Time flies when you're [in med school]

At 10am this morning, by handing in my psych self exam, I officially completed my 3rd year of medical school.  I am now 3/4 of the way to my MD!

However, I am also officially taking a year off to do research next year, which means I'm on the 5 year medical school path.  So I guess I'm really just 3/5 of the way to my MD.  I'm really excited about the research I'll be doing and the city I'll be living in.  I'm a bit relived that I now have a little more time, and will have more exposure, before having to faithfully decide on obgyn.  Plus, it is allowing me to feel like I'm doing everything in my power to make up for my [first attempt] failed step 1 score.  I'll never actually know if it'll make a difference in my life path, but at the same time I can't imagine that it'll hurt anything! A year to re-learn spanish, exercise, sleep regular hours, travel, cook/eat healthy, socialize with friends, be close to family, ....  what is not to love?! 

I can't believe it has already been a year since I started on the wards!  A year since I wrote this post.  A year later, I still struggle with empathy, compassion, and time management.  While I still feel like I know nothing, I can also tell that I've become more proficient in presenting patients and writing progress notes.  I am better at answering questions.  I have learned to suture, catch a baby, drive a laproscopic camera, do complete neurological and psychological exams, and so much more.  I am also learning to forgive myself when I make a mistake, make an idiot out of myself, and when I have a visceral emotional response to my surroundings.  One year down on the wards and a life time to go.  Every day I spend with patients, I become more and more excited that this is my life!

Lost in Translation

I recently had my first experience using a medical translator in order to communicate with a patient.  Actually, I had to use 2 different translators for 2 different patients in the same day.  One experience was relatively neutral, the other extremely frustrating as the entire conversation seemed to be lost in translation.

At the hospital I'm currently rotating through, the translators come via a speaker phone on a language line.  My understanding is that this has become the most financially affordable way to translate and also allows for access to an increased number of languages.   Speaker phone means distraction from background noise in a busy hospital, a lot of need for reputation, decreased clarity, and a lack of visual ques. 

The frustrating experience involved an attempt to gain informed consent for a necessary surgery.  Informed consent is already a complicated song and dance as it is a multi-step process with nuanced details that make little sense to someone without strong medical literacy.  [The predicament of informed consent can, and probably will, be a whole different blog post all together.]  Add in a speaker phone, translator without proper terms for female anatomy, and language without words for "laproscopic", and you have an ugly mess.  We spent an hour and a half with that patient and I'm pretty sure she walked away more confused than when we started.   She answered in the affirmative to statements of understanding and denied having any questions but her face said different.  I'm sure that I'm not the first to be frustrated with these experiences and I have no idea how to make them better, but I really hope that this conundrum progresses throughout my career.  Part of my interest in healthcare is to educate my patients and I certainly hope that I can learn to do better than what I experienced.

Playing catch!

I caught my first baby today!!!  Then, tonight, I caught my second!!   [and I didn't drop them!]

As awkward as it was to be draped in a sterile field moving my hands into new positions, it is absolutely amazing.  I was the first person to lay hands on these two new beautiful beings.  I was allowed to be present at, and to be part of, a hugely piviotal moment in these families' lives. 

AMAZING!!!

11 things I'm thankful for in 2011: MS3 edition

11. The PxDx app on my smart phone that lets me log actual patients on the go instead of having to make them up at the end of a rotation.
10. The MyFitnessPal smartphone app that is allowing me to not gain weight while living off crappy hospital food.
9. Protein bars & peanut butter packets for keeping my energy up when meals don't exist.
8. Big pockets in my white coat as I'm not sure how else I'd manage to keep my whole life on me at all times.  Seriously, my white coat may weight 20 pounds, but I can survive anything with it on!
7. Old handed down notes & advice.  Save time, save energy, learn from someone else's mistakes.
6. Finally being done with step 1!
5. Knowing exactly how many exams stand between me and the end of medical school: step 2, 4 shelf exams, and 1 departmental exam.
4. My immune system for keeping relatively healthy while expose it to every germ under the sun.
3. Nurses.  Particularly scrub nurses.  They repeatedly save my ass over and over again when I have no clue what I'm doing on the floor.
2. Family & friends that seem to understand why I don't have time to call them back.
1. My patients for being extraordinarily patient and generous with their time and bodies as a bright eyed and bushy tailed medical student learns from them.

What are you thankful for this Thanksgiving?

Becoming a statistic

Monday, 3 weeks into my surgery rotation, I became a statistic.  I stuck myself with a suture needle in the OR while attempting to close the patient.  There was a moment of silence in the OR.  The scrub nurse and my attending glared at my with wide eyes while their masks concealed their facial expressions.  Were they smirking?  Were they frowning?  The sound track of "shit! f#@k! Damn! I screwed everything up!" echoed in my head. 

As per the scrub nurse's orders, I placed the needle on a non-sterile field and pulled off my glove to have my hand inspected by the circulating nurse.  There, on the palm on my left hand was a small little speck of blood, signifying that I broke skin.  The circulating nurse's response was "shit!... well, I guess you need to go to the ER now."

What did I do?  I went to the sink and washed my hands with soap & water for a good long time.  I looked through the patient's medical chart weighing my options.  Then, in one of my less proud moments, I decided to forgo the OR in trade for going home.  I had been at work 11+ hours for the last 8 days.  I was exhausted, and embarrassed, and not wanting to make a stick of something with such a low risk. I didn't want to be put on HIV prophylaxis as I'm sure it'd screw up my diabetes big time.  There isn't anything that can be done for Hep C...  Plus, since being on surgery I've heard so many attendings tell war stories of being stuck and mocking the whole contact precaution protocol. 

"Researchers surveyed surgery residents at 17 medical centers and, of 699 respondents, 415 (or 59 percent) said they had sustained a needlestick injury as a medical student. Many said they were stuck more than once. Of the surgeons-in-training whose most recent needlestick occurred in medical school, nearly half of them did not report their injury to an employee health office, thereby avoiding an evaluation as to whether they needed treatment to prevent HIV or hepatitis C." -Medical Students Regularly Stuck By Needles, Often Fail To Report Injuries 

The story doesn't end there though.  I fixated on the needle stick, kept contemplating my decision, weighing my options.  I talked to my girlfriend, a few other medical students and a few residents whose opinions I trust.  Then, on wednesday, I made the mistake of mentioning the stick to my program site director & the surgery clerkship director.  That was it.  Wheels started turning leading me to employee health.  Phone calls were made.  Documents were filled out, papers were faxed, and emails were sent.  4 tubes of blood were drawn and plans were discussed to report back in 6 weeks, 3 months and 6 months.  


Nearly a week after the initial stick, I still feel like an idiot.  My dexterity is clumsy when it comes to using a needle driver, as was pointed out in my mid-block evaluation yesterday.  It did prove to be a lot of hoopla for a little event, a tiny tiny stick.  But you know what?  Wednesday night I went to bed with a clear conscious that I was doing the right thing.  Yesterday I breathed an even deeper sigh of relief in learning that I'm currently HIV and Hep C negative and Hep B immune.

A day of firsts

Today's been a day of firsts:
*my first time scrubbing into multiple consecutive surgeries, 3 to be exact.
*my first time using a scalpel on living human flesh.  Gross anatomy was the first time I had cut into other types of human flesh.  
*my first patient died, as in a patient I had followed from the very beginning of her hospital course to the very end.

Driving home I kept thinking about a comment a friend made to me when I started med school: "Keep a journal because medical school will change you.  You'll want to look back and see how." It is days like today when I realize how very right she was.

First real day of surgery

-Lasted 10.5 hours.  Of which, the majority were spent on my feet and 6 hours were spent in actual surgeries.
-I scrubbed into my first actual surgery and took my proper medical student place as a professional retractor.
-Due to the circumstances of said surgery, I had a lovely vaso-vagal episode in which I had to ask the scrub nurse for a stool so I didn't pass out or vomit on the patient.
-When sitting didn't prove to be enough, I broke scrub and excused myself briefly to re-compose myself.  I ended up being fine.  The rest of the team was fine with it.  Yep.  It turns out that I'm THAT medical student.  The one who nearly passes out & vomits in my first scrubbed surgery.
-I called my lovely girlfriend on my way home to strike a deal.  She's not allowed to break up with me during my surgery rotation, as I am sure that I will be a miserable and neglectful partner for the next 2 months.  Her response: "I bet we wont even talk enough to break up.  I'll have to do it over text message."  I do love her!
-My feet hurt.  A lot.  Disappointed my in well loved, and very old, danskos.  Here is to hoping that my body adjusts.
-Career hypothesis to date: surgery is looking like a no go.  OB/GYN is falling below peds due to the surgery component.

the dark side of peds

Over the past few days I've increasingly been exposed to the dark, depressing, and horrid side of pediatric care.  Parents who abuse their children either directly or through neglect.  Caregivers who can't look up from texting long enough to answer my questions.  Parents who ask how soon they can go home with complete disregard to the fact that their child is sick enough to warrant being admitted to the hospital.  Caregivers who overtly, and horrifically, abuse their children. I want to scoop up all these children and protect them.  A tiny infant, a sweet little toddler, a loquacious mini person, all of them.  I want to wrap my arms around them and bring them into my home.  I want to be able to promise them that there is better out there, that they deserve to be loved and have the right to be a child. 

I seriously envisioned myself adopting the sweetest little 2 year old yesterday, a 2 year old that will be spending way too many days in the hospital for the horrors he has already experienced in his too short life.  I imagined myself sitting by his bed day in, day out, as he overcame this event and regained a childhood.  I had a vision of what my life might be like if I did take him home.  In that moment, a decision was made.  I will foster and/or adopt children at some point in my life.  There are way too many little ones, and not so little ones, that need safe and loving homes.  There are way too many horrible parents and caregivers out there and not nearly enough safe refuges. 

My heart hurts.  I'll never forget the signs of evil that draped this small child's body.  I hope I also don't forget the angles who took him in.  I'm seeing the good and the bad of the system.   Currently, it seems the bad is winning, and I'm quickly growing jaded.  My faith in humanity is becoming scared by the abuse case that never surmount to anything, with the child being placed back into an unhealthy environment because there is no where else to put him.  The parent who is unable to afford a necessary medication, even when it is on the cheap generic list, but is fully occupied by her very expensive phone.  The disengaged parent who is depriving their child of maximal growth and development through their lack of interaction.  The child that was abused in foster-care; the place that is supposed to be safe after experiencing neglect or abuse in their biological home.  How am I supposed to pick myself up from all of this?  How can I make a positive difference in this world with such a cruel reality?

Peds: day 2

What I learned today is that cranky children can be soothed by continuing with their familiar routines.  A crying toddler while obtaining an H&P from his mother may be crying simply because he missed his breakfast, not necessarily because I'm in the room.  The same child was a blissed out cuddly monkey, patiently cooperating with this 3rd year medical student haphazardly conducting my first pediatric physical exam; all because I excused myself from the room so he could have breakfast before I proceeded.

A slightly older child required some teasing about having a dragon in his ear, and pretending to look in my ear, before he let me proceed with the otoscope.  There is lots of goofing around, taking time to explain things to parents and then again to the child on a level they understand, and time outs to clean up pee or vomit that were projected across the room.  It is all about the children when on peds: their schedules, their cooperation, their level of understanding.  So far, and not surprisingly, I LOVE it! 

What are your tricks for working with the little tykes in both in & out-patient settings?

Beginning of the end

Today marked the beginning of the end for my 2 newly admitted patients and for me. For them, it is the downward slope to the end of their life, presenting with acute decompensation of chronic illness. Comfort care is being established and loved ones are being integrated into the process. Today I had the blessing of spending some quality time with one of these families. The way they are embracing the inevitable is a truly holy spectacle. May we all have such bravery, wisdom, and strength at the end of a well lived life of our dear ones.

For me, it is the end of my medicine clerkship. Today we took the written departmental exam. Tomorrow we take an oral exam on the H&Ps and clinical course of 10 of the patients we followed. Friday we take the medicine shelf exam. I can not believe that 8 weeks are over, and my first 3rd year clerkship is wrapping up! While I am relived to be done with in patient hospital medicine, I will very much miss the incredible teaching and mentoring that I have been privy to. It really is true what they say about medical school: as soon as you get comfortable with the day to day routine it is time to switch it up again.

Here is to hoping that I finish this block on a high note!

First, do no harm.

After only 6 weeks of medicine, I'm pretty sure that we as doctors do harm all the time. We see patient after patient get admitted to the floor for serious conditions (renal failure, heart failure, electrolyte abnormalities, etc.) brought on by the medications we're prescribing for the underlying serious condition already plaguing them. We put patients through painful and costly diagnostic tests to be able to tell them they have metastasized cancer, and that we can't do anything for. Urinary catheters and central IV access become hot zones for infection. The hospital itself breeds nosocomial madness of highly resistant bugs.

There is a lovely old lady who was in amazing health until a few days ago. Then she hit a wall. We treated her and sent her with many new diagnosis, and many more medications. Not even 24 hours later she came back in with the same symptoms. This time she's convinced it is the medication making her sick. I have to say that I am not entirely sure she's wrong.

I'm way to sleepy to make anything of this post currently, and I have a hunch that it's going to be an ongoing conversation as the years [and secrets] of clinical medicine unravel before me. Currently, I just hope that the good we're doing for this lovely lady, and everyone, outweighs the harm that is unintentionally done on the side. I also hope we're learned enough in our practice to properly educate our patients about the risks involved with everything that is done to them and for them.

In the humbling words of my attending: "We will do everything for her/him, but you need to know that there is nothing we can do."

VOMIT

Today I learned a new term: VOMIT
Victim of Medical Imaging Technology

The idea being that if you begin searching too deeply, you'll find something that may not even be there. One elevated number on a blood test leads to an x-ray, which leads to a CT scan or MRI for more detail, which leads to a biopsy, which leads to an infection, which leads to prolonged course of antibiotics with side effects... which eventually leads to the realization that it was just a touch of dehydration and a bad x-ray angle to begin with. It's like the "If You Give a Mouse a Cookie" story we read in elementary school.

Sure, there are times where advanced testing leads to early diagnosis, but most of the time it leads to unnecessary diagnostic procedures which each carry their own large risk and price tag. In the 2.5 weeks I've been on medicine I've already seen it numerous times. Patients coming in for chest pain, or abdominal pain, or mild limb swelling end up spending multiple nights in the hospital, get poked like a pin cushion, exposed to nasty bugs, and end up going home perfectly resolved without any real treatment or known causative agent.

I don't know what the right answer is though. Clearly these tests and procedures have their role in medicine. I reckon that it is all about finding the balance between the view that every life is as valuable as the world and the oath that all doctors take to do no harm.

The flip side

Since last posting I've moved apartments, progressed to a 3rd year medical student, and gained a year on my age. I surpassed Step 1 and now am just praying that I passed as I patiently wait for my score. I've also passively watched as state governments have chipped away more and more on abortion access. It seems that as I get closer to my role of a comprehensive reproductive health care provider, reproductive health care becomes more and more restricted.

This week [after passover ends] I'll be in 2 different states: flying to one state for a national leadership retreat and then to another to present a poster of my summer research. When I return, next Tuesday, I begin my clinical rotations!!! So I have until next Tuesday to learn how to keep my [very] liberal views to myself as I gain on the job training from superiors...

Cool as a cucumber

Yesterday, my preceptor (a 3rd year resident and really wonderful teacher) was telling us stories about his med school psych rotation. He explained how he was at an inpatient hospital and saw the crazy-of-the-crazies. He gave us a few patient vignettes, each one crazier than the one before. We were wide eyed listening, with growing excitement about the possibilities of our future psych rotations.

And then, "There was this one woman who thought she was a man!" Crash! Back to reality. Back to remembering that I am a medical student in the conservative South. He went on explaining the case, and when he got to a natural break, I spoke up. "You know they're in the process of removing gender identity disorder from the DSM?" I did my best to stay calm. To engage in a rational discussion about shifting understanding of gender identity. He tried to justify his comment and then quickly moved on to "And then there are narcissists! I had this one patient..."

It isn't his fault. It wasn't malicious. Even though he is a young doctor, he had never learned otherwise and so he was just passing on what he knows. This was a perfect case study in why medicine is a slowly evolving profession. But regardless, it is also a little heartbreaking. A sharp reminder that there is so much work to be done in this world. That the most effective way to do this work is to stay calm. To be cool as a cucumber. Slowly, I will rationally and politely educate my professors and peers one person at a time.

choices, part 2

In an update to this post last month, I just sent in an application for the program. Still not completely sure it is what I want to do, but I am also not ready to give up on it. The sticking point is the possibility to work with state officials on improving health care. To work on health policy reform in the state capital! Or at least working within the hospital to make policy changes. That'd be SOOOOO cool and so up my alley. I figure that by applying I'm allowing someone else to decide for me &/or buying myself more time to decide on my own. Only time will tell how this all pans out!

choices

For 3 & 4th year clinical rotations, I have a choice to make: stay in the city I live in, or move our schools satellite site in the state capitol. In hopes of making the decision easier I went up there today to check it out. However, I'm now just more confused about what I should do.

The advantages of going: way more hands on experience (as in getting to be first assist in all surgeries, delivering babies myself, etc.), working directly with attendings, a special focus on leadership, nice on-call rooms, tuition incentives, cheaper housing, free meals & parking, and getting to be in a small close knit cohort of students with administrations who deeply care about us and our experience. Plus, it is only an hour drive away so coming back is an option. Oh! And we found a gluten free bakery/restaurant.

The disadvantages: The satellite site is new, small, and clam. It is not an official academic hospital, and the ER is a level 2 rather than the level 1 here. They see a little less trauma and don't seem as busy overall. We also wont have the formal lectures, though they do teleconference or make us come in to the main campus for some of them. The city has a lot less unique funk; there is also a smaller young activist community and basically no Jewish or queer community. With so few student there, no residents and interns, and no already established outside community, it seems somewhat isolating. Also, not all the doctors know what to do with students, but that has already improved a lot since this first class started last May. I will have to do a 4 week elective in non-clinical leadership on top of the 4 weeks I already have to do for my MPH, reducing my elective time to 16 weeks total.

Students at both sites seem generally happy with their experience and are learning a lot. Either location will afford me solid training and the chance to become a good doctor. It is unclear whether one will be more advantageous than the other for residency applications. Seemingly, both decisions are good which makes it even more difficult to choose.