If there's one thing that every medical student knows, its that medical school is really just a bunch of humbling experiences all strewn together under the ruse of "education." Most people out there know that doctors are smart. And that they know lots of stuff. But I don't think anyone can truly realize how much there is to know and how much practicing physicians DO know as part of their daily functioning. I have studied day and night for 8 straight months and still am barely able to interact on a fairly elementary level. And just when you start to forget that and start to think you might actually be making progress on this whole doctor thing, bam, along come some attending wielding his massive sword of knowledge, striking you down from your high horse to go mingle again with the peasants.
Take for example today in clinic. I was talking with a pediatric hematologist about an interesting patient I was about to see with him - a 17 year old patient with Blackfan-Diamond Anemia. The typical first line of treatment for this disease (a erythroid progenitor disease that prevents red blood cells from properly maturing) is steroids in hopes of resuscitating the patient's own marrow's ability to pump out those cute little RBCs. So the physician was discussing the various steroid treatments they have tried on this patient and asks me "do you know what some common clinically pertinent adverse effects to steroids?" I proceeded to stare at him like a stoned pufferfish.
Now, deep in my brain somewhere, I actually know some "common clinically pertinent adverse effects of steroids." They include weight gain, hypertension, osteopenia, and psychosis. But like 99.9% of the things I've learned this year, they were stuffed into my tired and overfilled brain and subsequently left to dissolve back into this bizarre long term memory twilight zone where they come back to me during weird moments like when I'm watching Futurama on a Monday night (read: now), but never when I actually need them.
Massive Sword of Knowledge: 1
Me: 0
Of course, I currently hold the ultimate wild card: the totally awesome "I'm a first year" card. Play this card in any situation and the attending will smile with a fond reminiscence at you, reward you for demonstrating any shred of medical knowledge whatsoever, and then proceed to explain things to you at the level of a first grader. If you've been there, you know what its like, and its truly hilarious.
But like all good things, the totally awesome "I'm a first year" card will come to an end. In exactly 10 weeks (not like I'm counting) I will graduate from a cute little first year to a second year. And then I might be actually expected to know something.
Uh oh.
Venti Coffee, Hold the Sympathy
Good news for me: Goodbye kidney. I have now put in my requisite time for the year learning about pee. Yippee.
Leading up to this last exam, I've noticed a trend that's been developing over the last few months. See graph:
The funny thing about burnout is how it sneaks up on you. Time starts to slip away from you, the days start to blend together, and before you know it you're sitting in starbucks with 3 empty venti cups strewn about you staring bleary eyed at the same page of notes you've been looking at for the last 1/2 hour, listening to the crazy woman in the corner talk on her corded phone thats not hooked up to anything, then getting a free 4th coffee from the barista who looks at you with a sad sympathetic look in her eyes as she says "you're always here."
Thanks for the free coffee.
Luckily, I have two of the most potent drugs possible for combating the dreaded burnoutosis (its not quite developed into a full blown -itis yet). The two magical medicines are:
-SevenDaysOfDrunkenessonix (generic name: spingbreakatol)
-Guinnessium (generic name: stpatraxia)
Applying my mad pharmacokinetics skillz obtained over this last block, I had my proper loading dose of stpatraxia on Saturday and now plan to work my way into therapeutic levels tomorrow, March 17th, the greatest day of the year. Hopefully this can help keep off some of the more severe symptoms of burnoutosis until I had get onto a steady regimen of sprinbreakatol on Friday. And yes, my life has now degenerated to the point where making lame jokes turning fun things in my life into fake drugs is highly amusing to me.
I have a couple cool stories from clinic to share sometime soon (one thing I've learned about pediatric oncology - there's always stories), but given my current level of motivation (read: none) it will have to wait. Maybe when I'm sufficiently medicated with springbreakatol (I'm so funny!)
Charlotte's Web
They say if you want to go into surgery you have to love the OR. I've always said yeah... that makes sense. You don't become a professional baseball player if you're allergic to grass.
Which brings me to one of the most disconcerting experiences of my life. From a very young age, I was fascinated by surgery. I watched operations on the Discovery Health Channel, the UW Medical Channel (which conveniently got pumped through the cable into my dorm room in college!). I've always envisioned myself as a surgeon. Told people I wanted to be a surgeon. People always told me I looked and acted like a surgeon. Hell even my Meyers-Briggs test matched me as a best fit into... surgery. Which brings me to my first OR experience in medical school.
After the initial thrill and the incredible sight of the surgeons disassembling someone's body (dramatic embellishment) and the OH MY GOD I'M IN SURGERY! ... I was bored. I'm almost ashamed to type it, but I was. My legs ached from standing, my goggles kept fogging up, and I couldn't follow what was going on. It was horrible.
The good news: things got better. The surgeons let me do a couple menial things a few times, which helped keep my attention better. But it still felt boring. And it scared me, because I almost felt like my visions of my future self were slipping away, and needless to say that was a bit frightening.
At the beginning of our Systems Processes and Homeostasis block, we got to sign up for a variety of labs which helped reinforce a variety of the concepts we were taught in class. One of the labs was a controversial lab where we worked with anesthetized live pigs, learned how to put in central lines, and observed various effects of the cardiovascular system with some manipulation.
I signed up for it, mainly because it sounded like a cool experience. I arrived in the lab this week and found our team's pig on the table, quietly unconscious and on a ventilator. Our team divvied up tasks and the task of cutting into and exposing the internal jugular vein in order to insert the central venous line landed on me (with a little bit of coaxing by myself).
Now, I've been through 12 weeks of anatomy and dissected and studied the entire human body (which was equally thrilling and boring). Any medical student can attest to the fact that working on a cadaver is both an exciting and frustrating experience. Things adhere to each other, vessels and nerves snap if you don't meticulously search them out beforehand.
With that in mind, I made my very first incision into live tissue. Unlike preserved tissue, the scalpel glided through the dermis as smooth as silk. The capillary beds bled then closed off as the body's clotting mechanisms kicked in. I found the fascial layer beneath the dermis and slowly dissected to open the incision. Unlike in a human, where the jugular is conveniently located in the easily exposed neck, in a pig it is buried down beneath layers of muscle and connective tissue. I delve deeper, finding an experience completely contrary to that of anatomy.
And it all clicked. I saw the thyroid gland, sitting with its glistening arteries wrapping themselves around the enclosed clusters of thyroglobulin. I saw the recurrent laryngeal nerve looping back up supply CNS control. I found the carotid, briskly pulsing with the powerful pressures of the heart. The vagus running down along as its mate to its destination on the heart. And I found the jugular, slowly pulling it out of its enclosing carotid sheath.
I finally understand and appreciate surgery. The elegance of it, the concentration needed during it. The care and the meticulous nature of it. I can understand why it can seem boring if you're not locked into the moment of it, but when you're involved in it, when you're focused so intensely on what you're doing, focused so intensely on what you're planning next, its like being in 'the zone.' If I end up in surgery (and I'm keeping an open mind throughout medical school) I think this will be the experience that I can look back and point to that sold me on it. Which is funny. Because if that's the case, I didn't decide on surgery because of some dramatic and amazing experience in the OR with a human. It will have been because of a pig.
Jesus, my future professional career can theoretically now be traced all the way back to Babe.
Past Self, Meet Self.
It's amazing how thing's in life come full circle. While in college, I was a 'child life' volunteer during the summer at Doernbecher Children's Hospital in Portland. We really didn't do much of anything clinical, but it was a great opportunity to get to know and connect with a great number of brave and incredible children (and families). I operated mainly on the 9th floor acute card ward, but would occasionally float up to the 10th floor cancer ward. Needless to say, the kids I met up on the 10th floor provided me with some of the most inspirational encounters of my life, and ultimately shaped my decision that no matter what area of medicine I went into, I wanted to subspecialize into pediatrics (screw the lower reimbursement!).
Well, I'm back. For the next 13 weeks, my clinical preceptorship will be on Doernbecher's 10th floor following and learning from a pediatric hematologist/oncologist. Nearly 3 years ago, I roamed the halls with a bright blue volunteer polo with a big red wagon in tow. Now I'll be roaming those very same halls with my white coat in tow. Besides the obvious opportunity for my own personal reflection on how far I've come in those past 3 years (and even past 6 months), it gives me a great opporunity to integrate those incredible experiences which made me want to be a physician in the first place into my current medical education and growth.
Cancer is tough. When kids get cancer its really heartbreaking, on an indeterminable number of levels. But the kids in pediatric oncology also showed me one of the greatest aspects of working with children in medicine: kids fight. They fight so damn hard. It's what makes pediatric oncology one of those most interesting areas of medicine in my eyes. The failures are that much more gut-wrenching. But the success is even more rewarding.
I think this is a great way for me to round off my preceptorship experience for the year. I got to work with an orthopaedic trauma surgeon... and learned that really wasn't for me. I got to work with a cardiology specializing in congenital heart disease... and learned that right now my passion still lies along those lines. And I get to work with a pediatric oncologist... which means I finally start to get to see and work with kids again.
That's my update for now. We just finished a particularly brutal stretch of the curriculum, 3 exams and 2 quizzes in 4 weeks. One more exam next week and I'm back to normalcy. And on that note, I'm out.
Drugs For Me.
We've reached the pharmacology segment of our education.
They say we will know 100-200 drugs by June. 500 drugs by the ends of second year. And over 1000 by the time we graduate. Right now I know... 12 (and three of those are aspirin, ibuprofen, and acetaminophen - I know, I'm so smart).
There's a lot of hate directed at the pharmaceutical companies in this nation these days, with their high prices and shady marketing tactics. I've started to hate the pharmaceuticals too, but for an entirely different reason: they have to come up with their own damn propriety name for every drug they make.
Say you're riding on the light rail and overhear a guy talking about how he had a bad experience with his sildenafil and had to go to the emergency room cause of... complications and the misses was hysterically crying the entire time in the waiting room. You would probably shrug off his comments, feel a little bad, go back to reading your New Yorker (you trendy ass), and queue up the next indie track on your iPod.
Now what if I say you're riding on the light rail and overhear a guy talking about how he had a bad experience with his Viagra™ and had to go to the emergency room cause of... complications and the misses was hysterically crying the entire time in the waiting room. Well then you'd probably laugh, dial up your college buddy on your phone, tell him the story then when he picks up then blast The Starland Vocal Band's "Afternoon Delight" from your iPod headphones loud enough the dude might hear it.
And its all Pfizer's fault that you might have missed a perfectly good joke in scenario #1 because they marketed their pill as "Viagra" (what the hell is that supposed to mean anyways?) instead of it's drug name: sildenafil.
Ibuprofen? or Advil?
Carvedilol? or Coreg?
Simvastatin? or Zocor?
Hell, the brand names don't even make sense. Celebrex? Sounds like a weird sex fetish, not a COX II inhibitor. Zoloft? Sounds like a planet in a galaxy somewhere, not a SSRI. Lipitor? Sounds like a name of an evil alien warlord out of Scientology (zing!)
But mainly I'm just pissed because it doubles the number of drug names I have to memorize.
Of course, it'll be worth it. We're finally reaching the part of our education where our lectures are for the most part directly related to the clinical aspect of medicine. Which is cool. Cause I kinda got into this doctor thing for the whole "helping patients" part and not the whole "memorizing 500 different enzymes" part. And its always fun when you start a new subject in medical school. It brings back a little bit of that "WOW! COOL! MED SCHOOL!" in me that was running out of my nose back in August.
So, for now...
WOW! COOL! DRUGS!
P.S. A big props to the people who have left comments recently. I love comments. They remind me people actually read this thing and I am not talking to myself all alone out in cyberspace. Way to go readers!
P.P.S. Just learned today that the propriety name for Benzocaine is HURRICANE®! Now that's what I'm talking about UltraMed! A name which inspires fear and confidence in your product!
Merry Chrismakwanzanukkah
DECEMBER 24, 2007
Driving by the OHSU emergency room today, I thought back to three years ago, when I shadowed an OHSU ER doc on Christmas Eve. Being in a hospital during the holidays is a very unique and interesting experience. The hospital staff seems to work together a little better, and those who have to give up their holidays with their families to roam the wards seem to understand the sacrifices each other had to make in order to care for patients. There's a certain soldier mentality to it, and the bond between staff seems to be a little more palpable around Christmas time. And inevitably, the holidays are some of the busiest days of the year.
During my shadowing experience, I saw a gunshot victim do into v-fib (ventricular fibrillation), bleed out and die on the table. I saw the doc have to tell a diabetic that they would have to amputate his legs. I saw countless people come in trying to score their pill of choice. Difficult experiences in medicine are always difficult, but seem to hit a little closer to home in the holidays. It's not coincidence that suicide rate is at its highest around Christmas. Christmas, for all its warm and fuzzy intentions, can often be an isolating time for those who don't have the family and friends to share it with that most of us do. Tragedy on Christmas has the unfortunate effect of bringing us back to reality, and a hospital around Christmas time is full of tragedy. To put a bit of an exclamation on the sights I saw, I left OHSU that Christmas eve three years ago and went directly to another hospital, where a friend's mother was in intensive care after having a stroke behind the wheel of her car. No one thinks they would ever have to spend Christmas in a hospital - until they do.
Be safe this year everyone. Take a moment and really appreciate the blessings you have. And have a merry Christmas!
Dear Journal,
DECEMBER 16, 2007
Christmas break. A time to sleep, I mean, reflect.
As I write this, I started med school exactly 100 days ago. It's really hard to quantify the change I've undergone in that time, but its really fascinating for me to think about it. I've been challenged more then I've ever been before: academically, socially, emotionally. I've developed an incredible capacity to absorb information, beyond what I ever thought was physically possible. I've witnessed medical miracles, children given life who in the past would have left behind grieving parents and a book full of "what if's." I've witnessed tragedy, people who I was talking to one moment and who slipped into death moments later as their heart quivered inside their chest. I've learned the power of the scalpel to flesh, the power of a pill. I've learned the subtlety of disease heard through a stethoscope, the devastating effects of a cancer that spreads to every reach of the body. I've experienced the thrill of putting someone back together with a needle and thread. I've learned I currently suck at putting someone back together with needle and thread.
I recently went back and read my med school application, skimming through all the points I spilled to schools about "why I want be a doctor" and "what I know about the medical field." It was amazing how much I was wrong about things. Medicine is definitely one of those fields that is difficult to "get" until you are in it. I remember back in August coming into school being afraid that once I learned what being a physician is all about that I would find it wasn't really for me. I think its a danger that we all face entering medical school, and there are stories of people who find out once they're in that they don't really want to be doctors.
Luckily, I've found myself more committed then ever to my career choice. Medicine is highly romanticized in our society and on our televisions, and I'm glad that after that glossy veneer was taken off that I still like what I see. But my visions and thoughts of who I will be when I finally move to practice on my own have definitely been shaped and shifted by the past 100 days. I think most of us come to realize we will not be those shining saviors riding into work every day curing disease with the touch of our stethoscopes. Real daily medicine is a lot more mundane then that. But there's still a thrill in it (and there still is the thrill of that truly miraculous cure every once and a while).
They say the changes you undergo in medical school only get swifter the longer you are in it. If I've experienced this much in only 100 days, I cannot even begin to predict what the next 100 (or 1000, yes I will sadly be in school that long) will be like. The time has been flying by, but the next 3.5 years still seems like a truly insurmountable climb. Luckily, I've learned that I can function much better if I break things down to much smaller pieces to chew on. The next week ain't bad and the next day is definitely do-able.
I think above all, I'm looking forward to continually gaining more skills in what I do. While being the wide-eyed new med student who looks at everything with wonder has been fun, I'm truly in my element in the realm of competency. It makes me frustrated to get pimped in clinic or the OR and to not know the answer. But I know I have to have patience, because such a large breadth of knowledge and such a radical transformation of my person can't come overnight.
Here's to the next 100 days.
Jiffy Lube Hospital.
DECEMBER 6, 2007
My car has a bad belt at the moment.
Which means it makes this awesome squeaking sound when the engine idles at a stop light.
(Which gets me plenty of looks from the ladies when driving downtown - 'Yeah baby, wassup? I'm ass-load in debt and my car is broken. But I'm gonna be a doctor! Wanna hop in?')
Since my life as a med student is a combination of incredible busy-ness and incredible laziness (for example, today I went to four straight hours of lecture, a presentation from a cardiothoracic surgeon, came home, passed out face down in my bed with my clothes and coat still on cause I felt like it, drooled on my pillow, woke up 20 minutes later in said drool, went to the gym, studied for four hours, and am now home effectively wasting my evening), I haven't been able to get my car in to get the sound checked out. But while idling at an unusually long stop light today and listening to the musical tones coming from under my car's hood, I had an incredible flash of insight.
Mechanics = Doctors. Or Doctors = Mechanics. Whatever.
The key is that there is an eerie amount of similarity between how a mechanic tackles a problem with a car and a doctor tackles a problem with you. Being the massive nerd that I am (contrary to my reputation), I just had to take the analogy further. So without further ado, here's the SOAP note for my car.
For those of you not in the know, a SOAP note stands for subjective, objective, assessment, plan - it's a specific method of writing notes in a patient chart used in health care to track patient history, progress, and future planning. There are specific sections to be covered in a specific order with a specific type of language - its one of those "medicine things" you never knew about until you get on the wards and realize you don't know jack. I'll break this one down for y'all.
|| SUBJECTIVE ||
ID/CC (Identifying Information/Chief Complaint): Patient is a black '00 Nissan Sentra XE Sedan who presents with an irregular squeaking sound deep to the hood which began unexpectedly three weeks ago. Patient reports squeaking as high pitched and inconsistent and occurs when engine is idle but ceases when engages in acceleration. Patient has not noted any worsening of squeaking since it began. Patient is concerned and annoyed by squeaking but has reported no other more significant symptoms.
PMH (Past Medical History): Patient reports no serious mechanical work done prior to the initiation of squeaking. Patient has no history of serious accidents. Patient has had routine maintenance performed at appropriate times throughout lifetime.
FamHx (Family History): '00 Nissan Sentra Sedans have a history of surge and hesitation, engine clatter, and transmission failure. Patient believes both parents exhibited symptoms of engine starter squeal and 5th gear popout.
SocHx (Social History): Patient reports aggressive but not reckless driving style. Frequently takes corners at above average speed. Does not drive while intoxicated. Undergoes frequent oil changes.
ROS (Review of Systems): No reported decrease in power of acceleration or performance in day to day driving.
Meds (Medications): Patient reports usage of regular unleaded gasoline.
|| OBJECTIVE ||
Vitals: Engine idles @ 750rpm. Gas mileage 24mpg. Radiator temp 170 deg. F
Physical Exam: Car appears clean and functioning well. Mild stratching and denting of fender observed. No abnormal smell noted from engine. Consistent shrill squeak emanating from drive belt. Sound ceases upon depression of accelerator.
Labs: Couldn't think of a good analogy for a blood panel or CT scan. So sue me, its almost christmas break.
|| ASSESSMENT/PLAN ||
Patient is a black '00 Nissan Sentra XE Sedan who presents with an irregular squeaking sound deep to the hood.
For the problem of the engine-focused shrill sound, the likely cause is misalignment of the drive belt. The following are recommended:
-Further tests performed on engine performance to rule out deeper issues.
-Replacement of drive belt.
-Further followup for reckless driving habits.
So there you have it, a SOAP note. These things are the bane of the medical students existence, making for long tedious hours of paperwork as we learn how to effectively write one, but to tie my analogy full circle, I'm sure mechanics would go through the exact same sequence when a car is brought in for service. They ask the customer what the problem with the car seems to be (chief complaint), whether the car has had any serious problems before (past medical history). They begin service with an idea of common problems for that make and model of car (past family history). They ask the customer a few specific questions about the nature of the problem (review of systems). They examine the car and run appropriate tests to find the problem (physical exam and labs). They then draw up what the problem is and what they need to do to fix it (assessment and plan).
So there ya go. Your doctor tackles your abdominal pain the same way your mechanic tackles your RAV4's windshield wiper problem.