The Differential: Medscape Med Students Blogs

Accepting Help

Thomas Robey -- Taking care of patients is hard work. Medical students are expected to collect loads of data from patients, send the right labs, order the correct studies, review all of the information to decide on a differential diagnosis, and refine it all into a 3-minute speech, on which entire grades may be decided. Wow! But learning medicine is not just about patient care. On top of learning the facts of medicine, we students have to figure out the lay of the land in new hospitals, new cities, and new departments every 4-8 weeks. In the hierarchical structure of academics, students must be careful not to step on anyone’s toes, presume too much or scoop others’ roles. All the while, we must keep smiling, connect with patients, and bring in baked treats for the call team. Antacids anyone?

In the midst of the stressful condition known as medical school, there are still, small voices that can help you through your day. It took me a while to listen to, or even hear them at all. If you can tune them in, you’ll be surprised how much easier your time will be on the wards, in the operating room or out in the clinic. Here are some that I listen for:

“Would you like to...?” --> This is code from the nurse that, “usually in this situation we do this and I’m ready to do it, why don’t you write an order.”

The instrument cue --> If the scrub tech hands you an instrument in the operating room, take it. She’s worked with the surgeon for years and can anticipate his actions better than you can. If you don’t know what to use it for, pay better attention to the field.

“Could you please get me the...?” --> No matter who asks this, the answer should always be yes. You may think it is scut work to get the warm blanket or the line cart, but you are saving the team time –- time that can be used to teach you how to put in that central line.

“Have you seen a <insert medical condition here> before?” --> This is sometimes tough to respond to. If the answer is a firm yes, you’ll be able (and expected) to show off what you know to an attending or resident. Other times the answer is a soft yes –- you don’t really know the topic very well. In that case, your superior may be willing to provide a little teaching. The best answer is “I know about <the one thing you know about the condition>, but could you help me understand this patient’s situation?” Or, if you haven’t seen the disease, just say no and expect to get some teaching. Pay attention though, because you will be expected to shine when you see the next patient with that problem.

My experience has been that most people in academic medicine want to teach. If they have time, nurses, techs, attendings and residents are happy to have willing learners. Be on the lookout for these folks and their coded offers of help.

Seekers

Thomas Robey -- Anyone who watches television has heard of drug seekers. From “House” to the news, examples abound of prescription pain killer abuse. Who hasn’t heard of the high profile pundits and Hollywood "who's whos" getting into trouble because of addiction? I have to wonder if these interest stories are painting an accurate picture of drug use and abuse. Something tells me there’s something more to the story. The drug and research minded blogger DrugMonkey brought to my attention an interactive map detailing trends in pain killer consumption in America. And while it’s hard to gather whether this map correlates best to street use, addiction or even just prescribing habits, total use is clearly on the rise. Thanks to media coverage of pain-killer use, it’s plausible to look at this map and think only about the white-collar narcotic users.

Other people abuse prescription pain meds. For me, these are the wrenching cases. If I follow a career working as an ER doc in a public hospital, I’ll be a seeker myself -– a seeker of patches for a broken heart. It’s only been a week and I’m already trying to suture in my first.

Back when I was entrenched in a life of cell culture, pipettes and animal colonies, my weekly dose of medicine was as a volunteer STD counselor at a free medical clinic for homeless teens. My job was to be an information portal. I helped kids live safer, told them if they had gonorrhea or that they were HIV negative (thankfully, all my consults gave this result), and could point them in the direction of other community resources. Many of these kids used illegal substances. Harm reduction and motivational interviewing were my modi operandi. I wasn’t connected with prescription or other medical issues, and I certainly was not involved with pain control -– as a matter of policy the clinic never distributed or wrote scripts for narcotic pain meds.

The outcomes of this volunteer experience were:

* I now love working with homeless young people.

* I can talk with kids about sex and drugs.

* I feel like I understand a little more than the average bear about the complexities of homelessness, especially in the teen and young adult population.

It’s this last point that has already gotten me into trouble. Now that I’m working in a county hospital ER, I’m encountering these same kids (even the same individuals) in an entirely different capacity. No longer am I simply an information portal; I’m responsible for their health. Previously, I could aspire to be a friend so that the information was more relevant to them. “Friend” drops much lower on the physician’s priority list, especially when the patient is aiming to take advantage of a perceived friendship for gains in conflict with their own good health.

An opiate addict will pursue any opportunity to acquire substance to sate his craving. This includes finding friendly doctors. Helping the medical student find a vein for an IV makes the student feel good, and improves the chances of receiving IV pain meds. Walking in the door wearing a cervical spine collar (even if it is medically indicated) may help the doctor sympathetically overlook a not-so-distant history of polysubstance abuse. In this setting, it’s not good enough to try to be friends with the patient. Can you trust an addict with pain meds? I don’t think so. Addiction removes the capacity for trust. There’s always something more important to an addict: the addiction. That’s why I reminded the attending of my patient’s recent heroin and cocaine use before he prescribed oxycodone. After my shift (and after his discharge from the ER), I noticed that my patient’s 3/5 strength (can’t move against gravity) during my exam had changed to full capacity. As I watched him pick up a bag and step onto a bus, my feeling of vindication quickly was at war with guilt for not deciphering the patient well enough to offer some sort of medical or social help.

But does this mean that providers need to erect walls around caring for addicted patients? Personally, I think walls and policies would cause me to limit the amount I care for my patients, thereby limiting the quality of their care. My goal is to get it in my head that being a bad guy to them is as helpful to their health as sating their needs. I think it’s going to be tough -– even tougher when I’m the one signing prescriptions.

This entry is dedicated to Mavis Bonnar, an advocate for homeless teens for the better part of three decades.

Mistakes in Medical School

Thomas Robey -- How many times in medical school have you thought, “Wait a minute, was that right?” Sometimes we students question statements made from classroom podiums. Other times it’s a policy made by school administration. Maybe a classmate’s behavior raises concern. The further along I get in my medical education, the more I notice myself asking that question of my own clinical decisions.

My first week in the county hospital’s emergency room has prompted a spike in moments of post facto doubt that I did the right thing for a patient. Addressing mistakes in medicine is an important skill –- and it’s one that I feel I am not yet prepared for. All I know now is that I’m painfully aware of both the potential for and reality of medical mistakes.

As far as I can gather, this sort of introspection occurs when providers take on new and increased responsibility, are in the process of learning from experiences, and find themselves in a new environment. For me, the longish transits to and from work permit additional opportunities for reflection.

Students on my emergency medicine clerkship are given responsibility unrivaled by any other rotation in our training. We are expected to carry 3-5 charts at a time and take initiative for patients’ care from the moment they are put in a bed until their discharge or admission. There are caveats, of course. This doesn’t apply to trauma patients: students participate in care, but certainly do not call the shots! Also, attending physicians chart a complete note in addition to the student’s record, must co-sign orders and expect to receive regular updates. But the basic decisions are the student’s to make. Due to the busy nature of the ER, and the throughput, a faulty action may not be realized until the patient is out the door.

Take for example the injection drug user I cared for this week. She came in with a deep deltoid abscess in her shoulder. Why so deep? She had run out of veins so was now muscling heroin. I did a thorough exam of her lesion, determined there was no subcutaneous gas and used ultrasound imaging to identify the depth and size of the abscess. I was able to get a little bit of blood for labs and found her white count was 14,000 but her sodium level was normal. (Potentially systemic infection, but probably not necrotizing fasciitis.) Knowing that muscle abscesses cannot be drained in the ER, I referred her to the general surgery service. I was caught up on the logistics of her transfer; for example, no one could get satisfactory venous access, even with ultrasound guidance. I didn’t realize until after she was admitted to the operating room that I’d not listened closely to her heart. Yes, cellulitis can kill people, but the more fatal consequence of IV drug use is endocarditis and septic emboli to the brain. I was so caught up in doing the right thing for her wound that I lost track of the big picture.

It’s a good thing that my attending listened to her heart, and the anesthesiologist, and surgeons and... but in the end I am left with the truth that I let her down. I suppose that’s why experiential learning works. You can bet on my listening to every injection drug user’s heart from this point forward.

Don't Get Sick in July

Thomas Robey -- There's a proverb often spoken around academic medical centers this time of year: "Don't get sick in July."

Why? July is when the medical new year occurs. It's when interns appear on the scene. Young attendings often take their first jobs at this time. Chief residents are getting used to their new digs. Third year students are deer in the headlights; fourth years feel invincible. At every rung of the medical hierarchy, there's a new guy. The surgery R2 is running her first trauma code in the ER. The senior resident all of a sudden has 2-5 other people reporting to him. There's new paperwork, there are hundreds of new phone numbers –- even new sleep schedules. Not to mention the responsibility.

The theory behind the July warning is that with the guard changing, also goes the skill of care. More mistakes are made, diagnosis takes longer, healthcare is a little less... careful. Last year, as one of the deer-in-the-headlights students, I bought into this idea: I told family to stay away from procedures in July.

But things have changed. I think there's another story here.

That R2 leading the trauma code? She just helped teach the interns the ATLS course, she participated in 200 codes last year, she even practiced barking orders to her dog last month to develop that voice of confidence. Sure, she's scared... but she read the manual 23 times. She's terrified of making a mistake, but that fear heightens her observational skill, and polishes her decision-making process.

And the new senior resident on the ward team? Last year he worked under nine different R2s and R3s. He's been making mental notes. "I like how Dr. Schroff involved the medical students in care." "Dr. Wright had an efficient system of collecting information for discharge summaries." "Dr. Miller was intolerable on rounds because of her endless questions (but they helped in the team room)." This new senior may not have his system quite in place, but he makes up for it with his freshness and enthusiasm.

And what about the deer-in-the-headlights category? (Interns and third year students: that's you!) It will take longer to make the diagnosis, you will carry fewer patients, and you will get things wrong. After I realized as an M3 that the work gets done without me there, it helped me fit into the team better. The intern had already figured out what to write and sometimes took care of it before I could come up with a differential or treatment plan, and that was for the good of the patient. Early on, you hope for an intern who helps you figure it out with her; you won't learn by being told the answer! Likewise, every intern has that superstar of a senior backing her up. Even higher on the rung is the attentive attending. In times of transition, the medical hierarchy pays off.

So is it safe to be a patient in an academic medical center in July? I think it's safer than in June... I'd rather have a little extra adrenaline pumping through my team's blood than the residue of burnout and the debris of casual care.

Seasons of Med

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

Happy New Year!

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

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

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

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

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

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

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

Credit and apologies to Jonathan Larson

Personal Statement or BUST!

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

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

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

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

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

CONTENT

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

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

* How your skills match those valued by your specialty.

* Coursework that shaped your specialty decision.

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

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

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

STYLE

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

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

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

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

PRESENTATION

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

2. Support your opinions with experiences.

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

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

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

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

What's That Smell?

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

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

1.    Ketohalitosis (fruity breath)

2.    Pungent Urine (usually dried into clothes)

3.    Feculent Abdomen

4.    Anaerobic Abscess

5.    Operating Room Flatus

6.    Bromodrosis (smelly feet)

7.    Ichthiosmia (the fishy smell of bacterial vaginosis)

8.    Post-Op Diarrhea

9.    Halitosis (applies to some attendings)

10.   Vomit (ideally, not on your scrubs)

11.   Bromhidrosis (body odor)

12.   The Smell of Labor

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

Recycle This Entry

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

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

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

* recyclable cardboard glove boxes in the trash

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

* no beverage container recycling

* disposable sterile or contact precaution gowns

* no white paper recycling

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

* shredded patient information sent to the regular waste stream

* plastic water bottles at every conference

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

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

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

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

Pros and Cons of the Away Rotation

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

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

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

In favor of away clerkships are the following:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Laughter in Medicine

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

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

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

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

I almost cried.