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:

Listen, the patient is telling you the diagnosis.

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.

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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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Fumbling with the Tools of the Trade: Empathetic Statements

"... So I pulled out this empathy comment in front of a patient at my Family Practice class on Wednesday. I figured I hadn't used one in a while. I tried hard to mean it but I guess I didn't really, and so soon after I started saying it I began hoping the patient wouldn't catch me. It was slightly misplaced, and a little bit out of context. I felt really phony and I hated myself for it for a brief few seconds..."

---

I sometimes feel a little awkward using my new set of tools of the trade.

I'm not talking about the otoscope, or the opthalmascope, or the stethoscope, or the rectoscope (I can't wait!), or the tongue blade (apparently the technical term for 'tongue depressor'; the public caught on and started using the medical term 'tongue depressor,' so 'they' had to change the medical term to something more scientific and dangerous sounding. "Tongue blade should suffice," said the men in the white coats in the dimly-lit strategic medical equipment naming room.) Yeah, I'm all thumbs with all those tools still (as is my classmate who inflicted great pain on me whilst using one of the above scopes in a Clinical Skills learning session), but those aren't exactly the tools I'm referring to.

The 'tools' I'm referring to are the tools we learned during Communications Skills class, or "We Have A Past History Of Taking Crap for Our Graduates Being Socially Awkward And Insensitive To Patients So We Will Mandate That All Of Our Medical Students Take This Class On How To Talk To Patients Without a) Them Thinking The Doctor Hates Them, b) Them Thinking That They Will Sue The Doctor, Or Worse Still, c) That They Should Stop Donating Money To The Medical School From Which The Doctor Graduated." (That's the course title. Look it up.)

These 'Tools' are the Sit Down, the Get Consent or Die a Painful Immediate Death, and the most difficult to master secret ancient ninja maneuver, the Empathetic Statement.

The first two are pretty easy. "Sit down to create the impression of spending more time with the patient," we were told. Funny, I figured I'd just create that impression by spending more time with my patients. Shows how much I know. Moving on.

The second tool, Get Consent or Die a Painful Immediate Death, is pretty self explanatory and consists of making sure that the patient is willing to be interviewed by me. I have to get permission to talk to the people and I still don't even examine them on my own yet. Even if I screw this one up, my Medical School has covered their legal bases by layering - the patients are told when they book their appointment that medical students will be there, there is a "This Doctor is Teaching Medical Students" slash "Go Easy on the Medical Students, We Can't Have Them Quit On Us This Far In" certificate in the waiting room, the doctor asks them if it's OK to be questioned by a rookie, and finally I, the Medical Student of whom the patients have heard so much and are by now wondering why they have to be so sure they want to talk to me, ask them if it's OK.

(On a bit of a side note, in case there aren't enough side notes already, there are patients who decline to have their appointment on Wednesday afternoon once they find out that there are medical students in the office then. I'm collecting names so that I can decline to treat them or their children in the future. Just kidding, there are still some things that I don't mind putting off seeing in real patients until I've had a chance to be trained with standardized patients. You may recall what I'm referring to.)

Back to the tools. While the first two could be mastered by any layman, the final one, the Empathetic Statement, has pretty much become one of those things that haunts you even when you've punched your clock and have left work. It's awkward to wield, and takes a while to master, and at times you just close your eyes and hope it's working and you're not just embarrassing yourself, but when it is effective, man is it a deadly blow. It's kindof a secret weapon of new doctors, too, so don't tell anyone I told you this, we're sworn to confidentiality (which is why I'm sworn to anonymity)... I'll tell you, but I just don't want you, in your next doctor's appointment, to start wondering if a doctor is genuinely nice, or they have had to receive training on being nice to patients and are whipping out a full blown Empathetic Statement assault on you. Assume the former.

So I pulled out this empathy comment in front of a patient at my Family Practice class on Wednesday. I figured I hadn't used one in a while so I should get some more experience. I tried hard to mean it but I guess I didn't really, and so soon after I started saying it I began hoping the patient wouldn't catch me. I was interviewing this patient about her painful urination, now on my list of afflictions that I hope to treat rarely and acquire never, and I then chose to pull out an Empathetic Statement. It was slightly misplaced, and a little bit out of context. I felt really phony and I hated myself for it for a brief few seconds. If she wasn't so busy trying to make sense of my questions while I asked her to describe her pain in terms of its location, intensity, nature, character, mood, demeanor and favourite food and color, she might have noticed that my Empathetic Statement, "That must've been difficult," isn't exactly the most ideal interviewer response to "But the pain got better when I drank cranberry juice."

Okay, it wasn't actually that bad. I think what actually happened was that she told me that the pain was worse than ever before and I said that it must have been difficult. But I still felt phony saying it. This is what I'm talking about when I say that work stays with you even after you punch out. You see, it's rough when I do say something like "That must've been really frustrating!" spontaneously, even in normal conversations, because I feel like people - especially if the conversation is with someone in my class - they think I'm just pulling that out of my ass(ignment book for Communications Skills class). We joke around enough with FIFE (ie. Classmate approaches me and tells me they locked their keys in their car; I respond, "Awwww, how is this affecting your functioning? What are your fears?") so it's logical for them to think that I'm pulling out an Empathetic Statement because we were taught to, and not because I actually mean it.

Fortunately it doesn't usually go that bad. I have never actually gotten in trouble or accused of brash falsehood when I have used an empathetic statement, genuine or not. But I still hope this will stop being so awkward soon, and that when I actually do mean the statement, or even on those rare times that I don't and am just trying hard to be a bit more human, that my efforts will be appreciated nonetheless.

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"Don't Ask Shit Questions": To FIFE or not to FIFE

Another med school first.

I'm about to tell you about the first time that I was sworn at by a patient.

I've heard patients swearing at doctors before, but never at me. This was a wholly new and wonderful experience and I am taking it as though I have reached new depth in my irreversible spiral of being sucked into the health care profession, complete with its highs and lows, the latter of which can include being sworn at, among other things.

I'm happy to recount this saga. Unfortunately, it does not come without a lengthy, but hopefully entertaining, prologue.

Prologue

In our medical school we're taking a course on how to interview patients. Sure, most of it is common sense, but in the day and age where doctors are taking hits on having poor bedside manner, the logic behind this can be understood. I have seen, and have heard first-hand accounts, of physicians such as a surgeon who would enter a patient's room, remove the surgery bandage, look at the wound, write in the chart, and leave, without so much as a word to the patient. Yeah, these cases are in the minority, but there are enough of them for the medical schools to start teaching doctors how to be compassionate and how to talk to patients and show empathy and feeling.

So, someone somewhere in medical school curriculum development land decided that there were not enough acronyms for med students to remember and separate them from the general public untrained in medical expertise other than through what they see in ER and Grey's Anatomy, and thus invented "FIFE."

The students in my class have taken very dearly to this acronym, and instead of talking about "asking a patient the FIFE questions" or "using FIFE," my classmates have taken towards stating it in terms of "FIFEing the patient." "In this interview I'll be sure to FIFE my patient," I have heard often, or in further abuses of the loose resemblance of the term another word in the English language, some students will say "FIFE your patient! FIFE them until you can't FIFE any more," or "I definitely FIFEd the _ out of my volunteer patient." No disrespect is meant to the patients, just to the dude who thought that "FIFE" would be a safe word to give to young men and women early in their medical training.

Even our faculty tutors sometimes use this term in a way that could possibly be phrased more gently. A medical student at my school was practicing interviewing a volunteer patient in our communication skills class, and called a "time out" because she didn't know what to ask. "Did you FIFE your patient?" the tutor asked. The patient, with a look of surprise and horror on his face, exclaimed, "'FIFE?!' You're going to FIFE me? What do you mean FIFE?!!"

If you don't know what this means, you're probably wondering by now what the heck I'm talking about. You are not alone, and I have chosen to enlighten you. FIFE stands for Feelings & Fears / Ideas & Impressions / Function / Expectations, and are headings for a number of questions that doctors can ask patients about their illness to determine where the patient is coming from.

For example:
F: "Do you have any specific fears or concerns?"
I: "What do you think might be causing this illness?"
F: "How is this illness affecting your daily functioning?"
E: "What are you expecting from this visit to the doctor?"

You get the idea.

Some doctors don't use these guidelines, some doctors do. Some avoid even the idea of it. A girl in my class told me that her clinic preceptor pretty much used "the anti-FIFE" - don't ask any questions about their feelings because there just isn't enough time if we're going to fit in 6 patients per hour.

In some cases, though, the FIFE questions can be very helpful. To demonstrate this, the course directors brought a standardized patient (an actor portraying a patient with an illness) who complained of wheezing and chest tightness. Questioning the class made it clear that we were all ready to assume that proper treatment would be along the lines of doing a lung test and prescribing asthma puffers; however, FIFE produced valuable additional information that would not have been discovered otherwise. The best example came upon asking the E portion of FIFE ("What are you expecting from this visit to the doctor?"). The patient revealed that she knew of friends and family that had suffered from heart conditions, and she wanted a heart test to rule out this possibility. Us budding physicians hadn't considered that the patient might have been hoping for this, so FIFE prevailed and we were all immediately and wholly convinced as to its efficacy and even stopped making fun of it just a little bit.

Saga

With that introduction I can now move in to the saga of my being sworn at.

I was in my third week of Family Practice clinic and was sent to a room to interview a patient. I walked into the room to see a gentleman in his late thirties peering out the window through the blinds. I wasn't sure how to approach this odd situation, so after composing myself I asked, "What are you looking at?"

"My car. I don't want my car to get towed," he said hurriedly.

He turned around to reveal a gentleman in his late thirties, I'm guessing blue collar, with blond spiked hair, an earring, and a large tattoo on his back and neck. He was the type of guy you might see get out of a beat-up pick up truck at a bar to have a few beers, watch a hockey game, and yell at the TV with his buddies.

I respected his implication that time was of the essence so I decided to proceed a bit more quickly, without asking about his family and hobbies and the like. I introduced myself as a medical student and asked if it was okay for me to interview him; he almost cut me off: "Yeah, yeah, do whatever you need to do, that's fine with me."

I proceeded ask him about the chest pain that had brought him in, and the typical questions about how long, how painful, and the like. "It hurts like hell," he said. I asked, "On a scale of 1 to 10, where 10 is the worst pain you ever experienced, how bad is it?" He replied, "Well, I have gout, and that is horrible pain. Compared to that, this would be like a 1. But this hurts like hell." I tried to figure out what that meant while I scribbled notes on my clipboard.

Once I had gotten a good idea of his pain, admittedly a bit flustered that I was thrown off my normal questioning routine by trying to rush the interview, I realized that I was running out of questions.

Without skipping a beat or showing any signs of distress, I immediately resorted to FIFE. I had the good sense to not ask this man about his feelings, and instead asked what he thought was causing the pain.

"My smoking, for sure."

Score one for FIFE.

I reached into my trusty FIFE question kit and carefully selected another question to present to him.

"What do you hope to achieve by coming in today?" I asked.

He stared at me.

"Um," I rephrased, "what are your expectations for this visit to the doctor?"

He looked at me as if I had just grown a third ear.

"I want to know what it is. I want to know what the fuck it is. Make the fucking pain go away."

And then the fateful blow:

"I just want to know what the pain is. Don't ask me any of your shit questions."

"Shit" questions?! I was devastated. I thought I had been armed with the tools of interviewing by my infallible supervisors, and yet here I had gone and agitated a patient to the point of cussing. How dare he call FIFE "shit questions"!!! FIFE had failed me. And it only went downhill from there.

I tried not to look too flustered and tried to wrap up as fast as I could. I asked if he wanted a flu shot, then I asked if he was taking any medications. He mentioned a drug for his gout, then looked at me and said,

"Dr. Milton knows about all my conditions. I've talked with him about all that already. My history is not your fucking business. Do what you need to do with this, and ask me nothing else."

Again trying not to act too flustered, and sensing something less than appreciation for my efforts, I ended the interview, and told him, "You know, I usually come back in with Dr. Milton, but if you prefer the doctor can just see you on his own."

His response was not what I expected.

"Oh, no, no, that's fine, I don't care if you're here."

A bit confused, and a lot flustered, I left and presented the case to the physician quickly, and hoped that this paradoxical patient would stop trying to test my limits. The doctor came in, diagnosed the illness, and wrote down a prescription. As the doctor was finishing up, he told me to take the patient's blood pressure.

I realized I had subconsciously edged my way as far as possible away from this patient and had my back against the wall, and so upon being asked to take his blood pressure I slowly made my way towards this man that I realized I had been distancing myself from.

He didn't make it easy for me, either. As soon as I put the blood pressure cuff on his arm and had inflated it with a single pump...he freaked out. He jumped and pulled his arm away.

"What the hell!?" he shouted.

I was pretty much at my wit's end, and shocked and confused as to why this guy was reacting this way to the very minor pressure that a blood pressure cuff exerts after only one squeeze of the bulb. I looked up at him in surprise.

"Just kidding," he said.

What the heck!? I'm not sure if there was something not right in this patient's head. My classmate suggested he might be bipolar. Either way, he was enough to make me seriously wonder about his sanity.

Postlude

(Any story with a prologue must have a postlude. It's just good Englishing, and I am a huge proponent of doing grammar correct.)

So that was my first experience being sworn at by a patient, and I can probably expect it to happen again. Fortunately, in the grand scheme of cusses that patients can direct towards their health care providers, this was very mild. At least he didn't start swinging at me or anything; heck, he didn't really even swear at me, just around me. And I couldn't wait to tell my interviewing class small-group tutor what the patient had said about FIFE.

I'll definitely be more selective about when I choose to pull out the "shit questions."

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Top 10 list: Things that make me feel like I'm becoming a doctor (as of First Year)

EDIT (11/21): I had to add a number 11. Find it here.

I kindof had to make this list to convince myself that I'm actually in med school. Like I've mentioned before, our first semester is a lot of just basic biology, things I learned in undergrad (biochem, physiology, etc.), so I can't help but feel that I'm still just taking more biology classes. Until I get to third year, where I report to the hospital every day (and on weekends...and I am given evening shifts...And I'm put on call...) it still seems kindof like school, still. Hopefully this changes a bit in January when we start going through the body organ systems, block by block. Until then, I have this list to go by:

10. Got my second issue of the CMAJ today
It always makes me feel like a member of the profession.

9. Calculating IV infusion rates
Finally, there is an applicable use for algebra and natural log calculations. Boy, was I rusty on those for a while, though!

8. Getting my ID tags
I wear these a bit too often, my excuse being because they're on the same retractable carrier as my bus pass. The third-years make fun of me.

7. Being allowed to shadow doctors in the area
It's hard to arrange this when you're a pre-med!! I've already shadowed an ER doc back home, an ER doc here, and going to shadow a surgeon next Monday.

6. Learning how to interview actor patients in my interviewing class

5. Interviewing real patients in the family practice clinic

4. Getting sworn at by a patient in the family practice clinic for asking questions I was told to ask in my interviewing class
I'll definitely tell this story soon!! EDIT (11/20): This post is now available here. (Title will be: "Don't ask shit questions" - To FIFE or not to FIFE. Another time, though; I'm keeping busy and don't have the time right now).

3. Cadaver lab
Partly because I get to wear scrubs, and partly because this was something I envisioned doing when I got to medical school, since not many people get this privilege.

2. Giving injections
This isn't #1 because some of my friends who were in nursing when I took my undergrad were giving injections way before me, so I was jealous of them and when I got to do it I only felt like I was caught up to them.

1. Getting my stethoscope
The excitement of this has started to wear off, but the day I got it I felt like I was pretty much ready to graduate and be called "Doctor". Don't laugh. Small things amuse small minds. And when you pay that much for something, you may as well appreciate it.

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Extraeducational Patient Encounter

I felt like a real doctor today for a brief moment.

When I was switching buses on my daily commute home, I saw someone waiting for the bus whom I recognized - a woman who had been a patient of mine!

Okay, I'm not a doctor yet. Not even close. And in actuality, all my "patients" to date are either cadavers or fake - hired actors.

The one I fortuitously saw on the street today fell into the latter category, in case you were wondering.

Even though my feeling as though I am a doctor lasted for less than a measurable time quantity, it was kindof neat. I know that happens to doctors all the time, running into patients of theirs. My friend's dad is a GP in a small town, and it happens to him. It must be nice for doctors having these little reminders that they've made a difference in somebody's life, every time they bump into them. Or perhaps they're more like reminders of what a nightmare the patient was and how stressful the doctor's practice is.

Maybe I'm just stretching for ways to feel like I'm becoming a real doctor, since I don't get that feeling very much in class. All our classes so far are a repeat of fairly simple concepts we learned in undergrad, or even worse, high school. I've learned how cells divide about six or seven hundred times already, and that meiosis happens in the somatic cells and mitosis in the germ cells (don't freak out, I'm on it, that was a little joke for you science people out there). It seems like it's going to be like this for the rest of the first term, too, since it's designed to catch up the people who, unlike myself, do not come from a science background.

There's just enough new information that I have decided to heed the words of pretty much any second year I've talked to: "Don't get behind! Stay on top of the material." So my days of little to no homework are gone; I've started making work for myself, namely, reading and studying the notes, so that when study time for our midterm comes up in a few weeks I won't feel too pressured. But still, that midterm's only worth 5% of our grade...so how much pressure can that be?

That being said, you can probably understand how it's a relief to study things that are more clinically related, like our small group session on hypertension today. Though the second half of the first-year curriculum promises to be a lot more work, my friends in second year say it's a lot more clinically relevant and a lot more interesting. I think I'd rather have lots of interesting work to do than be bored reviewing things I've already gone over.

I have a feeling that I'm going to regret saying that someday.

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