The Differential: Medscape Med Students Blogs

My First Autopsy

Jeff Wonoprabowo -- The woman instructed me and my classmates to gown up. I wasn't sure who she was. She never introduced herself. Maybe she was a nurse. Or maybe one of the investigators. After I had put on the shoe covers, mask, hairnet and gown, I was led into a large room that had a number of exam tables lined up along the walls, each next to a sink.

I had been to an anatomy lab with cadavers before. But this sight was strange. The bodies lying on the metal exam tables weren't donated to science. They were waiting to be autopsied by a medical examiner.

My partner and I soon found out we would be observing Dr. X (identity withheld) perform an autopsy on a homicide victim. The victim, who I'll refer to as Joe, lay waiting on the table, his eyes still open. He was a little bloody. I could see the bullet wounds. Some were small with superficial, circular abrasions indicating an entry wound. There were, of course, larger wounds that appeared to be exit-wounds.

Dr. X called and pointed us towards the report that had been filed about Joe. The first page contained a written note about what was found at the scene. The next few pages included color photographs of the crime scene. X-rays of Joe's chest and abdominal area hung on a nearby wall.

Five hours later, Joe's heart, lungs and liver had been removed, cleaned and weighed. Over ten blunt-force trauma wounds and twenty-one bullet wounds had been labeled, photographed and measured. Entrance and exit wounds were connected -- at least as best as one could, given the circumstances.

After five hours I left. My legs were tired. Maybe I'll cross off surgery from "my list." I also left with a renewed sense of how delicate life really is. Nothing slams that home more than seeing a human being whose life was ended prematurely under a rain of bullets. I couldn't help but think of the men and women in the armed forces fighting overseas.

Many of my classmates got "lucky" and only had to witness a 40-minute autopsy. I'm glad I got to see a homicide autopsy -- even if it was five hours long.

Tell Me What You Want!

Kendra Campbell -- I’ve been contemplating writing this blog post for a few days now. I wanted to write it, but thought I should wait until I had calmed down a bit, so that it didn’t sound like a huge ranting session. I guess I might as well just tell the story. I think it might help release some of the stress.

Let me begin with some background. I have no idea how to say this without sounding conceited, so I’ll just say it anyway. Echoing the thoughts of Jeff Wonoprabowo in his recent post, I have also always struggled to be the best. I have always maintained a very high GPA. I have always excelled in my exams. I am a bit of a perfectionist. I am a natural leader, and I always try to do everything to the best of my ability. I am generally not lazy, and I am good at “getting things done.” Okay, I hope I don’t sound too full of myself. I am certainly “not good” at many things (singing is an excellent example), but there are some things that I’m really good at, and making good grades has always been one of those things (as is common with most med students).

I did very well during the basic science years of medical school. I maintained a high GPA and performed well on both written and oral exams. I also did very well during my first two clinical rotations. My third and fourth clinical rotations, however, have been a bit different.

Okay, so now I’m going to come right out and say what I’ve been beating around the bush about. I received a “B” in my surgery rotation. Now, I know there are probably many people out there who are thinking, “seriously, SERIOUSLY, she’s complaining about getting a 'B?!' What’s wrong with this girl?!” But I’m hoping that many of you are still reading, and maybe there are even a few of you out there thinking, “hey, I understand!”

Here’s the thing. My surgery rotation was very tough. The hours were grueling, and the work was at times quite challenging. But I rose to the challenges. I stayed late when no one else would. I offered to do consults and other non-required tasks. I scrubbed in when no one else wanted to. I went out of my way to help my patients. I spent more time with them then I had to. I got along well with “most” of the nurses, residents, and attendings. I always did what my residents asked of me, and tried to always go above and beyond their expectations. I also did comparatively well on all the exams and quizzes. I can honestly say that I think I deserved an “A.”

I think the main problem with the surgery rotation was that we were never really told how we were being evaluated. Unlike my first two rotations, which provided clear guidelines on how students were graded, we were basically in the dark. When I got my grade, I didn’t even know who actually gave it to me. I also don’t know what I could have done better to earn an “A.” I certainly can’t think of anything shy of actually performing the surgeries myself.

Unfortunately, my current internal medicine rotation seems to be going similarly. I don’t really feel like I know what is expected of me. And this time, I really don’t know if I’m even doing a good job because I’m not sure what a good job is!

So, that’s my rant. I know it seems like such a silly thing to be upset about, but I just don’t like the feeling of “not knowing,” I guess.

I’m wondering if this lack of information about expectations has to do with the hospital, or the rotations, or the attendings, or something else. I’m actually very interested to know if anyone out there has experienced anything similar. Do you always know how you’re being graded during your clinical rotations? Or have any of you also experienced what I’m going through? Also, have you ever received a grade on a rotation that you thought was not a true reflection of your performance?

Enough Whining About Primary Care

Colin Son -- My student loans are forcing me to contribute to the primary care crisis. And with that facetious remark, I initiate a rather controversial discussion.

Let me be clear that I’m a firm believer that primary care is in a crisis in America. There is no doubt that U.S. medical graduates are choosing to go into primary care at rates lower than in previous years.

Many primary care physicians believe that the main factors influencing this trend are primary care’s comparatively poor earning potential plus students' rising educational debt. I’ll be quite frank, I’m profoundly annoyed by this essentially unsubstantiated claim. And it is a persistent claim, even around the medical blogosphere.

It is so pervasive that it has become accepted as fact. What is a little depressing is that these are physicians leaping to this conclusion -- physicians trained to look for evidence of causality. No matter how obvious the association between student debt and specialty selection may seem, the causality simply is not there in the sum of the evidence.

In September, JAMA published a research letter by family physician Mark Ebell. It was a near repeat of a study he had done in 1989 (Ebell M. Choice of specialty: it's money that matters in the USA. 1989;262:1630). In both cases, Dr. Ebell found a statistically significant correlation between a specialty’s median income and its percentage of residency spots filled by U.S. medical grads.

Talk about circumstantial. To draw the conclusion that debt is influencing specialty choice from such removed observations is dangerous. And yet, that is what some have done. One of my favorite medical bloggers over at Medrants was certainly guilty of such in a post on Dr. Ebell’s publication: duh - money matters in specialty selection. MedPageToday, a major online medical news outlet, also gave the study’s conclusions some credence.

My point isn’t to disparage the JAMA study. But the way it was held aloft, despite its obvious leap in conclusion, is a sign of the more systemic problem.

A cursory literature search reveals that few other studies have found student debt to be a statistically significant factor in specialty selection. In the same issue of JAMA that carried Dr. Ebell's study, another study failed to find that connection for general internal medicine. Other evidence to consider: a huge study published in 1999 in the Journal of General Internal Medicine found that, over more than three decades, indebtedness was never a statistically significant factor for female medical students in choosing primary care versus a medical specialty; a 2006 survey published on Medscape General Medicine found that students' debt level did not significantly influence their specialty choice; and, the June 2006 edition of Minnesota Medicine included a study done by a fourth-year medical student that showed the debt burden of students at the University of Minnesota’s main campus did not significantly influence career choice.

I’m not trying to present this as a comprehensive look at the data. But it is representative. I stand by my claim that the sum of the evidence favors the conclusion that medical students are largely not picking their specialty based on their debt load.

In fact, becoming a primary care physician remains a good investment compared with most other career options, even with an average indebtedness of $140,000 for students with debt. Yes, you lose some years during training when you could have been saving and investing. Educational debt means devoting more of your income towards paying off loans and less towards something more meaningful like retirement. Those factors certainly add up, but not to the extent some physicians make it out to be. The choice of specialty has never been simply, largely influenced by debt or future earning potential. It has always been multi-etiological.

That's certainly true for me. I came to medical school thinking I wanted to enter a field where I could work with my hands. But any thought of primary care died when I entered my clinical years in medical school. In my experience, I met only one happy primary care physician. If I were to listen to all the primary care physicians I know, or who I read in journals and online, I would think it was the apocalypse for primary care.

Granted, there are problems with America's lack of focus on improving primary care. But do they warrant the state of fear being spread by the primary care community? Why would any medical student want to enter such a downtrodden, depressing community?

I rarely hear about the rewards of a primary care career these days. Yet despite the widening income gap between primary care and specialists, and the horde of patients each primary care physician is expected to see, there must be some good left in practicing as a primary care physician. I think we need to start talking about that and do less externalizing of the reasons why medical students aren't choosing primary care.

The privilege of practicing medicine should be cheered and cherished. This whining about the state of primary care and medicine in general are just too much for me to take. I’m going to sit back and marvel at the career of caring for patients that stretches out in front of me.

I'm Trying To Grow Up

Jeff Wonoprabowo -- As I write this it's raining outside. It's finally starting to feel like winter here in southern California. I used to love these rainy days as a kid. Playing in the rain was always fun. And I loved sitting in the car when it poured outside and the streets were filled with rushing streams of water. I used to hope my mom or dad would drive through the water. They didn't like to. I never understood why. But on occasion it was unavoidable and then I would sit wide-eyed as the water splashed high and the sound of the water hitting the bottom of the car echoed through our minivan.

The rain isn't as welcome these days. Sure, it's nice to be inside on a rainy day. But the joy of playing outside isn't quite the same. I drive my own car now. Going somewhere when it rains just means I get wet and the inside of my car will probably get dirty, too. And I don't drive through puddles. Who knows what could be hiding beneath the surface?

I've changed. And maybe that's part of growing up.

In high school I found my anatomy and physiology class absolutely fascinating. That class allowed me to realize my own interest in the human body and how it worked. In high school, though, I didn't know what it meant to be a doctor. I didn't know what it would take. I didn't know what kind of lifestyle the residents had. But I liked the idea of being a doctor. You could help people. You could make things right.

It's a little different now. Sure, I still believe that you can help people as a doctor. But I have a better idea of what goes into the making of an MD. Medical school is tough. (I heard that before, but now I know just how tough.) Residency is long, the hours are grueling. And attendings have to worry about the practice of medicine in the 21st century. It's no longer just about patients. Modern practice involves worrying about being sued, malpractice insurance, billing insurance companies that hardly ever pay what you bill, and dealing with endless bureaucracy and time constraints.

I guess I've changed in this area, too -- at least my understanding has. And I guess that's also part of growing up.

Later today I'll be going out to meet some friends for lunch. The rain will probably hit me on my head and, with my boots on, I'll probably walk through a puddle on purpose. It won't be the same childhood glee, but the amusement will still be there.

And when I once again come face to face with real patients instead of an exam, I know that the same wonder I had about the human body will return. It'll be tempered with the realities of modern practice. But at least the wonder hasn't died.

I guess growing up is about finding balance between childish naiveté and cranky, old cynicism.

Why Do We Do It?

Lucia Li -- “I have come to the conclusion that my subjective account of my motivation is largely mythical on almost all occasions. I have no idea why I do things.”

Every medical student must reach some crisis point in their training where they ask themselves “why am I doing this?” In my case, it’s usually precipitated by either a severe lack of solvency, someone I know jetting off to warmer climes, or having to learn microbiology.

At times like these, being a student feels like very hard work, and it helps to ask myself why I chose medicine in the first place and why I’m still here.

One of my housemates is a die-hard OB/GYN. From the tender age of 3 when she chastised the OB/GYN consultant for forgetting to take her blood pressure in a make-believe consultation, to her feverish planning of an OB/GYN elective, she has always known where she wants to be.

Yet there are students in my year who switched to medicine late in the decision process, people who were going to be linguists, lawyers, mathematicians, English literature students, art students… What changed their minds? Usually something practical, like job security, a good profession etc. A couple of my friends even said that they picked medicine for want of anything else to do!

Have their reasons changed? Would they pick medicine again? Most of my friends said that their reasons were still the same, and that, reassuringly, they’re glad they picked medicine. One of my friends said something especially interesting: “I had undervalued the idea of a profession.” That sentiment seems to encapsulate a lot of what medicine means to me now.

I never applied with the altruistic attitude of “helping people” (there are easier and less bankrupting ways to do that!); I applied because I loved human biology at school and wanted to learn more. Having a doctor mother, I thought I understood what being a doctor was. But even I underestimated how much of a lifestyle choice it is; being a doctor means something more than just going in to work everyday. It means being able to put my learning of the human body into useful practice, making a contribution to society and, with research, to knowledge. It represents the trust with which complete strangers entrust their health, their families, their confidence. It means working in a busy, ever changing environment, with lots of different people in different branches of medicine, learning and working together. And this is now what keeps me going.

So, why did I apply back then? To read medicine. Why would I apply now? To be a doctor.

The Difference Between a Doctor and a Nurse

Kendra Campbell -- While rounding today, I auscultated a patient’s heart and then reported my findings to the resident. Luckily, I was correct in my diagnosis of aortic stenosis, based on the murmur I heard. My resident applauded my findings and then said something which offended me a little bit. He said, "see, now that’s the difference between a doctor and a nurse... You were able to diagnose aortic stenosis based on a clinical finding. A nurse would have to read the echocardiogram report to make the diagnosis." While I know that he was trying to give me a compliment, I felt that he was doing so at the expense of criticizing nurses.

Today was not the first time I heard a physician utter the phrase, "that’s the difference between a doctor and a nurse." Actually, I’ve heard many doctors use the phrase to demonstrate the ways in which doctors are superior to nurses. I’m sure sometimes doctors use the statement to simply point out the differences between doctors and nurses, but I happen to feel that the words are a bit diminutive towards nurses.

I’ve never worked as a nurse, but I did work as a technician for over three years and was a part of the nursing team. While I didn't have as many duties and responsibilities as the nurses, I did take vitals and performed other nursing types of procedures. Because of this experience, I have a good idea of what nurses go through every day. I’ve been on that side of the equation.

Now that I am a physician in training, I am on the other side of the equation. I see everything from the doctor’s perspective, and the nurses are now the ones that I ask to do things, instead of the other way around.

The conflict between doctors and nurses has been around since the beginning of both professions. Most physicians would agree that nurses can be your best friend or your worst enemy, and it’s hence a good idea to stay on their good sides. However, I’ve seen a lot of variation in the ability of physicians to interact with nurses positively.

Having been on the nursing side, I feel like I’m more hyperaware of the importance of maintaining an excellent working relationship with the nurses (and for that matter, every other member of the clinical team). I also realize that condescension and superiority complexes can lead you into precarious waters with the nurses.

Ultimately, our patients are what matter the most, and we should all be able to put aside our differences in order to provide them with the best care possible. I think it’s important to recognize and appreciate the unique contributions that each member of the team makes. I’ve seen some physicians who are quite skilled at working well with the other team members, but I’ve also seen ones who have a touch of the god complex, and can’t seem to come down from their high horse for long enough to appreciate the work of the techs and nurses, in particular.

Perhaps it would be easier if we all walked a mile in each other’s shoes. If every doctor had to spend at least a few days working as a nurse and vice versa, maybe there would be a lot more respect for each other’s jobs, and for the so-called "differences."

Will a New President Affect Medical Education?

Colin Son -- In case you somehow missed it, a month ago the United States elected a new President. I’ll spare you my personal politics except to say I’m smiling. I will point out the obvious: it appears we are in for a little bit of a change in this country.

What that might mean for health care is a matter of some contention. Major health care reform is undoubtedly expensive, and the current economic climate may make such reform difficult. At least in one jump. Not that Obama's health care plan is comprehensive; it lacks any serious discussion of how his dream reforms would control rising health care costs.

What I’m interested in right now, however, is what an Obama presidency may mean for medical education. Admittedly, a new president is likely to have less of an immediate impact on how physicians are educated than on how health care is delivered to patients. But there are some things that may change, especially concerning how medical students finance their education.

U.S. physicians earn more than their counterparts just about anywhere else in the western world. But many trainees have to take on substantial debt: nearly $140,000 for the average American medical graduate. The burden of repayment over many years with interest can be substantial, especially early after graduation when newly minted physicians are serving as residents. In addition, medical student debt may be affecting health care in the United States, as circumstantial evidence suggests that increasing debt loads are pushing students away from primary care careers.

Last year in the reauthorization of the Higher Education Act, the federal government eliminated the 20/220 economic hardship deferment for residents, which had allowed them to defer a large portion of their federally guaranteed loans for most of their residency, until they were earning substantially more as fully practicing doctors. While Obama hasn’t commented on the 20/220 deferment, and the HEA isn’t up for reauthorization any time soon, I feel safe in declaring that the potential for new advantageous repayment options is substantially better under the incoming administration than under the current one.

Obama may also need to consider longer term changes to how we finance medical education. His health care plan stays away from calling for a single payer system, but it limits the long-term viability of private insurers and potentially brings federally run "insurance" plans in direct competition with them. While a near future without private health insurers is not inevitable, it certainly isn’t unreasonable to imagine either.

In a single payer system, it would be difficult for the physician lobby and their legislator allies to maintain physician reimbursements at their current levels. In other places, global budget systems have done much to lower health care costs, including physician practice costs, so bringing physician earnings more in line with the rest of the world may not be the catastrophe that some physicians make it out to be.

What would have to happen in such an admittedly hypothetical world, however, is that the cost of medical education would have to decline significantly. If physicians are to earn less, it must cost substantially less for them to be trained.

President-elect Obama has many big issues on his plate as he comes into office. The expectations are incredible, and I don’t doubt that health care reform will get its time. Let us just hope that medical education gets its time as well.

Struggling To Be Best

Jeff Wonoprabowo -- People say that you need to know your own limitations. I think that you need to do more than that. You need to learn to accept those limitations. For most things, it is easy for me. I can accept that I'll never run like Usain Bolt, swim like Michael Phelps, ride like Lance Armstrong, or hoop it up like Kobe Bryant. But for other things, it can be hard. Who really wants to accept that they aren't as good as they thought they were? Or that they just can't achieve the same things others can? I sure don't. It's a humbling experience.

Before medical school I heard people say that the entire medical school class would be people who, for the most part, were at the top of their respective undergraduate classes. And they were probably also near the top of their high school classes. But within every medical school class, there will always be someone ranked first and someone ranked last. And nobody ever entered medical school planning to end up at the bottom.

The problem is that, in general, the kind of people who make it into medical school are pretty competitive. They want to be the best. And it is pretty difficult to not have the class ranking one is used to having.

Maybe the solution is to just be content. I guess I may have to accept the fact that I am not the best. But maybe I can hold on to the idea that my best can still be very, very good. And when I try to think like this I feel better -- I feel that as long as I give my all, I will be content with my performance.

And then I think about people who have risen to the top of their fields. Did they ever just "let off the gas pedal" and accept that they weren't the best? Did they ever feel that "just good enough" was really good enough?

How does one navigate between the desire to be better and the wish to be content with a job done well enough? I don't know. I wish I did. I guess I'll struggle with it some more.

Resident Work Hours Debate Continues

Many of you applauded the new Institute of Medicine report calling for stricter limits on resident work hours. Now, professional neurosurgery organizations have come out against the report, arguing that it does not address issues of patient safety or continuity of care. (Read more about that here.) What do you think? Join in the discussion below.

Christine Wiebe, Editor, Medscape Medical Students

Med Student Gift Guide

Ben Bryner -- It can be difficult to find a good holiday present for someone when you're a medical student. Money is very tight, and so is free time to do shopping. But the pressure is on, since the holidays represent a key opportunity to rebuild the personal relationships that you've let crumble because you've been so busy studying or interviewing.

Medical students can be especially tricky to buy for. Before you object, I agree with you that the winter holidays have become way too commercialized and we should just scale it all back a little bit. I'm not trying to encourage shopping at all, but if you're already going to shop, some of these suggestions might make it a little easier.

So, here are some gifts for the med student in your life:

* U.S. Senate seat (OK, you probably guessed this was coming. Seriously, though, I've been fascinated by the recent news about the attempt by the governor of Illinois to sell a Senate seat. There are so many amazing aspects of this story, but most of all are the various harebrained schemes that he [allegedly] thought of to sell the seat. Incredible.)

* Germ stuffed animals (from Giant Microbes). You can buy a plush treponeme (the agent causing syphilis) here. The jokes kind of write themselves with that one.

* Nerdy pun/slogan shirts (from Threadless). Medical students are huge nerds and the sooner you admit that, the more successful your shopping will be. The "Nerds 2^2 Ever" one is obviously perfect.

* "Avocado's Number" guacamole from Trader Joe's. Again, huge nerd points for naming a line of premixed guacamole after a pun on the constant named for Italian chemist Amedeo Avogadro. Well done, Trader Joe.

* Board review books (from multiple publishers). This gift says, "Study more, I want to see you less often."

* A sticky hook and some sheet protectors (from any office store). For someone with boards coming up, give them some plastic hooks they can stick to their shower wall. Then give them a bunch of sheet protectors, so they can stick pages of notes in the sheet protectors and hang them on the hook so it’s easy to study in the shower. No more wasting valuable study time by only getting clean!

* Arrested Development DVDs (from any entertainment store). Every medical student needs a study break every so often, and an episode of this series, twenty minutes of sheer comedic gold, is perfect. (Or you can just send them this link and say, “click, watch, thank me later.”)

* Homemade gifts (from you). The best gifts are always ones that show you were thinking about the recipient, and often a handmade gift is the easiest way to convey that. Obviously, whatever you give depends on your talents and your time. If all you can do is write a nice letter or email to someone you don't talk to enough, that's better than almost anything that people are out there fighting over in store aisles.

Good luck and happy holidays.