The Differential: Medscape Med Students Blogs

I Love the Smell of Freedom in the Morning

Kendra Campbell -- When I walked out of the room into the hallway and announced that I was finished, the lady looked at me like I was crazy. She was responsible for administering the exams. “I thought you were taking the USLME Step 1,” she said. “I was,” I replied. Apparently, she’d never seen anyone finish the 8-hour exam in less than 4 hours. And I’m sure she didn’t suspect that the girl with pink hair would be the one to set the new speed record.

That’s right, today I took the first test in the series of U.S. medical licensing exams, the so-called Step 1. I only have two more Steps to go, and I’ll be eligible for licensure in the States.

Today was an interesting day. I woke up early this morning, drank my coffee and forced myself to eat some breakfast. At around 8:00 a.m. my partner dropped me off at the testing center to take the exam. When I walked into the testing area, the lady informed me that I had to remove my headscarf, per policy. I reluctantly removed the scarf, revealing a pile of pink, greasy, hadn’t-been-washed-in-days-because-of-my-study-marathon, matted hair. Luckily, that turned out to be the worst part of the exam.

Less than four hours later, I strolled out of the testing area, took the elevator to the ground floor, and waltzed outside to breathe in the warm, city air. Ahhh, I do love the smell of freedom in the morning, it smells like victory.

I’ve been studying for this exam for over a month. My entire life had been reduced to memorizing a monumental pile of seemingly random facts. I had been living, eating, and breathing this exam for so long. And now it’s finally over!

It definitely wasn’t the easiest exam I’ve ever taken, but I don’t think it was unbearably difficult. Some of the questions I knew right away, and others I had to take a wild guess on. However, I don’t want to comment on how I think I did because I don’t have any wood to knock on nearby, and I’d rather not jinx myself.

The good news is that I have the next two weeks off, and then I start my first clinical rotation. I plan on enjoying every minute of the next two weeks. I don’t plan on reading a single medical textbook, and I’m certainly not going to be memorizing pharmacokinetic equations.

Instead, I’m going to enjoy the sweet smell of freedom, and savor every last drop of it, since I know it won’t last forever.

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?

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.

Just Say "No"

Kendra Campbell -- I’m currently waist-deep in studying for my upcoming board exam in ten days. Yesterday was “pharm” day, where I devoted the entire day to studying pharmacokinetics, drug indications, contraindications, side effects, etc. I only allowed one day to cover all of pharmacology, and I’m now realizing that was a big mistake. I managed to cover a lot of drugs, but I still have a lot more to study. At one point, I nonchalantly thought to myself that there were just too many drugs to study. But then I really started thinking about all the drugs that are available right now, and how the consumption of drugs has been rising.

A recent study reported that 51% of insured Americans were taking prescription drugs for at least one chronic health condition. The study found that over one in five people were on antihypertensive medications, and almost one in seven were taking cholesterol lowering drugs. For insured American men ages 20-44, cholesterol-lowering drugs were among the top four meds, and their use of these drugs has increased over 80% in seven years. In addition, almost 30% of children under age 19 were taking a medication for a chronic condition, the most popular ones being asthma, ADHD and depression.

What does all this mean? Not surprisingly, Americans young and old are taking more and more drugs. There are, of course, plenty of reasons for this trend, but I’m going to focus on just two of them.

I haven’t had access to television for a while, but the last time I sat down and watched it at a friend’s house I was astonished to see the number of drug advertisements in just a one hour period of time. The use of direct-to-consumer advertising (the promotion of prescription drugs through newspaper, magazine, television, and internet marketing) is currently banned in all developed countries except the U.S. and New Zealand. But some drug companies won’t stop campaigning to have it legalized in Europe and Canada.

If you’ve spent any time in the States, you’re probably all too familiar with the television advertisements for various drugs. The basic plot line is a person whose life is miserable until they discover drug X. Once they start taking the magic pill, their life is transformed and they run through fields of flowers and look more beautiful and happier than ever. The next thing you know, the person watching this commercial is in their doctor’s office, demanding that they, or maybe even their child, get a prescription for drug X. And how can the doctor say no to someone who is convinced that they will be beautiful and happy if they have drug X? Yes, I am taking this example a bit far, but I think you get the point.

The second reason I think that Americans are taking more prescription drugs is directly related to our increasing obesity, as I’ve written about before. It’s simply more work to eat healthy and exercise. Popping a pill is much easier than changing one’s entire lifestyle. While there are other factors (genetics, etc.) that contribute to hypertension and high cholesterol, a poor diet and sedentary lifestyle are certainly important risk factors. Obesity in children is also well documented to be on the rise. And no one seems to be arguing the fact that lack of exercise and poor diets are significantly impacting the health of Americans, both young and old.

There are, of course, many other factors that are contributing to the increase in prescription drug utilization in America and other countries, but I shall save those topics for another entry. The point is that Americans are using more and more prescription drugs, and it’s not just older people anymore. Our children are increasingly becoming the targets of pharmaceutical advertisements, and are being prescribed increasing numbers of medications for chronic conditions. While there are significant positive impacts because of the availability of new drugs, especially for chronic conditions, I don’t think the trend is necessarily a good thing.

In the 1980’s, the U.S. first lady Nancy Reagan coined the phrase “just say no” as a slogan to help decrease the use of recreational drugs, especially by children. Now our children and young adults are actually using more and more prescription drugs for chronic and preventable conditions. If our child seems a little too anxious, we seek out an antidepressant. If they’re a little too restless, we put them on Ritalin. When they start getting fat, we put them on statins.

I want to know when are we going to start taking responsibility for our own health and the health of our children? When will we realize that we can’t always take the easy way out and pop a pill whenever we have a problem? When are we going to start “just saying no?”

What To Look for in a Medical School

Ben Ferguson -- What to look for in a medical school, in this order:

1. Location, location, location! I’ve mentioned this before, but it’s well worth passing on again: You will be spending four (or more) years at whichever school you choose to attend, and you should be sure that you can handle living there for that long. An amazing location won’t add all that much above and beyond a solid school, but a poor location can and will drive you crazy and distract you from your work as a medical student.

2. The grading system. This, to me, is by far the most important academic feature of a school. I cannot put into words how beneficial the pass/fail system used at my own school has been in every single aspect of my daily life as a medical student. Schools’ grading systems were not something I closely looked into while applying, but in retrospect, a pass/fail grading system should have been at the top of my list of requirements for a given school. I’ve clearly not attended a medical school that employs letter grades, so it’s tough from a personal experience standpoint to directly compare them, but based on stories I’ve heard from friends and colleagues at such schools, let’s just say I do not envy them in the least.

3. Happiness. When you visit a school, take a pulse of the emotional well-being of its students. Do they seem happy? Do they seem suicidal? Do they seem to get along with each other? Does anyone smile or laugh or crack jokes? Are there people studying together, or is every table you come across occupied by a single wallflower with his or her nose buried in a book? Try mentally inserting yourself into the school’s environment and see what happens. See how it makes you feel right then and there. See how it makes you feel one hour after leaving, and the next day, and the next week. Sometimes gut feelings can be great decision points, and this area is based almost entirely on your gut. A school’s social environment is almost as important as #1 up there, although at most schools, the classes are big enough that you can find friends and like-minded people practically without trying.

4. A great supporting cast. How nice has a school’s administrative staff been to you throughout your application process? That is indicative of how they’ll likely be when you’re a student there, and the quality and helpfulness of the administrative staff can most definitely make or break your quality of life as a medical student. Some schools can make you feel like a rock star all of the time, and some can make you feel totally alone. Don’t disregard this one.

5. Financial support and knowledge. Medical school is stressful enough on its own without having to worry about money. Throw financial issues into the mix, and you can get mighty distracted. A school that gives a lot of money to its students is one that has a supportive and active alumni and community and one that clearly finds it important that its medical students are able to focus on learning medicine. A school that has staff who know what they’re doing and can explain to you in clear terms what you need to sign/pay/do/read is absolutely priceless (especially if you score a full ride!).

6. Everything else. Student mentorship, shadowing and research opportunities, enthusiasm of faculty in working with students, daily routines, curriculum formats, number and breadth of extracurricular groups and intramural sports teams (if that’s your thing), format of patient records in the teaching hospital(s), and even match lists (so long as you have some idea of what fields interest you) go here at the end. They are all important factors to consider, but to me, they pale in comparison to those above. They are extremely flexible and largely dependent on how you thrive upon, or cope with, them, and they should not make or break your decision in general.

What not to look for in a medical school:

1. Board Scores. I’m probably going to get reamed by some for saying it, but this really shouldn’t be taken into account when you’re deciding between schools. There are so many confounding factors that go into a school’s average board performance, and overall it’s a poor judge of academic quality in my opinion. If you’re a genius, you’re probably going to do very well on the boards no matter what school you attend, and a few extra points in a school’s average board score doesn't come anywhere close to making up for other shortcomings it may have. If you’re not so good at standardized exams, there are far better ways of determining what sort of professional success you’re going to have other than a given school’s average board score, and going to a school with very high reputed average board scores doesn’t in any way guarantee you a very high board score.

2. US News ranking. Seriously? It’s a magazine just trying to sell issues like everybody else. In 20 years, none of your patients are going to come to your clinic on the basis of your medical school’s #11 ranking in the April 2004 issue of US News and World Report. They are going to come to your clinic because you have a medical degree, you are an expert in your specialty, you are comforting, and you don’t kill your patients. If you are lacking any of these things, a poor US News showing from 20 years prior is the least of your worries.

3. Hottest potential suitors/faculty/patient population. You don’t even have time for that anyway. Professionalism, people.

4. How many derm/plastics/rad-onc residencies the Class of 2006 matched into. These numbers tend to vary widely from year to year and are largely based on whether anyone was even interested on an individual level in these fields in a given year. If you think this is an important thing to look at, you need to reconsider your priorities.

A Syncope Mystery

Anna Burkhead -- This month, I am working at a Family Medicine clinic, my last core rotation of third year. It’s been a great opportunity for me to work on my basic diagnosis and treatment plan skills.

Last week, a middle-aged man came to the clinic for a hospital follow-up visit. He had recently been hospitalized after an episode of syncope in his bathroom at home and a subsequent loss of consciousness while driving later that day. In the hospital, a CT showed a small subdural hemorrhage, probably produced when he hit his head on the sink after fainting in the bathroom.

During his hospital stay, the man had an extensive workup, including several CTs, an MRI, echo, EEG, carotid doppler studies, tilt table test, and an EP study. All of the test results were within normal limits.

At the man’s clinic visit, we reviewed the results of his tests, including a follow-up CT that showed no residual subdural blood. The neurologist had cleared him to drive with caution. The patient had had no further episodes of syncope since being discharged from the hospital.

The doctor and I explained to him that no apparent etiology for his syncope had been found in his medical workup. He was surprised to learn that this was not uncommon; isolated episodes of syncope are very often followed by negative workups, and the episodes remain unexplained.

As the visit progressed, I observed the initially calm and friendly man become more and more agitated, desperate, and frantic as he realized that we weren’t able to provide an explanation for his fainting. He stuttered questions, produced a few beads of sweat, and after we left the clinic room, he called me back for more questions.

This man’s anxiety was palpable. For a brief moment, I wished that the workup had provided a reason for his syncopal episode. Then I realized that wishing such a thought meant wishing that this man had something structurally or metabolically wrong with his brain or heart. I tried my hardest to explain that isolated episodes of syncope were often just that: single (non-recurrent) incidents, without significant associated pathology.

The man eventually ran out of questions and left the clinic. He had arrived expecting an explanation, something to make the scary events he had suffered make sense. He left with little more than a copy of his hospital test results.

There was little else to do in this situation. Every reasonable test and study had been done. There was nothing left to do but reassure the patient that no significant pathology had been found. Sometimes doctors and medicine cannot provide answers. Whether that’s because the answers don’t exist, or because we’re unable to uncover them, I’m not sure. But I know that it can be frustrating to the patient looking for logic, as I observed here.

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.

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.

Have Aliens Stolen My Brain?

Kendra Campbell -- I told myself that I’d write this blog post a few days ago. But here it is already Wednesday, and I’m just now starting it. I think I just realized why it’s been so hard for me to think of something to write about. I’m pretty sure that aliens kidnapped me, stole the creative parts of my brain to use as a giant battery charging device on their planet, and returned my body back to my apartment, all without anyone noticing anything.

Okay, so maybe there is another good explanation. I’m now several weeks into my studying program for my board exam. I only have two more weeks left until the day of pain and torture arrives. So, what has my life been like for the past few weeks? Unbearably lifeless and boring.

Yes, I have taken breaks to enjoy life and have fun with my friends, but the only thing that I’ve done related to medicine is study piles of basic science information that I once learned what seems like millions of years ago. At first, I was excited, and really started to have fun with the studying, but I’ve since hit a wall.

There is simply no context. There are no patients. There are no doctors. There aren’t even any professors or fellow med students as far as the eye can see. It’s just me, my books, and my laptop, banging away for hours in a creepy vortex.

I have lost all sense of space and time. And I think I’ve also lost all inspiration and creativity. I love to write. I have always loved scribbling down my thoughts and going on lengthy written rants. It’s always been a hobby that has kept me entertained. But sitting for hours upon hours, cramming seemingly pointless facts into my poor little brain has apparently sucked the creativity right out of me. It’s either that, or I was actually right about the alien theory.

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.