Medical students calling doctors by their first name

Earlier this week, I stopped by the Academic Building to drop off thank you letters to the two doctors who helped me with my Spring break clinical interlude. I was planning on just leaving the letters with their respective secretaries, but I turned the corner and Dr. S. was standing right there. "Hi Josh!" I said, reflexively. I was immediately mortified that I had called him by his first name.

Dr. S. is young for a neurosurgeon, has a very laid-back personality, and looks a lot like a friend of mine back home, all of which contributed to my mistakenly calling him by his first name. He didn't notice - or, at least, he didn't appear to care much about the informality. A quick mental calculation, and I decided that it would be more awkward apologizing for my slip-up than to mask my embarrassment and carry on. (Aside: He ended up showing me angiogram images of a patient with a very large aneurysm coming off the anterior cerebral artery and invited me to the surgery the next day. It would have been fascinating, but I regretfully declined because I had class.)

This incident brought up the issue of how medical students should address doctors. I grew up around doctors - none in my family, but many of my close family-friends are doctors, and I obviously call them by their first name. When I was doing research at UCSD, the doctors who I worked with regarded me as a colleague, and I also called them by their first name. As a medical student, though, I have entered a long-established pecking order in which seniority is given its due respect. With this in mind, I've developed the following guidelines for addressing doctors (to be taken with a grain of salt):

1. ALWAYS address an attending physician as "Doctor." If he/she invites me to be more familiar, I still address him/her as "Doctor" in the professional setting. Usually, I just try to dodge the situation entirely by avoiding the use of pronouns when possible.

2. ALWAYS address an established or older physician as "Doctor" at first. If interaction with this doctor is out of the clinical setting and he/she invites you to be more familiar, then I usually feel comfortable using his/her first name. Roles can change, though, and I would definitely switch back to "Doctor" if we were later interacting in a clinical setting.

3. ALWAYS address an intern/resident as "Doctor" at first, but it's likely that he/she will be much less formal with you and expect the same in return. I've found that younger doctors in general aren't quite used to their title yet and still remember clearly what it felt like to be a medical student. During my Spring break clinical interlude, every single resident introduced themselves to me by their first name and expected that I address them as such, even in the clinical setting.

These guidelines (which I've instinctively understood but never before spelled out as I did in this post) have helped me avoid most embarrassing breaches in etiquette - when I'm sensible enough to follow them.

Spring break: Interventional neuroradiology clinical interlude

At the end of last semester, my classmates and I were required to complete a clinical interlude. I spent mine in the emergency room then followed a cardiothoracic case (aortic dissection) upstairs to the operating room. I enjoyed the clinical interlude so much that I decided to spend a couple days out of my Spring break doing something similar.

I wanted to get exposure to neurosurgery/neurology/radiology and so arranged to shadow a neurosurgeon who practices interventional neuroradiology. It was really a perfect fit.

Interventional neuroradiology: Procedures

My clinical interlude started with an embolization procedure to fix an arteriovenous malformation, which is basically just a tangle of blood vessels in the brain that predisposes the patient to a constellation of complications (e.g. intracranial hemorrhage). The whole point of the embolization procedure is to selectively block off blood flow to the region of malformation to make surgical resection of the malformation easier. It's common for patients to have many embolization procedures before surgical resection, each time blocking off a few more blood vessels feeding the malformation. Yesterday was this patient's fourth embolism procedure.

It's extraordinary, when you think about it, that such a procedure is even possible. A catheter is inserted in the femoral artery in the groin area. From there, a wire is fed up through the abdominal and thoracic aorta, through the aortic arch, and into the brain via the carotid or vertebral arteries. What's even more amazing is what happens once the wire is inside the blood vessels of the brain, which get smaller and smaller as they continue to branch off.

Doctor S. navigated the maze of tortuous arteries simply by twisting the wire in his hands so the tip of the wire would point one direction or another. Meanwhile, he tracked his progress in real time using fluoroscopy. In this way, he was able to make his way to the arteriovenous malformation in the frontal lobe. Once there, a thick liquid substance called onyx was slowly injected into the artery to occlude it. The onyx moves through the artery like lava and interacts with components in the blood to harden and form a permanent plug. The onyx injection is also tracked in real time: it appears on the screen as a black blob that gradually fills the vessels surrounding the malformation. One of the primary concerns in tracking the onyx injection is to make sure that it doesn't enter the venous outflow, because then blood flowing into the malformation from other arteries would have fewer routes of escape and pressure would build up.

Fluoroscopy imaging involves radiation, which means that everyone in the operating room must wear protective lead shielding, including a lead neacklace to protect the thyroid. After so many hours, that lead sure did feel heavy! Also, I was excited that I got to scrub in. There's a particular way to put on the surgical gown and gloves in a sterile manner that has a way of exposing a novice. Being a first-year medical student, I have license to own up to my inexperience, and the nurses were great at showing me the ropes. During a diagnostic angiogram today, the nurse also took the time to explain to me how all the different types of catheters and wires work, which I greatly appreciated.

Academic day: Conferences

Tuesdays are academic days, so today after rounds in the neuro intensive care unit (NICU), I attended two conferences. The first was a neuro-oncology conference during which neurosurgeons, oncologists, radiologists, and pathologists all meet to discuss cases. This was a nice course correlate, considering I was recently studying pathology for Disease and Defense.

The second was a "Morbidity and Mortality" conference during which neurosurgeons presented recent cases that had complications. The real purpose of this conference, it seems, is to identify mistakes to learn from them and prevent them from happening again. Although the majority of complications were straightforward, a few cases prompted some animated debate. It was fascinating to watch this group of neurosurgeons think through a case together and argue their differing opinions (all in a collegial atmosphere, of course). There was also one patient who had intracranial bleeding that a resident explained by acknowledging that he had made a mistake. Mistakes happen; they are a reality of training. Still, I was somewhat surprised to hear it discussed so matter-of-factly. The resident obviously did not appear too pleased with himself, but the attending neurosurgeons talked through the case in an academic manner that highlighted the factors that led to the mistake. I'm glad that I was able to get a glimpse into this aspect of training.

Overall impressions

Even though it meant a shorter vacation back home, I'm very glad that I decided to set aside these two days of my Spring break for an unofficial clinical interlude: a welcome refresher of why I'm in medical school. I got my exposure to neurosurgery/neurology/radiology, I learned a lot about embolization and angiograms specifically, and I also networked with many doctors and residents who invited me to come back when I get the chance.

Now, it's time for a real vacation.

Medical hypnosis

I have always been fascinated by the brain and its mysteries, so this semester I took advantage of a medical hypnosis elective. It was just two classes, each two hours long, and really only served as a very brief introduction to the role of hypnosis in medicine.

What is hypnosis?

"A good date is a mutual hypnotic state."

Hypnosis is a special state of mind that is brought about by intensely focusing on something and is characterized by a sort of dissociation from self. Have you ever been driving home and, once you arrived, realized that you didn't remember how you got there because you had been driving on "autopilot?" You focused on the road and allowed your mind to relax into whatever thoughts it pleased so that you lost all sense of time, and your body mindlessly performed the motor tasks necessary to get you home. That's a hypnotic state: a combination of intense focus and relaxation that somehow lends a person more open to suggestion.

Inducing a state of hypnosis involves both of these elements, focus and relaxation. The instructor demonstrated this by hypnotizing the class, the five of us. He had us imagine a "safe space" in our mind and asked us to explore every little detail of it. I noticed that the suggestion was vague and open to interpretation. This is called a "lead and follow" technique: the operator (hypnotist) leads the patient in a given direction then follows where the patient's mind goes. The effect is to reinforce imagination as reality to induce a deeper hypnotic trance. Four out of the 5 of us experienced a hypnotic state. Some people are inherently more easily hypnotized, and some people are less so.

Being the hypnotist

Next, the instructor invited us to practice on each other. Sitting down with my classmate in front of me, ready to do and feel and imagine what I suggested, I had a much clearer understanding that only experience can teach of what it means to hold such strong control over another person's mind. The sensation was exhilarating and a bit unsettling. I quickly learned that not only my words themselves but how I spoke mattered greatly. So, despite the adrenaline pumping through my body, I was careful to speak in a calm and measured manner, slowly, so the full impact of my words could be absorbed.

I discovered that I am good at hypnosis! I induced a hypnotic state in my classmate quite easily, but I didn't know what to do with it. This was partly due to my inexperience as an operator, but it's also because there was no real purpose to the session other than to practice inducing a hypnotic state.

Hypnosis and medicine

Hypnosis is not just used in psychiatry, which is what I'm sure most people believe. The instructor pointed out that pain is a particularly good inducer of a hypnotic state because nothing better focuses one's attention than pain. In fact, a patient with pain is often in a hyper-suggestible state of mind. Then the doctor walks in the room wearing a white coat and/or stethoscope, which are both symbols associated with the promise of alleviating that pain. I have myself witnessed such a hyper-suggestible state in my own patients, for instance when a man in excruciating pain from a fractured rib allowed me to touch him in exactly the spot that hurt the most.

The meat-and-bones of this elective was first recognizing this unique psychological state that we'll see in many of our patients, and second to learn techniques to take advantage of it to better serve our patients. My favorite example was using a pinwheel to distract a child from pain (e.g. a splinter, a scrape, getting a shot). I wish I had had this trick up my sleeve last semester when I was giving children shots at Warren Village. Asking the kid to blow on the pinwheel first offers the child something else besides pain to focus on. More than that, though, there are physiological benefits to breathing deeply to blow on the pinwheel, and the pseudo-trance is strengthened by the immediate effect of watching the pinwheel twirl.

My first hypnosis patient

Some time after I finished the hypnosis elective, a classmate of mine was trying to study but couldn't concentrate because she was so tired. "I can hypnotize you to make you concentrate better," I suggested, half joking. But she said yes, and I got myself my first hypnosis patient. I hypnotized her easily enough and suggested that when she woke up she would feel energized to study more and a sharpness of mind so that she would understand and remember the material better. For what it's worth, she reported to me the next day that she was able to finish out the night studying, and she's sure that otherwise she would have fallen asleep in her books.

I'm eager to keep practicing hypnosis. Any volunteers?