Sorry, I’ve been busy lately. I’m sure a lot of people have, premeds are applying for medical school right now. Newly minted MD’s just started their internship year last week. Right now, medical students are doing a variety of things with their ‘last’ summer. For myself, and many others, it’s clinical research. During the school year, I was sort of in an emotional rut. Medical school is really rewarding, but it’s also very taxing on your interpersonal relationships (with people not in medical school). For, example when my cousin died of terminal cancer I couldn’t find the time between exam blocks, less lose momentum, to fly back to California and then back to Boston while juggling exams. Instead, all I could do is use the “training” I was given on consoling families and patients over the phone — it was surprisingly effect. After a while, I just felt buried under classwork and charts to memorize, reviewing membrane potentials, memorizing what phosphorylates what, how many blocks your kid should stack by age 3, and learning just why everyone despises (and rightly so) the trigeminal nerve. My best time during the first year was spent with patients, it was the time that I felt pretty happy. So, I decided a while back that instead of lying around in my depression cave, I’d instead spend my summer with patients — to be more particular with patients who have heart problems, getting me closer to the sun (cardiovascular disease has killed many in my family).
Lately, it’s been Monday-Thursday ambulatory cardiology (research), with the occasional Friday mornings tagging along with the cardiology team for their rounds on the cardiology wards — I’m the most inexperienced out of the team: a 3rd or 4th year medical student, two residents, one cardiology fellow, one attending, and a pharmacist. Rounds are a staple, especially at teaching hospitals, and it’s worth noting now that rounds will be however the person in charge allows it to be. The rounds of my experience are straight forward. Someone, a resident or medical student assigned to the patient. The person who has that patient does the presentation. The presenter will give a ‘quick’ history and feedback: chief complaint, pertinent history (health and social), details in labs/scans, and pertinent negatives (helps with differential diagnoses), most likely diagnoses, and finally management strategy. Labs and scans are brought up on computers on a cart, the attending or fellow typically asks a few more questions about things that weren’t clear, or specific findings on transthoracic echocardiogram or ECG. Finally, once everyone (the attending) is satisfied the whole team does the ceremonial hand sanitization (or the occasional sanitize then glove) and enter the patients room.
The most interesting part is that, you never know who you’ll see in the room. It might be a widowed grandfather and retired mechanic, a former nurse, a an inmate cuffed to the gurney with their guard escorts — sometimes you see the worse, people who remind you of people you know and those younger than you. Patients are remarkably tolerate of rounds, unfortunately many of them are probably used to it by now because they’re hospitalized so much. The chief complaint and history are then again discussed, this time with the patient being able to put their input in. Unfortunately, not every patient takes advantage of this period, perhaps patients don’t know medicine is moving away from paternalism and inviting the patient into the mix. I’m not really sure, but there’s a variety in patient responses and their levels of health literacy. As such, there’s always a variety of outcomes for this patients. Some outcomes are good, like being discharged on a false alarm via an occult finding. But, often it’s not very good news. The strange thing about news is that, good news is easy to comprehend for patients while bad news is typically not. You can give the exact same explanation to a patient with identical diseases, one patient will suit up to fight the big fight, some will be underwhelmed and tell you they don’t have time to sit around in the hospital bed over the weekend.
In contrast to the inpatient service, these patients are doing leaps and bounds better. When I see patients here, I leave my white coat and stethoscope and home. When I see patients in this capacity, we’re one on one and we speak for 30 minutes to an hour and a half (all depending on the patients verbose nature). I appreciate this time, because unfortunately I’ll never get to speak with patients for so long later when I actually am a doctor. Because of the nature of my research project, we end up really diving into their lives. In a medical setting, it’s rather astounding what people will tell you in confidence. We discuss their disease, we talk about their medications, about their living situation, their ambitions and goals. Part of my project involves a chart review (which I currently should be doing), but beforehand I tend to not look at the patients chart except to screen them for the study. This strategy only works because I do not have to worry about addressing their concerns or treatment. I like to hear from them first, before I bias my recording of their answers with my assumptions. Though, for more difficult interviews I need to pull up their chart to make sense of things on my notes mid-interview. I’ve learned some interesting things from patients:
1. Some patients confuse their lack of symptoms, thanks to treatment, as lack of disease
2. As a consequence of the first realization, some people skip their medicines intended to be taken on schedule because they “Don’t need it as much”
3. Some patients actually have no idea what they have, even if it’s been diagnosed for years
4. Patients often don’t make lifestyle modifications because the seriousness of their situation isn’t understood (e.g. some people have no idea they were hospitalized just 3 months prior due to heart failure)
5. Some patients are remarkably on top of their disease management, and it’s immediately obvious “who” does after learning who (at the same age and income level) can still make it up a flight of stairs or watching an elderly gentlemen prove his health by performing exercises
6. Some patients come with their family in tow, it’s likely a cultural thing. I like it, it can make some parts of what I need to do more difficult (getting the patient to answer without bias or outside input). It also makes some things easier, especially since some symptoms are better observed by others than by one’s self
7. People grow accustomed to not being happy, and start to find that the new normal. As a consequence, when I try to learn about the negative things in their life, they put things in relative terms, and give me a cheerful interpretation to an otherwise bad situation. A lot of them just chalk it up to getting older. Sometimes it is simply normal wear and tear, sometimes it’s just life catching up with them, and sometimes people are just unlucky
Oh yes, there’s one more cool perk about this gig, like drawings from patients:
Report on Patients and Journal Club
So, my research mentor for this project is an attending physician. My partner and I work together to update them on our progress, or lack thereof, and we make suggestions on what we can tweak on our process to make things better. I’ll take the time to say that the success and enjoyment of research is chiefly based on your team, I’m lucky my partner and my mentor became (I’d like to think) good friends and work well together. Once a week or so, we meet to discuss the research articles in our niche of cardiology. My partner and I take turns leading the hour long discussion, spending an ornate amount of time with the statistical methods and research design. Part of my scholar program requires me to help run an undergraduate version mid week, so I also help with that as well (these presentations are about 12-15 minutes each, and fortunately I don’t need to present in these anymore). The undergraduates in the program are impressive, I think there were 7,000 applicants and they selected 12 or so. I admire their ambition. Technically, I’m one of their co-mentors, though I’m not sure of how good of a job I do with that — I’m not exactly dripping with wisdom.
It was a good experience to go from ambulatory to inpatient, especially in broadening my understanding of the patients’ story on cardiac disease progression (both in physiology and seeing learning to see past their diseases). It’s too early for me to say I’ll definitely be a cardiologist, but let’s just say it’s the leading the specialty decision race. Either way, I suppose, everyone has a heart. So, it’s going to be useful to learn these lessons now. I’ll probably forget them later, but I think it’s better to have know and have forgotten than have never known at all.