Posts tagged med student

The Problem With Shorthands

I saw a patient on the ward on call recently where the patient’s complaint was some mild shortness of breath. Upon reviewing the progress notes, one of the issues low down on issues list was titled PE.

My heart skipped a beat.

Pulmonary embolus. My thoughts raced at the possibility that this patient had a recurrence. I quickly went back to see the patient but found that his story and physical exam did not quite add up to what I had imagined. I decided to go back and read the chart notes carefully again.

The more I read the notes in its reverse chronology, the less this PE sounded like a pulmonary embolus until I finally found the source, some ten pages back, buried in the middle of their already thinned chart.

Pleural effusion.

Over time, a relatively benign finding had been unintentionally shortened to a grave and emergent issue by the student writer. I breathed a sigh of relief.

It was yet another reminder of how shorthands and acronyms can cause miscommunication.

A Word with Fourth Year

For the students who have survived their foray into clerkship, congratulations for making it this far. You are only a year away from finishing your medical schooling. Here are some words of wisdom as you draw closer to the end as an undifferentiated stem cell and down the new path as a resident.

  1. Stay healthy. Surely by now you will have managed to find a daily routine that allows you to work hard but also enjoy time away from medicine. However, third year is also a time when one can pick up bad habits. Plan ahead, and take this opportunity before residency begins to really iron out the sore spots in your life.
  2. Explore your interests. Fourth year is really about finding your career interest and honing in on that goal. This is where you can start to expand on your career choice and take electives that give you inspiration, skills, or both. 
  3. Prepare early. Residency applications are meaty things and the deadlines come sooner than you think. Research the programs early, write cover letters early, and think about planning your electives early and in line with the residency matching schedule. 
  4. Have a backer. In third year, I mentioned that making a good impression was important. That trend continues on in the fourth year electives as well. The good will and social capital you accumulate with your attendings are what will fuel good reference letters. For a competitive program, these letters, particularly if they are from respected members of the faculty, can make or break an application.
  5. Study and keep studying. Elective choices can change the entire atmosphere of fourth year. While flexibility is welcome, it is never a license to take the easy road. Still take some time to read and study. At the end of it all, regardless of what program you match to, the licensing exam tests you on all facets of medicine.
  6. Big brother, big sister. When you began third year, you were the fresh face on the ward. There was some stuff you knew back then but a tonne more you had no idea about. Remember how stressful and terrifying it was once.
    Now that you are a fourth year, do not forget how that felt. When you meet a third year student on your team, help them along, guide them, impart your experience to them. Remember the kindness of your senior students and residents and pay it forward.
  7. Have fun. Medical school goes by very quickly. As a student, there is a flexibility and freedom that you will simply never come across again. Enjoy your rotations with your peers. Make the most of your electives. Take the residency interview tour as a nation-trotting adventure. Never forget to have fun on this job.

Related posts: A Word with First Year. A Word with Second Year. A Word with Third Year.

The First Week: Thoughts on Being a Doctor

Today marks the end of my first week as a doctor. To say the least it has been exciting, interesting, but above all, scary.

I have hit the ground running here, starting my first rotation in internal medicine. The days thus far have been long, hard, and busy. Everything feels more real, more high stakes; after all, I am now the one who needs to make the decision overnight. 

However, every resident feel like this when they begin practice. What I would like to share instead are some of my other experiences:

  • People are addressing me as doctor: This continues to feel very out of place to me. While I now do refer to myself this way, I still ask people to address me as Tom.
  • I can give verbal orders over the phone: As a medical student, I was never allowed to give a verbal order over the phone. In order to start investigations or medications, I always had to go to the ward and write it myself. Not anymore.
  • What orders should I give over the phone?: While I used to have time to think on my way to the ward as well as the luxury to phone the resident for approval, this is no longer the case. I cannot emphasize enough how awkward it is to be asked for directions on the spot. “Can I call you back?” or “Let me lay eyes on the patient first.” are my go-to phrases now.
  • Accepting my orders as they are: On very few instances when a pharmacist is on hand, no one has questioned my orders. It is a scary burden to carry as a new resident. “Is what I am about to order safe?” Unfortunately, no switch flips on in our head when we become a resident, granting us all the knowledge and competence we need to make these decisions on our own. Even for some of my simpler orders, I still run them by my senior resident first.
  • The work does not change: Honestly, while the responsibilities have increased, the work we must do is the same. That also means that time for sleeping, eating, and peeing is still at a premium. Already, I have done a 36 hour straight call shift. And more are to come I am sure.
  • Billing: I never had to learn about earning money as a medical student but now it is part of my daily life. The flip side to doing all of the clinical work is all of the paperwork, now billing included.

There are still two years ahead of me in this residency and much to learn, see, and do. Expect more thoughts on this transition in the future.

Four Stages of Competence

In the 1970s, Noel Burch described four stages of learning any new skill and it could be summarized as follows:

  • Unconscious incompetence, where one does not recognize a deficit;
  • Conscious incompetence, where one does recognize a deficit and how to improve their skill;
  • Conscious competence, where one is competent but requires concentration to perform the skill, and;
  • Unconscious competence: where the skill has become second nature.

Everyone strives for unconscious competence. The mastery of a skill has become so complete that you can do it effortlessly. The scariest state to be in is the first stage. “You do not know what you do not know.” That can be a terrible position to be in, especially when a patient’s life is on the line.

That is why receiving feedback is so important. That is why we train for so many years, under the watchful eye of so many experts to be a master of the craft. Sometimes, in order to make that transition to the next step of our competency, it requires someone else to point out where we need help.

MD: A Degree in Review

It still shocks me that I am only a few days away from beginning my residency. Four years have come and gone. I now have a degree and letters behind my name to show for it. This last year has presented with its own unique challenges and a lot has changed in four years. Let’s have a look back.

Year One

It was here that I first learned how to correctly use my stethoscope, how to speak with patients, and how to act like a doctor. These were my baby steps. I studied a whole host of topics, covering the broadest and biggest organ systems. It was also here that I learned anatomy and had the privilege to work with cadavers. 

Year Two

In many respects this was the most stressful year. While clinical work is taxing in its own right, nothing came close to the mental toll this year had on me. Studying was both a necessity and a compulsion. Easily I spent entire days sitting a library, reading, memorizing, understanding. I had never studied that much in my entire life.

Year Three

This time, the stresses of clinical work were balanced between the mental and the physical. By far the most challenging year of all but also the most enjoyable. Having sat in class for the better part of my life, now I would have to do.

It was an adjustment to work in a hospital, to see volumes of patients, to do call shifts. But I adjusted and grew used to the pace of the ward. Gradually, I learned to move from knowing how, to showing how, to doing.

Year Four

On top of the clinical work, I had a number of additional challenges this year. I had an all encompassing OSCE, residency applications and touring, and a licensing exam to complete. By this point, clinical rotations were not quite as overwhelming or scary as they used to be, but I still had many hard days.

The brunt of the stress this year came from the latter additions. Those three things were for all the marbles, and the consequences of missing any one of those were a constant worry. The OSCE wound up showing some of my weaknesses that I would need to improve on. The CaRMS tour would take me across the country from colder to coldest winters in Canada. The licensing exam ended up being a two-week mad dash to the finish line. For six months, the pressures mounted through these three main events.

But I eventually reached the end of my four year journey. I graduated, I was admitted to a residency program, and I passed my exam. 

It has been a roller coaster ride through four years of medical school. I am happy I could document it all here in these posts. Now I start a different journey through residency and look forward to reflecting more on this new adventure.

Medically-Themed.
A medical graduation would not be complete without some obligatory medically themed treats for graduates, families, and friends. Here are some of the cupcakes that were available to us today.

Medically-Themed.

A medical graduation would not be complete without some obligatory medically themed treats for graduates, families, and friends. Here are some of the cupcakes that were available to us today.

Graduation: Part Three

For the third and last time, we walked across the stage to receive our medical diplomas from the dean of medicine, conferred to us by the president of the university. Convocation was the final chapter of our graduation. 

Finally after eight years of university schooling, I was an alumni. It took tremendous amount of academic fortitude to reach this point. But it also would not have been possible without the support and understanding of my family and friends. These are the unsung heroes, the honorary MDs who were there when I took my first blood pressure reading, who volunteered for my abdominal exam, who learned and taught me about being a patient and being a physician. 

Graduation: Part Two

The graduation festivities continued today with valediction speeches and some key words of wisdom from classmates and physicians respectively. Instead of donning the white coat today, I received my graduation gown for the hooding process. This is the act of conferring an academic hood to signify the completion of my degree in medicine. In addition, we all swore our Hippocratic oath for the first time while preceptors and physicians present for the event reaffirmed theirs.

To Hang Up One’s Shingle.
In the early half of the nineteenth century, this colloquialism came into use. When a new establishment was constructed, an extra roofing shingle would be used to create the signage. Initially, the term was associated with lawyers opening up a new firm before also being applied to doctors, then any professional starting up.
As newly minted physicians, we were offered a ceremonial shingle. Generously gifted to us on behalf of the alumni community, it is a welcome gesture into the medical profession as their new colleagues.

To Hang Up One’s Shingle.

In the early half of the nineteenth century, this colloquialism came into use. When a new establishment was constructed, an extra roofing shingle would be used to create the signage. Initially, the term was associated with lawyers opening up a new firm before also being applied to doctors, then any professional starting up.

As newly minted physicians, we were offered a ceremonial shingle. Generously gifted to us on behalf of the alumni community, it is a welcome gesture into the medical profession as their new colleagues.

Graduation: Part One

"Nelson Mandela once said: ‘It always seems impossible until it is done.’"

That was how our graduation ceremony began. We were ushered into a hall where our friends and family were gathered; some of our preceptors were also able to take the day off to watch us make the transition into residents. It would be the first of three parts to my graduation.

A number of speeches were planned for the event. Some recounted the establishment of the school, its goals and its aspirations; others offered words of wisdom, advice from one generation of doctors to the next; each had a special place in the ceremony.

The main event for the day however was the donning of our white coats. Gone are the days of short white coats that separated us from our attendings. As the roll call came out, establishing where we had matched to for residency, we each received a long white coat, embroidered with the coveted title we had worked four years to achieve:

Doctor.