The Differential: Medscape Med Students Blogs

Super-Sized America

Kendra Campbell -- I’m currently sitting in a suburb outside of Washington, DC, the capital of the United States. I’m on vacation from everything that is med school. So far, I’ve had a wonderful time with my family, hanging out with my friends, and eating all the delicious foods that I can’t get in the country where I go to school, Dominica.

When I first stepped off of the plane a few days ago, I had a similar experience to the last time I was in the States, over eight months ago. As I wrote in a blog entry before, I was immediately shocked by the large size of many Americans, as well as the overabundance of incredibly unhealthy food options. Yesterday, my partner and I went to grab a bite to eat for lunch at a popular restaurant. I wasn’t that hungry, so I offered to eat half of whatever he ordered. He picked the steak special (I’m currently a meat eater but was a vegetarian for 13 years), and I agreed to eat some. When the server brought out the plate, my first reaction was that he was playing a practical joke on us. The plate was huge! On top of the plate was the largest steak I’ve ever seen, covered with huge pieces of greasy bacon, and topped with a one-inch pile of cheese! On the side were mashed potatoes (about 4 potatoes worth), and a small pile of greasy spinach. At that moment, I could barely contain myself. I looked outside into the parking lot filled with huge SUVs, and around the restaurant at the many large patrons, and realized that America had in fact become a super-sized country.

My experience at the restaurant really got me thinking about public health and responsibility. Why would a restaurant even offer a meal that provides 500% of the daily recommended allowance of fat? Shouldn’t restaurants be more responsible when it comes to the health of their patrons? I guess it all comes down to supply and demand. If people want it, restaurants will offer it. Then I started thinking about the public health department and their responsibility. When is it necessary for the government to step in and do something? New York City, for example, has passed a law banning trans fat in all restaurants. Should cities also ban dishes that contain over a certain amount of fat? Fried chicken? Doughnuts? Where should they draw the line?

I guess it all comes down to free will. We certainly all have the ability to make our own choices when it comes to eating (except of course that cost does play a major role… but that’s another rant). But what about our children? Many public school systems have been trying to provide children with healthier food options in their cafeterias. Should we be doing the same thing for adults? I know that many restaurants have been trying to provide healthier options for their patrons, but at the same time, it seems like they are providing even more unhealthy options. Some restaurants have even begun to list the nutrition information on the menus. I think this is definitely a step in the right direction.

It’s no secret that America’s expanding waistlines are directly correlated with our expanding health woes. I think one of the problems is a general lack of responsibility and action on everyone’s part. Hopefully, people will start stepping up and finding some solutions, because everyone’s health is at risk.

For the record, I actually did try a few bites of the steak we purchased (between the two of us, we couldn’t even eat one-fourth of the meal). It actually made me a bit nauseous, so I stuck with the greasy spinach instead.

Terrible at Goodbyes

Pin-Chieh Chiang -- This is my third draft trying to write this blog, which will also be my last entry. I have always been terrible at saying goodbye. Should I leave with some words of wisdom? Or a funny last story? How about I just write as if I’m giving an update about my life?

I’m currently sitting on my bed which I share with my husband and daughter in Shenzhen, China. Through our bedroom window I can see Hong Kong and the bridges that connect the two places. This is my vacation block and so far I’ve spent the last three weeks doing only one thing: being a mom. Each day I’ve looked after my baby’s sleeping, feeding, bathing, and playing. This is the most child care I’ve done since her birth. Typically during rotations, I’ll wake up and leave the house before she gets up. Then daddy takes her to grandma’s house for the day while we both work. At night I see her for only 3 hours before she goes to sleep. Here it’s been 24/7 just being with baby; a very rewarding vacation so far.

My family is truly my number one priority, especially my bouncing bubbly baby girl. Medical school would be my number 2. With just these two priorities, it’s already sometimes too much for me to handle. This is why I’m saying goodbye and this will be my last post. I had a wonderful time writing for The Differential and I’ve enjoyed everybody’s comments.

When I look back through my blogs, I wish I had written more about Osteopathy. It’s more than just an extra set of tools of manual medicine, it’s also a way of thinking. One of my favorite teachings in Osteopathy is, “To find health should be the object of the doctor; anyone can find disease.” Since starting 3rd year rotations, I’ve been so focused on diseases and pathology, I’ve easily forgotten about finding the health in my patients. Then I was reminded of this concept by Dr. McAffrey when she gave a grand rounds lecture on Traditional Osteopathy. She told the audience that the first thing she does with any patient is list five healthy things about them. She challenged everyone to try and find five healthy things about their patients.

To end this blog, here’s a list of five healthy things about me: I’m young, in general good health, lead a fairly active life, have a supportive family system, and am trying for another baby.

I'm a Mad Scientist!

Ben Ferguson -- Oof. What a few weeks. I’ve reached the inevitable period in pretty much every researcher’s career where absolutely nothing goes right. Experiments don’t work, data looks either bad or opposite from what you expected (which is sometimes really cool but usually bad), equipment breaks, and the list goes on.

All of these things have happened in the lab recently, and it’s really been testing my patience and my devotion to both this project and this career track. A few weeks ago, half of my pipettes went missing, meaning I couldn’t do most of my experiments for a while. (They all were later returned, thankfully, since they go for several hundred dollars a pop.) Then one of the PCR machines broke, and when we sent one of its parts in for repair, it was sent back repaired but reformatted for a different model, meaning it may as well have been broken still. Then the qPCR machine in the lab wasn’t working properly, and I spent about three weeks straight tinkering with it and optimizing experimental conditions on it without ever getting any reliable data. Then our antibodies, provided by a colleague who has used them successfully to publish a number of papers, didn’t work at all for five weeks until we finally tried a new detection method. Then...

You get the picture.

I’m trying my best to remind myself that this is just a funk, that eventually the skies will clear and I’ll get back into a groove. It really underscores the need in research to be persistent, to keep one’s head up and not get discouraged, and to employ a little creativity when seemingly nothing works. It also underscores the importance of realizing when to keep going and when to simply move on or try something else. Quitting (or at least taking a break) while you’re ahead is often a better solution than getting more and more frustrated with each failed attempt (and each hundred-dollar wad thrown down the drain). I’m sure most advisers funding researchers in their lab would feel similarly!

Here’s a slightly modified mantra I’m starting to live by: If at first you don’t succeed, try, try, try, try, try again. And get coffee and/or do a crossword or two in between. Then, if you don’t succeed, for God’s sake do it another way!

How to Study for a Big Exam

Kendra Campbell -- I have finished all my regular school exams for this semester and have about one week to study for the NBME's "Comprehensive Basic Science Examination." My score will not be counted towards my grades in school, but rather is a pass/fail exam that I must pass in order to sit for the USMLE Step 1 Exam (the medical licensing exam for the US). Having a week with nothing to do but study is a daunting task for me. At my school, we usually don’t have so much time to study for an exam, but since this covers all of the basic science material learned during our first two years in med school, they give us a week to prepare. I’m sure all of you out there have either already faced this issue, or will be facing it in the near future, so I decided to make a list of some helpful suggestions that have worked for me.

1. Make a schedule, and try to stick to it. This is probably the most important tip. Having a schedule provides you with structure, and is a good way to prevent falling into the trap of running out of time in the end. It also ensures that you always have a task at hand, instead of sitting around bored, wondering what you should do. I usually go as far as creating a schedule down to the hour, but depending upon how much time you have to study, this wouldn’t always be necessary.

2. Get up every day at a similar hour. This obviously goes along with #1, but it’s always a good idea. In addition to getting up around the same time every day, it’s also a good idea to "try" and go to sleep at a reasonable hour every night.

3. Don’t forget to schedule in "fun time" or time off from studying to relax. This is incredibly important, and will prevent the dreaded "burn-out." If you’re lucky enough to have a dog (or other pet), take them for a walk, or play a game of fetch. Playing with my dogs is one of my most favorite de-stressors. If you’re somewhat obsessed with cleaning (like I am), take off 20-30 minutes to wash your dishes or do some laundry. Do you enjoy being outside? If so, take a walk around the block or to a nearby park. You may have noticed that all of these activities involve physical activity. There’s an obvious reason for that. Unless you are studying while on the elliptical trainer (which I actually don’t recommend), you are probably sitting on your butt for hours at a time. We’re med students. We know that moving around and getting your blood flowing is advantageous to both your mind and body. Don’t forget what you know.

4. Do questions. This is a great way to learn. Use an online question bank, or one of the thousands of prep books. And don’t just look at the correct answers. Actually figure out why you got the question wrong (and even right), and learn from your mistakes.

5. Don’t study what you already know. This is pretty obvious, but people sometimes do it anyway. Stop wasting your time!

6. Caffeine is your friend. Never forget your friends.

7. Change it up! If you find yourself getting incredibly bored, and wondering if chewing your leg off might actually be a more enjoyable experience, change something! Either change the subject you’re studying, how you’re studying it, or where you’re studying. If you’re lucky enough to live by a beach, go there and crack open your books! It will save your sanity, and also your innocent leg.

8. Take the day or night off before your exam. Don’t forget to do this! I don’t care if you’re behind, or you think you can stuff more information into your head if you keep studying. Don’t do it! And especially don’t stay up all night before the exam. This might be the worst idea ever. Let all those pharmacology drugs simmer in your brain for a while. Give the information time to cement. Have a nice dinner or go see a movie (preferably a completely mindless comedy) and reward yourself for all your hard work.

Okay, those tips should help to at least get you started. Do you have some suggestions that I missed? Feel free to add them to the list.

How to Survive an Away Rotation

Anna Burkhead -- At my medical school, students in their clinical years do their rotations at hospitals all over the state and beyond. Of course, the most popular site to rotate is our “home” hospital at UNC-Chapel Hill. All the students put in site requests before the year starts, but if you don’t have a spouse or children anchoring you in the city, you’re pretty much guaranteed to get shipped out to another part of the state for at least one rotation during the year.

Not having a spouse or children, I knew that my chances of getting placed in Chapel Hill were slim to none, so I purposely requested to be sent to my hometown for most of my rotations. I figured that if I specified my hometown as an “away” site, I’d probably get placed there, instead of some more remote city I wasn’t familiar with. I played my cards right, and have done several rotations at home.

This month, I am assigned to a city near the coast, at a hospital I’d never seen, in an apartment provided by the hospital, with a roommate I’d barely met. It’s been a few weeks now, and although things started off a little rough, I’m adjusting to the setting. Too bad the rotation’s almost over!

To help other medical students adjust to “away” rotations, here are some tips and some vital pieces of information that will help you become more comfortable in a “foreign” city, hospital, or living situation.

1. The day before your rotation starts, take a walk through the hospital. Find the Emergency Department, Cath Lab, Radiology, Physician’s Lounge, and coffee shop.

2. On your first day, ask your intern to walk you through the hospital’s computer system and charting. Find out where to get patients’ vitals and up-to-date medication lists.

3. Bring your own bed sheets. They usually don’t provide them in student housing. (Would you want to sleep on them anyway?)

4. Ask for important phone numbers, and write them (as well as all the pager numbers of your team members) on a notecard. Numbers to know include the hospital operator, the Radiology listening line, long distance dialing code, telemetry monitoring room.

5. Cereal. Always a great meal in an unfamiliar living situation.

6. Ask a medical student who has spent time at the site to give you the details on call scheduling, pimp questions, and helpful things medical students can do during rounds at the site.

7. The day you get your ID badge, make sure it works at the entrances and badge-access locations. It’s a pain to get it fixed later.

8. Carry a little cash in your white coat and scope out the cafeteria. You never know when the department will have a “residents only” meeting, or when lunchtime conference will be cancelled and you’ll be on your own.

Although it’s difficult being uprooted and sent to unfamiliar hospitals, I feel fortunate to have the opportunity to do my rotations at several sites. This way, I get to learn different charting systems, experience different call schedules, and see different patient populations. If your school allows you to schedule rotations at away sites, I highly recommend doing at least one month in a new setting. Take these “Tips for Survival” along with you!

What Child Is This?

Kristen Heinan -- Another night in the ER. Steadily busy, but manageable... strep throats, non-strep throats, rashes, coughs... until we'd pretty much taken care of everyone by 1 a.m. or so, and everyone needing to be admitted was sent upstairs.

We had gotten a call earlier in the evening alerting us to a sick little girl who was going to be transferred to us from her local hospital a couple of hours away. Many phone calls were exchanged between the "higher-up" docs -- our PICU was busting-full, but her situation was serious. So they arranged to fly her in while they shuffled patients around upstairs to make room.

She arrives on the stretcher, wide-eyed and gray-pale. She is all tangled up in IV tubing, ECG monitoring leads, pulse-ox monitors, and an oxygen face mask. She is very cooperative, very sweet -- looks like she is on the verge of tears but is maybe too tired and dehydrated to make any.

In an attempt to make conversation, we tell her how pretty her ponytail-holder is. I think to myself also how pretty her long honey-brown hair is, and then my brain thinks: "too bad it'll start falling out soon." One of the nurses asks her what Santa's going to bring her for Christmas. My brain thinks: "hmmm, cancer." She meekly whispers that her "Daddy's supposed to be here."

He is. He had come by car and had actually gotten here just before she had -- he is in the waiting room, waiting for us to get her settled in. We bring him back right away. Other than looking like he's on the verge of terror, he is holding his own. Mom is still on the way.

She's waiting here in a darkened, quiet room. Her dad is sitting at her side. She's exhausted and sound asleep. My cold hands waken and upset her as I feel her big lymph nodes and splenomegaly. Mom's still on the way -- maybe 2 hours away at this point -- dad had been on business in the area so he'd been able to get here quickly (so, I guess Someone was looking out for this family?).

She wakes up crying in a panic. She is disoriented, doesn't know where she is. She sits bolt-upright. She is not comforted by our gentle reassurances. She doesn't want stickers or juice. She is standing on the stretcher on her tip-toes trying to climb up into Daddy's arms. She just wants Daddy to scoop her up and carry her somewhere else -- anywhere else -- to take her and go. She wants mommy. "Mommy's coming, sweetheart. Daddy's right here. You want him to lie in the bed here with you? Mommy's coming really soon. Daddy's here."

She trades the oxygen face mask for nasal cannula. She accepts a new blanket and allows herself to settle back down on the stretcher, beside Daddy. Just waiting to head up to the PICU, waiting for everything to really get started. My brain thinks: "this is just the beginning, sweet one. Poor thing, you have no idea. This is just the beginning…"

Why this? Why now?

You know God doesn't make people sick. He doesn't want her to be sick. He doesn't want all of this misery and distress for her family.

But why, then? Why this? Why now? Why this time of year -- it's Christmas for God's sake!

The internet radio rudely croons "Silent Night" and then "What Child is This?"

What child is this? Who, laid to rest, on a stretcher beside Daddy, is finally sleeping? To whom should we hasten -- with praises or pleading -- to make it just all go back to normal?

Living in the Moment

Kendra Campbell -- A week ago I began the end-of-semester final exam marathon, which involves eight exams. I just finished exam number six, which means I only have two left to go. My brain is tired, my motivation is dwindling, and my enthusiasm with med school is at an all time low. I’m at the end of my second year of medical education. On the horizon is the beginning of my third year, which will involve actually working with real, live patients in a real hospital. I’m looking forward to that, but I’m struggling mentally to finish this semester.

As all of you students and physicians out there know all too well, med school is basically about jumping through thousands of hoops to get to the final destination of becoming a practicing physician. I've experienced many setbacks along the way, but I've kept trudging along. First there were the pre-med classes and the MCAT, then came applying to med school (which involves about a million little hoops). Once you’ve been accepted, there are endless forms, exams and challenges. Each time you get to the next step, you give it all you’ve got, and then you look on your horizon and see the next hoop looming before you.

I’ve always been a somewhat spontaneous person. Okay, actually I would say that I’m prone to non-random bouts of calculated spontaneity. But nonetheless, I do have some flickers of true spontaneity. I also have always enjoyed living in the moment. I try to cherish the here and now, without always worrying about the future. This isn’t exactly congruent with the med school experience. It’s quite challenging to focus on all the tasks and exams at hand while at the same time living in the moment. This is the paradox that I face.

I’m trying to come up with a solution to this daunting issue. Is it really possible to keep your eye on the prize (graduating from med school) while continuing to appreciate life as you’re living it? My gut tells me that it is, but it will probably continue to be a challenge. I have two more huge exams looming on the horizon. After that, I will have to make it through the next semester at the hospital. After that, I will have to pass the USMLE Step 1. After that, I will have to fill out forms and get accepted into a clinical rotation. After that… okay, I think you get the picture.

Perhaps it’s better to just try and live life to the very fullest every day -- savor every last yummy drop of life’s nectar -- but always with one eye on the next goal ahead. Is this even possible? It certainly does sound nice. But for now, I don’t have another exam for two days, so I’ll just celebrate the one I just took with a glass of wine, and try my very best to savor its nectar.

The End of One Journey, an Uncertain Future Ahead

Ali Tabatabaey -- As I write these last lines, sorrow clutches my heart and my hands are unable to wipe my cheeks of the endless stream of tears that pour down from the corner of my eyes to my chin. As I write these last lines my hands shake in woe and I choke on my silent cries. As I write these last lines… well, maybe I’m exaggerating a little and things are not that melodramatic, but still I have to admit that I feel … (I really couldn’t find the right word so I gave up) by the fact that this is my last post to the blog. I think my best attempt at describing my current feelings would be to call the situation an “amputation”! Losing something that worked so well for me and that I had become so attached to. I guess that’s why it took me so long to actually sit down and write this one.

The fact is that soon I won’t be a student anymore, and now that I think of it, even now I am in a gray zone. My rotations are over, the graduation ceremonies have been held, and I’m only a defense session away from the finishing titles in this seven year drama!

The oath is behind me, or better said, will always be in front of my eyes, and the weight of the responsibility is clearly felt. Just as I expected, excuses are no longer accepted for a friend’s bellyache or a relative’s sore knee, but the good news is that I usually have an opinion to put forward and escape out the backdoor even if I have no idea what to think next!

The graduation ceremony was OK. We took charge of the most part ourselves and it proved to be fun. A friend of mine put together a couple video clips from all our memories, another prepared a slide show, and another a multimedia CD. I came up with the idea of the first ever “graduation day newsletter” only two days before the ceremonies, and I don’t know how, but I managed to put it together. I also presented a comic version of all that we had gone through during med school. All the graduates loved it, but I don’t think any of the families could relate. I dare to call the whole thing a success.

Yet after the party when the dust settled, there we were, a bunch of 26-27 year-olds looking at their pictures at 19 and shouting out “oh look how thin I was” or “look how much hair I had” or even “look at that smile! I haven’t grinned like that for a very long time”! And I, as always, was anxious about what life will throw at me next in a society characterized by uncertainty.

I’m not down or anything like that. I’m actually very proud of what I’ve achieved, but I am anxious. I’m just at a point that I need a mentor so badly. But in this quickly changing world, no one's experience can be put to use exactly. I know where I want to be yet it seems that all the doors leading to it are currently closed. So I either have to take a long, tiresome side road, or sit around and hope for a change of fortune. Maybe a third option would be to fight my way through, just maybe!

So I guess this is the end. I think I’ll take a couple of months to fully think my choices through and after that … I really don’t know. It was an amazing experience writing for the blog during the past two years and I’ve made so many friends. Who knows, if I manage to enter a residency someday, I might be back. Till then, take care.

PS: Meanwhile, I can be reached at alitabtab@gmail.com.

The Beauty of Checklists

Ben Bryner -- Atul Gawande has a great piece on The New Yorker's website about the power of checklists to transform health care, particularly critical care. I’ve basically declared myself a “Gawande groupie,” so I enjoyed this article where, in traditional Gawande fashion, he starts off with a case of a patient he saw, and then looks at the origin of the pre-flight checklist in aviation and its impact on safety. Then he identifies one particular physician who brought the concept to medicine, generating checklists for every little step of some procedures commonly performed in the ICU. After describing the astounding effect these ICU checklists have, he outlines the extent to which the checklist has been adopted elsewhere (not much), and concludes with another short but gripping case.

Gawande also talks about the widespread resistance to the idea of a checklist, since some people are afraid that using a checklist will take the art out of medicine and leave cold, dispassionate automation in its place. On the surface, this makes some sense. Patients certainly don’t want to be treated as simply fodder for an algorithm, as just another row of data in a spreadsheet.

And sometimes it seems like there’s already too much of a checklist-approach to medicine: every lecture in medicine seems to follow a dry checklist of its own. Anyone who’s been to a medical school lecture or grand rounds recently will recognize it:

1. Introduction while latecomers trickle in

2. Statistics on the extent of the problem, this being a plea to the audience not to tune out the lecture quite yet

3. Diagrams of the molecular pathophysiology of disease (usually featuring arrows flying in from the side of the screen)

4. Lists of treatment options and side effects

5. A New Yorker cartoon, this being a last-ditch attempt to make the lecture memorable

Check, check, check, and check.

It’s easy to see why people would not want medicine to turn into something this boring and formulaic. But checklists really do the opposite; they take a large part of the intellectual work out of the patient’s management, leaving more time for real thinking. This allows physicians to spend more time considering the twists of an individual case. By getting to know the patient better (which is itself an obvious benefit), physicians can really apply the art of medicine by adjusting the checklist and interpreting the evidence to fit that particular patient.

What about the fact that not all patients will fit into the algorithm? This is true; of course no real patient will fit the checklist perfectly, just like patient gowns don’t fit any patients perfectly. But a checklist has the potential to let a physician spend less time trying to remember all the basic preparations for a procedure like inserting a central line, and more time talking to the patient, considering the patient’s own special circumstances, monitoring the patient’s status, and anticipating problems before they occur.

And besides that, who says a checklist has to always detract from the artistic quality of an endeavor? Consider Gawande’s article itself; it follows pretty much the same overall pattern as all of his articles, but his writing and analysis are still fresh and engaging.

Before medical school, I’d never have imagined being interested in checklists, let alone interested enough to read an article on it outside of class. But the third year of medical school certainly gave me a new appreciation for and fascination with things like this; something simple that can make it easier to apply the art of medicine and get better results is exciting now.

An Awakening

Ben Ferguson -- Sometimes in medical school, especially during first year, you really feel like you’re back in undergrad again, learning about seemingly mundane details that don’t appear to be applicable to the practice of medicine. I got this feeling a lot during my first year and even at points well into my second year.

The first time I really, truly felt like I was a medical student was when I interviewed Mrs. D, a teacher from Chicago. We had just finished the heme/onc section of CPP that day and I felt like I was still really solid on most of the material. Anemias, leukemias, lymphomas, signs and symptoms -- all fresh in my head. (CPP stands for Clinical Pathophysiology and Therapeutics and is the best class at my school by far, the one that makes you realize there actually was a valid reason that you learned all that biochemistry and physiology and neurology and anatomy during first year that, at the time, seemed entirely detached from the practice of medicine.)

After a brief meeting with our resident who took us around to a few patients to expose us to some clinical findings like jugular venous distention indicating congestive heart failure, displaced point of maximal impulse indicating left ventricular hypertrophy, and spider hemorrhages from cirrhosis, I was introduced to Mrs. D and began to run through my lengthy list of questions just like with every other patient: absolutely robotically and without a clue as to the reasoning behind my questions.

After finishing up her history of present illness, I started to realize that I knew what was wrong with her. She had some of the same signs and symptoms that actual, real-life doctors had just told me should be present in situations like these. Fatigue, dyspnea on exertion, cachexia, lightheadedness, dark urine, hepatomegaly, severe jaundice, scleral icterus -- it was like she had memorized a textbook for the purpose of reciting it back to me. She couldn’t have been more spot-on had she been a standardized patient trained to present with these findings. And I felt so empowered. I felt resonation with the questions I had been asking all these patients over the past year instead of just reading them off a list. I at once knew their value like I hadn’t realized before, and I was able to direct my questioning according to her specific complaints. And it was great.

At the same time, it wasn’t great. I realized she had acute myelogenous leukemia, a nasty adult leukemia that is relatively aggressive and has a relatively poor prognosis. And I realized that I learned about this disease in a classroom, free from emotion and patients and crying and fear of one’s outcome, secure in my own worry-free environment.

Meeting Mrs. D there and coming to the abrupt realization that she was in dire straits was a very difficult situation to be thrust into. On the one hand, she introduced me to the true value in knowledge about diseases and their management; on the other, she showed me that we should always remember what we are learning. We are not merely learning scientific facts. We are learning about human diseases that affect patients’ lives -- not just their bodies -- in ways that we can’t always comprehend as hard as we may try. We should never forget that.

The Choices Patients Make

Pin-Chieh Chiang -- Last Friday, I had just finished my last surgery for the day when one of the O.R. nurses gave me a heads up that an emergency operation was just added. It was a case of a 57 y.o. female with a ruptured viscous, and the case was listed as an exploratory laparotomy with sigmoidectomy and colostomy. In the rush of things, I didn’t get a chance to learn more about the patient’s history. What I did know was that she had presented to the E.R. with abdominal pain, nausea and vomiting, and an abdominal film had shown air bubbles under the diaphragm.

As we started the surgery, the other two surgeons discussed this patient’s case. She had had symptoms of abdominal pain for at least a year. On a CT scan a couple of months ago, it was discovered that she had colorectal cancer. Then, what really perked up my ears was that apparently this patient was already scheduled for surgery this day, but had canceled earlier in the week. It was obvious to the surgeons and me that this patient has just been avoiding and putting off surgery for a while now.

This surgery would teach me about more than just medical science; I was also forced to ponder the nature of doctoring and disease. I’ve always had problems understanding what was going through the minds of patients like her. Why would they delay medical attention for a condition so severe?

This patient reminded me of another case I saw during my first surgical rotation. This other patient was over 80 years old and presented to the office with a breast mass. When I went to do the breast exam, there was a huge mass eroding through the skin of her left breast. Her left breast anatomy was very distorted with the nipple completed inverted and axillary lymph nodes were very palpable. I asked her how long ago she had first been able to palpate a mass in her breast and she told me 1 year. She sensed the “why?” question that was in my mind, and without being prompted she explained that she felt like she was already over 80 years old anyway. The reason why she was referred to surgery this time around was for symptomatic relief; the mass was causing her too much pain.

During the rest of the ruptured viscous case, I pondered why such patients push off medical care for so long. It would be so easy for me to just blame the patients themselves for being careless with their own health. During the exploratory laparotomy, we found foul smelling pus throughout her abdominal cavity. There was an abscess near the posterior wall where the colon had perforated. Towards the last 45 minutes of the surgery, the patient became very hypotensive and was resuscitated with fluids and pressors. After the surgery, she remained in the O.R. for further resuscitation from septic shock and was directly taken from there to medical ICU.

At the end of the surgery the head surgeon made some comments that were very enlightening. She told me that she never passes judgement on her patients. Perhaps both of these patients wanted to spend more quality time with their loved ones versus subjecting themselves to aggressive treatment. Maybe there are no wrong decisions.

Going Through Adolescence in Medical Training

Kristen Heinan -- I have spent the past month working with the Teen Health clinic. I definitely have seen lots of things we never see in the general pediatrics clinic. Lots of good practice doing OB counseling and STD testing, and so much more than that too, just helping them all navigate through this time of swinging gauntlets and shifting lava pits we call "adolescence."

It really has been a great experience. I enjoy working with the teenaged population. Maybe it's because I still feel relatively close in age and life circumstances to them? Though most of them have much, much more "life" experience than I do!

Maybe it's because I still feel like a bit of an adolescent... being an intern is somewhat similar, in that limbo between the two worlds of student and practitioner, of learner and learned. I can tell that I am way too easily offended when I'm not taken seriously, but at the same time, I dread having to make the tough decisions, and part of me wants to be told what to do. It seems like no matter how much I read, it never comes back to me when I need it… or if it does, I may know what to do but not exactly how to do it.

I guess that’s what residency is for -- for learning. But it’s just tough because this is a “job” too, and more than that, people are depending on us -- me -- to take care of them and know what to do. Hmmm.

The White Coat: Not Just for Hiding That Coffee Stain on Your Shirt

Anna Burkhead -- Lately, there’s been a lot of writing and comments on The Differential regarding the physician’s white coat. It appears that the “rules” and conventions regarding length and style vary from country to country, and even from school to school within the US. But one thing is constant, judging from the comments: physicians all over the world wear (or have worn) the white coat in some form. This got me thinking about the history of the white coat and its symbolism. Thanks to the magic of the Internet, I was able to unearth some information before you can say “Thank goodness for all the pockets in the white coat for I am beginning to feel like my team’s pack mule.”

The tradition of the physician's coat seems to have begun in the 1800s, as physicians turned to science to distance themselves from medical “quacks” and disreputable “healers”. Thus, the first “white coat” was actually a “lab coat”, and it wasn’t white, it was beige. Towards the end of the century, the coats became white to symbolize purity and cleanliness.1

Gradually, the use of the white coat became more and more widespread, and by the 1970s, almost all media depictions of physicians included a white coat as the identifying accessory.

There are many interpretations of the meaning and symbolism of the white coat. It communicates the physician’s intent as a medical healer, and it helps create and maintain a professional barrier between doctor and patient. However, some say this barrier is detrimental to the patient-physician relationship, as it conjures a formality that may dampen communication that is vital to medical care. Nowhere is this separation between plain-clothes patient and white-coated physician more evident than in the following passage from W.H. Auden’s 1969 poem, “The Art of Healing”:

Most patients believe

Dying is something they do

Not their physician

That white-coated sage

Never to be imagined

Naked or married

It is evident from those few lines that physicians were regarded at that time as being “above” most human functions, like dying, sex, or marriage. And still today, patients keep the expectation that a physician’s training places him above temptations of gossip, entertainment, and of the flesh, as they allow us insight into their darkest secrets, and they allow us to explore their bodies with our eyes, hands, and tools.

No matter how the tradition of the white coat began as a representation of a physician’s sincerity, or how it has evolved today to be the uniform of many other hospital workers, the fact remains that the white coat is a symbol of an intent to heal. And though it may occasionally incite crying in a child or blood pressure elevation in an adult, the white coat also engenders trust in many who see it. Accordingly, the next time you sling your coat over your shoulder to pre-round at 5am, or the next time you find yourself pouring bleach into your washing machine for the third time that week, remember that the coat is more than just a shirt protector and pocket for your reflex hammer. It’s a tradition that far precedes this generation of doctors and medical students, a privilege, and a responsibility.