Will I Be Ready?
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!
Skin Is In
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!
The Scariest Med Student of All
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!
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.
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.
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 :)
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.
Med Student Presents With New-onset 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.
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.
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.
How to Survive Pimping in the OR
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 :)