The Differential: Medscape Med Students Blogs

A Lesson (Not Just a Joke) From an Orthopedic Surgeon

Ben Bryner -- Most specialists have some kind of stereotype associated with them, perhaps none more so than orthopedic surgeons. One of the predominant stereotypes about them is that they’re into power tools and carpentry and things like that, and are less intelligent than other doctors. It makes sense when you walk into an orthopedic OR, and it looks like someone took an old guy’s garage and dumped it on the table, then sterilized the mess.

On your surgery rotation, you will be expected to learn at least three jokes about orthopedic surgeons (nobody loves the jokes more than the orthopods themselves). Here’s one: Q. How can you tell that a chart note was written by an orthopedic surgeon? A. It’s written in crayon.

Of course, not all people within any given specialty fit the stereotypes, and given how competitive it is to get into an orthopedic surgery residency, the stereotype about intelligence is false. But on one occasion in particular, it was a good thing that the stereotype of orthopods being mechanically inclined held true.

One night during my surgery rotation I was on call at another hospital, finishing up examining a patient in the ER and chatting with a friend who was in his last year of orthopedic residency. (This guy was actually one of my favorite people I’ve worked with in all of med school, very smart and competent as well as nice to students and excellent with patients.) A patient came in who had broken his femur doing some kind of extreme sport under the influence of cocaine. (He’d apparently done this once before.)

The orthopedic surgeon wheeled over his cart and got his supplies ready to put the patient in traction (fixing the patient’s leg to the bed to prevent his leg muscles from pulling the femur-pieces past each other) while the ER staff tried to track down the power drill to place the traction pin. For some reason, nobody could locate the power drill, and all they could find was an old (but sterile) hand drill. We asked the guy a few questions while we waited, and finally the surgeon gave up and said he’d use the hand drill, or more precisely, that I would use it. I injected some anesthetic into each side of his leg, and the surgeon showed me how to put the drill together. Maybe he’d had some kind of training for the hand drill in his residency, but it was a pretty weird setup and I got the impression that he was relying on outside knowledge. Either way, it was good that he knew how to put it together, because if I’d put it together I probably would have drilled into my own hand.

He drew a little x where the pin was supposed to go and told me I’d have to put my weight against the drill to provide enough force. I’ll be honest, I had faith in my friend, but with the first few turns of the drill, I was skeptical that this was going to work. It took a lot of pressure, but eventually it went through the bone and out the other side. It was a spectacle, even by ER standards. The combination of the old-school implement and the fact that the patient was awake made it feel like something out of the Civil War. I half expected to look behind me and see Matthew Brady making a daguerrotype in the corner.

The surgeon said “nice job,” hooked the leg up to the frame over the bed and that was it. While my friend filled out some paperwork (in pen), I thought about the fact that although technology offers us unparalleled advantages in diagnosis and treatment, doctors will always have to improvise and fall back on the knowledge of simpler medicine when things don’t go exactly as planned.

A Day in the Life

Ben Ferguson --

First-year medical student:

6am: Wake up, get ready, breakfast

8am: Arrive to campus in time for 8:30 lecture, sit in class until 10:30

10:30am: Lunch break

1pm: Lecture

2pm: Lab until 4 or 5pm

Evening: Arrive home, dinner, look over a few notes, read a chapter or two, watch some tube, pass out at midnight

Second-year medical student:

6am: Wake up, get ready, +/-breakfast

8am: Arrive to campus in time for 8:30 lecture, sit in class until 11:30

11:30am: Read over notes, +/-lunch

1pm: Lab until 4 or 5pm

Evening: Arrive home, +/-dinner, look over a few notes, read up for next day, do boards questions, freak out about boards, do more questions, chat online with classmates about how mutually freaked out we are, pass out at 2am

First-year grad student:

7:30am: Wake up, get ready, eat breakfast

9am: Arrive to campus, +/-lab, +/-go to lecture at 10:30

11:30am: Lunch break, check on samples in lab

1pm: Lecture

3:30pm: Lab until evening

Evening: Arrive home, dinner, +/-read paper for discussion tomorrow, +/-look over notes, +/-read up on potential thesis topics, pass out at 10pm or earlier

Early second-year grad student:

7:30am: Wake up, get ready, eat breakfast

9am: Arrive to campus, check email, check blogs, check news, check websites

11:30am: Finish checking email, blogs, news, sites; recheck to make sure nothing new popped up during initial round of checking

12pm: Lunch break

3pm: Think about starting experiment or two; decline

3:30pm: Finish thinking about starting experiment or two; begin round two of internet time

Evening: Arrive home, dinner, +/-care about anything, +/-read up on potential experiments for thesis, +/-consciousness, pass out at 10pm or earlier

Late second-year grad student:

5:30am: Wake up, +/-shower, +/-breakfast

6:30am: Arrive to lab, start experiments immediately, freak out about how, at this pace, you’re never going to graduate

12pm: Continue experiments, +/-check email, freak out more

3pm: Continue experiments, totally flip out

6pm: Continue experiments, call fiancee to get reamed for not calling/being home earlier, freak out and/or flip out, sweat profusely

8pm: Arrive home, dinner, +/-think about experiments, +/-catch up with the outside world, +/-appear to have a normal life, +/-freak out

9:30pm: Go back to lab, freak out more

Midnight: Pass out

Socializing 101

Thomas Robey -- Consider this column a plea for help.

All across the Pacific Northwest, third year medical students are studying for exams this week. As with the season, winter clerkships have reached their finale. For students at my school (the University of Washington) there is another potential stressor: the weekend switch. As in many programs, students here carry out their required clerkships in different cities. Unlike other programs, those different cities could be separated by 2500 miles (Cheyenne, WY to Fairbanks, AK). Such periodic migration creates interesting challenges and presents unique opportunities. I want to focus on one of the challenges here.

Apart from my wife, the only folks I know where we’re heading next have bushy tails. (When we were in Spokane, WA earlier this year, some squirrels took to apprehending peanuts we put out for the birds.) But we won’t be without human colleagues in Spokane. There are a handful of other students in each city, but thanks to a rupture in my educational space-time continuum, I know R3s better than I know my classmates. Thankfully, medical students tend to be an outgoing lot -– it’s easy to get along, and someone is bound to have a “We made it to Missoula” get-together to build local community. So what’s my problem?

I’m worried that grad school converted me to an introvert! I have to admit, six months into the third year, I’m still getting used to this medical student thing. Life in the land of PCR machines, mouse colonies, and lab slumber parties completely deprived me of interactions with my kindred classmates. There were the occasional social events as my colleagues advanced, but as a committed lab-rat, I found myself increasingly distanced from the social aspects of medicine.

When folks consider re-immersing themselves in the medical curriculum after a year abroad or time doing research, it’s usually the factual content they expect to have lost. My worries were endless. Will I keep straight bactericidal and bacteriostatic effects? Nephrotic? Nephritic? The differential diagnosis for dyspnea? Surprisingly, these facts have emerged from the recesses of my mind without much consequence.

What has been slow on the draw for me is filling the gregarious shoes of the social medical student. Do you know what I am talking about? It’s that little circle that forms at open social events where amazing accounts of patient care are shared, frustrations with curriculum are vented, and future schemes are planned. Working long hours with hardly a chance to reflect makes these confluences of experience vital to students’ mental health. (It’s also a good way to practice a succinct presentation of your patients’ histories!) This part of medicine presents me with the steepest learning curve. I’m too easily flooded in sensory overload.

Has anyone else noticed this phenomenon and had difficulty breaking in to it? Sometimes we offer tips on The Differential. This time around, I’m looking for a few myself.

To Test or Not to Test: That Is the Question

Kendra -- Have you ever seen a doctor for a simple complaint and been subjected to a plethora of blood tests, scans, x-rays, urine screens and other investigations, only to be told that you had something obvious that could have been diagnosed without a single test being performed? Perhaps you were sent home with a prescription, or maybe you were just told to go home and see if the symptoms resolved on their own? Many people would feel relieved to know that their doctor ruled out every possible diagnosis with all the various tests. Some people might feel frustrated that they had to be poked and scanned so many times, only to be told that they just needed to wait and see if they felt better in a few days or weeks.

An article recently published in the New York Times touched on this very topic. The author describes how medical testing has been on the increase for a while. He suggests that because of reductions in Medicare payments and the decline of reimbursement rates, doctors have to subject patients to many unnecessary tests just to break even. In addition, many people demand that doctors perform as many tests as possible. There’s a perception that more tests equals a more thorough investigation, and a higher quality physician.

I think there is some truth to his argument, but I think the problem is multifactorial. The number of medical investigations that can be performed has increased substantially over the past few years, for many different reasons. Part of the problem, however, is that many of these tests don’t necessarily rule in or rule out any diagnoses. While I’m not arguing that these tests aren’t important, I’m just saying that they don’t always aid in diagnosing a patient or even lead to a treatment plan.

All of these tests come at a hefty price. According to the article, the overuse of healthcare services probably cost hundreds of billions of dollars last year. And the data suggest that this increase in services is not causing a concomitant increase in the quality of healthcare in the U.S.

The question of whether or not to pay for expensive medical testing was really drilled home with me during the past two months. I’ve been rotating at a hospital in Dominica with much fewer resources than U.S. hospitals. In addition, the average patient is not wealthy and does not have health insurance. Not long ago, I met an elderly gentleman with obvious signs of a stroke. Unfortunately, he could not afford a CT scan, nor an MRI, for which he’d have to be sent off island. We ended up doing the standard interventions with the assumption that he did in fact have a stroke. He ended up faring about as well as he would have if he had the proper diagnostic tests. Obviously, it might not have turned out this well. It’s possible that he could have needed a surgical intervention, but since we don’t have a neurosurgeon on the island, he wouldn’t have been able to get the surgery anyway.

I’ve been amazed at how well the hospital here runs, even with very little means. Patients still get a good quality of care. Of course there are exceptions, but many patients are successfully treated at very low costs. The clinicians at the hospital are all too aware of the deficits, but they use low-tech methods of good history taking and physical examination to diagnose patients.

Because of the current structure of the healthcare system in the States, I don’t predict that rising healthcare costs and the misuse of diagnostic testing will decrease any time soon. But I think that as doctors and future doctors, we should all do our best to not add to the problem. The next time a patient comes in and we consider performing a huge barrage of investigations, we should ask ourselves how much information we really stand to gain, and whether or not it will actually benefit the patient.

Top 10 Signs You're Spending Too Much Time in the Lab

Ben Ferguson -- 10. During dinner, your fiancee reflexively asks whether you’re going back again tonight.

9. You come across seemingly random numbers, but to you they are far from random: They are the number of amino acids in your protein of interest (987), or the first page number of the landmark paper you read (again) that morning ($4.02), or the recipe for your cells’ media (449,501).

8. You feel naked without your gloves on and generous amounts of alcohol sprayed all over them. Surely you’ll contaminate something.

7. You develop a giant blister on your thumb from too much pipette use—”pipette thumb.”

6. You’re so tired/distracted/sick of loading plate after plate that you can barely insert a multichannel pipette into a set of strip tubes without hitting the top, so you decide to get some coffee. An hour later, you’re so jittery that you can barely insert a multichannel pipette into a set of strip tubes without hitting the top, so you decide that “some coffee” probably shouldn’t mean three cups in a row in the future.

5. You don’t know how you could possibly get through loading another plate without listening to the latest "Wait Wait... Don’t Tell Me!" podcast.

4. You become genuinely miffed when your lab switches from one pipette brand to another, signaling that fact that your life revolves around the differences between little pieces of molded plastic (and is more or less over).

3. Finding a good spot to hide your stash of pipettes is probably the most excitement you’ve had all week.

2. You know the catalog number for 96-well plates by heart.

1. When you have some free time, you write a blog post about how much time you’ve been spending in lab.

Surgery and the Blowfish

Ben Bryner -- I like talking about medical school with people who are in different programs or careers. I like explaining what it is I want to do and what I’m studying, and I like hearing about what other people are into. But when people who are less familiar with medical training ask me how long my upcoming residency is going to be, the answer (seven years of general surgery residency including two years of research, followed by two more years of fellowship) often makes their eyes glaze over. And rightly so; it's a long haul. But it’s not like my law school friends are going to be taking the lead in litigating right out of law school. (At least I hope not.)

True, medical training is more formal and longer than that for any other gig I can think of. But in some ways it's hard to believe that that's all the time there is. Especially when you compare the length of surgery residency to things like the two-or-three-year apprenticeship required to serve fugu. (Fugu, the infamous pufferfish that carries the potent tetrodotoxin in most of its organs, is a delicacy in Japan; you can get it at a few elite, licensed restaurants in the States that, by law, must import it all through New York City.) It has to be prepared just so, with the right organs taken out and meticulous avoidance of contamination. If it's done right, you get a delicious meal. If not, you go into respiratory failure and die unless supportive measures are instituted in time (there is no antidote).

High stakes -- hence a two-or-three year training period capped by rigorous examinations. And that's just to learn one procedure, the proper disassembly of a fish. By the time a general surgery residency program graduates one if its trainees, it's certifying that the newly-minted surgeon can safely perform all kinds of procedures, in addition to management of patients before and after operating. The range of skills expected from a new surgeon, or internist, or pediatrician, is astounding even given the length of training.

I remember one time listening to an ER attending explain that although he learned a fair amount in residency, the time when he learned the most was when he was an attending for the first time. He had a lot more time to stop and think about what he was doing, for one, due to the nature of the ER as an attending. But it was also because the new responsibility was a strong motivator for learning, as well as a new perspective. He said he was also fortunate enough to have a good department chair who taught him a lot. This made an impression, since at that point I was pretty new in med school and hadn't really grasped the constant process of learning that is involved in clinical medicine. But it makes sense.

Medicine is so overwhelmingly complex and changes every day; unlike the anatomy of the blowfish, it can never be comprehensively mastered. This continuous growth leads to the large number of subspecialties required to adequately cover all the diagnostic and therapeutic angles of modern medicine, as well as the need for constant learning and teaching by one’s peers. To me, the prospect of continuous learning in a medical career is still exciting -- even more exciting than eating a potentially deadly piece of sashimi.

How to Survive Pimping in the OR

Anna Burkhead -- WARNING: Attempt at humor ahead … Abort your reading if you must…

I’ve written previously about “pimping”, the well-honed tool of many attendings to test students’ knowledge, and/or torture them. Now that I’m on my Surgery rotation, I’m spending more face time with attendings than on any other service. To what does this translate? Multiple un-interrupted hours of being pimped, each and every day in the OR.

For the most part, I don’t mind being pimped, because I know I’m not expected to know everything. Also, I rarely forget the answers to the questions I miss. Pimping can be a good teaching tool.

But some students detest being put “on the spot”. This is a column for these students.

How to survive being pimped in the OR:

-When asked a question, try your best to answer. When wrong, try a pensive silence. If you’re silent long enough, maybe the attending (engrossed in his gastrojejunostomy) will forget he ever asked the question.*

*May be effective only with older attendings.

-Answer a different question (correctly). Example: Attending – “What are the boundaries of dissection for a mastectomy?” Student – “Well, I don’t know, but if we were doing an axillary dissection, the borders would be…” You can still sound smart!

-Never forget that the student wields the suction. Stick the sucker-thing in a shallow pool of blood in the abdominal cavity, and it may create a gross sucking noise loud enough to drown out the nonsense answer that you know is wrong … but you may risk a blood spatter. Due to the risk of this OR foul, this should be your last resort.

-Answer with another question. This is probably the most “smooth” escape plan.

-Before the surgery, tell the attending that you’re hearing impaired. Explain that with masks on, you can’t lip-read.*

*This is probably a bad idea.

-Ask if you can “phone-a-friend”. Most attendings are ok with you passing the question to your intern or resident. Unfortunately you only get an average of two “phone-a-friend”s per surgery.

-Use humor. Example: Attending – “In what situation would one observe a ‘winged scapula’?” Student – “When the patient is in a bathing suit.”

When all else fails, and you know you’re going to be pimped during surgery the next day, here’s a novel idea: Study in advance! The best way to survive long pimping sessions in the OR is to be prepared and to impress with your knowledge. It’s not the easiest or the most fun way to make it through your Surgery rotation, but it is gratifying and it works!

Good luck to all :)

The Curious Similarities Between People and Cars

Ben Ferguson -- Ever since my car started having serious trouble early last year and eventually had to be sold (if you can call it that -- it netted $400), I have been particularly sentient of the comparisons that are commonly made between glorified mechanics doctors and actual mechanics, as well as between the things they deal with: the human body and cars.

Both doctors and mechanics are sometimes seen as sketchy people who don’t always tell the whole truth, don’t appear to tell the whole truth, or tell outright lies at times, whether it’s because of potential financial gains, laziness, coercion, etc. Sometimes both are downright unethical in the way they communicate and interact with their patients and customers. Both are in possession of knowledge that most lay people aren’t privy to, and this places them squarely in a position of power relative to those they serve, allowing them to manipulate many aspects of decision-making about a person’s body or car should they want to engage in such decision-making.

Quick: Think of the last time you went to get an oil change and the mechanic told you that your system needed to be flushed in order for your car to run properly, or that you needed a new air filter because your current one is “reducing your car’s performance,” or that your battery may have needed to be replaced -- would you like to take care of that today? I bit the first time I was told some of these things, and I’ve been told them many times since.

Think of the last time repairs to your car were quoted at, say, $400 and you ended up paying $600. “Whoops,” they say, “we didn’t anticipate that.” But you know they did. You know -- at least you strongly suspect -- they underquoted you so that you’d have the work done. If they hadn’t, perhaps you’d have shopped around a bit more. Things like that happen all of the time in probably every field of work, but both doctors and mechanics are in especially enabled positions to pull that kind of crap. Trust can diminish quickly, and this is especially true in light of this recent evidence.

We are all unfortunately familiar with the universal fact of life that our bodies and our cars are expensive to maintain. They break down and inevitably need service every so often. When money is tight, the question of whether to spend money on needed repairs sometimes comes up with both. If you’re a college or grad student living from loan check to loan check, do you really need to get a referral for that back pain, or can you live with it? Don’t you ponder your account balance before filling that antibiotic script? Do you even fill it period? Do you really need to see a doctor for that wart on your hand, or for the abdominal pain you’ve had for the past 6 hours, or for the headache you’ve had for the past few days? Do you really want to blow all your money going to the ER just to r/o meningitis every time you’ve got a stiff neck? Do you think twice, like I did a few days ago, about making that dermatology appointment for five minutes just to get a skin cream script if it’s going to cost you $234.93 every time?

When money is tight, these things don’t seem so dire. What’s more important is not going broke, eating, preserving your sanity, etc. even if you have to live with an imperfect body for a while. Similarly, do you really need to head over to the body shop every time you see a dent in your car? Can you live without air conditioning for the last few weeks in September? Does the rattling under your hood really annoy you, or can you live with that too? Honestly, who needs side mirrors and hubcaps and AC dials anyway? When money is tight, these problems don’t seem like problems; they seem more like everyday annoyances, and even if they do seem like problems, what are you going to do about it beyond blowing the last few dollars in your bank account?

When money is tight, I think many of us would stop and think twice about fixing ourselves and our cars at the drop of a hat. Some extreme things just don’t seem all that extreme anymore. Even with insurance, there’s not much motivation to seek health care or car servicing. Is it really worth it to you to pay $25 for a medication when $50 of it is already covered and you’ve only got a few hundred in the bank to cover you for the month? Perhaps, but usually no: You’re still out $25 whether it’s discounted or not. Do you whip out your wallet and fork over the extra $100 over your $500 deductible to fix the body damage to your car? Likely, no; you can live with a deformed car for now. Spending money like that seems at times like a luxury, not a necessity.

The value of ourselves and our cars must come to mind too. Would you put $1000 worth of repairs into a car that’s worth $10,000? How would that decision change if fixing it would cost you $5000? $500?

You’re 90 and you’ve lived a great, full life; how much time and energy and money and optimism do you want to invest in yourself when you’re not doing so hot in the first place? How would that change if this were your first hospital admission in the past 20 years? Your twentieth in the past two years? How would it change if you’ve been diagnosed with a terminal, metastatic cancer just after your 90th birthday? Diagnosed with pneumonia? Diagnosed with the flu?

And so, as the cautious and skeptical former owner of a crappy car that was in and out of shops before finally breaking down for good, and the owner of a sometimes crappy body that has weird stuff happen to it from time to time, I am now, more than ever, aware of how cautious and skeptical patients who’ve been in and out of hospitals for the past year must feel and how most of the underinsured and, more often, uninsured population around Hyde Park must feel. I used to think it strange that some people with serious medical problems simply don’t seek care, but now I realize that “serious” becomes a seriously relative term depending on your life situation.

If Life Was A Circus, Medical Students Would Be (Commitment) Jugglers

Aaron Singh -- It never ceases to amaze me how medical students can have so many commitments on their plates and yet manage to do everything at once. Sure, I’m studying at Cambridge University, ostensibly home to some of the world’s most intelligent students (a demographic I am sadly not part of myself, having gained admission due to my unusually attractive eyelashes -- but that’s a story for another day) but still. The number of times I’ve met medics who manage to balance other pastimes and yet still score high marks contributes more to my hair loss than my barber does.

I’ve blogged before about medics who realised that their true passions lay somewhere else, and became big names in those other fields. But now I’ve discovered a whole new subspecies of medic: those who excel in sports, music, theatre, literature, etc. and yet still manage to score highly in medical exams. These people seem to be able to maintain (and in some infuriating cases, combine) their different passions and juggle the time needed to pursue these seemingly incongruous pursuits, yet still show up for lectures on time with all their homework done and not a hair out of place. I swear these folks must have a personal secretary, private helicopter pilot, and make-up artist hidden away somewhere.

Unfortunately, multitasking is as alien to me as talking is to a dog, thanks in no small part to an incident during my childhood involving me being born, a doctor’s slippery gloves, and a rather unfortunate collision between my infant head and the operating room floor. But as I’ve said before, medical school is somewhere you’d expect to find smart people who have been multitasking all their lives, and as much as I may sit and gripe about them, there exists a certain pressure to be just like them, to do more with my life and my time here at university. So I suppose meeting people like this is good for you from time to time, as it drives you and shows you just how much you could accomplish yourself if you just got off your bum, turned off that episode of ‘House’ and actually did some revision. (Metaphors not from personal experience. Cough.)

Take some time to look at yourself and ask: what type of multitasker are YOU? Are you Everywhere-At-Once-Dude, bending the laws of physics to do everything and be everything at the same time, thereby creating hundreds of jealous would-be assassins with your every success? Are you Slide-Projector-Dude, focusing on only one thing at a time but giving that one thing your all? Or are you Aaron Singh Hopeless-Ritalin-Overdosed-Mess, trying your best to do several things at once but inevitably ending up on the floor with all your juggling balls around you?

If you answered Types 1 or 2, good for you; we know why you’re in medicine, and you’ll probably make it big. If you answered Type 3, hey, wanna form a club?

The Politics of Health Care

Thomas Robey -- Blogging and politics are inexorably linked in today’s media. Bloggers whose core topics are news, health, sports, science, religion and celebrities invariably offer commentary on political issues. The Differential is at its core a blog for and about medical student life, and if you’re at an American medical school, you’ll be hard-pressed to avoid conversations about presidential politics. As a member of the medical profession, you may be called upon to offer opinions about the remaining candidates’ health care plans. Having already been asked by family, friends and fellow precinct caucus-goers which plan is best for America, I’ve done some homework on the competing proposals. Like any good medical student, I am happy to share my study guide with you here. Each of McCain's, Clinton's and Obama's plans have good ideas built into them. This post is my attempt in 700 words to provide a starting point for you to understand them. You don’t have to pick a candidate based on health plans, but considering health will be your business, health care is probably not a bad place to start. This is a ‘just-the-facts’ post. For my opinions about the candidates’ plans, you’ll have to head elsewhere.

Like just about every other issue in the 2008 campaign, there are two health plans that are more similar to each other than each is to the third. For simplicity’s sake, I’ll start with the third. John McCain’s experience as a legislator has shaped his approach to reforming health care in a way that avoids “the ‘perfect storm’ of problems that will cause our health care system to implode.” The main elements of his plan include (1) changing the way plans are purchased, (2) increasing the accessibility and use of generic drugs, (3) innovating new forms of health care delivery and (4) altering Medicare to cover more preventative care and to punish medical errors. The McCain plan leans heavily on point #1. The argument being that current health care coverage is dominated by employer-negotiated contracts and employees given more options and flexibility will force the industry to lower prices. Via tax code changes and other incentives, McCain would permit individuals to buy insurance on a national market and through groups like churches, professional associations and co-ops. His ideas for health care delivery center on a network of walk-in clinics tied together (eventually) with an electronic medical record. This is an attempt to reduce expenses incurred from costly ER visits.

When it comes to the remaining Democrats’ plans, it’s more difficult to parse the differences than to identify similarities. Let’s first consider the similarities. In TV and radio ads, both have claimed to cover all Americans. Because insurance companies still provide the bulk of reimbursement mechanisms, neither plan is fully universal health care. Both plans require insurers to offer coverage no matter the individual’s medical history. Both also allow consumers the option of purchasing government-offered insurance. Finally, both plans seek (via government subsidy) to make insurance affordable to poor Americans. The differences come down to the mandates: Clinton would require every American to be insured either by a public or a private plan, while Obama’s plan only requires children to be insured. In his plan, anyone may opt-out of insurance. He suggests that a more competitive industry faced with cheap government options will lead everyone to buy in. Some health economists have argued otherwise. Clinton would limit insurance costs to a percentage of family income, while Obama would disperse subsidies to income-qualified individuals to help pay their premiums. The main discussion surrounding these plans is how to pay for it and who is covered. Obama addresses more aspects of the practice of medicine by emphasizing a broader implementation of the electronic medical record and rewarding practitioners who keep quality of care high and costs low. Clinton also features cost-saving technologies, but speaks more of targeting insurance company excess than any incentives or punishments for health care practitioners. Interestingly, both plans have adopted elements from the no-longer-running candidate, John Edwards.

In the end, it seems like all three of the candidates are committed to improving the current American health care system. The Democrats argue for a more comprehensive overhaul than McCain, but each plan has pros and cons. As the 2008 contest for the White House intensifies, I expect health care will be argued more and more between the remaining candidates.

Will you be prepared to debate the future of medicine?

Some Good Advice

Ben Ferguson -- I generally have trouble talking about myself, especially in social situations where there are a lot of people I’ve never met. I say a few words and then don’t really feel like talking too much. I’ve often been told that I’m hard to get to know, that I have a wall up around me that’s hard to crack. (Granted, I say this as I’m writing about myself publicly in a weblog.) Regardless, I got some good advice from my mom several months ago when a bunch of family members were in town for a reunion.

She said, after noticing that I was starting to get pretty uncomfortable with the rapid-fire questions about what medical school is like, what I want to go into, whether I’m going to be a surgeon like my dad, whether I’m going to be an anesthesiologist like my mom, what my thoughts are regarding why they never started a surgical practice together, why I’m doing a PhD, how long it’s going to take, how much longer I have in school, what this thing on their foot is, why their fingers are so cold and whether they’re going to die from it and/or have cancer and/or should have it looked at, etc., “Ben, you have one of the most fascinating jobs on the planet. People are going to ask you about it every time they see you because they largely have boring jobs that they hate. You need to learn how to deflect the conversation to them: Ask them what they do, ask them how their job is going, ask them questions about them. Otherwise you’re going to go crazy with all the questions about you you you.”

The more I thought about it, it’s true, and it’s especially true with members of my extended family, who for the most part can and will talk and smother you until you sometimes want to take a bat to their head. Or your own. It figures that once the convo is placed squarely on them, they’d roll with it and back off of me so I can get a breather once in a while.

My dad also had some good advice for me a few years ago, something a mentor of his told him while he was a medical student, and it’s particularly timely for me given that I’m starting to put together some publications in the lab. It was regarding how one goes about writing journal articles: “First, you tell ‘em what you’re gonna tell ‘em, then you tell ‘em, then you tell ‘em what you just told ‘em.”

Great! If only it were that easy.

Recipe To Destroy A Medical Student's Will To Live

Aaron Singh -- Easy peasy. Step 1: Get said medical student's laptop to die, preferably under mysterious circumstances and without warning (bonus points if you can squeeze in one of those head-poundingly irritating “illegal operation” error messages). Step 2: Make popcorn. Step 3: Watch, laugh, and eat popcorn as said medic goes crazy and bounces from one IT department to another like a pinball flicked by Mike Tyson.

I know it sounds weird, but anyone who's ever lost a laptop will know exactly what I mean. It's like having a part of your life ripped out of you, dangled tantalisingly in front of you whilst you jump through hoops to get it back, then pulled away just as you make a final leap for it only to fall flat on your face to the sound of canned laughter. (What's that you say? If you have to read any more of my metaphors YOU'LL lose your will to live? Okay, okay. Sheesh.)

Seriously though, just like in many other places, laptops become indispensable in med school. Remember Kendra's old post about having her notes stolen and literally combing the entire town for them in a panicked frenzy? Well, my notes are on my laptop, along with my dissertation drafts, my 'Productive Mode' study music (hey, I'm terminally lazy, okay? don't judge me) and three years' worth of photographic memories. But one day it just goes on the blink without explanation, and I spend the next few days shuttling it between the College and University IT departments with enough desperate efficiency to get a job at FedEx. To cut a long story short, in the end my laptop came back to me with its hard drive wiped and no explanation of what went wrong (sneaky buggers, these laptops). Fortunately for me, I had all my essential data backed up, but a week without my laptop made me realise just how dependent I am on this thing.

Lesson learnt: back up anything important. And for heaven's sake, buy a Mac if you can afford it.

Blunted Empathy

Ben Bryner -- The title of a recent article in Academic Medicine asked, "Is There Hardening of the Heart in Medical School?" I initially thought, "I don’t know about the heart, but my arteries have sure hardened in med school from all that free pizza! Ha ha!" Then I realized I was being lame, so I just read the rest of the article. Basically, the investigators tracked medical students at one U.S. med school to see how their level of empathy changed over the course of their medical education (as measured by a standardized questionnaire). The conclusion is that each year in medical school is associated with a drop in empathy (with a differential impact by gender and specialty choice).

This is all fine; I’m sure that empathy (as measured by a questionnaire that includes items like "Unhappy movie endings haunt me for hours afterward") does indeed decline during med school. There are some easy explanations for this: sleep deprivation, outlandish debt burdens, and scut work probably don’t build empathy. But I think this study is giving people the wrong idea. When people read this paper, they dream up a first-year medical student getting her class schedule for the initial week of med school: Insensitivity 101, Seminars in Detachment, lunch, then an introductory hands-on workshop on ignoring patients. Of course, this isn’t true… these are all upper-level classes for M3s.

No, I’m kidding. The authors blame the old standby, the "hidden curriculum," or the unspoken transmission of (sometimes anti-humanistic) sentiment from faculty to residents to students in the course of daily work in the hospital. I don’t dispute this; a huge percentage of the total knowledge imparted in medical school is done in this way. My disagreement is with the word "curriculum," which makes it sound like all of this anti-humanistic sentiment is planned out meticulously. Which is not true -– as you bounce around from rotation to rotation in the clinical years, it seems like the real curriculum is barely planned.

The reason students are receiving this implicit teaching and becoming disillusioned during the clinical years is because they’re being introduced to a flawed medical system. Since medical school is the only way into this system, that’s where you see this disillusionment. First-year students are fresh from the application process, where they feel like their lives depend on how well they’re able to proclaim their selfless desire to help people. I think most students genuinely have that desire, but it’s a lot easier to express that desire in application statements before you have any idea about what system exists to help you carry out that goal.

The transition from second- to third-year student, as the director of our clinical years told us, is the biggest transition of our career. Moving to the clinical years is a major adjustment, like moving from a light appetizer on to the main course. Sure, you get a huge helping of responsibility and a big scoop of extra work when you become an intern, but you’re still eating the same kind of meal. (I think dessert might be retirement.) Many students realize when they hit the wards that the health care system is far different from what they imagined. And these are the students who often have the hardest time picking a specialty or even staying in clinical medicine. So with that kind of change going on, it’s natural for personal traits like empathy or anything else to change -- but it's not because medical school is structured to do that.

I completely agree with many of the claims in the paper. For example, the gap between the ideals presented formally in the white coat ceremony and the practical realities of day-to-day medicine are very disheartening to medical students. Little kids, let alone med students, are smart enough to know when something they’re being taught doesn’t line up with what they’re experiencing. Case in point: this article starts out talking about empathy in very high-minded terms in the abstract, but what does it say in the second paragraph of the main text? "Empathy is one of the most highly desirable professional traits that medical education should promote, because empathic communication skills promote patient satisfaction and adherence to treatment plans while decreasing the likelihood of malpractice suits." Oh, so that’s the real reason you want me to be more empathic. Now that’s cynical, and that’s exactly the kind of obvious disconnect between rhetoric and where the actual importance is placed that is so disillusioning to students.

The authors state that "Although a hardening of the heart may aid physicians coping with patients on a daily basis, this runs counter to the patient’s need for an empathic caregiver." This, I think, frames the problem in the wrong way. A huge part of the frustration I see stems not from difficult patients but from not being able to help the good ones. Sure, every primary care doctor has that group of Cluster B patients that absolutely drives them crazy. But what really undermines your faith in what you’re doing with your life is when you can’t help someone because of the system you operate in -- not, as this paper suggests, trivial things like hearing faculty place importance on how much research money the hospital receives.

Still, I applaud the authors for realistically describing the overall impact of the interventions designed to increase humanistic qualities during the first two years of medical school: they don’t make much difference. It doesn’t matter how good these programs are; they can’t do that much to shape you for the massive changes of the clinical years, any more than a pair of water wings can prepare you for a trip over Niagara Falls in a barrel.

Let me sum up: I love medicine, and I like medical school. I think I’m reasonably empathetic, and I’m fine with spending time on the humanities in the preclinical years, because it’s a nice break and helps you talk about ideas like a normal person. We should just be honest with ourselves that that’s all we’re doing. And we should talk about the importance of humanism in the preclinical years, but if we want to do more than talk about it, we need to make some much larger changes.

The Operating Theatre Performance

Kendra Campbell -- I’ve spent the past two weeks rotating in anesthesiology, which means I’ve basically put in a lot of hours in the operating room (or theatre, as it’s called here). In just two short weeks I feel like I’ve come a long way. When I first started, I barely knew the right way to put on my mask or sterile gloves, and now I understand most of the rules (both unwritten and otherwise) in the OR. I can hold the oxygen mask properly, start IV lines, and I even intubated my first patient the other day! I haven’t yet scrubbed in for a surgery, since I am with the anesthesiologist, but I know that I’ll be doing that in the near future.

At this point, I’ve only seen 20-30 surgeries, so I know that I am still “green,” but I have enough knowledge to at least avoid getting yelled at by the nurses and surgeons, and I can even help out every once in a while.

The doctors and nurses that I’ve seen working in the OR absolutely amaze me. They handle patients so efficiently that it’s obvious that most of them have been in this business for years. In fact, they are so good at their routines that they sometimes forget to explain their procedures to us ignorant med students.

I think the relationship between the surgeon and the surgical nurse assistant is the most fascinating. The nurse has seen enough surgeries that he or she knows exactly which instrument the surgeon needs at any moment. I realized during a surgery the other day that the surgeon rarely had to request an instrument. Rather, the nurse had it prepared and waiting for him before he even asked. Some of the nurses even know the details and personal preferences of each surgeon, and take that into account when assisting.

During a surgery, there is a wonderful ballet between the anesthesiologist, surgeons, nurses, and techs. When you add the sound of the beeping heart monitor, the ventilator, and all the other various background noises, it really does create a scene reminiscent of a spectacular performance. And as with any good show, the actors and actresses are all dressed in elaborate and purposeful costumes. Perhaps the United States has it wrong in calling it merely a room. It seems that it is much more similar to a theatre.

Watching the surgeon skillfully slice, clamp and suture reminds me of cheironomy, or the process of using hand gestures to indicate melodic shape. This process was used beginning all the way back in the Middle Ages, but has since mutated into the modern conducting baton, which is used more to keep the beat of an orchestra. And similar to a conductor, the surgeon’s hands, scalpel, and needle provide the beat for the entire operating theatre.

(The picture is of my friend and me preparing to head into the operating theatre.)

What Makes a Bad Medical Student?

Anna Burkhead -- Residents on “core” services such as Internal Medicine, Surgery, and OB/GYN work with a lot of medical students. Since their schedules don’t always entirely line up with students’ schedules, they may work with a new student as often as every 1-2 weeks, or as long as a month, for every year of their residency.

That’s a lot of medical students! And as much as I would like to believe that all of the students are stellar in knowledge, dedication, and attitude, I know it is not true.

I would venture to guess that most of the medical students reading this entry have been told by a resident or attending at some point that they are “good” students, or that their work has been “excellent”, or their write-ups “outstanding”. It’s easy to praise someone to their face. It’s not as easy to tell them they’re doing a bad job. Therefore, if you’re a “bad” medical student, you may not know it until you get your evaluations back. And at that point, it’s too late to change.

(At this point you may be asking yourself, “If I’ve never received any true positive feedback face-to-face, does that mean the residents have only negative feedback for me, and that I’m a ‘bad’ medical student?” Hmmmm….)

I’ve asked a few residents to give me a few tips, and I’ve compiled a list of things that make a medical student “bad”:

-#1 overall = BAD ATTITUDE. If you balk when your intern asks you to write the note on your patient for that day, or if you repeatedly say no to scrubbing in on late afternoon OR cases, you may be a bad medical student.

-Disappearing for extended periods, multiple times per day, to read or nap or goof around. I’m not saying you need to be married to your team, but make them aware you’re available and willing to help.

-Not appearing interested. Even if you detest surgery, or if you’d rather poke yourself with a MRSA-flavored fork than interview a manic patient, try to make a conscious effort to look engrossed. This may be as simple as altering your resting facial expression.

-Correcting your resident on rounds, or its extreme variant, “The Reverse Pimp”. Some medical students get so bent out of shape over being asked difficult “pimp” questions that they decide to try the “taste of your own medicine” routine. If you ask your resident or attending a question that is fact-based, a picky detail, or something that you’d find in a long paragraph of your basic science book, and you don’t ask it in a curious “I’m asking because I don’t know” manner, you may be a Reverse Pimper. Steer clear.

The above are just a few characteristics of “bad” medical students; there are countless others. Take a glance at the column “How May I Help You?” and think of the opposite.

My last point is this: even if you’re not the smartest 3rd year ever to don a short white coat, never fear. Not knowing answers does not make you a bad medical student. Attitude and work ethic count for a lot!

(Disclaimer: In no way am I claiming to be the polar opposite of a “bad” medical student, that is, a “perfect” medical student. Just sharing observations and solicited advice :) )

Game, Set, and Match

Ben Ferguson -- Match Day is upon us. On Thursday, March 20, thousands of medical students and recent graduates will find out where they’ll be spending the next several years of their lives in training. Some will have their prayers answered, some their hearts broken.

I literally would not be more excited or antsy if I were going through it myself, but I am not. My original classmates, those of the graduating class of 2008, are. These are people that I’ve known for four years and who have become some of my best friends. They are people that, at least for two years, went through the grind of medical school with me, took naps with me, helped me, taught me, and understood me. They, like me, began as lambs naive to medicine and have now emerged from the wards speaking a completely different language, one that feels so far removed from our pathophysiology and clinical skills courses that ended just a few years ago.

I remember an encounter I had with a former classmate shortly after we parted ways and I started grad school. “What are you on these days?” I asked -- that’s all anyone asks who’s trying to catch up with old colleagues. “Gens, Q4. Not too bad. After this it’s smooth sailing until winter,” he said. I nodded in acknowledgement as if I knew what the hell he was talking about. He had a partial beard and was wearing mismatched scrubs; I couldn’t even begin to tell you whether he was on a rough surgical service or had a few too many medicine patients, and I didn’t ask.

I see other former classmates randomly, walking down the street in Chicago, or at a street market, or reading books as they hustle through the bowels of the hospital (here, they truly are bowels, ones that have just been emptied in preparation for colonoscopy, perhaps), or running by the lake, or darting onto AIM for a quick semblance of a social life, or during pickup poker games during which everyone drinks Capri Suns in place of perhaps more exotic beverages because they need to be up at 4am to make grand rounds the following morning. They all look the same, not the same as before but the same as each other. They are unexpectedly awake, and they are unexpectedly alive. The ones on surgery don’t look any different from the ones on family medicine or on psychiatry, save for slight changes in facial hair upkeep. They largely do the same things outside of the hospital as they always have, albeit in less quantity. They are fighting to stay alive and to become doctors, and they are doing fantastically.

Fantastically enough, even, that in less than a week, they too will experience that rush of emotion that dozens of classes before them have felt, emotion that will fill an entire auditorium palpably as if surrounded by a thick, saline-filled ether. It’s truly one of the most incredible experiences I have in a given year, but this year will be even more special. I know them. I have listened to their dreams and watched them -- the dreams and the dreamers -- take shape and morph and evolve. I cannot wait until I too have that opportunity. But, for now, I’ll settle for getting as close as I can to theirs.

The Difference Between Medical School And Graduate School

Ben Ferguson -- Everyone always argues over whether graduate school or medical school is harder, or more difficult, or more tiresome. Everyone. If you’re not currently arguing over it at this very moment, you’re totally missing out.

Some say the former is far, far tougher; it comes in like a lamb, has its lion phases here and there, and then exits more or less like a lamb again depending on the niceness of one’s thesis committee and the degree of copying-and-pasting of one’s previous journal articles. Some feel that the latter, by its sheer time and physical demands and by its ubiquitous emotional toll, is far, far tougher; then they become interns and laugh it off. Some say that each is difficult in its own right, that each is physically and intellectually demanding in ways and over time periods different from the other.

Regardless of which is actually harder (for the record, at this point in my career, they’re about equal in my book), there are most definitely some black-and-white differences between the two:

1. Each has schedules to follow and places to be. It’s just that in medical school, you’re expected to be somewhere at a certain time of the day, but in graduate school, you’re expected to be somewhere at a certain time of the decade.

2. No one cares what you look like in graduate school. No one cares when you arrive, or how much progress you make, or how inattentive you are toward others, so long as you get your work done in a reasonable amount of time. (This all goes out the window when your advisor walks in.) In medical school, your appearance matters very much, both to attendings and to patients. You must arrive on time, make strides in making patients feel better (or at least act like you’re trying), and always be cordial to them.

3. The “DOOR CLOSE” buttons in hospital elevators actually work. In other educational buildings, not so much. (Isn’t it fascinating, though, that we always try? Apparently the variable ratio reinforcement is too engrained in us to ignore.)

4. In graduate school, you worry about the lives of worms and mice and rats and immortalized microscopic fragments of tissues that were intact decades ago. In medical school, you worry about the lives of humans, which is slightly more stressful.

5. Neither medical students nor graduate students are particularly well-versed in dressing well. They may even be known for their inability to dress well, or to even dress appropriately for the conditions or given situation at all. In this department though, medical students totally dominate. Graduate students are completely hopeless for the most part, but that’s okay because no one ever sees them anyway. (I’m not in any way excluding myself from this group, either.) Note to future graduate students (and future medical students for that matter): Black pants + black shoes + white, pilly, holey socks (+/- publication(s) +/- international awards +/- bubbly personality) = immediate rejection. Write it in your lab notebook so you don’t forget it.

6. In graduate school, you often spend entire days transferring liquid from one tube to another, perhaps after waiting for the liquid to thaw, and then adding some other liquid(s) to the tube, and then adding the mix to some other receptacle. If you’re lucky, you get to invert it several times, or if you hit the jackpot, you pipette up and down. Your life is liquids, receptacles, and vectors to get the first into the second. Amazingly, the final outcome of this fails more often than not, and you must redo everything several times. In medical school, depending on the service, you often spend entire days transferring liquids from vials to patients, removing pooled liquids from patients, observing liquids (and solids...ooh!) that patients excrete, measuring pressures of liquids, and writing stuff down about all of them.

7. The most common question you’re asked as a medical student, by far, is, “What are you going to go into?” (I have no idea.) The most common question you’re asked as a graduate student, by far, is, “When are you going to be done?” (Never?) or, if you’re also a medical student, “What were you thinking?” (At times, I wonder that myself.)

One Book, PRN

Thomas Robey -- Do you remember your favorite childhood book? Was it a chapter book that you read on your own? Or the picture book you insisted a parent read to you every night? Perhaps, like me, it was the Si-Sz volume of the 1984 World Book Encyclopedia? If you have fond memories of books, you probably grew up in a book-rich environment. Consider this tidbit: in middle-income neighborhoods, the ratio of books per child is 13 to 1; in low-income neighborhoods, the ratio is 1 age-appropriate book for every 300 children. And it turns out the only behavioral measure correlating significantly with reading scores is the number of books in the home.

What does this all have to do with being a medical student? I learned from an insightful pediatrician that the top five ways to prepare kids for long, productive and meaningful lives are: love them, keep them safe, feed them well, keep them healthy, and teach them to read. You may think that pediatricians focus only on the “keep them healthy” task, but after a couple dozen well-child checks, the third-year student will be able to ask parents about family life, smoke detectors, car seats, diet, and developmental milestones as readily as checking on the immunizations, recent illnesses and vital signs. Is encouraging reading habits on your list? Parents who were not read to as children may not realize the value of reading to their own kids. As a result, children from low-income families enter school at a disadvantage. Adults who were read to as children tend to assume all children are read to. What category do you think most doctors fall into?

Last fall, I had the pleasure of spending half of my pediatrics clerkship at the Odessa Brown Children’s Clinic, an outpatient clinic associated with Seattle’s Children’s Hospital. Apart from the opportunity to learn pediatrics from an enthusiastic team of docs and nurse practitioners, I was privileged to help care for kids from widely varied social, economic and racial backgrounds. I learned first-hand about sickle-cell disease, asthma and juvenile obesity, along with colds, rashes and ear infections. It was the problem of illiteracy that surprised me. When money is tight, books are a luxury. Fortunately kid’s health care isn’t yet a benefit for the rich. Thanks to the State Children’s Health Insurance Program (by the way, the Federal bill that’s the backbone for SCHIP has been vetoed twice this year), most kids from poor families are eligible for free or inexpensive health care. Our society values kids’ health. (Insert toothpaste commercial voice here: “Studies show that ten out of ten pediatricians want their patients to succeed in life.”) This is where health and literacy converge. Why not give a book to every child at every doctor’s visit?

This is not a new idea. A national organization called Reach Out and Read provides funding to give kids who are six months to five years old a new age-appropriate book at every well-child visit. Some clinics raise funds to expand the age range and number of books given per year. Taking kids back to the book pharmacy to select their reward was a favorite part of the patient encounter for me. Thousands of Seattle children have Odessa Brown libraries in their homes where previously there wouldn’t have been a book in sight. By providing books to a population of kids who may not otherwise have exposure to reading, doctors can do as much for kids' futures as giving shots and antibiotics. If you end up in pediatrics, consider prescribing one book, PRN ad lib for all of your patients.

(Federal legislation to help sponsor programs like Reach Out and Read is included in HR 4449 and S 1895. Check out the legislation and let your representatives know if you support it. Special thanks to Hillary Chisholm who directed me to much of the data presented in this post. Statistics collected from studies were presented in the Handbook of Early Literacy Research, Vol. 2, edited by Susan Neuman and David Dickinson.)

More Tips for Pediatrics

Ben Bryner -- After writing my last post on tips for the pediatrics rotation, I thought of several more (which I've trimmed down to the ones here). I realize it might seem like I'm overdoing it, but I cannot overstate how different the pediatric wards are from the rest of the hospital. There’s no other rotation where I would have been berated for referring to an attending by her last name instead of her first, but then praised for making faces at my patients on rounds. So I’ll make one more attempt to ease the transition, again with advanced-level tips for the gunners out there.

4. Wear something or have something attached to your clothes to distract the patient. Most everyone in pediatrics has some kind of distracting item on at all times; a goofy holder for their ID card, a sticker or a funny pin, or maybe a necktie with some kind of small animal print on it. Keep it under control; I’m not saying you should wear a propeller beanie or anything. And we’ve all seen people with so much “flair” that it looks ridiculous. For example, I was given a monkey-shaped stethoscope cozy, but I am a little too embarrassed to wear it lest I see… well, anybody. Still, it often comes in handy to have something entertaining for the kid to focus on that takes away from the scariness of your official outfit, whatever it happens to be. This is especially important if you’re wearing your white coat (which many pediatricians don’t wear, but as a student that decision is usually not yours to make).

- Gunner tip: Go all-out and buy a pediatric stethoscope.

5. Don’t call your patients’ parents “Mom” or “Dad.” (Unless the patient is your brother or sister.) When one of my kids needs medical attention, the worst part is seeing my child sick and uncomfortable. But the second worst part is being called “Dad” by some nurse, medical assistant, or doctor. I hate it. I’m not their dad (I’m usually younger than them), so it doesn’t make any sense. More importantly, it always comes across as condescending. Don’t get me wrong, I understand these people are busy. I don’t expect people to look up my name, and I understand that you can’t assume what the parents’ last names will be based on the kids’. And I understand that there’s not always time to ask what I’d like to be called. If I ever don’t know a parent’s name I always go with “ma’am” or “sir,” not because I’m a formal person but because I’d rather be called “sir” or “hey, you” or “yo, idiot” than be called Dad by someone who’s older than me. So don’t do it. As a student you’ll always have plenty of time to look the name up or, better, ask them what they go by.

- Gunner tip: Trust me, gunners, you can take one second away from that peds shelf exam practice book to get the parents’ names right. Even if you’re not motivated enough to learn names because it’s polite, do it because your residents and attendings are usually impressed when they can tell that you know the parents well.

6. Watch your language. By that I don’t mean that you shouldn’t curse in front of the kids (although you shouldn’t), but that you need to tailor your way of speaking, tone, and vocabulary to the age of the child you’re seeing. This is important in the outpatient clinic, where you have a very brief amount of time to build trust (unlike the hospital where the patient is more of a captive audience). If you’re trying to guess a kid’s age, make sure you err on the high side. Make sure you’re using words he understands, but without sounding condescending. Talk about things you’d guess she would be interested in, but without sounding judgmental or using gender stereotypes. Basically what you’re trying to prove to your patient, his or her parent, and your attending is that you’re reasonable and trustworthy enough to keep being involved in the patient’s care. You can do this by playing peek-a-boo with babies, talking about sports or movies with older kids, etc. The bright side is that this trust-building is a lot more straightforward with kids. If there’s a trust-building equivalent of peek-a-boo for ex-Marines at the VA, I’m not sure what it is.

And a special bonus gunner tip:

-Try to work the phrase “Children Are Not Just Small Adults” (the most overused phrase you’ll hear on this rotation and part of the title of almost every presentation you’ll see), into every conversation you have with an attending.

Best of luck!

Can Med Students Save the World?

Kendra Campbell -- I am a total sucker in many ways. I can’t count the number of wounded squirrels, rabbits, mice, deer and other animals that I’ve brought home in the past. When I see an animal in need, I lose all sensibility, and immediately pick it up, bring it home, and figure out the best way to care for it.

This certainly became a problem for me when I moved to Dominica. There is an abundance of neglected, homeless and abused animals everywhere you look. Within days of moving here, I found what I thought were two homeless dogs, brought them home, cleaned them up, and gave them plenty of food and water. Then came the puppy phase. For about a year, my apartment served as a makeshift puppy shelter/rehabilitation center. I’d bring home puppies and de-worm, de-flea, de-tick, and rehydrate them. After they were overwhelmed with food and love, I’d put a collar on them and try to find them a good home. I even ended up keeping three of them for myself. (Unfortunately, one passed away.)

Eventually, however, I became somewhat overwhelmed by the shear number of animals that needed care. It was simply more than I could handle by myself, and I realized that I was barely making a dent in the problem. So, I stopped taking in the strays and just focused all my attention on my two puppies. Now, when I see a homeless or neglected animal, my heart still goes out to them, but not in the same way it did in the beginning. I think I’ve become somewhat desensitized to them. Has the harsh reality set in? Has my empathy been pounded out of me, leaving only apathy behind?

In many ways, my transformation reminds me of the one that many med students go through. In their pre-med and first two years of med school, they want to save the world. When they first start seeing patients, they have the utmost empathy for them and go out of their way to care for and help them. Then the reality of the overwhelming number of people in need sets in. Not only that, but they begin to realize that in many cases, people can’t be saved. Patients don’t listen. The healthcare system fails them. It all becomes an exercise in futility. The process reminds me of Martin Seligman's famous experiments on learned helplessness. The dogs in the experiments eventually learned that they couldn’t escape the electric shocks and hence gave up. Med students eventually learn that they can’t save the world, and in a way, they learn to give up trying to save everyone.

In a study recently published in the journal Academic Medicine, researchers found that undergraduate medical education does in fact reduce vicarious empathy in medical students. So, there is some proof that the medical education process is not always promoting empathy and compassion. Ironically, the schooling process seems to have a deleterious effect on a med student’s ability to care.

I can tell that I have yet to have all the empathy sucked out of me. The other day at the hospital, I met a 1-month old baby whose mother had left him at the hospital. The staff had been unable to contact any of the mother’s relatives, and there are no orphanages in Dominica. So, the baby will remain in the hospital until a home is found. Of course, I reflexively wanted to take the baby home with me and care for it. Seconds later, reality sunk in, and I knew that I couldn’t handle the responsibility. But there is still a part of me that wants to run back, grab the baby, and take him home with me.

We see many patients who can’t afford to have necessary surgeries performed. Every time I meet a patient in this predicament, I want to write them a check from my own bank account for the surgery. Of course, I quickly realize that I’d eventually run out of money, so I don’t.

So, while I know that I can’t help everyone in the world, I still have the instinctual response to try. And every once in a while, I am actually able to help a person or two. I don’t think it’s wrong to have those kinds of feelings. I think the problem will come the day I stop trying to save the world.

Could It Be?

Anna Burkhead -- What is third year doing to us?? A few days ago, my third year class had our required meeting to plan for fourth year. Scary, right? Besides nearly making everyone’s incidental aneurysms burst from stress about schedules, away rotations, and residency applications, this meeting is generally dreaded for another reason.

My Class of 2009, I love you all, but we are a little ridiculous sometimes.

We had a similar meeting about a year ago to plan for third year. Also included in this meeting was information about registering and studying for Step 1. At this time last year, our “ridiculousness” as a class was evident in full force. People asked the exact same questions, phrased differently, over and over. Other people groaned out loud when this happened. Gunners asked questions that weren’t applicable to our class for another 12 months (personally, I still think some of them do it on purpose to freak the rest of us out). My “favorite” type of question is the one asked by an individual medical student on a situation that applies only to that person, and to no one else. Then the rest of us are stuck listening for five minutes to a solution to a problem we will never have. Ask these questions later people!!

The paragraph above is a description of the meeting in 2007. This year, things were different, thankfully and shockingly so.

We arrived on time (mostly). We were dressed appropriately to meet with faculty from our desired specialties (with a few exceptions). We (more often than not) avoided question re-asking. (Almost) no one wanted to know what to do about their individual research project that will be presented in August which is the month they wanted to do their away rotation in Surgery but not with Dr. XYZ because he’s mean but they like Dr. ABC and would like to get a letter of recommendation from him and who can they call to set that up?

What has third year done to us? Is it possible that the petty students we were last year are morphing into mature professionals?

In fourteen months will we be ready to be called “doctor”?

I think we are on our way.