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.
1.31.2008
1.23.2008
"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.
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.
1.21.2008
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.
1.15.2008
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.
--------------------------
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.
1.07.2008
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
------------------------
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
1.03.2008
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:
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
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
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
12.22.2007
Merry Christmas
I scraped by my ass by my latest path exam...apparently I was supposed to prepare for a clinical cardiology exam instead of a cardiovascular pathology exam. That wasn't what the syllabus or the previous year's exams said, but such is life. I still passed the class...but this P=MD after weeks of studying my butt off is just sucking the life out of me. I don't know what I'm doing wrong but it's quite disheartening to study your face off for 3 weeks straight and walk out of an exam to find out you're barely pass the class because of your awesomely half-assed performance. Regardless, I'm still class of 2010
Fortunately, I've got the next two weeks off to get my head on straight, re-evaluate what I'm doing wrong and set up a plan to get me through step 1 and into third year with my sanity and relationships in tact. Oh yeah, I get to spend time with my family and non-medical friends too!!! Merry Christmas to all, and I'll be back in the new year
Take care,
Bostonian
Fortunately, I've got the next two weeks off to get my head on straight, re-evaluate what I'm doing wrong and set up a plan to get me through step 1 and into third year with my sanity and relationships in tact. Oh yeah, I get to spend time with my family and non-medical friends too!!! Merry Christmas to all, and I'll be back in the new year
Take care,
Bostonian
12.15.2007
I've lost that lovin' feelin'...
(Cue Anthony Edwards: "I hate it when he does that!")
For about the umpteenth time this year, I've lost that lovin' feelin' that I had when I was a pre-med, came again for about the first 3 weeks of medical school, and then again for the first few weeks of this year after my fun EM internship. Whenever I walk over to the library, I feel the life being drained out of me. Whenever I look at Robbins, I'm told I get what has been described as "a really pathetic look" on my face.
So I am pondering:
Why is it that the entire medical education process is built around separating us from the things and people that we care about and totally immersing ourselves in the material? I spent 22 years of my life focused on becoming a well-rounded individual with interests outside of medicine, with relationships beyond the walls of my educational institution, with emotions, creative energy, compassion and a decent credit rating. Hell, I even ran a half marathon at one point at sub-8 minute mile pace.
But all of that is gone now, at age 24. I gave myself away the second I put on that short white coat and signed away my first master promissory note. I can rattle off obscure medical facts with out blinking, but I can't have a normal conversation with friends from high school. I can talk to a schizophrenic and elicit the history of his life, but I can barely hold a 10 minute phone conversation with my mom or my girlfriend without long silences. I know the intricate workings of the human body and mind, but I'm losing touch with my own soul.
I suppose that if this was the former USSR circa-1965 and my parents and local government officials had determined that I would be a physician from the age of 3 because I was good at the knock off Soviet version of Operation, this total dedication of my life's energy to Mother Medicine would be a bit more palatable. But, I guess that physicians are made and not born... and hundreds of thousands have gone through this training process and come out alive and with their minds somewhat in tact.
5 days...until freedom, sleep and feeling like myself again.
12.12.2007
Under Pressure...
::Cue Queen::
Dun dun dun dundundun dun...
Dun dun dun dundundun dun...
8 mere days left until winter break...3 cumulative exams to go...
I can't wait!!!
I'll post again soon!
Dun dun dun dundundun dun...
Dun dun dun dundundun dun...
8 mere days left until winter break...3 cumulative exams to go...
I can't wait!!!
I'll post again soon!
12.06.2007
Holy Crap!
More than 1000 views of this page, many of which are not my own!
Thanks for reading my drivel, if it gets your through your day, more power to you.
If you come here to anonymously spy on my suffering, there's plenty more coming up you're a sick person and should probably seek professional help, you sadist you.
Seriously, thanks for reading
BinNY
Thanks for reading my drivel, if it gets your through your day, more power to you.
If you come here to anonymously spy on my suffering, there's plenty more coming up you're a sick person and should probably seek professional help, you sadist you.
Seriously, thanks for reading
BinNY
12.05.2007
Demotivation
I know that it's perfectly natural to go through up and down periods within medical school, but I swear that I swing back and forth faster than a bipolar crack addict.
This morning, I had a great amount of difficulty dragging my sorry ass out of bed to study. I walk through the cold over to school, and as soon as I get through the front door I can feel my shoulders sag and my posture slouching and the joy being dragged out of me as I head into the library for a little bit of light reading (Viruses...hooray). 20 ounces of black coffee couldn't even get my sorry butt motivated.
Later this same day, I head to a mandatory small group session with one of the fourth year students and I almost enjoyed interacting with my small group in yet another extremely inefficient clinical correlation exercise...the leader actually managed to get a discussion going and some interesting tidbits were addressed and some of her knowledge was thrown down and the session actually ran itself instead of morphing into mandatory lecture time like usual. I finally felt like I was actually learning something that might be clinically relevant in my career, instead of staggering through endless lists of cell markers, random correlations pulled from pubmed and obscure diseases that have an incidence of 1:10,000 in a tiny corner of Bulawayo province of Zimbabwe.
Then again tonight, I head on back over to the library with my dinner and my virus reading, same life-sucking feeling, same slouching posture, same falling asleep in the pages of my book out of sheer disgust. I try chewing gum...still can't concentrate. I try taking a dinner break...still can't concentrate. I try commiserating with some of my study buddies...can't focus. Finally after about 6 hours of on and off productivity, (consisting of 2 class transcripts, phone calls to mom and the girlfriend, an hour of screwing around with classmates, 30 minutes of dinner, and at least 6 bathroom breaks) I threw in the towel and headed for home, defeated by viruses and my own demotivation.
All I can do is remind myself of a few things:
This morning, I had a great amount of difficulty dragging my sorry ass out of bed to study. I walk through the cold over to school, and as soon as I get through the front door I can feel my shoulders sag and my posture slouching and the joy being dragged out of me as I head into the library for a little bit of light reading (Viruses...hooray). 20 ounces of black coffee couldn't even get my sorry butt motivated.
Later this same day, I head to a mandatory small group session with one of the fourth year students and I almost enjoyed interacting with my small group in yet another extremely inefficient clinical correlation exercise...the leader actually managed to get a discussion going and some interesting tidbits were addressed and some of her knowledge was thrown down and the session actually ran itself instead of morphing into mandatory lecture time like usual. I finally felt like I was actually learning something that might be clinically relevant in my career, instead of staggering through endless lists of cell markers, random correlations pulled from pubmed and obscure diseases that have an incidence of 1:10,000 in a tiny corner of Bulawayo province of Zimbabwe.
Then again tonight, I head on back over to the library with my dinner and my virus reading, same life-sucking feeling, same slouching posture, same falling asleep in the pages of my book out of sheer disgust. I try chewing gum...still can't concentrate. I try taking a dinner break...still can't concentrate. I try commiserating with some of my study buddies...can't focus. Finally after about 6 hours of on and off productivity, (consisting of 2 class transcripts, phone calls to mom and the girlfriend, an hour of screwing around with classmates, 30 minutes of dinner, and at least 6 bathroom breaks) I threw in the towel and headed for home, defeated by viruses and my own demotivation.
All I can do is remind myself of a few things:
- 903 days until graduation.
- 1.5 years finished, $117,000 spent on school
- 7 months until I am released onto the wards and Step 1 and the end of this pointless suffering in the bowels of the library.
- Most importantly, 2 weeks until Winter Break: sleeping in, skiing, family and friends around, no Robbins, no Murray, my dog, and contact with the real world outside of my personal hell. Basically, I get the things that matter in my life back firmly in my possession for 2 entire weeks (probably for the last time until 4th year, but I'll face that realization later on...with a healthy dose of angst and scotch)
11.30.2007
The Debt Card
So I've noticed a couple debt postings over the past week, so I'm hopping on the bandwagon too. I just received my bill for the spring semester of year 2: I now owed something on the order of $117,000. I've never even seen $1000 in cash, I can picture $100, but I cannot fathom owing that much money without having seen more than 10% of it hit my bank account at one time.
To bring that down to my level, I've come up with some nice equivalents to help myself out. Please stick with me until you find an equivalence that hits home:
I am currently projected to have something on the order of $260,000 in debt after medical school. Sure it's "good debt" but really, I'm going to have to enter a fairly lucrative and short residency to actually be able to pay it off in a reasonable amount of time. My repayment plan calculator says that I'll be paying $3,000 a month at 6.8% for the next 10 years and that I will actually end up paying on the order of $360,000 when all is said and done. 6 digits of interest...great. At that rate, I'll be 26 when I get my MD, 29 by the time that I enter repayment after deferring for residency and 39 by the time that I finish repayment. Something to think about when you're filling out your AMCAS while watching Scrubs/Gray's Anatomy and thinking how awesome your life is going to be.
To bring that down to my level, I've come up with some nice equivalents to help myself out. Please stick with me until you find an equivalence that hits home:
- A Mercedes Benz SL550 with every option possible- $120,000
- A house somewhere in the mid west
- A Fender Stratocaster owned and played by Jimi Hendrix himself
- A 36' YACHT
- 75 Karats of Diamonds attached to a platinum necklace
- Over 9 pounds of solid gold at the current price of $795.20/oz.
- 80 years eating 4 items off the dollar menu at Wendy's every day
I am currently projected to have something on the order of $260,000 in debt after medical school. Sure it's "good debt" but really, I'm going to have to enter a fairly lucrative and short residency to actually be able to pay it off in a reasonable amount of time. My repayment plan calculator says that I'll be paying $3,000 a month at 6.8% for the next 10 years and that I will actually end up paying on the order of $360,000 when all is said and done. 6 digits of interest...great. At that rate, I'll be 26 when I get my MD, 29 by the time that I enter repayment after deferring for residency and 39 by the time that I finish repayment. Something to think about when you're filling out your AMCAS while watching Scrubs/Gray's Anatomy and thinking how awesome your life is going to be.
11.13.2007
Medical Education Philosophy Rant
Forest or trees?
Looking back on the last exam block, it seems that there is something inherently wrong with the way that I am being educated. I get the joy of trying to cram 3-500 pages of material into my brain and regurgitating it in the form of trivia questions and little black circles. How many of those circles I bubble in correctly corresponds to my grade, which in the context of the performance of 200 of my peers determines a small portion of where I will be allowed to work in the future and what I will be allowed to specialize in. It's an asinine process where I'm not really retaining a whole lot of material that matters. Instead I'm focusing on memorizing which CD's are expressed in which developmental stages of which WBC cancers...and it will have VERY little to do with the rest of my career from here on out. I'd assume that the forest was more important than the trees, but apparently we're going to examine every cell of every tree in the forest.
Multiple guess/Alphabet soup
Loosely thrown into the mix is an attempt to get interaction from members of the class in small group sessions. Unfortunately, these sessions turn into more of a lecture than a discussion/problem solving exercize. My concern comes when I'm actually going to have to make diagnoses and see patients and interact with other physicians. Will I see the patterns, will I know what tests to order, will I even know what to look for when it's not presented in a multiple choice format. It's not as if people are going to present with the choice of ABCD or E with me able to bubble in the correct choice with only the price of my grade on the line. These will be people's lives, and I don't even know how to make a differential diagnosis work or even what should be listed together. But I can tell you the different markers on the different flavors of Non-hodgkins lymphoma...what is more important in your future physician: performance on a multiple-choice exam or knowing how to diagnose a patient??? I saw an article from AAMC that the Step 1 is being re-thought.
I think what has bothered me most about my very expensive education thus far is that I could have learned most of the material with about 6 books and a ticket to Body Worlds at the Museum of Science...
Looking back on the last exam block, it seems that there is something inherently wrong with the way that I am being educated. I get the joy of trying to cram 3-500 pages of material into my brain and regurgitating it in the form of trivia questions and little black circles. How many of those circles I bubble in correctly corresponds to my grade, which in the context of the performance of 200 of my peers determines a small portion of where I will be allowed to work in the future and what I will be allowed to specialize in. It's an asinine process where I'm not really retaining a whole lot of material that matters. Instead I'm focusing on memorizing which CD's are expressed in which developmental stages of which WBC cancers...and it will have VERY little to do with the rest of my career from here on out. I'd assume that the forest was more important than the trees, but apparently we're going to examine every cell of every tree in the forest.
Multiple guess/Alphabet soup
Loosely thrown into the mix is an attempt to get interaction from members of the class in small group sessions. Unfortunately, these sessions turn into more of a lecture than a discussion/problem solving exercize. My concern comes when I'm actually going to have to make diagnoses and see patients and interact with other physicians. Will I see the patterns, will I know what tests to order, will I even know what to look for when it's not presented in a multiple choice format. It's not as if people are going to present with the choice of ABCD or E with me able to bubble in the correct choice with only the price of my grade on the line. These will be people's lives, and I don't even know how to make a differential diagnosis work or even what should be listed together. But I can tell you the different markers on the different flavors of Non-hodgkins lymphoma...what is more important in your future physician: performance on a multiple-choice exam or knowing how to diagnose a patient??? I saw an article from AAMC that the Step 1 is being re-thought.
I think what has bothered me most about my very expensive education thus far is that I could have learned most of the material with about 6 books and a ticket to Body Worlds at the Museum of Science...
11.07.2007
Re-dienchanted again...
I pretty much have the non-hormonal, non-gonadal, medical education-based version of PMS these days. I'm deeming the acronym NHNGMEB-PMS. At my lovely institution, epidemic NHNGMEB-PMS seems to flair up every 6 weeks with intense spasms of anxiety, grouchiness, eating crappy food, not sleeping well, excessive caffeine consumption and excessive distractability. I think it's spread by the special human body louse that lives inside every copy of Robbins. The natural reservior seems to be restricted to second year medical students. There's another variant that affects first year medical students to a similar degree, but the etiology and timing is slightly different. I'm sure it happens other places with different frequencies.
Anyway, it's just about exam time again and I've been studying diligently for the past several weeks, I've even been ahead of the game at a few points. Now that I'm getting closer to exam time and taking some practice exams...they're not looking so hot. I don't actually know what I am doing wrong, or how many more lines of Robbins I could memorize and randomly recall at the whim of a very convoluted "All of the following, except" type multiple choice question. That combined with one of the hardest sections in Path (Blood cell disorders and Cancer) is not making for a very rewarding studying experience.
Such is life here however, I'll do what I can, but it's not going to be pretty getting these exams back. I wasn't exactly in the running for AOA in this lifetime, but I'd at-least like to be riding high on the curve (i.e. not failing miserably). Putting a positive twist on it: maybe having to know this level of detail now will make the USMLE's seem a little bit easier????
I'm off to bury my face in some Micro...and boost my ego a little by not miserably failing a practice exam...I'll post after the exam.
Anyway, it's just about exam time again and I've been studying diligently for the past several weeks, I've even been ahead of the game at a few points. Now that I'm getting closer to exam time and taking some practice exams...they're not looking so hot. I don't actually know what I am doing wrong, or how many more lines of Robbins I could memorize and randomly recall at the whim of a very convoluted "All of the following, except" type multiple choice question. That combined with one of the hardest sections in Path (Blood cell disorders and Cancer) is not making for a very rewarding studying experience.
Such is life here however, I'll do what I can, but it's not going to be pretty getting these exams back. I wasn't exactly in the running for AOA in this lifetime, but I'd at-least like to be riding high on the curve (i.e. not failing miserably). Putting a positive twist on it: maybe having to know this level of detail now will make the USMLE's seem a little bit easier????
I'm off to bury my face in some Micro...and boost my ego a little by not miserably failing a practice exam...I'll post after the exam.
11.04.2007
The List Shortens...Heme/Onc
Heme/Onc
To begin, any subject that has enough detail to make a pathologist complain about the amount of detail automatically turns me off. I think I read "but that is beyond the scope of this text" four times in the most detail oriented sections of that damed tome of Path. Robbins and Cotran basically wave the white flag of surrender.
Hematopathology is the detail masochists' dream subject. There are officially 2-bagillion distinctly individual pathologies of blood cells recognized in Robbins, each coupled with it's own set of complications, prognostic indicators and cytogenetic/molecular nuisances and uninformative name. Then there's the verbal diarrhea explaining the difference between the cell types, the uninformative naming schemes, the treatments, the lab value changes...and my head just exploded. Oh, and everyone of these damned patients presents as being tired and having lost weight.
And then there is oncology. God bless the person that can go to work every day and tell at least one person that they have cancer. I swear that half of Robbins is devoted to neoplasms of each organ system, and the equivalent to watching a Fox special "When good cells go bad". I'm going to leave it at that out of respect to the people that toil to keep those pesky neoplasms at bay...it's something that I never could do day in and day out.
To begin, any subject that has enough detail to make a pathologist complain about the amount of detail automatically turns me off. I think I read "but that is beyond the scope of this text" four times in the most detail oriented sections of that damed tome of Path. Robbins and Cotran basically wave the white flag of surrender.
Hematopathology is the detail masochists' dream subject. There are officially 2-bagillion distinctly individual pathologies of blood cells recognized in Robbins, each coupled with it's own set of complications, prognostic indicators and cytogenetic/molecular nuisances and uninformative name. Then there's the verbal diarrhea explaining the difference between the cell types, the uninformative naming schemes, the treatments, the lab value changes...and my head just exploded. Oh, and everyone of these damned patients presents as being tired and having lost weight.
And then there is oncology. God bless the person that can go to work every day and tell at least one person that they have cancer. I swear that half of Robbins is devoted to neoplasms of each organ system, and the equivalent to watching a Fox special "When good cells go bad". I'm going to leave it at that out of respect to the people that toil to keep those pesky neoplasms at bay...it's something that I never could do day in and day out.
The list shortens...OB/GYN
As I take my little whirlwind tour of potential medical specialties in Pathology and Microbiology, I have knocked off about half a dozen specialties from my list if possible career choices. I'll make this a regular installment for your reading pleasure.
Disclaimer: If you are interested in any of the fields that I mention or are currently working in aforementioned specialty or potentially grading me/evaluating me in anyway, please understand that this is nothing more than my somewhat twisted justification for not going into your field. I respect you for doing what I never could. Please don't mess up my life over my poor attempts at humor.
OB/GYN-
Between my microbiology lectures on STD's and a couple of less-than-pleasant encounters with some purulent cervices, genital warts, fungal infections and unpleasant/irresponsible pregnant mothers-to-be I couldn't run away fast enough from this specialty.
"But what about bringing a beautiful new life into the world?"
Listen. I've seen the TLC series about making the baby or whatever (while switching between "Mythbusters" on Discovery and Sportscenter). The horribly violent act of bringing a human child onto this Earth is utterly horrifying to me. You couldn't pay me enough to be on the business end of a hormonally imbalanced woman passing an 6-12 pound bowling ball of a HUMAN BEING through a slightly elastic tunnel that is roughly the size of a roll of dimes in its relaxed state. At 3 AM. On Christmas Eve. In a blizzard.
The female body may have taken millions of years to become a baby producing machine, but the female mind/consciousness has been evolving away from that role over the past century or so. I am not getting in the middle of that argument or spending the rest of my career catching the equivalent of a vaseline-covered football worth a couple million dollars as it flies out of an angry vagina that's being torn to shreds.
"But there's plenty of fun surgical procedures without the long surgery residency!"
Yeah, but there's also cutting into an oriented x 3 mother that is anesthetized from T12 down, sewing back together that now septic birth canal, being sued because I wasn't gifted with Randy Moss' hands, being sued because mom died of DIC or being sued because some baby I delivered as a resident didn't become MENSA material because I may have made a mistake, at 3AM, on Christmas Eve, in a blizzard.
OB/GYN...you are the weakest link...GOODBYE!
Disclaimer: If you are interested in any of the fields that I mention or are currently working in aforementioned specialty or potentially grading me/evaluating me in anyway, please understand that this is nothing more than my somewhat twisted justification for not going into your field. I respect you for doing what I never could. Please don't mess up my life over my poor attempts at humor.
OB/GYN-
Between my microbiology lectures on STD's and a couple of less-than-pleasant encounters with some purulent cervices, genital warts, fungal infections and unpleasant/irresponsible pregnant mothers-to-be I couldn't run away fast enough from this specialty.
"But what about bringing a beautiful new life into the world?"
Listen. I've seen the TLC series about making the baby or whatever (while switching between "Mythbusters" on Discovery and Sportscenter). The horribly violent act of bringing a human child onto this Earth is utterly horrifying to me. You couldn't pay me enough to be on the business end of a hormonally imbalanced woman passing an 6-12 pound bowling ball of a HUMAN BEING through a slightly elastic tunnel that is roughly the size of a roll of dimes in its relaxed state. At 3 AM. On Christmas Eve. In a blizzard.
The female body may have taken millions of years to become a baby producing machine, but the female mind/consciousness has been evolving away from that role over the past century or so. I am not getting in the middle of that argument or spending the rest of my career catching the equivalent of a vaseline-covered football worth a couple million dollars as it flies out of an angry vagina that's being torn to shreds.
"But there's plenty of fun surgical procedures without the long surgery residency!"
Yeah, but there's also cutting into an oriented x 3 mother that is anesthetized from T12 down, sewing back together that now septic birth canal, being sued because I wasn't gifted with Randy Moss' hands, being sued because mom died of DIC or being sued because some baby I delivered as a resident didn't become MENSA material because I may have made a mistake, at 3AM, on Christmas Eve, in a blizzard.
OB/GYN...you are the weakest link...GOODBYE!
Professional Organizations
Just a warning for all of you med students/physicians out there.
So you just started medical school, you're sensory overloaded, strapped for cash and looking for any free thing that you can get. Your friendly AMSA rep runs up to you and says "Sign up and get a free Netter's!" and your gut reaction is GREAT! You get your Netters for free and a fancy little card showing you your benefits of joining AMSA shows up a few weeks later. Take a little look at what you're signing up for.
So you just started medical school, you're sensory overloaded, strapped for cash and looking for any free thing that you can get. Your friendly AMSA rep runs up to you and says "Sign up and get a free Netter's!" and your gut reaction is GREAT! You get your Netters for free and a fancy little card showing you your benefits of joining AMSA shows up a few weeks later. Take a little look at what you're signing up for.
Here's the mission statement:The American Medical Student Association is committed to improving health care and healthcare delivery to all people; promoting active improvement in medical education; involving its members in the social, moral and ethical obligations of the profession of medicine; assisting in the improvement and understanding of world health problems; contributing to the welfare of medical students, interns, residents and post-MD/DO trainees; and advancing the profession of medicineI'd like to point out how the second to last concern of the group is contributing to the welfare of medical students. Funny thing is that their associated lender is part of the probe by NY AG into the predatory lending practices...Good job AMSA...good job.
10.29.2007
Parallel Universe
Sometimes when I'm dealing with other medical students, I feel like I'm entering a parallel universe where human interaction and expression of emotion has become some weird hybrid of what it should be. Granted, I was born and raised in New England which makes me a bit emotionally stunted, thereby warping my perspective slightly. But I digress...
Seriously though, a production is made out of every little happening. Case in point: I tried to go out to dinner with my room mates last night...a simple task in my former life. But here in the Twilight Zone, the roommates disagree on time and no compromise can be reached. This leads to other grievances being aired, crossing of arms/stamping of feet, awkwardly silent rides to the restaurant, awkward silences over dinner, and general discomfort for the Bostonian in the middle of all of this. Oh and the temper tantrums...don't forget those.
I've noticed that this toddler/kindergarten level of maturity also extends thorough a good portion of my class and it's frustrating to think that I will have to cater to these types of personalities for the rest of my career. Hooray future doctors of America!!!
Seriously though, a production is made out of every little happening. Case in point: I tried to go out to dinner with my room mates last night...a simple task in my former life. But here in the Twilight Zone, the roommates disagree on time and no compromise can be reached. This leads to other grievances being aired, crossing of arms/stamping of feet, awkwardly silent rides to the restaurant, awkward silences over dinner, and general discomfort for the Bostonian in the middle of all of this. Oh and the temper tantrums...don't forget those.
I've noticed that this toddler/kindergarten level of maturity also extends thorough a good portion of my class and it's frustrating to think that I will have to cater to these types of personalities for the rest of my career. Hooray future doctors of America!!!
SOX WIN
Obligatory post...sorry. I love this piscture of Pap...
Overall, this year was probably the best years of baseball that I can remember, but the World Series was kind of bittersweet. Do I miss Shaugnessy's Curse of the Bambino? NO! But there is something missing in my soul...it's that potent longing that only a lifetime of being a lovable loser can bring. 86 years of disappointment no longer tug at my heart strings. Billy Buckner letting the ball through his legs in the '86 series doesn't make me quite as angry. Falling to the Tribe in '95 and '98 and losing to the Yanks in '99 are just distant memories from my adolescence. The heartbreak of the 2003 game 7, 11th inning ALCS loss that forged my love of the Sox no longer makes the bile rise in my throat. 2004 put all of those things to rest. The fatalist Sox fan is gone from my soul.
There was no elation this year for me, just satisfaction and a lot of hope for the next few years. With the young core of players that have come up through the farm system, a passionate owner that cares about his fans and team, competent management at the helm and another red banner hanging over Yawkee Way for me to look up at, I am satisfied.
10.21.2007
Getting my groove back
So a funny thing has happened over the past two weeks. After my last post, I found myself battling some of the same feelings that I had addressed: Med school sucking, wondering why I would ever put myself through this, wondering what my motivation in all of this is, etc. The motivation problem is what has come to the forefront of my mind as of late. I just can't seem to come up with a single concrete answer other than the $94,000 that I've racked up in debt over the past year and a half.
Is it for my family? No, my parents are proud of me no matter what. Is it for my kids? No, I probably wont have them for a while thanks to the inter-state relationship that I'm in for the foreseeable future. Am I doing this for me then???
At one point, somewhere back in the application process, I was doing this for me, to give myself a solid career where I wouldn't just be a cog in the wheel of industry like my father and brothers, merely making a product to make a paycheck. I would much rather a career where I could look back at the end of every week of work and see that the hours of my life that I am investing into my career had a positive impact on the lives of others...and be compensated for my skills and time.
Well, I wish the naive younger version of me had known the sacrifices he'd be making in the near future for that fulfilling career and decent paycheck. I look at other people my age that are traveling the world in their free time, keeping themselves healthy at the gym, starting their marriages, starting their families, broadening their social networks, finding their niches in careers and generally living life.
And then I look in the mirror and see my life, filled with sitting in front of a couple of books, in a small group discussing that pile of books or in an auditorium listening to the highlights of those books. No impact on other people, nothing but the same 200 faces day in and day out, the same books day in day out, nothing to look back on at the end of the week to say to myself "wow, I actually contributed to humanity today."
I think the lack of a rewarding feeling in the pursuit that I spend the majority of my time in is the worst part of this whole process. I'm literally working my butt off, spending weeks of my life glued to a chair for nothing but a number on a piece of paper...ok so couple of numbers (Exams, USMLE, Clinical Evals and shelf exams, Deans letter, interviews and the actual match). My life for the next 3 years is lined up for me and I feel like a cog, just what I wanted to avoid... pointless, unrelenting, unrewarding toil.
Like I've said a couple of times now: It's hard to look past all of this to the actual practice of medicine when your head is burried in the pages of a book and won't be coming out for some time now.
Is it for my family? No, my parents are proud of me no matter what. Is it for my kids? No, I probably wont have them for a while thanks to the inter-state relationship that I'm in for the foreseeable future. Am I doing this for me then???
At one point, somewhere back in the application process, I was doing this for me, to give myself a solid career where I wouldn't just be a cog in the wheel of industry like my father and brothers, merely making a product to make a paycheck. I would much rather a career where I could look back at the end of every week of work and see that the hours of my life that I am investing into my career had a positive impact on the lives of others...and be compensated for my skills and time.
Well, I wish the naive younger version of me had known the sacrifices he'd be making in the near future for that fulfilling career and decent paycheck. I look at other people my age that are traveling the world in their free time, keeping themselves healthy at the gym, starting their marriages, starting their families, broadening their social networks, finding their niches in careers and generally living life.
And then I look in the mirror and see my life, filled with sitting in front of a couple of books, in a small group discussing that pile of books or in an auditorium listening to the highlights of those books. No impact on other people, nothing but the same 200 faces day in and day out, the same books day in day out, nothing to look back on at the end of the week to say to myself "wow, I actually contributed to humanity today."
I think the lack of a rewarding feeling in the pursuit that I spend the majority of my time in is the worst part of this whole process. I'm literally working my butt off, spending weeks of my life glued to a chair for nothing but a number on a piece of paper...ok so couple of numbers (Exams, USMLE, Clinical Evals and shelf exams, Deans letter, interviews and the actual match). My life for the next 3 years is lined up for me and I feel like a cog, just what I wanted to avoid... pointless, unrelenting, unrewarding toil.
Like I've said a couple of times now: It's hard to look past all of this to the actual practice of medicine when your head is burried in the pages of a book and won't be coming out for some time now.
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