3rd Year Quotes

Inspired by Liz Baltaro (medicaljourneyliz.com), I attempted to jot down some of the funny/disturbing/quirky/disparaging/are-you-kidding-me quotes I overheard this year in the hospital. I admit I did a poor job, as there were so many more that I forgot to transcribe immediately into this blog. However, this should give you the gist of some of the many conversations that patients (hopefully) don't hear in the hospital. I tried not to quote patients directly, keeping it just to what providers said, but there was one quote I just couldn't leave out (it's hard to miss). So without further ado, I bring to you the third year of medical school...


"Robert, what is the only organ you can't transplant? That's right, the human brain. But when they do figure out how to do brain transplants, they are always going to use the brains of teenagers. Why? Because I believe those brains have never been used, and transplanting one will make you an automatic expert at everything." - on Neurology.

"Robert, if you're going to be a surgeon, you're going to have to learn how to think, talk, and suck at the same time." - as I was answering questions poorly and trying to suction at the same time during a hernia repair.

(in a booming voice) "AND THE AORTA WAS PERFORATED AND BIOPSIED IN THE USUAL STERILE FASHION... AHH HAHAHAHAHA" - as the medical student tried to put in a central line, and the patient's heart rate started beating through the roof.

"Hey, what are you planning to do with Jabba the Hut in room seven?" - doctor to resident about an overweight patient in the Emergency Department.

"Robert, earmuffs." - a frequent request when I wasn't supposed to hear what people were saying.

"Believe me, we could have a whole fellowship here for 'Weak and Dizzy.' It's a great subspecialty." - describing the types of patients that come into the hospital.

"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." - a word-for-word reprint of part of my very first dictation on pediatrics.

"Oh, she can miss a meal. A lot of big girls like to be told they're big girls. So I told her." - physician on rounds.

"Sir, it would be a tragedy if you walked out of here and fell down the stairs when we could rehydrate you and probably prevent that from happening."
"A tragedy? A TRAGEDY?!? Nay. A tragedy would be if Obama got reelected! Falling down the stairs is not a tragedy." - patient who wanted to leave the hospital against medical advice (AMA).

"Have you ever seen a guy that fat? I've seen TempurPedic mattresses that are less spongy than him." - as an extremely obese patient is hoisted onto the cath table.

"Okay, rock-paper-scissors for whether we discharge this kid tonight or tomorrow morning... GO!" - ah, the Art of Medicine...

"Wait, what?!? He decided to give up his Coumadin for Lent?? Who does that?" - about a new stroke patient who was no longer taking his life-saving anticoagulation medication.

"This is why all Podiatrists should be shot." - on an X-ray showing a metal screw inserted into a foot in order to "cure" the symptoms of flat feet.

"Room 20 has chlamydia. Does she need to be on contact precautions?"
"Not unless you want to have sex with her. In that case, yes, I would probably use protection..." - nursing conversation.

"Oh yeah, he's easy on the eyes. That tall and a body to boot? Yeah I'd f*** him." - a patient to my attending as we entered the room. I had already completed the initial interview.

Master Chef of Tarragon Deliciousness

As we are in the sixth month of the year, it is time to check up to see if any progress has been made on those three New Year's resolutions. The first was "to learn how to cook something." In an effort to get this going, I picked up The Best 30-Minute Recipe Book and began flipping through. So far I have made about 20 recipes in the book (averaging about 1 new recipe per week), and I have been delightfully impressed with about 19 out of 20 of them (my artichoke-chicken-sauce thingy really didn't have much punch). My goal will be to work through the entire book over the next couple years, thus stocking my recipe armamentarium for real life. So. I give you "Sausage in Penne with Spinach and Sun-Dried Tomatoes," one of my absolute favorite dishes, complete with my own (minor) modifications. This actually happened to be the first recipe I picked out of the book in January! First the ingredients...

• 1 tablespoon of olive oil
• 1 pound Italian-style turkey sausage
• 4 cloves of fresh garlic
• 2.5 cups of low-sodium chicken broth
• 2.5 cups of water
• 8 oz. penne pasta
• 1/2 to 1 cup of oil-packed sun-dried tomatoes, rinsed and finely chopped
• Salt and ground black pepper
• 1 bag of baby spinach (6 oz.)
• 1/2 cup grated Parmesan cheese

The prep is simple! Heat the oil in a large non-stick skillet over medium-high heat until it starts to smoke. Add the sausage (cut or ground how you like) and cook for 3 minutes until lightly browned. Stir in minced garlic for 30 seconds, then add the broth, water, penne (yes, add it raw - Ronnie and accidentally cooked it first when we initially gave this recipe a shot), sun-dried tomatoes, and 1/2 teaspoon of salt. Cook on high, stirring often, for about 15 to 18 minutes, until the sauce is thickened and the pasta is cooked. Finally, stir in the spinach, a handful at a time. It will all wilt down (unbelievable). Take this delicious dish off the heat and stir in the Parmesan cheese; then salt and pepper to perfection. Muah!

When I cooked this for my parents, I also made a mixed-green salad with halved little cherry tomatoes and french bread. I don't know how to pair wines, but I downed a bottle of Malbec whilst cooking, and that seemed to work out just delightfully.

This will have to be the only New Year's resolution that I continue to work on throughout the year, as my #2 and #3 have actually already been completed (in theory). My second goal was to get an MPP next year (check), and the third was to "go someplace crazy." Today I will purchase tickets to Belize and Costa Rica for a two week vacation with the rents this summer. It has been a good amount of time since we have been able to take a trip together as a fam, and my sister was able to take off a whole week of work. I'm going to head off to Belize for a week and then meet the team just south. Scuba diving, check. Volcanoes, check. Beaches, check. This year is moving along quite swimmingly.

Empathy and Ethics

I often joke that I wish I could take Kathy Meacham with me all the way through my medical career. Our class Ethicist could fit quite snugly into my white coat pocket, living happily as my personal ethics consult and better consciousness. If and when I find myself between a rock and a hard place, I could pull her out and hear her say, "Now, Robert. You need to be asking the tough questions!" And on days when I'm feeling jaded or down, she could sit on my shoulder and remind me to keep the focus "patient-centered." I jest, but there is a modicum of truth in the sentiment. I must say that our ethics curriculum has changed (and will continue to influence) the way I practice medicine for the better. Because of working on the Ethics Committee and attending our regularly scheduled ethics conferences, I think we as a class are asking the tough questions, and we are incorporating the psychosocial idiosyncrasies of medicine more frequently into patient care.

It has been shown over and over that medical students start losing their "empathy" in the third year of medical school. Once the long hours and the rigors of hospital commence, students often stop seeing patients as people. Instead, Room 432 is now "that Gallbladder" or the "Narcotic Overdose" instead of "Ms. Jenkins" or "Mr. Smith." The need to churn out notes, finish scut work ("trivial, unrewarding, tedious, dirty, and disagreeable chores"), and the hospital culture can supersede the real needs of the patient. Thus, we try here in Asheville to prevent this "empathy erosion" before it starts. Following individual patients throughout the year and getting to know them as people is part of the idea, but equally imperative is our training in ethics. When else can third year students sit down and wonder, "Why is this patient not taking their blood pressure medication? Is it because they can't afford it? Is it because it labels them as diseased? Or as a provider, am I not adequately explaining the benefits of this therapy?" If we don't ask these questions, we move on without becoming better providers. We forget to question ourselves, failing to perform our own personal quality improvement. There are few simple answers in medicine, but an empathic doctor is more likely to be able to answer them.

This empathy has actually been quantified, even with such a small sample size of students completing this type of curriculum. When students at a similar pilot program at Harvard Medical School (called the "Cambridge Model") were asked about their preparation during third year, they scored higher than their traditional compatriots with respect to confidence in "truly caring" for patients, understanding social complexities surrounding individual patient care, and relating well to a diverse patient population. Using a scale from 1 to 6, when asked if they felt prepared to become a "reflective practitioner," Cambridge Model students ranked their abilities a 5.50. The traditional students scored only a 4.10. And when asked if the students felt ready to deal with the many ethical dilemmas they would face as future physicians, the disparity was even greater: 5.13 vs. 3.70.

And with respect to the "ethical erosion," before the start of third year, Cambridge Model students "ranked psychosocial concerns slightly, but not significantly higher than did the traditional students. However, by the end of the year, [these] students' scores had increased, and those of the traditional students had decreased, suggesting that ethical erosion did not occur in the students participating in the [new model]."

I know these numbers aren't perfect. Nobody knows if preventing the ethical erosion in the third year stops it from occurring throughout residency. But I think of it as similar to "bending the cost curve" in medicine. We may not be able to completely reduce the rising costs of medical care here in the United States, but if we can bend that rising curve downward, we can save ourselves quite a bit of money. If we can stop students from losing their empathy early, hopefully we can keep our doctors from bottoming-out later.

There is also anecdotal evidence that suggests that students in this model not only are more empathic, but are also happier (wait, I thought medical students are not supposed to be happy!). This seems to make quite a bit of sense in my mind. Frankly, happier people have more room to care. I certainly am less grumpy when I get my full 8 hours. So one must ask, if students are performing at the same level or better with respect to tests and on quantitative assessments of medical learning (which they do!), don't we want to have students who are happier, healthier, and more empathic? I certainly do; it seems like a no-brainer. These are the type of people I want treating my family and friends. In my mind, there is a direct correlation...

Getting to know patients as people + asking the tough questions = more empathic and happier future physicians!

So when we think about "bending the empathy cost-curve," the question is not, "Should third and fourth year medical students receive ethics training throughout these clinical years?" The question is, "Why doesn't training in Ethics continue all throughout residency??"

It should. And I hope to make that a part of my own residency training. At least it is something to consider, and we're asking the tough questions.


Ogur B, Hirsh D, Krupat E, Bor D. The Harvard Medical School-Cambridge integrated clerkship: an innovative model of clinical education. Acad Med. 2007;82(4):397-404.

Medicine In 55 Words

At a recent "Art of Medicine" meeting (where seasoned attendings and our med student cohort coalesce around a long table with wine and cheese, discussing the softer side of being a physician), we considered literature in medicine. Why do physicians write? Why do they write what they write? And why do we read what they write? There are many answers to these questions, but it gave me an opportunity to reflect on this blog, and why I have continued to write every week.

For me, there are two reasons. The first is that this blog is cathartic. It is a release every week to be able to put my thoughts to paper (or keyboard). It has been a way to vent my frustrations, celebrate the wonderful journey, and allow my mother to know what I'm doing without having to call home every day (I love you, Mom). Writing has been a way of dealing with the day to day, good and bad. Secondly, I have thoroughly enjoyed looking back and realizing how little I knew a year or two ago. This blog has been a way of charting growth, keeping a journal, and reflecting how I can continue to improve as a physician and as a person. So that is why I write. Hopefully this is also good practice for the future, as I would love for writing to become an ongoing ritual, both in the public and private setting.

In discussing medical literature, we were asked to read several short stories and poems. One of the articles included an exercise in "55 word stories." These were written by students, residents, and physicians, attempting to tell a story in just a few words (55 to be exact). Each of us tried our hand at this style, using our clinical experiences from the past year to paint small portraits of the indelible moments we've encountered. I have shared a number of these experiences as weekly posts, but there are so many more that I wish to capture and hold onto. I want to share one here, using the 55 word format.


Unprepared

"You have lung cancer," I said. "It's not pneumonia."
"Wow, cancer. That's pretty heavy, man."
No tears, no anger. He just sat there and nodded.
I have never broken the news to a patient that he has cancer.
"But I never smoked."
Please cry. I can't bear your stoic acceptance.
He was 31 years old.