Words of wisdom...

Usually when I relay the words of a patient, it's because they made me laugh or were so ridiculously ironic in the context of the situation that most people would have become incontinent in the situation. This isn't one of those times. Suprise...another week at preceptor, another depressing medical story.

WWII veteran in his 80's, presenting to VA Oncology clinic seeking treatment for one of his many cancer related complications. For 80 something, this man has it really well together and the history is going all too smoothly. He relays in exquisite detail the past 20 years of his medical history with exact dates and physician names...better than most 40 year olds I've worked with.

Start the physical and start to get the story about his PICC line, and in the middle of his story the patient starts to lose it. He's so frustrated with the private oncology group currently administering his chemo that he cant help it. Apparently they make him pay in full before he sees the oncologist, 3-4 times per week. During a recent hospitalization, the oncologist asked to do a series of non-invasive tests that the patient assented to, and a marrow biopsy which the patient declined until he talked to his PMD about it. Not five minutes later was the oncologist back to do all of the tests and the biopsy. It's not like you can just sneak in a biopsy without the patient noticing. Anyway, the patient reminded the oncologist that he had not consented the biopsy, that he needed to call his PMD to understand why they needed the biopsy. The oncologist apparently threw a temper tantrum and stormed out of the room.

Long story short, he is VERY dissatisfied with his oncology group treating him like a piece of meat. He feels helpless when dealing with them and the fact that the doctors wouldn't listen to him makes him very unsafe and unsettled. He made sure, in his grandfatherly tone and through the tears of frustration, to tell us to always be sure to listen to our patients, to show empathy and human dignity and honesty to our patients. It was the most touched that I've ever been in dealing with a patient and I hope that his advice never is forgotten forgotten by the two of us.

Just another reminder that the white coat isn't as impenetrable as it seems.

"Ain't my job..."

One of the things that I'm quickly learning through my preceptor sessions is that there is a pervasive attitude of "it's not my problem" present in the medical community. I've seen patients bounced around between 3-5 doctors telling them different and obscenely wrong bits of information, ignoring complaints of pain and even missing completely classic presentations of their specialty's bread and butter. It seems that the oncologist is the place that people come for complete care addressing all of their symptoms. It pretty much horrifies me every week.

Case in point came today: A pleasant elderly gentleman came in for a routine oncology follow up expecting some blood work. I'm expecting a fairly simple history, a well correlated physicial and about 30 minutes of discussion about what the blood work showed. Instead we we're launched into his current symptoms of his last 18 hours of orthopnea, sleeplessness, dry cough and A Fib. Concerned that it was his third episode in 2 weeks, he presented at a local heart clinic that morning. The cardiologist got the same history that we did, listened to the heart sounds and sent this poor patient on his merry way with a slight change in his meds and an order for an ECHO later that week. Great, the guy is in congestive heart failure and a CARDIOLOGIST let him walk out the door to buy himself a trip to the ICU on a vent before the end of the week.

So we start taking the history, and by the time we get through the Chief Complaint (step 1 for those who don't know) my preceptor looks over at me and then takes control. He specifically targets every key point in the history for someone in CHF. He ends the history, looks at me, points his finger and says in his thick accent "This is a VERY CLASSICAL PRESENTATION...you'll never forget this." We start the physical: laterally displaced PMI, elevated venous pressures, rapid pulse, bilateral crackles at the lung bases, pitting pedal edema, 3/6 holosystolic murmur, essentially the textbook CHF presentation...you get the idea. The Oncologist calls the Cardiologist to tell him that his patient is in CHF, he's being admitted to get it back under control. Here's the kicker: After this whole ordeal is through, the patient asks my preceptor if the Cardiologist did a good job. My preceptors response: "Out of professional courtesy, I'm not going to comment on that."
---------

Not surprisingly, this whole event was quite unsettling for me. How could a man in the midst of acute onset congestive heart failure be allowed to leave a cardiologist's office when he is quite clearly about to buy himself a vent in the next week? How could a second year medical student elicit more pertinent points in 2 minutes of taking a history than a cardiologist? It is just plain irresponsible to let someone in this shape leave your office just because he's old and not in acute distress. If I take one thing from this whole physical diagnosis class it will be the importance of a thorough history and physical. Yes, the time crunch and meeting patient quotas are an excuse, but letting someone this sick leave your office is absolute negligence and laziness. A quick listen to the lung bases in a patient with a holosystolic murmur while your steth is in your ears still may have been a good idea? A quick "How are you?" Perhaps listening to the patient would have given you the clinical picture of someone in heart failure? I'm angry that people like this are allowed to practice medicine, but more so I'm scared of who will be taking care of the people that I care about.

I'm a real boy!!!

I just got back from a nice long weekend up in the Mountains of Vermont skiing Jay Peak, drinking heavily, and generally feeling like a real person, despite the fact that I was with a group of medical students. It's amazing how not seeing medical books for 3 days, heavily enforced drinking penalties for mentioning anything medical school related, and not having to ask new people about every crevice of their personal life in excruciating detail has helped to make my life feel balanced again...although the amount of Pharm and Path that I have to catch up on has officially become daunting and will throw me off kilter sometime probably within the next 36 hours.

Another one bites the dust: Oncology Revisited

As part of out physical diagnosis class, we are assigned to a preceptor site in order to practice our physical and history taking skills. Joy of joys, my preceptor is an Oncologist at a VA hospital. As I've already posted, oncology is not even on my list of career list, but I gots to do what I gots to do and I put on as positive a demeanor as I can muster at this point in my young medical career.
--------------------------

I walk in the door 10 minutes early, get a cup of coffee and have a quick introduction to the office staff and nurses. We've got 2 patients on the docket for the day. The first patient is cooperative, pleasant and even humerous at times in spite of his scars, his fair prognosis and his lovely home situation. His history went about as smoothly as I could have dreamed, and we were only responsible for vitals and a head and neck exam, which had several pertinent positives related to his prior surgery. His BO was just 2/5 so, I could deal. I was thinking to myself that if every patient were like this, oncology might not be so bad. We went over the history and physical quickly before the next patient and nothing but good comments.

Then the shadow of the next patient and his 6'4" son darkened the door, but not my elevated mood...yet. Patient was wheeled in the door by his son and after a cursory introduction we got down to business.

Bostonian: So, why'd you come in today?

I could tell but the look in his son's eye that he was not a happy fellow and that the proverbial . It was about as obvious as his name "PAUL" branded across his belt. He launched into a story about how they had been bounced around between 4-5 doctors, the last two without even a perscription for his father's 8/10 pain presumably related to the softball-sized necrotizing axilary mass that had been misdiagnosed twice as an abscess with clean cultures and cytology. The son wanted answers, then and now. I kept it together...

Bostonian: Since it's your first visit, the Doc and I need to get as much information as we can in your words so we don't miss anything. So any other medical problems?

Son looks at me like I have 2 heads and again son launches off on a tirade of how his father had 15 surgeries for his diabetic feet, stents for his CAD, a complicated small cell lung CA and now this on top of it all. It's all in this packet. Can we just look at my dad's lump, get something for his pain and get the hell outta here? He tossed the tome onto the desk. I looked at my preceptor for help...

*****
Now as part of my medical education, I've already had about a year of training in how to take histories and practiced them in a little pediatric office, as well as the ED this summer on a few patients. We learned a nice little outline form of questions that flows from one to the next, how to be empathic, how to extract what we need from uncooperative patients, how to deliver bad news and how to deal with our own emotions. NEVER ONCE did they attempt prepare me for dealing with a large and aggravated man who is uncooperative and afraid to hear what is going to come out of one of our mouths: that his father is dying. Another smooth day 1 experience...just like I expected.
*****

My preceptor took over at that point. Needless to say, these folks were having a tough time understanding what was going on. I sat through probably one of the most painful patient encounters I've ever witnessed that stemed from a non-native English speaker trying to distill oncology down into plain English for a patient that was not willing to listen and jumped to about 50 conclusions that were incorrect. As a medical student, I cannot actually offer medical advice nor council anyone on medical matters...just ask questions and poke at them. I have never bitten my tongue so hard in my life to keep myself out of trouble. 60 minutes later, when the patient education portion of the interview was over, the doc had managed to get the pertinent points across to the son and their case worker that would schedule everything for them, I needed another cup of coffee and some quiet time. We debreifed quickly and I left as fast as possible.

My worst nightmares of oncology came to life before my very eyes: telling someone that they have months to live, no cure for what they have, you're going to have side effects in the attempt to make the rest of your life a little bit longer, your family is going to suffer, you are going to suffer.

I have never felt so exhausted at the end of a day. When I got home, I sat down and drank a nice deep glass of whiskey in silence while staring at the wall, vented to my girlfriend for 20 minutes on the phone and watched some mindless TV. A week later when I have to write up the H&P, I can barely bring myself to do it.

What is it in me that causes the visceral discomfort of telling someone that they're going to suffer and die? Whatever it is, I don't want it to go away. It may have been one of my least fun experiences in the clinic, but I felt like a human being for the first time while wearing the white coat. The armor was chinked.

Here we go again (again)

Just started up again with classes this morning: 3 hours of pharm...which wasn't all that bad considering that have a Bachelor's in Chemistry. Hopefully it will continue to be mildly interesting for the rest of the semester so I can pull myself out of the academic P=MD quagmire I put myself in.

------------------------
On a different note, responding to a comment that I received on an earlier post ranting about medical education philosophy asking for suggestions on how to address my rants:
I honestly don't know if there is a viable way of addressing my concerns of being left to my own devices to learn the super-detailed basic sciences that will have little, if no relevance to my future career. At my institution, we're basically thrown 200 pages of outline, reading assignments and small group assignments at the begining of a semester along with a copy of Robbins. For each subject section, we're given a cursory overview of the relevant topics, a few shallow ventures into interactive learning/problem solving and an all-but comprehensive review of what we'd expect to see on microscopic/gross inspection. And then we are examined to a very detailed level that I somehow manage to never quite prepare adequately for. There is no remedy for this problem because the vast amount of exquisitely detailed knowledge we're expected to amass over a short period of time is determined by the NBME and the content of the USMLE.

I guess my personal problem is that I get bogged down in all of the details and checking off all of the learning objectives after reading them twice and don't have an accurate way of ensuring that I have adequately prepared to answer questions about the material. Unfortunately, our learning objectives are somewhat vague in comparison to the depth we're expected to prepare. I suppose that having something more than a vague list of clues as to the depth of prep needed would be helpful, as would a self assessment tool to guage where I am at. We are provided a bank of old exams, but they are in no logical order for me to organize my studying. I suppose that if there was a better resource for me to ensure that I had prepared to the proper extent for the exams that I am expected to take, I might be better able to achieve the learning goals.

For what it's worth, I think that the current system of medical education needs to be severely overhauled to incorporate an integrated knowledge of basic science and clinical information and that the Steps of the USMLE need to be done away with. But for the time being, we just have to deal

The year of the Boards

Happy 2008! Ok, so it's January 3rd, but I haven't really been in the mood/had anything to write about until today. It's hard to find something to write about when you're sleeping 10 hours a night and catching up with the family and friends that are still close to home. It's been nice but far from entertaining to read about. I feel like my time off has helped me get my head on straight again and get my life back into perspective. I finally feel balanced again, which should last all of 3 weeks, but at least I'll have that going into one of the busiest/most challenging semesters of my life thus far.

Anyway, I finally got around to ordering all of my Step 1 materials, registering for the exam and laying out a schedule (over $1000 later). Here's my current plan of attack:

• Mandatory mock board in April at school and taking a look at where I stand after that
  
• The free NBME exam the day after classes end to give me an idea of what I am weak in to guide me in my overall studying.
  
• 6 weeks of studying with 1 integrated catch-up/Qbank day per week to allow for some level of flexibility/sanity/mixing it up.
• A goal of doing 50-100 random Q-Bank questions per night with explanations to get into the groove of answering questions
• 1 timed NBME exam per week to show me where I stand (in place of the Qbank/catch up day) for the final 4 weeks leading up to the exam
• 2 days of focused review based on Qbank/NBME indicated weaknesses right before the exam

Hopefully, that will be good enough to get me a 230, but my confidence in my academic abilities has been pretty much crushed over the past semester in Path since I rode on the back side of the curve for most of the semester. I'm a SD above average in all of my small group sessions, but I'm just not testing well and I'm not exactly sure how to remedy it.

I've taken a look at how I studied for the exams thus far and it looks like I'm getting bogged down in all of the nitty-gritty details and losing sight of the big important themes. Putting off studying for way too long between exams hasn't helped either. If I stay on top of my stuff and incorporate Rapid Review/BRS/First Aid as a frame work to fill in the nit-picky details from Robbins and Cecil, I should be able to kick myself over to the other side of the curve. Between that and doing questions before the exams, I should start doing better. But only time will tell