You know you're consumed by studying when...

I found this list in a friend's Facebook notes... and with her permission, am reproducing it here for your reading pleasure. I won't pretend that I'm coherent enough to be this creative at this point right before finals... this many 15-hour study days in a row is enough to shut down most basic cognitive functioning.

You know you're consumed by studying when...

10. You think osteoclasts are cute (white furry balls!)

9. It seems like you're studying more than breathing

8. Things that secrete mucus are mucous-secreting
(clarification for those not in our class: incorrect spelling = incorrect answer = no marks. because we don't have enough stress!)

7. Breaks consist of eating

6. You don't sleep, you nap

5. You look forward to sleeping

4. Taking a shower is a relaxing activity

3. A change of scene involves studying a different block

2. Hearing "6 days til the holidays" provokes fear, not excitedness

1. You think personal hygiene is an option, not a necessity

Okay... back to work!

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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:

PHQ-9 QUESTIONNAIRE
Over the last 2 weeks, have you been bothered by any of the following problems?

a. Little interest or pleasure in doing things
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!)

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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.

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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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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.

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