Category Archives: Uncategorized

USMLE

Uncategorized, USMLE

Your First Big Hurdle in Medical School

I got a fairly decent but not spectacular score on both Step 1 and Step 2 of the USMLE (United State Medical Licensing Exam) so I am not claiming any revealed wisdom or special insight into the tests. You must take what follows as my opinion alone and I caution you to study for the test in a manner which feels right for you.

OK?

For the uninitiated, the USMLE is a three part test which you will take at various times in your medical education. Step 1 is typically taken at the end of your second year of medical school and covers what you should have learned during that time. Step 2 is typically taken during fourth year and emphasizes the clinical aspect of medicine. Step 2 includes the “Clinical Skills” test which is a day-long standardized patient exercise that will cost you a thousand bucks. The only difference between paying a thousand bucks for the clinical skills test and being mugged is that you can’t file a police report after the test. (But more on that in a future post.)

Step 3 is usually taken early in your second year of residency and is your last hurdle to becoming a licensed physician.

Let’s talk about Step 1. Although you have spent the previous two years in the intense study of medical knowledge you will have to study for this test. I am sure that the average medical student can take the exam “cold” and probably pass it three times out of four with a grade close to the minimum passing score. A pass is a pass of course but a low Step 1 score will adversely impact your ability to match into a competitive specialty or a generally non-competitive specialty at a competitive program. In fact, many residency programs screen applicants by Step 1 scores so a low score will automatically close many doors for you.

Additionally, at all American medical schools Step 1 is a “must pass” test and you cannot advance through third and fourth year until you do so. At most schools you will get three chances to pass it. Upon failing the first time you will probably be pulled out of the third year rotation schedule and during the block you sit out you will be expected to study for and pass the test (this time comes out of your vacation). If you fail it for a second time you will be dropped back a year. Fail it a third time and they stick the fork in you as you are done.

At most schools you must attempt Step 2 before graduation but passing or even having the scores back is not required to graduate.

The question then becomes how long and what should study?

The answer depends on your school. My medical school had an eight-week break between the end of second year and the first day of third year. Most of my classmates elected to take Step 1 during this time either earlier or later depending on their comfort level and study habits. I believe that eight week is too long as you will invariably both lose your edge and also start to forget what you studied ealier. Three weeks is not enough time as you do have a lot of information to cover. Five to six weeks seemed to be the average in my class.

If your school doesn’t give you this kind of time then you need to make the best of it.

To study effectively you need to understand the format of the test. Step 1 and Step 2 are day long, computer-based, multiple choice tests. They are broken into hour long blocks of fifty questions selected more or less randomly from various subject areas of medicine. No two tests are exactly alike but an effort is made to keep the relative level of difficulty and mix of subjects more-or-less constant.

The tests are multiple choice but are not like the multiple choice tests which are probably the norm at your medical school. First of all, many of the questions have choices “a” through “k” rather then the standard “a,b,c,d.” You are consequently going to work a lot harder at eliminating wrong answers.

Additionally, the tests are concept-based, not fact-based, and feature many of what I like to call “double pump” questions. Rather than presenting you with a set of information and asking you to name the disease, for example, the typical Step question presents you with a brief case summary after which rather than asking you to name the disease the question might be, “What is the next step in the management of this patient?” Your excitement over knowing the disease was premature as this is not the answer they are looking for.

Heck, in many questions they tell you what is wrong with the patient. Consequently it pays to read the question at the end of a long paragraph first as the presentation is irrelevant once you know the diagnosis.

Another popular question style is to present you with a case followed by a selection of different lab results, your task being to pick the one which fits the presentation. You can usually eliminate most of the possible answers as obviously wrong (high pH in a set of lab values that you know should describe acidosis, for example) but invariably you will be left with a handful of reasonable looking results.

A variation on this is to present you with various simplified graphs and ask you to select the one which correctly represents the case.

Then there are the deceptively simple Behavioral Science questions which present you with a scenario and give you a list of choices only a few of which you can obviously rule out. The rule of thumb here is when in doubt go with the politically correct answer. Spanking is always wrong and it is never correct to advise a patient take responsibility for their actions.

I would say that of all the questions on Step 1 and Step 2, only a handful had a discrete, definite answer like “Sickle Cell” or “Guillan Barre Syndrome.”

So how should you study?

First, do not attempt to go back and review two years worth of class notes. The typical lecture curriculum probably has close to 4000 lectures in two years and you simply do not have the time. Not to mention that since the Step tests are standardized and your curriculum is not (despite the best efforts of your faculty) you might waste your time studying something taught at your school which is not emphasized at another and not likely to be included on the test.

Second, do not read text books because if your lecture notes are full of trivia the text is even more so. Again, you do not have time. This also goes for review books and I confess that I had a change of heart on this between Step 1 and Step 2. You simply do not have the time to review two years worth of material. The four weeks or so you will devote to study will dwindle quickly and your studying will bog down in a quagmire of detail.

Frankly, the best way to study for Step 1 is to do well and study hard during first and second year. You will retain more than you imagine and this is the best base for the most effective Step test study method which is to do practice questions and little or nothing else for your alloted preparation time.

The best practice questions, in my opinion, are those sold on-line by Kaplan or USMLEworld qbank. These are subscriptions to about 2000 questions each which are formatted exactly like the real questions, cover the same mix of subjects, and can be taken in Step-like blocks of questions exactly like the real test. The best part about the service is that you can read the explanations to the correct answer as well as to the wrong answers which in my book is just as important.

As I did the questions I made a point of reading or at least skimming all of the explanations to the right and wrong answers on all of the questions about which I had any doubts at all.

The advantage of these (and similar) on-line question banks are many. First, they are the exact same format and feel of the real test and will get you used to the “physics” of the computer test. That way there will be no nasty suprises on test day when you suddenly run out of time on several blocks or wrestle with the interface.

Second the questions focus on subjects which are actually tested. This means that you are going to get the typical standard presentations and basic medical knowledge with nothing coming out of left field. It was my sense that the questions are not written to trick you and it is only your lack of knowledge which can confuse you. The hoofbeats are always horses, never zebras.

Another advantage is that the questions are phrased and presented in a similar manner to the real test with the important distinction that the practice questions from Kaplan and USMLEworld seemed harder than the real questions. In fact, I scored considerably lower on the practice tests than on the real thing. The practice questions distributed by the USMLE are almost exactly like the real questions in difficulty.

Finally, doing practice questions will put you in the test-taking mode. If all you do is read review books you will have a store of rapidly disintegrating facts jumbled in your head. Doing practice questions narrows your focus to answering questions based on patterns which you have seen before.

Each of these services costs about 100 bucks for a one month subscription . A couple or three thousand quesitons should keep you busy for a month.

A word about “First Aid,” a popular USMLE review book which has an almost cult-like following.

Save your money. First Aid is a collection of “buzzwords” and supposedly high yield facts which are touted by some as all you need to study for the Step tests. I understand that in the old days the Step tests were twice as long but had shorter questions with discrete answers. First Aid might have been useful for a test like that but the nature of the test has changed making First Aid less useful.

Like I said, some people swear by it and claim to to make fantastic scores by studying nothing else. I am skeptical. I hit First Aid pretty hard for Step 1 (before I got smart and started doing practice questions) but I could remember only a few questions on the test where I thought First Aid had even remotely helped me.

Just a few random thoughts:

1. Avoid the temptation to cram the night before a Step test. How much are you really going to retain and more importantly, of the two years of knowledge required to take the test, how much of it can you cram into one sleepless night? Relax. I stopped studying a week before I took Step 1 because I literally could not stand doing another question or reading another page of review material. Remember what I said about peaking early. You just have to know when to say “no mas.” Let your conscience be your guide but it is better to go into the test relaxed (but alert and ready) than to panic and lose sleep over it.

2. It will be a long day. Bring a lunch, of course, and wear comfortable clothes. Paradoxically the day will seem to fly by once you get into the test. You are given plenty of break time but most people just plow through most of their breaks to just get the test over with.

3. I thought I had failed Step 1. I mean, looking back it seemed that every question was renal physiology and that there were only a handful of the 350 question on the test of which I was sure of the answer. It seemed that I could get most of the questions down to two or three choices but I was never really sure on most of my answers.

So I dreaded getting my score and anticipated failing even though the first time pass rate for American medical students is something like 93 percent, I am not stupid, and I studied pretty hard. I asked around and this seems to be a common perception after finishing the test. Almost everybody thinks they bomb it but most people don’t. Move on. Enjoy the rest of your vacation. Unfortunately it will take six weeks to get your results so you have a long wait.

4. Step one is divided into seven one hour blocks of fifty questions. I am a very fast reader so my strategy was to read the question, quickly select an answer, and if I wasn’t sure mark it for later and move on. (The software allows you to select questions within the block for review.) I found that I was able to get through the block in about half and hour leaving me with half an hour for review. Typically I had about half of the questions marked and spent the time wrestling with them. There were always a handful of questions for which I didn’t have a clue and these I marked “C” without wasting any more time trying to figure them out.

The key is to have a system that works for you and not to get hung up on one question. If you don’t know the answer mark it for review and move on. Don’t win the skirmish but lose the war.

I repeat: Take my advice as free advice and thus worth what you paid for it. I welcome your comments but please don’t flame me because we disagree. I am perfectly willing to be corrected, proven wrong, or convinced of your point of view.

Sensitivity Nazis

Uncategorized

Dissent Will Not Be Tolerated

You are about to run the guantlet of the vast subculture in medical education devoted to sensitivity training. Your personal views, the values instilled by your parents, or your religious beliefs are about to be dismissed as detrimental to your functioning as a physician. All of these must be replaced by the latest politically correct memes fresh from the minds of pseudo-educated hacks with way, way too much time on their hands since they achieved tenure.

This training will come at you in various guises. It will be easy, of course, as reflects the shoddy academic credentials of its proponents and if you are hard to intimidate it can be a lot of fun once you get over the the fact that large chunks of your medical education are being wasted on this kind of thing.

You will be taught certain things which are to be internalized as articles of faith.

First, patients are not responsible for anything they do. After all, they didn’t have the advantages that you had growing up with that silver spoon in your lily-white gated community so they cannot possibly be held to the same standards. Therefore you are not allowed either to expect or, more importantly, to encourage your patients to be responsible for their own actions.

If Mr. Jones refuses to buy his blood pressure medications spending the money instead on cigarettes and beer then this is your fault for not motivating him properly. If you could just use the right combination of psycho-babble you might have a breakthrough where the patient slaps his head and says, “But of course! I’m having intercranial bleeds because a systolic pressure of 240 is a tad higher than normal!”

Eureka!

Of all the techiniques used to shut down debate, the assertion that the advantages we enjoyed as children negates our authority is the most spurious. I will grant you that many of my poor, uneducated patients will never amount to much because of poor upbringing or worse education. On the other hand we’re not asking them to work like dogs to get into medical school, work hard for four years, and struggle through from between three to seven years of residency training. We’re just asking them to take a couple of friggin’ pills every day and maybe keep a couple of clinic appointments.

My residency program gets all tied up in knots over how to make our patients more compliant. In fact, the term “non-compliant” is frowned upon and is instead replaced by the less-judgemental “pre-compliant.” Their current holy grail is a system where we essentially follow the patients home and plead with them to take their medicine. I subscribe to a different point of view, something I like to call the “French Hooker Rule” which postualtes that no matter how beautiful, no matter how accomplished the young lady is, she can only give you what she can give you.

You come to the clinic. I spend twenty or thirty minutes with you at every visit setting up your medication regimine, your smoking cessation strategy, and your weight loss goals. I’ll refer you to the appropriate specialist if indicated and I will neither belittle nor patronize you but in the end I can only give you what I can give you. When you walk out of the door you are on your own with nothing but your desire for good health to make you well.

I will certainly not treat any adult as a helpless child. Underneath all of the happy happy, joy joy, kumbayah talk about patient autonomy and respect is the patronizing and often-times racist assumption that certain patients are incapable of making decisions.

The point is that most adults make decisions about their health based on many complex factors the least important of which sometimes is your input as their physician. We might call them bad decisions but some patients enjoy smoking and eating fatty food more than they enjoy dieting and taking their blood pressure medications. Once you lead your horse to water through education it is up to them to drink.

So suggest that personal responsibilty needs to be stressed and watch the fireworks fly.

Let us discuss being non-judgemental. We mustn’t judge. After all, who are we to say what is right and wrong, good or bad? We sure are non-judgemental except of course when we are confronted with people who smoke, drink, eat Big Macs, own guns, spank their kids, watch TV, or don’t want the schools handing out condoms to their fifth grader. In that case we develop a superior attitude that would warm the heart of self-righteous puritans everywhere.

I want those of you who are now worked up to a fine lather of indignation (being highly judgemental, I might add) to step back a minute and ask themselves where it is written that non-judgementalism is the highest virtue of a physician?

Nowhere, my friends. It is merely the residue of the 1960s and all of the psycho-babble that resulted from it now manifested through the establishment who came of age during that idiotic, self-indulgent time.

Naturally your patients will expect and deserve a high level of tolerance from you. This does not mean that you need to subordinate your morality to theirs. If you don’t want to refer a woman for an abortion or put a fifteen-year-old on the pill then don’t do it. Likewise if you think that asking patients about guns in the house is an intrusive bit of politically correct idiocy then don’t do that either.

I don’t belong to the AMA because they are anti-gun and very intolerant of the anti-abortion position. I guess some judgementalism is hunky dory.

Sensitivity is a religion and the sociologists with their fuzzy degree are its priesthood. You will, in the course of your training run up against these happy people who hold nebulous positions in the institutional hierarchy but teach nothing, treat no one, and don’t even administer anything remotely related to patient care. They have fancy titles and speak in a strange language full of phrases like “brainstorming” and “intergroup dynamics” which they bring to bear on fabricated problems which are of no concern to anybody with a real job.

Political correctness is an industry, my friends, which employes an army of bearacrats to try to put a happy, sanitized face on everything. Must be nice to have a job at the Office of Institutional Diversity or some such sinecure from which one may pretend to work at fictional problems for which no measurable results can ever be expected.

Things You May or May Not Need: Part 2

Medical School, Uncategorized

The Two Week Rule

Eventually you will fill all of the pockets of your white coat with various pocket reference books, tools, and pens the wieght of which will suprise you. These things will accumulate on you like barnacles on a whale and you will be reluctant to scrape them off against the possibility that you might need one of the items and not have it.

A good rule of thumb is that if you have not used something in two weeks you probably don’t need it and it is safe to leave it home.

The advent of the PDA has gone a long way towards reducing the load carried by interns and medical students. The contents of Harrison’s Textbook of Medicine, which in print weighs ten pounds, fits easily onto a small corner of my PDA’s memory so you can see that with a decent PDA you can carry around a complete library of reference books.

Which you’ll never use, of course. The best applications for the PDA are the electronic equivalents of the pocket reference books. The best, in my opinion, is Eprocrates.

Epocrates is the “killer app” for medical handheld computing and does for PDA what the spreadsheet did for the personal computer and what porn did for the internet. The current version includes a drug reference handbook, a concise medical texbook, a catalogue of lab tests and their interpretation, a medical calculator, and a few more goodies. All of them are cross-referenced and formatted to be read easily on the typical PDA screen.

Epocrates got it’s start as a drug reference and in this it is superior to any other product on the market. You can search its database by drug class or name. It gives you dosages for adults and children, contraindications, mechanism of action, and even price.

Epocrates also has a rapid clinical reference database which I mentioned earlier. Let’s suppose you are treating a Sickle Cell patient. With a couple of taps you can pull up everything you really need to know about the condition including its pathophysiology, treatment, prognosis, and even what labs and studies to order on your patient. Now, to be honest the detail isn’t quite as good as a medicine textbook but it is surely good enough for rounds and will keep you safe in case you are pimped.

On a similar note the “Five Minute Clinical Consult” series is pretty good. They are written for practically every specialty and now that you can load them into your PDA you don’t have to carry around a huge book.

A “Sanford Guide to Anti-Microbial Therapy” is another one of those essential little books (which you can also get for the PDA). It is a good place to look when starting an antibiotic regimine on a patient, especially if you are considering “empiric” therapy, that is, before cultures and sensitivities come back from the lab.

Most medical centers also publish their own small infectious disease manual which lists characteristics of the microbes specific to the medical center.

The trend now is to tie wireless devices into the hospital database. At Duke this works pretty well and you can easily access lab results and other improtant rounding data on your PDA. Some schools are years away from this. Wireless connectivity is a nice plus but not essential and sometimes more trouble than it’s worth unless your school has implemented the technology to make it seamless for the user.

I despise mucking around with computers. All I want is to turn them on and use them,

Good PDAs can be pretty expensive. Many schools make their purchase manatory (along with a laptop computer) and this just adds to your student loan debt. If I could, I’d hold off getting one until third year because you will not need it for first and second year and any PDA you buy as a first year will be pushing obselecnce by the time you start third year. Either that or the prices will come down.

It should go without saying that you will need comfortable shoes. Whether you are in the OR or rounding on a medicine service, you will spend much of the day on your feet. Your dogs will be barking for not the least of which reason as that during first and second year you spent most of your day sitting down. Clogs are very fashionable for men and women and you will see the surgeons wearing them. I think they look kind of silly but then I prefer a more conservative look.

Whatever your preference in fashion, a pair of shoes that are comfortable, cool, and easy to slip on and off will make your long hours on the wards more enjoyable. If you can slip them on and off this will let you really rest your feet if you have a moment to sit down as well as making it easier for you to get moving when you are on call and are startled awake by your beeper.

Would it kill you to buy more than one white coat? Presumably you should change the oil on your coat every three or four thousand miles. Still, you will see medical students and residents rounding with white coats which are almost gray from use. I know it is just me being superficial and that many of the folks I see skulking around in greasy, off-brown white coats are ten times the physician I will ever be but that’s no excuse to look like an ass-bag.

Buy three. Wear one for a few days then wash the the stupid thing. Hit it with an iron too, if you are to cheap to buy the polyester blend.

Oh, and get your wife, girlfriend, or same-sex spousal equivalent (as we say at Duke) to sew a few extra pockets on the inside to carry your gear. A pocket with a velcro or button closure is nice for your PDA. Most scrubs don’t have very good pockets and the minute you break into a trot when the code pager goes off your PDA will slide right out onto the floor.

Trust me.

Talking Turkey

Uncategorized

I’m Not in it for My Health

Folks, there is absolutely nothing wrong with wanting to make a good income at your chosen profession or with trying to get the best salary you possibly can on the basis of your skills. And I don’t really care if the door greeter at Wal-Mart thinks it’s unfair that a physician makes twenty times his salary.

Your typical Wal-Mart employee didn’t just spend the whole day changing dressings on the rotting feet of diabetic vascular surgery patients, nor does he get up at zero-dark thirty to write notes on patients to have ready for rounds at a time in the morning when most working people are hitting the snooze button.

The correct phrase is “investment in human capital.” By the time we finish our training we will have been at it for little or no pay for between seven and twelve years depending on specialty. If you don’t think there should be some salary distinction between that kind of commitment and a fast-food worker then, with respect, you place very little value on your time.

I don’t mean to bust down on regular working folks. Still, my neighbor comes home at five and generally sits out in his back yard drinking beer and listening to the radio except when he goes hunting or fishing. I sometimes say hello to him early in the morning as he backs his bass-boat into the street. He is a decent, stand-up guy but hunting, fishing, and a few “irregular pleasures” are the extent of his ambition and I’m not going to cry “crocadile tears” if, with luck, I make more in a month then he will make in a year.

On the same note, I don’t envy those people who either make or have more money then I could earn in fifty lifetimes. Their wealth has no effect on me in the same way that my salary has no effect on my neighbor.

The moral here is not to count other people’s chips. A hard lesson to internalize especially since it is so easy to be envious of others.

Things You May or May Not Need: Part 1

Medical School, Uncategorized

Save Your Money

As you can imagine, medical school is a fairly expensive undertaking. It will also consume huge quantities of your time. With this in mind I’d like to go over a few things that you do and do not need either because they are expensive or because they will complicate your life rather than simplify it.

Just my opinions, of course. Your mileage is going to vary considerably depending on your comfort level, your school, and your financial resources. I will endorse some products but I am not being paid to do so (not that I wouldn’t like to be, you understand). Please don’t post angry comments.

First and most important, you really don’t need textbooks. Good Lord. Why would you sacrifice huge quantities of your study time parsing closely packed text for the few important facts buried therein? Of course you need study materials but like everything in medical education, you want them to be “high yield.”

The typical Biochemistry textbook, for example, is an 8-pound 1200 page behemouth full of essentially useless trivia. Not only that but you could easily drop 150 bucks for it, barely open it, and then lug it around from residency to fellowship to your first job before you get the courage to throw it away.

The first thing you need to understand that in a lecture based-curriculum, the tests are based on the lectures. In other words, essentially all of the questions you will be asked on any test will come from either the material presented in the lectures or from the course syllabus (Oftentimes a packet of handouts and notes). Occasionally you will get a list of “required reading” from the approved textbook for the course but this is usually just wishful thinking on the part of the professor.

I suppose a professor could enforce the required reading by taking his questions from obscure details only to be found in the textbook. In two years of lecture, however, this never happened. Occasionally the professor would throw in a few trivia question from the textbook but, as medical school tests usually run into the hundreds of questions, the potential to miss a couple of questions is not much of an inducement to miss potentially forty or fifty questions through wasting time studying trivia.

The key is to have access to good notes. Notice I didn’t say “take good notes” because it is almost impossible to take notes during a medical school lecture. Unlike undergraduate education where the courses proceeded slowly, dwelling over the subject matter and allowing time to digest and annotate, medical school lectures are a study in information overload and there is just no time to take decent notes.

But don’t despair. Usually one of the first orders of business of your newly elected class officers will be to set up a note taking service. There are many variations of this service. Some classes divy up the lectures among the students who are each responsible for preparing the notes for the lectures they are assigned (usually by transcribing from a tape after the lecture) and then emailing them to the class.

Our class hired a professional note-taker who sat in on every lecture with her tape recorder and then emailed the finished product to the people who subscribed to the service. I never bought the notes because my school posted the lectures (Power-point presentations, mostly) on our class web site and I studied directly from these. I though the note-taking service was redundant as it usually just recapped the Powerpoint presentations.

So don’t sweat it. With a few exceptions, eschew the textbooks. Instead, judiciously acquire review books. High Yield and BRS are the most popular and they have them for every subject. You will probably pay 20 bucks for a good Biochem review book which will have only a small fraction of the information in it’s bloated cousin but since you will actually read it and only the relevant information is covered you are going to come out way ahead.

With all this being said, you probably need to get a good anatomic atlas. Netters is the gold standard and you cannot go wrong buying it. A photographic atlas is also pretty useful. I liked my Rohan’s Photographic Atlas and still use it. Avoid buying a big pathology or physiology book. First of all they have them in the library or on line and if you really need to read them you can find them their. Second the review books will cover the things you really need to know.

Remember. Medical school is all about time management. Use your time efficiently and effectively.

How about diagnostic equipment? What will you need and what can you avoid buying?

You will need a good stethoscope. Most people get the Littmann Cardio 3 or one of similar quality. Not only is auscultation of the heart an important diagnostic skill which should be an inducement for you to get a good quality stethoscope but your stethoscope is kind of de facto badge of authority. You will probably end up wearing it around your neck and your patients will recognize this as your license to stick your finger in their rectum pretty much at will.

In the old days a rolled up piece of paper sufficed as a stethoscope. There are still old-school cardiologists who insist that they can hear just as well with the el-cheapo Rite-Aide stethoscopes but for my part I like to be able to hear the heart and any technical advantage I can get I will take. I would unashamedly get one of those new electronic stethoscopes except I am a resident and can’t really justify the expense. By all means look on line for a good deal but don’t skimp here. You will probably use this thing every day for your entire medical school and residency career.

Otoscope? Opthalmoscope?

Save your money.

I know. I know. It is on the “required equipment list.” Maybe you can’t avoid buying them but buy the absolute cheapest models you can possibly find because you will probably only need them for standardized patient exercises where it doesn’t really matter if you see anything or not. The patients are pretending to be sick and you can pretend to look at their retinas and into their ears.

When you start seeing real patients in third and fourth year you will find that every clinic will have an otoscope and an opthalmoscope on the wall. You will never, ever bring yours to work with you for several reasons.

First, even if they are not lost or stolen if you bring them invariably somebody will want to borrow them and in a matter of days they will somehow wander away and become common property somewhere in the hospital. The only way to prevent this is to exercise constant vigilance which you will not have time to do. You may have paid 400 bucks for them but to a causual user they are just like a pen or other “freebie.”

Second, they are heavy and bulky and you will already invariably be carrying around a white coat “combat load” which would make a Marine wince.

Trust me. Nobody carries them around. If you must, look on line for the really, really small otoscopes which fit in your pocket like a pen. They run around 100 bucks and are all you will need for a pediatrics rotation.

Blood pressure cuff? Don’t make me laugh. I suppose you’re going to carry all of this stuff around in a little doctor’s bag. (Neurologists who need a lot of tools actually do carry around little bags.) Nurses usually take blood pressures and measure other vital signs. You may occasionally want to verify a blood pressure but the cuffs are on the wall in most clinic and hospital rooms.

Reflex hammer? Why not. You can use the bell of your stethoscope of course but a nice reflex hammer will only set you back a few bucks and it will fit in your pocket.

A penlight is indispensible for examining the eyes and for looking into the mouth and other body cavities. These also fit in your pocket and are cheap. Knock yourself out.

To Be Continued…

Gallows Humor

Uncategorized

Compassion Fascists

No matter what you think now or what you wrote on your AMCAS personal statement, as you mature you will find a great deal of humor in your patients, even some who are pretty sick. This is called “gallows humor” or “black comedy.” Some try to pass this off as a coping mechanism but I am more inclined to think that some situations are just funny, even if they do involve patients. It is hard, for example, not to find humor in a 500 pound pregnant woman delivering a baby about which she knows nothing and which she denies even as you hold up the infant to show to her with the cord still running to the placenta.

Yeah, yeah. I know. Eating disorder. Body dysmorphic syndrome leading to poor self-esteem. Socioeconomically disadvantaged. Blah blah blah.

I get it. But the situation like many you will encounter is just funny. You would be absolutely wrong to make fun of a patient or laugh at them but physicians are notorious for the funny stories they tell amongst themselves.

Now, some will become sanctimonious and insist that all human misfortune including mind-numbing stupidity is the result of fate, not personal choices, and that there but for the grace of God go we. Or the dreaded commandment against being “judgemental” will be invoked, as it often is, as an attempt to stifle the debate.

I have no doubt that if my program, which is very uptight and sanctimonious, heard me make a humerous or disrespectful remark about a patient I would be called in for discussions and made to explain my thoughtcrime. It has happened to a collegue of mine.

The point is that you have to be circumspect. There are some people around whom I would never make an off-color joke or insensitive remark because they are sensitivity Nazis whose zeal for politically correct conformity would put the most vigilant of puritans to shame. With my very few close friend we hardly do anything but make off-color jokes and insensitive remarks. (My wife always asks me what my compadres and I talked about to which the standard answer is, “We exchanged vulgarities.”)

I am a former United States Marine Infantryman. I am happily married and am the father of three. I have worked for my whole life. I respect the law, vote, attend church and am a pillar of the community upon whose back the whole edifice of our civilization is supported. (And I was raised in the bad old days before political correctness made us all so hyper-friggin sensitive.)

Yet, if I was overheard by the wrong people to make an insensitive remark on any of the politically protected subjects than at the very least I would be formally reprimanded and forced to undergo sensitivity indoctrination at the hands of the thought-police from the compassion beauracracy. I would actually probably be fired and my career destroyed such is the insipid age in which we live where what someone says is more important than what they do.

In other words, watch your back. Sensitivity is a religion. There are well-paid people at every academic institution whose job it is to enforce the articles of this faith, usually by creating problems where none really exist. The priesthood of this faith are the poorly educated beauracrats at places like the “Office for Instutional Diversity” who hold nebulous and important-sounding titles in the hierarchy of your institution but teach nothing, treat no one, and don’t even adminster anything remotely realted to patient care.

For God’s Sake, Don’t Be a Tool

Medical School, Uncategorized

Is This Person a Tool?

1. Asks questions during lecture, especially near the end when everybody else just wants to get a break.

Folks, lectures are mostly a passive affair more often than not delivered straight from the Power-point slides. This is why most lectures are sparesly attended. In the old days we relied on a note-taking service. Nowadays the professor usually posts his slides and notes on line making it virtually uneccessary to actually attend the lectures.

Still, many of us are old school and feel cheated if we don’t sit in a lecture hall most of the time. We certainly don’t want to hear you’re idiotic questions the answers to which you could easily look up on your own except you think you are scoring points with the professor.

2. Claims to never study.

Everybody studies in medical school. Sorry. In fact, many people are rudely awakened with failing grades on the first exams of first year when they try to apply their undergraduate studying paradigm (just cramming before tests) to medical school. You will soon see that the people at the top of the class are always in the library, the student lounge, Barnes and Nobles, or somewhere studying all the time.

3. Takes student government seriously.

There is nothing wrong with running for class office. It looks good on your resume, gives you as little bit more insight into medical school policies than you would otherwise have, and allows you to implement minor but none-the-less appreciated changes.

Our student government upgraded our school’s weight room which was great.

On the other hand you are not going to change anything big, at least not without a lot more support than you are going to get from your class who care less and less about school policy the closer they get to graduation.

When we were first years with an enternity of medical school ahead of us we could get all irate and self-righteous about some of the school’s policies with which we disagreed. By the middle of third year we didn’t care not the least of which because the policies now made much more sense.

And we laughed at the pretensions of the first years even though we knew we were just like them in our time.

4. Is an insufferable zealot.

Come on. Admit it. Many of you have never met a real conservative or anybody, for that matter, with religious, political, or a moral point of view that differed substantially from yours. No harm done. Although a majority of physicians are either conservatives or Republicans, academia is almost exclusivley liberal and Democratic.

Therefore it is not unsual to go through four years of undergrad and even four years of medical school living in something of a bubble. With this in mind don’t get all sullen and indignant with your collegues who have a different point of view than yours.

Here is a list of a few things which do not disqualify someone from being a physician: Serving in the military, supporting the troops and our current war, being pro-life, being against affirmative action, for the death penalty, voting Republican, being a devout and observant Christian, telling a few off-color, homophobic, misogynistic, or ethnic jokes here or there, being against socialized medicine and being for market capitalism.

Not to mention expecting to make a decent living as a doctor with only a marginal interest in serving the underserved.

Like being pro-choice or voting Democratic, all of these things are well within the mainstream of American culture and there is no need for you to act sanctimonious or have a hissy fit if some of our views differ from the liberal orthodoxy which is the de facto religion of academia. I have observed this on many occasions and marveled at the the sheer bad manners of anyone who will make contemptous remarks about religion or politics to a room full of strangers.

5. Is Hypersensitive.

Sometimes you are going to get criticised. Sometimes you are going to be the object of a little good-natured and usually well-deserved ribbing. Heck, sometimes you will be the target of cutting insults which are not good-natured.

This is medical school and residency. Grow a thick skin. Everyone is over-worked, tired most of the time, and pissed off at one thing or another. It just goes with the territory. People will not have time to spare your feelings or coddle your fragile ego. If you let every little slight get under your skin you will be desperately unhappy for the next seven to ten years depending on the specialty you choose.

Conversely, be unflappable and polite with everyone from the janitor to the chief of staff. Never get mad. Never insult anyone. Never show your frustration. Just smile and ask what you can do to solve the problem.

Scrubbing In: Part 2

Medical School, Third Year, Uncategorized

All Dressed Up, Nowhere to Go

Are you essential to the running of the OR? Will your skills be of any value?

Of course not.

On the other hand, just because you don’t know your ass from a hole in the ground when it comes to surgery does not mean that the team does not want you there. On the contrary, because everyone likes to show off to an appreciative audience your attendings and residents will be happy to have you there even if they will occasionally poke fun at you.

You would have to be a hoary old misanthrope not to appreciate the opportunity to demonstrate what you do well to someone who has not seen essentially the same resection of the colon fifty times. There is a certain thrill in impressing the new guy and, believe me, you will be impressed.

While it is true that many surgeons have personalities that would make Ghengis Khan wince in shame, there is no denying that over the course of their training they learn amazing skills. Be appreciative but do so silently because, as I have said elsewhere on this blog, nobody likes a tool.

Don’t be a tool.

So there you are. Scrubbed in. Ready to go. At this time if no one has told you, you should ask your resident or attending where she wants you to stand. Usually you will stand to the right of the attending. The resident will stand across the patient from the attending. This is not written in stone as sometimes it might just be you and an upper level resident loosely superivised by an attending who may or may not think it necessary to scrub in.

Your job now is to keep you mouth shut, your eyes and ears open, and to above all not do anything stupid. Leave your ego at the door. Being silent and respectful neither makes you a suck-up nor a tool. Do not take any good natured ribbing personally. Hell, don’t take anything personally.

I have a friend who’s attending threw him out of the OR after cursing at him and then throwing a few (non-sharp) surgical tools at him. He had forgotten to take off his ring and the attending could see it under his glove.

In a situation like this, do you go to your school’s office of cultural sensitivity and file a complaint? Of course not. He’s a surgeon. His personality, failed marriage, and long hours are more than enough punishment. All you will do is establish a reputation as a cry-baby and somebody who can’t take the heat. At the very least my friend always remembered to take of his ring so we can probably file the whole incident under “learning experiences.”

I keep coming back to not being a tool. For your surgery rotation more than any other you wil have to grow a thick skin as this is the rotation which cares the least for your hopefully non-fragile ego.

If you are asked to hold something hold it. In fact, your primary job will very likely be to hold retraction which usually involves holding body cavities open. Either that or to hold up limbs during orthopaedic procedures. Not too much else, if even that, will be expected of you until you show a little bit of interest and a little bit of the ability not to crush important organs.

Sounds easy but occasionally you will hold retractors for what seems like and often is hours. Pick up a light book and hold it out at arms length. See how long you can do it. That’s what holding retraction can feel like.

No doubt your school will have a suture lab during the end of second year at which time you will learn the mysteries of both suturing and knot tying. Pay attention and practice on your own. It is unlikely that you will be asked, on your first day, to close an incision but you might be asked to tie a few knots and nothing says “loser” quite like not being able to tie a simple sugeon’s knot. If you can do it, on the other hand, don’t expect any accolades. It is a basic skill, after all.

You might also be asked to use the suction catheter to keep the surgical field clear of blood and fluid. Watch what the resident does and imitate him. Do not poke and prod randomly and when in doubt, ask.

Invariably as the hours creep by your legs will get tired, you will itch all over, and you will regret skipping breakfast. Or nature will call with increasing urgency. Tough luck. You will just have to gut it out.

A few pieces of random advice:

1. Don’t lock your knees.

2. Do not doze off and fall into the surgical field. It can happen. Some operations are long and boring especially if you are not actually doing anything but watching.

3. Eschew the extra cup of coffee in the morning.

4. Turn off you pager. Residents and attendings typically put theirs on the board in the OR so the circulating nurse can answer their pages but you are just not that important.

5. Study the relevant anatomy before the operation. Typically you will look at the OR posting sheet the night before to determine where you will be. At the very least have a copy of Netter’s in your locker so you can quickly brush up on the arteries supplying the colon or anything else you might be asked by way of pimping.

6. Be scrubbed in and ready to go before the attending. This is not always possible but you should do it if possible.

7. Try to relax. Remember, as a medical student you have no real responsibility. Whatever happens you will be done with the rotation in a matter of weeks. If you don’t like it, tough it out.

8. If you really don’t like it surgery more than any other rotation offers you abundant opportunities to “hide and slide.” There are a thousand reasons, some of them actually quite good, not to scrub in on cases. In the end nobody will really keep that close track of you and you are only depriving yourself.

With that being said I had a friend who knew that he wanted to do psychiatry and nothing else so he saw absolutely no reason to to get jiggy on his surgery rotation.

let your conscience be your guide.

Scrubbing In: Part 1

Medical School, Third Year, Uncategorized

Yes, the Scrub Nurse is Laughing at You

The dreaded day has arrived. You are on your first surgery rotation. After a brief orientation you are told to report to the operating room to “scrub in” for your first surgey.

Get ready to run the gauntlet. You have the potential, in the next few hours, to screw up pretty much everything. Either that or you will do everything right and blend into the woodwork which is about as much as you can hope for on your first day.

I just want to give you a few general guidelines about what to do as a medical student in the OR. By all means take what I say with a grain of salt because I am not a surgeon, local customs vary, and maybe your surgeons are caring, compassionate souls who will calmly take you by the hand and lead you gently into the world of surgery.

Or not.

The operating rooms are generally clustered in one part of the hospital. Street clothes and more importantly, street scrubs (the ones you wear to and from the hospital) are not permitted in this area. Even before you enter the OR itself you will need to change into clean OR scrubs, shoe protectors, and a hair covering of some kind.

Now, while it is true that the OR suites are not sterile, the idea is to minimize the introduction of environmental pathogens. When you are in the hallway outside the OR it is not generally necessary to wear a mask. On the other hand, everytime you go into the OR itself you must have a cap and a mask on at a minimum even if you are not scrubbed in.

In other words, if you are asked to help position the patient you can enter in just scrubs, shoe covers, a mask, and a cap. Likewise if you are just observing from outside the sterile field as you will often do.

You will notice also that the nurse or tech who is prepping the patient will not scrub in but will wear sterile gloves as he shaves, swabs, and otherwise prepares the patient.

But you are instructed to scrub in. What do you do?

Outside the OR you will find the scrub sink. Obtain a scrub pad, open it, and place it on the ledge over the sink. (Usually these pads are pre-loaded with hibi-cleanse or other surgical scrub soap.) Next put your mask on because once you scrub your hands you can’t touch anything that is not sterile and your mask, my friend, is a hotbed of bacteria and other nastiness.

Usually either goggles, glasses with side-shields, or a mask with a transparent face shield are required in the OR. These things will all fog up on you quickly if you don’t take certain steps. Most surgical masks can be fitted to your face by bending the nose guard. Still, I always found that either the face shield or my glasses would fog up no matter what I did. Consequently I started putting a two inch strip of tape across the bridge of my nose, taping the mask flat and sealing it to my nose.

Do whatever it takes. You may laugh but you might want to take a mask home and try this to see if you can get it right. I prefer goggles to the face shield so unless your residents tell you otherwise as long as you have a mask on and your eyes are shielded you can do whatever you want.

Put everything on right and make sure they are comfortable because once you start scrubbing in you can’t touch your face or anything on it for the duration of the operation…and I have been in some that lasted almost eight hours.

Unless it is emergency surgery (as you may do on a trauma surgery rotation) scrubbing your hands should take you at least five minutes. This is why their is a clock over the scrub sink. If your residents and attendings only scrub for two minutes that’s their perogative but you, my friend, need to do it right.

First take the pick out of the scrub package and clean under your nails. The water is usually turned on by a foot valve or other no-touch mechanism. You will not touch anything non-sterile from now on.

Next, carefully and methodically scrub your hands and arms up to the elbow. First use the brush side of the pad to scrub your fingernails. Then, systematically scrub every finger, the palm, and the back of each hand in turn. Scrub hard with the sponge side.

Oh wait. Did you take off your watch? How about your rings? Sorry. All rings and jewelry below the elbow must come off. Better to leave these things at home. I put my wedding ring on a loop attached to my ID badge. Do not leave anything on the scrub sink that you don’t want to walk away.

After scrubbing one rinses, starting at the hands and letting, as much as possible, the water run down your arms away from your hands. Just do what your residents do. Do not touch the sink, the faucet, or anything else for that matter. Keeping your hands away from your body enter the OR by opening the door with any part of your body but your hands.

I should also mention that before you scrub you need to let the circulating nurse know your glove size so the scrub nurse will have them for you once you enter the OR. Typically you will wear green indicator gloves under your outer gloves. The green indicator gloves provide an extra protective layer and also show you if your outer glove is torn.

Since your hands are still wet, the scrub nurse will hand you a sterile towel. Keep the towel away from your body. Start at the top of your arm and dry in one direction. Then reach under the sterile towel to the hanging end opposite from the side you used and switch hands to dry the other hand. Drop the towel somewhere, where depends on your OR’s procedures but don’t touch anything while you do it.

While gowning and gloving without assistance is a skill you need to learn, in the OR the scrub nurse will hold your gown up for you to put in your arms. Put them into the sleeves but do not extend anything more than the fingers past the cuff. Usually the circulating nurse will tie your gown for you in the back. Note that only the front of your gown, your arms, and hands are going to be considered sterile so a non-sterlile person can tie you up in the back.

At this time the scrub nurses will hold up your first glove oriented for you to put in your hand. Reach deep into the glove but don’t touch the floor for god’s sake. For your other hand the scrub nurse will hold the glove up for you but in this case you will reach under the cuff with your gloved hand and open it up for your other hand.

Sometimes your fingers will go in the wrong fingers of the glove. Don’t worry and do not reach over with your ungloved hand to adjust your glove. Even though you have scrubbed your hands, all you have done is knocked down the number of colonies. Your hand is non-sterile even after scrubbing and if you touch your gloved had with it you will be asked to scrub out and repeat the whole procedure.

Once you have both hands gloved you may, with perfect aplomb, adjust your gloves to your heart’s content as your gloved hands are both sterile.

Now here’s the tricky part. The front of your gown has a cardboard tab attached to the wrap-around ties. Grab one tie with one hand (pulling it free of the tab) and hand the red end of the tab with the other tie attached to it to the circulator (or anybody) being careful not to touch your gloved hand to the non-sterile person you hand it to. Spin once to wrap the closure around your gown, hold the two ends of the closure and let the circulator pull the tab off of the cord. Tie your gown with the cord.

There you go. You are now scrubbed in. Keep in mind that the scrub nurse, the circulator, and anybody else who loves to harrass medical students will be watching you intently to catch you in a mistake. Maybe you touched something non-sterile. I once, for example, reached up to adjust my goggles and had to “scrub out” and repeat the whole procedure from the top.

Don’t take it personally. While it is legitmate fun to pick on medical students, the insides of the human body provide an ideal culture medium for bacteria, spores, and viruses. Surgical infections are serious business and the best way to deal with them is not to let them happen.

A word about the sterile field. You will note that the patient will be completely draped in sterile coverings leaving only the operative site exposed. The operative site will have been scrubbed before the drapes went on. The sterile field extends to all sides of the operative site which are covered by a sterile drape. Your hands, your arms, and the front of your gown from slightly above waist level to about the clavicular line are part of the sterile field. Never drop your hands below your waist. It is acceptable to fold your arms if you are just going to be standing around. Never touch anything above your waist which in not part of the sterile field.

By all means rest your hands on the sterile field. That way you will not get into any trouble. You can play a game of soitare on the sterile field (if the cards are sterile natuarally) without comprimising sterility as long as you never touch anything outside the field.

The scrub nurse’s table is part of the sterile field and is covered in a sterile drapes upon which sterilized instruments are placed. These instruments are passed back and forth between the patient and the table but as long as they don’t leave the sterile field they are sterile.

Are you seeing a pattern here? Everything in the OR is structured to keep a small area of the room sterile. The point of entry is the scrub nurse who always takes her job seriously. She may be defferential to the attending but she is not afraid of residents, interns, and least of all medical students. Do what she says in regard to protecting sterility. If you are in doubt, politely ask her what you should do.

Next: Retracting 101.

First Day on the Wards: Part 1

Medical School, Third Year, Uncategorized

Are We Healing People Yet?

So there you are, on the first day of third year about to start your clinical training. Two years of lectures behind you, thousands of facts disintegrating in your brain every day, and you are standing sheepishly in your new short white coat at the nurse’s station about to start your first real day of your new career without a clue as to what exactly is your job and what you should do first.

You’ve had the orientation, of course, where you are told what is expected of you but somehow it doesn’t exactly translate on a Monday morning at 6 AM surrounded by the bustling world of an academic medical center.

Relax. Here’s how a typical ward rotation works.

First thing: By “wards” we mean a rotation dealing with patients who have been admitted to the hospital and who reside there for the duration of their treatment. Some rotations are all “outpatient” (as opposed to wards which are “inpatient”) and you will be seeing patients in a clinic. Family medicine is a good example of an outpatient rotation. We will discuss these rotations in a later post. Just keep in mind that even on an inpatient rotation you may spend some time seeing outpatients in a clinic setting.

As you will find out, third year is divided into short blocks, typically two months long, during which you cover all of the major areas of medicine such as Surgery, Obstetrics and Gynecology (OB-Gyn), Internal Medicine (“Medicine”), Pediatrics, Surgical Subspecialties (such as Urology, Opthamology, and Otolaryngology), Psychiatry, and a few other things depending on the priorities of your school.

These two month blocks are typically further broken down into shorter sections. You might, for example, do one month of General Surgery and one month of Vascular Surgery in a two month surgery rotation. On a two month medicine rotation, as another example, you might do one month of General Internal Medicine, two weeks of Cardiology, and two weeks of Nephrology.

Suppose you start on General Medicine. Let’s flesh out a typical day. Bear in mind that every medical school is different and other’s may have had different experiences.

How early should you show up?

Get to the floor early enough to pre-round on the patients you are assigned to follow. This simply means that you must see the patients, examine them, and make a note of any changes in their condition before morning rounds. You must also follow up on pertinent labs or studies from the day before and be familiar with their treatment plan (including the all-important discharge plan) as well as any pending tests and their current medications. How early you show up depends on the number of patients you are following, your familiarity with them, and how efficiently you work.

Keep in mind that you will be waking most of the patients up to do your exam. (Usually a focused exam dealing only with the presenting complaint. You do not generally need to do a neuro exam for someone being treated for a small bowel obstruction.) While they expect to be disturbed during their stay, 4 AM is a little early to be turning on the lights and poking them in the belly. (Examining a patient in the dark is called “groping” and is a no-no.)

You will probably not be assigned more than two patients when you first get started, Still, as you will be completely unfamiliar with almost everything about the workings of the hospital I’d allow plenty of time. If you show up too early the worst that will happen is that you will be standing around with nothing to do before morning rounds. The converse to this is not having enough time and being asked embarrassing questions about your patients that you can’t answer.

Typically, you will be responsible to make a note in the patients chart before rounds summarizing what you have learned. This is the famous “SOAP” note of which you have probably heard. The SOAP note is easy to grasp but difficult, initially, for most medical students to execute. The usual problem is trying to cram too much into the note. It should be concise, not wordy, and should not recapitulate the admission History and Physical except to remind the reader about the patient. (Believe me, the admission H & P, especially on medicine, is where you can go crazy with detail.)

The parts of a SOAP note are as follows:

Subjective: Who the patient is, a brief summary of the reason for their hospitalization, and what they or the nurses told you about their hospital course overnight.

“Mr. Jones is a 63-year-old man admitted for congestive heart failure exacerbation. The patient reported difficulty breathing and a non-productive cough last night at around nine PM but these resolved after administration of IV lasix. Patient is currently without complaints.”

Objective: Subjective is just that, subjective. It does not cover things that you observed in your exam or were reported by the lab, radiology or other consultants. These things are all objective, that is, facts that do not depend on the patient’s interpretation.

Typically you record the last set vital signs making particular note of anything unusual like a fever overnight or a string of high or low blood pressure readings which were unusual for the patient.

Next you will record the results of your physical exam. Generally, every patient regardless of their complaint deserves at least a cardiovascular exam, a lung exam, and an abdominal exam. Listen to the heart in several locations, listen to the lungs, listen for bowel sounds and palpate the abdomen. You can record this succintly using any number of “boiler-plate” abbreviations such as “lungs CTAB” for “lungs clear to auscultation bilaterally.” Of course you need to note any new findings,

Although opinions vary, on my SOAP notes I like to record pertinent lab values. I know that the results are usually on a computer somewhere but it simplifies the job of the person reading your note. I also give brief summary of any new imaging results or the results of any other tests which were not available for the previous note.

assessment/Plan: This is the list of what is wrong with the patient and the ongoing plan to address these problems. Typically it is also preceded by a brief recapitulation of the patient as in the first line of the note. Is this necessary? Maybe not but since most people jump to the assessment and plan when they read a note, particularly a long one, the recapitulation is always helpful. People will read your notes. might as well make them useful and user friendly.

You might say “Mr. Smith is a 63-year-old man with a history of congestive heart failure, Diabetes, hypertension, and gout admitted on January 3rd for a CHF exacerbation.” Then you make a list, by problem, of the plan to address that problem and how things are either working or not working.

For example:

CHF: Patient diuresed of approximately three liters of fluid over last 24 hours on 60 mg IV lasix every eight hours. Chest xray shows continuing resoution of pulmonary edema. Last ejection fraction was 25 percent by transesophageal echo on January 1st.

Diabetes: Well controlled on sliding scale insulin.

Hypertension: Blood pressure well controlled on Hydralzine etc. etc. etc.

You get the point. Also, you might want to add in your note how the patient is doing towards meeting his discharge criteria. Use accepted abbreviations but try not to get too jiggy with them. Most people have to think a little before they realize that BRBPR stands for “Bright Red Blood Per Rectum.”

Why is a the SOAP note important? Several reasons. However, let’s not kid ourselves into thinking that your attending or your resident is going to rely on your assessment and plan for her treatment decisions. Ain’t going to happen. Sorry. What the note does is provide a framework for your over-worked resident to quickly add her own pertinent comments as an addendum to your note. Sometimes the addendum can be as simple as “Agree with medical student note.” At other times the resident will add her own assessment and plan. Either way it saves her a little bit of time.

For you, the medical student, the big advantage of the SOAP note is that if you copy them and carry them around you will be well-armed when the time comes to present your patient.

More on that in Part 2.

What is it Really Like?

Uncategorized

Getting Past the Hype

Only one percent of all visits to physicians take place at academic medical centers. And yet, because as medical students and residents we spend all of our time at these institutions our views of the profession are colored accordingly. As I am a resident at a large academic medical center (Duke) you need to take what follows with a grain of salt.

Medicine is not as glamorous as you may be lead to believe by depictions of the profession in the media. I know that you, gentle reader, already know this but I don’t think the typical medical school applicant realizes exactly how much of a grind certain aspects of medicine can be.

First of all, the patients are not all nice looking and don’t all come with compelling stories. Sometimes your patient is going to be an 87-year-old senile lady transferred from a local nursing home on a “soft admit” who’s past medical history runs to two pages and who is taking twenty different medications. She will be demented, diabetic, fluid over-loaded from heart failure and renal failure, a double below knee amputee from diabetes, and she will just lay there making occasional primitive noises.

Name a system and she will have a major problem with it. Dialysis on Moday, Wednesday, and Friday. Ileostomy for total colectomy. History of multiple angioplasy. This is a patient who will be wearing an adult diaper and will be spoon fed by a nurse’s aid if she’s not being fed through an nasogastric tube or a PEG.

And the transfer note will give as a reason for transfer, “Shortness of Breath.”

Duh.

Or you may find yourself in the Emergency Department working up a local gang-banger and you will realize that the typical thug is just not that glamourous. They beat their girlfriends, have the emotional development of twelve-year-olds, and do not have the souls of poets. Not that I don’t enjoy this kind of patient, because I do, but these are not gritty philosophers who have any legitimate things to tell you about your own life except perhaps to reinforce your decision to send your kids to private school.

After you pick up a patient, you will also find that the majority of your interventions and decisions are going to be pretty routine. Many aspects of medicine lend themselves to algorithms which you pretty much follow mechanically for most patients. Someone comes in with chest pain, for example, and you will automatically get an EKG, chest films, cardiac enzymes, and lytes while you start him on oxygen, nitro, and morphine. If his enzymes are elevated or he shows acute EKG changes you will route him to the CCU for thrombolytics or to the cath lab for an emergent cardiac catheterization.

Most chest pain patients, however, do not have dramatic EKG changes and elevated cardiac enzymes and settle down pretty quickly under the onslaught of your algorithm. When you first start your cardiology rotation as an intern you will be terrified when the Nurse pages you with a patient in acute chest pain. By the end of the rotation you will be non-plussed unless they show you the money.

On the other hand you always have to be wary of the patient who will not follow the algorithm.

Anatomy Lab

Medical School, Uncategorized

Don’t Get Carried Away

Exactly how much anatomy do you need to know and how much time should you spend in gross lab? Opinions vary. Some people love lab and eat it up (figuratively speaking) maintaining that there is no way to learn anatomy other than to spend hundreds of hours elbow deep in a cadaver. These are the folks who come in on the weekends to poke around a little for that one little nerve that they can’t seem to find.

Others spend the least amount of time in lab required by decorum and school policy.

How much anatomy do you need to know?

A lot, no question about it. I’m not convinced, however, that gross lab is the place to do it.

While you need to go to lab and poke around a little to get the feel for things, it is much more efficient to get a Rohan’s Photographic Atlas and use this as your non-smelly, non-gooey, portable anatomy lab.

Understand that most schools test you on gross anatomy by holding what is called a “practical.” In this test, you circulate around the lab from tank to tank (as if in some unholy buffet ) and are given a certain amount of time at each cadaver to identify a tagged item. The tagged item is usually well dissected and does not require any digging on your part.

Since there are usually anywhere from twenty to fifty cadavers in the lab (depending on the size of your class) most of the tagged items will be on cadavers with which you are unfamiliar. With this being the case, you might as well use a photographic atlas which usually shows structures unambiguously dissected in several views from which you generalize to any cadaver, not just the one that you have butchered.

The Rohan’s atlas has the legend on the side or under the photograph with numbered leaders to the structures. It is practically tailor made for quizzing yourself.

You will find that most of your lab time is spent dissecting rather than learning. By this I mean that you will spend hours picking through what looks like leftover thanksgiving turkey looking for an obscure nerve or blood vessel which you could have identified in your photographic atlas in three different views in thirty seconds.

I’m not saying that you don’t need to study anatomy, only that you need to do it efficiently.

So You Want to Go to Medical School

Medical School, Uncategorized

Relax

Several years before I applied to medical school my daughter became ill and had to be admitted to our local teaching hospital. Twice a day, the head of the Pediatrics department would make his rounds followed by an impressive entourage of about a dozen residents and third year medical students rotating through pediatrics. As they stood in my daughter’s room, the head of the department would pepper his followers with questions about my daughter’s condition, prognosis, treatment, and other relevant medical knowledge. Standing in the back of the group was a third year medical student who looked incredibly awkward, especially after he mumbled and stammered incorrect answers to several questions directed at him.

A few years later, I found myself on a third-year pediatric rotation at the same hospital and realized that I was “that guy.” As smart as my mother thinks I am I was in full mental vapor-lock unable to recall the simplest item of medical knowledge.

It is a popular misconception reinforced by inaccurate stereotypical descriptions of medical students in the popular culture and wildly inaccurate medical school guide books that medical school is incredibly difficult and can only be successfully undertaken by a student with a photographic memory, the stamina to study sixteen hours a day, and a robotic obsession with medical knowledge. While it is true that medical schools are full of students who fit that description, there are an equal or greater number who are just slightly-smarter-then average regular people.

My purpose in writing this blog is to share some of my experiences and observations about life in medical school and residency from the perspective of a guy who is not at the top of his class and likes to keep stress to a minimum. I also hope that when you arrive at medical school you will have a fairly good idea of what to expect and how things really work. I want to show you that while you must study, if you are efficient and disciplined you can get by without studying long into the night on a regular basis. (But by no means am I going to give you easy study tips or a fool-proof studying system.)

I also want to pass on some essential information about third and fourth year which will not eliminate all of your stress or the awkwardness you will feel the first time you show your face on the wards but will at least give you an idea of what you are supposed to do.

Additionally, I want to make you aware of some of the potential pitfalls of the residency match so you will not make some of the mistakes I made.

Let’s get a few things straight, however. First, you will have to study in medical school. Someone who spends his undergraduate years trying to get into medical school and then blows off studying is a fool and will find himself as one of the tiny elite who are kicked out of medical school for bad grades. (It happens but not as often as you think.)

Second, you should know that many residency programs in highly selective specialties almost always require excellent grades and high class rank. If you want to do Dermatology or Ophthalmology as a specialty then I wish you luck but maybe you need to be reading a different blog.

Keep watching this blog for updates.

Things You Should Know

Uncategorized

Things that Suck About Medicine

1. People who don’t wash. Come on, folks. Soap is cheap. If I ran the hospital every patient, before being allowed to enter, would have to wash his feet, wash his crotch, and wipe his ass. Oh, and tooth-brushing, that’s important too.

2. Manual disimpaction. Enough said.

3. Overnight call.

4. Dumb, lazy, ignorant, irresponsible patients who will spend several hundred dollars per month on booze and smokes but can’t spare $15 for their Dilantin.

5. Nebulous, non-specific chief complaints like “my back hurts” or “headaches” which remain nebulous even after a meticulous review of systems and physical exam. You know, the kind of thing where when you are done spending half an hour with the patient you can only conclude, “Yes, you have a headache.”

6. Patients who think that medical students and residents make “six figures.”

7. Really, really fat patients. three-to-five hundred pounders. What’s the use? Can’t hear their heart through all the padding. Can’t palpate squat. They have every friggin’ complaint from OSA to knee pain. Their real problem is their weight so every treatment regimine we put them on is just an attempt to distract the Grim Reaper. Not to mention pelvic exams.

I bet nobody asks you, when you interview, how you will like being in a small exam room with a patient who hasen’t bathed since the Clinton Administration, is covered with his own urine, and is threatening to blow chunks or crap himself or both.

A Subversive Thought

Articles You Must Read, Uncategorized

Can You Be a Pro-Life Physician?

You all might as well know that I am very pro-life. Without arguing the merits of the position, I want to dispel a common misconception among medical students and physicians, namely that even if a physician is pro-life he must still refer a patient to an abortion providor even if, because of religious or moral principles, he objects to the practice and does not want to become an accomplice to what he considers a crime.

Nothing could be more removed from the truth. Almost all of the states have laws on the books which explicitly protect a physician from legal jeopardy for refusing to take any part in the practice of abortion. This includes referral.

These laws, collectively known as “Conscience Clauses,” are the best kept secret in the medical profession. In fact, when I was a medical student the faculty wanted to discipline me for taking this position. They called me for a meeting and were all set to chastise me severely when I calmly pulled out a copy of the pertinent law and, figuratively speaking, rolled it into a tube and deposited it in that place where the sun doesn’t shine.

Just for good measure I also showed them the law which prohibits abortions or the discussion of abortions at the public hospitals in my state (Louisiana) of which my medical school was one. And then, just to add insult to their injury I produced the official hospital policy which pretty much followed state law.

I have seldom been so right, from a legal point of view, in my entire life.

Now, the AMA and various quasi-official bodies will make a big deal about their “guidelines” and “standards of practice.” The AMA is blatantly pro-abortion. Just keep in mind that the AMA is a lobbying organization and has no power over any physician. Only state and federal legislatures can enact laws and these can only be implemented, as it applies to the practice of medicine, through duly constituted State Medical Boards.

The AMA can rage and howl, can puff themselves up into paroxysms of self-righteous indignation but I ain’t a friggin’ member of their club so I don’t give a rat’s ass. On this matter I am directed by a higher authority. And the law, not to put too fine a point on it, is the law.

Here is the applicable North Carolina law: (Italics mine)

North Carolina General Statutes:

§ 14‑45.1. When abortion not unlawful.

(a) Notwithstanding any of the provisions of G.S. 14‑44 and 14‑45, it shall not be unlawful, during the first 20 weeks of a woman’s pregnancy, to advise, procure, or cause a miscarriage or abortion when the procedure is performed by a physician licensed to practice medicine in North Carolina in a hospital or clinic certified by the Department of Health and Human Services to be a suitable facility for the performance of abortions.

(b) Notwithstanding any of the provisions of G.S. 14‑44 and 14‑45, it shall not be unlawful, after the twentieth week of a woman’s pregnancy, to advise, procure or cause a miscarriage or abortion when the procedure is performed by a physician licensed to practice medicine in North Carolina in a hospital licensed by the Department of Health and Human Services, if there is substantial risk that continuance of the pregnancy would threaten the life or gravely impair the health of the woman.

(c) The Department of Health and Human Services shall prescribe and collect on an annual basis, from hospitals or clinics where abortions are performed, such representative samplings of statistical summary reports concerning the medical and demographic characteristics of the abortions provided for in this section as it shall deem to be in the public interest. Hospitals or clinics where abortions are performed shall be responsible for providing these statistical summary reports to the Department of Health and Human Services. The reports shall be for statistical purposes only and the confidentiality of the patient relationship shall be protected.

(d) The requirements of G.S. 130‑43 are not applicable to abortions performed pursuant to this section.

(e) Nothing in this section shall require a physician licensed to practice medicine in North Carolina or any nurse who shall state an objection to abortion on moral, ethical, or religious grounds, to perform or participate in medical procedures which result in an abortion. The refusal of such physician to perform or participate in these medical procedures shall not be a basis for damages for such refusal, or for any disciplinary or any other recriminatory action against such physician.

(f) Nothing in this section shall require a hospital or other health care institution to perform an abortion or to provide abortion services. (1967, c. 367, s. 2; 1971, c. 383, ss. 1, 11/2; 1973, c. 139; c. 476, s. 128; c. 711; 1997‑443, s. 11A.118(a).)