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Summer Plans

The summer between the first and second year is pretty much the last free summer. After second year, students have to take Step 1 of the USMLE exam. Then third year begins in July. There is also no summer break between the third and fourth year. I do keep hearing of some extra time during 4th year, but in theory, that’s supposed to be used to interview and different residency sites.

Anyways, this is my last free summer. Quite a few of my classmates are doing mission work. One has blogged about a trip to Africa. If you’re interested, you can read about it at doctajay.com. Other classmates are doing research to pad their CVs for those ultra-competitive residencies.

I had applied for an externship and my first choice was Chicago. Unfortunately I received an email stating that there was so much interest in the program and that they were sorry I couldn’t be offered a spot in the program.

I didn’t really have any backup plans. And because I really wanted to go to Chicago, I didn’t apply for any of the research projects on campus. So now my summer vacation has really become my summer vacation.

But I think I should do something. So I’ve told myself I’d review the material from this year. I think Anatomy is tested on Step 1 and there won’t be any Anatomy lectures next school year. Besides, a review never hurt, right?

So that’s the plan for the summer. Since I’m on vacation, I’ll probably have to draw from first-year experiences I haven’t previously written about.

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The Differential – A medical student (group) blog

A while ago, I mentioned that I received an email from one of the editors of The Differential — a medical student blog that is part of Medscape. Medscape is a part of WebMD and is aimed at health professionals and students.

The email, as I wrote before, asked if I would be interested in joining The Differential as a student writer. After a few email exchanges with the editor, I am now one of the medical student bloggers at the Differential. As per our agreement, the posts I write for them will not be showing up here (at least not immediately).

So check out that site. There are currently seven authors, all medical students. And everyone should be posting at least once a week.

Medscape Logo

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The Pursuit of Excellence

I had the chance to attend a meeting in which the famous Dr. Leonard Bailey spoke. For those who don’t know, Dr. Bailey performed the first infant heart transplant surgery in 1984 at Loma Linda University Medical Center. (By the way, I really don’t intend this to be a discussion on the ethics of that operation…) Each week during winter quarter my school invited a speaker to speak on one of the values of Loma Linda University. Dr. Bailey spoke about excellence. It was a good speech. I’d even call it inspiring.

During his presentation he read something that Vince Lombardi said to his Packers team many years ago:

Gentlemen, we are going to relentlessly chase perfection, knowing full well we will not catch it, because nothing is perfect. But we are going to relentlessly chase it, because in the process we will catch excellence.

He proposed that each of us sitting there had experienced excellence at one point or another. After all, we had all been accepted into our respective programs. I sat in my seat wondering about a pursuit of perfection — a pursuit with the hope of catching excellence.

And I wondered: can I be excellent?

This year one of my year long classes has been a course called Physical Diagnosis (PDX). In short, the class is all about the physical exam. We learn normal “human morphology” as well as the skills needed to carry out a physical exam, starting with the patient history. We have been learning to auscultate for heart sounds and lung sounds, percuss the lungs and even liver, and palpate an abdominal. In one of the PDX Labs, we learned how to perform a funduscopic exam (eye exam with the shiny light).

At the end of the year we are given a skills test, frequently referred to as the Freshman OSCE. The exam is approximately one hour long, and all the students are paired up with a partner. The examiner, one of the PDX staff members, will announce which exam to perform and one student will perform the exam on his or her partner.

Because of its difficulty, the funduscopic exam is one that all students have to perform. Funduscopic Exam I received a tip from an upperclassman. He said that since we will have had plenty of time to practice with our partners, we should just remember how many times to we need to turn the dial in order to focus in on the cup and disc of the eye. That way, in the exam, we can fall back on just counting how many clicks we need. If necessary, we can just fake the exam and pretend to look in the right areas even if we don’t see anything. The tip seemed really useful. Obviously one cannot do that with a real patient because every eye is different and counting the number of clicks will not work in that scenario. But I can see how this can really make things easier when the stress levels are high.

And then I wonder to myself, “Can I be excellent if I ‘help’ myself by counting?” Am I cheating myself out of perfect opportunities to practice my funduscopic skills on a healthy patient, when the only thing at stake is my grade and not someone else’s health? More importantly, am I cheating my future patients?

If I wanted to be selfish about it, I could probably conclude that I can’t afford (financially and professionally) to be careless with patients. But medicine is all about the patients, isn’t it? So maybe it is the patient that cannot afford for me to be careless. In one PDX Lab session the instructor, a pediatrician, said, “Your patients’ lives depend on you not screwing up. Don’t do it. Don’t do it!”

That was it. That was the pep-talk in less than fifteen words. That was her encouraging us to aim excellence in our clinical skills.

Throughout this school year I have witnessed numerous examples of excellence:

  • A blind doctor who needs a seeing-eye-dog and walking stick is able to “see” patients and remember details about each one. His memory and hearing constantly amazed me. If he can get through medical school without sight, what do I have to complain about?
  • A psychiatrist is able to deftly negotiate peace between an angry young lady and her mother. Only moments before, a resident struggled with how to deal with them. But the attending came in, took charge, and diffused a volatile situation.
  • A surgeon speaks to an old patient who is terrified about chemotherapy. He comments that he has fought in three wars, but “this” freaks him out. She (the surgeon) took his hand, told him the pros and cons of treatment, and told him that no matter what his choice was, she would not care for him any less. It was absolutely amazing the way she addressed the patient. Clearly, there was a solid doctor-patient relationship there. A textbook example of “bedside manner.”

Since I heard that speech I have wondered if I can be excellent. That may not be the right question for me to ask of myself. There shouldn’t be a question of whether I can or cannot relentlessly pursue excellence. Because in the end, when a patient’s life could be on the line, excellence is the only choice. There can be no other alternatives. That’s a lot of pressure. And that’s scary. But if I can’t handle that, I probably don’t belong here.

Oh, and by the way, I passed my OSCE. And I didn’t use the counting method.

*Image of funduscopic exam from Merck Frosst

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On the Wards – General Surgery (Day 6)

A third year told me, “you do a whole lot of sitting around and waiting during third year.”

That pretty much describes my last day on the General Surgery service. Well maybe not completely. A fellow first-year and I chased around senior residents and attendings trying to find someone to fill out our evaluation from.

I asked an attending in the morning at around 9 (right after she finished lecturing on the large intestine to a group of 10 of us). She looked at me, smiled, and said, “How do I know you?”

That’s the problem when you are a first year and only spending a week and a half (7 clinic days) on a “rotation.” Each day I saw a different attending. And she suggested that I speak up more so that she could get to know me.

I have no idea what to speak up about, though. When I round with the team, I’m the bottom of the totem pole! After only one year of medical school, I still have no idea what they are talking about. There’s no way I can put together a sensible question that would do anything more than waste time and slow them down.

Well the attending then looked to a third year and said something to the effect of: “I don’t know why we have to fill out an evaluation on for the first years. They’re here for a week. What are we supposed to evaluate them on?”

And she’s right! How are they supposed to get to know us when we hardly see them? And what exactly are we there to do? Watch and observe. So why can’t we just sign an attendance sheet or something like that? We need a full page, triplicate sheet to be evaluated on our performance (that consists of showing up to clinic and watching attentively)?!?

Well the attending asked if I’d be around later in the day and I said I would. So she said she would do it later.

Well my classmate and I finally found a senior resident who agreed to sign it off for us. But he wanted to sit down and talk to us. But before he actually signed it, he was paged to go round with the attending (the same one I talked to earlier). So we followed like little puppy dogs waiting for a treat — in this case the signature.

Well after rounding ended, the chief resident walked off without a word. We thought he was coming back since the attending was still around. But then she walked off in another direction. Unsure about what was going on, we hung out with some of the interns since they were still with the patients. Then, deciding to go look for the chief resident, we went to the OR and found him and the attending scrubbed in and ready to begin a new operation.

So then we sit in the call room for two hours just talking to the interns about life and medicine before we decide to go back to the OR and see if the case is done. It is, but we have to wait till the patient is taken to the recovery room. Finally the chief resident takes us back to the conference room. He talks to us for about 40 minutes about medicine, surgery, and life. The conversation was great, though. I learned quite a bit from him and really appreciate the fact that he took time to be so candid and share with us. For that I am very grateful!

My frustration stems from these evaluation forms we have to fill out. I could’ve scrubbed in on another case today. But instead, I’m sitting around trying to wait for a signature. Now that’s a really useful and educational use of a day! Well, if I am to stay positive, then at least I got in some very interesting and enlightening conversation.

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On the Wards – General Surgery (Day 5)

Well I finally was able to Scrub in on a surgery case. This is one week after my time on the General Surgery service was supposed to start. The case was a morning case with a scheduled start time of 8:45. But we ended up late.

It was an abdominal surgery case so I was excited about what I might get to see. (I am purposely being vague about the details of the case to protect the identity of the patient. I have no idea how many operations were done this morning.) However when I got to the OR, I realized that the surgery would be laparoscopic. So instead of standing over a human body with a large incision, I stood staring at LCD monitors for over two hours.

I counted at least six holes through which either a laparoscopic instrument or camera was inserted. There was only one camera. The third year I’m following got to hold the camera for the last part of the surgery.

I stood quietly trying to stay out of the way. So it was a long morning for me. When the operation was finally over, the surgeon looked at me and told me to stick my finger in one of the holes. Air had been pumped into the abdominal cavity during the surgery. (This provides space for the surgeon to work.) I was then instructed to stick another finger in a second hole. The residents proceeded to suture the other holes while I waited for them to get to mine.

My first time in the OR was definitely not exciting, nor was it something to write home about. But for completeness, I’m blogging about it. And I’m sure I’ve written about more boring things before.

In the afternoon I spent an hour and a half in clinic, but there was nothing outstanding about that.

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On the Wards – General Surgery (Day 4)

Since I’m writing a little bit each day during my time on General Surgery, I decided to split the post up. Here’s day 4. You can find days one through 3 by scrolling down or clicking here.

Day 4: I think I have a little better idea of what it means to get “pimped.” I thought I had a taste a couple days ago when an attending quizzed me about a CT scan displayed on the computer. It was basic anatomy. Identify the indicated organ (pancreas) and vessel (splenic artery) on the image. Well today, it was a whole other level.

I attended a lecture with other medical students and residents in the surgical conference room. There were a total of 3 first year medical students at the beginning. The attending asked who the first years were and we sheepishly raised our hands. Then, looking to one of my classmates, he asked what is the blood supply to the stomach. My classmate replied that it was the gastric arteries coming off the celiac trunk.

That answer is true, but the attending wanted more. Not getting any more answers he asked, “Did you make it to second year?”

Honestly, at this point, I was telling myself not to laugh. Not because I could’ve done any better. I just think its funny when people have power trips and think they’re so much better than other people. I’m glad I didn’t, though.

He then looked to another first year and I. I said “gastroepiploic,” while the classmate next to me answered “right and left gastrics.” Well we both were right (since there are five vessels), but then we got lectured for answering a question with the wrong intonation. He told us we need to be confident. No questions. And then the follow-up, “You want to be doctors, right?” (For those of you wondering, a third year finally correctly answered, “left and right gastrics, left and right gastroepiploics, and short gastric.”)

The rest of the hour he spent pestering the residents, particularly one female resident who had the nerve to say “I don’t know” to one of his questions. He retorted that her response was unacceptable as a second year resident. And proceeded to call on her to answer a question at least once every ten minutes.

Oh well. I’ve always heard attendings could be rough on us learners. I just have to use this as motivation to learn my “stuff.”

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On the Wards – General Surgery (Days 1-3)

I switched to General Surgery after a week and a half at Child Psychiatry. For this rotation, I’ll try to give a day-by-day account of how it went down. And I guess I should write that I was assigned to one third year for the whole time. In a sense, I’m discovering what the life of a third-year is like.

Day 1: Didn’t do much today. The third year I was following was assigned to Minor Surgery. So watched as two patients had sebaceous cysts removed from their backs. The cuts were about an inch deep (if I remember correctly). Not much blood and since this was a minor procedure, the patient had only local anesthesia and was awake the entire time.

The attending asked the 3rd year to suture one patient using a particular method. He replied that he had never done that before. But that didn’t stop him because the attending explained it and had the student do it anyway. I wondered what the patient was thinking as he heard this conversation.

Makes me wonder if, should I ever need a major hospital stay, I want to be admitted into a teaching hospital.

Day 2: All the third years had lectures this morning. In the afternoon there was clinic. Apparently it was a very busy day with a lot of patients. Before I left, I got to see two patients with either an attending or the 3rd year I am following.

There was one attending with whom I was absolutely impressed with. She is a surgical oncologist and invited me to come see a patient with her because I didn’t seem to have anything to do at the time. The patient was an elderly gentleman who had colon cancer. She had resected the cancerous part and was now suggesting that he undergo chemotherapy. Chemotherapy was suggested to reduce the risk of the cancer recurring.

The man told us that he had fought in three wars, but this situation scared him. I was so impressed with the “bedside manner” of this attending. She took his hand, explained to him the pros and cons, reassured him, answered all his questions, and then told him that the choice was his to make but that she would not care or love him any less whatever he decided. He remarked that he was glad she was his doctor. He kissed her hand. She hugged the patient’s wife. It was clear that she had cultivated an excellent doctor-patient relationship in which the patient and his wife truly trusted and liked their doctor. I even heard the patient say that he and his wife would adopt the attending.

I can only hope that one day I can have that sort of relationship with the people I treat.

Day 3: My third year was post-call today. I came in for pre-rounds at around 6 AM. We went around with the senior resident and everyone presented to her. An hour later we joined 2 attending surgeons and rounded with them. Apparently everyone was a bit high-strung because the attendings were present. I learned that the attendings normally only round on certain days and the rest of the week the residents and medical students present their patients to the senior resident. So there was a little more stress since no one wanted to mess up or not have an answer for either of the attendings.

Still wondering if I will get in the OR before my time here is up. But then again, I wouldn’t be able to do much…