Our medical school has a strategy to fight the sagging number of doctors choosing family medicine as a profession: expose students to the profession through a mandatory course in family medicine. Unfortunately, if you ask anybody in my class, it's quite apparent this strategy is probably doing more harm than good.
It involves exposing us to family medicine by arranging for us to shadow family physicians for a few hours per week in our first two years, assigning various time-consuming projects, and providing a number of family medicine-related lectures, attendance to which is encouraged (with limited success) more by sending threatening e-mails to the students than by providing interesting topics.
Then, we are given an exam for each of our first four semesters, asking medically relevant minute details from the lectures, such as, "How many people died in Somalia last year?" "Which of the following is an example of grey literature?" and "What does the E stand for in FIFE?" (the latter of which I know quite well after getting yelled at by a patient for using said technique).
I'm not sure who thought making medical students write exams on boring lectures that they've been guilted into attending would develop in us a passion for the field, especially when we're already overwhelmed with the study load for our other courses. It's a good thing we are instead able to develop this passion by spending time with family doctors, right?
Well, it's not that simple. Personally, I lucked out, and ended up with outstanding tutors. I'm among only a few people who had an excellent experience with all my various tutors, getting the chance to regularly see patients on my own and conduct histories and physical exams, and fill out prescriptions, referrals and lab requisition forms.
Unfortunately, for many people in my class, the taste of family medicine they got from this experience is a very bitter one.
First of all, urban family practice is very different from what family medicine used to be. While rural doctors still do a lot of procedures and deliveries, most of the doctors we shadow have cut down on the amount of these extra services, including following patients in the hospital.
Secondly, with the increases in class sizes, only a small number of students are one-on-one with the doctor, and even after grouping students, the faculty is still having a hard time finding
doctors willing to teach.
So, the preceptors they do sign up aren't all doing it out of a love for teaching, and the students suffer for it. Two students that I know spent most of their shifts with one physician sitting at the end of a hallway, called in only once to see patients. Two others I know spent a semester watching the doctor perform alternative medicine such as waving his hands over the patient (all of which he billed the government for), and they even spent a whole shift punching out pieces of aluminum foil, to build up the doctor's supply of tinfoil confetti to tape on to patients' hands as an (undoubtedly ineffective) alternative medicine method.
However, despite the lectures, exams, and poor shadowing experiences, the course is by no means a complete failure. Some students, like myself, have a fantastic experience with the doctors, getting to do and see a lot, including surgeries and infant deliveries. And even if it didn't convince anybody to become a family doctor, the amount of clinical and patient experience we got will give us a step up for when we start our medical student internships in the fall.
Additionally, the course also gave us the chance to practice a few office procedures, such as prescription writing, suturing, biopsies and excisions, which is the fun 'doctor stuff' that everyone looks forward to in med school. Unlike the medical students from some Canadian schools, though, we never got the chance to learn how to place IVs in our first couple years of med school.
As well, everybody in the class was exposed to the huge variety of sub-specialties of family practice that exist when we spent time with two specialized family physicians. Family doctors can tailor their practices with a focus in prenatal care, oncology, surgical assist, inner city medicine, emergency, hosptialist, sports medicine, and many other fields, something I didn't know before med school, and a realization that definitely piqued my interest as I search for a specialty that satisfies my desire for variety.
Finally, the rural exposure component of the course is one that is apparently a lot of fun. After two years of medical school, we get the chance to spend some time in a rural community, an experience I'm looking forward to right before I start my third year. This is evidently one of the redeeming factors for this course, and hopefully when I'm shipped out, I'll have a few interesting stores to share... and not spend the whole time punching out tinfoil confetti.
Monday, July 14, 2008
The failed mandate of our family practise course
Sunday, June 15, 2008
Top 10 List: Ten things I learned in second year med school
Keeping with the tradition, my classmate Jay wrote another list of things he learned. Again, used with permission.
1) Chest pain at rest can also be diagnostic of 3+ cups of coffee before 10am.
2) Being in med school, I achieve a high Woodcock-Johnson every morning.
3) After one week of teaching us about chronic pain, the take-home message is to not call our patients liars.
4) I get all teary-eyed in only 2 situations: watching the ending of the movie Rudy, and being bedside at a live birth.
5) It is possible to almost completely forget what you had known front-to-back the previous week... and do this over and over for 20 straight weeks.
6) Me, and possibly most of my friends, have this condition called Orbitofrontal syndrome.
7) Apparently, the local hospital administration is willing to disrupt/discontinue the medical education of hundreds of 2nd year medical students, because of food and drink inside a lecture hall... and that hundreds of 2nd year med students respond by shrugging and using that forget-what-just-happen-last-week ability.
8) Toxic megacolon is pretty much exactly what it sounds like.
9) Everything you do in med school is the next hardest thing you've ever done.
10) Oh my god... in 2 months, they're going to expect me to make real-life decisions about patient care... wtf, I'm PRETTY SURE that I'm not ready to do that.
If you enjoyed this, check out the top 10 things Jay learned in first year.
Sunday, June 08, 2008
Vitum experiences medicine down under!
I didn't expect to find myself seeing patients in Australia this week, but there I was, in a general practitioner's office, shadowing as a medical student, just hours after getting off the plane to Australia.
I have a buddy of mine to thank. I've always wanted to visit the Southern Hemisphere, and since he is one of the estimated 1500 Canadians studying medicine abroad (a quick tribute to the limitd number of medical school spaces in Canada) it worked out well to combine a trip here with a visit to an old friend.
Not only that, but his preceptor graciously agreed to let me tag along with him during his placement in her office this week, an opportunity that I was very interested in taking part. It was fascinating learning about the similarities and differences between medicine here and in Canada, identifying some rashes I had just learned about in our Dermatology unit, and actually feeling like I have learned something in the last two years as I was able to pass on some things to the first-year medical students.
Don't worry, I'm not spending my entire break doing medical things...you'll find me laying on beaches and hugging kangaroos the rest of the time I'm here. But it was really neat to see what a doctor does halfway across the world.
What's different?
So, based on my afternoon in a GP's office here, how does medicine in Australia differ from that in Canada?
Well, the first difference that I noticed right away was the layout of the office. In Canada, GPs generally have an office with their desk where they do paperwork, but that is in a separate room from the rooms where they see patients. In Australia, however, the GPs have a large office, one half of which looks like a typical office with a desk and computer and bookshelves, and the other half - sometimes separated by a curtain - is the clinical area where they see patients, with a patient bed, sink, and various instruments hanging on the wall.
Another difference I noticed was the hints of the two-tier health system here. The public system, known as "bulk billing," works alongside the private system, funded by patients or their insurance companies. I've been told it isn't that profitable for a doctor to only see bulk billing patients, and for the most part those that do are more similar to what in Canada is a walk-in clinic - where patients go for minor issues after hours, or mostly to get prescription refills. GPs who have their own patients shake their head at the mention of a patient getting antibiotics from one of these bulk billing "medical centres"... just like GPs in Canada shake their head at the mention of a walk-in clinic. As well, driving through a smaller town in Australia, I saw a large public hospital... and right down the street from it, past the independent pathology labs that contract out to the hospital, was a private hospital - smaller, and much fancier.
Finally, a comment about the public health victories in Australia. Like in Canada, doctors here have had a major influence on smoking rates and seatbelt use - but before even coming to Australia, I had heard that the doctors here have had incredible success with the "slip, slap, slop" campaign - to get Australians to be "sun-wise" and significantly decrease their risk of sun-associated skin cancers by covering up with sunscreen and long-sleeved clothing. Based on their efforts, wearing hats and long-sleeved clothing to outdoor events has become a way of life in Australia.
What's the same?
Indeed, those differences aren't really that major, and I'll go so far as to admit that the thing that stunned me the most was that there are actually many, many similarities between medicine here and how I've seen it done in Canada.
Many of the things I heard the doctor mention - drug names, medical conditions, and investigations for medical conditions (such as a glucose tolerance test, nuclear studies, ultrasounds, biopsies, lab tests) - had the exact same name and terminology we use in Canada, much to my surprise. Even those rashes I had recently learned about in our Dermatology unit showed up, and are called the exact same things they are in Canada. I suppose I had the idea in my head that everything would all be called different things here.
Not only that, but a couple came in to talk about their plans to get pregnant - every single thing the doctor mentioned in the prenatal counselling, right down to the numbers ("you have a 20% chance of getting pregnant each month" and "if you don't get pregnant within 12 months, that's when we'll start looking into the reason for that") and advice ("take a folic acid supplement" and "don't drink any alcohol now that you are planning to become pregnant!!!!") were identical to what I had just learned in my reproduction block.
Overall?
I'll admit that the rumours I've heard about how hard it is for Australian doctors, and international doctors in general, to come to Canada had always given me the idea that the doctors here are perhaps less competent than those in Canada, or that maybe Canada is keeping them out for the protection of our own people. However, having seen these docs in action first hand, this misconception of mine has been pretty much wiped out. From what I saw of the docs here, they're just as competent as any doctor I've worked with in Canada...if not more so than some.
All of the doctors in the office seemed very enthusiastic to have students, and took the time to try and teach me. It was also really interesting to go to class with my friend and meet many other Australian medical students, see that they are learning exactly the same things I am learning in class in Canada, and share perspectives with some more of the Canadians in his class who are all studying here for different reasons.
Many thanks to my friend's GP (and all the docs in the office) who were more than willing to make this unique experience a possibility for me.
One last random thing...
If you want just a normal, regular coffee in Australia, ask for "filtered coffee" - it's not the same as "percolated coffee" (ask for that and you'll get an espresso). That should save you the argument with the barista... which, based on my experience, ends up with them thinking you're crazy, you thinking they're crazy, and you settling for a "tall black" (their name for an Americano). Just a tip.
Saturday, May 31, 2008
One patient, five minutes, I'll never forget
Even though we only had about six hours a week during which we saw actual patients in our first two years, we’ve seen enough by now that the details of individual patients start to blend into each other and fade away.
As for some patients I’ve met, though, I won’t forget them as long as I live.
It was during one of our many small-group clinical skills sessions that I met one of those patients. The goal of this particular session was to apply some of our neurology physical exam skills by practising them with some chronic paediatric patients who displayed neurological symptoms.
Memorizing a set of symptoms suggestive of a lower motor neuron disease (as opposed to an upper motor neuron disease) can be mundane when you read it in a library (or on a blog), but it can be life-saving in an emergency room – learning the intricate connections between the brain and the muscles is one way a doctor can tell if a patient’s sudden-onset drooping face could be because of a harmless palsy that will settle back to normal in a couple days, or if it might instead suggest a life-threatening blood clot cutting off the oxygen supply to the patient’s brain.
On the paediatrics ward, we went from room to room, playing with the cute kids, meeting their parents, and checking reflexes, feeling for stiffness, and looking for other neurological symptoms. At the same time, my efforts to keep my eyes open competed with my efforts to remember the relevant physiology. It was sad to see a number of children who are bedridden and have severe cognitive deficits…but everyone has seen a child in a wheelchair at some time or another, and the pre-exam study blitz was starting to take its toll on my sleeping habits.
Then we entered her room.
As he had done in all the rooms before, the doctor asked us to check for reflexes and stiffness as he started to tell us about the reason the girl was in the hospital. “Chloe came to us about six months ago after a non-accidental injury, suffering from cigarette burns, broken limbs and a fractured skull.”
I suddenly wasn’t sleepy anymore at all.
“What did he say?!” I thought to myself. “Non-accidental injury??!”
The doctor had already moved on and was talking about the clinical signs. “Notice the hyperreflexia, and positive Babinski sign on her feet,” he continued, but I couldn’t get past what I thought he had said.
“Non-accidental injury?? What, like abuse?” I thought.
That’s exactly what the doctor meant. After going over some more of her symptoms, we asked for more details about what the doctor meant by “non-accidental injury.” I regretted asking that. The doctor went on to explain the atrocious abuse this poor, beautiful young girl had suffered at the hands of her stepfather.
I was shattered. She was about nine years old, in a purple dress, with her blonde hair tied up in cute piglets, sitting in a tiny wheelchair just the right size for her small figure. I looked into her big, blue, eyes… they didn’t work quite in unison after being struck in the head so many times, but every so often she would look right at me, and smile so big, and I actually felt like crying. I was looking at a beautiful young girl who will never be able to live up to her full potential, because some utter idiot could find no better way to take out his rage than to use her tiny head as a punching bag. Honestly… can someone sink any lower?
It was then I realized I could probably never work in a chronic care paediatrics ward. I don’t have what it takes. I based that on my sudden urge to want to find out who the person was that did this to Chloe, hunt him down, and beat him utterly senseless. Nothing so far in my medical training has made me so angry as seeing the effects of the abuse on this poor girl.
Apparently Chloe had recovered immensely since she first came in to the hospital. She had been in a coma then, and here she was four months later sitting up, making noises, responding to people calling her name – much more than any of the doctors thought she would be able to do by now.
I hope she continues to recover beyond expectations, and that her life’s potential isn’t completely obliterated because of the useless sack of dirt who abused her. And I have high hopes for her, because despite the fact that she cannot talk, or walk around her own, she’s already making a life-changing impact…in those few minutes, without so much as a word, she left an impression on me more unforgettable than any conversation I’ve ever had.
Tuesday, May 06, 2008
Cool body tricks: Nystagmus
In class a few weeks back, we learned that if you put hot water in one ear and cold water in another (the "Caloric test"), you can induce nystagmus, a symptom that involves your eyes quivering back and forth.
A guy in my class changed his MSN name today to: "I just did the caloric test to myself... it works."
Med students are a funny breed.
Of course, the coolest tests come with a cool mnemonic: the mnemonic for this one is COWS.
Saturday, April 19, 2008
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.
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.
Sunday, April 06, 2008
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.
Monday, March 24, 2008
Is there anything in your life causing you stress?
The reason for the patient's visit only said "difficulty sleeping," and the inexperienced first-year medical student had been sent in to take a preliminary interview.
It was going well, as usual. The patient was asking about work stress, home stress, and the like, and the patient kept responding that there wasn't any stress in those areas.
"Is there anything else that could be causing you stress right now?" the student asked.
The patient replied, "Well, nothing, other than my trial."
"Your trial? Are you a lawyer?"
"No," replied the patient. "I'm currently on bail, but I have a trial date coming up next month. I have to go on trial because I murdered my boss."
Note the patient didn't say "on suspicion of murder." The patient flat out admitted that he was on trial "BECAUSE I murdered my boss."
Apparently the doctor knew about this rather unsettling part of the patient's history, but sent the student in unaware... just to teach the student that you should never make assumptions about your patient.
Lesson learned? I'd say.
I am so glad that my family practice supervising doctors never put me in a situation like this.
Oh, and yes, while identifying details have been changed, this is a true story.
Sunday, January 27, 2008
How To Clean your Brain, as told to me by a schizophrenic patient
Shortly after I decided to go into medicine, I knew the day would come when I would have to deal with a branch of medicine that both fascinates and intimidates me: psychiatry.
I'm not sure what it is about dealing with psychiatric patients that makes me so nervous. Perhaps it's how much I value my own cognitive abilities. Maybe it's the stories I've heard of patients in acute psychotic episodes, throwing furniture and yelling obscenities. Or it could be that every psychiatric ward I've ever been to or seen in movies sends chills down my spine.
But now that I've started my Clinical Skills unit on interviewing psychiatric patients, my naivety has resulted in a few surprises. I was blown away when I interviewed someone who has a severe form of a psychiatric condition, yet could still carry on a coherent conversation. I was also quite stunned after the patient told me about their ability to carry on conversations with squirrels in the park and according to their chart had to be tied down in four-point restraints on admission to the hospital, yet answered a number of Mental Status Exam questions testing insight, judgment and thought process as any normal person would.
Of course, the psychiatrist training us told us that there are a few exceptions to this.
For example, some patients will speak in what is termed Word Salad (ie. "I was running down the sidewalk, over the alleys in the supermarket. Sometimes the store is full of nuns, and sometimes the airplanes fly lower. But when I was younger, they threw me over the furnace and the time was singing."), and another patient he remembers didn't speak a single word in the interview, later revealing that he did so because he thought the psychiatrist could read his thoughts.
The patient I interviewed was a bit shy at the start but completely warmed up to me after a little bit. I was a bit nervous when the patient listed off their favourite weapons, stood up to demonstrate self-defence fighting techniques with intense enthusiasm, and then looked at me with hollow, peircing eyes and shouted "I'M GOING TO F------ KILL YOU!" (fortunately while recounting a conversation with somebody else, but it was still pretty intimidating!).
After getting a bit of history from the patient, I looked through the interviewing handbook we'd been given, and asked a couple questions from the "Anxiety" and "Depression" categories, but didn't get very far. Then I picked a question from the "Psychotic" category: "Do you have any abilities that other people don't?" and the patient lit up like a Christmas tree.
"Oh, definitely. I can clean out my brain."
"Really?" I replied, trying hard to stay professional and not crack a smile.
"Oh, yeah, I do it all the time."
"Could you tell me how you go about doing that?" I inquired.
"Sure, all you have to do is fill up the inside of your skull with water. Let it fill up slowly - not high enough that you'd drown, but close to the top." The patient held up hands to demonstrate the appropriate depth. "Then, all you do is shake it around a bit" - again I was given a demonstration of proper procedure - "and after that let it drain out, all through your nose and drool it through your mouth, all the way out until it reaches your navel."
After the interivew, I mentioned to the preceptor that I was stunned that given a demonstration like that, the patient could still answer a number of simple Mental Status Exam questions testing insight, judgement and comprehension correctly. "That's normal for someone with this disorder," said the psychiatrist. "Some of my patients with schizophrenia are incredibly high-functioning - they carry on normal lives with successful jobs - accounting, engineering for example." I wonder how many are doctors.
So that was my first psychiatric patient. I'll get to watch other students in my small group interview a number of other patients over this unit, and hopefully see a variety of pschiatric conditions. For me, however, after a few weeks' exposure to psychiatry, I've concluded that to me, psychiatry is a speciality just like pathology. While I'd never want to become a pathologist given the stigma, I have to admit that the more I learn about it, the more fascinated I am by it.
Friday, January 11, 2008
Rite of passage (or, Delicious Irony)
Every medical student comes to a point in their career where they must perform their first digital rectal exam (DRE).
Today, during a clinic rotation, was my turn.
In a delicious twist of irony that I think was lost on my preceptor, another physician in the office was having a going-away party which we visited directly after this little procedure.
In other words, within minutes of performing my first DRE I was celebrating my new-found skill with a slice of...
...wait for it...
...chocolate cake.
Sunday, December 09, 2007
Final are depressing. No, really - I can prove it.
School in itself is a challenge for most of my classmates and myself, especially with finals study time in full swing. Apparently they want doctors to know a lot of things.
I looked at a post I wrote about this time last year and it's very similar to how I feel right now.
One of the differences this year, though, is I know my classmates a lot better, and so I'm much more aware this time around that many of us have a lot of additional stress outside of class. There are a number of students that I am genuinely worried about - I honestly don't know how they have the strength or stamina to get out of bed every morning, considering what they have going on in their lives.
This year in clinic I learned about a questionnaire called the PHQ-9, which the physicians gave to some patients as part of a comprehensive assessment for depression.
As I got to know the questions better, I began to realize that if you took a survey of my class right now - in the middle of finals season - based on this questionnaire I wouldn't be surprised if the vast majority of them would register as "severely depressed."
In fact, to prove it to you, I'll go through it right now:
Over the last 2 weeks, have you been bothered by any of the following problems?
Check. Even things I used to like doing, like learning about medicine. Too much of a good thing, you know? Like a dump truck full of ice cream.
b. Feeling down, depressed, or hopeless
Check. Despite the overwhelming statistical precedence that 99% of us will pass, everyone I talk to thinks they will be the one person who will fail.
c. Trouble falling asleep, staying asleep, or sleeping too much
Some of my classmates are so revved up that they are self-medicating just so they can sleep at night.
d. Feeling tired or having little energy
Try exhausted. And I don't think it's African Sleeping Sickness.
e. Poor appetite or overeating
One classmate told me that her theory is that "everyone in our class either gains or loses weight during finals."
f. Feeling bad about yourself, feeling that you are a failure, or feeling that you have let yourself or your family down
Wow, I swear the writers of this questionnaire talked to my classmates
g. Trouble concentrating on things such as reading the newspaper or watching television
Haven't had time to do either of those. But trouble concentrating while studying...check.
h. Moving or speaking so slowly that other people could have noticed. Or being so fidgety or restless that you have been moving around a lot more than usual
Absolutely. Mini-anxiety attacks will do that to ya.
i. Thinking that you would be better off dead or that you want to hurt yourself in some way
Not me in particular, but there are some in my class who might...I've heard comments like "I want to crawl in a hole and die," "Maybe I should just drown myself in the bath," and "If only I had a gun." Which ones should I be taking seriously?
Major Depressive Syndrome is suggested if:
• Of the 9 items, 5 or more are checked as at least "More than half the days."
Proven. Voilà.
In fact, if I could find a checklist for "Cabin Fever," given the number of students cooped up in a study room for the last few weeks I can guarantee we'd score pretty high on that one too.
At least our faculty isn't like some other ones I know of, which, in response to student comments that the curriculum is stressful, recommend that the students a) seek counselling - kind of not an option given the limited free time during finals study time - and b) take anxiolytics, ie. medicate the stress away. Thanks for your support.
Gonna get back at it. Wish me luck.
(Again, this is not a place for you to be getting medical advice, but if any of the above apply to you - and things won't return to normal on a set date ie. you aren't in the midst of finals - please book an appointment with a professional!)
Monday, December 03, 2007
The Opposite of Turnstile Medicine
My clinic experience this year was an incredible treat for me. It was a rare setting where the doctors are paid a set salaried wage, rather than based on the the number of procedures they did (fee-for-service). I was amazed at how differently the day went than it might go in a walk-in clinic.
Instead of racing through the patients as if there was a turnstile at the door that went 'ka-ching' for every patient in and out, the doctors were taking the time to address the whole-body health of the patient - something I hadn't seen a whole lot of in family practice so far.
Though I could give many examples, I keep thinking about one particular patient for whom this clinic worked particularly well. He presented with a rash.
If he had gone to a walk-in clinic, he would probably have gotten some steroid cream within a minute and been told to come back if the rash didn't go away.
At this clinic, however, knowing that she had fifteen minutes for this patient, the doctor took the time to take a full history, considering a wide possibility of conditions that could be causing the problem.
Through this history, the doctor learned that the patient was in a high-risk relationship for a number of sexually transmitted infecitons, and as a result, was able to counsel the patient on a number of risk-reduction measures and vaccinations that he should consider.
Another benefit of this clinic was that it was incredibly integrated - there were counsellors, nurses, a travel medicine specialist, a mental health intake worker, a sexual health specialist, and a physiotherapist all on site. I have heard a lot of team medicine, but haven't seen it come into play very often, so it was amazing seeing these professionals work together for the best interests of their patients.
For example, with this same patient, when the relationship came up in the history it became evident that his partner was a source of a lot of stress. Upon going over the additional stresses in this patient's life, and calculating the toll they were taking on him, the doctor uncovered that the patient was at risk for suffering from depression... and scheduled a follow-up visit - not only with a doctor - but with the counsellor on site as well.
Not only did the doctors simply refer the patients to the other health professionals, but I saw on a routine basis these other clinic staff come chat with the physician - or the physician go to their offices - to talk about a particularly unique patient and brainstorm on how to best take care of them.
These doctors really cared for their patients, more so than just getting the right diagnosis or catching the most medical conditions. Time and time again, they were willing to go above and beyond, even if it meant pouring a bit of extra effort and energy into a certain patient. It was obvious that time and time again they were making a difference in their patient's lives, and occasionally actually saving lives.
Don't get me wrong - there are rarely any physicians who don't want to take good care of their patients, and a number of family practitioners work as their own business and thus have to work extremely hard just to make ends meet - but after my past experiences observing family medicine, I was amazed to be coming home at the end of each shift thinking, "If family practice can really be like this, instead of just trying to cram in as many patients as possible, maybe I could see myself doing that kind of medicine in some form." Up until now, family practice was near the bottom of my list of interests.
I don't think the uniqueness of this clinic could all be attributed to how the payment schedule is structured, especially considering how much care these doctors had for their patients. But when I look at how this clinic is structured, and how every work day isn't a race to pile up completed charts, I now have a bit of a better idea of what type of career I'd prefer for myself, and also what I'll look for when I choose my own family doctor.
Thursday, November 15, 2007
Listen, the patient is telling you the diagnosis
There's an old saying attributed to Sir William Osler that you'll hear dozens of times even one year into medicine:
We've also been told that if you've done an extensive list of investigations and still don't know what the patient has, re-taking the history can sometimes bring a diagnosis to light.
Being able to spend time in clinic is great, but to be honest, we don't really know what questions to ask yet. Yeah, we know a few: does it hurt? how much? where? and for how long? But it takes a long time and a lot more training to learn all the important associated conditions - that I should ask the patient with Crohn's disease if their joints hurt, or the patient with chronic hypertension how their vision is.
Some of these things come second nature for doctors who have been doing this for years, but when you're new at this, you feel like getting a diagnosis just by asking the patient a few questions can be pretty difficult.
Getting the diagnosis from the history has started happening to me, though. At my clinical exam at the end of the year (the OSCE - Objective Structured Clinical Exam) where medical students go from room to room at the sound of the tone, read the instructions on the door, then either take a history or do a physical while an examiner watches, there was one station I won't forget - I figured out what the patient had, just by asking the right questions.
She presented with a cough. As I asked her more and more questions, I was able to determine that she had been coughing up blood, and she had been exhibiting what are known as constitutional symptoms - fever, weight loss, and fatigue - all indicating a serious, chronic condition. As I finished asking her my questions, it began to dawn on me in my head... oh my gosh, lady, you've got lung cancer... and you've probably only got a few years left to live.
Okay, yeah, the patient was an actor, and it was a strucutred environment, and that was the point of the entire exercise, but it was still a neat feeling to almost be certain about a patient's diagnosis just by asking her some questions.
I was pretty excited about my success. Inevitably, however I came crashing down to earth while chatting about that patient with another student.
I'm still kicking myself - as I spoke with my friend I realized I didn't ask the patient the most obvious respiratory history question:
"Do you smoke?"
I won't make that mistake again.
Monday, November 05, 2007
Can't be too careful with physical exams...can I?
"Well, given the problems you've mentioned, I'm going to need to do a quick physical exam."
Now that I'm in second year, that's something that I've been able to do, and be confident doing: if a patient presents to me in clinic with an ear/nose/throat issue, a heart or lung problem, a musculoskeletal problem, or an abdominal problem, I'm able to do a focused physical exam before the doctor comes in.
"The doctor will come in and do an exam as well in a few minutes, but for now could you lay on your back and lift up your shirt so I can examine your abdomen please?"
I turned my back to wash my hands as the patient, a friendly, effervescent girl my age, set her backpack down from her lap and hopped up onto the exam table.
She had been explaining that she had been going #2 once every four or five days, and that was "normal" for her, and even though she had been that way for a while she constantly felt abdominal pain and fullness and bloating. So, after asking her a few more questions, I decided to put my new-found gastrointestinal clinical skills to good use and see if I could palpate any abdominal masses or liver enlargement.
I dried my hands, threw the paper towel away, and turned back to the patient. "I'll just start with a general visual inspection before I begin the exam, looking for asymmetry or scars or any abnormalities," I explained,
before I moved on to the hands-on part. Everything looked normal.
"Now, I'm going to do a procedure called percussing your liver, which basically involves me sortof tapping on your stomach. Your liver is a bit behind your rib cage so can I ask you to lift your shirt just a bit more?"
Her shirt was only half exposing her stomach, and in order to percuss the whole liver the shirt usually needs to be lifted up to right where the bottom of the bra is. (On a really good exam the patient would be in a gown and that wouldn't be an issue, but in clinic I'm not going to ask a patient to gown up for an abdominal exam.)
I always feel awkward asking a patient...especially a girl...especially one my age... to remove more clothing, so I try to explain myself really well. As well, despite what I've seen some doctors do, I always try to get the patient to remove their own clothing rather than 'help them out.'
She complied without hesitation, and pulled up her shirt a bit... but when she let go, it fell back down to basically where it was before.
Great, I thought. Now I have to ask her to lift her shirt again. Awkward.
I worked up the courage and asked again. "Um... could you lift it a little bit higher please? Just about an inch or two, just to expose the whole liver."
"Sure!" she replied. She grabbed the bottom edge of her shirt and promptly pulled it ALL THE WAY UP to her neck, revealing her entire chest, pink bra and all.
Call me a prude, or whatever you want, but I had a bit of a minor freak-out.
"Woah.... no, no! It's okay! Not that high!" I exclaimed reflexively. I almost grabbed her shirt and pulled it down.
"Um... Vitum..." she said slowly, almost condescendingly.
"Yeah?" I murmured.
"It's okay...
...You're a doctor."
Up until then I had never before been corrected for being too cautious, and it was a bit of a relief to have a patient remind me that while it is important to be respectful of a patient's privacy, it's also important to be thorough. That's what patients are expecting when they see the doctor, after all.
It's still gonna take some getting used to, though, being able to tell complete strangers to remove their clothing, and while this might not seem like that big a deal I still try to be very careful around issues like this. Hopefully I don't ever get too comfortable, though. And for now, I think I'll try to always err on the side of modesty.
Sunday, September 30, 2007
Getting used to palliative patients might take some time.
For our clinical skills classes, we spend most of our time on actors / standardized patients, who come into our clinical skills training rooms at the hospital and we learn how to do basic exams on them.
However, the odd time we'll go onto an actual hospital ward and get the opportunity to examine symptomatic patients.
Last semester we were at the hospital practicing our cardiac exams on a couple of hospitalized patients. My group was assigned a patient who was really friendly, and such a great sport - she didn't complain once about the four medical students percussing and auscultating her chest, tapping for a lung here, listening for a murmur there, asking her to sit up and lie down, even though it was obvious that due to her bad back the ordeal wasn't entirely pain-free for her.
Over the twenty or so minutes we spent at her bedside, she told us more and more about her condition, but she also talked her life - her job, her family, and the things she enjoyed doing before she ended up in the hospital. She wasn't too old, and she was pretty coherent. She seemed like a really nice lady, and I really enjoyed the chance to get to know her.
After our exam, we went to the nurse's station with our physician tutor, who called up the patient's lab tests and CT scans on the computer. We talked a bit more about the patient - she had a few other conditions that weren't related to our cardiac exam which we briefly talked over - and then were ready to move on to the next one, when the doctor said something that hit me like a truck.
"So that's Mrs. Walters. With all of that going on in her body, she doesn't have much longer to live."
I was shocked. I had just spent twenty minutes with this patient. She seemed to be functioning cognitively pretty well, and I figured she was in the hospital getting fixed! Never in a million years would I have thought she was about to die.
The seriousness of her situation started to set in, and from a medical perspective I realized that yeah, if I had been given this patient as a narrative case, I probably would have figured out that the prognosis was dismal. But because I met the patient as a person first, and didn't know all the details of her condition while I was talking to her, I hadn't really thought about what her prognosis was. Even while our tutor was going through the patient's chart, listing her conditions, the impending outcome of the sum of her conditions never hit me until the doctor put it into those words.
I suppose that now that I think of it, I might as well get ready for my clerkship year next year, when I will be meeting dozens of patients on a regular basis - some of them who don't have much longer to live. I've never really been in that situation before, and I think it's going to take some getting used to.
Sunday, September 23, 2007
"I'll show you, bitch!"
The other day at the hospital, while I was shadowing in the emergency department, a physician called me over to the x-ray computer terminal.
"Vitum, come take a look at this."
He showed me an X-ray very similar to the one I've borrowed from Wikipedia thanks to the GNU Free Documentation License, photoshopped to match my story, and placed here.
"What's wrong with this picture?" he asked.
"Well," I replied, "I haven't done my musculoskeletal study unit yet, so I could be way off... but aren't hands supposed to be attached to arms?"
"Right!" the doctor replied. "Trust me, the story is just as good as the X-ray. It even made the newspaper."
Assuming that a story in the newspaper presents fewer issues of confidentiality, I'll share the exciting story with you here, with only a few altered details. Truth is indeed stranger.
Apparently, this gentleman was involved in a fight with his girlfriend, and all hopped up on drugs. The fight got more and more heated to the point where our patient reached his boiling point. "FINE!" he shouted. "I'LL SHOW YOU, BITCH!!!"
And show her he did. He proceeded to leave the house, go to the garage, and fire up the chop saw. He placed his arm under the saw, and sliced his hand off clean through at the wrist.
It gets better.
He realized that he was bleeding profusely, as typically happens when you slice your hand off (I assume), so he figured he should do something about that.
He went into the kitchen, fired up the stove, and in tribute to what happens in one of the Rocky movies - so I'm told - he mashed
the freshly-severed stump of his arm into the red-hot stove element, cauterizing it to stop the bleeding. SSSSSSSssssssssttttttt.
Monday, September 17, 2007
One Story, Two Endings. Clearly I'm not a doctor yet.
The doctor looked at the patient's chief complaint on the chart. "Palpitations, SOBOE." He looked up at the nurse and made a joke out of it.