To everyone who had written a message to me in the last little while, I want to first start by apologizing for taking me such a long time to get back to you. It has been a busy couple of weeks. With that said, let us get started on the big mailbag.
Pendere:My pen of choice. I use a Lamy Safari Vista, which is fully transparent so that I can see where I stand ink-wise and refill in advance.
I have to check the tiny window on opposite sides of my pen that allow me to see how much ink remains. Generally once it appears empty, there is about 20% left in the converter.
Ashenmemories:Agreed. The Safari is pretty durable and a smooth writer for a reasonable price as far as fountain pens go. Have you thought about turning any of the disposables into eye dropper pens? You wouldn’t have to worry about ink as much while at work.
I have not thought about it but perhaps that can be a future project of mine. I am actually considering getting another fountain pen for a different purpose at the moment. Perhaps I can shed some light on that if I get a chance to review it.
Rarelyposts:Resisting the urge to buy, but slowly losing…
Resistance is futile. In all seriousness, if you have thought about getting into fountain pens, I think this would be a decent one to start with. There is an investment up front - there are definitely cheaper pens out there - but it was built as a trainer and it writes fantastic.
Wayfaringmd:Only a doctor could write such a thorough review of a pen.
I should have become a dermatologist then. Then I could apply that level of scrutiny to a mole. I kid. I kid.
I have always found fountain pens to be intoxicatingly beautiful, but I never brought myself to buy one. Partly I simply did not know where to look, partly I was also lazy. I had grown up using throwaway pens and they worked fine for me. But I was inspired to consider them more seriously when I saw my attending writing with not one but four fountain pens on the ward. “Why?” I asked him. He told me: because his hand ached at the end of a long day of writing page after page of notes; the fountain pens had put an end to all of that and they got rid of the callouses on his fingers.
I looked down at my right hand, thick callouses along the side of my three fingers. I decided it was time to get a fountain pen.
Polyacrylamidepensieve:Woah can you use the credits for anything? I have no idea how many hours I’ve spent on uptodate, but my account’s not a personal one so it’s awesome to know they have that feature!
UpToDate does have a CME credit submission tool that allows you to describe how you applied the information you reviewed in practice. At this time, because I am not in a practice of my own just yet, I cannot submit them. That will have to wait until after residency.
Now that I have started residency, I have also invested into an UpToDate subscription. This online clinical resource logs the time you spend researching and reading different topics. In less than three months’ time, I have already amassed 42 continuing medical education credits.
A single credit is the equivalent of an hour of additional reading.
In essence, I am averaging roughly 12 hours of reading every month on UpToDate. This is in addition to some other bits of reading I do here and there on guidelines, position statements, and textbooks.
However, it just goes to show that a little bit every day goes a long way.
A woman living in China’s Shandong Province got a bit of a surprise recently when doctors at the Chinese PLA General Hospital told her that her brain was missing one of the most important centers for motor control: the cerebellum. She had initially checked herself into the hospital because of a bad case of dizziness and nausea.
Her diagnosis helped explain some of the challenges she had experienced through the course of her life, including slurred speech, delayed onset of walking until the age of seven and troubles with maintaining balance her entire life.
This time, I answer questions about alternative medicines, the challenges of medicine, the feelings of inadequacy, the unease of dissections, disclosures of personal illness, and late blooming interest in medicine.
I apologize for the delays in replying. I have been very busy lately in my personal life and have not had as much time to read and answer them. I will try to get to them as quickly as I can. I thank you for your patience and understanding.
In the span of twenty minutes while seeing a child in the emergency department, we had bonded over a variety of characters including Spongebob Squarepants, Transformers, Toy Story, Wall-E, and Justice League.
Suffice it to say we spoke the same language and operated on the same wavelength.
As a European non-med (Faculty of Medicine - Speech and Hearing Pathology) student, I was wondering if you have any thoughts about the European system of not having pre-med, high school graduates going straight into 6-or-7 year med school instead.
I think there are pros and cons to both systems. I feel that it certainly streamlines the process for people who already have an inkling that they are going to pursue medicine in the future but I feel that it comes at the cost of exploring other experiences, youth, and just overall maturity level.
Medicine is a physically and mentally demanding field. I think that having a certain amount of life experience and maturity that only comes with age can give you some level of resilience.
While the more indirect admission system can take longer to complete, I think it works to the benefit of people who may not have realized they were interested in medicine until later on. The age demographic for my class is quite broad, with some members being in their 40s. That level of flexibility and that understanding that not everyone has that epiphany at a young age normalizes the experience. In addition, their added wisdom and experience becomes quite apparent once the educational journey begins.
Yesterday was special. A classmate and dear friend of mine who has been out of province for her residency came back for a weekend getaway. We had an opportunity to meet and catch up on how our respective residencies have been thus far.
While war stories were exchanged, the focus was never about the medicine side of things. It was more about how life has been and what we were up to. It was a nice change of pace from my regular conversations nowadays.
For four hours, we were able to disarm ourselves of our ward personas and talk about regular, “normal” things. From the movies we watched, to my recent vacation stories, to her relationship challenges.
At four hours, that mental vacation seemed too short.
Just when I thought I was out of the woods, I was re-exposed to the most dangerous paediatric affliction of all:
Contrary to its name, this troubling and traumatic condition is just damn hard to let go. It infects the motor and memory recall systems and results in people unconsciously humming or singing to its tune. It has the potential of infecting other people. Prognosis: Very contagious. A full recovery is possible but in the order of weeks so long as you are not re-exposed to it.
The challenge of my current schedule is that I must juggle my responsibilities between my core rotation and those of my clinic, to which I am obligated to spend time as well.
Sometimes it means missing out on some good learning opportunities due to conflicting schedules. Other times, the days off of one schedule coincide with the days on of another. I can be particularly hit hard if, like today, the day could have been spent sleeping post night shift.
Thankfully these scheduling anomalies are few and far between. However, when I think about how well established the challenges of balance are in residency, having an awareness of these issues can go a long way towards improving resident resilience.
I'm 19 and I'm on the track to becoming an RN. Do you think having nursing experience will help me become a better general surgeon. That's my ultimate goal
I think that your nursing background gives you a different perspective on health care and that is always to your benefit. Adding new schools of thought into the culture of medicine helps breeds progress and change. It allows others to consider approaching a problem differently. Ultimately that is a good thing.
In my last community survey, I asked how you assess your stress level. The responses demonstrated just how diversely and how uniquely each person’s stress manifests.
This time, I would like to ask a follow up question and allow everyone to share how they deal with stress.
Beyond identifying and dealing with the source of the stress, I personally take more time to spend with my wife. I try to sleep earlier to catch up on rest. I take a step back from studying at home and instead take up sketching and drawing again while listening to music to help me relax. At work, I try to meditate during my breaks.
How do you cope with stress? Share your tips with everyone.
Whenever I am stressed, there are some subjective markers I look at. I find myself more tired, I have a harder time concentrating, and I feel less motivated.
Objectively however, I also have something to gauge my stress level. I have a tendency towards grinding my teeth at night, a condition known as bruxism. It is brought on by stress and goes away in its absence. The more stress I have, the more I grind my teeth. From inspecting my mouth guard every morning, I get a decent idea of how stressed I am.
So how do you gauge your stress level? Let me know in the comments and discussion below.
One of the very first patients I had admitted was a 50-some year old father of three with a newly diagnosed colon cancer. His case read just like my father’s. Sudden changes in stool caliber. More bloating and fatigue. His wife started noticing that he looked thinner.
By the time I had approached him in the hustle and bustle of the emergency department, the news had already been broken by the emergency physician. “You have colon cancer,” he remarked on the bluntness of that interaction. It had left him in such shock that he had little to say for most of the day. I took my time to be thorough, answering questions, gathering the history, doing the physical - his moderately ascitic belly and an enlarged liver already hinted at something more sinister. Having already been subjected to one rectal exam, he asked if I needed to double check again. I politely declined to which he breathed a great relief.
I excused myself to review his CT scan, to get a better understanding of what was driving everything. There, on the black and white screen I saw a liver so large it seemed there would be no space for anything else in that belly. Pocked full of cysts and irregular tissue, it screamed only one conclusion: gross metastasis.
"A few more tests," I reassured him and then he would go home, to follow up with the oncologist for further management options. I explained that the cancer had spread and that the options will be limited. He digested the news silently, his eyes flickered across the floor as he concentrated. When his wife arrived, I made sure to break the news gently. She wept regardless.
By the time I had sent him home, his belly was flatter once again, having been drained of all of the malignant fluid. The oncologist was to follow up with him within a week’s time. The prognosis was guarded but we agreed that he will be fine for at least the week.
Or so we thought.
It was a surprise to me then that not one week later, I saw him again on call in the emergency department, this time looking worse. He was confused, agitated, and grim - his skin had turned yellow. I quickly texted my attending: “Encephalopathy. Icterus.” The response was immediate: “Shit.”
Because most of the patient’s liver had been replaced by metastatic tissue, his body could no longer bear the burden. The liver had started to fail and with that, his kidneys were beginning to shut down. He was quickly transferred to the ward.
We rediscussed code status with the family with the end drawing near and it was decided to change his care to palliative. We kept him comfortable until he died a few days later.
Precipitous multi-organ failure is uncommon to see in someone who is still very high functioning. We never would have expected him to decline so rapidly. It was a surprise to everyone that he could be here one week and gone the next. Given his disease, there would not have been much more we could do medically.
But there are always things we could have improved on. From delivering the diagnosis with care, to advocating for a private room in his final days, to addressing the psychosocial needs of the family. These are areas that we can strive to do better. At the end of the day, this patient was not his colon cancer, he was a person. With a wife and three children. A friend to many.
These were the pieces, in the torrent of changes that ensued on his second admission, that were lost.
"The patient died surrounded by his loved ones. We are grateful to have been involved in his care and offer our deepest condolences to his family and friends…End dictation."
I am almost a high school graduate and I'm very seriously considering entering the medical field. The only problem is that I've read many articles talking about how difficult and stressful it can all be and I'm worried that I don't have what it takes even though I want it very badly. Do you have any advice?
Medicine is one of those careers where you will not know if you can handle it until you get your feet wet. There are no words to really convey the mental and physical highs and lows that it puts you through.
Everything in life that you are passionate about is worth fighting for. I think that if you find yourself drawn to medicine, you find yourself answering the call for something that speaks to you deep within, then I think you should seriously consider it.
We are all our qualities, from the strengths and weaknesses to the good and bad. The sum of those parts and experiences are what give us the mettle to overcome the challenges we face. Once we believe in ourselves to meet them, we can do wonders. Perhaps the greatest challenge of all is starting.
We all need to start somewhere in order to get anywhere. That road you take might not necessarily always take you to the original destination you intended. You can always change your mind halfway but that starting momentum is what keeps you moving forward. It allows you to push yourself.
I would encourage you to take a leap of faith and try anyways if medicine is what beckons you.
I have spent the past few days on a short weekend getaway with my wife. We enjoyed some attractions, nightlife, and even tried a bit of our luck. In any case, it was a great way to get away from work to focus on us and live a little.
Disclosure: I was contacted by the author who provided this book to me without expense. In exchange, I was asked to provide an honest review of this book. I have no affiliation with its author, its publisher or Amazon.
Set in the late 1970s, the Reluctant Intern by Bill Yancey tells the story of Addison Wolfe, a recently graduated doctor who failed to reach his aspirations of working for NASA and instead finds himself in the rotating internship of the University Hospital in Jacksonville. The story chronicles his experience from his first day until his last as an intern.
The hidden curriculum is taught by the school, not by any teacher…something is coming across to the pupils which may never be spoken in the English lesson or prayed about in assembly. They are picking-up an approach to living and an attitude to learning.
You probably have answered this question, but I didn't see it on a quick scroll through so... Where are you studying medicine?
For many reasons, privacy included, I am unfortunately not at liberty to say at this moment. Perhaps in the future when I have less strings attached I will be able to disclose this. But at the moment my hands are tied.
Hello, your blog has been an inspiration for me regarding my aspirations for becoming an MD for almost a year now and I'm confident it will continue to be for much longer. I question myself if I will be physically and emotionally equipped to handle the responsibilities of becoming a physician and was wondering, did you think the same thing before medical school? How did you answer yourself? And do you feel medical school adequately equips you in those domains?
Thanks for your question.
I was definitely in a similar state of mind before going into medical school. In some ways, I still do sometimes. What allowed me to alleviate those fears was the conclusion that every doctor that I will ever meet was exactly where I was then and there, even now. And yet they all have made it.
That is not to say it is an easy process. Medical school and residency are processes that disassemble and rebuild you to fit the mould of the doctor. There is a steep learning curve as you make the transition from academia to clinical work. But eventually, you do get used to the emotional and physical demands of the job.
I would be careful not to equate tolerance with acceptance. Some days the stresses can be overwhelming but between your family, friends, and most importantly your classmates, you find supports to help you through those challenges times.
I thought that this was an interesting article and would be interested to know what others think of this dichotomy. Can one maintain the hard edge needed to practice at their peak when the training emphasizes a softer touch? Can one be malleable, capable of being both at the same time?