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