Random Thoughts: My attempt at a cynical post

Thoughts that defy categorization or enough bulk to earn their own post. Oh, and when I started this blog I wanted to at least be somewhat like my e-idols The Fake Doctor (Ah Yes, Med School) or Fingers & Tubes in Every Orifice, because for some reason I find it hilarious and way more entertaining than "Today in med school I felt..." so I will try to sound more cynical than usual. Now that I've read The House of God (which I hope to post a review of sorts about soon), I feel like I might have the hang of it. Tell me how it goes.

• Horray for pyjama day tomorrow in class. I'm sure our tutors for our morning small-group sessions will be anxiously awaiting assigning our "Professionalism" marks when they see me and my classmates in loafers and a robe. (Yes, we do get marked on Professionalism.) I went and bought pyjamas so that everyone else in my class thinks that I wear some sort of clothing when I go to sleep. I guess this 'event' is because we can't look forward to a career wearing something as comfortable as pyjamas (implication: scrubs), we have to have pyjama days during our training, apparently.
  

• I didn't expect so many people in my class to gasp or moan "Eeeeewww!" when shown disgusting photos of fungal infections. You're in frikkin' medical school. Did you not expect these photos?! They're why I signed up. In my first day of undergrad microbiology we were shown large, graphic photos infected penises. Not sure what my prof's obsession was, but you get the point.
  

• It's kindof funny watching med students during a lecture on head and neck facial anatomy. Everyone has the desire to palpate their facial bones, for some reason. I guess they're just trying to do their homework in class so they don't have to do it later.
  

• If you ask the prof a question, make sure it isn't something they JUST covered. And don't turn and talk to your buddy behind you about what you are doing for lunch while the prof is answering your question.
  

• So far we have been strictly told NOT to be giving out medical advice. Funny, for a profession that revolves around giving advice, you'd think they'd be training us to do this right from the start. I've given plenty of advice on this blog. Sorry.
  

• Even though in the first week or two I heard a lot of "I'm not sure how I got in" or "I'm waiting for the call to tell me I was a mistake admission," now there is none of that. I guess people in my class are too busy having their feet kissed by pre-meds. The other reason I went into med school. Just kidding.
  

• Dear Administration, If you are going to tease us with complete note packs for the first few weeks, please tell us in advance that you're going to stop making the note packs complete and force us to start printing some lectures individually so we don't rely on you. You have developed laziness in all of us and for that you should be ashamed, and I refuse to take blame. Oh, and hire a new receptionist. The one you have now is a, well, let's just say massive cholesterol reservoir that refuses to help anybody and about whom people talk behind her back. Friends 4vr, Vitum.
  

• Why do people get upset when the 'patients' in the case-based learning cases die? Here's a quarter, go buy yourself some emotional stability. Who cares if it's a kid and the doctor messed up. It's fiction. Learn the lesson from the fictional case and move on. Patients won't die when we get into the real world, anyways, unless you're a crappy doctor. Oh wait, they will. You might as well develop resilience now so that you don't burst out crying like an infant in front of a patient's family. While sensitive is a good thing, so is imperturbability; did you even read the first chapter of Sir William Osler 1849-1919 A Selection for Medical Students, which you got in the first week of medical school?
  

• To the person who e-mailed Ask Vitum (actually, left a comment) about what wallet to buy for someone who wears scrubs, sorry I didn't get back to you but a) you tried to communicate with me during finals, which is a no-no, and b) you're asking the wrong person. I only get to wear scrubs to anatomy lab so far and I don't take my wallet in because the smell of death tends to get into everything and I don't want my MasterVisa to smell like morbidity and mortality the next time I buy Skittles at the convenience store. People will point and stare. I don't do anything in a hospital, let alone in scrubs, except when I shadow doctors, or walk through the emergency ward in my downtime with my ID badge clipped on to make myself feel important, which I will never admit to actually doing nor doing often.

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"Oh, you can come in for this, it's not a breast exam."

It turned into a breast exam pretty quickly.

I was at a family physician's office for my mandatory Family Practice class. I'll be going 14 times this semester. Typically its the one time each week we 1/8th doctors can actually put on our humbling little short white coats (white enough to look doctor-ish but not long enough to look cool - especially for guys), fling our hardly-used stethoscopes around our necks, walk proudly into actual clinical exam rooms, and see real, live, sick people. Maybe ask them a few questions. And hope not to get sworn at by patients (speaking from experience here).

It would be anything but a typical day. I was told that my clinic partner, being of the female gender, would be interviewing the next patient. 'This patient is here for a breast exam,' said the doctor, "so Vitum, maybe you can sit this one out." I didn't mind. I was entirely used to - and comfortable with - not observing something like this until I have been well-trained in the process.

My clinic partner interviewed the patient briefly, then came out of the room and described the patient's complaint as a lump below her left breast. The doctor told me: 'Oh, Vitum, I suppose you can come in for this, then; it's not a breast exam.' He checked if it was OK with the patient and it was. In I came.

It turned into a breast exam pretty quickly.

I'll admit that a while ago I was a little nervous about how I'd end up doing my first 'intimate' or 'gender-specific' examinations - nervous enough to do a bit of research on the subject. After doing Google searches using creative combinations of the search terms "medical student," "breast," "exam," "vaginal," and "how the hell do male students not show signs of awkwardness or even arousal when being taught to perform professional medical exams on patients," I censored my search results and carefully chose a link and hoped to find something telling me something of the process.

I got lucky. I ended up reading a well-written article by Jules Lipoff, a second-year medical student at the Albert Einstein College of Medicine entitled "Dr. Strangeglove, or, How I Learned to Stop Worrying and do Breast and Pelvic Exams." That article appeased some of my misconceptions about training in these areas. While I had initially pictured being herded into a patient room at a hospital with 7 other medical students following a resident or attending physician and being instructed to 'check out' a patient, one after the other, I was relieved to see that the article addressed
a) thoughts...of ...and during ...the experience,
b) the fact that medical schools work hard to increase professionalism and minimize awkwardness by using trained clinical educators, from whom medical students gain both insight and practical experience, and
c) the fact that students have fair warning about when their first exam of this nature will be (the students in the article were given a month's notice).

I didn't get a month's notice. "We might as well do a breast exam since it's been a while since we've done one with you." The patient consented a little too readily.

When something happens in front of a patient that's a little shocking, as a medical student with common sense you know it's not right to make it obvious that you're going through mild forms of shock. So I hid my surprise at the fact that I was not expecting to watch a breast exam, and yet now, here was one being performed, right in front of me. "Use this part of your finger and go in little circles," said the doctor. "They say to spend five minutes on each breast when doing an exam, but I never have time for that in my practice." I didn't catch much else. My mind was busy reeling from the situation.

Fortunately, the patient didn't add any awkwardness; she was totally fine with the whole situation and was chattering away happily about the history of her originally "A-cup" breasts, her choice to acquire implants, the rupture of said implants, the removal of said ruptured implants, and subsequent natural growth of a well-endowed pair after said removal of said ruptured implants.

My mind continued reeling. In fact, I was still getting over what I was watching when the doctor turned to me and said, "Vitum, your turn."

Damn.

I'm not sure how well I hid the shock that was pretty much taking me over at that time. It was enough to watch this. Now I was expected to monkey see, monkey do. What was I going to do, say 'no'?!

So, somehow confidently, I stepped forward, and reached out, and put my hand down on the breast of a woman whom I'd never met before, a woman that was old enough to be my mother. I still have to get used to how much nakedness doctors see. I began moving my hand around in circles, like I'd been shown. I also began thinking to myself, "Think professional thoughts."

Looking back, I don't think I did that for more that about six seconds before I stepped back to let my clinic partner have a go at it. "No lumps?" said the doctor. My mouth made some sort of a sound, and the doctor replied, "Good!"

So that was my first breast exam. Yay for me for reading up what my first clinical breast exam would probably be like, and yay for it being absolutely nothing like that.

You never forget your first time, do you... especially if it's as unexpected as that.

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Speaking of repetition....

Speaking of repetition, my Clinical Skills small group learned how to take blood pressure today. Again.

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My faculty's Admissons Committee has great taste

Other than a few exceptions, I'm really encouraged by the exceptionally good taste that my Faculty of Medicine has displayed in choosing our class. (And by exceptions, I'm not referring to myself. I'm one of the good-taste choices. Obviously.)

There are some incredibly fascinating people in my program. Students who have competed in the Olympics, played various sports at a high level, been politicians, media pundits, entrepreneurs and businessmen, matriculated from the world's top universities, or defended our country as soldiers or fighter helicopter pilots... there are so many people in my class whom I admire that I had to write a whole other post about it.

Beyond the incredible accomplishments of individual students, it's neat getting a group of medical students together and taking a look at them all. While there are differences between us, we're all so similar in many ways. A lot of us are really motivated, driven, and clearly know what we want to do with our lives (and in some cases that has come after trying several different things). We all care a lot for other people, and we are generally quite outgoing and love to chat (though this results in our class sometimes being overly chatty and not shutting up when it's time for class to start).

The thing that has fascinated me the most, however, is this: while everyone in my class brings a huge skill set to the table and our class is generally very intelligent, there are hardly any nerds; most people are really well-rounded and involved in a lot of different things. It's really interesting meeting people who are really outgoing and seem like your average cool guy or girl, but then you see them in a small group or talking about something we're covering in class and you suddenly see a brilliant side of them you haven't really seen before, watching them talk about the voltage-gated potassium transmembrane ion channels that play a role in the regulation of the insulin release from beta cells of the pancreatic islet, or something like that.

We've got a class full of really quality people, and it's been a blast getting to know everyone. I'll be proud to refer my patients to almost any one of my classmates someday, and I'd be willing to put my life in their hands.

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Learning by repetition, repetition, and repetition

A comment left on my blog on an earlier post reassured me when I wasn't sure if P = MD was such a good idea. My good friend and mentor "Anonymous" wrote, "a 60% average in non-clinical years will still set you up to be a very competent physician-in-training during your clinical years."

This came to mind again in our Family Practice class today. We were taught in lecture how to write notes in patient charts using SOAP (Subjective, Objective, Assessment, Plan) and how to FIFE our patients...

...for perhaps the fourth time.

Clearly, Mr. Anonymous was correct in telling me something that I now know well about med school: They won't let us out of here not knowing the important stuff.

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Reflection upon Semester 2, written on the eve thereof

After a bout of finals like that last one, I've really enjoyed spending the Christmas break at my parent's house, just vegging. For the first Christmas break in perhaps a decade, I have not been anxious to start school again. I feel like I'm still recovering from finals.

Over the past fortnight the stress of finals has slowly melted away, and my thoughts of dropping out and switching careers (discussed previously) have faded.

During the break I watched a lot of TV, since I deemed that as a responsible and debt-laden medical student, I ought not own one of my own.

As a result, last semester I studied a lot more than I would have, had I owned a TV.

Okay, that was a lie.

I studied a bit more than I would have, if I had owned a TV. Throughout the semester, until my three weeks of final study frenzy, I supplemented my lack of television with a healthy regimen of YouTube, Google Video, http://www.yourtvlinks.com/, Facebook, and the like.

Also during the break I began reading a pair of medical novels. I have already finished reading this year's Giller Prize winner Bloodletting & Miraculous Cures, and am 80 pages into a book I've wanted to read for a while, The House of God, which is enough to produce several laugh-out-loud moments and to allow me to highly recommend it to anyone who dreams of being a doctor some day. I'll post more about those books here in the near future.

Anyways, now that finals are over, and it's the day before I start the actual medical curriculum, learning about diseases and medicine and the like (the things I expected to be learning about in med school), I am looking forward to school starting again with mixed emotion.

On one hand, I am very excited to begin the semester. I'm living my dream right now. I'm doing what I fought so hard to be able to do. I made it through first term finals successfully (anyone beyond first term in medicine, shut up and let me enjoy my small victories, I have already been told several times by several friends and classmates that of which I am very aware: 'it gets harder'). I'm excited to head back to school and start learning physical exams, surface anatomy, how to actually use a stethoscope properly, and spend more time in the clinics and learning about actual pathology and pharmacology, the things doctors do, diagnose diseases and make the pharmaceutical companies happy. And I'm surrounded by great people in my class and have already made some quality friends, and it will be really good to see them again.

But on the other hand, my entire first semester has been 20% learning basics of human physiology (the provided curriculum), and 80% learning how much doctors know compared to how little of that I know now. And now that we're jumping into the content of the preclinical* medical school years, I'm realizing that this coming semester is going to be a lot of work, and a lot of learning, and a lot of time spent studying and even less time socializing. It's a bit intimidating. I'm not quite sure when my time to be overwhelmed by studying will come, but I know it will, and I expect it to arrive much sooner than it did for the first semester.

So, despite its feeble motor, apparently the clock in my house is still strong enough to drag the inevitable commencement of Semester 2 towards me. I guess I'll accept the challenge with open arms and an open mind and give it my all, and try my best to experience more excitement than panic during the inevitable coming storm.

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g l o s s a r y
a bonus feature added for this post exclusively

added in light of the fact that there may be those readers out there who,

unlike myself,

have chosen not to spend their entire post-primary school lives

obsessing over the process of becoming a physician

*Preclinical: another term for the first two years of medical school. Traditionally, medical school is composed of four years; the first two are preclinical years, involving class time and lectures, followed by two years of clinical years, time spent in clinics / hospitals. Some medical schools in Canada, though, specifically University of Calgary and McMaster University, offer a three-year program by not giving their students the summers off.

Despite the traditional divisions of preclinical and clinical years, medical schools in North Amercia are now increasingly exposing medical students to patients in their preclinical years of education, thus reducing the accuracy of the term 'preclinical' as it is currently used. I spent four afternoons in a Family Practice clinic last semester and will be in clinic 12 times this coming semester.

A few physicians I have spoken to have said that this change -- combined with the fairly recent habit of selecting medical students for personality and not just for marks by way of the admissions interviews, essays and the like -- is a drastic improvement in the way physicians are now trained.

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Observing Brain Surgery, or, "I can see it thinking!"

As soon as my classes ended on that specially marked day in my calendar, I headed from school towards the hospital. On the bus, I paged the doctor who had replied affirmatively to my e-mail shadow request, as per his directions. I was lucky to have had case-based learning that morning; our small group tutor was an MD who worked at that hospital and was happy to explain how to page the surgeon, a medical procedure I had not yet been trained in. I paged him, and got no reply, so I called his office and his friendly secretary with the British accent told me that he was in operating room 19, and gave me the extension for the phone in the OR.

After debating in my mind whether or not it was appropriate to actually call the OR, I finally worked up the courage to phone. A very friendly voice answered and after I introduced myself and explained that Dr. Otto had agreed to let me shadow, the voice identified itself as Dr. Otto's resident. "We're in OR 19, come on up." I explained that I had never been to the operating rooms in that hospital before. "Fine, that's no problem, page me when you get here at 35-26104, and we'll get you up here." After I hung up I felt a little embarrassed for being nervous to call, but I was relieved that I had chanced upon a friendly member of the health care profession, and that I had chanced upon him between surgeries.

As per his directions, I paged him from the info desk in the lobby of the hospital, and waited for fifteen minutes. No reply. I knew the OR was on the 4th floor, so I decided to go find it on my own, not bothering to waste my time asking the info desk staff, "How do I get into Operating Room 19?" I assumed that they aren't there to answer such questions for people who seem to be members of the general public, as I probably did.

My decision to search for OR 19 on my own led to what must have been the oddest part of the afternoon for me: one minute I perceived myself looking like a random person off the street wandering through the hospital where I didn't necessarily belong, and the next minute, I was wearing scrubs and a mask, standing in an operating room and looking at a living person's brain.

While I was making my way to the OR, pointed in the right direction once or twice by helpful nurses and hospital staff after explaining who I was and ready to brandish my "this bumbling person is a doctor in training" credentials, I became very appreciative of my extensive experience in operating rooms during my pre-med trip to Nigeria. Had I not learned the rituals and rules of the operating rooms in Nigeria, and had I gone trying to find my way into the OR without this experience, I could very well have busted into the OR after maybe trying to scrub in like I'd seen surgeons do on TV, wearing my street shoes and lacking a hairnet or mask. Fortunately I had been briefed on OR rituals long ago and knew to slip on some shoe covers, put on a surgical cap, and find where they kept the masks, and that observers don't spend five minutes at a sink brushing all surfaces of their hands, fingernails, wrists and forearms. Scrubbing is only for the people lucky enough to be assisting or operating, not observing, and I would not be offered the opportunity to assist my first time watching neurosurgery. This was entirely fine with me, and I assume the patient as well.

When I got into the OR, Dr. Otto, the neurosurgeon was incredibly friendly. He greeted me cheerfully, and after the surgery was well underway he was happy to provide the odd clinical tidbit here and there. "Come look, Vitum, here's the cerebellum... pulsating... as it should." Wow, I thought. I can see it thinking. It wasn't moving rhythmically like a large vessel with blood being pumped through it at regular intervals; instead, it almost looked alive, like a jellyfish or the head of an octopus undulating gently and peacefully within a protective layer of bone that had been chipped away to reveal its hiding place. "What happens to the bone after the surgery? Does it grow back?" I asked. "Nope." I pictured this person recovering with a soft spot in the skin on the back of their head, where they could poke their brain through the skin and muscle using their finger, and presumably affect their balance or other functions associated with the cerebellum.

As interested as I had been in surgery after my time in Nigeria and before observing the brain surgery, I soon became impressed by how bored I was with the procedure. There was a lot of waiting on my part; a lot of meticulous cauterizing (burning) of blood vessels in the process of removing the two tumours, each smaller than a walnut; a lot of slow cutting and bone chipping before that; and a lot of slow sewing after that.

So, to not spend my time craning my neck around the operating doctor and assisting resident and observing clerk (third-year medical student), I spent a fair bit of time chatting with the other members of the health care education hierarchy who were coming in and out of the room. The clerk on rotation in surgery took me over to the X-ray monitors in the corner of the OR, and spent some time explaining the basics of looking over and presenting an X-ray. "First make sure it's the right patient. Then, check the date. Comment on the other things in the X-ray; ECG wires, or chest tubes and the like. Move on to the quality of the film; if you can see the vertebrae distinctly it's a good exposure." He continued on through the art of presenting an X-ray, using a film from a surgical patient from earlier in the day who had developed acute pulmonary edema. I was excited when this condition was mentioned in lecture a few days later, and I already knew what it was from my time shadowing in the OR.

The neurosurgery resident was very chatty and also friendly, as I had experienced on the phone. He told me that a prerequisite of being accepted into the neurosurgery residency is that you have to have a girlfriend before you start, because you sure as hell won't have time to meet a girl while you're a neurosurgery resident. I actually ran into him in the ER when I was shadowing another ER doc a couple weeks after I shadowed brain surgery; at first I knew that I knew him from somewhere but didn't know exactly who he was until shortly after he started talking to me. Honestly, I would probably have recognized him sooner had he been wearing a surgical mask.

Another resident in the room, an Asian doctor who was in a residency in interventional radiology or something of the sort, and she recounted a story of how difficult it is for female doctors to pick up guys. "A friend and I were at a bar, having a great conversation with a cute guy. He asked us what we do, and I replied, 'I'm in medicine.' He asked what specifically, and I replied, 'I'm a doctor.' At that point, he literally turned around 180 degrees and started a conversation with another girl." I told a friend in second year about this. She told me that "we call that the 'M-bomb', telling someone we're in medicine. I get around that by telling potentials that 'I am in science; I'm interested in becoming a doctor someday.' That seems to intimidate a lot less."

The neurosurgeon and I even had a good chat. I was able to pass on a message from someone else in my class, that he had influenced her to enter medicine when he gave a talk to a group of pre-meds she was in a few years back.

I even cracked a joke that made the whole OR laugh; they were talking about how rich the two creators of YouTube must be now that Google had bought their little website for 2 billion dollars. I piped up, "Yeah, but they have to split it..."

I didn't have a conversation with the anesthesiologist, but he successfully perpetuated my stereotype of what anesthesiologists do during surgeries, as he was busy working on a PowerPoint presentation on his iBook laptop computer. That will be added to my anesthesiology stories of members of that profession who do crossword puzzles, sudoku, nap, or perform yoga on a mat in the corner of the OR during surgery. "It's ok if they fall asleep," my medical student friend told me; "their alarms will wake them up if something goes wrong, and the surgeons wake them up if it's time to close."

After standing around chatting for so long, checking up on the previous surgical patient who ended up with pulmonary edema, and coming back to the OR and chatting some more, I decided to call it quits. I said my farewells, and was welcomed by the surgeon to join him again at any time, but I'm not so sure anymore if surgery is for me.

I was told by an anesthesiologist that one way to categorize medical specialties is into two types: those that have you do one thing, finish it, and move on to the next, versus those that handle you juggling several balls at once. Surgery and anaesthesiology would fall under the former. I think I'm leaning more towards the latter. Fortunately I've got lots of time to decide for sure. But, I don't think that brain surgery will be something I find myself doing as a career.

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New Year's Resolution

What could be a better New Year's Resolution than reading every issue of Grand Rounds?

Start with the first one of the new year, located at Musings of a Distractible Mind.

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What I Say won't be What They Hear

I went to see my family doctor this week. After watching several people get their annual physical as part of my training, it kindof sunk in that I haven't seen a doctor for a routine check-up in years, so I scheduled one for myself.

My doctor's secretary told me that my doctor wasn't booking physicals until June, so I felt special when I got a call back saying my doc was willing to squeeze me in over Christmas. I told another doctor about him not booking physicals until months in advance. He told me that isn't exactly a proper policy.

I didn't feel odd at the time, but looking back on it, it was my first time in an exam room as a patient in a long time. The nurse came in and took my blood pressure. I was hoping she'd ask what I was doing, and after I answered, what I was studying. She did. Seven months after finding out about my acceptance it still feels nice telling people.

My family doctor is great, and he's really friendly. He moves quickly, but he always makes me feel like I've got his full attention. As I was hoping, he was genuinely interested in the fact that I was in medical school, and didn't treat me like a regular patient. "Make sure you try to stay active, though I'm not sure how you do that while you're a med student." He related what I was doing to my education. "I do this a bit differently than you'll learn, but it works," and, "This is how I do my review of systems..."

Later, he asked me what I wanted ordered in my blood tests. "You know, it'll be kindof neat for you if we get all these levels; you'll be sitting in lecture and hearing about triglycerides, HDL, and LDL levels, and it's kindof fun knowing where you stand." Sure enough, I got a phone call a couple days later saying that I could come in and pick up my lab results. One piece of advice I can pass on: don't let an abnormal urine dipstick test worry you too much until their results are confirmed by lab work. They can be over sensitive.

That's all beside the point. The story that I sat down to tell is this one. While I was at the doctor I started to think of a conversation I had with a friend.

Earlier this semester, I was telling him how we're being taught how to interview patients, and how we have to be careful the way we phrase things, because our patients might hear it differently depending on their context; how they view a certain condition, whatever circumstances are going on in their lives, their past experience with the health care profession (they have a term for this last one, 'transference'; the opposite, where a health care provider brings their past experiences into a relationship, also has a term; 'counter-transference').

In other words, what you say might not necessarily be what they hear. Anybody married could tell you that, but it doesn't hurt to have it re-emphasized. To put it a different way, I once heard: "If you tell a patient they have cancer, and then go on to tell them what type of cancer it is and what happens next and how to manage it, nine times out of ten your patient won't hear any of that. They won't hear a word you say beyond 'cancer.'"
After I told my friend about all this, he replied, "Now that you mention that, it makes me think of when I went to the doctor the other day.

"I was having a bit of an off day, just feeling down a little bit. During my checkup, my doc took a quick glance at my back. She said, 'Oh, let me get that blackhead for you on your back. Not like anybody else is going to catch it.'

"I missed what she said next, because I was hung up for a second on that comment. It's funny how when you're depressed, your mind can jump to conclusions. 'Nobody else is going to ever see that? What, she thinks I don't have a girlfriend? How does she know that I'm single? Why is she assuming that?'

"It wasn't a big deal at all, and I shook out of it pretty quickly, but I guess when you told me that right now I recalled that moment, and realized that for a moment, I was kindof pissed off at my doctor, for no good reason at all. She was just trying to be friendly and make conversation and I took what she said the wrong away and got all worked up about it."

Obviously, my friend overreacted. He even said that. And I don't even think anybody could say the doctor was wrong in making that comment; I'll probably never be told in class that comments like that are risky, because I'm sure that 99% of the time, they're not. But it reminded me that if I want to come across to my patients as a respectful physician, a habit of paying attention to how they're feeling and choosing my words extremely carefully will be one more tool I can put in my skill set.

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