Final Exam: Book Discussion

What follows is an essay I wrote about Final Exam: A Surgeon’s Reflections on Mortality. 

“I had never expected to deal with the dying so intimately or to face mortality so directly.” Pauline Chen’s words reflect what I think many in the medical profession feel. She notes earlier in the book that she went to medical school to save people, not care for the dying. I think the potential for cure draws many to medicine. Whether directly or indirectly, we have felt the pain and dismay of disease and medicine offers a way to treat or even prevent that suffering. But the limitations of medicine become clear very quickly. We cannot treat or prevent all suffering, and even if we could we cannot prevent death. Death is something that each physician must face. As a transplant surgeon Dr. Chen is keenly aware of this fact. Her book takes us on her journey learning how to better respond to death and fill a huge void in her education.

I cannot remember a lecture on death in medical school. I know we talked about palliative care and hospice but I can think of little mention of what the death process looks like or how to care for someone who is dying. Dr. Chen had a similar experience. She notes the various ways she was exposed to death throughout her training, first with a cadaver in medical school, then as a part of her first code and then the first patient to die under her care. But the training in how to respond to death was part of the “hidden curriculum” of medical education, it was something she picked up from those around her.

Some examples made her uncomfortable like the resident who showed her how to declare someone dead, claiming “See how easy it is?” Other examples were more positive, like the attending physician who stayed with a family as their father was dying and explained what was happening. This changed how she interacted with dying patient’s families. “I stopped slipping away from my dying ICU patients and their families. Instead with my hand in my pocket, I would usher the families into the ICU. I would bring them to their loved one’s bedside and close curtains around not them but us. I would point to the irregularities on the monitor and describe the characteristic last breaths of the dying. I would touch family members, embrace those who looked particularly lost, and tell them of the final comfort of their presence.”

This passage resonated with me. I know if I were in that situation I would make any excuse to not be around a family during that time. I would justify it in my head, and tell myself I would be intruding in their moment. But this passage challenges me to face my own discomfort. In the midst of such sadness and confusion, I imagine it would be a great comfort to have someone explain what was happening when a loved one was dying. If I chose to miss that opportunity because of my own fear I would be performing a disservice to a family.

One of Dr. Chen’s more disturbing stories was about an infant. The boy named Max was born with a severe defect and required multiple surgeries to correct it. These surgeries led to complications which led to more surgeries. One of the complications was the need for a liver transplant. Dr. Chen’s team took Max to the OR on twelve separate occasions. He died as a result of a fungal infection. Dr. Chen was talking about the case with a nurse who remarked, “Maybe it was a good thing, huh? I mean, how much can you do to a person?”

There does seem to be a point in medicine where the treatment can become worse than the disease. This is hard to think about, especially with children. Stopping treatment may be viewed as giving up. With an infant there can be no comfort in saying, “Well he lived a good, full life.” But as I read the story about Max, I wondered how I would feel if he were my child. If I truly wanted the best for him would I continue to put him through multiple surgeries for a slim chance of a normal life? I truly do not know the answer. But it helps me to try and put myself in a parent’s shoes. I can use that to try and guide conversations about the care I will provide.

As a pediatrician I may not deal with death as much as other specialties. However I still need the tools and experience to guide parents and children through such an ordeal. Final Exam helped me realize some of the gaps in education I have in regards to issues surrounding death and gave me some ideas to think about how to address those gaps. While I still fear being around death (especially with children) I think I will approach the issue with more self-awareness. This will allow me to recognize my fears and subsequently better serve my patients and their families.

I pose this question to my readers: How will you deal with death as a physician?

AAP Conference and Step 2 CS

I’ve had a busy week. Last weekend I went to the American Academy of Pediatrics National Conference in Orlando (thank you AAP for the generous scholarship!) and yesterday I got back from Step 2 CS in Chicago.

The conference was a great experience, I met some awesome people and gained a better appreciation for what exactly the AAP does. I came away very impressed. The AAP does some great work overseas (see the Helping Babies Breathe project) as well as lobbying for children’s health in the United States.

Have I mentioned that I love Pediatrics? One day I’ll write about what led me to choose it as a specialty.

I also heard Atul Gawande speak! He’s a cool dude. He talked about how complex medicine is becoming and how we need better tools to handle this complexity (he advocates for the use of checklists). Good stuff.

Step 2 CS on the other hand was not so much fun. For those who don’t know, Step 2 CS is the “practical” Step exam. You see twelve fake patients and write notes on each of them. It also costs $1200.

I’m not a fan of this test for a few reasons. Check out this article which states:

“Of 17,852 examinees taking the exam in a given year, we predict that only 32 per year would not pass the exam on a repeat attempt. Even if no examinee had to use a loan to pay for the exam, the cost of identifying a single “double failure” would be $635,977; using the adjusted expenditure figure of $36.2 million, we calculate the cost as $1.1 million.”

Basically it’s an incredibly expensive test that serves little purpose.

Here is my question: why can’t we trust medical schools to administer this test? Get the AAMC to require a similar exam that meets certain standards in order to be an accredited as a medical school. Creighton already does this in order to prepare us for Step 2 CS and I have a feeling many other schools do as well.

Cut out the huge fees, cut out the inconvenient travel that interferes with our actual education (CS is only administered in five cities across the US) and cut out another source of anxiety for medical students. I see no downside to this.

Medical school sometimes seems like a series of hoops to jump through. While many are necessary, Step 2 CS seems especially arbitrary.

Anyway, sorry about the rant. Thanks for reading- stay tuned to the blog the next couple weeks. I am going to start giving away books that I no longer need and want to see others use! For free! It will be awesome.

Tips for the Third Year of Medical School

Forget what you know about 4927466850_53ce280aa5medical school, the third year is a completely different animal. On top of being able to absorb a large amount of information, third year will test your ability to adapt to new environments, communicate effectively and work well with others. What follows is a list of tips I think will help you thrive during the third year.

1. Be Flexible

It’s number one because it is probably the most important. You will likely be changing clinical sites every 2-4 weeks. This means learning a new system, interacting with new people and having different expectations. This is probably the most difficult part of third year. You begin to become comfortable and then you are shipped off to a new place. Roll with it, get used to introducing yourself to new people and smile.

2. Practice Empathy – For Everyone

I see empathy as putting yourself in someone else’s shoes. Obviously this is useful when interacting with patients, but have you thought about being empathetic towards your residents, your attending, the nurses or your fellow students? For each of these people I asked myself, how can I make things a little easier for them? I found trying to think about things from my resident’s perspective allowed me to be a more helpful and involved medical student.

3. Put Away the Smartphone

I know there are incredibly helpful resources available online and through smartphone apps. But in general I think it is better to keep the smartphone in your pocket. You may think you are being discreet but people can tell when you are looking at it and even if you are looking up something relevant it still looks bad. More importantly it is a temptation that allows us to be easily disengaged from what is going on around us.

4. Read about your Patients and their Diagnoses

Everyone will say this because it is true- it’s the best way to learn. Things stick better when you can attach them to a real person. Countless questions I have answered on exams thinking back to clinical experiences I had with patients. It also allows you to ask relevant questions to your attendings and residents. You can say something like “I was reading about this, can you clarify something for me?”

5. Expand your Reading Beyond UptoDate

UptoDate is a useful and simple to use resource. If you want to go a little deeper, nothing beats finding relevant journal articles. I have found very helpful articles by searching Pubmed and specifying “Review” under article types on the left side.

6. Emulate the Best

You will have the privilege of working with and observing many physicians during your third year. Carefully observe the attendings and residents you respect the most and incorporate what they do into your own practice. What phrases do they use when they talk with patients? How do they talk with each other? What physical exam tricks do they use?

7. Adopt a “Craftsman” Approach

I highly recommend Cal Newport’s book So Good They Can’t Ignore You. In it he advocates for a craftsman’s approach to all kinds of work. Essentially that means identifying skills and then constantly practicing and improving those skills. This can easily translate to medicine. Taking a history is a skill. Physical exam. Suturing. Communication with others. All these are skills that can be practiced and improved upon. Find areas you know you need improvement on and actively seek out opportunities to practice.

8. Relax

I hope I haven’t seemed too intense with these tips. Being perfect all the time is impossible. You have the freedom to make mistakes. Ultimately, if you show up and are eager to learn and participate third year will go great for you.

That’s all I’ve got for now, I hope these are helpful. What tips have you found to be useful during the clinical years?

Photo Credit

On Third Year

Perhaps you’ve noticed a lack of posting on my part. Perhaps not. Either way I want to address why I haven’t been writing much recently.

It is not for lack of ideas of what to write about. In fact it may be the opposite: I feel paralyzed by how much I want to express. I have so many stories, observations and random thoughts about my third year of medical school that I’m not sure where to begin.

Let’s start with one general observation: the third year is a lot more fun than the previous two years of medical school. Knowledge actually comes easier as I apply what I am learning to actual patients. It is much easier to wake up in the morning knowing I will actually have meaningful experiences with patients and colleagues. Lectures are fewer and generally very practical.

But there are difficulties too. Just as you start to get a little comfortable , you are shipped off to a new location to start over again. Even within each rotation I’ve been at a different site each month. At my last rotation the staff was so used to new students each month one nurse just called me “student” the whole time even though I worked with her every day. She slipped up once though and actually said my name and the other staff joked about how that was a big deal. Ha.

I can’t help but look forward to a little more stability. Working with the same people, learning their names and understanding their expectations. Working in the same place and knowing simple things like where to find a bandage. Having a well defined role. Can I look forward to these things in residency? I guess we’ll see.

How I Became a Patient

Four weeks ago I was riding my normal route to the hospital, a ten minute trip on my bicycle most days. It was cold and windy but there was no snow or ice on the roads. There is one spot along the way where I make a left and then an immediate right turn.

I make the left turn.

Then nothing. Darkness.

The next memories I have are cloudy and dreamlike. I remember handing my school ID and health insurance card to someone at a desk. I vaguely realize I am at the hospital but I don’t know why. My face hurts. A young guy tells me I was in an accident and he brought me to the hospital. He is using my phone to call my wife, I stumble through some expression of gratitude and then he is gone.

That is how I ended up a patient at my own hospital. I was on my surgery rotation, so I had been working with the residents and physicians that were seeing me. It was… a little weird. I remember apologizing to the trauma resident for creating more work for him. I was a little out of it but I legitimately felt bad. Ha.

Overall, the experience has lead to some positive things. Before I get to that, let me just say that I am fine. I was wearing my helmet. I stayed in the hospital one night as they wanted to repeat my head CT the following morning. I have a nice scar from a gash on the right cheek (see below). I had headaches for about a week, but returned to work after a few days off. I still can’t remember exactly what happened. I think my bike just slipped as I made that turn. I seem to have about 15 minutes of memory I’ll never get back. As far as I can tell there are no other residual effects, but if I failed my surgery shelf I am blaming the traumatic brain injury.

My experience with the hospital was very good. I hope I wasn’t treated very differently, but I have no way to know for sure. I did learn how overwhelming it felt to be surrounded by a team of physicians and students. It’s amazing how quickly your mind can go blank when the doctor asks “Do you have any questions?”

This whole thing has lead to a lot of jokes. It’s funny how many people will ask me what happened and before I even respond they’ll say, “I should see the other guy, right?” I wasn’t even going to say that! I also had a few fellow students accuse me of crashing on purpose so I could get out of my surgery rotation. Surgery was rough but it wasn’t that bad!

My favorite so far was a patient I had this week in clinic. She asked about the scar and I told her the story. Later we were talking about her quitting smoking, and she said “Everyone has bad habits. For you, it’s falling.” Touché.

Some other upsides: I have always been a big proponent of helmets and now I have a personal story to use when I implore people to always ride with one. Also, a random stranger helped me out of the street and brought me (and my bike!) to the hospital. Faith in humanity restored!

Today I swapped bike crashing stories with a elderly gentleman. He said that into his fifties he was riding 40-50 miles a day. I was so inspired I had to get back on the bike. He I am four weeks to the day after my accident:

photo (26)

It’s good to be back!

Need somewhere to Stay During an Away Rotation? Trying to Sublet your Place? Check out RotatingRoom.com

RotatingRoom is a great idea that solves two common problems for medical students.

First, where do you stay during externships or away rotations? If you don’t have a family or friend in the area and the away institution isn’t helping, you may be stuck with an expensive hotel stay or a sketchy place found through craigslist. RotatingRoom allows you to find available sublets from other medical students.

It also allows you to sublet your own place, giving you an opportunity to cover rent while you are away on your own rotation.

The site is simple and well designed. And free. Find or list your room here.

Obstetrics Abroad

Tomorrow I take my OB-Gyn shelf exam, marking the end of my first clerkship this year.

Today I stumbled across this photo from National Geographic. The caption reads:

  Asia, a 14-year-old mother, washes her new baby girl at home in Hajjah while her 2-year-old daughter plays. Asia is still bleeding and ill from childbirth yet has no education or access to information on how to care for herself.

I could say so much, but is it really necessary? Ultimately these are the sort of health inequalities I hope to be working toward solving in the near future.

Saving Money While in Medical School

Note: This is a guest post from Elsevier Health.

Medical school is expensive. It is a time where being thrifty and more conscious of how you spend your money can pay off in the long run. You may have to prepare yourself for this lifestyle change. The median tuition at public medical institution was $28,685 and $46,899 at a private institution in 2011-2012, according to the Association of American Medical Colleges. Keep in mind that this does not include textbooks, lab fees, food and housing.

Student Discounts and Renting Textbooks

First and foremost, you can use your student status for discounts. Your student ID card might come in handy at museums, movie theaters or restaurants. Check business websites to see if they offer student discounts. Student Rate offers local and national student discounts that can aid in saving money on computers to clothes. You can research online and take advantage of daily deals you come across on Groupon or Living Social.

Using coupons and online discount codes can also save you tons of money. From food and house cleaning needs to school supplies and books. Taking the time to cut out coupons and researching for discount codes for online ordering is a smart and easy money saving technique.

You also have the option today to rent textbooks through the new e-readers that are available, such as the Kindle or iPad. Books can be easily purchased and downloaded through Amazon and the iTunes store. You only pay for the amount of time you need the textbooks, such as a semester or two. However, when you are in the medical profession, it is often helpful to have textbooks handy for future reference. Purchasing hard copies of textbooks are often the best option for medical students. Looking up promotional codes online and comparing various textbook sites for the best prices is very helpful.

Take Advantage of Campus Resources

Using resources available on your campus is a great start to saving money during the school year. For example, take advantage and utilize the campus library. The library is filled with free books for studying or reference materials. Free Wi-Fi and computers are also available to you. It is also full of space for you to study quietly and effectively.

You may also want to see if your campus has a gym that is free for students. Staying healthy and fit will help relieve stress and focus better on your work.

If you live off campus, doing away with a TV will also help in lowering your living costs. Between schoolwork, rotations at the hospital and studying, you will most likely find that you have very little down time to watch TV anyway. Full episodes of your favorite show are most likely streaming on the internet, or if you’re a sports fan, head to a friend’s house to catch the game.

To save on food, perhaps there is a discount for employees at the hospital in which you are working? Making coffee at home and cutting out cups of coffee from Dunkin Donuts or Starbucks can save significant money as well. Eating healthy on a budget may not be easy, and as medical professional, you
know high sodium foods such as Ramen Noodles or Campbell’s soups, while affordable are not exactly healthy. Finding healthy foods on a budget may be hard but worth the investment.

Keep in mind that you are doing a noble thing. You are educating yourself to become a physician someday. Soon you will be saving lives and helping people stay healthy and live longer. Keep in mind that this point in your life will be a distant memory someday. Embrace your time in medical school and enjoy your experience while it lasts! Saving money is helpful, but remember to treat yourself as well! If you score high on a test, go out to dinner or to a movie with friends. If you find you have some extra down time, attend a party, or hang out with some close friends. Keeping sane and staying true to you is very important – to you and your patients!

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Relief, Disappointment and Fun–Yep I’m in Med School

I received my Step 1 score yesterday. I was relieved to find out that I passed! This is a huge step (ha ha) towards becoming a physician.

At the same time, my score was well below what I desired. It was not a complete shock as I struggled with some practice tests before the exam. I hoped to have a similar experience to the MCAT, where I scored 2 points higher than any practice test I had taken. That was a foolish hope.

I don’t need to get into exact numbers, but I will say that my score was below the national average. This is not the end of the world. Obviously 50% of test takers are in the same boat. But I am a little worried about it limiting options for my future. I have never had much desire to enter a hyper competitive specialty but I would like to end up on the west coast and have heard that residencies there can be more competitive in general.

So relief… and disappointment. I know that Step 1 will be just one aspect of my application programs will look at. I know a higher Step 2 score can help. I know I will still have many options. But a higher Step 1 scored would have relieved some pressure, and honestly any way to take a little pressure off in med school is welcome.

I can’t change my score now. What I can do is continue to take every opportunity in my training to make sure I’m the best physician I can be.

And that brings me to fun. I have been in third year for about a week and it already is so much better than the first two years of school. Delivering babies, assisting on surgeries, talking to real live patients – it’s all fun! I am actually doing something, and learning a ton at the same time.

So goes the roller coaster that is medical school.

Congratulations to all the new MDs and DOs!

Several med student bloggers that I follow recently graduated from medical school! I want to take the time to acknowledge their hard work and perseverance. I appreciated this post by JeffreyMD, where he notes “In the grand scheme of things, I am still at the beginning. I have ‘leveled up,’ but I’m still at a very low level.”

You may be still at a low level, but you’ve still accomplished something great. Congratulations!

Here are a few other new physicians who just “leveled up.”

Medaholic

Off-White Coat

Adjacent Possible Medicine

Doctor Fishypants

Medical-School-Insider