“But, for better or worse, in medical school you don’t have time to really “deal” with how you feel or else things would never get done.”
Yes, it’s finally over and I get a break from medical school. I have a few days off, though I trauma duty this Friday night on Black Friday (this is more of a treat for me than anything else). I wanted to update you on what’s going on, it started off rather short post and then expanded into a meandering account of my brief foray in medicine white a short white coat.
It’s only been about 3.5 months since medical school has started, but as many medstudents would admit, looking back it feels like a year has elapsed. In 3.5 months we’ve crammed a year or more worth of graduate education. But, the course that stands out the most to me was gross anatomy. Yes, the human body is interesting, it’s probably the best example of organized chaos leading to something good.
The poster child for medical experience is Gross Anatomy & Dissection. As a person, you change a lot after Gross Anatomy, it’s practically a rite of passage for almost all MD (and DO) candidates. I still remember the emotional experience we had the week before our first “cuts” into our donor. We were hesitant on the first day of dissection, that is to say no wanted to make the first “cut” into the person laying on a slab of lustrous aluminum table. You see, whatever excitement we had about the process was taken to another level when we learned more about the donors as we watched one speak on video about why she decided to donate her body. Seeing her, I couldn’t but help think how much I’d of enjoyed meeting her. After all, she seemed rather friendly, quick witted, and rather friendly. So, on the first day when we dissected, I couldn’t help but wonder what the woman lying in front of me was like. Did she have a sense of humor, did we like the same movies (Groundhog’s Day, or anything with Bill Murray), did she have good stories to tell? But, for better or worse, in medical school you don’t have time to really “deal” with how you feel or else things would never get done. Then 3.5 months later, we’ve done a lot more in dissection I’d ever imagined possible or feasible — I also have a lot of new funny-awkward, and likely for you, disturbing stories and sights. It’s an experience.
The biggest shock about medical school isn’t how hard it is — well I take that back, it feels like we’re in
mental medical school bootcamp. It’s a new experience for most people in medical school, how hard it is and what it takes just to get an “average” score. No matter the institution, compared to their peers in college, most people who made it into medical school probably were on the right side of the bell curve academically. In medical school, that changes rather quickly and at best you’re like everyone else. That can either be intimidating or motivating depending on how you choose to see it. Conceptually, the course work isn’t very difficult. Instead, it’s just that you’ll cover a ridiculous amount of material in even one day, and you’re responsible for a ridiculous amount of more (but ‘different’) information the next day and so forth. Unfortunately, understanding will often take a back seat until you’ve remembered a large heaping of information that you must have ready at a moments notice for regurgitation. Then, if you’re lucky it’ll somehow all become clear before the exams, typically though as fate would have it expect it to be after the exams. I don’t have any grand stories to tell you about how to make this process easier, it’ll get easier because you’ll grow accustomed to it because of the consequences of not.
The biggest shock isn’t the difficulty of medical school, after all there’s rays of sun in back of the clouds. Instead, it’s the level of responsibility and trust thrusted upon us. Before, as a premed in the hospital, the most that was expected and allowed of me as to perhaps fetch water and if I’m lucky bring a stool sample to a lab. As medical students, one classmate has already intubated someone under supervision, another has done CPR for 15-20 minutes until the patient was announced deceased. Besides trauma, many of us spend time with either inpatient or outpatient hospitals or clinics around Boston, I’m placed at a community hospital and clinic. I suppose my capstone experience for this “course” was when the doctor just gave me her new patient, said get “Get a health history, after that we’ll do a physical” and left the room leaving only me and the patient. You may wonder why, out of all the things I spoke of being trusted with a history is so important. Well, it’s often said that perhaps 2/3 of all medical diagnoses can be correctly deduced from a good “health history”. It’s an interesting experience, while having a conversation with a patient, you try to extract information that might be pertinent to their health. This often means you, underhandedly, lead the conversation into a direction where the mountains are rich with information. If someone comes in with back pain, you lead the conversation in a way that their history might give enough clues to both elucidate and eliminate possible causes. If you ask too many questions in a rapid fire fashion the patients won’t communicate with you, or might just eject you out of the room. For example, here’s a typical exchange with patients as I go in blindly without seeing their history:
As introducing myself, and asking a few probing questions
Me: do you have any health issues or diseases?
Me: sorry, maybe I’m mistaken but when I asked about medication you said you’re taking X medication?
Patient: yes, I have diabetes but I’m healthy.
Me: oh okay (writes down diabetes)
Often a patient will just misunderstand what I’m looking for, or in this last case perhaps misinterpret the difference between having your diseased being properly managed and being free of disease. There’s insider information in medicine, just like how there’s insider information your car mechanic knows because of their trade. There’s also two of my favorite typical exchanges:
Me: do you smoke?
Patient: smoke what….?
Patient: oh, NO.
Me: so, what do you smoke?
Protip: to those not in medicine, your doctor or the medical student working with you doesn’t care about what you decide to inhale, or stick into any orifice. We care about you and we care about your problems and health, but learning of your addiction to prostitutes or meth isn’t a black eye in our book, it’s simply part of the puzzle of trying to get patients healthier. Fortunately, most patients are rather frank with the drug and sexual history, making presenting and giving a differential diagnosis easier to my attending (thank you), as long as they tell the right stories and we ask the right questions. You’d also be surprised to learn that the most important part of the visit is likely the last few minutes:
Me: okay,..(recite history back to them), do you have any questions?
Then as I’m walking out the door
Patient: actually, there’s one more thing…
As a rule of thumb, patients postpone the most embarrassing questions for the end, i.e. genitals not in tip-top shape, or the real reason why they likely visited that day. So, during the history, if you can help get this information from them earlier you can both save time (after all there’s a waiting room full of patients waiting) and that person may even receive better treatment. Once you realize that you’re wearing a white coat and a stethoscope therefore most people trust you with it gets easier to just ask someone about their safe sex practices, depression issues, or the hue of their bloody poo. Red feces means the bleed is more distal, i.e. near the anus, whereas dark (tarry) colors infer an upper GI bleed. Red feces is typically more innocuous than darker stools, and therefore all of my follow up questions are different. If you had fresh red blood in you toilet, I’d try to ask questions to eliminate dehydration for example — but the trick is that I can’t use the word dehydration in my questioning otherwise the patient would likely just respond “No” because their definition of dehydration isn’t the same as the medical one. At first doing all of this is really hard, to keep track of things so that you can lead the conversation towards trying to obtain a differential diagnosis, but it’s fun and we’re all getting better at it and I’m sure we’ll continue to. I’ve heard amazing things about some my classmates as well, and we usually swap our horror stories or goofs.
Some days are less fun, for example being there as you watch a physician try to communicate that maybe the patient won’t be okay, that cancer has moved faster than expected. Interestingly, you’ll have to move room to room and patient to patient, while not bringing the weight from each patient with you.
Differential Diagnosis Training
You may have wondered I brought up “differential diagnosis” as a new responsibility. One thing we learned really quickly is that the peking order goes, from highest to lowest: attending, resident, medical students. But, while being at the bottom of the totem pole, it’s still a team, and you’re expected to contribute a quick witted input or two from time to time. No, you don’t need to try to diagnosis someone with Kuru, but you should be able to understand that the bladder cancer patients cancer has grown and is now likely impinging on the nerves in the ischioanal fossa based on what the patient has recently told you about pain while sitting. You should be able to understand how the patient’s refusal to take Vitamin D while still taking their prescribed dosage of calcium explains why they’ve gone from osteopenia to osteoporosis. We have a course on how to do this, we learn how to research on diseases and how to integrate so that we may differential diagnose, it’s not a set of skills you’re expected to walk into medical school with. In fact, our final exam, was similar to an episode of House (without the grumpiness) where we got a brief paragraph and lab results and tried to differential diagnose a mock patient, our tools being a white board and a few other medical students for brain storming.
So, my first couple of months of medical school has had ups and downs, a lot of difficult times and exceptional ones. But, I enjoy the experience more than I’d ever imagine, because if anything my worst fear is abated: I’m never bored in medical school. As a classmate said today after we finishes our first semester, “I feel like a different person than when I started”.