One of the many ways med school irritates me

Medical schools really want to humanize the patients to their students. One method my school has adopted is including a photo of the patient to go with each case we get in PBL.

(PBL is problem-based learning. Each session we get a new patient case where the information is presented to us as if the patient came to see the doctor. I'm sure I'll rant talk about PBL a lot this year so you should remember this.)

I generally like the photos when they fit the description of the patient because they help me remember the patient's symptoms and their diagnosis. But many photos do not fit the description of the patient. One common problem is that the photo does not fit the description of the patient. For example, the woman in this case is 5'3" and weighs 157 lbs.

This is the photo:

http://www.flickr.com/photos/sharon_love/4154466098/

This woman does not weigh 157 lbs! Even if you're a smartass and tell me that people with large muscle mass weight more, blah blah blah, this woman does not look like a bodybuilder. She probably weighs 110 lbs.

It annoys me so much that this is such a simple thing but the school can't get it right! I'm pretty sure it's not that hard to find on flickr a photo of a woman who is 5'3" weighs closer to 157 lbs. Whoever is finding these photos is doing a terrible job of making these patient cases more realistic. This defeats the purpose of including photos!

8-year-old African American...

IT'S SICKLE CELL!

http://www.flickr.com/photos/snapeverything/4158509106/

A fellow classmate would blurt this out every time an clinical vignette featured an African-American patient. It become a joke that if there was a sick African-American man, woman, or child, that person had sickle cell disease before we even got to his or her symptoms. Every time we learn about diseases with an ethnic predisposition, sickle cell disease is always the prime example. While it is a fact that sickle cell trait and disease is more prevalent in people of African descent, it's troubling that sickle cell disease and thalassemia seem to be the only two diseases that people of African descent according to clinical vignettes we get in medical school. Caucasian patients are the default in most other clinical scenarios.

Oh every Jewish baby has Tay-Sachs.

3/3 of the depressing future: Attendings tell us about their lives

(attending: a physician who has finished all training. So actually a doctor.) 

So we've learned about how terrible Step 1 is, how terrible clerkships are, and how we've learned how terrible it is even after we're actually doctors.*

There was a panel of docs, one of whom was a doctor in his last year of orthopedics residency. They told us the following things:

"If you stand still, you will get passed over." - 5th year orthopedic surgery resident

"When I was a resident (in internal medicine) at one point all the attendings I worked with had been divorced. I'm now divorced." - pulmonologist

"I have four kids and just went through a divorce." - urogynecological surgeon

"I get home around 10pm every day and get up around 5am." - either the urogynecological surgeon or the orthopedic surgery resident, I can't remember which

"I leave work at 5:30 every day." - a radiologist. At this point all the students decided they want to be radiologists.

At the end of the panel, the career services coordinator sensed the mood of the event and had to beg the panel for encouraging closing thoughts.

*unless you're a radiologist and leave work at 5:30pm every day.

Part 2 of 3: Ethical Issues during clerkships

One of our classes this semester is ethics. The first day of ethics class was a panel that all students were required to attend. There were a few third and fourth year students who shared with us some "ethical dilemmas" they faced during their clerkships. (Clerkships are rotations. You follow around a resident (usually), wake up at ridiculous hours, and get asked questions to which you don't know the answer.)

Basically three of the four stories had this moral:
Don't say anything if you think you're resident or attending is wrong or is just acting like a jerk. 

(The last one wasn't about the attending or resident being wrong or a jerk. It was about a teenage patient who feigned pain in order to be admitted and then her boyfriend tried to sneak onto the floor during the night or something. It was weird.)

The soul-crushing future, part 1 of 3

My entire med school class has assembled for a few required class meetings and career development sessions in the past few weeks. These meetings are supposed to prepare us for the future months and years. I wish these meetings hadn't happened because I have now seen the future. It is soul-crushing. 

Part I: about 8 months into the future, I will have to take USMLE Step 1

Class meeting about USMLE Step 1: 

Step 1 is the first of a series of standardized exams all American medical school students and foreign graduates must pass in order to apply for residency. It is the only real test of two years of basic science knowledge because most med school classes have pass/fail grading. It is, with few exception, the most important part of a student's residency application.

A few third and fourth year students were pulled away from their rotations in the hospitals to share with us some of their study strategies scare the shit out of all second year students. 

These were actually said by third and fourth year students. I'm not kidding. 

Students generally take about 6-8 weeks after the end of second year classes to review for the exam. 

"I studied every day for 12 hours for 6 weeks. Once I took a break and had dinner with my parents." 

"My study break was going for a walk around campus. I would also listen to pathology lectures on my iPod." 

"Every student gives their blood, sweat, and tears for this exam. And the average score is 222. What will you have to do to get above that?" 

I have two healthy kidneys, as far as I know. How many points will that buy me? 

(Parts 2 and 3 will be about third and fourth years, and residency and practice!)

Not on my watch

In my ethics class, we talk a lot about medical interventions and dying. It's pretty well-known that many medical intervention are overused. The patient's underlying condition won't improve, the treatment will decrease the quality of life in the time the patient has left, or the treatment won't relieve pain. Patient and families often feel that medical staff push interventionso on them that they don't actually want.

I generally believe that we should try to change this culture of excess intervention, respect the patient's wishes, known when to "let go". I think many students also agree to this principle.

But I can also understand doctors and medical staff who end up intervenening more than is necessary. I think it's because we all want to avoid death even though the hospital is full of death and dying. In a recent post in "A Cartoon Guide to Becoming a Doctor" talked about how doctors want to personally avoid patient death,  "Every time I cross covered the hospital as an intern, I would pray to get through the night without harming anyone." (Cross cover is when interns receives the patients from the day team and takes care of them through the night. It's problematic because the new doc doesn't know the patients well.)

I haven't experienced the death of a patient I had responsibility for but I know that it'll be a milestone experience. It'll be something I'll remember for a long time even if my medical decisions did not cause premature death. I'm not really looking forward to it either.

Docs don't want patients to die "on their watch" so they end up prolonging dying until the next shift takes responsibility for the patient, and the next after that...

The hardest two months

I saw on the facebook of a third year student something like this:

So relieved I finished the two hardest months ever!

This was in response to finishing her first two-month rotation.

I was surprised by this because the two months before that, she studied for and took Step 1. I guess there are things more difficult than Step 1. It seems that each month in med school gets more difficult than one before.

Things I learned in my first year of med school

Tomorrow classes will start again and I will be a second year medical student. My first year of medical school was really difficult. During that time, I feel that I learned a little about myself.

The most productive place to study is a desk in a silent place. 
It's not the most pleasant place. I'm depressed and angry when I'm studying here but I actually get studying done. I still sometimes study at coffee shops but I'm ultimately doing a disservice to myself because I'm less efficient when the environment is noisy so I end up spending more time studying.

I enjoy seeing patients even when I can barely remember questions to ask or the components of a physical exam. 
Most of my patient interactions have come from volunteering at a weekend clinic for uninsured and underinsured people. Medical students are responsible for taking vitals, interviewing patients to find out the reason why they're in the clinic, their health history, and conduct a physical exam.

I can learn an enormous amount of material when I have to.
I listened to an NPR segment about children competing in a Koran memorization competition. I'm impressed by their abilities but more so by their dedication. I don't believe it requires a prodigy to memorize the Koran or to be a doctor. It requires a lot of work and time. I could memorize Robbins and Cotran's The Pathologic Basis of Disease by heart if I needed to.

I can make sacrifices for medical school.
I don't find it enjoyable to study on Friday and Saturday night but I do because that is the only way I will pass my exams. I look back on my old blog entries on my undergraduate days and at my flickr photos from when I traveled throughout Europe. That seems like a different life.

I can make time to spend time with the people who are important to me.
One of my greatest fears about medical school is that I would not have any friendships or relationships with non-medical students because I had to study all the time. This was proven by the fact that during my first semester I spent almost every night studying until about 11pm or midnight and I still found exams difficult and the material overwhelming. I didn't spend time with friends I had made during undergrad who were still in the area even though I missed their company.

But second semester showed me that it is possible to sustain meaningful relationships with people outside med school! I felt less isolated and more hopeful that I wouldn't be stuck in the medical world forever. I sometimes quit studying at 9pm so that I could spend time a couple hours with my boyfriend. That was a big decision for me even though it doesn't seem like much. I thought I was so close to failing exams during first semester that the only option was to study more during second semester.

But somehow during the second semester I had more exams -- one almost every Monday -- but spent more time with and got better grades than I did first semester. It's was very strange. I still can't figure out why but I hope that I can do that again.

Medical school is really hard but not impossible. 

med student pickup lines

An incoming freshman asked me what the nerd cave was. I didn't tell him because he'll find out soon enough. 

Heard this from my fellow student. It's a nerd cave pickup line: "The cubicle next to mine is empty. Wanna study there?"

"Research" or Glorified Microsoft Office suite operator

I'm doing research this summer. It's not any research. It's cancer research, which automatically makes people think it's important research. This means I'm getting paid by my medical school to work with a faculty mentor full time for seven weeks.

It's actually epidemiology research that's sort of related to cancer but not really. To most people, that sounds a lot less impressive than cancer research because they don't know what the hell epidemiology is about. (Wait, I don't know what epidemiology is...) It actually means that I wait around for my mentor to give me some numbers that I can make into a diagram, textbox, or table and put it in a powerpoint slide. My chief job responsibility is formatting a powerpoint slide that's to be a poster and writing the manuscript for a paper that I really don't understand.

I'll be getting a W-2 this year! This is the first paying job I've had since ... summer 2009? I had forgotten about the magic that is direct deposit.

Does anyone have experience carrying a large poster tube on the airplane? Please get in touch with me. I will have to do this in about a month's time.

The good news is that I felt a little less incompetent during my weekly meeting with my research mentor and Skype call with her collaborator, an epidemiologist at the University of South Carolina). Usually It was not because I contributed meaningfully to the discussion between my mentor and her collaborator because another (soon-to-be) second year student was there who seemed just as clueless as I was.

I've been reading a somewhat famous blogger on the med student blog circuit, Action Potential (http://apotential.wordpress.com/), who wrote about her summer research frustrations here. She's funny.

You might not believe it but I did learn how to do a complete physical exam

There's an order to conducting a physical exam. I took a class on it and passed the exam, which consisted of doing a physical exam on a classmate including memorizing the steps and performing them in the correct order.

You wouldn't know this if you had seem me at the weekend clinic where I volunteer.

What goes on in my head:
Me to patient: I'm going to conduct a physical exam on you.
OMFG WHAT'S FIRST??? OHHH I SEE EYES. OHH I SEE AN OPHTHALMOSCOPE AND OTOSCOPE ON THE WALL. WAIT. IS IT EYES FIRST OR NOSE FIRST??
Me: I'm going to look into your eyes now.
AHHH I CAN'T CLOSE MY RIGHT EYE WHILE KEEPING MY LEFT EYE OPEN...
OH SHIT. WHAT'S NEXT AFTER EYES AND EARS???

This went on until I went through the motions of enough components of the physical exam in no particular order until I thought maybe  the patient was fooled into thinking I gathered any useful information. (I didn't.)
  
When I left the exam room to report to the attending physician, I realized that I forgot to palpate lymph nodes. Oops.

Ridiculous mnemonics

Hey everyone! It's my revamped blog! I figured since medical school consumes my entire life now, I'll make this blog about medical school.

There are a lot of things to memorize in medical school so students and doctors come up with mnemonics to help remember them. However in my experience, some of them don't actually help you remember whatever it is you're supposed to remember. Furthermore, clinicians tend to publish papers introducing their mnemonic as if it's the greatest thing ever. This I find ridiculous.

HEADSSS is supposed to help pediatricians remember important questions to ask adolescents. However, all I could remember was that it was sort of like the word "head" but with some extra letters but I couldn't remember which letters, let alone what each stood for. I had to Google it when writing up this post.

HEADSSS:
H: home
E: education/employment
A: activities
D: drugs
S: sexuality
S: suicide/depression
S: safety

PPQRST has the honor of being the first ridiculous mnemonic I learned back when we were all bright-eyed first semester students. It's purpose is to help clinicians thorough assess a medical complaint. The problem is that we can't phrase the question to the patient the way the mnemonic is. We are supposed to ask questions simply and directly. Words like "palliative" and "provocative" are out so we have to remember to ask what makes the pain better and what makes it worse.

P: palliative factors
P: provocative factors
Q: quality of the pain
R: radiation
S: severity
T: temporal course
T: treatment

An internal medicine resident told me that for Step 2, PPQRST doesn't cut it because the student has to elicit a lot more specific information about the complaint. He has many more mnemonics for that. Yikes.