1. As many of you have heard, sometimes tempers can flare in the clinics. Remember that 95% of the time, it’s not about you. Is there something that this resident or attending needs to do, or a statement that they feel they need to make by acting this way? Does it really have to do with you, your knowledge, or your performance? Of course, honest self-appraisal of your own skills is an important part of learning to be a physician as well. But this may save you some undue heartache.
2. On services where there is a list, your intern should not beat you there in the morning. Make your intern’s life easy, and you win the game.
3. Write about your experiences. You have to log each patient anyway. Try taking the time to write a few sentences or a paragraph about what you learned from each patient outside of the realm of “medicine.” You may find it re-engages you with your daily duties as it refreshes why you went into medicine in the first place.
4. Everyone handles pressure/stress/failure/sorrow/death differently. Respect those differences.
5. Make your patient look to you as their primary physician. When you walk in to their room on rounds, lead the team in and make the initial introduction for the morning to the patient. When a patient asks a question about their care in the presence of your whole team, they should be looking at you. You are learning how to become a physician.
6. Make friends with the nurses – they can be your biggest ally or your worst enemy. The vast majority of them want to be your biggest ally, and those that don’t have never met a student like you.
7. Never suck up or throw a fellow student under the bus. Everyone on your team has been in your position: the student. In fact, many were there just a few years ago. They understand what’s going on and the pressures to perform and achieve certain grades. But make no mistake, they see right through your brown-nosing and colleague-under-bus-throwing – they know what you’re up to. Don’t do it.
8. “Try on” every specialty. They are going to make you do the rotations anyway, right? See what the life of a neurosurgeon is like or what the emotional stresses of a psychiatrist are. What is it like to be called by a patient in the middle of the night? And don’t forget to take note of what the attending physicians are doing. You won’t be a resident forever, and sometimes life as a resident and an attending in a certain specialty are vastly different.
9. “No,” and “I don’t know how” are never the right answer. “I don’t know how to do that, but if you show me how this time I can do it in the future” is much better received and helps you learn new things.
10. Have an academic (grade) as well as a personal goal for each rotation. I knew that I didn’t want to do OB/GYN, but my personal goal for the rotation was to not have to duck in a crowd of people if someone shouted, “Is there a doctor here?! This woman is going into labor!”
11. Not everyone will like the third year. It’s a hard transition, and for a lot of the clinical situations, despite your best efforts, it can end up being a shadowing experience. At times it can feel like “playing doctor.” There can be quite a bit of “meta-behavior” in the clinics when people know they are being evaluated at the end. This can be frustrating and disheartening, but try to look beyond that.
12. As #11 states, sometimes there is little role for a medical student on a certain service. Don’t just “get through it.” Your new goal when a rotation turns into more of a shadowing experience is to try to be of use to the team. You’re not above doing any work that needs to be done. Neither is your attending physician for that matter.
13. If you’re five minutes early, you’re ten minutes late.
Blake J. Hyde, MSIV
Class of 2011 Co-President, M.D. Candidate
University of Colorado School of Medicine
Wednesday, January 19, 2011
Advice for incoming third-year medical students
The co-presidents of the Class of 2011 (current fourth-year students) spoke to us about Phase III clinical rotations. I found their perspective very helpful. Blake actually prepared 13 specific pieces of advice, which he was kind enough to share, and which I want to pass on:
Sunday, January 16, 2011
Phase III orientation "retreat"
The administration recently held a retreat for the class of 2013 to demystify Phase III. "Retreat" is a bit of a misnomer since the conference was held in a lecture hall on campus. Regardless, a lot of thought and energy went into organizing this event, which was primarily for our own benefit and turned out to live up to its purpose.
So many questions...
What are clerkships?
Clerkships are the same thing as "clinical rotations." Their purpose is to expose the third-year medical student to a particular field or specialty. The student experiences that field from the clinical perspective and becomes as clinically proficient in it as he or she can get in the number of weeks allotted to that rotation.
What clerkships are required?
Ten clerkships must be completed during Phase III:
These clerkships are then scheduled within six 8-week blocks starting April 25, 2011 and ending April 20, 2012. Mixed in there are three clinical interludes (about which I know very little) and a few federal holidays sprinkled here and there.
So, you get some holidays off?
Maybe. Holidays during Phase III "may not apply at all clinical sites." It's at the discretion of my attending physician. That said, the holidays listed on my schedule are:
I also get a Fall break from August 15-19 and a Winter break from December 17 - January 2. Those breaks are certain, but they may fall in the middle of a clinical rotation, in which case I imagine the break wouldn't be completely worry-free.
In what order will you do your clerkships?
I don't know, yet. I will post my Phase III schedule here when I get it in early February.
Do you get to choose your schedule?
Not really. But, the administration has set up a system in which every student identifies two priority clerkships. Last year, every student but one got their first priority clerkship. On top of that, there is a student-led swapping program that permits two students to switch clerkships if both students agree and if the switch does not cause any other scheduling conflicts. As you might imagine, a lot of anxiety surrounds this whole process.
What were your first and second clerkship priorities?
I chose to have the Adult Ambulatory Care and Rural Community Care rotations (they are scheduled together) first (priority #1) and my Internal Medicine rotation second (priority #2). My reasoning for this was several-fold.
Numerous people - including my preceptor - suggested doing Internal Medicine earlier rather than later because it serves to prepare students to perform better in subsequent clinical rotations. In fact there is an article in the Journal of the American Medical Association (JAMA) that provides evidence supporting this notion:
I have other personal reasons for requesting these priorities. I prefer to approach the longer clerkships earlier so I'm less tired and burned out for them. I prefer to do the rural rotation during the Spring/Summer months when the whether is more forgiving. Also, several interns and residents I've talked to said that Adult Ambulatory Care and Rural Care are relatively easy ways to transition into the clinics.
Regardless, the administration was careful to emphasize that there are no guarantees that we'll get even our first priority. So, let's just put this out of our minds and wait until February when I'll have a concrete schedule.
What's this about a rural rotation?
Yes, a rural rotation. Except for Denver, Colorado Springs, and a few other smaller cities, Colorado is a very rural state. As such, the School of Medicine places a strong emphasis on rural medicine. That includes requiring a clinical rotation in rural Colorado. Housing is provided by a program called the Colorado Area Health Education Center (AHEC), either in condos or town homes owned by AHEC, or with a host family. I don't know all of the rural sites, but we select our top preferences from a list in a process similar to prioritizing our clerkships.
It's also worth noting that many of the clerkships have rural sites. Emergency Medicine, for example, has a rotation at St. Mary's community hospital out in Grand Junction. The Women's Care rotation has sites in Colorado Springs, Frico, and Brighton. If I wanted to, I could probably arrange to spend more than half of Phase III outside of Denver.
Will you have a life during Phase III?
No. In fact, this point was specifically emphasized in case there was any ambiguity on the matter. We were told to ask our friends not to get married during this coming year. In fact, it would also be best if none of my family or friends have birthdays or decide to die over this coming year. I'm not to get sick, either.
In all seriousness, though, the administration explained how there are involuntary absences (e.g. sick) and voluntary absences (e.g. wedding, birthday). They then told us that any absences - voluntary or not - may delay our graduation date if we are unable to make up all of the clinical requirements that we miss as a result of our absence. So far, it's certain that I will miss my Nana's 80th birthday celebration. Still up in the air is a close friend's wedding. Luckily, I will most likely be able to attend my sister's graduation, but only because it happens to be local.
This is depressing. But as I told my little sister when we were discussing her graduation and my Phase III schedule, I knew that this was coming when I signed up for medical school.
The rest of the conference
The rest of the conference consisted of presentations by the various clerkship directors. We were also given an opportunity to talk in small groups with the clerkship directors and ask them any questions we had about that particular rotation. I found this extremely helpful.
The co-presidents of the Class of 2011 (current fourth-year students) spoke to us, imparting their hindsight-is-20/20 wisdom. One of them made a list of concrete pieces of advice for incoming third-year medical students, which I will provide in a separate post.
Finally, the 8-hour conference was capped off by a dinner hosted by Student Affairs. A chief-resident sat at each table and chatted with us in that informal setting. The keynote address was given by Dr. Steve Lowenstein, an Emergency Medicine doctor with a degree in public health. His entire speech was excellent, but one quote stood out to me. On how to avoid and deal with burnout, his advice was to fall back on kindness: "Kindness is easy to administer and exceptionally well tolerated." Moreover, kindness speaks to the reasons why I decided to go into medicine in the first place.
There's no doubt about it: Phase III will be physically and emotionally exhausting. But I am looking forward to jumping into that next phase of my medical education.
P.S. Please e-mail me or write a comment if you have any questions about Phase III that I did not address. If I don't know the answer, I'll probably want to figure it out just as much for myself as for you. I may write a follow-up post on Phase III if there's a need for one.
So many questions...
What are clerkships?
Clerkships are the same thing as "clinical rotations." Their purpose is to expose the third-year medical student to a particular field or specialty. The student experiences that field from the clinical perspective and becomes as clinically proficient in it as he or she can get in the number of weeks allotted to that rotation.
What clerkships are required?
Ten clerkships must be completed during Phase III:
* Hospitalized Adult Care (a.k.a. Internal Medicine) - 8 weeks
* Infant/Adolescent Health (a.k.a. Pediatrics) - 6 weeks
* Musculoskeletal Care (a.k.a. Orthopedics) - 2 weeks
* Women's Care (a.k.a. OB/GYN) - 6 weeks
* Urgent and Emergency Care - 2 weeks
* Psychiatric Care -4 weeks
* Neurologic Care - 4 weeks
* Operative/Perioperative Care (a.k.a. Surgery) - 8 weeks
* Adult Ambulatory Care - 4 weeks
* Rural and Community Care - 4 weeks
These clerkships are then scheduled within six 8-week blocks starting April 25, 2011 and ending April 20, 2012. Mixed in there are three clinical interludes (about which I know very little) and a few federal holidays sprinkled here and there.
So, you get some holidays off?
Maybe. Holidays during Phase III "may not apply at all clinical sites." It's at the discretion of my attending physician. That said, the holidays listed on my schedule are:
* Memorial Day, May 30
* Independence Day, July 4
* Labor Day, September 5
* Thanksgiving, November 24-25
* Martin Luther King Jr. Day, January 16
* Presidents' Day, February 20
I also get a Fall break from August 15-19 and a Winter break from December 17 - January 2. Those breaks are certain, but they may fall in the middle of a clinical rotation, in which case I imagine the break wouldn't be completely worry-free.
In what order will you do your clerkships?
I don't know, yet. I will post my Phase III schedule here when I get it in early February.
Do you get to choose your schedule?
Not really. But, the administration has set up a system in which every student identifies two priority clerkships. Last year, every student but one got their first priority clerkship. On top of that, there is a student-led swapping program that permits two students to switch clerkships if both students agree and if the switch does not cause any other scheduling conflicts. As you might imagine, a lot of anxiety surrounds this whole process.
What were your first and second clerkship priorities?
I chose to have the Adult Ambulatory Care and Rural Community Care rotations (they are scheduled together) first (priority #1) and my Internal Medicine rotation second (priority #2). My reasoning for this was several-fold.
Numerous people - including my preceptor - suggested doing Internal Medicine earlier rather than later because it serves to prepare students to perform better in subsequent clinical rotations. In fact there is an article in the Journal of the American Medical Association (JAMA) that provides evidence supporting this notion:
The positive association between initial internal medicine clerkship experience and subject examination performance throughout the clerkship sequence may reflect general understanding of internal medicine concepts, providing a fundamental basis for medical knowledge in all clinical disciplines.
JAMA. 2010;304(11):1220-1226.
I have other personal reasons for requesting these priorities. I prefer to approach the longer clerkships earlier so I'm less tired and burned out for them. I prefer to do the rural rotation during the Spring/Summer months when the whether is more forgiving. Also, several interns and residents I've talked to said that Adult Ambulatory Care and Rural Care are relatively easy ways to transition into the clinics.
Regardless, the administration was careful to emphasize that there are no guarantees that we'll get even our first priority. So, let's just put this out of our minds and wait until February when I'll have a concrete schedule.
What's this about a rural rotation?
Yes, a rural rotation. Except for Denver, Colorado Springs, and a few other smaller cities, Colorado is a very rural state. As such, the School of Medicine places a strong emphasis on rural medicine. That includes requiring a clinical rotation in rural Colorado. Housing is provided by a program called the Colorado Area Health Education Center (AHEC), either in condos or town homes owned by AHEC, or with a host family. I don't know all of the rural sites, but we select our top preferences from a list in a process similar to prioritizing our clerkships.
It's also worth noting that many of the clerkships have rural sites. Emergency Medicine, for example, has a rotation at St. Mary's community hospital out in Grand Junction. The Women's Care rotation has sites in Colorado Springs, Frico, and Brighton. If I wanted to, I could probably arrange to spend more than half of Phase III outside of Denver.
Will you have a life during Phase III?
No. In fact, this point was specifically emphasized in case there was any ambiguity on the matter. We were told to ask our friends not to get married during this coming year. In fact, it would also be best if none of my family or friends have birthdays or decide to die over this coming year. I'm not to get sick, either.
In all seriousness, though, the administration explained how there are involuntary absences (e.g. sick) and voluntary absences (e.g. wedding, birthday). They then told us that any absences - voluntary or not - may delay our graduation date if we are unable to make up all of the clinical requirements that we miss as a result of our absence. So far, it's certain that I will miss my Nana's 80th birthday celebration. Still up in the air is a close friend's wedding. Luckily, I will most likely be able to attend my sister's graduation, but only because it happens to be local.
This is depressing. But as I told my little sister when we were discussing her graduation and my Phase III schedule, I knew that this was coming when I signed up for medical school.
The rest of the conference
The rest of the conference consisted of presentations by the various clerkship directors. We were also given an opportunity to talk in small groups with the clerkship directors and ask them any questions we had about that particular rotation. I found this extremely helpful.
The co-presidents of the Class of 2011 (current fourth-year students) spoke to us, imparting their hindsight-is-20/20 wisdom. One of them made a list of concrete pieces of advice for incoming third-year medical students, which I will provide in a separate post.
Finally, the 8-hour conference was capped off by a dinner hosted by Student Affairs. A chief-resident sat at each table and chatted with us in that informal setting. The keynote address was given by Dr. Steve Lowenstein, an Emergency Medicine doctor with a degree in public health. His entire speech was excellent, but one quote stood out to me. On how to avoid and deal with burnout, his advice was to fall back on kindness: "Kindness is easy to administer and exceptionally well tolerated." Moreover, kindness speaks to the reasons why I decided to go into medicine in the first place.
There's no doubt about it: Phase III will be physically and emotionally exhausting. But I am looking forward to jumping into that next phase of my medical education.
P.S. Please e-mail me or write a comment if you have any questions about Phase III that I did not address. If I don't know the answer, I'll probably want to figure it out just as much for myself as for you. I may write a follow-up post on Phase III if there's a need for one.
Tuesday, January 11, 2011
Infectious Diseases: A thin layer of poop
One of our Infectious Diseases professor this morning: “We virologists see the world as being covered by a thin layer of poop. It’s remarkable that we don’t all have diarrhea all the time.”
The Infectious Diseases block runs concurrently with the Life Cycles block. It covers microbiology (bacteria, viruses, fungi, protozoa) and goes into pharmacological treatment in greater depth than we received last year in our Disease and Defense block. We also have a fair amount of instruction time in the lab. This week, we're learning how to identify both endemic and pathogenic bacteria commonly found in stool.
The Infectious Diseases block runs concurrently with the Life Cycles block. It covers microbiology (bacteria, viruses, fungi, protozoa) and goes into pharmacological treatment in greater depth than we received last year in our Disease and Defense block. We also have a fair amount of instruction time in the lab. This week, we're learning how to identify both endemic and pathogenic bacteria commonly found in stool.
Monday, January 10, 2011
Learning the female breast, gynecological, and male urogenital exams
Notice: This post contains medically-relevant graphic descriptions of pelvic exams.
We tend to have very personal and complex relationships with our sexuality, and it is perhaps because of this that the pelvic exam is one of the more salient (traumatic?) experiences associated with going to the doctor. "Turn your head and cough" is a phrase that is burned into our collective psyche. Likewise, my impression is that a woman's first gynecological exam is as much a rite of passage as menarche.
So, it's natural that I approached learning the male and female pelvic exams (a rite of passage of its own) with a little anxiety. "I would be worried if you weren't a little anxious," one of our professors said as she prepared us for the experience.
Learning how to perform the male urogenital exam and the female gynecologic exam, which I did last week, is the Foundations of Doctoring clinical correlate to the Life Cycles block. The class is divided into groups of three students per instructor. These instructors are specifically trained to teach the respective pelvic examination using their own body. Instruction for the two exams were done on separate days, and each lasted around 3 hours.
Male urogenital exam
I feel lucky that I was assigned to learn the male urogenital exam first. It's much less invasive, and there's a certain comfort level in working with someone of the same gender. It also turned out that my particular instructor was very personable, laid back, and made the experience as enjoyable as possible.
I was grouped with two other male classmates, so when the instructor opened his gown for the first time and was talking to us with his genitals exposed, the interaction almost had the feel of a locker room conversation - except that he was pointing to his genitals and expecting us to look at them. It only took a few moments for me to get over that initial shock, which I felt despite my best mental preparations. After that, the experience was wholly professional and natural.
Much of the instruction focused on the interpersonal aspects of administering this exam. Be confident, because patients can smell nervousness and inexperience. Look the patient in the eye, and watch for non-verbal signs of discomfort. Use a combination of technical and common language so the patient understands what is happening and so the examination remains professional.
Language is a very big deal. For instance, one of my classmates asked our instructor to "please spread your butt cheeks." We all busted out laughing because in that moment he couldn't think of the right way to say such a thing. We were instructed to instead say, "Please spread your buttocks."
We were also shown the different positions in which we could perform the digital rectal exam and the relative pros and cons for each position. Myself being younger than 50 years with no risk factors for prostate cancer, this was all new information to me. The preferred patient position for examining a healthy man is standing with feet shoulder-width apart, leaning over and resting the elbows on the exam table. Many of my classmates have done this before while working with their preceptor, but this was my first time performing a prostate exam.
My last comment about the male urogenital exam is that we were taught to encourage our patients to do self exams (mostly to check for testicular cancer) much like women are encouraged to monthly self breast exams. There is so much publicity about breast exams, but before this I had never heard of male self exams either from my doctor or from the media. Lance Armstrong's battle against testicular cancer did help to raise awareness with his Livestrong campaign. I believe that his organization does promote testicular self exams, but for me at least that message never got through.
Female breast exam
My experience learning the female breast and gynecological exams was quite different. First, the course coordinators broke up our all-male group, so I was with one male and one female classmate. I was grateful for this, since it might have been a little awkward having an all-male group for this particular examination. Second, our instructor was much more serious - necessarily so, again given the invasive nature of this exam.
Just like with real patients, we started with the least invasive procedure and progressed toward the more invasive ones. First on the list was the breast exam. We were instructed on both how to administer the breast exam and how to teach our patients to examine their own breasts once a month. The female breast self-exam has become so much a part of popular culture thanks to breast cancer awareness campaigns, so I was happy to learn something so practical.
Much attention was paid to patient comfort. One absolute rule was to only touch the patient with one hand at a time. This struck me as odd. Why would touching the patient with only one hand make her feel less threatened? Couldn't I do a quicker and more effective breast exam using two hands? We were told that a doctor who used two hands to do any part of the breast or gynecological exam would not be in business for very long because patients would not return to that doctor. Fair enough. But the explanation that makes more sense to me is that the patient herself will be able to use only one hand when doing the self breast exam.
Gynecological exam
After learning the breast exam, we moved on to the gynecological exam. "Who wants to go first?" In these sessions, the person who goes first gets the most detailed instruction while the other two students run through the exam as if they were administering it to a real patient. Both I and my male classmate looked over at our female classmate: "I guess it's me!" she laughed.
I have seen many pelvic exams in the emergency department, but the exam itself was never explained to me. For example, what is the doctor feeling for when he or she pushes down onto the stomach with the fingers inserted into the vagina? The point of the bimanual exam is to palpate (fancy medical terminology for feel/touch) the edges of the uterus to determine its shape and where it sits. The fingers inserted into the vagina put pressure on the cervix, while pushing down on the abdomen locates the fundus of the uterus (it's top-most border). When done correctly, we're supposed to feel pressure from the cervix pushing back onto our fingers.
It happened that my female classmate who was learning the exam first has small hands, and she was having trouble getting her fingers in deep enough to touch the cervix. Her hands started cramping. We all had a little laugh about it in this relatively relaxed setting (compared with seeing a real patient), but our instructor also took the opportunity to teach us what to do in such a situation: tilt the bed a little downward so gravity pulls everything closer toward the fingers. She was also careful to point out that having small hands should not keep someone from pursuing a career in OB/GYN.
I was surprised to learn that the gynecological exam includes a maneuver that involves insertion of a finger into the rectum. My female classmates were equally surprised, and I have yet to talk with anyone whose doctor performed this maneuver. Regardless, we were taught that no gynecological exam is complete without it. The doctor inserts the index finger in the vagina and the middle finger in the rectum simultaneously. The middle finger eventually penetrates into an open space called the pouch of Douglas. So positioned, by pushing down on the top of the uterus, the doctor can palpate the posterior (back) side of the uterus. The purpose of this is to feel for cysts or fibroids. This doesn't sound like a very comfortable procedure to experience, which probably explains why I couldn't find anyone whose gynecologist included it in the regular examination. I wonder how long it will take for this to be standard-of-care.
When it came time for me to perform the gynecological exam, the only part that gave me problems was visualizing the cervix with the speculum. We used disposable plastic speculums instead of the metal variety. To put this in perspective, my instructor went through five of these exams before me: I was her sixth and last exam of the day. Although I can't speak from personal experience, it's my understanding that these exams are uncomfortable at best. This is something of a heroic task for these instructors to lend their bodies in such a way for the purpose of educating medical students such as myself. After teaching five medical students, the tissues in her vagina and surrounding the cervix were irritated and slightly inflamed making it more difficult to use the speculum appropriately. My instructor used this as a teaching point, saying that in such a situation it may become necessary to use a slightly larger speculum. After moving from a medium to a large, I was able to find the cervix with minimal difficulty.
One last word about the gynecological exam. Just as with the male urogenital exam, using the correct language is important. Women put their feet in foot rests now instead of stirrups: "We're not riding a horse now, are we?" says our Foundations instructor. Likewise, I "remove" my finger instead of "withdraw" it, since the latter terminology may have a sexual undertone to it.
Summary
I know this was a long post, but given the potency of this experience, I feel that its length is warranted in order to communicate what I and other medical students actually experience while learning the pelvic exams for the first time. I should note that not all medical schools provide this instruction for their students. This experience makes me all the more eager to start my clerkships coming up in Phase III.
We tend to have very personal and complex relationships with our sexuality, and it is perhaps because of this that the pelvic exam is one of the more salient (traumatic?) experiences associated with going to the doctor. "Turn your head and cough" is a phrase that is burned into our collective psyche. Likewise, my impression is that a woman's first gynecological exam is as much a rite of passage as menarche.
So, it's natural that I approached learning the male and female pelvic exams (a rite of passage of its own) with a little anxiety. "I would be worried if you weren't a little anxious," one of our professors said as she prepared us for the experience.
Learning how to perform the male urogenital exam and the female gynecologic exam, which I did last week, is the Foundations of Doctoring clinical correlate to the Life Cycles block. The class is divided into groups of three students per instructor. These instructors are specifically trained to teach the respective pelvic examination using their own body. Instruction for the two exams were done on separate days, and each lasted around 3 hours.
Male urogenital exam
I feel lucky that I was assigned to learn the male urogenital exam first. It's much less invasive, and there's a certain comfort level in working with someone of the same gender. It also turned out that my particular instructor was very personable, laid back, and made the experience as enjoyable as possible.
I was grouped with two other male classmates, so when the instructor opened his gown for the first time and was talking to us with his genitals exposed, the interaction almost had the feel of a locker room conversation - except that he was pointing to his genitals and expecting us to look at them. It only took a few moments for me to get over that initial shock, which I felt despite my best mental preparations. After that, the experience was wholly professional and natural.
Much of the instruction focused on the interpersonal aspects of administering this exam. Be confident, because patients can smell nervousness and inexperience. Look the patient in the eye, and watch for non-verbal signs of discomfort. Use a combination of technical and common language so the patient understands what is happening and so the examination remains professional.
Language is a very big deal. For instance, one of my classmates asked our instructor to "please spread your butt cheeks." We all busted out laughing because in that moment he couldn't think of the right way to say such a thing. We were instructed to instead say, "Please spread your buttocks."
We were also shown the different positions in which we could perform the digital rectal exam and the relative pros and cons for each position. Myself being younger than 50 years with no risk factors for prostate cancer, this was all new information to me. The preferred patient position for examining a healthy man is standing with feet shoulder-width apart, leaning over and resting the elbows on the exam table. Many of my classmates have done this before while working with their preceptor, but this was my first time performing a prostate exam.
My last comment about the male urogenital exam is that we were taught to encourage our patients to do self exams (mostly to check for testicular cancer) much like women are encouraged to monthly self breast exams. There is so much publicity about breast exams, but before this I had never heard of male self exams either from my doctor or from the media. Lance Armstrong's battle against testicular cancer did help to raise awareness with his Livestrong campaign. I believe that his organization does promote testicular self exams, but for me at least that message never got through.
Female breast exam
My experience learning the female breast and gynecological exams was quite different. First, the course coordinators broke up our all-male group, so I was with one male and one female classmate. I was grateful for this, since it might have been a little awkward having an all-male group for this particular examination. Second, our instructor was much more serious - necessarily so, again given the invasive nature of this exam.
Just like with real patients, we started with the least invasive procedure and progressed toward the more invasive ones. First on the list was the breast exam. We were instructed on both how to administer the breast exam and how to teach our patients to examine their own breasts once a month. The female breast self-exam has become so much a part of popular culture thanks to breast cancer awareness campaigns, so I was happy to learn something so practical.
Much attention was paid to patient comfort. One absolute rule was to only touch the patient with one hand at a time. This struck me as odd. Why would touching the patient with only one hand make her feel less threatened? Couldn't I do a quicker and more effective breast exam using two hands? We were told that a doctor who used two hands to do any part of the breast or gynecological exam would not be in business for very long because patients would not return to that doctor. Fair enough. But the explanation that makes more sense to me is that the patient herself will be able to use only one hand when doing the self breast exam.
Gynecological exam
After learning the breast exam, we moved on to the gynecological exam. "Who wants to go first?" In these sessions, the person who goes first gets the most detailed instruction while the other two students run through the exam as if they were administering it to a real patient. Both I and my male classmate looked over at our female classmate: "I guess it's me!" she laughed.
I have seen many pelvic exams in the emergency department, but the exam itself was never explained to me. For example, what is the doctor feeling for when he or she pushes down onto the stomach with the fingers inserted into the vagina? The point of the bimanual exam is to palpate (fancy medical terminology for feel/touch) the edges of the uterus to determine its shape and where it sits. The fingers inserted into the vagina put pressure on the cervix, while pushing down on the abdomen locates the fundus of the uterus (it's top-most border). When done correctly, we're supposed to feel pressure from the cervix pushing back onto our fingers.
It happened that my female classmate who was learning the exam first has small hands, and she was having trouble getting her fingers in deep enough to touch the cervix. Her hands started cramping. We all had a little laugh about it in this relatively relaxed setting (compared with seeing a real patient), but our instructor also took the opportunity to teach us what to do in such a situation: tilt the bed a little downward so gravity pulls everything closer toward the fingers. She was also careful to point out that having small hands should not keep someone from pursuing a career in OB/GYN.
I was surprised to learn that the gynecological exam includes a maneuver that involves insertion of a finger into the rectum. My female classmates were equally surprised, and I have yet to talk with anyone whose doctor performed this maneuver. Regardless, we were taught that no gynecological exam is complete without it. The doctor inserts the index finger in the vagina and the middle finger in the rectum simultaneously. The middle finger eventually penetrates into an open space called the pouch of Douglas. So positioned, by pushing down on the top of the uterus, the doctor can palpate the posterior (back) side of the uterus. The purpose of this is to feel for cysts or fibroids. This doesn't sound like a very comfortable procedure to experience, which probably explains why I couldn't find anyone whose gynecologist included it in the regular examination. I wonder how long it will take for this to be standard-of-care.
When it came time for me to perform the gynecological exam, the only part that gave me problems was visualizing the cervix with the speculum. We used disposable plastic speculums instead of the metal variety. To put this in perspective, my instructor went through five of these exams before me: I was her sixth and last exam of the day. Although I can't speak from personal experience, it's my understanding that these exams are uncomfortable at best. This is something of a heroic task for these instructors to lend their bodies in such a way for the purpose of educating medical students such as myself. After teaching five medical students, the tissues in her vagina and surrounding the cervix were irritated and slightly inflamed making it more difficult to use the speculum appropriately. My instructor used this as a teaching point, saying that in such a situation it may become necessary to use a slightly larger speculum. After moving from a medium to a large, I was able to find the cervix with minimal difficulty.
One last word about the gynecological exam. Just as with the male urogenital exam, using the correct language is important. Women put their feet in foot rests now instead of stirrups: "We're not riding a horse now, are we?" says our Foundations instructor. Likewise, I "remove" my finger instead of "withdraw" it, since the latter terminology may have a sexual undertone to it.
Summary
I know this was a long post, but given the potency of this experience, I feel that its length is warranted in order to communicate what I and other medical students actually experience while learning the pelvic exams for the first time. I should note that not all medical schools provide this instruction for their students. This experience makes me all the more eager to start my clerkships coming up in Phase III.
Tuesday, January 4, 2011
Ten weeks
A year ago, I watched the class above me juggle two concurrent blocks (Life Cycles and Infectious Disease) and study for the USMLE Step 1 board exam at the same time, and I wondered at how they could pull it off. Now it's one year later and I'm faced with the same task. To paraphrase one of our professors: "The next ten weeks will be among the most challenging of your medical careers; you will have to synthesize new material while reviewing old material." But, at least there is a light at the end of the tunnel - I'm really looking forward to clinical training. Ten weeks is manageable.
Sunday, January 2, 2011
Psychiatry shelf exam
We were required to take the psychiatry shelf at the end of the Fall semester. This was the culmination of the psychiatry thread that was integrated into the CVPR, Neuro, and DEMS blocks. Shelf exams are standardized national exams in a particular medical specialty (e.g. psychiatry, OB/GYN, etc...) that are usually taken after a third-year or fourth-year clinical rotation.
It's fairly unusual for second-year students to take a shelf-exam. I haven't heard of other medical schools requiring second-year students to take a shelf-exam. The reasoning of our course directors, I think, was to provide us with a sneak peek into what kinds of tests we'll be taking once we start clinical rotations. Maybe they also wanted to give us a reason to start studying psychiatry for Step 1.
"Shelf exam" sounds kind of scary, but it was actually very low-pressure because the test doesn't contribute at all to our grade or academic record. There are no negative consequences from bombing this test, but someone who does well could be eligible for some sort of scholarship.
To prepare for the psychiatry shelf exam, I just read through Psychiatry Blueprints and did practice questions, both at the back of this book and through USMLE World Qbank. I found this to be sufficient preparation.
It's fairly unusual for second-year students to take a shelf-exam. I haven't heard of other medical schools requiring second-year students to take a shelf-exam. The reasoning of our course directors, I think, was to provide us with a sneak peek into what kinds of tests we'll be taking once we start clinical rotations. Maybe they also wanted to give us a reason to start studying psychiatry for Step 1.
"Shelf exam" sounds kind of scary, but it was actually very low-pressure because the test doesn't contribute at all to our grade or academic record. There are no negative consequences from bombing this test, but someone who does well could be eligible for some sort of scholarship.
To prepare for the psychiatry shelf exam, I just read through Psychiatry Blueprints and did practice questions, both at the back of this book and through USMLE World Qbank. I found this to be sufficient preparation.
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