Fourth year: What lies ahead

With just three more clerkships left in my third year (psychiatry, pediatrics, and OB/GYN), the time is quickly approaching when I will have to start making some serious decisions about my future.

The fourth year schedule is by design flexible, allowing me the freedom to choose those courses that I'm interested in and are relevant to my future career. The problem I'm faced with is figuring out my fourth year schedule when I still have more than a few possible career paths before me. Although we sign up for fourth year classes in February (so soon!), a friend told me that it's usually pretty easy to change the schedule in the middle of fourth year. That's comforting.

But it's more complicated than that. By the end of August, I will want to have completed all fourth year coursework required for applying to whatever field I choose. The Dean's Letter is written in September; residency applications are submitted in October; and I'm interviewing November-January. That means I have a short four months to play around with in my fourth year before I start working on my residency applications. Yikes!

As it stands now, my top interests (in no particular order) include: adult neurology, pediatric neurology, and internal medicine. In order to prepare myself for all of these eventualities, I would need to do the following: 1) internal medicine sub-internship (sub-I), 2) adult neurology elective, 3) pediatrics sub-I, and 4) pediatric neurology elective. Four months right there. Plus, with psychiatry in the back of my mind, I could end up wanting to do a psychiatry elective, as well.

Regardless of what I end up deciding, there will be a period of dead time between my last interviews in January 2013 and Match Day on the third Friday of March 2013, when I find out where I will be doing my residency training. Then more dead time between Match Day and graduation in June 2013, eighteen months from now.

Operating on a friend

One morning during my surgery rotation, I looked at my list of patients and was shocked to see a friend's name scheduled for surgery later that morning. I went down to pre-op immediately after rounds, deciding that providing emotional support was more important than respecting her privacy. I'm glad I did because she really appreciated me being there for her. She expressly invited me to watch her surgery, even though I hadn't even planned to ask, so I accepted her invitation.

The moment my friend slipped into unconsciousness, I struggled against my habit, acquired out of necessity, of relating to the person on the operating table as just another body that needs to be fixed. The legs were spread open to insert a tube into the bladder; taking care to pad pressure points, the body was contorted into a position convenient for the surgeon; the surgical field was sterilized with a solution that turned the skin a robotic bronze hue; finally, everything was draped so all that remained of my friend was a rectangle of this bronze-colored skin neatly wrapped in thin plastic.

I cringed behind my surgical mask when the first incision was made. I cringed despite such measures that effectively obliterated any hint that the body on the operating table was a human being, let alone my friend. That initial discomfort passed quickly, though, as the laparoscopic camera entered the patient's body and I saw the familiar array of organs on the monitor. Looking up at that monitor further distanced me from my friend. Young or old, fat or skinny, we're all made of the same building building blocks and put together approximately the same way. Without consciousness, we're all just another body.

The surgery went well, no complications. It was over before I knew it. Perhaps the time flew by quicker than usual because I was so transfixed by this internal struggle of remembering who owned those organs displayed on the monitor. The surgeon, who I had worked with many times before, knew that the patient was a friend of mine. "Do you want to help close?" he asked me when the surgery was nearing the end. That was his way of acknowledging that I had broken my routine of always asking if I can help sew up. "No thanks," I replied, "I want her to have a perfect job." "We wouldn't let you close if we thought you'd be anything less than perfect," my resident said. Still, I passed.

With the procedure finished, the surgeon invited me to go with him to the waiting area. In a bland windowless room, I silently observed the conversation between the surgeon and my friend's loved-one, reassurances that the surgery went well. I was struck by the solemnity of the conversation. I was also impressed by the respect and appropriate emotion afforded by the surgeon throughout the conversation. This was the only time I had the privilege of being included in a post-operative conversation with loved-ones.

I spent more time than usual with my friend in post-op, holding her hand and telling her that everything went great. Later that day, after she had been moved to a room upstairs, I spent more time than usual checking up on her. The standard post-op questions about nausea and vomiting and urination and ambulation seemed less important; I stayed for more than an hour, visiting, quality time. Rounds the following morning were somewhat awkward as I had to balance my dual roles of friend and medical student, not being able to give as much time to my friend as I would have liked.

I wish that I was able to give all of my patients this VIP treatment. Even if I can't always carve out time to connect with my patients on a more personal level, I think it's worth remembering to go back to the bedside when I do have a few minutes to spare. Observing my friend's operation and caring for her afterward also highlighted how easy it can be to accept the sufferings of my patients as routine and how I must guard myself against that attitude.

Why I decided against anesthesiology

Over the past few weeks, I have been "trying on" anesthesiology as a career. I started collating a list of anesthesiology programs I would be interested in, I attended an anesthesiology information session during the clinical interlude week, and I networked with some anesthesiologists.

Specifically, I talked with a neuroanesthesiologist, since concentrating in neuroanesthesiology is the direction in which I would want to take my new career. He was very encouraging, in fact excited, about my neuroanesthesiology interest and strong research background. We talked about a scholarship program designed for anesthesiology residents interested in research, and he helped me sketch out a plan for applying and getting accepted to the Colorado program. Wow, things couldn't be better!

I left that meeting with the neuroanesthesiologist, my spirits high, to complete a standardized patient encounter. The purpose of this exercise was to hold a family meeting about a patient at the end of her life. Although these conversations can be especially difficult and emotionally taxing, the patient-actor gave me remarkably positive feedback: "I am glad that you're going to be a doctor. No matter what field you go into, you're going to need to use these skills to talk with patients, and you're a natural at it." These words meant all the more to me because patient-actors are known to be very liberal in their criticisms.

Through the flush of receiving such high praise, I noted with a pang in my stomach that I wouldn't need to use these skills often, if ever, as an anesthesiologist.

More confusion, bred from conflict of what I wanted anesthesiology to be versus its reality. When thinking about the prospect of following through with applying to anesthesiology residency programs, which all of a sudden seemed much more real, I felt a heaviness in my shoulders, a shortness of breath, a quickened heart rate. All of these symptoms were so slight, subliminal, easy to dismiss as a normal reaction to thinking about an uncertain future.

A good friend and classmate, sensing this inner conflict, asked me a simple question: "Why wouldn't you want to be an anesthesiologist?" He kept quiet and listened, allowing me to verbalize thoughts that until then I wasn't ready to consciously recognize.

When you get down to it, anesthesiologists have a different kind of relationship with their patients. It's condensed down to 5-10 minutes during which the anesthesiologist obtains informed consent and reassures the patient about the upcoming procedure. Sure, there's a little room there to insert your personality, but that's about the extent of the relationship. Talking to patients is something that I both enjoy and am actually good at; plus, it is something that can make a lasting difference in people's lives. It would be a shame to waste that talent in a field with minimal patient interaction.

Relief. Having finally verbalized my concerns about anesthesiology, it was impossible to ignore the fact that lack of meaningful long-term doctor-patient relationships is a deal-breaker for me.

Home sweet home

Ahhh, it feels wonderful to be home and on vacation.


If I wasn't burnt out already, I was getting dangerously close to it: unhappy, irritable, lacking enthusiasm, increased cynicism. Separating myself from school physically, mentally, and emotionally, and spending quality time with my family and friends, will do me a world of good, so I can return in 2012 refreshed and ready to continue learning.

Inpatient psychiatry at the VA is next.

Why I decided against surgery

Over the past 8 weeks, I have been giving serious consideration to surgery as a career. I love it. I love the OR environment, the immediate gratification of doing something tangible to fix a physical problem, and I think that I would be good at it. I've watched my surgery residents, imagining myself in their shoes a few years from now, jealous that they actually get to do the surgeries rather than watch from the sidelines. They work hard, really hard. All that hard work would be worth it, though, to do something that I truly love.

But I have other considerations in deciding on a career. A lot of introspection has led me to understand that I need to find a balance between my career as a physician and the rest of my life. I'm speaking mostly about a hypothetical family. This may be just an abstract concept right now, but I know that the importance I place on family now will only magnify when there's an actual flesh-and-blood family to care for.

It's an unfortunate reality that surgeons must sacrifice more in terms of family life than do most other medical specialties. However, most of the surgeons at my community hospital seemed to be able to find a balance between their professional and personal lives. My surgery mentor, for example, has six children! Even the surgery residents at this community program seemed relatively sane and well-adjusted. But the bottom line is that, even if I chose a community versus academic program (usually a more stressful and toxic environment), going into surgery would still require too much sacrifice from other areas of my life that I value.

This reasoning felt like a cop-out when I was first coming to terms with the realization that surgery is not the career for me. My wise older sister picked up on this sentiment, which I hadn't quite consciously expressed, offering me this advice: "Don't feel apologetic for choosing a career that allows you to find balance in your life. There's a difference between wanting to find a career that makes you happy in all areas of your life and being lazy."

At the beginning of this rotation, I laid out three questions to ask myself to help me decide if surgery is right for me:

• Do I absolutely love being in the OR? Yes.
• Can I see myself happy doing surgery when I'm 60 years old? Possibly, but the chances are slim.
• Can I see myself happy in any specialty other than surgery? Yes, I think so. Before this rotation, I felt pretty optimistic that that specialty could be pediatric neurology. It's still high on my list, but this rotation has made me a little less certain. I learned that I like doing things, that I do well with a mix of action and cogitation. I hadn't seriously considered anesthesia as a career until this rotation, but from my one-week exposure to anesthesia, it provides both action and cogitation.

Backup plans

A patient was brought back to the OR for an emergency exploratory laparotomy one night while I was on call. I didn't scrub in on the case but instead hung out at the head of the bed with the anesthesiologist. Soon after he intbuated this patient, it became apparent that everything was not going according to plan. Oxygen saturation was dropping to the mid-80's indicating that the patient was not being ventilated properly.

The anesthesiologist quickly confirmed correct placement of the endotracheal tube then determined that the problem was with the ventilation machine itself. There was a leak. "Let's bag him," the anesthesiologist called out (referring to bag-valve mask ventilation). Ordinarily, the Ambu bag is kept in the back of the mechanical ventilator cart, but no Ambu bag could be found.


In this moment, I saw an "oh sh*t" look of panic in the anesthesiologist's eyes. Pointing to a nurse: "Go get me an Ambu bag from another room." Meanwhile, he started troubleshooting the leak in the ventilator machine. He found the faulty valve and fixed it in about 30 second to a minute, before the nurse came back with the Ambu bag, and stabilized the patient who by that time had oxygen saturation in the high 60's.

The surgeon quietly watched this all unfold, letting the anesthesiologist do his job without interfering. "I thought I was going to have to do mouth-to-tube ventilation," the surgeon joked after the patient was stabilized. I chuckled. After the excitement passed, though, I realized that the surgeon had probably actually considered the possibility of ventilating his patient by breathing into the endotracheal tube.

This gave me a lot to think about.

Narrowly, this experience has taught me that I should always have an Ambu bag at my fingertips before intubating a patient. More broadly, every anesthesiologist who I worked with has emphasized the necessity of having backup plans. Know what you're going to do to stabilize a patient if something goes wrong. Have a backup-backup plan if your first backup plan fails. It's one thing to hear it, but that lesson takes on a much greater significance seeing it unfold before my eyes.

Early mornings on surgery

As much as I enjoyed my surgery clerkship, I was just plain exhausted by the end. It turns out that the extra hour between 4am and 5am makes a huge difference in terms of being happy and well-adjusted. The early-early mornings and long hours in the hospital, without natural sunlight and little interaction with people other than patients or healthcare providers, had a dissociating effect that made me feel as if I was living apart from the rest of the world. In many respects I was, though in all fairness that is hardly unique to surgery.

I won't miss those 4am mornings. There's something about driving empty streets that made me feel like I was in a zombie movie, eerie and slightly unsettling. Maybe I had turned into a zombie myself but just didn't know it. Still, I appreciated those early-early mornings for being peaceful and silent, for having the city to myself.

I've already had a few days of "sleeping in" to a normal hour, and I feel like a new person again.

I'm done with surgery!

I'm done with surgery! I'm done with surgery! I'm done with surgery! Very excited. It feels good to have that rotation under my belt.

More thoughts to come about my surgery rotation as a whole.

Laparoscopically visualizing anatomic relationships

I recently observed a laparoscopic sigmoidectomy, the removal of the sigmoid colon. The patient's uterus figured prominently in the center of the screen. As the surgeons followed the left descending colon into the sigmoid colon and rectum, I noted that the large bowel tracked posterior to the uterus.


Flashback to a little less than a year ago when as a second-year medical student, lacking any meaningful clinical experience, I was taught how to perform a pelvic exam with a standardized patient. I remember being surprised at the time that a complete pelvic exam includes inserting a finger in the patient's rectum, the purpose of which is to check for cysts or fibroids on the posterior aspect of the uterus.

Afterward, I looked in Netter's to better understand the anatomical relationship between the uterus and rectum. I got it then, but it wasn't until this past week when I saw the actual anatomy directly from inside the abdominal cavity that I really got it.

Anesthesiology

The Surgical Care clerkship includes a one-week exposure to anesthesiology. Admittedly, I entered this week with considerable bias against anesthesiology. It's boring... All anesthesiologists do is put patients to sleep before surgery and wake them up after it's over... There's not much patient interaction... It turns out, though, that my prejudices against anesthesiology were wrong.


The primary job of anesthesiologists, medically speaking, is to keep the patient alive and stable, numb, asleep, and motionless, so the surgeons can do their job.

Anesthesiology is mostly applied physiology and pharmacology. It's the application that interests me. Anesthesiologists use drugs and the ventilator machine to micromanage a patient's vital signs for the duration of the surgery and immediately afterward. Physiologic changes take place right before your eyes. Push propofol and watch the patient fall asleep, completely unarousable. Push rocuronium and watch them stop breathing. Push phenylephrine and watch their blood pressure rise and their heart rate drop. Instant gratification.

Minor procedures are another component of the anesthesiologist's job description: placement of arterial lines and central lines, epidurals, spinals, and of course endotracheal intubations.

I couldn't get enough of the procedures. Over the past week, I placed my first arterial line (after one failed attempt), and my entrotracheal intubation record was 6 successful placements for 13 attempts. Pretty good for a third-year medical student, I was told by my anesthesiology mentor, but he was probably just trying to encourage me. An actual anesthesiologist needs to have a perfect record.

I was also struck by how happy and well adjusted everyone seemed to me. One anesthesiologist just got back from a trip to the Galopagos Islands, and another partners with a team of surgeons on regular missions to Africa. At lunch one day, we determined that all six anesthesiologists at the table were runners. My anesthesiology mentor actually runs 5 miles to and from the hospital a few times per week! I felt like I fit in.


Now, I'm left feeling more confused about my future than ever. I had to write out a list of pros and cons for anesthesiology:

Pros:

• Optimal lifestyle
• Lots of procedures
• Taking away pain makes people happy
• Instant gratification
• No rounds
• Work in the OR, get to wear scrubs to work
• Happy, interesting, and active colleagues
• Good compensation

Cons:

• Does not fit the archetype of a physician that I have carried in my mind since childhood
• No longitudinal patient contact and minimal face-time with patients
• Not the star of the show

Surgery is halfway over

That went by quickly. Mid-point gut check: I like surgery, I like doing procedures, I'm willing and capable of working the long hours required of a career in surgery, and I think I would be a good surgeon. But I'm still very skeptical about the lifestyle issue.

Feeling useful as a third-year medical student

During my last call night, I worked with an upper-level resident who treated me more like a sub-I than a third-year medical student. "Go get a history and physical on this new patient in the ED. I'll see you in 20 minutes." I can't emphasize enough how much I appreciate this management style. He gave me a clear task, he clearly communicated his expectations of my performance, and those expectations were appropriately high. I'll go out on a limb, here, but I think that I was actually useful that night. This is something to hold onto given that I have felt decidedly not useful during much of third-year so far.

Daylight savings

Another perk of being in the middle of my surgery rotation now:

Fall daylight savings. Tomorrow morning when I wake up at 4:15, it'll feel like 5:15. Too bad that effect wears off after a few days.

Desensitization to grossness

I finally saw the movie Contagion, which is about the the human response to a viral epidemic in its first days and weeks. Fascinating movie. Fairly realistic, too, according to one expert. Without spoiling the movie, there was one graphic autopsy scene during which the whole audience groaned in disgust. I chuckled to myself at the dramatization and realized how far I've come through my medical education in the process of desensitizing myself to sights and experiences that would make most people queasy.

My experience in the OR so far

Once I got past the physical demands of standing in place for hours on end, I quickly realized that spending time in the OR observing surgeries is my favorite part of the surgery clerkship. Depending on the day's OR schedule and whether there are any didactic sessions in the afternoon, I might see anywhere between 1 and 5 surgeries in a given day. So far, I've tried to give myself a wide variety of cases, which represent the vast majority of bread-and-butter general surgery. These include:

• Laparoscopic appendectomy
• Laparoscopic cholecystectomy
• Colectomy with end ileostomy
• Ileostomy takedown
• Direct inguinal hernia repair
• Femoral hernia repair
• Epigastric hernia repair
• Thyroidectomy
• Breast lumpectomy

I've also had the opportunity to stand in on some surgical sub-specialty cases: laser transurethral resection of the prostate (TURP) with a urologist, vitrectomy with an ophthalmologist, biopsy of a posterior tongue mass with an otolaryngologist. I'm really grateful to have exposure to the surgical sub-specialties because I elected to do general surgery for all 8 weeks of this clerkship. I know that I don't want to be a urologist or otolaryngologist. I was fascinated by the eye surgery, though, and plan to observe more of them.


Here's a rough breakdown of what my OR time looks like:

50% - Standing quietly behind the attending or resident, trying to stay out of the way, and waiting to be pimped or rewarded for my good behavior with a gift from Above.
40% - Human retractor. Special features: Retracts 360 degrees along all three axes; Variable tension; Responds to verbal and tactile commands; Central processor allows for experience-based learning and adaptability.
5% - Sewing up laparoscopic port incisions or tying knots.
The remaining 5% - Split between driving the laparoscopic camera, electrocauterizing vessels, and other odd jobs.

Climbing the ladder

One of my surgery attendings likened a career in surgery to going through junior high school all over again, every few years. You graduate medical school thinking that, finally, you're climbing your way up the ladder, only to realize that you're just an intern. Interns are dirt: they take care of all the jobs that residents and attendings don't want to deal with and that medical students aren't allowed to do.

You progress through residency and think you're hot stuff by the time you're a chief resident, then you do a fellowship and realize that fellows are dirt, too, low suregon on the totem pole in that given sub-specialty.

Then you finish fellowship and get a job in the real world thinking that finally you've made it, except you realize that you're the most junior member of the practice. Everyone else is looking at you like, "So you think you're a surgeon now, huh? We'll see about that."

It's a recurring process of having to prove yourself to those with more surgical experience. Every few years, you'll be the new kid on the block who everyone picks on. Until you're old and gray, there will always be someone more senior who will serve it to you.

What I found most amusing about his analogy is that medical students aren't even on the proverbial ladder. This correlates strongly with what I've observed so far, that surgeons in general tend to avoid recognizing the presence of medical students except in the function of teaching.

Exhausted

I'm post-call today, meaning I just came off a 28-hour work day. Slept less than an hour last night. My resident called last night a 7 out of 10 in terms of how busy we were. It's the first call night I've experienced that is actually representative of what call is really like for interns and residents.

This was the fourth call night I've taken in 12 days. We have to take call a total of 6 nights spread over 8 weeks. I front-loaded on purpose for two reasons: 1) so I will have more time and energy available toward the end of the block to study for the departmental exam, and 2) to experience the exhaustion that surgery interns and residents have to go through taking overnight call every 3-4 days.

So, how did I handle it? I was surprised by how easily I stayed awake and alert when there was action, like when I had to get a history and physical exam from a patient in the Emergency Department or lay eyes on an unstable ICU patient.

I also noted with some sadness how I had much less patience for the circumferential responses my patients would give to open-ended questions like "Tell me why you're here tonight." What I really meant, I realized, was "Tell me why you're keeping me from sleep." Even as much as I wanted a busy call night, it's amazing how sleep deprivation makes everything except sleep seem much less important.

I hope that my impatience wasn't apparent to my patients in the way I interacted with them. This is something for me to keep an eye on in the future when I'm similarly exhausted.

Ironic, I thought when 4am rolled around and I had been working all night, that this is the time when I would have been waking up for the next day's work. It used to be much later. I learned that a half-hour "nap" before pre-rounds can make a huge difference in getting me through the rest of the morning.

Trauma at Denver Health

St. Joe's is a private hospital that doesn't see any trauma surgical cases, a competency of this clerkship. Surgery students at St. Joe's and other hospitals that don't get a lot of trauma are required to take overnight call once during the clerkship at Denver Health, a Level 1 trauma center.

I did my trauma overnight call at Denver Health last night. The Friday night before Halloween with mild weather. I was expecting (and was actually hoping for) a very busy night, but we ended up seeing just one trauma case, a stab victim.

I wished that I could have been one of the trauma surgeons: blood squirting on my gown, my arms elbow-deep guts, running the bowel to rule out perforation. The surgery was fascinating to watch, even banished as I was behind the curtain at the head of the bed in the anesthesiologist's corner, not scrubbed in.

I want to see more trauma.

Brevity

Everything about surgery, except surgery, is brief.

A prime example:

On rounds the other day, an intern was presenting a patient who I had seen the previous night. The surgery team was consulted to rule out ischemic colitis, which is a surgical emergency. As often happens, the chief resident interrupted the intern after about 2 minutes into his presentation and jumped to discussing the plan, all the while making movements toward the patient's room.

Since we had skipped the physical exam part of the intern's presentation, the chief turned to me as we were entering the patient's room and asked me, "What did you find on physical exam?" I knew that I had exactly three seconds to respond, so I said quickly, "Abdominal pain was not out of proportion to exam." The end.

Doctors use objective facts like physical exam findings and laboratory data to communicate opinions. In this case, I needed to tell my surgery chief, "I don't think this patient has a surgical belly," using one sentence summarizing my physical exam. That's a lot harder to do than it sounds, which is probably why my chief rewarded me with high praise: "I'm glad you said that; it's exactly what I wanted to hear."

The surgery routine

The early-morning routine:

0415: Wake up
0415-0440: Get dressed in clean scrubs borrowed from the hospital.
0420-0440: Eat a quick bowl of Cheerios and otherwise get ready.
0440-0445: Drive to the hospital.
0445-0530: Pre-round on 2-3 patients.
0530-0700: Rounds.
0700-0800: Morning lecture (Tu-Fr).

Mornings and afternoons:

My time after 0800 is surprisingly unstructured. Medical students are expected to sign up for surgeries in the mornings. In the afternoons, I tend to either sign up for another surgery, if there's something interesting scheduled, or find my intern and try (not always successfully) to make myself useful. On non-call days, I've been leaving the hospital around 1700-1800.

Evenings:

I grab dinner on the way home and watch some Daily Show or Family Guy while eating. Then I try to get some studying in before crashing. I shower at night, now, to speed up the early-morning routine. My entire schedule has shifted up a few hours so that I'm going to sleep between 2100-2200 for an average of 6.5 hours of sleep per night.

The on-call routine:

When I'm on call, the schedule is exactly the same except that I go to sign-out (when the day team hands off patients to the night team) at 1700. Then I tag along with the mid-level resident for the rest of the night doing things like putting in arterial lines and consulting on Emergency Department patients who might be surgery admissions.

This doesn't last all night. In the two times I've taken call so far, I slept for 5 hours and 4 hours. In contrast, my classmate got slammed with a busy Saturday night and only slept for 2 hours. It's really hit-or-miss.

Post-call:

On post-call days, I get to go home after morning conference and after I finish writing my progress notes. That's the end of a 28-hour work day. I head straight to bed and sleep for a couple hours, then I have the rest of the day free to relax, go for a run, write in my blog, and take care of chores like laundry and grocery shopping.

Going hungry on my surgery rotation

"Dude, you're going to lose weight on this rotation." So said a classmate and good friend who just finished surgery at University and also happens to share my ridiculously fast metabolism. After a week on surgery, is the food situation as bad as my friend said it would be?

I lucked out because St. Joe's has a decent cafeteria, gives out a monthly meal allowance, and on top of that provides free breakfast four days out of the week. Free food is a big deal.

Still, the surgery culture pervades. It's a badge of honor for surgery residents how long they can go without food and water. One resident was telling me that at Denver Health he regularly went a whole day with no food, two cups of coffee, and no bathroom breaks. That just doesn't seem healthy to me. Or pleasant. Yet I heard a certain amount of pride in the way he said it. This culture is self-perpetuating, passed down from resident to intern to medical student.

So as someone who needs to eat something every few hours, what am I doing to get myself through this surgery clerkship?

First, I have a protein bar on my body at all times. That can usually stave off hypoglycemia for another hour or so until I have an opportunity to eat something more substantial.

Second, I keep a protein milkshake in the doctor's lounge refrigerator. A few swigs of that can also keep me going for about another hour.

Third, I try to eat low glycemic index foods to minimize the blood sugar roller coaster. This means lots of fruits and veggies, scrambled eggs, and double-decker peanut-butter sandwiches on whole-wheat bread.

Fourth, if there's an opportunity to eat, then I take it even if I'm not really hungry, because who knows when I'll be able to eat next.

Surgery slumber party

I just finished my first overnight call ever, coming in at 5 yesterday morning and getting home at 9 this morning for a total of 28 hours. Surprisingly, the time went by very quickly. I helped my resident place arterial and central lines, and he let me aspirate a cystic mass. Very fun.

I didn't even feel too tired at 11pm last night when things calmed down and my resident told me to go get some sleep. Even more surprising is that I woke up almost immediately, with minimal grogginess, when I got a text at 5am from my resident to meet him downstairs. Perhaps most surprising to me is that I remained alert and for the most part engaged during breakfast rounds that lasted 1.5 hours.

It seems that a lot of my medical school experience is about dispelling myths that I "can't" do one thing or another, simply by doing them. Last night was admittedly a soft overnight call since I actually got to sleep for a few hours. But I took away from that experience two important lessons: 1) I can do it, and 2) It's not that bad.

Upcoming Surgical Care clerkship

I'm heading into my Surgical Care clerkship tomorrow with excitement and some nerves. Given how much I've talked with my classmates and other medical student friends about the surgery rotation, even specifically at Exempla St. Joseph Hospital (affectionately called St. Joe's) where I'll be working, I don't expect too many surprises.

I know that the surgery sub-culture is much more steeped in hierarchy and tradition than other areas of medicine. I know that I will be sleep-deprived. I know that I will be hungry. I know that my feet will hurt from long hours of standing in the OR.

But on the bright side:

The surgery program at St. Joe's is known for being relatively relaxed compared to other hospitals. My friend who just finished surgery at St. Joe's told me that the hours are for the most part around 12-14 per day, which is about what I was putting in on my Medicine rotation. St. Joe's is also well-known for feeding its medical students: free breakfast most mornings, plus a meal card for call nights. And I finally broke down and got a pair of Danskos to take care of my feet (thanks, Mom and Dad!).

So, at this point, is surgery still a possible career choice? Yes, with reservation. I want to experience the surgery clerkship before making up my mind one way or another. Throughout the clerkship, I will be asking myself these three questions:

• Do I absolutely love being in the OR? If the main source of happiness in my life is not being in the OR, then I shouldn't do surgery.
• Can I see myself happy doing this (or a surgical sub-specialty) when I'm 60 years old? An attending during my Medicine rotation told me that answering no to this question convinced her to choose internal medicine over surgery.
• Can I see myself happy in any specialty other than surgery? If so, I will be much happier doing that than surgery. I've heard this advice from numerous surgery residents.

Regardless of whether surgery turns out to be the right path for me, these 8 weeks will for sure be interesting.

Musculoskeletal clerkship: Feedback for change

The musculoskeletal clerkship is a two-week pass/fail course that exposes medical students to orthopedics, rheumatology, physiatry, and orthopedic radiology. It is entirely clinic-based and observational, which I find puzzling given that orthopedists spend a considerable amount of time in the operating room doing hands-on work.

I haven't written much over these past two weeks because I haven't had anything nice to say, and I don't enjoy writing about negative experiences, no matter how germane they are to my medical school experience. Normally, I would just wait until the end of the clerkship then speak my mind through anonymous evaluations.

But a strange thing happened earlier this week. One of my orthopedics preceptors happened to be a block co-director. Dr. S asked me how MSK was going. My reply: "It's going well. I really enjoyed rheumatology clinic." The first part was polite and perhaps politic; the second part was true.

Apparently I wasn't convincing enough because he asked me, "Can I speak with you in private?" Oh boy, what did I get myself into? I would've felt like I was being called to the principal's office except for the fact that Dr. S has a very kind and non-intimidating demeanor. He sat down, crossed his legs, looked at me thoughtfully, then said, "Tell me how the clerkship is really going."

"Are you looking for frank feedback?" Yes, frank feedback. Dr. S reassured me that my comments wouldn't have any impact on my grade; he also convinced me that my feedback was valuable to him and would likely be used to shape the future MSK curriculum. Then I told him what I really think about this clerkship. I won't get into the details of my criticisms here in this forum.

The conversation lasted much longer than I expected, even eating into clinic time. I was impressed by the importance Dr. S seemed to place on this feedback by virtue of the fact that he was making his resident and patients wait. I walked away feeling that my voice and frustrations had actually been heard by someone who will use that information to make substantive changes to improve the MSK block.

It's obvious that Dr. S has been listening to many students before me; I admire him for that. In fact, Dr. S says that major changes to the MSK block may be implemented as soon as next semester.

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As a consolation prize for the unfortunate reality that I will not benefit directly from those changes, Dr. S invited me into the operating room to watch some surgeries. I saw a carpal tunnel release surgery, a couple surgeries to correct trigger finger, and removal of a cyst that was impinging on the radial nerve causing pain. Dr. S had me hold retractors, the age-old role of the medical student, but more importantly he took time to teach me.

I loved it. Great to end the clerkship on a high note. Plus, this was great practice for my upcoming Surgical Care clerkship.

Pediatric neurology as a possible career path

I enjoyed pediatric neurology much more than I thought I would. Since I have a background in neuroscience, and hold a special curiosity for the workings of the nervous system, neurology has always seemed a logical career choice. But "logical career choice" doesn't necessarily mean that it's the right one for me.

My hesitancy with respect to neurology dates back more than 10 years when I watched my grandfather slowly deteriorate from Parkinson's Disease. Like a teenager's epiphany that Mom and Dad are just human beings, too, I realized that neurology couldn't cure my grandfather. This disillusionment with neurology in part steered me toward neuroscience research instead of medicine. At the time, I didn't appreciate that, through levodopa and other wonder drugs, neurology had given my grandfather and me a full decade of time together during which I didn't even know he had Parkinson's disease.

The pain of his passing dissipated, and so too did the grudge I held against neurology. This freed me emotionally to choose medicine as a career, late as I did, and now, to even seriously consider neurology as a possible career path.

Regardless, the extent to which I as a neurologist could "cure" a patient, versus treating symptoms or improving quality of life, is a real concern at this point in my education when I am deciding to what specialty I will devote my career in medicine. A close family friend who is a physician strongly urged me to keep in mind the emotional toll of caring for patients who will not get better despite all medical interventions. My colleagues on the Student Doctor Network neurology forums have grappled with this issue before me. One perspective that I find especially helpful comes from Dr. Rodger Elble, Neurology Professor and Department Chair at Southern Illinois University School of Medicine, in a June 2006 department newsletter (I love the internet!):

People become neurologists because they are fascinated by the nervous system, and they are not intimidated by disabling diseases that have no cure. Like Sherlock Holmes, neurologists love to use careful systematic investigation and deductive reasoning to tackle problems that are mysterious to others. Most importantly, neurologists understand that they can help people even when there is no cure. [PDF]

This will be the crux of my decision of whether to pursue a career in neurology. Can I find a fulfilling career caring for patients who have diseases with no quick fix, who will deteriorate and sometimes die despite my best efforts to treat them?

This is a particular concern if I go into pediatric neurology because the patients are even more heart-wrenching. I went into my neurology clerkship at Children's skeptical that the emotional burden of caring for such sick children would be too much for me; I left my neurology clerkship reasonably well assured that I could handle such a burden. Moreover, given my neuroscience background and my INTJ personality with a twist of goofiness, I think that I'm well suited to the task and that I'd be good at it.

What I like about pediatric neurology:

• First and most importantly, I enjoyed working with children. This surprised me. Those who know me know that I like children, but it's another matter entirely to do a physical exam on a sick kiddo.
• I like the challenge of figuring out how to get a good physical exam on children of various ages. For example, you can't ask a 6 month-old to touch your finger then its nose and back again to test for dysmetria, so instead I get the baby to reach for a toy. Examining a three year-old, I will bust out a tennis ball and play catch; toss the ball down the hallway to observe gait. Tons of fun.
• I like the observational and intuitive nature of pediatric neurology.
• I enjoyed working with all of my attendings and residents. This counts for a lot. Many doctors who I've talked with have said that they chose their specialty based heavily on where they felt they fit in best.

Having just a hair more than half of my third year of medical school under my belt, I'm still reluctant to pigeonhole myself into a specialty. At this point, though, I'm comfortable saying that neurology, possibly pediatric neurology, is at the top of The List.

Farewell, Emergency Medicine

I just finished my last shift of my Emergency Care clerkship, and I have to say that I'm sad to see this rotation end. I've had a blast these past two weeks, thanks to a couple rock star residents who provided a great hands-on educational experience.

Among the procedures that stand out in my mind: performing a lumbar puncture (champagne tap), draining a perianal abscess, suturing a few lacerations, and helping to set a dislocated shoulder and hip.

For as much fun as I've had on this rotation, it's important to keep in mind that my Emergency Medicine experience as a third-year medical student is not very representative of the daily routine of an Emergency Medicine resident or attending. All of my shifts were from 12n-8p, whereas residents and attendings work plenty of overnight shifts. Most of the patients I saw over the past two weeks were cherry-picked specifically because they were interesting and had educational value, whereas Emergency Medicine in general is mostly a bunch of chest pain and belly pain with some altered mental status mixed in. I only saw a few patients over the course of an 8 hour shift, whereas attendings see on the order of two dozen patients in a shift.

Keeping all this in mind, and despite some of its drawbacks, Emergency Medicine is still on The List.

Emergency medicine teaching service

The Emergency Care clerkship at University has a dedicated teaching service. What that means, practically, is that an attending physician and two residents are there with the express purpose of teaching third-year medical students. The attendings rotate daily, but the two residents stick with the teaching service for the whole two weeks, making for some much-appreciated continuity.

The teaching service sees different patients from the rest of the department, usually picked for educational value. The pace is much slower, too, with time specifically allotted for rounds, which just consists of sitting in a conference room or outside in the courtyard, presenting a patient to the group, and discussing pertinent teaching points that the patient raised. It's ironically a very relaxed learning environment.

Pros and cons of emergency medicine

Pros:

• I like fixing acute problems and seeing immediate results.
• The idea has always appealed to me of being a doctor who can ring the call button when the flight attendants ask if there's a doctor on board.
• I like the fast-paced ADHD environment.
• I like doing procedures.
• I get to wear pajamas (scrubs) to work everyday.
• I would be doing shift work, which would allow for a life outside of medicine.

Cons:

• I don't like dealing with the drunks and drug addicts; I can easily see myself getting disheartened by humanity at its worst.
• I've already decided that I don't want to do primary care, but too many people use the Emergency Department as their primary care physician.
• As a resident and attending, I would have to work a lot of overnight shifts. I can handle disruptions to my circadian rhythm, but I don't like it.
• I value the long-term physician-patient relationship, which Emergency Medicine lacks (except for the frequent flyers).

Mock terror attack: Operation Mountain Guardian

Denver Metro and Front Range first-responders held a drill today simulating a terrorist attack. I don't really know many details, aside from what's included in this Denver Post article, but I do know that the University of Colorado Hospital participated in the drill, receiving the "wounded," which consisted of actors and actresses as well as dummies. Being in the Emergency Department, I became an accidental participant. The idea was to test the capacity of the ED to handle multiple seriously injured patients at once.

Contrary to what would happen in real life, the attending physicians were facilitating the exercise with the senior residents at the heads of the beds and the medical students assisting. I put a tourniquet on the stump of a dummy's severed arm and bagged another dummy patient; my classmate did CPR and successfully "revived" another dummy patient.

This was a fun exercise and interesting in terms of putting into perspective the role of the ED within the larger first-responder infrastructure.

Denver Paramedics ride-along

I wish that I could say that today's ride-along with Denver Paramedics was action-packed, but it wasn't. Over a 10-hour shift, we had a grand total of three calls: a Denver CARES patient in alcohol withdrawal, a minor fender-bender with no injuries, and a dialysis patient needing transport. Pure bad luck, a sleepy day in Denver.

This was a very similar pre-hospital experience as the ride-along I did during my first year as an elective, except this time it was a requirement for the Emergency Care clerkship. I think future students would have more luck scoring an exciting shift if it were scheduled for a Friday or Saturday night.

Emergency medicine

I start my Emergency Medicine clerkship at University tomorrow morning. It's only a two-week clerkship, graded pass/fail. The best part is that I've already been working at the University emergency department for the past year-and-a-half with my Foundations of Doctoring preceptor. That means I already know where everything is, how to use their computer system, and I already know most of the attendings and residents and nurses. This will be a welcome change, starting a new clerkship with absolutely no learning curve.

Also, all of my shifts except for one are from 12pm-8pm with no rounds and no pre-rounds. This is quite a change from the 5am mornings I have gotten used to over the past several months.

Halfway there

I'm officially done with Neurological Care! I'll write more about my overall impressions of neurology, and more specifically pediatric neurology, later. The more important thing to celebrate is that I am now halfway through my third year of medical school! Despite all the hard work and out-of-my-comfort-zone stress, I'm really enjoying it.

At the risk of waxing poetic, I feel that I am in the midst of a metamorphosis. It hit me while I was out to dinner with a group of classmates to celebrate the end of the block. We were sharing war stories. I stepped back from myself for a few moments, observing each of my friends in turn, how they listened to me describe my Medical Curiosity patient, and observing myself, how I had turned a History and Physical into a conversation. The structure of The Presentation has been chiseled into my subconscious as it has been for every other third-year medical student before me.

I'm still a long way off from being a doctor, but at least I'm finally starting to think like one.

Non-accidental head trauma

You know it's bad when you see police officers roaming the halls of a pediatric emergency room. It usually means that some child has been abused to the point of needing emergent medical care. Of these poor innocents, the pediatric neurology consult service usually sees those who have suffered head trauma.

My attending last week told me that the politically correct term to use in my notes is "non-accidental head trauma." That phrase didn't sit well with me because it skirts the real issue, that the head trauma wasn't just "non-accidental" but rather a result of gross physical child abuse. I was relieved this morning when my new attending told me to refer to it "abusive head trauma."

Call it as it is.

Inpatient neurology at The Children's Hospital

The Neurological Care clerkship at The Children's Hospital is split into two weeks of outpatient clinic work and two weeks of inpatient service. Most neurology inpatient services are rather low-key, but not this one. For the past week, I've been working between 13 and 16 hours per day.

A major contributor to these long hours is that my attending physician is a long-rounder. Starting rounds at 9am, we never finished before 2pm. On Friday we paused for lunch (he treated) and finished up around 3:30. The upside: this guy is a master of the neurological exam in infants and children. I learned a lot by watching his exams and started incorporating many of his tricks into my own exam.

Another reason for these long hours is simply that I'm slow. It still takes me a long time to put together a good History & Physical or a progress note. But I'm getting faster with each day.

We get a new attending for the second week of inpatient service. It will be interesting to see how this coming week compares with last week.

Jedi mind tricks

If you work at The Children's Hospital in August or September, back-to-school season, you're almost guaranteed to come across conversion disorder. This is the subconscious “conversion” of psychological stress into physical symptoms and can often be metaphorical. Conversion disorder is a diagnosis of exclusion, which basically means that you have to assume the worst and order a bunch of expensive tests to rule out all the bad stuff. While needlessly spending lots of money is never a good thing, it starts to get serious when we talk about invasive procedures, such as lumbar puncture, that carry a real risk of complication.

The phrase of the week was "Jedi mind tricks." My attending is a Jedi Master.

One kid presented with altered sensation. With his eyes closed, he tells the doctor that he doesn't feel the light touch of a cotton swab. Next, still with his eyes closed, the instructions are, "Tell me if you don't feel anything." Sure enough, he said that he didn't feel anything each time he was touched by the cotton swab. Unprompted. He's a precocious little bugger but not good enough to outsmart the Jedi Master!

Another kid presented with seizure-like episodes that were suspicious for not being true seizures, so-called pseudopesizures. When she was told that she wouldn't be able to eat dinner until her seizures stopped, her seizures suddenly stopped. Go figure.

My attending emphasized that conversion disorder is a subconscious maladaptive response to stress, a distinction that merits consideration when discussing the diagnosis. Patients will understandably get upset if the doctor implies that they are faking it. My attending has a standard script to open this conversation:

"People do funny things when they are under a lot of stress. Some people bite their fingernails, some people pull at their hair, some people pick their nose, and some people do what you're doing. I believe you that you're not making this up. That's why it's so important to figure out exactly what's going on with you. What kind of stress do you have in your life?

He also says that neurology is a glass-half-full specialty when it comes to such patients. "Give them the benefit of the doubt. Leave it to the psychiatrists to figure out whether it's conversion or factitious."

Escape from medical school: Labor Day weekend wedding

I spent Labor Day weekend celebrating a close friend’s wedding. Wait, isn’t a third-year medical student not supposed to have a life outside of medical school? The stars aligned to make this happen.

First, I arranged to have a clerkship that was known to give whole weekends off. Since clerkships are assigned based on a lottery system, I got lucky that this actually happened. Second, I arranged to do outpatient neurology during the first two weeks of the clerkship, leading up to this weekend, and inpatient during the latter two weeks. Anything inpatient tends to have longer hours, which had the potential to mess up Friday evening travel plans. Again, I was fortunate that the block director deferred to us students to decide who would do outpatient first. The way things worked out, I didn't even have to ask to get out early on Friday afternoon.

Even with all of this planning and scheming, months ahead of time, I wasn't 100% sure that I would be able to go to the wedding until I looked at the schedule during orientation on the first day.

I already missed another close friend's wedding and my Nana's 80th birthday party, which were both during my Hospitalized Adult Care clerkship. I was just slightly bitter about missing them. Such are the sacrifices we're asked to make for the privilege of training to become a doctor.

Pediatric neurology: Still on the short list

A friend asked me toward the end of my first week of neurology, "Are you still considering pediatric neurology as a possible career?" The short answer is yes. I was prepared to discover that in fact I did not like trying to coo my way through a neurological exam, or that dealing with the parents of very sick children would be nightmarish.

On the contrary.

Sure, most children aren't as cooperative as an adult, but I take it as a challenge to figure out how to get the information I need. For example, I needed a hide-behind-my-mommy toddler to close his eyes tight to assess facial muscle strength and symmetry. He wouldn't cooperate, no surprise. So I decided to play hide-and-go-seek. "Now close your eyes while I go hide!" Done.

I also noticed that, in general, the sicker the kid the nicer the parents. Knowing me, I will start plotting subjective parent pleasantness versus severity of child illness then calculate the correlation.

Another aspect of pediatric neurology that I like is that my entire approach to the neurological exam will be different depending on the child's stage of development. In one day, I saw a 9-month-old, a 2-year-old, a 5-year-old, a 10-year-old, and a 17-year-old. That 17-year-old would think I'm a lunatic if I busted out the finger puppets to assess his eye movements.

I'm excited for these next three weeks to see how my perception of pediatric neurology evolves.

Pediatric neurology: Tools of the trade

Because little kids are afraid of doctors, and doctors are associated with white coats, I suddenly found myself with five fewer pockets to carry my tools and other miscellany that are vitally important to the survival of the third-year medical student. The situation is even more grave because neurology uses a lot more tools than most other specialties, and pediatric neurology even moreso. This is my solution:

It's an elephant-shaped lunch bag! So far, it contains:

• Ophthalmoscope and otoscope (borrowed from a classmate): For the eye and ear exams. All of the exam rooms are fully equipped, though, so I don't really need to carry these around in clinic.
• Tuning forks (128 Hz): For vibration and warm/cold sensation. My attending calls it the tickler. "Tell me if you feel it tickling your toe!"
• Reflex hammer: For reflexes, obviously, but it's also a great stand-in toy and distractor.
• Safety pins and paper clips: For sharp/dull sensation. But I hardly use them because poking kids with sharp objects is not a good idea.
• Measuring tape: My attending says, "The only head circumference measurement I trust is my own."
• Tennis ball: To play catch! And fetch! Easy way to assess coordination and running gait. I take the kid out in the hall, throw the ball, and observe the kid as he or she runs after it.
• Crayons: To draw on the exam table paper and examine ability to draw various shapes.
• Finger puppets: A frog and a pink rabbit. Pure distraction for the little kiddos, helps with assessing eye movements and tracking.
• Bell: To test hearing; also a great distractor.
• Wooden blocks: Six of them. Ask the kid to stack them up to test fine motor development.
• A bottle and raisins: Ask the kid to put a raisin in the bottle to test grasping (whole hand versus three-finger pincer versus thumb and index finger).

I'm already running out of room in my spiffy new tool bag.

Breaking bad news

One of my patients came in to the hospital for gastritis but ended up staying for a couple weeks because we discovered that she had acute worsening of chronic kidney disease secondary to diabetes and hypertension. Dahlia didn't seem to understand that out-of-control diabetes and hypertension directly caused her kidney injury. Up until this point, she had been asymptomatic. When sick people don't feel sick, and they lack education to understand the illness and money to buy medications, they tend to not take care of themselves properly.

"I know that you came here for your stomach problems, but the reason you're still here is because we found out that your kidneys aren't working well. We think you've been feeling nauseous because of your kidneys, not because of your stomach."

"Okay, doctor, what does that mean?"

"It means that we want to keep you here for a few more days to make sure your kidneys start working better and to get your blood pressure and diabetes under better control."

"Oh, okay doctor. Whatever you say I need to do to get better."

After a few more days with steadily climbing creatinine and continued worsening of kidney function, it became clear that Dahlia was going to need dialysis. If she was lucky, we'd be able to place a fistula for scheduled dialysis rather than start dialysis emergently.

Regardless, I took responsibility for talking to Dahlia about her worsening kidney disease and the need for dialysis. I dreaded the conversation. Like a good medical student, I printed out materials and prepared a pretty little speech to teach my patient about chronic kidney disease and dialysis. She only had one question for me when I finished: "Am I going to die?"

This question nearly knocked me to the ground. I wish that I could say that I provided a thoughtful and reassuring answer. But I didn't. Afterward, I went to my intern to see if he had any advice about how to handle this situation. "Ooooh, I can't believe you pulled the I-don't-have-a-crystal-ball line!"

I felt ashamed, even though implicit in his poking fun of me was the admission that once upon a time he too had fallen back on the crystal ball line. I wanted to be a doctor to my patient, not a medical student, an admittedly impractical aspiration given my inexperience in breaking bad news to patients.

This conversation continued over the next couple of days as her creatinine continued to creep upward, my patient languishing in the stench of her hospital-acquired depression. Each night on my way home from the hospital, I asked myself why I couldn't bring myself to tell my patient the truth. It didn't matter: I just had to tell her.

Brenner and Rector's The Kidney, 8th ed. Figure 17-9. Adjusted 5-year survival of U.S. incident dialysis patients by modality and primary diagnosis. (From U.S. Renal Data System: USRDS 2005 Annual Data Report: Atlas of End-Stage Renal Disease in the United States. Bethesda, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2005, p 131.)

"The graph on the left shows you what your chances are of being alive five years after starting dialysis. You have an 80% chance of being alive at 1 year, a 60% chance of being alive at 2 years, a 40% chance of being alive after 3 years, and a 20% of being alive after 5 years. That means that for every five patients with diabetes starting dialysis, only one will be alive in 5 years. The outlook is a little better for people with kidney disease but who don't have diabetes; that's why we've been so concerned about controlling your blood sugar. Keeping both your blood sugar and blood pressure under control is the best way to keep you healthy and slow the progression of your kidney disease."

Dahlia's eyes drifted downward then darted upward and rightward and leftward then settled on the picture-perfect 9th floor cityscape that seemed to represent escape from this prison of disease and death. Her eyes looked everywhere except at me.

I finally realized that I had been afraid of burdening my patient with the knowledge of how she was going to die, and when, as if I could somehow protect her with a shroud of ignorance. How small and selfish I had been.

I looked out at the cityscape where Dahlia was still gazing with blank eyes.

"I want to go home."

Fragmentation of team-based clinical learning in hospitalized adult care

Over the course of my 8-week Internal Medicine clerkship, the composition of my team changed a total of 8 times. Settling into a smooth team dynamic with a new resident or attending takes at least a few days. Once I got used to working with one set of people, the teams were shuffled around, and I had to restart the process of getting to know a new resident or attending. This instability frustrated me.

Resident work hour restrictions

Why is the system like this? Part of it has to do with resident work hour restrictions, which currently limit residents from working more than 80 hours per week, averaged over 4 weeks. They further restrict interns from working more than 16 consecutive hours and upper-level residents from working more than 24 consecutive hours. Medical students have to follow these restrictions, too. My understanding is that there was much more continuity of team composition, and patient care, before resident work hour restrictions were put in place.

I was talking to one of my residents about this lack of continuity, for medical students and residents alike, and how that takes away from clinical learning. He described how he had taken 30-hour calls with the rest of his team as a third-year medical student; he also agreed with me that medical students get short-changed under the current system.

The way I see it, a solid clinical education, at all levels of training, is very much in the best interest of patient care. So again, why is the system like this? The movement to restrict resident work hours was aimed at increasing patient safety and reducing medical errors due to fatigue. It dates back to the sad case of Libby Zion, a young woman who died after mismanagement by two sleep-deprived residents.

Effects of fatigue on performance

A 1997 study published in Nature reports that being awake for 21 consecutive hours is equivalent to a blood alcohol content of 0.08% (the legal limit for driving). Furthermore, every 0.01% BAC increase was found to correlate with a roughly 1% decline in psychomotor performance on a standardized task, and that correlation was linear.

Before the new work restrictions, residents were ending their 30-hour shift at an equivalent BAC of 0.17%, or more than twice the level at which society has decided that it is unsafe to drive a car. With the new work hour restrictions in place, residents are ending their shift at an equivalent BAC of 0.11%, an improvement, but still over the legal driving limit.

My opinion

Medicine is regarded as a conservative institution for good reason. By graduating from medical school and completing residency, physicians gain a vested interest in the status quo. Institutional change doesn't come easily to medicine, so these new resident work hour restrictions are monumental.

I agree with the restrictions on resident work hours from a theoretical standpoint, and I appreciate them for protecting my future sanity and my future patients' safety. I sure wouldn't want a drunk internist to care for me in the hospital, or a drunk surgeon to operate on me. However, based on my (admittedly limited) two months’ experience with hospitalized adult care, it seems to me that these work hour restrictions have unintended negative consequences, not the least of which is a more fragmented clinical experience for third-year medical students. In trying to balance adequate physician training with work hour restrictions to protect patient safety, there are no easy answers.

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Late update: Several of my colleagues are of the opinion that resident work hour restrictions have less to do with team discontinuity than the mismatch between the schedules of medical students, residents, and attendings.

One person said:

Our M3 rotation cycle doesn't match up with the monthly resident switch, and then the attendings all have 10 days on inpatient straight and then they switch. So our high composition turnover was simply due to the fact that attendings, residents, and medical students all have differing cycle duration through a given team.

Another person agreed, saying:

It is hard enough to line up Residents with each other. Let alone attendings with their resident teams. And, as always, the bottom of the barrel is the medical student who gets last dibs.

I observed the same phenomenon during my Internal Medicine clerkship and agree that it probably more directly led to team discontinuity. However, particularly at Denver Health, it seemed to me that this off-cycle rotation of medical students, residents, and attendings was made worse by a call cycle structured partly as a consequence of resident work hour restrictions.

A much-needed vacation

I'm done with my Internal Medicine clerkship! It feels especially good because now I have a whole week of complete freedom and relaxation before starting my Neurological Care clerkship at The Children's Hospital. This is a much-needed vacation, and I suspect that it will fly by all too quickly.

Homecoming: Return to the library

We had to return to campus today for standardized patient testing as part of the Hospitalized Adult Care evaluation. Since we also have the Internal Medicine shelf exam tomorrow, and since I was already on campus, I figured that I might as well study at the library. It feels good to be back in the library: no post-traumatic stress disorder from my Step 1 studying days. I had almost forgotten what a good study environment the library is compared to studying at home and at coffee shops.

Daily routine at Denver Health

My daily routine while working on the Medicine service at Denver Health was surprisingly predictable.

I woke up between 5:00-5:30 am to get to the hospital between 6:00-6:30 am, which gave me enough time to pre-round on my patients before rounds at 8:30 am. Rounds usually lasted until 10:00-11:00 am, depending on how efficient we were and how many patients we were carrying.

From the end of rounds until 12 noon, I took care of my patients. This included things like consulting various specialists (infectious disease, renal, etc...), following up on labs and studies, and ordering new labs or medications. At Denver Health, medical students can place orders, but they must be signed by a licensed physician, usually the intern or sometimes the resident.

Then we had Noon Conference until 1:00 pm, lunch catered.

Afternoons were also generally reserved for patient care. If I finished earlier in the afternoon, I would go back around and visit with my patients, then study until around 5:00 pm, then check in with my patients one more time, then ask my intern and resident if there was anything else I could do to help out before going home. On late days, I would stay until 7:00 pm or so.

Overall, I would guess that my average day was 11 hours long. I worked a couple 9-hour days and several 14-hour days, but the rest were between 10-13 hours. Of course, that's not counting the time spent at home studying or reading up on my patients.

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I attribute the regularity of my schedule at Denver Health to its rolling admissions structure. At Presbyterian St. Luke's and many other hospitals, doctors take call (i.e. admit new patients) every fourth day; that's not the case at Denver Health. Instead, the medicine team with the lightest census (carrying the fewest patients) takes the next admit. This makes good sense to me: whoever has the least amount of work admits the next patient.

However, this isn't the traditional model. Some interns and residents don't like rolling admissions because it eliminates post-call days, which are essentially an extra day off. From my perspective as a third-year medical student, though, I love this set-up because it secures for me a steady flow of patients. On any given day, if I wanted a new patient I could generally get one. That meant a lot to me in terms of my educational experience.

Getting sick in the middle of a clerkship

What happens if I get sick in the middle of my Internal Medicine clerkship? I know that I wasn’t alone among my classmates in worrying about this question as third-year began. We’re expected to work 12+ hours per day, six days per week, and we’re not allowed to have any personal life or suffer any illness that would cause us to miss a day of work. That’s a little melodramatic... but not overly so.

Well, I did get sick: a low-grade fever, chills, sweats, fatigue, and nausea. I didn’t have any upper-respiratory complaints and probably wasn’t contagious, so I showed up at the hospital at the usual time. I mustered enough energy to attend to my patients properly before rounds, but I had to pass on taking a new patient. My resident took note of this because I had been gunning for a new admission the night before.

I almost didn’t make it through rounds. I somehow presented my patients to the team adequately and answered a few pimps, but the rest of the time was a haze. Rather than actively participating in rounds, it was all I could do to save face and act like I wasn’t about to collapse on the ground.

After rounds, my resident told me that I should go home. Can I really? Will my resident think less of me for it, i.e. will this negatively impact his evaluation of me? I felt uncomfortable leaving right after rounds because that meant my intern would have to pick up my slack. “If it’s okay with you, I’d like to stay until I take care of all my patients.” This just meant ordering some labs, following up on some studies, and doing some other miscellaneous tasks that would save my intern some scut.

“Sure, but I don’t want to see you here past 12 noon.”

Deal.

I crashed right when I got home and slept for four hours straight, the kind of hard afternoon sleep that the body demands when it needs to mend itself.

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It seems to me that the personality of the resident greatly determines how the sick-in-the-middle-of-a-clerkship situation plays out. I very easily could have been working with a less sympathetic and understanding resident. Having a nice resident basically bought me the afternoon off when I really needed it.

I can also see how the particular clerkship might matter. Getting sick during an inpatient rotation such as Internal Medicine negatively impacts continuity of care. Even though I did everything I could to tie up loose ends before leaving, I fell behind the ball on the status of my patients by missing a whole afternoon. During an outpatient clerkship like Adult Ambulatory Care, in contrast, patients are seen in discrete 20-30 minute appointments. Missing an afternoon of outpatient care doesn't impact my ability to see new patients the next day. Also, missing any time during a short 2-week rotation might be more problematic.

Here's to hoping that I don't get sick again for the rest of third-year.

Expectations of a third-year medical student on Internal Medicine clerkship

My new attending sat down with me to discuss his expectations of me during the next couple of weeks. Previous attendings have also sat down with me to have a sort of introductory conversation, mostly so they can get a sense of who I am and where I"m at in my training. This was different, though, because my new attending enumerated for me exactly what he expected of me, in no unclear terms.

1. I should be carrying between 4-5 patients at any given time, and I should know all of my patients inside and out.
2. I should read as much as possible about my patients' diseases (pathophysiology, diagnosis, clinical presentation and course, treatment) since that more than anything will reinforce my learning.
3. History and physical exams should take about 20 minutes.
4. Initial patient presentations should take about 7 minutes, but I can take as much as 10 minutes if the patient is complicated. They should be structured.
5. Follow-up presentations should take no more than 5 minutes. They can be a little less structured.
6. During oral presentations, I should avoid reading from a paper and instead talk directly to my attending as much as possible. If I did a good job talking with my patient, then all the information should already be in my head.
7. I should be familiar with all of the other patients on our service, since I may be asked about any of them.
8. I should attend all rounds. They are sacred. That means no skipping rounds to go watch a procedure.

Some of this advice is common sense. Some of this advice is specific to my stage of training. The rest of it, though, is wonderful general advice for any third-year medical student on the Internal Medicine clerkship.

The storage clipboard

The storage clipboard has changed my life. Well, it's at least improved my organizational skills in the hospital. When I didn't have any clipboard at all, my white coat was bursting at the seams with papers of various sorts (progress notes, blank order sheets, uptodate articles, etc...). I even had a system to help organize what went where: reference and educational materials in the right inside pocket, work-related papers in the left inside pocket.

Needless to say, this didn't work very well. I started using a folding clipboard that fits into my white coat pocket. That worked fine for a few weeks, but I got frustrated with it because any papers it was holding would get roughed up if I ever folded it. What's the point of a folding clipboard if I never fold it?
Thus, we arrive at the storage clipboard. I don't mean to get into the business of product endorsement, but this thing has revolutionized the the way I "practice" medicine. I'm going to honor my Internal Medicine clerkship for no other reason than that I have this storage clipboard.

Clinical case presentations

Case presentations are one of my favorite things about Internal Medicine, apart from patient care. They're essentially a patient's entire hospital course compressed into one hour. A resident, intern, or medical student presents a particularly interesting or educational patient to the entire group. The chief resident moderates the discussion, pausing at certain points to allow the group to further investigate the case. The idea is for the group to collectively "work up" a patient as we would in real life.

I enjoy thinking through the case in my mind, figuring out what questions I would ask or what other labs I would order, then comparing that to what the group comes up with. As a medical student, I find this exercise invaluable in using the interns and residents as models for how I should approach a patient. Plus, I feel so actively engaged in the case presentation that the clinical lessons seem to stick almost as well as seeing a real patient.

Case presentations are generally similar at PSL compared to DHMC; their differences are mostly due to individual personalities of the faculty moderators. At PSL, the faculty moderators tended to give the chief resident and the group discussion more free reign, adding to the discussion only when an experienced opinion was needed.

At Denver Health, though, the faculty moderator is an old-school personality locally famous for his chest x-ray readings and his bow-ties. He takes more control over the discussion, explaining his diagnostic approach step-by-step. Every piece of information you gather should inform your next question to the patient, he says. He also reinforces a systematic approach to thinking about all possible causes of a given set of signs and symptoms. I feel smarter just listening to him.

I hope other clerkships have case presentations, or something like them.

Realities of working at a safety-net hospital

One of the patients I'm following managed to put together quite the interdisciplinary team. We consulted: infectious disease, GI, neuro, psychiatry, nutrition, speech therapy, social work, physical therapy, and occupational therapy.

Despite so many people and so many resources devoted to this patient, she still insisted on returning to the poor lifestyle decisions that landed her in the hospital in the first place. She understood how her actions negatively impacted her health and that she would likely wind up back in the hospital with the same problems, or worse. "Why change now?" I had a dozen answers to that question, but none of them mattered. She didn't want to die, yet she also seemed to accept early death as a consequence of living the rest of her life on her own terms.

I think what I'm feeling now is the prodrome of disenchantment.

A familiar face on my team

I got really lucky with my team for the first two weeks of my Internal Medicine clerkship at Denver Health. My attending just happens to be one of my favorite professors from my pre-clinical years! He teaches biochemistry and endocrinology (nutrition and metabolism). Aside from being an excellent teacher, he's also just an all-around nice guy. He has a calming demeanor; just talking with him, you get the sense that he is fully listening and truly cares about what you're saying.

This is particularly helpful since I have been struggling a bit with some anxiety surrounding oral presentations. Over the past few days, I think that my oral presentations have been much better than they were last month at PSL. This is partly because I have more confidence stemming from more experience and exposure, though I also attribute this improvement in part to decreased performance anxiety in this new learning environment. It's not really what I was expecting from Denver Health.

Both my resident and intern are also excellent, but I'm only with them through the end of the week before they rotate to a new team. I wish that I had more time working with them, too.

Internal Medicine clerkship schedule at PSL

Presbyterian St. Lukes Medical Center

Call: When your team admits new patients.

Call is every fourth day ("call q4") at PSL. Residents and sub-interns (fourth-year medical students) are there for the full 30 hours; the two interns per team split the call day in two 12-hour shifts; third-year medical students stay until they get their 2-3 patients, but no later than midnight.

Rounds: When your team talks to the attending physician about current patients.

Rounds can be a bit confusing because they're held at different times depending on the day in the call cycle. Post-call rounds are usually at 7:30am, and the attending usually invites the team to eat breakfast in the physicians' cafeteria. Rounds are held at 8:00 and 8:30 on the second and third days after call, and they're held at 9:00 on call days.

Pre-round: When you visit with your patients in the morning and collect all new information (e.g. labs, studies, significant overnight events, physical exam).

I usually gave myself around 2 hours to pre-round on 2-3 patients. The earliest I got to the hospital over the past month was at 5am, and that was on a post-call day when I had 3 patients to pre-round on before rounds at 7:30.

My pre-round looks something like this:
1) Talk to the night nurse about overnight events.
2) Look in the patient's chart (both physical and electronic) to check for new orders or follow-up notes.
3) Start filling in my own follow-up note with the information I got from the overnight nurse and objective data like morning labs or any studies done since the previous morning's rounds.
4) Visit with my patient: get their perspective on how they did overnight.
5) Do a targeted physical exam.
6) Finish writing my follow-up note before rounds.

Classroom learning

In addition to clinical duties, I also had to attend various lectures and seminars. We had Morning Report every day from 10:30-11:30 and Noon Conference every day from noon-1pm. On Thursday afternoons, we also had to attend the Chief Resident Lecture Series from 2:30-4:00.

The end of the day

I got lucky that both of the residents who I worked with over the past month were laid-back and considerate of my time. They usually told me to go home rather early in the afternoon, sometimes even as early as 2pm. I didn't really know what to think about this, at first, especially given all of the horror stories I've heard about Internal Medicine being one of the hardest clerkships.

Typically, when my resident told me to go home earlier than 4-5ish, I would go find one or both of my interns and see if there was anything I could do to make their life easier. This amounted to scutwork, yes, but these were the kinds of tasks and chores that I'll have to be doing myself when I'm an intern. Plus, I know that both of my interns appreciated my scutwork services because it helped them get out of the hospital earlier. If both of my interns sent me home, too, I'd either study for the shelf exam in the hospital's library (I'm not exactly a procrastinator) or I'd actually go home and relax or go for a run.

Overall, I had a few 18-hour days and a few 8-hour days, with most of my days falling somewhere around 10-12 hours. It'll be interesting to see how my schedule at Denver Health compares.

Loose ends

I left loose ends at PSL.

The most important loose end is a patient who we admitted quite awhile ago. This patient has a rare disease with a very poor prognosis, and there were several times over the past month when we thought that he might pass away. I have observed with great interest the dynamics between the medical team and my patient's family and how those dynamics have impacted his process of dying.

I care very much for this patient. The last time I saw him awake, I held his hand to comfort him. There really wasn't anything else I could do to help. He looked up at me and whispered "Thank you." I could barely hear his words over the noise of the breathing machine and the mask over his mouth. The meaning was in his eyes. A single tear rolled down his cheek, and I caught it with my finger.

Then I squeezed his hand one last time and left. It was so much more difficult for me to leave him than to hold his hand.

Preparing for the Hereafter

My resident came to me with a new patient who he wanted me to follow: “This is an elderly lady complaining of dizziness and fatigue [details changed]. On a scale of 1 to cute, she’s cute.” He was right. I immediately made a connection with Alice [pseudonym]. Even through her pain and discomfort, she was always pleasant and smiling and quietly encouraging me as a student of medicine in her gentle Southern twang. An aura surrounded her that she had experienced a lot of life and had perhaps learned some of its secrets.

When it came time to discharge Alice, I was selfishly sad that I would no longer have the pleasure of her company. That was when I decided that I would ask her if I could visit her in her home as part of a required assignment for this clerkship.

The point of this assignment is to emphasize the human component of the patients we see. My perception of my patients is very much colored by the only environment in which we have interacted, the hospital. I may have had some enjoyable conversations with Alice, and I may have met some of her family and friends, but my perspective of her throughout her hospitalization was necessarily one-dimensional.

What is her home environment like? I knew that her son was taking care of her, but what is the exact nature of that relationship? How does she manage her medications? How does she get around the house? What does she do for fun?

Alice and her son welcomed me into their home. It’s a small house located on a busy street, and it’s equally busy inside bursting with plants and pictures. Alice was in the living room when I arrived; I watched her get out of her chair and make her way to her motorized wheelchair 10 feet away, assisted by her walker. The whole process took about 2 minutes.

Alice explained that she likes to move about by herself, but her son is usually nearby to help her if she needs it. She further explained that her son does all the chores around the house, including managing her medications and preparing food. I noted the dozen or so medicine bottles perched on a tray built into her walker and the smell of an early dinner coming from the kitchen, where her son was humming and cooking away.

I asked her about her hobbies and what she does to keep herself busy. Without trying to hide her disappointment, she described how she had previously been very active in her church community but is now unable to get out and socialize. She doesn’t leave her house much at all. Even getting to her doctor’s appointments is a big deal.

Then she voiced her biggest concern: “My son is getting tired. It’s a big job taking of caring of me. I don’t know when I’m going to have to move into a nursing home.” I realized that this issue must weigh heavily on her mind. I didn’t have any easy answers for her.

We spent the rest of our visit together looking at pictures on the walls and talking about the people from her past who she has loved. Then it was time to leave.

“Goodbye, Alice. Thank you for your hospitality.”

“There ain't no goodbyes, honey. I’ll see you in the Hereafter.”