The greatest difficulty I've had during my psychiatry sub-internship is deciding when to take away someone's personal freedom by placing them on a mental health hold (MHH) or a short-term certification (STC). My attending told me at the beginning of the rotation, "I want you to make decisions about your patients. We'll do what you want, so long as you can explain why you're doing it and you have your head screwed on straight."
This responsibility hit home a few weeks ago when I knocked on my attending's office door to talk with him about a patient. I was uncertain about whether to place this patient on a STC. My attending sat back in his chair and listened while I explored both sides of the argument.
On the one hand...
This is a middle-aged guy with an unclear history of psychosis who's experiencing paranoid delusions to the extent that he has isolated himself from the entire world, including his family. He has a history of attempting suicide, and there is evidence of increasingly bizarre and disorganized thoughts. According to the police who originally placed him on a MHH, the patient's apartment was a disaster. Charcoal briquettes were placed around the periphery of each room, bed and couch and lamps were turned upside down, curtains were turned inside out, and two pennies were placed in strange places like in the refrigerator and in the shower. This is a man who could certainly benefit from continued hospitalization and treatment.
On the other hand...
The patient does not want to stay in the hospital, does not want treatment, and does not believe he has a mental illness. He shows no depressive symptoms and denies wanting to hurt himself or other people. He sure has some bizarre and paranoid thoughts, and doesn't have a job, but he pulls in a Social Security disability check each month and is able to clothe and feed himself. He may or may not meet legal criteria for being "gravely disabled," which would justify holding him on a STC.
When I finished, my attending leaned forward, looked at me intently, and asked, "So, what are you going to do?" I understood what he was doing: pushing me to make a tough decision and stick by it. This is part of my education, the process of becoming a doctor.
"I don't know, that's why I came to you for advice."
"Do you think this patient is mentally ill and needs treatment?"
"Yes."
"Do you believe that he is a danger to himself or others?"
"No."
"Do you believe that he is gravely disabled?"
"Possibly."
My attending then advised me to remember that my primary responsibility is to my patients. As long as I believe that I am following the law, I should do what I think is necessary to take proper care of my patients and let the judge decide if our actions should be upheld.
"So, what are you going to do?" my attending asked again, this time with an amused smirk.
"I'm going to cert him."
Although he never explicitly said so, it was clear to me that my attending thought that we should keep this patient on a STC. I made the decision, though, based on my gut feeling that my patient was indeed gravely disabled and would benefit from treatment.
The patient stayed for another week with nominal improvement of his paranoia and disorganization. He agreed to keep taking medications after he left the hospital. That was something.
Everything about this patient's case was ambiguous to me. Did I really help him by keeping him in the hospital against his will? Was I justified in holding him on a STC? Was he really gravely disabled? Sometimes there are no clear answers, and I just have to make a decision that seems best at the time. I feel better knowing that I would make the same decision again if I had to do it over.
Sunday, May 27, 2012
Monday, May 21, 2012
The legal side of psychiatry
Most of the inpatient psychiatry patients I have seen were admitted voluntarily. But some patients can be held involuntarily if they meet certain criteria: 1) They pose a threat to themselves, 2) They pose a threat to others, and 3) They have grave disability. Those first two are self-explanatory; "grave disability" just means that a patient's psychiatric illness impairs his or her ability to properly care for themselves. Think food, clothes, and shelter.
A mental health hold (MHH) is the shortest involuntary hold at 72 hours. Its purpose is to further evaluate a patient's mental state according to the above three criteria. There are important legal implications of the MHH. Most importantly, since the purpose of the MHH is fact-finding, the psychiatrist is allowed to obtain medical records from other institutions, and talk with the patient's friends and family, without the patient's consent. This means that if a patient is initially admitted on a MHH then switches to voluntary status, the psychiatrist is no longer able to get that information if the patient doesn't agree to it. I saw this happen a few times.
Short-term certification, which lasts for 3 months, is the next step of involuntary hospitalization. By the end of a 72 hour of a MHH, the psychiatrist must convince a judge that short-term certification is necessary, again demonstrating that the patient poses a threat to himself or others or has grave disability. Long-term certification lasts an additional 6 months and also has to be argued before a judge to be granted.
Lastly, there are involuntary medications (i-meds), which are exactly what they sound like. Typically, a patient flies out of control after refusing voluntary medications, emergency medications (e-meds) are given to control the patient in the short-term, then the case is brought before a judge to grant power to administer i-meds. Concern for the physical safety of fellow patients and staff is often cited as justification for requesting i-meds.
The gravity of depriving a person of freedom is not lost on me.
Going to court
One particularly memorable patient took his case to court. Among other problems, this patient had delusions of grandeur that led to increasingly serious run-ins with the law.
The patient was shackled and escorted to the courthouse by a sheriff, while the rest of us piled into a government-issued van for a field trip. The intern would be testifying, a first for him. He practiced his testimony on the ride over, and the attending prepared him for what to expect. "The public defender is going to try to discredit you as an expert witness. Don't worry: It's not personal, and the judge will likely rule in your favor."
That's exactly what happened. My intern became a newly-minted "expert" with the privilege of providing testimony related to the matter of placing our patient on a short-term certification. He stood at the podium with his hands clasped tightly behind him, so tightly in fact that his fingertips were white. His back was straight, his shoulders squared, his head held high, and in that pose he answered questions thoroughly but succinctly in a clear and certain voice. I was very impressed.
After some back-and-forth questioning from the public defender and city attorney, the patient/defendant had the opportunity to address the court. It turned out that our patient sealed his own fate with a diatribe that clearly demonstrated to the judge that he poses a threat to himself and suffers grave disability. We won short-term certification and the ability to administer involuntary medications.
Observing the legal process in action was fascinating, a valuable component of my psychiatry education.
Update: This patient is now doing fairly well. My intern writes:
A mental health hold (MHH) is the shortest involuntary hold at 72 hours. Its purpose is to further evaluate a patient's mental state according to the above three criteria. There are important legal implications of the MHH. Most importantly, since the purpose of the MHH is fact-finding, the psychiatrist is allowed to obtain medical records from other institutions, and talk with the patient's friends and family, without the patient's consent. This means that if a patient is initially admitted on a MHH then switches to voluntary status, the psychiatrist is no longer able to get that information if the patient doesn't agree to it. I saw this happen a few times.
Short-term certification, which lasts for 3 months, is the next step of involuntary hospitalization. By the end of a 72 hour of a MHH, the psychiatrist must convince a judge that short-term certification is necessary, again demonstrating that the patient poses a threat to himself or others or has grave disability. Long-term certification lasts an additional 6 months and also has to be argued before a judge to be granted.
Lastly, there are involuntary medications (i-meds), which are exactly what they sound like. Typically, a patient flies out of control after refusing voluntary medications, emergency medications (e-meds) are given to control the patient in the short-term, then the case is brought before a judge to grant power to administer i-meds. Concern for the physical safety of fellow patients and staff is often cited as justification for requesting i-meds.
The gravity of depriving a person of freedom is not lost on me.
Going to court
One particularly memorable patient took his case to court. Among other problems, this patient had delusions of grandeur that led to increasingly serious run-ins with the law.
The patient was shackled and escorted to the courthouse by a sheriff, while the rest of us piled into a government-issued van for a field trip. The intern would be testifying, a first for him. He practiced his testimony on the ride over, and the attending prepared him for what to expect. "The public defender is going to try to discredit you as an expert witness. Don't worry: It's not personal, and the judge will likely rule in your favor."
That's exactly what happened. My intern became a newly-minted "expert" with the privilege of providing testimony related to the matter of placing our patient on a short-term certification. He stood at the podium with his hands clasped tightly behind him, so tightly in fact that his fingertips were white. His back was straight, his shoulders squared, his head held high, and in that pose he answered questions thoroughly but succinctly in a clear and certain voice. I was very impressed.
After some back-and-forth questioning from the public defender and city attorney, the patient/defendant had the opportunity to address the court. It turned out that our patient sealed his own fate with a diatribe that clearly demonstrated to the judge that he poses a threat to himself and suffers grave disability. We won short-term certification and the ability to administer involuntary medications.
Observing the legal process in action was fascinating, a valuable component of my psychiatry education.
Update: This patient is now doing fairly well. My intern writes:
The patient became less and less resistant to medications as he become more linear and logical. He never quite thanked us for forcing medication on him, but he did start saying positive things about the way he was thinking. Before he left, he actually became quite socially appropriate, responding to social cues, which previously he had not been able to do. He started telling jokes, some pretty funny and some bizarre. But he would occasionally follow a bizarre comment with reality testing saying, "Does that sound crazy?" and then laugh it off. At discharge, he was nervous to go home and thought it was happening too fast. Last I checked, he was making his outpatient appointments. His home visits have found him pleasant; he has been very welcoming to his case worker and showing off how clean and organized his apartment is, as well as new writings he has been working on.
Sunday, May 20, 2012
Acting intern
Two weeks into my psychiatry sub-internship at Denver Health, and I'm having a blast. I was right in guessing that Denver Health would be a great place for a psychiatry sub-internship, given that it is a county hospital and a safety net for indigent and socioeconomically disadvantaged people.
The psychiatry inpatient service is capped at 12 patients, 6 patients for each of the two interns covering the service. On the first day, my attending told me that he wants me to build up to seeing 6 patients by the end of the month. This is consistent with the purpose of a sub-internship to prepare medical students for being an intern.
I'll get a chance to do exactly that this coming week. For the first part of next week, my attending will be away at a conference, and one of my interns will be out taking Step 3. The doctor who is covering for my attending spent some time with the team on Friday to help smooth the transition on Monday.
"You take three patients, and I'll take three patients," he said.
"What?" I said it without thinking, and it may have come out somewhat indignantly.
The new attending looked a bit surprised. He sat back in his chair, smirked, and asked me, "How many patients have you been carrying?"
I told him that I had been carrying 5-6 patients this past week. "Good! Then you can take your own team." He went over to the white board at the nurse's station, where all the patients are listed according to which resident is taking care of them. He erased my intern's name and wrote in my name. "Make sure to bring your pager on Monday. The nurses are going to be paging you when they have questions about your patients."
This promises to be an interesting week.
The psychiatry inpatient service is capped at 12 patients, 6 patients for each of the two interns covering the service. On the first day, my attending told me that he wants me to build up to seeing 6 patients by the end of the month. This is consistent with the purpose of a sub-internship to prepare medical students for being an intern.
I'll get a chance to do exactly that this coming week. For the first part of next week, my attending will be away at a conference, and one of my interns will be out taking Step 3. The doctor who is covering for my attending spent some time with the team on Friday to help smooth the transition on Monday.
"You take three patients, and I'll take three patients," he said.
"What?" I said it without thinking, and it may have come out somewhat indignantly.
The new attending looked a bit surprised. He sat back in his chair, smirked, and asked me, "How many patients have you been carrying?"
I told him that I had been carrying 5-6 patients this past week. "Good! Then you can take your own team." He went over to the white board at the nurse's station, where all the patients are listed according to which resident is taking care of them. He erased my intern's name and wrote in my name. "Make sure to bring your pager on Monday. The nurses are going to be paging you when they have questions about your patients."
This promises to be an interesting week.
Saturday, May 12, 2012
Fourth year scheduling
As rigid and uncompromising as third year was, that's the degree of flexibility that I have in determining my fourth year schedule. Senior year of medical school is all about further exploring specific career interests, taking courses that will help for getting into residency, and filling gaps in education. The requirements: take at least 32 weeks of coursework (out of 52 total weeks), take at least one sub-internship, and take enough research to finish the mentored scholarly activity requirement.
Also, fourth year is all about add/drop. A web-based program is used for scheduling. At any time, I can log in and sign up for a new class or drop a class that I signed up for earlier. The only restriction is that any dropped courses must be dropped at least 30 days prior to the start of that course.
As of now, my fourth year schedule is as follows:
May: Adult psychiatry sub-internship (at Denver Health)
June: Medicine sub-internship (at Denver Health)
July: Child psychiatry elective (at The Children's Hospital)
August: Time off to study for USMLE Step 2 CK and CS, and to work on residency applications
September - November: Set aside for externships
December - January: Set aside for interviews
February: International Spanish immersion elective (I'll write more about this once it's finalized)
March: ICC, and a fun "Film in Mental Illness" 2-week elective
April - May: More ICC, plus a 2-week "Cardiac Diagnostic Skills" elective
Then graduation at the end of May!
It's shaping up to be a good year.
Also, fourth year is all about add/drop. A web-based program is used for scheduling. At any time, I can log in and sign up for a new class or drop a class that I signed up for earlier. The only restriction is that any dropped courses must be dropped at least 30 days prior to the start of that course.
As of now, my fourth year schedule is as follows:
May: Adult psychiatry sub-internship (at Denver Health)
June: Medicine sub-internship (at Denver Health)
July: Child psychiatry elective (at The Children's Hospital)
August: Time off to study for USMLE Step 2 CK and CS, and to work on residency applications
September - November: Set aside for externships
December - January: Set aside for interviews
February: International Spanish immersion elective (I'll write more about this once it's finalized)
March: ICC, and a fun "Film in Mental Illness" 2-week elective
April - May: More ICC, plus a 2-week "Cardiac Diagnostic Skills" elective
Then graduation at the end of May!
It's shaping up to be a good year.
Sunday, May 6, 2012
Taking stock of year three: Advice for rising third-years
"The transition from classroom learning to the the clinical years will be the most difficult transition of your careers."
So said one lecturer preparing my class for clinical rotations, one year ago. This sentiment has been echoed by numerous other doctors over the past year. The transition from classroom to clinic represents a fundamental shift in the way that learning takes place, not to mention the additional considerations of teamwork and professionalism. Other major transitions in the medical career (e.g. graduating medical school and becoming an intern, or finishing residency and becoming an attending physician) represent increased responsibility, which is arguably more easy to deal with than a fundamental shift in the way one thinks.
Because of this, I decided that now would be an ideal time to step back, think about all that I have learned over the past year, and pass some of those lessons on to those who will follow me. Keep in mind that that what follows are my own opinions drawn from my own experiences. Other people will have different opinions, and I don't pretend to have all the answers.
1. Attitude. This can be said about anything in life, but I think it's especially true during third-year: A good attitude goes a long way. You are transitioning from learning in a classroom setting to learning in a clinical setting. You will have to figure out how to function well as part of the healthcare team. The reality is that there are many factors outside of your control that will cause you to be a burden on the team. This is more true at the beginning of third year than at the end. Try to minimize your burden on the team, and the best way to do that is to have a good attitude.
3. Study. Treat all of third-year as one long study period for Step 2 Clinical Knowledge. In my opinion, every shelf exam that I took was harder than Step 1. For each shelf exam, start studying early and study frequently, a little bit every day. My general approach to studying:
So said one lecturer preparing my class for clinical rotations, one year ago. This sentiment has been echoed by numerous other doctors over the past year. The transition from classroom to clinic represents a fundamental shift in the way that learning takes place, not to mention the additional considerations of teamwork and professionalism. Other major transitions in the medical career (e.g. graduating medical school and becoming an intern, or finishing residency and becoming an attending physician) represent increased responsibility, which is arguably more easy to deal with than a fundamental shift in the way one thinks.
Because of this, I decided that now would be an ideal time to step back, think about all that I have learned over the past year, and pass some of those lessons on to those who will follow me. Keep in mind that that what follows are my own opinions drawn from my own experiences. Other people will have different opinions, and I don't pretend to have all the answers.
1. Attitude. This can be said about anything in life, but I think it's especially true during third-year: A good attitude goes a long way. You are transitioning from learning in a classroom setting to learning in a clinical setting. You will have to figure out how to function well as part of the healthcare team. The reality is that there are many factors outside of your control that will cause you to be a burden on the team. This is more true at the beginning of third year than at the end. Try to minimize your burden on the team, and the best way to do that is to have a good attitude.
- Be happy; if you're not happy, don't show it.
- Be easy and fun to work with, even if you don't like your resident or attending.
- Be excited to learn, even when you're exhausted.
- Take the initiative when caring for patients.
- Take as much responsibility as your resident is willing to give you, even if you feel it's a stretch. If a question starts out with "Do you want to..." then the answer is always "Yes."
3. Study. Treat all of third-year as one long study period for Step 2 Clinical Knowledge. In my opinion, every shelf exam that I took was harder than Step 1. For each shelf exam, start studying early and study frequently, a little bit every day. My general approach to studying:
- Learn from patients. Your patients are your best teachers. Read about your patient's disease on UpToDate: review its pathophysiology, learn different ways that it presents clinically, know its diagnostic criteria and how to treat it. Do a pubmed literature search, if there are any questions related to your patient that can be answered by evidence-based medicine. Then bring back to the team what you find. Information sticks way better when you associate it with one of your patients.
- Pre-Test. This is a specialty-specific series that offers about 500 questions meant to prepare for shelf exams. I only used the surgery, psychiatry, pediatrics, and Ob/Gyn versions. They are all available as real books or as apps on iTunes. I borrowed the book versions of pre-test for psychiatry and pediatrics but decided to splurge for the $30 iTunes apps for surgery and Ob/Gyn. I'm glad I did, too, because there is a lot of waiting around during those two clerkships, so I would just crank out 5-10 questions whenever I had some time to burn. I finished all 500 questions before each respective test. It's important to note that these questions aren't nearly at the level of difficulty as questions on the real exam. In retrospect, I think pre-test would have been helpful for my family medicine departmental exam. I would stay away from pre-test for Internal Medicine, though, because there's MKSAP, a question bank published by the American College of Physicians.
- Step 2 CK question bank. I bought a year-long subscription to Kaplan's Step 2 CK question bank at the beginning of my surgery clerkship and immediately wished that I had gotten it earlier in third year. I'm told that, like Step 1, Kaplan's Step 2 questions are a little harder than what is on the real test. They worked well for me as a shelf exam study aide. Throughout the clerkship, up until the last week, I did just 5-10 questions every other day or so. Then during the last week I did timed full blocks of 44 questions until I ran out of questions, of course reviewing explanations for every question. If I had extra time, I re-answered questions that I got wrong.
- Specialty-specific textbook. Most clerkships recommended specific text books. The family medicine departmental exam was drawn heavily from Essentials of Family Medicine, which unfortunately is an awful textbook (poorly written, poorly edited, too much emphasis on arcane statistics rather than big picture). The Internal medicine text is Internal Medicine Essentials for Clerkship Students 2 versus Step-Up to Medicine. I chose the first option because it is published by the ACP and is linked to the MKSAP question bank, which I also bought. The surgery departmental exam was drawn heavily from Essentials of General Surgery, which is actually a very well-written book, albeit heavy on text. Ob/Gyn recommended Beckman's Obstetrics and Gynecology, which provided a decent start to studying for the shelf exam. The rest of my clerkships did not recommend any specific textbook.
- Case Files. This is a specialty-specific series that offers case studies as a means of learning the materials. A patient's case is presented, then questions such as the most likely diagnosis or the diagnostic tests to establish the diagnosis or the means of treatment are asked. A short discussion then expands on those learning points. Each chapter is accompanied by a few softball questions that I found relatively useless. The major utility of Case Files, in my opinion, was talking over the cases with classmates. I only used Case Files for neurology and psychiatry, clerkships without a recommended textbook.
- Be methodical about how you collect your patient's history. The conventional order is 1) chief complaint, 2) past medical history, 3) past surgical history, 4) medications, 5) allergies, 6) family history, 7) social history. This will quickly be burned into your mind so deeply that it becomes the way you talk about patients in normal conversation. If it helps, create a template for you to fill in as you're interviewing your patient.
- Sit down when you're talking with patients, even if it means excusing yourself to get a chair or stool. It sets the patient at ease and gives them the impression that you're spending way more time with them than you actually do.
- Figure out how to end patient interviews without being rude or awkward. This is especially important because you'll often be pressed for time.
- Try to do a full physical examination, even if it means coming back to see the patient later when you have more time. Obviously this is not always practical, especially in the clinic where an entire patient visit is only 15-20 minutes. But the more normal exam findings you see, the easier it becomes to recognize an abnormal finding.
- Be proactive about seeing abnormal exam findings, even if it's not on one of your patients.
- Look to the fourth-year medical student notes as good examples to follow. The attendings and residents typically write more abbreviated and utilitarian notes that are not as useful for learning how to write a good note.
- Run your assessment and plan by the intern or resident before presenting a patient on rounds, if possible. This is an opportunity to see if he/she agrees with your plan or wants to change anything, and it helps make you look better in front of your attending.
- Find someone who you can present to as practice, if oral presentations make you nervous. This can be a friend or family member or a significant other. I was fortunate enough to have a resident who taught me how to present, but given how busy residents are, I think this is more the exception than the rule.
- When presenting, fall back on the methodical approach in which you took the patient's history. This will also save you if you're having a nervous brain-freeze. As you progress, you'll figure out how to pick out pertinent positives and negatives that tell the patient's story and guide the listener to your assessment.
- Don't forget to present the patient's vital signs!!! Some attendings want to hear each individual vital sign, but most of the time you can summarize it conversationally: "Patient is afebrile, normotensive, normal heart and respiratory rate, and satting well on room air." Or, more succinctly, "Vital signs stable and within normal limits."
Thursday, April 26, 2012
Code C: Emergent Cesarean Section
"Code C, room 8 to OR 3! Code C, room 8 to OR 3!"
The Labor & Deliver control room burst into activity with the overhead announcement. A quick glance at my resident, whose head nod told me to go for it, and I rushed back to OR 3 just in time to catch the patient being transported down the hall.
She smiled at me as she wheeled by. In the middle of a labor gone awry, surrounded by nurses and doctors moving and talking much faster than usual, lying in her inclined hospital bed, breaking speed limits as she flew down the hallway on her way to the operating room where she was about to undergo an emergent Cesarean section - this woman met my eyes and smiled at me. It wasn't a frightened smile or a nervous smile; she actually appeared serene, an emotion that didn't belong in this moment.
The patient was already on the operating table by the time I entered OR 3, nurses buzzing about the room as if their hive were being attacked. I stood near the patient's head, mesmerized by the serenity of her smile that was now hidden behind a face mask and then a few moments later faded with her consciousness. I moved down to the foot of the bed, out of the way but with a good view of the operating field, then stood frozen lest I get stung.
The anesthesiologist was preparing for a rapid-sequence intubation. The scrub nurse was already dressed in her sterile gown, governing her table of sterile instruments. Two Ob/Gyn doctors were already dressed in their sterile gowns and posted on either side of the operating table, one looking at the anesthesiologist expectantly and the other posed like a runner in the starting blocks, her scalpel blade millimeters from the patient's pregnant belly.
"Tell us when you have her airway!" said the first Ob/Gyn in a commanding voice that couldn't be ignored.
"Do you have her airway?" ...
"Do you have her airway?" ...
"Got it!"
Cut, a curved incision. "Cut again!" Yellow fat and gushes of blood. Scalpel down. The two doctors took a firm grip at either side of the incision and pulled with all the weight of their bodies to open the incision. Sound of ripping flesh. Underlying muscle. More blood. "Cut again!" More ripping flesh. More blood. Then the uterus appeared, large, holding a baby whose life was in danger. "Cut again!" Amniotic fluid washed away the blood. Hand inside the uterus. Some pushing, some pulling, then Baby. "Knot in the cord!" Clamp it, cut it, then Baby was whisked away to the care of NICU nurses.
No more than 30 seconds passed from first incision until Baby's birth.
With Baby out, the doctors turned their attention to controlling Mom's bleeding. I stood there planted in my out-of-the-way spot at the foot of the operating table, even as the flurry of activity around me dissipated, dumbstruck by the sheer speed and exquisite coordination of the emergent C-section I had just witnessed.
Mom recovered beautifully, and Baby was entirely healthy.
The Labor & Deliver control room burst into activity with the overhead announcement. A quick glance at my resident, whose head nod told me to go for it, and I rushed back to OR 3 just in time to catch the patient being transported down the hall.
She smiled at me as she wheeled by. In the middle of a labor gone awry, surrounded by nurses and doctors moving and talking much faster than usual, lying in her inclined hospital bed, breaking speed limits as she flew down the hallway on her way to the operating room where she was about to undergo an emergent Cesarean section - this woman met my eyes and smiled at me. It wasn't a frightened smile or a nervous smile; she actually appeared serene, an emotion that didn't belong in this moment.
The patient was already on the operating table by the time I entered OR 3, nurses buzzing about the room as if their hive were being attacked. I stood near the patient's head, mesmerized by the serenity of her smile that was now hidden behind a face mask and then a few moments later faded with her consciousness. I moved down to the foot of the bed, out of the way but with a good view of the operating field, then stood frozen lest I get stung.
The anesthesiologist was preparing for a rapid-sequence intubation. The scrub nurse was already dressed in her sterile gown, governing her table of sterile instruments. Two Ob/Gyn doctors were already dressed in their sterile gowns and posted on either side of the operating table, one looking at the anesthesiologist expectantly and the other posed like a runner in the starting blocks, her scalpel blade millimeters from the patient's pregnant belly.
"Tell us when you have her airway!" said the first Ob/Gyn in a commanding voice that couldn't be ignored.
"Do you have her airway?" ...
"Do you have her airway?" ...
"Got it!"
Cut, a curved incision. "Cut again!" Yellow fat and gushes of blood. Scalpel down. The two doctors took a firm grip at either side of the incision and pulled with all the weight of their bodies to open the incision. Sound of ripping flesh. Underlying muscle. More blood. "Cut again!" More ripping flesh. More blood. Then the uterus appeared, large, holding a baby whose life was in danger. "Cut again!" Amniotic fluid washed away the blood. Hand inside the uterus. Some pushing, some pulling, then Baby. "Knot in the cord!" Clamp it, cut it, then Baby was whisked away to the care of NICU nurses.
No more than 30 seconds passed from first incision until Baby's birth.
With Baby out, the doctors turned their attention to controlling Mom's bleeding. I stood there planted in my out-of-the-way spot at the foot of the operating table, even as the flurry of activity around me dissipated, dumbstruck by the sheer speed and exquisite coordination of the emergent C-section I had just witnessed.
Mom recovered beautifully, and Baby was entirely healthy.
Wednesday, April 25, 2012
USMLE Step 2: Clinical Knowledge and Clinical Skills
Step 2 has two components to it: Clinical Knowledge (CK) and Clinical Skills (CS). Both CK and CS must be taken during the fourth year of medical school. Some residency programs want to see that one or both have been taken before offering an interview, but all residency programs require that CK and CS are completed before ranking students for the Match in February.
The CK portion of the test is a multiple choice exam very similar to Step 1 in both format and grading. However, rather than testing basic science knowledge, Step 2 CK questions are more designed to test the ability to evaluate symptoms, establish a diagnosis, and manage disease. Regardless of the question stem, the variety of questions is rather limited:
The CS portion of Step 2 is quite different. It is an 8-hour pass/fail exam that makes use of standardized patient-actors to evaluate clinical skills in a simulated clinical setting. There are 12 patient encounters, each one lasting 15 minutes with an additional 10 minutes afterward to write a note summarizing the encounter. In the 15 minute encounter, we're expected to obtain a full history from the patient and perform a focused physical exam that addresses the patient's presentation. The patient note written in the 10-minute post-encounter is meant to be just like any note I would write on a real patient, though parts of the note are standardized for the purposes of grading.
The CS exam is only administered in five locations nationwide: Atlanta, Chicago, Houston, Los Angeles, and Philadelphia. Because of the nature of the CS exam, the grading is necessarily complicated. Scoring is separated into three "subcomponents": 1) Integrated Clinical Encounter, 2) Communication and Interpersonal Skills, and 3) Spoken English Proficiency.
The ICE subcomponent is graded by checklists. Observers behind a one-way mirror check off physical exam maneuvers and such, and the patient note is reviewed to see if it incorporates certain information that the creators of the test deem important. The CIS subcomponent is necessarily based on subjective feedback from the standardized patient, though I have no idea what criteria or grading rubric they use. The SEP subcomponent is obviously not an issue for people who speak English fluently.
As part of the end-of-third-year ICC, everyone in my class took a five-hour CAPE exam to prepare for the USMLE Step 2 CS. A lot of effort was put into making this practice exam as close to the real thing as possible. Except for the CAPE exam being 5 hours instead of 8, and 10 patient encounters instead of 12, I think that this experience did a great job of preparing me for what the CS test experience will be like.
The CK portion of the test is a multiple choice exam very similar to Step 1 in both format and grading. However, rather than testing basic science knowledge, Step 2 CK questions are more designed to test the ability to evaluate symptoms, establish a diagnosis, and manage disease. Regardless of the question stem, the variety of questions is rather limited:
- Which of the following diagnostic tests can most likely establish this patient's diagnosis?
- Which of the following is the most likely cause of these findings?
- Which of the following is the most likely finding on physical exam?
- Which of the following is the most likely diagnosis?
- Which of the following is the most appropriate next step in management?
- Which of the following is the most appropriate intervention?
- Which of the following would be the best initial treatment in this patient?
- Which of the following is the most appropriate pharmacotherapy for this patient?
The CS portion of Step 2 is quite different. It is an 8-hour pass/fail exam that makes use of standardized patient-actors to evaluate clinical skills in a simulated clinical setting. There are 12 patient encounters, each one lasting 15 minutes with an additional 10 minutes afterward to write a note summarizing the encounter. In the 15 minute encounter, we're expected to obtain a full history from the patient and perform a focused physical exam that addresses the patient's presentation. The patient note written in the 10-minute post-encounter is meant to be just like any note I would write on a real patient, though parts of the note are standardized for the purposes of grading.
The CS exam is only administered in five locations nationwide: Atlanta, Chicago, Houston, Los Angeles, and Philadelphia. Because of the nature of the CS exam, the grading is necessarily complicated. Scoring is separated into three "subcomponents": 1) Integrated Clinical Encounter, 2) Communication and Interpersonal Skills, and 3) Spoken English Proficiency.
The ICE subcomponent is graded by checklists. Observers behind a one-way mirror check off physical exam maneuvers and such, and the patient note is reviewed to see if it incorporates certain information that the creators of the test deem important. The CIS subcomponent is necessarily based on subjective feedback from the standardized patient, though I have no idea what criteria or grading rubric they use. The SEP subcomponent is obviously not an issue for people who speak English fluently.
As part of the end-of-third-year ICC, everyone in my class took a five-hour CAPE exam to prepare for the USMLE Step 2 CS. A lot of effort was put into making this practice exam as close to the real thing as possible. Except for the CAPE exam being 5 hours instead of 8, and 10 patient encounters instead of 12, I think that this experience did a great job of preparing me for what the CS test experience will be like.
Sunday, April 22, 2012
Information about combined medicine/psychiatry residency programs
What is combined medicine/psychiatry?
A lot of people, even medical students and doctors, have never heard of combined medicine/psychiatry residency programs. So, what exactly is med/psych? A regular internal medicine residency program is three years; a regular psychiatry residency is 4 years. Combined medicine/psychiatry residency programs shorten this training period to a total of 5 years.
How are the two programs combined?
The two residencies can be combined without compromising the integrity of the training because much of the training overlaps between the two programs. For example, the psychiatry program at Duke University requires 4 months of internal medicine and 1 month of neurology during the first year of residency, while the entire fourth year is comprised of electives and research. Likewise, Duke's internal medicine program includes a 5.5 months of electives. Adding up all that time gives you about 2 years that are saved by combining medicine and psychiatry into an integrated training program.
How many med/psych programs are there?
The National Residency Match Program (NMRP) reports that 11 combined medicine/psychiatry programs participated in The Match in 2011:
How competitive are combined med/psych programs?
I tried to get a better idea of how competitive combined medicine/psychiatry programs by looking at "Results and Data" documents published by the NRMP for the last five years, 2007 through 2011. I compiled all the Match data for med/psych programs and used those data to put together this table:
There are a lot of very interesting observations in these data:
Altogether, this is a pretty thorough presentation of what a combined medicine/psychiatry residency program actually is, what programs there are, and the Match statistics. I will likely update this with a follow-up post when I have more information, which will be sometime after I have finished interviews.
In the meantime, more information can be found on The Association of Medicine and Psychiatry website.
A lot of people, even medical students and doctors, have never heard of combined medicine/psychiatry residency programs. So, what exactly is med/psych? A regular internal medicine residency program is three years; a regular psychiatry residency is 4 years. Combined medicine/psychiatry residency programs shorten this training period to a total of 5 years.
How are the two programs combined?
The two residencies can be combined without compromising the integrity of the training because much of the training overlaps between the two programs. For example, the psychiatry program at Duke University requires 4 months of internal medicine and 1 month of neurology during the first year of residency, while the entire fourth year is comprised of electives and research. Likewise, Duke's internal medicine program includes a 5.5 months of electives. Adding up all that time gives you about 2 years that are saved by combining medicine and psychiatry into an integrated training program.
How many med/psych programs are there?
The National Residency Match Program (NMRP) reports that 11 combined medicine/psychiatry programs participated in The Match in 2011:
- Charleston Area Medical Center; Charleston, WV
- Duke University; Durham, NC
- East Carolina University; Greenville, NC
- East Tennessee State University; Johnson City, TN
- Emory University; Atlanta, GA
- Medical University of South Carolina; Charleston, SC
- Southern Illinois University; Springfield, IL
- Tulane University; New Orleans, LA
- University of California, Davis; Sacramento, CA
- University of Iowa; Iowa City, IA (This program's website is especially informative and well-presented.)
- University of Kansas; Lawrence, KS
How competitive are combined med/psych programs?
I tried to get a better idea of how competitive combined medicine/psychiatry programs by looking at "Results and Data" documents published by the NRMP for the last five years, 2007 through 2011. I compiled all the Match data for med/psych programs and used those data to put together this table:
There are a lot of very interesting observations in these data:
- The average number of positions offered per year is 22 (Range 19-26) with the greatest volatility over the past two years.
- There are consistently two med/psych positions per year that are left unfilled, and those tend to be at the same institutions year after year (Kansas, East Carolina).
- The number of med/psych applicants in 2011, both US seniors and total applicants, seemed to decrease significantly from previous years.
- Med/psych applicants, both US seniors and everyone else, apply on average to about 3 programs.
- Over the past 5 years, the percentage of total med/psych applicants who were US seniors ranged from 35% (2011) to 50% (2010). Likewise, the percentage of matched med/psych applicants who were US seniors ranged from 47% (2009) to 75% (2010). There are two major points here. First, most applicants are either international students or people who took some time off after medical school. Second, US seniors have a better chance of matching to med/psych than non-US seniors.
Altogether, this is a pretty thorough presentation of what a combined medicine/psychiatry residency program actually is, what programs there are, and the Match statistics. I will likely update this with a follow-up post when I have more information, which will be sometime after I have finished interviews.
In the meantime, more information can be found on The Association of Medicine and Psychiatry website.
Saturday, April 21, 2012
I'm a fourth-year medical student!
As of yesterday at 4pm, when I finished my Ob/Gyn shelf exam, I can officially call myself a fourth-year medical student. Holy cow! Time has passed so quickly with practically every minute of my life accounted for by clinical duties, studying, or scheduled relaxation so I can work and study some more. Also contributing to this feeling of time dilation, the past year has been divided into discrete 2-8 week blocks of intense focus on one subject matter.
This next year promises to fly by even quicker. Sub-internships, externships, USMLE Step 2, residency applications, interviews... and so much more!
This next year promises to fly by even quicker. Sub-internships, externships, USMLE Step 2, residency applications, interviews... and so much more!
Friday, April 13, 2012
Oral presentations: The urge to keep talking
I have made amazing progress in terms of my oral presentations since the beginning of third year. I started out having literally no idea how to properly present a patient. A stellar resident taught me the basics during my Hospitalized Adult Care clerkship, and along the way other residents and attendings interested in teaching have helped to fine-tune my presentation.
Today, I was presenting to my attending an obstetric patient who was in for a regular check-up. The attending remained quiet as I went through all the pertinent subjective information about my patient's pregnancy, described the fetal heart rate and height, and gave her my assessment and plan for this patient.
I was about to talk about the patient's breastfeeding and post-partum birth control plans when my attending said, "Stop!" It's not uncommon for attendings to interrupt oral presentations of medical students. So I stopped, wondering what she was going to say. "Your presentation was perfect. You covered everything I wanted to hear, and you said it succinctly. I know your assessment and plan. You don't need to say anything else. Stop talking!"
The lesson: Part of a good oral presentation is knowing when I've said enough. I should be confident that I have covered all the pertinent details and act on that confidence by ending my presentation. For a third-year medical student who is just now starting to feel comfortable giving oral presentations, this is a valuable lesson to learn.
Today, I was presenting to my attending an obstetric patient who was in for a regular check-up. The attending remained quiet as I went through all the pertinent subjective information about my patient's pregnancy, described the fetal heart rate and height, and gave her my assessment and plan for this patient.
I was about to talk about the patient's breastfeeding and post-partum birth control plans when my attending said, "Stop!" It's not uncommon for attendings to interrupt oral presentations of medical students. So I stopped, wondering what she was going to say. "Your presentation was perfect. You covered everything I wanted to hear, and you said it succinctly. I know your assessment and plan. You don't need to say anything else. Stop talking!"
The lesson: Part of a good oral presentation is knowing when I've said enough. I should be confident that I have covered all the pertinent details and act on that confidence by ending my presentation. For a third-year medical student who is just now starting to feel comfortable giving oral presentations, this is a valuable lesson to learn.
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