The Differential: Medscape Med Students Blogs

Horses, Zebras, Ninjas

Ben Bryner -- I was reading this story the other day, in which a camp counselor was mistaken for a ninja, which then prompted a school lockdown. It reminded me of the old medical adage, "when you hear hoofbeats, think horses, not zebras." Briefly, if you’re in an area where horses are more common, when you hear hoofbeats outside, it's much more likely to be the sound of horses, not zebras. The idea is that when a patient presents with symptoms that are consistent with a common disease, but are also consistent with a much less common disease, you work under the assumption that it is the more common disease until you can confirm it. In other words, if you’re in New Jersey, a person dressed in a ninja getup is more likely to be a regular person who’s just into karate or dress-up than an actual ninja.

The saying is usually used to correct a student or resident’s differential diagnosis. When you’re on rounds and presenting a new patient with an unknown or not-quite-certain diagnosis, when you get to the end of your presentation, your attending will generally expect you to list the “horses” (the more common diseases) first and the “zebras” second. If you don’t, the attending may request that you do so by saying “Horses, not zebras,” or by the less-conventional technique of whinnying while slapping his or her legs to simulate hoofbeats.

So you should follow what I like to call the “Family Feud” strategy of presentations, based on the game show of the same name. (If you are wondering whether I think all of medical school can be reduced to elements of game shows, the answer is: No, only 80%.) The point of this show was to guess the most popular answers to open-ended questions, with one team trying to list off the top answers to build up points, and the other team waiting for their chance to pounce and steal the points by giving an answer the other team neglected. In a presentation, if you go through the most common possible diagnoses and then get down to the more obscure ones, it’s less likely that someone else on your team will steal the diagnosis you’re waiting to reveal, or that you’ll get interrupted before listing the most important diagnosis. Also, if you’re on a surgical rotation, you should look around after listing off more than two or three potential diagnoses, as your team has probably already moved on to the next patient.

This is not to say that you can ignore the zebras. You try to confirm the presence of a horse before moving on to investigate the presence of a zebra. And you do this mindful of the setting. If you are in feudal-era Japan and you see a shadowy masked figure running around outside, then “Ninja!” is a pretty good theory. By the same token, identical symptoms in a newborn, a teenager, and an adult may prompt very different diagnoses.

As long as you’re not in a true emergency situation, in which you have to try to rule out even uncommon diagnoses if they could cause death rapidly, taking the Family Feud approach to diagnosis has its advantages. Less money is wasted on low-yield tests and evidence-based medicine has a better chance of being followed. When you jump straight to the weird diagnoses, patients get scared, easy fixes get missed and everyone gets confused. Think of the kids in that school who are probably less likely to take a future lockdown seriously. They’ll laugh -- “What is it this time, a pirate in the cafeteria?” And then when ninjas really do attack, they won’t be ready.

   

And if you’re not ready for a ninja, you don’t have a chance.

Will I Be Ready?

Anna Burkhead -- Folks, it’s time. Prepare yourselves. The final frontier is upon us.

Well, the final frontier is upon me really, not all of y'all. And not really a final frontier actually, just the beginning of my last year in medical school. Forgive me, for I’m prone to hyperbole.

On Monday I will commence the first rotation of 4th year. It is an away, “audition” rotation, and will surely be the topic of a later blog. The fact that the rotation is entirely across the country, at a school I’ve never visited, with people I’ve never met, none of that scares me. What scares me is that a year from now, I (and every other newbie 4th year out there) won’t be starting a rotation, but instead starting work as a new doctor.

Our orders will matter! Our progress notes will be read and taken seriously! Our pagers will go off first! We will be the ones on call! We will be the ones making decisions at 3am! We will be the ones who are responsible when things don’t get done! We will….

Good gracious. We’re in for it, aren’t we?

I know that all doctors start off as interns, and that nearly all of them survive it. I know that I still have another year of learning before I will be expected to do the job myself. But I also know that I’m already thinking and worrying about what it’s going to be like. Is that normal?

I know that several residents and medical students out there have revealed their secret question, “When is someone going to realize that I don’t belong here / that I’m not smart enough / that I am never sure of my decisions?” It’s my secret question too. (I need to know… seriously… when’s it going to happen?)

Maybe I’m getting a little ahead of myself. It certainly wouldn’t be the first time. I’m a bit of a worrier. I still have a whole year to get more comfortable with medicine.

A whole year. The last year of this chapter of learning!

The Dog Days of Med School

Kendra Campbell -- I just returned from taking my two dogs to the veterinarian. These dogs were once puppies that I adopted while living in Dominica and taking my pre-clinical coursework. Over a year ago I wrote about an intensely emotional experience involving the death of another one of my puppies. Interestingly, the stress of med school had never brought me to my knees at that point, but the death of an animal, combined with other stressors really sent me on an emotional roller coaster.

As a child, I grew up on a dairy goat farm, and we had many other types of animals as well, including chickens, pigs, and many dogs and cats. I guess you could say that I grew up in a very animal-intense environment.

Okay, so now you’re thinking, “this is a blog about med school, not vet school, what does all this rambling have to do with human medicine?” Well, I actually happen to think it has a lot to do with it.

I’m going to go out on a limb here and say that being surrounded by animals all my life has definitely shaped my personality. I’ll even go as far as to say that it may have served to foster my compassion and ability to care for all living beings, humans included.

The two puppies that I adopted in Dominica turned out to be immensely valuable to me in medical school. I have fond memories of taking short breaks from studying to pet and cuddle my pups. Cuddling with them never failed to rejuvenate me when studying had sucked all the energy and life from my body and mind. And when I was stressed out about an upcoming exam, taking my pups for a walk on the beach or rubbing their bellies was always guaranteed to provide me with much needed stress relief.

You could assert that all this psycho babble about having dogs, or any pets for that matter, is a bunch of holistic mumbo jumbo. But the existing research actually supports my anecdotal evidence. Studies have shown that owning a pet can nurture both their owners’ physical and psychological well-being. Some of the medical benefits include lowering blood pressure and cholesterol levels, improving survival rates after surgery, and decreasing the number of visits to the doctor. As for psychological health, pets can help people cope with stress, reduce rates of depression, and even reduce loneliness.

So, I guess what I'm trying to say is that while there are some disadvantages (cost, allergies, responsibilities, poop-scooping) to owning a pet, the benefits shouldn’t be underestimated. My now almost two-year-old doggies are proof enough to me that owning pets can have a myriad of wonderful rewards. And that’s exactly what I told myself when I signed the $900 credit card charge at the vet’s office tonight!

Do I Really Want To Do This?

Jeff Wonoprabowo -- Throughout the year, one question loomed over me, haunting me like a bad dream: "Do I really want to go through all of this to become a doctor?" It's a question I think is harder to answer now than when I was in college, especially now that I’ve started to see what I am getting myself into.

One day while I was in high school, I was sitting on the couch in front of the television. I’m not sure what I was watching. I do remember my mom calling me away from the tv set. She called me into the living room because she wanted to talk. I found it rather odd; it seemed totally out of the blue. But, I suppose, this shouldn’t have come as a surprise. Conversations with mom sometimes seem, at least to me, to come right out of left field. That evening my mom defied the stereotype that all Asian parents want their children to become a doctor or a lawyer. She sat me down to tell me she didn’t want me to become a doctor. That conversation was in high school.

The thing is, I was never the child who grew up with dreams of becoming a doctor. When my mom found out she was pregnant, she decided that in order to stay at home with me she would have to start her own business. She started a data entry business. As a result, I grew up around computers and decided that one day I wanted a career that involved computers.

But here I am, now a medical student. Although I have only completed the first year, I’m on my way towards earning the right to add the initials M.D. behind my name. Not that I need any more letters; my last name is long enough.

It’s scary, though. I have put myself on a path towards becoming a physician -– a path that is long and quite expensive. Should I continue down this path, I know I will find myself in a very rewarding career with enough money to keep a roof over my head and food on the table.

It's a frustrating journey. There's a ton of information that is force-fed during the pre-clinical years. At times it's a challenge to see how some of it is even relevant to patient care. More than once during my first year, I wondered if I really want to do this. It was almost a monthly cycle; it coincided with exams that came about every five weeks. I hated exam weeks. Actually, I still do. But those were the times when I wondered, considered, and longed for being somewhere else. I enviously think about friends who have finished school and are earning a good paycheck. Then I take a look at the numbers on the statements I receive from my lender. It is always a little shocking to see how quickly those numbers grow. Sadly, the balance of my checking account has the opposite trend.

Yet there are times where I am truly grateful for the chance to be where I am. And there are many more times where I am excited about the possibilities of where I’m headed. Because medicine -– being invited into the depths of patients’ lives –- is exciting. I wouldn’t blog about medical school if I thought it was boring, depressing, and monotonous. On second thought, I probably would. But if you're reading this site, you probably wouldn't be my target audience.

Sure, it can be hard and time-consuming. Obviously it can be very frustrating. But after having spent six weeks in the wards with attendings, residents, and medical students (2 at the beginning of the school year and 4 after), I think I have found a source of inspiration and motivation. It's not about the prestige; I don't think all the training is worth what prestige is left in the profession. It's not about the money; there are easier and shorter paths to earning a decent living. It’s not about being your own boss; the current medical system has made that terribly difficult. It's all about the patients.

And now I think I've found the answer to that looming question. I just hope my answer doesn't get lost in the deluge that will come in the form of my second year...

Dia dhuit From Baile Átha Cliath (or How To Succeed In An Audition Rotation)

Colin Son -- I’m writing this post from over in Ireland, which explains the Gaelic-English hybrid title.

I've got approximately two weeks free from my last third year rotation until my first rotation of fourth year, and I'm incredibly lucky to be getting to spend it in Europe. As much as I'm enjoying myself, it is difficult not to let my mind slip back to medical school on occasion. That little 'type A' that is a part of even the chillest of medical students' personalities is showing. I can almost promise I was the only sap in the pub with a neurosurgery review book open as the Spain-Russia Euro 2008 semifinal played out.

Excuse me for missing Guiza's beautiful second half goal but you see, I want to match into something pretty competitive. Towards matching in any residency you've got a number of measurements which are applied to you. Everyone is familiar on what you're judged -- your board scores, your GPA, your letters. In some of the more competitive specialties, especially the surgical ones, I think you can add another measurement -- your performance in audition rotations. I know that some don't but I actually like the title 'audition rotation'. Maybe you're auditioning for a better letter or for an actual interview at the program, but these rotations often do serve as weeks-long auditions.

I spend three of my first four months of fourth year doing neurosurgery sub-internships. That includes my first rotation, which starts in a week. Not to let any semblance of anxiety show (not me, ever, as a future surgeon) but that is a whole lot of neurosurgeons I'm hoping to impress. Such helps explain why I packed some review books in my backpack before I hopped on a plane.

I obviously haven't done a fourth year sub-i yet. Even so, I think I've gotten some good advice and a general idea of what I'll be facing. I thought it worth sharing as fourth year starts for so many medical students. Here are three (perhaps obvious) things I think fourth years should strive for during a sub-i:

First, and foremost, the distinction between your sub-internships and your third year rotations should be in you demonstrating more initiative and spontaneously taking on more responsibility. If the rotation is a specialty you're interested in, then you should take the name 'sub-internship' to heart and, without prompting, try to pick up the work load similar to what an intern would have on the service. To the extent that is possible of course without an M.D. after your name.

Second, use the time to learn to teach. This is a sometimes forgotten role of being a resident. Every third year medical student feels it when they've walked off a service with a resident with such a gift and when they've walked off a service with a resident who couldn't have cared less if they were there. Especially early in the year, fourth years can really be a guide to the incoming third years. I know I had an awesome fourth year doing an inpatient medicine sub-i early in my third year, and she made the rotation immensely better. Something as simple as going over hints for doing well on the rotation or over how to gown up in the operating room or over the intricacies of physical exam findings can help a lot.

Third, become more technically proficient. Whether you're going into a surgical specialty or not, there are technical skills it helps to be adapt at for the practice of medicine. I stumbled across interns during my third year who weren't sure they could draw blood or had never even seen a lumbar puncture done. True, this may not be required of them, depending on the ancillary services and their specialty, but isn't it at least a little embarrassing to be called Doctor and not possess some basic skills? With a surgical or procedure based specialty the demand to be able to demonstrate technical skills, even as a medical student, is even greater.

These goals are not exclusive of course, but hopefully they will provide a good foundation as I head off into fourth year.

I promise I'll keep you updated.

Choosing a Specialty

Ben Bryner -- If there's one thing I enjoy about medical school, it's talking to people about what specialty they're going into and why. Most students change their minds a few times during medical school. I was one of the lucky ones who knew exactly what I wanted to go into (surgery) after rotating there as a third-year, but for most people in my class it was not so obvious. It’s a hard decision; you’re making a choice that will affect almost every aspect of the rest of your life. At many schools, if you’re interested in a field that doesn’t have a required third-year rotation, it’s hard to get a lot of exposure to the field before your fourth year, when decision time comes up quickly. And if it turns out that you don’t like that one, it isn’t always easy to switch gears at a later stage in the game (but it’s certainly possible). To address this difficult situation, there have been a lot of different tools proposed to help you decide on a specialty beyond clerkship and elective experiences.

You might have already seen this graphic, which reflects the growing trend in medicine to reduce decision-making to following an algorithm. An even simpler method is the Goo Tolerance Index, which simply ranks the specialties by their exposure to “goo,” so all the student has to do is identify his or her desired level of goo exposure and pick from a short list. Both of these are pretty easy to use. Oddly, they both leave out OB/GYN (which would probably fit under the “crazy” and “high-goo” categories, respectively).

If you want to take a more comprehensive approach, you can take the Medical Specialty Aptitude Test online. It will ask you a series of questions (130!) and at the end will list the specialties you should consider. I didn’t get through all of them because it kept asking me the same questions over and over, but you might have better luck. Similar kinds of things are available at the AAMC’s Careers in Medicine site, but you need a password from your med school. And of course there are a few books on the subject.

But there’s no substitute for rotating on those services. Hearing about the field from others, shadowing, getting involved in interest groups, etc. are all somewhat helpful, but they can give you a very different picture of the field than your rotations. Of course, rotations are far from perfect tools for evaluating specialties. Since you’re mostly spending time with residents, you may get a pretty good idea of what the residents are doing, but not necessarily what it’s like to be a practicing physician in that specialty. And despite the fact that residency can be quite long and seems so imposing during medical school, it’s a lot shorter than your career. So it’s worthwhile to really try to get a feel for what the attendings’ workdays are like.

There are a lot of good choices out there, so good luck.

Seasons of Med

Thomas Robey -- June and July are the transition months for medical students, residents, and the entire medical community in the United States. Many schools and programs have a brief respite that allows trainees to recover from a busy year. Now is as good a time as any to wish you a:

Happy New Year!

525,600 minutes, 525,600 moments so dear.

525,600 minutes -- how do you measure, measure a year?

In call nights, in lectures, in complaints, in cups of coffee.

In write-ups, in IVs, in needles and thread.

In 525,600 minutes -- how do you measure a year in the med?

Congratulations to graduates and well wishes for moving to a new city and starting your residency. To all the medical students who got to step-up to the next level this week, well done! Good luck on USMLE Steps 1 and 2 if you haven't taken them yet. Applicants and first year students: keep up the hard work that will prepare you for a healing career.

My resolution for this coming medical year is to take more frequent pauses to consider those 525,600 moments so dear.

Credit and apologies to Jonathan Larson

Um... Hello?

Jeff Wonoprabowo -- Hello, everyone. My name is Jeff. I don’t think I’ve ever been great at introductions. I’ve always preferred meeting someone while doing something. It seems easier -– more casual. I always cringed when a teacher or group leader insisted that everyone in the room take turns to say hello, introduce themselves, and then say something interesting about themselves. It just felt kind of forced. I remember mentally scrambling for something to say before it was my turn. What can I tell them that is unique about me, but at the same time won’t make me sound like a total oddball?

But I’ll try my best; so here goes. I was born and raised in Southern California. In high school I enjoyed English, history, and Physics. I didn’t enjoy Biology (no interest in plants) or mathematics (didn’t see how it was applicable to my career). During high school, my mom also pulled me aside and told me she didn’t want me to go into medicine because she worried I wouldn’t have time for my family.

After high school, I attended Walla Walla College (now Walla Walla University) in Walla Walla, Washington. When I began college I was a computer engineering major, but I switched majors during my sophomore year. I ended up receiving a B.S. in Bioengineering with a minor in mathematics. I have just completed my first year at Loma Linda University School of Medicine, and I should be graduating from medical school in 2011. In the free time that I do have, I enjoy playing basketball, ping pong, tinkering with my computer, reading, watching movies, and practicing martial arts. I also write on my personal blog at JeffreyMD.com.

It would be foolish for me to think that my experiences in medical school are unique. So many students are currently going through the same things (and a few have been so eloquently writing about it here), and many, many more have gone through it before me. But maybe I can share with you my perspectives on my journey. And hopefully, somewhere in the words that I type, there will be something that will have made the post worth writing and your time worth spending here.

The Gift of Psych

Kendra Campbell -- Oh my goodness, I’m quite tuckered out. I started my psych rotation last week, and I just had a full day packed with all kinds of psych goodies. I promised to share my feelings about my first clinical rotation, so here goes. To sum up everything that I’ve seen in six days on the psych ward: I am soooo in love with psych!

As I’ve mentioned before, while just out of college I worked for three years at a state psychiatric hospital. My undergrad degree was in psychology and neurobiology, so I do have some decent experiences in psych. But since leaving the field years ago, I’ve really considered going into a different specialty. I’ve recently been leaning towards emergency medicine for various reasons. However, being a “green” third year medical student, I realize that I simply don’t have enough experience to make a definite specialty decision. And I have one of those personalities where I tend to enjoy just about anything I do, so I am always suspicious when I fall in love with anything.

All that being said, man I really do love psych. The hospital that I’m rotating at is in Washington, DC, and it’s a district (DC is not a state) facility. What this means is that the patient population consists of clients with very serious mental illnesses. The facility is not a place for persons with simple psychological problems. Everyone who finds their way into the halls is extremely ill.

This patient population is exactly where my experience lies. Having worked at a state hospital, I’m very familiar with schizophrenic patients who are refractory to treatment. I’ve worked with homeless folks, and while I’m no expert, I do have experience helping those who are less fortunate.

I know I still have many rotations to complete, and I’m sure that I’ll probably change my mind a few more times. But right now, psych is certainly starting to look like a very tempting field.

The population of very ill patients really grabs my attention. Those who end up in state facilities tend to have a lot in common. They are the poor, the neglected, and the ones that have very little hope left. Often times, their friends and family have abandoned them. In the past, society has overlooked many of these unfortunate souls.

I guess what I’m trying to say is that to be able to share with these folks, to be able to help them in any way, to be able to make even the smallest impact in their life -- in my opinion, that’s one of the greatest gifts I can imagine.

An Introduction Is Probably in Order

Colin Son -- It is a real pleasure to be writing for The Differential. Based on the example my fellow bloggers have set, I thought it proper to introduce myself with my first post.

I am a very recent fourth year medical student at the University of Texas Health Science Center in San Antonio.

I was born in east Texas and raised in San Antonio. I grew up in a family of physicians and, partly because of that, I actually had no interest in medicine as I hurried off to college. I loved screenwriting and making videos with my friends when I was in high school and so, like many who dream of being filmmakers, I headed off to film school in Los Angeles.

I imagine I’m one of the few current medical students the world over with a Bachelor's of Fine Arts, which I received from the University of Southern California. I loved film school but realized during my sophomore year that I wanted to do something more substantial with my life.

Searching for something meaningful to commit my life to, I was lucky enough to get to shadow several awesome surgeons. Granted, I had grown up around medicine but it was my shadowing experiences in the operating room that convinced me I wanted to go to medical school. Getting all the medical school pre-requisite classes and the MCAT completed during the last two years of film school was a bit of a challenge time wise. I made it though and now find myself a year from putting that M.D. after my name.

I’ve wanted to be a surgeon since the first day of medical school and now, with third year under my belt, I can say more specifically that I want to be a neurosurgeon.

Since getting to medical school I’ve been extremely involved in organized medicine and have held a whole bunch of leadership positions in my state medical society and at the national level. My major health policy interests lie in health care financing and access to care. If my school had offered a combined MD/MPH program when I entered, I have no doubt I would have been a part of it. Alas, formal policy study, while inevitable, will have to wait a bit.

Besides screenwriting, outside of medical school I am a big college football fan, I am a history buff (especially the American Civil War), I enjoy video games and I love to travel internationally.

Again, I am really excited to be here on The Differential and to be sharing my thoughts on medical school. I look forward to hearing back from all the readers and encourage y’all to drop comments frequently.