Laughter in Medicine
Thomas Robey -- In the past year, I’ve realized that experiencing strong emotions is part and parcel of a career in medicine. Should providers cry with patients? How do pediatricians manage the celebration of childhood with the heaviness of disease? Cancer elicits universal questions of “Why me, now?” Birth and death are each tied to pain and joy. And then there is laughter.
Laughter in medicine can be divided into two main categories: doctors with patients and doctors with doctors. Humor in both settings builds rapport, enables discussion of awkward topics, and is even therapeutic. Imagine yourself laid up in the hospital; the right type of levity in the right amount could make your day. One patient shared with me that my frequent bedside visits were better entertainment than cable television. One day, she asked if I could sing and dance. I encouraged her to look me up “on the outside,” but now regret not breaking out into an old musical number right then. We still shared a laugh about how I’d appear to my attending while belting out, “I am I, Don Quixote!” I’m daily amazed by how easy it is for someone to smile and laugh when they are in so much pain.
The other type of laughter -– between doctors -– is almost as important as the first. Care providers see much of what is broken in society. We see the worst of disease. We are witnesses to the ills of society. Injustice. Abuse. Addiction. When docs (and medical students!) get together, it’s natural to talk about these things, and this is how we understand each other. How do people in any stressful situation cope? The unique bonds between combat vets, firefighters, and social workers are echoed in medicine. Frustration and pain often expresses itself as gallows humor and cynicism. Is it wrong for a doc to speak pejoratively of an injection drug user if the patient’s identity is confidential and the comment is safely in the company of other docs?
My time as a surgery clerk has confused these two types of humor. I had been able to keep separate humor with patients and humor about them. This all breaks down in the operating theater. The patient is asleep -– sedated and paralyzed. If he can hear what is going on in the room, he will not remember it. When the drug user is on the table with necrotizing fasciitis because he muscled bad heroin and then sat in a hot tub for an hour, is it okay to make cynical jokes about the choices he made? His legs are spotted as a jaguar with injection ecchymoses and you’re cutting through intricately penned tattoos on his shoulders, hoping to excise the infected tissue before it spreads to his heart. When the surgeon dryly points out that it’s a shame this guy has to lose his tattoos, when in reality, he’s likely already lost his life, is it okay to laugh?
I almost cried.
Anna Burkhead -- The field of medicine pretty much has its own language, and as a medical student, you have to learn it fast! However, doctors, nurses, and other healthcare workers are not the only ones who have to learn this doctor-speak. There are regular non-medical Joes and Josephines out there, who, by virtue of birthing, marrying, befriending, or just having a conversation with a person in the medical field, have to understand some of this language.
Additionally, writing for and reading comments on this blog has shown me that medical systems in different parts of the world use different terms for what appears to be the same position.
Medical dictionaries are available to look up the meanings of words such as "cryoglobulinemia" and conditions such as "Osgood-Schlatter Disease". But other basic everyday medical words cannot be found in these dictionaries. For the benefit of any non-medical readers of this blog, as well as non-US medical students, here is a short list of terms (and their meanings) that we throw around on a daily basis.
-Pre-Med: A college (undergraduate) student taking classes with the anticipation of applying to medical school. This student has completed high school, and is usually working towards a BS or BA degree.
-Medical Student: A college graduate in a training program to become a doctor. These programs are almost always four years, and degrees earned are MD or DO (aka osteopathic student).
-Residency: a medical school graduate training program for a particular specialty. Examples: Pediatrics residency, Urology residency, etc. Related words: Resident – a medical school graduate in one of these training programs.
-Internship: The first year of residency, or the first year of post-graduate training. Related words: Intern – a medical school graduate in his first year of post-graduate training.
-Fellow: A doctor who has completed residency training, and is enrolled in a subspecialty training program.
-Attending / Attending Physician: A doctor who has completed residency training, and can supervise/train fellows, residents, and medical students.
-Rotation: Most often a term used by medical students to describe 4-8 week periods spent on specialty services. Example: Surgery rotation, Anesthesiology rotation.
-Boards: Also known as USMLE Step 1, 2, 3. These are tests that assess medical knowledge and ability to apply concepts and demonstrate skills in the medical field.
-Shelf: A standardized test at the end of a rotation (see above).
Just call me Merriam-Webster :)
On Graduate School and the Practice of Science
Ben Ferguson -- Graduate school seems to be fascinating to people who are not in graduate school. More fascinating, say, than the IT industry is to people who are not in the IT industry, or the janitorial profession to people who are not janitors, or even the medical profession to people who are not medical professionals. I say this not because I enjoy exaggerating my chosen profession’s level of interestingness, but because I always seem to get the same questions about it in passing conversations and with people I’m meeting for the first time. The most common seem to be, in this order: 1. “When will you be done?” 2. “What do you … actually do?” often followed up with “Huh?” and/or blank stares; and 3. “What on Earth is wrong with you?”
Honestly, it’s tough, for me at least, to answer these questions over and over and over again without boring my counterpart (or myself) into a deep sleep, and I think one reason that many of these questions even come up is because people have a general lack of understanding of what grad school is and what grad students do with all of their time. To be sure, almost the whole of graduate school, as I have said before, is transferring liquids between their receptacles and occasionally analyzing those liquids in different ways. Much of the rest is reading about other scientists’ experiences with their own successful liquid transfers, trying not to fall asleep, and trying not to fall asleep while reading about other scientists’ experiences with liquid transfers. Despite all indications to the contrary, the reading part has some utility.
Today, in a seminar class I’m taking, I realized that the practice of science -- graduate school included -- really is a lot different from most professions in a number of ways. Perhaps the biggest fundamental difference is that, in science, one is expected to know a number of different things -- pathways, techniques, etc. -- that rarely ever come up in one’s specific focus or area of expertise. For example, in this seminar class, we students discuss assigned papers by going through the figures and explaining them as if we have some clue about what the researchers did to generate the data within. None of us have ever actually done experiments analyzing facial phenotypes in embryonic knockouts, and none of us probably ever will in the course of our career, but we’re still loosely familiar with the concepts and rationale underlying the experiment (and even more loosely familiar with how to interpret the data). None of us have ever done wound healing assays, or mass spectrometry, or protein crystallization, or in vivo metastasis modeling, but we are expected to know what they’re all about. Through reading about them and about how others design and interpret experiments, we, then, are expected to be able to add these options to our own arsenals in case such techniques present themselves as useful methods for answering unique questions that come up in our future work.
For the most part, medicine isn’t like that. IT work isn’t like that. Janitorial work isn’t like that, and most other jobs aren’t like that. In most other fields, including medicine, you are trained broadly but then focus on a specific aspect, however large or small, of that field.
In medicine, you practice surgery, or dermatology, or pathology. Yes, in the course of your training, you’ve seen psychiatry and you might have even placed a central line or two. No radiologist though, for example, would be expected to perform trauma surgery at the drop of a hat (or even after a short amount of training), nor would any orthopedic surgeon be expected to treat schizophrenia. Reading about it in papers certainly wouldn’t cut it for these things. (This is why we specialize in the first place, no?)
In science, though, most everyone knows what siRNA does. Everyone knows what a Western blot is and how to interpret its information. Everyone has at least heard of flow cytometry, C. elegans, confocal microscopy, G proteins, and knockout mice, and would be able to become relative experts in these methods and topics within a couple of days (say, for the purposes of writing a last-minute grant). (Perhaps that’s why science, at its most basic level, is easier than medicine. Literally anyone can learn it and then go do it.) In order to be a successful scientist, you absolutely must have at once this breadth of loose knowledge alongside your hardcore, focused obsessions, or else you risk not knowing at all what others are talking about. You must also be able to interpret these data and methods and experimental rationales in the context of your own work, or else you risk not taking full advantage of what’s available to you as an experimentalist. There are only so many proteins to assay using Western blotting (and only so many conditions under which to collect the proteins), and it’s important for any scientist to stay up to date with information not only in one’s own field, but -- dare I say -- in all of science.
Medicine? IT? Janitors? Important for those too, yes, but not so much.
Life Before Med School
Kendra Campbell -- The pre-med curriculum has been at the forefront of academic medicine discussions for years now, and many people have written about proposed changes to the current system. An article that recently appeared in the journal, Academic Medicine, discussed how the primary purpose of pre-medical education is to provide students with a broad-based education that prepares them for medical school and for becoming a physician. The author purports, however, that we’ve not really succeeded in this endeavor. Instead, the pre-med curriculum prepares students for the med school admissions test, and doesn’t always succeed in creating a well-rounded student, armed with everything that is needed to become a competent, caring physician.
In addition to the pre-med curriculum, many people have been discussing the other experiences necessary for preparing for med school, such as shadowing physicians and doing volunteer work. A few days ago, I received an email from a pre-med student asking about ways to “fluff” their resume with additional activities that might make them a better candidate for acceptance into med school. This really got me thinking about how the current pre-med experience is set up.
The “traditional” route into med school in the U.S. involves graduating from high school at around 18, spending about 4 years in undergrad to obtain a bachelors degree, and then applying to med school after graduation. During undergrad, students are supposed to take all of their required pre-med courses, and also gain experience in medicine.
I’ve recently been wondering if this “traditional” path might be flawed in one important way. If a student continues straight through school, with no breaks, they will eventually graduate from medical school, finish their residency, and make it to the “real world” where they can practice medicine and make a reasonable living. So, by the time they enter the work force, they’ve had little or no actual work experience. It’s possible that they had a part-time job, or even a few full-time jobs, but the majority of “traditional” students have never lived without student loans or parental financial support. Many of them may have never lived away (or far) from home.
There are plenty of “non-traditional” students, myself included. But the current system isn’t set up to encourage this path. I’ve thought a lot about the path I took to enter medicine. Do I think I made the right decision? Absolutely. I can’t emphasize enough how having experiences outside of school, and outside of medicine, have made me better prepared for handling med school, and I think eventually for becoming a competent, caring physician. I also know many other “non-traditional” students who feel exactly as I do. They believe that their path to becoming a doctor has better prepared them, and that they have an advantage over “traditional” students who never left school long enough to experience the world.
So, the question arises, “why do we encourage the current route to becoming a doctor?” What are the “traditional” students losing along the way, and can they ever make up for that lost time? What do you think it means to have a life before med school?
These Pretzels Are Making Me Thirsty
Ben Bryner -- I'm sorry, everybody, for blogging about death for a while there. Today I’m going to talk about the show Seinfeld. I apologize to those of you not familiar with the U.S. television series, as well as casual fans of the show who aren't obsessive enough to be familiar with the episode in question. I realize that includes something like 95% of people reading this entry, but stay with me. In one of my favorite episodes, the aspiring actor Kramer is given a single line in a Woody Allen movie: "These pretzels are making me thirsty!" The four main characters of the show debate the best way for Kramer to deliver the line. As usual, Kramer overdoes it (and makes Woody Allen cry). But through the rest of the episode, each of the characters utters the line "These pretzels are making me thirsty!" When each of them says it, the phrase takes on a meaning like "I am extremely frustrated, and I am to blame, yet I am powerless to do anything to change the situation." It becomes a kind of shorthand between the characters and the audience, a simplified (and funny) way of conveying a complex reaction to a particular event.
In medicine we sometimes use similar kinds of phrases. For example, a procedure that should be relatively simple but gets more complicated and frustrating is called a "flog." (Atul Gawande uses the example of placing a central line; it should go smoothly but can suddenly turn awful.) We twist words from their true meaning toward a different one: when I describe a lecture or meeting as "painful," another med student understands this as not literally causing a sensation of pain, but being slow/boring/incomprehensible, etc. Not that this ever actually happens.
It seems like a lot of these terms are derogatory, which is partially true. My theory is that these phrases evolved to allow med students to vent quickly to fellow med students in the short amount of non-supervised time they have together. (Since you never, ever complain to a resident, or when residents are around, you have to be efficient at airing your grievances to your fellow students over a quick lunch or other chance encounter.) I'm sure a lot of other groups have this kind of term too. Certainly the military does -- one of my VA patients, a Vietnam vet, was less than satisfied with the way his care was going -- with life in general, really. I’d say things like:
"Good morning, Mr. Smith. Did you sleep well last night?"
"No, it was a total cluster."
"Hey Mr. Smith, did you get all your questions answered about your CT?"
"No, it was a total cluster. I don't know anything."
"Hey Mr. Smith, how was lunch?"
So I picked up on that term. I liked the guy, and he wasn't really mad at us personally, just frustrated at the system (common even in the best of VA hospitals). But even though he favored us with the less profane version of the term, we all got kind of sick of hearing everything described as a "cluster," and finally on rounds one day my intern (a psych resident) got annoyed and sort of told him to shut up. I liked him, though, and he was my patient, so I kept going to talk to him and in the process heard him describe everything from his bed linens to scheduling surgery to the weather as a "cluster."
Anyway, not all our informal descriptions are negative; there are more positive shorthand terms too. I heard one of my favorites today -- describing a pediatric patient who has recovered well and is doing much better than expected as a "rock star." It doesn't mean the kid is really ready to play the Hollywood Bowl. It doesn't even mean that they're really good at Guitar Hero. But we all know what that term means: the patient's doing well, recovering, on the road to discharge.
This is part of the reason med students aren't always terrific conversationalists; for example, it's just easy for us to describe our day in clinic as "a huge flog" (a flog-a-thon?) to each other. That's so much easier than talking to a non-medical person where you have to explain a) what should happen in clinic and then b) how things went wrong and c) why each of those is particularly frustrating. I try to resist using these terms in polite society (by which I mean people who are not med students or doctors). And one of the reasons I like talking to non-medical people is to get a regular perspective on daily life. But as hard as I try, words slip in here and there, and before I can stop myself I'm describing a trip to the grocery store as a "flog." Then I have to explain what I mean, and apologize for sounding like an idiot; and the worst part is that I haven't saved any time at all. These pretzels are making me thirsty.
Surviving the Tough Times
Thomas Robey -- May is a tough time of year for medical education. The Step 1 board exam is looming for second year students, third years are exhausted from solid months of clinical clerkships, fourth year students are nowhere to be found, and interns, well, they're as exhausted as third year students but raised to the exhausted power (a mathematical expression). For many, this fatigue is not the running on empty, "I'm almost finished" feeling that we might expect in June, but rather an "I'm drowning, but I'm too busy to call for help" situation. Yes, not all feel this everyday -- to get this far, we have to have good coping mechanisms -- but there's a greater chance that overwhelming feelings get the best of us this time of year. (I wonder if it's by design that the medical year's most stressful time coincides with spring's unleashing of hopeful, happy and even manic episodes.)
But for those of us with real struggles to get through an understandably difficult year, it is helpful to recall why we are here. The patients we try to cure can be the very medicine we need to get through the day. In the rest of this article, I've picked out some of my more memorable patients in an effort to cheer myself, but also to jog your memories and invite accounts of your favorite patients.
There's the 8-year-old boy with Crohn's disease who drew a portrait of me. When he had unbearable pain and bloody stools, it took a day for him to warm up enough to communicate with more than head nods. Some day he will need large chunks of his intestines removed. It's too bad his overflowing heart cannot be used as donor repair tissue.
Can you remember your first delivery? Mine was a complicated Caesarian section, which made the emotions cycle extra quickly. In the end, mom and baby did just fine, and I try to draw strength from the resilience they both exhibited.
There was even the time when I delivered bad news to a patient with metastatic prostate cancer. He probably knew this was going to be the diagnosis, but had been in denial. The time he spent ignoring the problem was probably too long, but in his acknowledgement, he re-established care and is actually doing well. It has been nice to check in on his check-ups, if only via the electronic medical record.
And finally, there is the aged southern belle who could be a poster child for a "hugs not drugs" campaign. In the process of administering the Dix-Hallpike maneuver to assess canalith dizziness, we discovered that even medical professionals need hugs now and then.
These are the golden patient encounter memories that keep me looking forward. What are the stories that pull you through the difficult days?