Heart of the Matter

The reality of medical school has hit, and I am trying to get use to all the feelings that coexist at the same time: 1. feeling overwhelmed, and behind with the work load, 2. excited about all the cool new things that I am learning, and 3. tired, tired, tired. Yes it's true, medical school is a marathon and I have just shot out of the starting gate.

Last week was our first exam. Tension was high as everyone crammed as much as possible into the time available to study (outside of eating and sleeping, and sometimes instead of), not to mention all we crammed into our heads (I swear we MUST be growing new neurons in our brains). We all breathed a sigh of relief when it was over, and then waited anxiously for the results. Our scores would determine not how we rank in the class, but rather, whether the amount of time we have spent studying is enough.

OHSU has a grading system of satisfactory, near honors, and honors. There is a saying in med school that C = MD, and a joke: "What do you call the person that graduates at the bottom of his or her med school class?" DOCTOR! Ha Ha Ha. So no, the grades aren't really that important, and you can study just enough to get by, BUT, we have to know all this stuff to do well on the board exams, so we may as well study our little tushes off. After all, we signed up for this marathon right? No one forced us to send in all the countless applications; no one forced us to sign on the dotted line; we chose this and so...... we study, study, and then study some more. I myself, even though I like getting good grades (stroke stroke for the ego), am more propelled by the desire to KNOW what the body is made of, how it works, and what happens when things go wrong. I love what I am learning, despite the fact that I get tired, overwhelmed, and feel behind. I've decided that I can feel both - I can love medical school, and feel the strain of it simultaneously. (some would call this masochism I know I know....)

So guess what we did the day after the exam? Got up early to go to lecture, and then move right on in our dissection of the chest area. There is no rest in this race (that's why the second year students advised us in orientation to pace ourselves, now I get it). We opened up the chest cavity, cut out the lungs and heart, and held them in our hands. Nothing before in my life has prepared me to hold a heart in my hands. To see and feel all those little parts, valves, and muscles that are at the center of life, was astounding. The heart is a perfect pumping vessel: the first functioning organ in the embryo (a mere 24 days after conception), which will then beat millions of times until it's very last beat, heralding in death. Life begins and ends with the heart, and we have therefore spent countless hours in lab and lecture, learning the secrets of its development, the mistakes that cause defects to arise, and the journey of blood through its chambers.

Of course there is more to medical school than tests and studying. We are also challenged to learn another central tenant of the profession of medicine - how to act, dress, question, and answer like a doctor. This is where our clinical preceptorship comes in, as well as the readings for our Principles of Clinical Medicine class. The case studies we read about will (hopefully) encourage us to develop the other non-intellectual muscles. We pretend in small groups to be patients and doctors; we make up stories and practice listening to each other's hearts, as well as doing physical exams of the joints. I know I'm in the right field when I remember what I used to play at when I was a child. I played doctor! And now I get to play doctor again, except now the stethoscope is real, and soon, the patients will be real also. This, more than the tests, the memorizing, the studying, this seems to be to be the heart of becoming a doctor. I look forward to more play time, and more studying!

"It is a burden and a privilege to bear witness to patients' suffering and to intervene on their behalf." Mark B. Mengel, 2002

Through my Hands

Two firsts this last week. The first time I cut open a human hand (albeit a dead one), and the first time I held a child sized stethoscope to the chest of an eight week old baby. Both were startling and humbling moments.

The human hand took two days of dissection to unravel. In part because the skin and connective tissue on the palm of the hand is so tightly connected to the underlying tissues, which is no divine accident. Without that tight skin, we would not be able to grip anything, let alone open up a stubborn lid on a jar, or twist a screwdriver. So removing that skin and connective tissue is like trying to take super glue off the tips of your fingers - it pulls and tears at the underlying vessels and tissues. We tried hard to not damage any blood vessels or nerves underneath, as we needed to identify them, but of course, since we don't yet have the skilled hands of a practiced surgeon, we cut the recurrent branch of the median nerve, which supplies the muscles that move your thumb. Oh well, he wasn't going to be moving his thumb anymore anyhow.

But it's not just the connective tissue that demanded our time, and our meticulousness; there are 19, yes 19, muscles in the human hand. Now compare that with the fact that there are also 19 muscles in the shoulder region (to move your arm), and 19 muscles in the forearm (to move your wrist, forearm, and your hand). The muscles and supporting arteries, veins, and nerves, get continuously smaller as they flow downward. The muscles in the hand are tiny and so specific: four to move the thumb in its myriad directions, three to move the pinky finger, and lots in between to move the other digits. I won't bore you with the names, but they are long Latin trains, such as abductor pollicis brevis, flexor digiti minimi brevis, and palmar interosseous muscles, to name just a few.

The hand is truly astonishing. Those 19 muscles are attaching to 27 bones in the hand and fingers. No wonder we have such dexterity with our hands. I found it so ironic that I had to use the incredible dexterity of my own hand, in order to dissect Larry's hand. (OK, we finally decided to name Mr. Old Man, Larry. He's 6 foot tall, white, and we decided given his great musculature for a 89 year old man, he MUST have been a basketball player, and so we named him after that famous Bird character from the Celtics, plus we don't have any friends named Larry, and no one in our class is named Larry - that we have met so far anyway). The tools you use in dissection are simple. The scalpel is used only to cut the skin. If used under the skin, it tends to cut vessels and structures that we need to identify (not to mention that we are being evaluated on our dissections). Under the skin we do what's called blunt dissection, which is taking a closed set of rounded ended scissors, and then opening them up inside the tissue, in other words, we use the scissors backwards. This tends to separate out the connective tissue (which is literally everywhere) from the muscles and vessels. Then we can pick up small structures, very carefully, with some forceps, to pull or tug on them, oh so gently, to try to determine where the vessel goes, and from this information, guess what it is. Nerves and arteries and veins all look alike when there is no blood coursing through the blood vessels.

It is so easy to get so absorbed into the small musculature of the hand, that I forget the smell in the room, the ache in my low back from bending over, the time ceases to exist, and I even forget that the hand is connected to a body that was once alive. A hand that once opened jars, grabbed screwdrivers, gripped the steering wheel of his first car, caressed the palm of his first lover, and hopefully, held the tiny body of his first grandchild.

That thought leads me to the second first of the last week. The first day in my clinical preceptorship. I am teamed up with a family practice doctor, and I will meet with her every Thursday afternoon until next June. I love that I am with a family practice doctor, as opposed to a specialist, which will come next year. With this doctor I will get to see all ages, all sexes, and all different types of disease processes. Already in the first day I learned about gout, chronic pain, infectious viruses such as mononucleosis or cytelomegalovirus, prostrate hyperplasia, as well as stage 3 kidney disease. I don't know anything about them yet, (we don't learn any pathology until we finish learning normal anatomy and physiology), but I can see what all my years of studying will eventually create - a solid but always expanding body of knowledge that I can use to help others heal.

The highlight of the day came of course when we did a well baby checkup for an 8 week old girl. The parents were so attentive, and loving, and asked all kinds of questions about their baby. When to introduce solid foods, how to lay the baby down in the crib (to avoid that monster SIDS), and whether or not to use bumpers in the crib. Then came the exam time. The parents gave permission for me to examine their little girl along with the physician. I put the stethoscope to her heart, and heard.....nothing. I pretended to hear what I knew would be a very fast heart, and while the doctor was talking and examining, I turned the stethoscope around so that the valve was open to the small diaphragm, and not the adult sized one. Whoops.....no one seemed to notice my inadequacy though, as the baby cooed and smiled. After the doctor checked all her limbs, and abdomen, and neck, and hips, I put the stethoscope on the baby's chest one more time, this time in the open position, and heard the most wonderful music. The fast lub dub - lub dub - lub dub of a smiling, precious little angel.

So thanks Larry, and thanks little girl; I'll remember you letting me practice on you both, in the first steps on this highway of medicine.

So whatever your hands find to do

You must do with all your heart

There are thoughts enough

To blow men's minds and tear great worlds apart

There's a healing touch to find you

On that broad highway somewhere

To lift you high

As music flying

Through the angel's hair.

Don't ask what you are not doing

Because your voice cannot command

In time we will move mountains

And it will come through your hands

John Hiatt, Through Your Hands

Care of the Patient

This upcoming week we will get to experience something that is quite rare in medical school curriculum - our first real patient contact in the third week of class. OHSU differs from other medical schools in that we start to see patients in clinical settings right away, rather than waiting until the third year of clinical hospital rotations. This of course has advantages (we will get comfortable right away with taking patient histories, and vital signs), and disadvantages (it takes two afternoons a week away from all of our scientific studies). We have all been matched with a preceptor-physician, either a primary care physician or a specialist, in the Portland metropolitan area, and will spend one afternoon a week with them for the whole year.

Of course there are those that grumble about the time spent away from the cadaver lab, away from memorizing the brachial plexus, away from all those precious hours spent learning the "body of knowledge" that medical school will provide us. But medical school has another, and I would argue, just as important job: to transform us into competent and compassionate physicians. We have to learn how to talk to patients, how to interview them, how to deal with sticky issues such as difficult patients, making mistakes in our practice (after all we are human), as well as all the myriad issues of legality, malpractice insurance, and health insurance bureaucracy.

So I am thrilled to have permission to take several afternoons off every week to stop studying scientific fact, and to embrace what I consider to be the integral part of becoming a physician. For what good is all the knowledge we acquire if we cannot learn how to apply it in a clear, thoughtful, and empathetic way to our patients? It was with this enthusiasm that I eagerly read the required readings for last week and this week: the nuances of the doctor-patient relationship and how to cultivate it; as well as the first steps in taking vital signs. I realize that it is just the first childlike step in the journey of claiming that title "Doctor" (and hence the photo above), and that we will need lots of practice along the way. So already I have pulled out my brand new stethoscope and am listening to the heart beats of my family. I don't yet have the knowledge to understand the subtleties of the "lub dub", but I trust that will come in time. So thank you to my family, and to that patient next week who will officially be my first patient.

"One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient."

Dr. Francis Weld Peabody (1881-1927)