2011 to 2012

Ok, I promise this will be the last reflective post for a while. But as the year 2011 comes to a close, I need to take a quick look back on my New Year's Resolutions, and see if I accomplished any of my goals. I also have to establish my resolutions for 2012, since my personality is often obsessive about goal-setting and life-planning.

Last year I tried to keep my resolutions pretty simple. I wanted to amalgamate all the information I had learned during our first two years into some legit knowledge, culminating in the first Step of our Board Examinations. Somewhere between working EMS, making music videos, health policy yada-yada, and making poor life choices (PLCs) at med skew prom, we learned a few things. To this day, I still do not know how I passed our Renal exam first year (finishing up Five Star Nerve was full-time employment), but somehow I got my "P" in Physiology and made it through. Using Step 1 as a means to put together all these classes and subjects was crucial to getting started on third year, and I am very glad I put in the time in effort (although it was a bear of a final semester). I can say that it honestly helped prepare me for the questioning and "pimping" that physicians like to do, especially during Surgery. That preparation let me get a running start after July 1.

I also wanted to take more responsibility for my patients, specifically developing a cohort of patients here in Asheville, NC (Resolutions no. 2 and 3). I was lucky even to have the opportunity to work out here, and I couldn't have found a program that fit my personality better. My ring of 3x5 notecards with all my patients and their medical issues on it makes me feel like I'm an integral part of the health care team (and I am, Kelly!). I speak to my patients on the phone, see them in other clinics, and I feel personally responsible to study their illnesses and problems so I am ready to answer as many questions as I can. Both of these goals were also accomplished, although optimizing patient care is not a resolution just for 2011.

"Three" sounds like a pretty manageable number, so I think I'll have to set three more New Year's Resolutions in 2012. One is obvious: I need to learn how to cook something. My days of cafeteria gorging are over, and I am tired of feeling like an idiot when people talk about cooking. No, I don't know what a "pin-roller" is and what one would use it for, and besides salt, pepper, and cumin, are there any other spices? I'm lucky to know what "cumin" is anyways (thank you, Morocco). So I asked my gourmet-chef-friend Blake for advice, and I have purchased a book called The Best 30-Minute Recipe Book. I need easy to make, short recipes that I can eat over a couple days' time. If anyone else has any suggestions, please help.

Two is also simple. Just as I wanted to spend 2011 in Asheville, I would love to be at either Harvard or Princeton for a Masters in Public Policy later next year. It has been a dream of mine to study health policy since before medical school, and now is the optimal time to engage in this learning. If I am not accepted, I can always try to garner this degree during a year off in residency, but I would prefer to go back to school now. I want to be prepared for fellowship and public service opportunities earlier in my career (or at least have these options). Plus, I will have so much more perspective as a physician, understanding the global issues my patients face every day.

Three, I want to make sure I go one place crazy in 2012. The travel bug bit me years ago, and there are more white russians to be drunk. Southeast Asia anyone?

The year 2011 C.E. was wonderful. I traveled through Morocco, Egypt, and Turkey, I finally started work in the hospital, and I decided what kind of doctor I want to be. Even if I take a year off, I am more than halfway to MD. Tempus fugit. I don't know what 2012 will bring, but I am optimistic that it can be even better that the year prior. See you then.

Three Years Later

This picture look familiar? Yep, that's me. Three years ago this Christmas, unwrapping my first (and still my only) stethoscope from underneath the Swendiman Family Christmas tree. That next morning I drove back to Chapel Hill, and unwrapped one of the best Christmas gifts I had ever received: my first acceptance into medical school. Three years later, here I am.

Every year around Christmas, I reread my first blog post (A Littmann, A Letter, and Some Courvoisier). It brings back one of the most uplifting moments I've ever experienced. I can retrace each one of my steps that night before opening my letter to medical school: unpacking the car, doing the dishes, cutting open the envelope, and calling my parents. Every time I read it, I can't help but smile by the last paragraph (Yes, I do believe in Santa). Med school was (and still is) a dream come true. The reality has set in by now, but I can still feel the elation that warmed my heart that night in my kitchen in Chapel Hill. I can still feel the weight being lifted off my shoulders. I am so glad I recounted that experience, so I can relive it every year.

So was it worth it? I'd say so. This year brings a unique perspective to my annual reflection, because for the first time I am actually doing what I set out to do. The reason I was so excited to become a doctor was not because of the long hours in the Health Sciences Library or the weekly multiple choice tests. I wanted to be a physician to work with patients, to care for sick people. For the past six months, that's what I've been doing. Yes, I don't have an MD behind my name yet; and no, I don't have my own patients (although I would argue that in the Asheville program we do have our own people we follow), but finally I'm in the hospital and out of the classroom. So yes, it has absolutely been worth it. Those first two years in college-on-steroids were well worth the time to get where we are today. And yes, I'd do it all again if I had to.

I haven't flunked out (and neither Ronnie nor I have been kicked out), so I would have to say that the past 2.5 years have been a success. For the first time in my life I am excited about what I am doing academically and professionally. Sometimes I think back on my undergraduate career, and I wish I had worked as hard then as I do now. Oh, the possibilities! I could have picked up another major or actually learned Spanish (you have no idea how much Portuguese was a waste 5 years later). I could have broadened my horizons, taking classes in anthropology and American history. But I guess that's over now, and I shouldn't regret the hours and hours I put in on the X-Box, training my fingers for a future career in Surgery.

Well I guess it's appropriate to take this opportunity, three years after learning I would become a doctor, to come out and say what kind of doctor I actually want to be (I considered doing a parody on The Decision - LeBron James, but I don't know yet what city I will be taking my "talents" to). Plus, I think that cat is out of the bag already. Earlier this month I verbally committed (on the phone to my Mom, of course), to pursuing a career in Surgery, but I knew well before that. After my first 6 weeks here in Asheville in the OR, I was hooked. Two months before that, Surgery wasn't even on my top 3, but after getting the opportunity to work with some amazing mentors, and gaining a better understanding of the massive amount of medical knowledge it takes to be a great surgeon, I knew there was nothing else I wanted to be. As the year has progressed, that commitment has only been strengthened. Don't get me wrong, I have thoroughly enjoyed almost all of my time in other specialties, but Surgery remains the clear winner.

When I did recruiting as a captain for the UNC Swim team, people often asked me why I chose Carolina. Was it the combination of great athletics and academics? Was it the people? Or, did I just like wearing Carolina blue? I always told people that I had visited many other places; I had a great time at colleges with great academics, great swimming programs, wonderful people, and a positive atmosphere. But at Carolina, I knew I was "home." There were so many things about UNC that were good, but at the end of the day, it was just a feeling. In Chapel Hill, I was home. Why Surgery? It is where I feel the most comfortable with patients and providers. It is the specialty I feel to be the best balance between medicine and procedures. Frankly, I just feel at home.

My favorite game to play with my third year colleagues is "tell me your choices for future specialty, broken down by percentages." For example, when I was entering this year, I was somewhere around 60% Emergency Medicine, 30% Pulmonary/Critical Care doc, and 10% Pediatrician (see, Surgery wasn't even on the list). Now I'm 99% Surgeon, and 1% Pediatric Hospitalist. (So obviously I should combine the two? Peds Surgery anyone??). I guess that's enough to make it official; beyond a reasonable doubt. One of the benefits of the Asheville program is that by now I've seen a little bit of many specialties, so I don't have to wait until June until I've seen all the core clerkships. Another weight off my shoulders.

Three years ago I found out I would be a doctor. Three years later I know what kind of doctor I want to be. I wonder where will I be in another three years...

Limping to the Finish

I'm very tired. In fact, I can honestly say that today, Friday December 16th, I am the most academically burnt out I have ever been in my life. I can only compare how I feel to junior year of college, right at the end of the collegiate swimming season. I was mentally and physically exhausted, and I needed a break (in fact, I tried to quit the sport - but no quitting here!). As I limp to the finish line, aka Christmas break, I am ill. My mental exhaustion has turned into a terrific cold, and I had to miss my first clinic ever yesterday (NB: Moms don't want you coughing all over their kids, and I don't want their kids coughing over me). It is time to relax, do nothing, and forget about medicine for a whole two weeks.

This year has been a long year, and I don't really think I ever got a real break. Beginning in January, the race to learn all the things that I should've learned over the first 18 months began, and I worked my way through spring break. The six weeks that we had off between second and third year were filled with Boards studying and a not-so-relaxing vacation across North Africa. Between losing our bags, night time train rides, and driving back to Chapel Hill from Charlotte at 4am (after 18 hours of flying) for Orientation the next morning, I didn't get much sleep. Then after a week of acclimating to the new time zone, I jumped into Surgery full-throttle, followed by Obstetrics and Gynecology, which was full of night floating and vagina. Finding a place to live in Asheville was a mess (damn you, Craigslist). The transition into continuity clinics was hectic as always, and I threw in the GRE just for shits and giggles. Then there were applications to Masters in Public Policy programs due December 1st, and Inpatient Medicine weeks through the weekend. General surgery research here, Athletes in Medicine speech there. So this will be the first real break I've had this year. And I need it so badly.

I look forward to a New Year that is a little less stressful. Having applications in is a big weight off my shoulders, and I plan to do much more continuity and less scheduled added clinics on the side. That should free up more time, and allow me to feel like I'm really spending time with patients inside of rushing from place to place. Fellowship applications (i.e. dollar dollar bill money for grad school) are due at the beginning of the January, so hopefully I will finish those over Christmas break (yes, I will probably have to do something productive over the next two weeks). I just can't wait to cut out some of the additional things I do, as I am a habitual over-committer. In the beginning of the New Year I will focus on school and relaxation, or maybe getting into better shape and learning new dishes (but I'll save those resolutions for my New Year's post!).

Ultimately, I just want to be home. I've only been back to DC once in the past year, and yes, that makes me a bad son, since my sister lives only a few blocks away from Mom and Dad. Palm Sunday was the only weekend I made back to Kensington, and I think my parents are starting to miss me (but believe me, by the end of Christmas they'll want me out again). Seriously though, it's time to sit on the couch, eat Continental pizza, watch Carolina games on my rents' new big screen, and pig out.

I'm pooped. In fact, I'm too pooped to poop. So I'm definitely too tired to write. This break will do wonders; I know it will. So look for a peppier, more thoughtful writer next week!

The Death Rate in America: A Follow Up

A couple weeks ago I wrote a post a about a patient who really touched my heart. He was a patient recently diagnosed with ALS, and the type of person that makes one ask, "Why do bad things happen to good people?" An incredible individual who had been dealing with health problems for a very long time, but kept his head held high. He was the first continuity patient of mine to hear such a grave prognosis.

I often hear physicians say it is very important to separate your work life and your home life. Not that you can't do work at home, or talk about medicine with your spouse or family, but you can't be up all night thinking about your patients. One, you will never sleep, and two that is a quick recipe for burn out. At some point you have to have mental space. With this particular patient though, I found that I couldn't keep him out of my head. I would brush my teeth and get into bed at night, and his case would creep into my consciousness. I think it was the helplessness I felt that I couldn't let go. I wanted to be able to do something. I guess this was the first time I've really dealt with the reality that doctors don't always cure. I know this has been a common theme of my posts this year, but saying it out loud helps me reinforce the idea that there isn't a magic elixir. There is no pill for age; everyone dies.

After dealing with this on my own for a while and writing about it, I reached out to one of my preceptors for guidance (something I probably should have done earlier, but hindsight is always 20/20). She helped me change the way I was looking at this whole situation. I really shouldn't feel "helpless;" that really isn't the right word, because as a physician I can help. I can try to give each person the best quality of life possible, and ultimately, isn't this what we are trying to do for every patient? She noted that patients with incurable diseases are often some of the bravest and strongest people she has ever met, and it is an honor and a privilege to spend precious moments with these individuals. There are fewer things in life more rewarding. It is often with these patients that one can make the most difference in a medical practice.

Another wise woman is my mother, who (God bless her) has been watching and reading about my early journey through medicine with a different perspective: a non-medical one. Yes, she still is the only doctor in the family (Dr. Mom?), but in a few years that title will fall to me. She told me that there is a "first" in everything that we do, and as this journey continues, there will be many more "firsts." There will be a first saved life, and a first mistake. A first surgery, and a first crazy diagnosis. Every new disease is a first. This first just hit me a little harder than I expected.

I don't want to become desensitized to either diseases or people. I understand that some desensitization is necessary: meditating on the fact that one is delving into the human body during every surgery is probably going to get in the way in the operating room. But I don't want to forget the person. I want to find that happy medium: understanding the gravity of a diagnosis or a procedure, but also turning energy on its head to help in a positive way. Appreciating the human condition, but not dwelling on it. This is a balance I've discussed with my ethics professor and a number of my preceptors. It will be a significant part of my journey.

I will be joining the hospital Ethics Committee in January, which will add quite a bit of perspective. There will be many firsts there as well, and I look forward to sharing what I can of those with you.

Inpatient Medicine

As I've mentioned before, four weeks of this year are on the inpatient service: two on Pediatrics and two on Internal Medicine. I already completed my first week with the kids, so in my final three weeks of the semester I am spending seven full days on "Medicine." This week of Medicine is the closest we get to the hours that we'll work during residency. Morning report starts at 6:30am, and sign out occurs somewhere around 8:30pm (usually a 14 hour day). Wednesdays we have a slight break because we have lecture from 1pm to 5:30pm, and then have the rest of the night off. We work the weekends, with no break going into the next week of continuity clinics. Basically it's a long week, but I better get used to it. I'll be doing this for years and years to come. The 80-hour plus week is upon me.

The morning for the med student is usually fairly relaxed. At 6:30am we get the scoop from the night residents, hoping that nothing crazy happened the night before. Usually it's a lot of patients asking for more pain medication, and it seems that pain control often dominates the discussion during morning report (and rounds later). At 7am we get going on seeing patients. I generally see 3-4 patients, each of the Interns sees six patients, and the Chief Resident checks in on everyone. The Attending also sees all 18 peeps, and somehow keeps them all straight (I can barely keep track of the three patients I see daily - I hope this is a skill that improves over time). I've had the opportunity this week to read about all of my patients before rounds, which helps me know what I'm talking about when we're all together.

At 10am we "round." Rounds are where the whole team gets together and discusses the treatment strategy for each patient. On many services, Pharmacy, PT/OT, nursing, social work, and chaplaincy will also be present to discuss patients, but on Internal Medicine we have only had Pharmacists with us. All 18 patients are presented in a very systematic format (subjective, objective, assessment, and plan or "SOAP"), with specific attention to the overnight events. How long the presentation lasts depends on the Attending and the service. For example, my presentations in Surgery needed to be 15 seconds or less (surgeons are go, go, go); in Pediatrics they were between 1-2 minutes (peds is always a little more chill). Medicine is notorious for longer presentations, greater detail, and tedious rounds. While we rounded on six pediatric patients in 20 minutes, our Medicine rounds will last three hours - three times as long per patient. Needless to say, a second cup of coffee is mandatory. However, I actually have found that I enjoy rounding, although it is very Attending specific. The demeanor of the Attending physician makes or breaks those three hours, and I have been lucky to have very good teachers this week.

Everything is discussed in the rounding round, from medications to social issues. Pain control is the biggest topic covered though. There are an amazing number of patients who enter the hospital already addicted to prescription medications, and so many more patients who are in severe pain. Deciding whether to use NSAIDs (like aspirin), or the best pain-killers available such as narcotics (morphine, etc.), can be a tricky choice. The goal is to use the least amount of medication to keep the patient comfortable and the pain controlled, but balancing use vs. abuse is difficult. Sometimes it really comes down to a gestalt or gut feeling from the physician, and some docs are more willing to sign off on narcotics than others. How much a patient needs may also depend on how much time the physician actually spends with that person. Some people joke that in the future we'll all be out of jobs because machines will take over the world, but these are the types of decisions that a computer can't make. Dealing with pain is part of the Art of Medicine; a very difficult and subjective choice.

After rounds we start admitting patients. The Interns discharge any people ready to go, and then fill up the beds so we always have 18 on our service. Most of our admissions come from the Emergency Department, so I find myself constantly running down to the ED to take a history, do a physical, and then present to the Intern and the Attending. Here again, how you a present a patient totally depends on who you are talking to. Sometimes I just want to ask, "Do you want 5 seconds or 5 minutes? Just tell me and it'll make this all go smoother." But you're expected to get to know the individual docs and figure out what they want to hear. I do my best. If the physician starts looking bored, it's time to wrap it up. If they're snoring, just quit. Everyone gets interrupted, but ultimately if you move quickly and confidently, I've found the results are generally good. Some Attendings you will never please.

Admit, admit, admit, and then time to sign out, turning the patients over to the night residents! I have to be honest, being here over the weekend is depressing. Everyone else is enjoying the time off to catch up on work and sleep, and here I am back at the hospital (where the weekend meals are just terrible - Sunday is by far the worst...). But I better get used to it; welcome to residency. I'll just have to keep counting the days until Winter Break.

A Milam Thanksgiving

Every fourth Thursday in November, the Swendimans sit around the dining room table and pray. We all hold hands; the meal is blessed. But, before we can partake in a delicious meal whipped up by Aunt Kathy, each of us must say one thing for which we are thankful. Now, as a child, I always wanted to be one of the first ones to be called upon. When you’re seven, what else is there to be thankful for, other than "family," "friends," and "Jesus?" So, if I wasn't one of the first three kids to state my thanks, I would have to get creative (I think one year I said my elementary school teacher, and I had to suffer 365 days of jeers before redeeming myself). No one wants to be put on the spot, especially when the rest of the family is drooling over the homemade cranberry sauce. One pause, one stutter, and the whole family would jump all over you. So every year I took the easy way out… "Friends!" That’s what I’m thankful for! "Friends" was my go-to.

This Thanksgiving was the first ever in which I didn’t go home for break. Living in Asheville, I just wasn’t willing to make the 12 hour drive back on Sunday, around I-495 and down 95 through Virginia. I can think of other ways of raising my blood pressure. I would have been only able to spend 2 days with the fam, and I just didn’t have enough books on tape for a round trip. So, as a vagabond in North Carolina, I was picked up by my second mother, Millie "Misdemeanor" Milam, and I spent Thanksgiving at the Milam Manor with Ronald and the Fam.

It was sad being away from home, but I couldn't have spent the day with better company. The food was absolutely delicious, and all the neighbors and extended family gathered for the festivities. As we chowed down on turkey and hominy (my favorite!), I realized that until then I hadn't truly appreciated how much I was thankful for my friends. All those years of screaming out "FRIENDS!" before Thanksgiving dinner, simply to get it over with and start the meal, was foreshadowing the years later in life when I wouldn't be able to spend the holidays at home. Sometimes we forget how lucky we are to have people we can trust and rely on, people who will take us into their homes on a family holiday and treat us like their own. There are so many people in America who either don't have a place to call home, or don't have close friends willing to take them in. While I wasn't home in DC with my immediate family, in Charlotte, I felt like I was still part of a family.

Friends. For them I am thankful.

So, there was no fighting over the baseball this year (we'll save that for Christmas), and no tipsy Mom after a half a glass of wine, but there was food, family, and Catch-Phrase. Ronnie has told me that I'm not allowed to write Thank You notes to the Milams anymore, but old habits die hard. So here is my Thank You for such a wonderful Thanksgiving dinner. Just a quick post of appreciation for making me a Milam at such a special time of year. I had a great time; I hope I can return the favor sometime in the future. Just know that every Milam is an honorary Swendiman, and Alan and Kathy would be more than happy to switch me for young Ronald, at least for a year or so. Thank you again.

On that note: Happy Thanksgiving everyone!

How We Die

Sometimes when I close my eyes and my mind wanders, I think about death. Not my own, usually, but of the many patients I see in the hospital that are on the edge, living their last few moments in a tiny white room on the eighth floor with no view. Medications, drugs, and fluids are pumped into them as they negotiate the fine line between life and death, slowly inching towards an inevitable fate. When I close my eyes, I can see the 75 year old man who shot himself in the belly, lying with his mouth wide open. A propofol drip keeps him sedated. He won't make it. I see him from my chair in the nurses' station, visible through the clear sliding doors of the Intensive Care Unit. Six floors up is an 85 year old woman fighting off metastatic melanoma. But she really isn't the one fighting; her husband wants absolutely everything done, even if it only means a few more days or weeks, and even if it causes pain. Agony is irrelevant; death is avoidable. I see her as I sit at the foot of her bed, as her husband tells me that God gave doctors the power to heal. Anything less than a war against this disease would be going against God. I sit and listen.

These images remind me of my own mortality. The thought of spending my last days in a hospital evokes a visceral reaction. If I make it to the ripe old age of eighty, I will view every additional moment as a blessing. But, I don't want to be anywhere near a hospital at that point (as a patient, of course; I may very well still be practicing). This feeling has grown stronger over the past six months. Every time I see another 95 year old admitted, I ask myself, "Does she really want to be here?" This can't be the last place where you would want to live. A place where we wake you up every couple hours to take your vitals, a place without a breeze, a place that is not a home.

There are millions of good reasons to be in the hospital. I'm just not sure "dying" is one of them. And I'm not the only one in my field who feels this way. I was sent an article from our Ethics professor, Dr. Meacham, called How Doctors Die, which better explains how many doctors feel about the inevitable.

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds—from 5 percent to 15 percent—albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.

It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

Part of taking a full History and Physical is asking about the "social history." This is where we document such things as tobacco and alcohol use, family support, and prior occupation. I haven't been at this long, but I have yet to meet an older patient in the hospital who has been a physician. I haven't met enough patients to have a large sample, but perhaps this fact is not surprising. The place where many of us will work for thirty-some years is the last place we want to spend our "free time." It will be something to keep track of though; I look forward to hearing the thoughts of a physician spending his last days in the hospital, or of anyone who has worked much of their life in the place with no breeze that is not a home.

Over the next several weeks I will be preparing to drive back to Washington, DC for the Christmas holidays. I have sent the above article to my immediate family, because I want to talk about last wishes over break. I want my wishes known, and I want to know exactly what my family members want, especially while all of us are healthy and thinking clearly. I will review my living will and make sure that nothing has changed over the past few years. I think this is when the best decisions are made: before, not during, the weight of the moment.

As I watch the propofol and chemotherapy drip, I ask myself if this is how I would want my family members to live their last days. That choice is up to them, but I will choose to watch the sunset without IV drips or blood pressure cuffs. I want to feel the cool breeze through my own window.

The Death Rate in America: One per Person

You're not supposed to have favorite patients. Every patient deserves to be treated with the same professionalism, respect, and care. I do think it's human nature, though, to enjoy spending time with certain individuals. Or maybe I'm simply justifying the fact that I have favorites. All I know is that there are patients that make me particularly happy when I walk into the exam room. These are typically patients (and often their spouses) with whom I've developed a strong relationship. They're pleasant and caring, willing to work with students, and often have a good sense of humor. Some of them have been very sick, others are just returning for another routine checkup. I hope that having favorites doesn't make me a bad doctor.

About a month ago, one of my favorite patients was diagnosed with amyotrophic lateral sclerosis (ALS), commonly known as Lou Gehrig's disease (NB: a significant amount of patient information has been changed for privacy reasons, but how this story has affected me remains true). ALS is a disease of one's nerve cells, specifically the ones that are in charge of "voluntary muscle movement." Very slowly, the patient begins to lose muscle control and coordination. It affects one's ability to walk, stand, and sit upright, speak, swallow, and eventually breathe. Death usually occurs within about 3-5 years. During all this, cognition is generally unimpaired. Your body dies slowly, but your mind knows exactly what is going on.

I can't even begin to understand what must have been going through my patient's mind when he received this devastating diagnosis. From the perspective of a budding clinician, I can say that while standing in that room, I have never felt so helpless. In medicine, we should be able to do something. At least something. Your appendix is acting up; we can take it out. You're in pain; we can take the edge off. You can't sleep; here's a pill. Isn't that what we do? Cure? What happens when there's no cure?

This diagnosis, with all its difficult life and death issues, happened during one of my Neurology clinics on Thursday afternoons. Neurology is one of the highlights of my week. Not only is it a great clinic, but it's a specialty where the physical exam is paramount. The steps and tests are methodical. Diagnoses can be made with your fingertips. Simply by watching how a patient's eyes track the movement of your finger, lesions of the ocular muscles and deep brain can be brought out in physical form. With a simple tap of the patient's knee cap, one can tell if disease is present in the brain and spinal cord or somewhere peripheral. Just by inspecting a patient's muscles for atrophy or hypertrophy, the clinician can learn so much about the patient's condition. The Neuro exam is a true art; the master clinician diagnoses with laying of the hands. And yet with all this information, moments later I find myself standing there, feeling helpless. You have ALS, and we can't cure you.

Maybe that's why I'm drawn to the operating room. "When in doubt, take it out." When a hug and reassurance is all I can give, internally I can't stand it. Of course I should point out that with many of these degenerative diseases, clinicians can ameliorate some of the disease's side effects and perhaps slow the progression of the disease. There is potential for quality of life improvement. But this patient will continue to deteriorate, and that's what makes it so hard for me. Dr. Nortin Halder, a UNC physician who has written extensively in the medical literature and lay press, has given me my favorite medical quote to date: "The death rate in America is one per person." Everyone dies.

That's true, but it doesn't make it any easier.

I had to write about this experience because it is a lifelong dilemma for physicians. Understanding that one can't "fix" everything is difficult for some doctors to grasp. I've heard plenty of stories about physicians who were willing to go to extraordinary lengths to prevent death. If this is our goal as physicians, we will always fail. I guess I am beginning to understand where this mentality comes from. Here I was presented with a patient, one of my favorite patients, who is sick. I want to make my patient all better, but I can't. There's no Band-Aid, there's no pill, there's no procedure. The death rate in America is one per person.

However, there are some things we can do. Knowing the available resources is a good start. These illnesses can be an enormous financial burden (not to mention the emotional toll these conditions take on patients and their families). ALS and some other neurodegenerative diseases are listed by the Social Security Administration as Compassionate Allowances. These 113 medical conditions allow patients to be fast-tracked to disability status because these diagnoses are "so serious that their conditions obviously meet disability standards." There are also support groups, and there are medicines to take the edge off of symptoms (including the psychological sequelae, such as depression, which are extremely common). And then there's compassion.

I don't know how to end this post. I don't have a resolution or a solution. This is a patient that I think about frequently. He is a person who makes me think critically about both life and death.

His and my own.

What's a few days?

On the last day of my week on inpatient Pediatrics, I had the opportunity to spend the afternoon in the Neonatal Intensive Care Unit (NICU). It's the place for very sick babies. Many of them will get better soon; others are there for the long haul. I met an infant who was just there to monitor her breathing for a couple hours after delivery, but I also watched a very impaired premature infant get a chest tube for a collapsed lung and an IV put into her belly button for resuscitation. This is the spectrum. However, what moved me that afternoon was a conversation I got to sit in on with a pregnant mother and the NICU physician. She was a very high risk pregnancy, right at 23 weeks gestation. She had what's called a "placental abruption." In short, this means that the placenta (the baby's connection to mom in the womb) becomes detached from the wall of the uterus. This can cause vaginal bleeding for mom, but it also puts the mother at risk for delivering her baby prematurely. Many of these mothers will have to stay in the hospital until their baby is born. That can be minutes, hours, weeks, or months. In other words, it's a very serious condition, especially at 23 weeks.

The conversation centered around what to do if this baby were born today, tomorrow, next week, or the week thereafter. This is a very important conversation because the older the fetus is, the more likely it will survive. In general, babies born at 22 weeks or earlier have almost no chance of survival, whereas babies born at 25 weeks or later have survival percentages up to 80%, depending on the study (1). So it was important to talk to this mom and find out what she wanted to do if this baby were born right now. What if the baby is born next week? Or the week after? One thing to keep in mind: even if the baby at 25 weeks survives, a majority of these children are likely to be neurologically impaired for the rest of their lives.

It's a difficult dilemma, and I cannot imagine the burden of this decision on the mother. At 22 weeks and prior, it is almost universally the standard of care not to resuscitate the baby if it is born and starts to deteriorate. On the other hand, at 25 weeks and beyond, doing everything possible is the norm (and the NICU doc told me that at Mission in Ashville, this would be the standard of care). But during the 2 weeks in between, the burden mostly falls on the mother. It's these crucial two weeks where there's an ethical gray area. How do you prepare for that?

To give you an idea of how likely a baby is to survive, with or without neurological impairment, you can use this link: NICHD Outcomes Estimator. This has been developed by a subdivision of the National Institutes of Health to calculate percentages based on gestational age, estimated weight, gender, singleton birth, and whether or not they've had the opportunity to receive beneficial steroids. There's a reason that we want babies to get to term, a full 9 months. You can see it with these calculations.

These guidelines are based on our best scientific evidence. But one night you go to sleep at 24 weeks and 6 days gestation, and the next morning the baby is 25 weeks. Now much has changed according to the guidelines, and the decision-making could shift. Has it though? What's a few days? It seems so arbitrary. The infant has a right to life, and a right to mercy. The parents have a right to information, and a right to make decisions on behalf of their child. Life vs. Death. And the possibility of a life of permanent impairment and pain. Is this a life? Sitting in the middle is you, the clinician, trying to provide adequate information, allow autonomy, and keep in mind the best interests of the mother and the infant.

Two weeks. I can't imagine making decisions in those two weeks.

I don't have any answers; I am still trying to figure this out on my own. But I think it is an interesting case-study in ethics. What would you do as a parent? What if suddenly you had to make these decisions? Do you do everything, or do nothing? Or something in the middle. As a guide, here are UpToDate's current recommendations (1):

• Below 22 weeks gestation – Resuscitation is not offered or provided due to the zero or near zero chance of survival.
• 22 0/7 to 22 6/7 weeks of gestation – Resuscitation is offered to parents if there is at least a small chance of survival based on available information (e.g. the NICHD outcome estimator for patients receiving mechanical ventilation) and is then provided only if requested by informed parents.
• 23 0/7 to 23 6/7 weeks of gestation – Resuscitation is offered to parents but provided or withheld based on the preference of informed parents.
• 24 0/7 to 24 6/7 weeks of gestation – Resuscitation is offered to parents and may be provided or withheld based on the preference of informed parents. However, if the newborn is predicted to have greater than 50 percent chance of survival without neurodevelopmental impairment, resuscitation is provided. That likelihood is determined using the NICHD database outcome predictor for patients given mechanical ventilation, and using best obstetrical estimate of gestational age and estimated fetal weight.
• 25 weeks of gestation and higher – Resuscitation is provided.

Thoughts?

1. Ehrenkranz RE, Mercurio MR. Limit of viability. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2011. 

Dictations of a "Drelf"

I was told I would fail my Pediatrics clerkship if I didn't have a ballin' costume for my first day of inpatient Peds, which just so happened to be Halloween. Throughout the year, each of us spends four weeks on inpatient medicine: two weeks on Internal Medicine, and two weeks on Pediatrics. Since nine months of our curriculum is spent in the outpatient setting, these four weeks help us garner the inpatient experience necessary to function in a teaching-style hospital. It is our time to learn how to admit patients, formally round with the team, present, and dictate admissions and discharges. And what better way to start on Pediatrics than on Halloween.

Since I had been given my charge through a game of Telephone, I was left to figure out whether I needed to go balls-to-the-wall, or whether Julia Brant was playing tricks on me. Since it was for the kids, and I'll do anything for the kids, I tried to find a middle ground. Rebekah Macfie and I went to a costume store on our way back from Chapel Hill, and we decided that I should probably work within the confines of my green scrubs. As much as I would have liked to purchase an adult-sized Superman outfit, or perhaps "Sexy Nurse," I didn't want to be the only member of the team garbed in "French Maid" (and, what would the parents think!). So, what goes with green scrubs? First thought was Gumby; we have a similar physique. But, as we perused the store, it appeared that Gumby masks were completely sold out. Go figure. Ninja turtle was option number two, but we settled on something we found in the Christmas section. There before me were elf boots, an elf hat (complete with ringing bells), and a finely crafted elven belt. After a quick stop at the dollar store to find my elf tools (which ended up being a giant pair of plastic elf scissors and some snowflakes to pin on my scrub pants), I was ready.

Turns out not showing up in a mask from Scream VI was probably a good idea. My residents went the classy route: a cow and a lady bug, tail and wings included, both working well with their medicine-business attire. Our attending rounded as a witch, and we all were big hits with the chillens. The last patient we rounded on was a kid about 6 years old who was as adorable as can be. We all lined up in the room and watched patiently as our attending examined him and set forth the plan. Meanwhile, our little one decided to play the "Guess What I Am!" game with our costumes:

What do you think I am?
A cow!

What do you think she is?
A ladybug!

And what do you think he is?!
Ummmm... a dragon?

My heart sank. I was being discriminated against because of my height! No elf can be 6 foot 5. Clearly my proportions are closer in approximation to a dragon than a tiny elf. Henceforth, I was no longer "Robby the Elf." I was a Dragon-Elf. The "Drelf."

Later that day I had the opportunity to "admit" my first patient (still wearing my elf gear, obvi). "Admitting" means that a patient comes to the hospital, usually from the Emergency Department or a private practice, and needs to be in the hospital for an extended period of time. There is an entire History and Physical (H&P) form to fill out in order to get the patient into the system. This entails taking the history (chief complaint, history of present illness, family history, social history, etc.), doing a physical exam, and writing an assessment and plan. I presented to my attending, and then did my first "dictation," which was a complete and utter disaster.

If you listen to an experienced physician dictate, it is a blur of words. ThisisDr.TomArnold-A-R-N-O-L-DdictatinganH&Ponpatientnumber34243243285dateofbirth5/2/2000for... They have the entire format memorized, and they can bang out the whole plan in two minutes or less. It is a skill. A couple hours later, a typed up report pops up in the electronic medical record (EMR), fully visible for all to see. Like most things a medical student does for the first time, my first dictation was a train wreck. If I hadn't known how to "press 2 to pause," I would be still attempting to dictate that first H&P today. The whole thing is supposed to flow like a story; a beautiful soliloquy that anyone can read and follow. It should be chronological and orderly. Instead, my first history went something like this:

Um, yeah. So this patient, um, is being admitted for abdominal pain? So 6 months ago he sneezed, um, and then again a couple weeks later. He sneezed that is. But yesterday he started cramping up. In his abdominals, that is. But I'm not sure if that was a new finding because he gets that all the time, like once the week before. And oh yeah, he's lactose intolerant and he ate a lot of cheese. But not yesterday. Shoot! Did I mention the sneezing? Um.

This accident-in-slow-motion went on for about 45 minutes. When it finally popped up on the computer, I decided to rewrite the entire thing before my attending discovered my total incompetence (thank God for the ability to revise history). It would have been much quicker for me to write it all out in the first place, but time and practice are key to acquiring a new skill. By the end of the week, my dictations were a million times better. The biggest question is always whether the dictation will be transcribed correctly. This is an exact copy of the last line of one of my dictations:

"Dr. T and rhythm position him Mary it would go to feel with the transcriptionist the name of the game to straight Liza Young tube Mary Elizabeth Young. Thank you very much for this transcription in this wound."

Fortunately, this was the only word vomit of the week, but I now try to enunciate my words more clearly. I guess that particular transcriptionist didn't speak Elvish...

Monday Mornings

Well, I never have a case of the Mondays; that's for sure. As I look at the first few months here in Asheville, I realize how lucky I've been to have this opportunity. Everyone in our class is receiving a wonderful education; UNC is known for having some of the strongest clinical years out there. But I've especially lucked out with my preceptors. So as I go through this year, I want to say a few things about each clinic. Thus, we must begin at the beginning: Monday mornings. Every first of the week I head over to the Family Health Center to spend a morning as a Family Medicine doc. I am really as close as you can get to a doctor in this clinic, and probably have more autonomy here than in any of my other clerkships. So, I especially look forward to Monday mornings.

The goal for the year is to be able to operate as closely as possible to Intern status. I am set up with the Electronic Medical Record (EMR) with a username and password so I can log on as a provider. For each patient I see enter their chief complaint, take the history, perform a physical exam, and then quickly type up my assessment and plan before consulting with my attending physician. I am learning to ePrescribe and order lab tests. In Family Medicine, I get to see the patient before the real doctor does. Some patients are wary about seeing someone who looks like a teenager, but they are usually calmed by the fact that the real doctor will be there in just a minute.

Actually (and I know this certainly a biased view), I think most patients enjoy seeing both a student and the doctor. It's like having a "team" attending to their care (which is semi-true, although I certainly don't pull any weight). I've had very few patients hold back information or fail to divulge pertinent details to me when giving the history. When my preceptor and I see the patient together after my presentation, patients usually have moved from curious skeptics to excited participants in the patient-centered experience. Many are used to seeing students and are happy to help; of course a few others think I'm a waste of time.

Every week I get to the clinic at 8am (it is amazing to sleep in - no more 4:45am wake up for a while!). and we start with a brief oral quiz. At the end of each session, my preceptor identifies a "learning issue" to research and prepare for next Monday. These are traditionally bread and butter topics that all clinicians should be familiar with: diagnosis and treatment of hypertension, medications used in diabetes, goals for cholesterol and statin therapy, etc. Julia and I both work with the same preceptor, so we get to learn from each other in the process. Then it's off to our computers to get started on the day's patients. We usually "open" the notes the night before so we are extra ready to see our peeps, and then it's "knock knock" let's begin! After seeing the patient and presenting my plan, I return to the exam room with my doc. Sometimes my plan is right, often it's wrong. Fortunately, during the wrap up I can edit the details on the EMR, making sure everything's entered accurately. That way when we leave the patient's room, I am ready for round #2. Typically I see 3-4 patients each morning, but that will pick up as the year goes on.

The other thing I love about Family Med clinic is that many of my longitudinal patients are starting to return for follow up. When prescribed a new medication, patients often need to be seen again in 2 weeks or a month to check in. So, now I'm starting to see the same faces again, which is one of the big bonuses of this program. Keep learning, keep reinforcing. Recognize a name and face; it's what makes it all worth it (although, I guess it depends on the name or face). In between, I see plenty of acute and urgent issues as well.

When the clinic is over, I have the rest of the day off. I try to keep Monday afternoons open for work (gotta do it while the week is fresh). My other free half-days are Tuesday and Friday mornings, and that's the time I try to use to schedule other clinics, meetings, and continuity visits. Usually I frequent one of the local coffee shops, but I recently, in the evenings, I've taken to studying at the Grove Park Inn, reading Harrison's with a beer in hand. I watch the sunset through the clouds and over the city, with the mountains looming in the distance...

And, that's why I never have a case of the Mondays.

Work Hurts

There are certain patients I know I will never forget. Several people from my years in EMS have made such an indelible mark. I'll never forget one of the first calls I ever was a part of: a man in his mid-30s who had stabbed himself five times with a kitchen knife. I can still see the blood stains all over the carpet as we rushed through the front door. The mixed smell of blood and sweat. I was sitting in the airway seat in the back of the ambulance, leaning over him, trying to keep him awake and talking... "Why won't you just let me die??"

I remember the first time I did CPR. I remember the first time I got duped by a drug-seeker (and the second time). Each of these experiences will stay with me, some perhaps longer than others. I always had a moment of detachment, just a brief second, when I was acutely aware that this encounter was different from others. For the patient with multiple stab wounds, it was right after he asked us why we were trying to save him. It was a real "wow" moment: "Wow. This man really wants to die."

As always, I have to change most/all of the patient identifiers for obvious reasons, but I recently saw a patient who will stay with me for a long time. A couple weeks ago, a young Hispanic lady, maybe upper-30s to mid-40s, presented to the clinic with a chief complaint of elbow pain. She sat quietly in gray sweatpants and a navy hoodie sweatshirt, hands folded in her lap. She was unassuming, and maybe a little embarrassed that she had to see a doctor. She told me her the pain started a couple weeks prior, but now it was interfering with work. When I say "she told me," I mean she wrote all this down on a piece of notebook paper. She was deaf. The history and physical were all communicated via a sheet of yellow, wide-ruled notebook paper. Each question was asked individually.

When did your pain start?
Three weeks ago.

What brings you into the clinic today?
Work hurts.

Work hurts. I asked her where she worked. I put toys in boxes. How many hours do you work? There and at my second job. She was working every single day, Monday through Sunday. Packing and sewing, sewing and packing. She was averaging about 12 hours on a good day, and her symptoms were getting worse. She had tried taking pain-killers, but when I asked how many, the lady had only tried to take one pill here or there. There was a clear lack of education. After going back and forth trying to gather the history, I wrote that I was going to take a look at her elbow. I put the pen down and mimed the motions I wanted her to make. I inspected, palpated areas of point tenderness, looked for good pulse and sensation, and tested her full range of motion. She squeezed my hands. They were coarse and calloused. They were working hands. The exam was almost universally benign, but she did have pain when I pressed on certain areas of bone, as well as during pronation of the wrist.

I'm going to go and get doctor in charge. I will be right back.
Ok.

My preceptor joined us after talking quickly about the case. There was no need for X-rays. He did a full examination on the joint, and then wrote out the diagnosis. There was clearly an inflammatory process present, but nothing immediately concerning. As we had discussed outside the room, a trial of 800 mg of ibuprofen 3-4x a day with light duty at work would be a good trial, with follow-up in a month. If it got worse, she might need to see a specialist. This was all communicated via computer paper now, each instruction carefully written down.

Four 200mg tablets at a time. You can take these 3-4 times a day for 1 week, and then use them as needed.
Ok.

She had just one more question. I need a note for work. Just for this morning. She wasn't even asking for the whole day off. With just a signature she could have had the entire week off. I thought, "Fly to a beach somewhere! Do you need a stronger pain medication? Rest! Come back and everything will be fine and dandy! Please." But she needed to work. The note was written for the morning.

I got lost daydreaming in the room. I'm a wonderfully good complainer, an expert really, and I had been agonizing over a couple assignments that I had been putting off. That afternoon I had to have my nose in Harrison's Internal Medicine, scrolling through UpToDate, writing and learning about a couple of diseases I would report on later that week. I would have to sit in some fancy coffee shop with an overpriced decaf Americano and my laptop as I bunkered down and studied. I would have to eat a home-cooked meal, and then spend an entire hour ironing my dress-shirts. Ironing. That was what my terrible evening would be filled with. Ironing. Whoa me, what a terrible and tough life I live! I felt sick. This woman may not know when her next meal would be, and I spent the night before talking with friends about which new restaurant we would try next weekend. I realized I was tearing up as I was daydreaming.

I snapped out of it. I don't know why this visit affected me like it did. For some reason she just hit a nerve. There are many patients who are just as desperate and deserving; so many who make me realize I'm a piece of shit for ever taking my situation for granted. I don't know why this was different. I get to be a doctor. I get to do something that is so well-respected, so well paid, such an honor... the fact that I ever forget this is just disturbing. I'm too busy being caught up in myself to realize the world doesn't revolve around my Google calendar.

As she got up to leave, all I could think to do was write, "It was so nice to meet you!" in my little black notebook, scrawled quickly over the last page. It was so inadequate; a pathetic attempt to show that I cared. I mustered up the best smile I could. All I wanted to do was hug her.

She smiled and walked out the door, off to work. I realized I probably wouldn't see her again.

Priority #1: Just Show Up... Hopefully On Time

And so it begins! This week marked the beginning of "longitudinal" learning, and it did not disappoint. I flipped from Family Medicine on Monday morning, to sewing pigs' feet in our Emergency Medicine orientation on Tuesday. I raced from Internal Medicine in Arden, NC, to lectures on the liver and chronic diarrhea back in Asheville on Wednesday. An afternoon of Neurology here, Psychiatry there, and somehow peppered in library literature searching, meetings, didactics, and reading reading reading. As I drove back and forth from clinics to the hospital to the coffee shop and back to clinic, I did put a couple holes in the ozone layer; but hey, that's why I bought a manual Corolla. It was an exhausting five days, but extremely rewarding. I finally understand how "continuity" works, and I've started accumulating a cohort of patients to follow. Pamphlets explaining who I am, why I should be your personal medical student, what exactly that means, and how to contact me, were handed out to my "continuities" (although I reminded everyone that in the case of a medical emergency, CALL 911! - and same goes for the rest of you...).

"How does continuity work?" you might ask. Each preceptor has identified certain patients who would be extremely high yield to follow-up on throughout the year. Three reasons: 1) they said "yes" to having a med student, 2) they typically have chronic conditions or medical problems requiring multiple follow-ups, and 3) there is a lot to be learned (although every patient is a learning opportunity! - score brownie points to me for appropriate medical student response!). I, also, will identify patients throughout the year that would be good to follow. To ensure the continuity aspect, I typically walk patients to the front desk after our encounter is completed, and ask to schedule the next appointment for a day when I will be back in clinic. For example, if I see a patient Monday morning in Family Medicine, I try to make sure his or her 2 month follow-up is on a Monday morning when I will be there. My name is tacked onto their chart and BOOM! Continuity.

Additionally, I met a patient this week who needed an appointment with another service (NB: details have been changed to ensure privacy, as always). After our encounter in Internal Medicine, my preceptor and I needed to refer our patient to Neurology. Since I am on outpatient Neurology every Thursday afternoon, we scheduled the patient for a work up a few weeks later when I would be in Neuro clinic. Everyone wins: I can act as a advocate on the patient's behalf, the docs have better coordination of care, and I learn lots of medicine. The trifecta.

The big challenge will be keeping all these continuity patients straight (especially when answering phone calls... Ms. Jones who?). Per suggestions by former Asheville program students, I keep note cards on all my continuity patients, hole-punched into a ring, filed in alphabetical order. With a name, age, and quick notes to remind myself about specifics of each patient (e.g. "works at Carolina Cafe"), I can keep everyone straight. As the list grows, so will my roladex.

It may sound overwhelming, but I've found peace. The only way to cope with the new schedule is to make my own "weekly calendar" on an 8.5'' by 11'' standard sheet of paper with a template of the week's events. Each Sunday I print a new copy of the template, add my ED shifts, extra clinic times, meetings, and didactics. It keeps me on track so I know when I'm going to read for Family, Internal, Neurology, etc., when to lift, run, grocery shop, and do laundry. I happily express my OCPD with this sheet of paper folded and tucked safely into my shirt pocket. I will need this organization even more when I add Pediatrics (my preceptor was saving lives in Haiti this week), Cardiology (our first session!), and possible OR time with Ortho Trauma next week.

I had only one goal as we eased into conintuity... show up on time. If I could do that, the rest would be gravy. Ninety percent of life is just showing up, so I'm happy to say that I accomplished 100% of what I wanted to do during our first 5 days of chaos.

Next week's goal? Smile, and don't look so damn new.

Another Test

I'm not actually sure why I continue to torture myself with more tests, but I do. The SSAT, the SAT, the MCAT, the GRE, etc. etc. I might as well just take the LSAT and GMAT, and that way I'm covered for all the graduate schools for the next five years. So today, in order to propitiate the admissions committees at prospective public policy schools, I took the GRE. And although it was painful to study during my "week off" (orientation for the longitudinal program this week!), I did learn a few things. With the goal of taking the positives out of every situation, I can admit that absconding down to Greenville, South Carolina for the afternoon was not time wasted (yes Mother, I did "abscond" - I left Asheville "hurriedly and secretly to avoid detection or arrest"). This is what I learned...

• However ephemeral, I did learn a few words. I used the Kaplan book and memorized the 150 most used words on the GRE. I would say that at least 10 of these were part of questions on my exam (hint hint for anyone out there). There are three types of verbal sections on the "new" GRE: fill-in-the-blank with the appropriate word, fill-in-the-blank with the two most appropriate words that complete the sentence (in an equivalent fashion), and the typical reading comprehension passages + questions. This is wonderful because it means there are no more of those damn analogies... "oxen yoke" is to "North Korea" as "cattle prod" is to... blank. You know, I just don't care. No patient, attending, grocer, financial advisor, or parent has ever asked me a question is this form before. Let's keep it that way.
• I know triangles. Like, I really know them. In the biblical sense. I'm a little rusty, so I probably knew them better in the ninth grade, but damn it feels good to 5-12-13 again. You want me to solve for an angle? Length of the side? How about the area of the space between a circle a triangle inscribed in said circle? One half base times height. BOOM. It is a skill that is literally only useful for standardized tests and for those that sell triangles (maybe architects too... or painters), so who cares? Don't even give me a calculator. Pythagorean Theorem? Pythagorean Theorem-schmearem! And now I will promptly forget it all. As the Dean of Admission of UNC School of Medicine, Dr. Robert Bashford, once famously said, "I learned the Krebs Cycle five times in my life for a total of 17 minutes. That's all." I think the same applies for triangles.
• This blog is not helping my test taking skills. While I am accustomed to the typical weekly opprobrium (actual word that was on my exam) from my mother with regards to my liberal variations of English language words, I did not recognize the damage it's done until now. Generously expanding the meanings of words to fit my own creative insights actually made it difficult to answer the "fill-in-the-blank-with-two-synonyms" practice questions. I prefer to use my imagination and pretend that words can be similar if you just give them the right inflection. My guidebook proved me horribly wrong, and I was appropriately conditioned to black and white definitions. Poo-poo.
• A 4 hour exam is not grueling. While I must forgive Kaplan's chicanery, I'm just not impressed. Step 1, an eight hour exam, is grueling. This was just a drop in the bucket. I'm getting used to the 3-4 hour test length with the Shelves each Block. No, I don't need to do deep breathing, Kaplan!

Sorry to be so laconic this post, but there just isn't much to say about a test that caused me so much capriciousness for the entire week. If there's nothing further, I'll be off to my usual daily nepotism.

The Longitudinal Model

A lot of people have asked me what I mean when I say I'm doing a "longitudinal program" for my third year of medical school. Usually I say that instead of doing all eight clerkships in separate 4-8 week blocks, we do them all at the same time. Plus, we follow "continuity" patients all throughout the year, and we have ethics meetings, and we have half days to explore other areas of medicine, and we do radiology, cardiology, and emergency medicine, plus, we do...

So, bottom-line I'm not drawing a good picture of what I'm doing out here in Asheville (mostly because I'm not totally sure yet!). But we do have Orientation this week, and our schedules have begun to pop up on our Google Calendars, so now I can give you a better idea of what the year is going to be like. We started off in the "traditional" model; I spent 6 weeks in Surgery and 6 weeks on OB/GYN (the other traditional clerkships are Family Medicine, Internal Medicine, Outpatient Medicine, Psychiatry, Pediatrics, and Neurology). Surgery was a wee bit different in that we weren't working with residents, only attendings. Still our first three months were more traditional, but now in October we begin our unique curriculum. So here is a typical week in Asheville, NC...

• Monday - in the mornings I am working in Family Medicine. Basically, as I understand it, I will be working with one of the docs in the clinic seeing patients, or we will be in the hospital if my doc is rounding at Mission. Shadowing is a thing of the past, as I will be taking the history, performing the physical, creating an assessment and plan, and then meeting with my attending to present the patient and my course of action. My plan will be accepted, tweaked, or thrown out, depending on the accuracy of my assessment. As trust builds with each attending, I will be able to take on more and more responsibility for my patients. Certain patients will become part of my "continuity of care" population. I will follow-up on these patients in the clinic, at referrals, at the hospital, and in the emergency department (we will be getting more information on this in the upcoming week, so we're all still a little uncertain as to how this will work). I have a new phone number specifically dedicated to these patients, and will take on the responsibility of being their care provider and advocate. I will work with the same attending all year in order to facilitate my own continuity.
• Tuesday - every other Tuesday afternoon I will be in Cardiology. Cardiology is not actually one of the "traditional" clerkships that most students take, but we are lucky enough to build in time with an outpatient group. No matter what I choose to practice, I will see congestive heart failure, heart attacks, and many other common cardiovascular abnormalities every day. I realized how important this block will be for me when I was describing a heart beat to my intern on OB/GYN as "lub, dub, SQUEAK! lub, dub, SQUEAK!" These hours will be well spent.
• Wednesday - in the mornings I am in outpatient Internal Medicine, and then we will all congregate in the lecture hall for afternoon didactic sessions. We will have lecturers from all the specialties, starting with Internal Medicine, Emergency Medicine, and Pediatrics this October. Other didactics are interspersed throughout the week, sometimes occurring immediately before or after a morning or afternoon clinic day. For example, I know that on Fridays I will be having Psychiatry group learning sessions before my afternoon shift. We also have Radiology lectures on Friday mornings at 7am, and Master Clinician Series teachings once a month. Two weeks out of the year we will drop everything and spend the entire week in Inpatient Medicine. This allows us to see what IM is like in the hospital, and care for patients on the floor and in the ICU.
• Thursday - Pediatrics in the morning and Neurology in the afternoon. Again, these follow a similar teaching style and development of continuity of care. For Pediatrics, I believe we are spending 6 months in a primary care clinic and 3 months in "specialty" Pediatrics (Cardiology, Neurology, etc.). And just like with Internal Medicine, we will take 2 weeks out of our schedule to spend a week in Inpatient Pediatrics, continuing to develop our inpatient skills.
• Friday - I will spend each afternoon in outpatient Psychiatry. As I understand it, the patients are aware that students will be part of their care on Mondays and Fridays. We are also extremely lucky to work in Adolescent Psychiatry later in the year.
• Weekends - about 3x per month we work 5 hour shifts in Emergency Medicine. Typically these are scheduled on the weekends, but a number are scheduled throughout the week. There will be a lot of time dedicated to skills development and emergency management. This year we will get academic credit for our work in the ED, which is a huge bonus because it gives us an extra 4 weeks of flexibility as fourth years.
• Free Blocks - as you may have noticed, there are typically 2-3 free mornings/afternoons a week. These are used to hone our skills in other clinics and to read about our patients. Also, as we begin to pick up continuity of care patients, we will follow them to their other appointments and procedures. We will also be rounding on these patients in the hospital in the mornings if any of them are sick enough to need inpatient care. Otherwise we can use free blocs to beef up our knowledge in other specialties. I am looking forward to spending more time on Trauma Surgery and additional sessions in Radiology, just to start. As I begin to see where my weaknesses are, I can fill in some of the gaps. For example, if I realize that my eye exam knowledge is lacking, I can spend a day in Ophthalmology. So these free blocks will fill up quickly!
• Group Meetings / Ethics Discussions - interspersed throughout the weeks we will continue to have group meetings and discuss ethics cases. As you can see, while there is free time each week, there is also a ton going on. Apparently, past classes have experienced the highest levels of internal stress in October, as they tried to figure out where to be, what to study, and how to start assimilating massive amounts of information. I'm sure our group will be no different.

Whew. Basically we were told by last year's group to check our Google calendar every morning so we know where we are supposed to be. Things can change on a moment's notice. So, actually I think my initial explanation of the longitudinal model was indeed correct. Instead of doing all eight clerkships in separate 4-8 week blocks, we do them all together at the same time. Plus...


For a video presentation on the program, see our YouTube video here!

Oral Boards and Night Float

Every clerkship has something "special" to look forward to... and by "special" I mean something scary. It's those little things that the prior classes tell stories about; infamous tales of medical student drudgery and potential maltreatment. Some are true, more are not. For Surgery it is the tales of the long hours and the perpetual berating by attendings...

Hey, medical student. What is the difference between dog crap and a medical student?
I don't know.
You don't go out of your way to step on dog crap... (insert hearty laughter). Also, dog crap does not say "thank you" after you step on it.
Wow, I am having a great time here! Thank you! I wish you would tell me that joke 4 to 5 times per day.

No, that wasn't from an actual encounter, but these jokes make for good YouTube videos (Med Student vs. General Surgery). I personally didn't hear any crass jabs thrown my way, but I certainly wish I would have. And why not? My parents tell me they walked to school barefoot in the snow as children, uphill both ways. I have to at least be able to tell my kids that I got a little hazing down the road.

Obstetrics and Gynecology is no different. I heard plenty about the torturous hours on Gyn-Onc and spillage of bodily fluids (although no one fully warned me about the placenta...). But for us here in Asheville, we had two new gauntlets to look forward to: the oral boards and a week of night float.

First, the oral exam. Standardized tests you can BS. You can study how the questions are asked, and sometimes even know exactly which questions are going to be asked. Two or three answers can generally be eliminated before even fully looking at the question stem. It is possible to do very well on these exams, even with a knowledge base that is just so-so. Not the case with an oral test. This is where the attending truly finds out if you know what you're talking about. You can't "recognize" the answer from five choices in front of you. You either know it or you don't. That's why I have to respect this type of test. No bullshitting.

The one thing I was warned about before the exam began was that my preceptor has a perfect poker face. Whether you're right or wrong, you're gonna get nothing from her. So be confident, and keep answering questions until you can't anymore. And eventually that will happen, and that's the point. Every trail of questioning will lead to something you can't answer. That's why everyone thinks they do poorly on the exam, because you only remember the wrong choices you make, not the right ones. So when we got to the review portion of the exam, I thought I had been toasted... although we all did just fine.

Second tribulation, night float. One of the weeks on OB/GYN is completely nocturnal. Starting from Sunday night at 5:45pm, we worked 5 straight 14 hour night shifts. Rounding with the AM team first, we then picked up the patients for the evening through early morn. The service seemed to be a bit quieter, especially since there were fewer staff and no scheduled surgeries, but anything can happen at night. Anything. The random patient that was told to go to the hospital at 1400 for labor will show up at two in the morning, water broken and baby halfway out. As an added bonus, our last night (or "day") finished with 4 hours of lecture from 8am to 12pm. The only positive from this is that it kept me awake long enough so I could flip back to a "normal" human schedule. Even then, I went to bed at 3pm, woke up at midnight, and started reading for my 12 hour day shift that Saturday. It's like switching time zones. This is what I signed up for though, so I better get used to it.

A couple keys to surviving this... first, black out the room. Per Blake Pemberton's suggestion, I taped multiple black garbage bags to the windows to make my bedroom pitch black. It was a cave. There was no way to tell the sun was shining so brightly just outside. I also changed my clock so the "AM/PM" button didn't light up. That way when I went to bed at around 9am, I thought it could have been 9pm. When I woke up at 5pm, I might as well have been waking up at 5am like I did on Gyn-Onc or Labor and Delivery. Tricking your mind is crucial. Blake even suggested that sunglasses should be worn each morning on your drive home. Don't let your eyes see the light!

Night float was actually quite a bit of fun though. I got to do more at night than any regular shift (and I got my first birth! See The Miracle of Life). And every morning after breakfast we watched the sun slowly rise above the Asheville skyline during rounds...

Which makes it all worth it.

The Miracle of Life

9:51pm. It all started with a high-five. I would have preferred the classic 8 mile Eminem opening scene: I can hear the crowd in the other room as I retch over the bathroom sink; I look up at myself in the dirty mirror, breathing heavy and wiping the vomitus off my chapped lips. Lose yourself in the moment, you own it... However, beggars can't be choosers, and this is my first baby. Well, not mine, obviously. This is my first delivery. Legs spread across stirrups; baby crowning in front of my eyes. I had practiced over and over on the "fake baby, fake pelvis" at the rounding table. Left hand, perineal support. Right hand, two fingers on baby's occiput. Control the head. Pushing slows. Use both hands to guide the head, fingers point in the direction of the baby's mouth. Check for a nuchal. Birth the anterior shoulder. Grab the neck with superior hand and control. Pull up and out to deliver posterior shoulder, supporting the arms from arbitrary extension. Deliver the lower extremities. CATCH and HOLD. Untangle the cord. Turn. Present to mother. Clamp the cord. I knew the progression; I just hoped the birth would be easy and slow. These multiparous women can pop out an infant quick. Perineal support. Two fingers on occiput. Control the... "Robert! Let's go birth a baby. You can do this (insert noise of proverbial high-five slap here); I'll coach you through." We enter 391 quickly, disinfecting our hands in stride, pushing through the wide swinging door. This will all go just fine, as long as I don't drop the baby...

9:52pm. Knock, knock. "Robert, go ahead and gown up. What's your glove size?" I put on the face shield first, careful to make sure the clear plastic is miles from my face. Can't birth a baby if you diaphorese (is that a word?), or sweat all over your view. Gown next, then gloves. This is where I put on a show for everyone in the room. Ever seen a med student try to put on a pair of latex in the usual sterile fashion? It's like watching your seven year old kid try to ride a bike for the first time. Do you just let her fall over and over again? It's like putting socks over your hands and then trying to put on a pair of mittens in minus 40 degree weather, barefoot. Cut me some slack. It doesn't help that I have a mother screaming on the other side of the room as I continue my awkward display of incompetence. The little one waited 38 weeks; it can wait another minute and a half. I say a little prayer. Please God, whatever happens, don't let me drop this baby. That's what happened to me, and see how I turned out?

9:53pm. I'm still fumbling with these damn gloves. Where's the scrub tech when you need him?! "Robert! Hurry up!" Just a minute dammit. I'm going to need my gloves on if I'm going to keep from dropping this baby!

9:54pm. By now I'm standing in front of the mom. She's got her legs in the stirrups, and her pelvis is at my knee level. Ergonomically, at 6'5", this is a problem, but I'm used to it. The med student doesn't make the rules, nor does he or she set the table height. So if I D.F.O. ("done fall out"), then I get to blame it on back spasms. I lean over the introitus and begin the progression. Left hand gives perineal support, right index and middle finger control the baby's head. My coach "J" is on my right; Chief stands approvingly at stage left. It's my first birth; anything and everything can go wrong. We already know that the baby is head down via ultrasound, but the rest is completely unpredictable. Who knows, maybe the baby is reaching for the light and a hand will pop out first. Maybe the baby was doing crunches to work on its abs in utero, and the feet will present next after the head. What if the umbilical cord is wrapped five times around the baby's neck? What if there are twins? Or triplets?? And what if I drop this damn baby on its head?!

9:55pm. This is when all hell breaks loose and the shit hits the fan (NB: although defecation is a common occurrence during delivery, no "shit" hit the fan during this delivery). I have my two fingers controlling the head, and then out of nowhere the baby starts shooting out of the mom's vagina. Doesn't it know this is my first time?! Four hands come flying in. I try to get my hands in place to grab the neck, but I had forgotten to check for a nuchal. My coach gets her fingers in first. The umbilical cord isn't wrapped around the baby's neck, but I have no time to switch my hands to deliver the anterior shoulder. "STOP PUSHING!" Any more pushing and this baby is going by using my chest as a backboard. Bank shot! At least thirty fingers are now controlling its progression. I finally get my right hand firmly around the nape of its neck, my left arm rigid beneath this miracle of life. Okay, so this delivery has not been perfect so far, but I WILL NOT DROP THIS BABY. In any case, there are now two pairs of mitts lurking underneath mine, spotting expectantly. All are ready to catch if the med student turns into Mr. Butterfingers. Abdomen, thighs, knees, toes: the entire lower half of this kid slips out in half a second. And there I am in my moment of glory, the moment of truth. The baby has left its warm, comfortable habitat, and entered the real world in majestic fashion: through the vagina and into the arms of a novice, as nature intended. My eyes narrow because I realize now is the time for utmost concentration. If this baby gets dropped, now is when that would happen.

9:56pm. The cord is untangled, and I'm ready to present the infant to its mother. "NOO! HOLD ON!!" I am a little over-exuberant I guess. The cord isn't long enough yet, so my coach leans in to gently lengthen it in order to prevent avulsion from its owner. "Now, you're ready. Go ahead." I spin the baby carefully in my arms and rest its body on mom. Smiles and grins all around. "It was worth all that work, huh?" Internally, I think this question should be directed to mom and me both, but I realize attention has shifted to the new addition to the room. The cord is clamped and cut; the baby cries as fluid is sunctioned from its newly opened lungs. All is right in the world. I rest in my moment of satisfaction. Mainly because I didn't drop the baby!

9:57pm. I stand and watch. At least one minute is dedicated to joy of birth instead of the science of delivery.

9:58pm. "Alright, Robert. Go ahead and deliver the placenta." My reflection is cut short as I realize that after the birth is the afterbirth. I start at the beginning with a gentle fundal massage. A familiar thought creeps into my consciousness... whatever you do, Robert. Don't drop the placenta.

Ode to the Placenta

Placenta, oh Placenta! Why are you so vile?
I cannot believe you follow the birth of a child.
It's the miracle of life, a baby is born!
And then you too must pass, from uterus torn.
It's such a wondrous event, as child enters the world,
Mothers weep, fathers cheer! for their new boy or girl.
Yet when baby breathes its first breath in the hospital ward,
It is still not rid of you, attached firmly by cord.

I stand in front of mother, offering a hand of support,
I checked in every 2 hours, building a strong rapport.
Then when the time came, I put on my gown and my glove,
A mask on my face to protect from splashes of love.
Push! we yell to mom as the contractions come quicker,
Push! Push! through the crowning, the head's getting bigger!
I put an arm underneath, and secure the nape of his neck,
While dad passes out and mom's screaming like heck.

Oh my God! It's a boy! Congrats all around!
The baby is out of his sac and on solid ground.
The family rejoices, they've waited 9 months for a son,
But while they cheer on, I am nowhere near done.
Even after the baby is out, and the cord has been cut,
I stand between her legs, til the placenta's unstuck.
I tug and I tug, gently pull and then twist,
Throw it all in a bucket, unless membranes persist.

And as you lie there amorphous in a bucket of steel,
A little sick to my stomach is how you make me feel.
An organ of tissue, all gooey and gross,
All grimy and oozy, all slippery and morose.
In some cultures you're eaten, in others you're buried,
For me it's bad enough that in my hands you are carried.
I'm usually not squeamish, but I loathe you and your stroma,
I think the only thing worser is the mature teratoma (yuck!).

So Placenta, Oh Placenta! You're so gross that just maybe,
Next time I'll quickly unscrub, status post birth of the baby...