Notable Quotables: SC

"You have to decide and ask yourself. Am I starting from scratch with this patient or am I merely laying a hand as they pass by ?" 

- S.C. [Psychiatrist]

An amazing attending I had an opportunity to work with during my inpatient psychiatry rotation once mentioned this in reference to a new admission that came in.  He made this distinction which really opened my eyes up to evaluating your role as a physician, I hadn't realized how much this can vary based on the context in which you are seeing a patient.  The outlook and management you would exercise in a patient who is routinely yours, one that you see in the office once a month who happens to be hospitalized for acute stabilization will be 180 degrees different from a patient that was brought to your hospital because thats where the ambulance came and usually receives care from an outpatient doctor 80 miles north of where you are.  

Notable Quotables: Sir William Osler

"One of the first duties of the physician is to educate the masses not to take medicine" 

- Sir William Osler 

If you haven't heard of Dr. Osler yet I would recommend clicking here to read a little bit.  He basically invented the idea of residency training and was the first guy who thought maybe medical students should get some bedside training and get out of lecture halls.  I think the sentiment of this quotation is fantastic, it really drives home the core of practice which shies away from the idea of overmedication and really medication at all.

Code 52

Names and other identifiers have been changed to protect the identity of all involved

"Code fifty two, Emergency Room.  Code fifty two, Emergency Room," blared over the loud speaker in the hospital.  Simultaneously a chorus of beepers went off, like crickets on a sticky summer day.

I glanced down at my pager that echoed the same message "CODE 52, EMERGENCY ROOM".  The same message flashed across the screen three more times as I ran quickly down the main hallway.  Code 52 meant trauma.  I was about to partake in my first trauma ever.  Dr. Shyer suddenly appeared from a small tributary hallway leading into the main one that led to the ER.

"Come with me," he said and I stepped in line behind him as we continued swift down the hall.  Dr. Shyer waved his ID card up to the scanner--this was followed by a quick beep and mechanical whir as the automatic door lurched open.  I felt the tail of my white coat brush up against the barely half opened doorway.

A small army had assembled near trauma bay one.  Slightly blurred through the sliding glass doors of the entrance I saw a flickering red and blue light quickly grow in size.  The sound of sirens broke me out of my trance, instead of the usual dopplering of the sound as it zoomed past, the sound grew from a distant whine to a persistent and ear shattering level as the ambulance pulled into the drive.

EMTs clad in all black uniforms with yellow block lettering brought him in on a stretcher.  A coordinated heave transferred his limp, seemingly lifeless body onto the ER bed.  A flurry of activity commenced.  Two large bore IVs were stuck to continue adequate fluid resuscitation.

"Single motor vehicle accident.  Car was wrapped around a telephone pole," I overheard a woman in all black say.

"We need a chest tube, now, " Dr. Shyer calmly stated, with the slightest thread of urgency stringing along behind his request.

"Someone get shears. I need shears now," a trauma nurse barked at her colleague.  There were hands coming from all directions, working on multiple things all at once.  Suddenly a tentacle shot out and sheared through what remained of his clothing.

"You! Have you put in a foley before?," Dr. Shyer glanced in my direction.  Of course I'd put in a foley, it was a requisite job of the medical student on a surgery rotation.  But in a fast paced environment where it might actually matter, no absolutely I had not.

Before I had time to respond a nurse threw a sterile foley kit at me.  It was like my body switched to a survival instinct driven place and I was on autopilot.  The countless times of gingerly placing the sterile glove pack on the table and practicing gloving without breaking sterile field paid off for me as I effortlessly gloved myself.

Break seal.  Sterilize with iodine. Lubricate piping.  Advance until a flash of urine.  Inflate balloon.

A stream of pale yellow slowly snaked its way through the piping.

Pete, the other student and I exchanged glances as I weaved out of the way and traded spots with him.  Just one beat was missed as I took over the rhythmic chest compressions, on a sardonic note, to the beat of 'Stayin' Alive' in my head as we had been instructed in CPR training.

The ER attending took a step back.

"Is there anything that we have not tried that anyone would like to try?" he glanced around the room and continued "I believe we have done everything we can.  Time of death 1346."

And suddenly the room  was empty.  We donned our white coats that had unceremoniously been thrown over the nearest chair back as we had rushed into the room.  I slowly reaffixed the flat, pearlescent buttons on the front of my coat, redraped my stethoscope around my neck, clipped my pager to the waist of my sea foam blue scrubs and waived my ID card to let myself out.

Notable Quotables: MH

"A lot of it is a process of elimination, but when you pick your specialty that better be a process of selection.  Pick something that really just turns your wheel. " 

- M.H. [General Surgeon]

Its dawning on me that I have about a year to figure out exactly what I want to do with the rest of my life. Sometimes people say things to you in passing that really stick with you so keep an eye out for more Notable Quotables, the initials just help to maintain anonymity but still allow me to mentally catalog who it was for future reference.

 Have any of your own from mentors, friends, family or famous folks?

Teachable Moments III: Harm Reduction

I happily trotted through the front door of the clinic and planted myself in front of the elevator waiting to go up.  Although many students complained that their preceptors didn't know their names or didn't acknowledge them my experience was completely the opposite.

Dr. Parker was fantastic.  Not only was I clinically useless but mostly incompetent but he never made me feel that way.  He was kind, he was warm and he had this way of being reassuring that not only gave you confidence in him but in yourself, just for under his guidance.

A long time patient of Dr. Parker's, we'll call her Maria, came into the office for the 3rd time to finally be given a clinical diagnosis of hypertension.  Her BP was off the charts (in retrospect probably it wasn't that off the charts because if it was it would have been malignant hypertension--see me dropping that M2 knowledge--and we would have called and ambulance to take her to the hospital).  The obvious answer here was to start her on some pharmacotherapy and then make sure we could assure some compliance to keep her within a healthy range.

Much to my surprised Dr. Parker turned to her and asked what she thought.

Maria responded, "You know doctor, I really don't want to take a pill.  I know its really high.  I see that, but that is just not something that I want to do.  What are my options?"

"Well if we can get you a little bit more active and check in for another BP reading and see if its declined maybe we can hold off on taking a medication," said Dr. Parker.

For the next ten minutes Maria shared that some ladies at work had been walking a few times around the block at lunch time and doing yoga after work two days a week.  Dr. Parker and her decided she would try to get on this regimen with them and if the next time she came in it was still elevated she would choose to take the medication.

In my head I was screaming.  She had high blood pressure! She needed to take medicine to bring that down otherwise . . . and that was when I figured it out.  Otherwise what? She had been walking around  with this pressure for a while another week or two wasn't going to kill her, but giving her the opportunity to make a lifestyle change could alter the course of her life, could save her.

Too many of us, medical students I mean, are the type of people that see a problem, synthesize a solution and implement it in rapid succession.  Slowing that down, breaking the solution down into incremental chunks is a challenge for me.  I had the opportunity to witness a harm reduction principle in motion, before my very eyes.  For those of you who aren't familiar with the term it is essentially the idea that when you're wresting with a very severe outcome from an adverse event, any small decrease in the adverse event is a great.  Allowing free needle exchanges for IV drug users in order to reduce the transmission of HIV and Hepatitis C by infected needles is a direct correlate of this public health principle.

Dr. Parker met her where she was.  She wasn't ready to take a medication but she was ready to discuss adding some physical activity to her life.  If that didn't work or she wasn't happy with that outcome he would be there to guide her down another path.

At the time I left the clinic that day I was still baffled as to why the so obvious solution was not implemented immediately--but after some reflection I realized that making the conscious choice to delay use of that solution exemplified far higher level thinking.

Teachable Moments II: Low incidence ≠ Low Importance

One of the most interesting aspects of second year is the team based learning components that are usually led by a physician who is a specialist on the particular topic we are studying (ie dermatopathology is taught by dermatologists).  These sessions are interactive and allow us to exercise some applications of the knowledge we have learned.  I really appreciate the higher percentage of MDs associated with our curriculum now versus first year that is very PhD heavy.  This isn't a criticism but rather an observation but is to be expected with a first year focus on basic science while second year starts to diffuse a serious clinical background into our learning.

While working through a patient case regarding some highly rare disease we all were disgruntled at the professor for having chosen something that was so unlikely.  One classmate raised his hand and voiced this concern: what's the point of talking about something that is so rare.  The professor's response to this is something that really resonated with me he said

"just because a disease is rare does not mean that it is rare for that patient"

It really hit me what those words meant and why we learn all of the minutia that we do.  Someone somewhere has this and if that someone happens to wander into my office I want to have the ability to help--to identify, to diagnose, to treat--with humanity.  Thats what got me, it was a reminder of the humility and humanity that is so quickly drowned out in a sea of lab values and patient findings.

When you step outside the house and its raining your first thought probably isn't welllll the chances of precipitation were only 25% so the fact that i'm 100% sure its currently raining is bothering me less.  To always be cognizant of each and every patient as a person, however cheesy and obvious that sound, is a principle I will strive to uphold in my career.

I have to admit that I never expected to be sitting in a classroom being lectured at and having that shape my clinical perspective, but it has.  Bringing physicians to us in a learning capacity provides us a tremendous asset in bridging the gap between book learning and clinical experiences.  That being said I think the most lasting and impactful lessons I am learning are when someone who has been a doctor for 30 years passes on a pearl like this one.  All day people teach at me how to read an EKG, how to differentiate between crackles and rales or how best to use an ophthalmoscope (left, left, left <-- more on that later) but what I want is someone to remind us how to do this while maintaining poise, grace and ultimately respect for the people who we serve.  I want more professors to remind us that becoming doctors doesn't gives us superhuman status, that it doesn't automatically grant us some kind of authority but instead we are being entrusted with an amazing responsibility.

for even more naive optimism and borderline preachy rhetoric see this old post

Teachable Moments I

**please note: names have been changed for reasons of privacy**

Finally, no more shadowing and awkwardly stumbling around while my overly dressed up self scrambled to follow a doctor from room to room, nope because I’m a medical student.  It was time for me to get assigned to my preceptor for the year!  If you’re as confused as I was about what that is let me explain: physician shadowing, except this time you get to wear a white coat and a stethoscope.

 As first year students we come equipped with a severe lack of any clinical knowledge juxtaposed with a strong desire to act cool in clinic.

 A memory I know that I will reference for a long time in the future, as a yardstick for measuring how I have connected with a patient and family is from a day that I spent in the hospital with my preceptor rounding on patients on the Family Medicine service.  The day was essentially over and he decided to go check up on a few patients before heading out for the day.  One of the last patients we saw was an older African American man who was recovering from a brain surgery after a severe stroke.  The following is my recollection of that encounter:

“Hi, I’m Michael Parker, I’m one of the physicians taking care of your loved one today”.  Can we stop right there? Have you ever heard a doctor introduce themselves as not doctor? I feel like by the time we complete all of our training we wear our title of doctor not as a badge of honor but rather a triumph.  Maybe it was unintentional, maybe not, but in knocking on the door and simply stating his own name he put himself at the level of the patient and his family.  It made him immediately accessible.  There were two women and one man visiting the patient and he was wavering in and out of consciousness.  He was not able to interact at all, at that point the doctor would probably not have much to do, right?

Dr. Parker took the time to introduce who I was to the family and ask if it would be okay if I stepped into the room, they were more than happy to allow that.  He then inquired about how the patient was recovering from surgery and the family related that they were unsure how he was doing because of the unstability of his consciousness.  

Here it comes, teaching moment for life.  Dr. Parke proceeded to relate to me how difficult it can be for a family when they are going through a recovery process from such a major surgery especially when the course of recovery can be so varied.  He addressed me but also engaged the family in the conversation and they could be heard expressing hushed agreements—“mmhmmm” and “that’s right”—and nodding along as Dr. Parker conversed with me.  He then turned back to the family who had been listening to him with rapt attention and asked them again if they had any other questions.  The woman sitting at the patient’s bedside echoed some of the sentiments that Dr. Parker had shared with me while the other family members nodded in agreement.

It was amazing for me to see how in such a creative way he was able to express the uncertainty of the situation for their loved one without robbing them of hope or giving a promise of too much.  By the time we were ready to leave the room the patient’s visitors were wishing me the best of luck in my career and relating that they had a niece who had similar aspirations.  Before we left Dr. Parker thanked the family for allowing us to speak with them and noted that someone would check in with them again shortly. 

The lesson I’ve learned from Dr. Parker is that we will have an urgent responsibility as physicians not only to treat patients but also to effectively interact with the environment around them. In that conversation there was nothing Dr. Parker did directly for the patient, but he reinforced the support system that will be vital to this patient’s recovery, something that is integral albeit indirectly to the patients health.  In that moment he transcended race, gender, age, ethnicity and socioeconomic status.

It is of great surprise to me to know that no matter how much we prepare and study it will only be with time and an active desire to improve that we will come close to delivering optimal care to our patients, I think I now have a greater understanding of why we practice medicine.