The most repetitive lesson of medical school

1. If it doesn't make sense, or you don't know how to do it, fake it 
2. Just keep faking it and moving forward
3. If you fake it long enough, it will eventually make sense / you'll figure it out
4. As soon as it makes sense it will be time to move on to the next thing that doesn't yet make sense*
5. Repeat

It amazes me how many times this cycle has repeated itself during my medical school experience.  And yet, it still continues to repeat. 

*Sometimes, you actually have to move on before you realize it makes sense, but then you move on and that last thing just "clicks".  Slightly out of order but the process still holds true.

Dear ACGME,

As a 4^th year medical student I highly value the work that you do in ensuring my training in residency will be sufficient.   However, I am horrified to learn that you are proposing the removal of family planning training guidelines for family practice residents.  Many US women go to a FP as their primary healthcare provider for comprehensive health care – from the treatment of acute sickness to the delivery of their babies and everything in between.  The vast majority of women in the United States use contraception.  Now, if a FP isn’t trained to provide their female patients with counseling on contraception, pregnancy options, and the such, where are these women expected to turn?  It is an equation that makes no sense at all and will lead to subpar care for many US women, especially poor women and those in underserved communities. 

Please do not change the requirements for family planning physicians.  Women count on their providers, and we as providers need to be trained in how to provide comprehensive reproductive health care.  If we’re not trained, then who will be?  It is your responsibility as an accrediting organization to look out for our best interests as future physicians and the best interests of our future patients. 

Thank you,

PAIT

 

I wrote my letter - now where is yours?

 

ACGME is debating cutting family planning training for family medicine residents.  They are accepting feedback through tomorrow.  Please speak up, and ask everyone you know passionate about this issue to do the same. 

Comments are being accepted at familymedicine@acgme.org.  Also, the Reproductive Health Access Project has an online campaign going here.  More information can be found here.

And tangentially related, what is going on in Kansas is disturbing.

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!

Listen to your patients

"Listen to your patient, he is telling you the diagnosis" -Sir William Osler

Over my past 2.5 years of medical school, I have heard this quote over and over again.  It is mostly used in stressing the importance of taking a complete and detailed history.  It is used to say that the patient will relay the pathological signs as puzzle pieces, pieces that even a low level clinician can put together.  Think about the big wood toddler puzzles where there is no way a piece can be places in the right place.

My surgery attending, an old seasoned veteran surgeon, has recited this quote every time a patient comes in with mid-epigastric pain that radiates to the shoulder and is accompanied by years of "reflux" pain that is non-responsive to medication.  The patient may not use those exact words or explain it in text book order, but the patient is painting a clear picture of gallbladder issues.

I was recently reminded that listening to the patient can work the other way too.  Patients who come in with complex, in-congruent, complaints.  Patients who have pathology that clearly did not read the textbook.  These are the patients who are negative for every horse and most zebras, the patients who end up with diagnoses of exclusion.  The amazing part though?  We as providers approach the patient totally defeated, as if we have only apologies to offer, and they respond with complete affirmation and relief, as if they have known this to be true all along.  Their shoulders sink down, their spine uncurls, and they relax for the first time in a long time.  Then, when empowered, the patient begins to tell stories about why they expected this diagnosis long ago or how this diagnosis explains so many seemingly trivial signs they didn't mention before.

It amazes me how many different ways there are for a patient to tell you the diagnosis.  We just need to learn all the different, and subtle, ways to listen.

Let us reinvision institutional norms instead of simple reform

"In 2000, the British psychologist James Reason wrote that medical systems are stacked like slices of Swiss cheese; there are holes in each system, but they don’t usually overlap. An exhausted intern writes the wrong dose of a drug, but an alert pharmacist or nurse catches the mistake. Every now and then, however, all the holes align, leading to a patient’s death or injury. "

This quote is from The Phantom Menace of Sleep-Deprived Doctors which was published in the NYT magazine earlier this month. I finally got around to reading it today.  (dearest gf: sorry for letting it sit in my inbox so long)  I also happened to stumble across this video today, which is an awesome visualization of a powerful speech given by Sir Ken Robinson.  Read then watch, or watch then read.  Let the two sources simmer together in your brain.

When watching the video all I could think about is how relevant the issue is to medical education.  The standardized testing, the individualization, the pacified boring lectures- yep, that sums up my last 2 years.  Sure, schools now are going all out to include group sessions, simulation centers, case-based education; butt it isn't enough.  Overall though, they are still working within the old system of education, still limited by the boxed in ideology of our forefathers.  There are schools, programs, that are drastically different such as the Program for Integrated Learning (PIL) at Drexel, but they are few and far between.

Looking at the article in collaboration with the video, it illuminates the undertone that drastic change is needed.  Passing new work hour regulations may be helpful but it is not actually addressing the underlying problem and is actually causing all new problems with hand off.  So now the powers that be need to formalize hand-offs, need to expand the length of residency programs so budding doctors can see all they need to, need to come up with night-time formal curriculum so that those on extended night float don't miss out... and the list goes on.  But will filling these holes really solve the problem?  Or will it just expose other holes that already exist in the system and create new ones?

I'm enamored by medical education. This interest fueled my decision to do my clinical years at my school's satellite site.  We're learning in a new model, one that involves more kinesthetic and team based learning, one that reads more like an apprenticeship than traditional 3rd year clinical rotations.  This out-pouching of our medical school also challenges us to be non-traditional, to think outside the box, and to come up with innovative revisions to the medical community in this city. 

From being at the satellite site, from watching the video, and reading the article, I'm inspired to think outside the box.  I hope that others are too and that we can collaborate to create tangible change in the future. I want to challenge more divergent thinking for those involved in medical education, that is if they (if we) can tap into our inner-kindergartner.