The Differential: Medscape Med Students Blogs

Horses, Zebras, Ninjas

Ben Bryner -- I was reading this story the other day, in which a camp counselor was mistaken for a ninja, which then prompted a school lockdown. It reminded me of the old medical adage, "when you hear hoofbeats, think horses, not zebras." Briefly, if you’re in an area where horses are more common, when you hear hoofbeats outside, it's much more likely to be the sound of horses, not zebras. The idea is that when a patient presents with symptoms that are consistent with a common disease, but are also consistent with a much less common disease, you work under the assumption that it is the more common disease until you can confirm it. In other words, if you’re in New Jersey, a person dressed in a ninja getup is more likely to be a regular person who’s just into karate or dress-up than an actual ninja.

The saying is usually used to correct a student or resident’s differential diagnosis. When you’re on rounds and presenting a new patient with an unknown or not-quite-certain diagnosis, when you get to the end of your presentation, your attending will generally expect you to list the “horses” (the more common diseases) first and the “zebras” second. If you don’t, the attending may request that you do so by saying “Horses, not zebras,” or by the less-conventional technique of whinnying while slapping his or her legs to simulate hoofbeats.

So you should follow what I like to call the “Family Feud” strategy of presentations, based on the game show of the same name. (If you are wondering whether I think all of medical school can be reduced to elements of game shows, the answer is: No, only 80%.) The point of this show was to guess the most popular answers to open-ended questions, with one team trying to list off the top answers to build up points, and the other team waiting for their chance to pounce and steal the points by giving an answer the other team neglected. In a presentation, if you go through the most common possible diagnoses and then get down to the more obscure ones, it’s less likely that someone else on your team will steal the diagnosis you’re waiting to reveal, or that you’ll get interrupted before listing the most important diagnosis. Also, if you’re on a surgical rotation, you should look around after listing off more than two or three potential diagnoses, as your team has probably already moved on to the next patient.

This is not to say that you can ignore the zebras. You try to confirm the presence of a horse before moving on to investigate the presence of a zebra. And you do this mindful of the setting. If you are in feudal-era Japan and you see a shadowy masked figure running around outside, then “Ninja!” is a pretty good theory. By the same token, identical symptoms in a newborn, a teenager, and an adult may prompt very different diagnoses.

As long as you’re not in a true emergency situation, in which you have to try to rule out even uncommon diagnoses if they could cause death rapidly, taking the Family Feud approach to diagnosis has its advantages. Less money is wasted on low-yield tests and evidence-based medicine has a better chance of being followed. When you jump straight to the weird diagnoses, patients get scared, easy fixes get missed and everyone gets confused. Think of the kids in that school who are probably less likely to take a future lockdown seriously. They’ll laugh -- “What is it this time, a pirate in the cafeteria?” And then when ninjas really do attack, they won’t be ready.

   

And if you’re not ready for a ninja, you don’t have a chance.

Choosing a Specialty

Ben Bryner -- If there's one thing I enjoy about medical school, it's talking to people about what specialty they're going into and why. Most students change their minds a few times during medical school. I was one of the lucky ones who knew exactly what I wanted to go into (surgery) after rotating there as a third-year, but for most people in my class it was not so obvious. It’s a hard decision; you’re making a choice that will affect almost every aspect of the rest of your life. At many schools, if you’re interested in a field that doesn’t have a required third-year rotation, it’s hard to get a lot of exposure to the field before your fourth year, when decision time comes up quickly. And if it turns out that you don’t like that one, it isn’t always easy to switch gears at a later stage in the game (but it’s certainly possible). To address this difficult situation, there have been a lot of different tools proposed to help you decide on a specialty beyond clerkship and elective experiences.

You might have already seen this graphic, which reflects the growing trend in medicine to reduce decision-making to following an algorithm. An even simpler method is the Goo Tolerance Index, which simply ranks the specialties by their exposure to “goo,” so all the student has to do is identify his or her desired level of goo exposure and pick from a short list. Both of these are pretty easy to use. Oddly, they both leave out OB/GYN (which would probably fit under the “crazy” and “high-goo” categories, respectively).

If you want to take a more comprehensive approach, you can take the Medical Specialty Aptitude Test online. It will ask you a series of questions (130!) and at the end will list the specialties you should consider. I didn’t get through all of them because it kept asking me the same questions over and over, but you might have better luck. Similar kinds of things are available at the AAMC’s Careers in Medicine site, but you need a password from your med school. And of course there are a few books on the subject.

But there’s no substitute for rotating on those services. Hearing about the field from others, shadowing, getting involved in interest groups, etc. are all somewhat helpful, but they can give you a very different picture of the field than your rotations. Of course, rotations are far from perfect tools for evaluating specialties. Since you’re mostly spending time with residents, you may get a pretty good idea of what the residents are doing, but not necessarily what it’s like to be a practicing physician in that specialty. And despite the fact that residency can be quite long and seems so imposing during medical school, it’s a lot shorter than your career. So it’s worthwhile to really try to get a feel for what the attendings’ workdays are like.

There are a lot of good choices out there, so good luck.

Defining Yourself

Ben Bryner -- Most of the people who started medical school with me are doctors now and are starting their internships this week. (Although there are quite a few of us who took an extra year to do research or get an additional degree and will graduate next year.) I think most of them are excited, and probably a little terrified, too. It's kind of similar to the way a lot of us felt at the beginning of med school: a mix of excitement at taking another step toward becoming a doctor but uncertain about exactly what was in store for us.

Although my school's curriculum was based on class-wide lectures, we had weekly small-group meetings where a dozen or so of us students would meet with a faculty member. Usually we spent most of the time discussing a fictional patient case that got us into some interesting conversations. But one of the more important aspects of the group was that it gave us a fixed setting to get to know a group of people. When you're starting medical school, the pace and volume of material can make it hard to really know your classmates very well.

On the first day of these small groups, we had the typical introduction process, where we went around the room and said our names, where we were from, where we went to college, etc. By way of an icebreaker, the moderator asked us to name a song that described us. This is a fairly good question that lets you get a feel for what a person is like. But it's a difficult question to answer. It's certainly not the same as your favorite song, and it has to be one that most people know for it to mean anything to them. I ended up choosing the Theme from Shaft, Isaac Hayes' groundbreaking theme from the 1971 movie. I said it applied because I'm "the cat who won't cop out / When there's danger all about" (not because I am similar to the Shaft character in appearance, occupation, or awesomeness).

There was a kind of awkward silence for a second, and I worried that everyone thought I was crazy. But the faculty advisor laughed at least, and we moved on to somebody else. I'll admit the reference is a little dated, but what kind of song am I supposed to pick? It's not like there are hundreds of songs about first-year medical students that make you say, "Yep, that's me in that song."

It was the first time we had to classify ourselves in medical school, to distinguish ourselves from others. This process continued throughout our preclinical years; some students were inevitably identified as gunners and others as slackers.

Once our third year was underway (another time of great excitement and terror), people were still being classified as gunners (since gunners behave differently on the wards, and closet gunners are revealed). But far more significant was the way in which we started classifying ourselves by the specialties we planned to pursue. The more people began really settling into their specialties, the more that became the predominant classification. "What are you going into?" became the first question we asked a classmate who we hadn't seen for a long time. And since it was often the first question our residents would ask us on a new rotation, we got used to identifying ourselves as future surgeons, pediatricians, radiologists, or whatever, in almost all contexts. I think a lot of us started changing our personalities slightly to accommodate expectations; when you meet somebody new and all they know about you is your name and your specialty of choice, it's hard not to subconsciously start acting the way you think an obstetrician or a neurologist should act. (I'll resist the temptation to describe specifically what I think those stereotyped behaviors are.)

A few weeks ago a few of us from the small group had dinner with our group's faculty member. Since our last meeting had been during the third year, the first thing he wanted to hear was what specialty everyone from the group was going into. He also remarked on how interesting it was to watch our group go through the many transitions of medical school. We had all picked up new skills, new attitudes, and new classifications that described ourselves. I thought about that too; I've certainly changed a lot in medical school, and have fallen into categories now that I wouldn't have predicted when I started.

I also thought about the way I first classified myself to the others in my small group. Could I honestly say I'm "the cat who won't cop out / When there's danger all about?" By saying I am, I set a goal for myself. It's a lot like the way I classify myself as a future surgeon; claiming that label also shows me the work I have to do, and gives me a lot to live up to. I will certainly try to be a good surgeon, just like I will always try to be "the man / Who would risk [my] neck for [my] brother man."

A Father's Example

Ben Bryner -- My dad has a problem. He accumulates books like nobody I've ever seen. I guess this is an occupational hazard (he's a professor), but it's still frankly out of control. When I was growing up I always liked going over to his office. It's always been full of books piled literally from the floor to the ceiling; shelves all the way up one side of the narrow office, file cabinets full of articles, and bookshelves above the cabinets on the other side. And always a couple of rows of books on the floor, lined up with their spines facing the ceiling, and cardboard boxes full of more books stacked up behind the door so it only opened about 45 degrees. I remember when I was a kid he would sometimes hire me to try to organize the books on a Saturday. I realize now that this must have been a ploy to humor me since I liked going there, because by the end of the next week he'd have more books and any system to organize them would be overwhelmed. That office was also where I first used this crazy thing called the Internet, and although my dad has embraced the digital age, he keeps amassing books.

Perri Klaas, the noted pediatrician, author and founder of the Reach Out and Read program that distributes free books to kids at their well-child exams, has said that she can always tell when a kid in her office has been raised in a home full of books. Needless to say, I was very much shaped by the many books I grew up with, not just by the ones I read but by the fact that my parents had so many books that were prominent in the house and they clearly valued them. You can tell something about the people in a house by what's most prominent on the walls, whether it's antique china, old photographs, or taxidermied moose heads. At my parents', besides art that's been made by people in my family, the dominant objects of decor are books, because my dad's book collection has spread from the office and invaded the house.

As my dad took on more and more different projects, folding what most people would consider a second career into his existing one, the book collection expanded. This photo shows my dad's home office when I went to visit a couple of weeks ago, but the "playroom" where my brothers and I used to build Lego castles and pretend to be ninjas is also now full of bookshelves and small book-piles as well. My mom seems to be OK with (or at least resigned to) what others might consider a biblical-scale plague of books. Once you consider the books part of the furniture you can sort of ignore them; if my brothers and I were still kids we'd probably just be playing Ninja Librarians around them ("Are you returning this book late? No, no fee... just a katana-battle to the death!!").

What does medicine have to do with all of this? Well, doctors are surrounded by piles of information, new evidence that piles up daily all around them and never gets any smaller. Much of it is useful, much of it can be summarized, but there's no getting around the fact that there is more information than anybody can ever hope to categorize and master. This lesson gets reinforced every time I undertake a literature search before starting another research project. All of us in medicine are surrounded by heaps of information, and while we can hopefully convert some of that into our own actual knowledge, there will always be another heap waiting.

As much as I make fun of my father for this seemingly uncontrollable propensity for collecting books, I love books as well. Another trait I inherited from him is that I'm only really satisfied with work when I have too many things to do. My dad thrives on the challenge posed by juggling several projects, researching and writing so much that it amazes me, while traveling around to dozens of conferences and meetings and still staying very involved in our lives. This year I've tried my hand at juggling more projects than before, and in doing that I've recognized that my dad must have truly amazing time-management skills. Time management is probably the most important skill you learn in medical school, because without it you don't have enough time to learn the other ones.

More importantly than a love for reading, though, was the emphasis my dad placed on the need to stand up for the disadvantaged and to be a responsible citizen. I've gone into a different line of work than he did, and while I never felt any pressure to go into any particular field, it was always clear that I should pick a career that allowed me to make a difference in people's lives. I certainly hope my career will do that -- my choice to be a doctor had something to do with him anyway, since it was on a trip to northern Mexico with one of his classes when I realized I wanted to be a doctor. I was 15 years old, and the trip both opened my eyes to the reality of poverty in other countries, and showed me the need for physicians who are passionate about global health. So hopefully, twenty years from now when I'm neck-deep in clinical duties, research projects, conferences, and work on global health issues and trying to balance those with family, I'll still be inspired by my dad’s example. By then the books will fill their entire house, so I’ll picture my dad looking up from his typing, searching up and down one of many imposing nine-foot pillars of books for the right volume, and then forging ahead with his work.

Obviously my dad's got a large backlog of reading to do, and he may not get a chance to read this for a while. Anyway, Dad, when you do get to this, Happy Father's Day 2015, and thanks for everything.

Love, Ben

Chicago on $1000 a Day

Ben Bryner -- Of the many hoops through which one must jump to finish medical school or obtain a residency in the U.S., the United States Medical Licensing Exam Step 2 – Clinical Skills Examination is perhaps the most awkwardly named. It’s also one of the most expensive, at just over a thousand dollars. Besides tuition, it’s hard to think of a larger single expense associated with medical school. It’s expensive because it involves several standardized patients in a series of exam rooms, around which test-takers rotate in rapid succession. These patients are trained to offer a complaint and a history and cooperate with a physical exam consistent with a disease from almost any area of medicine. Good news for those deathly afraid of children, though -– no kids are among the patients. Instead, in one exam room you may find a telephone with a parent on the other end of the line, describing his or her child’s complaint.

Once the history and exam are completed, the test-takers step outside to draft a note describing the encounter and list potential diagnoses and necessary tests. These can be typed or handwritten, depending on your preference. Since my hospital’s medical records are electronic, I’m more used to typing and I went with that, but it seemed like most of the people around me were writing with pencils. It probably doesn’t matter much, although I ran out of space in some of the typing fields.

The American Medical Student Association recently ran an article on the test. Key quote, from Dr. Ann Jobe of the National Board of Medical Examiners’ (NBME) Clinical Skills Collaboration Evaluation: “Most students spend $2,000 or less for everything, including travel and lodging. Students spend more going to residency interviews than taking this test.” Medical students are probably the only group of people who anyone would try to pacify by telling them that a test costs less than $2,000. And interviews allow you to meet and evaluate your potential teachers and workplace, while the exam allows you to hang out with strangers in an office building for a day.

The test seems like an unnecessary burden on students, who must travel to one of only five testing centers in the country, and adds one more expense to an already long list. Although I’m not too far from the site in Chicago, some students have to trek pretty far. I have my doubts as to its ability to weed out those with inferior skills, and the assessments of the test will not be available for years. For me the test was certainly anticlimactic –- like many, our med school already has a similar (but more difficult and comprehensive) clinical skills exam at the end of the first clinical year.

On the other hand, the pass rate is very high and no numbered scores are reported, as they are for other USMLE exam steps. Not having the scores takes a lot of the element of stress out of the CS exam. It also beats board exams for dental school, in which patients must find their own patients (sometimes paying quite a bit to find them) on which to perform certain procedures. Also, since it takes up most of a day to do Step 2 CS’s paperwork, see the standardized patients and write notes, at the lunch break they give you a sandwich and a can of soda. It’s not much, but for a standardized test it’s unorthodox in its generosity -– when I took the SAT and the MCAT I certainly had to bring my own sandwiches.

So I tried to enjoy the sandwich, just as I tried to enjoy the test in general by making a weekend out of it. I had a good time hanging out in Chicago for a couple of days after the test. Including the testing fee it was the most expensive vacation I’ve taken in a while. But if I don’t have the time or money to take the vacations I want, at least I can enjoy the ones I’m forced to take.

Rage Against the Machine

Ben Bryner -- At my university's hospital, everyone who wants to enter the operating room area must wear the hospital’s scrubs. The main rationale for scrubs is to reduce infection rates. (Also, they provide the backdrop for the comic highlight of Wes Anderson's films.) So, like everyone else in the hospital, when students rotate on surgery we get our scrubs from large metal dispensers, shown here.

The odd aspect of the scrub machine is that all the instructions on it are written in the first person. Instead of saying "Swipe card and press button to obtain scrubs" like a normal set of instructions, it reads "Swipe your card through my reader and press a button on my keypad, then open my door to get your scrubs" or something like that. Just trying to make the machine friendlier, I guess. It's only weird because the scrub machine is right there when I change clothes. If a machine is going to be watching me undress, I think I'd rather not have it talk to me in the first person. Frankly, I'd prefer to keep things professional.

The machine is there to cut back on scrub theft, which is up because of the deplorable trend toward making scrubs acceptable wear outside the hospital. In principle, I'm all for anything that combats this. And the machine is convenient, easy to use, fairly quick, and it doesn't run out of scrubs that often. But after I was looking for a picture of the machine, I came across the company's sales pitch. Their website blames most problems with scrubs on the "Vicious Circle," which consists of six different groups of scrub-wasters. The "vicious circle" is helpfully illustrated with a drawing: included in this rogues gallery are "The Hoarder," "The Yanker" and "Messy Marvin," as well as that most awful of creatures, "The Student." (Look at him, carelessly wearing a backpack and drinking some kind of beverage through a straw!) I don't enjoy being lumped in with "Messy Marvin," but what's worse is that the company's website describes these six people as a "vicious circle" just because they've arranged the six pictures in a circle, not because the process represents an actual vicious circle (a self-reinforcing feedback loop with increasingly negative consequences). You can insult me all you want, but have the decency to use economic terms correctly.

Compounding students' problems is the fact that we are sometimes only granted access to one pair of scrubs; we have to turn in one pair to get a credit back on our account, wait for it to process, then pick up another one. That process takes time, meaning more time for the scrub machine to ominously watch us. Don't get me wrong, I'm sympathetic to the principle of wanting to hold onto hospital property. And the manufacturer claims that the machine saves the average hospital $70k per year. Although that sounds like a lot of money for a mom n' pop hospital (if those existed), $70k isn't that much out of the yearly operating margin for a larger hospital. My feeling is that you should make it as easy for people to change scrubs as possible to avoid infection (which is very expensive to treat). Also it should be easy to change scrubs before going out to talk to a patient's family, since even if you've avoided getting blood on your scrubs, plenty of other chemicals commonly found in the OR (betadine, chlorhexidine, Piña Colada Slurpees) look like blood when they end up on scrubs.

I'd like to protest, but how do you picket the scrub machine? There isn't enough room to march around in the locker room. And what good would it do? The scrub machine watches people change clothes all day without averting its LCD screen -- it truly has no shame.

Telling the Whole Story

Ben Bryner -- When I was a teenager I loved documentary films, and I thought making them was what I wanted to do for a living. I loved watching sprawling films about the Civil War or Watergate or basketball players. I came pretty close to majoring in film and pursuing that route, but by the end of high school certain experiences had pointed me pretty firmly toward medicine.

I haven’t had much time in med school to watch documentaries, but I’ve managed to see a few. One of the better ones I’ve seen is The Smartest Guys in the Room, which describes the collapse of the energy company Enron brought on by fraud committed by its top-level executives. It’s a fascinating story; maybe to some people it’s fascinating because of the business and financial aspects. But in the documentary, Bethany McLean, the reporter credited with breaking the story observed, “[P]eople, especially outside the business world, think that Enron is a story about numbers and complicated financial transactions that you couldn't understand even if you wanted to, but the Enron story is really a story about people.” This made a lasting impression on me, and it really helped me understand my interest in medicine. (Not because there’s any connection between the Enron scandal and medicine.) It was because McLean found the people involved to be the most important aspect of her story, and in medicine as well, the people involved are the most interesting and important element.

Don’t get me wrong, for all the time you spend studying in medical school you have to have a strong interest in physiology and disease. If you don’t have a high baseline level of curiosity about the ways in which disease can occur and can be treated, I think a career in medicine would be unbearable. For me as well as most other people in my med school class, every so often a particularly enthralling disease would be discussed in lectures and some of us would think about specializing in that field to have more involvement in researching and treating that condition. Some rotations that I’ve done have allowed for the most interesting teaching opportunities I can imagine: rare inflammatory diseases, even rarer genetic conditions, medical mysteries that unraveled over the course of the month.

But to me, there’s no more interesting aspect to a disease than how it affects the patient. Since every patient is different, in a way every episode of a disease is its own special case study. This is something we’re told fairly often, but I understood it first on the cardiology service, where over the course of the month I was assigned to a number of patients with the exact same condition. Of course, the same disease affected each patient in a different way. Each patient’s social, financial and educational background influenced the way they dealt with disease, and the disease in turn affected each aspect of their lives in various ways.

This is what I think makes the medical student’s experience so valuable; as a student you have time to dig a little deeper into these individual histories to pick up on unique aspects of each case. The more you get to know the person, the more you put together an often-remarkable story.

Plenty of attendings and residents will give you the same advice when it comes to the student’s duty to present patients: “Tell a story.” Sure, the presentation has to include certain elements and unfold in a formal way, and in some situations you don’t have the time to really get into it all. But whenever you get the chance, especially on rotations where rounds and presentations make up a big part of your day, my advice is to try to make your presentations as much of a story as you can. An efficient but engaging story can convey a lot –- it illustrates the context of the patient’s life before the disease of interest, it conveys the patient’s goals for treatment, it helps the team focus on that patient and effectively discuss his or her needs. As in a good documentary, a good medical story isn’t just about a disease, but about a person.

The Laziest Hitman

Ben Bryner -- There are a few important skills you learn during the third year of medical school. These are skills that you’ll need no matter what field you go into or what type of patients you see. Basically, you have to learn these during the third year because you can’t progress much further in medicine without learning them. The three main skills I’m thinking of are taking a history, doing a physical exam, and presenting a patient (summarizing their case in oral form for the rest of the team). Sure, you learn all kinds of other tricks, too, from inserting lines to suturing to delivering a baby, but these are specialized to certain disciplines and you won’t get much practice at any single one.

The theory is that those three skills are the essential tools you need to be able to diagnose patients with any given complaint. And while you learn some principles of treatment in medical school, learning actual treatment modalities is the formal goal of residency training, so they are less emphasized in medical school and on students’ licensing exams. Instead, those three fundamental skills are emphasized on each clinical rotation, and this is the main rationale, I think, for making students rotate through all the major areas of the hospital.

All this is to explain that the psychiatry rotation is actually useful for those of us who plan to spend more time poking scalpels, endoscopes, or cardiac catheters into patients rather than probing the depths of their psyche. This is not to say that psychiatry is somehow less important. But I went into the psychiatry rotation sure that I did not want to go into psychiatry, and I left the rotation 100% convinced of that. (The same was true of some other rotations, too.) But I will be the first to say that I appreciate the patients and attendings of the psychiatry service, because they definitely helped me improve my history-taking skills.

For example, one attending really focused on the nonverbal aspects of the patient encounter, like my distance from the patient, and my posture. This kind of thing really matters with psychiatric patients –- it can be the difference between a useless visit and a very helpful one. But the lesson applies more widely; all (conscious) patients take note of the nonverbal cues from their doctors, so body language is not just a psych-only concern. Plus, psychiatry plays a critical role in basically every discipline. I was talking to a general internist, and his comment about the psychiatry rotation was, “It may not be the most fun, but it was the most useful” of his third year rotations because he deals with psychiatric issues several times a day in his clinic.

So one day, that psychiatry attending sent me in to talk to a patient and see how he was doing. Since part of the trick to taking a history is being able to talk to anyone about any given condition, I didn’t know too much about him going into the visit. He was a middle-aged guy, neatly dressed and not obviously agitated, but as soon as I introduced myself he announced that he did not trust me, that he knew I would tell “everyone” what he told me. I assured him that I took both the laws and the moral principles involving confidentiality very seriously, but he dismissed that as “just words on paper.” Even so, I pushed ahead into a discussion, and through some careful, incremental questioning was able to get him to talk about what he did for a living. He hinted at some dark secret, and with some coaxing he told me that his previous job was sneaking into hospitals and disconnecting specific people from life support, for which he was well paid. Basically, he was claiming to be the world’s laziest hitman.

While the story is funny now, the important part of the history is to get the patient’s full story on their own terms, and there certainly isn’t anything funny about the genuine daily-life problems that this kind of person experiences. At this point I’d been taking histories in various situations for a year, and while I certainly don’t claim to be an expert, I was able to keep him focused and trusting enough to elicit his feelings about this job (he claimed to have no remorse; disconnecting people was “just business.”) So this was really interesting, not only because this was a strange kind of false idea he was creating, but we were getting to his feelings about these imagined events, which is important in pinning down a diagnosis and, hopefully, helping him recover.

Of course, I have very little idea of how to do that stuff, but I was happy that my job, the history, was at least going in the right direction. Just then, my attending knocked on the door and joined us. (One thing that was constantly true on psychiatry was that when patients wouldn’t open up, the short time I had seemed like an eternity, and when things were going well it seemed like only a couple of minutes before the history was over.)

At the end of the rotation I passed the shelf exam, which was mostly on the side effects of drugs and the aspects of personality disorders. But the day I gained the trust of the world’s laziest hitman was the day I knew I’d passed the most important practical test of that rotation -- taking a half-decent history when someone doesn’t even want you to.

These Pretzels Are Making Me Thirsty

Ben Bryner -- I'm sorry, everybody, for blogging about death for a while there. Today I’m going to talk about the show Seinfeld. I apologize to those of you not familiar with the U.S. television series, as well as casual fans of the show who aren't obsessive enough to be familiar with the episode in question. I realize that includes something like 95% of people reading this entry, but stay with me. In one of my favorite episodes, the aspiring actor Kramer is given a single line in a Woody Allen movie: "These pretzels are making me thirsty!" The four main characters of the show debate the best way for Kramer to deliver the line. As usual, Kramer overdoes it (and makes Woody Allen cry). But through the rest of the episode, each of the characters utters the line "These pretzels are making me thirsty!" When each of them says it, the phrase takes on a meaning like "I am extremely frustrated, and I am to blame, yet I am powerless to do anything to change the situation." It becomes a kind of shorthand between the characters and the audience, a simplified (and funny) way of conveying a complex reaction to a particular event.

In medicine we sometimes use similar kinds of phrases. For example, a procedure that should be relatively simple but gets more complicated and frustrating is called a "flog." (Atul Gawande uses the example of placing a central line; it should go smoothly but can suddenly turn awful.) We twist words from their true meaning toward a different one: when I describe a lecture or meeting as "painful," another med student understands this as not literally causing a sensation of pain, but being slow/boring/incomprehensible, etc. Not that this ever actually happens.

It seems like a lot of these terms are derogatory, which is partially true. My theory is that these phrases evolved to allow med students to vent quickly to fellow med students in the short amount of non-supervised time they have together. (Since you never, ever complain to a resident, or when residents are around, you have to be efficient at airing your grievances to your fellow students over a quick lunch or other chance encounter.) I'm sure a lot of other groups have this kind of term too. Certainly the military does -- one of my VA patients, a Vietnam vet, was less than satisfied with the way his care was going -- with life in general, really. I’d say things like:

"Good morning, Mr. Smith. Did you sleep well last night?"

"No, it was a total cluster."

or

"Hey Mr. Smith, did you get all your questions answered about your CT?"

"No, it was a total cluster. I don't know anything."

or

"Hey Mr. Smith, how was lunch?"

"A cluster."

So I picked up on that term. I liked the guy, and he wasn't really mad at us personally, just frustrated at the system (common even in the best of VA hospitals). But even though he favored us with the less profane version of the term, we all got kind of sick of hearing everything described as a "cluster," and finally on rounds one day my intern (a psych resident) got annoyed and sort of told him to shut up. I liked him, though, and he was my patient, so I kept going to talk to him and in the process heard him describe everything from his bed linens to scheduling surgery to the weather as a "cluster."

Anyway, not all our informal descriptions are negative; there are more positive shorthand terms too. I heard one of my favorites today -- describing a pediatric patient who has recovered well and is doing much better than expected as a "rock star." It doesn't mean the kid is really ready to play the Hollywood Bowl. It doesn't even mean that they're really good at Guitar Hero. But we all know what that term means: the patient's doing well, recovering, on the road to discharge.

This is part of the reason med students aren't always terrific conversationalists; for example, it's just easy for us to describe our day in clinic as "a huge flog" (a flog-a-thon?) to each other. That's so much easier than talking to a non-medical person where you have to explain a) what should happen in clinic and then b) how things went wrong and c) why each of those is particularly frustrating. I try to resist using these terms in polite society (by which I mean people who are not med students or doctors). And one of the reasons I like talking to non-medical people is to get a regular perspective on daily life. But as hard as I try, words slip in here and there, and before I can stop myself I'm describing a trip to the grocery store as a "flog." Then I have to explain what I mean, and apologize for sounding like an idiot; and the worst part is that I haven't saved any time at all. These pretzels are making me thirsty.

To Cry or Not to Cry

Ben Bryner -- I've been thinking about breaking bad news a lot lately, and an interesting article in the New York Times addressed that topic. Briefly, the author presents both sides of the issue of whether crying when delivering bad news is appropriate.

My scant experience with this kind of discussion (limited both in number of cases as well as limited by my student-level role and knowledge) has been that there's wide variability in these discussions, and therefore variability in the appropriate response. While the article tends to pigeonhole individual doctors as criers or non-criers, as Dr. Lerner concludes, it depends mostly on the individual patient. I'm sure all the people in the article do tailor their approach to each individual patient. And it's absolutely true that doctors can convey deep empathy without crying.

But the article takes the study by Dr. Anthony Sung (archived here, scroll down to page 5) a little out of context -- his survey found that a majority of third-year medical students and interns (69% and 74% respectively) had cried in a medical setting, but that "the most common reported cause for both students and interns was burnout," not from discussing bad news with a patient. Also, the abrupt shift in the article from talking about attendings to talking about students and interns is not a trivial difference; the role of an attending is very different than that of a trainee in this kind of situation.

Hopefully the following example will help explain what I mean by that.

I witnessed a very good example of breaking bad news on my neurology rotation. I had gotten to know a patient in his mid-50s with glioblastoma during clinic visits at the beginning of the rotation. At those visits he was talking about going back to work, but over the next couple of weeks his condition deteriorated. It became clear that the several experimental chemotherapy regimens he tried had failed, and that the chance of another regimen slowing down his disease progress was basically zero. He was admitted, and when his neurooncologist stopped by his room to tell him the results of the latest scan, I went with him.

The news was no real surprise to the patient and his wife, but it was still devastating when he heard that the scan was discouraging, the chemotherapy was not working, and that it was almost definitely not worth pursuing more chemotherapy. Importantly, the oncologist still left the option of chemotherapy out there for him to take if he liked, but included his recommendation against it. As the message set in, the patient and his wife began to cry, and so did the oncologist. It was a very appropriate display of emotion from the oncologist, I thought, and the patient later told me how much it meant to him. But I didn't feel like crying, and didn't feel like I needed to. It was fine that I was there, but our brief student-patient relationship was not enough to allow for my crying in that situation. If I had cried too it would have cheapened the experience for them, which was the last thing I would have wanted.

A doctor's emotional display also depends on the type of visit. In the above example, there was plenty of time to talk, the setting was quiet, and nothing needed to be done immediately. (Hospice care was arranged over the next couple of days). But in some of these discussions, especially in the ICU setting, practicalities dominate the conversation and the emphasis needs to be on helping the patient and family through difficult decisions. In these discussions, I can't remember the attendings ever crying, although they were compassionate, helpful, and empathetic towards patients without exception. And for all patients who have strong emotional relationships with their loved ones, those are far more beneficial than the most empathetic doctor's tears could ever be.

Another doctor is quoted in the article as saying it's not a doctor's job to cry with patients. I agree that that's not what a doctor's essential role is. The physician's role is to help the patient through difficult medical decisions (and perform procedures as necessary). Working with the patient, forming a team with him or her, carefully assessing what the patient knows and what he or she still needs to learn, and then making careful recommendations (sometimes very strong recommendations) are the true elements of compassion and empathy in the doctor-patient relationship. Whether the doctor cries or not while delivering bad news is only an outward manifestation of that relationship.

Which brings the topic back around to one of Dr. Lerner's original points, that medical school doesn't teach a lot of these things. Too often, we're taught about things on the superficial level -- what words to use, how close to sit to the patient, whether to cry or not. And while that's a good place to start, medical education has much further to go toward comprehensively preparing new doctors to develop empathic relationships with their patients.

Breaking Bad News

Ben Bryner -- As a medical student, I have informed exactly one person that they have a terminal illness and are soon going to die. Of course, this wasn't a real patient, but a "standardized patient"  (or SP), someone trained to act like they have a medical complaint and then answer questions and sometimes simulate physical exam findings like a real patient would. The SP's role has been popularized by Kramer (from the series Seinfeld) who took a job as an SP. However, Kramer's SP performance was a little over the top. Plus, in real life, the session with an SP usually includes a complete history and physical as well as talking about possible diagnoses and treatments, not just med students shouting out potential diagnoses. (Also, isn’t that med student the guy from Lost?)

Any field has some kind of facility for simulation, and this is it for the history and physical exam. Generally, our SPs have been very good. Most of our experiences with SPs are in the first two years, to gain experience in clinical settings before we are sent off to the wards, or in testing situations to formally assess our history-taking and examination skills. But occasionally in the clinical years, our school sets up SP experiences to help fill in gaps that don't get addressed on rotations.

On the surgery rotation, there are plenty of patients who get bad news, but students often are not around when the surgeons inform the family (often because they lack the longitudinal relationship with the family, or they're simply busy in the OR or conference, or other reasons). So during our third-year surgery rotation, we practice giving SPs "bad news." There are some articles to read beforehand, as well as some advice on how to answer the most frequently asked (but impossible to answer) question of "How long do I have?" Maneuvering around this question is one of the hardest aspects of breaking bad news, because the goals of communication in the doctor-patient relationship -- including accuracy, encouragement and openness -- are completely at odds when answering it.

Breaking bad news is perhaps the toughest task in medicine. For that reason, if you Google “breaking bad news” you can find dozens of books and articles devoted to the subject. You may also find the words to 50 Cent’s song “Bad News,” which are actually not very helpful in this case.

But speaking of words, one of the other difficult things we are supposed to learn from this SP experience is using specific language, like the words "dying" and "death" instead of euphemisms that are likely to be misunderstood. This table is about my favorite of all the tables I've ever seen in medical journals. The rest of the article (Berry S. Just Say Die. Journal of Clinical Oncology. 2008;26:157-159) is an oncologist's discussion of how physicians can help their patients by being direct when the situation requires, and how this is compatible with a compassionate doctor-patient relationship.

Dr. Berry sums up: "One of the reasons physicians find end-of-life discussions so difficult is the belief that these exchanges, and in particular using the words 'death' and 'dying,' could distress our patients. Avoiding harm is a central tenet of our ethical conduct as physicians. However, it is possible to use the words 'death' and 'dying' in talking to seriously ill patients, as long as it is done sensitively; their use may actually avoid harm if they clarify the discussion." (And as Dr. Berry points out, calling them "end-of-life issues" is just another euphemism we use to avoid the word "death"; we don't congratulate new parents on their "beginning-of-life event.")

It's worth practicing. Even in an artificial setting, even telling myself beforehand that I needed to be direct, I had a hard time telling my standardized patient that she was going to die. I had to force it out, even though it would have been easier to hide behind phrases like "your cancer is terminal" or "the prognosis is very poor in this kind of situation" that I'd use if I were describing the case to another health-minded person.

Of course, at some point I'm going to have to take responsibility for giving a patient bad news for the first time. Since that rotation I've had a few chances to observe the process of giving bad news, and hopefully I will be able to adapt what I've seen and heard. I was glad for the experience with the SP if for no other reason than to become aware of how difficult it can be for a doctor to speak openly and plainly when discussing bad news, and how important it is to be clear.

Please Hold

Ben Bryner -- The "hang-up" button on my phone is broken. It's several years old and most of the buttons require some firm pressure to operate, but the button with the little red phone is totally dead. For a while I was at the mercy of the person on the other end of the line; they got to decide when the conversation was over and how many minutes I used up and there was nothing I could do about it. Eventually, I figured out that there was another series of buttons I could press to get the phone to hang up, but it wasn’t very convenient.

I decided my phone is like the health care system (at least in the US); it lacks a good system for "end of life issues" just as my phone fails at ending calls. A stretch, maybe, but stay with me. Most of the time, patients are swept along by the formidable (if not always efficient) process that is modern medicine, and all the stops are pulled out in an attempt to provide the best possible outcome for the patient. But what to do when all our efforts are clearly in vain? Even when the patient knows exactly what he or she wants done for them, it's hard for the health care system to switch out of a maximalist approach to care. Surprisingly, the hang-up button was the only button on this phone that wasn’t absolutely essential to operating of the phone. Similarly, our health care system can move along fine for most patients, but when a patient needs something other than the full court press, suddenly things get complicated.

Hospice, a comprehensive institution devoted to addressing the needs of the dying patient, started in England in the 1960s. Aimed at those with terminal diseases who wish to change the goals of their treatment from curing their disease to making the most of one's remaining time and managing pain, hospice has grown in the U.S. and around the world. I toured a hospice in Ann Arbor during one of my rotations and was very impressed. But the problem is that hospice in the U.S. hasn’t really been integrated into the health care system, unlike in the UK, where many inpatient hospices serve a huge number each year at no direct cost to the patients. A health policy professor once described hospice as having been stuck onto the U.S. health care system like an afterthought, or an annex hastily added onto an already-finished building. Many terminally ill patients aren’t referred to hospice at all, or it isn’t brought up until far beyond the appropriate time. One of the statistics often cited is the proportion of people who die in an intensive care unit (ICU): one in five. Clearly, some of these patients would have preferred to spend their final days at home. Really, of all the places I spend much time, the ICU is the least like my home. And although the lighting's much better in the ICU, it's not as quiet or comfortable as my place -- which is why most hospice care is given in the home.

As it stands, hospice hasn’t become a comprehensive answer to the problem, any more than the series of buttons I pressed to hang up my phone was a permanent answer to my broken phone. None of this is to denigrate the good people involved in end-of-life issues -- there is one surgeon in particular at our VA who leads a team of palliative care specialists who do terrific work and are tirelessly raising awareness of these issues. One of my VA patients had a very unfortunate diagnosis, but having them get involved in his care while he still had time to have a say in his plans for death was truly a silver lining.

Of course, my phone has an easy fix; I can get rid of it and get a new one. But all doctors can't just outsource their end-of-life problems to palliative care specialists; there aren't enough, and all of us from pediatricians to geriatricians have to deal with terminally ill patients and help them manage their final days and weeks. Assisting our terminally ill patients is much more complicated than just calling in a consult. (The standard reading giving the physician's perspective on these complex issues is David Eddy's "A Conversation with My Mother").

Addressing the systemic problem of allowing the terminally ill to die in the way they choose will require innovation, commitment of new resources, and action from concerned physicians throughout our careers. Graham has touched on this issue in his excellent "Health Care's Broke" series. I recommend it -- if you're on call right now, make your fellow student take the next admit while you read the whole series. Thank me in the morning.

A Lesson (Not Just a Joke) From an Orthopedic Surgeon

Ben Bryner -- Most specialists have some kind of stereotype associated with them, perhaps none more so than orthopedic surgeons. One of the predominant stereotypes about them is that they’re into power tools and carpentry and things like that, and are less intelligent than other doctors. It makes sense when you walk into an orthopedic OR, and it looks like someone took an old guy’s garage and dumped it on the table, then sterilized the mess.

On your surgery rotation, you will be expected to learn at least three jokes about orthopedic surgeons (nobody loves the jokes more than the orthopods themselves). Here’s one: Q. How can you tell that a chart note was written by an orthopedic surgeon? A. It’s written in crayon.

Of course, not all people within any given specialty fit the stereotypes, and given how competitive it is to get into an orthopedic surgery residency, the stereotype about intelligence is false. But on one occasion in particular, it was a good thing that the stereotype of orthopods being mechanically inclined held true.

One night during my surgery rotation I was on call at another hospital, finishing up examining a patient in the ER and chatting with a friend who was in his last year of orthopedic residency. (This guy was actually one of my favorite people I’ve worked with in all of med school, very smart and competent as well as nice to students and excellent with patients.) A patient came in who had broken his femur doing some kind of extreme sport under the influence of cocaine. (He’d apparently done this once before.)

The orthopedic surgeon wheeled over his cart and got his supplies ready to put the patient in traction (fixing the patient’s leg to the bed to prevent his leg muscles from pulling the femur-pieces past each other) while the ER staff tried to track down the power drill to place the traction pin. For some reason, nobody could locate the power drill, and all they could find was an old (but sterile) hand drill. We asked the guy a few questions while we waited, and finally the surgeon gave up and said he’d use the hand drill, or more precisely, that I would use it. I injected some anesthetic into each side of his leg, and the surgeon showed me how to put the drill together. Maybe he’d had some kind of training for the hand drill in his residency, but it was a pretty weird setup and I got the impression that he was relying on outside knowledge. Either way, it was good that he knew how to put it together, because if I’d put it together I probably would have drilled into my own hand.

He drew a little x where the pin was supposed to go and told me I’d have to put my weight against the drill to provide enough force. I’ll be honest, I had faith in my friend, but with the first few turns of the drill, I was skeptical that this was going to work. It took a lot of pressure, but eventually it went through the bone and out the other side. It was a spectacle, even by ER standards. The combination of the old-school implement and the fact that the patient was awake made it feel like something out of the Civil War. I half expected to look behind me and see Matthew Brady making a daguerrotype in the corner.

The surgeon said “nice job,” hooked the leg up to the frame over the bed and that was it. While my friend filled out some paperwork (in pen), I thought about the fact that although technology offers us unparalleled advantages in diagnosis and treatment, doctors will always have to improvise and fall back on the knowledge of simpler medicine when things don’t go exactly as planned.

Surgery and the Blowfish

Ben Bryner -- I like talking about medical school with people who are in different programs or careers. I like explaining what it is I want to do and what I’m studying, and I like hearing about what other people are into. But when people who are less familiar with medical training ask me how long my upcoming residency is going to be, the answer (seven years of general surgery residency including two years of research, followed by two more years of fellowship) often makes their eyes glaze over. And rightly so; it's a long haul. But it’s not like my law school friends are going to be taking the lead in litigating right out of law school. (At least I hope not.)

True, medical training is more formal and longer than that for any other gig I can think of. But in some ways it's hard to believe that that's all the time there is. Especially when you compare the length of surgery residency to things like the two-or-three-year apprenticeship required to serve fugu. (Fugu, the infamous pufferfish that carries the potent tetrodotoxin in most of its organs, is a delicacy in Japan; you can get it at a few elite, licensed restaurants in the States that, by law, must import it all through New York City.) It has to be prepared just so, with the right organs taken out and meticulous avoidance of contamination. If it's done right, you get a delicious meal. If not, you go into respiratory failure and die unless supportive measures are instituted in time (there is no antidote).

High stakes -- hence a two-or-three year training period capped by rigorous examinations. And that's just to learn one procedure, the proper disassembly of a fish. By the time a general surgery residency program graduates one if its trainees, it's certifying that the newly-minted surgeon can safely perform all kinds of procedures, in addition to management of patients before and after operating. The range of skills expected from a new surgeon, or internist, or pediatrician, is astounding even given the length of training.

I remember one time listening to an ER attending explain that although he learned a fair amount in residency, the time when he learned the most was when he was an attending for the first time. He had a lot more time to stop and think about what he was doing, for one, due to the nature of the ER as an attending. But it was also because the new responsibility was a strong motivator for learning, as well as a new perspective. He said he was also fortunate enough to have a good department chair who taught him a lot. This made an impression, since at that point I was pretty new in med school and hadn't really grasped the constant process of learning that is involved in clinical medicine. But it makes sense.

Medicine is so overwhelmingly complex and changes every day; unlike the anatomy of the blowfish, it can never be comprehensively mastered. This continuous growth leads to the large number of subspecialties required to adequately cover all the diagnostic and therapeutic angles of modern medicine, as well as the need for constant learning and teaching by one’s peers. To me, the prospect of continuous learning in a medical career is still exciting -- even more exciting than eating a potentially deadly piece of sashimi.

Blunted Empathy

Ben Bryner -- The title of a recent article in Academic Medicine asked, "Is There Hardening of the Heart in Medical School?" I initially thought, "I don’t know about the heart, but my arteries have sure hardened in med school from all that free pizza! Ha ha!" Then I realized I was being lame, so I just read the rest of the article. Basically, the investigators tracked medical students at one U.S. med school to see how their level of empathy changed over the course of their medical education (as measured by a standardized questionnaire). The conclusion is that each year in medical school is associated with a drop in empathy (with a differential impact by gender and specialty choice).

This is all fine; I’m sure that empathy (as measured by a questionnaire that includes items like "Unhappy movie endings haunt me for hours afterward") does indeed decline during med school. There are some easy explanations for this: sleep deprivation, outlandish debt burdens, and scut work probably don’t build empathy. But I think this study is giving people the wrong idea. When people read this paper, they dream up a first-year medical student getting her class schedule for the initial week of med school: Insensitivity 101, Seminars in Detachment, lunch, then an introductory hands-on workshop on ignoring patients. Of course, this isn’t true… these are all upper-level classes for M3s.

No, I’m kidding. The authors blame the old standby, the "hidden curriculum," or the unspoken transmission of (sometimes anti-humanistic) sentiment from faculty to residents to students in the course of daily work in the hospital. I don’t dispute this; a huge percentage of the total knowledge imparted in medical school is done in this way. My disagreement is with the word "curriculum," which makes it sound like all of this anti-humanistic sentiment is planned out meticulously. Which is not true -– as you bounce around from rotation to rotation in the clinical years, it seems like the real curriculum is barely planned.

The reason students are receiving this implicit teaching and becoming disillusioned during the clinical years is because they’re being introduced to a flawed medical system. Since medical school is the only way into this system, that’s where you see this disillusionment. First-year students are fresh from the application process, where they feel like their lives depend on how well they’re able to proclaim their selfless desire to help people. I think most students genuinely have that desire, but it’s a lot easier to express that desire in application statements before you have any idea about what system exists to help you carry out that goal.

The transition from second- to third-year student, as the director of our clinical years told us, is the biggest transition of our career. Moving to the clinical years is a major adjustment, like moving from a light appetizer on to the main course. Sure, you get a huge helping of responsibility and a big scoop of extra work when you become an intern, but you’re still eating the same kind of meal. (I think dessert might be retirement.) Many students realize when they hit the wards that the health care system is far different from what they imagined. And these are the students who often have the hardest time picking a specialty or even staying in clinical medicine. So with that kind of change going on, it’s natural for personal traits like empathy or anything else to change -- but it's not because medical school is structured to do that.

I completely agree with many of the claims in the paper. For example, the gap between the ideals presented formally in the white coat ceremony and the practical realities of day-to-day medicine are very disheartening to medical students. Little kids, let alone med students, are smart enough to know when something they’re being taught doesn’t line up with what they’re experiencing. Case in point: this article starts out talking about empathy in very high-minded terms in the abstract, but what does it say in the second paragraph of the main text? "Empathy is one of the most highly desirable professional traits that medical education should promote, because empathic communication skills promote patient satisfaction and adherence to treatment plans while decreasing the likelihood of malpractice suits." Oh, so that’s the real reason you want me to be more empathic. Now that’s cynical, and that’s exactly the kind of obvious disconnect between rhetoric and where the actual importance is placed that is so disillusioning to students.

The authors state that "Although a hardening of the heart may aid physicians coping with patients on a daily basis, this runs counter to the patient’s need for an empathic caregiver." This, I think, frames the problem in the wrong way. A huge part of the frustration I see stems not from difficult patients but from not being able to help the good ones. Sure, every primary care doctor has that group of Cluster B patients that absolutely drives them crazy. But what really undermines your faith in what you’re doing with your life is when you can’t help someone because of the system you operate in -- not, as this paper suggests, trivial things like hearing faculty place importance on how much research money the hospital receives.

Still, I applaud the authors for realistically describing the overall impact of the interventions designed to increase humanistic qualities during the first two years of medical school: they don’t make much difference. It doesn’t matter how good these programs are; they can’t do that much to shape you for the massive changes of the clinical years, any more than a pair of water wings can prepare you for a trip over Niagara Falls in a barrel.

Let me sum up: I love medicine, and I like medical school. I think I’m reasonably empathetic, and I’m fine with spending time on the humanities in the preclinical years, because it’s a nice break and helps you talk about ideas like a normal person. We should just be honest with ourselves that that’s all we’re doing. And we should talk about the importance of humanism in the preclinical years, but if we want to do more than talk about it, we need to make some much larger changes.

More Tips for Pediatrics

Ben Bryner -- After writing my last post on tips for the pediatrics rotation, I thought of several more (which I've trimmed down to the ones here). I realize it might seem like I'm overdoing it, but I cannot overstate how different the pediatric wards are from the rest of the hospital. There’s no other rotation where I would have been berated for referring to an attending by her last name instead of her first, but then praised for making faces at my patients on rounds. So I’ll make one more attempt to ease the transition, again with advanced-level tips for the gunners out there.

4. Wear something or have something attached to your clothes to distract the patient. Most everyone in pediatrics has some kind of distracting item on at all times; a goofy holder for their ID card, a sticker or a funny pin, or maybe a necktie with some kind of small animal print on it. Keep it under control; I’m not saying you should wear a propeller beanie or anything. And we’ve all seen people with so much “flair” that it looks ridiculous. For example, I was given a monkey-shaped stethoscope cozy, but I am a little too embarrassed to wear it lest I see… well, anybody. Still, it often comes in handy to have something entertaining for the kid to focus on that takes away from the scariness of your official outfit, whatever it happens to be. This is especially important if you’re wearing your white coat (which many pediatricians don’t wear, but as a student that decision is usually not yours to make).

- Gunner tip: Go all-out and buy a pediatric stethoscope.

5. Don’t call your patients’ parents “Mom” or “Dad.” (Unless the patient is your brother or sister.) When one of my kids needs medical attention, the worst part is seeing my child sick and uncomfortable. But the second worst part is being called “Dad” by some nurse, medical assistant, or doctor. I hate it. I’m not their dad (I’m usually younger than them), so it doesn’t make any sense. More importantly, it always comes across as condescending. Don’t get me wrong, I understand these people are busy. I don’t expect people to look up my name, and I understand that you can’t assume what the parents’ last names will be based on the kids’. And I understand that there’s not always time to ask what I’d like to be called. If I ever don’t know a parent’s name I always go with “ma’am” or “sir,” not because I’m a formal person but because I’d rather be called “sir” or “hey, you” or “yo, idiot” than be called Dad by someone who’s older than me. So don’t do it. As a student you’ll always have plenty of time to look the name up or, better, ask them what they go by.

- Gunner tip: Trust me, gunners, you can take one second away from that peds shelf exam practice book to get the parents’ names right. Even if you’re not motivated enough to learn names because it’s polite, do it because your residents and attendings are usually impressed when they can tell that you know the parents well.

6. Watch your language. By that I don’t mean that you shouldn’t curse in front of the kids (although you shouldn’t), but that you need to tailor your way of speaking, tone, and vocabulary to the age of the child you’re seeing. This is important in the outpatient clinic, where you have a very brief amount of time to build trust (unlike the hospital where the patient is more of a captive audience). If you’re trying to guess a kid’s age, make sure you err on the high side. Make sure you’re using words he understands, but without sounding condescending. Talk about things you’d guess she would be interested in, but without sounding judgmental or using gender stereotypes. Basically what you’re trying to prove to your patient, his or her parent, and your attending is that you’re reasonable and trustworthy enough to keep being involved in the patient’s care. You can do this by playing peek-a-boo with babies, talking about sports or movies with older kids, etc. The bright side is that this trust-building is a lot more straightforward with kids. If there’s a trust-building equivalent of peek-a-boo for ex-Marines at the VA, I’m not sure what it is.

And a special bonus gunner tip:

-Try to work the phrase “Children Are Not Just Small Adults” (the most overused phrase you’ll hear on this rotation and part of the title of almost every presentation you’ll see), into every conversation you have with an attending.

Best of luck!

Channeling Your Inner Pediatrician

Ben Bryner -- Pediatrics can be one of the best rotations, even if you’re not planning on going into it. I went into my peds rotation not considering it at all, and by the end of it was fairly certain that I wanted to go into some sort of pediatric specialty. But it’s very different from the other rotations. A lot of peds-haters will tell you that dealing with parents is so bad that it ruins pediatrics. True, they can be really difficult. But on the other hand, you’re really treating the entire family when you treat a kid; and when they get better it’s like an entire family has been healed and made whole again. Certainly the tragic cases on pediatrics are harder to handle than about anything else the hospital can throw at you. But nowhere else will you routinely see patients recover so completely; nowhere else will you laugh so much, nowhere else will you get peed on and still love your job. Here are three tips that I hope will help out for this rotation.

Note: If you haven’t heard the term, gunners are students who are fanatically driven to get top grades, even if that means interfering with their fellow students to get ahead. Like Swiper, the kleptomaniacal fox from Dora the Explorer (see tip #2), they can really ruin the fun. Still, I’m trying to provide something for everyone, so each tip has a gunner-level modification for the gunner who wants to take things up a notch.

1. Carry around a small plastic toy to “entertain” (i.e. distract) small children. Do not bring a fuzzy stuffed animal to share with multiple children; that is disgusting. Bring a plastic toy that you can wash or wipe off with an alcohol swab between each patient.

- Gunner level: Steal your fellow students’ toys so you are the only one who looks prepared on rounds.

2. Memorize all the songs and dance steps to High School Musical. OK, I actually don’t know any of them. But one evening in the Peds ER, I was able to tell a kid watching the movie that I had been to the actual high school in which the musical takes place (the exterior shots were filmed in Salt Lake City). She was duly impressed, and let me stitch up a big gash in her arm with almost no complaints. The larger point here is that it helps to know the names of popular references for kids of different ages. But you can always just ask, since most kids can ramble on about whatever topic they’re into for 18 hours or so.

- Gunner level: Memorize all the songs and dance steps to High School Musicals 1 AND 2.

3. Know your milestones (i.e. kids should have a good pincer grasp by nine months, be able to ride a tricycle at age 3, etc.) If you have some experience with kids, that’s helpful for a very rough guideline. But almost any given kid will be ahead of the “magic number” for some milestones, right on for some milestones, and maybe slightly behind on a few. But the shelf exam demands to know specific months, even when it doesn’t really matter, so on a certain level you’ll have to memorize them. I had the hardest time with milestones because I kept picturing my own kids, who are brilliant and wonderful, and therefore the worst kind of kids to have when it comes to learning these things.

Gunner level: Commit the entire Denver II to memory.

Have fun!

Don't Go Breaking My Heart

Ben Bryner -- Around Valentine's day you see pink heart shapes everywhere, symbolizing love and all kinds of warm feelings. But of course, the heart is actually entirely unsentimental -- beating constantly and relentlessly, billions of times over a lifetime. It's the hardest-working part of the body -- the James Brown of organs. The shadowy, impossible mysteries of the brain, the alien squirming of the gut, the intricacies of the eyes -- these are all fascinating, but the brute force and dedication of the heart make it quite impressive. It's hard not to be struck by the heart when you see it up close. I remember being particularly impressed during a dissection of a pig's heart in a high school biology class. Dissecting the heart was one of the most rewarding parts of our gross anatomy class in the first year of med school.

But (again like James Brown) seeing it perform live was a whole different experience. Last year I watched a CABG (coronary artery bypass graft, or "cabbage"). The whole procedure was very interesting, but the most amazing part of the whole spectacle was at the beginning, right after the surgeon opened the chest. He sliced through the sternum and parted the bony halves, revealing the heart pumping away with incredible force. I hadn't expected to see it contracting so violently; it looked like a wet towel being wrung out over and over, but without any hands doing the wringing. I'm sure a sternotomy is something you get used to seeing if you're in that line of work, but to a newbie it was pretty impressive. It was hard to believe my own heart was working that hard under my layers of gown, scrubs, skin, and bone. I resolved to treat my own heart better from that day forward.

That said, I'm not planning on going into cardiology or cardiac surgery. There's a difference between finding an organ system academically interesting and actually wanting to work on that system for the rest of your life. The nervous system is endlessly interesting, and before medical school I thought I might end up in one of the specialties that deal with it. But when I got actual exposure to those fields in the third year, they just didn't feel like the right place for me, despite the fact that I worked with some great people on those services. (Since I can't do everything, I feel fortunate to have found something I am really interested in, as well as to have found lots of fields that I'm not interested in going into.) Of course, you certainly need to know a lot about cardiac pathology and treatments to be a good doctor in any specialty. But I'm happy being impressed with the heart from afar, not from inside the cath lab or the cardiology clinic. Also, the idea of treating my own heart better hasn't really panned out. I ate way too many heavily-frosted sugar cookies this week, all of them shaped like little hearts.

Come On Down!

Ben Bryner -- I didn't always want to be a doctor. Though it's sometimes fashionable in personal statements to act like you wanted to go into medicine since implanting into the uterine wall, it's not true for me. When I was four, I had it all figured out: I was going to be a game show host. This, I was convinced, was the best job in the world. They played games all day! They gave things away! What more could anybody want?

Somewhere along the line my plan got derailed. I've gotten over the disappointment, though, because some of the things we do in the hospital are a little like some of these classic game shows.

For example, when you're considering asking for a consult on a patient, it's kind of like playing Hollywood Squares (a show where the contestants played tic-tac-toe with the help of celebrities). When you're part of the primary team for a patient, consults may be providing a lot of the care, but you need to arrange and coordinate it all, making sure any questions are resolved. When asking for a consult, there are a lot of choices: Do I want Infectious Diseases? Psychiatry? Plastic Surgery? Dentistry? Who's going to help me answer this question, and who (like some of the celebrities on the show) is going to try to make a joke and then leave me hanging?

Coming up with a diagnosis in the ER is a little like Wheel of Fortune (where contestants guess a phrase from a limited number of letters). Complete information is rarely there; most of the time you have to take a limited amount of information and make an educated guess. Sometimes the diagnosis is easy to guess up front; sometimes you sit around buying vowels (ordering imaging studies, requesting consults, drawing labs) to get closer to the answer.

And of course there's the crown jewel of American game shows when I was growing up, The Price is Right. Each episode, hosted by the epitome of game show hosts, Bob Barker, featured a series of games that tested the contestants' knowledge of how much things cost. Actually, this is the opposite of modern medicine, in which (as is often bemoaned) we do all sorts of things with no thought for the costs. Some attendings get a kick out of asking students about how much it cost to do the workup for a given patient, and then watching the student's eyes glaze over as the dollars add up in their heads. Between tuition bills and the astronomical costs of health care in general, the kind of numbers students see can start to lose meaning.

Anyway, the unquestionably best game on The Price is Right was Plinko. Not to be confused with "pinko," the slang term for a Communist sympathizer, Plinko was an all-American game of chance. After the contestant earned cardboard discs by correctly guessing prices, he or she stood at the top of a large board with pins in it. Then he or she would drop the disc down the board one at a time, watching as it bounced randomly between the pins and into one of several bins at the bottom that determined how much they won. Ultimately, despite all the advantages we can give patients, there's an element of chance to their outcomes. Once somebody gets sick, virtually anything can go wrong outside the control of medical interventions. Any very sick patient in the hospital is one of those Plinko discs, first careening toward a full recovery, now bouncing toward death, now angling for survival but with a long stay in the rehab hospital. We can certainly do a lot for patients, but as in every other part of life there are no perfect predictions and no absolute guarantees.

Obviously patient care is not a game (although laparoscopic surgery feels like one) and should be taken very seriously. But I think virtually any physician who enjoys his or her job will say that part of what makes it enjoyable is the intellectual challenge. Finally, I realize a lot of these programs are not familiar to some readers, and I apologize that I can't explain them better. Not only have game shows really gone downhill in this country, but we have never produced anything quite as amazing as this.

Sometimes a Donut Is Not Just a Donut

Ben Bryner -- Somewhere, people are preparing for Mardi Gras -- putting together floats, finishing costumes, and, disturbingly, baking baby-shaped pieces of plastic into cakes. But in Michigan, where it's so cold it feels like your eyeballs are freezing after a trip to the mailbox (ah, Great Lakes Weather!), nobody's about to parade anywhere. So here, as in some other areas with strong Polish communities, that day revolves around eating paczki, or big, dense jelly-filled donuts. These are heavier and bigger than the donuts you usually get at a donut store, and they do come in a red box, but this still seems like a flimsy foundation on which to build a celebration. Still, I am all for any occasion that involves food of any kind, so I get excited about Paczki (prononced "pohn-cheeky" or something like that), but not quite as excited as some of the local newscasters.

Last paczki day I was working the night shift on labor and delivery. I had been up all the night before with a very nice couple about my age as she gave birth to their first child. They were kind enough to let me observe and participate in the whole process, which was a terrific experience. They were very welcoming, open people, as evidenced by the fact that they had about twenty people coming and going in and out of the room as labor slowly progressed. (These are of course the best kind of patients for a student wishing to gate-crash the miracle of childbirth; approaching a quiet, very reserved couple there for their first birth without any visitors was always a little awkward.) They immediately asked for my speculation on the sex of the baby, which I ended up being right about. I wished I had put some money down on it -- but I am always very professional, and I have a strict no-gambling-with-patients policy.

As her labor stretched on into the night, our conversation turned to paczki, which they also enjoyed, and to many other random topics. Finally, well after my shift was supposed to end, she delivered a beautiful baby girl. The parents were overjoyed. I congratulated them both and left them beaming at their new arrival. I must say, if there is anything sweeter than witnessing a new life being brought into the world, it is eating a huge jelly donut on the drive home after a really long shift on which you witnessed a new life being brought into the world. It was perfect.

As is usually the case on paczki day, my eyes were bigger than my stomach and I bought one pastry too many. That night when I got back to the hospital for my next shift, I stopped by this new mom's room to see how things were going. She was fine, but all her friends and family had stayed up all night waiting for news about the baby, so they had all been too tired to bring her a paczki and were asleep. So I gave her my extra one, and I've never seen someone so appreciative of a baby gift. Clothes, blankets, toys... these are all fine presents, but sometimes a mom just needs some food.

I realize that furnishing patients with donuts isn't a very responsible thing to do in most cases. I wouldn't have done this on my cardiology rotation, for example, or brought donuts in for any other occasion than paczki day. But in this case it was less about the donut than about trying to help a patient regain control over her life, to accomplish at least one thing she could have done if she weren't in the hospital. I tried to remember this on my later rotations too, when holidays came near or when patients told me about family events they were missing. Whenever possible, it's worth spending the extra time to try to bring a little bit of real life to a patient, however small it seems.

Leveling With Patients