The Differential: Medscape Med Students Blogs

Why Do Attendings Verbally Abuse Med Students?

Anthony Rudine -- I think it was Jerry Seinfeld who said something to the effect that it is just that little bit of arrogance in the medical community that we could all just do without. I have to agree.

I am not sure what your background is, whether or not you were raised around physicians, know physicians, or are one yourself, but it really doesn’t matter. I was not raised around any physicians, so perhaps my attitude towards the medical community is different that yours.

On my most recent rotation, where I will not use names, largely because I haven’t been graded yet, the arrogance was palpable. I have never in my life heard people speak to each other the way we students were spoken to by a few select physicians. Male or female, it makes no difference, the curse words and expletives and insults were rampant.

Now, some of you may expect this. I expected some of it myself. It wasn’t until I thought about the situation more fully that I realized how ridiculous it was to curse, scream, slam things, etc, at medical students.

First off, medical students are paying for their education. Yes, the public pays a large portion of the costs and fees, especially at a state school, but for the individual, like myself, who needs loans, the amount is substantial. Second, these physicians were once students themselves, although it seems that they have forgotten. I can find no valid reason why a self-respecting physician at an academic institution would speak this way to anyone, much less future colleagues.

I think that the very few physicians who I am talking about must have such a low self image and be so insecure that they must berate others. That is the only explanation. I have not noticed any correlation in intelligence of the cursers. There is nothing to explain why these doctors speak to us this way other than they are so afraid of life itself that they have no other option than to yell at those doing their best to help.

Some Patients Pay the Price for Physician Training

Anthony Rudine -- Hello again, friends. I have just recently finished my rotation in psychiatry and have now begun to delve into the world of obstetrics and gynecology. Allow me to be brutally honest -- I have been dreading this rotation for about 2 years. In recent months, my dread has steadily increased to reach a new high on the day before beginning the rotation.

My reasons for dread? Simply put, I realize that obstetrics and gynecology is a very personal specialty, which hinges on the trust of the physician-patient relationship. As such, I feel like an intruder.

I know that I am supposed to be there, that I have a legal right to be there, and that I have a duty to future patients to be there to learn. But I feel intrusive nonetheless. Unlike some other students, I do not consider myself one of those "cowboy physicians" who jumps into things without reflecting on the possible implications and consequences. So what are the implications?

Well, we are at a teaching hospital, obviously. This teaching hospital, like many, is attached to the county hospital, which means that we see many indigent patients, Medicaid patients, and immigrant patients. From what I can surmise, no female would "choose" to go to a clinic where they will have their most private examinations performed by a student; yet, they have little choice.

Medical education is a strange beast to tame. As a society, we have come to accept the idea that, for the betterment of future generations, physicians must be trained in an environment such as this; naturally, some pay the price -- by being examined by students.

I am not saying that this is a bad way of doing things, I am just saying that there is a disparity here. In the book "Complications," the author states that when his son had heart difficulties, and it finally came time for the surgery to be performed, he requested that the resident physician not perform the surgery -- even though he was a resident physician himself -- because he simply wanted the best possible care for his child.

The interesting fact here is that this surgeon knew how things worked, and chose to bypass the system. While it is fair to say that most parents would choose the best care for their children, few are given the choice between a student, resident, or attending.

The dichotomy of care thus continues.

Don't Make Me Treat Patients Without Supervision

Anthony Rudine -- I recently had an experience that made me think twice about working in a teaching institution in the future. I was seeing a patient on their initial visit, and I made some recommendations to the resident physician about what I thought the diagnosis might be and what medication I would like to start. Without missing a beat, the resident talked to the attending and regurgitated my diagnosis and treatment opinion -- without ever seeing the patient.

This made me quite uneasy. Although I do think of myself as a fairly diligent student, a reader, a thinker, I certainly do not think of myself as a physician. Not anywhere close. Let's be straight -- I have no problem with the resident using my thoughts and notes as a template for presenting to the attending; I do, however, have a real problem with my diagnoses sticking on the chart because the resident and the attending never saw the patient on the initial visit. There seems to be something wrong with this picture.

I am reminded of an article I once read, although I have no recollection where from, that stated that in the months leading up to July, morbidity and mortality in teaching hospitals will stay even or decline. However, as July comes, morbidity and mortality both increase drastically, and then steadily decline again until the next July.

What happens in July, you ask? The new residents and students assume their new responsibilities. On one hand, there seems to be no way around this -- future physicians must have a place to learn, and the teaching hospital, under the guise of elders, provides this platform. On the other hand, as a society we are knowingly harming our patients with the addition of new residents and students each July.

Perhaps there is no solution, I don’t really know. For starters, however, it would be nice for the patient if the resident and attending physician went in and performed their own examination, rather than relying on a novice like me.

Discharging Patients "Against Medical Advice"

Anthony Rudine -- I often have discussions with my attendings on issues outside of specific patients' problems, and more generalized philosophical conversations on medical care. The most recent discussion was perhaps the most interesting.

I spoke with two different physicians, both board certified in psychiatry. The discussion centered around the relevance and the usage of the "against medical advice" discharge. To be honest, I had never thought about the relevance of this particular discharge.

The first physician, who brought up the conversation to begin with, claimed that an AMA discharge should never be used in clinical practice because it is essentially meaningless. His thinking was that the patient is in control of their own treatment and that physicians must be careful in separating what is best for the patient from what is best for the patient medically. He claimed that it was their right not to follow the treatment and advice of the treating physician, and that if it was essential that the patient stay, they should be held under an operation of protective custody, or something similar. He also stated that in his thirty years of clinical practice, he has rarely used a discharge of AMA.

The other physician I spoke with, however, felt much differently. She stated that a discharge of AMA is vitally important to the medical community, and not for the reasons that I would have thought. Her reasoning was that, although a patient may not be suicidal, homicidal, or hallucinating (the generally accepted reasons for holding a patient on an emergency detention), they still could present a clear psychiatric danger, yet it might not be possible to keep them for treatment against their will. Thus, a discharge of against medical advice must be used. She also stated that patients often fall through the cracks of the system in not meeting criteria for emergency detention, while the physician still feels that there is a danger in releasing the patient.

I had never really thought of the arguments of the situation, and am personally convinced that the AMA discharge is useful. What do you think?

Flirting Patients and Hospital Romances

Anthony Rudine -- Recently, while seeing patients in clinic, I was exposed to an odd situation. A patient of mine had two issues. One, the problem she was being seen in clinic for. And two, she wanted a date. With me.

Now, I like to think that I have an unspoken agreement not to date my patients. But still, it threw me off guard and I was briefly unable to answer her.

Here’s how it happened. Long story short, I was through with my examination and was about to leave to present to the others, and then it hit me like a ton of bricks: "Do you want to take me out for drinks? Do you want to buy me a margarita?"

Under normal circumstances I would have laughed it off and went on my way, because under normal circumstances, the patient would have been joking. This was no joke, I could tell.

In the past, I've had many patients flirt with me, and usually I just take it with a grain of salt and say something so they are not embarrassed, and walk out. But as I said, usually it is clear they are joking.

Anyway, I ended up making it clear that I could not go out with her, and went to present to the others on my team like nothing had happened. However, I became curious how often these things happen in the hospital. How often do patients flirt with you – or ask you out? For that matter, I have seen physicians flirt with nurses, nurses with medical students, medical students with physicians, nurses with physicians, etc.

Sometimes I feel like I live in an episode of Grey’s Anatomy.

Does this happen where you are?

Let the Pimping Begin ...

Anthony Rudine -- In the last couple of weeks, I began my rotation in Neurology and Psychiatry. My family is always interested in what I am doing, anything going on in the hospital, etc. However, I think they are confused as to what I actually do. A common remark goes something like this – “But you don’t know that much about (fill in the blank), so how can you make decisions and see patients by yourself…?”

Well, allow me to answer. First off, I make no decisions, I simply make suggestions. Some are right, some are wrong. I see many patients by myself, and my primary job is to get a clear picture of what has been going on, why they are here, if the medications have been working or not.

Essentially, I explain, this is how medical students learn. We go in and see the patient, read up on their condition, quickly, and try to formulate some sort of plan for their treatment. Then, at will, the pimping can begin.

For those of you unfamiliar with the term, pimping is common lingo in our hospital used to describe the barrage of questions that are directed at you like scud missiles coming overhead. This is also how we learn, and when some students learn to keep their big mouths shut.

The questions range from anything from treatment options to risk stratification, and here’s the point – no one will answer all of them. They are usually asked until you begin to be wrong.

I guess what I am saying is that no matter how smart you think you are, there is always someone smarter, so it's better to be humble and know your limits than to be arrogant and feel boundless. Pimping is just my way of explaining that to you.

Knowing Your Limits as a Med Student

Anthony Rudine -- While speaking with a friend the other day, he informed me that his wife was ill. As a medical student, I hear this a lot, from friends, family, and of course patients. However, my friend also requested that I come over and take a look at his wife and examine her. This made me somewhat uncomfortable.

In the hospital, I examine patients all of the time, suggest lab tests to order, even perform some minor procedures. But the difference is that there is a safety factor there -- other doctors watching me and helping me.

I am unsure of the legal boundaries, in our litigious society, and was unsure what to do. What I did do was go over, examine her, tell her what I thought, that I was not a doctor and that she needed to see one. She went the next day. My diagnosis was the same diagnosis that the doctor gave to her the next day, I just don’t have the expertise yet to be sure.

It is very difficult as a medical student, when half of the population believes you to be a physician already, people at the hospital call you Doctor, etc, to not give advice when asked, to not overstep your boundaries.

I think there is a very thin line that exists here, and we must always be certain not to cross it. Either way, if I crossed a line or not, my friend was at least compelled to go to the physician, if nothing else.

I just cannot wait until I can prescribe the pills and make the diagnosis myself.

Dealing With "Bounce Back" Patients

Anthony Rudine -- It is quite disconcerting to see patients whom I assisted treating last week, or two days ago, or last month, showing up in the emergency center when I am on call. On one hand, the patient is obviously sick or they would not be there. On the other hand, it is frustrating to treat someone, "heal" them, send them home on medications, and have them return with the same problem three days later. When you ask them when the "new" problem started, they reply commonly -- "when I stopped taking the medications you gave me."

What am I to do? On one hand, we have the obligation to treat patients who are sick and in need of help. On the other hand, we have indeed treated them correctly, and likely due to their noncompliance, we are forced to admit them and treat them again, basically changing nothing from the last four admissions.

This could suggest two things. One, are they noncompliant because they simply do not see the reason for following their doctor's orders, or because they have some other issues going on that prevent them from obtaining their medications? Two, what could we do differently to prevent future admissions for the same treated problem?

The first issue is rather easy. If they are noncompliant because they cannot afford their medications, which is common, we can prescribe cheaper medications, call the social workers, give them samples, and set follow-up appointments in our clinic, which is very cheap. However, if they are noncompliant because they do not want to take their medications, or do not understand the reasons, then where does the fault lie? In the treating team for not providing a formulaic expression for the patient to fully grasp, or with the patient, who for whatever reason, will never take their medications?

For the second issue, what can we do to prevent this? Well, for starters, we can not admit the patient, treat them in the ER with the same medications, and send them home. But that doesn’t always sound so peachy when it comes down to it. Or we can transfer them to a different team, but the different teams already have their share of problem patients, and certainly do not need any of ours to deal with. Or finally, we can admit them again, like we usually do, treat them again, and discharge them again with the same message.

But clearly, this is not working. There are multiple patients like these, whom we call "bounce backs," and this is not a new issue.

I just don’t know how to solve it. I am still new at this game.

Does Every Person "Deserve" Health Care?

Anthony Rudine -- Probably the most difficult topic I have had to wrap my mind around is also probably the most controversial in American medicine today – the uninsured. So I guess it is about time for my two cents.

Let me give you my personal history on this. Formerly, before working in the hospital, even before medical school, I firmly believed that healthcare was a privilege to be provided to contributing members of US society. I believed that illegal immigrants and everyone else were a drain on the economy and did not deserve the resources of the taxpaying American citizens. I believed that their health problems were a result of their bad decisions and I certainly wanted nothing to do with paying for their, usually, very expensive treatments.

Now, I am not sure what I believe. Seeing patients in the hospital has really put a face on American healthcare and consumers for me. Sickness and disease are certainly color blind and show no mercy, whether wealthy or poor.

Additionally, US citizens are frequently denied treatment, or at least timely treatment, because they are unfunded as well. Illegal immigrants, a very touchy subject, have gained press recently as people finally realize what a catastrophic implosion it would be to not allow them to work. And their healthcare is restricted just like citizens.

I guess the bottom line in your beliefs boils down to a philosophical question for which no right answer exists. Is healthcare a right or a privilege? Do all those who come upon you asking for treatment deserve the best treatment available, or are tiers of healthcare necessary?

I firmly believe that those in need should be helped. But to what extent? We have all heard the economic arguments regarding healthcare – that the majority of money is spent on the final months of a person’s life. But is it their right to receive this healthcare even though it may hurt a future patient’s chances of receiving treatment? Should a life be prolonged at any cost irrespective of the cost it takes to prolong it?

I think there is likely no right answer. I certainly do not have one. I want to know what you think.

In Defense of Drug Reps and Free Lunches

Anthony Rudine -- Just a little word about drug reps.

As I said before, two days per week, usually, the drug company representatives come and provide lunch to the internal medicine department. With them, they bring many pamphlets and gifts and toys for us to play with. About one day per week, we get an invitation in our mailbox to go out to a nice dinner and hear a lecture about a new drug or vaccine, etc.

To be clear, many people do not like drug reps, but I am not one of those people. From my very limited experience, they have been nothing but helpful. They provide numerous drug samples to our patients who have no way to pay, they provide informational brochures about the drugs they are representing, and are indeed very knowledgeable about their specific pills. Often they bring with them charts, books, or other goodies to carry around in your pocket and help you quickly diagnose. And the pens are great, top quality.

I must be honest that with my MBA we discussed drug companies often, and the feelings were often mixed. The drugs are either too expensive, not good enough, not really an improvement, etc. But here is the deal: no one makes you prescribe a drug. If it were not for drug reps, it would be difficult to keep abreast of the new drugs that actually do provide an improvement over treatments past.

We all know that drug companies are one of the biggest lobbying groups in the US. They provide billions of dollars to their constituents and certainly have an objective. But isn’t that what lobbying is for? Are drug companies the only ones who lobby? I think not.

We also all know that drug companies are a part of one of the largest marketing pushes in recent years. How else are they to promote their new products?

What many fail to realize is that drug research is expensive. For every drug that makes it, which takes about ten years in development, many more do not. We all hear stories of drug companies falsifying information to make their drugs better or more efficacious, and they may be true.

But the bottom line is, drug companies provide a good service, both to the medical community and the patients. Just remember it is your decision whether or not to prescribe the drug. And the toys and food sure are nice.

Are HIPAA Privacy Rules Too Restrictive?

Anthony Rudine -- The other day, just before I left to go home, I was walking through the hospital to finish some things – the usual daily tasks – and out of the corner of my eye, I spotted an old friend. I was not completely sure, but after walking back across the doorway once again, I was indeed correct. I walked in to say hello, and it turned out that this old friend of mine was there visiting with another friend's mother, who had recently been admitted to the hospital.

After some brief "hellos" and "how have you beens" this old friend inquired if I knew anything about the patient’s condition. My reply? No, I don’t, I’m sorry.

Here is where the story gets a little tricky, so be sure to pay attention. My other friend, the patient’s daughter, by way of the patient, asked if I could look and see if there was anything serious going on that they should be concerned about. Not a good question to get, ever.

I knew this would be a HIPAA violation, so I went to speak with the physician, and certainly not look anything up.

I stalled for a minute outside the room and then went back in to say that I was not allowed to look anything up in the computer system about the patient’s condition, etc.

I'm not saying that I did not want to look it up. I'm not saying that it made sense for me not to look it up, because it didn’t. I'm just saying that I didn’t do it, because we all know that would be illegal. And I don’t want to break any laws here.

The problem I have with this is the following: this patient, and her loved ones, knew nothing of her condition. They did not know the severity of the condition. They did not have the slightest idea of the prognosis. And they were simply asking for some information. No doubt they asked their physician earlier in the day, and were not given satisfactory information. No doubt the same questions were posed, but went unanswered. And here I was, in a position to help, but restricted by the guidelines of a poorly written law.

Does this make any sense to you? It certainly doesn’t to me. A patient is asking for their own health information, which I had access to, and I could not give it to her. I could not tell her if she needed to phone other family members to come to the hospital, or if this was something she should be worried about. I could give her nothing but an apology.

What a load of bull. Was I supposed to get this patient to sign a release and authorize me to tell her how sick she was? It seems grossly unfair to patients that healthcare providers are restricted from doing their primary job – helping those in need, in case you forgot – because an obscure and overwhelming law precludes my actions. Make all of the good apples pay for the few bad ones. That seems to be the logic here.

What supporters of HIPAA fail to realize is that it is not the physicians who lose here – it is the patients.

Am I wrong?

The Nuts and Bolts of Third-Year Rotations

Anthony Rudine -- For those of you who did not know, I have now been on clinical rotations as a third year student for about a week and a half. I am on Internal Medicine now and for the next 6½ weeks. Some time will be spent in the clinic and some time will be spent in the hospital. It is absolutely great. I am truly glad that I stuck out the last two terrible years and made it to this point -- what a relief.

Since I had no idea how everything would work once I got to the hospital, I thought I would share my schedule: The alarm goes off at 4:30 am to get up and eat breakfast. I put on a shirt and tie every day, unless I'm on call or the day after call. By 5:30 I'm at the hospital, on the floor, seeing the patients that I admitted along with my team. I do this for about an hour, talk to the nurses and see how my patients did overnight, and make my progress notes. At 7 am I have morning conference, dealing with a different clinical topic each day – this week it is nephrology. Conference lasts for one hour, and then we meet at 8:30 for "pre-rounds." This is where the residents and interns on our team get together and discuss the patients, what we will do, things for the day, etc. At 9:30 we have rounds with our attending, whom we have to present our findings to each day. This usually lasts about an hour, then we get a short lecture by him/her until lunch. We then take a short lunch break, if we do not have a noon conference, and read up on our patients. Twice a week we have lunch conferences, and twice a week our lunch is paid for by drug company representatives.

For the rest of the day, we discharge patients, help out with prescriptions, and help out with procedures and orders. It is truly a great experience.

You will absolutely love it.

Expressing Appreciation for Other Members of the Healthcare Team

Anthony Rudine -- Well, I started my clinical years this week, and the excitement has been almost palpable. Step I is over, and of course I am thrilled about that, and my healing days have hopefully begun.

This summer I spent some time chilling out with my sister, who is also entering the healthcare profession as a nurse. She will start nursing school this fall and is quite excited. We often discuss healthcare, the things we like, the things we dislike, and we enjoy the discussions. In these discussions, I have begun to truly realize the importance of a complete healthcare professional system. I have never been one to think that physicians are of such great importance as to be immortal and omnipotent, but simply a person who wanted to be a doctor and help out where I could. My sister has the same philosophy, but her dream is to be a nurse rather than a paramedic, physician, etc.

I just want to take this opportunity to tell all of the nurses, paramedics, and other members of the healthcare community how much I appreciate what you do. I know that at times it certainly seems, even to a student, that the physicians get all of the credit, but this should not be the case. Without the help of the nurses and other professional staff members we would certainly lose many more patients than we help.

My sister and family have always been big proponents of following your dreams, no matter what they are. And although it is my dream to be a physician, those of you with dreams other than the Hippocratic Oath, fear not. You are important, too. Much more important than society lets on.

Another Take on Step 1: Not So Bad

Anthony Rudine -- I have finally taken the Step I examination. I must say, the anxiety leading up to the exam was far worse than the exam itself. Once it began, everything progressed smoothly, and the day progressed quickly without stress.

I think that the first two years of medical school prepare you quite well to take the exam. All in all I felt pretty comfortable with the test, however, I think that in the weeks leading up to Step I, there is little that a person can do to further prepare. In my opinion, there is nothing really new that can be learned, the trick is reviewing high yield information and facts and doing practice questions.

For those of you that have not taken the test yet, a small piece of advice: do not stress. Easier said than done, I know, but truly, in all honesty, the test is doable. It is passable. The medical knowledge you have learned in the past two years is adequate to pass the test. Of course, there are questions on the test that I could not even come close to answering, but such is life. There were also questions on the test that were so obvious that I almost read over the answer. For many of the questions, I knew the answer before even reading the choices. And believe me, I am certainly not the smartest cat in town.

I think the key is just to relax and take the test. Have confidence, and move on with your life. In the days since the test, I have had some interesting experiences. The day after, I had some long awaited dental work done, also known as legalized torture to a person like me who is so scared of the dentist that I almost left when I got there and went back home. In fact, I did leave and go back home, but I returned later. I know, I am such a chicken. The day after that, I began a road trip with my sister to her home in Virginia. We arrived after about 26 hours of driving, the last three of which ended up on back country roads thanks to some not so great directions from the internet.

So the plan is this: spend a couple of days with my sister, fly home to Dallas, return to West Texas on July 3rd, have orientation on July 7th, and start my clinical rotations on July 10th. I finally feel like I have arrived at the point in my life where I am becoming a physician. And it is truly a great feeling.

Delaying Step 1 for More Time to Study

Anthony Rudine -- Well, I officially chickened out and changed the day for my Step 1 examination.  As much as I dislike studying for this blasted thing and as much as I do not want to prolong my agony, I would much rather get a good score this time and not have any regrets.

I guess my primary reasoning for the switch was that I had wanted to get certain study guides read and questions done, and I did not feel that I had the time to complete them while maintaining sanity. So the switch was made, and luckily there was a time that worked with my schedule. The new exam date will give me about one and a half weeks off before my clinical rotations begin. I cannot wait.

I have a feeling that the clinical years will be even more than I am expecting, a thrill greater than I can imagine. I have been told by older and wiser students who have gone before that the third year is in fact great, much better than the second year. I just hope they are right. I know they will be.

I think that I have just become so incredibly tired and frustrated with studying for Step 1 that I have missed the big picture. It is about the patients and the experience – not what some test score turns out to be. I just hope that the test score that actually appears on my scoring report is somewhere close to what I am hoping for. Time will tell. Until then, good luck, and see you in a week.

Benefits and Dangers of Discussing Patients

Anthony Rudine -- I read a story today about a medical student who wrote an article about an autopsy he witnessed and was expelled from school for breach of confidentiality.  While I do not know the specifics of the case, I did read the student’s article and found no problems with anything that was written. Of course, the student sued the school for breach of his first amendment right to free speech, and the courts agreed with his position.

As a medical student who likes to write and is encouraged to write about patient contacts, this article disturbed me very much. At what point does my first amendment right end and the confidentiality of a patient begin? Is there a clear line?

In business school, we are taught about the legal aspects of HIPPA and patient confidentiality and told that we should never reveal anything that would allow the public to identify the person in a line-up. However, I'm also concerned that the fear of litigation will make me hesitant to write about patient encounters that could provide insight to other healthcare workers.

I do not want to give the wrong impression here; I think that patient confidentiality is an absolute must, and it has nothing to do with the first amendment. However, when speech about unidentified patients becomes litigious, I feel the first amendment is being trampled on.

I am a big proponent of the first amendment, and I want it to be protected to the fullest extent. However, because I am not in the law field, I do not fully understand where the first amendment ends and HIPPA begins. I know I am not the only one who feels this way, and I would enjoy hearing what others think. For that matter, does the law present other problems that you think need to be changed?

How Important Are Physicians in the Grand Scheme of Life?

Anthony Rudine -- Just the other day as I was taking a break from my studies (which are going better, by the way), I was helping my mother in the garden. As I was pulling the weeds next to the waterfall and putting the mulch in the flowerbeds, I began to ponder the world, which I often do. And as I was pondering away, with weeds in hand, I thought about a physician’s place in the world.

I think the image of a physician has changed over the years, even from twenty years ago. What seems to be happening is that the reverence of the physician is decreasing, and the physician's autonomy is certainly decreasing, too. But I still think that many people view the physician as possibly the most important occupation in the world. A person who dedicates their life to healing and saving lives should be revered, right?

Well, physicians and other healthcare workers should without a doubt be rewarded for the job they perform, when it is a good job. But I do not believe the physician is the most important job in the world, not the occupation with the ability to make the largest difference for mankind per expenditure.

When you think back throughout history and view the major advances in disease prevalence and incidence, what comes to mind as the most important factor that contributed to the change? What occupation throughout the course of history has improved human life the most?

Certainly not physicians. Only in the last 100 years have we truly begun to make advances over our counterparts of thousands of years ago. What about research scientists? No doubt important, but the amount of time and money needed and the incredibly slow process of drug development make this occupation an unlikely candidate.

What about the leaders of various nations around the world? They certainly have the power to implement new policy and make decisions that affect, indirectly or directly, large masses of people. But as far as historical changes in human life have gone, I would not put leaders of nations even in the top five.

I think, without a doubt, that the one occupation that, if it ceased to exist, would destroy human kind in the shortest amount of time is the sanitation worker. Thinking back on the many human disease epidemics and pandemics, would they have happened to the same degree with proper sanitation? I think not.

The number of lives that have been prolonged and saved by the proper use of sanitation is incalculable, far greater than all of the lives saved by all of the physicians in history, in my opinion.

Where Have All the Average Students Gone?

Anthony Rudine -- I must say that it is difficult to focus at this time in my life. I am trying to maintain some semblance of sanity as I proceed with my studies for the licensing examination. But it is oh so difficult.

I find myself spending more and more time thinking about how great it will be to be a physician in the future, and less and less time trying to get there. I spend more and more time trying to calculate my estimated score on the exam and less and less time actually studying for the test. It is what keeps me going, I guess.

However, as I began to delve into the medical student forums today, I was amazed at some of the things I read as I tried to find correlations between practice tests and actual examination results. My findings? It seemed as if the only people willing to give an estimate were the students who scored off the charts on the exam. There were obviously very few of these.

I am by no means a student who will score off the charts. If I get above average, mission accomplished. However, I wonder if it is misleading to others who read these types of correlations and become discouraged. I find myself becoming less motivated as the test gets closer, because I feel so inadequate already. And I still have a month left. I am not studying 20 hours a day, skipping meals, and drinking coffee pots for lunch. I am pretty much leading a normal life. I just cannot imagine doing it any other way.

I would much rather keep my sanity than attempt to get an enormous score on the test. But, hey, that's just me. We'll see what happens.

Competition in Medical Training and Practice: Too Much?

Anthony Rudine -- My studying for USMLE Step 1 has begun. The reality has finally sunk in that the big test to determine the course for the rest of my life has arrived. But has it?

I have historically not put too much emphasis on test taking, and not given much credence to the tests themselves, but this one feels somewhat different. I have been told, as I am sure all of you have been told or soon will be told, that your score on this test, taken in one day over eight hours, will determine what quality and specialty of residency you are competitive for.

It seems as though there are so many more aspects to a residency candidate than just a simple score on a test. For example, how far does a well-placed letter of recommendation go to alleviate a possibly low score on Step 1?

Although I do not plan on doing poorly, the thought has crossed my mind: What if I fail? What if I do not fail but barely pass? Are my healing days over before they even begin?

It may seem like I am already planning for the worst case scenario. Not so. I believe that your performance on a particular test is quite predictable, but the anxiety leading up to the test is certainly not. And it is this anxiety that can cause one to question their career choices.

For physicians and other healthcare workers, does it seem like the competition never ends? That your guard can never be let down? Is this a good thing?

In my opinion, competition is important, so long as it is not so intertwined with medical practice that the patient loses in the end. I hope this is not the case.

Do MCATs Really Measure the Quality of a Future Doctor?

Anthony Rudine -- Some time ago, I was speaking with some attending physicians in the Emergency Department about the value of the first two years of medical school. Their argument was that much of what is taught in the first two years is purely science, and much of it is not critical for learning to treat patients appropriately in the clinics.

One physician suggested that a better system would be to select people finishing high school who show a distinct capability to become physicians, and then reduce some of their undergraduate requirements, much like some of the European systems apparently do. By taking the top students from each high school and further selecting those who wished to be physicians (as opposed to engineers, lawyers, firefighters, etc.), the theory is that you would end up with better candidates when the true learning begins. In theory, at least.

But to me, this seems unfair. Many of my peers did very poorly in high school but blossomed in college, for whatever reason. Maybe they were not adequately challenged, did not care, or had no one to believe in them, but the result was the same – poor performance. However, many friends in this category have now gone on to pursue medical careers and are doing fine.

I also feel that much of what is learned in college is not necessarily required to be a good physician, but is certainly applicable to being a good healer. The difference? The human experience. English and the arts might not help you diagnose an MI, but they may help you when speaking to a family who has lost a loved one – allowing you to truly appreciate the world beyond gene splicing and clot busting. A better understanding of the world is gained outside the boundaries of science, when combined with a physician’s knowledge. And non-science knowledge is essential to the healing process, too.

I guess I'm asking, are the great physicians, the true healers, born out of ability or out of desire? My feeling is that the desire to be a great physician is far more important than ability. Sure, a surgeon may need dexterity and the ability to focus, for instance, but I think that much of what is taught in the first two years of medical school can be learned by anyone who has the right amount of courage and desire. The limiting factor, in my experience, is not brains but perseverance.

It just seems that the educational system can select for the wrong reasons, like medical schools using MCAT scores, for example. Does an MCAT score really measure the quality of a future physician?  Does performance in high school really indicate good candidates for future physicians? Does scientific achievement measure the quality of a physician?

I have a hard time believing that.

A Life or Death Position

Anthony Rudine -- Imagine with me for a moment: You are a healthcare worker walking down the street on the way home from a long day of work. The sounds of silence come over you as you plan on enjoying a glass of wine when you get home from a particularly stressful day. You begin to cross the street and hear two interesting sounds -- two pops, if you will. Then you hear some screeching tires and see a car speed away. To your dismay, you see a man lying on the ground bleeding from two gunshot wounds. There are already other people running over to help the man, but what do you do? You are trained for these kinds of things – do you walk away, knowing the hospital is only blocks away, or do you run up to begin treatment on the man, at least a primary survey?

Now follow me again, if you will. Same story, same situation. The only difference is this time, you recognize the man on the ground from news stories and reports. You realize that he is an escaped convict, who was convicted of murdering a child. In fact, there was no doubt, as it was caught on tape. He is the killer, and now he is lying there in a pool of blood in front of you. What do you do? Same answer? Do you help him or slip away into the night, secretly hoping that he never makes it to the hospital?

Let me tell you what I would do. For the first man, without question, I would stop to help. For the second man, without question, I would stop to help – not even a moment's pause.

I feel it is my duty, not as a physician, but as a human, to help those in need – murderers or Nobel laureates. I do not make the distinction, as I am (hopefully) a future healthcare worker. I am not a judge, not a lawyer, not an executioner.

I feel that many of you would agree with me on these first two scenarios. But let's go one stop further down the hypothetical trail: What if the convicted murderer in scene two was perfectly healthy, and instead of helping him live, you helped him die – by voting for the death penalty.

In the human body, there is a process called positive and negative selection, whereby the useful immune cells are positively selected for future use, and those immune cells that provide no benefit, or even a detriment, are "selected" against. But in the real world, do we not have the same rules? Either we choose to do something, or we choose not to do something with the same result.

As the Zaccarius Mousouii trial continues and the question of the death penalty arises time and again, these questions enter my mind. What would I do if I was on the jury? Positively select or negatively select?

When I tell people I am against the death penalty, they are usually in shock because I have such opinionated views on many things; they are surprised to see a Southern Baptist Republican from Texas making the choice against the death penalty. I guess the question is, do healthcare workers inherently have a higher respect for life than other people? I think not, as we all value life, but we also have to deal with death continuously?

I assume that many of us would help a dying man on the street, but is sentencing a healthy man to die any different than walking away from the murderer in the street? I think not, but I'm curious what you all have to say on the subject.

Learning to Deal With the Loss of a Child

Anthony Rudine -- I have been trying to write this entry since April 8. That date is always a test for my family, as it is the birthday of my sister who passed away many years ago. I have never known what to say to my family on this day, nor has my other sister or my brother; we all know something should be said – but what?

The loss of a child, for whatever reason, is something I will never truly understand. Children are so innocent and full of life, and their loss signifies a great tragedy to me. I recall the many special times we spent together and how my family was deeply affected by her loss, and I look back with regret.

For physicians, the battle against death is ever present, one we will ultimately lose many times in our careers. But it seems to touch a special nerve when the patient is a child.

I cannot truly understand what my parents have gone through because I have not lost a child. But I will never forget the effect my parents have had on me when I have to face Death in the battle over a child's life. The strength and courage of parents, as I have personally seen, is something to be truly appreciated. Nothing is greater than the loss of a child, I am sure, but experiencing the strength of parents in the aftermath truly allows you to appreciate what you have been given as a human being, and as a child.

To my parents, I say thank you. You have helped me understand the trials and tribulations in dealing with the greatest loss, and in turn, you have helped many children and parents that I may have the pleasure of treating in the future.

Making Sense Out of Hard Times

Anthony Rudine -- As I sit here at my computer, I find myself trying to think of an analogy for my life. The first thing that comes to mind? "My life is slowly draining out of the bathtub of life," or something to that effect. Pretty depressing. Let's be honest here, not every day shall be a good day, nor is every day to be filled with happiness. But being the scientist that I claim to be, I feel it necessary to think further about this analogy.

If my life is draining out of the bathtub of life, that would make me water – and I know that the human body is mostly water, so, so far so good. My analogy is working. As I play with my dog on the couch and we finish the movie "Must Love Dogs," – I know, corny, but true - I find myself thinking more about the analogy and about the last time I gave him a bath.

The water draining out of the tub was colored – from the dirt removed by shampoo - and it did indeed drain slowly. However, the mud, being more dense than water, accumulated at the bottom of the tub and did not drain out. Science at its best.

If you can't tell already, life has not been going as planned these last few months, and last week – test week – was indeed as bad as I feared. I find myself torn between the life I had envisioned in my dreams and what it is turning out to be.

Going back to my analogy, I find that it rings true. We are water. I am water draining out of the tub, slowly but inevitably. And I leave the bathtub colored with the experiences of life, the good and the bad. And the mud of life – those things that really get us down, those things we regret, hard times - ultimately sinks to the bottom, and the water leaves the tub.

Then I wonder – is my life really so far from what I imagined, or am I just stuck in the mud right now? All my life I have wanted to be a physician, and here I am, in medical school. For years I have had a passion for writing, and here I am, communicating with you, faithful reader. And all my life I have wanted to be happy, truly happy. And I recall the love of my family and friends, who provide the soap and shampoo to my metaphorical body as it is needed.

My conclusion: the water is never clear. But it is the experiences of life, and the gift of patients, family, friends, and of course dogs, that bring soap to our lives at the most needed times, gently removing the mud as it sinks to the bottom, and another chapter of our lives leaves the tub.

Cramming It All In

Anthony Rudine -- Exhausting. Exhausted. Trying to stay afloat. That would pretty much sum up the past week for me. Just terrible in every way. Unbelievable.

This past week we had block exams in each class. Under normal circumstances, the week comes and goes and I usually don't worry too much. I just let things happen, let the pieces fall as they may, and I come out on the other end alive, happy, and feeling good. Not the case with this past week.

Usually I am in bed by 10 or 11 the night before a test. Usually I watch a movie to relax or iron some clothes -- one of my favorite pastimes. Usually I get up tired, but able to refresh myself on the last few details before the test. But this week was different.

I found myself not being able to learn the material to my satisfaction for the first time since I began medical school. Sure, it's always been hard, and this week was hard as well. But something was different. I simply could not get the material in my head quick enough and found myself cramming the night before -- a very unpleasant feeling. I tried to go to bed at 3:30 am each night and get up at 5:00 am. Bad idea. I usually could not do it, and ended up getting up at about 6:30 am instead, with no energy, no knowledge of the subject, and feeling like a fish out of water.

I was hoping the week would get better, but let me assure you it did not. I just stayed at the same level of fear.

I thought about the saying, "This too, will pass," and I found myself thinking about it time and time again throughout the week, hoping it to be true. And you know what, the saying is true. The week is over, and tomorrow is another day.

I don't know how I did on my tests, but I do know this -- I start over tomorrow, and a new journey begins. This too, will pass. Indeed.

Socializing Outside Medicine

Anthony Rudine -- Last weekend, I had the fantastic experience of being the best man in a wedding. It was my first time to be a best man, but I certainly hope not the last. The wedding was incredible, the reception was top notch, and I fulfilled my duties appropriately.

However, aside from seeing one of my very dearest friends move into the realm of marriage, I was taken aback at some other developments as well. First and foremost, I was completely out of the medical world – no doctors in sight. However, during the mingling, it amazed me how the fact that I was in medical school kept popping back up.  I feel I may never escape into just being a regular guy again, as I now am required to comment on all medical conditions, hear stories about all doctors – good and bad, and constantly be treated as if I am already a physician; which I most certainly am not.

The other surprise was meeting people that I had known all of my life. Do you ever get that feeling? I mean, I have known one of the guests for 19 years, and only over the weekend did I truly get to "meet her." I find it so interesting that within our busy schedules, we rarely take the time to truly get to know someone. We many times think we know them already, knowing them for 19 years. But casual acquaintances and conversations rarely reveal the depth of a person, deep inside.

I guess what I learned was that each person truly has a gift to offer – you just have to be there to receive it. And what a gift it is to have a person open up to you, as a conversation of depth and importance arises.

Be a Hedgehog, Not a Fox

Anthony Rudine -- As I promised some time ago, it is now time to delve into Jim Collins' "The Hedgehog Concept," included in his most recent book, Good to Great. Basically, Mr. Collins and his research team identified factors that separated those companies that outperformed the market and sustained their growth from similar companies in the same markets, faced with the same challenges, that did not sustain growth that beat the market. One of the key factors, according to Collins, is The Hedgehog Concept.

He illustrates the point by telling the story of the hedgehog and the fox -– the fox is smarter and quicker than the hedgehog, but the fox never prevails with a hedgehog for dinner that evening. Why? Because the hedgehog, as slow as he is, knows what the fox doesn't –- all he has to do is curl up in a ball, and the fox can no longer attack; he is protected. So as the fox devises all of these magnificent plans each day, the hedgehog simply does what he is good at –- curling up -– and beats the fox every time.

Now comes the interesting part: According to Collins, without a clear Hedgehog Concept one cannot "beat the market," as all decisions for the company must revolve around this. The Hedgehog Concept consists of three circles: What can you be the best at? What are you passionate about? And finally, how do you measure your success?

As I was reading this, I was thinking to myself –- what is my Hedgehog Concept? Can it apply to people, or is it only businesses? Lest you forget, dear friends, a physician could be considered a business, and to be successful, must be considered a business. So applying the concept to medicine -– What can you be the best at? For me – emergency physician. What am I deeply passionate about? Treating all patients from all walks of life. But how would I measure success? Treated patients per hour? Lives saved per day? Smiles created per family? What? I think I would measure success as patients correctly treated per day.

The point is, if you are not passionate about being a physician, if you cannot find a measurement of success, and if you cannot truly dedicate yourself to the treatment of patients –- to be the best at that time -– then why be a physician at all? If you define your Hedgehog Concept as something else, maybe you have become the fox, and that friends, is a futile battle. The hedgehog wins every time.

On the Mend ...

Anthony Rudine -- Well, how things can change (again) in a week's time. I figured I would follow up with my ongoing saga from last week. Here is the brief update: I am still "broken up," shall we say, and have no hopes for the future of the previous relationship. However, I have high hopes for the new relationship that I began on Sunday with a young pup named Rusty.

I figured that because I couldn't get a dog while in a relationship, now was as good a time as any. For all you naysayers out there, this brings up some interesting questions: Am I simply using the dog to cope with the "loss" of my girlfriend? Or am I just finally able to realize my dream of owning a dog, and the time was just right, and all the pieces fit? Allow me to answer.

I am still somewhat upset about the breakup, but time heals all wounds. I must say I am far better than I was at this time last week. But in response to the first question, the answer is no. I am not using my new-found friend to cope or heal my wounds quicker, although he does have that unexpected benefit. Let's just say that it was meant to be. Better yet, the Lord works in mysterious ways.

I mean, what other explanation could there be for this bundle of animal fur? A purebred Pembrough Welsh Corgi, male, tricolored, coming on the market the exact day that my family arrives in town and we decide to "just see what dogs are available?" Better yet, I purchased the little fella for the amazing price of absolutely nothing. What a deal.

Coping with any loss is hard. I should know, I have gone through many, even just since I started writing this blog. But one thing is for sure – nothing can replace a true friend, and nothing heals the wounds of loss like a good dog and some time. Man's best friend in every sense of the word.

How Can You Mend a Broken Heart?

Anthony Rudine -- Well, how things can change in a week's time. I had been debating which topic to discuss for a couple of days now. Should I discuss Shani Davis and Chad Hedrick's Olympic demeanor and relate it to medicine "off the ice?" Then I thought about discussing what Jim Collins, a management expert, calls "The Hedgehog Concept," where a company defines its passion and core concept, which I could easily relate back to medicine.

But as I woke up yesterday, my girlfriend of over 2 years decided to end things with me. I understand all of the reasons, and I won't get into them here other than to say it was somewhat of a surprise and was one of the few times I have produced a tear.

So, to be totally honest, I really didn't feel like writing anything after that. Maybe we shall talk about The Hedgehog Concept at a later date, as right now I am feeling more like a hermit. So, with the advice Tom Hanks offered to Barry Pepper in The Green Mile - "Dry your face, Dean, before you turn around" - I shall, because it's time for hospital rounds and I have a patient to see.

Olympic Gold for Patient Care

Anthony Rudine -- I just finished watching American speed skater Chad Hedrick win the Olympic gold medal in the 5000 meters. What an incredible feeling. What a great end to my test week!

I cannot imagine what he must feel like to stand on the medal podium and be rewarded for being the best in the world. But that makes me wonder: In this day and age of competitiveness and rewards, could those same events occur without the reward at the end?

In medicine, there is no "greatest doctor in the world" competition every 4 years. Sure, we have the Nobel Prize in medicine – but a reward for the best physician, the best healer? It almost sounds counterintuitive. Shouldn't we be in this for different reasons? I think a reward does exist in what many might consider a profession without rewards. I see increasing bitterness developing in the medical field because some feel that the reward strategy is not there, that lawsuits are taking their place. I beg to differ.

I spoke with a patient the other day who was not in good shape, but in a great mood. Lots of family members, but none there to visit. As I talked to him, I received a reward not unlike the rewards given to our top athletes, albeit in a different form. I received the reward of thanks – without even having heard the words. I could see it in his eyes, as he was glad that someone cared enough to stop by for more than a passing minute.

The point I am trying to make is this – as a medical professional of the future, I hope to take the time to step away from the bitterness and heartbreak of the day-to-day grind and recognize the gold medals that can be achieved every time we pass through a door and affect a patient's life, because for that period, as their physician, we are the best in the world.

And truthfully, I would much rather have a healed patient hanging around my neck giving me a hug than a gold medal.

Pack Up Your Troubles in Your Old Black Bag

Anthony Rudine -- Well, I am in our school’s histology laboratory, along with many of my classmates, attempting to get ready for this coming week’s block examinations. What a stressful time this is. Next week we will have 4 exams – Clinical Medicine, Pathology, Epidemiology, Pharmacology.

Luckily, there is some overlap between the topics, so it makes studying a little easier – but no less stressful.

This time, I have tried to implement a new study tactic in order to reduce my stress load. I call it the "I don’t care" philosophy.

Briefly, here’s how it works. I know that most residency programs look relatively lightly at my first 2 years of non-clinical grades. Most of it is based on Step I. So why worry about the exams themselves, if they matter little in the scheme of things? To begin my studying for the weekend, I went to see a movie – Syriana, and loved the relaxation.

Don’t get me wrong, I am still studying at a level that I need to, just worrying less. After all, we’re here to live life, not live in a continual state of fear. If I don’t make an A on a test, you know what, it's not the end of the world. Bye bye worries, you have met your match.

Off to See an Autopsy

Anthony Rudine -- In my pathology course, we can do an extra credit project to aid us in our quest to complete the second year. A few of us get to participate in a pre-approved project: "assisting" with an autopsy and presenting the case to the class. I was one of these students.

I have always been an enormous fan of forensic pathology, although I know I would not like being a forensic pathologist. I have read many books on the subject, and especially enjoy those written by Dr. Michael Baden. Suffice it to say that I was indeed looking forward to the autopsy experience. I wanted to be in the club without actually joining, so to speak.

I showed up at the medical examiner's office and was greeted by the physician with whom I would be 'working' that day. We first went over some confidentiality documents, as my signature was needed. Then we went on to another topic.

"Anthony, we don't expect this to happen, but we need to let you know – some students begin to feel faint during the autopsy. It is important for you to know that it happens to a lot of people, and I don't want you to be tough. I want you to tell me if you are feeling faint, dizzy, woozy, etc., and we will get someone to help you outside. People are usually better after they get a drink of water."

At this point I was thinking, I've been looking forward to doing an autopsy for many years, and I don't plan on getting woozy or dizzy or anything of the sort.

Then there was another thing to discuss.

"Anthony, the patient is a baby," the doctor said.

A baby? I had assumed the autopsy would be on an elderly patient whose family or physician had requested it.

Before we even went into the autopsy suite, I began to feel strange. Very strange. I was not here to see an autopsy on a baby. This was not what I signed up for. I began to feel timid, even reluctant to enter the room.

An assistant came and helped me 'suit up': 2 sets of gloves, gown, booties, etc. Much like going into surgery – except nothing was going to be fixed.

As I entered the suite, I began to feel like an intruder. It was very sad. Very hard to see. And yet, it had to be done.

We began the procedure … and then we were done. This post is not about the procedure itself – you can read about that anywhere.

I never did get dizzy during the autopsy, but a different feeling came over me. I don't think it was shame. Something else. Sadness, of course, for the family and for the patient. But what for myself?

I think regret is probably the right word. I felt regretful that I had been so excited to participate in an autopsy.

I told the physician that I did not, at this point, know what to feel. Science is interesting, medicine is fascinating, and I have been looking forward to seeing an autopsy for years. But here, now, we were both looking at what once was a human being. And I was confused.

Her reply? "I know how you feel."

I am not used to dealing with my feelings. In the past I have often felt like the Tin Man in The Wizard of Oz. Not anymore. Through this experience I have learned that feelings are what make us human, and hiding them, suppressing them, detaching ourselves from them only serves to detach us from the world.

I wish I could thank that patient, but I cannot. I will, however, try to approach patients from now on as the Lion rather than the Tin Man.

The 'Flattening' of Global Healthcare

Anthony Rudine -- As part of my MBA in Health Organization Management, I am required to take a business class this semester – Organizational Behavior. Our professor has assigned us to read the book The World is Flat by Thomas L. Friedman. The book's premise deals with the globalization of the world's economies, claiming that the world is changing in a way that it has never changed before. For example, it discusses outsourcing and its impact on many industries, most notably that of information technology.

Many of you know that US hospitals outsource some of their radiology services to the other side of the world, so that more immediate results can be received for the patient, as radiologists in the Western hemisphere can be awake for only so long. I wonder how the increasing globalization of the world -- its "flattening" -- will affect medicine and medical education.

For starters, the one thing that cannot be outsourced, or influenced by flattening, is the physician patient relationship. Service at the bedside in a time of need can come only from the physician at hand, at the hospital. However, does the traditional physician patient relationship even exist any longer? Some of you will argue that it does, and I tend to agree in some instances. However, I have heard other physicians discuss that the physician patient relationship of old is now only a myth, a fairy tale of sorts.

So, my point is this – if the physician does not have the relationship with patients as it once was, what is to stop the further globalization of the US, and for that matter, every country's healthcare industry?

In the age of cost cutting, hospitals are continuously looking for ways to improve efficiencies and save money. As are insurance companies. As is every other company in every other industry in the world – I see no problem with that. I just am unsure of the future of the industry as a whole.

At my medical school, there are many small towns that surround our somewhat larger city. Telemedicine and teleconferences are becoming common as physicians in underserved areas look to the major academic institution for assistance.

Following this logic, it makes just as much sense to globalize the telemedicine conferences – patients get sick at night, too. And the cost is substantially lower.

Where will globalization take us? If the world is truly becoming flatter, what will the future of medicine and the practicing physician be in 20 years? More interestingly, how will patients respond to the globalization of healthcare if it is in fact, inevitable?

Only time will tell. But one thing is certain – I hope that in another 20 years, I can still practice medicine in the way I envisioned it to be when I signed up.

Seeing Death Differently

Anthony Rudine -- A classmate of mine recently expressed some concern that he feels grossly unprepared to treat patients. He said it makes him very uncomfortable to know that he has to treat patients in the future.

Of course, the simple reply is, "Well, you are not supposed to know how to treat people yet, that is what we are here for." However, a deeper question must be asked.

Should he feel more prepared to treat people at this stage of the game? Is the current system of medical training the best it could be? Are all doctors prepared in the same way?

I know that the easy way to ensure proper training for all future physicians is the US medical licensing exams, followed by residency. However, is this the best way? My school is currently changing the curriculum from a traditional "separated" curriculum to a more systems-based philosophy with earlier clinical experiences.

As I thought about what my friend said, I realized that I too, feel some anxiety when I realize that I will be responsible for people's lives in the future. This, however, is not my biggest concern – it's dealing with the families of the patients and the patients themselves when I have no good news to bring.

I cannot imagine what it is like to tell a person that they will die, or that they have an untreatable disease. I cannot imagine telling their families that their relative will not make it to Christmas time.

When I was home for the break, I spent a lot of time with my grandmother, as she was staying with us for a couple of months. We spent a good deal of time talking and just enjoying my time off.

However, our talks were always tainted. As you might remember, my grandfather passed away a couple of months ago. Thus, much of my time was spent talking to my grandmother about her husband. This was difficult for me.

I have talked to my grandmother many times before, obviously, but there were many times where I simply had nothing to say. I could not find the words to comfort my grandmother about losing her husband of 40 years. What was I to say?

In light of this, I have experienced what it is like on the other end of the spectrum. Outside of the hospital. This is the first time I have experienced the family end of a death since "entering" the medical field. And to say the least, it is different.

I often catch myself in the hospital looking for the "interesting cases," the "rare cases," and the good teaching cases. I think all of us do, for that is the reason that we are in medical school – to catch the zebras and treat the horses.

However, spending time with my grandmother over the break has helped me realized that there are no "interesting cases," just interesting people. People with families just like mine, and grandmothers just like mine who will have to deal with what I tell them long after I leave.

This weighs heavily on me. I catch myself thinking – could my grandfather's physicians have done anything differently to help my grandmother? What can I do in the future to help others' relatives with the burden of losing a loved one? Can I do anything?

It bothers me somewhat that, as I saw my grandmother for the first time since my grandfather's passing, I had nothing to say. I knew that I should say something, anything, but I simply could not. I think I did not want to see her cry. Maybe I did not want to cry myself.

Eventually, however, I began to ask her about her husband and just listened to her open up to me – what a weight that lifted off my shoulders.

As a result, I now know this – just allowing someone to open up to you is a major part of the healing process. As a future physician, I pray I will find the time during my likely busy schedule to form relationships with my patients and their families that will allow them to trust me enough to open up and talk.

Now that I have seen both sides of the equation – before and after entering medicine – death has changed quite a bit. As a medical student, I often forget about the families that are awaiting the arrival of the diagnosis and how that will affect them in the future. My grandmother has taught me to never forget that again.

Seeing Zebras

Anthony Rudine -- Well, it's a new year and a new semester. I just can't wait. I am extremely excited that this will be my last semester of actual classroom instruction, then I am on to my clinical years of treating and healing.

As is usual over the Christmas break, I had a round of checkups from my own physicians to make sure I was still hanging in there, and as usual, everything checked out fine.

Unfortunately, my family physician diagnosed me with a new disease this year – medicalstudentitis. I informed him that by learning about new diseases in medical school and learning of their symptoms, many of my friends and I had begun to diagnose ourselves with everything imaginable. He gave a quick chuckle and told me not to worry – what a great guy.

Medical school is an interesting beast. I'm sure you all have heard of the saying – 'when you hear hoofbeats, think horses, not zebras.' This is meant to say that the most obvious cause and the most simple explanation are usually correct. It is exceedingly unlikely that we, as medical students, will even encounter some of the rare diseases discussed during morning lecture.

My issue is this. How am I not to think I have a rare disease when the teaching is focused more on recognizing symptoms, of which many conditions share, and less on the statistical representation of the disease in society? How am I to separate the rare from the common, when much of my learning focuses on the rarities?

Let me elaborate. I live in Lubbock, Texas, a dry and windy place at any time of the year. A couple of months ago I started to itch. My first thought? Liver failure. Not dry skin from the dry and windy climate, but full blown liver failure. By the end of the day I figured I had hepatitis and was quite close to checking myself in to the hospital for further evaluation. Thank goodness I did not.

When I explained this to my family physician, he acted like he had seen the symptoms before -- medical students coming in (he is a professor at a medical school as well) to his office and describing to him why they had some rare disease because they had recently developed symptoms. He had seen it many times. Medicalstudentitis. And I had a severe case.

Another example. A good friend of mine in medical school showed up to class with a headache one fine morning. Unbeknownst to me, he had already diagnosed himself as well, and was seriously considering requesting an MRI of his head. His diagnosis? Brain tumor.

Here is the point. When am I to recognize that the rare diseases and conditions are actually rare? When can I distinguish the simple headache from the brain tumor? Certainly not now.

It is not, in my opinion, a question of knowledge – some symptoms are simply the same for many different conditions – it is a question of judgment. One must see so many presentations of the same problems to begin to notice abnormalities in the common versus the rare.

What took me some time to realize is that everyone has symptoms of many diseases. Additionally, I forget that I'm learning about the worst diseases possible while in school, and much more time is spent on the abnormal than the common and normal variations. So, it is only logical for me to conclude, based on that knowledge, that it is the worst case scenario – it is the only thing I know.

I'm just curious when this will change.

Home, Sweet Home

Anthony Rudine -- Well, friends, the holidays are almost over. What a bummer.

This is probably the most fun time of the year for me because I get to spend the most time with my family that I will get to spend with them all year. This year was especially fun because my little brother (also known as the kid who beats me in foosball) bought a foosball table, so we have been playing lots of foosball.

I had a wonderful Christmas and hope to have an even more wonderful New Year, even though the New Year is directly followed by the beginning of classes.

Unfortunately there will be no fireworks this year as there is a fireworks ban in the county where my family lives – thus, there will only be visiting and enjoying the last couple of days before my return to medical land.

While I am on the topic of holidays, I must say that I hope to remember how this feels. As I said before, I have not had this much fun in some time, and although I know that to be a good thing, it saddens me as well.

Why have I not had this much fun in years? I worry that it is because I have spent so much time worrying about school and patients and becoming a physician, that I have forgotten what it is to be a person first. As I said last time, I don’t know if I can turn the medical brain off.

But the larger issue is this – as my breaks shorten and I near the beginning of a great career in medicine, will my enjoyment of time off increase or decrease? One could argue that it will increase because after so many years of training the breaks will become more important. However, one could also argue that the enjoyment of breaks will decrease because my mind will be warped with medical knowledge and understanding.

However, I think this – I love my family very much and I will continually try to make each new experience with them the best that I have ever had.  Whether my mind is filled with medical knowledge, sports knowledge, banking knowledge, or no knowledge, it makes no difference. Each member of my family represents a different aspect and a different attitude towards things – that is what makes them great.

And the sooner that I decide to enjoy all the family time that I get and vow to make the next family time better, the better off I’ll be. 

On that note, I can’t wait until the next time that I come home.

A Medical Mind

Anthony Rudine -- Although I am thoroughly enjoying my break, I must say that I am having some difficulty in changing my mind over from medical thinking to regular person thinking. Many of my friends and family are beginning to ask me about bumps on their bodies and bruises on their heads, and asking for a diagnosis. This is occurring at the same time that I am trying to turn off my medical thinking brain and turn on the relaxing one. It makes me wonder – will I ever have a non-medical brain again? Will there ever be another time in my life when I can come home and not discuss hospital issues and treatments and diagnoses for friends and family?

I fear that this may be the case. Unfortunately I am unable to give a diagnosis at this time, so here I sit; in a lingering nowhere – neither fully medical nor fully normal. It is certainly a strange place to exist.

As I sit here and think, it becomes difficult for me to remember a time when my brain was not ‘medical.’ Although I know it was only a couple of years ago, I cannot remember what it was like to not know what a cell was. Was there ever a time that I didn’t know some of the things I know now? I don’t know. I just said I can't remember.

It is strange though. I will begin speaking with my family or friends about something that we learned in school, or something on the news, trying to relate it to those not in medical school, and the same thing always happens. The receiver of the conversation usually listens intently and asks a question that is so simple to me that I saw no reason to explain it. 

The point is, I am sure that a barrier must be crossed to ‘know’ about patients and medicine and science, I am just a little unsure about when that will happen. I know that I have never really understood the science behind what my physician was saying to me, so I could never fully understand the complexities of each decision that he makes. However, when will that time come for me? I know everyone else thinks that time has already come – I can explain many things that they ask. However, when will I cross the barrier of knowledge? 

I only hope that it will be never. As long as I can keep learning, I can keep treating, and that’s what I am here to do.

Nothing to Do

Anthony Rudine -- Well, the semester is finally over. I took my last test for the fall on Wednesday – the Microbiology and Immunology NBME. It was tough, but it is over. Alas, I have become free for yet another 2 weeks of complete relaxation.

Well, sort of.

It is during the times when school does not exist that I try and reenter the world of a non-medical student. I will see old friends, in the workplace by now, and briefly adapt to their schedule, and my own of maximizing relaxation.

I have heard comments lately regarding USMLE Step I. Are you going to study over Christmas? What are you going to study? Do you have a schedule made out yet?

No, I will not study over Christmas, I will not be studying anything, and I will be making no such schedule that deals with medicine in any way.

I think it is difficult for some people, especially med students, to understand that when I say I am going to do nothing – that is literally what I mean. I will be sitting on the couch, watching movies, going out to eat, and hanging out with family and friends.

I must say, this past semester was certainly not the easiest for me to complete. Sure, I passed everything, but I think my burnout came a little too soon this time – around August.

I think a lot of people have a hard time with breaks, whether they admit it or not. Med students become so adapted to the environment of ‘study all the time’ that when there is nothing to study, there is nothing to do. In my case, when there is nothing to do, I just do nothing. I don’t find something to do; it's just not my style.

At this point in my ‘career,’ I am so excited about the prospect of the clinical years that it is difficult to contain. The book work gets me down, but in only 7 months, I shall enter the world of the hospital for the remainder of my life.

Don't Forget Milky-White Skin

Dermatology is so sweet and delicious and satisfying. (At least, it used to be.) Why, you may ask? Allow me to enlighten you.

Let's start off with some juicy strawberries, honey, oranges, and cherries as appetizers. We may follow this with some pork, chicken, and cottage cheese, while others may care to partake in the spaghetti and meatballs. Others still may enjoy the beef the best. We will have Swiss cheeses to snack on and will follow the meal with some coffee and milk, and finally, a good piece of bubble gum to end the night.

What am I talking about? All I know is that it is now difficult for me to look at any of these foods the same way ever again.

Why does everything involved with the skin have to be compared to food? For that matter, why do so many things in medicine have to be compared to things that I love? But that’s another story.

All the examples above describe things found in the realm of dermatology. Juicy? Subacute dermatitis. Strawberries? Hemangioma and toxic erythema. Honey? Impetigo. Oranges (the peel, actually)? Breast carcinoma. Cherries? Hemangioma. And that’s just the appetizer.

The disturbing thing is, it actually helps to compare unknown things to something known, like food. I may not know what oral thrush or a neurofibroma look like, but I do know what cottage cheese and bubble gum look like. Connect the dots.

The interesting thing is, my vision on the world has changed. Greatly. I now know that when a patient describes their skin disorder as ‘Swiss cheese,’ that description may be entirely correct: Pemphigus vulgaris.

In fact, the food comparison helps me relate, and that is something we all need help with. I think too often, physicians are put on a pedestal; people think we are incapable of making mistakes, and we speak in a language so complex that the mere sight of our white coats strikes worry into the patient in the room. Not a good way to start.

Imagine a scenario: “Doc, I have this ‘thing’ on my skin, and to be quite honest, it looks like Swiss cheese.”

Now, instead of saying, “Yes, that is an IgG autoimmune disorder you have. Your body is now attacking your keratinocyte’s desmosomal proteins and leaving you with intraepidermal superficial flaccid bullae and a positive Nikorsky’s sign,” I would much rather say, “You know, it kind of looks like Swiss cheese to me too, and the good news is, I know what it is, and I can help you.”

I would much rather envision myself as a physician who treats the patient and not the disease. In my opinion, relating to patients' own descriptions and working off of their personalities is a good way to start.

So I shall now put on my white coat and go get something to eat. Who knows, maybe I’ll learn something new today.

If only diseases and treatments were related to Big Macs and chicken fingers, I might actually do well on a test.

An Unresolved Choice

I am told that blogging is supposed to be somewhat therapeutic. So, I figured I'd give it a shot.

One of my best friends in the world passed away last weekend: my grandfather. I probably spent more time with my grandpa, Peep as we called him, than most members of my family. I saw him over the Thanksgiving holidays, just before my last post, and although he looked sick, I did not realize he was as sick as he was. After all, most hospital patients look sick; that’s why they are there.

I have actually been feeling quite conflicted lately. My reason? Block exams began this week: Micro on Monday, Pathology and Internal Medicine on Wednesday, and Pharmacology on Friday. Next week we have a physical exam test and the Micro board exam.

The funeral services were held yesterday in Dallas. I live in Lubbock, and we are taking exams.

My issue is this: I did not attend the funeral and have been at odds with myself over my decision. I talked to many members of my family over the days leading up to the funeral services and they encouraged me not to attend. I heard story after story about family members who missed the funeral of a grandfather, grandmother, or other relative. They assured me no one would think badly about me if I could not make it. In fact, I was not expected to attend. So I didn’t.

I was told that seeing him alive and spending the countless hours with him when he was healthy were far more important than attending his funeral, which is for the family, anyway.

The problem is, I could have moved my exams to attend the funeral. I could have spoken to my student affairs office and asked what my options were. But I knew the options: move the exams to a later date (next week) and go to the funeral, or keep the exams the same and do not attend. I did not move my exams, and in fact, I took 2 exams just yesterday.

My family even asked my grandfather’s physician, Should Anthony move his medical school exams around and attend the funeral? His reply: Absolutely not. Tell him to stay there. They passed the message on and I did just that.

However, I am now concerned that I just followed orders. I feel like I should have been there. I could have hopped on a plane and been gone for about a day, just in time to start studying again. But I didn’t. And I don’t know why.

I think to myself, Would I want my relatives to miss exams and finals just to come to my funeral? I absolutely think not. But that doesn’t help much.

I have never put too much weight on grades, and have always done well, so why were these exams so important that I couldn’t (possibly) sacrifice a few points to attend my grandpa’s funeral? I don’t know the answer to that. I just know I didn’t go, and I feel strange. Not guilty -- I know what my grandpa would have said (don’t come) –- just strange. Like I sold out.

I guess my point is that I don’t know what I should have done. Did I make the right decision? Did I subconsciously offend my family? Would I do it again?

I don’t know. I just feel strange and needed to be therapeutic for a while.

Love you Peep, miss you. Tell my other relatives up there I said hello. Thanks for everything.

'Students Begin to Snap'

I always dread the end of the Thanksgiving holidays, because that signifies the end of the last week of classes, and thus the beginning of test week. For those of you unfamiliar with this particular type of torture, allow me to enlighten you. Test week, or block week as it is known here, occurs about every 5 to 6 weeks – at the end of each ‘block’ of information. During this week we will have a test in every major subject that we are taking – for me, pathology, pharmacology, and microbiology & immunology. The information, all interesting, is also quite overwhelming, to say the least. For example, on the upcoming pharmacology test, we will be tested on about 230 drugs and are expected to know the mechanism of action, side effects, toxicity, adverse reactions, treatment protocols, and contraindicative situations for each. Of course, I am not excited about this, but, that is why I am here.

On another note, this is the time of year that some students begin to snap. In the coming days, tempers will run high and the environment will become more stressful. However, in the midst of all the uproar, we will somehow survive and come out clean on the other end. 

Med school is thus an interesting place to say the least. On any given day in the coming 2 weeks of tests (regular school written tests and one week of national board exams), you will find a variety of oddities. The pizza delivery places come to know what ‘deliver to medical school' means, the coke and coffee machines run low on products, and many students go into a spending spree on cheeseburgers and cokes that seems to have no end. You will find the nocturnal students in the laboratories at 5:00 in the morning on the day of the test. You will find some who simply didn’t have the energy to make it home and fell asleep at the medical school itself (although this activity is more prohibited with our 24-hour security guards). You will find those whose eyes are so red and their hair in such shambles that you wonder how they will actually finish the test. And finally, my personal favorite: the student who falls asleep during the middle of the test itself. Due to lack of energy (Snickers), hydration (Dr. Pepper) and sleep, this person simply runs out of energy about 1 hour too early.

As you will see, there are many types of students attending med school, and most can be grouped into a few categories – the gunners who study continuously; the slackers who study about 2 days before the test; and the many more groups in the middle consisting of different sleep patterns, etc. It is the students who make much of this experience for the first 2 years bearable, as they will carry you through the torturous levels of school to the end of your education. Some are hated, some are loved, and some just get by, but all together it makes for some interesting days.

Meet a Biz/Doc

Anthony Rudine -- Well, hello there. This is entry number one of a long line of entries and topics that shall follow. I thought that this would be a good time to say a little about myself and give a quick intro, so here goes.

I am a second-year MD/MBA student at Texas Tech University – in deep West Texas, the home of Buddy Holly, Pat Green, and lots and lots of cotton. I have a bachelor’s degree in Animal Science and enjoyed working during my collegiate career on a pig farm. I’m 24 years old, and my birthday is October 15th, for all of you who feel the need to send me a birthday gift. I read quite a few books, mostly non-medical lately – I’m reading The Tipping Point right now - and watch an enormous amount of television (too embarrassing an amount to mention here). I am neither at the top of my class nor at the bottom, but who really cares anyway.

As far as medical school goes, over the course of the next who-knows-how-long, I am only promising to be honest. Medical school is probably the most fascinating thing I have ever been a part of, but it’s not all pretty, it's not all happy, and it's certainly not all fun. Medical school is about a lot more than just passing tests, which anyone can do. I want to talk about what it's like to see patients, what it's like when you don’t know what you’re doing, when you think your career is over before it has started, and anything else that comes to mind.

As far as the business side of my training goes, well, it's not medicine, but then, medicine isn’t business, either. They each have their separate frustrations, but we’ll get to that at a later date.

I would be more than happy to address popular subjects within the realm of being a medical student and of course anything else. Feel free to let me know what you think.

In the meantime, welcome to my life – it’s going to be fun.