Witty response of the day

I’m sitting in class listening to a professor describe our upcoming Preceptorships and I believe I’ve just heard my “witty snarky response of the day”

We’re hearing about all of the little things that students have done in the past during these “active” shadowing experiences. (we’ll be expected to take the Histories and (surface-level) physicals of patients in the hospital) and our professor has repeatedly reminded us that we can’t

Student- “Do we have to ask the patient if they’d like a rectal exam?”

Prof: “Nobody “would like” rectal exam”

Student – Do we have to ask them if they would like to decline a rectal exam?

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Real people

(One from last year that never made it out)

Its amazing how quickly one can forget.

I had the opportunity to spend a year working as a Scribe in two twin cities’ ER’s over the “year-off” between school and…well, more school. As you can imagine, hours spent with these patients gave me a different impression of the value and place of healthcare than some of my more…educationally streamlined (?) classmates. Drug addicts? no sweat – My sheltered suburban eyes have been opened. Blood? no more off-putting than re-gifted fruit cake. (sorry – only pun in my arsenal today.) Mental disorders? A reality of life, as was the rest of what we had studied in class.

You see, today we began “Preceptorships”. That wonderful period of time spent shadowing playing Doctors, our first real change to see patients, take their vitals, their histories, and their relevant physical exams before presenting all (in a not-so-concise fashion) to the attending physician. Admittedly – I’ve been looking forward to this part of Med-school for AGES; because didactic learning has been…well, brutal.

Ours was at the VA (Veterans hospital – 50 minutes out of town)

I mean, FINALLY, a chance to flex a lil’ scribe muscle and show these newbies how a real doct…med student does it. Bring on the patients – those ailing masses who seek my caring touch! With a word my orders shall be carried out, yielding nothing but healing and wholeness for all!

Or so I imagined.

After the countless hours of class, “small group learning” and studies, (not to mention the skills practiced on fellow students (yeah…one of the better part of school, testing the reflexes of that annoying student. relax, his bruises eventually healed.) I was pretty confident walking into our first patient of the day, an Ex Vietnam vet with “Ascites” on his chart.


As a quick heads up – Ascites is basically fluid collection in the abdominal cavity ( yo’ – belly) that starts when the liver begins to slack in its duties, (whether due to alcohol, injury, cancer, hepatitis etc. etc.) The proteins that normally help keep all your squishy bits juiced up (yes. medical definition) don’t exist, and so fluid collects freely and expands the abdomen.

The textbooks all show a reasonably normal white male with a uniquely large and rounded stomach, and what child hasn’t teased their father after thanksgiving meal? Big stomachs are one of those realities of first-world life non?

no.

Our patient, no taller than me, had what appeared to be an exercise ball stuck in his stomach. An almost cartoonishly impossible, taut, bulging stomach large enough that his XL hospital tunic, which had given up attempting to cover it, merely drifted to the side.

The poor guy hadn’t slept in a week.
Dear lord, a week?
And this was his, (gasp) third time coming in with this severe “abdominal distension”?

Like three timid little lambs myself and the two other students assigned to our hapless patient stood on either side of his bed – white coats little more than a symbol of our ignorance – and started firing off questions.

Firstly – When did I suddenly lose the ability to talk to humans? Here I am talking to a patient with a hearing aid, and an uncomfortable condition, and suddenly words escape me. Those that I do find are clumsy and overly-technical.

I had to take a moment and literally shake it off. Our patient, ever gracious – answered each question, despite our spending nearly an hour to finish off a complete history and physical.

“Oh, the physical exam, how did it go?” you ask.

Thank God I don’t have be treated by me (yet). Scratch verbal stumbling, we actually tripped over ourselves trying to examine our patient appropriately. The United States Medical Licensing Exam (USMLE Part 2) tests clinical skills, and docks points for unnecessarily repeating painful examinations. I can’t believe what this guy must have been going through as we “gently” poked and prodded his stomach to identify the boundaries of his liver, etc. Every time we insisted on waiting for the attending physician, our patient encouraged us to continue the exam. (Whadda-guy) I will admit, the moment I first touched his FIRM stomach ( I mean…it was tighter than a water balloon at capacity) I forgot the entirety of my medical knowledge.

There is simply nothing like touching a real person. And there is nothing scarier (or more exhilarating ) than knowing that his condition isn’t a test question.

An Attending and some Third-year medical students came in shortly after us, examined the patients (in seconds) and proceeded to puncture his stomach (“Paracentesis”)

Eleven (11) liters of fluid were released from this patient’s abdominal cavity.
Dear sweet snow…Eleven liters. This patient was sleeping with five two-liter sodas strapped to him, with a seltzer water on the side.

It barely made a dent.

Fifty years of 10 drink-per-day living will have that effect.

War is hell.

Medicine – Tech – Capitalism

Medicine – Tech – Capitalism

Given the current battle between the “socialism” of “Obamacare” (heretofore referred to by it’s Christian name, the Affordable Care Act) and the “capitalism” of big Pharma – it’s easy to forget that there’s a line between the two worth finding.

David Green may have just found that line –

The linked article above describes his efforts to design simple, affordable versions of health technology with the goal of allowing market forces to work as they should, cheapening the price (but not the quality) of health tech for the masses.

Suffice it to say David Green, keep your phone on, I’ll be calling you.

…Like a boss

USMLE Step-1.

The dragon, the beast, the…well really it’s just a test. While an important one, capable of wedging open the doors of higher learning and career pursuits, I’m beginning to worry considerably less about it. In fact, I’m looking forward to it.

Why?

Some weeks back I read an article in the Harvard Business Review: “How to negotiate like a boss .( As a card-carrying millennial, I click anything that says “like a boss’ for better or worse. ) The article highlighted a simple principle,  

“Promotion-focused people think about their goals as opportunities to gain — to advance or achieve, to end up better off than they are now. Whenever we think about our goals in terms of potential gains, we automatically (often without realizing it) become more comfortable with risk and less sensitive to concerns about what could go wrong. Prevention-focused people, on the other hand, think about their goals in terms of what they could lose if they don’t succeed — they want to stay safe and keep things running smoothly. Consequently, when we are prevention-focused, we become much more conservative and risk-averse.”
(HBR-…like a boss)

This claim was tested by a relatively low-powered experiment: 54 business students negotiating for a contract. One was told to avoid losing money for their company, the other, to gain as much as they could. Predictably, those whose backs weren’t against the financial wall fared better – but the underlying principle might just be applicable to medical practice, and (more immediately) medical studies. There’s a fine line between the two worth exploring, for the sake of my personal development and future patients.

Promotion- focused people excel at:

  • Creativity & innovation
  • Seizing opportunities to get ahead
  • Embracing risk
  • Working quickly
  • Generating lots of options and alternatives
  • Abstract thinking

(Unfortunately, they are also more error-prone, overly-optimistic, and more likely to take risks that land them in hot water)

Prevention-focused people excel at:

  • Thoroughness and being detail-oriented
  • Analytical thinking and reasoning
  • Planning
  • Accuracy (working flawlessly)
  • Reliability
  • Anticipating problems

(Unfortunately, they are also wary of change or taking chances, rigid, and work more slowly. Diligence takes time.)

 

For safety’s sake I combine this “promotion” mindset with the tried-and-true Ben Carson M.D. risk analysis:

Four questions: ‘What’s the best thing that can happen if I do this? What’s the worst thing that can happen if I do this? What’s the best thing that can happen if I don’t do it? What’s the worst thing that can happen if I don’t do it?
 

Ever learning, ever growing.

#apptlychosen

Video

Food & Family

Finally had a chance to edit the footage filmed of friends and family while at home over Christmas break.

It serves as a reminder of why I must continue to study.

Disruption and Digital, my two favorite words…

MILLENNIAL MEDICINE: KNOWLEDGE DESIGN FOR AN AGE OF DIGITAL DISRUPTION

Join us on April 26, 2013 as we envision the future of medical education.

Millennial Medicine will be a unique, one day symposium that focuses on creative solutions to the grand challenges facing medical education today. Our goal for “Millennial Medicine: Knowledge Design for an Age of Digital Disruption

“What is that you say? Disrupting medicine?” [Some of you stopped reading there.]

For the remaining few, I thought I would share some interesting events/opportunities on the “meded” horizon. Some classmates and I have been somewhat heavily invested/interested in the culture change swallowing the medical field over the recent (read: decades-old) period. Frankly, it’s the same one that attacked the music industries with Napster, Emails with Mailchimp, Phones with…”i” ?, and more importantly twitter, Facebook, square, and LORE . The “digital revolution.”

Sure, we’ve had computers in medicine for years, and most of the doctors I know are more than comfortable with the increasingly digital world. My professors (and my sources tell me your professors too) however are just beginning to  catch on to this new way of thinking. Here are just a few of the changes I witnessed in the last 365 days.

1. A 70 year old anatomy professor goes from printed pdf’s and a whiteboard to teaching his lectures with an ipad wirelessly projected onto the 10 screens of his anatomy lab. (even know I claw at my beard with joy)

2. A team of students does questions “together” not on paper and pencil, but via iPad-projected question banks

3. Fundraising at all levels stops requiring cash donations and adopts Square

4. Students submit challenging questions, explanations, and sources online into an ever-ready (free) repository of medical (Awesomeness!) education.

5. Professors figured out how to effectively serve secure quizzes online. (with frequent – and almost annoying notifications of material changes popping up on student’s phones)

6. The iPad mini appears in lab coats. (the original ipad was forced in by some…but always looked imbecilic

7. Medical student designs his OWN software (no…not me) for the above mentioned repository, then creates an iOS app for it.

Pretty cool huh? – I may have to cut this post short, as there is yet much work to do, but it seems there are many changes inbound, (most of which are …FREE?)

I’ll keep you, and myself updated.

 

 

Prom, TPP, and TPA

I may have mentioned this before – but the statement is crazy enough to risk repeating again:

“The average medical student will forget more information that the average American will learn in their lifetime”
– Unvetted source

And so – the battle continues. We’re back from Christmas break, and with Step 1 USMLE (united states medical licensing exam) 6 Months out the panic is beginning to set in on a lot of my classmates. Admittedly – its a pretty big deal, as the door to one’s dream career seems once again opened by a ____ point score (Uppper-Mid 200’s) . (Oh, did I mention that one can only pass the exam once?)

Looking at myself – I had hoped to go back to the environment that made studying for the MCAT so effective, but without daily home-cooked meals, or the Refrigerator from The lion the witch and the Fridge, it seemed I would have to find another way to take the studying to another level. I’ve picked up a sea of interesting reading on the topic ” Building the step1 brain”, “Mind-Gym” etc, however the most valuable lessons so far have been introduced by a wildly illustrated book called “The SketchNote Handbook” (By Mike Rohde). I saw it on the blog 33 Charts (by Eric Topol) – which usually highlights social media, technology, and the eventual “creative destruction” of medicine the way I imagine this blog will some day do.

but back to the point –

There is SO much information out here – recording it all, retaining it all, heck, regurgitating it all has been quite the challenge – Fitting that the first and most important’ topic of the Sketchnote handbook (which uses mini doodles like a 1980’s CPA used a calculator) is “Picking the Main idea”

Ah, that ever-present golden ticket : The Main Idea. Ignore the minutiae the professor will probably ask on the exam, the Main idea is often embedded deep within a professors lecture, or, (as i’m reading now) a journal article.

I’m currently reading about TPP, “Thyrotoxic Periodic Paralysis” (Not to be confused with the Clot-Buster TPA) …and the author didn’t bother to explain the thyrotoxic part of the disease until five-pages-in. Imagine my notes – sketchnotes rather – following their long circuitous path only to bank left and travel up to the top of the page with a long arrow that says “Main Idea”.

“Why complain?” I hear you asking –

Because I’d already read about the 2% of patients with Oriental (yes…that’s how old this article is) descent who suffer from the disease, followed the in-depth explanation of the arrhythmia-inducing hypokalemia and internalized the names of the genes which mutated to cause this disease.

The culprit is KCNJ18…

The moment I read it “All my life” by K-Ci N’ JoJo started playing from the heavens, and for one blissful moment, I was 18 again, dancing awka-suavely with my date to the last song at Prom.

I will absolutely NEVER forget that KCNJ18 is the gene responsible for TPP….but the main idea…come to think of it, I had better go back and remember what it was.

I love Medschool.

Has it really been that long?

Greetings and salutations all,
forgive me for the incredible hiatus that I have (apparently) taken while “in da books”. I thought I would describe some of the incredible creativity that I am surrounded by at almost all times.

It seems our professors do their best to provide the full gamut of teaching styles, from tear-inducing (boring) to downright hilarious, we’ve been besieged these last few months with about 30 different PhD’s, M.D.s PDF’s, and MP3s, (see what I did with that?) who each focus on the pharmacology, physiology, pathology, (and sometimes even clinical medicine?) of the various organ systems of the human body.

We are indeed lucky enough to have one of the esteemed “kaplan” professors as our pathology prof. Dr. C, (as I’ll call him from henceforth) makes every effort to keep students awake during his lectures. It seems he is entirely unburdened by political correct-ness, and has more than once finished a lecture with a quick witted phrase that left more than a few mouths agape.

ah yes, here’s one:

Professor C. : “And class, when do you see fatty change in the liver?”
Enterprising (show-off) student: “whenever more than 8 oz of 80-proof alcohol is ingested in a 24-48 hour period”
(multiple students let out a low curse )
Professor C : Wrong!
(collective gasp)
It happens whenever Mr. Johnson gets an A or an F on an exam!
(Collective laughter – minus enterprising student)
Professor C: Just kidding – you’re completely write [enterprising student ] your sharp man, sharp. Epididymus – on the ball.
Enterprising Student: clear signs of silent self praise

In case you missed this joke…look up the location of “the ball” on which the epididymus is so proudly placed.

Most days are this entertaining – filled with some student-driven incident, or non-medical epiphany.
However, every so often – there are days that are special. Instead of write about it – I thought i’d embed a video of a classmate of mine who noticed cardio notes written in dry erase marker on the mirror of one of our peers. Like any red-blooded american, he decides to approach the notes “creatively”. His “off-the-cuff” reaction will amaze you. ( the first 10 seconds are merely a lead-in beat.)

NGH (Nashville Gen. Hospital)

Salut All,
I’m writing this time as a medical student, friend and (temporary) Nasvhillian.
You may or may not have heard about the pending alterations to Nashville General Hospital, (which is staffed by Meharry Medical College), so here’s the skinny,

Around 1996, NGH, Nashville’s only safety-net hospital was burdened by far more patients than it’s limited medical staff could handle. Simultaneously, Meharry had far too few patients for effective student training. The agreement made at that time has successfully staffed NGH with Meharry Physicians and students with the benefit of a city subsidy of $43 million annually for hospital costs.

The unfortunate reality however is that the hospital is running at a $8-12 million shortfall/loss annually, and the City is tired of it. They hired a consulting firm (known for their skill in closing down hospitals) to “evaluate” the hospital and provide a recommendation. For their 1Million dollar fee, the company provided a financial assessment only, ignoring the social aspects of cost such as “quality/years of life lost” and the impact to the medical school attached to the hospital. Their recommendation was in essence to turn the hospital into a day clinic – providing ambulatory services alone.

While the decision would effectively force 400 Meharrians to rotate at another (possibly non-TN) hospital, more concerning is the effect it would have on Nashville’s poor/underserved populous – 25% of whom are cared-for at NGH.

While I don’t believe the hospital should be kept as is – I expect every option to be considered before a palliative approach is adopted. Meharry provides academic-level care to the poor, with a focus on education. We’re just beginning to see how such a world without that would look.

If you wouldn’t mind – join me in signing a student-created petition written to the Nashville Mayor. We only need so many more signatures (to reach the 3,014 required for a committee-level referendum to be called) and I’d love it if you’d be one of them.
(the links for more details about the issue can be found on the site)

http://www.change.org/petitions/mayor-karl-dean-keep-inpatient-services-at-nashville-general-hospital-at-meharry

The Tea(student)cher

I’m sitting in a review session right now.
My mind has been blown.

Standing 8 rows below me is a 4th year medical student serving as a TA for our cardiovascular block of lectures. He’s wearing a white coat, and speaking with a (lovely) suther’n drawl, and tapping an expo marker on a table.

He’s tapping an expo marker on the table and blowing my mind wide open.

Forgive my enthusiasm, and allow me to explain
Cardio – one of the coolest subjects in all of clinical (non-surgical) medicine deals with the heart and vasculature (arteries/veins). Usually We’re treated to a mind-numbingly boring lecture by a PhD who did her thesis on the subject, (thus feeling the need to elaborate endlessly on some minute detail to warrant her years decades of misery) Usually, a good 40% of the class skips the first lecture in favor of a few extra minutes of sleep or in favor of some pre-recorded lectures by a well known, well paid test-prep company…However with this guy, we’ll call him “Ernest” the first 5 rows are full (primetime seating) and the back is empty.

Ernest lectures slowly, VERY slowly – and yet discusses mounds of information, while highlighting on the history (Did you know that our modern EKG was developed with a bow & Arrow and a fine filament!?) as well as the clinical value of every concept. He learns every name, taking the 3 seconds to pause class and ask us for our surname as well so as to call us “Dr. ____” (I swoon even now.)

He illustrates concepts like stories, suggesting that the S4 Heart sound is best ascribed to Grandma (the Right atrium) pushing more blood (a Key Lime Pie) into the family bellies (Right Ventricle) on thanksgiving, despite said family members having eaten too much.

He pauses, as if struck by lightning – stating, ” The Lord just gave me an idea,” “Let me take off my glasses for this one” and outlines cardiac principles with incredible ease.

He calls introverts to the front of the class and they come willingly. They leave satisfied, and un-embarrassed.

Only this southern gent could make 2 hours seem like twenty minutes while speaking at half-speed.

I Know what I want to be when I grow up…