Pimped, finally.

Unlike the impression you may have gotten from reading this blog, not everything in med school is rosy and wonderful.

I've finally had one of the dreaded 'pimping' experiences that I've heard so much about.

For those of you who don't know what 'pimping' is, it refers to the age-old practice in medicine where a medical professional will ask a difficult question of someone lower on the medical education pecking order than themselves. From what I've learned, the pecking order goes something like this: chief of medicine > department chief > attending > fellow > resident > intern (archaic term for a first-year resident) > clerk (third or fourth-year medical student) > medical student > pre-med volunteer. The pre-meds have nobody to pick on. Some of them try to pick on nurses. They don't go far, rightly so.

The smarter docs know that nurses transcend the pecking order... after all, who do you think knows more about emergency medicine, the resident in his second year of an ER residency, or the underappreciated traige nurse who has worked in that ER for thirty-five years? Again, you get it. Kids, respect your nurses.

True 'pimping' relies on the art of progressively difficult questions: if you get a question right, then you will be asked a harder question; if you get that one right, then you will be asked yet a harder question, on and on until you answer one wrong and look like a fool. Pimping. You get it.

Anyways, we are learning about the cardiac examination right now, and we go to clinical skills practice rooms in various hospitals in small groups, and are set up with a tutor, an M.D., who is supposed to train us about the basic cardiac exam.

All is well and good, until we match with this guy, who took it up on himself to drill us like there was no tomorrow. Rather than let us practice on the patient, he simply asked us question after question after question. We all ended up feeling like a bunch of idiots.

Okay, it wasn't too bad the first time. At that point it was actually helpful. You see, I didn't know my stuff when I went in there and the whole time I was thinking, "I should have done the pre-reading." At the time, I didn't even know that he was in actuality asking us stuff way beyond what we had to know for this intro session.

So, knowing that I would have him as my tutor for one more session, I went home and studied. Boy, did I study. I won't make that skip-the-prereading mistake again.

Move ahead to week two. He quickly realized that since last time, we'd all studied, and knew our stuff. Fair enough. However, rather than follow his instructions which probably said something like "Teach these young 'uns the basic steps of the basic cardiology physical examination," he decided to get intimidated.

So, he started asking us progressively difficult questions about the material. Once he realized we knew all those answers, he started talking about things that people only learn in fourth year or cardiology residencies. Or, better still, he'd ask an ambiguous question, then feel happy when we got it wrong...strictly because we couldn't understand what he was getting at.
It began right near the start of the 2-hour session. "Vitum, what is pulsus paradoxus?" he asked, reading off my name tag. Question 1.

He picked the wrong guy to ask about Latin phrases. Apparently he doesn't know I take a fancy to them.

"Latin for paradoxical pulse," I replied, feeling brilliant (shut up, I know it's an easy one). "Refers to the difference between systolic blood pressure between inspiration and expiration."
I was unfazed. So was he.

Dr: "How does it change with breathing?"

Question 2. Serial questions. I could see he was pimping. I was game. I had studied this.

Me: "The systolic pressure increases with expiration, and decreases with inspiration."

Dr: "What's the normal difference?"

Question 3.

Me: "If the difference between inspiration and expiration exceeds the normal physiological variable range of approximately ten milimeters of mercury, the pulsus paradoxus is considered abnormal."

Dr: "What major condition does it indicate?"

Question 4.

Me: "Cardiac Tamponade."

At this point I was pretty glad I had studied for this. It was in our notes. Still fair game. He was getting a little agitated that I knew the answers but wasn't going to let it show.

Dr: "What is cardiac tamponade?"

Question 5.

Me: "When blood fills the pericardial space."

Dr: "What does result in?"

Question 6.

Me: "Difficulty for the heart to contract?" I was starting to feel a little unsure.

His face lit up like he had chanced upon a dancing leprechaun in a forest.

"Actually, that is wrong. When there is cardiac tamponade, it becomes difficult for the heart to relax."

Dammit. I knew that. This two-hour session was starting to feel like a whole day.

Still, he wouldn't let up. He had to prove that I was still the student and he was still the teacher, and ask me one more question. One question that was so vague that I couldn't possibly get it right.

Dr: "What is that effect?"

Question 7. I had no idea where he was going. He could be asking about the effect on anything. I asked him to clarify, and he mumbled something that didn't help, so I ventured a guess: "Increased afterload?"

Dr: "Ummm....", he replied, apparently surprised that I knew what afterload was, or never having considered the effect of cardiac tamponade on the afterload of the heart; probably the former. "Uh... no, that's not correct." Dammit, I knew that one too. I should have thought about that a bit more and realized that wasn't the case. I was nervous. I hadn't been pimped before. It wasn't fun anymore.

He went on. "Preload would be decreased. But what I was referring to is the ..." ...and on he went, explaining some advanced pathophysiology of cardiac tamponade, something that we definitely haven't been taught yet and aren't supposed to know in our basic intro to cardiac exam. I tried to understand, but couldn't.

I know what you're thinking. "Doctors should know this stuff." I'm not disagreeing with that; we should learn this stuff. But you see, we aren't supposed to learn it all at once. Our faculty knows that it will be overwhelming to learn everything in first year. That's why they made med school four years.

In fact, they clearly wrote in the course manual for today's session of this clinical skills course, and I quote: "Understanding the reasons for performing cardiac manoeuvres requires an appreciation of the underlying physiology of the manoeuvres and the pathophysiology of the murmurs that they affect" and that this is "beyond the scope" of this first-year course.

Which is why they provide a list of what we do need to know now, and a separate list of what we do need to know by fourth year. Right there in the book. So, when he decides to ask us about Osler's nodes and Janeway lesions, we know we aren't expected to know those things until fourth year. And when he decides to drill us on things like frikkin' leg-elevation and amyl nitrite auscultation maneuvers, we can see right in our book that he's pulling stuff that we don't have to know until a residency in cardiology, let alone before we graduate.

But aside from all that, this guy clearly wasn't asking us questions for our benefit. He was taking pleasure in putting us on the spot and watching us squirm. When, other than in boot camp and in horror stories of medical residency in decades past, is that okay? I doubt that's how Michelangelo learned from his instructor. We probably wouldn't have the Mona Lisa if he did. (I'm just kidding. I know my art history...Leonardo da Caprio panted the Mona Lisa).

I thought about calling this doc out on some stuff that I knew he was doing wrong ("shouldn't we inspect the hands and feet for cardiovascular signs such as clubbing or pitting edema before we look at head and neck and do the jugular venous pressure?"). He probably would have just shot me down.

In fact, he did shoot someone down when she called him out. "Why do we roll someone into the left lateral decubitus position when we auscultate?" he asked. "Mitral stenosis," she answered. "Nope," he replied. "I was referring to aortic stenosis." In disbelief, she double-checked what she had just read in our course manual. Sure enough, it says, "Mitral stenosis is an example of a murmur that is more easily appreciated in the left lateral decubitus position." She didn't bother to try and correct him.

Later on, he told us about "IHSS" and how it stands for Idiopathic Subaortic Hypertrophic Stenosis. Even if that is the proper term for it, his abbreviation letters didn't match up with his term. Idiot. I didn't bother being 'that guy' who says "don't you mean ISHS?"

The worst part was, even though we might have learned something had he talked slower and brought it down to our level, at the end of the day, we never accomplished the single objective of the entire session: practicing on the volunteer patient.

Listen, man, a little constructive criticism: Clearly you know your stuff. We expect that. You're a cardiologist. But, there is no need to show off here. And, don't take it personally when we know the answers to your first-year level questions. Instead of responding by asking us third- and fourth-year level questions that we haven't studied and will just confuse us, maybe try encouraging us.

If you're incapable of doing that, then how about you let us actually practice our skills on the volunteer patient, who has given up their afternoon so we can practice, and which is why we're actually here. They're getting bored of laying there and listening to you lecture, too.

Oh, and P.S. - the big yellow letters that say "Roll Up the Rim Contest" on your coffee cup mean that you should roll up the rim before you discard it on the counter. I rolled it up after you left and won a prize.

Boo-yeah. I feel better now.

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Heart in my Hands for Valentine's... literally...

This week we studied congenital heart defects. For our case-based learning assignments, we were to look up heart murmurs and congenital heart defects. "That's easy," I thought. "Murmurs... whatever, there's probably 1 or 2 types, and congenital defects, I've heard about that before. Hole in the heart. Good as done."

I was in for a surprise.

The list I ended up with had over twenty separate congenital heart defects that presented with murmurs. Apparently anything and everything about them can go wrong; thickening of the blood vessels (aorta, pulmonary artery); hole in the atrial septum; hole in the ventricular septum; valve issues; the vessels get switched around; portions get enlarged; or combinations of the above. The list goes on. It turned out to be one of those things that you think you understand, but never really put much thought into, and then you realize there's way more to it than you ever imagined.

I ended up feeling like I learned a whole lot just from lecture this week (a rare feeling; usually I have to sit down and start going over stuff myself). After our five or so weeks of microbiology, infections diseases and the like, a block that was poorly organized and not so motivating, it's nice to finally feel like we're learning something applicable and medical (I think I've said that a couple times over the year but it's getting better and better).

The climax of the week ended up on Friday afternoon. Everyone was bitter because up until now we'd had Friday afternoons off, so nobody was impressed that we had to go across town to the teaching hospital to do a pathology 'lab' in the small group rooms there. While there was a bit of variability in the groups (and 3 of the groups had tutors who were on call and thus did not show up), it turned out it was actually really interesting. Each group was given six pathological specimens of human hearts taken from infants that had died in their first few weeks of life (aww, yea it was a bit sad but babies do die and I suppose this is a way that they can help others in a huge way even though nobody was able to help them). Each heart had a congenital defect, and given the specimen we donned gloves and went through the chambers of the heart looking for it.

For me, it was neat enough to be given specimens in formalin in glass jars and being allowed to actually handle them. Most times when you see things in glass jars they're not to be touched. I felt special.

Besides that though, which I'm not entirely sure I should've admitted, it was really neat being able to investigate and problem-solve in a way that was applicable and solidified the content we'd learned that week. Being a visual learner, as well, seeing the defects in front of me, and being able to put in a probe into the vessels to see where it came out made a lot more sense for me than the description we'd had in lecture.

For those who are as nerdy as I am, here's a bit more. We had one specimen that displayed a congenital defect called Transposition of the Great Vessels, where the major vessel leading from the heart to the body (the aorta) is switched with the major vessel to the lungs (you might remember that the left of the heart pumps the blood to the body and the right side pumps it to the lungs). I figured the best way to repair this surgically would be to switch these vessels; but supposedly that's too tough when the hearts are small, so instead they do a Mustard procedure, where they put in a baffle, a piece of synthetic material that switches the inputs of the heart rather than the outputs. That way these people's hearts end up backwards; the right side pumps blood to the body, and vice versa. It was interesting to see how this little heart had compensated for the change; instead of the left ventricular wall being thick and muscular, the right side had this morphology. Fascinating. Seeing these hearts with surgical repairs and synthetic materials sutured in definitely gave us an appreciation for the minute surgical procedures that are involved in fetal surgery, and for the remarkable way in which surgical interventions can be a lot like rewiring a car engine.

It was all kindof solidified when a lecturer did something that doesn't happen often enough in our classes. The prof brought in a former patient who was born with transposition of the great vessels, and who had had the mustard procedure done when he was a kid, and interviewed him in front of the class. Other than shortness of breath for a few days if he exerts himself too much, he lives a normal life and owns a successful company and has a few kids. Nice to see a human face rather than just being lectured about a condition.

I'm still in awe at how much they're teaching us, and it seems like every week I find out a whole other pile of things that doctors know that I'll have to learn as well. What I thought was just one possibility for heart defects quickly turned into 20+, each with a different pathophysiology, set of signs and symptoms, treatment and prognosis. Not only am I learning medicine, I'm learning a lot about medicine, and how much there is to know, and that it doesn't necessarily line up with what my expectations were in every way. Fortunately, though, finding this out is more exciting for me than anything. So far.

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