The Excitement of Starting Clinical Medicine
This time last year, I was starting clinical medicine for the first time. Taking my first steps into a ward, not quite used to the prescribed chaos of day to day hospital medicine, everything a bit bewildering and wonderful. Over the past year, the "firsts"’ have become routine and the excitement wears off.
Which is why I’m so grateful for the arrival of the new first years. True, they have taken over the common room and filled in all the crosswords before I can get to them. But they also get excited about taking blood and watching appendectomies. It reminds me that, yes, what we see and do everyday is actually pretty cool. I was watching a partial lobectomy of a lung today, and the trainee nurse standing next to me whispered “this is amazing!” For a moment, I stopped trying to figure out management plans and just took a step back and thought, “yes, actually, wow!” It was nice -– to have that feeling of utter awe and amazement again.
The other thing is that I see reflected in the new first years the same worries that I had when I first started. Worried about how on earth I was ever going to get the hang of 5 different examinations, about when heart sounds would click (no pun intended) and sound more than just whooshing, and about hurting patients every time I touched them. And I realise how much more confident I am now with examinations and dealing with patients in general, after practicing on umpteen patients. It just goes to show how much we learn in that one year!
But what an insurmountable task it appeared to be at first… Because no matter how much I reassure my "children" in the first year that it will all come together before the exams, I am met with the same disbelief that I doled out to my "parents" in the year above when they told me the same thing. History certainly does repeat itself where medical students are concerned.
And in keeping with that, I realised something. I am half-way through my penultimate year. In 18 months, I’m going to qualify. By Christmas, I will have covered all major specialities except OB/GYN and peds. Theoretically, I should know enough to diagnose and formulate simple management plans for any adult male with a medical issue. Now that’s enough to give anyone palpitations.
My Life These Days
Oh wait, I’m not on a rotation now, I don’t need to get up.
Get up anyways. Maybe some residency program coordinator on the east coast is an early bird, and is sending out interview invitations at this hour. Check my email. Wishful thinking.
Make some coffee. Read a news story online. Check email. Read another news story. Check email again.
Random cleaning / errand / meeting. Check email. No residency interview invitations.
Pick up suit from dry cleaners. Wonder if anyone notices or cares that I wear the same thing to each interview. Think about how I can’t afford another suit anyway because of the plane flights and hotel rooms. Check bank account balance, pout briefly.
Check email. WHERE ARE THE INVITES, PEOPLE?! Check Dermatology student forum to see if anyone else has gotten an interview invitation today. Feel better that everyone else is sitting in front of their computer repeatedly pressing “Get Mail” button in between idle online browsing sessions.
Write thank-you notes to interviewers. Lament the fact that today’s second graders are no longer taught how to write in cursive.
Check email. Check spam folder, just in case.
Phone call from a friend who’s out on the interview trail. Canned “I don’t know” when asked why the Dermatology programs wait until late in the season to offer invitations. Check email while on the phone.
Double-check arrangements for three piggybacked one-way flights so I can attend the most interviews possible. Try to forget that I hate flying.
Scroll through my ridiculously color-coded interview spreadsheet. Hope no one else ever sees it.
“Business Casual” for interview dinner. Eat well, ask a lot of questions, drink a little wine.
Lay out suit for interview tomorrow. Set alarm. Dream about March 19th.
My Christmas Rush
Jeff Wonoprabowo -- The Christmas season is here, and it seems like there is no forgetting it. All around, decorations are being thrown up, lights are being strung, and commercials are insisting that with just one more purchase we will achieve happiness for ourselves -- or our loved ones.
The Holiday season is also a tiring one. Everyone is frantic. It's a hectic time. It's the Christmas rush. People are scrambling around town hunting down that perfect gift. They're checking their schedules, planning parties, writing cards, and making trips to the post office to send parcels to distant friends and family.
And all of this is done with one date in mind: December 25.
I started thinking about my own December. It has definitely begun with a rush. My rush, however, is not about racing around finding the perfect gift, scribbling out greeting cards, or mailing packages. Actually, I'm thinking I should send a Christmas gift to my sister who is spending the year studying abroad in Argentina.
I find myself rushing full speed ahead towards Christmas vacation. The only thing in my way is a week of exams. Two of the eight exams will be NBME subject exams -- affectionately referred to as "mock boards" by many.
The full speed hurtling almost feels like I'm lying on my back speeding down a mountainside on a street luge. No, I haven't tried it. It looks fun -- and terrifying at the same time. Those guys have to manage the twists and turns. Fortunately they probably know the route beforehand so the turns aren't totally unexpected. But at those speeds, even the expected seems unexpected.
Maybe the equivalent for medical school would be trying to remain flexible amid the fray -- which has been difficult for me. I'm the kind of person who likes to know what's going to happen during the day. I'm the kind of person who doesn't like to begin studying if I know I'll have to stop in 30 minutes. It may sound silly, but I feel like it interrupts the momentum.
Student life -- and I guess life in general -- is full of interruptions. I remember being excited that I had a whole afternoon free to study (yeah, I know that sounds sad) only to find out I had a nail in my tire that needed fixing. So instead of sitting in the library for the entire afternoon, I ended up sitting at Walmart's tire shop reading microbiology notes while waiting for the repair. It felt like I lost time because of this interruption.
On the other end of the spectrum I have felt like I gained time. A couple times I have gone to class only to have the teacher not show up, which left me with time I should've gladly embraced.
So it's a juggle. And I'm working on it. I still don't like things popping up randomly when I'm trying to study. But I have to "roll with the punches," learn to be flexible, and use whatever time I do find wisely. After all, medicine is not a field where daily events follow a script or schedule.
Will Resident Work Hours Be Reduced?
Thomas Robey -- One of the (many) things I pay more attention to now that I'm interviewing for residency is work hours restrictions. Granted, residents in emergency medicine (EM) typically fall well under the current limits of 80 hours a week (averaged over a month), maximum 30-hour shifts, and a minimum 12 hours between shifts. (EM residents have their own numbers: 12-hour shift limit, at least an equivalent period of time off between shifts, and a 60-hour work week with an additional 12 hours for education.) But when it comes to off-service rotations –- when I work in the ICU, for instance, or on the medical floors -- I'll log my hours along with everyone else.
Some of my stock questions when I interview include direct inquiries about work hours. Thanks to an Institute of Medicine (IOM) report issued on December 2, I have a new way of asking. You can try it too: “How do you expect your institution will respond to the new IOM recommendations that resident shifts be shortened to 16 hours?”
At my medical school, most rotation sites provide sleep rooms for students so that they may take overnight call with the team. This means that I've had a taste of 30-hour call and 80-hour clinical work weeks. (Keep in mind that these restrictions do not apply to medical students -– there are no restrictions for us!) My experiences on call helped me learn how to work up a patient from start to finish, introduced me to multitasking between several clinical tasks, and provided several others on my team with interesting diversions (in the form of delirious post-call musings). Low on the list of why I chose emergency medicine is that I will not have very many 30-hour call nights. But it is on the list.
So when the IOM report came out last week, I took notice. Keep in mind that these are recommendations, and are not policy (yet!). Here are the details:
Shift length now: 30 hours (admitting patients up to 24 hours, then 6 additional hours for transitional and educational activities)
Proposed shift length: 30 hours (admitting patients for up to 16 hours, plus 5-hour protected sleep period between 10 p.m. and 8 a.m., with the remaining hours for transition and educational activities); 16 hours if no protected sleep period
Time off between shifts now: 10 hours
Proposed time off: 10 hours after day shift; 12 hours after night shift; 14 hours after any extended duty period of 30 hours, with no return until 6 a.m. of next day
Days off now: 4 days per month; 1 day (24 hours) per week, averaged over 4 weeks
Proposed days off: 5 days per month; 1 day (24 hours) per week with no averaging; at least 1 48-hour period off per month
There would be no change to the 80-hour weekly limit or to emergency room shifts. A one-page digest comparing the current policy with the IOM's recommendations is available here.
Remember, these are just recommendations. It is hard to say whether the Accreditation Council for Graduate Medical Education (ACGME) will act on these recommendations. My biased hope is that they do, even if it doesn't change my off-service rotation work hours. The ACGME indicated in a news release that work groups within the council will convene in April to consider the IOM recommendations.
Among the issues to be discussed will be the cost of these proposed changes. Perhaps there is something to the oft applied phrase “cheap labor” when discussing residents: The IOM estimated the annual cost for additional personnel to handle reduced resident work could be $1.7 billion. That's less than 0.5% (yes, one half of one percent!) of what Medicare spends on Americans annually. But something tells me the current economic situation may be a detracting factor in progress on this issue...
So, what can we medical students do? I think a good first step is to talk about it -– with peers, residents, and the residency directors we interview with this year.
Know Your Place?
In the hierarchy that is medicine, you enter at the bottom as a lowly medical student and attempt to make your way to the lofty heights as a consultant. Self-evident from the start, this unwritten hierarchy is followed by all. Which really makes life difficult if you feel the need to break it. This hierarchy is based on knowledge, with the presumption that your superiors will know more than you. And, by extension, are more right than you. But, just occasionally, that’s not the case, and then all the fun begins…
In one of our lectures, we were told an anecdote about a surgeon who was conducting a left nephrectomy. However, on the same day, a right nephrectomy had also been scheduled… you can guess what happens next. The anecdote goes that although the medical student observing that day thought that this was the wrong patient, he didn’t say anything. Maybe he wasn’t sure what was really going on. Maybe he wasn’t sure that this patient wasn’t the right nephrectomy patient –- it is, after all, often easier to doubt yourself than someone senior. Maybe he was just hoping someone else would say something?
Happily, most consultants I’ve come across treat their team as just that; management plans are formulated together with the flow of ideas and information going both ways. This is as much a teaching process as patient care, so there are advantages for all parties.
But as medical students, it can be hard to feel like you’re ever in a position where you can correct a senior. Maybe it’s because as students, we don’t feel qualified to do anything yet, never mind suggest to a senior that we think they might be wrong. Maybe it’s because in our current situation, where we don’t really have a job or our own patients, we don’t feel enough part of the team to say anything.
In this lecture, we discussed if there were possibly ways to deal with this issue, and the idea came up that being a medical student was positively advantageous. Asking the surgeon to talk through what he’s doing or, as one of my colleagues put it, “to express keen interest in the unusual approach” seems a fairly tactful way of doing things. After all, as a medical student, it’s practically our privilege to be a bit ignorant!
I Have Insurance But No Doctor!
Kendra Campbell -- As I alluded to in my recent post, I have a health insurance plan provided by my medical school, but have been unable to find a primary care physician. It seems that whenever I make calls to find one, they are either not accepting new patients, or the first available appointment is so far into the future that I can’t even guarantee that I’ll be able to make it. I live in New York City, so can you imagine what it would be like if I lived in a small town somewhere in rural America?
The unfortunate consequence of this situation became even more real to me a few weeks ago when I became sick and needed to see a doctor. Since I was unable to locate one, I ended up going to the Emergency Department of the hospital where I’m currently rotating. You can imagine how silly I felt sitting in the waiting room for many hours, clogging up the system, wasting the doctor’s time, when all I really needed was for someone to take a quick listen to my lungs, check out my throat, and write me a prescription for some antibiotics.
At least I was lucky enough to have access to a doctor at all. Not everyone is always this lucky. So many people out there don’t even have health insurance at all. What is going on?!
I’m sure most of the readers of this blog already have a good idea of how broken the U.S. healthcare system is. I could rant for many hours on this topic. However, I’m just going to focus on one specific part of the problem right now.
- 78% believe there is a shortage of primary care doctors in the U.S.
- 49% said that over the next three years they plan to reduce the number of patients they see or stop practicing entirely
- 94% said the time they devote to non-clinical paperwork in the last three years has increased, and 63% said that paperwork has caused them to spend less time per patient
- 82% said their practices would be “unsustainable” if proposed cuts to Medicare reimbursements were made
- 60% would not recommend medicine as a career to young people
Now, the results of this study must be taken with a grain of salt, as there was only a 4% response rate, and there is obviously some self-selection bias at play. However, I don’t think anyone would disagree that “the proof is in the pudding.” I was unable to find a primary care physician in New York City, one of the largest cities in America, in a reasonable amount of time. There is something seriously wrong with the system, and with the future of primary care in this country.
I encourage you to read some of the actual responses from physicians at the end of the report. It was pretty eye opening for me, and it might just make you want to get out of your chair, go to the window, and scream, “I'm mad as hell and I'm not gonna take this anymore!”
I found this response to be particularly saddening:
“I put everything I have into treating my patients. I’m about to lose my family for nothing. Just because I try to take good care of my patients – but it’s just too much work and nothing in return. My children have suffered because of time without their dad.”
What are we to do?
What I Was Thankful For This Thanksgiving
Ben Bryner -- I had some time off last week to celebrate American Thanksgiving. I love Thanksgiving because it is one of those common-denominator holidays that includes everyone. (Well, it's easy to feel a little left out as a vegetarian, but it’s still not bad.) This time of year is obviously a good time to reflect on the blessings of family and friends, home and food, and the other important things. And if you're interviewing for med school or residency, it's also a stressful time where you might be thankful for a few different things than most other years. Here is a partial list of things I'm particularly thankful for on the interview trail:
1. Interviews. Although they're expensive and the arrangements are stressful, it's nice to have them. And as far as the actual interviews go, the ones I've had so far have been surprisingly low-key and enjoyable.
2. Stain removing solution. There are plenty of lunches and receptions with awkward eating arrangements on the interview trail that make this a must-have.
3. Stock questions. Sometimes the only thing that gets you through a late-afternoon Q&A with residents is a good stock question. Just as a good pile of snowballs is essential to a post-Thanksgiving snowball fight, developing a list of questions you want to have answered about every program is a wise move.
4. The patients I've learned from. Most of the questions in these interviews are about me as an applicant. These get pretty repetitive and aren't that interesting from my perspective. But sometimes an interviewer will ask about a memorable patient, or a more specific situation where it also makes sense to bring up an experience with a patient. And to me, this is a more interesting avenue for discussion than my research or volunteer experience or my year in Cirque du Soleil (okay, that last one would be interesting if it were true). Discussing memorable patients in an interview has basically the same rationale as Grand Rounds or other conferences that center around individual patients: that disease processes and therapies are only so interesting in isolation, but become much more comprehensible and captivating in the context of an individual person.
Not just while interviewing, but as a medical student in general, patients are the thing I am most thankful for. When you get down to it, access to patients is the whole rationale for building teaching hospitals and affiliating them with medical schools; patients are one of only a few elements of medical education you absolutely couldn't get by without. Last year at this time I reflected on how patients reminded me of Squanto, and I stand by that analogy even if nobody else thinks it makes any sense.
So these are a few of the things that I appreciate at this time of year. While you’re eating that turkey sandwich I’m going to go refill my supply of stain remover and stock questions before I hit the trail again.