Posts tagged medical student

Hit him with everything!
When we get desperate with a patient - be it a cardiac arrest, a septic shock, or just outright aggressiveness - this is what the escalation of interventions feels like.

Hit him with everything!

When we get desperate with a patient - be it a cardiac arrest, a septic shock, or just outright aggressiveness - this is what the escalation of interventions feels like.

Our Deepest Condolences

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."

A yawn is a silent scream for coffee.

A yawn is a silent scream for coffee.

Medical Education, Beware the Hidden Curriculum

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.

-Dr. Roland Meighan

Is the Quest to Build a Kinder, Gentler Surgeon Misguided?

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?

πάθει μάθος

From the Agamemnon of Aeschylus (written c. 458 BCE)

Pathei Mathos can be translated as learning from adversary, or wisdom arises from (personal) suffering, or personal experience is the genesis of true learning.

Understood in its original context, Aeschylus expresses that wisdom arising from personal experience is more valuable than what any impersonal words, faith, or doctrine can impart to us. 

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.