End of Block One

I took the NBME (National Board of Medical Examiners) exam this morning. We had yesterday off from clinic to study, but I mainly spent the whole day in bed and just did a little reading. There is nothing that I'm going to learn in one day that I should have learned in the past four months. This NBME is a practice Step 2 test that is now optional for CCLCM students but still required for UP students. The good thing about the test being optional is that it is not at all stressful for us. The downside of it being optional is that it is now only offered at Case. I went over there with some of my friends from the UP, because I still get hopelessly lost every time I try to find my way around the Case medical school buildings. The test itself didn't seem too bad. I think I probably did better this time, even without specifically studying for it.

After the test, we had to go back to CCF to meet with the BAT (Block Assessment Team). This time they just had us all meet as a group and we went through to give our suggestions about each rotation. They also gave us a free lunch. We were supposed to have individual meetings with the BAT afterward, but fortunately the faculty decided that it wasn't necessary. I went and met with my PA and then went home.

I am incredibly grateful to be done with Medicine for good. If I were still on this rotation, I would have had another black weekend this weekend. My team was joking with me on Wednesday that I could still come in and take call with them if I wanted. I told them I'd try not to feel too bad for them while I was sleeping in tomorrow! Now that I think about it, they really got screwed, because this weekend is the end of Daylight Savings Time. So they are going to have an extra hour on call since they both will be on in the middle of the night when the clocks get switched back.

Some of my classmates are going to the Weatherheadless Ball at the business school tonight, but my exciting plans for Halloween include a fluffy pillow and a down comforter, both of which I have seen way too little of over the past few months.

Last Call

We have a new attending this week, and I think it's fair to say that she doesn't like me very much. It probably didn't help that when she asked what specialty I want to go into, I was in a particularly foul mood and told her that I didn't want to do any of them. I'm so sick of internal medicine, and I'm REALLY sick of being asked what specialty I want to go into. My senior knew I was in the College program and helpfully piped up that I was going to be a researcher, not a clinician. That's not really true, but at least it ended the discussion.

At another point, the attending asked one of the other residents (not mine) why he had ordered a test that wasn't necessary to make the diagnosis. The resident said he had just wanted to see the results. I thought the attending would chew him out for ordering a purposeless test, but instead, she told him that if he had ordered it for educational purposes, that was fine with her. And people wonder why health care is so expensive! Our last attending had always emphasized how important it is to not order tests unless the results will change your management, and I agree with that philosophy.

Yesterday was my very last night of call. It wasn't a particularly good one. I guess all these long days and long nights were catching up with me, because last night I was really dragging. By 3 AM, I couldn't keep my eyes open any more and told my team I was going to bed for a few hours. I had just gotten all settled in the student call room when my pager went off. It was my senior wanting me to come down and see a patient in the ER. Swearing to myself, I got dressed again and went over there.

During the interim ten or fifteen minutes that it took me to do this, the patient was moved to one of the medicine floors in the H building. The senior told me to go to the H building and examine the patient. Now I was really pissed, because I had gone through the H building on my way to the ER from the call room. I went back to H, located the patient, woke her up again, examined her, and found nothing noteworthy. When I caught up with the senior, I told her that I wasn't sure what I was supposed to have found. She said she thought the patient might have had one eyelid drooping lower than the other, but it was very minor. I struggled to keep control of myself. Then she said with utter sincerity, "See, wasn't that worth getting up for? It's such an interesting case!" I contemplated strangling her to death with her own hair, but managed a weak smile. By that point, it was already 5:30, so I went to go preround on my patients.

Today was my last day on General Medicine, and I hope it wasn't too obvious when I dozed off during rounds this morning. We did have an interesting moment though when one of our patients wanted to check himself out AMA. It was freezing cold and snowing hard outside, so the attending asked the patient where he was going to go, how he would get home, and what would happen if he went outside with no coat on. The patient didn't have a good answer for any of those questions, and the attending decided he was delirious and wouldn't let him leave. We wound up pink slipping him. I got to go home at 1 PM since I was post call, and I have tomorrow off, ostensibly to study for the NBME on Friday. And that is the end of the General Medicine rotation.

Facing Fears of Contaminated Blood

Yesterday morning, I did my second point/counterpoint. This debate was about how to counsel a woman who was BRCA-positive and had an extensive family history of breast and ovarian cancer. I was charged with arguing the pro-surgery viewpoint to prophylactically remove her ovaries and breasts. The opposing position was to monitor and screen her regularly. Since we don't have any way to biochemically or radiologically detect ovarian cancer until it is probably too late, screening women at high risk for ovarian cancer is really an untenable position. After the debate was over, I told the facilitator that the debate should really be about whether to use prophylactic surgical management versus medical management with an anti-estrogenic drug like raloxifene. At least that would be a real debate, because screening is known to be ineffective for preventing ovarian cancer, while prophylactic surgery is known to work in most cases. For those reasons, I thought only screening her for ovarian cancer was tantamount to malpractice. He agreed that the debate was too one-sided, so I think future students will have a medical versus surgical management debate instead.

In the afternoon, we had a POD session on innovations. It was awful. First, we got a one hour talk about the CCF Innovations office and how they would work with us if we had something we wanted to patent or whatever. I'm thinking, all I want to do is survive the next week of IM! Then, we had to break into small groups to work on projects. Our biomedical engineer facilitator gave us a problem and told us to innovate, as if you could order people to come up with creative ideas on the spot like that. The project was on designing a better artificial knee implant. I had been up late the night before preparing for P/CP and had a night of call ahead of me, so I wasn't in the mood for this nonsense. When the guy asked if I had any suggestions, I said no. Then he asked if I had any engineering background, and I said no. After that, he pretty much just ignored me, which was fine by me. I even managed to doze off a little. When it was over, I went to the cafeteria for dinner and then caught up with my team.

Last night wasn't too bad for a call night. I spent most of it with the intern, who, like I already said, is awesome. He let me do a bunch of procedures. First, we had to get an ABG (arterial blood gas) on one patient, so he asked me if I wanted to draw it. Well, I hadn't ever drawn one before, but I said I wanted to, and he walked me through it. Fortunately, things went well and I only had to stick the patient twice. Unfortunately, getting an ABG drawn is extremely painful for the patient. I don't know why drawing blood from an artery hurts so much worse than getting it from a vein, but it does. This patient was semi-comatose, but he could definitely withdraw to pain! I have no idea if he could hear me when I apologized for hurting him, but I hope so.

The intern and I took the ABG down to the lab ourselves instead of sending it through the pneumatic tube so that we could be sure it got done right away. However, we wound up neglecting to fill out some form that needed to go into the bag with the blood samples. So a few minutes after we left, the lab paged us, told the intern they couldn't run those samples, and asked us to bring over new ones with all the proper labels and paperwork. That was aggravating, because obtaining the blood for an ABG is very unpleasant for the patient, and the samples did have labels on the actual tubes of blood. But the lab was firm, insisting that the labels on the tubes had gotten smeared or could get smeared or would get smeared. Anyway, to make a long story short, I got the opportunity to draw a second ABG, and this time I hit it on the first try. But I felt really bad about having to do it at all, and we didn't tell the patient why we needed a second sample. Of course, I'm assuming he was even aware of what we were saying.

Later, we went to try to start an IV on a patient that the nurse hadn't been able to stick. I don't understand why the intern on call is expected to do sticks that the nurses can't get, when the nurses have way more experience starting IVs than the interns do. But we got called, so we went to try. The patient was really dehydrated and obese, which were major contributors to his being a hard stick. The intern tried first a few times but couldn't get it. Then he asked if I wanted to try, so I did. The patient was calmly lying in his bed and didn't jerk at all when I pierced his vein. I got a little flush of blood, but the needle came out again. After one more cautious attempt, I gave up. The patient's IV would just have to wait until a phlebotomist showed up in the morning. Normally I'm not the kind of person who has unsteady hands while performing procedures, but last night I did. Plus, I probably didn't try as vigorously as I could have, because that patient was known to be HIV+.

This was the first HIV+ patient I had ever knowingly encountered, and I was thinking later about how mindful I was about his HIV status the whole time I was poking around in his arm. Being stuck by an HIV-contaminated needle is every health care worker's nightmare. When the intern first asked me to try starting the IV, I had a fleeting thought of refusing. There would have been no repercussions if I had refused. I am only a medical student, and there was no inherent expectation that I would try to start that IV. But I tried anyway, even though I was afraid. I tried even though the entire time, the thought that this patient's blood contained the HIV virus was in my conscious awareness. But I managed not to be overwhelmed by that fear even though I was so aware of it.

As a preclinical med student, you tell yourself that your fear of contracting HIV would never interfere with your sense of duty to help patients. But somehow, the situation is a lot more ambiguous when you're poking an HIV+ person with a hollow needle, and the only thing preventing his blood from contacting your bare skin is a thin, latex-free glove.

My Last ICU Visit

I met my new intern and resident yesterday. The new intern is really cool. He is going to be a neurologist, and he's another intern who loves teaching. Considering how bad my neurological exam is, I can use all the help I can get. Our first call together as a team last night was fairly uneventful, and we all got to go home early today since we are post call. But I only got a few hours of sleep last night, and overall I still feel pretty cranky and even a little bitter about the whole overnight call thing. Q4 call (every fourth night) sucks. You're always either on call, about to go on call, just getting off call. I have decided that I don't want to do any residency that requires Q4 call.

As promised, I stopped by the ICU on Monday last week to see my heart failure patient. I went into his room to find him intubated and sedated. Over the weekend, he had coded. When I went into the room, I pulled one of the chairs next to his bed and held his hand. I asked him to squeeze my finger if he could hear me, and he did. Then we just sat together like that for a while. For the rest of the week, I came in every day to sit with him for a few minutes, and every day he squeezed my finger when I asked him to let me know if he heard me. During one visit, his nurse saw me sitting there and asked if I was taking his pulse. “No,” I said. “I’m just holding his hand. He knows we’re here with him.”

Today, I got to his room just after a code was being called off. He had arrested again, and this time the code team hadn’t been able to revive him. Everyone had left except his son, who I had never met before. He asked me if I had brought the papers for him to sign. “No,” I said. “I’m a medical student. I came here to see your father. I’ve been coming to see him every day.” The son said something about how his dad didn’t want to be kept alive on a machine, and thanked me for taking such good care of his dad. Then he left me alone in the room with his dad's body to go searching for the paperwork.

At first, I was really put off by his seeming lack of emotion, as well as the fact that he had not ever come to visit his father in the hospital. But everyone deals with their grief differently, and maybe that was what he had to do to cope. At any rate, I am glad that I had the chance to know his dad, because he was a really great guy.

Drawing Boundaries

I found another old friend (a patient) waiting for me when we went on rounds last Monday. Taking care of her was a challenge for any medical team. She had multiple major medical problems, both physical and psychiatric, that made her a difficult patient to manage. She found it difficult to be flexible. In particular, she was resistant to adapting to the frequent changes in the treatment plan or her daily routine that are the norm in any hospital. Whenever she got upset enough, she would sign herself out of the hospital AMA (against medical advice).

I had done her H & P when she came on the Cardiology service the first Friday I was there, and I spent a lot of time talking to her and her husband during my black weekend. My goal had been to keep her in the hospital all weekend so that we could cath her heart on Monday morning. Each time I left the room, I joked with her, "You'll still be here the next time I stop by, right?" She laughed and said she would. Even though there were some minor rough spots, we managed to get through the weekend without her demanding that someone bring her AMA papers. She had her cath, which turned out normal, and she was released from the hospital.

Now, one week later, she was back. Since I knew her, I asked my residents to let me follow her. They were more than happy to oblige, because she had done nothing but complain since landing on the General Medicine service. I checked on her several times during the day and encouraged her to have some patience with the doctors, who were doing their best to help her. Tuesday morning, I found multiple notes in her chart from the night nurse describing how she (the patient) had accused her (the nurse) of disliking her, and purposely avoiding helping her. I talked to the day nurse about my patient's psych history, and asked him to please keep an eye on her. The patient calmed down and was getting along fine with the day nurse.

One of the things that upset this patient the most was when she didn't get her breathing treatments on time. She really did have severe COPD (chronic obstructive pulmonary disease), but she would also work herself up whenever things weren't going according to schedule. I went home Tuesday afternoon after reminding the resident to put in orders for the patient to have her breathing treatments every four hours all night long. Wednesday morning, I came in to find her in the sorriest state I had ever seen. She could barely breathe, and she was very tachycardic. Somehow, the order for her breathing treatments had been discontinued, and she hadn't gotten any treatments all night long. No one had noticed her, because she had been given extra lorazepam in the evening to help her sleep and keep her calm. In her drugged state, she hadn't been able to complain, and the night nurse understandably hadn't gone out of her way to check on this patient in depth.

I listened to her heart and lungs, then went to get my senior. We got the respiratory therapist to come to her room stat to treat her. We also took her off the lorazepam. I spent a lot of time talking with her and her husband. She wanted to leave, but the residents and I convinced her to stay. So she did, and the next couple of days passed uneventfully. Yesterday evening when I was finished with my short call, I went by to tell her that I had didactics today and wouldn't see her in the morning. I promised that I would come by this afternoon before I went home. Her husband gave me their phone number and told me that I should come over for dinner some time. But at some point during the night, she got upset again, demanded that the resident on call bring her the AMA papers, signed herself out AMA, and left.

I was worried about her and even thought briefly about calling her at home, but I decided it was best if I didn't. Although she has a psychiatric disease, she is fully competent to decide that she wants to leave the hospital AMA. But I felt a little guilty when I heard that she left while I was gone. I was sure that if I had been in the hospital overnight, I could have again convinced her to stay. Maybe I could have, and maybe not. But it dawned on me that my approach to her was becoming personal as opposed to professional. I wanted her to stay in the interest of her own health, but I also wanted her to stay because I felt like it reflected badly on me as her health care provider if she left AMA. Of course, her leaving the hospital does not really reflect on me at all. I was the one who had been making her decision into some kind of referendum of my performance as a clinician.

General Medicine Service

I came in this morning to be pleasantly surprised that I already know my senior resident. Last year, she worked with my longitudinal preceptor in the outpatient clinic sometimes, and that is where I met her. My new intern used to be a pharmacist before he went to med school, which is pretty cool. I am only working with the two of them for this week, because the residents change rotations on Monday of next week.

My new attending holds sit-down rounds instead of going room to room. Then he goes to see the patients on his own afterward, leaving us to do whatever scut needs to be done before the noon conference. I like this system a lot better than when we all had to go on bedside rounds with the attending! The team discussed all of the patients, and then my senior and intern, who were post-call, went home. I had gotten yesterday off, so I didn't get to go home. But there wasn't much to do this afternoon with all the team gone, so I had plenty of time to read. All in all, not too bad for a first day.

Heart Failure and EKGs

This is my last week on Cards. I should have had to be on call again this weekend, but since I'm switching to a general Internal Medicine (IM) team next week, I lucked out and will get the whole weekend off. I'm grateful for that, because it's been a hectic past couple of weeks.

Yesterday and the day before, we had two EKG sessions led by one of the chief residents. They gave us sample EKGs and helped us go through them and practice interpreting them. Since my cardiology attending is the CCF guru of EKG and has been doing impromptu teaching sessions with my team over the past two weeks, I came in already feeling pretty well prepared. Then last night, my intern was going over EKGs with me in the ER while we were on call. Like I've said before, this intern really likes to teach, and I've learned a lot from him over the past two weeks.

I am still following one of the patients we were consulted to see in the ER a while ago. He had come in short of breath with a 25 pound weight gain due to an exacerbation of his congestive heart failure (CHF). Because of retaining so much fluid, he had the most impressive pitting edema (swollen legs due to excess fluid) that I had ever seen. Saying that his edema was pitting means that when I pressed on the swollen ankle with one finger and then let go, the pit made by my finger would stay visible on his ankle for a few minutes afterward. It's almost like how a piece of clay will still have an indentation after you push your finger in and then take it out.

Anyway, he had so much excess fluid in his body when he showed up to the ER that he couldn't even lie down--if he did, his lungs would fill up with fluid, and he wouldn't be able to breathe. He also couldn't walk because it made him too short of breath. So he had to stay sitting in a chair all the time. In spite of that, he was cheerful and joked around with me. We spent an hour in the ER going through his history and physical until my team came down. Then my intern admitted him to the floor.

The obvious solution was to give him an IV diuretic (similar to a water pill) to try to get some of that fluid off, which is exactly what we did. However, it created a real catch-22: every time we tried to increase his dose of diuretic, his kidneys would start to fail. But if we decreased the dose of diuretic to improve his kidney function, he would gain back a few pounds of fluid, negating the progress we had made in diuresing him. After several days of this stalemate, the team decided to transfer him down to the heart failure ICU. He still had so much fluid on him that he had to stay sitting up in his chair all the time, and he couldn't walk, talk or lie down without becoming severely short of breath.

Now that he's in the ICU, he isn't my patient any more. But he and I get along pretty well, so I have still been stopping by the ICU to check on him when I have some time. Today, he introduced me to some of his friends who were visiting him, and I told him that I'd come by again on Monday when I get back. Unfortunately, so far, the ICU team isn't having any more luck with diuresing him than we did.

Black Weekend

It's entirely possible that this has been my worst week since starting medical school. Thursday was another full day of rounding and scut, so it wasn't any more boring or awful than any of my other days on IM so far. But on Friday, I found out that my last surgery patient had died. Even though I wasn't on the surgery team any more, I had been checking his electronic chart each day all week to see how he was doing. I knew he wasn't doing too well since he had been admitted to the ICU earlier in the week, but I kept hoping that he'd pull through. When I checked on Friday, I saw that he had been disconnected from all life support and had died soon after. That put me in an even worse mood to begin my black weekend.

A black weekend means that you get no day off for the entire weekend. In other words, you work for 12 straight days, from Monday of one week until Friday of the next week. Whenever you have a Saturday call, that's a black weekend because you come in Saturday morning at 7 AM and leave at 1 PM on Sunday. Then you still have to come in Monday morning at 6:30 AM like normal. I came in on Saturday already feeling cranky because I didn't find out that we had a 30 hour call until Friday afternoon. My confusion was because on surgery, weekend calls started at 6 PM and were over the following morning at 8 AM. So I blithely made plans for yesterday, only to be told by my intern the day before that no, I had to be here all day.

Being in the hospital on Saturdays is not much different than being in the hospital on weekdays. You still round on the patients, do scut, and write notes. The school gives us money for our call meals, which is a really nice perk. But as I found out, that call money can't be used at lunchtime, only for dinner and breakfast. So I still had to pay for my lunch even though I was on call, which annoyed me too. After lunch, I went back up to the floor and was standing right outside of a patient's door when a code was called. It wasn't one of the patients that I was following, so I didn't really know her. But I went into the room with everyone else.

Codes may look cool on TV, but they're pretty awful when you're there in the room for one. The code team members were compressing the patient's chest, and she was flopping around in the bed like a doll. I could hear her ribs cracking, and then the anesthesiologist intubated her. The team defibrillated her a few times and got her pulse and blood pressure back. The patient's family was outside the room, and her husband was crying. I went out to be with them just as the chaplain arrived. A few minutes later, one of the code team responders came out to tell the family that the patient had been resuscitated and they were moving her to the ICU. He said very matter-of-factly that the patient was in very bad shape and might die. The husband started sobbing even harder, and the responder just said, "sorry," turned, and walked away.

There have been plenty of times here and there when I have thought that I probably made the wrong decision to go to medical school, but that was one of the times it hit me the hardest. What really got to me was watching that responder's back as he walked off to go fill out his paperwork.

Inpatient Cardiology

This is my first week of inpatient medicine/cardiology. I think it works a little differently at the other hospitals, but at CCF, we spend two weeks on inpatient cards and three weeks on inpatient general medicine (IM). Most people do IM first, but I have been scheduled to do cards first.

Monday was not the greatest start. I had paged my senior resident a few days earlier to find out when I should get to the hospital and where to meet, and he told me to be in the medicine residents' room at 8 AM. So I showed up on time, but then I sat around for the next hour and a half while he wrote his notes. Fortunately I had brought something to read, so it wasn't a total waste of time. At 9:30, we met with the attending and the rest of the team and started rounding. This made me realize two things: first, I really hate rounding for hours at a time. Second, it felt pretty weird to be wandering around the hospital floors all morning when I had always been in clinic or in the OR by 8 AM up until now. I think this has been the first time that I've been up on the floors while it was still light out!

After rounding for what seemed like an eternity but was actually only a couple of hours, we went to the IM noon conference. I had been to a few of these before, but not every day like now. They're not the most exciting things either, and I think the biggest reason people like to go to them is because we get free food. Then, we basically spent all afternoon doing scut. Scut consists of things like contacting outside hospitals to get medical records, sending faxes here and there, and making phone calls to various people. It's not very exciting, but it's still better than rounding because at least I'm doing something.

Monday night, I got to go home around 6 PM, but last night I was on call. That pretty much involves admitting people and answering pages from the nurses for this or that. The bad thing about call for the residents is that not only do we have our own team's patients to worry about, but we also cover the patients for three other teams as well. It's impossible to really know the details about 80 different patients, and the pages keep coming in nonstop all night long. The good thing is that seeing the patients is fun, and now I have two of my own patients to follow. They came into the ER and I did the H & Ps (histories and physicals) before we admitted them. After that, I got to sleep for a few hours.

This morning I saw my two patients again on my own before I met with the team for rounds and presented them to the attending. After my first kind of disastrous surgery call experience, I have gotten better about being more organized when I present. Right before rounds started, I printed out all the notes I had written so that I'd be able to remember the details and all the test results from the ER, along with the most recent lab values and vital signs. My patients are both very sick with multiple diseases, so there is a lot of information to collate. Since we were post-call, we got to leave at 1 PM after we signed out to the other team. 30 hours can seem like an eternity, especially when it's all you can do to keep from nodding off right in front of the patients and the attending while you round the morning after call.

Besides me, the attending, and the senior, there is also an intern on the team. He is really awesome. Since he wants to be a cardiologist, he is very enthusiastic about cards and has been going out of his way to teach me and help me with my notes. I've been doing extra scut for him in return, not only because he's nice and it gives me something to do, but also because I felt sorry for him. I think medicine interns must have the worst job of anyone with an MD. But when he found out that I had to take overnight Q4 call (every fourth night) with him and the senior for my whole rotation, he told me that he felt sorry for me! I hadn't realized that at a lot of other med schools, students aren't required to take overnight Q4 call. That does not thrill me, but at least I get the rest of today off. Tomorrow I will be back in at 7 AM to round on my patients.

Tips for Doing Well in the Surgery Rotation

I think a lot of people are pretty intimidated by surgery, especially if you don't see yourself as the surgery type. But honestly, surgery is a lot of fun if you work hard and make an effort to learn how to be useful in the OR. Here are my tips for getting more out of your OR experience. Some are only applicable to Case students, but most are applicable to any med students.

1) Learn how to tie knots. I had a terrific attending who let me do a lot in the OR, and she let me do even more once she realized that I had learned how to tie knots. It was terrific. The best thing to do is to get one of the residents to show you and then practice on your own. You can probably get a few suture kits from the OR and use those to practice. Once you get the hang of it, practice using gloves. It's a lot harder tying knots with gloves on because the gloves are kind of slippery, and you can't feel the sutures as well.

2) Be assertive. Surgery is not going to be as much fun if you are more the quiet wallflower type. You have to tell residents and attendings that you want to scrub, suture, etc. and not wait around hoping for them to notice you. I don't consider myself to be particularly quiet, but my attending thought I was anyway because I'm not as forceful as she is. No other preceptor I've ever worked with has said that I need to be more aggressive. I really think it's a surgery thing!

3) Don't take being yelled at personally. It's not just you. Surgeons are tired, overworked, and a bit obsessive compulsive. They love efficiency, and third year med students are the wrench in their works. We're all a little clumsy, so we all get yelled at.

4) Don't fight with scrub nurses. No exceptions on that one. Just don't do it. You've already lost with the very first word out of your mouth. If a scrub nurse tells you that you've contaminated yourself, apologize and ask them what they want you to do. If they tell you to re-scrub, re-gown, and re-glove, do it without arguing. If you don't fight them, they won't make your life nearly as miserable. I had to change a few gloves and gowns, but I never had to re-scrub from scratch.

5) Try to read for half an hour every day. Surgery is one of those rotations that is more a 5-to-9 job than a 9-to-5 job. But you still need to read about your patients, log them, and complete your learning objectives. If you keep up with this regularly, you won't be swamped and panicky at the end of the rotation. I liked the NMS Surgery Casebook and did not use the Lawrence book that was recommended for the rotation at all. I also liked Cope's Early Diagnosis of the Acute Abdomen, which was one of the recommended supplements for the rotation. It's kind of quaintly written, but it's also written in a conversational style. Since most of us were on gen surg or colorectal teams, understanding indications for abdominal surgery is pretty important.

6) Don't be a martyr when preparing for the oral exam. When I first started the rotation, I wanted to prepare for all of the questions by myself. I quickly realized it would be impossible. There just aren't enough hours in a day when you're on surgery. Things went much better after I split the work up with one of the other students on the rotation with me.

7) Try to read about the surgeries before you scrub, including the anatomy you are going to see. This is good for two reasons: one, you will get more out of the surgery if you know what is going on, and two, you will be more prepared if you get pimped. I at least tried to read the appropriate chapter of Surgical Recall before scrubbing for my subspecialty surgeries. For those of you who are at CCF and don't want to buy your own copy, they have one in the library. I checked it out instead of buying it since I was pretty sure I wouldn't be going into surgery.

8) Eat breakfast every morning, especially on OR days. A lot of people try to eek out those last few minutes of sleep and skip breakfast. It's a bad idea. Really. Your chances of passing out will be seriously higher if you skip breakfast. Don't forget that if you're scrubbed in all day, you probably won't be eating lunch, and there's a very real chance you won't be eating dinner, either.

9) Make sure you keep tabs on your patients and know what's going on with them. Check their labs every day and pay attention to anything that is irregular. When you write up your notes, make suggestions for what you think might be wrong and what you think should be done about it. You'll be wrong at least half the time, but it's better to try to figure it out and be wrong than to not try and just look uninterested.

10) Don't despair when the going gets tough. Surgery is physically and mentally difficult, but it's doable. Thousands of other med students have made it though this rotation, and you will, too.

End of Surgery

I can't believe that my entire surgery rotation is over already. It was way too short. Here I have finally reached the point where I was starting to get the hang of things and enjoy the rotation, and bam, that's it. Time to move on. Apparently I'm not the only one who feels this way, because the new clinical curriculum is going to have more time devoted to surgery.

The rest of this week has been kind of easy and relaxed. On Wednesday, I wanted to scrub in for a vascular surgery. But there were some bigwig visitors from another hospital there, so I got relegated to watching the screen in the control room. The surgery wasn't all that interesting anyway, at least not up until the point where they deployed the stent. That was really cool. The stents are self-expanding. I'm still not totally clear about what they do to get the stent to stay retracted while they're manuevering it, and then to expand once it is in place. But you can actually watch it spring open on the screen.

Afterward, I went to see what my team was doing and find out if my attending wanted me to scrub. They were running late in the OR, so I offered to go round on our patients myself and then present to them. The attending agreed, and I went to collect our patients' labs and check on their progress. This worked out tremendously well. Not only did I help get all of us out earlier by presenting to them in the OR, but she wrote a very good eval for me about the initiative and teamwork I had shown.

The attending has her outpatient surgery day at one of the satellite clinics on Thursdays, so I had a reading day to get ready for my presentation today. I presented on a woman who had a breast lump. There was a mammogram and an ultrasound available, but I couldn't figure out how to get them to open in Epic. It turns out that only some computers on campus have whatever karma is necessary to open those films, and the fellow on my team had one of them. So he helped me get the films open and copied into my presentation, and overall it went well.

Our didactic today was on bariatric surgery, which is cool. But we had already seen a lot of this stuff last year, so it wasn't the most exciting. The afternoon research seminar was even more painful. It was on how to make a good presentation. Why the research curriculum people thought we should cover this topic in our third year of med school is beyond me, since we've been doing research presentations for two years already. I also don't understand the need to beat the topic to death for three straight hours on a Friday afternoon. But no doubt this is why I am not designing medical school curriculums. To make matters even worse, we had a class meeting afterward to teach us how to sign up for electives and advanced rotations. I've already signed up for some of both with no instructions, and it is extremely simple. You go to the online elective catalog, pick out what rotations you want and when you want to take them, and email the list to the registrar. That's seriously all there is to it. (You may have noticed that I feel a bit cranky this afternoon!)

Oral Exam and a Lucky Break

I spent the weekend studying for my oral exam, which was supposed to be this afternoon at 2:30. My attending let me out of evening rounds early yesterday so that I could study, and she told me not to scrub in this morning either. So I was feeling pretty relaxed because I had so much time, and I even slept in this morning. Then I got a page at 10:30 saying that my examiner wanted to move the oral three hours earlier, in one hour. Crap! That call made me finally start feeling a little stressed, because now I wouldn't be able to get through the whole review in time.

I was cursing myself for not getting up earlier, but it turned out ok. Even though I struggled a little with the first question, I got it in the end with some prompting. The second one I knew cold, and the doc couldn't find anything wrong with my answer to that one. It was kind of hard to concentrate during the exam because his telephone and pager kept going off every other minute. He is a transplant surgeon, and an organ (a liver) was possibly going to arrive this afternoon. First the organ was coming, then it wasn't, then it was again, and finally he told his assistant to contact the patient and get the team and OR set up. He made a comment about all the calls, and I felt bold enough after doing well on the second question to ask him if I could scrub in. He said it would be ok, and to page his assistant in a few hours to find out where and when the surgery would be. Then he said I had passed, and I left to go have lunch. The thought also occurred to me that I shouldn't have asked him to let me scrub for the transplant before checking with my attending. Fortunately, she was excited that I had passed the exam and enthusiastic about me getting the chance to see a transplant, so I didn't get into any trouble for not asking first.

The operation was long and laborious. This time, I was mostly watching and retracting (although I did get to do a little bovieing), but it was totally worth it. It took the team a few hours to remove the patient's old liver. That liver was shrunken, hard, a sort of sickly greenish color, and knobbly all over. (The patient had really bad cirrhosis.) In contrast, the new liver was large, brownish and glistening. Its surface was smooth, and it felt soft and spongy to the touch. Putting in the new liver took several hours also, because all of the hepatic blood vessels had to be anastomosed (connected). Once they were all connected, the surgeon opened the clamps, and blood began to perfuse the new liver. First, the tissue closest to the hepatic artery turned pinkish, and then slowly that pinkish color began to spread like a wave all throughout the organ until the whole thing turned pink. It was so amazingly alive compared to the old liver. Everything had gone well. We scrubbed out at 8:30 while the residents finished suturing.

Tonight I am on call, but I'm not doing too much. I'm tired and not really in the mood to stay up all night. Fortunately, I am here with the same cool resident again, and he didn't mind that I showed up three hours late for call. He also told me it's ok if I leave, and I think I will do that in another hour or two. All in all, this was a pretty awesome day. I don't want to live a surgeon's lifestyle, but I can definitely understand why surgery is so appealing to a lot of people.

More Cool Subspecialty Surgeries

I've scrubbed in for a lot of cool surgeries in different subspecialties this week. Tuesday it was ortho, as I've already mentioned. Wednesday I scrubbed for a mastectomy. This was a lot more interesting than I expected it to be. The surgeon I scrubbed with does what is called a nipple-sparing mastectomy. Besides him, there is only one other surgeon in the entire country who does this particular procedure.

In a nipple-sparing mastectomy, the surgery team takes out all of the fat and glands from the breast, but they leave behind the skin and nipple. They also remove what are called the sentinel lymph nodes (lymph nodes closest to the breast) from the patient's armpit. This is done instead of taking out all of the lymph nodes in that area. The benefit of taking out fewer lymph nodes is that it decreases the chance that the patient will get really bad edema (swelling) in that arm. Edema can occur because with the armpit lymph nodes gone, fluid tends to back up in the arm with nowhere else to go. It's cool how they find the lymph nodes, too: they inject a blue dye (methylene blue) into the breast, and the dye gets carried out into the lymph nodes under the patient's arm. This dyes the lymph nodes that are closest to the breast a dark blue so that the surgeon can see them. The nodes are pretty small, about the size of a pencil eraser.

The woman can choose either to have implants placed in the breast during the surgery, or use temporary implants so that she can see what she'll look like before having permanent implants put in, or not have any implants at all. Some women choose not to have implants because of all the problems (leakage, immune reactions, more difficulty screening what is left of the breast tissue for cancer, etc.) that can happen with implants.

The main question that occurred to me while I was watching all of this was how they can keep the nipple and skin of the breast from dying. They are removing all of the tissues underneath, so how does the nipple get enough blood supply? Well, amazingly, it does.

Yesterday, I scrubbed for a nose septoplasty with an ENT (ear, nose and throat) attending and his resident. The surgery was cool to see, but I didn't get to do anything since it's all laparoscopic. It's also really tight to be in there around the patient's head with a few other people! ENT is cool, but as you can probably imagine, it's also pretty gross. The attending was surprised that I thought ENT was grosser than colorectal surgery, but I did. Somehow, sinuses full of snot and pus kind of get to me.

This morning, we had our normal surgery and medicine case presentations. I have to present again for surgery next week since there are only two of us in my group on surgery right now, so that kind of sucks. I'm getting a little tired of preparing these presentations. It's a lot of work, especially when you're on a time-intensive rotation like surgery. Afterward, we had a seminar on coughing and shortness of breath. That was pretty good. There were a bunch of cases, and an internist and surgeon went through them with us.

In the afternoon, we had an FCM session about apologizing to patients for medical mistakes. We had to do an exercise where one person pretended to be the doctor who had to explain about a mistake, and the other person pretended to be the patient. I was "lucky" enough to be selected to play the doctor, and I was doing my best to try to explain the mistake (the patient was given an antibiotic she was allergic to) the way I would have really done it. My partner kept laughing every time I looked her in the eye and started talking. After a few false starts like that, she started apologizing to me for not being a good actor, so by then, everyone was laughing. To add insult to injury, one of the faculty came in to tell us that we had standardized patients we could use instead of having a student pretend to be the patient. At that point, we were all hysterical. My classmate told me later that the reason she kept laughing is because I looked so serious. :-P

Next week is my last week on surgery. I just found out that my oral exam will be on Tuesday afternoon, so this is not going to be a weekend of fun and games. Tuesday night is also my last call. Yeah, I really know how to have a good time.

Drunk Driving Aftermath and Total Knee Replacement

My Saturday call was pretty quiet, so I wound up leaving at 10 PM. I had the same cool senior as last time, and mainly I just ate dinner and hung out with him for a few hours. He had taken some time off before going to med school, and I found out that he had been a chaplain for a few years. That is probably the most interesting thing I have ever heard of someone doing before med school. It's especially interesting that he went from being a chaplain to being a surgeon! Sunday I mainly spent working on the questions for the oral exam. It's going faster now that I've been dividing up the questions with the other surgery students, but sadly I am still not done.

Yesterday, I was in clinic all day with my surgery attending. We spent a couple of hours with one patient who had a very sad story. He was a college kid who was driving drunk on the highway when he lost control of his car and hit a tree at high speed. The airbag deployed and saved his life, but his lower body was crushed. There was a girl riding with him who was killed. We were seeing him because he had become fecally incontinent since the accident. He had to have several tests to measure his anal sphincter function, and at the end, the attending told him that unfortunately, there wasn't anything she could do. The kid didn't say much, but his mom was sobbing. It was really awful on so many levels. Maybe the worst thing is that all of this tragedy was preventable. Now this guy will probably have to spend the rest of his life in a wheelchair, wearing diapers, and living with the knowledge that he killed his girlfriend, all because he made a really dumb decision to get behind the wheel that night.

Today I scrubbed in for an orthopedic surgery. It was a bilateral knee replacement, and it was really cool. The patient couldn't have general anesthesia, so he was awake and talking to the anesthesiologist the whole time. That was kind of weird. But I got to watch a spinal block, which I hadn't ever seen before. It's kind of like a spinal tap, except that instead of withdrawing spinal fluid, the anesthesiologist injected anesthetic. Then the patient was prepped like normal. I mostly watched for the first knee, but I got to do some drilling and cementing for the second knee. At the end, the attending left the intern and me to suture up the patient's knee. It took us a while since neither of us was very experienced, and the anesthesiologist and scrub nurse were kind of getting annoyed with how long we were taking, but we got it done in the end.

I don't really want to be an orthopod, but I can understand the appeal. You get to play with a lot of cool hardware and instruments that don't get used in other surgical fields. It's also very physical work and requires a pretty good understanding of geometry and biomechanics. For any of you readers who ever scrub into an orthopedic surgery, make sure you wear a face shield, because it's messy. Also, you might not want to make a knee replacement the first surgery you see, because it's a lot bloodier than the other surgeries I've scrubbed for. Fair warning!

Finishing My Second Week of Surgery

The rest of this week has been a lot easier than last week was. Wednesday, I scrubbed into a pediatric hernia surgery. That was an incredibly pleasant experience compared to scrubbing into adult surgeries. The peds OR areas are decorated with cartoon characters and colors instead of being stark and white. The scrub nurses are really nice. (For anyone who has never done a surgery rotation, the phrase "nice scrub nurse" is almost an oxymoron.) I didn't get to do very much besides retract since the patient was a little kid, but it was still a good experience nonetheless.

Yesterday, I lucked out and got a study day because my attending was off doing surgeries at one of the satellite family centers. I'm still working on those surgery prompts for the oral exam, which I have to be ready to take in nine days. But I got a lot done yesterday, because the only clinical thing I had to do was go on rounds in the morning and evening.

I also had to present a patient at morning report today. Since I didn't have a really good surgery case, I decided to present the patient with abdominal pain who I saw on my first call night, the one who turned out not to have a surgical problem at all. The presentation went well, and the surgeon who was leading the discussion wrote me a very complimentary eval. Afterward, we had our medicine presentation, and then our seminar was on diabetes. That was a bit crazy, because the original seminar leader was sick or something and didn't show up. So the block leader led the seminar instead. To her credit, she did a pretty good job, especially considering that she didn't find out she was going to have to do this until the last minute.

This afternoon, we had a research seminar on designing questionnaires. I don't think I'd have liked it even if I wasn't sleep deprived and cranky from being on surgery, but that certainly didn't help. They also made us do this stupid group exercise. All in all, I am really starting to hate these Friday afternoon seminars. I understand that physician scientists need to know things like how to tell if a questionnaire is properly designed. But I still don't think it's necessary to make us sit through three hours of it on a Friday afternoon when it could have been covered in one hour. Plus, I still had to go on evening rounds afterward, so I didn't get much of a break.

Tomorrow night I am on call again with the same senior resident I had call with last time. Amazingly, I am actually looking forward to taking call this time. It doesn't hurt that I'll get to have Sunday off afterward, either. :-)

Dealing with Being Post-Call

Saturday I came in to round on my patients in the morning, and then I spent most of the day working on my surgery questions for the oral exam. Sunday I did my laundry and all that kind of stuff that is hard to get done while you're on surgery. Later, I went in for my call night, which started at 6 PM. I had a different senior this time because the residents are on a new rotation month now. After we introduced ourselves, he told me that I could do whatever I wanted. I jokingly asked if I could just go home, and he told me, "Go ahead if you want." I have to admit that I was more than a little tempted, but I decided to stick around for a few hours at least. I mean, I was already there anyway, and the administration would probably not be too happy if they found out I had blown off my call completely.

The first page we got was for a patient who had just coded and died in the ICU. The senior had to pronounce him dead. So we went to the ICU, parted the curtains, and there was the patient, lying in bed like any other patient, except that the heart monitor and the respirator were eerily silent. My senior handed me a pair of gloves and told me to feel for a pulse at the patient's wrist. While I was doing that, the senior was feeling for a pulse on the man's other wrist. The patient had obviously just died, because he was still warm. I didn't really feel much of anything, but the senior told me to keep pressing on the man's wrist. He said, "If you wait long enough, you will start to feel a pulse." Sure enough, I did feel one after a minute or so. It was really freaky. He told me, "That's your own pulse you're feeling." Wow. We filled out the patient's paperwork and the senior signed the death certificate. I decided that I was going to hang around some more.

One of the interns was in the surgery resident office when we got back. She got paged a few minutes later, and I went with her to see the patient. This patient was a woman who was post-surgery for breast cancer (lumpectomy). We took her history and did an exam. All of her lymph nodes on that side had been removed, so she had really bad lymphedema (swelling because there are no lymphatic vessels to take the fluid from the tissues back to the blood vessels). Her arm and breast were swollen to the point that they were at least twice the size on that side versus the normal side. Unfortunately, there's not any surgical solution to lymphedema. We had her elevate the arm and told her to keep it elevated. Then we paged the senior to discuss whether the patient needed antibiotics, too. I wrote a note and the intern corrected it and gave me some feedback.

Things slowed down for a while, and I practiced tying knots a little, then just hung out with the senior in the resident office. Around 2 AM, I was getting pretty tired, so I decided to go to bed. I had to get up at 4 AM to pre-round, but at least I got a couple of hours of sleep. I wasn't feeling so hot though. My attending had clinic all day Monday, so I went in for the morning. It felt like the room was spinning, and I was pretty nauseated. I asked one of the nurses if I could lie down for a minute when things got slow, and I managed to doze off a little. My attending didn't realize that I had been on call the night before, so she thought I'd be there in the afternoon, too. I told her that I would stay if she wanted me to, but she said I should go to bed since I was post-call. I didn't need to be told twice.

This morning, I was supposed to scrub in for a vascular surgery, but it got cancelled. So I went and scrubbed in with my regular team, and it was a crazy day. We were in the OR for 12 hours, during which we did four surgeries with no meal breaks. I was really glad I had at least eaten breakfast. Today she let me suture, and I am getting pretty good at it. But now I feel too tired to eat and too hungry to sleep. The one good thing about missing so many meals on surgery is that you don't gain weight.

Here are the answers to a couple of surgery questions that I have been asked. First, yes, it really is possible to doze off in the middle of an operation. Assuming you are just standing there retracting and no one is pimping you, it's quite simple to close your eyes for a few minutes here and there. Second, needing to use the bathroom during the surgery has not been a problem for me so far. I go right before it's time to scrub in, and then since I'm often not eating or drinking anything all day anyway, it hasn't been an issue. I do come out of the OR feeling really parched though. When you first walk into the OR, it's freezing cold. But once you get gowned and gloved and those hot lights are beating down on you, it gets warm enough to make you start sweating. If the patient is being warmed by the anesthesiologist, oh wow, that really gets uncomfortable.

First Call

I had my first call on Wednesday this week. It was kind of rough, mainly because I felt like a total jerk by the time it was all done. CCF has a night float system, which means that the residents who are here at night get to sleep during the day. However, the students do not get to sleep during the day. So I was in clinic in the morning, in the OR all afternoon, and then on call that night. The senior resident had me go see a consult in the ER who was having abdominal pain. My patient was an elderly man and kind of out of it because he had been given pain medication, but he was still in a lot of pain. I had no idea what was wrong with him based on the history and physical. Really the only thing I could find was that his stomach hurt any time he moved, and there was a huge bruise on the lower part of his stomach where he had been injecting himself with blood thinners.

When I went to present to the senior, I wasn't the most organized. Afterward, I realized that I should have taken notes while I was talking to the patient, because my memory was just shot by that point. Somehow, I muddled through with the resident correcting my presentation every few sentences, and then the resident asked me if I had done a rectal exam. Done a what?!?! He scolded me a little for not having done one. We went to see the patient and he did it himself. The poor patient was in pain every time he had to move, so rolling over for the rectal wasn't exactly a small ordeal. I had spent a couple of hours doing my history and physical, and then the resident poked and prodded the patient for another half hour or so. I still couldn't figure out what was wrong with the patient, so the resident finally told me that the patient had a rectus sheath hematoma. That's basically a fancy name for a big abdominal wall bruise. I found a review article about it, read it, and wrote up my patient log. At that point, it was 2:30 AM, and the resident told me to go to bed.

I was feeling pretty bad about having basically tortured this patient for a couple of hours for something that wasn't even a surgical problem. The building where the call rooms are was completely deserted except for a janitor who was mopping the floor. As I passed by him, he said, "Good night, Doc." That made me feel even worse.

Yesterday morning I was back in the OR with a different attending who was doing a laparoscopic repair of a hernia. The senior on this team was into teaching, and she let me do some suturing. Fortunately, I had been practicing while I was on call and at home. There are some really good websites that have instructions for suturing. My favorite is the site from Boston University. I also got to drive the camera for a while, which is a lot harder than it looks. It was a good experience, but I was feeling kind of sick because I had only gotten about two hours of sleep. But since I was post-call, I got off at noon and could go take a nap. At 5 PM, I met my team for evening rounds, which was incredibly stupid of me. We didn't get done until 9:30, plus my attending gave me three new learning objectives to do. That's what I get for trying to be responsible and part of the team. Sigh.

Today we had another point-counterpoint presentation, this time on the best way to treat atrial fibrillation (quivering of the upper chambers of the heart). I wasn't presenting this time, and it was a lot less fun being in the audience. Afterward, there was a seminar on treating blood clots. In the afternoon, we had another round of meetings with the Block Assessment Team. I can't even put into words how much I hate these stupid, pointless BAT meetings! I was so tired and cranky and not in the mood for this. It was hard to stay awake all morning in class, and then I was sitting around in the libary on my so-called afternoon off, waiting to have a five minute meeting so that the faculty can tell me I'm doing fine so far. Don't even get me going about how they assign the order for our meetings. After the block leader changed the order around for the third time today, we didn't wind up meeting with the BAT in our scheduled order anyway. Stupid, stupid, stupid.

Surgery is Awesome!

My weekend wasn't very exciting, and I didn't get very many of the questions done. At first I wanted to try to do them all myself, but now I realize that it's impossible. Each question takes me like 3-4 hours, and there are 20 of them. So now the students are working on different questions and sharing our answers.

This morning I got up at 5 AM and went on rounds with the fellow at 6 AM. Then we went to the OR. Today was my first day scrubbing in, and it was just amazing. No one yelled at me for my scrubbing technique, and I muddled through getting gowned and gloved with the scrub nurse's help. Our first case was for a patient who needed part of his colon resected. The surgeon hands me the scalpel and tells me to go ahead and make the incision. After hearing stories from my friends at other schools about how all they did was just hold retractors and get pimped, I was not prepared for this. I didn't even know how to hold the thing! So she showed me, and I muddled through that too, albeit with some comments that I was not carving a turkey. I didn't mind her mocking me a little bit though, because it wasn't malicious. Then she hands me the bovie (an electrocautery instrument--see picture) and tells me to cut through the fascia (layers of connective tissue under the skin). So I did that too.

Next, she and the fellow started working on the colon, and she asked me to hold the small intestines out of the way. While I was doing that, I had some time to just observe everything that was going on in the surgical field. I was watching the arteries pulse all over this patient's abdomen. There were big ones and little ones, all pulsing in unison. It was awesome. Then I noticed that the patient's intestines were moving in my hands. I was watching as they were peristalsing (contracting by segments--this is how the intestines move food through down to the colon), and I could actually feel them moving. It was incredible. I don't think I'll ever forget that feeling for the rest of my life. We closed up the patient and I got to do the staples. That was surprisingly easy and fun to do. Using the surgical stapler is not so different from using a regular desk stapler.

By this point, it was 1 PM and I was so hungry that my stomach felt like it was eating itself. The surgeon turns to me and says that she and the fellow are going to start the next case. Was I doing ok? Of course, I wanted to scrub out and go eat lunch more than just about anything, but how could I do that while she and the fellow kept going? There's no crying in surgery! So I told her that oh, no, I was fine to go for another case. Fortunately, the second case went faster, and by 3 PM, the fellow and I had about 5 minutes to run downstairs to the cafeteria and wolf down a sandwich before we went back for the next case. We did four cases in all, and then we went on evening rounds. The surgeon didn't really pimp me in the OR, but she did pimp me a bit on rounds. It wasn't awful though. I knew some of the questions and didn't know some of them. Overall, this was a very long but good day, and surgery is much cooler than I could have possibly imagined.

Preparing for Inpatient Surgery

I'm done now with all of the surgery subspecialty outpatient clinics. Since I'm going to be on the colorectal team, I had a half day of general surgery on Wednesday morning. I also had half days of urology, vascular surgery, and pediatric surgery. Most of the general surgery patients I saw were men who needed hernia repairs, really basic bread-and-butter stuff. My urology preceptor was a pediatric urologist, so I saw a bunch of kids with undescended testicles. Just in case any of you are new parents and worried, the testicle will usually come down in the first year or two of the kid's life without requiring surgery. Vascular surgery is really cool. The attending I worked with does 3D imaging of the patient's aorta and other vessels that have aneurysms. (Aneurysms are weaknesses in the blood vessel wall that lead to it expanding, kind of like a balloon. If they get too big, there is a danger that they could burst and quickly kill the patient.) Then he orders grafts that are made in Australia. It takes a few months for them to arrive since each graft is custom-made for that particular patient.

I have this weekend off and should be starting inpatient surgery on Monday. But I lucked out and got the day off for Labor Day since it's the first day for the two of us on this track. The other current surgery students who started the week before us did not get it off. (They are on a different track.) So needless to say, the two of us did not publicize this good fortune. It's not like I'm going to be spending the weekend doing anything fun anyway. We have 20 work-intensive surgery question prompts that we have to prepare for an oral exam at the end of the rotation, and that's what I'm going to spend this weekend doing. I know there won't be a lot of time to work on these prompts once things get going on Tuesday!

Outpatient Surgery and Orientation

This is my first week of surgery, and I have outpatient subspecialty clinics all week. Starting next week, I will be on inpatient surgery. The rationale for having this outpatient week is that I am supposed to try to scrub in for a surgery in each surgical subspecialty. So far I have done one half day each of orthopedic surgery, breast surgery, and ENT (ear/nose/throat, also called otolaryngology). I also had orientation this morning along with one other student who is starting surgery this week with me.

The ortho clinic was really cool, and the attending spent a lot of time teaching. He had a whole collection of replacement joints. Some were modern, and others were the kind that got used a few decades ago. We also looked at several x-rays, and he showed me what to look for to identify osteoarthritis. I'm not very good at reading x-rays, but even I could see the jagged edges of the cartilage in a patient with severe osteoarthritis. The breast clinic wasn't as exciting. I've already done several breast exams, so there wasn't much new. I did get to see some mammograms. It's hard to see the calcifications if you don't know what you're looking for. ENT was pretty cool, but it's also kind of disgusting. One of the patients had an in-office nose procedure, which I got to watch. Another had a sinus infection. We put a scope up his nose into the infected sinus, and when I looked through it, I could see all the green, infected mucus up there. Wow, that was gross. No wonder that patient was in pain!

The orientation was this morning. It wasn't all that exciting. First, we saw a video that I swear was made in the 1970s based on the clothing and hair styles. It was describing sterile technique and the importance of sterility in the operating room (OR). Then we got a tour of the ORs, and there are lots of them. There is also a stairway I didn't know about until today that leads from outside the ORs straight down to the cafeteria. That's a useful stairway to know about! Then we were given scrubs and lockers up in the ORs. Unfortunately, we have to share them with other people. Seeing the ORs again has gotten me excited for next week. I'm a bit nervous too, because surgery is so different than anything else I've done since I started med school. But I think this is going to be a very interesting month.

End of Outpatient Medicine

We had another P/CP today on gastroesophageal reflux disease (GERD). It's a lot easier participating in these talks as part of the audience instead of one of the speakers, but it's a lot less fun. Basically, this was another surgical treatment versus medical treatment case. After the debate, we had a seminar on dysphagia (difficulty swallowing) and hematemesis (throwing up blood). It's not the most appetizing discussion to have right before lunch, but it was a pretty good seminar. In the afternoon, we had an FCM session on empathy. We were asked to read a couple of articles about doctors who had become patients and found themselves treated without much empathy. We also had to write a brief essay about an example we saw from our rotations where a doctor did not treat the patient with empathy. I wrote about the GI doctor I worked with last week who wouldn't stop to answer any of the patient's husband's questions.

I'm done now with outpatient medicine. Cards was a lot better than GI, but I still am glad that this rotation is over and ready to start something new. Monday I start surgery. I will have a week of outpatient clinics, then four weeks of inpatient surgery on the colorectal team. This is with the same surgeon who evaluated my P/CP debate last week. The word is that she loves to teach, and the med students get to do a lot on her service. I hope that's true!

Outpatient Medicine and Cards

This week is my last week of outpatient medicine. I still have general medicine clinic in the mornings, but now my afternoon specialty outpatient clinics are in cardiology. Many of the patients are here to follow up for pacemaker placements or MIs (heart attacks). But I had one patient whose cardiac problems were at least in part due to psychiatric problems. She told me that she measures her blood pressure every hour or two, at least a dozen times a day. She always brings her home cuff and the meds with her to work so she could take both all day long. She was worried because her pressure is always high, and she takes extra blood pressure meds whenever it's too high. The problem now is that sometimes she was getting dizzy and feeling like she might faint.

I wasn't quite sure what to do. Usually, we can't get patients with high blood pressure to take their blood pressures and meds consistently. This was the first time I had seen a patient who was massively overdoing the monitoring and taking too much medication! She had kept a thorough record of every reading from the past month, and not even one of her measurements was above normal (120/80). So I explained all of this to the attending, and then we went in to see the patient. The attending explained to her that she shouldn't take her blood pressure more than once or twice a day at most, because worrying so much about her blood pressure was probably making it higher. He also told her not to take more of the meds than had been prescribed. I could see that the patient was skeptical though. Now that I'm thinking about it, we should have probably referred her to psych, because she's obviously obsessive-compulsive enough that it's affecting her quality of life.

Surviving GI and Point/Counterpoint

This has been a rough week. Wednesday afternoon, things started out well. I had a preceptor who seemed to really like teaching. He spent a lot of time with me going over the differential and treatment for my patient's disease. But then when we went into the room to talk to the patient, the doc started talking at her about treatment options and didn't bother answering any questions or explaining anything. She sat stolidly and said nothing, while her anxious husband looked at me and pantomimed what he thought the doctor was saying. I tried to pantomime back, but it was an awkward and embarrassing experience. After the doc and I left the room, he told me not to bother submitting an eval, because he wasn't going to fill it out anyway. Of course that annoyed me, but I felt a lot worse about what had happened in the exam room. When the doc dismissed me for the day, I left by a side entrance because I just didn't feel like I could face the patient and her husband.

As bad as that experience was, yesterday took the prize. It turns out that the doc I was supposed to work with had cancelled clinic for the day, but no one had bothered to tell me. While I was hanging out once again in the hallway, I struck up a conversation with a patient and his wife. This happened because I had gotten my white coat caught on the door as I was going out of the administrator's office, and this patient started laughing at me. I thanked him and offered to do an encore. The next thing I knew, I was sitting with him and his wife in the hallway, and the patient was telling me all about his GI issues. I figured since I had gotten his whole history anyway, I might as well get some credit for it. So I asked him who his doctor was, got his doc's permission to see him officially, and went on from there. That doc was really awesome. He went out of his way to make the patient feel comfortable, and he spent time teaching me as well.

Today we didn't have morning report because we had a surgery/medicine debate (called Point/Counterpoint or P/CP) about the best treatment for ulcerative colitis (UC). UC is an inflammatory bowel disease similar to Crohn's disease, but it mainly affects the colon. There were four of us who participated. We were given a patient scenario and then assigned to take sides. Two people discussed the basic science behind the medicine and surgery options, and the other two debated the actual treatment options. I was assigned to advocate for surgery to remove the patient's colon. Apparently most people in the past have debated with powerpoints, but I didn't want to do that. What kind of passion can you show with your audience staring at a powerpoint? So I decided to do my presentation with just a page of notes to jog my memory. The surgeon who was in charge of the debate snapped at us when she heard that my partner and I hadn't made powerpoints. But when I got up there, I really did my best to make the pro-surgery case. Out of the corner of my eye, I could see the surgeon furiously scribbling notes the whole time I was talking. When I was done, she didn't say a word to me. She just told the medicine people to come up there to present. That was how I knew she thought I had done a good job.

After P/CP, this same surgeon gave us a seminar on anal diseases. Some of the more interesting things I learned were that sitting too long on the toilet increases the chance of getting a rectal prolapse, and that hemorrhoids are only painful if they're external. That has to do with the nerve supply to the anus, which is different than the nerve supply to the rectum. I also learned that everyone has hemorrhoids, because hemorrhoids are just veins that drain the anus and rectum. The last thing I learned is kind of the stuff of nightmares, and that is about the existence of anal fissures. Wow, talk about a disease I hope I never see, let alone experience....

My last class today was POD, aka ARM. This class is incredibly painful. Picture this: it's Friday afternoon, you're exhausted from the whole week, and now you have to sit through a three hour seminar on how to write abstracts for scientific papers. The worst part was when they broke us up into groups, and we had to write an abstract on a project that we basically knew nothing about. All in all, it was the perfect rotten ending for a generally bad week.

Outpatient Medicine and GI

The bronch I was supposed to see yesterday wound up getting cancelled, which was disappointing for me--I'm sure my patient was relieved though. This week, I still have general medicine clinics in the mornings and specialty clinics in the afternoons. General medicine clinic has been very slow so far. For some reason, a lot of the patients are no-showing. On the bright side, it gives me a lot of time to write my patient notes and get my logs done during clinic, and that means I have my lunch hours free (and sometimes even get to go to lunch early!).

I have GI clinic in the afternoons this week. So far that has not been the greatest experience. Yesterday, my preceptor showed up to clinic an hour and a half late. I only got to see one of his patients because after a while I got tired of waiting for him and just went to see the patient on my own. He showed up when I was done with the interview and about to start the exam, and he took over from there. After that I pretty much just shadowed him all afternoon. It's a good thing I went and saw the patient when I did, because otherwise I probably wouldn't have gotten to do anything on my own. I was also annoyed because he kept me until 6 PM for no good reason. One of his patients was late and showed up at 4:45 PM. It was only supposed to be a 15 minute appointment, so we should have been done on time or at most been 15 or 20 minutes late. Instead, he spent 45 minutes with that patient and then made me stay an extra half hour afterward so that he could tell me about how stressful his job was. I am supposed to work with him again on Thursday. Wow, can't wait.

My GI preceptor today was a little better, but I still had a kind of strange experience. He sent me in to see a patient with one of the fellows. The fellow was really nice and well-intentioned. He was demonstrating how he does the complete abdominal exam for me. Considering that I got no teaching yesterday, I was very appreciative that he was making this effort. But he was basically ignoring the patient. After some time, the patient made a kind of funny noise, and the fellow asked her if anything was wrong. The patient said, "I feel like I'm some kind of guinea pig." The fellow started stammering that I am a med student, and he was showing me how to do the exam so that I could learn, etc. etc. I turned to the patient, who was a graduate student, and introduced myself. Then I asked her what she was studying. After we chatted for a few minutes, she was fine, and the fellow and I continued with the exam. When we came out of the room, he kind of laughed and shrugged about what had just happened.

I was pretty surprised he still didn't seem to realize that the patient just wanted us to include her in the conversation. I guess his med school didn't make him take any classes to learn how to communicate with patients. Maybe all those communication classes that we had to take over the last two years weren't so stupid and pointless after all!

One Quarter Done with Block One

I am officially 1/4 of the way done with this entire block as of today. It was a good week up until today. I spent the mornings in general IM clinic, which is pretty much like the longitudinal clinics we did last year. The main difference is that this year there is a lot more focus on differentials and treatment instead of physical diagnosis skills. I spent all of the afternoons in the pulm clinics and that was really cool. After two days of lung transplant clinic, I had one day of asthma clinic and then a patient yesterday who was just really cool and interesting. He needs a bronchoscopy on Monday morning, so I am going to go for that. The patient himself asked if I could come, which was a real compliment as far as I am concerned.

Today we had classes in the morning and then our first Block Assessment Team (BAT) meetings in the afternoon. The lecture was on wound healing and it was ok. It was nice not having class in the afternoon, but those BAT meetings are pretty ridiculous. We had to come up with a learning plan based on our evals so far by Wednesday, which seems like a sensible requirement. We were also required to fill out evals on the preceptors and on the rotations we've completed so far, which seems reasonable enough as well. Of course, the stupid eval system locked all of us out and there was a whole to-do for us to get the evals done by noon yesterday like we were supposed to. But in the end, I got them all done in time by working on them during clinic yesterday morning.

Next, some mysterious combination of the order we filled out the evals, where our last name falls in the alphabet, and the alignment of Venus with Mars was used to generate an order for when each of us would meet with the BAT. This order was guarded like Fort Knox and only revealed to us on the morning of the BAT meetings (this morning). The order was also changed at least two or three times during the course of the morning, thus making it impossible to plan anything for the entire afternoon. So basically, what we did all this afternoon is hang around in the library complaining about how stupid this system was while awaiting our turns to meet with the BAT.

The BAT has one family med doc, one internal med doc, and one surgeon on it, although my team's surgeon was in the OR and couldn't come. When you go in to meet with them, they have copies of your evals and your learning plan. The meeting lasts about five minutes, most of which is spent chatting about nothing in particular. Then they told me that it seems like everything is going well so far, and keep up the good work. I went out and told the next student it was his turn, and that was it. So much for my afternoon off.

Outpatient Medicine and Pulmonology

For the next three weeks, I will be doing general outpatient medicine in the mornings, and then specialty clinics in the afternoons. The general medicine clinics are exactly like the longitudinal clinics that I was doing for the past two years on Tuesday afternoons. In fact, I even spent yesterday morning in the exact same clinic that I worked in first and second years (though not with the same preceptor, because my old preceptor is now out at one of the suburban satellite centers). The general medicine clinics seem downright slow after the hectic bustle of the family medicine clinics. I am only seeing two, maybe three patients each half day, and I never have trouble finishing my notes or logs before lunch. To be fair though, the IM department cuts back the schedule so that the preceptors have more time to teach us, and the patients tend to be older and have more complex problems compared to the typical family medicine patients.

My specialty clinics for this week are all with pulmonologists. These are lung specialists. It's a really cool and interesting specialty. I spent the past two afternoons working with people who evaluate patients for lung transplants. Most of the patients have chronic obstructive pulmonary disease (emphysema) due to having smoked for a few dozen pack-years. (A pack-year is equivalent to 365 packs of cigarettes, or one pack of cigarettes per day for a year. So someone who smokes two packs per day is actually accruing TWO pack-years in a year.) There are a lot of factors that go into deciding whether to list someone for a lung transplant. First of all, the patient has to be sick enough to need a new lung (or pair of lungs), but not too sick to perform the surgery. Second, there are many psychosocial factors that come into play. If the patient is still smoking or doesn't have enough psychiatric or social stability to comply with the demanding anti-rejection regimen that they will need to take for the rest of their life, they won't be eligible for the transplant.

I learned several interesting things from the past two days. One is that the Cleveland Clinic performs the second largest number of lung transplants in the country. (Interestingly, the preceptor wasn't sure who performs the most!) Another is that Cleveland Clinic operates on much sicker patients than most other centers do. For example, one of the restrictions for lung transplants is age, but some of the patients who have received lungs here are older than the upper limit. The last thing I took away from these past two days is a strong reminder of the importance of talking to patients who smoke about quitting in the general medicine clinics. The COPD patients have to have a really awful quality of life by the time they are sick enough to merit being listed for a transplant. They're in wheelchairs and have to be on oxygen all the time. They can barely speak one sentence without getting short of breath. And all of this suffering is for what, exactly? It is sickening to see teenagers or young adults smoking and know that in a few decades, they could end up in this exact same pulmonology office with a life-threatening illness that is entirely preventable.

Tips for Doing Well in the Family Medicine Rotation

Here are my tips for doing well in Family Medicine.

1) Be enthusiastic. This is good advice for every rotation actually, but especially in the outpatient clinic. You might feel like you have no intention of going into family medicine (which I don't), but that doesn't mean you can't learn something from the experience or that it isn't important.

2) Read about your patients. Even though your contacts with most of the patients will be short-term (just one visit) because the rotation is so short, you should still read up on the patients and learn more about their diseases. Discuss what you read with your preceptors.

3) Be on time. This should be an obvious thing, so don't be "that student". You'll be fine if you always keep in mind that it is ok for you to wait half an hour for the attending to show up, but the opposite is not true! ;-)

4) Keep up with your logs. You should write your H & Ps and fill out your logs every day (every half day if possible). Yeah, it sucks spending your lunch hour writing logs and H & Ps. But you see so many patients in the family medicine clinic (I'd usually see about 8 per day on average) that there is just no possible way that you will remember what you saw or did if you don't write the notes as quickly as possible. Plus, if you get all of the notes done while you're in clinic, you won't have to write them at home.

5) Read a family medicine book. The book that was suggested for this rotation wasn't very helpful, in my opinion. It's too long to possibly get through during a three week rotation. Get Case Files: Family Medicine instead and read it cover to cover. That's definitely doable in three weeks.

6) Submit EVERY log for assessment. Some preceptors won't write you an eval. If you submit every log, you will have no problem getting enough evals for the rotation. Just be sure to batch them each half day so that the preceptor isn't getting like four different eval requests per day.

7) Any time a preceptor asks, "Hey, would you like to do....?" always say yes. Stay the extra half hour, do the extra Pap smear, interview the extra patient. The more interest you show in learning, the more willing the preceptor will be to teach you something interesting.

8) Be nice to the nurses and MAs. Yes, they have been in medicine way longer than you have. Yes, they do know more about clinical stuff than you do. Yes, they will talk about you behind your back if you're an arrogant idiot. I was hearing stories about previous med students who are long done with their residencies by now....assuming that they made it through the rest of their third years!

9) Work your way into the rooms one baby step at a time. Sometimes you may run into patients who don't want to see a med student. What you should do is ask them if you can just talk to them for a couple of minutes to get their meds or find out why they came in today. You can even point out that it will speed things up since you can put their info into the computer for the doctor. Once they have been talking to you for a while and you have had a chance to build up some rapport, you can then ask them to let you listen to their heart and lungs. While they're on the exam table, you can throw in an HEENT exam or an abdominal exam if appropriate. This strategy worked for me every single time. I never had a patient refuse to let me talk to them "just for a couple of minutes," and I never walked out of the room without doing a focused physical exam. The key is that you need to project an attitude of confidence and humility at the same time.

10) Even if you hate family medicine, look at the bright side. It's only a few weeks, and there are no weekends or calls. You're totally going to miss this rotation once you start slaving away 80 hours per week on one of the inpatient services!

First Presentation

I did my first presentation today, and it went well. We wound up discussing the patient's psychosocial issues and how they could be contributing to her problems with headaches. It's interesting that so many people have these nonspecific complaints (headaches, stomach aches, muscle and joint aches). They go to multiple doctors and no one can figure out what is wrong with them. Maybe they have some random degenerative changes on an x-ray that are related to their pain, and maybe those changes are just coincidental. It's tough to know. But regardless, there are a lot of depressed, anxious, and stressed people out there, and it's important to ask people about their moods and stress levels. You cannot be in good physical health if you are not also in good psychological health.

First Rotation Done

Today was my last day of Family Medicine. I can't believe how fast these three weeks have gone by. I went around to thank all of the doctors and staff and to say good-bye, and they were amazed at how fast the time went too. I am going to come back this winter for a physical, though. It turns out that the Cleveland Clinic doctors are on the new Student Health plan that we have through Case this year. (This is the third insurance company that I've had since starting medical school, which is a whole other nuisance, but I won't get into that now.)

Tomorrow we have didactics. I'll be presenting one of my patients for the IM/FM morning report, and the group will be going over the differential diagnosis for headaches. I chose this patient to present because we haven't gone over the differential for headaches yet, and I thought her case had some interesting psychosocial issues that could be contributing to the problem. After that we will have a clinical seminar about chest pain, and I have the POD research class (I still can't get used to calling it ARM) in the afternoon. So it's going to be a long day, because the third year POD/ARM class is three hours long and we have a class meeting after that. Yikes. 7AM to 5PM with an hour off for lunch is a lot of time to spend in the classroom. At a school like CCLCM, a full day of classes ought to just about qualify as treason. I mean, one of the reasons that I came to this school was so that I wouldn't have to spend all day in classes!

End of Second Week

I'm done now with my second week of family med, and the time is really flying. I am still having a great time. You never know what you're going to see when you come into the clinic. Yesterday I got to observe and help a bit with a minor outpatient surgery. I also met a really fascinating patient who survived pancreatic cancer. The coolest part of his story is that the cancer was found incidentally when he participated in a research study that involved imaging his abdomen. He was extremely lucky that it was found so early, because pancreatic cancer is often too advanced to be cured by the time it becomes symptomatic.

Today we had classes. Like I said before, there is never clinic on Fridays unless you are unlucky enough to have call Friday night on one of the inpatient services. Again, we had a surgery patient presentation, then an IM patient presentation. For both cases, we went through the differential and talked about what studies to order to figure out how to narrow the differential. We never did figure out what was wrong with the IM patient, but that's ok. None of the docs who were caring for this patient figured it out either. After that we had a clinical rounds session on abdominal pain led by two surgeons. We didn't get through more than about half of the cases, but I can see now why the surgeon said that he likes abdominal pain so much. There is a huge differential, especially if the patient is female and of childbearing age. The surgeons ran over, but we had to stay afterward for a path presentation on appendicitis. I was having a very hard time concentrating by this point, and the UP students were upset because they had to get back to Case by noon for an orientation and it made them late. Somehow, we got this whole afternoon off, so I had plenty of time to run all of the errands that I needed to do.

Finally Got My Step 1 Score

I didn't sleep very well at all last night. I kept waking up at least once every hour, and I was having these totally bizarre dreams. In one of them, I had gotten a 34 on the MCAT, but it was a 15 VR, 4 PS, and 7 BS. (Note: VR = verbal reasoning, PS = physical science, BS = biological science.) I was worried that I wouldn't get into medical school because of the 4 in PS. (For the record, I know that these subscores only add up to 26, but somehow they added up to 34 in my dream!) In another dream, I was washing my favorite pet cat, now deceased. I had to wash him a little at a time so that he wouldn't struggle while I was bathing him. Because of this, it took me several hours to wash the whole cat. When I was finally done, he was emanating a soft, whitish light. People were crowding around and commenting about how silky and shiny his coat was.

Once my alarm finally went off at 5:20 AM, I got up and went to the computer. I had left it on all night so that I could check for my score as soon as I woke up. My heart was pounding when I logged into the NBME website and saw that the score report was indeed there. I opened it up, and the first thing I saw was the word, "PASS." This caused an immediate resolution of my palpitations (pounding heart) and tachypnea (faster than normal breathing). Then I scrolled down a little farther and saw my actual scores. Total, utter relief. I have been trying so hard for the past three weeks not to think about the USMLE that I hadn't even realized how anxious I was about it subconsciously. I feel like such a huge weight has been lifted off me. I know that this one test score is not the end-all, be-all of residency applications. But I am just relieved to know that if I don't get the residency of my dreams, it won't be because I bombed Step 1.

The score report breaks down your performance by subject area, just like the practice tests I took did. Interestingly, my best subject on Step 1 was micro/immuno, of all things. My worst? Yeah, it was anatomy. No surprise there. :-P