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.
Saturday, October 29, 2011
Thursday, October 27, 2011
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."
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."
Tuesday, October 25, 2011
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.
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.
Saturday, October 22, 2011
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.
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.
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.
Sunday, October 16, 2011
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:
Regardless of whether surgery turns out to be the right path for me, these 8 weeks will for sure be interesting.
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.
Friday, October 14, 2011
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.
----
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.
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.
----
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.
Saturday, October 1, 2011
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!):
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:
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.
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.
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