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Posts tagged rotations

This video made by some fellow medical students is clever and entertaining. Medical school can drive you crazy, but thankfully while working our way through the process, we can find ways to escape and claim our sanity back. 

It’s an old joke: a long line of people waits at the Pearly Gates as St. Peter slowly checks them in, taking an eternity. Little guy in a white coat shows up, carrying a leather bag, stethoscope around his neck. St. Peter waves him through. “What the hell was that?” someone asks. “Why does that doctor get cuts?” “Oh, that wasn’t a doctor,” Pete says. “It was God. He just likes to play doctor once in a while.”

But it’s no joke. Whereas I don’t buy the “playing God” aphorism, I’ve had to make life-and-death decisions on occasion, and I don’t like it. I mean “life and death” literally: this person lives. That one dies. Saving a life is nice, and part of the job; failing to save one is horrible, yet inevitable. But deciding in advance — looking at a situation and concluding it best to let things go, or choosing to render help when the outcome might be regrettable — is a responsibility beyond understanding. Maybe it also comes with the territory, but who has the roadmap?

Bowel infarction is a good example. Dead bowel happens for a lot of reasons. Untreated, of course, it’s fatal. In operating, one may find — depending on the cause and the anatomy — a small segment of intestine the removal of which is not only life-saving but free of side effects; or you might find essentially the entire gastrointestinal tract dead and black. Removal in that case is possible, too, leaving the person entirely dependent upon permanent intravenous feedings. Or there might be enough small and large intestine remaining to handle oral intake with or without intractable diarrhea, with or without the need for complicated supplemental nutritional support.

And there you are, in the operating room at three in the morning, looking into a belly. No crystal ball, no outcome-prediction software; no moral counseling or ethics committee with two-cents worth of advice. What resources do you marshall; how do you decide whether to close up and deliver the bad news to the family, or to go ahead? Can you make a decision without interjecting your own moral values? Should you? Surely it’s conceivable that two people might make different decisions; ergo, it’s subjective. Who, then, has the right? Rarely, you may know enough about the patient to have an idea of what he/she would want. But how can you apply that when you’re not sure what kind of life will result from going ahead? Wrongful death? Wrongful life?

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As a medical student, you’ll have to be on call during your third and fourth year. Not only do you have the typical 10 to 14 hour work days (depending on the rotation), but you also have to study for the shelf exam, and the boards. On top of all that, those responsible for the rotation make you take call.

The last time I was on call, I had to come into the hospital at 5:00 am to do my normal ward work and round with the team. As soon as this got done, that blessed pager started going “beep beep”, beeping away. I ended up being busy — working for the residents (doing mostly scut work) from around 11:00 AM until about 1:00 AM, and then I had to get up a mere 3 hours later to go see my patients, and do it all over again. For those of you not in medical school yet –- or haven’t had the pleasure of experiencing call –- this scenario is not uncommon.

What’s the deal with the pagers from the 1990s?

I think most people have that thought sometime during medical school. When we get our first page as a medical student and hear it chirp, we get ridiculously excited — someone wants to talk to us! Inevitably, it’s just one of our co-students trying to figure out if they can page correctly.

The pager quickly becomes the heaviest thing we carry. Like Tim O’Brien’s, ‘The Things They Carried’, the pager becomes a marker of who we are. While we are at work, it is a tether, a leash we cannot turn off, a link to the hospital at all times. We learn to dread that vibration, to have a reflex of touching our hip whenever anyone’s tone goes off.

Anyway, what is it about pagers?

Is it an obsolete artifact of days of yore, still in place because of physician reluctance to change? The truth is, I’d very much prefer to do everything by cell phone — though giving out my phone number to all the staff would be worrisome. Furthermore, pagers are really inefficient; to text-page someone, I need to find a computer, log on to a secure website, send my text page, go wait at a phone for them to call me back, and then finally talk to them. Pagers, I suppose, remain in use because they are reliable. In the bowels of the hospital, few phones get reception, but pagers magically remain viable. Ahh, the bliss..

Tell me — What do you think about medical students having to be on call, and having to carry pagers? Come on now, I want to hear what y’all think..

I’ve been rather busy with my Internal Medicine clerkship as of late, but I thought I’d write a post on the importance of a History & Physical Exam (H&PE) in medicine. There are several basic pieces of information that can be joined to establish the proper diagnosis by us.  

These are:

1. History (which must be accurate, skillfully elicited, carefully interpreted, and coherently expressed).
2. Physical Examination (which should build on the existing information and provide clues for obtaining additional history).
3. Ancillary data (routine and special studies, consultations, etc.).
4. Observations of the course of the illness (usually less expensive and more rewarding than extensive excursions in the use of ancillary studies, e.g., lab).

Our basic thesis is that the vast majority of clinical problems should and can be resolved by the effective use of the H&PE. In most cases the history should be and is the most productive. You will find this conclusively and objectively demonstrated when dealing with patients about whom no history can be obtained. 

To put it another way, the diagnosis should be clear based on the present illness and related points of the history most of the time.  In fact, if the diagnosis is not apparent at the end of the history and the physical examination, there is little likelihood that such will emerge by the use of ancillary data/or special studies. 

Laboratory studies should be viewed and used primarily to confirm a diagnosis rather than make one. Furthermore, experience has taught us that thoughtful observation of the patient and his or her illness can be the most effective tool of complex, particularly chronic, problems.

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Medical students and their slightly more mature physician counterparts are typically competitive people. In order for us to jump through the hoops of organic chemistry, biology, physics, biochemistry, the MCAT reading comprehension section, and embryology, we need that inner drive to succeed. That drive is often helpful because it motivates us to learn, makes us work hard to achieve, and helps us find success.

And then there are gunners.

We can all spot them: They exist in every class, in every year, and in every medical school. They ruin the whole “helpful competition” vibe for everyone. It’s much easier to avoid them during your preclinical years, but what to do when you’re on a clerkship with them?

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Preclinical training is called preclinical for a reason: it will form the knowledge base for your practice as a clinical student, resident, and attending. However, it’s not always presented in a way that’s clinically relevant. That is probably the reason for the move in some medical schools to do more case-based learning.

That being said, having a strong preclinical knowledge base will make your clinical life much easier: it often tells you the “why” of clinical practice. If you can remember why a practice is a certain way, you don’t have to memorize X, Y, and Z: diagnosis and treatment will just be based on your background knowledge. Just a caveat: people don’t always work the way we think their physiology is “supposed” to work, so this doesn’t always work, but it often does.

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I get to work at the one that looks like it’s from a sci-fi movie! Starting from tomorrow, I’ll be rotating at Saints Mary & Elizabeth Medical Center in Chicago, IL.

I’m so excited, and a little anxious — that I just can’t wait.. We’ll see how it goes.

As I complete my rotations (clinical clerkship), I’ll be posting HIPAA friendly updates about my experiences as a Caribbean medical student at a major U.S. teaching hospital.

Your third year of medical school can be exciting and also daunting. Many students ask what the “best” schedule is for their third-year clerkships. Although there is no right answer, there are a few guidelines that can be helpful.

First, try to determine your chosen field of interest. Take some time during your first and second years to shadow physicians, talk to residents and faculty, and make an educated decision about your future plan. This is especially important if you want to go into a field that is either competitive or not a core rotation (such as dermatology, ophthalmology, or emergency medicine).

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It’s 3 in the morning. You’re a third-year clerk, and you’re 21 hours into your on-call day on a busy internal medicine service. Suddenly, a page from the emergency department; “Mrs. J, a 78-year old woman with a history of heart disease, is coming in with what sounds like a CHF exacerbation, and it looks like it’s going to be a direct-to-medicine admit.” You kick into gear, grabbing your stethoscope and your iPhone, and head down.

Because you’re feeling lazy (or tired, or whatever: It’s 3am), you take the elevator intstead of the stairs, which affords you a couple moments to think. “Wait a minute,” you think. “I’ve never seen anyone with CHF before, and I know I’m going to get pimped like crazy on this by my evil resident, Dr. X. I should read up before I get down there, or else I’m going to look like I don’t know anything.”

So you hit the emergency stop, pry open the elevator doors, and crawl out, sprinting to the nearest computer, and pulling up your go-to source for easy-access medical information: Wikipedia.

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I’ve seen this patient so many times!  Another reason to love the ED.