Don't Do That
Ben Ferguson -- Writing my previous post reminded me of two other “don’t” stories to share.
A good friend of mine -- let’s call him Jon -- was scrubbed in on an operation during his third-year surgery clerkship, working alongside a surgeon who is well-liked here but has a reputation of being rather intimidating among the medical students. Being a green medical student (yet certainly feeling lucky to have some hands-on responsibility in the first place), Jon was relegated to working the laparoscopic camera during something like a lung resection. The surgeon asked him to reposition the camera to get a better view of the surgical field, but he replied that he didn’t think he could maneuver at such an angle because if he were to try, he was afraid he might break one of the patient’s ribs.
The surgeon stopped what he was doing, put down his cautery probe, looked directly at Jon across the table, and cleared his throat.
“Don’t do that,” he said flatly, as if he were lecturing on the innervation of the puborectalis. Then he picked up his instruments and went back to what he was doing.
Jon said only a little urine came out.
A few weeks ago, I was having a chat about some trouble I was having with one of my projects and how I was going about troubleshooting it. (I’ve been troubleshooting for about a month now; accordingly, we’ve been having a lot of these conversations.)
I started cycling through my options: “Well, I could run my samples on a gel again, or I could resequence the construct, or I could redo the mutagenesis entirely, or I could digest with Ava1, or I could re-digest with Dpn1, or I could try a different polymerase, or I could increase the transformation volumes. OR, I could just shoot an email to [our collaborator] and ask him to send some of his -—”
“Don’t do that,” my PI said. “Stick with the other stuff and you’ll get it to work eventually.”
The thing is, I will get it to work eventually, but I wish I didn’t have to. I wish someone could just send me the final product so I can use it immediately in my experiments, but it doesn’t work like that most of the time. Or any time, really, unless you’re extremely lucky, have extremely generous collaborators, and/or have a PI with a fat, disposable wallet. These thwarting words weren’t very encouraging to hear, but it’s the right thing to hear in the end and it has taught me that the best solution isn’t always the easiest one or the one most readily bought or mooched. For rapidity of data, that may be true, but it doesn’t hold up when taking the broader goals of graduate work into consideration, not the least of which are learning how to master basic techniques and learning how to deal with them when they inexplicably fail.
The Scalpel is Always Shinier on the Other Side of the Operating Table
Kendra Campbell -- I’m currently sitting in a new chair at a new table in my new apartment in Brooklyn, New York. I’ve had the past two and a half weeks off from school and I will be starting my surgery rotation at a nearby hospital in just a few short days. It’s been quite an adventure relocating all of my belongings to a new city and a new state yet again. This will be my fourth move in less than two years, and it’s definitely becoming a little taxing.
It’s taken me almost my whole break to find an apartment, move all my belongings, unpack my stuff and get completely situated. However, now I am completely finished and I no longer have anything to do. Yes, I am only a fifteen minute subway ride away from Manhattan, and yes there are approximately eight billion things to do and see in NYC, but strangely enough I am still bored. I think I am just one of those people who always needs something to do, and it’s difficult for me to switch from “unpacking mode” to “fun and relaxation mode.”
When I begin my surgery rotation, I know that I’ll be working an insane amount of hours every week. I’ve been told by other students that this rotation is especially difficult, and that I won’t have a lot of time for sleep or relaxation. And interestingly, I am awaiting this with eager anticipation.
During my first two years of med school, there were times when I was incredibly busy. I went without sleep and fun for many days in the name of studying. At the time, all I wanted was a few extra hours to run errands and enjoy myself. All I could think about was my next break, and how much fun I’d have.
Now, here I am with all the time in the world, in one of the coolest cities on earth, and I’m absolutely bored out of my mind! I’m starting to think that maybe I’m just a chronic complainer at times. However, on the other hand, I definitely do know how to appreciate many things.
So, it seems that whatever I’m doing, the grass is always greener on the other side of the fence, or if you will, the scalpel is always shinier on the other side of the operating table. When I have no free time, it’s all I can think about. When I have too much free time, I long for a busy schedule.
Actually, I think what it comes down to is the amount of time involved. I do need breaks, and I can enjoy myself. But if I have too much free time, I tend to go a little whacky. Perhaps two weeks would have been enough time in this case, but I got three.
Okay, I’ll stop complaining now and try to enjoy my last few days before I join the ranks of all the other sleep deprived med students on my surgical rotation. Perhaps I will go take that fifteen minute subway ride to Manhattan. Hopefully my next post will not involve me complaining about my busy schedule!
Jeff Wonoprabowo -- Like many Americans and non-Americans alike, I have been following the 2008 Summer Olympics. It's been fun watching Michael Phelps grab a record 8 gold medals, Misty May-Treanor and Kerri Walsh dominate on the sand, and the "Redeem Team" (I'm not sure who came up with that nickname) led by Kobe Bryant and Lebron James handle business in the early preliminary rounds.
But it's also been amusing to read the news about how Beijing has focused on putting on the perfect show. First there was news that some of the fireworks outside of the Olympic stadium were faked using the wonders of modern technology. Then I read that the cute little singing girl dressed in red was, well, just cute and little. She wasn't actually singing. The real singer wasn't "cute enough" and so the red-dressed girl was told to lip-synch.
It looks like China has been doing a whole lot to convince the world that all is well and perfect in their country behind that bamboo curtain. And maybe it is. But most likely it isn't. Of course, I have yet to find any place on earth that is perfect.
The whole idea of projecting perfection, though, reminded me of some of the things we discussed in class. One professor noted that doctors have this strong desire to stick together. They want to give a colleague the benefit of the doubt. As a result most doctors are very slow to offer any criticism, often exercising their right to remain silent because they weren't present during the procedure.
I think that giving the benefit of the doubt is great. False accusations can lead to devastating consequences. But there have been instances when certain doctors no longer deserved the benefit of the doubt. An extreme situation is described in the book Blind Eye by James Stewart. In that book, Stewart writes about a doctor that got away with murder.
Would transparency in the medical field be beneficial to both doctors and patients? I'd like to think so. But sadly, with our current litigious environment, complete transparency would be a nightmare.
And so, doctors may very well have to continue painting that picture perfect image of medicine.
Advice for First-Year Students
Colin Son -- I’m getting to spend some time with the new first year medical students at my school, as I’m tutoring in the anatomy lab. It is a transcending experience for each class going into the anatomy lab and then taking a look at the incredible human body, up close for the first time. It is also an incredibly time consuming course for the first years. That only adds to the stress of starting medical school.
It is true, medical school is a rigorous, time consuming, sometimes difficult journey. I doubt many would hope anything less was required of future physicians. But the rigors of medical school have taken on a mystique of their own. Medical school attracts incredibly smart and driven people. Cramming together such Type A personalities only makes the situation worse.
The first year, specifically the first semester, can be filled with worry and just a touch of angst -- especially before the students grow comfortable with how they will be tested and evaluated. As I said, one of the most pressing courses your first year of medical school is the anatomy course, not because the grading is difficult but because with the lab thrown in with the course requires a major time commitment.
So, tutoring anatomy early in the year is half acting as therapist. I spend some of my time reassuring the first year students that medical school is a completely conquerable ordeal. I thought if such encouragement was so frequently required at my school, it should also be posted online for any first years who have stumbled across The Differential.
First, whatever the philosophy of your school (traditional lectures, problem based learning), in the end you learn the basic sciences the same way you did your undergraduate work. There is nothing mysterious about how students are educated, there just happens to be a bit more material in medical school. But for most students who have made it this far, the volume is completely shoulderable. Yes, medical school is tough, but don’t put it too high on a pedestal. Most students starting their first year have learned everything they need to know about study habits and time management.
Second, taking a test is taking a test. In the U.S., whether your school writes their own questions or uses the NBME shelf exams, the way medical students are evaluated on their knowledge is the same. I’m surprised by the number of new medical students who expect something dapper and mysterious in the way they are to be evaluated. But there is none of that.
Third, don’t get caught up and overwhelmed in experiences that are new. One of those is the anatomy lab. I know I had never been in a human anatomy lab before medical school, I had never seen a cadaver, I had never even had a formal dissection course. It seems to suck students in. Consider that the gross anatomy course during the first year is often worth about the same as the physiology course. You might not know that, especially during the first semester. As a result, many students seem to grow increasingly concerned about doing well in the anatomy lab, sometimes at the expense of studying for other things.
One thing we should realize is that, by and large, faculty educators realize experiences like the anatomy lab are new, and expectations are tailored accordingly. Yes, you need to know your anatomy backwards and forwards, which is a doable task I might add, but your dissections don’t need to look like you’re working for a Body Worlds exhibit.
Remember, medical school is a marathon. That is what I’ve taken to telling some of the first years in the anatomy lab. They all have the skills to muster the journey and they shouldn’t get so riled up and worried.
Easy for me to say, so far from my own "riled up and worried" year as a first year.
We Heart Nurses
After being on numerous attachments, personal experience has taught me that nurses really can make or break the experience you have. Not that I’m surprised by this: nurses are the ones who know the patients best, who know where everything is, who will be implementing the care you instigate and, most importantly, who offer you biscuits. It’s surprisingly tricky, however, navigating the minefield that is nurse-doctor etiquette, but something I’d recommend all medical students start working on whilst they’ve still got the cloak of ignorance to hide behind!
From experience, talking with nurses and watching the best (and worst) examples of doctor-nurse communication, I have devised my top 5 tips for getting on with nurses:
1. Introduce yourself to them at the start of attachment. A name is so much nicer than an ID badge, or even one of those sexy little tags saying "medical student." I know, common sense, but it’s surprising how it’s lacking in your average medical student…
2. Admit ignorance. Most nurses are quite mumsy in nature –- they like nothing better than to look after a lost little medical student. Don’t look too lost or for too long, though; nurses do actually have better things to do. Like look after doctors.
3. Run everything past them. Even if your consultant has said it’s ok to go speak to a patient, s/he may not have seen them for a few days and the patient may have deteriorated. Or they might be about to do something to the patient. Either way, they rule the ward so it’s probably best.
4. Understand how hard it can be for them. There was a doctor on my second attachment who, on starting his early ward round, was told by the nurses that they’d had a really busy night and weren’t quite ready. I’ve seen other doctors snap at the nurses for that, saying that if they could be ready, so should the nurses. But this doctor quite calmly said that he’d do another ward first and then come back. "Manners maketh the man." How true.
5. Pitch in. As medical students, our role in patient care is to learn, and this should be our focus. But sometimes, we need to pitch in. Even if wiping soiled bottoms or helping a patient go to the toilet isn’t quite what we signed up for, it’s a simple thing to do that helps a fellow healthcare worker who will appreciate it.
Other people with whom it’s important to get on in your firm:
1. The junior doctor, aka general dogsbody. This poor person will be rather harassed, so they’ll love you if you make an effort to help them, e.g. find blood forms. They’ll especially love you if you bolster their fragile egos by asking for advice and/or teaching (when they’re not busy); depending on how long it's been since they experienced the dizzying success of passing Finals, they will have had their self-confidence crushed into the ground several times.
2. The ward clerk. This person doesn’t participate directly in patient care, but s/he keeps the log of all the patients. This is also the first person you’ll see every day coming into the ward, and who wouldn’t rather be met with a smile than a glare?
3. The other medical students. No kidding.
As much as the patients, I personally feel that it really is the people on the firm to which you’re attached that make the difference to your enjoyment and your learning. Whilst it’s absolutely natural to try to get on with your consultant, your relationships with these other members of the team are just as crucial… and they’re the ones who will be there with a cup of tea when the going gets tough.
What Did You Say?
"What?!?" she asked. I looked at her, while safely driving down the street, and laughed. The way I said it, it sounded like I was going in for my own autopsy. And for a few seconds she doubted whether she remembered what an autopsy was.
But I cleared it up. I wasn't going in for an autopsy. It wasn't a back-to-school thing like getting a physical. I had to view an autopsy being performed -- not have one done on me.
The whole situation reminded me about the importance of clear communication. Communication is important in daily life; it can be vital in the medical arena.
Last year I had a class called "Understanding Your Patient." During one lecture we discussed giving patients bad news. We watched a video clip of an oncologist demonstrating how he gives bad news, using actors as patients. The actors didn't know what he was going to say and so their reactions were genuine.
He, the oncologist, discussed breaking things down and repeating often. It's not easy to take bad news. It's also easy to jump to conclusions at certain trigger words.
My mom battled cancer a couple years back. To this day, she remembers the moment she heard the word "cancer" from her doctor. I haven't asked her too much about that conversation, but sometimes patients will shut down and come to their own bleak conclusions once they hear a word like that. So it's important to slow down, repeat, and get feedback from the patient to make sure they understand.
I also heard an orthopedic surgeon, Doctor A, talk about one of his experiences with a patient. A patient came to see him and told him what Doctor B had done. In passing, he made some comment like "Why would he do that?"
Well, one year later the patient comes back –- this time with a lawyer. The patient wants to file a lawsuit against Doctor B. And the patient wanted to use Doctor A as an expert witness because Doctor A had made a single comment wondering why Doctor B did what he did.
It turned out that the patient had misunderstood what Doctor B told her. And the patient had given Doctor A the wrong information. And Doctor A realized he shouldn't have made that comment to the patient.
Twisted, I know... but it reminds me that I have to be careful with what I say –- especially when I am around patients and still have no idea what I am looking at. They see a white coat and assume I have some body of knowledge. Well, I do have some body of knowledge, but at this point in my training, it isn't the kind the patient needs.
Anna Burkhead -- As I’m writing this entry, I’m seated in sweatpants on a horrid floral and fringe sofa. In a few hours I will hop in my twin bed and sleep until the night float team sends their 4 am page with the overnight admissions.
It’s not my first time on this couch; I spent a month at this hospital on the North Carolina coast last year. In fact, I requested to come back here for this month to do my acting internship in Internal Medicine. So I can’t complain too much.
However, this living-out-of-a-suitcase lifestyle I’ve led basically during the whole of third year and now extending into the first two months of fourth year is getting tiresome. Before the beginning of my clinical years, knowing that my unmarried and childless status would mean more than my share of away rotations, I requested to be sent to my hometown hospital. It was nice for a while. I enjoyed not paying rent!
Last month I did an away rotation in dermatology at the University of California at San Francisco. While I learned a lot and got to know some good people in the program, it was a hard month for me. Being away from my home and my school (and my cat!) was very difficult for me.
On the last day of the rotation, I received a phone call from my apartment complex office back in Chapel Hill. They informed me that there was a problem with a major water leakage from a burst pipe into my apartment. It is unknown how long the stagnant water was sitting, because no one had entered the apartment. The office managers have been very good about keeping me updated and I am confident that things will get cleaned up appropriately. That said, I have not been able to return to Chapel Hill to check out the damage since it occurred. I’m basically taking a near stranger’s word as to what appears ruined and what appears salvageable, and I’m not there to “encourage” the cleaning and repair process.
I flew back from San Francisco and drove straight to this coastal hospital without passing through Chapel Hill. I will take my first glimpse of my water-logged home this weekend, when I return to Chapel Hill for a required practical exam.
While I’m bothered by the situation in Chapel Hill, I’m trying not to stress. After all, there’s not a lot I can do about it right now. I’m just feeling weary and tired of being away from home. Fortunately this is my last away rotation until February. In December and January I’ll be flying all over the place interviewing for residency, but those will be more tolerable short trips.
My apologies for this “downer” column. Medical school isn’t always peaches and cream, and it’s sometimes hard to live your normal everyday life and do your normal everyday things, especially from three hours away. But I guess learning to juggle all the responsibilities of being a student, learning medicine, and being a person all at the same time is part of this process.
How Not to Give a Presentation
Ben Ferguson -- I’m currently at a conference on worms (don’t ask), struggling to stay awake through 22(!) rapid-fire presentations each day. Some are average, some are really quite good, and some are just annoying and terrible.
We all know the typical no-nos -- don’t talk too quickly, don’t put too many words on one slide, don’t read directly from your slides, don’t make the text too small to be legible, don’t be rigid but don’t move around too much either. So many don’ts.
Even if you didn’t think it was possible, I have more. It’s weird, but people always forget how to do the most basic things when they’re in front of a large audience. If you can help it, don’t do this either. Some pointers for your own future presentations:
• Don’t mistake the wireless slide changer for the laser pointer. If you absolutely must, at least recognize this within the first few slides, and try not to use the slide changer as the laser pointer for your entire presentation or until an annoyed audience member interrupts you to inform you that you are not, in fact, actually pointing to anything. Also, don’t make this mistake if several dozen others before you have also done it.
It’s always a bit uncomfortable watching someone point to the screen with a non-lasering piece of plastic while believing that they’re demonstrating exactly what they are referring to, and I’ve never quite figured out why this oblivion sometimes occurs and why it occurs for such a long time. I suspect it has something to do with extreme focus on the content of their presentation at the complete expense of attention to their surroundings (save, of course, for audience members shouting at them). Maybe there’s some mental image they’re creating in their head in lieu of an actual visual signal confirming a laser point showing up on the screen. Who knows.
• Don’t fumble around with the wireless slide changer when you don’t know how to operate it. (Expressed another way: When the slide changer does something you didn’t expect or want, don’t continue to press that button several dozen more times hoping it will eventually comply.) Also, don’t not know how to work the wireless slide changer in the first place. They’re all THE SAME: right moves the slide ahead one, and left does the opposite. Also, if it turns out that you are completely inept or have ignored this tip, and the computer from which you are presenting is within arm’s reach, you may just consider using the computer itself to change the slides.
• After you have the laser pointer vs. wireless slide changer thing down, don’t point to items of interest on your slides using gigantic, frantic circles as if you have just pushed a bolus of caffeine into your arm. This is especially true if you’re attempting to highlight single words on the screen, or a phosphate group, or part of a cell taking up the entire screen. Also, if you must make gigantic, frantic, caffeine-driven circles, try your best to at least keep them smaller than the screen itself; otherwise, it’s quite hard to determine what you’re pointing out.
• Don’t say “in conclusion,” or “in summary,” or “and finally, I’d like to end with...” more than six times per presentation, and don’t say these things at all if you plan to be talking for another 20 minutes. It really can drive your audience nuts. Instead, say “to conclude this portion of my presentation,” or “before I move onto something else, I’d like to summarize...”
• Don’t go too long over or under your alloted time, especially if there are people following you on the agenda or if you’re early in the day. It can really mess up the rest of the schedule, putting pressure on those presenting after you to cut theirs short in an attempt to comply with the preset agenda or stressing people out if they thought they had a bit more time to touch up their slides or get their wording right.
I’m realizing that my tone is really bordering on arrogant here, but I’ll be the first to admit that I’m completely and utterly fallible when it comes to presenting my own research. If anything, this is food for thought; most of us don’t think about these things before taking the stage, but given how our senses seem to unintentionally go by the wayside sometimes while presenting, maybe we should.
Thomas Robey -- Taking care of patients is hard work. Medical students are expected to collect loads of data from patients, send the right labs, order the correct studies, review all of the information to decide on a differential diagnosis, and refine it all into a 3-minute speech, on which entire grades may be decided. Wow! But learning medicine is not just about patient care. On top of learning the facts of medicine, we students have to figure out the lay of the land in new hospitals, new cities, and new departments every 4-8 weeks. In the hierarchical structure of academics, students must be careful not to step on anyone’s toes, presume too much or scoop others’ roles. All the while, we must keep smiling, connect with patients, and bring in baked treats for the call team. Antacids anyone?
In the midst of the stressful condition known as medical school, there are still, small voices that can help you through your day. It took me a while to listen to, or even hear them at all. If you can tune them in, you’ll be surprised how much easier your time will be on the wards, in the operating room or out in the clinic. Here are some that I listen for:
“Would you like to...?” --> This is code from the nurse that, “usually in this situation we do this and I’m ready to do it, why don’t you write an order.”
The instrument cue --> If the scrub tech hands you an instrument in the operating room, take it. She’s worked with the surgeon for years and can anticipate his actions better than you can. If you don’t know what to use it for, pay better attention to the field.
“Could you please get me the...?” --> No matter who asks this, the answer should always be yes. You may think it is scut work to get the warm blanket or the line cart, but you are saving the team time –- time that can be used to teach you how to put in that central line.
“Have you seen a <insert medical condition here> before?” --> This is sometimes tough to respond to. If the answer is a firm yes, you’ll be able (and expected) to show off what you know to an attending or resident. Other times the answer is a soft yes –- you don’t really know the topic very well. In that case, your superior may be willing to provide a little teaching. The best answer is “I know about <the one thing you know about the condition>, but could you help me understand this patient’s situation?” Or, if you haven’t seen the disease, just say no and expect to get some teaching. Pay attention though, because you will be expected to shine when you see the next patient with that problem.
My experience has been that most people in academic medicine want to teach. If they have time, nurses, techs, attendings and residents are happy to have willing learners. Be on the lookout for these folks and their coded offers of help.
Google Your Future Doctor
Colin Son -- My school recently sent out an email to its students detailing the risks of publishing personal information online. We’re not talking about identity theft here. Instead, the email was prompted by a University of Florida study that looked at medical student use of the popular social networking website Facebook.
The study authors found what they considered a dangerous level of personal details which medical students made public online. For instance, more than half of all medical student profiles which the researchers looked at revealed the students’ political affiliation and sexual orientation. More than one in twenty students made their home address available.
A more in-depth look into several medical student profiles on Facebook found a plethora of examples of what the study lays out as “unprofessional.” Such included racist and sexist comments and pictures documenting excessive alcohol consumption.
The concern over online social networking is nothing new. I’m sure, like me, many have heard anecdotal stories of employers or schools "Googling" applicants or looking them up on websites like Facebook and MySpace. For future physicians in particular, the risk may be especially high because an elevated level of professionalism is expected of physicians.
This isn’t to denounce the rise of the social internet. This internet has bred a generation less concerned with privacy, and more willing to generate content for all to see based on their life experiences. That of course is for another intellectual discourse; the point is, though, that it has become the social norm. And I’m not even willing to bemoan that fact.
We should strive to find a balance where medical students (and others) can engage in online social activity and maintain a level of professionalism expected of them, even outside of the hospital.
One, you may want to give a little bit more thought to what you post online before you do so. As the University of Florida study points out, plenty in my generation are guilty of jumping before we think. I have pretty considerable exposure online between my participation in some social networking sites and my blogging, and I know at times I’ve been guilty of this myself.
Two, you may want to limit who can access what you publish online. One of the problems identified in the University of Florida’s study is that a majority of medical students made their Facebook profiles open to the public.
Generations past engaged in all the same "non-conformist" behavior that my generation has; just never was it so publicized. So, there will continue to be hiccups as the internet continues to reduce privacy. We need not be alarmist, though. What I think we are witnessing (and will witness) is generational friction, but social networking is too widespread to hold its use against all. We’ve entered a bit of transition in terms of defining privacy boundaries and, despite the truth in needing to have a little more discretion about what is revealed, in the end I don’t expect my generation to regret what they’ve published online about themselves nearly as much as others (say, the University of Florida study authors) imagine they will.