The Waiting Game
Thomas Robey -- Like many fourth year students, I'm anxiously awaiting notice from residency programs about interview invitations. Some specialties have been sending invites for a few weeks, while others wait to make an offer until after they receive your medical student performance evaluation (MSPE, formerly called the Dean's letter). My chosen field, emergency medicine, is in the latter category. So when my colleagues who've applied to surgery, family medicine and pathology tell me about the 10-15 interviews they have, I have the opportunity to practice some of the calming techniques we teach patients with panic disorder.
It's also nice to rehearse the clinical interviewing technique of reflective conversation. With it, I'm getting to know my friends and colleagues better. Reflective conversation is when the interviewer summarizes what the patient says. This helps the care provider both understand the patient's position and reinforce the therapeutic alliance. By focusing on the other person's challenges of navigating cheap airfare sites, organizing program information, and their worries about how to offset their expanding carbon footprints, I'm learning what could be in store for me over the next month when emergency medicine programs start contacting me.
Even with these constructive approaches to dealing with my own anxiety, there are still the sheepish check-ins with my colleagues applying to EM residencies. I see one classmate rather regularly on my commute to the hospital. We're at the point where he greets me with, “Still only three.” And I reply: “Two here.” (We each applied to about 30 programs.)
Sometimes I see the glint in residents' eyes when they overhear our conversation. They're thinking, “those medical students... what a big deal they're making of this!” I know because it's the same thing I think when a contingent of first year students board the Metro bus after being released from afternoon class. We talk about trans-continental airfare and living expenses; they compare study strategies and small group assignments. Soon, we will be focused on work hours and continuing education.
But now, we fourth year students have sent in our applications, confirmed a number of interviews and are antsy about learning about what's next. In a few weeks, the emails will be flying about interview date preferences, the cash will be flowing to online flight booking agencies, and the dark suits will be dusted off for more adventures in interviewing. By comparison, now is the calm before the storm. It's funny though -– I don't feel very calm.
An Encounter With Oriental Medicine
Jeff Wonoprabowo -- A couple weeks ago I made a trip to see the chiropractor with four classmates as part of a requirement to observe complementary medicine in action. This week the same group of us went back to the same facility, but this time to see some acupuncture in action.
Well, it turned out we had more in store for us than just acupuncture. They split us into smaller groups (2-3 students) and we rotated through the clinic spending 1 hour observing different doctors (with OMD degrees) and interns (students about to graduate).
My group consisted of another classmate and myself. We began our first hour in the "pharmacy." Now, I type pharmacy in quotes because it is not the pharmacy most people in the United States are accustomed with. The pharmacy had a large wooden cabinet with lots of drawers, and each drawer was filled with, maybe, three or four different herbs/roots. One of the things they had was ginseng. The ginseng looked like small instrument reeds (for clarinet or saxophone), and I sucked on one while my classmate chewed hers. While my mom has taken ginseng before in a tea form, I never tried it. It must be an acquired taste and after I spit it out, I excused myself as I went to get some water.
After I had my drink of water, I had my pulses read. Apparently, a lot can be discerned by reading the radial pulses. The intern noted that I had a quick pulse and she checked my tongue; she told me it was very red. Those two meant that I had a lot of "heat inside" and that I probably am easily irritated. She didn't tell me anything about the state of my heart, lungs, kidneys, or spleen (all these organs are supposed to be represented in the radial pulses).
The rest of the day was spent with various OMDs. I saw acupuncture, cupping (http://en.wikipedia.org/wiki/Fire_cupping), scraping, and heard about acutorture. I know that acupuncture has been studied and there has been evidence that it can be helpful in pain management. But aside from acupuncture, I don't know of any researching into the techniques I saw. Moreover, I didn't really understand what they were treating when they used the techniques.
I got the idea that cupping and scraping were used for muscle pain. But I would venture a guess and say that they use it for more than just that. It looked like it might feel nice, though. I might have to go find a cupping set and try it.
The acutorture was something that I really did not understand. The doctor I saw who does this stepped out and instructed the intern to explain to us what acutorture was. The intern, though, seemed really nervous and flustered. He couldn't explain it at first, but finally managed to say that it was like physical therapy. I'm not sure how accurate that statement is. I heard (from classmates who saw it done) that it is quite painful.
A lot of what I saw was foreign to me even though my ethnic background is Chinese. They say the results of these techniques speak for themselves as their patients are satisfied with the results. But the explanations they give about meridians and channels seem off-putting for many people who train in western medicine. Personally I found the visit fascinating -- almost a cultural experience. My curiosity has been piqued. But whether I go back as a patient or not... well, I don't know yet.
Has anyone had any experience with Traditional Chinese Medicine? I'd love to hear about it, good or bad.
Physician, Heal Thyself
Thomas Robey -- How many colds have you had this season? I'm working on number two. This is from a man who can count on one hand the number of times he missed school in grades K-12 because of illness. Okay, maybe two hands, or a polydactalied hand. Whatever. I've been sick in the third and fourth years of medical school more than any other time in my life. For example, the only time I remember vomiting (ever!) was on my medicine clerkship in Spokane. And I even drink from mountain streams. So what gives?
1. Stress. Lots of it. Long hours. Wanting to learn EVERYTHING, like memorizing the eMedicine article about hepatic encephalopathy.
2. Not eating well. Granted, hospital food is great, especially when it's free. Wait a minute... “Hospital food is great?” I am sick.
3. Not exercising as much. Taking the stairs helps, and that 20 pounds I lost on my emergency medicine rotation wasn't only because I forgot to eat twice during the 12 hour shifts, but being on your feet doesn't cut it for getting the heart rate above 120.
4. Vectors, fomites, sick contacts... we get them all.
5. Sympathy for your patients.
6. Sleep? We don't need no stinkin' sleep.
7. “But I got the influenza vaccine...”
You get a medal if you get through these two years without a viral URI, the flu (stomach or real), strep throat, sinus infection or scabies. For those of you without a medal around your neck, the next test is what you did after you got sick.
The sick doctor has an obligation not to infect her patients. “First, do no harm.” How do you draw the line about deciding to come to work? Stay home with active vomiting? Sure. Is it okay to have a runny nose on pediatrics because everyone else does? In the OR, you'll get you no sympathy from the scrub techs. “Aw, the medical student is spotting his mask...” is as uncomfortable as if I were spotting somewhere else. Lower GI problems? No one wants you around. Don't even think about it! But I'm sure some of us do. After all, not only are we students part of the provider team, we are learning and being evaluated. Missed work equals missed opportunity, right? I don't think so. If you are sick, you're not going to learn. Instead, stay home. Yes, students help the team. But remember your first month on the wards? The team got on without you. They can get by one more day, but be sure to call in. They'll probably thank you for staying home, too.
So what can you do to get back ASAP? There's a lot of stuff that people say works. Many swear by that effervescent pill Gas-Birth. (Names were changed to protect the clinically disproven.) There's something special about chicken soup -– especially if someone else makes it. Drink fluids when you're down. Stay healthy with fruit, exercise, sleep. You know the drill: you've told patients hundreds of times. The CDC promises us the flu vaccine is going to work this year -– get that not for yourself, but for your immunocompromised patients. And you probably know you should be washing your hands AND using hand gel more than you think you need to. Cover your nose. Wipe down your workstation. In the end, the best advice I've received is simply to stay home. You'll be back to your eager medical student self faster that way.
Is Doing Nothing Sometimes Doing More?
Kendra Campbell -- I’m currently re-reading the famous book, The House of God, by Samuel Shem (Steve Bergman’s pen name). I read this book many years ago before ever starting med school, and I really enjoyed it. However, now that I’m doing my clinical rotations, I’m enjoying it with a new found appreciation, and I’m really starting to understand all of the subtleties and nuances of the story. I highly recommend this book to anyone thinking about going into medicine, med students currently doing clinical rotations, doctors, nurses, and just about anyone who enjoys a well written novel.
In the book, which focuses on the lives of interns in particular, the name “gomer” is given to the elderly, terminally ill patients that are always filling up the hospital, and who never seem to die. In fact, the first “Rule of the House of God” is that “Gomers don’t die.” The book gives an alarmingly accurate portrayal of how the main character, an intern, begins his internship with the medical student mentality that it’s possible, and in fact the doctor’s duty, to do everything possible to save a patient’s life. A much more seasoned resident tries to explain to him that for the gomers, this is not the best approach. Although the intern resists the advice of the resident at first, he soon learns the harsh reality that there is much truth to this approach.
Eventually the intern takes the resident’s advice and instead of “doing everything possible” to save the gomers, he does the exact opposite: he does nothing. Instead of running huge batteries of tests on the gomers, he doesn’t run a single one. Instead of administering all the medications and treatments that “medicine and science” would demand, he gives them little or none. And what’s the amazing result? The gomers end up doing way better on his watch. In fact, he becomes known as the hospital’s best intern, as he develops an amazing patient care track record.
I recently had an experience with a patient that was frighteningly similar to one described in the book (some details have been changed to protect patient confidentiality and to demonstrate my point). An elderly patient came in with the simple complaint of numbness and tingling in her arm. A chest x-ray was performed and showed a mass highly suspicious of lung cancer in the apex of her lung. A mediastinoscopy was performed in order to better visualize the mass and perform a biopsy. After the procedure, the patient developed a large hematoma and had to be rushed back into the OR to stop the bleeding. Because of blood loss, she ended up becoming very anemic, but couldn’t be transfused because she was a Jehovah's Witness. The patient also developed pleural empyema and eventually a chest tube had to be inserted. The chest tube ended up causing a pneumothorax, which had to be corrected. After the pneumothorax, the patient developed subcutaneous emphysema. After all this, she eventually developed a nasty case of hospital-acquired pneumonia. The story goes on and on and ends with the patient having a very lengthy stay in the hospital. In addition to that, the mass turned out to be inoperable and the patient eventually left the hospital with the same complaint that she came in with, in addition to having to deal with all the complications that arose from all the procedures!
While this is an extreme example of complications arising from hospital care, I think it serves to bring home my point. Would this patient have received better care if her doctors had simply chosen instead to do nothing? This is just one case, but I could describe many others where a very sick patient’s life was extended by a few weeks, only to cause them to endure countless complications and pain. How do we know when doing nothing is doing more? How and when do we make the decision to institute hospice care? I know hospice care is not “doing nothing” (actually, in some ways, it is doing much more), but it is a different (and I think in many ways better) method of approaching and caring for the terminally ill.
I have so many thoughts on this, but I’ll save those for another post. I’d love to hear what all of you think. Do you think choosing to doing nothing (in terms of medical treatment, not necessarily patient care) can ever mean doing more for the patient?
When Does Fourth Year Slow Down?
Colin Son -- The myth is that the fourth year of medical school here in the United States is a time to kick back and take in the future, maybe with a margarita by the pool. You’ve come through a time-consuming third year and your application for residency is set and eventually you reach a point in the year where you can just relax. That is sometime after interviews come and Match Day is approaching.
I’m wondering when that day might be. The horizon does not look all too clear, at least in terms of my schedule. I want to go into a specialty that is relatively competitive and it has clouded the "ideal" of the fourth year.
In my first three months I will have done two away rotations, and sub-Is are typically brutal, at least in terms of the hours put in. I’m in my second sub-I right now and within days of finishing I will go on my first interview for residency. I will be gone almost half of the month of November on interviews. December and January get a little better as my schedule now stands, but interview invites are still coming. Considering I want to give myself the best shot possible to match, I’m considering going on twenty interviews, although I’m continually told that will be difficult and I’ll get exhausted and run out of money before I make it to that many.
Whatever the case, I really didn’t consider how much time so many interviews would take up. I have already rearranged my schedule to take November, December, and half of January off just so I can work in that many interviews without interrupting an actual rotation. In February, when interview season is over, I go abroad to do an international rotation. Granted, that is a personal choice but still is far from a vacation.
My school has mandatory didactics for fourth years during March. Those are supposedly an easy time, but unfortunately, it means I cannot schedule a rotation during that time. With my schedule as it is I will still owe my school a mandatory home outpatient rotation in order to graduate. The only time it works in is during April. That is the last month I will be in school. To be taking a required rotation the last month of medical school is a little unheard of. In fact, I may have to beg to try to get it because they typically don’t let students do those rotations in April. There are a couple of reasons I can think of:
First, what if something went wrong and you got sick and couldn’t complete the required rotation? There would be no time to make it up.
Second, and most importantly, you’ve already matched. You can imagine that the effort put into a rotation post-Match Day may be a little haphazard.
Granted, I get some time from May to June. And I intend to take advantage of it. But my fourth year schedule is a little more hectic that I imagined it would be when I was a first year dreaming of the future.
Let me be clear, I know the next six or seven years of my life will be a whirlwind and I’m not really complaining about my fourth year schedule (okay, maybe a little) except that it is unexpected. Fourth year was supposed to be a little more laid back before you entered the rest of your life.
What Is PM&R?
Jeff Wonoprabowo -- I have yet to figure out what specialty of medicine I would like to enter. Fortunately, "they" tell me that I have plenty of time as I am just at the beginning of my second year. In an effort to discover the specialty of my dreams, I occasionally attend interest group meetings. The problem is that every time I attend one of these meetings, I pick up on the aspects of the specialty that make it appealing. I mean, what specialist would really come to an interest group meeting and tell you all the negatives?
The most recent interest group meeting I attended was for the specialty of Physical Medicine & Rehabilitation (PM&R) where the physiatrist (PM&R specialist) was proud to let us know that the school has one of the five PM&R residency programs in the state of California.
Of course, free lunch was provided. I showed up early and picked up my croissant sandwich, two cookies, and a 20 oz. bottle of root beer. As is my custom, I chose an aisle seat in the back row so that, should the need or desire arise, I could make a quick and easy exit.
PM&R is a specialty that is somewhat difficult to define. The presenter noted that it is sometimes hard to tell people what he actually does because of what PM&R is not.
PM&R is not an organ specific specialty like Nephrology or Cardiology.
PM&R is not a procedure specific specialty like Surgery or Anesthesiology.
PM&R, he said, is more like a general specialty like Family Medicine.
Within the practice, the doctors in PM&R deal with stroke patients, amputees, and athletes. They work with various medical specialists (doctors, physical therapists, etc.) to help patients rehabilitate and regain as much mobility and function as possible.
At the end of the meeting I was still there. And I left with another specialty that looks pretty appealing, too.
If you're interested, you can also check out the website of the American Academy of Physical Medicine & Rehabilitation.
Ben Bryner -- I think one of the weirder phrases in medical slang is the term "Golden Weekend." This refers to a weekend in which an intern doesn't have to work at all, which usually only happens once a month. I don’t know how widespread this term is, but whenever I hear someone use it, it reminds me of the Mitch Hedberg joke about corn on the cob:
"You know how they call corn on the cob 'corn on the cob,' right? But that's how it comes out of the ground, man. They should call that 'corn.' They should call every other version 'corn off the cob.' It's not like if you cut off my arm, you would call my arm 'Mitch;' but then reattach it and call it 'Mitch all together.'"
Same issue here. The "Golden Weekend" is a plain weekend in its natural form; you should call it a "weekend," and call a weekend where you have to work a "working weekend" or possibly something more derogatory. One time I even heard a resident call a weekend where he got one day off a "Bronze Weekend." This is getting ridiculous, because winning a bronze medal in something is still a big deal. If you win a bronze in the Olympics, that means there's only two people or teams better in the world at that particular thing than you. Two people -- that's pretty cool. I certainly can't think of anything where I would say, "I bet there are only two people in the world who are better than me at this." But awarding a weekend a bronze medal just because you don't have to be at work for the entire thing? That's serious grade inflation for weekends.
Of course, looking closely at these phrases is interesting only because of what it tells us about the social structure where they're spoken. I think the phrase "golden weekend" tells me that I should appreciate each day off that I have during my fourth year, because once I start residency I'll start thinking of them as some rare shiny object to be treasured and guarded.
Ben Ferguson -- Unfortunately, I’ve got to stop writing for The Differential, and this will be my last post. As an aging grad student who still has half of medical school remaining, I’ve got other responsibilities to attend to (and no one wants to read about the exciting life of a researcher anyway).
Looking back, it’s been so much fun writing for this blog. I’ve been amazed by the amount of discussion some of my posts generated, undoubtedly not because of my chosen topics but because of your enthusiasm as readers. Undoubtedly, too, I imagine that some of you might be happy to see me going, as I’ve at times been called “annoying,” stuck-up, arrogant, “unmistakably egotistical,” “dead wrong,” racist, sexist, classist, discriminatory (not otherwise specified), bigoted, small-membered, hypersexual, ignorant, bellyaching, unthankful, “unprofessional,” offensive, “jaded,” narrow-minded, “stochastic,” AND overbearing, all within the past year. Whew. Those are some flowing emotions. The thing is, however nasty, most of them were well-intentioned and helped me to scrutinize and improve my own writing (except maybe the small-membered jab).
Like I said before, I’ve run out of stories to tell for now -- except for this last one.
When I was four, I broke my leg. It happened after I had one of those slo-mo, running-across-a-field-of-tall-grass-toward-a-lost-lover scenes, except this one was with a dog. Couldn’t tell you why this dog and I were running toward each other with such gusto (or at all), or how it was that neither of us realized the need to 1) stop, and/or 2) change course, but we ended up colliding with each other and falling-down-going-boom.
You’d think that having two doctor-parents would increase the likelihood that I’d get some medical attention, wouldn’t you? Isn’t that the logical outcome, that I’d go to the hospital and maybe have some x-rays following lengthy complaints of intolerable leg pain?
No. You would be wrong.
As I remember it now, I walked miles (in reality, probably to the bathroom and back) all day (maybe a couple of times per day, actually) for about 6 weeks (likely the next morning) before ever seeing a doctor, and when I did eventually persuade them to take me in, the diagnosis was that my leg fell completely off (tibia frx). I did get a cool cast, though, and was for a few weeks the cool kid at school who endured a vicious and life-threatening attack by (accidental collision with) a rabid, blood-hungry doberman on the loose from the pound (the neighborhood golden retriever chasing a ball down the sidewalk).
There is no moral to this story, unless you’re four, in which case: Where applicable, tone down the massive hypochondria, lest your parents think you’re whining excessively about your leg being broken in an attention-getting fashion when, in fact, you’ve actually just broken your leg and would like to see a doctor. Also, stay away from rabid dobermans.
Common Things Are Common
Kendra Campbell -- There’s a famous saying in medicine that common things are common. This is a rather obvious statement, but is so very true nonetheless. Seven weeks into my surgery rotation, I can completely confirm this observation. Today on consult, I saw three patients with appendicitis, two with cholecystitis, one with pancreatitis, and one with gastritis. For general surgeons, these patients are the bread and butter of their practices. And just as the textbooks would have me believe, the appendicitis patients were all young males. The cholecystitis patients were fat, female and forty. The pancreatitis patient was an elderly alcoholic male. The gastritis patient was a stressed out, heavy drinker who abused NSAIDs.
Today’s patients represented about 85% of the patients I see every day. Throw in some hernias and DVTs, and you have the gist of my experience with general surgery. It really got me thinking about the curricula in medical school. It seems that 90% or so of what we learn in med school is about obscure diseases. We learn about Pompe’s disease, Klinefelter syndrome, and Creutzfeldt-Jakob disease, but how often do we come across patients with these pathologies? Sure, they do happen, and we need to be prepared for their presentations, but should we be spending over 90% of our time learning about them? We barely covered topics like pancreatitis and cholecystitis, but this is what we see every day.
I’m really not sure what the solution is. Physicians need to be well versed in most diseases and pathologies, but how much time should be spent covering these topics? Might our time not be better spent going over common maladies, their presentations, and their treatment?
I think one of the reasons that we have to cover all diseases is because by understanding their pathophysiological processes, we are better able to understand and appreciate normal anatomy and function. Learning about how the body can be attacked or go awry helps us to truly understand how the body works. And then maybe we are better able to understand and treat the common diseases that we see.
I’m not the first person to bring up this topic, and I certainly won’t be the last. Many people have discussed various changes that need to be made to the med school curricula. Should we really force pre-med students to take organic chemistry? Should we make students planning on going into psychiatry memorize obscure dermatological diseases? I don’t have a good answer.
Perhaps it makes sense to focus on everything that can possibly go wrong during our pre-clinical years, but then hone in on the more common diseases during our clinical years. For me, it seems like this is how things have been going thus far.
Another famous saying in medicine is that if you hear hoofbeats, think “horse,” not “zebra.” But the reality is that one day we might have a zebra walk in to the hospital, and we could make a grave error if we call it a horse. But for now, I guess I will continue to see and treat the horses, while trying to keep my eyes peeled for the black and white stripes.
What a Doctor Does Best
The couple who walks into the neurology clinic are young and, ostensibly, in the prime of their adult life. The husband, the patient, is ex-army and used to being in perfect health. The consultant, who has already voiced his concerns to us before the patient came in, takes the history and leads the patient through a gauntlet of examinations. These elicit signs which are so classical that even I, the inexperienced student, know what the diagnosis will probably be. The consultant is gentle but firm and hints to the couple that the man’s symptoms indicate the more serious of two possible conditions.
The patient jokes wryly throughout the whole consultation, half using it as a defensive tool against the potentially life-shattering diagnosis. He openly admits that he’s in denial about his situation and expresses dissatisfaction at the blunt way in which his referring doctor told him "when you see something that looks like a blackbird, it probably is a blackbird." So the consultant explains his symptoms to him, helping the patient come to the conclusion himself. At the same time, the doctor tells the couple that he understands the serious ramifications of a certain diagnosis for the patient’s life and decides to withhold the label until the confirmatory scan has been done.
The patient’s wife has done research on the internet and has many questions, especially regarding a very experimental new treatment. This happens to be the consultant’s research interest, and he is able to explain his concerns in simple yet unpatronizing terms.
He guides the patient through the uncharted water of the probable diagnosis, discussing frankly best-case and worst-case scenarios, both comforting and yet imparting no false hope. When the consultation ends, the patient and his wife request that he continue to be their neurologist despite living 3 hours drive away.
As with such experiences, this one embodied all that medicine means to me -– the good, the bad, and the painful. Here was a doctor who was both competent and humane. Who was both scientific and clear in his explanations. Who understood not only the condition, but also the person. Seeing such an excellent clinician at work reminded me of the type of doctor I aspire to be. Medicine will always be defined and advanced by its people and it is always a privilege and pleasure to see one of their best, doing what he does best.