How Hard is Medical School (Made to Sound as Depressing as Possible)

Medical School is extremely hard.

First, you arrive at medical school. A bright, cheery MSI.

And you are really, really excited to be here. I mean, possibly more excited that you will ever be for anything thus far in your life (unless you're already married, had a child etc.) You recognize that it is going to be hard but at the same time you think to yourself, "Well I got in, didn't I, hopefully the administration didn't make some huge mistake." Have I mentioned that you are excited. Tens of thousands of people didn't get in to medical school this year, but you did.

Then you get done with the lazy week of orientation, which you probably skipped half of anyway, and you arrive at your first class.


ANATOMY- Day One

Welcome to Medical School here at the Medical College of the United States. Blah. Blah. Study a little every day. Blah. Blah. This is going to be the most challenging thing that you have ever done. Blah Blah. This is the axilla. Blah blah.

Video begins:

"This is how to disect a human body..."

Professor: Ok class now we are going to go downstairs and begin disecting, there will be 6 people per cadaver.

You (thinking to yourself): This is great! I'm finally doing something that is interesting. No more boring stuff like General Chemistry for me!

And that first night you study better than you ever have in your life, because if you know one thing, it's that you don't want to be one of those 5 or so people that drop out (and you definitely don't want to Modify, which means that you end up taking 5 years to complete medical school instead of the usual 4.). And you keep studying every night for the next month, and on some levels it's actually fun (or at the very least tolerable).

Then the first test arrives.

And you pass! Not only that, but you do pretty well--not honors by any means, but since your main concern was just getting through, finding out that you are an "average" medical student is actually not all that bad.

So you keep studying, and studying, and studying, every night for the next few months. Not only for anatomy, but also for embryology and histology which are taken concurrently. And very gradually this sense of newness begins to wear off.

(to be continued...)

The Depths of Memory

Isn't it funny how a word, a place, or a stage of life can have so many associated feelings.

When we think of childhood, our mind doesn't immediately think of a top-down summary of how good or bad our childhood was, no, instead we immediately pick a single memory, a moment in time. The night when dad let us Trick-or-Treat until the wee hours of the morning, no matter how tired he was. The time that we went sledding down a 20ft high hill that seemed like Everest to us. Humans seem to have a knack for taking something that is irreducibly complex and forming a few overarching memories.

Equally surprising is that we can have a negative memory of a place where we had countless days of pleasure. But whenevere someone calls that place to mind, our first thought is that of sadness.

For me that place is Ludington.

Growing up, we would often travel up to Ludington to visit with my grandparents and other family members. A town of about 60,000 or so, Ludington is at once both beatiful and quaint. It has a turn-of-the-century downtown area, great beaches, and large swaths of natural forests.

When I was younger we would play wiffleball outside for hours on end, or go out for ice cream at the nearby dairy queen. Other times I would ride my grandpa's old 8-speed bicycle down a winding dirt path through the forest, a path the bike was definitely not made for. For me, Ludington was the place our family always went to.

Yet for some reason whenever I am reminded of Ludington, I picture it in the middle of winter; overcast and empty. But why? Why is it that a place that has been the site of so much enjoyment in my life become a place that I remember with such a sense of sadness and melancholy.

The more I thought of it, I realized that I have come to associate Ludington with death. The memories that I had of Ludington with both my parents are now tainted with the pain of divorce. The memories that I had with my granparents now are associated with the realization that they won't be around forever. Memories of riding grandpa's bike make me think of a time where I will no longer be able to talk to him whenever I want to.

But why is it that our brain puts that all into one feeling, one image. Maybe it's just easier. Maybe we don't really want to think off the hurt, so our brain puts out an imposing image to scare us off. I think it's one of the more interesting defense mechanisms that we have.

Once my grandparents leave Ludington, I don't think I'll ever go back there (alone at least). It's one of the most beautiful towns in Michigan, but for some reason I can't get passed the dark image I have of it.

Learning vs. Studying

Are learning and studying the same?

Most people that are in medical school have probably had a conversation that goes something like this.

Non-Medical Student: "You're in medical school! You must love school, I could never put up with four more years of it"

You (or Me): "Well I don't know, I don't really think that I love schooling all that much..."

If you are anything like me, you probably find it really hard to give someone a satisfying answer to that question. I've thought about my own motivations a lot, and this is what I've been able to come up with.

I love learning. I love finding out something new that I think is applicable to my life (or to my future life). I love when I finally understand something, when I spend time trying to wrap my mind around something and then I finally "get it."

I hate studying. I hate being told to read 200 pages of notes and commit it to memory. I hate sitting down in a lecture hall for 5 hours of lectures followed by 3 hours of lab. For me at least, there is nothing fun about that.

I'd love to learn another language, or how to play a musical instrument--or even another sport--but the medical school curiculum is so constrained that there is no time for that. So what you end up with is a bunch of people who are (on some levels) miserable for the better part of two years with one test after another hanging over their heads.

I agree that much of the information learned in medical school is very valuable, but I think that there are much more efficient (and less costly) ways of training our future doctors.

So how would I change medical school to make it better.

The biggest change I would make is to switch to a 3 year preceptorship, broken down like this:

First year: anatomy, histology, physiology (6 months) pathology, pharmacology, microbiology (6 months)

Second-Third Year: 6 months of family practice at 2 different sites, 4 months of internal medicine, 4 months of general surgery. 1 month of Emergency Medicine, OB/GYN, Psychiatry, etc.

Fourth year: 8 months of required electives, 4 months for interviewing etc.

In this system you would have to expand the "shelf" tests to account for longer periods in each rotation, but I feel like this would be a better situation for everyone.

Current doctors can feel like they are having a greater influence on future doctors. Medical students will absorb much more information when facts are associated with real life situations. Patients will have better trained doctors, and hospitals can hire a few less MAs and save some money. In my mind, it seems like medical education is stuck in the dark ages--where medical students are still being taught to memorize side effects for 100s of drugs, even though that information is now only a PDA click away.

Wouldn't that time be better served learning how to be a better doctor instead of a fact-spitter-outer. How many times have you heard from doctors that many of their colleagues in medical school who were great students have made terrible doctors--isn't that a sign that something needs fixing?

Time to Start Throwing the Baby Out with the Bathwater, Studies Show

It’s common knowledge that young children are nothing more than freeloading ner-do-wells, but could they also be making you sick? That’s the question researchers from the University of Alberta wanted to find out.

“We were all sitting around the lunchroom one day when out of nowhere John starts coughing,” said Todd Maste, a doctor of homeopathic medicine. “And I said to him: ‘Hey didn’t you say your kid was coughing last week?’ And he was like, ‘Yeah he was.’ All the sudden it hit him. His kid was making him sick.”

But mere anecdotal evidence was not enough for this modern day Sherlocke and Homes. They sought a degree of certainty only attainable via a double-blind, randomized study.

“We took, uh, 20 kids who were sick, uh, and within two weeks 12 of [their] parents got sick too. Clear cut kid to parent transmission of disease.”

Armed with this knowledge, Maste and his colleagues sought out the manufacturing giant Pharmista, makers of Hydroxyfatburnercooker™ and Schlonger™ to see if there were any marketing possibilities for a new over-the-counter drug. Matt Barnes a marketing executive explains:

“The information that Dr. Maste had come up with was so groundbreakingly earthshattering, that I thought ‘We’ve got to take this and run with it.’” Barnes later added, “All the way to the bank.”

Sir, Do Helicopters Eat Their Young?

Be careful how you respond to this question if you find yourself looking up from a hospital bed--the wrong answer will get you admitted for Stage 3 alcohol withdrawl. Either that or the alcoholics just know something we don't.

Words That Draw People to This Blog

In looking at the demographic information about who actually reads my blog I found that there's been a gradual change from "people who accidentally find it because they typed in a google image search" to "people who accidentally find it because they were searching for something else."

Just for the fun of it here are the most common searches that lead people to my blog (in the past year):

How hard is medical school 20ppl 6.08%
medical hierarchy 16ppl 4.86%
Medical school is hard 13ppl 3.95%
medical school quotes 10ppl 3.04%
how hard is medical school? 6ppl 1.82%
med school quotes 4ppl 1.22%
is medical school hard 4ppl 1.22%
hierarchy of medicine 4ppl 1.22%
school of hard knocks baseball 3ppl 0.91%
hierarchy in medicine 3ppl 0.91%

I guess there are a lot of people out there concerned with how hard medical school is--maybe if those people got together with the "medical school is hard" people then they wouldn't have to search anymore.

Mostly for my own curiosity (and to record it for posterity) here is the geographic breakdown.

United States 713 67.90%
Netherlands 129 12.29%
Canada 40 3.81%
United Kingdom 38 3.62%
Australia 15 1.43%
Mexico 14 1.33%
France 8 0.76%
Italy 8 0.76%
New Zealand 7 0.67%
Spain 6 0.57%

In order to maximize the number of people to read my blog, I think I'll title my next entry: "Is Medical School Hard in the United States? Yes, Medical School is Hard in the United States." And then I'll throw the word "hierarchy" in there for good measure.

Addendum: I am now the number two hit on google if you were (for some unknown reason) to type "medical school of hard knocks." And I've got a message for someone out there, you'd better watch your back 'guy-who-once-wrote-an-article-for-TheOnion-using-the-words-medical-school-of-hard-knocks' or your going to lose your number one status.

My First Surgery

A week ago today I saw my first surgery. It was a sigmoidectomy. The patient has cancer that was occluding most of his/her sigmoid colon and as a result (s)he was unable to eat normally.

I was there was due to my working on some research involving tumor detection.

Specifically, the project that I am working on is trying to differentiate between tumor and non-tumor using a laproscopic probe and a special kind of laser (and a database of scanned regular tissue and different tumors). Put simply, the goal of the research is to be able to tell whether something is cancerous or not in a much shorter time than it takes to get results back from pathology, and the doctor doing today's surgery thought that we might be able to glean something valuable if we saw a tumor resection.

Back to the surgery, the patient also had secondary metastatic tumors in the liver, but these did not spread any further, thus making her a candidate for surgical removal of the primary tumor. (S)he previously had been undergoing chemotherapy, but from what I understood this has not been successful.

Before I entered the operating room I had the slightest bit of nervousness that I wouldn't be able to stand the sights and sounds of an operation without getting squeamish. I was afraid that (even though it was laproscopic) I wouldn't be able to handle seeing the blood or the inside of someone's abdomen, but luckily there was very little smell, and I tolerated the blood just fine. I think the key was not really taking the time to think about it, it's a bit sad but it seems like the best way to get through the first few times is to not think of the person as a human being--whether you're in the anatomy lab or watching a surgery.

The surgery went on for a few hours without anything especially exciting happing, but I was extremely excited to be there. To see someone performing a surgery made me feel like I could someday be doing it--which isn't to say that it wasn't an incredibly complex process, I just felt that it was something that I could learn.

The other thing that I was struck with was how advanced the tools are that the surgeon used, especially the staplers. I had seen/heard about cauteries before, but to see how a miniature stapler seals off both ends of the colon, and how they pull it out through a gel "hand port" to resect it--it really is a feat of engineering and antiseptic technique.

Altogether it was a very exciting 2 hours, but I definitely need more comfortable shoes if I'm going to be standing up for that long ever again.

An Argument for Detroit

If someone tries to start an argument with you while on a Detroit bus, think twice before saying something incindiary. Oh, and watch out for snakes.

Charts

My summer work involves helping an orthopedic surgeon with some chart research. Here are couple of things that I thought were funny.

"patient appears to be significantly older than she claims"

I love how every patient seems to be described as pleasant. For instance, "Jane Smith is a pleasant young lady who presents to my service with..."

Referencing a 50+ year old: "The patient is here with her parents."

On a surgical note there always has to be a diagnosis. So commonly you would see something like "Diagnosis: left distal comminuted fracture of the radius." But because you need a 'diagnosis' for every procedure, when someone is just having surgery to remove plates and screws the diagnosis reads "Retained Hardware." As if some patients' hardware magically disappears when they no longer need it, while others have to come back for surgical removal.

For some reason it seems that doctors need to go over the top in thanking referring doctors. Many read like this, "Dr. Smith kindly/graciously/generously refered patient X to me to treat her..."

Objective Structured Clinical Examination

Today I took the first of many examinations involving standardized patients. It's called the OSCE, but to call it anything more than a checkpoint that 99.9% of med students pass with flying colors is giving it more credit than it deserves.

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Here's how it goes at the best medical school in the country:

You arrive at a floor of an old hospital and stand around and wait for a few minutes with a bunch of other medical school students that are just as nervous as you are even though you all know there is nothing to be afraid of.

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You have some idea that this is going to be a pretty straightforward case ("my elbow hurts"), but the med students who just finished joke that they "never expected that the patient was going to be playing the part of a deranged psychopath," as they walk past.

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Next your herded like cattle into a room where you are given some basic instructions, but all the while the proctor is talking, students are frantically scribbling notes of all the questions that they want to ask while they are in the room--only to find out that you had a few minutes to write after the instructor finishes talking.

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Overhead you hear a mechanical sounding voice say, "Three minutes remaining! Three minutes!" Which is a warning to the students who are currently interviewing patients in rooms 1-10.

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All the while I'm thinking to myself, "What if I seize up in there and forget to do things in the right order, or I ask all of the questions in too mechanical of a way." Or, "What if my patient is a total jerk like the guy that I had to interview during one of our small group practice sessions."

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Then time was called, all of the medical students in the waiting room exit and find the room to which they are assigned (mine was room 5).

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As I'm standing there, my mind is going a million miles a minute. "Should I knock, or shouldn't I--or I could just see what everyone else does--but what if no one knocks and we were supposed to."

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Everyone knocked, so I did. Then I walked into the room and handed the grader (there is a patient and a grader in the room) a sticker with my name on it--from then on you are expected to completely ignore the grader.

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Here's a synopsis of how the interview went (I lucked out and got a really nice patient):

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Me: Hi Mrs. Samples, I'm a medical student at Wayne State--What brings you in today?

Mrs. Samples: Well I've been having this stomach pain for the past few days.

Me: When did it start, what makes it better or worse, how severe is the pain, what kind of pain etc. (waiting in between questions for her to answer)

Mrs S.: 2weeks ago, worse with spicy foods, 5-6, burning

Me (because I knew we were being graded on transitions): So in order to delve a little deeper, I'm going to ask you some questions about your Past Medical History.

(and so on, until I got to social history when I asked her about whether she was sexually active with a partner--which is how they want you to phrase it)

Mrs. S: A PARTNER, I am with my HUSBAND if that's what you mean (she said it jokingly, but her volume took me aback)!

Me: I see. (mumbles something else)

(next up was alcohol--I thought that we were supposed to ask specific questions if someone said they drank anything at all)

Me: So Mrs. S do you drink at all? Alcohol, that is.

Mrs. S: Well I like to have a couple of imported beers every few weekends.

Me: Have you ever felt like you should cut back.

Mrs. S: TWO BEERS, have I ever felt like I should CUT BACK from having TWO BEERS a week. No I haven't

Me: (tentatively) Has anyone ever been annoyed by your drinking?

Mrs. S: ANNOYED BECAUSE I HAD TWO BEERS!?

Me: (not getting that I probably don't have to ask these questions) So I take it you've never felt Guilty about your drinking or had an Eye opener?

Mrs. S: NEVER

Me: Okay, I think it's time we take your blood pressure (which I think I got a little low, by then I just wanted to get out of here--I finished in 12 minutes but most everyone else took less time)

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Then we were sent off to a room to write a SOAP note before we were free to leave. One of my friends had a doctor in the room who asked him if there was "anything else he wanted to ask about the patients past medical history," which worried him because he thought he had already asked all of the questions. I'm just glad I got a trained grader instead of a doctor.

Locus Motivatius

Recently scientists have discovered a new region of the brain found in primates and higher species that has been named the locus motivatius.

Functional MRI studies have shown that this area at intersection of the occipital, temporal and parietal lobes is chronically underdeveloped in the interlopers, the malcontents and the miscreants of the world. But perhaps more interesting is the transient loss of function recently seen by researchers in the United States.

Recently, it has been demonstrated that accute, short term lesions of the locus motivatius are a common occurence around the months of April and May in students of all ages. Symptoms include: lethargy, time wasting, tv watching, and blog posting.

There are no known treatments, but often times symtoms spontaneously resolve with the onset of "warmer weather" or the conclusion of all required classwork for the year.

When Good Anticipation Goes Bad

Played in my first softball game of the season tonight which we won 16-14. Unfortunately all of the planning and anticipation in the world couldn't help me this game. Anticipation without execution was worthless, and I made a couple of errors in the field--fun night though. It's good to be playing on a team.

Here's what I looked like:

Baseball

Very few people appreciate baseball. Most people think that it is just a bunch of standing around swinging a bat as hard as you can. But there is so much to baseball that Joe Smith Fan doesn't even notice.

Baseball is about moving a step to the left because you know that the batter likes to pull the ball. Baseball is stealing on an 0-2 count because the pitcher is likely to throw a breaking ball.


I'll admit it, 99% of baseball is anticipation, and I understand that anticipation isn't that interesting to watch.

But for those who have the willpower to struggle through learning how to hit an unpredictably-moving ball the payoff is enormous. Sure it's satisfying to score a basket in basketball, but you could score 40 points in a quarter and still lose. In baseball, I would argue that there is the highest buildup and importance on any single play--on par with a goal scored in soccer.

Perhaps you might even say that the reason there is an ever decreasing number of baseball fans in this country (and children who learn to play it growing up) is because the way our society is being restructured. We want to be entertained now, not 10 minutes from now, this very instant. And heaven forbid, we have 10 minutes during the day where we aren't on the internet (guilty) or listening to our Ipods, or watching TV.

Where has all the time for contemplation gone, where is the anticipation in life anymore. We want instant gratification and nothing else.

Is it any wonder that there is an increasing number of kids who come down with ADD? Rather than teach our children to appreciate simple things such as a family walk through the woods, we sit them down in front of the TV so we can have some peace and quiet.

Bill Bryson the author of books such as A Walk in the Woods, once wrote:

“To an American the whole purpose of living, the one constant confirmation of continued existence, is to cram as much sensual pleasure as possible into one's mouth more or less continually. Gratification, instant and lavish, is a birthright.”

Take the time to appreciate the anticipation of life.

Red Wings

A few Hockeytown brawls and hits before the big Wings-Avs series starts tonight.

Sleep

Sleep. Most people sleep for about 1/3rd of their life, but rarely do people even think about what is going on when we sleep. For most people sleep is just a required part of living--but few people realize that sleep is essential to life.

When I was at the greatest college on earth I had a friend that purposely went without sleep for as long as he could. After about three days, when he could no longer consciously force himself to stay awake (despite any additional caffeine) his body forced him to drift off to sleep--on the floor where he was sitting.

When I was talking to him a few days later he reported that he began to experience hallucinations after staying awake for ~60 hours straight. After about 70 hours without sleep his body overrode his willpower and forced him to enter the sleep cycle. Without this he would have eventually died.

Of all the things that I've learned this year, probably the most interesting is that those who are physically unable to sleep will eventually die, usually within 9 days of the last time they slept. Although, for people who are able to voluntarily stay awake it has been shown that people can go upwards of 11 days without sleep, as described below.

One of the most common causes of death by insomnia is called Familial Fatal Insomnia. An exceedingly rare condition, FFI is an autosomally dominant condition that has been identified in only 28 families worldwide (according to wikipedia). It was first reported in the 1970s in Italy when two women from the same family died from an insomnia-causing disease, but the actual mutation is thought to have occured in an Italian doctor living in the 17th century.

The cause FFI is somewhat similar to diseases such as variant Crutzfeld-Jacob disease or Kuru inasmuch as it is a disease that results in a buildup of misfolded proteins in the brain (prions). In FFI, a mutation in the genetic code causes the improper translation of genetic material to proteins which causes the protein to improperly fold and aggregate with other misfolded proteins. In FFI, these proteins collect in the sleep regulating region of the thalamus, causing insomnia.

Once the first symptoms appear (usually when the patient is in their 50s), patients have around 7-36 months to live. There is a definitive course of progression for those with FFI.

First patients experience panic attacks, then hallucinations, then weight loss and insomnia, and subsequently dementia and death. At the end of its course, FFI causes patients to forever be stuck in a semi-sleep state which appears much like sleepwalking to observers. Any attempt at drug therapy such as sleeping pills only resulted in a faster spiral into dementia and death.

Equally interesting is the study of forced total sleep deprivation and its affects. In 1964, a 17 year old named Randy Gardner stayed awake for a record-12 days. What follows is the account from wikipedia.

"It is often claimed that Gardner's experiment demonstrated that extreme sleep deprivation has little effect, other than the mood changes associated with tiredness (mood swings, short temper, loss of concentration).[5] This is primarily due to a report by researcher William Dement, who stated that on the tenth day of the experiment, Gardner had been, among other things, able to beat Dement at pinball.

However, Lt. Cmdr. John J. Ross who monitored his health reported serious cognitive and behavioral changes. These included moodiness, problems with concentration and short term memory, paranoia, and hallucinations. On the fourth day he had a delusion that he was Paul Lowe winning the Rose Bowl, and that a street sign was a person. On the eleventh day, when he was asked to subtract seven repeatedly, starting with 100, he stopped at 65. When asked why he had stopped, he replied that he had forgotten what he was doing.[6]

On his final day without sleep, Gardner presided over a press conference where he spoke without slurring or stumbling his words and in general appeared to be in excellent health. "I wanted to prove that bad things didn't happen if you went without sleep," said Gardner. "I thought, 'I can break that (Peter Tripp's 1959) record and I don't think it would be a negative experience."

Getting Along

For those not familiar with The Screwtape Letters (as I was not until I read it recently), CS Lewis wrote The Screwtape Letters from the perspective of the a demon writing to his nephew.

“When two humans have lived together for many years it usually happens that each has tones of voice and expressions...that are almost unendurably irritating to the other. Work on that. Bring fully into the consciousness of your patient (the human that is targeted) that particular lift of his mother’s eyebrows that he learned to dislike in the nursery. Let him assume that she knows how annoying It is and does it to annoy - if you know your job he will not notice the immense improbability of this assumption. And never let him suspect that he has tones and looks which similarly annoy her.”

-C.S. Lewis The Screwtape Letters

Many medical blogs that I have read seem to be filled with primarily angry criticism leveled at the health care system or patients.

And it's easy to do. Although I tried to write my last post as rationally, and un-emotionally as possible, I'm sure there was a bit of frustration throughout it.

So why are there so many angry people in healthcare? I would argue that it is undeniable that were working in an imperfect system. For everything that is wrong with the US health care system, the poorest person in the states receives health care 100 times better than many of the poor throughout the world. So how do we try to we form a productive critique of something, be it health care or otherwise.

I think that part of it is fighting the constant battle against complaint for complaint's sake. I think that it's important to think through whether what you are doing serves any positive purpose or whether it's merely blowing off steam (which isn't to say that there may not be a place for venting--but one should consider if complaints are always best aired amongst other doctors or medical students).

CS Lewis, the British writer who penned the Chronicles of Narnia series, seems to masterfully capture a nuance of our daily living. When we are faced with the same thing day after day, it is human nature to find things to dislike about it. This holds true in relationships ("She always clogs the toilet and leaves me to fix it...") and I think it also is true of medicine.

Just by the by working in close proximity with the same individuals, I think we can find (and perhaps sometimes invent) things to dislike. Medical school has taught me more than medicine, it's taught me to complain. "This is crazy that we are paying X number of dollars when Ph.D student are getting paid 1200 a month."

"I can't believe the questions they asked on that test."

"Professor X has no idea what he is doing."

And the funny thing is, who really cares? The truth is, I'm as guilty as the next person, and that type of complaining does nothing.

When I began medical school I had some idea that life in medicine wasn't going to be a breeze. Although I was a bit wet-behind-the-ears I knew that relying on being a doctor to bring me 100% of my happiness was not realistic. But is this overwhelming flood of complaint part of the problem behind why so many medical students finish their 4th year with little or no hope of enjoying the rest of their professional lives.

Pragmatic, thought-out criticism is vital to continually trying to refine the health care system that many of us will be working in, but I think it's important that we all try to cut out a healthy chunk of the pointless whining we take part in, especially myself.

Is There a Doctor in the House?

Recently I read something about the new program that has begun in nursing where a nurse practicioner has the opportunity to become a doctor.

What? A nurse who is also a doctor? How could this be?

I'll tell you. Nurse Practicioners in some areas now have the opportunity to pursue a degree known as a Doctor of Nurse Practicioning.

Maybe some of you are thinking: This is great! Another possible option for nurses to pursue. No longer are they forced to adhere to the constraints of what it means to be a traditional nurse, e.g. being involved in every aspect of patient care.

I'm not of that opinion. And here's why:

Here's a blurb from the University of Tennesse, Memphis:

"The DNP curriculum is Web-mediated including opportunities for synchronous and asynchronous learning. Students are only required to be on campus 4 times a year (July, December, January, & April) for 5 to 7 days each session. With faculty approval, clinical courses can be completed in the student's state of residence."

What is this, the University of Phoenix? Other reports I've heard have stated that nurses need only complete 1000 hours in order to complete the program. It's absolutely ridiculous on a number of fronts.

First, the amount of experience that a medical doctor gets is at least ten-fold higher the experience that a DNP candidate would have to gain.

Second, what does it mean to be a nurse anyway. What is so wrong about being called a nurse. Personally I think that nursing is one of the most selfless, noble professions that one can pursue. Why is it suddenly necessary that we need nurses proscribing medications and being addressed as doctors.

Third, there was such a righteous fervor over the inventer of the artificial heart (Jarvik) who is a Ph.D "doctor" that was supporting a certain medication on the internet. Where is the fervor now. We're going to see a day where someone with 1000 hours of experience is seeing a patient that has no idea about the difference between a DNP and an MD "doctor." It's disgusting, and I think the biggest reason is because the current doctors of America couldn't care less.

Where were the doctors when malpractice lawsuits have got out of control? Where were doctors when people saw the subtle signs that medicine in the US was going downhill? Where are the doctors now when an exer increasing number of "physician extenders" encroach on what it means to be a doctor? Sadly, the pay is still good, the hours aren't terrible--so the majority of doctors could care less what state the health care system is in when it is handed off to the next generation.

Instead they'd rather complain about duty-hour restrictions, and how medical student today "just aren't as driven as they used to be."

Edmund Burke once said, "The only thing necessary for the triumph [of evil] is for good men to do nothing."

Is what is going on in the medical system evil? I don't think so. But the only thing necessary for it to continue in its downhill trend is for enough of today's doctors to do nothing.

The debate over the validity of having Doctors of Nurse Practicion is sadly going to become a debate over whether the still male dominated doctors are just trying to keep the female dominated nurses down. And at its root I think many people will view it as a gender equality issue. But it isn't. The question is not whether a nurse could be as knowledgeable/valuable as an MD doctor, because I can tell you right now, there are some nurses that are smarter/more adept than some doctors. The question is what would be best for patients

The root of the question is this: What does it mean to be a doctor, and what does it mean to be a nurse? Are there roles that a doctor should fill that a someone trained as a nurse shouldn't be filling? In the same token, are there roles that are better filled by a nurse? I think that the answer to the last two questions are both yes. But if the DNP program (among others) continues, we'll continue to dilute the respect that the average person has for someone who is known as a "doctor" until we're all just "health professionals," despite our vastly different training.

4/48/04 Update: Today in class we had a family of acondroplastic dwarfs come and speak to our class as part of a genetics patient panel. Here is a phrase that the father used, I'll try to reproduce it verbatim.

"When we were at this conference in Dearborn one of the nurse practicioners / doctors got up to tell everyone a story..."

The person he was referencing turned out to be a nurse practicioner and not a doctor. I don't for one second think that John Smith patient has any idea what the difference between a nurse practicioner and a doctor is, and I think they would know even less about what the difference between someone who has NP-C and MD on their coat (if they even looked).

It's misleading to patients and those who keep pushing to expand the role of nurses are exploiting it.

Shadowing

The past two days I have been shadowing a family practice doctor per the requirements of the medical school for completion of the first year, and I was struck with a number of things.

1. I'd like to think of myself as a pretty good communicator, and I don't mean that in a self-aggrandizing kind of way--just ask my fiancee, I'm not always the best at remembering things--but there is something of an art form to medicine. The doctor that I was shadowing absolutely has it down. He know's the "character" that he needs to play during the medical interview process. At times he pretends to be the aloof, almost clown-like character to put people at ease or to get a laugh.

But he also knows that there are times when he has to play the role of counselor, or father, or disciplinarian. There is so much more that goes into medicine than words and formats: he never strictly follows OPQRSTAA (Onset, Provocative/Palliative etc.) when talking about a condition, but he does have his own schpeel that he gives to parents of children under the age of one, e.g. "I like to remind parents to use a lot of sunscreen even if the baby is going to be under an umbrella..."

Moreover, you realize that there are a lot of patients who come in, that he could probably diagnose in a matter of seconds, but still he takes about 5 minutes to talk to the patient about their concerns. For instance, one of the patients who came in clearly was describing a simple pulled muscle, but he still took about 10mins to talk to her about it, before he even began to examine her. Part of it was a desire to rule anything out, but part of it was making sure that the patient felt like she was being heard by someone who cared to listen.

2. The Power of Human Touch. I've heard this a few times throughout medical school but it's important for doctors to touch their patients. Sadly, in this day and age, the first thing that many people would think if you said that was, "Doctor's touching their patients--there should be less of that." Perhaps because of the stigma of the few doctors who touch their patients innappropriately or perhaps due to our Politically Correct/lawsuit happy culture, I fear many doctors may keep their patients at arms length--which is truly sad.

Many patients that come off the streets may have been physically abused or mistreated for their whole lives, and the chance to touch someone in a loving way--e.g. rest one's hand on their shoulder, or even hold the stethescope so that one's fingers rest on their back--is often lost.

3. There's so much pain in this world. One of the women who came into the office had been put on large doses of inhaled steroids to treat a very bad asthma attack that she had had. Her face was the slightest bit edematous and perhaps a bit moon shaped (as is common with high glucocorticoids). And a few minutes into their discussion she said, "My face is so fat...I feel like a freak." And she began to cry. My heart just broke for her.

Maybe because I could empathize or maybe because it is just human nature, but I couldn't help but well up with emotion for her. I wonder if you need to remember how to respond to the patient, while not letting it affect you. Or maybe you just let it affect you and move on, I don't know.

More to come

Good Quotes and Writer's Block

“Eventually, all histories must be formally structured, but much can be learned by letting the patient ramble a little. Discrepancies and omissions in the history are often due as much to overstructuring and leading questions as to the unreliability of the patient. The enthusiastic novice asks leading questions; the cooperative patient gives the answer that seems to be wanted; and the interview concludes on a note of mutual satisfaction with the wrong answer thus developed.”
Current Surgery J. Englebert Dunphy, MD, & Lawrence W. Way, MD

“Moderate pain is made agonizing by fear and anxiety. Reassurance of a sort calculated to restore the patient's confidence in the care being given is often a more effective analgesic than an injection of morphine.”
Current Surgery J. Englebert Dunphy, MD, & Lawrence W. Way, MD

"The details of the past history may illuminate obscure areas of the present illness. It has been said that people who are well are almost never sick, and people who are sick are almost never well. It is true that a patient with a long and complicated history of diseases and injuries is likely to be a much poorer risk than even a very old patient experiencing a major surgical illness for the first time."
Current Surgery J. Englebert Dunphy, MD, & Lawrence W. Way, MD

"All patients are sensitive and somewhat embarrassed at being examined. It is both courteous and clinically useful to put the patient at ease. The examining room and table should be comfortable, and drapes should be used if the patient is required to strip for the examination. Most patients will relax if they are allowed to talk a bit during the examination, which is another reason for taking the past history while the examination is being done."
Current Surgery J. Englebert Dunphy, MD, & Lawrence W. Way, MD

Saccadic Eye Movements

Put one finger about arms length in front of you. Now slowly sweep your finger from the far left of your visual field to the far right, while tracking your finger with your eyes. Notice how you can "see" the blurry background even if you are focused on your finger.

Now place the finger of one hand at arm's length near the border of your peripheral vision on the left and the finger of your right hand at about arm's length near the rightmost border of your peripheral vision on your right. Now quickly switch from focusing on one finger to focusing on the other finger.

By now you are probably thinking, "This is supposed to be interesting, it seems pretty routine to me." But dig a little deeper. In order for you to switch your focus from one finger to the other, your eyes "saw" everything in between. But did you experience a sweeping image, or did you see one image "jump" to the next image.

If our brain merely interprets the information from our eyes as is, you should see a fast, blurry sweep as you shift your gaze. But you don't! Somehow your brain blocks out almost all of the input from the time you decide to shift from one finger to the next. It's almost as if all that exists between one focus and the other is a timeless vacuum. The movement of focus from one object to the next is called Saccadic Eye Movement.

And where does the time go? When you looked from one eye to the other, did you perceive any delay? I don't think that I do. Although the time between looking at something on one end of your vision and the other end is only a matter of tenths of milliseconds, imagine all the times that you switch focus during a year--it must be on the order of minutes when all added together. Not to make this stray into the realm of science fiction, but where does all the time go? It seems as if your brain tells you that the time never existed.

We know so much about the human body but we know so little, and it's things like this that keep us coming back for more--despite the drudgery.

Where Do We Get Off

Where do we get off. When did medical students start thinking that they run the show? Has disrespectful behavior always been a problem at schools of graduate education? Is it because we all have a bachelor's degree in something and we think that qualifies us to complain nonstop?


One of the most disturbing trends that I have witnessed while at medical school is the drastic increase in the amount of complaining and improper conduct towards professors. During the class time, a student once raised his hand to ask a professor a question, here's how it went:



Student: Doesn't that enzyme do the opposite in the presence of insulin

Professor: Well, I don't think that is correct

Student: No, that is correct



Since when is this considered acceptable behavior? Since when have we decided that that is appropriate for future professionals?

I think it goes back to how many in my generation were raised. A lot of people have mentioned that our generation was the first "you can do anything!" generation. What I mean by that is that most of my generation had parents that told them they could do anything. Never mind that they have no singing ability, you are the worst parent in the world if you don't make them feel like they are the next Pavaratti.

I've always thought my parents did it well. When I was a kid, I wanted to play professional basketball. Rather than just say, "Sure you will someday, you can do anything you set your mind to," he was very pragmatic about it. He said things like, "If that is something that you want to do, than you will have to make big sacrifices to get better at the sport." And I did, for awhile--but then my friends wanted to play with GI Joes, or there was a new movie out at the theater, and I gradually realized that professional basketball wasn't in my future.

I think the best thing that parents can do is encourage their children that many things in life are attainable through hard work, but without having certain innante physical or mental gifts, not everything is possible. If I am 4'7" I'm probably not going to play center for the Piston's someday. If I don't have anything resembling a singing voice, I probably won't be a world famous singer. This doesn't mean that I shouldn't work hard, but I should have parents who can see the gifts that I have and steer me in the right direction.

Another reason that I think that there is so much trouble with respect and discipline is the Political Correctness wave of the 90s-2000s. Don't get me wrong, there are aspects of PC that seem reasonable, such as eliminating the terminology of phrases such as "you people," e.g. "you people are all the same... But one of the downsides of the PC movement is the idea that there is nothing that is right or wrong.

Heaven forbid a teacher uses red ink to grade a paper! Who knows what might result from that! The child's fragile psyche could be forever damaged as a result from the 70% that they got on a test. It's pure ridiculousness and I think that it has contributed to the mentality that many of my peers have that they are always right. Not to mention the fact that they are probably angered that medical school grades are on a strict curve, and that 2/3rds of the students don't get scores above 90% anymore.

In summary, it's very frustrating to be surrounded with so many smart yet rude medical students, especially when the few obnoxiously vocal will be thought of as representative of the entire class.

Top Ten Pistons Buzzer Beaters

I was wasting time on YouTube when I stumbled across this clip--my dad and I were at the game where Stack hits the game winner (#9). Also, if you look close you can see Alvin Gentry and Doug Collins--two former Piston coaches.



Here's one by Rasheed

The Allure of the Mountains

What is it about mountains that draw so many people to them? Second only to living on the water, people seem to have an almost magnetic draw to living at higher elevations (or at least near them). So sacrificing the rich, sea-level air millions of people either hike, climb or live among the mountains.

In my experience with some of my family members, you can never explain the allure of the mountains to someone that does not have an innate draw to them. So if you have never dreamt of what it might be like to stand atop a mountain, you may not resonate with any of this. I can explain to my parents what an awesome experience it was to climb Horn Peak (see above and right), but they just don't get it. Maybe it is because they are from a time where there wasn't alot of free time to pursue interests such as hiking or mountain climbing, or maybe it is just because they have no inner "call of the wild," but for some reason, I can try to explain my motives until I'm blue in the face but they never seem to "get it."

To me the mountains represent the unknown. Every step upward is a step into a world that very few get to experience. A world of mountain meadows, evergreen forests, and snow capped peaks. The time I've spent in the mountains has been an opportunity to spend a day in another world. In an age of urban sprawl and suburban developments, mountains represent one of the last natural frontiers onto which the spoiling hands of humanity haven't yet reached.

Mountains also offer one a measuring stick. A test of willpower and overcoming the screaming pain in your legs with mental toughness. They allow you an unparelled test of endurance, as many climbs last hours to days.

Mountains are the place where world class athletes and a run-of-the-mill healthy individual are brought to similar levels. Many people falsely think that anyone who climbs mountains, does it so that they can inflate their ego by saying that they summitted Mountain X. Perhaps due to the huge numbers of people who attempt to climb Everest with little previous experience, often resulting in unnecessary deaths, many people have it in their minds that the only reason you would want to climb is so that you will have one more trophy for the mantel. But for me, climbing was much more than just reaching the top.

It was the stream that we found halfway up, with hundreds of small waterfalls as the snow melt made its way down the valley. It was the 10 of us, encouraging one another to keep going. It was the last 100 yards that couldn't be covered more than 5 yards at a time. It was the 10 of us encouraging each other to keep going. It was the knee deep snow we had to tromp through. All of these things came together to make for a once in a lifetime experience.

In a world of entertainment with increasing television watching and increasing obesity, mountains offer the opportunity to step into a world that few others will ever enter. A world of reality, where goals their accomplishment are crystal clear. An opportunity to see the world around you in a way like never before. A chance to get away from the constant noise of modern society and think clearly for the first time in a long time.

Simple NCAA Tournament Picking Rules

Here is the backbone of my rules for picking teams in the NCAA Tournament.

1. Always choose the #1 Seeds in the first 2 rounds, almost always in the third round.

1a. The following rules should be disregarded in the final four. Then you are on your own.

2. Never pick a team whose name is "X State" unless it is Michigan State (Kansas St. got me this year, but it almost always holds true).

3. Never pick the underdog that everyone else is picking--George Mason proved this point.

4. Pick the Big Ten teams to beat any other team not in the ACC--even then think about picking the Big Ten team. See point 14 for a clarification.

5. Pick West Virginia to win unless they are seeded worse than 11.

6. Pick Syracuse to win at least two games any time they make the tournament.

7. Don't pick teams that got in because they have done well in the past, e.g. Arizona (I almost pick AZ because of Kevin O'Neill--the former Detroit Piston's assistant, but luckily I realized that would have almost violated rule 15).

8. Pick any team with the word "Texas" in it until you would be forced to violate one of the other rules.

9. Never pick 16 seeds over 1 seeds or 15's over 2's, nice try though Belmont.

10. If all else fails pick teams that you want to root for, it will at least make the games more interesting.

11. If you are going to pick a big upset, pick a team that is "hot" coming into the tournament. If George had beaten Xavier like it looked like they would, that would have shown this to be true.

12. Never pick Duke to go far if they are a 2-6 seed. For that matter, ACC teams that get seeds between 2-6 don't usually do that well.

13. Michigan State will either be eliminated in the first round or make it to the final four, in most years.

14. Never pick low seeded Big Ten teams, the probably suck and only got in because of the "strength of the conference."

15. Don't pick a team that lost its coach midseason. This could be called the Indiana 08 rule.

16. Never pick against a Tom Izzo disciple (this is one of my Cardinal rules). This applies to Tom Crean at Marquette and wherever Kelvin Sampson ends up. I never picked against Oklahoma when Sampson was there and I wouldn't have picked against Sampson at Indiana. In the case of a head to head pick Izzo over Crean and Crean over Sampson.

17. When rules contradict use your judgement.

18. Bo Ryan at Wisconsin is one of the 5 best coaches in college basketball, pick against him at your own risk.

Why Medical School is Awesome (Opening Black Boxes)

We live in a world of black boxes. Most of us go through the day fairly oblivious to why things are the way they are. We know that a spark ignites a mist of gasoline to power our car. But can we explain the process of the internal combustion engine much further than that? I know that I can't.

The same is true for our bodies. Which isn't to say that the average person is completely ignorant of biomechanical processes, I've known since high school biology that when one puts their hand on a hot stove a reflex arc is triggered that causes you to quickly remove your hand before you are even consciously "aware" of it. But with that level of knowledge, you sometimes don't even know what you don't know.

But one of the best aspects of medical school is that you are constantly confronted with aspects of medicine that most of the world views as a black box. For instance, the subject matter for today was the anatomical basis for pain. To me, pain has always been more of an idea than something concrete. Pain is what happens when you try to open a package with a sharp knife and it slips and cuts into your finger. But in medical school you get the opportunity to dive deeper.

You can understand the basis for why you rub your arm after bumping it on the table. You can understand why people with spinal cord damage have very little return of functionality below the damage, but even better you have a whole new set of deeper questions you can explore.

Somewhere within the difficulty of medical school are the things that keep us coming back, things like opening up black boxes.

An Out of Context Quote

"So if you wanted your orgy to go well you went to Bachhus"
-My Pastor

The Free Clinic (The Importance of Speaking a Patient's Language)

(the details of this story have been altered)

Yesterday at the Clinic that I volunteer at periodically there was a man who came in who is a missionary to Detroit. Yes, that's right he has been sent from his home country of Venezuela to be a missionary to the Spanish speaking population of Southeastern Michigan--perhaps a sad commentary on the work that the local churches were doing to minister to those of the inner city.

So I went out into the waiting room and called Mr. Hernandez back into one of the rooms of the clinic. As we were walking, I asked him if he spoke any English, to which he responded in the negative.

I did my best to stumble through some of the basic spanish that I still remembered from undergrad combined with a few of the medical terms that I had picked up while working at a clinic whose patient population is 50% hispanic. Most of the sentances sounded something like, "Uh...necessito tocar...uh...su......pression." But as is the case most of the time, he was more than happpy to pretend like he understood every word I was saying rather than appear rude.

This guy had really high blood pressure, and I mean really high. 196/120 high, and I noticed from his chart that he had somewhat poorly controlled hyperlipidemia (high levels of "bad" cholesterol etc.). Once I had taken all of his vitals I told him that I would be right back with the "doctor," who is actually a nurse practitioner--but I didn't know how to say "nurse practicioner" in Spanish, and even if I did, I doubt that he would have any idea what the difference was between that and a doctor.

The next time we went back into the room, we brought one of the medical technologists from the clinic who was fluent in both Spanish and English. Here's how it went.

Sandra
"Ask him if he has been taking his medication"

Translator
"Yada yada yada (for the next minute)"

Patient
(Talks to the translator for around 45 secs)

Translator
"He says that he always takes his medication"

Really. That's all that he said in 30 seconds of talking? I take my medication. Tocarlo. It seems like he could have said that in a word or two, what did he use the other 40 seconds to talk about? And what were you saying the whole time? Neither me nor the LPN said anything (and I'm not sure if she even thought about it, but for me it was a bit of a disconcerting experience).

I realized then why the other doctor wanted me to do as much as I could without using a translator--especially when the only translators that we have available have very little background in medicine. A couple more examples:

Later on the translator kept saying that if he came back and talked to the nurse who specializes in diabetes, they could give him a meter for checking his blood sugar. But when the translator repeated the phrase in spanish she said we would give him a machina para pression (basically, a machine for checking his blood pressure).

I really knew that the message wasn't getting across when the translator didn't know the English word "testosterone," when she was explaining what the patient said to her.

So much of the medical interview can hinge on a single word. Did the patient say he checks his blood sugar occasionally or often. Has he had high blood pressure for 5 years or 14 years. What is the nature of the pain in his chest, is it stabbing or is it like someone is sitting on top of him. These difficulties are increased when you get a translator that fancies herself as a doctor and feels that what gets asked during the medical interview is her business.

The best translators that I have seen are those that take one sentance the doctor says in their native tongue and translates it into one sentance in the patients language. When the patient responds, the translator should stop the patient every sentance or so in order to translate back to the doctor. But in a larger sense, this experience has reminded me how important it is to learn as much as I can of Spanish, as it would be one of the most valuable foreign languages to learn as a future doctor in the United States.

Very Old Posts--Take Three.

Here's the only post I ever wrote about medicine until I started this blog, it's funny how I have to learn this lesson over an over again.

Saturday, February 12, 2005

Someone said something that I really should take to heart the other day. At the meeting for pre-med students, I asked what sacrifices the three-doctor panel had to make in med school as well as during their residency, and one of the doctors said something really thoughtful. She said to enjoy the stage of your life you're in. That seemed so true to me because we, as humans, spend so much time wanting to be older when we're young and wanting to be younger when we're old. Not only that, but often times we fall into the trap of thinking that the next stage in life is going to somehow be easier. If I can just get through college then I can start living life and it'll be so much easier... But in reality life really doesn't get any easier. So why not make the most of the life that you're living right now, no matter how bad it may seem.

Second Thoughts on Information Sharing

After being very opinionated about how I would never share information relating to study material here, I found out something interesting about myself.

I received an email informing me of a new program that is just beginning this summer for students in between their first and second years of medical school. As far as I know, this email only went to me, and only because I had applied for a similar program that they decided to discontinue. At the bottom of the email they asked if I might be able to spread the word as they wanted to have 9-10 students take part in the externship this summer.

So what did I do. Without even thinking twice I put together an email that made this program sound like it was the best internship ever, and sent it out to the entire class. For a moment I thought about not sending out the email because the more people that applied, the more competetion I would face, but a second later I decided to send it out anyway. I guess it just goes to show you that someone can support healthy academic competition while still believing that competition doesn't have to extend to all parts of life.

Another Bit of Medical Information (Psychiatrists Take Note)

In The Know: Is The Government Spying On Paranoid Schizophrenics Enough?

Information Sharing in a School With Relative Grades

I'd like to think of myself as a pretty friendly, open person.

In the past I have played on team sports, I would hope that those people on my team would say that I am a "team player."

But if I knew of a website that I thought could help students to do better on a test, I would in no way feel morally bound to inform my entire class via an email.

First, for the unindoctrinated, this is what I mean when I say relative grades. The basis for grading in medical school is done by standardizing how you did on a test with how everyone else did. Therefore if you scored lower than average on one test, your standardized score would reflect that--even if your raw score was 98 out of 100 possible, if everyone else got 99% you would have an unimpressive looking relative score. In the opposite scenario, if the average score on a test was 50% and you got a score of 65% correct, you would probably honor.

ALL medical schools must quantify how students rank within their class. Before one of the two people who read this write an angry comment, read on. You may say, but my school doesn't have grades. Generally people that say that follow up by saying "all we have is Fail, Pass, and Honors." I've got news for you, when you fill out an application for residency you medical school must provide some way of distinguishing your Pass from the other 100 students, if I'm not mistaken this is given on a scale of 16 with the middle of the bell curve set at 8, and with a 16 representing the top 1% of students or so. Although I have not confirmed this personally, I've heard people say that the only time they are graded is in 3rd and 4th year--I find that hard to believe, but I'll take their word for it.

By way of example (hopefully I'm not belaboring the point), at Wayne State we have a system of Z scores where the average on any given test is set to equal a Z score of 500. For instance, if I scored 75% and the average was 75% then my Z score was 500. If I scored an 85% my score would be near 600 (considered "Honors"). A score of 65% would be on the border of failing. Unfortunately, as mentioned above, you can have a very high raw score and a relatively low Z score (once I scored 92% with a z score of 460).

Getting back to the topic, one of the questions someone told me to ask the interviewer when I interviewed for medical school was, "How competitive are the students at the medical school?" In other words, is there a sense of teamwork at the medical school or is it everyone for themselves. To which, most would answer that there is a sense of comraderie in medical school. And there is. But can there be comraderie among people that are competing. I think that there can be, and I don't buy that competition is a bad thing.

Like it or not, we live in the era of American Idol and banning red pens. Perhaps in a reaction to how they were treated as children, there is a whole generation of parents that thought they should lie to their children about their children's abilities. "Sure Johnny, you can be a professional singer, you've got a great voice!" "Of course you can play in the NBA, who cares that you can't make it in the basket." At the same time we tell our teachers. "Don't use red pen to correct homework--it hurts students feelings." Luckily my parents always told me I could do anything I set my mind to, provided that I had some degree of God-given giftedness (I could practice basketball 'til I was blue in the face, but there isn't much need for undersized guys who can't jump).

I hope that our generation treats our children the way that my parents treated me. So that we don't have shocked children who are told for the first time that they can't sing by American Idol. And who realize that to become a doctor/engineer/teacher, you have to outwork a lot of people and that maybe it takes a C or D to realize that.

I've come to the point where I can admit that having a life is going to cost me getting an "Honors" in medical school--it just isn't worth losing all social interaction in the name of grades. Because of competition, I am driven to study many times when I'd rather relax. Because of competition I am able to set realistic goals. Because of competition we have highly educated doctors. Because of competion, I won't send out a mass email. Now if I can just figure out where to find all the information I want to keep to myself.

“Life doesn't imitate art, it imitates bad television.”

-Woody Allen

RHS

Here's a condition that all aspiring doctors should familiarize themselves with.

Medical Hierarchy

Everyone in the medical field knows that there is a hierarchy in medicine. Those who are outside of the field of medicine may or may not have any idea. This is evidenced by experiences in the emergency room. When I was a kid and went to the ER, I had know idea that the guy in the white coat might have been fresh out of medical school, but not everyone is as blissfully ignorant as I was--I've heard many patients immediately ask for the "real doctor" (They must be frequent visitors to the ER).

But for those in the medical profession, there are countless points at which you are forced to realize exactly where you are on the totem pole. There are obvious things such as the ability or lack thereof of signing off a note on a patients chart. For medical students this means writing out what you think is a good note, then finding a doctor who will check it and sign at the bottom.

Aside from the more obvious things, there are a litany of lesser things by which people are kept in check. I would argue that whether they are intentional or not, they serve as an important check in keeping one from becoming too full of themselves or feeling that they had "arrived" and no longer needed to study.

One of the more commonly referenced is coat length. For those not indoctrinated, the white coat of a medical student only goes to the waist (if that), while the coat of an actual doctor (resident or attending physician) goes all the way to the knee. But I think that the hierarchy can be much more subtle, and even though it is not always recognized as such, those that step outside of it are punished in just as subtle of ways.

For the gunners, although people may tolerate them to their face, I would be surprised if anyone would go out of their way to help them. Say for instance someone knew of a chance to meet with several higher ups in the surgical world, I don't think that the first thing you would do is call them up to let them know about it. If someone wants to be a gunner to the point that everyone can see they're looking out for number 1, people will consciously or unconsciously punish them for it.

Although I personally can't speak to this, I've heard that the same principles apply to medical students on rotations. Don't make the residents look bad. It seems pretty straightforward, but I guess some people were never properly trained in the social graces. (bunny trail: a lot of people say things like "I just need to get past the basic science and start clinical rotations, then I'll really shine"--we can't all be right can we). I wouldn't have said a word when was at the Morbidity and Mortality conference, I don't care if they pointed at me and asked what my name was, I would have hoped someone else would have answered. Real or imagined, I've got a healthy (I think) fear of being blackballed.

Lastly I think there is an even more subtle component. Next time you are in a room, look at the seating arrangement. Say for instance you are in a room with a chair a couch and hardwood floors. I would venture to say that 9 out of 10 times, the most senior doctor will be in the chair, the three residents will be on the couch, and the medical student will be on the floor.

Signs You May Be At a Clinic That Reuses Medical Supplies

1. Patients are informed before their appointment that the need to "bring their own betadine."

2. While other health care providers are switching to computerized medical records, this clinic is trying out the whole "no records" thing.

3. Any box that once had now has

4. The insulin about to be injected is a deep shade of red.

5. You notice from his diploma that your "doctor" actually only has a Ph. D in economics.

6. Patients requiring surgery must bring someone with the same blood type for on site transfusions.

7. Bills can be paid in 10 easy payments of 11.99

8. Upon entering, patients take a number from a deli-style machine.

9. Before the doctor will see you, patients are fill out a questionaire asking, "What did WebMD say you have?"

10. Hand sanitizer is coin operated.

Very Old Posts--Take Two

Another blast from the past. Note: I never actually read this book--this was during the whole "people may actually care to know what you are reading phase." I was trying to be clever.

Tuesday, June 21, 2005

Currently Watching Go Paddle - Beginning to Intermediate Kayak and sit-on-top see related Open Water 2: Terror on Lamberton Lake (a true, albeit exaggerated, story) Scene 1 The scene opens with our protagonist (yours truly), calmly paddling in his kayak across a serene, sunlit lake. (foreboding music) When all of the sudden the protagonist thinks to himself (zoom in on face) "This kayak seems pretty stable, but you know what they say about kayaks..." (Flashback to mother's warning) "If you were to tip over in the middle of the lake, that would be a nightmare. Nightmare...nightmare...nightmare (fade out and snap back to reality...uhh-ope there goes gravity [bunny trail]) Zoom in on protagonist face again. "I wonder how much it would take to tip this over...I'm sure it would take an awful lot..." Scene 2 Scene opens with our protagonist gently rocking the kayak back and forth. "See it is hard to tip over!" When all of the sudden a trickle of water drips over the side. Quickly the drip of water becomes a stream. And then a torent, engulfing the right half of the kayak. The once proud Old Town kayak is now listing heavily to the right, but she wasn't about to give up without a fight. Lurching back to the left, the kayak struggles against the rushing water with all her might, but it was too late. With a gasp she rolled over, like Rasheed Wallace in the playoffs. Scene 3 (Quick shots of our protagonist swimming next to his disabled kayak, a look of sheer horror on his face) Alone and adrift in the middle of gi-normous Lamberton Lake our protagonist looks around for any sign of help coming. Nothing. He realizes that he must either sink or swim...literally. After a few failed attempts at flipping the kayak over in the middle of the lake, our protagonist realizes that he must swim to shore, all the while pulling his kayak behind him! (fade out with protagonist swimming toward shore) Scene 4 The Earth Shattering Conclusion After laboring for hours, trying to get back to shore, our protagonist finally crawls onto shore. Exhausted and relieved, he kisses the ground, before beginning his long walk back to the docks. Just when it seems he is out of danger, he slips, severly lacerating his right foot, blood jetting upwards. But he's already been through so much that day that he continues on, his resolve only further hardened. When at long last he arrives at home, to a grateful country... (roll credits) The Protagonist.........Myself The Kayak...............Old Town Kayak Burt Reynolds...........As himself a ©stew production

Cheers for Fears

Hey med students, please stop signing off letters with "cheers," we're not from England and were not in a 90s sitcom. And last time I checked, I don't have a glass of anything in my hand.

On Greed and Medicine

"Clark County prosecutors said they were investigating a medical clinic accused of shoddy injection practices that exposed patients to potentially deadly infections."

What's going on in the world of medicine of late? I realize that every time the media catches wind of a story about (actual) medical malpractice it immediately becomes headline news--if not nationally, at least regionally. Also, I think that as professions go, doctors are the most ethically minded. But why does this ever happen? How can someone make such sacrifices to get through medical school and residency (supposedly to help their fellow man) and then become an utterly different person after they become full doctors? How does a doctor snap, or have "angel of death" doctors already snapped before medical school, and are simply good actors?

For those that don't want to spend a lot of time reading about the long and short of it, I'll summarize for you.

Within the past few days a story has broken in Las Vegas that a small practice in the city (Endoscopy Center of Southern Nevada) has been reusing syringes in order to save a buck or two. Workers at the clinic reportedly were told by the doctor in charge of the center to reuse supplies and medications in order to save money.

Here's an example: say I come in to have some procedure done that requires intravenous anesthesia. The nurse (or whomever) walks in and begins an IV by sticking a needle into one of my veins. Little do I know, but a few minutes/days/weeks ago, that very same needle was stuck into a patient who came in for HIV. Many years later, I now have been infected with HIV as a result of almost unbelievable choices by people that I have been indoctrinated to trust.

"This should never happen in contemporary health care organizations."

The one thing I will never understand is how someone can go through a minimum of four years of medical training and still take part in practices like this. Let's say for the sake of argument that the nurses and other staffers were told to reuse medical supplies to save money, and let's say that there were not any incentives given by the doctor relating to number of items reused (which are both accurate assumptions, given the data). How on earth can you, in good conscience, keep silent. Do not get me wrong, the doctor who was in charge deserves the lion share of the blame, I hope this disgusting act of greed puts him in jail for a long, long time. But why didn't anyone say something. It seems a sad commentary on the modern view of responsibility in this country when a handful of people can all go along with something they know for a fact is wrong and endangering patients.

Doctors are consistently ranked as the most respected and trusted of professions. And 99.999% of doctors spend every day earning that trust, but a seemingly increasing number of health professionals are being found out as betrayers of that trust. How will this change medical practice in America. Will patients be less apt to agree to necessary surgical procedures? Will nurses have to remove packaging of medical supplies in from of patients (this wouldn't surprise me if it was required in the near future)?

"Southern Nevada Health District officials said last week they traced six cases of hepatitis C to the clinic, including five people who were infected on the same day."

If this is accurate, then this is unbelievable. I don't know what the chances are of getting Hep C from a needle stick, but I've heard that the chances of getting HIV from a contaminated needle (from a needle stick, which I would assume is less dangerous than the practices described above) are something on the order of 1 in 300, at least among medical professionals who are accidentally stuck. Basically (although I am by no means an expert) this would seem to point to the fact that the needles were used tens, maybe even hundreds of times.

"We need to let them come up with what exactly is the problem. In the meantime, that place is closed."

I'll tell you what the problem is. Greed mixed with zero care for patients well being. There seems to be a spectrum in medicine, a spectrum that goes deeper than statistics like "patients per hour." On one hand you have doctors who are completely absorbed with the pursuit of money. On the other hand you have doctors who can truly say that they are not at all concerned about their income. To the former, I would ask the question, why not go into business, chances are you could make a lot more than in medicine (bunny trail: I think the answer is a formula: middle class/lower class smart student sees 7 years of work = almost guaranteed 100,000 dollars per year for life)

In truth, I think that most doctors fall somewhere in between. I'm on pace to rack up $160,000 of debt and someday I'm going to have a wife and family to support. It's through taking a reasonable look at finances that I am able to say, yes I can stick this out and someday I can pay off my loans and live very comfortably. Does that make me a selfish person--if I drive a new car every five years and live in a million dollar house while many in the world are starving, I think the answer is yes. How do we keep from sliding down the slippery slope into unmitigated greed and waste? If we could answer that question then maybe we could decrease the frequency of outright malpractice.

African Watering Hole Webcam

Found this site the other day, it is strangely addicting. Generally the video focuses on the watering hole, but lately when I've checked it the operator tends to move the camera around.

A Tribute to RDK

This post is exceptionally long, I apologize. When I was an undergraduate student at the greatest institution of higher learning in the world. I had a really awesome adviser. Even though I was a biology major, and he was a chemistry professor--I knew from the classes that I had with him that I wanted him to advise me on life/professional decisions. It just reminds you of the huge impact that teachers have on our lives. What follows is an old excerpt from a xanga post I wrote during undergrad, and subsequently, an article I wrote about him for the college newspaper (please excuse the horrendous prose--oh and by way of explaining the title of the article, Calvin's mascot is the Knight).

"Tonight was the best lab ever. I actually understood everything and RDK was on top of his game. He was joking around the entire night, which definitely made it fun. He was like, 'Well if only one student understood the lab tonight then I can be happy... I'm not going to say who that is (points at me).' And I said, 'Oh stop it!' in the most obnoxious voice I could do. To which he laughed, good times."

Arabian Knight shares experiences

By XXX XXX
Guest Writer

Shells whistle overhead. A stray rocket crashes into the balcony of a high rise apartment building. A professor is gunned down in a parking lot by a crazed student. While this may sound like the script from the latest Scorsese film, these were just some of the experiences of one Calvin professor during the Lebanese civil war.

“I got my bachelor’s degree from Calvin in 1965, and then I went to Wisconsin for my graduate work,” said Roger DeKock, professor of chemistry. “But [in the early 1970s] there was a downturn in the chemical industry.”

Forced to work in consecutive post-doctorate programs that took him first to Florida and then to England, professor DeKock was more than ready for a teaching position. “While I was [in England] I got this job offer to go to the American University of Beirut. It was my first job offer, so [my family and I] decided that even though it was further from home, we’d better take this job.”

The first couple of years that DeKock and his family spent in Beirut were relatively calm, but the political climate in Lebanon was about to take a turn for the worse.

“People had been muttering things to me at the university, like, ‘Boy this place (Beirut) is getting to be a powder keg — and it really was a powder keg. From the Palestinians in refugee camps to the way the government was set up, there were so many pressures because of the [tensions between] the Christians, Shiites and Sunnis.

“April 13th, 1975. I still remember the day very well. It was a Sunday; the weather was beautiful; it was spring. I remember hearing late in the day that some fighting had broken out in Beirut.”

News reports would later say that a Palestinian gunman had opened fire on several people leaving a church in a Christian suburb of Beirut. In retaliation, a Christian group detained and then killed 26 Palestinian civilians. The fighting would only intensify.

“From certain parts of the campus you could see [two] high-rise hotels; one was the Holiday Inn and the other one was the Beirut Hilton. Opposing factions took over the hotels, and they started shooting at each other from the tenth story up. I distinctly remember trying to sleep that night and hearing shelling in the distance, and that created a very uneasy feeling — to hear fighting going on when one was trying to sleep.”

As the fighting intensified, DeKock’s need to evacuate his family became increasingly evident. “The airport would close periodically and then we couldn’t possibly leave, but one evening my wife and I were going out to get some food, and we saw an airplane landing. I said to her, ‘we’re going to get you and the two children a ticket and get you out of here.’ They got out of [Beirut] before the worst came.”

The sectarian violence between warring factions almost always resulted in collateral damage. “I heard bullets flying on campus — there would just be stray bullets,” said DeKock.

The apartment complex where DeKock stayed was not any safer. “There was a Lebanese army post right on the Mediterranean about a block from our apartment complex called “Bain Militaire.” The part of town that I lived in was the Muslim side of the city — the Christian side was the East side, and periodically the people running the rockets on the East side would try to take out that officer’s club.

“But they weren’t that good at aiming. If you heard the rockets go over you were safe, because they had overshot and they would probably go into the Mediterranean, but sometimes they would undershoot. We had one that landed on our street. It was at night.

“It was a huge explosion, and I thought, ‘Oh my goodness, what happened?’ But after everything calmed down, there was no shouting or screaming, so we guessed that nobody got killed or injured. We went out in the morning and looked, [and saw] that the rocket had hit on the sixth story balcony across the street and brought down the balcony on some parked cars down below — those cars were totally pancaked under concrete.

“Another thing that I noticed was that people who were normally unstable would really go off the deep end during times of war. That must have happened to one student, because he came onto campus with a gun — this was the spring of ’76. He came and killed two deans; one was the Dean of Student Affairs and the other was the Dean of Engineering.

“We heard on campus that there was some shooting, so we were told to shut our office door and turn our light off because we didn’t know who this person was shooting at. A few hours later we got the all clear and were told it was safe to leave. I went to walk home, and as I was walking by the School of Engineering, I walked by the pool of blood where the Dean of Engineering had been killed in the parking lot. He had tried to outrun the student.”

The atmosphere in the classrooms took on a different type of tension. “[Students] didn’t start talking politics to each other on campus — they knew not to do that. It’s like here at Calvin, if you know that somebody is a Bush supporter and you’re not, you just decide between each other to keep quiet. I think that there was a lot of disagreement among students but they didn’t start getting into shouting matches.”

The effects of the civil war stretched into other areas of civilian life. “I spent a lot of time just trying to get groceries. Something that would’ve taken me 30 minutes a day here, now could take two hours, waiting in lines to get bread, milk or meat.”

As many expatriates fled war-torn Beirut, anything that could not be taken on a plane was left behind. “Several of the people that we knew had pets, and they all left them behind with me. I didn’t want to just turn them loose, because when people started to leave, they just let their pets run loose in the city, and that was a horrible life [for the animals].

“I ended up with all kinds of propane gas cylinders that you would use for cooking. When people left, [all of their unused cylinders] ended up with me. I had 10 propane gas cylinders, and when I left I passed them on to someone else.”

The roughness of war contrasted the beauty of Beirut at peacetime. “When we lived there [before the civil war] people called Beirut the Paris of the Middle East. Arabs from the gulf countries would all come to Lebanon in the summer because the climate was so moderate.”

Because of the proximity to both the mountains and the Mediterranean, Beirut was once a popular tourist destination. “The mountains were about a 30 minute drive [from the Mediterranean]. People used to say that you could go swimming in the morning and skiing in the afternoon,” said DeKock.

In the summer of ’76, DeKock decided enough was enough. “The university would close periodically, the hotels were burning, the downtown — which was about three miles from where I lived — was destroyed while I was there. I left because it was dangerous, I thought, ‘why not get out while I can?’ I didn’t like being away from my family.”

From the mid-‘70s to the ‘90s the civil war in Lebanon continued in one form or another, and although formal warring has ceased, the area remains a hotbed of political strife, as evidenced by the violence between Hezbollah and Israel this past summer.

Professor DeKock had to send his family back to the United States for safety reasons while he spent time in Beirut alone.

Besides seeing war and violence first-hand, the DeKock family had experiences unlike many other young families.

DeKock, a professor of chemistry, lived and taught in a war-torn Beirut, Lebanon, in the 1970s.