A Journey Through Medical School

Perception

valerie.brooke@yahoo.com (Valerie Brooke) — Thu, 25 Feb 2010 19:08:00 +0000

Several weeks ago I sat down with one of the residents that was supervising me, so that she could give me feedback about my performance. I imagine that students fall into one of several categories when it comes to answering the question: "How do you think you are doing?" Either 1. a student will think they are kicking butt, when in fact no one can stand them due to a big ego, or they are slacking big time; or 2. a student will nail it, and see themselves exactly as their supervisors see them (doubt this happens much); or 3. a student will believe they are not doing as well as they should be doing for someone at their level of training. I can only speak for myself, but I imagine that most of us fall into the 3rd category: we constantly see ourselves as lacking, especially when it comes to comparing ourselves to all the other doctors on our team, who are smarter and more experienced. It doesn't matter that a part of your brain is aware that the resident and intern are years ahead of you in terms of the numbers of patients they have see, which only solidifies the book knowledge learned in the first 2 years of med school. Despite that nugget of understanding that's shoved somewhere in your consciousness, what rides above that is the all prevailing feeling that you are inadequate. Yes, we are perfectionists, otherwise we wouldn't have gotten this far in the first place, but I think it's much more than that that has so severely altered our self perceptions.

So I answered the resident with the statement that I felt very average as a student, not stellar, but not completely incompetent either. I felt I had an average fund of knowledge (can't remember all the details of medicine that I've memorized in the past several years, but I bet I've retained maybe half?), and maybe an above average work ethic and ability to communicate with patients and other medical providers on the team. Amazingly, both the resident and the attending whom I had this same conversation with the week prior, felt my perception was off - that I was actually way above average, in my fund of knowledge, and skills as a blossoming physician. Now I wondered, why was my perception so off? Is it that I hate not knowing the answers? Is it that I expect myself to know as much as my superiors? Or is it just that I am so internally driven, that what I know is never enough? I can always know more, do more, and study more, right?

In response to this discrepancy in self-perception, my resident said something that has literally rocked my world, and if I could really adopt her recommendation, it would probably make my life as a medical student so much easier. She said, "Valerie, just trust the process. This system of education has been producing competent physicians for a hundred years. Just show up, work hard, and you will be transformed into a physician."

Whoa! Trust the process? You mean accept myself for where I am at in my training? You mean stop complaining about all the long hours? You mean accept the imbalance as a inevitable part of the medical school training process? Or maybe she just meant to stop being so hard on myself so that I didn't have to add more stress on top of what was an inherently difficult process.

I have thought long and hard about her advice in the past several weeks, and I wish that I could so easily feel that trust and acceptance when my alarm goes off at 5 am, feeling like I'm in a Groundhog day movie script. Different day, same hours. Different patients, same stress. I always feel guilty when doing a mental status exam on a confused patient when asking them what day of the week it is, what day of the month, or even what month it is. I'm just as confused as they are! There are no separation of days or months for me, although I'm happy to say that I'm at least orientated to the year, 2010 right? How I survive these days, as I finish up the last 3 weeks of my 10 week internal medicine rotation, is to just put one foot in front of the other. Alarm, shower, tea, toast, car ride, hospital, patients, chart notes, car ride, dinner, bath, bed. That's my life these days, and although I keep telling myself that I should trust the process, surrender into it like a Buddhist, I still want to bitch and resist and fight, if only I wasn't so damn tired.

The First Code

valerie.brooke@yahoo.com (Valerie Brooke) — Thu, 28 Jan 2010 01:39:00 +0000

I am physically and emotionally exhausted. It's only week 4 of a 10 week rotation, and I'm dragging my feet, counting down the days, and watching the clock during the day. For me, this is worse than surgery. It's the hours, yes. Most weeks it's 70 hours, and if long call falls on the weekend (which is does for at least 5 weekends out of the 10 weeks) then it's 80 hours of work. It's the patients also, not that I blame them for being so very sick. Heart disease, kidney disease, lung disease, liver disease, blood disease....all the diseases that I have learned about in the last 2 years of lecture and self-study. I try to remind myself that the hours spent at the hospital, and with these sick patients, will help me to become a better doctor. Their suffering and diseases will help me to do better on my next board exam. I try to daily keep up with the vast array of knowledge that I am reminded I do not remember, or have never even learned. Yes, I am trying to see the cup as half full, but the truth is that I am almost completely empty.

I'm still trying to process the first code I have ever seen. Code is synonymous with some one's heart stopping, and the subsequent attempt to resuscitate the patient. It occurred 3 days ago, on our long call night, and the images still flash in my mind, right before I fall asleep at night, right at the time that I am most wanting to shut out the pain from my daytime hours.

I see her listless hand flopping up and down against the sheet, in between the ten or more doctors that surround her bed, as my senior resident does chest compressions. I glimpse her face, stark in the absence of life, and yet her eyes are open. I see one of the doctors intubate her with a breathing tube. I see yet another use a drill to put in IV access into the tibia bone of her lower leg. I hear the shouting of orders from the doctor leading the code. "How much epi has been given?" "Stop compressions! Check for pulse!" "More epi!"

Thankfully she wasn't my patient. I'm not sure that I am ready to loose a patient. She "belonged" to another student, who had seen her just an hour before, and although the patient was sick enough to be in the hospital, she certainly didn't look like some one who's heart was soon to stop. We stood in the hallway, running to get supplies if we could, otherwise feeling completely powerless, not only in our ability to help, but also in our ability to turn away. It was like watching a car accident in process. I couldn't turn away, certain that I would miss something, certain that she would definitely be gone if I walked away.

45 minutes passed. We did get some electrical activity in her heart, from the drugs given, but there wasn't enough to coordinate contractions to get the blood moving into her now floppy limbs. The lead doctor eventually decides it's time to stop. One by one, each of the doctors relinquish their duties. The anesthesiologist takes out her breathing tube. The heart monitor electrodes are peeled off her skin. The IV line that was drilled into her leg is removed. One by one they all leave the room. The nurses stay behind to continue cleaning her up, to prepare her for her family who is on the way. The same family that had just left hours before, with plans on returning in the morning to find out what we had discovered about her disease process. I waited in the hallway until the nurses closed the curtain. I was allowed to watch this heroic and seemingly barbaric attempt to bring her back, and yet was not allowed to be a part of what I hoped was a gentle apology for what we had put her body through. And that's just it. At the point of the attempted resuscitation, it was just her body, so clearly empty of life.

Her family showed up and were taken to the room. Crying could be heard from the hallway. I don't know that I could ever get used to telling someone that their loved one died. How will I keep the tears from my own eyes? We have no idea why she died, so unexpectedly, and will never find out as the family did not agree to an autopsy. We returned to our workroom at midnight, shocked, tired, and still with lots of work to do. We talked about what we could have missed. What signs did she give us that she was this close to death? What lab tests could we have ordered to give us a better sense of her sickness?

If that wasn't enough for one week, we got another very sick patient, dying of liver failure. At least with this patient, it was clear that she was going to die, it was just a matter of when. She lasted about two days in the hospital, as her organs shut down one by one. First her liver went (she was very yellow from jaundice), then her kidneys failed (no more urine production), her heart faltered (blood pressure dropped), and her lungs struggled for the last breaths of her life. We went into the room yesterday morning, to give the dismal prognosis to the family, telling them she was not a candidate for liver transplant, that her organs were shutting down one by one, that it would most likely be hours, and not days, before she passed. The tension and grief in the room was palpable. All of her children were there, as well as both of her parents, as she was a young fifty something year old woman. The only way I could keep my own tears from falling was to pretend to not be in the room. To not be present at all. Will I ever get used to this? And do I even want to? For now, I return home everyday with a heavy heart, and reluctance to get out of bed the next day and do it all over again.

Sick Doctors

valerie.brooke@yahoo.com (Valerie Brooke) — Mon, 18 Jan 2010 16:02:00 +0000

I remember once during my massage years seeing one of my regulars who was an ophthalmologist (eye doctor) and asking how he had been since his last massage. He reported that he was very very sick, sicker than he had been in many years. I asked him if he took any time off work, to which he smiled and said "Doctors don't take time off when they are sick," which I figured at the time was just a representation of his generation. He was an older man, near retirement himself after a life of giving up his time to medicine, and had that "old school" mentality where it is expected for doctors to work over 100 hours a week, and work when sick, all without complaint. After just two weeks working in the hospital with internal medicine residents, I've realized that the expectation for doctors to work when they are sick is still very much alive.

Take the intern for example. Last week while giving presentations out in the hallways he would have to take a break to wipe his eyes, and the sweat off his brow. While in the rooms leaning over patients to listen to their hearts, he would tip his head way back, and deeply sniff, so that he didn't drip any of his nasal secretions on the patient. After the heart exam he would quickly go over to the sink, blow his nose, then wash his hands, and return to the work at hand, until his secretions sent him to the sink again. We watched him suffer for many days with his illness, all the while being slammed with the work of an intern (something I am NOT looking forward to). He would be sitting at the computer in the call room, with blood shot eyes from being up all night, and a sweaty brow from his fever, with runny nose and eyes, trying desperately to keep up with the relentless incoming pages from nurses about medications or symptoms of his patients. You see when on overnight call, the intern is not only responsible for the ten patients that we have on our team, but is also responsible for what is called "cross cover" - he is also responsible for all the other internal medicine patients in the hospital (because the other interns are home sleeping). My heart broke for him, and I wish that we could have helped him, but unfortunately medical students don't yet have what it takes to do intern level responsibilities.

If that wasn't enough to believe that this whole working while sick thing in medicine is utterly ridiculous, I have been fortunate enough to experience it myself, so that I can know for SURE, that it's absurd. Last week, just days after the intern's snivels started to abate, I started with the infamous sore throat, that soon led to a dry hacking cough. After several days I just started wearing a mask, because more of my time was spent coughing than not. I drank cough syrup like it was candy, and went though a whole bag of cough drops in one day. Thursday was the worst day, as it was long call day, which meant an overnight shift. Thankfully my resident sent me home to do my work, as she was probably sick of hearing me cough in the workroom. So after examining my patient, I went home to spend hours writing my history and physical exam, assessment and plan, and slept a few hours sitting upright on the couch. I returned for rounds early the next morning at 6 am, and spent the next 4 hours in uncontrolled coughing spasms in the hallways of our medicine ward. My eyes watered, I slugged another few doses of cough syrup, and prayed to at least stop coughing long enough to give my presentation to the attending. 3 hours later, after listening to the other medical students give their presentation, as well as the intern discuss the other patients, I finally got to my 10 minutes of "fame" which of course, was interrupted by racking spasms of coughs.

Now what is most disturbing to me about this whole thing, other than the obvious fact that I did NOT belong in a hospital, around patients much sicker than I, who definitely couldn't afford to get my illness on top of theirs, was the fact that we all pretended it was completely normal for me to be at work while sick. I'm looking into the resident's eyes, telling her between coughs what I think we should do for my patient, and it's like a HUGE elephant in the room, my sickness, that is completely ignored. Oh sure, I know that everyone on my team was aware of my sickness, just like we were all aware (and feeling bad about) the intern's sickness the day before. But no one can say anything about it, because like my massage client/eye surgeon told me years ago, "Doctors work when they are sick."

That is one of just many things in the medical profession that is totally insane, from so many points of view. First, there's the possibility of infecting the patients; then there's the idea that when a doctor is sick, they are probably not thinking very clearly (not to mention when combined with the drugs taken to help control the symptoms);and how about being a part of a profession that takes the oath "first do no harm?" Could one argue that going to work sick is not only harmful to one's self (should be at home healing), but also possibly harming a patient?

These are all things that I have thought a lot about this past weekend, as I laid on the couch, coughing up my lungs. As I coughed like crazy this morning, I thought about calling in sick, as I knew that I really need more time to heal (2 days just isn't enough). But here's the thing: I realized that to miss a day of work means that I have to make up this day, and when would I make this day up? I only have one day off a week anyway, and I certainly don't want to come in on a weekend day to make it up. And I imagine the reason doctors go to work sick is the same - when will they make up the work? If they have a whole day of patients, or several surgeries scheduled, when will there be time to fit all those people in? Sure, maybe you would be lucky enough to have another physician pick up your patients for you, but most likely, they are also overworked and have no immediate openings in their schedule. So imagine that a patient has waited three months for an office visit to see their doctor to follow up on some lab results, and the doctor has to cancel because they are sick, and you have to wait another three months. Wouldn't you rather just listen to him or her cough behind a mask, rather than wait? Most of us would probably admit that we wouldn't want to wait, and alas, that is why doctors go to work sick. While I don't have any patients that wouldn't be taken care of in my absence as a medical student, I certainly don't want to spend any more days in this hospital than I have to. So here I am at work, cough, cough, cough.

Short Coats

valerie.brooke@yahoo.com (Valerie Brooke) — Sat, 16 Jan 2010 22:30:00 +0000

I just finished a 12 day stretch of work with no days off, that included three 28 hour shifts, on my internal medicine rotation, a ten week rotation that it the core of all medicine. The concepts reviewed in this rotation are the basic building blocks that hold up all other aspects or specialities in medicine. This rotation takes care of very sick patients who are put in the hospital because there is disease or illness in their internal organs - the heart, lungs, kidneys, gastrointestional tract, or blood, to name just a few. I've had patients with pneumonia, angioedema (swelling of tissues due to leaky blood vessels - in the case of my patient, his throat swelled up), AIDS (and the subsequent fungal infection in his brain), acute kidney failure, heart failure after a myocardial infarction (heart attack), endocarditis (bacterial infection of the heart valves), and blood loss due to a tumor in the stomach. As a medical student we are fortunate to only be responsible for one or two patients at a time, while the resident and intern have to know everything about all ten patients that our team takes care of (which I will have to do in only a year and a half).

Having only one patient to be responsible for at a time allows us ample time to talk to the patient, to practice our history taking and physical exam skills, and most importantly, to review the mechanisms and treatment of the diseases so that we can sound competent when we present our patient at the daily rounds. Rounding compromises walking around the floor to each patient's room, and discussing the "case" out in the hallway. There is a very strict order of how information about a patient is given to the rest of the team, and this is standardized across all medical schools and residency programs in the US. You start with a brief one liner that describes who a patient is, and why they were admitted. For example, "Mr. J is a 50 year old man with longstanding hypertension and coronary artery disease admitted for chest pain." You then go into what's called the HPI - history of present illness, which is a chronological account of how the current illness presented itself, a description of the symptoms, onset, duration, therapies previously tried, and any pertinent information that can help the listeners start to whittle down the potential list of what could be the problem for this patient.

After the HPI, you then launch into any other medical conditions the patient has, and what the status of that disease is, or how it is managed. Then it's onto family history of diseases (for example, it would be important to know with Mr. J that his father had his first heart attack at age 45). Then it's social history, where the person lives, what they do for a living, married, children, etc... plus their habits with tobacco, alcohol, and drugs. Then it's a list of their allergies, and medications.

Then you present what you found on physical exam, what the heart, lungs, abdomen was like, paying appropriate attention to those physical exam findings that will having a bearing on what the person was admitted for (you don't need to know Mr. J had clear tymphanic membranes in his ear, but you definitely need to mention what his heart sounds were like - regular rate and rhythm, and murmurs, rubs, or gallops?). Then it's on to the lab findings, where you list out the chemistries and blood cell counts, all the data that internal medicine doctors rely on to give them clues to what's happening with the internal organs. And if you've gotten an x-ray or a CT scan, you need to talk about the results as well.

After all this information is given, the most important part comes, the part where med students sweat the most. The assessment and plan. The "so what do you think about all this information, and what do you want to do for the patient?" You have to list each problem the patient had, whether in terms of their presenting symptoms (Mr. J's chest pain), or their past medical history (his hypertension), and any physical exam findings (say a heart murmur), and any lab abnormalities (say he has hyperkalemia - that's too much potassium in his blood).

No problem right? Well the first week the attending that we worked under wanted this presentation in 5-7 minutes. To make matters worse, while I am speeding through my presentation trying to decide what information is most crucial and cannot be left out, the attending is looking at the computer, most likely looking at the lab results I am trying to relay to him. By the way, the attendings and residents already know everything about the patient, and don't really need the medical student's presentation to make any decisions about care for the patient. This whole process is for the benefit of the student, which is hard to imagine given that most of the time the residents aren't paying attention, and are clearly just wanting you to hurry up so they can get their work done. At the end of my first presentation, the resident looked at his watch and said, "that was 9 minutes."

The second week was totally different in that the new attending gives us 15 minutes for our presentations, which feels so wonderful to have the time, and she actually listens to everything we say, to the point that we have to comment on every single abnormality, ones that the previous attending just blew off. I can say while the new attending means much more work, I prefer her thorough style because it forces me to look up reasons for any abnormalities, to understand the patient completely. It does of course mean that I have to get to work early, so that I don't make the mistake of not knowing why. As I've said before, I think most of the stress of this third year comes not just from the long hours, but from the constant evaluation that is occurring by the residents and attendings - those that will give you your grade, and have a say in your future. It's like constantly being on guard, hackles up, in preparation not for a discussion between equals, but for interactions that question your knowledge and skill as a doctor. I can't tell if the stress of this comes from the high expectations I have of myself (my inherent perfectionism) or from the unreasonable expectation that doctor's should know it all. All I know is that each day that goes by is one day closer to that MD next to my name, that day when I can no longer hide behind the short coat of a medical student.

Oh...Dr. Brooke?

valerie.brooke@yahoo.com (Valerie Brooke) — Mon, 28 Dec 2009 22:31:00 +0000

There's something that happens once you start medical school and you go home to visit your family for the holidays. Every family member asks you about their health, no matter that you usually have no idea what they are suffering from. No matter when you explain you are just a student, only in your third year, and that you really won't learn anything until you finish residency, and at that point, you will only know what you specialize in. No matter, you still get barraged with questions. One family member launched his questions just as I stepped into the door with the statement, "Dr. Brooke what's this thing growing on my upper lip." So I peer in between the gray hairs of the mustache, looking intently like I am trying to decide from a long list of possibilities what this little growth may be, and have to admit, "I don't know what it is, you need to go see you doctor." Then I get an incredulous look, with the underlying and implied response being, "God don't you know anything?", and "What are you paying all that money for?" and "Are you sure you're in medical school?"

And in fact, I am constantly being reminded at how little I know. Sure I knew at one point, right before I took a 4 hour exam, and right after which it all disappeared from my short term memory in preparation for the next cram session. The things that have stored themselves in my long term memory at this point are only the diseases that are associated with actual patients that I have seen and taken care of in the last 6 months. And because I have just started the third year of clinical rotations, there are not a lot of patients and their stories in my head quite yet. There is really something to be said for apprenticeship however, it works! Too bad I can't just start an apprenticeship in physical medicine and rehabilitation. Nope, have to continue learning all about all aspects of medicine, and if I did a rotation in dermatology, then I may be able to answer my family member's question about that little growth on his upper lip.

So sometimes I have no idea what my family member is suffering from, and at other times, I hear my family talking about medical things that are way off from the actual truth, and then I have to figure out how to explain it in a way that is not condescending. Take something another family member said to me, "You know there are cancer cells in mother's milk." I just took a deep breath, and thought about correcting her, and then thought about how I would go about explaining what cancer really is...and gave up before I even tried. So many times I have heard people in my family say that medicine will never cure cancer because "they" make too much money off of cancer! That's one statement that I have no interest in even taking a bite of, so I just nod my head, and say something lame like, "You know cancer is not one disease. It depends on which type of cancer you have, and each one is so different, and it depends on the cell type...." all the while watching the eyes glaze over, and my family member moves on to their next attack on the health care system.

Today I heard about how ridiculous it is for a blood test for testosterone to cost $600. Of course I do think that's an insane amount of money, but I couldn't come up with a good reason why it would even have to cost that much. Must be a very specific test, one that has to be sent out to some special lab. I just bought my husband a book called "Money Driven Medicine, Why US Health care Costs So Much," and I'm hoping to read it myself, and maybe I will be able to answer the question about a testosterone test costing $600, maybe not.

I think what I am realizing is that I thought that once I started learning medicine I would start to KNOW things, you know, like what is that growth on the upper lip, or what cancer is, or why a hormone test is so expensive. Instead I am constantly feeling like a visitor in a foreign country. The language sounds familiar, and I've heard the words before, but my short time in the medical world means I still don't know the answers. And even if I did, maybe when I am here visiting family on vacation, I would choose to not know the answers, just so I could have a break, and be the person I used to be.

PM and what?

valerie.brooke@yahoo.com (Valerie Brooke) — Mon, 14 Dec 2009 02:03:00 +0000

So I'm here in Bend OR for a rotation, but this time I get to help others heal not their minds (did a psych rotation back in Sept), but their bodies.....Vague, yes, because that is the problem I am having when it comes to telling others what kind of medicine I would like to pursue. It's unfortunate that I can't just roll off one word from the tip of my tongue, like surgeon, or pediatrician, with the subsequent complete understanding of the receiver. Everyone knows what a surgeon is and what they do, and the same applies to pediatricians, OB/GYNs, family docs, cancer docs. I'm sorry to say that I can't so easily just roll one word off the top of my head to describe the very very very specialized type of doctor I would like to become.

If you have been following this blog for awhile (not sure if any of you are still out there), then you probably know or at least have heard before about physical medicine and rehabilitation, or physiatry, or PM & R. Now, I am fortunate that most doctors know what I'm talking about when I say that is my chosen field of practice. But a lot of my fellow students don't know about it, most likely because my medical school does not have a residency in this area of medicine, which translates to there being ZERO exposure to the field. There are two advisers at my school that are physiatrists, twin brothers in fact, and they have been my tenuous link to this field in the past two years. I did find out about another doc in this field over at the VA, but after I had already been at OHSU for almost 2 years. I met with him once for 15 minutes, but was unable to continue the connection (he never returned my emails, so I gave up).

I'm very happy to say that I have been working for the past 3 weeks in Bend with a group of (get this) 6 physiatrists, and they have been fantastic. Each one has gone to a different residency program, so they have been a wealth of information about the training programs, as well as about the field in general. I haven't seen anything yet to turn me away from the speciality - in fact, I so enjoy going to work everyday with them that I can't imagine myself doing anything else.

So what do they do exactly? The PM&R Association website states "rehabilitation physicians are medical doctors who restore maximal function lost through injury, illness, or disabling conditions, and are experts in diagnosing and treating pain." That about sums it up, and there is a long list of conditions that physiatrist treat including stroke, spinal cord injury, traumatic brain injury, amputations, arthritis, work injuries, back and neck pain, to name just a few. So the question is, how can I easily describe what I want to be to those that are not in the medical field? I tried to tell my husband's cousins once, and after using way too many words, one of them replied, so you're going to be a physical therapist? Oh ya, and if I cut it way down and say I'm going to be a rehab doctor, most lay people think I mean drug or alcohol rehab. Sigh....

Understand that it's important for me to figure out how to describe what I will be doing for the rest of my life because I already feel such a great divide between myself and those in my life that are not in the medical field. With each new medical concept I stuff into my brain, I find it harder and harder to talk about everyday things. It's like my husband and other spouses of my fellow medical students notice about our medical school parties - we all get together and talk about medicine.

So I would like to take a vote for all those who are still reading this blog. Here are some ideas about short succinct ways to describe a physiatrist. Let me know what you think!

I'm going to be:

1. A doctor of physical disability

2. A doctor of muscle and nerve injuries

3. A doctor of physical medicine and rehabilitation (this hasn't worked so far)

4. A pain doctor

5. A doctor in between a neurologist and a orthopedic surgeon

6. A doctor of physical function

7. A doctor of injury

8. A doctor of musculoskeletal medicine

Any other ideas, just shoot them my way! Cheers!

Money

valerie.brooke@yahoo.com (Valerie Brooke) — Mon, 07 Dec 2009 02:10:00 +0000

A friend of mine in med school recently said to me that "you need to be rich to go to medical school," in response to the financial struggles she has had in the last few years. While I don't think you do have to be rich, there is an element of truth to her statement. Either you have money, or are able to borrow as much money that is needed for this long process. And the payback for this grand investment is not so great these days, as physician salaries have not keep up with the increasing cost of being educated. The American Medical Association reports that public medical school tuition went up 133% since 1984, and up 50% for private medical schools, preventing low income/minority students from entering medical school, and therefore decreasing the diversity of our physicians.

A patient of mine last week asked me if I was going to be a doctor so that I could be rich, and I had to chuckle.....the days of being rich as a doctor are way over, unless you 1. are incredibly bright and want to spend 10 more years after medical school learning how to cut into people's brains (neurosurgeons make the most, averaging $541,000 per year), 2. you create some durable medical device that can make money on the side, 3. you get paid by pharmaceutical companies to market their product (which is going by the wayside due to an "anti-pharm" movement from within the profession).

But before I get into physicians salaries, let's talk about what it costs to go to medical school. For OHSU, yearly tuition runs about $36,000, and most students take an additional $14,000 per year for living expenses. So that's $50,000 per year, for four years, leaving one with a balance of $200,000 for just medical school. If you have any undergraduate loans already accumulated, that is just added onto the top. According to the American Medical Association, in 2008, the average medical student in the US graduates with $154,000 of debt, and 80% of graduates have debt over $100,000.

There are a few issues that come up in the process of even getting the student loans. First, there is a minimum of amount that the government will guarantee to loan a student that does not have the money to pay. This is determined yearly by filling out a form, where you list how much money you made (if any), and if you are still supported by your parents, how much money they made in the previous year as well. This allows the government to determine who should get the loans, which have a pretty decent interest rate of about 6%. These government loans however, do not cover up to the $50,000 needed for a year of medical school. I'm not sure of the exact amount, but at least $15,000 has to come from private lenders, and for this you have to have good credit. If you happen to have bad credit, too much debt, or don't have anyone else to cosign for you to get the additional funds, too bad....no med school for you. Or you could always give up four years of freedom after residency by joining the armed forces, which two of my classmates did do, just so that they could pay for medical school.

So once you have secured the $50,000 you might think you are in the clear, that all will be just fine financially for the next four years. Not so. There are many other expenses that come up during medical school that are not accounted for in the financial aid packages. First, the cost of books. Yes there is some money in the student "budget" to allocate for books, but this amount definitely does not cover the cost of getting the long list of new edition books that are either required or recommended for each class. For this reason, many students either 1. don't get any books at all, and just use the syllabus to study from, 2. buy older used editions from upper classmates that are full of highlighting, 3. use their grocery money to buy books.

You see, the additional $14,000 per year is not a lot of money to live off of....because with that you have to pay for rent, car expenses, utilities, groceries, not too mention the balances of medical expenses you may have. Yes, there is a health care plan that comes with the tuition, but it is a deductible plan, where the student/patient has to pay out of pocket....all from that just over $1,000 per month that is left over after tuition is paid. Fortunately for me, I have a husband with a job that can support me while in medical school. And for anyone who happens to be a non-traditional student with children, you have to support your family on that measly monthly amount, leading again to a lack of diversity amongst our physicians.

In addition to books, there are A LOT of expense associated with the licensing process in becoming a doctor. You have to register for the board exams you are required to take during medical school (step one costs $480, step 2 costs $1,500, plus a plane ticket to fly to LA to take the practical board exam). Then in order to even pass the exams, you need to buy practice test question banks (step one costs $350 for 3000 questions, step 2 costs $500 for 3300 questions),not to mention the high yield exam books that are needed for review, because no student has the time to use the books we had to buy for our individual classes. You need the more succinct bullet type review books, a condensation of all we learned in the first two years.

Then there is the expense of applying to residency. Just like the expenses associated with applying to medical school, there is a flat fee for the first 10 programs that you apply to, with an addition amount added for each program above 10. The baseline cost for the online application is only $65 (phew!) with an additional $8 or $15 or $25 per program depending on how high you go. I heard of a current 4th year student that applied to 127 programs.....that comes to about $2,700!! Of course most students don't apply to that many programs....I think the average is around 15 - 20.

In addition to books, exams, and application expenses there is the HUGE expense of flying all over the country for residency interviews. If you are fortunate enough to go to medical school on the east coast, your expenses will be less because you can drive to many places that you need to interview. For us here in OR, we are not so lucky, as most places are far enough away that a plane flight is necessary, as well as a hotel stay. Now, you might think, people fly across the country all the time for job interviews, what's the big deal? It's the number that matters. Just like applying to medical school, you have to anticipate a certain amount of attrition at each level of the process.

It is recommended that you "rank" at least 10 residency programs. That means that you have interviewed at those ten places and liked what you learned about their programs. But each place only has a certain number of positions open for interviews, and not every interested student gets to interview. So, you have to apply to many many more than you will even get an invite to, in order to make sure that you can rank at least 10 programs in the end. So, that usually means you should apply to 20-30 programs, hope to get invited to at least 20 interviews, and actually attend about 15, in order to eventually put down your list of top ten.

So that means flying to 15 different programs, each of which will give you the limited months and days with openings. Fortunately, many programs will try to accommodate you if you know that you will be in the Chicago area for one interview for example, by interviewing you when you are in town. I don't know yet how much this process will cost, but I have heard estimates around $5,000 depending on how many programs you interview at, and how spread apart the programs are. I have heard that you can take out an additional loan for these expenses, but that the interest rates are high. Go figure.

I am not complaining about all the expenses involved....only trying to clarify it for those who are not aware of what it costs for a student to go to medical school these days. I will finish with around $250,000 in debt, and that's debt that used to be put off until after residency, with no accruing interest. Recently this has changed, in that the loans have to be paid during residency.

So what's the big deal when physicians make so much money right? It's true that doctors do make a very good living, but certainly nothing in comparison to corporate CEOs - the real money is in business. The top doctors (neurosurgeons) can make up to $800,000 or more, but there are very few of those. Most family practice doctors make between $128,000 and $200,000, so no wonder why many students are staying away from primary care because they are wondering how they are going to pay off their debt, have a family, buy a home and dependable car, and live the American dream. I wish that I could have given that patient that asked me if I was going to be rich all this information. Maybe then she would know that going into medicine these days is not about the money, it can't be. It's about doing what you love, taking care of others, and making those darn student loan monthly payments. Cheers!

Procedural Competency

valerie.brooke@yahoo.com (Valerie Brooke) — Sat, 28 Nov 2009 15:34:00 +0000

I walked into the exam room with my preceptor and greeted Mrs. and Mr. M warmly, already familiar with their faces as this was the third visit in three weeks for Mrs. M to get bilateral injections of Orthovisc (a substance called hyaluron shown to maintain joint fluid and support cartilage), into her knee joints. She had been diagnosed with severe degenerative joint disease of both of her knees, and was hoping this series of injections would eventually decrease her pain and increase her activity. She hopped up onto the table, and instinctively grabbed her husband's hand, as she had the previous two weeks. My preceptor asked her which knee she wanted done first, after which she glanced in my direction, and asked if I could do one of the injections. The previous two weeks the sports medicine fellow had been present in the room, and had done the other knee simultaneously so that she didn't have to suffer through the procedure twice. On this third visit she wanted the same as the previous two: the shortest and least painful procedure possible. My heart immediately began to beat fast, both from excitement at the opportunity, and total fear of incompetence at the same time. My preceptor reminded her that I was a third year student, and she asked me whether I had ever done an injection before. I replied I had not, but had watched several. She then asked if I would like to do one knee, to which I replied, "Yes I would love to," smart enough to not turn down a gift when it was offered. Her husband was visibly upset with the thought of someone new like me doing this, but she reassured him by saying that I needed to learn, and in order to learn I needed to practice. Talk about the perfect patient!

The next five minutes was a blur as I struggled to hide my rapidly beating heart and mildly shaky hands. I had seen this injection done, on this very patient, two times prior, and was confident that the needle would go right where it was supposed to. I marked the spot where the needle would insert, confirmed it with the "real" doctor, sterilized the skin, shakily opened up the syringe of Orthovisc, and attached the needle. One, two, three, and we both inserted our needles into this woman's knee joints. Fortunately for me, although not so for the patient, the knee that my preceptor was injecting was full of osteophytes (bony overgrowths that crowd the joint space). Subsequently he had to maneuver his needle all around, all the while she's blurting out "ow, ow, ow, ow," blowing out her breath like she was in labor, and squeezing her husband's hand white. My needle entered her other knee joint effortlessly, and the injection was over quickly. We placed band-aids over the little pin pricks, and off she limped out of the clinic.

My heart took some time to calm down, and as I wrote up the procedural note, many different thoughts struggled for center stage in my mind. Initially I was incredibly excited at having had this opportunity to perform such an "invasive" procedure, particularly as a third year medical student. In addition, I thought about what would have happened if my needle had also gotten stuck on osteophytes. This was not a pretty picture in my mind, as I imagined myself turning white, heart doubling in cardiac output, followed by a desperate glance over to my preceptor with the signal HELP screaming from my eyes. While I did have the confidence to slide the needle into a joint free of complications, I definitely was not trained at how to handle bumps in the road. How many injections into a knee joint would it take for me to not have shaky hands, and also, to know how to confidently handle potential complications?

Finally, I wondered what it was about the patient that allowed her to let me "practice" on her, and whether or not it was just a matter of her wanting to avoid the pain of a second injection. Was it something I had done in my previous two interactions with her? Was it the unspoken confidence my preceptor had in my abilities? Was it that she was aware of my previous career as a massage therapist, or my future intentions to be a physical medicine doctor? Why did she trust me, not yet a "real" doctor? In short, what does it take to have procedural competency from the point of view of the patient, as well as from a deep internal sense of confidence from within the physician?

This patient encounter occurred several weeks ago, and I continue to think about procedural competency as I do a rotation in Bend in physical medicine and rehabilitation, the specialty I plan on going into. I have seen tons of injections here, and I've only worked for 6 days so far. I've seen injections of knees, shoulders, hips, muscle trigger points, and spinal joints. At first it looks complicated, especially the spinal injections which take place with the guidance of xray. Every day it looks easier although, as I learn the bony landmarks that are palpated prior to an injection of a shoulder or knee joint, or as I learn to decipher the shades of gray shadows on the xrays. I realize that it's a numbers game. The more you do, the better you get, and the more confident you become. I am happy to say that I can imagine myself, someday, injecting joints of the human body, with confidence and a sense of satisfaction with helping my patients in pain. I look forward to a future filled with learning how to perform these procedures competently, and I thank in advance all the patients that will help me become a proficient physician. Cheers!

Nice

valerie.brooke@yahoo.com (Valerie Brooke) — Mon, 16 Nov 2009 18:56:00 +0000

I just finished yet another rotation, this one in family medicine. There are so many core attributes of family medicine that totally resonant with my values and beliefs about how health care should be delivered. Continuity of care is, in my mind, one of the best parts of family medicine - the fact that a doctor will follow a patient over many many years, in some cases also taking care of their children and/or their parents. It reminds me of my own small town Rutland physician who took care of my grandmother, my family, all my aunts and uncles, and my countless cousins. Dr. Wolk was a staple part of our family's life, and my early childhood is full of memories not only of daytime visits for colds or immunizations in his office right next to the hospital, but also dark nighttime home visits with him shrouded in black, carrying the black bag from which he was soon to pull a huge syringe from. He was there for me when I had weird heart sounds as an adolescent, and did a cardiac echo so that I could be cleared for school sports. He was there when I had an accident at age fifteen that scarred my face and knocked my front teeth out. And much later, I would find out that he was there for my birth, and was the one to transport me from the arms of my birth mother at three days of age, into a car that drove me to the new home of my adopted parents.

So I totally understand what it means to have continuity of care, and how this is one of the foundations of family medicine. But there are other aspects of this choice of careers that are unique to family medicine. These physicians have an incredibly broad scope of practice - that is, anything could walk through their door, on any given day, and they need to know how to recognize and treat whatever shows up. It could be someone with a cough or sore throat thinking they have the flu, someone coming in to check their lipids or sugars to manage their high cholesterol or diabetes, someone with a sprained ankle or sore shoulder from too much yard work, someone with suspicious looking dark skin spots on their face, someone newly pregnant and needing a prenatal ultrasound to confirm the expected delivery date, someone with low back pain, or depression, or headaches, or rashes, or.......the list can go on forever.

That's the cool thing about your family physician - they know about most everything the human body can suffer from, and can treat the most common conditions with compassion and solid understanding of disease mechanism. Of course, if they need too, they can consult a specialist, someone with more depth in one organ system, or a more specialized physician who can handle more complex cases of a disease.

If I had to sum up the family physician with one word I would say he or she is......Nice. Now I know that word is kind of blah, but I can't think of another that so adequately describes how easy it is to work with them, and furthermore, wouldn't you want your family doctor to be, at the very least, Nice? I couldn't say the same about surgeons; a word for them would be....blunt, just like the instruments they use for their operations. And for psychiatrists.......tweaky, allowing them insight and acceptance into mental illness. And for pediatricians.....smooth, giving them the power to assure an overanxious parent, or the ability to look at the eardrums of a screaming sick child. (A cool trick I saw to do this smoothly was saying something like "I think there's a little bird in your ear, chirp chirp, can you hear it? let's see if I can find the little bird...).

I have heard it said that medical students don't really choose their eventual speciality in medicine, that the specialty chooses you. What I think is meant by that is that you figure out who you are (nice? blunt? tweaky? smooth?) and then go into that specialty because you are surrounded by people that have similar temperaments. What happens when you can't decide, or fit into more than one category of personality? Then I guess you just have to work much harder at making a decision about which direction to turn. This is something that all students in my class are currently thinking about, even though we still have a year and a half of medical school left, processes are in motion that will determine what we will do for the rest of our medical lives. In 3 months we will give the dean's office our requested schedule for our fourth year, which begins next June. This schedule will need to have electives of one's own choosing that will hopefully give the students some good letters of recommendation for our residency applications which are sent in on September 1st of 2010.

So far about 30% of our class feels pretty confident of what type of physician they'd like to be, while the rest are struggling between two or three different choices. The frustrating part of this is that we still have not yet even finished our required third year clerkships, which are designed to introduce us to the different types of physicians. As for me, I feel pretty confident that I will end up going into physical medicine and rehabilitation, although I have gotten great feedback from all of my rotations thus far indicating that I would be a good pediatrician, psychiatrist, family physician, and I even saw in my surgery rotation the line "She will make a good surgeon someday!" Obviously on that rotation I was quite effective at hiding my intense dislike of the schedule and personalities associated with the "blunts." I know that I could be a family physician, pediatrician, or a psychiatrist, but the question is whether or not they would make me happy. And that's part of the internal growth process medical school forces you to undergo - who are you, what's important to you, what do you like doing, and what do you dislike? There are a few things that I do know about myself, and know that I will need in my chosen line of work. I get bored easy so I will need to be busy, and I will need some complexity or an intellectual process of figuring out what's going on with a patient. I need to use my hands, and so will have to practice something that allows me to touch my patient (psychiatry is out therefore), and some sort of procedures. I don't have to do procedures all the time (like surgeons), but at least some of the time. I have to have interactions with patients (radiology and pathology are out), and I need sleep (surgery is out, and most likely OB/GYN). What I know so far about physical medicine and rehabilitation fulfills all of the above, and I'm set to learn more as I begin a rotation in Bend in this area of medicine in just two short days. Here's to another exciting time of my education, the discovery of where I fit in best! Cheers!

Bubble of Luck

valerie.brooke@yahoo.com (Valerie Brooke) — Thu, 22 Oct 2009 18:23:00 +0000

My husband just finished reading a book entitled "Outliers" by Malcolm Gladwell, which discusses what goes into the creation of a successful person. Is it merely a matter of talent, education, socioeconomic status, free time to put towards a pursuit, or it is just a matter of luck? Of course it's most likely a combination, but I have to believe based on the experiences in the last few years that luck is a big piece of the pie.

Take for example some of the luck that has fallen across my path in the last several years while on this medical school journey. During my most recent rotation in Bend, I was faced with having to decide what to do for a one month elective period that is coming up in November. A long list of possible rotations in different areas of medicine was sent to all of us, and we were to rank our top choices, or decide to take the month off. As I looked at all the choices, there was only one that grabbed any interest of mine; it was in physical medicine and rehabilitation (PM&R), and the slot was already filled with a 4th year student, as they take understandable priority over 3rd year students. As taking a month off is not an option for me (I would be bored out of my skull), I remembered seeing next to the Bend hospital a big beautiful building called "The Center", and had learned it was the orthopedic and rehabilitation center in Bend. That morning I asked the education director if by any far stretch of the imagination, there might be a PM&R doctor at The Center who would be willing to take me on for a month and teach me their tricks. No promises were made, but the director said he would look into it.

Several hours later I got a call from a woman in the education department who told me that not only did they find a doctor who would take me, but that he had previous experience teaching students, and if I was sure, they would let the Dean's office know that I was coming down in November. I hadn't even talked to my family yet about leaving them for yet another month, but I jumped on it, and gave the thumbs up sign. 24 hours after I had merely thought it would be nice if I could do another rotation here in Bend, it was a done deal. To make matters even more intriguing, I later found out the doctor who will be my preceptor went to his residency at University of WA in Seattle, which at this point, is at the top of my list of places I'd like to go for residency. Working with him for a month means that I will be able to ask him for a letter of recommendation, which will increase the chances that I at least get an interview in Seattle. Is that luck?

Then I think about circumstances that have occurred in previous rotations. During psychiatry I was scheduled to follow one particular doctor for the first week, and was then supposed to rotate through with several different doctors. For one seemingly random reason or another (one doc had shoulder surgery, one was just out of residency and didn't have many patients yet, yet another switched services just when I was switching), I managed to stay with the same physician for the whole five weeks, not only getting great continuity with his patients, but also getting a great education as he was (in the staff's view anyway) the best psychiatrist, in terms of his ability to communicate both with the patients and with the supporting staff (nurses, social workers, etc). Was that luck?

Then during my painful five weeks of surgery I managed to avoid ever going into surgery with the most challenging attending surgeon, one who had a reputation for grilling the students and residents non-stop from the first cut on the skin until the last suture was placed. Granted she only operated one day a week, but somehow, not by my own design, I never had to operate with her. The first week I was scheduled to work with a different surgeon, the next week I was switched to vascular surgery, the next week another student was scheduled with her, and the last weeks she was gone on vacation. I would have tolerated her just fine, but it's like there was some other force in the universe that kept me from having to have interactions with her. Is that luck?

If I go back even further I can think of two very prominent circumstances that have luck all over them. The first was when I decided to go to medical school, and was in the process of applying. I asked one of my longest term massage clients to write a letter of recommendation for me. I knew he was an eye surgeon, but knew nothing else about him, and asked him for the letter since I had continuity of care with him for over 5 years. He chuckled after I asked him while he lay on the table, as he told me that he was on the residency board at OHSU for the opthlamology department (eye doctors), he regularly interviewed students applying for residency, and regularly read letters of recommendation. In short, he said yes he would write me a letter, and that he know exactly what to put in the letter that would help my application. Is that luck?

The most astonishing coincidence occurred over a year later after getting back my MCAT scores (that's the test you take to get into medical school). I was working in the Pearl district in downtown Portland at the time doing massage for a salon. I had just gotten to work at 8 am and told my boss that I had gotten a great score on the MCAT. She wanted to celebrate with me, so she went to the frig, and even though it was only 8 in the morning, she grabbed a bottle of champagne, opened the front door, and uncorked the bottle. It just so happens that at that exact moment, at 8 am on a random Saturday morning, the cork flew across the street and landed right in the path of two early morning joggers. The cork startled them, so they crossed the street, came over to us on the sidewalk, and asked us what we were celebrating. I told them that I was applying to medical school, and that I had just gotten back some great test scores. One of them smiled, and told me that he was the Chief Resident of internal medicine at OHSU, and he offered his services of helping me in any way he could. Several days later he and I were having a beer after work, did a practice interview (probably not a great one, given the beer going to my head), and offering all matter of advice to me about how to get into OHSU. Is that luck?

I don't know what it is, luck, or divine guidance, or some angel hanging out on my shoulder, but I seem to be incredibly blessed with all the different circumstances that have helped me along this path of becoming a doctor. I like to think of it as a bubble of luck, a protective sphere around me that keeps toxic events out, or a balloon that keeps me rising above the rocky aspects of medical education. Whatever it is, I give thanks everyday. Cheers!

Mania

valerie.brooke@yahoo.com (Valerie Brooke) — Mon, 12 Oct 2009 17:55:00 +0000

I'm back in Portland after 5 weeks of a psychiatry rotation in central Oregon, and am reflecting on the types of patients I saw and helped to treat. For every rotation we have a list of patient objectives that we have to fill out and return to the Dean's office, to prove that the medical school is doing it's job in getting us access to patients. For psych, this was a checklist that included patients with schizophrenia, substance abuse withdrawal and/or intoxication, depression disorders, anxiety disorders - including obsessive compulsion disorder, post traumatic stress disorder, and generalized anxiety disorder, as well as bipolar disorders (someone who has episodes of depression and/or mania). I did see patients in every category, but did not really comprehend the meaning of a manic episode until the last two days of my rotation.

The first "contact" I had with this patient came in the form of the intake coordinator coming to the psychiatric ER office and telling us about a mentally ill patient who was out in the community causing havoc, but was unable to be brought in by the police. I saw this happen many times - a patient who was psychotic, schizophrenic, or manic, would be causing some kind of trouble, but was not willing to come in to be seen. In this case, nothing can be done until the person presents as a danger to themselves or others - then they can be brought in against their will, put on a two-MD hold for up to 5 days, until they could then be treated or released, or brought to a judge for consideration of a longer term commitment.

The intake coordinator rushed into our room, needing to vent her frustration that the police were unwilling to bring in a young 18 year old who was clearing having a manic episode. They had spent over day chasing this guy, with the last attempt occurring at a porsch dealership in town where he was trying to buy a car. (This behavior meets one of the criteria for a manic episodes - a period of high impulsivity, in this case shopping). The coordinators distress was mostly due to the fact that he had threatened a medical provider the previous day, making death threats targeted against the provider and his family. This I guess, isn't even enough to get the cops involved, and so we listened to the coordinator vent.

It was only an hour later that we learned the patient was on his way, as the cops caught him trying to hot wire a car (which he hurt himself in the process, since he really did not know what he was doing - another criteria for mania - grandiosity - the belief that you are capable of things that you aren't). We cleared a path for him, and a whole gang of police and security brought him in, handcuffed behind his back, to a room where we removed everything but the mattress. The social worker and I went into his room to see if we could get some information from him about what had led up to this, and if there was any prior history of mental illness.

Trying to have a conversation with a manic patient is like trying take a breath while there is a fire hose blasting your way. He talked so fast, non-stop (called pressured speech in psych lingo), that it was impossible to get a word in edgewise. He moved rapidly from one topic to the next (distractible, flight of ideas - more lingo), and had grandiose beliefs. He could easily be a doctor (he had a stethoscope at home), and would soon learn how to fly helicopters. He was sure that if we just called his buddy Dr. So and So, he would be out of here lickity split. He had been up for 50 hours (decreased need for sleep, another criteria for mania), and was encouraging us to hurry up and do our urine and blood tests, as he had places to go and things to do. (increased goal directed activity).

I left the room thinking, textbook case mania, happy at having seen so many of the signs and symptoms of mania, satisfied that I could now easily check off the little box on my patient log that indicated I had evaluated a manic patient. How nonchalantly I initially viewed this patient's mental illness, and how quickly I would soon witness the ugliest part of mental health treatment. We went back to our safe little room, where we have video monitors for all 5 of the rooms with patients. While we waited for the lab results to come back, to do all the admitting paperwork, and to talk to the psychiatrist on call who would make decisions about how to treat this young man, we watched him in his full-blown mania in his locked room. First, he just did countless numbers of push-ups and sit-ups, then he moved onto running fast tight little laps in his painfully small room. I was like watching a struggling bug swirl around and around a bathtub drain; he moved all his limbs, running faster and faster, as if there was a hurricane inside him that he could not control. When the running was not enough, he put the mattress up against the wall, would run a few laps, and then launch himself up against the mattress covered wall. Soon this was also not enough to contain the bomb going off inside him, so he resorted to pounding his fists up against the window in his door.

As he was moving more and more closer to actually hurting himself with his agitation and physical activity, the doctor had been contacted and it was decided to give him a shot of drugs that would calm him down (haldol and ativan - an anti-psychotic combined with a benzodiazepine/sedative). To do this we had to call a "Dr. Strong" which is a well known code in all hospitals that means, "there is an uncontrollable patient, that needs to be controlled and/or contained). Health care workers are trained in how to do a Dr. Strong intervention, including how to approach and/or hold the patient in a way that will minimize risk or injury to both the patient and the health care workers. So I stood aside as 6 strong men came to the unit, and one nurse who drew up the two shots to be given once the men had the patient controlled. I stood aside to watch.

We opened to locked door to the room, and immediately upon seeing the 6 men, the young man backed up into the corner like a caged animal. He asked what was happening, and was told by the nurse that he was being given a shot of haldol and ativan to help him calm down and maybe sleep some. The look in this man's eyes was complete and utter terror. What happened next was such a blur, and over in seconds.

Instead of taking a swing at the nearest "strong man," which I understood later was a quite common occurrence, he instead launched himself head first over the bed, right in between the 6 strong men, and right towards me, standing in the doorway. Thankfully one of the nurses had caught his leg, and they were able to pull him back away from the door (and useless me), flipped him onto the bed, pulled down his scrubs, and one, two, shots were given in his buttocks. Each strong man let go of his limbs one by one, and slowly backed out the door, while the biggest nurse told him that if he got off the bed, they would use restraints to tie him to the bed. They all backed out of the room, his door was locked, and we retreated to our safe little office, where the events were needlessly recounted over and over by a group of men that were all reveed up, hearts pumping, adrenaline surging, much like the patient we had just forced two shots into.

There was nothing more tragic to me on this rotation than those events and the ones that were to follow on the following two days. This patients mania was barely touched by the medications that were given to him. He would sleep for a few hours, but then be back up running around, pounding on the windows, screaming out demands and profanity, scaring the other patients on the floor. The first night he actually escaped from his room when being given his tray of food, and immediately tore up the hallway, and one of the unoccupied patient rooms. He was like a bear in captivity, scared, enraged, and totally not able to be reasoned with. He attacked a security guard that night with a chair, had to be "Dr Stronged" for the second time in one day, and was this time strapped to his bed. I was supposed to learn the indications for the use of restraints as part of my objectives, but I can't say at all that I was happy this time to have checked off that box.

What I felt while watching this tragedy unfold, which just got even more tragic when the dad came to visit, not understanding the nature of his son's illness, screaming at us to let his son out, was a profound sense of shame. I was ashamed that we had to plummet to the means of physical restraint and forcing medications, all in the name of "protecting the patient" from hurting himself and others. I was mortified with how the men on the Dr. Strong team recounted the events, laughing when recalling the patient started crying after being slammed into a door on the second Dr. Strong. I thought to myself, is this just male machisimo? Or have these nurses and security guards been so desensitized to the suffering of others in all their years working in the psych wards. I never did answer this question, and I was happy to leave that place, to not have to sit by and watch the dehumanization that sometimes occurs within the practice of medicine.

Space

valerie.brooke@yahoo.com (Valerie Brooke) — Wed, 23 Sep 2009 22:03:00 +0000

I just started my third week of a Psychiatric rotation down in Bend OR, which for those of you not from around here, it's about three hours southeast of Portland, which has great significance in terms of the weather. Bend is east of the Cascade range of dormant volcanoes, which means that it doesn't rain nearly as much as it does on the west side of the Cascades, and more importantly for me, the SUN is out every day!!!

The first week of the rotation was rough, because the hours were so normal (8-5) and the people here so damn nice. Rough? Yes that's right; my adrenals were in such overdrive after 5 weeks of surgery that I felt an uncontrollable urge to work more and longer and harder than was expected. One day during the first week, the manager of the inpatient treatment center I'm working at saw me at my computer at 5:30 pm and asked with incredulous eyes, "What are you still doing here?" I thought that maybe I was on a different planet, or that maybe it was really midnight and not just 5:30pm! It turns out I am surrounded all day by social workers who clock in and out, never staying beyond their eight hour shift, and to them, it was unusual to see a "doctor" there late. One of the benefits of becoming a psychiatrist - the hours are such that you can actually have a life outside of work.

The truth is that I didn't know what to do with myself after leaving work, coming home to a cute little apartment I am living at right next to the hospital. Sure I would make dinner, clean up, listen to an online lecture, study for a bit, but then there would still be HOURS left before it was time to go to bed. And there was no rush to get to bed early, since my alarm wasn't going off at 4:30am anymore, and I could get up at 7 am, and still have time to dress, eat, and walk across the street to the hospital. I was quite neurotic that first week, and only now am relearning how to fill my "free" time. I've been doing yoga, walking/running, hiking, and even picked up a novel, which I have not done in I can't remember how long. I also have a lot of extra time since my family is in Portland during the week, and only come down to visit me on the weekends.

Now that I am more comfortable with the new "normal" schedule of work, I am faced with all the thoughts and feelings that come with working with a mentally ill population. This has been a frightening experience at times, a humbling one, and definitely an emotional one. I still have yet to master not letting my eyes tear up as a patient is pouring out their pain. And there is so much pain in psychiatry, as there is in all medicine, but this seems different to me somehow. Maybe it's just because I have to be open enough with my patients to really care about their well-being, but not so open that I feel their pain. It comes back to boundaries, and I just haven't learned how to do my job as a medical student, to listen to these painful stories, and not take in or take home the depression, anxiety, hopelessness, or even craziness.

Maybe it's also because in some ways I empathize with the patients; I can imagine their experiences, based on my own mental health history. I have never been sick enough to need inpatient care, but I know what depression feels like, what anxiety feels like, what it feels like to not want to be alive. It's been a long time since I've felt these things, but talking to these patients is a reminder to me of where I have come from, as well as a humbling realization that I never really had it that bad. Not even close.

I connect much less with the psychotic patients (thankfully I've never experienced hallucinations, delusions, or paranoid thinking), to the point that they scare me a little bit. I've had patients who believe many bizarre things like aliens operating on them in the daytime and nighttime, or a big machine with wires connecting to the palms, trying to upload a new consciousness, or even a clan of white robed people on roller skates living in a patient's house. There has also been a few manic patients who are really really intense, with no personal boundaries, and they get right up into your face, either talking nonstop, or just staring really intensely. I have to break eye contact with these patients because the intensity is so uncomfortable for me.

I try to be open minded, to see them through the light of someone who is severely mentally ill, but the truth is I have the same internal reaction that anyone else on the street would have - a feeling like there is definitely something wrong with this person, followed by a strong desire to get away. And then you throw in a patient who is both psychotic and angry, and I swear it takes everything I have to not turn and run. The seasoned psychiatrists tell me to make sure they do not sense your fear, because they feed off of it, and I'm thinking, How the hell do I do that?

Maybe it comes back once again to the whole boundary thing. If I have stronger boundaries maybe I won't get emotional when a patient cries, or feel heart ache when someone shares their pain, or feel scared when a patient gets intense or angry. But what if the process of forming these strong boundaries closes me off so much that I can no longer connect with the patient? That is my fear, and why I would not choose psychiatry as a speciality, because I do not want to see what would happen if I started to close myself off that way.

I've watched 4 psychiatric doctors here practice their skill, and I see each of them interacting with the patients in different ways. 3 of them I believe have perfected the art of having good boundaries; they come in, do their job, prescribe the medications that will hopefully change the person's brain chemistry in such a way so that they can make the changes necessary to lead more productive and successful lives. I know that they care, but I don't feel that they do, and I wonder what the patient thinks and feels.

There is one doctor that is incredibly gifted; he still has an open heart, and fortunately for me, I have worked almost exclusively with him. He gets his job done efficiently, and has appropriate boundaries with his patients, while at the same time, exudes a kind and sincere compassion. He sees them not simply as a diagnosis, but a living, breathing, suffering human being, that needs not only medications, but validation for their suffering. How he does this without his own heart breaking is something I keep wondering about; he clearly has found the right path for him and seems perfectly suited to this profession. I can only hope that I too will come across the perfect match for myself, one where I will not have to worry so much about keeping space between me and my patients.

Adaptation

valerie.brooke@yahoo.com (Valerie Brooke) — Fri, 11 Sep 2009 17:11:00 +0000

So I finally got through surgery, but not before having to learn to adapt to the tension riddled environment that clouds a surgical rotation. And given the feedback from my classmates that have had other surgical rotations, not at the VA with different residents and attendings, my experience doesn't seem to be unique. It was like being thrown into white water rapids without a life jacket, and I used my meager swimming skills to get around the huge rocks and avoid being pulled under.

Part of that adaptation came in the form of me just shutting my mouth. Don't ask too many questions, for several reasons: 1. because one of the attendings already said on the first day how frustrated he gets when med students ask him questions that can easily be looked up (OK, nowadays EVERYTHING can be "looked" up, which meant that when I was around him, I never asked any questions and he probably thought I was mute) 2. because one of the residents encouraged questions, but if you didn't know the answer then he told you to go home, look up the answer, and report back the answer the following day. Unless I wanted to go home and use up of some of my precious hours for studying rather than say, taking care of my bodily needs like eating or sleeping, I quickly decided to act like I already knew it all, and asked no questions.

I also learned by watching another student suffer (hey, I may as well use every survival mechanism possible right?). In this case I learned how to do more than just look up the specific answer to a question asked by a chief resident. Through watching another's punishment I quickly learned to think ahead and also gather any information about things closely related to the question asked, so that I could readily have the next question answered as well. A fellow student was asked one day while presenting her patient by the bedside, why it was important to know EXACTLY how much fluid was produced from a patient's NG tube (stands for naso-gastric - a tube put down the nose, esophagus and into the stomach, in order to suck out any excess fluid, in the cases of a bowel obstruction. The stomach has to be "decompressed" before the patient blows a hole in their bowels). Anyhow, after the student told the resident why knowing the amounts evacuated from the NG were important, she was then asked how much fluid the stomach produced on a daily basis. She did not know, and so was sent home to come back with the answer.

The whole time I was having my own flight or flight response, (increased heart rate, breathing, and sweating through that useless anti-perspirant I put on at 4:30 am), wondering how would I answer this question? 2 liters I thought, just say 2 liters, with no idea where this number came from my mind, whether it was an actual remembrance of a number memorized while learning this sometime in the last two years, or whether it was just a shot in the dark. This blurting out of some answer was something I frequently did with these residents. I always thought it was better to say something, and make it look like I was actually capable of thought, while others recommend never guessing, and just saying you don't know when you don't. My ego would have none of that; I would rather guess wrong than say I don't know, just another of my flaws.

Unfortunately for my classmate, she did not think ahead to the next logical question that would come after knowing how much fluid the stomach produces daily. The next day, while rounding on the same patient, the resident asked my classmate how much the stomach produces, to which she confidently replied, 2 liters. (Hey I would have guessed right, I must be really smart my ego thought, or just randomly lucky, my alter-ego replied). She was then asked, well, how about the biliary system? (that's your liver which produces bile), to which she painfully had to admit once again (cringe, cringe) that she did not know, and she was sent home for more research. The next day she returned with a list of all parts of the gastrointestional system and the amount of fluid each part produces (a total of 9 liters per day!), and to my chagrin was then challenged regarding the exact amounts (the resident would think it was 1.5 liters versus 2 liters), and was belittled for wherever she got her numbers from. Aaaaarrrrgh! Take home lesions: 1. Be more than prepared 2. Be prepared to never be right 3. Be prepared to feel stupid no matter what.

This never being right occured once while on call and participating in a day surgery over at OHSU. The first thing that was working against me (which of course I had no control over) was the fact that I had been working at the VA, and had not gotten to know or work with any of the residents or attendings over at OHSU. The second thing is that I had never even been in the operating rooms over at the OHSU, and like every different place that you work, everything is different in terms of where things are located. It was like the first day of surgery all over again. Not knowing where the patient was prior to the surgery; (it's imperative that you meet the patient prior to them being put asleep by the anesthesiologist). Depending on the reasons for the surgery, the patient could be found up on the floor where they had been located during their inpatient stay, or down in the pre-op area (which I had no idea where it was at OHSU), or in some special area where patients come for pre-op same day surgery. Luckily for me, I found the patient right off the elevator while going to the floor where I was told the OR was located.

Thank the gods I thought, I can visit and introduce myself to the patient. One test I knew I would pass when inevitably asked by the attending whether or not I had met the patient. This may sound trivial to you, but the ability to find a patient's location in the hospital is not as easy as you think. I can't tell you how many times I headed off to the pre-op area to meet a patient, was told by a nurse "they were just moved to the OR", and I would scramble to try and get there before the attending did, so that I could do the appropriate introduction. Now this is not a trivial matter. Of course you need to meet your surgeon prior to him or her cutting you open; but how important is it to meet the third year medical student who is scrambling around trying to act important, but is actually totally insignificant in the operating room? Will you remember the name of the medical student who told you they were going to watch your surgery? Of course not, but again this was one of the insane expectations of the surgical rotation which I think is meant to set you off balance. (an it worked)

But balanced I would be for this surgery, because I MET the patient, and got her story, without spending hours reading all of her past medial records in the computer (OK computers are not really my friends; I use them because I have to, but if truth be told, I fight them, and long for the days of simple pen and paper - a true English literature and writer's confession). So I go with the patient into the OR, feeling all smug, only to be quickly shut down during the surgery by the attending. First, let me tell you what it's like to be standing next to 4 other human beings and to be completely ignored. It makes you feel crazy, but in a surgical rotation you just learn to live with it. You expect to be treated like you are invisible and don't exist. You are merely there to watch, learn, and listen to those that are oh so much smarter than you, even the surgical scrub nurses, who bitch at you for not wiping your hands correctly. It's so ironic to me to be upset for being ignored, AND to also wish to be ignored, so that you aren't berated or pimped to the point of feeling stupid.

So there I am just counting down the minutes, looking so forward to the end of the surgery, when the attending decides he needs to give me a lesson in how to use scissors. So I allow him to teach me how to correctly cut the sutures (after the chief resident has tied the knot, I come in and cut them). Not a very difficult thing to do, but obviously I could use some help with cutting, so I accepted the advice of the surgeon (thank you, you arrogant ass I'm thinking). A few minutes later, during which time the the surgeon is talking to the scrub nurse (she's in the club too, also ignoring me) about the prices of condos in the Pearl district, he decides to teach me an even more important skill - how to hold the scissors in the palm of my hand. I guess I'm just acting way too eager with the scissors all ready to cut the next suture, and I need to non-chalantly rotate the scissors around my index finger, lay them in my palm, so that I can (his words) do "something else" with my hands! I wanted to laugh out loud! Like they are going to let me do something else other than hold the suction device! Of course I accept this advice with total humbleness, and continue counting down the minutes that I have to suffer this man.

A few moments later, the chief resident grabs the scissors out of my hand (she has also obviously decided I don't know how to cut sutures adequately), and cuts the suture. Of course the attending has turned to laugh and make some joke to the scrub nurse again, while the resident sets the scissors down in front of me. At this exact time, the attending turns back to the surgery (how annoying the surgery is interrupting his most important discussion of the real estate market, and the cute little condo he just bought his spoiled daughter), and he sees the scissors down and NOT in my hand. Strike number three - I am told in a stern voice that I need to HOLD the scissors, to be ready to cut the next suture. I think I mumbled something about the chief resident using them, but it didn't really matter what defense I may have made on my own behalf, or even if the damn resident had stuck up for me. In their minds, I was just the useless and stupid med student.

When I walked out of that surgery I told myself that I wouldn't do surgery with this group of people ever again no matter what. And sure enough, the next and last time I was on call, I told the residents that I would answer the trauma pager, and go to the ER when patients came in, but that I wasn't going to go to surgery that night. It's my education right? I'm paying the $50 K per year, I know that I can learn a hell of a lot more about surgery sitting in my call room, rather then scrubbing into another humiliating surgery. I can't believe that as students we either have to 1, put up with it or 2, participate in it, in order to be accepted into the clan. I saw that happening with my classmates, the ones that hope to go into surgery. They made excuses for their residents, attendings, and their atrocious behavior, saying things like, "they are really stressed out and tired." They bragged of 8 hour surgeries, and nights without sleep. They seemed to love, or at least, become adapted to the abuse. Not me. No way. Yes, I will adapt in order to survive the ordeals and trials of medical school, but I swear I won't let it destroy my humanity, or the basic standards of kind treatment of other people. If I loose that, then I will truly loose myself.

Blood, Guts, and Feces

valerie.brooke@yahoo.com (Valerie Brooke) — Sun, 30 Aug 2009 15:15:00 +0000

Ok, ok, I know it's a gross title, but some of the surgeries I have participated in are.....well, with no intent to disrespect the patient, gross. I have had the pleasure of working with a colorectal surgeon in the past week. We have repaired anal fistulas, removed polyps in the rectum, and last night, attempted to remove a large cancerous tumor of the colon that was stuck to the bladder.

What's a fistula you may be wondering? That's a hollow tube or tract that develops between two spaces (IE, between two hollow organs, or between a hollow organ and the outside world - the biggest empty space of all). These fistulas stay open and are unable to close due to several different mechanisms, so handily memorized by the oxymoronic mnemonic FRIEND - foreign body, radiation, infection or inflammation (like Crohn's disease), epithelialization (that's the process of skin or epithelial cells laying down a tract where they shouldn't be), neoplasms (cancer), and distal obstruction. Fistulas can develop between the large bowel and the bladder or vagina, or between the large bowel and the skin. (see photo above)

That's what happened to one unfortunate fellow whom we operated on - he had developed not just one, but two fistulas from his rectum to the skin outside his anus. This meant that fecal matter was coming out not just his anus as expected, but also out of the two fistulas near by. This patient developed these fistulas after some rectal abscess or infections that pushed their way out toward the surface of his skin, and then became epithelialized. Our job as surgeons were to go in and get rid of these fistulas so that the patient could resume normal bowel habits. This was much easier said than done.

The colorectal surgeon I worked with on this case, and several other cases involving the rectum (how does someone voluntarily choose this speciality????), had no inhibition about working in this area of the body. Shortly after gowning and gloving up he dove right into the case, all excited to show me, (literally by grabbing my gloved hand and pushing a finger into this patient's anus) the difference between the internal and external anal spinchters. These are probably two of the most important muscles in our body, allowing us to operate normally in the world, without poo falling out on it's own accord (medically referred to as fecal incontinence, not something you ever want to happen to you).

The nurses referred to this surgeon as a mad scientist, and they were right. He dove into this guy's rectum with such vigor, (no need to worry the patient is blissfully sleeping with the anesthetic drugs), it's like he's forgotten that the blood and stool on his fingers and instruments are in fact, blood and stool. Nothing seems to phase him. Not even the profoundly strong smell of feces, accentuated from time to time with loud farts, which myself, the nurses, and the anesthesiologist warded off with peppermint oil dabbed on our face masks just under the nose. Either he no longer has a sense of smell, or is so desensitized to the smells that it's become a normal part of this daily life.

After we identified both of the fistulas with our instruments as well as with blue ink that stained the tract from the skin to the rectum, the surgeons job was to then gently find a plane of dissection between the inner and outer spinchters I previously mentioned. This is such a crucial part of this surgery, because to cut something inappropriate, like a nerve or the spinchters themselves, could very well leave the guy with needing Depends diapers for the rest of his life. While moving into the tissue we did come across something unexpected, a spurting blood vessel - an artery. One clear way to determine in surgery whether or not you have cut a vein (which carries unoxygenated blood back to your heart) versus an artery (carried oxygenated blood to all of your body's tissues) is the force and pattern of bleeding. If it pulses and spurts, it's an artery, and that's what he accidentally cut. Still, the surgeon was not phased as blood shot out from this patient's anal area and covered the front of his body, gown, mouth mask, and eyeglasses, not to mention the spatters on his exposed neck and forehead, to which the nurses immediately got all agitated about.

One of the jobs of the nurses is to keep both the patient and the doctors safe, by making sure that the doctors are completely sterile at all times (many times I saw the scrub nurse force a surgeon to change his gloves if she thought his hand or arm went out of the sterile field), and in this case, all the nurses wanted to do was to wipe off the blood from this surgeon's forehead and neck. But he would have none of that; there were more important things to do - like stopping this artery from spilling too much blood, and returning to the task at hand, finding and obliterating these fistulas. He seemed to have no worries at all about whether or not the patient was positive for Hep B or C, or HIV.

And so we continued on, stopped the bleeding, and backed out of the plane of tissue we were in, since usually, according to the surgeon, the place he was looking for did not usually have blood vessels. Two hours later we finally finished the case, woke up the patient, and moved on to the next operation. It was so bizarre to look this patient in the face when he woke up, after having spent four hours looking at his anus with his legs up in stirrups. Such is the privilege we have in taking care of patients. We see and do things that seem so unnatural, and yet are so necessary for people to get healthy and restore dignity to their lives.

Unfortunately for the patient we just operated on, he returned to the ER one day after his discharge with severe bleeding from his rectum, and the nurses called us in panic, sure that he was "bleeding out" or in medical terms, exsanguinating. Luckily for him we took him back into surgery to stop the bleeding, he was transfused (given extra blood due to his loss), and eventually sent home. I wonder if the surgeon had any remorse or felt any guilt for the artery that was accidentally cut. One things for sure, there is no way on earth I would ever be comfortable operating on patients' rectums. No, that's a part of the human body, along with the rest of the internal organs, that I am just as happy to look at from pictures in a book. The real thing is much too slippery, bloody, and smelly for me. The image of this surgery will stick in my mind forever, and I'm afraid of what will happen the next time I smell peppermint oil.

Vascular Surgery

valerie.brooke@yahoo.com (Valerie Brooke) — Sun, 16 Aug 2009 05:03:00 +0000

I have found it to be true what all the previous students have warned us about the clinical years of med school - it's all team dependent. It's not such a novel concept actually, and can be applied to all areas of life - what you experience is directly dependent on who you work with. I am happy to say that the previous 75 hour work week was much better the the first one, but still not enough to make me jump out of bed with joy when my alarm goes off at 4:30 am, or enough to keep me awake past 10 pm studying for the next day. I got to work with a new "team" of residents and attendings (the "bosses") during this past week, and it was an improvement over the first week, if only because I finally got to actually do something during surgery. Oh sure, there was the usual "pimping" or endless stream of questions about the anatomy of the blood vessels, or the pathophysiology of blood vessel disease, or the indications for surgery for aneurysms, but at least I was able to both cut the skin, and suture up wounds. I was painfully clumsy as indicated by the deep sighs by the attending trying to show me how to tie knots with shaking hands and bloody gloves. Why can't they remember what it was like when they didn't have the stellar dexterity of single hand knot tying?

Yes surgeons don't win the prize for the most amount of patience, or the most compassionate way to tell a patient they are going to have to cut off a leg the next day due to the peripheral vascular disease causing necrotic dead tissue in the toes and foot. They do however, take the cake for their skill with the knife, with controlling bleeding, and with making life and death decisions while under extreme pressure. I am sure that I could learn how to tie knots faster (and was sent home to practice knot tying with some supplies), and I could relearn the anatomy of the human body in such detail that the names of the branches of the external carotid artery would roll off my tongue as fast as the names of my siblings. I believe however that in the process of learning these skills I would leave behind something much more important to me - the life and experiences of the patient. In just two short weeks of surgery I have already learned to minimize the patient to the exposed limb under the sterile drapes. In fact, there were times when I was a bit startled with the rise and fall of the lungs due to ventilation assissted breathing, or the jerk of a limb as the patient started waking up from the anesthesia.

Yes there is a body underneath all those layers of sterile blue drapes, a body with a mind and heart that is sad or angry or pissed off at having to go under the knife. I won't deny that I did enjoy the surgical part of the previous week. In addition to finally getting to practice my suturing, and electrocautery (that's using a small electric device to burn small blood vessels and stop them from bleeding - bigger vessels need to be tied off - something the more proficient vascular surgeons took care of while I suctioned up all the blood pooling under the exposed limb). By the end of the week I was capable enough to actually amputate a gangrenous (dead) finger, with the verbal guidance of the attending close by. I actually felt guilty cutting off this guy's finger, not because it wasn't necessary, but because while meeting him in the preop area to consent him prior to surgery he asked in a worried voice whether the "student doctor" (that's me) would be cutting anything. I reassured him that the real doctor's would be the ones. and that I would be merely watching and learning. Of course at the time we spoke I had no idea that I would be allowed into that hallowed space of actually participating in the surgery, but I felt guilty none the less, as if I had broken a promise. Another reason I wouldn't be a good or effective surgeon - too much feeling, and not enough.........hmmmmmm........

I'm not really sure what I don't have enough of to be a surgeon. Of course I have forgotten most of what I have learned in the past two years, maybe because I didn't really store it into long term memory, but merely memorized the information for the next test. I was always a good test taker, but the long term memory I believe won't come for me until I have context, or a foundation upon which to hang the newly learned information. You can be sure that I will never ever forget the arteries and nerves and muscles of the lower leg, as I helped to cut through the skin, fascia, muscle, artery, vein, nerve and even the bones, of a poor man who had to go home for a few days in order to prepare himself mentally to lose his leg. And you see, it's that part of the patient that interests me more - the discussion about losing his leg, the discussion and plan for post surgery recovery, and the plan for rehabilitation that has led me down this path of medical school. No the cutting is not really my thing, although I will continue to do my "duty" in the next three weeks, of workings 13 hour days, a 30 hour shift once per week, and withstanding the relentless pimping by capable surgeons. I can only hope that I will not have to go under the knife in my day, now knowing what goes on once the patient falls asleep. Cheers!

Why I Don't Want to Be a Surgeon

valerie.brooke@yahoo.com (Valerie Brooke) — Fri, 07 Aug 2009 04:40:00 +0000

I'm sitting in a tiny room stuffed tight with a bunk bed, table, chair, computer, and phone (think college dorm room, but 10 times smaller), somewhere in the bowels of the hospital. I'm on call. I can't even remember if I have written something about call nights yet, that's how my brain is these days, worn out, and incapable of remembering things I definitely should know. I'm waiting for the trauma pager to go off, at which point I will rush down to the ER, meet the resident who's also on call that night, and determine whether a trauma patient is going to need surgery or not. This is my first night on call in the surgical rotation, although I'm not a complete virgin, since I did 4 call nights while rotating through Pediatrics. Not sure if I will get sleep or not, and the truth is, I'd rather be awaken by the pager then sleep all night. I learned more on the call nights I did in Pediatrics then I ever did during the day shifts. It's probably because when on call there are fewer residents and students around, so that you actually get to do, and therefore learn, much much more.

By I digress away from what the first four days of my surgical rotation have been like. 4 days down, 31 to go. Does that give you any clues? My first day was spent all day in lecture, learning about suturing, trauma, anesthesia, and other tidbits that we need to learn, not only to take care of patients, but to pass the surgical exam which happens on the last day of the rotation. The second day was surgical clinic, which began with a five minute instruction on how to use the VA medical records system, including how to do a chart note, put in the doctor's orders, and set up the encounter for billing purposes. Then a nurse comes up to me, hands me a chart with a four page questionnaire, and says please have Mr. So and So fill this out, he's in room B9. Off I go to do my job, and meet a very sweet retired vet (my rotation is at the Veteran's Hospital), who answers all my questions. I was told by the nurse to then go present the patient to one of the attendings. So off I go to find the attending doctor, and I begin to let him know all the things I had written on the questionnaire. Very soon into passing off the information, the doctor starts asking me questions that I did not have the answers to, including the fact that I had no idea what medications the gentleman was on, and even worse, I didn't even do a physical exam! I rapidly realized that what I was supposed to do was a complete history and physical exam on the patients, and then present my assessment and plan to the doctor. All I had done was ask him the questions on the sheet the nurse handed me, and only later did I learn that the questionnaire was just a way the nurses were gathering data for some study they were doing.

That is just the beginning. After admitting to the doctor that I did not do the physical exam, (and feeling like an idiot), we went and saw the patient. All went well with that patient. Then I went to write my notes, had a terrible time getting into the computer system (remember the 5 minute training....yah, five minutes wasn't enough), all the while the doctor is coming up to me and rapidly asking me to add things to my note, like ordering a EGD, manometry (what the hell are those I'm thinking), and sending my note to so and so, and so and so, so that they can set up these studies, all the while nurses are coming up to me to ask if I'm ready yet to see another patient. By the time I got to see my second patient, I was beginning a stress headache that would be my friend for the whole rest of the day. So I did the history taking and physical exam right on the second patient, and went to find a doctor amidst all the people milling around, to present my patient to (behind the waiting room doors, the clinic is pure mayhem). I find a different doc this time (thank god, cause the first one has definitely decided I am impersonating a third year medical student), and present a great summary of what the patient is here complaining of. Then she asks me what I want to do about his gallstones, which are causing him pain and discomfort, and have been seen on an ultrasound. I struggle in my brain to remember what do we do about gallstones, and I'm wondering if there is some medicine we can give to help them pass? Or maybe we can break them up (wrong stones, I was thinking about kidney stones), and finally just looked at her and admitted "I don't know what to do about gallstones." She looked at me like I had three heads, and calmly replied, "we take out the gallbladder." Wake up Valerie, you are on your surgical rotation....and so the doctors are here in clinic to see if the patients need something cut out!

Oh my god, another doctor who is going to evaluate me on this rotation who I have totally blown it with. I can just imagine her and the other doc talking later. "Hey my student didn't even do a physical exam on her first patient," while the other replies "That doesn't surprise me since she didn't know that we remove the gallbladder for symptomatic gallstones." By this time my headache went up a few more notches, and off I went to do my note in the computer until the nurse forced another patient down my throat. The last patient was easier, a woman with a lump in her breast, in to see if it was going to be biopsied or not. The last doctor I presented to (a different one) thankfully did not ask me any questions that would further destroy my reputation. Only three patients and I was completely exhausted.

The next two days were spent in surgery, where I continued to commit more faux pas. Let's see, I left the room at the end of a surgery before the chief resident did (and got blasted for later); I wore long sleeves into the OR; I didn't finish my note from the morning prior to going to surgery; I wore the wrong color scrubs (dark blue for the VA, light blue for OHSU); and didn't grab the basket of surgical supplies while rounding (seeing) all the surgical patients in the morning. The worse part about making these mistakes is that no one told me, or my fellow students, what they expected of us, and what proper operating room etiquette is, until we screwed up. That is the first of many reasons why I don't want to be a surgeon. When they get to the "top" they forget what it was like to be a student on the first surgical rotation, new to the operating room and all the unspoken rules. Not every surgeon is arrogant, and mean, and difficult to work with, but the few that are spoil the whole rest of the bunch.

More to come as I finish the next 5 weeks, but for now, I should get an hour or two of sleep before a trauma rolls in. Cheers!

Golden Weekend

valerie.brooke@yahoo.com (Valerie Brooke) — Sat, 01 Aug 2009 17:57:00 +0000

I have a blessed two days off after just finishing my pediatric rotation yesterday, and just before starting surgery Monday; hence the well known term in Medical lingo - a "Golden Weekend". So what am I doing in these two wonderful patient free study free days? First of all, sleeping. I took a nap yesterday afternoon, after finishing the pediatric shelf exam. Even though the next two years have us students working in the hospital, we still have to study on our own time to pass an exam at the end of each rotation. The extra studying is necessary because in 5 short weeks there is no way that we will see patients with every possible disease or condition that we are expected to know about. Anyhow, the pediatric exam yesterday was hard to finish in the allotted time, but the topics were all things I had studied for....doesn't mean I didn't guess a lot, or that I didn't get some wrong, but I feel confident that I passed.

Which brings me to a side note before I discuss the rest of my plans for the weekend. During this rotation all of us got back our board scores. I felt very confident that I did well on the board exam - based on my average from the first two years of medical school, from the two practice tests I took in the weeks prior to the test, and from how I felt after leaving the exam. While I did pass the exam, my score was way below what I expected, and way below average for all students that take the exam, and below average for the speciality that I want to go into. Boy were my spirits crushed the day I checked my score. I didn't have too much time to dwell on the test result though as I continued to take care of kids in the hospital.

So why the lower than expected score? Either one, I am not as smart as I think. Two, the test was a lot harder than I thought. Three, there is a conspiracy out there to separate students into bright, very bright, and ridiculously brilliant in order to still have students going into primary care (which has the lowest board scores). At this point it doesn't really matter why, because I cannot change it, and I cannot take it again (you can only retake it if you fail, and this is worse because residencies will see that you failed the first time). How can I balance out this low score? I can take my step two board exam prior to applying to residency (which I will do), and I can rock my third year rotations, busting my ass so that I can get good grades in the clinical years. In my mind I know that it is not the end of my life that my score is less than what I wanted, and that my other skills will balance out this stupid test, but I have to be honest that it hurts. It's like I was not able to achieve something that I really thought was not only possible but inevitable. I knew that I would get into medical school, that I would get into OHSU, that I would do well in the first two years. There has not been many things in my life that I have not achieved once I set my mind to it. So a low board score is humbling, frustrating, and sad. Even though I know that I don't want to be a surgeon, it's sad to me that that door is now definitely closed to me.

But I digress. So despite the board score news, I was able to keep up with the demands of the pediatric rotation, which as compared to other rotations, I've heard through the grapevine, is totally mild. While I love kids, I have to say that it's really sad to see them when they are so so sick. I had a 7 year old patient that I followed for two weeks with Cystic Fibrosis, who almost died of her lung disease in the first few days of her admission, but by the end was singing Michael Jackson "Man in the Mirror" and showing me pictures of her dog that she couldn't wait to go home and see. When I said goodbye to her and her family, I did so knowing that she could be back anytime in the next few months with a flare up and that she wouldn't live to my age.

I took care of kids with osteomyelitis (bone infections,) viral gastroenteritis (severe dehydration due to vomiting and throwing up), failure to thrive (babies who don't gain weight), bacteremia (blood infection), accidental ingestion (of medications, lamp oil, and one girl swallowed a button battery), and the worse of all - Non-accidental trauma (child abuse). The abuse cases were the hardest of course. Our attending doctors told us that during times of stress and economic struggles (recession), the cases of child abuse increase. I saw babies with "shaken baby syndrome" (bleeding in the brain from being shaken so hard that the brain hits the skull and swells), broken bones (ribs are common, as well as chip fractures from where muscles attach to bones - this also occurs with shaken baby syndrome - from a type of whiplash of the arms and legs), bruises, (any bruise of the abdomen, back, or ears are suspect since this is not where kids tend to get bruises from falling), and burns (anything that looks continuous in shape - like a cigarette burn or a curling iron, since true accidental burns tend to have a splash pattern). I got used to seeing policeman and DHS (Department of Health and Human Services) in the hallways, taking pictures of the wounds, and interviewing family members. I saw parents being forced to leave, with anger in their eyes and tears on their faces, while their children were left in care with the State officials.

If that isn't enough to depress you, then the last day of my pediatric rotation will. There was a two year old girl who was just discharged to go home (discharge occurs when all the physicians and specialists involved in the childs care feel the child is medically stable and no longer needs inpatient care), and she was in the shower with her parents, all excited to go home and get back to their regular routine, when disaster hit We were in morning report, which is a 30 minute teaching every morning for the residents and students, where a case is presented, and everyone thinks aloud about how they would take care of the patient in question. During this morning report several pagers go off, which is not unusual when you are hanging out with physicians. Lab results, nurses questions about care, and information about new children being admitted all come over the paging system. But this time after a page, two physicians in the room jumped up and went running out of the room. A code was called. "Code" means that a patient has stopped breathing, or is in severe respiratory distress, or worse, that the heart of the patient has stopped beating. Every day there are several physicians who are on the Code team, meaning that in addition to their regular pager, they also carry a code pager, in order to attend to any pediatric patient that stops breathing.

So the two residents bust out of the room, and we all wonder what is happening as we try to concentrate on the rest of morning report. It is only later that we learn that the two year old girl stopped breathing, and her heart stopped beating, and that the team of physicians tried to get her heart started again for over an hour. My classmate was one of the ones who got to do chest compressions (trying to pump the blood in her body to her brain, since the heart isn't doing it any longer), while the surgeons tried to get access to her arteries to hook her up to a machine called ECMO (extra-corporeal membrane oxygenation - essentially a machine that removes her blood, gives it oxygen, and returns it to her body). After a night on the ECMO machine, and evidence that her brain had been without oxygen for too long and had suffered irreparable damage, she was taken off the machine, and died.

Our team was devastated. The resident left the room after telling the family and cried. The attending doctor tried to understand how this could happen. In the kidney doctors' many many years of practice, they had only ever heard of this happening once to a patient in her condition. She had a condition called nephrotic syndrome, which means that her kidneys were loosing protein in her urine, and that she therefore had some problems with maintaining appropriate blood pressure (it was too high). The condition also has the minor side effect of making the blood more sticky - or coagulable in medical terms. And this is how she died - a large sticky clot broke off and clogged a major artery to her heart.

So it was a sad end to a rotation that was filled with joy (when the patients got better and went home), a sense of futility (knowing my Cystic Fibrosis patient would be back, and would die of her lung disease sooner rather than later), frustration (with not understanding sometimes why a child was sick, or with dealing with understandably overbearing parents, or worse, uncaring and even abusive parents), and sadness (sometimes things happen, like death, that we cannot foresee or prevent). Tonight I'm going to a get together with other med students, who were in other rotations this past 5 weeks, where I hope to vent, and get support for all that I have seen and experienced so far. One thing that will be golden for sure, is the nice cold beer that I wash down some tasty ribs with. Cheers.

Mother Baby Unit

valerie.brooke@yahoo.com (Valerie Brooke) — Sat, 11 Jul 2009 01:27:00 +0000

Well I just finished the first two weeks of my pediatric rotation and I had the wonderful opportunity to be in the newborn nursery, evaluating newborns in the first few days of their lives. I worked with one intern, and an attending physician. The intern was a first year resident, and we had three different attendings (depending on the day). The attending physicians have been pediatricians for many many years, and taught us what we need to know about taking care of healthy newborns. I have to admit that I have cheated a bit in this area by having already experienced birth, breast feeding, and the exhausting newborn period. Even though I have been around newborns, my hand was still shaking the first time I listened to a newborn's heartbeat last Monday. After ten days of newborn exams though, I feel confident about checking out these new little additions to the human race.

So what does the newborn exam entail? You would be surprised to know all the possible abnormalities that physicians are checking for in the first exam. Unfortunately for the parents and for the little baby, getting naked and having doctors look and examine everything so closely can be disconcerting, especially for the newborn, who is much more happier all swaddled up in a position similar to the one he or she just spent 8 or 9 months in. It's amazing the power of the swaddle - a screaming baby will quiet immediately with this magic trick. The attendings tell me that it works for the first 3 months of life...wish I knew that when I was a young mom!

But I am getting ahead of myself. This is what a newborn exam is like, and what I learned in the past two weeks to become proficient at: We enter the room, introduce ourselves to the family as the pediatric team, and ask if we can take a look at their baby. Given that OHSU is a teaching hospital, and that mom is also considered a patient by the OB/GYN team of physicians, the family is interrupted a lot in the first few days after the baby is born. The nurse comes in to check vitals on the mom and baby every 4 or 8 hours, the lactation consultant comes in to help the mom with breast feeding, the social worker comes in to make sure mom and dad have adequate support at home, not to mention all the students - nursing, and medical students like me, who are trying to learn the skills of exam and taking patient histories.

So after the parents have reluctantly let us remove the little one from their arms, or worse, we wake them up from a much needed nap, we examine the baby in a crib right next to mom, explaining along the way what we are checking for and why. That way if the baby starts screaming, the parents know that we are not torturing their child, although there is a special trick we do to try to calm the baby. We glove up, and put one of our fingers in the baby's mouth. Not only does this calm the baby, who inherently has a sucking reflex after birth both for comfort and for feeding purposes, but it also allows us to check the palate for any abnormalities, such as cleft or extra teeth.

The head to toe exam includes examining the head for birth trauma. There can be swelling or bruising associated with a normal vaginal delivery, or the use of a vacuum or forceps to help the baby out. Other trauma from birth can include shoulder dislocation, especially if the baby is a big one. We check all the skin surfaces, to note any birth marks, or abnormal skin rashes that would prompt us to do a further evaluation for infection. Newborn babies skin vary depending on their gestational age (how long they were in the uterus). Early babies have soft smooth skin, while babies who were born late, after the 40 week due date, have more dry and wrinkly skin. We reassure the parents about the normal skin changes that are seen in newborn babies - rashes and little bumps that can look bad but are totally normal.

We listen to the heart (to check for murmurs), the lungs, and the guts (to make sure the digestive system is working). We check their anus to make sure it's open, and the boy's penis to make sure the meatus (hole where the urine comes out) is in the right place. We look at the feet, hands, and turn the baby over to check the back and spine. For feet we are looking for a reflex where they curl their toes around our finger (they will loose this "monkey" reflex in a few months), for the right number and separate toes (we had one baby born with only three toes on one foot, and several others that had what's called syndactly - webbing between two toes). We also check the hands to check for what's called a simian crease (one connecting horizontal palmar line instead of two that can be a marker of Downs syndrome). When we examine the spine we are looking for any sacral dimples that are abnormal (they may be connected to the spinal canal or indicate an underlying abnormality of the canal). We did have one baby with a little dimple and a heaped up layer of skin below the dimple that looked unusual enough to the attending that she ordered an ultrasound which came back showing a cyst in the spinal canal. We then called pediatric neurosurgery to evaluate the imaging and let the family know what to do next.

99.9% of the babies I spent the last two weeks with were completely normal, just getting adjusted to extra-uterine life. A few required some interventions, and one of the reasons we make the babies stay for 48 hours is that we want to monitor for possible infection, as well as for jaundice. Jaundice is yellowing of the skin that normally occurs in newborns and is a result of the liver being a little immature in it's ability to break down red blood cell and eliminate the pigment called bilirubin. Although bilirubin depositing in the newborn's skin is normal, we monitor the levels to make sure that they don't get too high and cause any damage to the brain. If we find that levels are too high, then we put the baby under UV lights, which helps to eliminate the excess bilirubin. If lights are needed, the baby is put in a warm incubator that has lights above, and the baby's eyes are covered. Once the lab values show an appropriately low level of bilirubin in the blood, we let the family go home, although we also make sure that they have a follow up appointment with a pediatrician within 2-3 days to check the jaundice again.

So what have I learned so far? Vast amounts of both normal and abnormal newborn physiology! I can't believe it's only been two weeks. Monday I start on the inpatient pediatric ward, which means that I will learn how to take care of sick kids. Monday is also my first call night - which means that I will be at the hospital from 6:30 am Monday until 2 pm Tuesday. If I am lucky, there will not be many admits over night and I may even get a few hours of sleep. This is what I have worried most about in going to medical school. How to survive a 30 hour shift without any sleep, and still make good medical decisions. Good thing that as a student I'm still mostly observing at this point. I'll let you know how it goes! Cheers!

Transitions

valerie.brooke@yahoo.com (Valerie Brooke) — Tue, 30 Jun 2009 14:19:00 +0000

Now that I've just finished transition to clerkship week, let me tell you all the things that have been added to my toolbox. I know how to give shots, intramuscular, subcutaneous, and subdermal (each have specific angles that you put the needle to the skin), and I know all the dos and don'ts about needle handling so that I don't stick myself and have to go on anti-viral therapy for the possible transmission of Hepatitis or HIV. (Most people fear getting HIV, but the chances of getting Hepatitis B or C is much much much higher - nasty little virus - and unlike HIV where you can live a long time on anti-retroviral drugs, hepatitis can lead to cirrhosis -hardening - of the liver and even liver cancer). Anyhow, the best part of this little workshop is that we got to practice on ORANGES! You would think that my $35K per year would have enough dollars to set aside some time to actually learn how to stick needles in human skin, heck, we were all more than willing to practice on each other, but no such luck. God save my first patient who has to suffer through my first few injections.....

The transition workshops also included the much needed skills of intubation (putting a plastic airway down some one's throat when they need oxygen and cannot maintain their own respiration), as well as how to do a catheter (that's when you stick a plastic tube up the urethra - the little hole your urine comes out of). This is done when a person is unable to empty their bladder themselves, or will be going into surgery. The best part about these two workshops were our patients - they didn't complain or squirm on the table as we jammed instruments into sacred places in their body. They were quiet because they were plastic! Another great thing about our education - they figure we need to learn how to do these skills on manikins first, before they cut us loose to do possible damage on real human beings.

That's one thing about medical education I bet you have never thought about - students need to practice. Atul Gawande wrote about this in his surgical memoir "Complications" - great book, highly recommend reading it, although you may decide to never have surgery once you're done. Is there any other way? Probably not. Although the introduction of these skills with the plastic patients is totally necessary, if at least to just introduce us to the different tools and hardware involved with the different procedures, the real learning will come by doing intubations and catheter placement on real patients, in real time. I pray in advance that I will learn to do these skills in a manner that causes the least amount of discomfort to my patients. Don't worry, I will most likely watch residents and interns do these procedures many many times before getting a chance myself, but I bet you still don't want to be my first try right?

The best workshop last week was the four hour introduction to surgery - we learned how to dress for surgery - where to go for your scrubs, what to wear to cover all of your body - hair net, shoe covers, gown, face mask, including a shield that comes up to cover your eyes (although the surgical scrub nurse was so kind to remind us that even the shield doesn't always protect you as he once had some blood fly up and across the table and land right in his eye behind his shield - the patient had hepatitis). So going into the surgical room is like going into a minefield, not only do you have to deal with body fluids, but you also have to know how to behave so that you don't contaminate what's known as the "sterile field", and you have to remember everything you have ever been taught about the human body, because the surgeon will pimp you (that means fire questions off at you and expect an answer. Rumor has it that one surgeon here at OHSU will make you leave the room if you can't answer his anatomy questions - please God don't let me get him for an attending).

Before you even get into the surgery room you have to spend quite some time at the sink, scrubbing your skin up to your elbow. There is a very specific way to scrub your fingers and arms - you can't do your arms and then go back up to your fingers, or vice versa. You have to start in one direction and continue down or up the arm. You scrub for ten seconds on each area - for each finger you scrub all four sides for ten seconds, then move on to the palm for ten seconds, back of hand for ten, wrist, forearm, etc. you get the picture. My first scrub would most likely not pass the guidelines for a successful scrub - I forgot to clean under my nails with the little plastic digger that comes in the soap container, I choose the wrong type of soap (there are three choices by the sink - you have to know the difference), I went the wrong direction on my arm, and I dropped my soap - which meant I had to start all over again. Oh ya, there's also a very particular way to rinse your arms - hand to elbow, since you don't want the soap from a dirty part of your arm to go over the freshly rinsed part. Sigh.......

Once I got through the hand rinsing part, it was on to the operating room (no patient, we're just practicing the whole scrubbing in thing), to learn how to dry your hands, get your gloves on, and gown yourself. I forgot to say earlier that you have to have all this stuff already set out and ready for you in the operating room - and it's laid out in a particular way so that you won't contaminate the sterile field. I screwed up first by having the towel I was wiping my hands on touch the front of my clothing - strike one - I was supposed to bend over at the waist while drying my hands to avoid that problem. Got the gloves on OK (I had done that once before last year) but messed up as I was pushing my hands through the gown sleeves - touched a piece of the equipment that was not sterile - strike two. If I had to do it all over again, I would have washed my hands at least three times that day. Thankfully the nursing staff told us that for the first few times they help us get gloved and gowned since they know we're terrible at it in the beginning.

A few more workshops finished off the week, and prepared us (hah!) for starting our rotations in the hospital this week. We were able to treat a heart attack in a pseudo-emergency room. Again, not with a real patient but with a guy we have become familiar with in medical school - Sim Man. He's a "simulation" manikin - complete with a beating heart, respiring lungs, pulses in his arms, and most disturbingly, he can talk via a microphone that is connected to a computer in the next room. A teaching physician is behind a one way glass testing us to see how we will handle any myriad of clinical situations. We even get to give medications and see on the monitor whether what we have done has helped alleviate the patient's discomfort and symptoms, or if we have killed the patient. In addition to a heart attack, we also had little "Sim Kid" who presented with an acute asthma attack. He was scary looking - just like the doll (minus the scars thankfully) in the thriller "Chucky."

I know that all these workshops are an attempt to introduce us to the reality of taking care of patients, and I so appreciate the practice. It's hard to believe that starting now, from this point forward, my patients will no longer be simulations. They will be living, breathing, pulsing with life, and pain, and questions, all of which over time I hope that I will learn to attend to. In the meantime, I watch and soak it all in. Cheers!

Phew! Half Way There.

valerie.brooke@yahoo.com (Valerie Brooke) — Mon, 22 Jun 2009 03:29:00 +0000

I can finally say that I am halfway through medical school, and 1/3 of the way to being a licensed physician. Two days ago I took the grueling 7 hour long Step 1 Board exam, an exam that I hope to never ever have to study for or take again. I'm confident that I passed, so I think I can throw away my study materials, since it's all in my brain now right? Ha! A lot is in there, right in the forefront of my mind, but unfortunately it will fade over time, as it did after the first time I learned it in class.

So I had a fabulous party on Saturday night for my local friends and family that have helped me through the first two years, and believe me, I have so so much to be thankful for. My closest and dearest friends Ted and Chia Chia cooked food for me every week, a dinner, and then lots of take home containers for lunch for school. And every few months I got to decompress with their two kids Bria and Miles with a overnight play date. Thanks guys!

Then there's my sweet dear husband and my daughter Erinna who took over the household (except for the cooking which I love to do and wouldn't give up to anyone). They cleaned, did all the laundry, took care of the cats (Mango our "dying cat" still is hanging in there, in part due to Ronando's daily diligence at giving him subcutaneous fluids daily to help his failing kidneys), and were there to support me every day. Thanks Ronando and Erinna!!

There were those that rubbed my knots, Jim and Jen and Stephanie at school - boy did my neck and shoulder muscles need the work! While studying for the boards I got a terrible neck sprain from looking down at my notes all day long, and I got some acupuncture and massage from my wonderful friends, plus a great adjustment from my chiropractor. What would I do without all my peeps standing behind me, holding me up?

And then there were all the great dinners and visits with Kim and Jason, Dave and Tiffany, Ted and Chia Chia, time to visit and have some great wine, and blow off steam. Thank you so so much everyone for helping me on this journey. I know that I couldn't have done this without you all. It takes a village to make a physician!!

So you may be wondering what's next? The next week is filled with workshops introducing to all the skills we will need to know to work in the hospital - it's called transition to clerkship week, and on the schedule is - Scrubbing and Gowning, Suturing, Airway Management, Emergency Decision Making, Need Safety, PIC/Central Lines, Pathology and Radiology. Its' going to be a long week, hours 7am to 7 pm, but it will be a welcome relief from sitting on my butt 12 hours a day studying!

After this transition week, we all move on to our rotations. For the next two years we will be rotating 5 weeks through many different areas of medicine - the order that I will be going through these clerkships my third year is - Pediatrics, Surgery, Psychiatry, Family Medicine, Elective, Internal Medicine (10 weeks), Rural Medicine, and OB/GYN. Fourth year then has a few required clerkships, lots of time for electives, and time to travel around the country interviewing for residencies (which is why fourth year is by far, the BEST year in med school). I've heard that third year is hard, in terms of the long hours, but that the time with the patients makes it all worth it.

So I anticipate having a bit more time to write (until my surgical rotation that is - known to be brutal). I start off my first two weeks in the mother baby unit here at the Children's hospital, and then three weeks in Pediatrics in the same hospital. I have spent the weekend relaxing, trying to get ready for the next piece of my process. I just finished sewing some extra pockets into my white coat, as they will soon be bursting with note cards, my Blackberry, my drug books, my pediatrics book, my stethoscope, and snacks to make sure I make it through the long days.

Love you all!

5 Days Down, 23 to Go

valerie.brooke@yahoo.com (Valerie Brooke) — Wed, 27 May 2009 16:23:00 +0000

I have a monthly calendar hanging up nearby, with big beautiful blue X's through each of the last 5 days. Underneath those blue sharpie lines are tiny notes of what I attempted to study for that day - renal, pharmacology, GI (gastrointestinal), anatomy, embryology, hematology, and oncology. That's what I've reviewed so far, and it's been a whorl wind mini tour through my brain. I'm happy to say that everything looks familiar - oh ya, the renin-angiotensin-aldosterone system, oh ya, carcinoid syndrome, oh ya, tetralogy of Fallot, oh ya, activated partial prothrombin time, and oh ya, Hairy Cell lymphoma. Familiar, Yes. Memorized, No.

So what am I talking about? Reviewing for the Step 1 Board exams. So OHSU is responsible for giving me my MD (if I pass of course). The NBME (national board of medical examiners) are responsible for allowing me to get a medical license. The two are completely separate. MD does not equal licensed and able to practice medicine. There are three board exams on the way to achieving licensure. Step 1 is taken after the first two years of medical school and its purpose is to see how much of the science you know. Step 2 is taken sometime in your 3rd or 4th year of medical school, and is geared toward clinical skills - not only what disease someone has (step 1 tests this), but more importantly, how do you treat it? Step 3 is taken during your residency and is specific for your chosen line of work.

I talked to an older physician the other day and when he found out it was board study time, he asked, "It's two weeks, two days, and a number 2 pencil right?" I had no idea what he meant, and he explained that when he was taking the board exams (20? years ago) students studied for the step 1 for 2 weeks, step 2 for 2 days, and not at all for step 3 (I guess by the time you get through part of residency you think you know it all). When he learned that not only do we at OHSU only have 4 weeks to study for the step 1, and that we wished we had more time, he smiled as if to say, "boy these med students sure are getting dumber, and they certainly do know how to whine."

I wanted to say that they probably only had a handful of drugs to know, versus hundreds now, and that they didn't have the wonderful genetic and molecular understanding of diseases that we now have...but since I didn't want to add to his perception that we whine too much, I just kept my mouth shut. But I left his office wondering, are we getting stupider? Is OHSU letting in students that don't have what it takes to cram all this information in? (Maybe our heads aren't big enough - ie. we have a little more heart, and maybe a little less ego).

I pulled out the stats on the step 1 board exam to see what the magical numbers have to say. In 2005 and 2006, 94% of allopathic medical students passed the step 1 boards. Not bad! Osteopathic students (who went to DO school, not MD school, but want to match into a MD residency and so take the MD boards) got a 77% pass rate, and foreign medical students who are trying to get licensed here in the US have a 71% pass rate. So how does OHSU fare? They tell us every year that we have an average board score when compared to all students taking the boards (includes DO and foreign students). If you take out the DO and foreign students, we have a below average pass rate for the step 1 boards.

While average, or just below average is nothing to be ashamed about, I can't understand why the Dean's office doesn't want to do everything possible to increase the pass rate, as well as the average score. When I've talked to curriculum leaders about the step 1 boards, they all adamantly shake their heads when it's suggested that we include board prep in our first two years of med school. They don't want to "teach to the boards" since that is not their job. Their job is to 1. teach us the science 2. teach us clinical skills. 3. teach us public health/epidemiology 4. teach us (or at least encourage) altruism.

There's nothing wrong with their goals except for this - When residency directors are overwhelmed with 1000 applications for a mere 40 positions, they need to make fast cuts, and the number one way this is done is with step 1 board scores. It makes no difference that you aced your science classes, that your patients and attendings thought you were stellar on your rotations, that you took a year off to go to Africa and set up an AIDs clinic, or that you published an article in the New England Journal of Medicine. It's a numbers game !!! At least to get you into the door for an interview. Once you get to the interview, you can impress them with your sweet bedside manner, or your altruism, or your research papers.

This is one way that medical school/getting into residency, and undergraduate/getting into medical school is way different. Yes there is a cut off for MCAT scores below which you will not get an interview, but there is way more leniency, and more willingness to look wholistically at the applicant. This is not the case for residency, especially when the competition is high. You learn very early on that if you want to go into a competitive speciality (surgery, dermatology, urology, radiology - all the specialties that make a butt load of money), you have to have stellar board scores, or your application will go right into the recycle bin.

This is fine for me, and for all those at OHSU who are planning on going into primary care specialities. Pass the boards (185 is passing), and it's all uphill from there depending on how competitive a program you want to get into. (Bottom line - you will match somewhere). Compare that to surgery where you need a score of 220 or above, or radiology 240 or above, or dermatology 250 and above! Thank god I don't want to do those specialties.

So why I am carrying on about all this? Partly because it's the inherent nature of medical school to keep climbing uphill. Getting to medical school (doing well in undergraduate, the MCAT, the med school interviews) is like getting up to base camp at 10,000 feet. The first two years are another climb, just to get you to the second camp at 15,000 feet, where you hope to do well on the step one boards so that you can then attack the next hump - fellowship, with the peak of the mountain always in view - that day when it will be just you and your patient, in a small room, and they say "Help me Doctor."

Cheers to all my supporters who won't see me much for the next month. Think of me, and send me good spongy thoughts. (I need all the sponge I can get to soak up these details and get me a 220 on the step 1 boards!)

Valerie's Growth and Development

valerie.brooke@yahoo.com (Valerie Brooke) — Sat, 02 May 2009 14:43:00 +0000

I choose this title because we are finishing the last class of the school year, Human Growth and Development, and as we go through the stages of fertilization, fetal growth, birth, childhood, adulthood, and the elder years, I realize that med school is so much like growing into a completely new person. I imagine that I am still in the stages of fetal growth, as I struggle to learn this last three weeks of new information, before the eventually birth that will occur with the board exam.

I bumped into an old friend yesterday who asked if I was still blogging, and I have to admit that I've been a bit lax lately, not for lack of things to talk about, but more for fear of saying the same thing over and over, as well as a hesitancy to say what's really going on in such a public forum. As I inevitably say when my family calls and asks how and what I am doing, I reply, no matter the day or time, I'm studying, and I'm OK. It's true, I am neither great nor terrible, and all I do is study. But to say that I am OK greatly understates the storm of emotions and thoughts swirling beneath the surface.

There is very little to look forward for while in medical school, unless you make a very strong commitment of doing something outside of school that "fills" you up. You know what I'm talking about, that thing, or those people, or activities, that make you relax, live in the present moment, and forget all your worries and stresses. What is it for you? Dancing is number one on my list, wine is number two, and the rest are probably all equally number three - watching episodes of ER (or any other series on DVD - no time for commercials), playing cribbage with Erinna, getting a massage, exercise class, and sex. Now, those things still decompress me, and bring a smile to my face, but for most of them, I still can't shut off the train of stressful thoughts in my brain. Which means my list has gotten shorter.

And I have voluntary chosen to take one of my list, at least for a short time. After a very very fun night of dancing with a school friend of mine several weeks ago (haven't been up so late to hear "last call" since I was in college...), followed by a useless day of studying due to a hang over, my friend and I decided to not drink at all for a month. We both struggle with depression and anxiety, and use a glass of wine at the end of the day to de-stress. Every few days I send her a text, with the update of what day we are on (today is day 21), and a question about how she is doing. And it sounds like she is experiencing the same as I am - a much healthier body, and more time to study, but a great increase in anxiety. I have bitten my finger nails down short short short, and I have picked my toe nails until they have bled. What an embarrassing thing to admit, but it could also be that simultaneously, I have tried to wean myself off my depression/anxiety meds. Probably not a great idea, but I want to see how I feel at baseline. Without alcohol, and without mind altering medication, how do I feel?

Well I've stuck to the "no alcohol for 30 days", but the process of getting off my medication has not been fun. My other school friends think I am crazy trying to do this when studying for the board exams (the most stressful experience of the first two years of med school), and I'm beginning to think they are right. (In fact, many med students become so stressed, depressed, and anxious during school that they begin medication). I don't feel depressed as I lower the doses, but the withdrawal effects are terrible (remember this if you ever go on the drug Effexor, or if you ever prescribe it to a patient). The withdrawal effects are so bad that I keep taking the drug, in a very small dose, so that I can continue studying.... I'm not sure when I will have a long enough break to detox, but it's obviously not going to happen anytime soon. So I have relinquished myself to staying on the drug, and as each day comes to a close, and my anxiety rises, I reach for my bottle of Effexor, and stay away from that wonderful bottle of Port that tempts me. Cheers! And thanks for listening.

The Sprint

valerie.brooke@yahoo.com (Valerie Brooke) — Thu, 16 Apr 2009 18:44:00 +0000

It's almost impossible to believe, but we only have a mere 6 weeks left of class before the first two years of medical school are completely over. So far we have taken classes in -
Gross Anatomy and Embryology
Cell Structure and Function
Systems Processes and Homeostasis
Biological Basis of Disease
Principles of Clinical Medicine
Circulation
Metabolism
Neuroscience and Behavior
Pathology of Blood
Human Growth and Development (in right now)

So in these ten classes we have learned everything there is to know about the normal workings of the human body, the pathology that occurs, and how to treat those pathologies. We have taken somewhere around 35 exams and another 8 quizzes. For those who attend lectures, we have sat in our seats for approximately 1,500 hours (no wonder we're having to move farther out on our belt notches). For those like me, avid readers, we have bought around 40 books, and read a few thousands of pages. We have cut up a cadaver, and interviewed live patients. We have listening to the heart beats of adults, children, and even fetuses the size of a walnut. We have washed our white coat week after week, listened to many sad stories of patients in pain, and watched our teaching physicians practice amazing as well as disappointing medicine.

So where does that leave us? Happy to almost be done with the class part. Scared as hell to take the board exam in a mere 10 weeks. And totally jazzed to start working more with patients, everyday, for the next two years. It's time to see what we remember, and if we can apply what we have learned to real patients. This is what I came for medical school for! Not for the biochemisty, nor for the memorization of drugs and their side effects, nor for the exact answer to a test question (although I recognize that these are important...there is more to medicine....I hope).

I anticipate the next few weeks to be harried, hurried, with the sun outside (like today) trying to pull us away from our studies. I will say though that studying for the board exam should be easier than learning new info. Yes there is an inordinate amount of information that I don't remember, but at least I have heard or seen the words and concepts before. Because I KNOW that there is no more room in my brain for new information (which is what I am struggling with right now in our last class - I'd much rather review/study for the boards, than cram more info in). But have to learn this stuff - and so I plod on ahead, one lecture at a time, one day at a time. The same thing that I have been doing since day number one.

So if you happen to see me at all in the next ten weeks, or try to call, or email me, I may not be around, as I am out sprinting towards the finish line. Meet me there with a congratulatory bottle of wine OK? (My board exam is schedule for June 19....pray for me). Thanks for following my journey - it's comforting to know that I have fans out there. Keep in touch! Cheers!

Blood from a Stone

valerie.brooke@yahoo.com (Valerie Brooke) — Thu, 26 Mar 2009 00:51:00 +0000

Ever wonder what this idiom means? I mean, you can't really get anything from out of a stone, except maybe a bruise if you slam it up against your head. I'm thinking that maybe that's what I will call my book about medical school, not only because the process is difficult, but also because it's like beating your head against a hard rock. And yet, everyday I get up, and do it all over again. Here I am , on my spring break, and what am I doing? Not lounging in my bikini on a beach with a Mai Tai in my hands, but I am trying to get through a massive to do list that has grown over the last several months. Oh, I'll catch up on that over spring break I thought. So here I am, in the thick of catching up.

I really don't mind having lots to do. In fact, I get irritable and bored when I have nothing to do. You could say that I need to relax, and learn how to meditate, learn how to not judge my competence on what I accomplish on a day to day basis, but that would be like trying to make a dog not be excited about chasing a ball. I love being busy; I love running around: and I love having things to get done. I am the Queen of productiveness. I have long let go of trying to meditate, or slow down, or zen out; it just makes my blood pressure rise, which is not the goal of meditation right?

I no longer feel any shame about liking to be busy, about enjoying challenge, about the love of competition. It's just the way I am wired. When the Goddess was giving out yogi personalities, I was obviously hiding behind the door. I WANT to DO. I WANT to EXPERIENCE, and I WANT to live life to the absolute fullest. And at this point in my life, what that means is hitting my head with the stone of medical school expectations.

So what I am banging my head against these days? Thankfully we have moved away from Neuroscience, which I have to say in retrospect was brutal but exciting at the same time. (I am such a masochist). Now we have moved to Hematology (the study of blood). We had heard through the medical student grapevine that blood was a much easier class, but you can't trust that information from an upper class that has a reputation for being gunners (more on that term later in case you are not familiar with it), as well as a class that has scored higher than ours on a lot of exams (as told to us from a course director who was trying to either motivate us to study harder, or shame us for our stupidity). Anyhow, for once, they were right. The first exam in Blood was the most straight forward (and easy) exam of medical school. It was like an exam in undergraduate classes - this is what we expect you to know, and every single question was related to those expectations. No curve balls, no "did you read the last line on page 155 of the book, nor any questions trying to trick us. It was such a relief, and at the same time, being used to the "abuse" of what exams are usually like, I left the room feeling a bit disappointed. I had WAY over studied, memorizing totally irrelevant details, statistics, and such, since during previous exams, you always had to be prepared for very very very detailed questions. I finished the exam thinking, WOW I think I can be a good doctor! I understand how to evaluate patients with blood abnormalities, and how to come up with a possible list of diseases.

Phew! Thank the gods and goddesses that this break has come at this time. Right at the time when students in my class are looking so ragged and are about ready to explode; we are not stones, and if we were to break we would spill our blood all over the lecture hall floor. But no need to rush us to the ER just yet. The course in Blood is straight forward and we can begin to concentrate on preparing for the boards.

So that's what I am doing, in part, during my week long vacation. Besides drinking some wine, reading a non-medical book (always wanted to read "Eat, Pray, Love"), and teaching my now sixteen year old to drive, I have been doing board study questions. I have been using a test bank that I purchased and so far have been getting 50-60% on the tests. When I told my husband how the practice tests were going, and what my scores were, he couldn't understand why I would be excited about a 50%. I guess he doesn't understand that 50% represents a successful trickle of blood from a stone. Cheers!

Cheating

valerie.brooke@yahoo.com (Valerie Brooke) — Fri, 13 Mar 2009 15:25:00 +0000

Got your attention huh? You may think that all I ever do is study, sleep, and eat, but there actually is time to do a few other things in my life, and one of them is called the "Student Resource Committee." About three years ago there was an incidence here at OHSU where one less exam got turned back in at the end of the examination period. Let me clarify to you how it works - a wonderful person from the Teaching Services Office (TSO) (and they really are great - they make it smooth for the students, thank you!), wheel in a humongous stack of exams, 120 to be exact, all of which are about 20 pages long, with a big thick staple. We have those wonderful scantrons that you have to correctly fill in the little bubbles, on which we put the correct answers, which we leave at a table in the front of the room, and the 20 page thick exam, when we are finished. At the end of the exam, the TSO person counts to make sure all 120 exams are still in the room. So three years ago, some idiot student decided to take one of the exams home with him....and TSO discovered the missing exam....and all hell broke loose.

No one ever came forward with the missing exam, or information about who had taken it, although it did end up mysteriously underneath the door of the TSO office the next day. Whoever had grabbed the test decided it be best to return it to its rightful owners! You laugh about ownership, and yet in each syllabus and at the top of each test reads the ominous warning: "The content of an examination is confidential and distribution of the content in the public domain is prohibited when the examination bears the School of Medicine Public Domain Advisory. In this circumstance the reproduction or transcription of the content of the examination by any means is unauthorized. Possession and distribution of the examination or the content of this examination outside of the classroom setting or of the supervision of the course director or his/her designee is prohibited. Individual possessing or distributing exams or exam content that is not authorized to the public domain will be subject to academic disciplinary action for failure to meet professional standards."

Not only did this raise the issue of professionalism on the part of one individual student, but it also brought to light the pressure students feel to not rat each other out when cheating or a lack of professionalism is witnessed. Chances are very high that someone saw something, and knew who took, and then returned, that exam.

Well, they returned it right? Well maybe they copied it, and will distribute it to the next incoming class, which makes all 120 questions that the course director came up with completely obsolete. You may think it's not a big deal, but believe me, after going to many exam reviews, it's very difficult for a professor to come up with a good question that will withstand the pleading and arguing excuses of students who feel like the question is misleading or unclear. So directors have these test banks of questions that have upheld the high standards of student feedback, and are therefore, fair questions. In each exam period we have the opportunity to comment, on a separate query sheet of paper, our reasons for thinking a question is unfair, or that there is more than one valid answer etc. So you see, this exam question thing is a serious business, and I imagine the course director was VERY unhappy to get rid of those 120 questions out of the test bank.

So in the spirit of trying to encourage students to first of all, not cheat, and second of all, to report any unprofessional behavior, the Student Resource Committee was born. It took many years and countless hours of work to come up with a Statement of Principles for the student body to sign, as well as a charter outlining how the council will work on a day to day basis. I was not involved in the writing of these documents, but after the four classes passed the Statements of Principles with a 83% vote, I decided to put myself on the list to be considered as a representative of my class, and was subsequently voted in, along with two other of my classmates.

Now at this point you may be thinking, Medical Students Cheat? But why? They are so smart to begin with, and why would you want to cheat on something that you are eventually going to have to know anyway, and further more, on knowledge that is required to take care of patients! Well, I'm with you. I am totally naive, and had absolutely no idea how much cheating goes on. Here are the results of a 31 medical school survey, with a total of 2,459 students responding, done in 1996:
"RESULTS: Thirty-nine percent of the respondents reported witnessing some type of cheating among classmates during the first two years of medical education, while 66.5% reported having heard about such cheating. When reporting about themselves, 31.4% admitted cheating in junior high school, 40.5% in high school, 16.5% in college, and only 4.7% in medical school. Reports of cheating varied across medical schools, but no relationship was found between rates of cheating and medical school characteristics. Men were more likely to report having cheated than were women. The best predictor of whether someone was likely to cheat in medical school was whether they had cheated before, although the data strongly support the role of environmental factors. Medical school honor codes exercised some effect on cheating behavior, but the effect was not large.

CONCLUSION: About 5% of the medical students surveyed reported cheating during the first two years of medical school. The students appeared resigned to the fact that cheating is impossible to eliminate, but they lacked any clear consensus about how to proceed when they became aware of cheating by others. The guidance students appear to need concerns not so much their own ethical behaviors as how and when to intervene to address the ethical conduct of their peers" Baldwin DC Jr, Daugherty SR, Rowley BD, Schwarz MD, Acad Med. 1996 Mar;71(3):267-73

So, you see, cheating happens, and as the system is currently set up, the only option you have if you see someone cheating is to go to the Dean's office. Of course, not many students want to go to the Dean's office, even if it has nothing to do with them. The Dean's office is responsible for writing a letter of academic and professional performance that will accompany your applications for residency. The Dean's office has power. The Dean's office is, from the students point of view, not a place you want to go to. After talking to the Dean's office staff, in the process of trying to figure out what relationship will exist between the Dean's office and our Committee, if any at all, we have discovered that a lot of what the office does is quite benign. They try to recognize students that are struggling with school, whether it be for emotional, financial, or academic reasons, and lead them to appropriate resources. The Dean's office really wants students to succeed, for it will not look good if OHSU graduates students that are unprofessional, emotional unstable, or lacking in the required knowledge to be a caretaker of patients.

Nevertheless, the stigma of the Dean's office remains, and we are attempting to provide a place for students to come with any concerns about medical school, be they personal, interpersonal - with another student or a faculty member, or even an attending physician, as well as a place to discuss potential breaches in the schools Code of Conduct. Our hope is that by having a student run committee, that operates with confidentially and independence from the Dean's office, we can allow for a safer place for concerns to come to light. As it is, we have already had several issues come to us, which if we had not existed, would never have gone to the Dean's office, and therefore, would have never been addressed. It remains to see how effective our committee will be, and if we can, in the long run, change the culture of medical school so that students will accept responsibility for the behavior of their colleagues. For when we get to be physicians, there will be no Dean's office around to approach a physician who is behaving unprofessional. It will be up to us, as physicians and colleagues, to talk to our fellow physicians, and find out what is going on. I'll let you know how this committee progresses as the years go on, but if you want any details or names, you aren't going to get them, because it's confidential!! Cheers!