The Differential: Medscape Med Students Blogs

In Defense of Sweet Traditions

Kristen Heinan -- Happy Halloween! Mmmwwwaahahahahhahahaaaa :)

So here I am, sitting with wonderful fun Halloween background music -- courtesy of that marvelous treat that is internet radio -- awaiting the impending cute (um, I mean scary) sugar-craving hunters and gatherers of the evening. I have some decorations on my door. I have my fun jack-o-lantern sweatshirt on -- the faces glow in the dark (thanks, Mom!) -- and I have had it on all day long in clinic too, for that matter (Yay pediatrics!). I am thoroughly ready to play my important and expected role in supporting the sugar-high-inducing, tooth-decay-promoting, unhealthy-snack-endorsing festivities adored by kids everywhere.

Really, though, you can come up with great arguments for these festivities that have become so belovedly associated with All Hallow’s Eve. For example, these activities

1. promote family bonding, as parents and children collaborate to decorate themselves and their homes, and then band together for the candy-gathering excursions;

2. they allow children (and adults) to express their creativity and explore their interests as they engage in that wonderful developmental essential that is “pretend play”;

3. they promote open-mindedness, acceptance, and celebration of differences as groups of princesses and pirates, ghouls and goalies, walruses and witches party hardy together;

4. they encourage the young and old to get up off the couch and get some good, healthy fresh air and exercise as they traverse the neighborhood terrain;

5. they promote social skills: please and thank you, meeting strangers, getting to know neighbors;

6. they promote reading: can we say “ghost stories”?

7. there’s even some science: red taffy after a blue lollipop turns your mouth purple;

8. and math: 50 houses x 2 pieces of candy each = 100 candies;

9. and finally, kids learn the art of negotiation: 3 peanut butter cups can be traded for 6 gum balls

You get the picture.

Besides, there’s a lot more scary stuff out there that kids have to deal with today (stating the blatantly obvious) than tricks and treats (and even temporary tooth and tummy aches). More on that later, but for now, let’s enjoy the evening.

Last Shift

Ali Tabatabaey -- It felt like the finale to a long-lived sitcom, or better said, a drama: leaving a room that had hosted so many memories, and knowing that I will not see it again. The last shift as an intern is behind me, and the end is ever so close.

It was a simple shift, no ambiguities, no casualties, and a relatively quiet night. I’m glad to say that things were not as stressful as my first shift, mostly because the patients seem more familiar. But maybe it’s also because during these last few shifts, I expected myself to know the patients and their problems, unlike the first shifts when I knew every patient was going to be a whole new experience.

I have to admit, though, the sense of responsibility has quadrupled. No more excuses are accepted and no more stupid mistakes are allowed.

Do I feel like a doctor capable of understanding every problem and solving every case? No. What I do think I’ve acquired in the past seven years are the prerequisites to think through a patient’s problem. Whether this is enough or not, I’ll leave it to the more experienced physicians to answer.

All that said, and amidst all the nostalgia, I really doubt that I’m going to miss this room. I guess the internship shifts are great MEMORIES which suit the past much better than the present. So, I close this door without any hesitation, hoping to soon open a new door as a resident. Let me rephrase that “wishing” to soon open a new door as a resident… but that’s a whole other story.

Average Medicine

Anna Burkhead -- In the lives of most people, “average” is not a good thing. Being called “average” or doing an “average” job is not good enough these days. But “average” is average for a reason; synonyms include “usual” and “ordinary”. By definition, and through easy interpretation of a probability density curve, “average” is the midpoint between extremes. It seems like an obvious statement, but “average” is the state of most things.

I think that this Cardiology block might be the most important rotation of third year. My previous rotations were Pediatrics, OB/GYN, and a short course in acute life support. While the skills I gained in those rotations are absolutely invaluable, and I enjoyed them immensely, the “average” American is not a child, a pregnant woman, or in cardiac arrest. The average American, according to statistics, is the patient I see every day, ten times a day, on the Cardiology rotation.

This is certainly not a diatribe on the state of my country’s people. It’s simply a statement that the Cardiology patient population overlaps with the American population more than many other specialties. The average American is late middle-aged, overweight, and has a few bad habits to spare. The average Cardiology patient is late middle-aged, overweight, and has a few bad habits to spare.

I don’t anticipate that I will end up specializing in Cardiology. But I am very glad that I was assigned to this service of Internal Medicine. No matter what field I enter, heart patients will be there. And they’re not the extreme characters portrayed on TV and movies, with exclusively McDonald’s diets, a permanent place on the couch, greasy hair and no job. They are our neighbors, teachers, family members. They lead average lives. They have average, non-extraordinary problems. They are average patients.

The medical student’s aversion to the word “average” is a matter to be discussed in another posting. Right now, this particular medical student is learning the true meaning of the word, how it applies to medicine, and in the process, learning to provide extraordinary care to ordinary people.

Hoping for an Identity

Kendra Campbell -- My world is very bizarre. As I’ve mentioned before, I live in a very small town on a small island in the Caribbean. The country is not very developed. The closest grocery store to me is not what I would actually call a grocery store. There are no fast food restaurants (except for a Subway on campus). There is no Starbucks or Target or Barnes and Nobles. I live on the top of a trail, surrounded by other med students, cows, goats, and the occasional chicken. I don’t have a car, a dishwasher, a toaster, a stereo, or really much of anything besides my laptop. These are all things I once owned.

Don’t get me wrong; I really do love living minimally. It’s a refreshing change from how I once lived in the States (not that I lived in excess, but I definitely had a lot more). But there are times when all I want to do is go out to a nice sushi restaurant, or go see a movie at a theatre, or play some billiards at the local pool hall.

I also miss my friends and family. I haven’t seen them in about six months. I want to be able to call up a friend and have dinner with them, or go to my parents’ farm and drink good coffee in the garden.

Because I live in such an isolated area, with nothing but med students as far as the eye can see, I don’t really ever feel like a med student. It’s difficult to explain, but imagine if the only people you knew were med students or doctors. You’d never form a real identity. You’d just be like everyone else.

I’m wondering how different things will be when I come back to the States in a few months. I’ll be finishing my third and fourth years of med school in U.S. hospitals. That means I’ll be living in the “real world” again. I’ll be able to see my friends, drink Starbucks coffee, and perhaps I’ll even get my old car to work again.

But most importantly, I’ll suddenly be a med student surrounded by thousands of other people who have nothing to do with med school. I’m hoping that I’ll actually be able to form some type of identity. I’ll be different. I’ll be able to taste life on the other side.

I know that I will miss this island for so many reasons. The beauty all around me here is magnificent. And I’ll miss not having a car, or a toaster, or 5,000 different restaurant options. (Hey, at least here you never have to choose where you’re going to eat!) I guess I have somewhat mixed feelings about everything. I want to step back into reality, but at the same time, I know that I’m going to miss my little piece of paradise here.

I’m looking forward to having an actual identity, though. At least I’m hoping that is what will happen. I might find out that I’m just as confused surrounded by lawyers and politicians and police officers as I am surrounded by hundreds of med students everyday. I guess I’ll just have to wait and see.

A Dose of Our Own Medicine

Ben Ferguson -- I often see fellow graduate and medical students while walking around campus, and while it’s not nearly as common as in the general population, I am appalled by the percentage of smokers among them. Keep in mind, I’m a medical student, and I’m a graduate student in cancer biology. It’s not as though my classmates are non-medical people who don’t have the dangers of smoking pounded into their brains for 4 straight years and don’t see the effects of smoking on one’s health first-hand. I guess what I’m trying to say is: You’d think they’d know better.

This is merely an extension of a question that’s often raised in the context of health care professionals: To what extent should they themselves remain healthy, for whatever reason? (Reasons here could include the promotion of good habits among their patients through exemplary living, health for its own sake, and, perhaps above all, the avoidance of hypocritical actions, e.g. a physician recommending to his or her patients that they adhere to a healthy lifestyle that the physician does not personally follow as a “lay person of society.”) Honestly, could you take a 300-lb. physician seriously if he or she told you to lose a few pounds? Would you follow the advice to stop smoking from a doctor who reeked of cigarette smoke?

Let’s face it. Medical students aren’t always exactly specimens of good health. We have irregular sleeping habits. We often eat too much while studying or too little while on a surgery rotation. We drive while exhausted. Screw driving -- we operate on patients and do procedures on patients and tell patients to get some rest … while exhausted. We are too competitive with each other for our own good. We drink, sometimes heavily so, after exams. We inhale pot after pot of coffee and pull all-nighters from time to time. We eat the communal donuts at nurses’ stations on slow nights. We will wind up divorcing our spouses more often than not, and we will pay too little attention to our kids. It’s all right there in the journals.

So where does it end? If it doesn’t end, where do we get off telling our patients to avoid all of these things? We -- our patients and us -- are human. We are the same, and we all care to some extent about our own individual health. We simply have different professions. Should we be expected to follow all of the advice we give others? In my mind, the answer is “not entirely.” The same could be said for police officers who break laws, or IT people who don’t have every single virus protection software suite installed on their home computers, or financial advisors who happen to have slightly less-than-perfect credit scores as remnants from some poor decisions in college.

But I would love it if we smoked a little less.

The Pros and Cons of Shadowing

Ben Bryner -- Someone in the comments section of another entry asked what “shadowing” is. It’s basically following around a doctor to get an idea of what his or her job is like. Typically you can talk to or email the person in charge of student education for a given department and ask if any physicians would be willing to have you tag along for a little while. (If there’s a student interest group devoted to that field at your school, that can be a way to set up shadowing as well.)

Your job is basically to show up on time, dress nice (usually in a white coat, or at least business apparel), pay attention, and ask questions as appropriate. Some physicians are better to shadow than others; these are the ones that will provide a running commentary on their job (as time allows) in addition to explaining to you what they’re doing. There’s a certain amount of variability in physicians’ workload, so it may be very busy when you shadow and you might feel neglected, or there might be nothing going on, making you feel cheated out of the life-changing experience you feel you deserve. Probably neither one is true, and you should go back again some other time to get another perspective on it.

Shadowing is pretty cool during your preclinical years, as it can put the things you’re learning into perspective and give you some idea of what your clinical life will be like. But shadowing also can give you a skewed perspective on things. I shadowed in the ER during my first and second years and really liked it. When I spent time in the ER as a third and fourth year, I realized it wasn’t for me. Shadowing kind of gives you a bird’s-eye view of things that doesn’t always match up with the ground-level view you get on rotations. I shadowed a neurologist before med school, and thought it was fascinating and amazing. When I rotated on neurology as a third-year, I found it less appealing. I really liked my neurology attending and learned a lot from some terrific patients that month, so I mean no disrespect when I say that I would rather shove my reflex hammer into one eye and my tuning fork into the other than go into neurology.

But shadowing can misrepresent things in the opposite direction, too. One time on my pediatrics rotation, I had to shadow for a couple of well-child exams. It was the most boring event of all of medical school. In fact, a common lament among third years in the cafeteria is that they’ve “only been shadowing” all morning in clinic rather than actually getting to see patients on their own. The morning moved so slowly that day that I felt like I could have knit an entire sweater in that time. (Bear in mind I don’t know how to knit, so that would have included the learning phase.) Sadly, I had nothing to do but pretend to be listening attentively. It felt like Absolute Zero of boredom. But when more reasonable attendings let me go in and talk to the kids and parents on my own, it was actually a lot of fun. I liked it enough that, although I never considered pediatrics beforehand, I got very interested in it. So you shouldn’t read too much into your experiences shadowing.

Still, shadowing is useful for a few reasons: if you think you know what you want to do, shadowing in that field can help you confirm that choice or rule it out. If you’re at a school with a traditional third-year structure, shadowing can be especially useful in fields not covered by the mandatory third-year rotations. Shadowing may be your best chance to see things like radiation oncology or ophthalmology before your fourth year begins. At that point, even though you have a couple of months to make up your mind, you want to have narrowed down your choices to two or three specialties. Just bear in mind that rotating or working in the field may be pretty different from your shadowing experience.

A Difficult Time

Ali Tabatabaey -- I know this post is long overdue. But I have my reasons. First of all, the friend that I talked about a couple of posts ago was officially nominated for liver transplant, meaning that if a donor is not found soon … well, you know the rest. Even if a donor is found, one in four patients don’t make it past six months. The news really spoiled any mood for writing.

On the other hand, I’ve been preparing my thesis, and who would have thought it was going to be this hard? Now I understand what all my predecessors were talking about when they sincerely advised me to start writing the dissertation long before the deadline. I mean, doing the research and getting the results together is one thing, but finding the time to write everything down is a whole other project, and doing so while shuffling shifts at “Surgery” is a mission impossible.

I guess the hardest part is managing the references, for which my sister has introduced me to a new software program. But it only seems to make everything more complicated, and I’m very close to giving it up and going back to the old fashioned way.

So that’s the status of my life. I think I’ll need a long vacation after all this is done. But that does not seem like a possibility in the near future. Just before going, one tip for you who are starting to think of a research project for your thesis: as the previous generations told me and I did not listen, I sincerely advise you to start writing it as you go along and don’t leave everything to the due date.

Dealing With Non-compliant Patients

Pin-Chieh Chiang -- Imagine that you’ve finally finished all those grueling years of medical school and residency training, and now you’re ready to go out and medically treat people. You are all excited to practice medicine, only to realize that your patients aren’t following your treatment plan. It’s not only a bummer when that happens, it can also be extremely frustrating. While I was in my family practice rotation, I had the opportunity to interact with such non-compliant patients.

My first experience was with a diabetic patient who came in with a high fasting blood sugar in the 300s. Overall he felt fine, reported that his fasting sugars at home were in the 100s, and that he was taking his medication as indicated. I decided to order an HbA1c and it was 13.5. I’ve also had patients who came in with a tension-type headache who absolutely refused to take any medications. In contrast, I’ve also had a patient who was on a lot of pain-killers for her arthritis, but refused to take prednisone because she didn’t want to be on a “steroid”.

It’s very interesting to see the range of non-compliant patients and their reasons for not following the treatment regimens. It’s even more interesting when I can see from their charts that while they obviously do not listen to their doctors, they still continue to come back for their regular appointments just to start from the beginning all over again. I’m not talking about the patients who are in denial of their diagnosis, or the patients who don’t understand how to take their medications. I’m talking about patients who will openly admit to understanding everything but just do not want to take their medications. I’ve actually heard my preceptors say things like “there’s nothing more I can do for you since you refuse to take the medications,” and the patient just responds with a plain “okay”.

I always thought it was common knowledge to listen to your doctor and that your doctor knows best. Intrigued by this idea that there are patients who truly ignore their doctors’ suggestions, I decided to ask family and friends about their experiences. As it turns out, quite a few of them also fall under the category of being non-compliant patients. Without going into specific examples, I’ve learned that my own parents don’t always take the medications that their doctor prescribes.

It’s always frustrating when you have to deal with non-compliant patients. I was even more frustrated when I couldn’t convince my own parents to take their medications as their doctor says. I think the best way to stay sane is to admit that there is only so much that a physician can do, and at some point the rest is up to the patient.

The Curse of the Short White Coat

Ben Bryner -- I have mixed feelings about my short white coat. Actually, I just hate it, but I'm trying to be objective and think through both sides of the issue. Here are my thoughts. (Note that I'm avoiding the issue of white coats in general -- I'm just comparing my short coat to the longer white coats of actual doctors.)

Cons of the short white coat:

* Wearing one is the equivalent of driving in a Student Driver car. Like the car, it screams to every passer-by, "Look at me! I don't know what I'm doing! Better stay about 50 yards back!" It's hard to inspire confidence and maintain self-esteem cruising around in either one. The difference is that you only have to drive that car for a few sessions, and you're stuck with the short white coat for two years.

* It allows people to use the term "short coat" to describe med students. Actually, it's not that I mind being reduced to a stereotype, or being referred to as a garment rather than a human being. It's that the people who use the term think they're being so hilarious, and that's what I can't take.

* It was kind of expensive. Not much in the grand scheme of things, but still, it was one more thing to buy.

* The pocket location means that all the weight settles right over the hips, which is not the place anybody really wants to increase their width. I don't mind that it's unflattering, I just hate having to turn sideways to step between people on rounds, or to get into a bathroom stall.

* No, wait, I do mind that it's unflattering. Long white coats billow out behind the wearer like the mainsail of a graceful ship. When residents run to a code, their flowing coats look like wings, bearing them on toward their patients. Short white coats do no such thing; they cling to you like plastic wrap and keep you from reaching over your head.

I could keep going, but why bother.

In defense of the short white coat:

* It's expected that a med student's pockets will be full, so you can actually keep a lot of stuff in them. In contrast to a resident, who is expected to have a moderate amount of reference material and brief notes on patients, students are encouraged and expected to cram their pockets full of stuff. That means you can have your review book for the rotation, notes on all your patients, your exam tools, your PDA, wound dressing supplies, and much more right at your hands. With that much stuff in there, you can go ahead and drop in your keys, a granola bar, your phone, whatever. Want to throw in a GPS device, too? A spare pair of shoes? A megaphone? Your raincoat? Go for it. The pockets are already so full that nobody will notice.

* Once in a while your white coat will save you. One time in the ER, I was helping a critical care fellow put in a line. He needed a little bit of goo for the ultrasound probe, and I happened to have one of the little flat packets of petroleum jelly (a good white-coat item both for ultrasounds and for rectal exams), so I was ready. "You're the man!" he said, and while that felt nice, I felt bad taking the credit when my white coat really deserved it.

* It's short enough that you can drape it over the back of a chair during lunch conference and not have it drag all over the floor. Watching a resident unknowingly roll the filthy wheels of a chair over the tail of his or her white coat is always good for some much-needed entertainment in one of those conferences.

You can make whatever you want out of these arguments, and please add your own take in the comments.

Personally, I'm looking forward to ditching the thing. Sure, residency will be intimidating, overwhelming, and humbling. But I look forward to facing those challenges without the help of my short white coat.

Recovering From a Vacation

Anna Burkhead -- OK, so the vacation time I wrote about in my previous post has come to an end. It was great while it lasted, but now I need to look deep within my heart … really get things pumping … develop a regular rhythm again…

Time for Cardiology!

I enjoyed the Cardiology block during second year. It was early in the year, and it was the first time that I found mathematical logic and problem-solving skills to be useful in medicine. But, I have heard whisperings from students in my class that the block is more than challenging for even the most prepared students in my class. I’ve heard the hours are cruel, the attendings intimidating and even harsh, and the patients’ medical histories frustrating.

To top it off, although I’m eternally grateful for the free time that is now coming to a close, it has gotten me out of the daily rhythm of the hospital. I’m worried that instead of being refreshed and rested after my vacation, I’ll be slow and unsure.

My time off was barely a couple of weeks. It makes me wonder what medical students or professionals do when they have to take off more than a few weeks. What if a family member gets sick? What happens if and when I have a baby? There are many other reasons why a person would need to take a sabbatical.

Is it easy to get back into the “swing of things”? Or do you spend as many days catching up as you spent away from the hospital?

Of course, a solution to ease the return-to-work shock is to maintain a diligent work ethic while away. A student could study, do practice questions, and organize resources. A doctor could keep up with literature and review old cases. But this maintenance work is not always possible, especially if an illness or a new baby is the reason for the time off.

I chose medicine as a career for many reasons, including the opportunity for lifelong learning, the ever-evolving information, and the fast daily pace. But these same factors make it difficult to take the breaks from work that are occasionally necessary throughout adult life.

Let’s hope I get off to a good start!

A Touch of the Med Student Syndrome

Kendra Campbell -- I woke up this morning with a headache and sore neck. I immediately concluded that I had meningitis. Of course, there’s no way that my symptoms could have been related to the fact that I slept with my neck in a strange position and that I was a bit dehydrated.

This isn’t the first time that I’ve had medical issues since I started med school. In the past year I’ve diagnosed myself with scoliosis, infectious mononucleosis, breast cancer, hyperthyroidism, a diphyllobothrium latum infestation, bacterial endocarditis, and leptospirosis. I guess that does seem like a tad bit much, don’t you think?

I have been struck with a nasty case of med student syndrome. Whenever I learn about a new condition or disease in school, I immediately begin exhibiting the symptoms. This is actually a pretty common occurrence amongst medical students. When we become ill, we hear hoof beats and think it’s the zebra.

I guess I could handle just diagnosing myself with all these illnesses and leaving it at that. Unfortunately, though, the med student syndrome is starting to spread. My poor partner has been devastated to find out from me that he has squamous cell carcinoma, irritable bowel syndrome, hepatosplenomegaly, complete left lung atelectasis, myasthenia gravis, and congestive heart failure. I think that it’s been quite devastating to him, especially considering that he’s only 33 years old (and he also had the audacity to question how he could be walking around with a collapsed lung and not know about it!).

Not only have I diagnosed myself with a myriad of problems, but I’m also convinced that I’ll likely be dying in the near future. I’ve been taking microbiology and pathology for the past five months, and I’ve learned about hundreds of ways the body can malfunction or be attacked. I’m scared to death that I’m going to get salmonella from my morning eggs, and I know that it’s only a matter of time before I get diagnosed with some type of cancer.

I haven’t figured out how to come to terms with the hundreds of diseases that I’ve learned about in the past year. I mean, if you sit back and think about all the possible things that can go wrong with the human body, it’s amazing that people aren’t hospitalized their whole lives. Okay, so I know that I should actually wise up and focus on the beauty of the human body, and the miracle that it works as well as it does. I guess I should use the knowledge that I have not to worry about what could possibly go wrong, but instead to appreciate the fact that I am currently in pretty good health (except, of course, for the meningitis).

A Graveyard's New Meaning

Kristen Heinan -- I drive to work and back the same way every day. It’s usually the fastest way; it’s the most direct way; and there’s really no reason to go any other way. So, for months now I have been driving this route, and for months I have been driving by a grave yard -- passing it on my right as I drive up the hill on the way to work, and on my left as I coast downhill on my way home. And normally, I don’t give it a second thought (unlike when I was in third grade and my friend convinced me that we needed to hold our breath when passing a graveyard -- in deference to all the dead people who couldn’t breathe).

But one morning last week was different. That morning, there was a dingy pick-up truck parked on the graveyard hill, with buckets and tarps and tools in the back. And, there were two flannel-shirted, blue-jeaned men with mud-encrusted boots working beside it. Digging a new grave. My heart sank a little as I thought about the family that would be mourning the loss of their loved one, and my stomach felt a little queasy as I noticed that the truck was parked on other graves while this new one was being dug.

And then, I felt like rocks were dumped into the pit of my churning stomach, as the thought crossed my mind, “that could be Bella’s grave” (not her real name). I tried to shake the thought out of my head -- who wants to think about a child dying? Children do not belong in the ground! It was a horrible, horrible thought, a horrible revelation there in my car, passing by the graveyard, on the way to work. I wanted to throw up.

Bella is a sweet and wonderful little girl I had met a couple of weeks before. She had been in the hospital just overnight, long enough to get some transfusions and some palliative treatments so that she would be feeling as good as possible for her Make-A-Wish trip. She is in the end stages of cancer. I had heard recently that she had gone into hospice care since she returned from that Make-A-Wish trip.

During med school, when I was volunteering with a hospice agency, I would have been pleased to hear that a terminal patient had chosen hospice care. But that was with adults, and mostly with elderly adults. Sure, it was sad, but it was also often a relief when they died -- they were freed from the pain, worry, and suffering brought by their illnesses. And sure it was sad for their families, but the families were freed from the pain, worry, and suffering of watching their loved ones be afflicted by their diseases. Right? And old people are supposed to die, eventually; it’s the natural progression of things. Right? But there’s just something so unnatural about little kids dying. I don’t like the thought of putting anyone’s body in the ground (or storing it anywhere else, for that matter), but the thought of burying little kids is just wrong.

I don’t know if Bella has died (yet) or not, but those were the thoughts that went through my head that morning. And since then, I haven’t been able to drive obliviously past the graveyard.

Solving Puzzles in the Lab

Ben Ferguson -- When I get really, reeeeaaaally bored in the lab, I tend to gravitate toward crossword puzzles and sudoku to pass the time. When I was finishing up a sudoku puzzle in the local paper this weekend, it occurred to me that these games closely mirror the life of a researcher, especially that of a graduate student.

In one regard, the pace of both puzzles and research is similar. Easy puzzles are quickly conquered. There’s nothing difficult about them, and the going is straightforward and methodical. Tougher puzzles can be done with short bursts of focus with other things interspersed (such as taking a bite of lunch, finishing up a Western blot, or making a gel). The toughest puzzles require more time and attention, and they almost always require periodic guesses, retractions, and rerouting. When you’re stuck and looking for answers, it often helps to try another route or do something else altogether. Upon revisiting the problem with a different mindset and further expertise, the answer is often staring you right in the face.

Life in the lab is much the same. Easy experiments are done repeatedly and can eventually be done in your sleep. They are more a matter of muscle memory and basic arithmetic than actual brain power. More advanced experiments and protocols demand more of your attention and time, and they often are multifaceted and require a number of different methods to reach a desired outcome. Often, they must be optimized and redone several times to ensure that they work properly and that observed results are not artifactual. The most difficult experiments are not isolated experiments at all, but they are more a sequence of experiments, convergences with other lab members’ work, and integration of individual projects into a larger theme, such as, say, a graduate student’s thesis project or a principal investigator’s R01 grant application. Often, they don’t work at all, and there are a number of different ways to approach the questions that they seek to answer.

The flow of progress in science and puzzles is similar as well. In each case, you start with minimal knowledge and work up to completion (or, in the case of scientific research, you work until one project is finished, and then you start a set of follow-up experiments or another project entirely). With the addition of each solution, you have gained knowledge about the current scenario that assists you in some way. This continues until, near the end, everything logically falls into place, each new solution comes more easily and is largely an expected result, and answers again stare you in the face. There is a clear apex and subsequent denouement, and it feels so good. The stars align, the water divides, the puzzle pieces fall into place -- whatever you want to call it.

I’m reminded here of something the dean of our medical school often tells us: Medical school is a marathon, not a sprint. Clearly, I must be doing an ultramarathon or something, but when I am forced to take breaks in the lab, I can rest well knowing that I’ll be rejuvenated to tackle a particular problem when I return to it. Now, 9-letter word for “extra supply”…

Behind the Fence in Forensic Psych

Pin-Chieh Chiang -- The first memo I received about my psychiatry rotation said not to wear khaki or brown colored clothes. This is because I am rotating at a mental health hospital where patients wear those colors. And if I dressed in khaki or brown, the guards might confuse me for a patient and not allow me back outside the fence, or so I was told.

To get through the fence, I have to go through the sally port, a controlled entryway with three gates, where one must enter and close the first gate before opening the second to proceed, and so on. While in between gates, I need to show my badge to the guards who check through a glass window. Once inside, I take my duplicate badge to exchange for a set of keys and a personal alarm. From there I head towards the ward that I am assigned to, which is on the opposite end and takes me a good 15 minutes to walk there. On the way I usually see a number of patients sitting on benches or walking around. These are patients who have been on good behavior and have earned the right to be outside their wards. They are always friendly and ready to greet me -- in another place, I would never have guessed that most of them are schizophrenic.

I have to fight the habit of greeting them back, because during orientation I was given specific instructions not to engage the patients. Safety was emphasized many times, since this is not your typical psych ward, but a place where patients are sent by courts for forensic reasons. This means that most of these patients have committed some crime and were either declared not guilty by insanity or incompetent to stand trial.

So, I typically smile and just move on towards my ward. In contrast to those patients seen on the grounds, there are also patients who haven’t been on the best of behaviors and are basically restricted to the wards. That is where the set of keys comes in. There are about 10 keys that I am given, but as far as I can tell, I only need two of them. One of them gets through most doors and the other one opens office doors. As I go through each door I have to remember to lock it behind me once I’m in. There is even a lock for the bathrooms.

Psychiatry is not something that I’m interested in choosing as a specialty, but I have to admit that it is quite interesting. I’ve only interacted with a few patients, but so far each one has a binder thick of enough history to write a good mystery book. I’m amazed that this field is just so far beyond what the typical doctor-patient encounter would encompass.

First Time in the Operating Theatre

Kendra Campbell -- This week was my first opportunity to shadow a physician at the hospital. Each group of students was assigned to a specific specialty. I had previously requested surgery, but I was assigned to anesthesiology. But that was no matter, because I spent all morning in the operating theatre (operating room) nonetheless. It was absolutely amazing! I had been a patient in the OR before, but I’d never actually seen the inside of an OR as a med student. I witnessed five different surgeries in the span of about four hours. I have to admit that the process of putting on the facemask and cap was quite exciting for me. I’ve been looking forward to this for years. Even though all I did was stand there (and look like a confused little med student), I felt quite privileged.

I kept thinking how surreal the whole experience was. I’ve had the dream of becoming a doctor for years, and I’ve always been very fascinated by surgery. Yet there I was, actually standing in the OR, watching a surgeon carefully and gracefully glide his scalpel through the patient’s skin. I know many of you reading this have probably seen thousands of surgeries. But please understand that this was my very first time seeing one on an actual living, breathing human! I was so thrilled that I found myself actually shaking at one point.

After one of the surgeries, the surgeon began grilling us on the anatomy of the larynx. The three other med students just stood there, without daring to answer his questions. I finally piped up and tried my best to answer his questions, knowing that I didn’t completely know what I was talking about. Although I didn’t do the best job of answering the question, I think the surgeon appreciated the fact that I was willing to at least say something, even though I knew it might make me look like an idiot.

That afternoon, we switched doctors and my group of students was assigned to an internist. After just a short introduction, he left us with a patient. We were expected to get a history and do a full physical exam on him. Sounds easy enough, right? Well, it was our very first time doing so; hence we were all a bit nervous and clumsy as we figured out what to do.

Luckily, the patient was super cooperative and I think things went well. The language barriers continue to be an issue here, however. The man was a Carib Indian (Caribs are the last indigenous people of the Caribbean), and he used many phrases that were difficult for me to understand. However, I did my very best to take his history, and we all took part in doing the physical exam.

So, I guess you can say that my hospital visit was a huge success. I’m actually starting to feel like I may have learned a thing or two in med school. Yet, I’m still pretty apprehensive and nervous about the huge gaping holes in my medical knowledge and expertise. I just hope that everyone is correct when they tell me that everything will come to me in time.

A Little Time Off

Anna Burkhead -- “Free time”? What do you mean by “free time”? Surely you meant to say “free T4” or “prothrombin time”? Oh, you really meant free time? I’ll take it!

After I finished OB/GYN, I had a week of training in the acute care setting to get ACLS certified. And now -- medical students pay close attention -- I have some real, un-interrupted, call-free and shelfless free time.

And I barely know what to do with it!

I find myself waking up, looking at the clock with red numbers spelling out 7:04, and having a moment of panic. I’m missing rounds! I didn’t even pre-round! And then I remember that I have no patients, there’s no one to round on, and I go back to sleep.

Also, in reading a book, (for pleasure!! Reading for pleasure! Remember that?) I find myself re-reading important paragraphs to glean all the worthwhile details, reflexively trying to think how a test question could be posed. And then I turn off my internal test question generator, for this material is not test-able!

I rented a movie, too. Jealous?

I am actually feeling a tad bit guilty; maybe I should be preparing for the next block. Maybe on these days off I should go shadow doctors in fields I haven’t seen yet.

I think not. As students, we are fortunate to remain under the motherly, scheduling hand of a university. We still get some time off here and there, some breaks between long stretches of patient write-ups and black weekends. When we become residents, we will not be as lucky. So, it would be crazy not to take advantage of the unscheduled time given to medical students, right?

With that in mind, if you’ll excuse me, I’ve got some free time to spend!

No Hablo Espanol

Pin-Chieh Chiang -- There are many forms of barriers to medical care including lack of access and finances. For the patients that come to the community health clinic where I am currently doing my family practice rotation, there is also the barrier of language. This is a clinic where all the patients are either on government insurance or have no insurance at all. Many patients don’t follow up on their chronic condition until they need some type of urgent care. Many of the doctors complain about the lack of continuity of care, because the patients will jump around from doctor to doctor and clinic to clinic. Many of the patients are also Spanish speaking, and I don’t speak Spanish.

Instead of the open-ended question that I was trained to start with, I typically walk into a patient room and ask, “Habla inglés?” Typically the patient says no and I have to turn back around and find a medical assistant (MA) to help translate. Even then, I find a lot of difficulty communicating with my Spanish speaking patients. I marvel at my preceptors that manage to continue the patient interview as if a translator wasn’t even in the room. In other words, they are still able to directly address the patient. Whereas no matter how hard I try, I always seem to end up addressing the MA instead. I find myself saying things like “Can you ask her…” or “Can you tell him”.

The biggest challenge I have with needing a translator is that my evaluation of the patient is just not as complete. When I present to my preceptors, I’m often criticized for missing crucial information that I normally would ask. I find my train of thought gets easily lost in translation. I feel limited by only being able to collect information from the translator and not being able to read into the words of what the patient is saying. For example, I once diagnosed a patient’s aches and pains as some type of inflammatory arthritis. On her follow-up visit, she was angry with me because all labs returned normal and she still had aches and pains. My preceptor was able to realize that this patient who was undergoing menopause also had a lot of anxiety and depression. Since he’s changed her medications, she’s been doing a lot better.

Throughout the frustration, there lies a solution, which is that I need to practice my Spanish. As someone who plans to practice in California, I have a feeling that I will continue to encounter Spanish speaking patients in my future.

Which Student Groups Should You Join?

Ben Bryner -- I went to Boston last weekend. I’d only been there as a kid, so it was fun to see a city that was essentially new to me. Boston has a kind of storybook feel, with a comical accent: roads lead nowhere, centuries-old buildings house Dunkin Donuts, and people keep talking about something called “The Big Dig.” Turns out to be a huge freeway tunnel, but it still sounds to me like something Clifford the Big Red Dog would be involved in. 

Anyway, I was there for the annual conference of Universities Allied for Essential Medicines. This is a group I’ve been involved with for a few years now; it’s a collection of students from law, graduate, and medical schools across the country that work at the university level to increase access to lifesaving medicines in poor countries.

My point’s not to talk about this group or these issues in particular (though I had a great time doing that at the conference), but to point out how valuable it can be to get involved in a group in medical school. At my school there are organizations devoted to cooking, singing, environmental work, planning trips abroad, evaluating medical innovations, visiting patients in the children’s hospital, and about anything else you could name. We had a pirate enthusiasts’ organization which shut down for some reason – something about them stealing all the ophthalmologists’ eye patches. There are groups devoted to individual specialties called “interest groups.” These are groups of students who organize talks, shadowing, and other events to learn more about a given specialty. There are, of course, students in the US medical student associations (AMA Student Section, American Medical Student Association) and even the International Federation of Medical Student Association. Since groups range from being narrowly focused to very broad, you can really make as much out of it as you want.

The trouble with student groups, like with all-you-can-eat buffets, is knowing when to say no. The trap that lots of students (including me) fall into during their first month of med school is to be so interested in various groups that are doing amazing, exciting things that they overcommit themselves. School itself takes up so much time that it’s really crucial to select one or maybe two groups that you just have to be a part of. It’s tough to pick up front, but it’s much easier than getting pulled in so many directions by multiple groups that you just start letting things slip. So instead of approaching this like a buffet, consider it more like walking into a new café for the first time. You may not know what’s best when you walk in or even after looking at the menu for a minute. But just choose whatever dish (or student group) seems best. Then close your menu, commit to the food (or that group’s projects) in your mind, and you’ll most likely enjoy whatever you get.

"So, Tom, Do You See Yourself as a Nice Attending?"

Ben Ferguson -- We’re fortunate at my school to have the opportunity as students -- yes, even as freak graduate-medical student hybrids who haven’t been in medical school-proper for a few years -- to interview applicants to our medical school. For those of you who are applying to medical school in the States now or in the near future, cover your eyes for a few seconds.

THEY’RE GETTING SMARTER, AND BETTER, AND MORE QUALIFIED EVERY YEAR.

It’s true. I can’t tell whether this is a phenomenon that’s specific to my school, but it’s definitely an actual phenomenon, and it scares me.

These people I’m interviewing are so much more qualified for medical school than I ever was. Were I to apply now for admission to my medical school, I’d be laughed right into rejection (if they even bothered to send me a rejection letter). I mean, holy crap. I’ve talked to people with publications -- first-author publications, no less. I’ve met students who were varsity letter-winners and Phi Beta Kappa at the same time. I interviewed an applicant who lives in Paris and London and flies back and forth, and occasionally to New York, for consulting meetings. One student I spoke to was a TV news anchor on a children’s show as a kid, and another was a Congressional page, you know, in his spare time. I’ve chatted with at least three students who have been given university-wide awards for their academic and research prowess and several others who have done international volunteer trips to care for indigent locals. (Okay, I did this once, but it was “only” for a week, and I “only” taught a few orphaned kids some English. These folks have, for months at a time, assisted in operations and delivered medical supplies and served as translators and … the list goes on.)

So, what have I done? Let’s see, I graduated from college (by the skin of my teeth), got into a PhD program once (narrowly), and … oh, that’s pretty much it. Unlike one student I interviewed a few weeks ago, I haven’t even designed a prosthesis for one-armed water skiers for God’s sake! How would I possibly get into medical school these days?!?

While it’s disheartening and almost makes me feel even less like I deserve to be here than I already did, I continue to interview and evaluate these applicants. Why? Because I like it, because I enjoy being involved with the well-being and progress of my school, and because, especially given my situation, I feel like I can make a difference. Interviewing allows one to influence decisions about the makeup of future generations of students, and I happen to be in line to actually join those future generations in a few short mind-numbing years. For me, it’s even more important to pick people I see fitting in here, because I’m going to need to fit in with them eventually. (In fact, they could either become fellow classmates, or they could even be my residents and attendings when I return to medical school! There’s a strange thought: interviewing my future superiors for their acceptance to medical school…)

So, the moral of the story here is that, yes, brighter and brighter people are flocking to the medical profession all the time, and I’m continually impressed with them. At the same time, to all you current or future applicants out there: If you’re not a genius, do not sweat it. If you don’t have summa cum laude status from Harvard and/or Princeton, fear not. Normal peasants like me get into medical school all the time, so don’t let the success of others intimidate you or make you think you’re any less of a person simply because you haven’t accepted your prize money in Sweden yet. As far as I’m concerned, getting into medical school is as great an achievement as any these days.

Finding Refuge in Medicine

Ali Tabatabaey -- Nagging about how stressful and straining med school is, is what we med students do best. It’s like we feed off nagging! It gives us the energy to keep going. I myself have used this tactic a lot during the last seven years. Yet recently, as I try to prepare myself for the real world of medicine, I’m starting to appreciate a certain comfort in the hectic world of medicine that one can’t find anywhere else.

Yesterday, as I stepped out of the hospital after a long 12-hour shift, something inside me didn’t want to go -- as if I missed the place already. Do you know what I missed the most? Its simplicity! We think of our job as a complex and mysterious duty, but from a philosophical point of view, it’s quite the contrary. Things at the hospital are much more clear and vivid than real life is.

Our job is the only job that is the same in any part of the world and in any circumstances. Even at war our job does not change a bit, we treat the most severely hurt. When wearing the white coat, there are no bad guys, there are just people who need help and you have the power to help them. You shouldn’t care where the patient is from, what he/she does for a living, or whether he has committed a brutal crime or not. You just sew his stitches, give him his shots, and ease his pain. But as soon as I step out of the hospital, everything gets so complicated again. The people around me must once again be classified as friends or foes. The subtle joy from the day’s achievements that adorns my face soon gives way to a blank look or a frown as I think of all the interpersonal relationships, bills, debts, deceitful politicians, war, projects, part-time jobs, global warming, injustice and so many other things that engage the mind.

As it turns out, the hospital that once seemed like a prison keeping me away from “the fun world out there” has become my refuge from the brutal world of reality.

Feeling Like a Fraud

Kristen Heinan -- There are days when you just don’t want to wear the white coat. You feel like it’s a big lie; you want to take it off and hide it way back in your closet. You feel like you’ve defiled it; you want to stuff it, crumpled, at the bottom of your dirty laundry pile. You feel like you’ve disgraced it; you want to hoist it up a flagpole -- offered up, waving in surrender -- and invite humanity to hurl cannon balls at it and blast it to tatters. Then, if you put it back on, it might adequately reflect what’s truly inside it.

You’re the “doctor.” You’re supposed to know what to do, right? Too bad you still freeze in your tracks when the exam and lab values are abnormal. You are dealing with an extremely ill child in the hospital... yet the complacency of expected recovery sets in and you let your guard down. Your brain does not expect disaster to slither up and prepare to strike.

In some sense, though, you saw it coming. He was looking better, yet somehow that nagging little voice kept warning, “PICU, PICU, he needs to be in the PICU.” But he was doing okay on the regular floor. He needed lots of care, but he was holding his own, even looking better. Until you sensed that maybe his breathing was becoming a bit labored. Until almost overnight, it seemed, the BMP started to look not good -- so you repeated it, expecting lab error or something -- but it came back the same. And the CBC went from “not good” to “much worse.”

So you tried to patch him up with medicines, electrolytes, and oxygen, and even different types of blood products. But you could see it wasn’t working. So PICU was called, first as just a "heads-up/possible transfer"… then, less than 30 minutes later, emergently.

Once he was gone, you felt some relief because now he was in more capable hands; now he could really get intense, personal care by people more experienced than you. But you also felt like you were abandoning him, handing him off to someone else. Depend on someone else to fix the problems. Depend on someone else to heal the broken baby … so you could go back to monitoring those stable physical exams and improving lab values.

Let's Talk About Sex

Kendra Campbell -- Recently, I learned how to perform a rectal exam. Luckily, we have mannequins to practice on before actually performing the exam on real people. Our professor gave us a demonstration, which included telling us about the relevant questions to ask during an exam. However, one thing that he said struck me as odd. He told us that we should make sure to ask all men if they are homosexual, especially if we see rectal tears or bleeding. To me, this seemed very short sighted.

There are homosexual men who don’t have anal sex, plenty of heterosexual women who do, and many combinations in between. To simply ask men if they are homosexual seemed to miss a lot of other possible factors. It got me thinking about how many physicians take very good histories and ask open-ended questions, yet sometimes miss relevant details related to their patients’ sex lives. I know that I’ve experienced this as a patient, and I’ve seen other doctors and students make this mistake.

A patient’s sex life is obviously quite relevant to both their physical and mental health. In order to properly address all of a patient’s concerns, it’s important to know relevant details such as their sexual activity, preferences, safe or unsafe practices, and level of functioning. It could be relevant to their transmission of STDs, medication side effects, emotional issues, and many other aspects of their health.

I think that the problem of physicians not delving deeply enough into a patient’s sex life is probably related to embarrassment, a lack of time, and a general ignorance with respect to the varieties of sexual experiences. I know that so far in my medical education, I’ve received only one very brief lecture about human sexuality, and I’d hazard a guess that many medical curriculums are similarly lacking information in this area.

Many people, physicians included, make a lot of assumptions about other people’s sex lives without being truly informed. For example, a doctor might ask a patient if they are heterosexual or homosexual, without providing for all the other options that exist. There is also a strong age bias that older people don’t have sex. However, there are many older people who would quickly dispel this myth. If a physician fails to ask an older person about their sex life, they could be missing out on many important clues to their level of health and potential problems.

The doctor-patient relationship is very intimate. Physicians have to ask patients about some of their most private details. Without this level of intimacy, the relationship breaks down, and patients can receive less than optimal care. I’m not saying that it’s completely one sided. There are plenty of patients who are less than honest with their doctors. But I think it’s important that as physicians, we do everything we can to put our patients at ease and to help them feel comfortable sharing intimate details with us. And in order to do this, we can’t forget to appreciate all the varieties of human experience, including sexual. We should try to be more mindful of individual differences, ask more open-ended questions, and we should not be afraid to talk about sex.

A Funny Thing Happened on the Way to the Nurses' Station

Anna Burkhead -- Being a medical student on the wards presents many new challenges, especially learning to think and act in a clinical environment. But there are many other aspects of the wards that take a little getting used to as well, including many of the social interactions.

The hospital environment includes many different people with many different titles. As medical students, most of our interactions are with doctors and nurses. The relationship between doctors and medical students is well defined. We are in training for the job that they perform every day. Also, the doctors and residents evaluate us and dictate a final grade.

The relationship between nurses and medical students is less easy to define. Although we are both in the medical field, we’re not entirely in the same line of work. Of course, all people should be treated with respect and in a professional manner, but what exactly is the working relationship between medical students and nurses?

So far during third year, I have met many nurses. Some of them have been extremely helpful and nice to me, going out of their way to show me the inner workings of the hospital. Others have been less polite.

Once, as I was standing in the hall looking at the Labor and Delivery board to determine which patient I needed to see next, a nurse I had never met walked up to me, held out a stack of papers, and said in a demanding voice, “Take this to 8A.” Reflexively, I reached out my hands for the papers, and the nurse turned around and walked off. No “please,” no “thank you,” no “Hi, I’m so-and-so, would you mind….”

On another occasion, I was sitting at a work station with my intern, and I overheard two nurses discussing a patient who was getting an IVC filter. “What does IVC stand for?” one of them said. She walked around the nurses’ station to my intern, who was on the phone. She tapped the intern on the shoulder and repeated the question, “What does IVC stand for?” The intern, on the phone with our attending, didn’t respond. Since I was less than two feet away from this interaction, I felt it was ok for me to answer the question. “It stands for Inferior Vena Cava,” I said, loud enough to hear. The nurse looked at me, rolled her eyes, and went back to the nurses’ station. When the intern hung up the phone, again the question was posed, “What does IVC stand for?” The intern answered, “Inferior Vena Cava.” “Oh,” came the response from the nurse.

I am 99.9% sure that these examples are exceptions, and that it was the personalities of these two particular people that caused them to act in this manner. But, I can’t help wondering if I’m missing something -- some unspoken dynamic that exists between nurses and medical students. I haven’t had similar experiences with the residents that I’ve worked with. Am I giving off an “I have a negative attitude” vibe? Do I exude the “I’m somewhat clueless” signal so strongly that everyone senses it, and treats me accordingly? Any nurses in the readership have an opinion on this matter?