Phlebotomy lab

This morning, as part of the Blood and Lymph block, we learned how to draw blood by practicing on each other. I didn't allow myself much time to get nervous about the prospect of tearing up one of my classmate's veins - or having my own veins stuck. Medical school is a series of new experiences, some of which are kind of intimidating because someone else has placed their trust in me to handle their body and do them no harm. I've found that the best way of coping with these types of new experiences is to first acknowledge to myself that I'm a little nervous, think clearly through what must be done, then to jump right in and do my best.

We were given a 5 minute introductory video, a page of instructions, all the necessary supplies, and one instructor per dozen students, then we were set loose on each other. I was fortunate to pair up with my dear friend Dreas, who is perhaps the most chill medical student I know.


I drew his blood first. I surprised myself by how steadily I was able to hold the butterfly needle, despite my nervousness. I hit his antecubital vein (the one in the middle of the crook of his arm) on the first stick and drew two tubes of blood.

But as I was getting ready to take the needle out, my hand accidentally caught on the tubing and yanked the needle out of Dreas's arm. "Oh no! Oh no! Are you alright?" Luckily, the nurse instructor was nearby and calmly told me to get some gauze and put pressure on it. "Yeah, I'm fine, don't worry about it!" Dreas laughed after we got the situation under control. The nurse was laughing at this point, too: "Oh, that was a good one!" The terror of almost shredding Dreas's vein gave way to embarrassment and then to humor. It's a good story to tell, I guess. Now I know to always keep my hand on the butterfly needle, and I won't ever make that mistake with a real patient.

Dreas drew my blood next and did an excellent job. I didn't even bruise.

First semester: Check.

The first semester is finished. Winter break is just about over. I took my relaxing seriously: lots of sleeping in, watching movies, reading for pleasure, playing games, spending time with my friends and family, running, and absolutely nothing related to medical school for two whole weeks.

Well, that's not entirely true, because everyone wanted to hear all about medical school. I found myself having the same so-how-was-first-semester? conversation over and over again (no mistaking - I enjoy relating my experiences). Just like my two weeks of Winter vacation, this first semester was over in a flash before I even knew what hit me. As I have talked with those who have gone through medical school before me, they all say the same thing, that it's all like this, a whirlwind.

Going into medical school, I was somewhat preoccupied by how many first and second year medical students I knew who were absolutely miserable because of the didactic curriculum and the sheer volume of information to absorb in such a short period of time. I for sure found my first semester of medical school to be grueling, but despite the intense work load (or perhaps because I'm that masochistic?) I genuinely enjoyed this first semester. Now that I'm all rested up again, I'm looking forward to starting Round 2 bright and early tomorrow morning.

Next up: Blood & Lymph, and Disease & Defense, which run concurrently during the first half of this semester. More on those courses later.

What is personalized medicine?

A consistent theme that has been hammered into our heads throughout this Molecules to Medicine block is how personalized medicine is the future of medicine. By and large, the current approach to medicine is "one size fits all," which the professors always utter with a negative voice inflection so we medical students are sure to know that this is a bad thing. Personalized medicine, in contrast uses genetic or molecular analysis in order to predict who might respond well to a given therapy over another.

The most well known example of such personalized is in breast cancer. A quarter of all breast cancers are characterized as being caused by a mutation in HER2, human epidermal growth factor receptor (EGFR), which becomes overactive when it's mutated. This EGFR, as its name implies, normally activates signaling cascades that control cell adhesion, migration, and proliferation, cellular processes that are all important in the generation of a tumor. A HER2 mutation thus causes a particularly nasty type of breast cancer, but a drug called Herceptin has been developed that calms down the overactive EGFR by binding to and inactivating it. As you might expect, only patients who are positive for this HER2 mutation will benefit from Herceptin treatment.

Several weeks ago, we learned about Li-Fraumeni syndrome, which is a disease of increased susceptibility to developing cancer at an early age caused by mutation of a particular protein called p53 that is responsible for "proofreading" the genome as each cell is being replicated and fixing any mistakes. If this genome housekeeper gene is mutated, it's all of a sudden much easier to accumulate more and more mutations until, by chance, you get a cell that divides like crazy (in complete disregard of environmental signaling) and acquires other characteristics of a cancerous cell. So, radiation treatment is probably not such a good idea for patients who have a mutation in p53, because the radiation will likely just cause more mutation events that their dysfunctional housekeeping protein p53 is unable to fix.

During this morning's lung cancer clinical vignette, the lecturer again drove home the idea of personalized medicine by showing how one type of lung cancer is responsive to drug A while another type of lung cancer is unresponsive to drug A but more responsive to drug B. A molecular characterization of the exact kind of lung cancer starts to look like a necessary first step before deciding on any therapeutic intervention.

Indeed, for some diseases such as lung cancer, or when a patient's family history is highly suggestive of a mutation in one of those genome housekeeping genes, the standard of care is already trending toward a personalized approach to devising a treatment plan.

Last Warren Village night

My fourth and last Warren Village session was this past Wednesday night. I've enjoyed pediatrics much more than I thought I would. I'm sad, though, because I will not be doing Warren Village next semester. The number slots is very limited, and I know that many of my classmates also want the opportunity to do this elective.

All four of my attending physicians at Warren Village have been fantastic: happy with their jobs, low-key, and eager to educate. They have also been very understanding of the fact that, in terms of medicine, I'm basically starting from scratch.

One of my patients on Wednesday was a teenage boy who complained of severe acne, mostly localized to his forehead but also spreading through his scalp. His mother was a "well-informed medical consumer" and wanted to know about more aggressive treatments for acne. On examination, though, this boy's skin looked exceptionally clear for complaining of severe acne.

When I presented this case to my attending, I made the rookie mistake of neglecting to mention that this boy also likes to use hair gel (a fact that came out while questioning Mom) but that he wasn't wearing any today. So, when the attending physician came in, he started working under the assumption that, like many other kids his age, he was just extremely sensitive to the self-image issues that accompany acne. Once the attending uncovered this hair gel issue, though, he soon concluded that this boy was suffering from dermititis as a reaction to the hair gel.

I felt stupid for forgetting to mention such a relevant piece of information, especially since acne typically doesn't even extend much past the hairline. But, the attending physician turned the mistake into a great learning experience. First, he provided an example of the type of questioning and investigation necessary to move past distractors and mis-information to get to the bottom of a presentation of symptoms. Second, afterward, he owned his own mistake of too quickly buying into the acne story instead of starting the examination tabula rasa.

This is the sort of experience that (I hope) will help me become a better doctor.

Art class in medical school?

Yes, that's right: art class in medical school. And it was part of the required Foundations of Doctoring curriculum, not an elective. Needless to say, I was skeptical that spending three hours of my Tuesday afternoon in art class was a better use of my time than, say, studying for the cellular biology test coming up this Friday. Despite my skepticism (and borderline cynicism), I found this Art in Medicine class useful in helping me learn how to better make observations and report them.

We were given several artworks in small groups. Everyone turned away without looking except for a few people who tried to describe the work of art so that everyone else could visualize it. Then everyone turned around and talked about how their mental image of the painting was different from reality. One difficulty this exercise highlighted was the need for consistent reference points and language to communicate left versus right - which is apparently somewhat of an issue in medicine. Even though sidedness is always described with respect to the patient, people still get confused.

I enjoyed describing the paintings to my classmates, but no matter how thorough and systematic I tried to be, I inevitably left out some detail that greatly changed how my classmates drew their mental image.

Also relevant to the clinic, this exercise highlighted the difference between observation and interpretation. In everyday life, people tend to mix interpretation in with observation. When presenting a patient to an attending physician, though, the practice is to first present hard facts and observations then to use those observations to support an assessment or an interpretation. Take this painting, for example:


What observations can you make about this painting? What interpretations? If you were going to present this painting to an attending physician as you would a patient, what would it sound like? Click here for more information about this painting.

Homecoming

It feels good to be home for Thanksgiving, the first time back since I left for school. I have a lot to be thankful for, especially this year. I'm thankful for the opportunity to pursue my dream of becoming a doctor. But at the top of my list of thanks are my friends and family - particularly my mom and dad - who have been incredibly supportive of me.

Patient interview techniques: invite, listen, summarize

We had a Foundations of Doctoring session yesterday afternoon that focused on developing patient interview skills. The point of the session was to practice three specific interviewing techniques: inviting, listening, and summarizing. Then, in a group of four students and two facilitators, each of us took turns interviewing a standardized patient while the other three students watched and provided feedback.

Inviting refers to prompting the patient to talk by asking opened ended questions rather than yes/no questions:

"So, what can I do for you today?"
"How does that pain affect your daily life?"
"What do you think might be going on here?"

These types of open questions invite the patient to say what is on his or her mind rather than answering targeted questions that may or may not have anything to do with the real matter at hand. The idea is that this approach "humanizes" the patient rather than relating to the patient as a collection of symptoms to be solved. Also, the doctor may catch something that otherwise might have gone unnoticed. All of this may seem self-evident, but when I'm actually sitting in front of a patient, it's surprising how easily I can fall into the trap of peppering the patient with symptom-specific questions.

Listening refers to both verbal and non-verbal cues. Most of these are sub-conscious facial expressions (e.g. raising eyebrows, narrowing eyes) or body language (e.g. posture mirroring, nodding head), or simply keeping quiet.

I had the most trouble with summarizing because it felt so unnatural to constantly repeat what the patient had just said. For example, if the patient tells me that her foot started tingling two weeks ago and started hurting one week ago, the instructors would want me to say something like, "So, what I'm hearing is that your foot started tingling two weeks ago and started hurting one week ago." Then they would expect the patient to enthusiastically exclaim, "Yes, that's right, Doc!" I understand that the purpose of this is to make the patient feel like he or she is being heard correctly, but if done the wrong way, constantly repeating what the patient just said can make me look like a dufus. I did my best to make it work within my own personality and within the context of the conversation.

Overall, I found the patient interview training to be very helpful.

So, next time you're at the doctor's office, pay attention to how the doctor is communicating with you. I'm curious to hear people's real world experiences.

"Fake patients are just what the doctor ordered"

A classmate sent around this Denver Post article about standardized patients, and I want to share it here to give my readers a better idea of what standardized patients are all about:

By Jennifer Brown
Posted: 11/24/2009 01:00:00 AM MST

More than one nervous medical student has entered Robin Mulroney's hospital gown from the bottom to listen to her lungs.

Aspiring doctors also have been known to forget to release blood-pressure cuffs after taking the vitals of their "patient." And there was the time a student inserted a speculum upside-down during one of LoriLynne Lawson's many pelvic exams endured in the name of training future physicians.

The days when medical students learned how to examine patients just by watching real doctors in action and then trying it themselves are now supplemented by people such as Mulroney and Lawson: "standardized patients" who are paid $20 to $50 per hour to let students poke inside their ears and tap on their stomachs.

These fake patients, many of them professional actors looking for extra money, can cry on demand when they are "diagnosed" with cancer or Alzheimer's disease. Strong memorization skills are a must: Patients have to stick to a script saturated with family history of disease, medications, sexual history and surgeries.

Standardized patients are in higher demand than ever in Colorado with the opening of a second medical school in the state last year, Rocky Vista University in Parker. Rocky Vista, an osteopathic school, and the University of Colorado Denver School of Medicine each employs about 60 actor-patients, some of whom work for both schools.

The universities also have high-fidelity simulators — manikins ranging from $20,000 to $250,000 that take over where actors cannot: Give birth, have heart murmurs, bleed out, receive drug injections and require intubation.

Many actor-patients say they don't do it for the money but to help future doctors develop empathy, better listening skills and a gentler touch. After their exam, patients evaluate students as part of their grade.

"I want them all to succeed," said Rich Beall, who also has worked for the Denver Center for the Performing Arts and had a TV role on "Perry Mason." He doesn't hold back when it comes to constructive criticism.

"If someone comes in with a lab coat that's not clean, you note it," he said. "I had one gal come in all dressed for a Saturday night."

"Patient" doing her part

Mulroney, who has worked as a standardized patient for nine years and now trains others, believes she's doing her part to prevent that rare "doctor from hell" encounter. She recalled a real-life experience in which a specialist walked into the hospital room of one of her relatives, flopped into a lounge chair and without even introducing himself announced, "So you have lupus." The doctor kept talking "90 miles an hour" even after the woman burst into tears.

"His empathy, his patient care for the whole patient, the emotions of the patient, it was just tragic," Mulroney said.

Last week at Rocky Vista, 10 first-year medical students wearing white lab coats and clutching medical bags lined up outside their assigned exam rooms. One was so nervous beforehand that she put her fingers in a yoga pose and sighed, "Zen." With the sound of an alarm, each student knocked on an exam-room door and stepped inside to greet an actor-patient sitting on an table.

The students had 50 minutes to perform a routine physical examination, observed by faculty and recorded in a control room down the hall.

Meredith Kirtland, 26, sailed through the "patient encounter" after she had practiced on her fiance and some friends. "Just a couple questions about your sexual history," she told her male patient at one point. "Sorry, it's a little uncomfortable topic."

Her professor's one small critique: She should have lowered her patient's pants farther to feel his lower abdomen.

Kirtland was too busy running through a mental checklist to think about the fact that the patient was an actor. It was a lot easier to examine him than her friends, who are "kind of giggly and you know it's not real," she said. "Everything else in that room is so real. What better way to learn it?"

The highest-paid patients are gynecological and urological teaching associates who guide students through pelvic exams. Lawson, a 53-year-old with scars from a C-section and a breast lumpectomy, has had up to 14 gynecological exams in one day.

She had one student remove the speculum without closing it. And she chuckles remembering some of the clumsy statements students have made, as in, "Let's just take a feel now, shall we?"

Lawson doesn't tell everyone she knows about her job. "Some people say, 'Ewww, how do you do that?' Some people think you are prostituting yourself," she said.

But Lawson remembers holding her daughter's hand during her first pelvic exam. "I was glad they knew what they were doing and hadn't just practiced on a plastic doll," she said.

"Making a difference"

Gynecological teaching associates typically are feminists "who know their bodies like no other" and have a "real strong belief that they are making a difference in the world," said Gwyn Barley, director of UCD's Center for Advancing Professional Excellence, which employs the actor-patients. Men submit to urological exams, she said, because there are "so few opportunities of any sort for students to learn the male genital exam."

"There is so much kind of mystery," she said. "You can't just ignore the male reproductive system."

Chelsea Williamson, 25, became a standardized patient after she was laid off as a cabinet designer last spring. She has found that some medical students need to work on their listening and sensitivity.

While she was portraying a girl with severe psychological problems who cuts herself, one student kept saying, "Gotcha." Another said "Great!" after she informed him that her parents were dead.

The past few weeks: two tests, and a lot of clinical exposure

The past few weeks have been busy - the status quo in medical school. I got through two more Molecules to Medicine tests (biostatistics and genetics), but more significantly, I've gotten a lot of clinical exposure.

My very first patient ever was at Warren Village, a two year old boy whose mother was concerned about recurring ear infections. A classmate and I teamed up for the interview and physical exam, which worked out well considering how nervous I felt. But somehow I muddled my way through it, and now every patient encounter is easier and easier insofar as I have prior experience to draw on. I have gone into Warren Village two more times since then and will talk in more detail about those experiences in a later post.

I've also gained some clinical experience through my preceptor. This is a program that matches medical students with a community physician with the aim of setting up a long-term (2-3 years) mentoring relationship. There is a wide range of preceptorship experiences that depend on factors like the setting, specialty, and the individual who is doing the mentoring. Typically, preceptors are in some sort of general practice like family medicine, pediatrics, emergency medicine, or internal medicine. My preceptor is boarded in both family and emergency medicine but does occupational health at Kaiser. I'll talk more about that in a later post.

Two other clinical experiences that also deserve their own dedicated posts are: 1) shadowing a senior resident in the ER, and 2) Clinica Tepeyac.

So many of the older doctors reminiscing about their medical school experiences recount how they never even saw a patient until their third year when they started clinical rotations. I feel incredibly lucky to have these clinical opportunities now, during my first two years of medical school, which are traditionally reserved for cramming as much information as humanly possible into the heads of poor medical students. Pairing together the classroom and the clinic is, in my view, a positive evolution of medical education.

First Molecules to Medicine test

The first Molecules to Medicine test is tomorrow. I'm not nearly as scared about it as I was going into my first Human Body test, but that has both its upsides and downsides.

Pro: I'm no longer a Scary Medical Student whose temporary best friend is his cadaver and who has to take vitamin D supplements because he studies 16 hours a day and doesn't get any sunlight because of it. In fact, I now have meaningful non-medical-school-related conversations with my family/friends, I've renewed my Netflix account, and I've even gone out a few times. (Okay, I've gone out once since anatomy ended. After the last exam.)

Con: Motivation is a problem. Whereas all the anatomy material was brand new to me, I've had a lot of molecular and cellular biology before, both in undergrad and graduate school. That's not to say that this block will be a cake walk, by any means, just that my mind is primed to re-learn a good portion of this material and to place new information within a pre-existing framework of knowledge. But, it also means that I have to guard against boredom and procrastination.


The material being covered in this first test includes: bioenergetics, DNA structure, DNA replication, DNA repair, DNA transcription (process of converting DNA to RNA), RNA structure and post-transcriptional processing, gene expression, amino acids and proteins, translation (process of converting RNA to protein), the cell cycle, and various tools of molecular biology.

Also, one of the highlights of Molecules to Medicine so far has been clinical vignettes. These are lectures of specific diseases that tie into relevant material being covered in other lectures. For instance, we learned about prion disease after a lecture on protein folding. We are also responsible for knowing the molecular biology of Alzheimer's disease and Li-Fraumeni syndrome for tomorrow's test.


N.B. Yes, writing this post was indeed an exercise of procrastination. Back to studying.