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Coming Out of the Closet

Thomasrobey72x721Thomas Robey -- "I’m going into emergency medicine."

There! I said it.

I’ve been surprised throughout my third year by how clannish the practitioners of medicine are. I don’t mean the useful divisions of "You treat the hypertension, he’ll cut out the tumors, she’ll deliver babies and I’ll prescribe lithium." I fully expected medicine to be a team effort where highly trained individuals contribute to the common goal of patient health. But I have the feeling that all of the players don’t necessarily have complete respect for their teammates.

Enter into the picture the third year medical student. As with many other colleges, my school divides the third year into core clerkships. The purpose of rotating in all the major fields is to educate students in the basic principles of medicine. A secondary goal is to assist future doctors in knowing when to refer their patients for specialty care. The third objective is to help students decide which residency to apply to. I don’t know about you, but I hadn’t a clue which specialty I would gravitate to when I started my third year. (Granted, part of my disorientation can be blamed on my sudden realization that I didn’t want to run a basic science lab.) For a while, I could honestly report to my inquiring residents and attendings that I didn’t know what I wanted to do next.

Things have changed. Now that I’m confident of a career in emergency medicine, I understand the dilemma that students with good ideas of their career goals have when confronted with the, "What are you going in to?" question. We are told to be up front and honest about our career interests –- to not let that get in the way of our education. But it’s not that easy. Whether it’s comments about the brevity of surgeons’ notes, caricatures of radiology as a 9 to 5 career, of ER docs doing triage shift-work or internists as ruminating second-guessers, the observant student will recognize that it might not be a good idea to disclose her chosen profession to those evaluating her. Don’t even get me started about what people say about my one-time career choice of pathology!

As it gets later in the year, the legitimacy of an "I don’t know" answer decreases. You’ve scheduled the fourth year to cater to your next step and you’re already thinking about residency programs. Hopefully, you’re pondering what will go into your personal statement. Even if you’re considering three fields, at least that’s down from the "everything seems interesting" non-answer (but still honest reply) that I used to give.

So what’s the lesson here? I say be confident in your ability to identify what you are best at, what you enjoy the most, and what career will contribute to a happy and meaningful life. When you’re on a team with docs who don’t understand your view, that’s okay. In whatever clerkship you are in, you’ll be best served by working hard and studying. In the end, that will affect your grade more than your professional choices. And when you’re out on the field with your own practice, don’t forget the value of teamwork. I can’t think of any way that trash talk benefits patient care.

April 8, 2008 in Thomas Robey | Permalink | Comments (55)

Third World Learning Curve

Kendracampbell572x721Kendra Campbell -- I have lived here in Dominica for close to two years. In ten short days I will be leaving my home and returning to the States to start my clinical rotations. I know there are a lot of students out there who have lived, worked, or gone to school in so-called Third World countries. For me, it’s been an experience that I will treasure for the rest of my life. For those of you out there who haven’t lived in underdeveloped countries, but are considering doing so for school or as a volunteer, I thought I’d compile a fun list of things that I’ve learned while living here in Dominica. Enjoy.

1. Having a rooster for an alarm clock. No matter where you live in Dominica, you’re likely not far from a rooster. Mine wakes me up religiously at 6:00 every morning, whether or not I ask it to. I guess I’ll have to go back to the electronic variety in the States.

2. Using Chinese food restaurants as convenience stores. In Dominica, almost everything closes on Sundays. If you need food, soda, or other beverages, your only option is to get them from the Chinese food restaurants, because they are the only businesses that are open.

3. Not having an address. They don’t have a mail delivery system in Dominica, and although I think the roads might have names, they don’t have any road signs. My address is “Banana Trail, Portsmouth.” If I’m getting food delivered, I specifically say that my apartment is past the green house on the top of the hill with the dogs that bark loudly, and across from the black and white goat.

4. People carry machetes instead of briefcases. Pretty much everyone here owns a machete, and it’s commonplace to carry it around with you. Instead of the bland briefcases that I’m used to seeing everyone toting around, people walk down the streets with sleek and stylish machetes.

5. Traffic jams because of runaway cows, sheep, goats, or other livestock. I was quite used to traffic jams in the States, but I’d never seen a herd of goats causing traffic mayhem as they run down the street with a torn rope around their neck dragging behind them.

6. Electricity is a luxury. No seriously, it is. The electricity usually goes out at least once a week, and I’ve seen it off for days at a time. You eventually learn tricks to live without electricity like having lots of candles, and making sure you have a gas stove. If you don’t have a huge exam to study for, it can actually be pretty fun. If you do, then you try to avoid the temptation to burn the house down.

7. Being kept up all night because of mosquitoes. The mosquitoes can get so bad here that they literally buzz you out of your mind! Even with netting, mosquito spray and special candles, the little buggers will find their way to your ear at 3:00 in the morning.

8. Eating expired food. Shipping things to Dominica can be tricky for a variety of reasons. It’s not uncommon to see food on the shelves of grocery stores that has been expired for over a year. I guess eventually you just get used to the taste of stale food.

9. Hitchhiking is safe. Actually, it’s not only considered safe, it’s pretty much the only way to get around. If you stick out your thumb, either a transport, a person driving a pickup truck with an empty bed, or just about anyone else will stop quickly and take you where you need to go. Even young children use this method to get to and from school everyday!

10. Taking showers in brown water. The water here is very unpredictable. After it rains, it will turn off for hours and then if you’re lucky, it will come back on. But it’s frequently a lovely shade of beige, and loaded with sand. It might sound unbelievable, but you really do feel cleaner after a muddy shower!

If any of you have lived or currently live in an underdeveloped country, please do add to the list!

April 7, 2008 in Kendra Campbell | Permalink | Comments (17)

Great Medical Acronyms

Benferguson72x722Ben Ferguson -- We all know the pedestrian medical acronyms and abbreviations -- bid, CXR, DNR, po, HMO, PE, AAA, CABG, appy, GSW, INR, lap chole. Pretty much anything and everything is acronymous or abbreviated in medicine these days, and if you’re not in the loop, you can go for entire conversations without knowing what the heck someone is talking about. Therefore, it’s important to stay up to date.

Here are some my favorites I’ve heard that are a bit more ... creative?

LGFD: looks good from door

LOLFDGB: little old lady, fall down go boom

CKS: cute kid syndrome

LFTWM: looking for three wise men (pregnant patient vehemently denying sexual activity)

CROACC: cannot rule out anything -> correlate clinically (often by radiologists)

UBI: unexplained beer injury

DBI: dirtbag index (roughly, tattoo count X missing teeth count = days since bathing)

LOBNH: lights on but nobody home

ECU: eternal care unit (dead)

TFTB: too fat to breathe

OBECALP: placebo backwards

OMGWTFBBQ: badly mangled patient, e.g. from MVA (among other things)

CCFCCP: cuckoo for Cocoa Puffs (a little demented)

LMC: low marble count

CTD: circling the drain (a patient expected to die at any moment)

WNL: we never looked

Got any others? Post them in a comment. I’ve come to the conclusion that this sort of creativity is absolutely limitless.

(I found two more comprehensive lists here and here, but they are a bit more on the profane/unprofessional side, as often seems to be any bored doctor’s want. Word to the wise.)

April 3, 2008 in Ben Ferguson | Permalink | Comments (39)

How We Learn

AnnascrubsAnna Burkhead -- I am three weeks into my eight-week surgery rotation. I’ve been in the OR every day, but except for an appendectomy or two, all the surgeries I’ve seen have been scheduled (ie – not emergent, not traumatic).

All scheduled, except for one.

On my last call night, the surgery intern paged me and told me to come see consults with him in the ED. When I arrived, he was examining a man on a stretcher, and he asked me to begin the work-up on an elderly lady with a large abscess on her back. I didn’t get a good look at the man he was examining, except for the fact that he had a very bloody bandage on his arm.

About an hour later, I was in the OR watching a lap-chole when the intern arrived to tell our mid-level resident and the attending about the patients in the ED. He gave the short story of the woman with the abscess, and then said, "…and the other patient is a middle-aged man on dialysis who is having bleeding from the site of his AV fistula. I wrote orders to admit him." The attending said he’d go "eyeball" the patient as soon as they were done.

Twenty minutes later, I was in the surgeons’ lounge when I got wind that there was an emergent surgery about to begin in OR 3. My stylish hairnet and I (see picture) scurried over. Upon entering the operating room, I couldn’t see much of the patient, who was already prepped and draped, but I did see a large clot hanging out of a ragged opening in the arm strapped to the armboard. It was the patient with the AV fistula.

After the attending and the chief resident speedily repaired the man’s leaking fistula, the chief approached the intern. "You know he would have died, right? He would have been admitted to the floor, the nurses would have thought he was getting sleepy, and he would have died." I watched from a respectful distance as the intern nodded at the chief’s words.

It wasn’t much of a scolding, more like a passing of wisdom and lessons learned from a senior to a newbie. I realized I was witnessing a moment and a lesson that this surgery intern would never forget. It might be the scene that he’d relate to his own young intern, four years in the future, when he is finally a surgery chief.

The fields of medicine and surgery have checks and balances because scenes like the one described above happen occasionally. This is how we learn.

April 2, 2008 in Anna Burkhead | Permalink | Comments (38)

Trust Me, I'm a Doctor

NewkendraKendra Campbell -- Last week I completed my very last clinical rotation for this semester. My group rotated in the psychiatric ward of the hospital. I met a lot of intriguing patients with all-too-familiar stories. Before medical school, I worked for three years at a state psychiatric hospital. In fact, the experience at the psych hospital is what gave me my first thirst for medicine.

Having met so many psychiatric patients in the States, I was very interested in discovering the kinds of patients I’d find here in Dominica. Surprisingly, the patients’ stories, experiences, and struggles with mental illness were strikingly similar to the ones I’d seen in the States. The ward was also set up comparably to the hospital I worked at and psychiatric wards that I’d seen in the States. The treatment team still consisted of almost the same group of people: a psychiatrist, a psychologist, a nurse, a social worker, and a nursing assistant. The pain and frustration that the families were experiencing was also sadly familiar to me. I immediately recognized their wrinkled and fatigued faces and knew that they’d encountered endless challenges and setbacks while trying to help their loved ones.

There was only one thing that I noticed that was prominently distinctive about the psych ward here in Dominica: the patients were not verbally or physically abusive towards the staff. Not only were they not abusive, but they were relatively pleasant. The patients actually listened to the nurses and doctors. They rarely defied them. The chief psychiatrist confirmed my observation. He said that it was exceedingly rare for a patient to attack a staff member and that the majority of patients respected the staff immensely.

I can’t emphasize how shocked I was by this revelation! For three years I came in to work prepared to deal with abuse. I worked on the acute unit and most of the patients were very unstable. I was continually verbally abused, and physically attacked on more than one occasion. We did everything we could to ensure a safe unit, but sometimes the abuse was just inevitable. All of the staff were on constant alert. We knew that at any moment a patient could take their rage out on one of us.

Not only were the patients aggressive at times, but they rarely listened to the advice or encouragements of the staff. Getting a patient to take their medication voluntarily was a daily battle. Convincing them to take a shower or change their clothes was no easy task. There were definitely some cooperative patients, but most patients downright hated the staff.

The contrast between the trustful Dominican psych patients and the distrustful American patients is profound. A common phrase uttered by Dominican patients is “yes, doctor.” The first time I heard it, I didn’t think much of it, but over this semester, I’ve heard it over and over again. It’s almost like a patient mantra. At first I thought they were saying it mockingly, but I’ve since realized that they actually mean it. They really do put all of their trust into their doctors’ guidance.

I’m so fascinated by this that I’d love to research how the differences in patient trust have evolved. I’d really like to know how the cultural aspects come into play. And the big question I have on my mind is how patient trust in their doctor might affect patient outcomes. Are the trusting patients more likely to be compliant with their treatment plans, and hence have better outcomes? Or is a little distrust important in keeping the patient super vigilant? How much do you think patients should trust their doctor?

April 1, 2008 in Kendra Campbell | Permalink | Comments (17)

My Quest To Get Into Clinical School And Become A Real Doctor

NewaaronAaron Singh -- And so it finally begins. After three long years of sitting in lecture theatres having obscure biochemical minutiae stuffed down my throat and reassuring myself I'd become a doctor someday by watching 'ER' and 'Grey's Anatomy' with my drooling tongue somewhere in the vicinity of my carpet; after three years of moaning about medical school to everyone who'd listen (including your lot, my landlady, the homeless dude across the street and his dog) resulting, so far, in the grand total of two hemorrhages, one death due to bleeding out of the ears, and a great reduction in applications to Cambridge; after all this, it's finally time for clinical school.

I know I've moaned a lot about the medical education system at Cambridge (heck I've even been quoted in the local student newspaper –- some of my friends wonder why I haven't already been expelled) but really, I can see the point of the huge emphasis on science and theory taught at traditional universities like mine. Not only does some of it actually come in handy in clinical practice, it also helps us understand why we do the things we do to patients (arguments and fistfights not included, of course). Perhaps more importantly at a science-heavy university like Cambridge, it sets you up for the third year, where you do a BSc year in a course of your choice (it's weirdly called a BA at Oxford and Cambridge, for historical reasons, as well as to confuse the heck out of potential employers).

But now it's finally time for that stage in my medical career that I really signed up for -– the clinical part. And another one of the myriad oddities of the Cambridge system is that you have to go through another whole round of application forms and interviews –- you don't get to march into the Cambridge hospitals, you have to APPLY there. ALL. OVER. AGAIN. The perk is that you can also apply to Oxford (shudder) or to a London clinical school. About half choose to stay, and the other half choose to get the heck out of there (or are kicked out, depending on their exam results).

There. I've explained the whole Cambridge sytem in a nutshell. Still with me so far? No? What's that you say? You're on the floor bleeding out of your ears? Send me your name, I'll add you to the tally.

I don't think I'll stay at Cambridge, because I might want to do surgery and people say you get more experience and a wider range of cases in London. Plus, of course, I expect to see an increase in the number of Cambridge dons sneaking into my room at night with chloroform-soaked handkerchiefs after they discover that newspaper article. Lock your ward doors and hide your IVs, patients, here I come!

April 1, 2008 | Permalink | Comments (9)