Surviving medical training

Greg Bratton, a recently graduated family medicine resident, writes the blog "Insights on Residency" and shared his top 10 list of how to make it through medical training intact.

 I've copied his list below:

10. In college, major in something other than pre-med. You will learn enough science in medical school. Choose something like art, philosophy, or dance. It will expand your mind, and you will become well rounded and able to communicate with patients on a “natural” level.

9. Remember that, ultimately, you are a person first and a doctor second. Patients will relate to you. They will trust in your treatment plans and adhere to your recommendations. Find time to decompress. Take weekends off. Schedule date nights. Get involved with charities. Go fishing. Do something to keep in touch with who you are as a person. Don’t let medicine define you. You were John Doe before medical school, be John Doe after.
8. Date. Get married. Have children. Some say that it is too much to handle with studying, it is too expensive, or it is “just not the right time.” I disagree. I think it makes you better. Plus, no matter how hard of a day you’ve had or how grueling your week is, when you get home, someone is there to take your mind off of it. As a buddy of mine said after having his first son, “there are no more bad days.”
7. Read gossip magazines. After hours of memorizing Robbins Pathology or Grey’s Anatomy, you’ll need something to purge your brain. And what is better than keeping tabs on Lindsay Lohan, Britney Spears, and all the other train wrecks in Hollywood?!?! In addition, it will help you understand the many psychiatric problems you will one day be diagnosing and treating.
6. While at dinner, no matter how many of your classmates or fellow residents are present, DO NOT TALK ABOUT MEDICINE!! It always happens — you go out for a relaxing evening and inevitably start talking about work. Don’t do it! It is not fair to the non-medical professionals listening. Instead, talk about sports, weather, or the latest happenings in US! Magazine (another reason #7 is so important).
5. Periodically, wear normal clothes. I think we all will agree that one of the benefits to working in a hospital is the that you can wear scrubs every day. But remember, scrubs are forgiving; they won’t let you know that you’re not tying the drawstring as tight as you used to. Whether you weigh 150 lbs or 180 lbs, you are still going to wear the same size scrubs. Put on your jeans — they will tell you the truth about your circumference.
4. Exercise. Endorphins are good. Plus it will counteract the late night Cheetos, pizza, and soda consumed while being on-call or studying. And before you say it, there is always time! Just find it.
3. Call home. Talk to your mom and dad, brother and sister, hometown friends. Just because you’re “in medical school” does not mean you get to stop being their son, sibling, or friend. They are your support. Use them, lean on them, involve them. And remember, you are where you are because of them.
2. Keep an open mind while doing 3rd-year rotations. Even if you think you know what you want to do, don’t force yourself to like it. Enter each rotation with an open mind. Go with your gut. I wanted to do orthopedics but found myself “tolerating” the OR, not loving it. Yet, I loved taking care of families, seeing the same patient routinely, and developing relationships with patients. So I chose Family Medicine. Had you told me during my 1st or 2nd year of medical school that I would end up doing primary care, I would have laughed at you. But I love it and can’t imagine doing anything else.
1. Take a deep breath and relax occasionally. Don’t be like me and wait until you receive your diploma to re-center yourself. Do it daily. Know that although the journey is long, it doesn’t have to be rushed. Enjoy the moment. Enjoy the challenge. Realize that you, too, are on your way to achieving your dreams.

It's so very relevant and serves as a reminder that first, we are people, then doctors. Easier said than done, especially the part about making time for yourself and others. I think the only point I disagree with is that it's okay, no it's necessary, to talk about medicine with your friends! I did this throughout third year and it was a lifesaver. In fact, at our school, it's mandated - we had weekly hourly small-group sessions with our fellow third years led by faculty members who did not grade us. Each week we'd tell the group how we were doing and usually, at least one of us would bring up something we were struggling with or found really difficult. These sessions became a safe place to share how we were feeling and coping, to reflect, and to find validation through others' experiences. Medicine can be so alienating, and it helped being surrounded by others who you knew could understand what you really going through. One of the guys in my third year cohort commented just the other day that it was like "we walked through fire together" and really bonded as a consequence.

P.S. I'm wearing scrubs right now.  And I'm not even on clinical rotations any more. I think I just failed tip #5. :)

Med student vs. surgery resident - best YouTube video ever!

This is the best "make fun of medicine" video I've come across so far.  Funny thing is - it is so true!

Enjoy!

Surgical culture

I just started week 2 on an inpatient general surgery service. My desire to ever venture into anything surgical has diminished even further. If first impressions are worth anything, then the surgical stereotypes ring true.

I was in the OR today with an old school surgeon. For 3 hours, the surgical resident and I put up with jokes that in any other setting would be misogynistic bordering on harassment. During the case, he tells me, "any attention [paid to the medical student] is good attention, even bad...the worst thing is to be ignored." True, but I think the implied message is I should appreciate that he is even talking to me. Awesome - I'm so grateful that this surgeon is even acknowledging my presence. Perhaps I should turn into a lump of clay. Later, he makes fun of our curriculum in cultural competency, which ironically, he may benefit from.

Rounds work something like this: there's the chief resident, the intern, the night intern, a surgical PA, and the med student. On each bay, the med student pulls all the charts and opens the chart to the proper page so the daily progress note can be inserted quickly. Then I hurry into the room, glove as quickly as possible, and hand dressings to the chief resident, whose path we've cleared so that she can enter the room first. During each 1.2 minute visit with each patient, the chief resident does all of the talking while the rest of us stand silent with gloves on ready to assist. I have never seen anything so overtly hierarchical. No teaching goes on. No one on my team has voluntarily taught unless I've asked a question and even then, the question is either fired back (which I don't mind) or answered very tersely. At times I wonder how surgical residents learn anything. There are no daily noon conferences, no morning reports, and no teaching on rounds.

I suppose I have it good though. My fellow medical student is being scutted out by her intern, who sends her down to the PACU and then to several floors throughout the hospital to collect vitals - on the entire list of patients, not just hers. Seriously, tell me why vitals are not electronically transmitted? It seems incredibly inefficient to run around to several floors, hunt down a paper vitals binder, and write down the vitals which were probably not even taken properly. It is a mess. Thank god my intern is an angel, apologizes for the scut, and sends me home at a decent hour.

Also, thank goodness this rotation is at the end of my third year. I would have been so jaded and disillusioned by now had this occurred earlier.

ED shift

I'm awake after napping over four hours after an ED shift last night, which was totally awesome. Not only did I have a fantastic resident, I was on the overnight shift with my one of my best friends, making it all the more fun.

Here's what I got to do/witness:
- Watch a trauma code (fortunately, the guy had some injuries but was stable) and suture his facial lacs (first time suturing from start to finish!)
- Witness a partial complex seizure and pull an intraosseous line. An "IO" line is a means of delivering fluids when an IV cannot be placed. It screws directly into the medial side of the tibial bone.
- Drain a perirectal abscess (ouch but the guy felt so much better afterward and was so grateful)
- Evaluate pt with abdominal pain who turned out to have gallstone pancreatitis
- Evaluate pt also with abdominal pain. Dx: rectus sheath hematoma requiring angioembolization
- Evaluate pt s/p MVA who had an impressive displaced thoracic spine fracture. Admitted to neurosurgery for stabilization in the morning
- Head down to the OR to catch the beginning of an emergency leg amputation for a pt with necrotizing fascitis. The pt was covered head to toe in purpura, on a thousand pressors, auto anti-coagulating, basically a mess...incredibly sad. The team kept the OR extremely warm to prevent hypothermia, as the pt could longer autoregulate his own temperature.

All in a night's work!

Last week, I saw a guy with Gardner's syndrome and two trauma codes, where I got to place a suture (just one haha) in one man's ear for a nasty ear laceration.

Novelty is exciting and I'm finally feeling that I'm getting to learn how to do stuff with my hands. Appropriate for a surgery rotation, I suppose.

Disconnected

Hmm. I feel really disconnected from the world.  We had a snowstorm like half the country earlier this week.  While classes, schools, and most offices closed for the day, for us, it was normal day.  After all, it's always sunny and 72 degrees in the hospital. Even the roads clear super fast around the hospital so the only remnants of the storm are man-high piles of dirty snow in parking lots.

This week, I'm on ortho and so far, I've seen a total hip, knee, and laminectomy.  There's some crazy drilling and hammering action in the OR.  Cool for a few days, but I am again reminded why I will not be a surgeon.  Also, ortho has got to be the most testosterone-driven field I have yet experienced.  The ortho workroom is mixture between a boy's frat and locker room. At least it doesn't smell bad.  But I exaggerate - I'm with a great resident this week who loves teaching, and I've learned more about MSK this week than my third year combined.

Immersion

“As my life grows richer within the hospital, it becomes less so outside of it.”  ~fellow third-year classmate.

In those words, my classmate alluded to ever-elusive work-life balance and challenge of maintaining relationships with friends and loved ones while devoting full days and nights to clinical work.  It is not so much the frank amount of time spent in the hospital (although the 80+ hour weeks on inpatient months certainly contributes),  it is the emotional energy required to be in a position of constantly caring.  Indeed, there are days where I am so drained by my patient interactions that I simply haven’t any more emotional energy left to expend.  Sometimes, at the end of the day, I simply cannot give any more of myself to others.   Our relationships suffer because of it.   

Another classmate, in tears, described learning that her friend had died suddenly of cancer during her surgery clerkship.  Our school’s policy mandates no absences except for immediate family emergencies.   Forced to miss the funeral, she clearly was filled with guilt and sorrow.   All of us entered medicine understanding full well that we would have to make sacrifices.   Yet it does not make it any easier. 

Then there is the emotional disconnect.   As I grow increasingly at home in the hospital, I become more isolated from those outside of it.  I’ve noticed it with my friends and even more so with my parents.  My parents are interested; they want to understand.  In our weekly conversations they will ask, “How are you doing? What stories do you have?”   Where do I even begin?   My parents are not physicians, and luckily, have little experience with the medical system.  Even the most superficial conversations require layers upon layers of explanation (think: a resident is a doctor who has an MD but is still training.).  I don’t blame them – how could they, or for that matter, others who have not experienced the immersion that is medical school, begin to understand what it is like?  Many times, we will just end up talking past each other, and that is okay.  I am still their daughter, and it is their concern and willingness to ask and listen that matters the most.

Would I trade this for something else?  No way.  I am truly happier this year than my first two years combined.   Sure, I have good days and awful days, but I am stimulated and challenged every day by what I learn.  I am excited to talk to my patients, to understand their experiences, and learn about their diseases.   I feel the camaraderie of working within a team and a strong sense of solidarity with my fellow classmates.   I see myself growing and changing in ways that I could never have predicted.  Eight months into my third year, I have become tougher and more real, yet I remain an idealist.

Tough

Today was tough - the kind of tough that makes you want to call your mom, dad, sister right after work and tell them that you love them.

We told a lady today that she had stage 4 lung cancer and that there's no cure.  She has a teenage daughter who recently started sleeping with her parents because she wants to make sure that their hearts are still beating at night. The minute we reached the stage 4 part, she developed that deer in the headlights look.  Pure shellshock.   I watched as her husband's eyes glazed over, as he reached over to squeeze his wife's hands, as his wife struggled to maintain composure.  "4 weeks ago, I was lifting weights," she cried.   And now this.  Sometimes, medicine sucks.

Resources

I had a patient who was admitted for diarrhea - 3 weeks, every day 3-4 times/day. He came to the hospital because his daughter was worried that he looked gray and weak.  Turns out, he was really dehydrated.  So much so that his kidneys became temporally injured (acute on chronic kidney disease) and he was found to be hyperkalemic.  We took care of the hyperkalemia, but what about his diarrhea?  Ironically, his diarrhea disappeared while in hospital, just resolved entirely!  We did the whole workup - fecal cultures, leukocytes, fat, ova and parasites, stool osmolality, celiac disease workup.  It all came back negative.  This patient stayed in the hospital for 4 days.  4 days!  His hyperkalemia we corrected on the first day.  His diarrhea was resolved the minute he landed in the hospital.   In the U.S., we have such luxury.  If we'd been in another country, this guy would have been sent home after day 1, as he wasn't acute ill after his hyperkalemia was corrected.  There's nothing that would have been different had he gotten this diarrhea workup as an outpatient.

Another patient we saw was in her late 80s, who we discovered had a Cr over 7 (baseline in the 1s).  Acute kidney injury and we're starting dialysis on Monday.  Our attending mentioned that in any other country, i.e. Australia, that these individuals would not have the option of dialysis.  In Australia, apparently, individuals over age 65 are not eligible for dialysis.  Is our aggressive approach to care appropriate?  I can't help but think - this is what makes our health care so expensive!  Yet if I were these patients, I'd want the Mercedes Benz workup too!

Pooped

12 straight days in the hospital.  Or 11 if you don't count orientation on the first day.  I'm on medicine.  I love it, but I'm pooped!  Tomorrow I have a day off and then I'm on call the next day.  q4 is really brutal! 

Half way finished???

I officially reached the half way mark of third year.  I can't believe it; third year is flying by way too quickly and at this rate, I'll still be clueless by the end of the year.  I took the neuro shelf and am pretty exhausted.  There were lots of questions about peds neuro and what the heck do I know about that, given that I'd never seen a kid the entire time while on neuro?  I hope that I passed the shelf!

This weekend, I definitely need to think, recharge, and prepare mentally for medicine.  I really want to get the most out of this medicine rotation and do well in it.

Cool (or perhaps not so cool but certainly memorable) things in neurology:
1.  Watching everyone's response to an acute stroke.  It's no joke and has been the closest thing to ER (meaning the TV show, with all the doctors/nurses running alongside a patient's gurney, mowing down everything and everyone in the way) that I've witnessed so.  The urgency of the situation is palpable.  Time is of the essence since there's a 3 hour window from symptom onset to give IV TPA and 6 hours to give IA (intra-arterial) TPA.  Sometimes we get transfers from outside hospitals and can only shake our heads: they scanned the patient, saw an ischemic bleed, yet didn't give TPA - are you kidding?  Now the patient is out of the time window!

2. TB meningitis.  So very rare in the U.S yet we had a patient in the Neuro ICU with what we are almost entirely sure had this.  The patient had the classic pattern of cerebral damage.  Unfortunately, she declined rapidly and passed away.

3. Serotonin syndrome.  Also no joke!  The patient's temp rose to 105, hypertension, tremor, and some serious clonus.  He was taking linezolid and demerol, the combination of which we think triggered the serotonin syndrome.  Did you know that linezolid, in addition to being an antibiotic, is an MAO inhibitor?

Publishing in EMR

Resident #1: Did you see that NEJM editorial that Annie (senior resident) published?

Resident #2: Yeah, she's a publishing machine.  Did you see the article she wrote for JAMA last year?

Resident #1: I heard about it...she did it on bedrest.

Resident #3 (overhearing): Ha, the only articles I've authored are in [name of electronic medical record system.]

Mr. G

Mr. G arrived on the Neuro ICU early Thursday morning.  A man who had barely crossed the threshold into middle age, he suffered from relapsed refractory leukemia.  The cancer had left him with few functioning blood cells, causing him to develop an intracranial hemorrhage.  The resident loaded him up with bag after bag of FFP and platelets, to no avail - his INR, at 1.7, would not budge.  Finally, she pulled the "big gun" and ordered Profile 9, a specialized blood product used as a last resort in coagulopathies.  The resident jokingly pointed out that with one click of a mouse, she had spent her entire year's salary on this patient.  (Profile 9 is apparently extraordinarily expensive.)  But the cancer had put its foot down, and his INR went up to 1.8.  The bleeding, however, was only one of his many problems.  Overnight, he had spiked fevers as high as 105 and no amount of antipyretics, chilling blankets, and even cold saline would touch his fever.

Mr. G's room was located directly across from the Neuro ICU resident "nook," where we sat to type notes,  examine images, and check lab results.  Even from 20 feet away, I could see that he was miserable.  Shivering and delirious, he managed to nod when we asked if he was nauseous.  His wife visited daily, and I learned that he had a young school-age daughter.  Over the next few days, I watched him slip further away and become less and less responsive.  Eventually, he was transferred to the oncology floor, where he died the next day.  In my short two weeks in the Neuro ICU, I would see 3 others on the floor pass away, but none that were as excruciating to witness as Mr. G.  I hope his family finds peace.

Neuro and the Stanford 25

It's been over a month since I've written and I feel that so much has happened since then. I see so many things in the hospital, and as I've written about in my last post, sometimes it is just easier not to think about them. Of course, the unconscious thinking doesn't, or rather, can't stop.

In any case, I'm currently on my neurology rotation, and it's been among my favorite so far. I finished two tough weeks in the Neuro ICU, spending long hours seeing very, very sick patients, most with such poor prognoses. I love neurology. I love how diagnostic it is, how doing a thorough neurologic exam correlates with the pathology. These neurologists are some of the best observers and diagnosticians that I've seen. I love how academic the field is, how we spend hours discussing patients and case reports and latest treatments based on clinical trials and pathology and pathways. At the same time, it intimidates me a bit. What I don't love is how little we have to offer these patients. Stroke - okay, let's watch it and make sure your BP doesn't dip too low. In the meantime, you're weak on your L side, encephalopathic, and probably just lost half of your ability to function.

At the beginning of third year, my top choice specialty was oncology. A field within internal medicine is still at the top of my list, and if I couldn't go into IM, I'd probably pick neuro. Neurology and oncology. Two extremely academic specialties. Two with very high morbidity and often, mortality. Tell me why I'm attracted to fields where the patients are sick, sick, sick and often die?

Other thing is that I really need to work on my physical exam. I can do the motions yet, but I certainly haven't any where near mastered the ability to elegantly palpate a spleen, access a thyroid, listen for heart murmurs. I like this site that I found from Stanford's Abraham Verghese, a physician-humanist who wrote The Tennis Partner. It's 25 "must know" physical exam techniques to master, called the Stanford 25. Yeah - go Stanford! It's here at: http://stanford25.wordpress.com

Sensory overload

I'm still in a low, funky mood tonight and therefore feel compelled to write more. Since third year started, I've experienced periods where my sleep is completely off. Not because of call schedules and long hours. In fact, I've come to love post-call days in a perverted way because the exhaustion makes for such solid, dream-less sleep. No, I think my problem is "sensory overload." Much for third year is so novel and raw. On gyn onc, it was the open laparotomies where we'd literally be digging and pulling out chunks of tumor - ovarian cancer - in 40 year olds. In peds, it was kids with anorexia, CP, kidney failure. In psych, well, psych is constantly sensory overload. Even radiology didn't spare me, as I'd spin stories from the films - patients with traumatic brain injury and the like. And it's not limited to patient experiences. Even day to day interactions with residents, attendings, and the rest of the clinical environment can be challenging.

In the hospital, it's usually go, go, go, and I end up unconsciously suppressing whatever reaction I have to a situation out of necessity. Things I don't even realize affect me at the time reveal themselves at night. Nighttime is when I do the processing, the reflection, and yes, sometimes the ruminating. It does not make for good sleep. I suppose medical training is about character building, but right now, I have yet to build a thick enough teflon coat.

Quick update

Feeling kind of blah today...many things that I feel pressured to do (i.e. navigate this university system and find a research project and mentor, write my psych report) and yet am procrastinating on. That, and a few worries creeping up like if I'll getting all that I can out of third year, if I'll ever be competent, and what I want to do when I grow up. Neuroses should be a DSM diagnosis, because I have many of them! Of course, I deal with all of this by doing PreTest.

The ah-ha moment (or perhaps self-admission) came today in psych didactics. We met an inpatient in psych today with schizoaffective disorder who was clearly psychotic and perhaps manic - impaired reality testing, bizarre delusions, expansive affect, pressured speech, the whole bit. Afterward, the psychiatrist said: this is a defining moment - either you think "this is utterly fascinating" or you think, "this is cool but not in my department." I fall dead in the latter camp. Fascinating, yes, and certainly amusing, but not something I could do long-term.

As an aside, this past weekend, I met up with some high school friends who I hadn't seen since high school! It was so fun to catch up. And go [big high school] - many of my high school classmates seem to be doing quite well these days, although it's not entirely surprising!

Psych

1 week of psych down. Finished with radiology. I'm assigned to a locked inpatient unit and am glad to be talking to patients again, although this time it's really different! One of my patients has MDD with catatonic features (so you can imagine how much talking is involved). He seemed much better today and was actually able to hold a conversation! The other has some schizoaffective features combined with anxiety and depression. Being on the ward is kind of surreal. Also, apparently our chief resident really loves squirrels and we're her baby squirrels. Psych people are nice.

Ants in my pants

I haven't wanted class to end so badly since high school. Something about sitting in a dark room, at 4:30 pm on Friday, at hour 8 of radiology lecture. Depressing. But I truly have nothing to complain about - I'm done by 5 pm every day on this rotation! If only we didn't have to sit in the dark...