Looking forward to my pager.

Yes, I'm a huge nerd.

Yes, I'm looking forward to the day when I get a nice, shiny, new, pager.

Yes, I am excited about what I'll have to run off and do when it first goes off.

Yes, I know that eventually I will look back on this post and realize how naive I am, and how pagers are of the devil, and how I should never have wished for one.

But right now I think that being in the clinical years will be so much better than the basic science stuff we are learning right now. Studying for finals sucks!

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How alternative medicine makes fools of us all

Here's a book I just found, that I definitely plan to read this summer.

Those of you who aren't new to my blog will remember that I consider myself open to learning about how alternative therapies can legitimately help patients, and I'm always open to discussions with my friends in naturopathy school.

However, I'm sure I'll have plenty to discuss after I finish reading this.

Find out more about the book...

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What trickery is this?

As soon as we opened the door to the clinic room, we could see the worry written all over her face. She sat in the chair, legs together, purse on her lap, and tightly clutching a piece of paper with notes scrawled all over.

Prompted by the doctor, I began asking her questions about why she had come in. While at first she complained of generalized fatigue, she quickly admitted, "But that's not really why I'm here. I had a question about my son's asthma treatment."

"Go ahead," said the doctor.

"Is it true that asthma puffers can make him committ suicide?"

"Well, actually, I haven't heard anything about that," he replied. "There are a lot of side effects for asthma medication, but depression isn't usually listed as one of them."

She didn't respond to his question. Instead, she shoved towards him another piece of paper that she had been holding - one with a printout of a newspaper article. I read the headline upside-down: "Asthma Drug Questioned for Suicide Risk."

The doctor read over the article, then handed it to me. Her concern was justified, but it only took a few seconds to tell that the patient was reading a little bit too much into the article. First of all, it was written in a sensationalist manner, written by a health website but not a reputable news source. Secondly, the article said nothing about a proven association - just that the link was about to be investigated further. And third, as the doctor clarified later, the article was about an asthma medication that her son wasn't even taking - a pill, not the puffer.

Not only that, but I didn't fault the doctor at all for not being aware of the news. The article had come out that day, and was based on a paper that was going to be published in a medical journal the next week.

We explained to her these things, but I couldn't help but think that I was a little disappointed in the patient. Instead of showing him the article right off the bat, she had asked her doctor a loaded question, one to which she knew the answer, but she wanted to see what he would say anyways. Not only that, but it was on a very recent topic... was she expecting him to be aware of every recent medical development on a suspected association, not yet accepted as a standard of care?

It reminded me of another patient who told me that she once asked her doctor for penicillin to treat a cold, then when he prescribed it to her, confronted him with the fact that she was allergic to penicillin.

Obviously there are two sides to these issues, but I still wondered how I would feel if I thought a patient had tricked me. It's true that doctors are expected to make few, if any, mistakes, and it's definitely good to have someone check up on you once in a while, but it might also prove difficult for me to be in a doctor-patient relationship in which the patient is frequently trying to get me to say something wrong. After all, trust in the doctor-patient relationship goes both ways.

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Was that a "click"?

A funny thing happened while I was studying yesterday. I finally felt like all these random, individual information bits I was learning in the neuro/psych block were all starting to come together... things finally 'clicked' into place.

You see, starting out the neuro/psych block feels like having to navigate a rainforest without a map. They might as well have written the entire set of notes in Latin. Every time you try to read something, you get about two sentences in before you don't know what something is. So you look it up... and... well... let me illustrate:

"Hmm, what is the 'caudate'? Oh I'll just look that up. It says here,

'part of the basal ganglia.'

Uh... okay.... better look that one up too. Basal ganglia... blazing danglia... here it is....

'large nuclei deep within the cerebral hemispheres.'

Good thing I know what cerebral means. Now... nuclei?? what's that? ok looking that up...

'a group of cell bodies and dendriates of neurons, such as the red nuclei, a part of the rubrospinal tract.'

Okay. Got it. Except... I still have no idea what the caudate is. and what is the rubrospinal tract?! Do I need to know that??"

Or it's also fun when you think you've learned something... for example, that a certain group of nerve cells ends in the thalamus of the brain... but then later on you read that they end instead in the ventral posterior lateral nucleus (VPL). Damned if you didn't already know that the VPL is a part of the thalamus.

Perhaps now you can see how excited I was to feel as though things were finally coming together.

Interestingly enough, a similar thing is happening with the entire program (not just the neuro/psych block).

It's coming to the end of two years of medical school, which means that by the end of this year we will have had units and lectures on every major body system.

At the start, it's all new, and that can be quite a challenge. Medical terms, lab tests, diseases, all of which you've never heard before. Starting out with things like cardiorespiratory is fortunately pretty straightforward, and you study those units hard, then you feel like you finally know something little about medicine.

But by the end of the two years, you start seeing things over and over. You start seeing how they relate. You start understanding how things fit together. You start doing the physical exam skills not just in a tutorial session, but also in a family practitioner's office, then in a clinical hospital setting, and learning the basis for those exams - for example shining a light into patients' eyes, tapping their knees, and asking them to say 'aah' - helps to learn the pathology and physiology that we need to know for courses outside of the clinical skills course.

One example of a disease we've seen many times now is hemochromatosis -a disesase in which the body can't get rid of iron, and so it builds up in various body tissues. It affects many different parts of the body, so we learned about its effect on the bloodstream in the blood unit, then talked about its effect on the musculoskeletal system in that block, and how it damages the liver in the gastrointestinal unit.

It's a relief to feel as though things are finally making sense, and while some students might give me flak for giving the faculty some credit, it does finally seem as though there was some method to this madness and that we might actually have learned something.

Then again, from what I have heard, that feeling of knowing anything disappears completely next year on the wards...

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Pap smear....on a man?!

"Before you go and see the next patient, shut the door and let me explain something," my family practice instructor told me.

I shut the door and took a seat in his office. This wasn't unusual - many of the doctors go over a patient's history with me before I see the patient. Fortunately I haven't had any of the doctors that like to play tricks on their students, and send them into an odd clinical scenario just to see how the students react, and teach them a lesson that you should never make assumptions about your patients.

But I would never have guessed what the doctor was about to tell me.

"The next patient saw me for the first time several years ago, and throughout the initial visits confided in me that he didn't feel comfortable in his body. He was born as a woman, and has lived his whole life as a woman - including many years as an award-winning female singer- but since I started seeing him, I've been working with him to help him transition to the body of a man.

"This involved a referral to a surgeon in Ottawa who is very skilled at 'top surgery,' which involves removing the breasts, as well as initiating regular testosterone injections to change the patient's physical characteristics."

The doctor explained to me the extensive pre-injection procedures, such as counseling, and showed me the waivers and government documents that needed to be signed to certify the change in gender. The doctor also told me that for many patients, their first testosterone injection is a very emotional and memorable moment, and some even take photos or have friends present for the event.

"Despite the changes he has experienced, he still has some female characteristics," the doctor went on. "For example, there is always some breast tissue that remains after top surgery, so people who have had top surgery still need to get regular breast exams to check for breast cancer. As well, this patient hasn't had any reconstructive surgery done for the lower genitalia, so he still needs regular screening pap tests."

It took me a while for me to wrap my mind around that sentence - he still needs pap smears.

"As always, I've asked the patient if he is comfortable seeing a medical student, and he has agreed to see you. Go in and find out how the patient is doing, ask he has any medical concerns since his last visit, and then tell him he can get changed for his exam. And if you feel uncomfortable at any time, just tell the patient that this is a new experience for you. He's more than willing to help you learn."

I appreciated how friendly the patient was. I admitted my inexperience right from the start and explained that I supported his decision, and if I said anything offensive it would not be intentional. He laughed and told me it wasn't a problem.

While I talked to the patient I noticed that if I had seen him on the street, I would have assumed he was just like any other guy. He looked, sounded, dressed and acted like a man - right down to having lots of body hair and all the other changes that would be expected.

And yet, after the patient changed, the doctor performed a breast exam pap test on him, as if he was any other female patient in for her regular screening.

Despite the fact that transgendered patients have a number of unique medical needs, I have so far received little training in interacting with transgendered patients. I am sure that it won't be the last time I will have to provide care to somebody who has had a sex change, and in the future even more issues will come up, such as transgendered men being able to give birth.

After seeing the patient, the doctor explained that there was an upcoming conference for health professionals on providing care to transgendered patients. Unfortunately I wasn't able to make it because it was held during my final exams, but I look forward to the chance to being able to learn more about this in the future.

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