The Differential: Medscape Med Students Blogs

Seasons of Med

Thomas Robey -- June and July are the transition months for medical students, residents, and the entire medical community in the United States. Many schools and programs have a brief respite that allows trainees to recover from a busy year. Now is as good a time as any to wish you a:

Happy New Year!

525,600 minutes, 525,600 moments so dear.

525,600 minutes -- how do you measure, measure a year?

In call nights, in lectures, in complaints, in cups of coffee.

In write-ups, in IVs, in needles and thread.

In 525,600 minutes -- how do you measure a year in the med?

Congratulations to graduates and well wishes for moving to a new city and starting your residency. To all the medical students who got to step-up to the next level this week, well done! Good luck on USMLE Steps 1 and 2 if you haven't taken them yet. Applicants and first year students: keep up the hard work that will prepare you for a healing career.

My resolution for this coming medical year is to take more frequent pauses to consider those 525,600 moments so dear.

Credit and apologies to Jonathan Larson

Personal Statement or BUST!

Thomas Robey -- It’s that time of year again. The leaves are turning a deep shade of green, the mosquitoes are in full force, you’re on the lookout for a swimming hole, and the ERAS and AMCAS websites are opening for electronic applications. It must be summer.

That’s right, it’s been about a month since prospective medical students could submit applications, and the residency application site opens July 1. Applications are the boiled-down concentrated version of you. They’re an abstract, so to speak, of all the things you’ve done leading up to this point. When it comes down to it, applying to medical school and residency is like applying for a job. Most jobs require applicants to complete an application, submit a CV, and write a cover letter. Most employers do not, however, require new hires to pay them a salary or leave it up to a lottery to determine placement.

Maybe that’s why medical school and residency programs request personal statements.

In any case, the personal statement is often approached with trepidation or avoided until the last minute. This is a mistake. If you’re just now thinking about your medical school statement, get cracking! Medicine class of 2009? Hopefully you’ve already started drafting your residency pitch, too. Personal statements are the best way to individualize your application. It’s where you can be your very best. It’s the only thing in the whole bundle you have total control over. When the reviewer reads your essay, she should know the answer to the following question: “What is it about what you want to do that make you want to do it, and what is it about you that makes you the best person for the job?”

So, maybe you haven’t started writing your statement yet. Or you’ve thought about it, but it’s not coming together. What are some of the things you can do? There are a number of helpful tips and tools out there for fretting applicants. I won’t tell you to look no further than this entry, but if you need a jump-start or a fresh take on the mechanics of a personal statement, here are some basic suggestions centered on three main aspects of a personal essay: content, style and presentation.

CONTENT

1. Provide the information requested on the application. Programs are less likely to accept people who don’t read directions.

2. Convey both the seriousness of your intent and your individuality. If you are applying to residency, consider:

* How your skills match those valued by your specialty.

* Coursework that shaped your specialty decision.

* Interests and experiences outside of medicine that demonstrate your values and individuality.

* How the reasons for selecting the specialty align with your personal and professional goals.

* Vignettes that you want to be asked about in your interviews.

STYLE

1. Write to be understood, not to impress. Don’t pen words you wouldn’t use in everyday conversation.

2. Aim for a readable document that lets the content shine.

* Use simple, uncomplicated sentences of varied length in short, well-developed paragraphs that avoid the use of “I.”

* Examine each sentence for its purpose. What does it do to further your content?

PRESENTATION

1. Make sure the essay is the correct length (ie, read the directions).

2. Support your opinions with experiences.

3. Revise and rewrite as often as necessary. Most people work 4-5 drafts that are reviewed by professors, classmates and family.

4. Follow standard rules of grammar and punctuation. Don’t rely on spellchecker!

I’ve been told by many people, “This is not the time to get creative.” I agree. Except that my AMCAS essay (back in the day) consisted of original poetry and a brief discussion of it. Maybe that’s why I didn’t get an interview at that one school. My approach was honest, and my interviews were followed by offers from several prestigious schools. In the end, just make a decision about who you are and how you want to speak for yourself.

If you need more concrete help in getting your ideas on paper (I did), consider workshopping your statement using this guide. Remember, people won’t find out how great you are until you tell them.

What's That Smell?

Thomas Robey -- Is there another profession where one can expect to routinely encounter such a diverse array of odors as occur in medicine? Clinical aroma may not be the most pungent or revolting of smells –- crime scene cleaners are probably worse –- but in what other career is identifying foul fragrances actually an important skill? The differential diagnosis from one odor could easily include abscess vs. BO vs. foot fungus. Sure, some specialties and patient populations may have an increased preponderance of smelly patients, but it’s a given that medical students and residents encounter a fair share of smells before choosing their practice.

As for me, I hope to refine an olfactory prowess so it may add to my clinical armamentarium when I practice in an urban emergency room. As such, I’ve compiled a list of top twelve smells of medicine. Why twelve? So that this can be converted to a calendar, of course! I’ll leave it to the comments section for proposed images for these smells. Note that I took liberties with some of the Latin medical-sounding words. Some are diagnostic scents, others are odors you just need to learn to deal with.

1.    Ketohalitosis (fruity breath)

2.    Pungent Urine (usually dried into clothes)

3.    Feculent Abdomen

4.    Anaerobic Abscess

5.    Operating Room Flatus

6.    Bromodrosis (smelly feet)

7.    Ichthiosmia (the fishy smell of bacterial vaginosis)

8.    Post-Op Diarrhea

9.    Halitosis (applies to some attendings)

10.   Vomit (ideally, not on your scrubs)

11.   Bromhidrosis (body odor)

12.   The Smell of Labor

Please let me know if you’d like to go in together in marketing a “Smells of Medicine” calendar.

Recycle This Entry

Thomas Robey -- I have to admit: my complexion has adopted a green hue after living in the Emerald City (Seattle) for 6 years. I’m not referring to gardening skill, increased nausea, or skin mildew, nor am I a Ralph Nader supporter. The green in me is due to being bitten by the environmentalism bug. I didn’t realize how bad it was until I found myself in a country where my habits clashed with everyone else’s. For example, when returning from a clinical rotation in Eastern Washington, I hauled eight bags of aluminum, plastic and paper home because it was not apparent that those items could or would be recycled in Spokane. Yes, I know this qualifies me as over the deep end. Your follow-up thought is “what has this to do with a medical blog?”

The differences in recycling between cities can be played out on a much smaller scale. Do your school or workplace recycling habits resemble your behavior at home? More and more of us know by heart the recycling rules in the kitchen: “#5 plastic is okay, but the lid goes in the trash,” or “save that deli container for my next art project.” Does this behavior get checked at the clinic door? Does your medical center recycle? If so, I bet that all attempts to reduce waste go by the wayside in the hospital’s operating room. There’s good reason for OR’s to make extra waste (namely, sterility!), but it’s hard to believe that all of that stuff needs to be disposable!

Change is always hard – how many of your patients quit smoking with their first try? As with other behavior modification, improvement is easiest on a small scale. Here are some small examples of correctable material waste that I’ve noticed in health care:

* recyclable cardboard glove boxes in the trash

* single use metal suture kits (forceps, scissors, needle drivers)

* no beverage container recycling

* disposable sterile or contact precaution gowns

* no white paper recycling

* only styrofoam plates and plastic utensils are available in the cafeteria

* shredded patient information sent to the regular waste stream

* plastic water bottles at every conference

And these are just the obvious ones. I hope you could hear the incredulous tone of voice as I listed these off! What waste do you see where you are learning/doing medicine?

International readers might wonder why hospitals allow steel instrument sets to be thrown away. The answer is expense. It costs more to collect, clean, package and sterilize the instruments than to buy lower quality ‘one-use’ tools. Even these cheap instruments last a while - I salvaged and sterilized one of the sets I used in an ER and practiced suturing at home before discovering how helpful they were for projects around the house requiring fine manipulations.

Presenting ideas to a large institution or making suggestions as the new guy who’s just here for 6 weeks is intimidating. But there are a number of little solutions to reduce waste that you can do as a student (i.e. as the lowest rung on the ladder). The surgeons in one red state thought I was a nut for putting out a box to collect aluminum, but a week later it was full. I take home papers without patient information on them for the bin. Even just inquiring about a clinic’s recycling policy could result in a system change.

As fuel and plastic prices increase and more people become aware of resource limitations, it will become more important to reduce, reuse and recycle, not just to save the planet, but to reduce the bottom line. And it may just be those energetic new students or house staff who help translate ideas into actions. What will you do?

Pros and Cons of the Away Rotation

Thomas Robey -- Many public medical schools have a specific mission to train physicians to work in their state or region where they complete medical school. In the United States, this could present itself as improving graduates’ chances at residency in a home state or even deferring some students’ tuition if they promise to work in an underserved area. Many of the larger state schools go one step further. They actually train their students in the cities and towns where students could one day return to practice.

Such is the situation at my school. I’ve spent only 10 weeks of my third year in Seattle, Washington. I’ve also been to a small fishing and logging town on Puget Sound, Spokane, a medium sized city near Idaho, and now Fairbanks, Alaska. Since the University of Washington is the only medical school for Washington, Wyoming, Alaska, Montana and Idaho (WWAMI) and it focuses on excellent primary care training, Step 2 is followed every year by a medical clerk diaspora. We affectionately refer to placement outside of Seattle as being WWAMIed...

Anna has written tips about how to survive an away rotation. I’m focusing today on why you might want to do an away clerkship in the first place and what some of the drawbacks might be. Do you remember the city mouse/country mouse fable? It’ll be hard to get the city out of my veins, but when it comes to clerkships, I am definitely a country moose -- I mean mouse.

In favor of away clerkships are the following:

* In surgery and obstetrics, the medical student is the first assist. Without residents, the hands-on learning occurs both in quantity and quality. On my first day in the OR, I cut out an appendix, drove a colonoscope, and tied a seton drain to maintain a fistula. In many instances parents are happy to have the student in the room. This is a stark difference to the urban academic setting.

* For male students, it is best to get out of the urban centers for Ob/Gyn. There is still a balance between male and female providers, so women tend to be more comfortable with students learning exams.

* Free food. Many of these hospitals see away clerkships as a way to recruit young doctors to come back after residency. As such, there is often plentiful free food.

* The student-teacher ratio is stacked for you. There may be only one or two students learning from 10 doctors, 15 techs, 25 nurses and hundreds of patients. If there are residents, you can often pick and choose which folks teach in a way that matches your learning styles.

* Students in small towns have the potential to be a sort of hospital celebrity. More people know my pager number in Fairbanks than anywhere else. I don’t even know my pager number. This all adds up to your seeing interesting cases.

* It’s easy to maintain continuity of care with the "build your own schedule" setup many away rotations have. I can see a surgical patient’s initial presentation, a pre-op clinic appointment, assist in the procedure, manage the post-op hospital stay, and participate in follow-up care.

* Free time exists in the community. You can use this to read (medical topics or otherwise), exercise, sleep or take on extra shifts in the community ER.

* Travel! I’m not sure when I’d ever be able to get to visit Denali National Park. It’s a lot easier when your medical school arranges transportation and housing 2 hours up the road.

It’s not all gravy away from the mother ship. Being a city moose does have its benefits.

* There’s a lot to be said for the stability of home. Living in a new city every 4-8 weeks is a drag. It’s hard to get in a study groove when you have to figure out where the grocery stores are!

* Residency letters sometimes need to come from department big shots. There are not many of these folks in Laramie, Wyoming. You will be able to get a letter from someone who really knows you, but unfortunately, residency programs will probably not know the writer.

* Administration issues and scheduling run a lot smoother when you are able to drop in for your appointment, rather than doing it by phone or email.

* Didactics are rare outside of the academic medical center. If you prefer learning in a lecture hall (I happen to not), it is a good idea to stick around town. Most schools have online streaming lectures, but as helpful as they are for remote students, it often just isn’t the same.

* Friendships are harder to maintain across distances. Significant others, classmates, friends and family may wonder where you are off to this month. When you’re as busy as a third year student, it’s easier to grab coffee if you’re in the same hospital!

* Are you considering a career in a medical or surgical specialty? Good luck finding a cardiologist or urologist in private practice willing to take time out for a student. Away rotations can be useful for the bread and butter of medicine, but there’s a reason why people travel to academic medical centers for care. That’s where the specialists are!

In the end, there is something to be said for having a touch of city and a bit of country in your medical education, but wherever you are, it’s important to identify the strengths and weaknesses of your location. And stay away from the moose calves this time of year... unless you want some medical student on an away rotation in Alaska to chronicle another tourist vs. moose story on his blog.

Laughter in Medicine

Thomas Robey -- In the past year, I’ve realized that experiencing strong emotions is part and parcel of a career in medicine. Should providers cry with patients? How do pediatricians manage the celebration of childhood with the heaviness of disease? Cancer elicits universal questions of “Why me, now?” Birth and death are each tied to pain and joy. And then there is laughter.

Laughter in medicine can be divided into two main categories: doctors with patients and doctors with doctors. Humor in both settings builds rapport, enables discussion of awkward topics, and is even therapeutic. Imagine yourself laid up in the hospital; the right type of levity in the right amount could make your day. One patient shared with me that my frequent bedside visits were better entertainment than cable television. One day, she asked if I could sing and dance. I encouraged her to look me up “on the outside,” but now regret not breaking out into an old musical number right then. We still shared a laugh about how I’d appear to my attending while belting out, “I am I, Don Quixote!” I’m daily amazed by how easy it is for someone to smile and laugh when they are in so much pain.

The other type of laughter -– between doctors -– is almost as important as the first. Care providers see much of what is broken in society. We see the worst of disease. We are witnesses to the ills of society. Injustice. Abuse. Addiction. When docs (and medical students!) get together, it’s natural to talk about these things, and this is how we understand each other. How do people in any stressful situation cope? The unique bonds between combat vets, firefighters, and social workers are echoed in medicine. Frustration and pain often expresses itself as gallows humor and cynicism. Is it wrong for a doc to speak pejoratively of an injection drug user if the patient’s identity is confidential and the comment is safely in the company of other docs?

My time as a surgery clerk has confused these two types of humor. I had been able to keep separate humor with patients and humor about them. This all breaks down in the operating theater. The patient is asleep -– sedated and paralyzed. If he can hear what is going on in the room, he will not remember it. When the drug user is on the table with necrotizing fasciitis because he muscled bad heroin and then sat in a hot tub for an hour, is it okay to make cynical jokes about the choices he made? His legs are spotted as a jaguar with injection ecchymoses and you’re cutting through intricately penned tattoos on his shoulders, hoping to excise the infected tissue before it spreads to his heart. When the surgeon dryly points out that it’s a shame this guy has to lose his tattoos, when in reality, he’s likely already lost his life, is it okay to laugh?

I almost cried.

Surviving the Tough Times

Thomas Robey -- May is a tough time of year for medical education. The Step 1 board exam is looming for second year students, third years are exhausted from solid months of clinical clerkships, fourth year students are nowhere to be found, and interns, well, they're as exhausted as third year students but raised to the exhausted power (a mathematical expression). For many, this fatigue is not the running on empty, "I'm almost finished" feeling that we might expect in June, but rather an "I'm drowning, but I'm too busy to call for help" situation. Yes, not all feel this everyday -- to get this far, we have to have good coping mechanisms -- but there's a greater chance that overwhelming feelings get the best of us this time of year. (I wonder if it's by design that the medical year's most stressful time coincides with spring's unleashing of hopeful, happy and even manic episodes.)

But for those of us with real struggles to get through an understandably difficult year, it is helpful to recall why we are here. The patients we try to cure can be the very medicine we need to get through the day. In the rest of this article, I've picked out some of my more memorable patients in an effort to cheer myself, but also to jog your memories and invite accounts of your favorite patients.

There's the 8-year-old boy with Crohn's disease who drew a portrait of me. When he had unbearable pain and bloody stools, it took a day for him to warm up enough to communicate with more than head nods. Some day he will need large chunks of his intestines removed. It's too bad his overflowing heart cannot be used as donor repair tissue.

Can you remember your first delivery? Mine was a complicated Caesarian section, which made the emotions cycle extra quickly. In the end, mom and baby did just fine, and I try to draw strength from the resilience they both exhibited.

There was even the time when I delivered bad news to a patient with metastatic prostate cancer. He probably knew this was going to be the diagnosis, but had been in denial. The time he spent ignoring the problem was probably too long, but in his acknowledgement, he re-established care and is actually doing well. It has been nice to check in on his check-ups, if only via the electronic medical record.

And finally, there is the aged southern belle who could be a poster child for a "hugs not drugs" campaign. In the process of administering the Dix-Hallpike maneuver to assess canalith dizziness, we discovered that even medical professionals need hugs now and then.

These are the golden patient encounter memories that keep me looking forward. What are the stories that pull you through the difficult days?

Picking Up the Pieces

Thomas Robey -- Some people write to understand or explain the world around them. Others use the pen as a vehicle to better understand themselves. The fact that one in ten Americans has tried their hand at blogging speaks to the appeal that the written word has in clarifying the mind. For me, my private journals, my personal blog and this column (in order of clarity) offer an outlet that is as important to me as a refreshing stroll at day's end.

Imagine how shocked I was to discover my eyes welling up and my fingers trembling as I wrote an email to my clerkship director about the struggles I described yesterday. Email as therapy?!?!?!??? What began as a simple request for advice on oral presentation skills evolved into a soul-bearing reflection.

By now you're thinking, "What's wrong with this guy?" I mean, really: get over it! In the grand scheme of things, what is a single blown presentation? But it wasn't just that. I had noticed myself getting grumpy, withdrawn, looking forward to the end of my shifts, cutting corners... and when this sort of thing happens, you can bet that you're the last person to see it.

To get to the bottom of all of this, we have to back up a week. Eight days before my bombed presentation, I learned that my grandfather had died. He was a great man, and his life was long. His passing was not fully unexpected, but news like this never comes easily. I mourned his passing that day, but I was also post-call. So I went to sleep at 6 PM and woke up the next morning ready for the wards.

The memorial was scheduled for three weeks after his passing, which happened to be the day of my medicine final. When my family heard about this, they reassured me over and again that the last thing Pappy would have wanted was for me to interrupt my studies to fly across the country for his service. I comfortably chose to stay home to finish the clerkship and take the exam. But in the end, this was the wrong decision.

It only took a week for my personal situation to negatively affect my functioning. I initially blamed this on fatigue incurred from a tough call schedule at a busy county hospital in a course I wanted to excel in. In retrospect, this conclusion was corrupted by the blinders I donned when I decided to delay mourning my grandfather's passing until "after the test."

Medicine is a career of delayed gratification. It takes, at a minimum, a decade to finish formal training as a doctor. There's always something to be sacrificed in the name of medical education. Hobbies. Exercise. Sleep. Friends. Family. We all struggle to maintain balanced lives, and many succeed to one degree or another. But as the end of my formal education approaches, it is clear that the training is just beginning. As such, there will always be something from the medical career demanding attention.

This brings us back to a third year medical student perched before a computer in the Team D workroom, tapping out a short note that brought tears to his eyes. Only then did it become clear to me why the previous week had been so miserable. Sure, I was sleep deprived; sure, I had encountered some stumbling blocks; sure, I was worried about my grade. What I realized while writing that email was that I had an unaddressed deep need to mourn my grandfather's death.

When I met with the clerkship director later, we didn't even mention oral presentation skills. The next day, I arranged to fly to Pappy's memorial service. As important as the medicine clerkship was to me, and as inconvenient as it would be to make up an eight-hour exam, a memorial for a dear loved one held no match. Fortunately, I will not have the option of regretting my choice.

It's strange to say, but the most important thing I learned on my internal medicine clerkship wasn't in any text. I learned to stop compartmentalizing work and family, so that critical needs in one would always trump the other. I am thankful for a mentor who helped me see what I was doing to myself by blindly committing to career. In experiencing loss, and addressing it, I have a new understanding of the proverb, "Physician, heal thyself."

When the Stride Becomes a Stumble

Thomas Robey -- My school's internal medicine clerkship is twelve weeks long. In contrast to shorter rotations, this format makes it possible to hit a stride as a productive member of the wards team. With two months on the floor under your belt, you know how to write admit orders, you can pre-round on three patients in under an hour, and you have the experience that comes from giving a hundred oral presentations. You even know the ins and outs of the electronic medical record. The last two weeks is your time to shine. And rightfully so: you've got a lot of information in that cavernous shell on your shoulders, and a lot of it's actually useful (the hospital cafeteria's night-owl hours, for example.) The tenth week is when you can legitimately take ownership of managing your patients. And at my school, management equals an honors grade.

With that in mind, consider this scenario... My team was on call the first night of our new attending's service; I picked up two patients and helped with a third. Usually that would afford a few hours of sleep before morning rounds, but in a portent of things to come, my admission H&Ps came together a little more slowly. Therefore, I wasn't able to catch my 4 AM beauty nap. No biggie: It's not like I had much beauty to start with, anyway.

In preparation for rounds, I had jotted important notes from the patient's presentation on a notecard; the admission note was tucked inisde my labcoat pocket like a security blanket; and, I'd recited my 4-minute oral presentation in front of numerous mirrors around the county hospital. I was enacting what students in medical centers around the country repeat every four nights: 18 hours of hard work boiled down to a rhetorical device that is partly polished statement of fact and partly persuasive discourse. I was ready.

What followed that morning was the most rambling, incoherent jumble of words I've ever heard emerge from my mouth. Which says a lot -- the oral presentation is what I've struggled with most over my third year's tenure. But I was improving, was gaining confidence, and even was comfortable working within this format to share medical information. You can imagine the frustration I felt when I suddenly transformed into a green third-year clerk in front of a new attending, just as I was supposed to be "hitting my stride." I went home later that afternoon crushed. It hardly mattered that my second presentation was okay and that one of the patients had turned the corner due to a treatment I suggested overnight. That "first impression" was lost. Instead of hitting my stride, I found myself in an uphill trudge.

But all was not lost. I'm probably not alone among medical students in admitting I have a fixer personality. When I see something wrong, I have to get in and wrestle with it; at the very least, I tinker. I woke up the next day resolved to fix this thing. After all, I LIKE clinical medicine! I would not allow my little stumble to precede a precipitous fall. Some of the strategies I came up with that morning could apply to any difficulty encountered in medical school, or (if you have one) in real life. They included:

1. Forget about it, move on, wow the team next time.

2. Acknowledge your mistake; ask the attending for pointers.

3. Practice, practice, practice. Practice again.

4. Consult with a third party adviser about the situation.

5. Take a long run.

Initially, I decided on #1. But I quickly grew impatient with this. (Recall that I'm a fixer.) When the attending offered pointers before I could request them, that took care of #2. #3's a given. And #5 offered a painful reminder of just how much an inpatient service messes with one's conditioning. In the end, it was tactic #4 -- emailing the hospital's clerkship director -- that helped me the most, and may have initiated the most important realization during my three-month medicine clerkship.

Continued Tomorrow...

Coming Out of the Closet

Thomas Robey -- "I’m going into emergency medicine."

There! I said it.

I’ve been surprised throughout my third year by how clannish the practitioners of medicine are. I don’t mean the useful divisions of "You treat the hypertension, he’ll cut out the tumors, she’ll deliver babies and I’ll prescribe lithium." I fully expected medicine to be a team effort where highly trained individuals contribute to the common goal of patient health. But I have the feeling that all of the players don’t necessarily have complete respect for their teammates.

Enter into the picture the third year medical student. As with many other colleges, my school divides the third year into core clerkships. The purpose of rotating in all the major fields is to educate students in the basic principles of medicine. A secondary goal is to assist future doctors in knowing when to refer their patients for specialty care. The third objective is to help students decide which residency to apply to. I don’t know about you, but I hadn’t a clue which specialty I would gravitate to when I started my third year. (Granted, part of my disorientation can be blamed on my sudden realization that I didn’t want to run a basic science lab.) For a while, I could honestly report to my inquiring residents and attendings that I didn’t know what I wanted to do next.

Things have changed. Now that I’m confident of a career in emergency medicine, I understand the dilemma that students with good ideas of their career goals have when confronted with the, "What are you going in to?" question. We are told to be up front and honest about our career interests –- to not let that get in the way of our education. But it’s not that easy. Whether it’s comments about the brevity of surgeons’ notes, caricatures of radiology as a 9 to 5 career, of ER docs doing triage shift-work or internists as ruminating second-guessers, the observant student will recognize that it might not be a good idea to disclose her chosen profession to those evaluating her. Don’t even get me started about what people say about my one-time career choice of pathology!

As it gets later in the year, the legitimacy of an "I don’t know" answer decreases. You’ve scheduled the fourth year to cater to your next step and you’re already thinking about residency programs. Hopefully, you’re pondering what will go into your personal statement. Even if you’re considering three fields, at least that’s down from the "everything seems interesting" non-answer (but still honest reply) that I used to give.

So what’s the lesson here? I say be confident in your ability to identify what you are best at, what you enjoy the most, and what career will contribute to a happy and meaningful life. When you’re on a team with docs who don’t understand your view, that’s okay. In whatever clerkship you are in, you’ll be best served by working hard and studying. In the end, that will affect your grade more than your professional choices. And when you’re out on the field with your own practice, don’t forget the value of teamwork. I can’t think of any way that trash talk benefits patient care.

Socializing 101

Thomas Robey -- Consider this column a plea for help.

All across the Pacific Northwest, third year medical students are studying for exams this week. As with the season, winter clerkships have reached their finale. For students at my school (the University of Washington) there is another potential stressor: the weekend switch. As in many programs, students here carry out their required clerkships in different cities. Unlike other programs, those different cities could be separated by 2500 miles (Cheyenne, WY to Fairbanks, AK). Such periodic migration creates interesting challenges and presents unique opportunities. I want to focus on one of the challenges here.

Apart from my wife, the only folks I know where we’re heading next have bushy tails. (When we were in Spokane, WA earlier this year, some squirrels took to apprehending peanuts we put out for the birds.) But we won’t be without human colleagues in Spokane. There are a handful of other students in each city, but thanks to a rupture in my educational space-time continuum, I know R3s better than I know my classmates. Thankfully, medical students tend to be an outgoing lot -– it’s easy to get along, and someone is bound to have a “We made it to Missoula” get-together to build local community. So what’s my problem?

I’m worried that grad school converted me to an introvert! I have to admit, six months into the third year, I’m still getting used to this medical student thing. Life in the land of PCR machines, mouse colonies, and lab slumber parties completely deprived me of interactions with my kindred classmates. There were the occasional social events as my colleagues advanced, but as a committed lab-rat, I found myself increasingly distanced from the social aspects of medicine.

When folks consider re-immersing themselves in the medical curriculum after a year abroad or time doing research, it’s usually the factual content they expect to have lost. My worries were endless. Will I keep straight bactericidal and bacteriostatic effects? Nephrotic? Nephritic? The differential diagnosis for dyspnea? Surprisingly, these facts have emerged from the recesses of my mind without much consequence.

What has been slow on the draw for me is filling the gregarious shoes of the social medical student. Do you know what I am talking about? It’s that little circle that forms at open social events where amazing accounts of patient care are shared, frustrations with curriculum are vented, and future schemes are planned. Working long hours with hardly a chance to reflect makes these confluences of experience vital to students’ mental health. (It’s also a good way to practice a succinct presentation of your patients’ histories!) This part of medicine presents me with the steepest learning curve. I’m too easily flooded in sensory overload.

Has anyone else noticed this phenomenon and had difficulty breaking in to it? Sometimes we offer tips on The Differential. This time around, I’m looking for a few myself.

The Politics of Health Care

Thomas Robey -- Blogging and politics are inexorably linked in today’s media. Bloggers whose core topics are news, health, sports, science, religion and celebrities invariably offer commentary on political issues. The Differential is at its core a blog for and about medical student life, and if you’re at an American medical school, you’ll be hard-pressed to avoid conversations about presidential politics. As a member of the medical profession, you may be called upon to offer opinions about the remaining candidates’ health care plans. Having already been asked by family, friends and fellow precinct caucus-goers which plan is best for America, I’ve done some homework on the competing proposals. Like any good medical student, I am happy to share my study guide with you here. Each of McCain's, Clinton's and Obama's plans have good ideas built into them. This post is my attempt in 700 words to provide a starting point for you to understand them. You don’t have to pick a candidate based on health plans, but considering health will be your business, health care is probably not a bad place to start. This is a ‘just-the-facts’ post. For my opinions about the candidates’ plans, you’ll have to head elsewhere.

Like just about every other issue in the 2008 campaign, there are two health plans that are more similar to each other than each is to the third. For simplicity’s sake, I’ll start with the third. John McCain’s experience as a legislator has shaped his approach to reforming health care in a way that avoids “the ‘perfect storm’ of problems that will cause our health care system to implode.” The main elements of his plan include (1) changing the way plans are purchased, (2) increasing the accessibility and use of generic drugs, (3) innovating new forms of health care delivery and (4) altering Medicare to cover more preventative care and to punish medical errors. The McCain plan leans heavily on point #1. The argument being that current health care coverage is dominated by employer-negotiated contracts and employees given more options and flexibility will force the industry to lower prices. Via tax code changes and other incentives, McCain would permit individuals to buy insurance on a national market and through groups like churches, professional associations and co-ops. His ideas for health care delivery center on a network of walk-in clinics tied together (eventually) with an electronic medical record. This is an attempt to reduce expenses incurred from costly ER visits.

When it comes to the remaining Democrats’ plans, it’s more difficult to parse the differences than to identify similarities. Let’s first consider the similarities. In TV and radio ads, both have claimed to cover all Americans. Because insurance companies still provide the bulk of reimbursement mechanisms, neither plan is fully universal health care. Both plans require insurers to offer coverage no matter the individual’s medical history. Both also allow consumers the option of purchasing government-offered insurance. Finally, both plans seek (via government subsidy) to make insurance affordable to poor Americans. The differences come down to the mandates: Clinton would require every American to be insured either by a public or a private plan, while Obama’s plan only requires children to be insured. In his plan, anyone may opt-out of insurance. He suggests that a more competitive industry faced with cheap government options will lead everyone to buy in. Some health economists have argued otherwise. Clinton would limit insurance costs to a percentage of family income, while Obama would disperse subsidies to income-qualified individuals to help pay their premiums. The main discussion surrounding these plans is how to pay for it and who is covered. Obama addresses more aspects of the practice of medicine by emphasizing a broader implementation of the electronic medical record and rewarding practitioners who keep quality of care high and costs low. Clinton also features cost-saving technologies, but speaks more of targeting insurance company excess than any incentives or punishments for health care practitioners. Interestingly, both plans have adopted elements from the no-longer-running candidate, John Edwards.

In the end, it seems like all three of the candidates are committed to improving the current American health care system. The Democrats argue for a more comprehensive overhaul than McCain, but each plan has pros and cons. As the 2008 contest for the White House intensifies, I expect health care will be argued more and more between the remaining candidates.

Will you be prepared to debate the future of medicine?

One Book, PRN

Thomas Robey -- Do you remember your favorite childhood book? Was it a chapter book that you read on your own? Or the picture book you insisted a parent read to you every night? Perhaps, like me, it was the Si-Sz volume of the 1984 World Book Encyclopedia? If you have fond memories of books, you probably grew up in a book-rich environment. Consider this tidbit: in middle-income neighborhoods, the ratio of books per child is 13 to 1; in low-income neighborhoods, the ratio is 1 age-appropriate book for every 300 children. And it turns out the only behavioral measure correlating significantly with reading scores is the number of books in the home.

What does this all have to do with being a medical student? I learned from an insightful pediatrician that the top five ways to prepare kids for long, productive and meaningful lives are: love them, keep them safe, feed them well, keep them healthy, and teach them to read. You may think that pediatricians focus only on the “keep them healthy” task, but after a couple dozen well-child checks, the third-year student will be able to ask parents about family life, smoke detectors, car seats, diet, and developmental milestones as readily as checking on the immunizations, recent illnesses and vital signs. Is encouraging reading habits on your list? Parents who were not read to as children may not realize the value of reading to their own kids. As a result, children from low-income families enter school at a disadvantage. Adults who were read to as children tend to assume all children are read to. What category do you think most doctors fall into?

Last fall, I had the pleasure of spending half of my pediatrics clerkship at the Odessa Brown Children’s Clinic, an outpatient clinic associated with Seattle’s Children’s Hospital. Apart from the opportunity to learn pediatrics from an enthusiastic team of docs and nurse practitioners, I was privileged to help care for kids from widely varied social, economic and racial backgrounds. I learned first-hand about sickle-cell disease, asthma and juvenile obesity, along with colds, rashes and ear infections. It was the problem of illiteracy that surprised me. When money is tight, books are a luxury. Fortunately kid’s health care isn’t yet a benefit for the rich. Thanks to the State Children’s Health Insurance Program (by the way, the Federal bill that’s the backbone for SCHIP has been vetoed twice this year), most kids from poor families are eligible for free or inexpensive health care. Our society values kids’ health. (Insert toothpaste commercial voice here: “Studies show that ten out of ten pediatricians want their patients to succeed in life.”) This is where health and literacy converge. Why not give a book to every child at every doctor’s visit?

This is not a new idea. A national organization called Reach Out and Read provides funding to give kids who are six months to five years old a new age-appropriate book at every well-child visit. Some clinics raise funds to expand the age range and number of books given per year. Taking kids back to the book pharmacy to select their reward was a favorite part of the patient encounter for me. Thousands of Seattle children have Odessa Brown libraries in their homes where previously there wouldn’t have been a book in sight. By providing books to a population of kids who may not otherwise have exposure to reading, doctors can do as much for kids' futures as giving shots and antibiotics. If you end up in pediatrics, consider prescribing one book, PRN ad lib for all of your patients.

(Federal legislation to help sponsor programs like Reach Out and Read is included in HR 4449 and S 1895. Check out the legislation and let your representatives know if you support it. Special thanks to Hillary Chisholm who directed me to much of the data presented in this post. Statistics collected from studies were presented in the Handbook of Early Literacy Research, Vol. 2, edited by Susan Neuman and David Dickinson.)

The Fix

Thomas Robey -- It is a widely held belief that medical students and coffee are inseparable. Almost equally connected (in collective impressions) are Seattlites and Starbucks. You’ll be surprised that this Seattle medical student can count on one hand the number of times he’s consumed said black beverage –- even the milk and sugar-laden preparations. Until my third year, I even fit qualifications for caffeine-naïve. Sure, I drank caffeine heavily as an undergrad, but I went cold turkey when I moved to Seattle.

When I relapsed about a year ago, I had forgotten about the world of stimulation available to me as a user... Now, I’m amped to share with you some of what I know -– endure my efforts to teach you about the science of caffeine, and you’ll get a new-found caffeine junky’s guide to improved cognitive performance.

We in the medical profession should know that caffeine is a potent drug. PICU docs give it to newborns to boost respiratory effort. Caffeine is used to relieve the pesky headache that follows a spinal tap; it treats other headaches, too. You’re probably familiar with the OTC labeled use as a stimulant (NoDoz, etc.) and for mild headaches (Excedrin, etc.). Caffeine is metabolized in the liver (demethylation by CYP1A2). The serum half-life for neonates is about 4 days; in adults it’s around 4 hours. The time to peak serum concentration is between 30 and 90 minutes for orally delivered drug. But caffeine is not limited to hospital use!

Caffeine is a member of the large class of mind-altering substances called nootropics. In drinking your morning coffee, you are not only gearing up for the day but increasing vigilance, the speed at which you work and, possibly, memory recall. Unfortunately, most medical students misuse caffeine.

I’m not talking about abuse here, but rather the failure to use it to its optimal benefit. Most folks I know have a cup in the morning and then some more in the middle of the day. This behavior works more to quench symptoms of withdrawal than to confer any benefit. Want to best use this most popular psychoactive substance in the world? Follow these tips:

1. Use caffeine in small doses. 20-100 mg per hour increase speed and accuracy of simple tasks. Don’t know how much you’re getting in your drink of choice? This page breaks it down for you. 8 oz of drip is 135 mg. One espresso shot is (surprise!) 30-50 mg. Soft drinks run 35-55 mg. Teas are 25-70 mg and energy drinks 75-150 mg.

2. Boost the effect of caffeine by consuming with sugar. A well-designed study showed that 150 calories of glucose -– the same as in a 12 oz can of cola –- with caffeine is better than either alone. It would be nice to know if such caloric intake is needed for the additive effect. Until that study is done, you’ll just have to weigh your waist against your cognitive ability. (I’m staying with diet soda.)

3. Drink responsibly. The cognitive benefits are lost after the body builds up a tolerance. So if you find yourself needing a fix every morning, you have probably lost any benefit that could be gained from regular small doses. Taper yourself off your high AM loading dose to reset your body. Then, when you need to buckle down for the next board exam, you can let loose the nootropic power of caffeine. Just try not to exceed 2500 mg in a day.

There you have it. That’s all this recently relapsed caffeine user can offer. Are you craving more info like your morning cup of joe? Head over to Chris Chatham’s blog, Developing Intelligence, for a nice summary of the major scientific studies testing the effect of caffeine on cognition, or to WebMD’s drug info about caffeine.

"How Much Longer Will It Be?"

Thomas Robey -- The third year of medical school is full of firsts. With new experiences, sensory collection mechanisms kick into overdrive and the brain says, “Hey, I should record this.” These first experiences and emotions stay with you forever. Some firsts that I remember as clearly as if they were yesterday are my first delivery, first terminal diagnosis, first surgical scrub, first admission, and first code.

I remember another first as though it was yesterday. It was yesterday. I was doing chest compressions an hour after a patient came in to the ER. I heard, “strong femoral pulse with CPR,” and focused on locking my arms, lifting my fingertips off the chest wall and maintaining a fast rhythm. In my mind: “four and five and six and...” I did not realize how fast she had deteriorated. When the attending ER doc told me I should stop compressions, I stepped away from the body only to notice her family watching from the hall. They had asked to observe. By the time I had gathered my thoughts, the tubes and wires had been removed from her body and she was covered to her neck in a clean white blanket. Her lifeless face looked at peace. No longer scared. No more strain. The family slowly filed in. How I wish I could transplant her last squeeze from my hand into her granddaughter’s palm.

She was 89 and had been discharged only days before following treatment for a pulmonary embolus. Lung function was compromised. Her anti-coagulation was therapeutic. Even so, we think a clot found its way into a renal vein. Her kidneys failed. She became toxic on the digoxin she took for her arrythmias and heart failure. This is all to say that she was very sick. Her family knew this. They had spoken with her about resuscitation. She wanted it, but not with an endotracheal tube.

Thirty minutes previous, she told me through her oxygen mask that she had not eaten in days: the nursing home food was terrible. Could we bring her some food? Yes, we could. No, she’s not in any pain, she says. She is very tired. I explain that we’ll need to admit her to the ICU tonight.

Later: “How much longer will it be?” I say “not long,” thinking she’s asking about the bed or the food. Was she asking me something else?

Note: This patient’s daughter-in-law told me I could write about this without using the family’s name.

Artificial Heart

It was my privilege to meet his wife

And find out he was a joyful man:

A doctor,

Always with a joke or smile,

With three children: an artist, a lawyer, an auto mechanic.

The youngest, he visited the most:

Always checking on the waveform,

Looking for assistance to love.

It was my privilege to teach the son.

It was my privilege to learn the procedures:

Which numbers required intervention;

Which were optimal.

Mathematics: a hobby of his

–You know, the games in the dime store window

That come in the mail from Aunt Betsy every Christmas–

Today he likes them for the bright colors.

It’s his son’s way of connecting to an age he once fought,

But now glorifies

It was my privilege to know the teaser’s trick.

It was my privilege to get to know a patient:

Two years I knew his shadow;

Now he tries to trip the caretaker.

Still the prankster.

Two months before we met,

A Reynolds number

In the outflow cannula

Leading to the mind’s demise

It was my privilege to witness this spiral?

It was my privilege to roll the machine back to the lab.

Like Atlas, bearing the console down five flights.

I do the diagnostic.

Did the computer fail?

It was my privilege to solve the final puzzle.

And my pain.

Third Year Learning Curve

Thomas Robey -- Four months into my medical clerkships, I’ve only recently grown comfortable with the unique tension inherent in being the team’s medical student. In my experience there are several characteristics of being a medical student that can play against one another. The three I’ve been thinking about recently are:

1. Medical students tend to know the least general information.

2. Of the inpatient physician team, students spend the most time with their patients.

3. It’s difficult for patients in the hospital to differentiate between attending, resident and student.

Whether it’s getting pimped on rounds or being stumped by a lab result or watching my intern crossing out order after order, it is clear that I know less than everyone else on the team. There’s a reason we’re called medical students: we’re still in school! It’s a wonder that patients let us touch them!

But maybe there is a benefit to the hospital patient in being cared for by a student. You will hear again and again that it’s the medical student’s job to collect a complete set of information. At first, this takes forever. Most of us laugh when we recall how much time we spent collecting our first medical histories. The third year introduces med students to reporting, diagnosing and managing, but most importantly helps students to refine their data collecting skills. It still takes me much longer to do the physical exam than my residents, simply because I need to be comprehensive in order to assure that I collect all of the data. Furthermore, we care for 2-4 patients in the hospital, while the resident is in charge of 5-7 and the senior as many as 18! The upshot of all this is that medical students have the privilege to form intimate relationships with patients. That extra time in the room, a complete fundascopic exam, deciphering the patient’s social situation, even performing a rectal exam, all tell the patient that this medical student cares about her health.

We care providers can take advantage of the codes that help identify students and doctors. As Ben, Anna and Ben have previously pointed out on The Differential, the white coat is loaded with significance –- to co-workers, patients and the public in general. Where I attend school in the Pacific Northwest, the coat is de-emphasized, if worn at all. On my current rotation, however, the coat is as good as my ID badge. But this only applies to nurses (“I need to call his resident to verify that order”) and consultants (“this guy is going to ask me about cryoglobulins”). A short white coat looks more like a white coat than anything else.

To a sick patient, coat length may not even register.

My standard clarification is the introduction, “I’m the medical student on your care team.” After all, it’s not fair to the patient for you to impersonate a physician. Medicolegal issues aside, the patient needs to know why you cannot immediately answer all of her questions. This is also the honest way to prevent yourself from over-extending your authority. Some may view “I’m a medical student” as a crutch; I see it as a polite way to say, “I’m sorry I do not know that answer right now, but I will go read about it, ask my teachers, and come back to talk about it.” (It wouldn’t hurt to say it that way sometimes, too!)

Someday, I will look back and laugh about how long it took me to do an initial history and physical exam for a patient. I hope I do not have to look back with regret about the time I was able to spend with them.

I Married a Med Student

Thomas Robey -- It’s past midnight, and (knock on wood) there’s not a single overnight admission for the call team. The intern is tucking in a patient upstairs, our senior resident has tucked herself in, and I have a rare chance to sit in the residents’ lounge with only my thoughts as company. Perhaps these comfy scrubs have me halfway to a more pleasant place, but that stack of papers I set aside to read tonight has long passed from accessible to mumbo-jumbo. It’s in quiet times like these that musings wander to "the outside." You know:

* Is it too early to call my sister on the East Coast?
* Did my basketball team win this evening?
* I wonder which of my classmates is working up an admission right now.
* How is my wife doing?

That last question is the one that comes to my mind most often. Medical school is tough enough when the only folks you need to care for are your patients. What? We are supposed to care for ourselves, too? Throw into the mix a partner, family member or children, and life as a medic adopts an entirely different flavor. It’s almost as hard to explain to classmates taking off early from a study group as it is to detail the etiology of a fowl post-call mood. It takes someone special to deal with the roller coaster of the third year. Of course, my marriage is special.

Assessment, how art thou biased? I’ll spare you my counting of the ways, only to say the chances are good the last two questions on my list above answer each other.

You see, I am married to medicine.

I’m in my call room on a slow night, but my wife is probably on the other side of town admitting patients. We are both third year medical students at the University of Washington, are each in the same city for our medicine clerkships, and have call on the same nights. While being the only two medical students in this particular clerkship is rather unique, being partnered to a classmate is hardly unheard of. Ever hear of the couples’ match?

Fortunately, after our school’s match-styled clerkship placement scheme fell out, we were scheduled in the same city as the other in all but 6 weeks of our third year. (In the end, we’ll spend 6 months between Spokane and Fairbanks, Alaska to pull that off.) Having started medical school in different years, we had never actually been in a classroom together; if we had, I’m pretty sure she would not have married me… Our markedly different approaches to learning shoot any chance of studying together. We worried about comparing one to the other. Would we ever share quality time?

Thankfully, we’ve discovered that it’s impossible even for clerks to be medical students all of the time. Walks around the neighborhood, a board game, the impromptu puppet show: these are the ways we remove ourselves from medicine. Sure, it’s sometimes hard to guess when to be a colleague and when to be a husband, but then there’s something about being married -– most of the time, you just know.

SAD Medical Students

Thomas Robey -- If you're like me, there comes a time in the winter (right about now, actually) when the go-get-'em, ready-to-ward mentality starts to break down. Raise your hand if any of this sounds familiar. Arriving at the hospital with sufficient time to pre-round requires an alarm set a few snooze cycles earlier. The little victories (a first successful ECG read, choosing the right empiric antibiotic therapy for community acquired pneumonia, finding a parking spot...) that were common each day in earlier clerkships are nowhere to be found. You show up at the hospital an hour before sunrise and leave long after dark. Night to night, it's enough just to get through the day -- if it's even the day shift you're working.

The third year of medical school is frenetic to say the least. Six months in, clerks are bound to get worn down. But there's something else going on. Those of you in northern climes know what I'm talking about: the winter blues. Think it's just in your head? You're right! It's actually in your eyes -- more on that later. Estimates are that between 0.5% and 3% of Americans suffer from seasonal affective disorder (SAD: what a great acronym). That's about 5 million of you. And guess where these people live... New England, Minnesota, the Pacific Northwest. The further north you go, the greater chance of seeing patients, colleagues, or that attractive soon-to-be doctor in the mirror with a real depression. So real, it has its own DSM-IV entry. Readers in the UK and Canada are even more likely to be SAD.

If you've heard of SAD, you've also heard about light therapy. If you pass off light boxes as voodoo, you've overlooked a body of scientific literature indicating otherwise. Long story short, SAD originates in the same neural centers as the circadian rhythm. The neurotransmitters that help humans understand night and day are activated (at least in part) by a pathway that initiates in the retina. In order to keep us on schedule, the brain needs to see a certain amount of light each day. Those overheads on the wards don't count. Neither do tanning beds. It turns out that the light has to be bright. That's where the light boxes come in: 15 to 30 minutes every day in front of one of those boxes each day is as good a prescription for SAD as SSRI antidepressants. Related to (but not as effective as) light boxes are dawn simulators. They gradually illuminate your room so that it is bright when your alarm clock sounds. Many people report that this is an easier way to wake up -- even if they aren’t SAD.

Either way, these devices will set you back at least $150. They're not the only way to beat the winter blues. Diet, exercise, anti-depressants and psychotherapy each have shown benefit, too. Whatever your strategy is to beat the winter blues, the ultimate antidote is just around the corner. With lengthening days, SADness goes away...

New Blogger Joins The Differential

Thomas Robey -- It’s a pleasure to join The Differential. I’ve been writing about science and society for about six months over at Hope for Pandora. That blog is a nursery for my musings about science, religion, medicine and politics. I’ll try to keep all of the messy stuff over there, but don’t be surprised if I don a different hat every so often. Differential readers should be used to eclecticism, however. Medical school is, after all, a hodgepodge of information, clinical approaches and personalities. (That is, if hodgepodges are even discernable from the messy contents expelled from the fire hose that is medical education.)

The last time I checked, I am a 7th year MD/PhD student at the University of Washington -- the one in Seattle. You may know of folks like us as “Mud-Phuds.” I prefer a moniker based on the acronym for Medical Scientist Training Program (MSTP = “Messed Up”).

While I was in PhD land, I pursued many seemingly disparate interests. I titled my thesis, “Reducing Cell Death and Fibrosis in Cardiomyoplasty,” which is a way of saying in seven words that I injected human embryonic stem cell-derived cardiomyocytes into infarcted mouse hearts and identified ways to better keep the grafted cells alive and integrated into the remaining myocardium.

That was the meat of my grad school education, but since I can’t seem to focus on just one thing at a time, I helped form an organization called the Forum on Science Ethics and Policy that sought to connect scientists, policymakers and the public about issues where science and policy overlap. I also served as an STD counselor for homeless Seattle youth. Working with controversial stem cells clued me into the complex relationship between science and politics. Working with an underserved population nurtured a perspective of compassionate care. Working with expensive, fast-paced science allowed me to probe first-hand the implications (economic and ethical) of the biomedical research complex. Working with a team of curious, risk-taking, and socially adventurous graduate students and post-doctoral fellows illuminated a number of potential career paths outside the standard physician-scientist mold.

This brings me to what I am doing here at The Differential. I wish to contribute to honest and informed discussions about science, medicine and public policy. More than in the past, physicians and scientists have an obligation to engage the public in dialogue about issues that will shape the future of medicine. How many structures are there to help trainees like us prepare for careers providing care and advocating for system improvements? Blogs like this are developing tomorrow’s communicators. For that reason, I repeat my opening sentence: It’s a pleasure to join The Differential.