Impressions

Impressions are damaging. They’re mocking recreations of others’ peculiarities and speech habits. And I’ve heard more than my fair share of them in medicine.

Now, I’m not sure why the people doing these impressions are physicians, because they’re so good they could be stand-up comedians. They are pitch-perfect facsimiles and hilarious ones at that. And they’re not always negative or bad. (One resident enjoyed quoting my attending Dr. Rosenow by saying, “Rose like the flower, now like right f***ing now.”) But more often than not they’re done out of frustration or exasperation, when they’re tired and stressed, overworked and underappreciated, without any thought to the person they’re aping.

One particular impression struck a chord with me during my neurosurgery rotation. One of our patients was somewhat of a curmudgeon at baseline. He was also hard of hearing. For a few weeks he had been encephalopathic and there was not much to do for him besides daily exams during rounds and fruitlessly attempting to get him placed at a skilled nursing facility.

He had a distinct personality, preferring some residents over others. His responses to our questions of person, place, and time were oftentimes disoriented. Or they were completely unrelated statements. “Where did BETTY go?” he would shout. When I was removing staples from his scalp incision, he would periodically jerk his head and grunt nonsensical sounds. I grew fond of him as the residents grew weary and annoyed.

During down time in the resident conference room, one of the junior residents did an impression of him that was nothing more than loud grunting. The senior resident commended him, “Hey, that’s actually pretty good.” I laughed, although I wish I hadn’t. I felt embarrassed and ashamed, and found it difficult to look him in the eyes the next day on rounds. I had to step outside of my environment, where it’s okay to say and do stuff because I know I’m not being watched or judged, and assess myself. Is this the kind of thing I can stand behind if someone were to overhear me and confront me about it?

Rising from the dead

My title isn't referring to something awesome. It's more of a reference to the fact that I'm posting on here again. I looked back and found that the last time I posted anything was in August and it was a stupid youtube video that is actually a dead link now. Yay. Deleted.

I've been reading Steve's posts and every time I think that I should post something about my parallel experiences since we're both in medical school. So I've heard. (Although he has to do short writing assignments for school.) But this is generally how things go for me I guess as all of my posts seem to start with "So I haven't written in a while..."

The inherent issue with publicly writing about experiences within medical school are the obvious HIPAA, or confidentiality difficulties. We have to watch out for 'patient identifiers' but they can be pretty damn vague sometimes so in the past I've attempted to write about something wild and crazy in the hospital, but I was hesitant to post at that time because, however ridiculously unlikely, someone could figure out location, time of year, and specific problem to a specific patient. I just didn't want the potential conflict. At least I wasn't posting pictures on facebook.

Anyway, in April I finished taking my last rotation exit exam, which are called our 'shelf exams' - they're a group of standardized questions for each specialty developed by the National Board of Medical Education (NBME) and they're pretty damn hard. What this really means though is that I'm done with all of my third year rotations and now I'm starting up fourth year. It's really hard to believe that I've finished all of my core rotations and that 5 of 12 months were spent at away sites like Roanoke Memorial, Salem VA Hospital, and Shore Memorial. In no particular order:

Psychiatry (Roanoke)
Internal Medicine
Ambulatory Internal Medicine (Eastern Shore)
Family Medicine (Fairfax)
Pediatrics (Roanoke)
Pediatric rehab
Plastics
Orthopedics
General Surgery (Salem)
Hepatobiliary Surgery
Neurology
OB-Gyn
Geriatrics/Anesthesia/Emergency (kind of a weird mutant hybrid rotation)

So far for my fourth year I've taken my big Step 2 Clinical Knowledge exam, rotated through the MICU (medical ICU), hematology consult, and now I'm in Sacramento working for a month in the UC Davis Medical Center Emergency Department. It's funny that this post comes right after Steve's post about complaining about the Emergency Department because that actually was a big hesitation for me until I finally decided to pursue Emergency Medicine for my future. In short, I didn't realize that people complained about everything and that the ED was just a natural target and so I just kind of saw EM docs to be shitty doctors. Well, I didn't want to be a shitty doctor, but now I really realize that it isn't up to the specialty that I pick, but rather it's more up to me anyway. Plus I love working in the ED. I'm currently in California trying to get a foothold out here and getting my face and name recognized so that when residency match comes along, hopefully I'll land a position somewhere out here.

Anyway, future posts will be rather quick and I'll probably go back and tell some funny or engaging stories from my third year rotations, like the guy who thought he was one of the four horsemen of the apocalypse, the 650 lb lady that I was assigned to deliver her baby (how did she get pregnant?!), or 13 hour surgery that I was scrubbed into, unable to eat, piss, or bring my arms below my waist. Forget sitting down.

Bright futures, bitches! Rising from the dead! Zombie medical student! Working hard to be a zombie doctor! "I CARE ABOUT YOU!!! GARRRARGGHHH!!"

Update!

Hi friends!

It's been too long. I'm going to break Steven's iron grip on this blog and share a little piece of news. I can elaborate more on the details to you guys separately since I don't want to spill everything in this forum, but...I got offered a job in DC! I applied for it before I went off to Australia in January (oh yeah, I went to Australia) and spent the past couple months interviewing. Just got the thumbs up yesterday.

So I would've killed for this job a few months ago, but now that I actually have the offer I have to think a bit harder. Would love your advice if any of you are free!

Medical Education

Neurosurgery and pediatrics are two very different rotations, especially when it comes to teaching. At Children’s Memorial Hospital, there are two hours (8am and 12pm) reserved every day for resident teaching. There are signs at every nursing station that remind them not to page during those hours unless it is absolutely urgent. The sessions are set up for case discussions and they focus on the important, relevant points of diagnosis and management. It was set up so that I could contribute and not feel stupid (even though I never did).

On neurosurgery, there are four conferences each week that students are required to attend. Two of them are for residents only, with presentations given by either attendings or fellow students. The topics themselves can be fascinating, but they often cover very specific details that are irrelevant for students rotating through. The latest conference I attended was nothing more than an overzealous attending and a 90-minute pimping session. Even if I knew an answer, there was no way I would offer it up, because the resident who didn’t know would probably feel insulted and proceed to make the rest of my rotation miserable. The other two meetings essentially consist solely of attendings arguing over the minutiae of rare and complicated cases and their surgical plans while the residents answer pages or stare at their phones for the entire duration.

On pediatrics, this constant learning mentality extends into the resident-student interactions as well. The residents took the time out to give us lectures, review cases, and quiz us. If anything, they were afraid that they were spending too much time teaching us. The first day on my inpatient infectious diseases service, the chief resident took me and my teammate aside, told us how the computers worked and where to find important information, printed out flow sheets for us to use, gave us advice on how to present, explained the team dynamics and roles, and made us feel welcome.

On my neurosurgery block, I blundered around my first day feeling ignored. No one seemed to care that I was there until I got in their way. After following them around on rounds not really knowing what was going on, I found a friendly face to scrub in with. By the end of the day, I had no idea what my roles or responsibilities were, how I could help out, or what kind of information I was supposed to learn from my rotation. It wasn’t until the end of my first week that I started feeling comfortable and part of the team.

It’s no mystery that I feel like pediatrics got it right and neurosurgery got it wrong. There is an inherent problem with how “teaching” occurs in neurosurgery. Everyone is always expected to know everything about neurosurgery before the rotation begins or even before their residency begins (except maybe the finer details of management, which you can argue about once you’re an attending). If you don’t know the answer, you feel embarrassed and study furiously after you get home from working for 14 hours. There really is no teaching; there are only unrealistically high expectations. As I was watching the train wreck that was one resident’s attempt at a logical answer to a question, I couldn’t help but think to myself how much more effective it would have been if they had just taught it first.

The Religion of Medicine

Spirituality is a nebulous term and I’m not sure I think of it the same way everybody else does. If it’s the same as faith, how does it differ from religion? If it’s just a set of values or a belief system, how does it differ from culture? Like religion, I think of medicine as a faith system instead of a factbook. Every time we prescribe a medication or send a slide to pathology we are secretly hoping and praying that we are in the 95% confidence interval. We use p-values and percentages to reassure ourselves that we know what we’re doing despite the inherent uncertainty of the scientific method. And if all else fails we can always seek comfort in describing a presentation as atypical.

But our patients often expect us to have the answers. We live in a world that highly values the tenets of science and technology; we live in a world that places empiric data and experimental reproducibility on a pedestal. Patients want the definitive diagnosis. We search for the pathognomonic feature believing that if we find it, we cannot be wrong. It didn’t surprise me to find a mother throwing stimulant drugs at her 4-year-old misbehaving son for a criteria-based diagnosis of ADHD, but it was quite a shock to find a patient who accepted the response, “We just don’t know.” But we practice medicine with the faith that we are doing our best, and there are times when our beliefs butts heads with other religions.

I come from a Christian household and a Chinese heritage. I think it is Asian culture that has convinced my mom that herbs are good and synthetic medications are bad. She views the body as a tumultuous entity constantly fighting to balance positive and negative chi. Disease occurs when one side wins out. She believes that, instead of restoring that balance, most drugs disrupt it further and cause side effects. But I think it is religion that has convinced her that, if she were diagnosed with a terminal disease, she would refuse life-prolonging non-curative therapy. She feels she has led a full and complete life, and she will be ready to die if and when God makes it clear that it is her time to go. Unfortunately, hypothetical situations can only reveal how we think, not how we act. I tried to take it out of the theoretical realm to find out what she would really do. Would she really refuse chemotherapy to prolong a prognosis from 1 year to 10 years so that she could see her son graduate medical school, get married, and have children? She didn’t answer, but her silence was a far more illuminating response. She didn’t know.

As far as religion goes, I have yet to encounter one of the “classic” confrontations between religion and medicine on my rotations. I haven’t seen any Jehovah’s Witnesses hemorrhage out and refuse blood. I haven’t seen any devout Christian family refuse to take a permanently unconscious family member off life support. What I have seen is a great many people confused about the role of medicine, searching for its place in their lives. I am always humbled when our patients realize that medicine is as much a faith as their religion is, but even more so when they believe in its power to help as strongly as I do.

My Hippocratic Oath

On admission as a member of the medical profession, I solemnly pledge:

• To keep the health of my patient as my first priority, understanding that treating the disease is not the same as healing the patient;
• To treat patients with dignity and respect, regardless of their social group or status, and keep in confidence their private histories;
• To work collaboratively with other medical professionals, community and religious leaders, and family members and friends;
• To commit myself to lifelong learning and recognize when I become unable to care for patients due to personal handicap;
• To encourage healthy behavior within communities, remembering that preventing disease is preferable to curing it;
• To maintain my own physical, emotional, and spiritual health so that I am able to effectively serve my patients.

 

JUSTIFICATION:

My intent with this pledge is to address the patient first. The biopsychosocial model of health teaches us that patients are more than pathologic processes. I address this fact in the first line and again in the third line, as it pertains to collaboration with other important people in the patients’ lives. The second line addresses the importance of the patient’s trust in the doctor. They must feel accepted regardless of age, sex, race, or religion and must feel comfortable revealing private facts that are necessary for us to diagnose and treat the disease. In the fourth line I discuss the fact that medical knowledge is not static, but constantly growing and changing. In order to be effective physicians, we need to keep up with this expansion. We also must be aware of our physical, emotional, and intellectual limits so we do not hurt our patients. In the fifth and sixth lines, I wanted to step back and remind everyone of a duty to our community health and a duty to our own health, which seems neglected in many similar oaths.

I removed some of the lines in the Declaration of Geneva because they seemed self-evident or common to all professions (e.g., treat colleagues as siblings, respect teachers, practice with conscience) and not unique to the medical profession.

Stress

I started third year on triple block. On psych consult I worked 8am-6pm and on inpatient psych I worked 8:30am-3pm. On primary care I worked 10am-4pm three days per week, I went to lecture once a week with similar hours, and had three-day weekends. Neurology was the most time-consuming of the three, starting at 7:30am and ending around 4pm. I had plenty of time after I got home to study, hang out, and watch movies. Third year seemed manageable. But after triple block I started ob/gyn.

Most days this past month I have woken up at 5am and have gotten home around 7pm. Occasionally I would leave before 6pm and consider it a good day. On one lucky day I got to leave at 5pm. I relished the days we had 8 hours of straight lecture (including a lunch lecture) because it meant that I could go home at 5pm and study. Unfortunately, the lecture days weren’t quite the godsend I’ve made them out to be: even though the lectures started at 9am, I had to round on my post-op patients at 5:30am, write notes on them by 6:15am, and attend M&M conference at 7am followed by grand rounds at 8am. I also had to work a Sunday shift, meaning I only had Saturday to relax and recharge (i.e., study) followed by six more grueling days of work.

When I got home at 7pm, I would eat dinner and read up on the next day’s cases (the patient’s history, the disease process, the surgical procedure, and the relevant anatomy). I tried to get 6 hours of sleep each night, but it was never enough. As the clerkship went on, I found myself too tired to keep up with my studying. I would literally fall asleep at my desk with my head bent over my book. Before ob/gyn I thought people were just exaggerating when they said stuff like that.

For me, the most stressful part of medical school is how constant and unrelenting the workload is. I no longer have time to be the good boyfriend, the good listener, or the good son. I no longer have time to make my own breakfast or lunch. I no longer have time to exercise (no, speed-walking and retracting don’t count). I no longer have the time to enjoy my life in the carefree manner I used to. Every decision I make to take a break by watching TV or meeting up for dinner directly impacts the time I have to study and how well I do in the rotation. But that is precisely what I need to do to ensure my mental and spiritual wellbeing. I simply have to accept the fact that I cannot be the best medical student I can be while simultaneously being the best person I can be.

It’s not the amount of information we need to learn that is so overwhelming, although that certainly contributes. It’s not the fact that we’re being thrown from team to team every 2 weeks as soon as we start to feel comfortable with and confident in our fund of knowledge, interviewing efficiency, and clinical reasoning. It’s not the uncertainty we feel from learning every new attending’s special way of doing things. It’s not the isolation we experience from never seeing our friends unless they’re on the same rotation. It’s the fact that we have to do all of this while working 60+ hours each week, with fewer and fewer days to catch our breath and re-evaluate and reassess our situation. It’s the fact that we’re on an unyielding, terrifyingly fast treadmill without the safety cord to stop it if we falter or fall off. At some point, we all need to take our feet off the machine and rest for a little while. And we need to take control of the treadmill instead of letting it control us.