That poor, poor transcriptionist. I almost admitted it was my first dictation.

I picked up the phone with a shaky hand, and slowly dialed the number for the hospital dictation system for the first time.

"Welcome to the Excelleris Express Dictation Service. Enter User ID , followed by the pound key," a cheerful voice said.

Good, I thought. She doesn't yet know that I have no clue what I'm doing.

I keyed in the number for the doctor who was dumb enough to ask me to dictate for him. 6-2-1-0-9-#.

Enter hospital ID. 1-6-#.

Enter work type. 1-0-#, specialist consultation of a patient.

Enter patient number. 2-1-6-2-7-8-1-#.

Beep beep. . . . beep beep. . . bee- okay, are you going to make me wait all day? this is where you start talking, idiot. Fortunately, it didn't actually say that to me.

I pressed 2 to begin, and slowly began to talk.

"This is Vitum Medicinus, M-e-d-i-c-i-n-u-s, medical student intern, dictating on behalf of Dr. Doe, a consultation note on patient James Smith, S-m-i-t-h, unit number 2162781, date of birth 02/20/1949. "

This isn't so bad, I thought. I picked up speed.

"Copy to Dr. Doe, copy to Dr. Wilson. Date of consult March 6 2009, date of dictation March 6 2009. New heading, patient identification. Mr. Smith is a previously healthy 60-year-old Caucasian male who presented to the emergency department with his wife and daughter. Period. New heading. Chief complaint. Open quote, I passed out in the McDonald's parking lot, close quote."

I was doing it just like all the doctors I had seen dictate before! I was dictating! How exciting! I went on.

"New heading. History of presenting illness. This afternoon Mr Smith was getting out of his car at McDonalds when he began to feel presyncopal, period, before he could stop himself he fell to the ground, period, he described his presyncopal symptoms as open quote I was light headed comma I felt like I was going to pass out, close quote, but denied vertiginous symptoms, period. he lost consciousness for approximately ten seconds and in this time did not have any tonic clonic movements comma nor did he lose control of his bowel or bladder or bite his tongue period."

Okay, it didn't go that smoothly. My actual transcription went something like this... or at least what it would have looked like if I hadn't known how to pause, rewind, and re-record:

"Uh.... um.... uh... consult...dictation.... on ... patient .... copy to... Dr.... heading...new heading.... History of, uh, no wait....go back... Mr. Smith..." ... well, you get the idea.

Starting to dictate on behalf of the physicians has been really helpful. I've done a fair bit since that first one, and the process has made me realize that as far as taking the history and presenting the physical exam goes, I've started to really get the hang of it. It's when it comes time to dictate the assessment of what the patient has going on, and the plan of how to treat them, that I kindof fall apart and realize that I still have a lot to learn; with my first dictation, I had a fair bit of trouble with it even though I had discussed the case with the doctor already. Obviously, that's what I'm here to learn in third year, and throughout residency.

After I finished my first dictation, I sat the phone down, and began to gather my notes. I took a deep breath in and out. I noticed that one of the other emerg docs had sat down at the same desk about two-thirds of the way through my dication, and turned to him and asked, "Do you remember your first dictation?"

He smiled really big, and laughed, as he replied, "I try not to!"

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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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"Um, is this your first time examining a woman there?" "Hell no!"

I gave in.

I know I said I was going to sit out the Maternity Hands-On night, but I didn't go just for the vaginal exams (and what if I did, anyways? I'm going to be a doctor, I need to get experience, nothing weird about that? right? why do I feel as though I have to justify this?) I went for two reasons: 1. I was there anyways for a meeting of the Emergency Medicine club, and 2. free pizza!

I'm glad I went, too. Not only did I get elected to a position in the ER club, but this was probably one of my most practical and interesting events since starting med school. Hopefully it's a taste of things to come in January when we stop the cirruculum of undergrad review and get into the doctory stuff.

I delivered a baby, determined how dilated a woman's cervix was, and felt for the position of a baby inside a woman's stomach!

Had I known the first two of those would be on fake silicone models, I wouldn't have been so shy about attending. Mind you, I was clearly not the only shy one. Even though there was a great turnout - almost a quarter of our class showed up - the men in the group were far fewer in number.

It was interesting, too, learning how much an experienced physician can tell from an exam; how the baby is lying / presenting, etc. Someday I'll be that good - someday at the end of my OB/GYN rotation, and it will probably all go downhill from there.

And the best part? If a woman ever asks me while I'm conducting the above procedures, "Is this the first time you've ever done this?", I can emphatically and truthfully say, "Hell, no!"

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Vaginal Exam practice and Free Pizza!

I don't think that the upperclasspeople in my medical school realize that to us first years, it's still a bit odd getting an e-mail that juxtaposes "practice vaginal exams" and "come for the pizza" in the same sentence:

Come to the OB/GYN student interest group's Maternity Hands-On Night! Stations include abdominal palpation, finding the fetal heart beat, vaginal exams, and charting; pizza and beverages will be provided! First and second year students especially will find this to be a fun learning experience.

As "fun" as this promises to be, I think I'll skip this one out.

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My First Patient: Mr. Box. Mr. Cardboard Box.

I felt like a nerd being excited to finish up my rotation with a 10:30 pm to 7:00 am shift in the ER.

So, just think how excited I must've been when the doc told me, "If there are any drunks that come in who need to get stitched up, we'll get you suturing tonight."

If there are any words which will guarantee that no more patients will come into the ER, that must be the magic spell. Between 2:00 am and 6:00 am when I went home, we saw two patients. Somewhat unusual for a Friday night.

It's probably a good thing. The rest of the time the doc and I and the nurses all sat around and chatted. Then, I did end up suturing - on a cardboard box - following one-on-one lessons with a physician. It was good to start on something that won't leave a lifelong scar. And I quickly learned that suturing is another one of those things that isn't as easy as a doctor makes it look - it's easy after a bit but you feel like all thumbs for the first few minutes. He also showed me how to hand-tie sutures

I did finally get a view of a patient's fundus using an opthalmascope, though! Well I was excited because I had tried a number of times, unsucessfully. All the more reason to buy an otoscope/opthalmascope set - so far in our registration package we've been told that only about half the class buys one; the other half thinks you can get by without one.

So that's it for me. Back to relaxing for the rest of the summer, until classes start.

I can't wait.

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Learn from someone else's mistake #1: Humour and patients

It feels good to sit down after an 11-hour shift. And, I get to sleep in tomorrow (that's the good news; the bad news is it's because I'm doing a night shift tomorrow starting at 10:30 pm.)

Story time.

As we left the patient, the doctor pointed to a dressing cart and said, "How about you put some gauze and tape on her cut so her dad doesn't have to hold that tissue paper on it."

"Oooh," I thought, "I get to talk to a patient! No doctor in the room! Awesome!"

I collected myself and grabbed a roll of tape and some gauze, and carefully put it on the ninth-grader's wound in a very amateur and untrained fashion that is probably contraindicated in every way and will cause the nurses to shake their heads and mock me under their breath as soon as they seen it. But as I left, I said the fatal line:

"That should keep your dad from having to have his arm up for the next few hours!" Ha, ha, ha, I thought. A few hours. I'm so kind-hearted, cracking a witty joke and keeping these patients smiling.

The reaction was not what I expected.

The girl's eyes went big in horror and shock.

"A few hours?!"


They had been there for hours already and had seen us walk by their room several times to see other patients - likely including patients who arrived after they did. I quickly learned a lesson from the poor girl's reaction to my offhand comment: When it comes to joking around with ER patients, they don't find it funny if you make a joke along the lines that they have a long time left to wait. Most of them have been there long enough just to see a doctor. Unfortunately, they will likely be waiting there for a while longer as they wait for labs and xrays to come back. But don't remind them. Especially in joke form.

I figure that this could be the first of many mistakes that I post here, mine and others (med school classmates beware). Yes, I have come to terms with the fact that I may do two or three things wrong over the course of my medical education. So I'll try to immortalize them as they come along in what could be a great new VM miniseries. And hey, why not just talk about my mistakes? Here's another one. One that I didn't make.

This I learned from the doc I was following: Never give a patient any definite indication of how much longer they'll have to wait. Not that you should avoid the question or lie to them. It's just that things can get crazy. A patient we were seeing was getting antsy to go home, and he asked how long he'd be. The doc explained, "We're going to refer you to a specialist, Dr. Frist. We've paged Dr. Frist, and she always responds to her pages right away, so you shouldn't be here longer than ten or fifteen minutes." On top of all hell breaking loose in the ER, this also marked pretty much the first time that Dr. Frist didn't return a page. I felt really bad when I noticed him still in his bed an hour later and went over to explain what had happened.

Shadowing doctors is great now that I'm a medical student and not just a pre-med. Maybe it's just the docs I'm working with, but I've noticed a difference. Even though what I'm allowed to do is still very limited, the doctors have that much more respect for me. I've had deep conversations with six or eight doctors where they've gone into detail on questions I've asked about about their experiences in med school, lifestyles of various residencies, pros and cons of specialties. One gave me good advice about going the military route to pay for med school. And I've been so surprised by how much they care about my future.

All the stuff they're letting me do is part of that respect. Even though it's just been little stuff like going to a patient on my own and explaining that we'll need to run some more tests, or reducing a dislocated shoulder, or putting on a cast (the last two under close supervision), it's a good feeling when the patient asks why more tests are needed and I can explain, or feeling the shoulder pop back into place, or hearing the patient say "that cast makes my arm feel better already."

It's also a good feeling that I'm no longer just doing the pre-med thing - watching. Instead, I'm practicing. For when I get to do this for real. For a living. It feels good. If I can choose to walk around an ER for "fun" for 11 hours, and still be willing to go back for another helping tomorrow (during a night shift, no less), I think this might be an indication that I've picked the right career.

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