Lack of blogging motivation

So I've kind of been out of ideas for writing lately, and for that I apologize to anyone who still regularly checks in. I've been running away from school for the past two weekends since my renal path exam and the rest of my free time is being eaten up by a stupid group project.

I'm not quite sure why as a 24 year old medical student I'm still assigned group work. Honestly, I am quite capable of working with a group to complete an assignment as well as doing it independently. I think that group science report that I did in elementary school proved that skill set. But here I am again, trying to coordinate 7 other classmates to create a paper that will live up to the nit-picky expectations of the course director. I've realized that I naturally gravitate to these types of positions where I take on the burden of getting a group of people to pull in the same direction, and usually I do ok with them. Hopefully, we can get a decent grade out of this project for all of us, I've certainly done my share. Especially with rewriting the sections assigned to the the one member of the group that struggles to write a coherent paragraph. I figured the 5 non-native english speakers would be the dead weight in the writing department, but they actually write quite well...it was one of the two native speakers that gave me trouble...figures.
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So I got out to my favorite spot on earth this afternoon again: Fenway Park.

There's just something about the hustle and bustle around the ball park that makes me feel invigorated. Once I'm through the ticket gates, I like to immediately descend from the overly comercialized and family friendly Yawkey Way into the dimly bowels of the stadium that has stood there, almost unchanged since 1912. It almost feels like I'm traveling back in time amidst the smokey aroma of sausage on the grill and the white noise of 37,000 people vibrating through the concrete structure. Each descent brings back floods of memories of dozens of visits before, all rushing back at once. It's similar to what I imagine seeing your life flash before your eyes is like, but you can do it whenever you like for the price of admission. There's the usual, comfortable ritual of procuring the correct overpriced mass produced American lager for my dad in appreciation for the tickets he preennially provides, of walking down the ramp past the same souvenir vendor that's always there with the same old overpriced stuff, past the nacho/pretzel and hot dog/sausage, Papa Gino's, Beer/Peanut and Ice cream stands (yes, in that exact order). Waving to the same beer guy that's always there with some clever remark while he happily pours his brews in the corner by the entrance up to our section. It's a ritual that always feels familiar and yet always exciting and new...like nothing else I've ever experienced. If you've been to Fenway and sat on the third base side of the stadium, you probably know what I mean...it's the least renovated portion of the ball park and instead of feeling like a dump, which is what I'm sure many people would think, it feels like I'm walking back into an earlier time where nothing else matters except for enjoying the home team playing the classic american game.

For me, the real magic begins as soon as I emerge from the musty underbelly of the beast into the light and fresh air and echoing sounds of the park. I like to look up at the skyline over the right field wall and scan the outfield and just take a few seconds to absorb the atmosphere, and it instantly takes me back to the first few times that I visited the stadium back in the 80's and sat on my dad's lap and ate cotton candy and watched Wade Boggs (one of my favorite childhood players) play his heart out at third base and be the RBI machine that he was. It's a great feeling. The world could be collapsing around me (as it indeed it often seems to be these days), but I wouldn't really care if I had my butt in one of those cramped old seats. It really is a special place for me and holds hundreds of amazing memories that make me feel at peace and at home.

It's quite a stark and welcome contrast to my other life in New York, where I constantly feel out of place and like something is looming over me waiting to rend my soul to it's very roots. I wish I could better express what it is that I feel in words, but it's one of those intangibles that just nags at the periphery of my consciousness. Like when you walk into a room and absolutely know that something is out of place but you're not even sure what it is or why you have that feeling, but it's there nonetheless. I guess that I just don't feel at home there in NY and it adversely affects everything I do and weighs me down. I guess that strikes at the heart of the reason that I started writing this blog in the first place...to get over that feeling of living in a place that I will never be comfortable enough to call home.

I've come to realize over the past two years that discomfort is the place where I have to learn to be comfortable through many experiences (see "Notes from the Vagina"). However, making that leap from conceptualization to actualization is more difficult than it appears on the surface.

So that's a little bit about where I'm coming from in my life at this point, and it only took 3 overpriced, mass produced American lagers at my favorite place on earth to bring it out...hopefully I'll have something less touchy-feely to write about next time, but here's where my flow of consciousness went tonight.

Peace out girl scout...

Clinical Competence

We arrived at the Morchand Center For Clinical Competence at about 11 am and had a nice little introduction of how the exam will run. The basic rules are that you get an hour to elicit a full H&P from an actor in 1 hour. Every move and every word are recorded on videotape for your school and you have 15 minutes of review/critique at the end. Three sections on the grading- History, Physical and Patient Interaction. The administrator kept calling it "an experience". Oh and was it ever.

There is a big cloud of mystery that hangs over the Morchand center at my school. Mostly it is talked about with a tone anxiety and whispered rumor. I've heard stories of people failing for pretending to give immunizations, I've heard of people failing for not taking it serious enough, I've heard of people completely freezing and forgetting large chunks of the history...there's a lot of rumors. My roomate got reamed for being "excessively happy and not respecting the patient" the day before I went. Not exactly the comforting aura of puppy dogs and rainbows like you'd expect.

Having done one full H&P on my own, and briefly practicing over the past few days, I was somewhat worried about the physical. I knew that I was solid on the history and patient interaction, but I haven't quite gotten the complete physical synthesized to the point where it flows. I had planned to spend about 2o minutes with the complete medical history and then move to the physical for the remainder, and I hit around 25 minutes...not too bad. What killed me was the neuro exam. It's so long, and my oncologist preceptor kept telling us that we didn't need to know the complete neuro exam no matter how much we asked to go over/practice it. Guess what Doc...we needed it. So I didn't finish my neuro exam or get a chance to wrap up the session...but the rest of everything went fine.

My patient was actually quite friendly and cooperative with me, and even managed to joke around with me despite having unstable angina. I was somewhat unsettled when I went over to the sink to wash my hands ended up staring directly into a camera mounted on the wall. I made sure to give the camera guy a little wink, so maybe that will show up on my eval. The most interesting part of the feedback came from the patient who told me what it was like to be my patient...and it was all pretty positive. I guess those empathy classes worked.

Overall I think it boosted my confidence in communication and showed me what I have to work on in the physical: PRACTICING!

Work out wagon

The combination of my pathology class, every patient that I've seen with diabetes thus far and a few of the MI's I saw over the summer have prompted me to get back on the workout wagon. Oh yeah, and the indignity of pannus retraction that I've seen on a few occasions. I fell off that wagon about 6 weeks into first year with the advent of "oh-crap-I-have-to-study" as one of the dominant emotions in my life. I've done some on and off running since then, but I've been feeling increasingly like crap, not had the energy to get out of bed, put on some apple shaped weight and generally become less than the healthy person that I once was. Seeing fatty streaks, atherosclerosis and ruptured plaques was pretty much like when I watched "Scared Straight" 20 years later back in the day...3 months later and I'm finally getting off my arse to do something about it.

The last time I self-coached myself through a half-marathon, I ended up needing 3 months of PT and a year of rest before I could run without pain. So, I bought myself a nifty heart rate monitor (Suunto t4) that has an interesting physiologically based training effect measurement that it uses to schedule in workouts and emphasizes not over training. Anyway, I'll occasionally be posting about running/working out with this infernal machine strapped to me as catharsis from time to time, so bear with my lameness. I'll probably put it away come time for my surgery rotation (I mean lose the majority of my rights as a human being) anyway.

Autopsy

My phone rang at 9:02 AM and pulled me from my 4th snooze cycle of the morning. Guess what, it was my group's turn to observe an autopsy...at 10:30 AM. So we gathered our group up and trudged through the frigid NY morning to the ME's office. After a very brief history of what had happened and what we were expected to record and write up, we entered the morgue...the other worldly place that you see on CSI or Law and Order.

Now being a second year medical student, you're not really used to seeing naked dead people on a slab. You're not used to the smells of a dead body. You've maybe seen a handful of patients, most of them semi-clad and in pretty good shape, all things considered. Sure you saw your cadaver in anatomy and hacked it to bits over the course of 4 months, but that guy was drained of bodily fluids and smelled pleasantly of fixitive and fabric softener (we used a mix of Downy and water to keep things moist). However, this was a living, breathing human being not more than 8 hours ago, and now he's D-E-A-D in front of you, on a slab, still kind of warmish. It was kind of an eerie feeling to be standing there looking at a complete stranger dead in front of you. You almost feel that you should be mourning the passing of this poor soul, or comforting a family member. But it's just you, the dead body and some creepy guy holding a HUGE scalpel.

So you take it all in stride and begin looking at the outward appearance of the body. Standard things like height, weight, eye color, pupil diameter, scars/identifying marks, lividity, just a general survey of what's going on with him. Then that creepy dude in a surgical gown and face shield comes in an makes the standard Y-shaped incision in about 2 seconds. He then dissects the layers of flesh and muscle from the rib cage so he can make a merciless series of cuts through the ribs and clavicles with his little reciprocating bone saw, being sure to shred the subclavian vessels thereby pouring about 2 pints of blood into the now open body cavity. Seeing this can make even the manliest of men feel queasy and I watched one of my group members run out the door to get some fresh air. Blood has never bothered me too much, and my first cup of coffee had put me in a good place gastrically so I just stood there about 2 feet from the body taking notes. Elapsed time: 5 minutes.

Once the chest cavity is opened, the tech goes about systematically removing each organ piece by piece, recording the weight of every organ. Then, one by one, the organs are dissected by the pathologist and sliced serially to see if there is any pathology happening. Every detail is carefully organized, noted and dictated. It's a tedious process, but a necessary one when you have no prior medical history to go on and are essentially screening for EVERYTHING that could possibly go wrong with a person who suddenly dropped dead in front of their family. I actually saw that it is possible to access every bodily cavity with a strong arm and a 16-gauge needle...I was floored. Samples of every bodily fluid imaginable are sent for analysis and toxicology. Several tissues are also sent for toxicology.

Total time to completely turn a body inside out and look at every organ thoroughly: 90 minutes. It was basically anatomy on speed, with a whole lot more gore and stench. If you think that you learned a little too much about your cadaver in Anatomy lab, I can tell you what my autopsy patient had for dinner a few hours before he died (rice and black beans). I highly recommend that everyone see an autopsy at least once in their medical training as it will give you a perspective on pathology that you've never experienced before. It will also make you think that being a pathologist might be cool for about 30 seconds. But then you get a whiff of the contents of the small intestines and you realize that you really don't want to eat very much for the rest of the day.

Forgetting Learned Helplessness

Behavioral scientists developed an animal model for depression. The model works on the premise that if you repeatedly expose an animal to a noxious stimulus that it can not escape from, the animal will become desensitized to the pain and basically become depressed. Usually it's performed with rats on an electrified grid. It is called the "Learned Helplessness" model. Many medical school professors have deemed it necessary to move these experiments into human trials...more specifically, they're trying their methods on us, the medical students.

This is my informal declaration to the investigators:
Over the past 18 months, I have been provided so much noxious stimulus in the form of crushing debt, sleep deprivation, impossibly difficult exams, stupid busy-work assignments, painfully boring lectures, and excruciatingly drawn out small group exercises that I have achieved a level of Learned Helplessness the likes of which I have never experienced. I actually hit the bottom of that depression before the end of last semester. I pretty much had given up hope of ever being more than mediocre. I was doubting whether I was worthy of the admission that my institution had even given me. I wondered if I would even want to go back to this grind. I even looked into transferring back home, but the chances were slim given that my application would basically state "I am a miserable med student 3 hours away from everyone he cares about, unable to strike a balance between the demands of medical school and the desire to put the pieces of the former life that I had built up over the past 24 years back into shape."

I took my winter break to look long and hard at what was happening to me. I realized that I had pretty much just reached the end of my wits focusing on how miserable I was and that was distracting me from everything at school. Instead of focusing on studying, I was thinking about being unhappy which lead to some very inefficient studying. Instead of going to lecture, I was laying in bed thinking about how much lecture sucked. Instead of focusing on doing my best, I was focusing on how I hard everything was. I looked around at my classmates and several of them were going through the same thing that I was. I told myself that things had to change this semester, that I had to make more room for the things outside of medical school because all of my free time is going away in a few short months when I hit the wards. I told myself that I have to make my study time as efficient as I could.

So I've been working at it. I've been diligent about paying attention to my girlfriend. I've been good about calling and talking to my parents and brothers and friends whenever I still have the time. I've even managed to fit in a few days of skiing in here and there. I put myself ahead of the curve on my last set of exams instead of on the back side of it. I almost feel like I'm back on track, or have I just learned to forget my helplessness?

Now with More Patient Wisdom in every box!

Another Wednesday, another happy Oncological encounter, Now with more patient wisdom:

For better or for worse, patients in the VA hospital are of a fairly unique breed. They don't resent medical students, they don't say "No Residents! I only want to be treated by attending physicians." They sit there and patiently tolerate our awkwardly in-depth histories and our bumbling attempts at physical examination. Not only are they amazing folks, they also feel the need to leave us with deep, meaning full comments on the experience of being a patient.

Enter Patient Biker Dude. CC: Itchiness, headaches, dizziness. Preceptor knows the patient and tells us to skip the history.

OncoDoc: "Bostonian, do the physical. Other guy, do the physical afterwards"
Bostonian: "His spleen seems to be enlarged"
OncoDoc: "We'll discuss that after Other guy has his turn"

Biker Dude's spleen is literally the size of a regulation NBA basketball!!! He actually has a long-standing polycythemia secondary to some kind of neoplasm, platelet count is about half a million, he's been having all kinds of CNS disturbances lately so he came in to get checked out. So we're shooting the breeze while he has his therapeutic phlebotomy (read: BLOOD LETTING!!! Literally dumping 450 ml of this guy's blood into a giant glass bottle. I thought they stopped doing that in 1800's). Biker dude is telling us how we have to be able to read patients and interact with them in kind. He tells us that he will only come to see my preceptor, 45 miles away from his home, because the oncologist closer VA tried to remove several hundred ml of blood therapeutically with a 10 ml syringe (Sticking the patient multiple times until the patient said that he'd had enough), gave him the "run around" with scheduling appointments and spoke down to the patient on numerous occasions. The way Biker Dude sees it, without veterans there would be no VA hospital and this doc wouldn't have a job, so why is he being treated like crap? Towards the end of the chat this gem comes out:

Biker Dude: "...and I don't like to be treated like a N*****!!!"
Bostonian and other medical student: Being the polite, east-coaster medical student gentlemen that we are, we pick our jaws up off of the floor, smile and nod and wish him good luck. Preceptor doesn't even bat an eye while typing up the chart.
Biker Dude: Walking out the door, placing his western-style hat on, raises his hand without turning around "Best of luck to you fellas, God Bless!"
OncoDoc: (Thick Indian Accent) "You see, this patient does not like being talked down to. Always treat your patients with respect!"

Nothing like a good racial slur followed by a hearty blessing to warm your heart...
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Then there was the patient with a history of alcohol abuse who couldn't remember how he got HepC and was surprised when told he had a mass in his liver. I'm guessing that it wasnt the only memory missing from that time in his life. He tells us that he read some patient education material saying that most people with HepC don't even know that they have it.

Normally, I have a little bit of trouble finding the liver edge, but this guy had a nice firm cirrhotic liver sticking down 2 cm below the ribcage, he must have been a hard drinker back in the day. Favorite quote from him:

"These things just keep sneaking up on me..."

He must have missed the part of pamphlet where they said "you've got a significantly increased chance of hepatoma with HepC, which is only exacerbated with heavy alcohol abuse." Lucky guy caught it pretty early. His last sonogram was negative a few months ago, but this one caught it.
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Then there was a sweet old man getting his chemo for a fairly involved pancreatic cancer, optimistic as all get out that he's going to beat this thing. He was chomping at the bit to look at the graph of his tumor marker levels (CA19-9 I believe) which wasn't scheduled until 2 month from now. Damn near broke my heart. He kept on telling us that we were very brave for going into the medical field, that it took a special person to be able to look into the eyes of a patient and honestly tell them exactly what is going on. It felt like trying to hold a straight face after being kicked in the gut.

His infusion pump signaled that his chemo treatment had finished, he smacked his lips and said "Good to the last drop." His optimism was very heart warming, yet it was still a sad interaction knowing his prognosis.
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Every day that I go through this routine, I wonder when my emotions are going to stop being dragged into the process. I vacillate between abject horror at how poorly these patients are being treated (both medically and socially) by so many of their private physicians, laughter with the patients at the funny moments, sad when my patients are crying, solemn as I recuperate after a mere 3 hours of precepting. I haven't really had a problem putting on the professional mask when the white coat goes on in front of the patient, it's when the white coat comes off and I have to go back to the library that I start rehashing and actually dealing with my feelings. I don' think I could do this for the rest of my career without developing a serious substance abuse problem.

I'm finding that the work of an oncologist is a labor of frustration, of integrating all of the loose pieces of the patient's fragmented medical care, of attending to the emotional, spiritual and medical needs of the patient, and of patiently waiting for the disease process to respond. I'm not a patient enough person to deal with that kind of waiting for results and that level of craptastic discontinuity of patient care.

Reason # 57 why medical school sucks

18-24 inches of light, fluffy, west-coast style powder fell over the Green Mountains of VT in the past 24 hours. I studied CNS pharmacology. I could be spending a weekend (like that guy) with my brother or my girlfriend skiing some of the BEST SNOW CONDITIONS EVER, but instead I'll be chillin in the library with Robbins, Cecil, Golijan and Katzung getting ready for my exams. Stupid priorities...Stupid expensive medical education...Stupid Bostonian for making responsible life decisions.

One of those days

Do you just ever have one of those days where the world conspires to keep you from being productive?

9AM- Roll out of bed ready to rock and slam about 30 pages of Robbins down
10 AM- After showering and breakfast, I get a text reminding me about a brunch that I agreed to attend
11:30 AM- Old college friend calls to catch up, cant get him off the phone for an hour
12:30 PM- Finally get down to studying
1:30 PM- Free lunch for Chinese New Year
2:30 PM- Check on friend who just found out her father is dying and has to fly across the country
3:30 PM- Get stuff from library to study with friend
7 PM- Free dinner
9 PM- Leave free dinner to check email, call girlfriend
10 PM- Open blogger, get distracted by 35 other things
10:27 PM- post blog
11-12 PM- read Robbins until unconscious, go to bed
12-1 AM- lay in bed angry at self for not getting enough done today. Fall asleep, start a similar day tomorrow

Pages of Robbins read: 11
Percentage of optimistic work goal met: 32%
Efficiency of studying: 5 of 16 waking hours (less than 35% efficient study day)

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."
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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.
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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.

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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

Advice about med school blowing hard...

I received a comment on one of my older posts commenting that the writer had found me by Googling the phrase "Med school blows." In the absolute lack of anything else to write about, I'm gonna throw down some knowledge/experiences...be prepared for awesomeness!!!

So you've spent the last 5-10 years of your life working towards this moment: getting into medical school. Now that you're here you think it sucks and you might have made the biggest, most expensive mistake of your life? Yeah, welcome to the club Anonymous. Many medical students have what I like to call an "Oh Shit" moment once they get into the day to day slog of medical school. I had one of those moments myself about 3 weeks into school for my first set of exams, and look at me I survived it!

It's VERY easy to get caught up in the feeling of "THIS STUFF BLOWS A GOAT" especially around exam time. It's even easier when you've just left a fairly easy job where you worked 40 hours a week, drank your paycheck away and really had very few cares when the clock hit 5PM. The transition was rough for me anyway. I imagine you have just come to the painful realization that you didn't want to study Anatomy and Histology. To be completely honest, you're going to realize that you don't really want to study Biochem, Physio, Neuro, Psych, Path, Pharm, Micro or Ethics either. So that begs the question why you signed up to be tortured for the next 4 years of your life whilst paying out of your ass for it?

Well it took me almost the entire first year of school to figure this one out. You'd figure someone who made it this far would be bright enough to conjure a silver lining somewhere in the midst of the shit-storm. Well, after a particularly rough final set of exams for Neuro, including a mini-board that was actually my worst exam performance in medical school, I did some soul searching. As with any good Irish fellow, my soul searching included copious amounts of whiskey and beer. I find that they help to slow down my brain to the point where instead of just making decisions based on the immediate situation, I take time to evaluate the entirety of the situation...it may sound like BS, but it works for me.

I looked at the big picture: Was this truly what I wanted? What am I doing here? What would I be doing otherwise? Why don't twinkies go bad for 40 years? Where did I put that bottle of scotch? You know, the important global questions.

I came up with a few very important answers that changed how I look at things:

1.) Medical School is not truly what I wanted out of life. Anyone who want's that is just plain SICK. What I wanted was to have a nice easy life where everything comes to me with minimal effort and I don't have to work very hard at all to get where I want, and I want oompa-loompas to bring me candy while I swim in a river of chocolate. That sort of life is not a possibility for me since my parents are neither wealthy nor willing to let me waste my life like that (and oompa-loompas aren't real either...sadly).

Short of that, what do I want out of life? I want to pay back my loans, to have a medium sized family and a good dog that will actually listen to me off the leash, to leave a lasting impression on a few of the people that I encounter in life and a job that changes on a daily basis and is somewhat unscripted so that I don't get too bored with it. In short, I want to look back on my life 45-50 years from now on my death bed and be able to say "Damn, that was a good life!" How can I have all of that? By going through with this beast.

2.) I am here at school to learn to be a physician. Physicians are not born, they are not pampered into existence. They are nearly ordinary people, broken down to a steaming pile of humanity by medical school, and then rebuilt into a slightly less steaming pile of humanity that is then baked by the heat of residency, forged by the flame of fellowship, and then made to crumble by the weight of debt, malpractice insurance, and CME obligations.

In other words, the training process sucks. It was designed by a bunch of single geeks at JHU with no aspirations outside of medicine. It always has sucked. It will suck more for the people that come after me...but it's not what the reality of your medical practice will be. If you can just look past the mountains of stuff that you have to learn in order to be certified competent by the NBME as a physician, you can then be tortured by a state liscencing board and allowed to pass and live your life how you want and take your career/life whereever you choose! I know it's tough when you're staring at Netter trying to memorize the Brachial Plexus (Roots, Trunks Divisions, Cords), but there is more to medicine than rote memorization.

3.) If I weren't here, I would probably be sitting in some analytical chemistry lab at some Ginormous Pharmaceutical Company in Connecticut (which shall remain nameless) pushing samples of the latest batch of "old-wrinkly-penis de-wrinkling" pills into a GC/MS while slowly growing my pension and counting down the days until I could retire. I could get married, pop out 1.5 kids, buy a modestly sized house in a modest neighbor hood, sending my kids to modest schools, living a modest life as quality inspection monitor number 1234 of 2000. There could be no imaginable fate worse than that for me. So whatever cool ideas that you've concocted in your exhausted, sleep-deprived mind as an excuse to quit, make them seem mundane and temper them with the fact that you'd have to pay for them somehow and the act of paying for them would take more time than the fun you'd actually have.

4.) Twinkies, Cockroaches and Dick Cheney will be the only things to survive the next nuclear holocaust. Hostess designed them as the perfect food, and well they did a little bit too good of a job. By the way, the bakery where the twinkie was originally created was torn down and replaced with a Nordstrom/Neiman Marcus. Hows that for progress??? Yeah, I got to visit (was dragged into) the Tiffany's that stands where the loading docks once were with the girlfriend a couple weekends ago...the place got a slightly different feel to it these days. I digress...

So anyway, Anonymous here's my advice, all wrapped up in a nice package:

-The first year of Medical School is not what the rest of your life will be like. You're studying random medically-related trivia at this point. Next year, you'll learn more medically relevant trivia, but it's when the good stuff your learned first year goes bad, which makes it slightly more interesting, like a Fox special. Third year, you lose all of your freedoms by becoming the lowest ranked person in the hospital...but you get to see patients and tell their stories to everyone else and pretend to be a doctor. Fourth year, they let you think you've learned something and allow you some freedom to sleep to choose what you do. Then depending on your specialty you get paid too little to work too much in residency for a few to several years. Finally, when all that's over, you can get a real job and have President Hillary Clinton (in her second term) signing your paycheck. (Or you can join the rebel forces and strike out on your own in private practice.) (Or you can avoid the whole ordeal and do a few fellowships and wait for the next fix.)

-It doesn't get better, you just learn to accept the crap they pile upon you more easily.
-You'll slowly realize that you will indeed, some day, need this knowledge to figure out what the hell is wrong with someone. That is why you're studying it after all.
-As much as this profession sucks, someone has to do it...it might as well be you doing it.

My suggestions
for the short term:
Go back and read the lies in your personal statement and secondaries, realize how naive you were. Laugh at yourself for not thinking this through better a year ago. Have a beer or 3. Write "I will not commit to 7 years of torture without thinking it through ever again" on a white board 50 times for emphasis. Pass out, wake up and remember the previous night from the white board, laugh because it's so true.

Medium Term:
Schedule a day to shadow in the ED of your school's affiliated hospital, put on your short white coat of indignation and listen to the patients' stories about why they're there, listen to the doctors' story about why they show up there day after day. Schedule a day in the Pediatric Oncology ward, read stories to the kids, play with them, talk to the doctors and nurses about why they go back to that floor day after day after day. Go to Hospice for a day, go to psych for a day. Lather, Rinse, Repeat with anyone else in the hospital.

Longer term
Go back to your room. Sit by yourself in the quiet and listen to why you're there. Write it down on your blog, read it whenever you're feeling like all of this isn't worth it. If you can't hear anything, you're not listening hard enough. If you honestly can't find one redeeming reason deep down in your soul to grab on to that makes all of this worth it, give up your spot, give as much of your loans back as you can, and get the hell out of dodge before you've bought a house that you'll never live in. Being miserable for the rest of your life is not worth a couple letters after your name.


What's the point?
Remember who you were, learn who you'll be, do something about it...that's all there is to it.

Best of luck
~Bostonian

P=MD?

Well, I actually managed to survive and pass both of my exams. Path was probably the most angst-inducing exam that I have ever been subjected to. 3 hours, 168 questions. I'd say for about 20%, the extent of my knowledge of the subject was covered in the question and the answers were just flat out beyond what I had absorbed from the readings.

Micro was mercifully fair, except for the level of depth we were expected to know about fungi...which I neglected to cram into my already over-full brain. Overall, last friday was a rough go at it for me and I'll need to severely modify my exam preparation techniques if I'm going to make it out of this year alive. I questioned my worthiness as a medical student a few times, and even pondered a career in the fast food industry for a few minutes. But I survived, with only a few gray hairs to show for it.

Feeling OLD, update

The combination of moving my little brother into college at Northeastern (as a frosh) and hanging out with some family friends at the beach who are entering their last year of college, has made this Bostonian feel very old. It seems like just yesterday that I moved into college and met so many of my good friends, finally grew up outside of my parents' sphere of influence, drank my first beer, met the love of my life and all the wonderfulness that comes with going to college. And now my 6 year younger brother is getting to do the same thing.

I remember holding him in the hospital when he was born...now he'll be an adult. I just feel old. No wonder my mom cries so much...
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Good news is that I got my final Day in on Nauset Beach (Robbins and Cotran came along) for the year. It was a beautiful day, the water was warm (60ish) and it was nice to see the actual sun and some non-med school folks for a couple hours. Although, I may be the first person in history to actually get a Robbins tan (consisting of a rectangular, book-shaped pale spot across my lap, beyond the normal shorts tan).
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Anyway, I'm still working on a write up of my backpacking trip experiences in my spare time, so stay tuned for that...it's completely non-medically related though. I'm still about 60-80 pages back in Robbins, so priorities need to be met first...I'll get to writing soon enough. Until next time
~Bostonian in NY

(PS...7 games up in the East after being swept by the Yanks doesn't look too bad at all. Especially when the yanks lose 2 of 3 to the D-Rays and continue their slide against the Mariners which simultaneously drags them closer to playoff elimination in both the AL east and wildcard races. I love Baseball in September...too bad I only have one more Fenway game left before October.)

Despite my being 60 or so pages behind in Robbins reading, there's always a little time to focus on baseball in August...especially when I'm stuck in this hellhole of Yankee-fandom 8 games up going into a 3-game series. Here are a couple stories that have warmed my heart while living here over the past year:

The Old Lady
Time stuck in Yankee Country: 36 Hours, give or take. Location: Bed Bath and Beyond for apartment supplies. I'm walking down the aisle, standing amongst the tea pots because I don't even have the means to boil water in my apartment as of yet, when all of a sudden I hear this angry voice with that accent that makes every hair on my neck bristle, "You know you better be careful around here."

"Why's that ma'am?"

"You're going to get yourself hurt wearing that kind of shirt around here."

Looking down I notice that I'm wearing my Bronson Arroyo shirt that I picked up for $5 after he got traded. I thought to myself -Great...and old lady just threatened to beat me up for wearing a Bronson Arroyo shirt in the middle of BB&B. At that time Arroyo was about 10-2 with an ERA under 3, and the Sox were in their skid, but still up 1.5 games at that point. To make things better, it was still about 3 weeks before the second comming of the Boston Massacre where the Sox dropped a 5 game homestand which essentially was the dagger in their playoff hopes.

Thinking quickly I retorted "Ma'am, I'm from the Boston area and just moved here yesterday. Bronson Arroyo, who isn't even on the Red Sox anymore, is one of my favorite pitchers who is currently leading the NL in wins and ERA. If anyone wants to beat the crap out of me over Arroyo, they need to seriously get a life. Enjoy the rest of your shopping" With that I
turned and walked away.

Random other Sox-hating events
Generally when I go to a bar, I'm still carded at the door despite the fact that I look like a 30 year old at the ripe old age of 24. Most NY bouncers see the Massachusetts license and give me grief about being from Boston/the Sox.

I also have Red Sox license plates. They were doing random safety checks on one of the roads near campus, and so the officer makes me stop and says with a dead-pan, straight face "Son, I may have to write you a ticket for those plates that you have there." I said: "See you in Traffic Court," with a smile, and he cracked a smirk.

In the ED
Patient: So where are you from?
Me: Boston
Patient: So why don't you have one of those stupid accents that they always have? (through her own thick Long Island/Queens accent)
Me: My parents taught me how to speak properly as a child...

Edit: at the time of this post the Sox are only up 7 games on the Yank-me's based upon Damon's 2 Run HR...Run support for Matsuzaka could have been better...especially if Manny hadn't strained his back.

Sorry

Path is hitting me harder than I thought it would and I'm still trying to figure out how much of Robbins I need to memorize to survive. Good stuff is on it's way at some point though
~Bostonian

A med student rekindled

Truth be told, I have not been a fan of medical school to date. I haven't enjoyed the hours of lecture on scientific minutiae, the exams focused on the obscure corners of said scientific minutiae covered in lecture, the people who spent endless hours memorizing the aforementioned corners of scientific minutiae without having anything else in life to talk about, and generally the solitary nature of the pre-clinical years of medical school. When it comes down to it, I have been downright frustrated about not learning any actual MEDICINE in MEDICAL SCHOOL!!!

But I digress. The past few weeks in the ED have somewhat rekindled my willingness to slog through another 12 months of studying before being thrown to the wolves on the wards third year. I think it was actually being immersed in the thick of the ED chaos that did it for me...seeing sick patients, seeing what the doctors do and how the department runs, seeing medicine in one of it's few remaining purer forms medicine where someone is sick (kind of, most of the time) and we supply the healing (or call in a consult from someone who knows what to do).

Honestly, I have never felt as at home in a hospital as in an emergency department. There are no pissing matches between the EM physicians, there are no patients that have been hopelessly "circling the drain" for months on end in one of the beds sucking the resources from other patients, just people who feel that they need emergency care for anything from poison ivy to shortness of breath in a guy with spontaneous pneumothorax diagnosed 30+ years ago to the lady that collapsed with a sudden "worst headache of her life to the guy with a complex medical history of liver failure, diabetes, CHF, COPD, and a case of "the Clap" flaring up since he bought that hooker in Vegas. It is the ultimate renaissance profession, where you get to know a little about a lot of illnesses, do procedures and coordinate with every service in the hospital to get people the help they need...and I think I'm in love with it.


Furthermore, outside of the confines of the stuffy auditorium, it is nice to see my limited knowledge coming into practice...well the random tidbits that I was pimped on by every service the saw me looking over their shoulder anyway. It was nice to expand the pile of notes into the practical realm FINALLY!!! It almost makes that $60k tuition worth it...:)