'll be alright and things will be fine. I've been through 'em before and they're just a necessary evil." Now my nervousness had shot through the roof. I wanted to grab Pragie by his lapels and ask him, "HOW DO YOU KNOW THINGS WILL BE FINE? THERE'S NO WAY OF KNOWING! WHY THE HELL DID AJIT HAVE TO PLAY THAT TOP GUN SONG?" Since he was my senior, I thought better of it. I just shook my head at my inevitable fate. We continued on to the dissection hall where our anatomy internal was to be administered. The doors were locked and closed and Beulah Cow, Maheswari, and Vijay Lakshmi were standing outside. They handed each of us a number which was to be our assigned seat. We filtered into the atrium and everyone went to their designated seat. The "tables" used for the exam looked an awful lot like the gurneys that carried cadavers. No expense spared at this institution, no-siree-bob. I got to my assigned seat in the middle of the hall. Seated across from me was Tolstoy. I didn't mention this before but Tolstoy has a brother named Karl Marx. I shit you not. Anyway, he gave me a smile and nod of encouragement. I'm sure he could read the fear on my face. I probably reeked of it. As soon as everyone was situated, the three amigo tutors came down the hall handing out sheets of unlined paper. These sheets carried the moniker "A4 Paper" to the unintiated. They also handed out a single piece of string with each set of sheets. I was curious as to what the string was for. It was too thick to be floss, so I deduced that they didn't have our oral hygiene amongst their top priorities. I picked up the string, twirled it in my fingers, and wordlessly asked Tolstoy what it was for with just a look of my eyes. He picked up his sheets of A4 paper and showed me a hole in each one at the upper left hand corner. He threaded the string through each aperture and then tied them together with a simple bow knot. I guess staples were a bit too much to ask for. I smiled at Tolstoy acknowledging his courteous explanation. Suddenly, an erie quiescence had befallen the populace. The bane of my existence, CDS, had made his grand entrance. He strolled up to the podium and started talking. "This is your first internal assessment. You will have 2 essays, 8 short notes (answer) and 30 multiple choice questions. You have 3 hours to finish the entire exam. If anyone is caught talking they will be expelled from this exam forthwith. DO I MAKE MYSLEF CLEAR?" Like the sheep we were, we all responded in unison, "Sir, Yes Sir!!" Then CDS proceeded to recite the essay questions, "Essay #1: Describe the course, relations, and applied anatomy of the MEDIAN NERVE." BONUS! The one thing I studied was one of the main questions! Yay me! Ajit and Mike gave me a look that translated into something akin to "You lucky son of a bitch!" "Essay #2: Describe the course, relations, and applied anatomy of the Great Saphenous Vein." Ooh. Not as good. I hadn't studied that one so well. But I did know one fact about it. It was the longest and largest superficial vein in the human body. After reciting the 8 short notes, they came to be comprised of questions like the profunda femoris artery, flexor retinaculum, lymph drainage of the breast (something I'm sure Abi nailed), etc. Before we began writing, we did the multiple choice questions. I'm the type of person who picks an answer and never looks at it again. I had a system for this one. I went through all 30 and completed the ones I was sure were correct. In this particular exam, that was 0 out of 30. Then I made a second perusal where I could pick an answer after eliminating 1 or 2 of the options. This took care of about 4 or 5 of them. The remainder were blind guesses. Once that portion was out of the way, it was time to do the written part. Since I had studied the median nerve well, I put most of my effort into that. I decided to finish the other essay first since I didn't know as much about it. My seniors gave me advice on how to write essays for exams a bit. The professors liked lots of diagrams and less words. After all, a picture is worth a thousand words. In that case, the picture of my great saphenous vein was worth fifteen words. I drew one large vein that took up the entire side of one A4 sheet. I colored it blue and labeled it as the "great saphenous". Next, I drew a smaller venous structure and likewise colored it blue. I labeled this little bugger as a "regular vein". Underneath both diagrams, I wrote my one sentence that would comprise the entire essay: "The great saphenous vein is the longest and largest superficial vein in the human body." Fifteen words seemed to do it. Next came the median nerve. I totally blasted that essay out of the water, if I did say so myself. I made diagrams of its course from the roots of the brachial plexus down the arm and forearm. The fact that I remember this much about it shows I haven't forgotten EVERYTHING. For the profunda femoris artery, I drew a blood vessel and colored it red. I labeled it as the profunda femoris. That was my short note. I had no idea what it supplied so I didn't go into detail. I kept things simple enough for a neanderthal, which I was probably proving to be in the eyes of the tutors and CDS. By the end of the exam, I had written about 5 pages front-and-back for the entire examination. I thought that seemed like enough. I checked the clock. HOLY SHIT! It was only 10 am! I was done writing what I needed to and didn't dare have the cajones to leave the hall early, not with CDS now the gatekeeper. I glanced up at Tolstoy and saw that he was writing furiously. What the hell could he possibly be writing for so long? The more and more I saw of him, the more I realized he was one smart hombre. Eventually, ennui took over and I felt myself starting to nod off. Practically everyone in the class was still writing even when the cowbell rang at 12 noon. I figured someone had to bring up the rear. After all, what do they call the person who graduates last in his or her medical school class? DOCTOR! At noon, our papers were collected and we were filed out of the hall in one big glob of humanity and suffering. Naturally, everyone wanted to talk about how everyone else did and what not. When I approached the guys, I saw Nisha, Lekha, Manju, and Rajana talking with them. They were discussing how they did, naturally. "Oh man. I did NOT do well. I only knew 3 mcq's!" Ajit said. "I didn't think it was too bad," said Nisha aka Hannibal. "Yeah it was rather easy, I thought," said Lekha aka Murdock. "Yeah it was a bit hard for me," said Rajana aka B.A. aka Big Red Manju just pouted. Our scores would be returned to us within the next couple of weeks. All we had to do now was wait to check out damage control. Since there was no point in fretting over the past, we all headed to the mess to soothe our souls with the potent libation of tea. Now there's one thing that never got old.