Will I Be Ready?
Anna Burkhead -- Folks, it’s time. Prepare yourselves. The final frontier is upon us.
Well, the final frontier is upon me really, not all of y'all. And not really a final frontier actually, just the beginning of my last year in medical school. Forgive me, for I’m prone to hyperbole.
On Monday I will commence the first rotation of 4th year. It is an away, “audition” rotation, and will surely be the topic of a later blog. The fact that the rotation is entirely across the country, at a school I’ve never visited, with people I’ve never met, none of that scares me. What scares me is that a year from now, I (and every other newbie 4th year out there) won’t be starting a rotation, but instead starting work as a new doctor.
Our orders will matter! Our progress notes will be read and taken seriously! Our pagers will go off first! We will be the ones on call! We will be the ones making decisions at 3am! We will be the ones who are responsible when things don’t get done! We will….
Good gracious. We’re in for it, aren’t we?
I know that all doctors start off as interns, and that nearly all of them survive it. I know that I still have another year of learning before I will be expected to do the job myself. But I also know that I’m already thinking and worrying about what it’s going to be like. Is that normal?
I know that several residents and medical students out there have revealed their secret question, “When is someone going to realize that I don’t belong here / that I’m not smart enough / that I am never sure of my decisions?” It’s my secret question too. (I need to know… seriously… when’s it going to happen?)
Maybe I’m getting a little ahead of myself. It certainly wouldn’t be the first time. I’m a bit of a worrier. I still have a whole year to get more comfortable with medicine.
A whole year. The last year of this chapter of learning!
July 7, 2008 by Anna Burkhead | Comments (0)
Skin Is In
Anna Burkhead -- Serpiginous. Violaceous. Herpetiform.
Who else gets to use words like this on a regular basis?
Dermatology is skin medicine. Dermatologists see patients with diseases they cannot hide. While the majority of skin conditions seen and treated by dermatologists are not life-threatening, they are damaging to self-esteem, relationships, and overall health status.
(Although, as a side note, I would like to reference the article “Psoriasis: the heart of the matter”, in the March 2008 issue of Journal of the American Academy of Dermatology, which describes the relationship between psoriasis and heart disease: “The degree of risk for myocardial infarction conferred by severe psoriasis was similar in magnitude to that of other major cardiovascular risk factors such as diabetes.”)
But besides being an important medical field in terms of prevalence of disease and patient-centered outcomes, dermatology is just plain awesome for many reasons.
1. You get to see people from newly out of the womb to nearly in the grave.
2. Teaching prevention is super important.
3. You get to practice medicine ranging from primary care to emergency to surgery.
4. Instead of boring color names, you say “violaceous”, “erythematous”, “honey-colored”, “dusky”.
5. You get to do biopsies and surgical excisions pretty much every day.
6. When you help people, they can see and feel the improvement.
7. Your eventual career path can range anywhere from private practice cosmetic procedures to caring for HIV and transplant immunosuppressed patients and their myriads of skin problems.
As you can tell, I am very much enjoying my elective in Dermatology. Skin is in, and I’m stuck on it!
June 23, 2008 by Anna Burkhead | Comments (6)
The Scariest Med Student of All
Anna Burkhead -- We’ve all seen them. Lurking in the library. Buying residents’ coffee. Offering to do extra presentations or talks.
You know those med students I’m talking about.
The Gunners. Every med school class has them. Usually there are multiple Gunners to a class. Being a Gunner isn’t necessarily all bad, all the time. In fact, some people take it as a compliment, meaning they’ll go the “extra mile” to learn.
But it doesn’t stop there. There exists something much more evil and far more frightening. The evil med student archetype that you may not know about, though nearly every class has one, is The Gunner’s more extreme counterpart, The Sniper.
Being a Sniper is different. It’s all bad, all the time. The term itself is relatively new, occupying the extreme end of the med school overachievement spectrum. While a Gunner is aggressive, a Sniper is malicious. While a Gunner shows off, a Sniper puts you down. Next to the guy who coughs in your face every morning during Pediatrics, a Sniper is the last person you want to do a rotation with.
A few comparisons:
-GUNNER: Reads. A lot.
-SNIPER: Checks out all four library copies of the “suggested” textbook for your rotation.
-GUNNER: Puts his pager number at the top of the list on any given service.
-SNIPER: Creates the pager list on any given service, and accidentally mistypes the pager numbers for the other two medical students.
-GUNNER: Suggests during rounds that perhaps he could give a short presentation on Disease X, prompting you to follow with “And I can present Disease Y.”
-SNIPER: Approaches the attending after rounds to offer a similar presentation, and then surprises you by doing said presentation the next day, while you remain presentation-less and lazy-looking.
-GUNNER: Finds obscure online resources and/or notes from previous classes, posts 20 links to online forum under the heading “FYI”.
-SNIPER: Finds online resources and notes, denies having any study materials when asked by a classmate in need.
Unfortunately for them and for all the hard work they put into their craft, being a Gunner or a Sniper can backfire. (You get it? A Gunner/Sniper backfiring? Haha. Ok.) Residents and attendings often see right through the aggressive attitude, and some don’t like it.
I’ve had classes with many a Gunner, and rotations with a few, and been called one myself. I don’t think I’ve ever made direct contact with a Sniper (although part of their sneakiness lies in their non-identification). They can be hard to spot. Beware!
If anyone out there has had a run-in with a Sniper, or a particularly bad experience with a Gunner, do share!
June 12, 2008 by Anna Burkhead | Comments (71)
A Guide to Guidelines
Anna Burkhead -- Before medical school, and probably up until the beginning of third year, I had never even heard of “guidelines” in medical practice. I guess I just thought that docs prescribed what they wanted and ordered the tests that they wanted whenever they felt the need. Well, it turns out that there are entire organizations devoted to the creation of “guidelines”. Medical guidelines (also known as clinical protocol or clinical guidelines) are based on evidence and current data, and provide suggestions and criteria for prevention, diagnosis, prognosis, and therapy.
Guidelines have existed in some form or another since the advent of medicine. In much older times, they were based on traditional wisdom and authority, whereas today’s guidelines are evidence-based.
The purpose of guidelines is to provide the ideal (most effective and most cost-effective) care to patients and reduce risk for all parties involved in healthcare. Following guidelines also standardizes medical care and thus serves to diminish conscious or unconscious prejudice in doctors.
Doctors are not “required” to follow guidelines (no medical police will come after you if your patient with blood pressure 144/82 is not treated), but there may be questions for the doctor if that patient had a stroke or heart attack with untreated hypertension.
Many, many, many professional physician organizations produce guidelines. It can be overwhelming to sort through them. Here are a few good places to look for US medical guidelines.
* National Guideline Clearinghouse: http://www.guideline.gov/
(You can browse by organization or by disease)
* Agency for Healthcare Research and Quality: http://www.ahrq.gov/
(This is the parent organization to the NGC, above)
* American Heart Association guidelines: http://www.americanheart.org
(Click on "For Healthcare Professionals", then "Statements and Guidelines")
* American Academy of Family Physicians guidelines: http://www.aafp.org
(Click on "Clinical Care and Research", then "Clinical Recs")
* American Diabetes Association guidelines: http://www.diabetes.org
(Click on "For Health Professions", then "Clinical Practice Recommendations")
I have one last plug for clinical guidelines. Of course, knowing guidelines and adhering to them will protect your patients, yourself, and your future employer/organization. But, to all the medical students out there, nothing will make you look smarter, and impress your attending more, than to say (in the least snooty way possible! Make a mental note that constantly quoting guidelines will make enemies of your medical school peers, and will not impress attendings), “The recent updates to the AHA’s STEMI Guidelines give a Class I recommendation to early oral beta-blockers for STEMI patients without contraindications, whereas IV beta-blockers are a Class IIa recommendation due to the higher risk of cardiogenic shock.” Whew, that was a mouthful.
June 2, 2008 by Anna Burkhead | Comments (6)
A Syncope Mystery
Anna Burkhead -- This month, I am working at a Family Medicine clinic, my last core rotation of third year. It’s been a great opportunity for me to work on my basic diagnosis and treatment plan skills.
Last week, a middle-aged man came to the clinic for a hospital follow-up visit. He had recently been hospitalized after an episode of syncope in his bathroom at home and a subsequent loss of consciousness while driving later that day. In the hospital, a CT showed a small subdural hemorrhage, probably produced when he hit his head on the sink after fainting in the bathroom.
During his hospital stay, the man had an extensive workup, including several CTs, an MRI, echo, EEG, carotid doppler studies, tilt table test, and an EP study. All of the test results were within normal limits.
At the man’s clinic visit, we reviewed the results of his tests, including a follow-up CT that showed no residual subdural blood. The neurologist had cleared him to drive with caution. The patient had had no further episodes of syncope since being discharged from the hospital.
The doctor and I explained to him that no apparent etiology for his syncope had been found in his medical workup. He was surprised to learn that this was not uncommon; isolated episodes of syncope are very often followed by negative workups, and the episodes remain unexplained.
As the visit progressed, I observed the initially calm and friendly man become more and more agitated, desperate, and frantic as he realized that we weren’t able to provide an explanation for his fainting. He stuttered questions, produced a few beads of sweat, and after we left the clinic room, he called me back for more questions.
This man’s anxiety was palpable. For a brief moment, I wished that the workup had provided a reason for his syncopal episode. Then I realized that wishing such a thought meant wishing that this man had something structurally or metabolically wrong with his brain or heart. I tried my hardest to explain that isolated episodes of syncope were often just that: single (non-recurrent) incidents, without significant associated pathology.
The man eventually ran out of questions and left the clinic. He had arrived expecting an explanation, something to make the scary events he had suffered make sense. He left with little more than a copy of his hospital test results.
There was little else to do in this situation. Every reasonable test and study had been done. There was nothing left to do but reassure the patient that no significant pathology had been found. Sometimes doctors and medicine cannot provide answers. Whether that’s because the answers don’t exist, or because we’re unable to uncover them, I’m not sure. But I know that it can be frustrating to the patient looking for logic, as I observed here.
May 19, 2008 by Anna Burkhead | Comments (9)
Doctor-Speak 101
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 :)
May 9, 2008 by Anna Burkhead | Comments (13)
Obstacles to Learning
Anna Burkhead -- Sometimes, no matter hard you try to avoid them, obstacles are presented in the path to learning. Some of these roadblocks are surpassable, and others, depending on how they came to be or who put them there, are not.
I am finishing up my 8-week surgery rotation with 2 weeks on a urology service. I picked urology from the list of surgical specialties because I didn’t know much about it, and because I heard the surgeries were interesting and never too long.
Now almost done with urology, I have learned a lot about the field, and I agree that the surgical cases are cool. However, there is one attending on the service who has created, in my opinion, some roadblocks to learning for me.
First of all, I get the sense that having a medical student is a nuisance to him. He has, on several occasions, "pawned me off" to nurses or PAs. Of course, I can learn from nurses and PAs as well, but I am supposed to be learning from him, and feeling bothersome is not fun.
Also, he often enlists me to do paperwork. In this regard, I feel helpful, and I don’t want to seem ungrateful for a learning experience in the "red-tape" aspect of medicine, but while I am doing paperwork, he is interacting with patients in a way that would be educational to me. In this way, I am missing out.
The third, and most significant obstacle is the one I’m most disappointed about. Most of the patients on the urology service are men, and most of their clinic visits require genital exams. I thought that spending time in a urology clinic would give me more experience and confidence with this exam, which will certainly be important if I become a dermatologist. However, at the point in the clinic visit when the genital exam is to happen, the attending has a habit of asking me to leave, or taking the patient into another room and shutting the door after them. These are patients with whom I have already had 30-minute conversations, including discussion of urinary and erectile function, so my presence during or participation in a genital exam would have been neither unexpected nor significantly embarrassing.
This is one of the first times I have felt that my presence is a nuisance to a doctor in a clinical setting. It’s also the first time I’ve been blatantly deprived of a learning experience, and I think it’s because I am a female, and a young one at that.
I know that one solution to this problem would be to address my concerns to the attending. Unfortunately, I do not feel comfortable with this option, and with only a few days left in the rotation, I don’t want to rock the boat. So, in my opinion, there’s not much I can do to solve this situation, other than to recommend improvements for next year’s class on my rotation evaluation. Just wanted to share the experience.
April 28, 2008 by Anna Burkhead | Comments (18)
Med Student Presents With New-onset Confusion
Anna Burkhead -- Chief Complaint: "confusion"
History of Present Illness: This is a 20-something year old female medical student who presents with new-onset "confusion" over creating her schedule for the final year of medical school. This state of mind has been slow and gradual in its onset for months but has been most evident and distressing since the patient’s required class meeting for planning. The bewilderment is characterized by indecision, staring spells, and detail obsession. Aggravating factors include conversations on the topic of 4th-year planning with peers and the rapidly approaching schedule due date. Alleviating factors include sleep and red wine. There are no associated physical complaints other than those already mentioned.
Review of Systems: As in HPI.
Past Medical History: No significant medical problems. No medications. No allergies.
Social History: The patient is a third-year medical student currently in her 3rd year surgery clerkship. She thinks her main field of interest is dermatology. Non-smoker, no drugs, occasional social alcohol.
Family History: No medical problems run in the family.
Physical Exam:
VS: Afebrile, vitals stable and normal
General: Well-appearing petite female with bitten nails, sitting on examining table and clutching surgery review book.
Neuro: Grossly intact.
Mental Status: Alert and oriented x 4. Calm with periodic psychomotor agitation including toe tapping and hair twirling. Good eye contact. Speech has normal rate, tone, volume. Mood is "sometimes anxious". Affect is congruent. Thought process is linear. Denies AVH, paranoia. Language is fluent, cognition is within normal limits. Recent and remote memory intact.
Assessment and Plan:
This is a young female medical student presenting with stress over 4th year scheduling. Suspect that this is due to the immediate issue of unclear process and intimidating paperwork, as well as the larger issue of major decisions about the future, including applying for residency, that need to be made soon. Will encourage positive actions such as researching electives, discourage obsessive arranging/rearranging of options, and prescribe consulting meeting with career goal advisor, as well as sleep when possible. Return to clinic as needed.
April 14, 2008 by Anna Burkhead | Comments (4)
How We Learn
Anna Burkhead -- I am three weeks into my eight-week surgery rotation. I’ve been in the OR every day, but except for an appendectomy or two, all the surgeries I’ve seen have been scheduled (ie – not emergent, not traumatic).
All scheduled, except for one.
On my last call night, the surgery intern paged me and told me to come see consults with him in the ED. When I arrived, he was examining a man on a stretcher, and he asked me to begin the work-up on an elderly lady with a large abscess on her back. I didn’t get a good look at the man he was examining, except for the fact that he had a very bloody bandage on his arm.
About an hour later, I was in the OR watching a lap-chole when the intern arrived to tell our mid-level resident and the attending about the patients in the ED. He gave the short story of the woman with the abscess, and then said, "…and the other patient is a middle-aged man on dialysis who is having bleeding from the site of his AV fistula. I wrote orders to admit him." The attending said he’d go "eyeball" the patient as soon as they were done.
Twenty minutes later, I was in the surgeons’ lounge when I got wind that there was an emergent surgery about to begin in OR 3. My stylish hairnet and I (see picture) scurried over. Upon entering the operating room, I couldn’t see much of the patient, who was already prepped and draped, but I did see a large clot hanging out of a ragged opening in the arm strapped to the armboard. It was the patient with the AV fistula.
After the attending and the chief resident speedily repaired the man’s leaking fistula, the chief approached the intern. "You know he would have died, right? He would have been admitted to the floor, the nurses would have thought he was getting sleepy, and he would have died." I watched from a respectful distance as the intern nodded at the chief’s words.
It wasn’t much of a scolding, more like a passing of wisdom and lessons learned from a senior to a newbie. I realized I was witnessing a moment and a lesson that this surgery intern would never forget. It might be the scene that he’d relate to his own young intern, four years in the future, when he is finally a surgery chief.
The fields of medicine and surgery have checks and balances because scenes like the one described above happen occasionally. This is how we learn.
April 2, 2008 by Anna Burkhead | Comments (38)
How to Survive Pimping in the OR
Anna Burkhead -- WARNING: Attempt at humor ahead … Abort your reading if you must…
I’ve written previously about “pimping”, the well-honed tool of many attendings to test students’ knowledge, and/or torture them. Now that I’m on my Surgery rotation, I’m spending more face time with attendings than on any other service. To what does this translate? Multiple un-interrupted hours of being pimped, each and every day in the OR.
For the most part, I don’t mind being pimped, because I know I’m not expected to know everything. Also, I rarely forget the answers to the questions I miss. Pimping can be a good teaching tool.
But some students detest being put “on the spot”. This is a column for these students.
How to survive being pimped in the OR:
-When asked a question, try your best to answer. When wrong, try a pensive silence. If you’re silent long enough, maybe the attending (engrossed in his gastrojejunostomy) will forget he ever asked the question.*
*May be effective only with older attendings.
-Answer a different question (correctly). Example: Attending – “What are the boundaries of dissection for a mastectomy?” Student – “Well, I don’t know, but if we were doing an axillary dissection, the borders would be…” You can still sound smart!
-Never forget that the student wields the suction. Stick the sucker-thing in a shallow pool of blood in the abdominal cavity, and it may create a gross sucking noise loud enough to drown out the nonsense answer that you know is wrong … but you may risk a blood spatter. Due to the risk of this OR foul, this should be your last resort.
-Answer with another question. This is probably the most “smooth” escape plan.
-Before the surgery, tell the attending that you’re hearing impaired. Explain that with masks on, you can’t lip-read.*
*This is probably a bad idea.
-Ask if you can “phone-a-friend”. Most attendings are ok with you passing the question to your intern or resident. Unfortunately you only get an average of two “phone-a-friend”s per surgery.
-Use humor. Example: Attending – “In what situation would one observe a ‘winged scapula’?” Student – “When the patient is in a bathing suit.”
When all else fails, and you know you’re going to be pimped during surgery the next day, here’s a novel idea: Study in advance! The best way to survive long pimping sessions in the OR is to be prepared and to impress with your knowledge. It’s not the easiest or the most fun way to make it through your Surgery rotation, but it is gratifying and it works!
Good luck to all :)
March 24, 2008 by Anna Burkhead | Comments (20)
What Makes a Bad Medical Student?
Anna Burkhead -- Residents on “core” services such as Internal Medicine, Surgery, and OB/GYN work with a lot of medical students. Since their schedules don’t always entirely line up with students’ schedules, they may work with a new student as often as every 1-2 weeks, or as long as a month, for every year of their residency.
That’s a lot of medical students! And as much as I would like to believe that all of the students are stellar in knowledge, dedication, and attitude, I know it is not true.
I would venture to guess that most of the medical students reading this entry have been told by a resident or attending at some point that they are “good” students, or that their work has been “excellent”, or their write-ups “outstanding”. It’s easy to praise someone to their face. It’s not as easy to tell them they’re doing a bad job. Therefore, if you’re a “bad” medical student, you may not know it until you get your evaluations back. And at that point, it’s too late to change.
(At this point you may be asking yourself, “If I’ve never received any true positive feedback face-to-face, does that mean the residents have only negative feedback for me, and that I’m a ‘bad’ medical student?” Hmmmm….)
I’ve asked a few residents to give me a few tips, and I’ve compiled a list of things that make a medical student “bad”:
-#1 overall = BAD ATTITUDE. If you balk when your intern asks you to write the note on your patient for that day, or if you repeatedly say no to scrubbing in on late afternoon OR cases, you may be a bad medical student.
-Disappearing for extended periods, multiple times per day, to read or nap or goof around. I’m not saying you need to be married to your team, but make them aware you’re available and willing to help.
-Not appearing interested. Even if you detest surgery, or if you’d rather poke yourself with a MRSA-flavored fork than interview a manic patient, try to make a conscious effort to look engrossed. This may be as simple as altering your resting facial expression.
-Correcting your resident on rounds, or its extreme variant, “The Reverse Pimp”. Some medical students get so bent out of shape over being asked difficult “pimp” questions that they decide to try the “taste of your own medicine” routine. If you ask your resident or attending a question that is fact-based, a picky detail, or something that you’d find in a long paragraph of your basic science book, and you don’t ask it in a curious “I’m asking because I don’t know” manner, you may be a Reverse Pimper. Steer clear.
The above are just a few characteristics of “bad” medical students; there are countless others. Take a glance at the column “How May I Help You?” and think of the opposite.
My last point is this: even if you’re not the smartest 3rd year ever to don a short white coat, never fear. Not knowing answers does not make you a bad medical student. Attitude and work ethic count for a lot!
(Disclaimer: In no way am I claiming to be the polar opposite of a “bad” medical student, that is, a “perfect” medical student. Just sharing observations and solicited advice :) )
March 15, 2008 by Anna Burkhead | Comments (103)
Could It Be?
Anna Burkhead -- What is third year doing to us?? A few days ago, my third year class had our required meeting to plan for fourth year. Scary, right? Besides nearly making everyone’s incidental aneurysms burst from stress about schedules, away rotations, and residency applications, this meeting is generally dreaded for another reason.
My Class of 2009, I love you all, but we are a little ridiculous sometimes.
We had a similar meeting about a year ago to plan for third year. Also included in this meeting was information about registering and studying for Step 1. At this time last year, our “ridiculousness” as a class was evident in full force. People asked the exact same questions, phrased differently, over and over. Other people groaned out loud when this happened. Gunners asked questions that weren’t applicable to our class for another 12 months (personally, I still think some of them do it on purpose to freak the rest of us out). My “favorite” type of question is the one asked by an individual medical student on a situation that applies only to that person, and to no one else. Then the rest of us are stuck listening for five minutes to a solution to a problem we will never have. Ask these questions later people!!
The paragraph above is a description of the meeting in 2007. This year, things were different, thankfully and shockingly so.
We arrived on time (mostly). We were dressed appropriately to meet with faculty from our desired specialties (with a few exceptions). We (more often than not) avoided question re-asking. (Almost) no one wanted to know what to do about their individual research project that will be presented in August which is the month they wanted to do their away rotation in Surgery but not with Dr. XYZ because he’s mean but they like Dr. ABC and would like to get a letter of recommendation from him and who can they call to set that up?
What has third year done to us? Is it possible that the petty students we were last year are morphing into mature professionals?
In fourteen months will we be ready to be called “doctor”?
I think we are on our way.
March 3, 2008 by Anna Burkhead | Comments (0)
When Doctors Become Patients
Anna Burkhead -- An otherwise healthy, middle-aged patient was admitted to the Neurology service last week with new-onset ataxia, clumsiness, and weakness. Pretty interesting, right? For me and the other students, yes. But for the Neurology residents, it was just another presentation of a new patient on rounds. Until came the punchline: “He’s an oncologist”. They looked up from typing their notes, entering orders, and whatever else they were doing to ask, “How old is he?” “When did this start?” “What are his symptoms again?”
We finished this patient’s presentation and went on to the next patient. But before we got too far into the H&P, a nurse entered the conference room and informed us that the “doctor patient” was getting agitated, because he thought we would be in to round on him much earlier in the morning. So, we decided to do “walk rounds” for the rest of the new patients, and we left as a team to go tend to the doctor patient.
He was still down in the Emergency Department, because a bed had not opened up on the floor. A family member was with him, and she promptly informed us that she was a physician as well. She demanded in a firm, bordering on insulting way to know why his blood pressure hadn’t been addressed since he arrived. Eight pairs of eyes immediately fled to the monitor blinking “160-something over 100” and one pair of eyes (the intern who had been on call) fled to her stack of papers as she tried to organize her thoughts.
We spent nearly 20 minutes in the ED bay with this patient, which is more than we usually spend (since there are usually at least five new patients on the service every day). The attending discussed his thoughts and differential diagnosis frankly with the patient. He showed him the MRI. The leading possibilities for what process was causing his symptoms were all fairly serious. When the attending recommended a lumbar puncture to be done later in the day, the patient nearly jumped off the bed in surprise. “NO WAY am I having that done,” he exclaimed. “I’ll let you think about it,” the attending replied.
Later in the afternoon, I went with my senior resident to check on the patient and to find out whether he’d made a decision regarding the LP. When the resident asked him if he’d agree to it, the patient said nothing and continued to stare out the window. His family member informed us that, yes, he’d go through with it, but he was not happy about having to undergo the procedure. (As if we couldn’t tell…) I stepped outside to get the consent form while the resident gathered all the necessary supplies. We decided to do the LP right then and there before he changed his mind!
I haven’t seen that many LPs, but I’ve seen a few. They go pretty smoothly; the patients tolerate it well. Afterwards they say, “That wasn’t as bad as I thought it would be.” I thought this LP would be no different, but I was wrong…
The patient, a grown, middle-aged, medical professional male squirmed and screamed throughout the entire process, from the application of the betadine to the application of the band-aid. The combination of the patient’s uncooperativeness with other non-controllable factors made it a difficult LP, and it took nearly an hour to perform.
The remainder of the patient’s hospital stay was equally difficult, with many special requests and lots of opposition.
It turned out that the patient did, in fact, have something serious as the cause for his symptoms. Maybe deep down he knew that, and his behavior was a reflection of his fear and uncertainty.
Has anyone out there had experiences with doctors or other healthcare professionals turned patients? This was my first time. How do attendings and residents usually react? Are they treated differently? Do they always make for difficult patients?
February 22, 2008 by Anna Burkhead | Comments (25)
Why It's Great to Be a Perma-Student
The clinical years of medical school can be a bit confusing, because at times, depending on the service and how much confidence they have in the student, the medical student can feel more like “a real doctor” and less like a student. But when the time comes to write orders, answer a page about a new admission, or cash a paycheck, reality sets in: We are still students.
But I am here to say that it is not such a sad reality. As much as I am excited to be a doctor in fifteen months, it’s not such a raw deal to be a student. In fact, it’s pretty great. Here’s why.
- Every six months I get a letter from the loan company I used during my undergraduate studies. Every six months, the gist of this letter is, “We checked. You’re STILL a student. Have another six-month deferment on paying this loan back. You’re welcome.”
- We can bounce crazy ideas and medical theories off doctors all day. We can even put them in the chart, since our notes only “sorta” matter. We are fortunate that we are not yet legally responsible for the medical care of patients.
- We’re not really expected to know anything… anything…
- It’s easier to explain your job to a person you’re meeting for the first time:
“I’m a medical student.”
vs
“I’m an intern. What? No, it’s different from an unpaid summer employee.”
or
“I’m a resident. What? Oh, yes, you’re a resident too. Of North Carolina.”
- We have more time to spend with patients.
- Two words: SPRING BREAK!!! (What happens in the med student call room stays in the med student call room….?)
- Who doesn’t love doing rectal exams?
- We occasionally get breaks from the tedium of rounds or floor work to attend a required lecture or workshop.
For the reasons listed above, along with many others, I am going to savor the next fifteen months. They may be my last years as a student, in the traditional sense of the word.
Sure, I complain with the best of them about all the board exams and shelf exams and digital rectal exams, but the truth is, a student’s life is a good life.
February 6, 2008 by Anna Burkhead | Comments (13)
Selfishness in Medicine
I was having a conversation with a peer recently who confessed to me that she finds herself to be more selfish than she was before medical school. Kendra wrote many months back about medical training magnifying that little square of selfishness that is in all of us. While it’s sad to say, much of the way that the medical school curriculum is set up (especially in the clinical years) is conducive to focusing on oneself.
And I guess a radical question might be, isn’t that the way it should be?
Yes, medical training teaches us to care selflessly for patients, putting their comfort and health above all else. That’s a given.
But in the clinical years of medical school, patient care is not supposed to be our priority. That’s the residents’ job. Yes, we are supposed to contribute and we are certainly supposed to be compassionate. However, the number one goal of med school’s clinical years is to continue to learn medicine (in a more concrete setting). And although being on the wards can certainly feel like being “a real doctor”, the fact is, we’re still students.
And what do students do? They study and take tests. They get grades. Those grades are important for future career plans.
It’s easy to forget about this part of med school’s clinical years. It’s easy to stay all day on the wards with your team, discussing patient care. And we should do a lot of that, but we also need to break away at appropriate times to study and complete some of the more structured learning components. After all, we’re still students, we’re still graded, our grades still matter.
So try not to feel too guilty (or “selfish”) when you take some time away from the team to study. Patient care will be your responsibility soon enough. For now, choose wisely how much learning you do on patients and with your team, and how much learning you do from your books. It’s not “selfish”, it’s smart.
January 30, 2008 by Anna Burkhead | Comments (11)
Psych Me Out
“Well, why don’t we try putting your belongings in the bags, and if they don’t fit, we’ll get some more bags.” My response seemed simple enough. My patience was running thin. I didn’t understand how a person could be so anxious about something as minor as fitting clothes in bags, especially when there was a simple and ready solution nearby (more bags), should any difficulties arise.
In this patient interaction I found myself reassuring the patient many times on many topics. To me, most of these topics were unworthy of the level of anxiety that this woman was exhibiting.
The funny thing is: on many days I find myself on the other side of an interaction very similar to this one. I am the anxious person, angst-ing about one thing or another, and someone, usually a friend or parent, is reassuring me and offering solutions. Of course, my angst-producing issues are worthy of the worry in me.
Or are they?
If anxiety is a spectrum, this patient would be at one extreme. I would place myself somewhere in the middle. To me, this patient’s worries are extreme and unreasonable. But what do my worries look like? Is my fear of flying irrational? Is my test anxiety excessive?
So far in my Psychiatry rotation, I have seen parts of myself and exaggerations of my traits in multiple patients. Every time I feel myself becoming frustrated with these patients, I stop and take note. Oftentimes, the behaviors that irk me are extreme versions of things that I (and many others) do.
The point I want to make is this: when you have a patient who gets your britches in a bunch, and you find yourself getting frustrated, make a mental note. It’s entirely possible that the quality that irks you is one of your own, only magnified a bit and shown in mirror image. Just a thought!
January 16, 2008 by Anna Burkhead | Comments (4)
Things to Come in the New Year
When the clock struck midnight, the champagne flowed, the couples kissed, and I sighed with relief because I had made it to midnight without falling asleep. I didn’t reflect on the previous year or anticipate 2008 too much for the rest of the evening, but my trip back to Chapel Hill the next morning provided plenty of time for that. I thought about the things to come in 2008. I came up with a few goals. I’m not going to call them New Year’s Resolutions, because I feel like it implies that there was a problem to be resolved. Instead, I’ll just stick with New Year’s “Ideas”.
This year, 2008, will be the year in which I apply and interview for residency positions. That, in itself, is a scary thought. But you know what’s scarier? In order to apply and interview for residency positions, I need to actually decide what I want to do with my life! Will it be delivering babies and living life in the fast line with OB/GYN? Or will I stick with my original love, and take a risk at the same time, by applying to the extremely competitive dermatology programs? This is not a small decision.
This year, 2008, will be the year in which I gain confidence in clinical decision-making and feel comfortable talking to patients on any service. In the next five months of third year, I will finish all my core rotations and hopefully have a clue, no matter which patient’s room I walk into.
This year, 2008, will be the year that I learn and practice new procedures and skills. My hands get antsy after talking to patients and doing hands-off interviews over and over. I will be more assertive about stating my desire and intention to perform (or at least participate in) new procedures.
This year, 2008, will be the year that I don’t ask for a fork in a Chinese restaurant. (I am working on overcoming a long-standing fear of unfinished wood… don’t ask.)
The upcoming year looks to be a big one! At this time next year, my fellow medical students and I will be a lot closer to a definitive career path, due to decisions made and plans put in motion in the next 365 days.
What are your New Year’s Ideas, professional or otherwise?
January 3, 2008 by Anna Burkhead | Comments (8)
How to Survive an Away Rotation
Not having a spouse or children, I knew that my chances of getting placed in Chapel Hill were slim to none, so I purposely requested to be sent to my hometown for most of my rotations. I figured that if I specified my hometown as an “away” site, I’d probably get placed there, instead of some more remote city I wasn’t familiar with. I played my cards right, and have done several rotations at home.
This month, I am assigned to a city near the coast, at a hospital I’d never seen, in an apartment provided by the hospital, with a roommate I’d barely met. It’s been a few weeks now, and although things started off a little rough, I’m adjusting to the setting. Too bad the rotation’s almost over!
To help other medical students adjust to “away” rotations, here are some tips and some vital pieces of information that will help you become more comfortable in a “foreign” city, hospital, or living situation.
1. The day before your rotation starts, take a walk through the hospital. Find the Emergency Department, Cath Lab, Radiology, Physician’s Lounge, and coffee shop.
2. On your first day, ask your intern to walk you through the hospital’s computer system and charting. Find out where to get patients’ vitals and up-to-date medication lists.
3. Bring your own bed sheets. They usually don’t provide them in student housing. (Would you want to sleep on them anyway?)
4. Ask for important phone numbers, and write them (as well as all the pager numbers of your team members) on a notecard. Numbers to know include the hospital operator, the Radiology listening line, long distance dialing code, telemetry monitoring room.
5. Cereal. Always a great meal in an unfamiliar living situation.
6. Ask a medical student who has spent time at the site to give you the details on call scheduling, pimp questions, and helpful things medical students can do during rounds at the site.
7. The day you get your ID badge, make sure it works at the entrances and badge-access locations. It’s a pain to get it fixed later.
8. Carry a little cash in your white coat and scope out the cafeteria. You never know when the department will have a “residents only” meeting, or when lunchtime conference will be cancelled and you’ll be on your own.
Although it’s difficult being uprooted and sent to unfamiliar hospitals, I feel fortunate to have the opportunity to do my rotations at several sites. This way, I get to learn different charting systems, experience different call schedules, and see different patient populations. If your school allows you to schedule rotations at away sites, I highly recommend doing at least one month in a new setting. Take these “Tips for Survival” along with you!
December 13, 2007 by Anna Burkhead | Comments (17)
The White Coat: Not Just for Hiding That Coffee Stain on Your Shirt
The tradition of the physician's coat seems to have begun in the 1800s, as physicians turned to science to distance themselves from medical “quacks” and disreputable “healers”. Thus, the first “white coat” was actually a “lab coat”, and it wasn’t white, it was beige. Towards the end of the century, the coats became white to symbolize purity and cleanliness.1
Gradually, the use of the white coat became more and more widespread, and by the 1970s, almost all media depictions of physicians included a white coat as the identifying accessory.
There are many interpretations of the meaning and symbolism of the white coat. It communicates the physician’s intent as a medical healer, and it helps create and maintain a professional barrier between doctor and patient. However, some say this barrier is detrimental to the patient-physician relationship, as it conjures a formality that may dampen communication that is vital to medical care. Nowhere is this separation between plain-clothes patient and white-coated physician more evident than in the following passage from W.H. Auden’s 1969 poem, “The Art of Healing”:
Most patients believe
Dying is something they do
Not their physician
That white-coated sage
Never to be imagined
Naked or married
It is evident from those few lines that physicians were regarded at that time as being “above” most human functions, like dying, sex, or marriage. And still today, patients keep the expectation that a physician’s training places him above temptations of gossip, entertainment, and of the flesh, as they allow us insight into their darkest secrets, and they allow us to explore their bodies with our eyes, hands, and tools.
No matter how the tradition of the white coat began as a representation of a physician’s sincerity, or how it has evolved today to be the uniform of many other hospital workers, the fact remains that the white coat is a symbol of an intent to heal. And though it may occasionally incite crying in a child or blood pressure elevation in an adult, the white coat also engenders trust in many who see it. Accordingly, the next time you sling your coat over your shoulder to pre-round at 5am, or the next time you find yourself pouring bleach into your washing machine for the third time that week, remember that the coat is more than just a shirt protector and pocket for your reflex hammer. It’s a tradition that far precedes this generation of doctors and medical students, a privilege, and a responsibility.
December 3, 2007 by Anna Burkhead | Comments (13)
A Little Encouragement Goes a Long Way
As third year students, we are required to request evaluations from members of the teams we work on. It feels like I hand out that evaluation form fifty times per rotation. Then it feels like I follow-up on collecting the fifty different forms from every attending, resident, phlebotomist, and candy-striper in the hospital. I am happy to say that most of the feedback I’ve received from evaluators has been positive. Not the knock-my-socks-off amazing type of positive, but I appear to be doing a fine job, judging from the comments.
While I always appreciate the feedback, it wasn’t until I received some very generous, complementary face-to-face comments on my Cardiology rotation that I felt truly encouraged. The attending took time to meet with me in his office, he personalized his comments, and he even asked if his pre-med daughter could email me for medical school advice.
At this point in my medical career, the confidence that I have in my clinical decision-making is pretty measly. I think one of the big goals of third and fourth year is to build this confidence, and my attending gave me a big boost in this respect. I left his office feeling encouraged, appreciated, and so happy I could bust the buttons on my white coat.
This feedback session came at the midpoint of my Cardiology rotation, and for the rest of the month I worked like a madwoman to impress. The positive comments sparked a burner under my butt to work hard and stay on my toes. After all, ‘tis a far worse crime to impress and then disappoint, than to never have impressed at all.
I am so thankful that my attending took the time to give me such personalized feedback. Here, at the halfway point of my first clinical year, I have gotten a leg up on the steep climb to feeling confident in my skills as a doctor. My upward pace was spurred by an experienced doctor’s approval, and I’m grateful for the push!
November 23, 2007 by Anna Burkhead | Comments (4)
How May I Help You?
However, it is entirely possible that a medical student could do absolutely zilch to lighten the work load. If your residents don’t expect you to write the patient’s daily progress note, follow-up labs, or call for consults, and if you leave the hospital after a lecture without checking to see if you can help out in any way, a medical student can get away with doing essentially nothing all day, and thus being essentially no help at all.
Hopefully most medical students aren’t that lazy, and hopefully most of us are a lot more invested in our learning than to just float by every day. For the students out there who want to be helpful, but aren’t sure how, here are a few things I have found that your residents will be eternally grateful for. (Warning: some of this qualifies as “scut work”, but we all have to start somewhere, right?)
1. Round on your patient before your resident does. That way the pertinent, most pressing issues will be addressed first, and the resident doesn’t have to weed through 80 lab values to find your patient’s elevated cardiac biomarkers.
2. Don’t rely on the resident to keep you informed of what’s going on with your patients. Take the initiative to ask last night’s on-call team for any overnight events. Know approximately when consults are going to happen, and follow-up on the note yourself.
3. If your resident doesn’t expect you to write the entire daily progress note, for goodness sakes at least write in all the vitals and lab values for them! A trained monkey could do that.
4. If the patient is a transfer or has gotten relevant medical care elsewhere, get the records release form, fill it out, fax it over, follow-up on the information.
5. Make your resident look good on rounds! Subtly mention that he/she taught you all about acid/base stuff or valvular disease or whatever, after you answer the attending’s question correctly.
6. Print out the patient census for everyone in the morning. Takes 30 seconds.
These are just a few easy things that any medical student can do to make their resident’s day a little easier. Because let’s face it, they have a whole lot more responsibility than we do right now. The next worst thing to being a horrible medical student is being a medical student who’s just “there.” Take initiative! Offer help! Your residents will thank you.
November 12, 2007 by Anna Burkhead | Comments (35)
Average Medicine
I think that this Cardiology block might be the most important rotation of third year. My previous rotations were Pediatrics, OB/GYN, and a short course in acute life support. While the skills I gained in those rotations are absolutely invaluable, and I enjoyed them immensely, the “average” American is not a child, a pregnant woman, or in cardiac arrest. The average American, according to statistics, is the patient I see every day, ten times a day, on the Cardiology rotation.
This is certainly not a diatribe on the state of my country’s people. It’s simply a statement that the Cardiology patient population overlaps with the American population more than many other specialties. The average American is late middle-aged, overweight, and has a few bad habits to spare. The average Cardiology patient is late middle-aged, overweight, and has a few bad habits to spare.
I don’t anticipate that I will end up specializing in Cardiology. But I am very glad that I was assigned to this service of Internal Medicine. No matter what field I enter, heart patients will be there. And they’re not the extreme characters portrayed on TV and movies, with exclusively McDonald’s diets, a permanent place on the couch, greasy hair and no job. They are our neighbors, teachers, family members. They lead average lives. They have average, non-extraordinary problems. They are average patients.
The medical student’s aversion to the word “average” is a matter to be discussed in another posting. Right now, this particular medical student is learning the true meaning of the word, how it applies to medicine, and in the process, learning to provide extraordinary care to ordinary people.
October 31, 2007 by Anna Burkhead | Comments (2)
Recovering From a Vacation
Time for Cardiology!
I enjoyed the Cardiology block during second year. It was early in the year, and it was the first time that I found mathematical logic and problem-solving skills to be useful in medicine. But, I have heard whisperings from students in my class that the block is more than challenging for even the most prepared students in my class. I’ve heard the hours are cruel, the attendings intimidating and even harsh, and the patients’ medical histories frustrating.
To top it off, although I’m eternally grateful for the free time that is now coming to a close, it has gotten me out of the daily rhythm of the hospital. I’m worried that instead of being refreshed and rested after my vacation, I’ll be slow and unsure.
My time off was barely a couple of weeks. It makes me wonder what medical students or professionals do when they have to take off more than a few weeks. What if a family member gets sick? What happens if and when I have a baby? There are many other reasons why a person would need to take a sabbatical.
Is it easy to get back into the “swing of things”? Or do you spend as many days catching up as you spent away from the hospital?
Of course, a solution to ease the return-to-work shock is to maintain a diligent work ethic while away. A student could study, do practice questions, and organize resources. A doctor could keep up with literature and review old cases. But this maintenance work is not always possible, especially if an illness or a new baby is the reason for the time off.
I chose medicine as a career for many reasons, including the opportunity for lifelong learning, the ever-evolving information, and the fast daily pace. But these same factors make it difficult to take the breaks from work that are occasionally necessary throughout adult life.
Let’s hope I get off to a good start!
October 21, 2007 by Anna Burkhead | Comments (0)
A Little Time Off
After I finished OB/GYN, I had a week of training in the acute care setting to get ACLS certified. And now -- medical students pay close attention -- I have some real, un-interrupted, call-free and shelfless free time.
And I barely know what to do with it!
I find myself waking up, looking at the clock with red numbers spelling out 7:04, and having a moment of panic. I’m missing rounds! I didn’t even pre-round! And then I remember that I have no patients, there’s no one to round on, and I go back to sleep.
Also, in reading a book, (for pleasure!! Reading for pleasure! Remember that?) I find myself re-reading important paragraphs to glean all the worthwhile details, reflexively trying to think how a test question could be posed. And then I turn off my internal test question generator, for this material is not test-able!
I rented a movie, too. Jealous?
I am actually feeling a tad bit guilty; maybe I should be preparing for the next block. Maybe on these days off I should go shadow doctors in fields I haven’t seen yet.
I think not. As students, we are fortunate to remain under the motherly, scheduling hand of a university. We still get some time off here and there, some breaks between long stretches of patient write-ups and black weekends. When we become residents, we will not be as lucky. So, it would be crazy not to take advantage of the unscheduled time given to medical students, right?
With that in mind, if you’ll excuse me, I’ve got some free time to spend!
October 10, 2007 by Anna Burkhead | Comments (8)
A Funny Thing Happened on the Way to the Nurses' Station
The hospital environment includes many different people with many different titles. As medical students, most of our interactions are with doctors and nurses. The relationship between doctors and medical students is well defined. We are in training for the job that they perform every day. Also, the doctors and residents evaluate us and dictate a final grade.
The relationship between nurses and medical students is less easy to define. Although we are both in the medical field, we’re not entirely in the same line of work. Of course, all people should be treated with respect and in a professional manner, but what exactly is the working relationship between medical students and nurses?
So far during third year, I have met many nurses. Some of them have been extremely helpful and nice to me, going out of their way to show me the inner workings of the hospital. Others have been less polite.
Once, as I was standing in the hall looking at the Labor and Delivery board to determine which patient I needed to see next, a nurse I had never met walked up to me, held out a stack of papers, and said in a demanding voice, “Take this to 8A.” Reflexively, I reached out my hands for the papers, and the nurse turned around and walked off. No “please,” no “thank you,” no “Hi, I’m so-and-so, would you mind….”
On another occasion, I was sitting at a work station with my intern, and I overheard two nurses discussing a patient who was getting an IVC filter. “What does IVC stand for?” one of them said. She walked around the nurses’ station to my intern, who was on the phone. She tapped the intern on the shoulder and repeated the question, “What does IVC stand for?” The intern, on the phone with our attending, didn’t respond. Since I was less than two feet away from this interaction, I felt it was ok for me to answer the question. “It stands for Inferior Vena Cava,” I said, loud enough to hear. The nurse looked at me, rolled her eyes, and went back to the nurses’ station. When the intern hung up the phone, again the question was posed, “What does IVC stand for?” The intern answered, “Inferior Vena Cava.” “Oh,” came the response from the nurse.
I am 99.9% sure that these examples are exceptions, and that it was the personalities of these two particular people that caused them to act in this manner. But, I can’t help wondering if I’m missing something -- some unspoken dynamic that exists between nurses and medical students. I haven’t had similar experiences with the residents that I’ve worked with. Am I giving off an “I have a negative attitude” vibe? Do I exude the “I’m somewhat clueless” signal so strongly that everyone senses it, and treats me accordingly? Any nurses in th