Too much has happened in the last month... so let chat about anatomy!

(Check out the picture I took of the church sign near my parents' house over thanksgiving!)

In the last month or so, I've started anatomy (lots of cutting and pulling at flesh/fat/tissue, exposing arteries, viens, nerves and defining muscle groups...), scored the winning goal in the graduate school soccer league finals , visited my god parents in Poughkeepsie NY with my girlfriend, studied harder than I ever have in my entire life, been completely destroyed by exams, and become the next director of the Sharewood Project , a free health care organization that Tufts med students run outside of Boston once a week. Simply put, its been really really busy and I've done nothing about blogging. Oh, I also had an amazing Thanksgiving weekend with family outside of Seattle.

Since that's a lot to cover, I'll just write about anatomy for now... maybe in the next couple days I'll start getting into some other topics.

Before entering anatomy the lab (a large cold room lit by fluorescent lights with light blue cement walls covered with cabinets with bones, organs in containers, and other samples, and lined with sinks to wash up with) many people worry about the shock of seeing a dead body. That was not a factor for me. Instead, my biggest gripe is that it SMELLS. It smells like formaldehyde and whatever else dead bodies smell like... It's also juicy at certain points. Our body - the youngest one in the lab, which has roughly 40 cadavers - was a woman who died of an aggressive metastatic cancer in her 40's and she was not frail and weak. She had plenty of extra fat and tissue to be cut away. I'll say other than the smell, yellow human fat is my other least favorite aspect of the lab. Along with my other group members, I equate the fat and other tissue to food almost every time we are down in the lab, and for your sake, I will spare the details... it can seriously make eating certain foods on lab day difficult... for example smoked salmon after my first day in lab... ANYWAY... no seriously, some stuff legitimately looks like foods human consume... moving on...

The point I'm trying to get to is that at first anatomy is slightly uncomfortable for everyone on some level, but you get over it very quickly. You have to. The first day one of my group members accidentally had a piece of fat flung into his face, and some more in his hair (I imagine he showered as soon as he had the opportunity to). For the reason of getting covered in juice and tissue as well as the smell, we wear scrubs and a set of shoes that we know we can throw out at the end of the course. You also get over being uncomfortable because effectively learning the material and doing well requires spending lots of time with the bodies. We've covered the lower limb, which is the most simple part of the body, and already I must say the body is amazing and pretty complex! Who would have thunk it? There is a lot to learn!

The knowledge I gain from anatomy is incredibly relevant to health care, but more importantly, working out! During this break I've finally had the opportunity and time to work out consistently. While at the gym, I was using the rowing machines and one of my butt muscles became really sore - my gluteus maximus to be precise (its the big one on your butt). For this reason I wanted to stretch it. "How do I stretch my gluteus maximus?" I wondered to myself, which was when I remembered, "the glut max is used for hip extension and lateral rotation! Ah, just do the opposite to stretch the muscle!" So I pulled my leg up toward my chest and rotated it in. BAM! Stretched! Doctored! Awesome!

On a more professionally relevant note, anatomy is important, especially if I pursue a specialty like Emergency Medicine where I need to make rapid physical diagnoses (along with anatomy we are taking a course called physical diagnosis, the content of which corresponds to anatomy). For that reason, I'm always trying to think in terms of, "A patient walks in with this hurting, what is the diagnosis?" The great part about Tufts is that the exam questions are clinically oriented. For example, "A 24 year old med student was walking across the street and tripped while walking onto the curb causing her ankle to invert. She limps into the emergency department with complete sensation on her foot, but pain with inversion. What might she have damaged?"

Seeing as its christmas eve, I'm going to get back to hanging out with the family. We had our traditional fondue dinner:

First course: Cheese fondue with veggies and bread to dip
Second Course: a broth for cooking small pieces of chicken and steak
Third Course: a soup made from the broth with raman noodles and veggies
Fourth Course: butterscotch fondue with fruit

I hope you're having a great holiday season!

Sobriety, a dish best served in med school...

Last May, while getting my immunizations and screenings to enroll in med school, I came back with a positive PPD test - I've been exposed to tuberculosis... In case you don't know much about TB, you can wikipedia it if you want to know what it's all about (side note: I recently donated 5 dollars to wikipedia, mostly because I appreciate how almost all of my questions during 1st year of med school can be answered on the site. ANYWAY, I was exposed to Tb, mostly likely in Venezuela two years ago. After testing positive I was immediately sent to get a chest x-ray, which came back clear. Good news, for the most part - It's not an acute problem, and I can't give TB to anyone else.

Normally nothing happens after this, and the patient with latent TB is just routinely checked to make sure they dont start to develop active TB, which can be spread to others, and must be treated with a ridiculous amount of powerful antibiotics. However, I am involved in health care so it is important for my safety and the safety of others that I rid my body of this obnoxious bacteria, meaning I take 9 months of a drug called Isoniazid (you can wiki that too if you like). This is an antibiotic I take daily, along with a vitamin B supplement to limit the chance I get nasty side-effects like neuropathy.
Now that I'm taking this powerful antibiotic I have to get my liver enzymes checked every month to make sure my liver is functioning alright and not being damaged, which also means I should avoid anything that can lead to liver damage like alcohol or the active ingredient in tylenol (acetaminophen).

This littles story of mine leads me to the original inspiration to write this: As I sit in the Boston airport, ready to head back to Seattle, I really want something I can't have - a beer from the stupid airport sports bar 20 yards to my left. This is the first true craving I've had since starting my antibiotics almost a month ago. I recognize the reason for this is probably because I haven't been bored in the last month - school, constant exams, studying, cutting up cadavers, having a girlfriend, studying, studying, cooking a meal here and there... this all adds up to almost no free time and hence no real opportunity to enjoy a drink. With that I'm pretty happy that now is the time I'm doing this treatment. The only major downside is that the holidays are starting up, which means family, good food and great wine, the latter I will be abstaining from... because I don't want liver failure.

Cheers!

The Sharewood Project

Here is a link for a segment that nbc news aired on the Sharewood Project - a free clinic run by tufts med students that I've been volunteering at since I arrived this summer. Yep, a lot of people in the video are people I know pretty well. How neat is that!?!

http://www.msnbc.msn.com/id/3032619/vp/40182965#40182965

I'm no expert, and I don't get pregnant! - Medical Student Panel

Today was my first experience on a "medical student panel" for a conference that was being held at Tufts. I can remember being on the other side as an undergrad and wondering how the med students were so relaxed, settled with their life - I assumed that they must be so hard working, accomplished and at the top of their class. Now I'm on the other side of the panel, telling a group of undergrads about what I did to get to medical school, why I made the decision to take a year off of school after graduating, why I decided to take this route, how I'm adapting to life in Boston, and why I chose Tufts. I was not the top of my class, I wasn't some crazy smart kid who set the curve in my science courses, and I didn't know that I wanted to go into medicine until after entering college (I wasn't absolutely sure until my third year in school).

I have to admit, it felt pretty good to be viewed as an "expert" in the medical school application process, and it felt great to look back and realize that I've actually accomplished some pretty neat things. This is easily forgotten, with major exams every 2-3 weeks, and feeling like I'm just plugging away, constantly studying, with my head down, pushing through the hard science courses.

One of the undergrads, asked a question about family planning. She originally focussed the question on the women, but I felt that it also pertains to men, including myself (No, men don't get pregnant - I should know, I'm a medical student!). As med students, we all plan. It's no mystery to us that some specialties make it more difficult to be an active parent (surgery), and for that reason I have a couple friends who know when they want to get married, pregnant and how they will handle family life with residency. It's nuts - in the last 3 months I've had more conversations about family planning than I have in the last 3 years (I actually don't know if thats true, but it feels that way!). Whenever this question comes up I usually see myself in a specialty that allows me to be involved with my future family (whoever they end up being). That is one of the benefits to Emergency Medicine, you can work part time, set your hours, and when you leave the hospital you are not on call. That freedom, I feel, would decrease stress and allow my life to be more flexible... so we'll see if this is what I actually end up doing.

Time to put my head back down and hit the books!

(Photo is from my halloween weekend in SF - view from my friend's apartment that he recently moved out of)

Beginning to Learn from Patients

For the past couple months, I've spent thursday afternoons with 3 of my classmates to practice our interviewing skills in elderly homes and hospitals. It strikes me as absolutely amazing that we are allowed to walk into a room and ask a 66 year old woman, who is suffering from her third bout of cancer - who hasn't talked to her family about it and is awaiting a procedure - anything we want. Including why she hasn't told her family, if she is sexually active, the history of the diagnosis, is she worried or afraid?... Why are we granted that?
We are part of the club, we wear our white coat, and in a few years we will have patients of our own who rely on us... As strangers we hear a patient's deepest fears, hopes, desires, worries, we hear things that they keep from most of the world. Then, after walking into that room and sitting down to talk to the patient, we walk out, thank them for their time, and never talk to or see them again. We don't know what will happen to them, and we don't think much about it after leaving the hospital and riding the T back to wherever we are going. Sometimes it feels like we are more concerned with our "patient presentation" that we deliver to the group and resident supervising us. We stress out about our performance, making sure we include all the necessary details - the reason why they are in the hospital, their medical, surgical, familial, and social history. It's truly selfish, that the time we spend with the patient is so very much unbalanced, serving our education, while we have so little to offer. We are granted a luxury unlike anything I've ever experienced in my life.

However, through these experiences we have an amazing learning opportunity: To hear a patient's story. We may never see them again, but we will remember how they felt being on dialysis three times a week, and appreciation of a family member sitting through each 4 hour session they spent plugged into a machine to filter their blood the way their kidneys no longer can. We hear about their life, what matters to them outside the white walls of the hospital, and in these stories sometimes we get a glimpse of some of the issues we are all afraid to bring up... will they ever live a normal life again? Will they live to see this next new year? How are they coping?

I write this sitting on a plane headed to SF for the weekend, to see a few of my closest friends, to get away from the same med school crowd and to change up the pace. The constant studying, lecture, library, apartment, occasionally clinic or hospital, exercise/soccer when I have time, rarely cooking for myself... it's healthy to break that routine. On top of that, YOLO - you only live once. If it matters to you, find a way to make it happen.

What would have become of me in The City

Sitting in grand central I'm waiting to meet up with my friends for the drive back to boston. The second I get off the train I feel the pulse of the city, the way that if you pause you notice the world rushing by you, it's like being a rock in the rapids, it's calming and exciting at the same time. I wonder what life would be like had I chosen to go to nyu. Would I become a different physician, find different hobbies, make as many new friends as I have in boston, would school be more difficult or easier? What would it be like, and what would I be like. I chose tufts for the community, support, faculty and adminstration. I'm happy with my decision, but I will always wonder what would have become of me in the city.
Standing in the middle of the concourse, i hear 3 different languages at the same time. I love it.

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What I see is normal to me...

On the train headed back into the city from a weekend in poughkeepsie to visit my god parents. Along the hudson, the trees are a mix of orange, yellow, red and brown...i understand that this is why so many people love fall and the change of seasons, however I can't appreciate it. I have an x chromosome that limits the wavelengths my cones can pick up on... put another way, matching ties to shirts is a struggle for me, which is why I insist on shopping with women, who have 2 x chromosomes, and rarely are color blind for that reason. After just a few months in med school I have a stronger understanding of our genome, how and why many birth defects occur, and I've effectively become paranoid about my future children being negatively affected by the dna I may or may not know I'm carrying... Thanks genetics!
On my last exam, one of the courses I was tested on was molecular biology. On one of the questions, I was given the description of a virus im not familiar with (but I understand how the general class of virus it belongs to functions), applied concepts i learned, and essentially described how a virus can cause cancer. Yes, thats right, we learned how certain viruses can cause cancer. I imagine 10 years ago med students did not learn this... Meaning that 10 years from now students will be learning things well above what I know now. They say that the majority of the science that you learn in medical school is discovered to be no longer valid, or just completely incorrect 10 years after you graduate. Crazy to think that but also amazing that our collective medical knowledge is developing so quickly.




The girl sitting next to me is on the phone and having a personal conversation, making it tough to focus on what I'm texting, yeah I'm on my cell phone right now, how cool.
Cheers

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Trying something new... first blog from my phone.

If you want to know how soon my next exam is, ask me to tell you today's date.... the further off my response, the closer the exam. This morning i thought it was the 9th. Then I quickly corrected myself and stated that it's the 11th! proud of my amazing memory, even under times of high stress I was impressed by how quickly time has gone by in medical school.... That's when I was told that it in fact is the 16th.... as I write this, I'm on the T (subway) headed to school for another 12+ hour day of studying. Realizing that med school is probably the most time consuming and challenging thing I've ever done, I've decided to try something new. In order to keep up this blog, I'm going to attempt to write shorter and more frequent entries when I have "forced" down time, such as when I'm commuting to and from school, clinic or hospital, which means I'll probably be on the T while doing this. My idea is also an excuse to spend more time using my amazing new phone. It's all touch-screeny, light-weight, super fast and neato. :)

Time to finish up... Next stop, Tufts Medical Center.

You see some crazy stuff in the Emergency Department, and every now and then a good film on a Saturday night...

The T (subway car) smelled like hard alcohol... it was the last one of the night, which meant it was just before 1am, and filled with a lot of people leaving the bars and heading home to skip out on paying for a cab fare. I just got out of seeing the movie "Waiting for Superman," a documentary about our public school system, the impacts of teachers unions, politics, effective teaching, social issues including income levels and neighborhoods surrounding schools... and a lot more... and how this is all affecting the education of kids in our country...

It was very well done, told engaging and powerful stories, and sent many necessary messages, but it was also incredibly frustrating and sad to be reminded that education is not equal in the U.S. Not every student has access to a great education, and the repercussions of that affect all of society. I'm not going to get into the details, I want to go to bed and it's late, so instead I'll say you should definitely see this film.

This movie reminded me of why I'm here in Boston studying more often than not, and spending my weekends in the library... because like education, health care is not equally delivered in this country. Both systems are broken, and I've spent most of my adult life engaged in both of them. During the last couple days in the emergency department I've seen a toe nearly cut off by a chainsaw, metastatic lung cancer so far developed that an untrained eye like myself can immediately see it on an xray, infected hands that require multiple operations to clean out, broken bones, chest pain, heart attacks, head injuries, people without homes who drink so much they arrive unresponsive, and a lot more... This experience is amazing, thrilling to be a part of, and a privilege to learn from, but I wonder, when I become a physician, what will I be doing to change the system, to have a positive effect on the patients who don't have the resources to be treated and don't have the voice to advocate for themselves... Luckily I'm in my first year and have plenty of time to figure it all out (I need to put more worry into passing my exams before I try to save the world), but I'm still not sure how I'll do this.

In the mean time, I'll be mildly upset and frustrated that the Huskies are about to lose to Arizona... not cool.

Damn Brits...

I have a love-hate relationship with british soccer players. Today was the Tufts grad school team's first game, and we played Harvard's business school... I'd say 80 percent of their players were from the UK, something I appreciate - growing up with british soccer coaches, but I'm also not a big fan of playing against them. They tackle so tough... I walked away from the game with multiple knocks on my knees and ankles. Limeys know how to play hard, which I respect, I just hate being on the other end of the tackle. It felt good to play hard, to win and to compete on the soccer field again. Oddly enough it reminds me of why I'll never be a surgeon. What does that have to do with soccer? Good question, I'll tell you:

I've broken my hand twice. Both times playing soccer. Imagine doing seven grueling years of residency after 4 years of building up debt in medical school, breaking your hand and then losing your money makers... Not a good place to be. For that reason, I will never be a surgeon.

Now that I'm on a consistent soccer team, I'm starting to feel a little more settled in Boston. I wonder when it will become "home"... There are a few things, however, that I will never be happy about in this city...

1. Drivers/driving in Boston. The roads are a mess and regularly lack signs, but that's nothing compared to the sh*t-show caused by the way people drive. I watch accidents almost happen every day on my 3 block walk to the T station (subway). I've seen pedestrians almost get hit and watched a lot of drivers shout and flip each other off. Chill folk.

2. Boston is an awesome city, but it lacks landscape. If you've been to Seattle you understand. After moving I realize how beautiful that city is. FTW.

3. This isn't particular to boston, but the amount of damage done to my ears on a daily basis... The T is super loud. What amazes me are the people who listen to their ipods on the T... especially when its loud enough for me to hear what they are listening to... when I'm not even sitting next to them. I can't say it enough, invest in companies that make hearing aids now... you'll be able to retire quite well if you do that. Us kids is losing our hearing from all our ipods and our crazy rap music and technology!

The photo is from the Blue Scholars show I was at on Wednesday. They are an amazing hip-hop group from Seattle, and also went to UW. Fantastic.

One-year anniversary...

Exactly one year ago I met one of my current medical school classmates (who is now one of my closests friends) at my first interview, which happened to be here at Tufts. It's amazing to think of the chances, that we would end up here together and then become such close friends. I remember sitting at the table during lunch, nervous, eager, excited, stressed… basically full of emotion… talking to a current Tufts med student and listening to his experiences and take on life in medical school.

Today, exactly a year later, my friend and I are on the other side of the table…. one might say "the tide has turned," or "the winds have changed…" what I mean by that is we are back at that same table but this time eating lunch with interviewees who are asking about our experiences in medical school and our take on Tufts. A lot has changed in a year. I have an entirely new set of friends, live in a new environment, switched from the West to East coast, officially went into major debt, and have even seen patients who take my clinical advice as if I were a physician…. silly.

With our first exam behind us followed by an awesome night of dancing and partying, we are back in the mix. Starting at 8:30am the next day, we had a patient presentation on Lupus, followed by more dull science-heavy courses, and now preparing for the start of my shadowing experience in the emergency department at Tufts med. The amount of time to unplug and chill is essentially zero. During lunch with the interviewees, we were asked how med school compared to being an undergrad…. as much as I want to say its not a huge change… it really is. Imagine having a midterm in Genetics, Biochem, cell bio, and molecular bio on the same day (a 3.5 hour test), but instead of having plenty of time to study, you don't because so much is going on… clinic, other activities, soccer, seeing friends, sleep, cooking food, exercise… yep, it gets to the point where you actually factor in how much time you will spend cooking… I rarely cook anymore. It's sad.

On the note of time, I've run out of it and will have to write/blog some more stuff later. Off I go to the emergency department to get a taste of life in the fast lane!

Stick it.

The room was warm, but that wasn't why I had to wipe my forehead with my arm to keep the sweat from dripping on my patient's left arm where I was about to put a needle into her vein. In a moment like this you have to be confident, hide the fact they are the first non-medical student that you will be drawing blood from, and not doubt for a second that you will succeed... even though you can't see her vein... That's when the confidence kicks in. Relying on tactile senses, I felt for the vein, stuck the needle in, saw the flash of blood in the first chamber, and with a little bit more maneuvering (mostly putting the needle in a little deeper), we filled the test tube with dark red, minimally oxygenated, venous blood. After that, I became the first 1st-year to be certified to draw blood at the free clinic that Tufts students run. I stuck it.

You wouldn't think it, but the first couple times you put a needle into someone else is actually quite stressful. A few weeks ago, the first student to practice on me, one of my friends, was shaking so much that she had to pause and collect herself. We then talked through and reviewed the steps she would take, and after settling herself, she got back to drawing my blood. Now that I've drawn blood a handful of times, I can't stop touching my veins, or noticing when one of my friends has superficial veins. It's strange.

I wonder, what will it be like the first time I assist in a surgery, or even just place a chest tube, or drain fluid from someone... will I be feeling the same way I felt when I first drew blood? Does it get easier? Does it get more or less exciting?

As you can see, the clinic experiences are the ones that carry the most weight for most medical students. In class, we get wrapped up in details and stress about the next exam which happens to be a week from now. We will be assessed on our knowledge of a combination of the courses we are currently taking, biochem, genetics, cell bio... They'll give us 3.5 hours, and after that we'll be that much closer to four years from now when we become what the outside world considers "competent..." This material is simply not my thing, which makes it that much more frustrating that I've spent roughly 20 hours since friday studying this stuff (its monday right now). I'm looking forward to neuro and anatomy, which both come later in the year. Until then, I shall keep on studying (this was my study break).

I am now two days in to my second week of medical school. Unfortunately it is true; this process consumes your life and eliminates much of your free time. When you aren't in class, clinic or hospital, you are studying, and if you're not studying you are eating food or working out, and if you aren't doing those things, you feel guilty. As I write this I'm deciding which of the classes I have tomorrow that I'll make time to study for today, because I know I won't be able to cover them all. I'll do a quick skimming of the biochem lecture after writing this, then eat some food, then breeze through one of the cell bio lectures while riding the crowded T (metro/subway, which will be full of people leaving work and headed home) as I head to the free clinic I'm volunteering at. If there is any down time there, I'll consider reviewing some notes, but most likely end up talking with 2nd years and practicing blood draws, taking blood pressures and listening to heart and lung sounds... With that, it means that I won't go over any genetics and lack time to read for the second cell bio lecture I have tomorrow. Shucks... at least we have a 3-day weekend coming up!

Luckily, not all of school is hard science. Tuesday I work in the clinic, and Thursday we have patient interviewing. This is where I discovered that I never want to age past 30... it sounds terrible. The course gives us the opportunity to interview patients about their life, their experiences with the health care system and understand their medical history and current state of health. Many of the patients are of an elderly population, and it is simply amazing to hear all the medications they take, specialists they see, surgeries they've had, and other chronic and acute diagnoses that they've dealt with. I simply can't imagine having to keep track of all that for myself. When asked about their health, often the response is, "I feel great. I'm 83 and still staying active." Then after a few more in depth questions you come to find they recently visiting the emergency department for an injury, are taking a handful of medications for chronic illnesses, and are limited in what they are able to do in their day to day life due to surgeries or other diagnoses. It was incredibly eye opening to hear their stories and understand that its not a rarity to be so tied into the health care system as we age...
*Apparently the fastest growing population in the United States is currently that of 85+

On a much lighter note, the photo above is what I see after walking about 20 yards outside my building. It's a great way to start my day, walking to the T to go to school, a view like that can't hurt. For the sake of my sanity, I'm going to retire to study. I was told by a friend that they actually read this blog, so I promise I'll make an effort to write more entries.

Seattle is # 1

The first day of real class starts tomorrow. My first 1.5 hours of medical school will be hearing a patient's story about living with cystic fibrosis. After a week of orientation (to sum it up - going to a lecture hall, listening to Deans and instructors, then at night going out and partying... a lot... seriously, a lot.... the future doctors of America know quite well how to play hard... this week we'll see how hard we work) it will be important to have our first in-class experience not learning the biochemistry of our genes (that's at 10:30am tomorrow) but instead to hear someone's story. To hear what their life is like, and to better grasp the world through someone else's point of view. In my opinion, the ability to listen and take in someone's story is one of the most important skills and abilities that any physician can have. We are not treating a disease, but working with someone to better their health.

On an unrelated note: Seattle is number one... when it comes to best cities in the country to have a heart attack... This was something we learned when becoming CPR certified. Apparently a lot of people are CPR certified in Seattle, leading to higher survival rates when an event occurs out-of-hospital, than other cities. I was proud to hear that.

Hear is a quick run down of the first few steps of what we learned:
1. Check for responsiveness
2. Activate emergency response - send for help and get an AED (defibrillator)
3. If unresponsive open the airway - tilting head back and chin up
3. Look listen feel for breathing - If none, give 2 rescue breaths to see if airway is open (watch for chest rise)
4. Check for pulse
5. If no pulse, begin chest compressions and breathing (30 compressions to 2 breaths at 100 compressions a minute)
That's just the first couple steps, which vary depending on age and setting of the incident...

After completing the CPR training, I had the song "Staying Alive" stuck in my head because we learned that the beat of that song is roughly the pace at which you are supposed to perform chest compressions. You can also do it to the beat of "Another One Bites the Dust," which might be a bit dark for my liking... These songs are roughly 100bpm, which is the ideal pace for performing compressions.

Although we learned to include breaths while performing compressions (30 compressions : 2 breaths), we were told the guidelines will be changing to not include breaths and simply perform compressions at 100/minute. A few reasons are leading to this change: First, not many people are eager to put their mouth on the mouth of a stranger, that might mean less are willing to perform CPR. Secondly, taking breaks from performing compressions leads to less blood getting to where it needs to go. The pressure created in the heart from compressions increases as you perform them, and when you stop to give breaths the pressure drops and then takes time to build back up to an optimal level. So, instead of stopping, because a person has almost 8 minutes of oxygen reservoir in their body if compressions are continually administered, it becomes less necessary and sometimes detrimental to take breaks to give breaths.

Now, it's time to prep for lectures tomorrow. Here we go...

CPR

I'm currently taking an online course on how to perform CPR. The first half of the course we take an home, filled with reading and assessments, while the second half we perform a hands on assessment that we take at school during orientation next week.

Contrary to popular belief, slapping the patient is not listed as effective way to revive them when performing CPR... however, Ed Harris might disagree...

http://www.youtube.com/watch?v=UHkB1rJHEGA

Summer Camp and High School

Something not many people talk about when they tell you about med school is that leading up to it is just like summer camp. Then once school starts its like high school in the sense that you are stuck with the same small group of people for 4 years. The social circles are small and clicky. Every little piece of information will probably turn into gossip (watching second years talk about their classmates is all too common an occurrence). At the end of the day, I guess a lot of life is like that... in the office, a hospital, or any other workplace. As an undergrad it's easy to diversify the social groups you're a part of through clubs, sports, friends of friends, class, living situation, and so on... The trick over the next few years will be to attempt something similar to maintain balance and sanity. I imagine soccer, living with two second-year students, and maintaining friendships outside of school should do the job just fine.

I was told by a second year to watch out for a version of Stockholm's Syndrome that tends to come out during the depths of winter... Apparently in the dark gloomy months of December/January/February, after being stuck with the same people every day, we forget what the rest of the world is like, and that person working in the anatomy group next to yours suddenly seems much more attractive than they would in any other environment. For the sake of limiting the gossip and the number of potential mistakes that one might make in their first year of medical school, I'll definitely be keeping an eye out for this particular situation... But if it's anything like grey's anatomy, I guess we are all doomed to make plenty of mistakes and spend most of our waking hours gossiping about it. (I don't know why I keep referencing that show, I don't watch it)

Lastly, med students are planners. The average age of a student entering 1st year is somewhere around 24, which means that after four years of school they will be 27 or 28 and after 3 - 7 years of residency they will be in their early 30's... If a student is interested in having children, and they are single entering medical school, you can bet that there is some plan that they've thought through regarding the timing of it all. As a group we micromanage almost every aspect of our life, so its not surprising that I've already had way too many conversations with students about their personal and professional future. For better or worse, it makes sense. We're on a track, the train has left the station, and now its like "The Little Engine that Could..."

"I think I can, I think I can..."

I get more care from my auto-mechanic than from my doctor...

Yesterday was my first shadowing experience in the US. It has been nearly two years since I was in Venezuela following surgeons and a radiologist in local clinics and hospitals, so I was very excited, especially because I would be spending the day in the emergency department (ED). Some of what I saw was exactly what I was looking for, while other aspects of the day made me worry about what kind of profession I'll be getting myself into.

Just in case you were wondering... Yes, like on TV, everyone is as attractive as George Clooney and they're all having sex with each other like on grey's anatomy... just joking.

The term "shadow" gives the perfect depiction of what I did while in the emergency department (ED) as I literally followed around an attending physician, moving from a workstation with computers, to each patient's room. Although it was a slow day, with only 6 or 8 of the 27 emergency rooms housing patients at any given time, we were always moving from one place to another. I was impressed by the way the physician could think about and handle so many different cases and so much information at one time. While a 15yr old female was vomiting and nauseous from a head injury sustained from fainting in her art class, labs were being ordred for a patient experiencing multiple symptoms including fatigue, abdominal discomfort, trouble sleeping (just to name a few), at the same time, x-rays were ordered for an injury to a 78yr old patient's ankle that would definitely need suturing. I also loved the way that decisions were made... after briefly talking with a patient, a list of tests were sent out and a differential diagnosis was being formulated. Everything was quick, on your feet and no two patients were the same. The opportunity to see all types of people and symptoms, work with teams of nurses, residents, social workers and other physicians, while requiring an understanding of how to treat and diagnose nearly every system and issue in the body (not just the heart, and not just the skin, and not just the bones... but everything) was exactly what I could see myself doing in the future. However, I was thoroughly unimpressed by some of what I saw while shadowing...

Walking toward the first patient's room I noticed the hand sanitizer... then I noticed that we walked right by it. As a society we've known for many years that the hands of a physician can spread disease. Puerperal fever is a perfect example. Doctors, many of which carried bacteria on their hands, often from working with cadavers or other patients, assisted in childbirth. After this, the mother would become ill and die. Why did this happen? Because the physician's hands were disgusting and not clean. The point being, wash your hands before seeing every patient. That is one of the main reasons why so fewer women die from childbirth than before. I can understand that a doc working in EM (emergency medicine) might be rushed, but honestly, just put your hand under that dispenser for 3 seconds and you'll be set...

After a handfull of interactions with patients, I noticed that the amount of time the attending spent in the room was on average 1 - 3 minutes. Why did this happen?

Hypothesis 1: He works in EM so he is rushed to see lots of patients and needs to be quick...
Hypothesis 2: The resident and nurses have spent a prolonged amount of time with the patient, so the attending doesn't feel its necessary to do so...
Hypothesis 3: This guy is a *ick and has no sense of bedside manners
Hypothesis 4: There could be a lot of different reasons and I don't know what they are.

Any of those could be possible...

After visiting one of the patients that I mentioned before (presenting multiple symptoms including, fatigue, nausea, abdominal pain, missed period), we received her lab results concluding that she was pregnant. This was a learning moment. Apparently whenever you have a female patient, the first 3 things you assume are, 1. pregnancy, 2. pregnancy, and if the patient is not sexually active, 3. pregnancy.

So now that we had this information, I asked the attending, "Is this news that you deliver, or does the resident do it? How does this work?" I asked this in a way that insinuated the gravity of the situation. The woman had no inkling of an idea that she might be pregnant, but there she was on the hospital bed with a little bun in the oven.
The attending responded, "We can go talk to her now."

Pause for a moment and imagine you're a patient. The doctor walks in. He sits down. Tells you you're pregnant, and before you can say a full word he rattles off some random information including concerns about pain and pregnancy complications. You might be in shock, and that is O.K.
Now let's imagine you're the attending physician. You are in the emergency department. You walk in the room and deliver the information quickly. You vent your concerns about abdominal pain, because if it's in her right lower abdominal quadrant, it could be an ectopic pregnancy... not good.
Now imagine you are me, going into your first year of medical school. You watch a physician walk in to a room, without warning deliver news that the patient is pregnancy and see the reaction on their face of an unsettled surprise. You hear the brief explanation of why pain and ectopic pregnancy should be checked for and understand the patient is not getting any of this. You hear the patient state, "I feel like I'm in shock..." which results in more clinical information about abdominal pain being given by the attending physician, and you immediately feel like a piece of your hope and faith in your future career has been taken away from you. You then hear the patient ask for an STI/HIV screening, and watch the physician struggle to agree with it.... This is when you think, "What the hell just happened? Why did he not address or acknowledge her feeling of shock or ask why she felt the need to get tested for STI's/HIV when this patient was married with three children... WTF?"

In less than 3 minutes we were out of there. I couldn't believe what happened. A patient stated they felt shock and needed testing, while the attending only seemed to care about a potential ectopic pregnancy. I honestly can't imagine what that patient felt or how upset she must have been about how she was treated. There were so many questions to be asked, but really just two that NEEDED to be asked, "Why do you feel shocked? Why do you feel the need for STI/HIV testing?" After walking out of that room, all I could do was hope that one of the other health care providers followed up and asked the important questions that needed asking... or even just comforted her and listened to her story. On a day when the ED is running slowly and not crowded, can an attending physician afford to spend an extra 3 minutes with a patient and just listen? If not then I think I've completely lost my faith in this system, and I will fail as a medical doctor.

After leaving the ED, I remembered how I sometimes equate physicians to auto-mechanics for the body. We go to school to learn the ins and outs and then open up the hood, tinker around to see what's wrong, fix the problem, then close you up. After seeing the patient who is pregnant, I felt that when bringing your car in for some mechanical or electrical issue, your auto-mechanic may end up building a stronger, more trusting and comfortable relationship with you than your doctor... your doctor being the one you're supposed to share EVERYTHING with.

Today we had a chance to reflect on our shadowing experiences in our doctor/patient relationship class. From discussing my shadowing experience, the Dean leading the discussion who practices internal medicine, reminded us that we might end up seeing situations like these much more often than we like, however as medical students on rounds, we can be the ones to listen to the patient, and we can be their advocate. While shadowing we aren't allowed this opportunity, but I'm feeling a little more comfortable knowing that in the near future I will need to be the one to recognize an event like the one above and then work with the patient to ensure that they receive the best health care possible.

Yes it is late, so I'm off to bed. This weekend I'll be out partying and also taking care of a cat while one of my new friends leaves Boston for the weekend.

Buenas noches.

Acronyms

CAGE. This is one of the many, and most simple acronyms we've learned thus far. Medical school is full of them. To pass anatomy, you need to know a great deal of acronyms, when taking a patient history you use a number of different acronyms, and in almost every course we will be learning and using multiple acronyms. The amount of information stored in a short list of letters is amazing. For example, OPQRST, which is used for pain (Onset - when it started, Position - where it hurts, Quality - what does it feel like, Radiation - does it go anywhere else, Severity - scale of 1 to 10, Timing - when and how long it hurts and what makes it better or worse), can help you remember to ask all the necessary questions when creating a patient's History of Present Illness (HPI) and give you enough information to establish a Differential Diagnosis (DDx).

We were learning about mental health assessments in our class on Patient Interviewing/Physical Diagnosis when alcoholism came up. The first thing we were told was a joke:

When in med school, how do you know if a patient is an alcoholic? - They drink more than you do. Ha. Yep, we all laughed or chuckled.

Next, we learned CAGE - Cutdown, Annoyed, Guilt, Eye-opener... (C - If you've considered or tried to cutdown on drinking, A - if others are annoyed by your drinking habits, G - if you feel guilt after drinking, E - if you need a drink in the morning). If two of these criteria fit you, you might be an alcoholic. What does that mean? I almost started to laugh because I knew most of us in the room had experienced at least 3/4 of the criteria, which would lead some to think, "You must all be alcoholics... or at least functioning alcoholics!"

That is when you wonder about "criteria" for diagnoses. As a healthcare provider, It is important to have a line to draw serving as an objective baseline and reference. It is also important to use subjective judgement because it is pretty clear that the group of us in class are probably not alcoholics, even though the "criteria" says we might be. It is instances like these that are quite sobering. We remember that medicine, is not a perfect science, and it is not all about data and objectivity. It is called "a medical practice" for a reason, because like all other things related to humanity, medicine is flawed and we are always trying to improve ourselves.

Now, time to grab my laundry out of the dryer...

Hello, My name is ____ and I'm a first year medical student."

I've always wondered if physicians are ever explicitly taught how to introduce themselves to a patient... Unfortunately, I've visited a few in my life that I'd argue have never thought twice about it...

Until recently, I wasn't entirely sure how to do it. That is why, a few days back, while volunteering at the free student-run clinic, I made sure to ask the second-year med student that I was shadowing, what to say when we walked in to see the patient. Just steps outside the patient's "room" (I'll explain why I put "room" in quotes) she told me, "Don't worry, just say, 'Hello, my name is ____ and I'm a first year Medical Student."
(I put "room" in quotes because this clinic is assembled and taken down in a community church gymnasium once a week. It's put together with moveable walls no taller that 7 feet high that we velcro together. Each room has an exam table, a few chairs, and a stash of necessary supplies. Totaling about 14 rooms, it's split into the general clinic, the STI/HIV clinic, and has one room with a social worker to help patients sign up for healthcare and find other social services.)

Done. That was easy enough. First step, introduction, out of the way...

The second step: "What brings you in here today?" Time for us to hear the patient's story.

We were seeing patients in the STI/HIV clinic, so probably something related to sexual health... Her response was "pregnancy". This seemed simple enough, that is, until you ask the next question, which opens the door to sexual history, which opens the door to lifestyle, which is when you find out the concern of Hepatitis C from sharing needles. This is when we discovered the stress she has been experiencing from unemployment, lacking health insurance, and missing her period for the past two cycles. Was pregnancy really the chief concern in my eyes? Not really. She had lost 5 pounds in the last month, and had been pregnant before, but was not experiencing any of the same symptoms as last time... After 45 minutes of working with the patient, collecting samples, blood draws, and discussing her lifestyle and personal health, I felt much more comfortable in the clinical setting. I was also excited for more. The experience was eye-opening, humbling, and an amazing introduction to being on the practitioner-side of healthcare delivery.

My role was minute during that first visit. I asked a couple questions and didn't provide much to the interaction. Luckily the patient was comfortable enough to allow me to be there, to learn from her and the other med student. I realize that at this point, I'm simply taking from my experiences. I'm learning and walking away to reflect on what I did. I look forward to when I'll be able to contribute, so that it is not only the patient giving me insight into their life and beliefs, but also my chance to be a part of helping them improve their health. I remember, during the visit, looking at the second-year and thinking, "Wow, this is where I'll be in a year. I'll have a deeper knowledge of clinical work, and I'll probably have a new first-year shadowing me."

After the clinic shut down, we went out to get some food/drinks, which was when I was reminded that his next year is going to be very socially active, which is fantastic, however it will potentially be like high school because each class is roughly 200 students, something I'm not terribly excited about...

The next day I started reviewing what we've learned about patient interviewing. Awesome.

My goal now is improving my patient interviewing skills through deliberate practice:

1. Set specific goals (To improve my patient interviewing skills)
2. Obtain immediate feedback (Utilize self-reflection and other med students and clinicians to see how I did)
3. Concentrate on both technique and outcome (How did the interaction go? what skills do I perform well and what needs to improve?)

In the mean time, if you hear about/want to know about/want me to learn about a disease/illness/symptom/treatment/drug/whatever, ask me about it, not because I know the answer, but so I can use the library resources they provide us to learn about it. It's really amazing what we can access, seriously, its hella cool (I get made fun of sometimes for using hella being a West Coast term).

I have a lot more to share, but I really need to eat some food before I go to pharmacology lecture.

Wrapping up week 1

Your patient has an abnormal mammogram. You schedule a surgical follow up appointment and she doesn't go in to get a biopsy. You talk to her, and she says she'll be there at the next one, so you set it up again. She doesn't show, no follow ups. One doesn't want to assume, but worst case, it probably is cancer, so its important that the patient gets it sorted out before it gets worse. After some time you finally get ahold of her and find that she believes the medical intervention isn't necessary, that she feels healed through her church and prayer, and so she sees no need to continue with you or the surgeon...

As her doctor, what would you do in this situation?

After my second day with this program I and roughly 10 other med students were asked this question. This was an actual scenario that the Dean who was leading the discussion experienced. We shared our thoughts and avenues for working with the patient, and then she told us what she did and how she managed to work it out, see the patient get a biopsy, which lead to a successful surgery to remove the cancer.

That course started to get us thinking about the theory behind how to work with patients, but when it comes to actual skill or applicable knowledge, we know close to nothing. I don't know about pathologies, how to treat patients, or what to do when I see a patient, which is why I'm terrified for next Tuesday. A small group of us will be going to the Sharewood Clinic and most likely see patients. Talking with other students in the program, we have a limited idea of what to expect, or what we are supposed to do. Needless to say we're a bit scared (Apart from being incredibly excited. It will be our first chance to put some of the skills we learn in class into practice, and learn from other medical professionals). However, I do find comfort when realizing that this situation echoes the first time a college student mentor goes out to Seattle high schools to work with students on their college applications for the first time. You worry, wondering, what if I don't know how to help them, what if I say the wrong thing or give them bad information? Some how, even after all the pre-visit anxiety, the college student leaves feeling great and excited to go back and work with their students. I'm going to assume that this is how it will work out for me next week, because I remember, this program wants us to succeed and do well. They will support us so that the patient receives the best care possible.

If you're like me, you're watching the show Boston Med. No, none of the hospitals my school is affiliated with is on that show, they are all Harvard hospitals. 24 hours after discussing patient-doctor relationships and how to communicate, be empathetic, listen, and help the patient on their path towards better health, I watched a surgical intern on Boston Med have the sort of interaction with a patient that resembled the bickering with one of my siblings back in grade school... I'm simply amazed at how he didn't appropriately handle the situation. With an "I know what's best attitude," he did not listen, acknowledge the patient's feelings, or what the patient's daughter was saying, he started leaving the room while the patient was still talking, he was simply rude. Forget empathy, or compassion, he acted rude. It's not a mystery as to why so many frustrating stories come out of the health care system. If he manages to keep going the way he's going, he has a much higher chance of being sued. The evidence shows that professionalism and the way you treat patients is one of the strongest indicators of malpractice lawsuits. That doesn't mean professional and caring physicians don't get sued, but it means that they experience a lawsuit less often.

On an unrelated note, I have a home. I'll be out of the dorms and moving in with two second-years at the start of August. Wicked awesome. Yep, imagine me saying that in a Boston accent... I was practicing it last night out at the bars. Anyway, I lucked out, because the student I contacted about playing soccer needed a third roommate, and after playing a couple games of pick up with him and a bunch of other Bostonians, I landed the apartment.

Time to get ready to watch the consolation match for the world cup!

Cheers

It's official...

They gave me an ID badge... I can swipe it and enter into the dorms, the med school and anywhere med students are allowed. In 8 hours I'll get to show it to the security guard as I head to the start of the summer program. It's official.

This is roughly my 43rd hour in Boston, and already I've been to a 4th of July BBQ in Allston, a roof-top firework-watching party in Back Bay, a 2:30am run to Chinatown for some grub, and a drive up to a great beach in Manchester by the Sea where I picked up the start of my summer tan (bringing me closer to what I believe to be my natural skin color... something Seattle had a difficult time assisting me with). If my memory serves me right, it was also my first time swimming in the Atlantic. None of this would have been possible without already having one connection, a friend who moves back to Seattle this summer to start med school at our alma mater, UW. I am very appreciative of his time, bringing me into his circles and showing me around the city. He has already introduced me to many of his friends, some of which I expect will become my friends after he leaves. With that I feel comfortable saying that the first couple days has treated me well.

Right now, in my air conditioned dorm room (which I'm excited to move out of... I just need to find a place to move into), I'm slightly frustrated by not at all feeling sleepy (thanks to the 3 hour time difference with Seattle) and realizing that I'm going to be relying on a quick shot of adrenaline in the morning from the excitement of the program kicking off, but after that I'll simply have to push through the sleepiness and remember that the next 4 years of my life will involve much less sleep than I am used to... something I will just have to take in stride.

In the mean time I think I'll put on the Departed or Good Will Hunting, solely for the sake of practicing my Boston accent, which I only plan on using when visiting family back in Seattle... because I am obnoxious.

Cheers

This Blog...

In less than 48 hours I will be on a flight to Boston where I'll be starting four years of medical school. This blog is intended to be a collection of reflections on my experiences during that time while also serving as a way to update my parents on what's happening in my life. Much of it, I imagine, will be tied to medicine or health care, but I also anticipate occasional posts to be unrelated... What this will look like, I don't really know or care. I do care that I actively utilize this outlet for reflecting on what I consider to be a very important period of my life.

If you find reading this to be worth your time, I very much appreciate it.

Cheers

Stephen