A Poem: USMLE Step 1 Boards Studying

Twas the month before Step 1, when all through the house
Not a creature was stirring, not even a mouse
The laptop was open, the questions studied with care,
In hopes that answers could now be found there

The cats were nestled all snug on the bed
while I reviewed flashcards; drugs-- please stay in my head!
Clover in his sweater, me in my sweats
going through USMLE World, multiple question sets.

When downstairs from a cat, arose such a clatter
I went down to investigate and see what was the matter
Nothing was there, a ghost perhaps?
or maybe I'm losing my mind after trying to remember SIGECAPS

Mneumonics, mneumonics, mneumonics and more
how many diseases can I possibly remember these mneumonics for?
Cysteine, SAM, carbamoyl -- it's all a jumble
I wish I had time to cook since my tummy is arumble

Antibiotics -- bacteria they kill
Can i remember their uses? I hope I will
Viruses, it's you I really hate
dsDNA, proteases -- oh! you really determine my step 1 fate

Now Albendazole! Now Metronidazole! Now Flucanzole and Diazepam
On, Clonidine! On, probenacid! on, on Indomethacin and Lorezepam!
Into my brain! side effects and mechanisms too!
Oh so many drugs, my mind is turning to goo.

First Aid with chapter introductions to quote
and phrases to help with memorization, rote
NBME practice tests, I only have seven more
Now I only hope I can significantly increase my score

I exclaim, as I study on, only more diseases in sight
"January 19th -- it will be all over!", and over it already, I am this night.

A Drop in the Bucket?

Today I attended a lecture on an OB/GYN physician's experience in South Sudan promoting and teaching family planning. She spent 4 weeks teaching local healthcare workers, midwives, and doctors everything from basic anatomy to how to implant an IUD. Her talk highlighted many of the difficulties in global health work such as financial obstacles, language obstacles, and cultural obstacles.

One hospital (term used loosely -- a few 1 room/1story buildings on the same property) where she worked didn't have much/any materials and medication. The hospital pharmacy and THREE small bottles of antibiotics. They didn't have sutures, speculums, or a constant source of power. If a family needed/wanted a c-section, they would somehow have to find their own supplies to bring to the hospital and hope that there is a doctor there who knows how to do it (not to mention traverse horrible, unpaved road for hours upon hours to get there)

Another barrier she faced was 1) the lack of education on why family planning is important (ex -- why can't you have 11 babies starting when you are 14?) 2) the acceptance of physical abuse as a form of aggression in households. This creates problems when you are trying to provide contraception to a women without her husband knowing (ex -- concerns about husband feeling IUD strings). She would have to start from scratch explaining how baby after baby after baby (especially at a young age) increases the maternal mortality rate and decreases the country's productive output.

Although her lecture was extremely informative and enlightening, I couldn't help feeling discouraged as I left. People like this doctor and my medishare team going to Haiti do their best to make a difference, but in the end, what is really accomplished? She left South Sudan with not a single medical professional up to competency to provide contraception (such as IUD and the arm implant). However, they are about a million miles closer than before she arrived and are continuing training in her absence. What about that hospital that can't even function due to lack of supplies? It just makes me really sad about the whole global health picture in developing countries. I know there are NGOs and non profits trying to fill the gap, but it almost seems like trying to put a bandaid over a gushing wound. What would happen if no one did anything though?

I guess I can only hope that all the drops in the bucket eventually add up to make a significant impact. I also know that I am extremely privileged to live in this country with all these resources available to me when I just as easily could have been another person born in South Sudan, seemingly without hope.

A Caveat on Psychiatric Diagnosis

—"If a man does not keep pace with his companions,
perhaps it is because he hears a different drummer.
Let him step to the music which he hears,
however measured or far away"

. -- Henry David Thoreau (1817-1862)

90 Seconds in Heaven?

Today was another eventful day in the Grady ER:

An elderly lady with a possible stroke, a middle-aged man who overdosed on tylenol in a suicide attempt, a young man in diabetic ketoacidosis because he can't afford his medicine for his diabetes, and lastly, the miracle patient who came back from the dead.

____

We got a call from EMS, "We're about 5 minutes away with a patient that is unresponsive and losing a lot of blood through the oropharynx(throat). We can't intubate him because he's clamped up." The physicians hurried into the CPR room to prepare the intubation equipment along with airway drugs (to paralyze and anesthetize the airway for intubation). As EMS wheels the patient into the room, the paramedic reports the patient lost about 2L of blood in the ambulance and went into ventricular fibrillation (vfibb) and they tried to shock him, but he was still in vfibb.

There about 10 people in the room at this time (interns, residents, attendings, nurses, medical students). Everyone got busy working on the patient. Someone cut off his shorts, the resident started a central line in his femoral vein, an intern started chest compressions, another resident worked on intubating him, another resident was getting an ultrasound of the heart, another resident was giving epinephrine injections, a nurse was standing by ready to shock when needed. People kept switching turns doing chest compressions. Every two minutes, they would stop compressions and check for a pulse. Every 6 or so minutes they would give a shock. After 20 minutes of working on the patient, the resident in charge of the code asked if anyone else thought that they could do anything to bring this patient back. No one said anything, and time of death was declared.

A chill ran down my spine. Through this whole process, I had been standing in the corner, trying to stay out of the way, watching everyone trying to desperately to bring this man back to life. I felt like crying (but I didn't). He was a stranger, yes, but the loss of another human life is hard.

As people were leaving the room, the resident I had been shadowing came over and asked me if I had any questions. As we were discussing the patient, we hear someone say, "He has a pulse!" With this, the activity in the room picked up again as the patient was ventilated and given more blood and fluids.

After having no pulse for about 20 minutes, the patient's heart had started to beat again on its own...a few minutes after he was declared dead.

12 Steps to Freedom

1. We admitted we were powerless over alcohol—that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
10. Continued to take personal inventory and when we were wrong promptly admitted it.
11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.

________

As part of the psychiatry/neuroscience II module, we are required to attend an Alcoholics Anonymous meeting. I went to one tonight about 10 minutes from where we live.

I was apprehensive about attending the meeting. I wasn't sure how to act and if I should introduce myself. "I'm Lindel and I'm not an alcoholic?" That didn't seem right. I didn't want to be perceived as judgmental. I didn't want them to think "Why is she here?."

As I walked into the building, I saw a room where a few people were gathering. Unsure if it was the right room, I stepped in and sat down. I then saw that everyone had the 12 Step Book with them and I was assured that I was in the right place. As I sat there waiting for the meeting to start, I was unsure of what to do. So, I started reading the 12 step book that was in the chair next to me, listening to the conversations around me, and contributing to them when I could (The extent of which was naming Simon as the third chipmunk of Alvin and the Chipmunks and remembering LaLa as one of the teletubbies.) Everyone was friendly and no one seemed upset that I was there. As I looked around, I was surprised at the amount and variety of people who were at the meeting. I had expected less than 10 people, and honestly, I had expected them to look...different. I'm not sure if I could have told you before this experience what I thought "an alcoholic" looked like, but I (ignorantly) expected them to be identifiable-- maybe a bit disheveled? looking like they've seen the harder side of life? I don't know. The people around me looked like people you would see in the grocery store, in church, at school. On other words...like ordinary people. I should have known better since I have a friend who is an alcoholic, but I guess I always thought that he/she wasn't your typical alcoholic. There were old, young, men, women, black, white, rich, poor....all different kinds of people.

The meeting started off with people around the room taking turns reading alternating paragraphs from chapter 11 of the 12 step book. This chapter/step is concerning prayer and meditation to gain the insight into God's will for you and how to accomplish His will. After the reading, people around the room would take turns giving their impression and thoughts of the 11th step. Some people spoke directly about how their thoughts on prayer and meditation. Others spoke about other issues tangentially related to Step 11. A lot of times, people spoke around their issue, never directly addressing it, which made it more difficult to understand.

Something that struck me was that no one directly spoke about their problems with alcoholism. Before anyone would make a statement, they would say "Hi, I'm ______ and I'm an alcoholic." However, none of them spoke directly about their problems with alcohol in the past, temptations they face in the present, or how they ended up in AA like I expected they would. It was a lot more focused on the individual step they were discussing for the night.

The meeting closed with recognizing people who's "anniversaries" of sobriety fell on today's date. There were two women -- one who had been sober for 1 year and one who had been sober for 5 years. The group then gathered in a circle, held hands, and recited the Lord's prayer.

This assignment really provided insight into who are alcoholics. By going to this meeting, I got the chance to see "the face" of alcoholism. It really can be anyone.

OPEX Reflections

Yesterday was my last day at OPEX (out patient clinical experience).

Yesterday I worked with Dr. X, a resident. We saw a wide variety of patients -- an 8yo boy with pink eye, a russian woman with migraines, a U.S. health service worker with an infected finger, and a mom wanting her 7 yo to be evaluated for ADD.

There were several things that struck me as we saw each patient--

1) It was so refreshing to see a child -- a talkative, friendly, outgoing 7yo boy at that. You don't realize you are missing anything working in a primary care adult clinic, but seeing that boy yesterday made the appeal of family practice care clear to me. You see a greater variety of patients. It was fun to take care of an enthusiastic little kid that talked about baseball, his best friend in school, and playing outside.

2) Cultural, communication, and social barriers. Our patient with migraines was an middle aged woman from Russia whose second language was English. My preceptor was also an immigrant whose second language was English. There were several times that I witnessed communication breakdown between them.

Dr. X -- "Was your head trrrobbing [throbbing]?"

Patient -- "What? No, I had a migraine."

Dr. X -- "you know? pulsating? what did it feel like?"

Patient -- "the pain was just on my right side"

Ai yi yi...and so it continued. The problem wasn't just the communication though. I really didn't like the way the interaction was going. Dr. X was acting very paternalistic and started lecturing her on how she shouldn't be taking ambien because it continues the insomnia cycle when she mentioned that she wasn't sure if she could take ambien and imitrex(migraine medication) together. Whenever she asked a question, he would continually interrupt her and say "now, listen to what I'm saying." Lastly, he kept touching her knee or her arm or hand when he was talking to her. Now...I like my personal space, and I know if I was that patient, I would have felt very uncomfortable about the doctor continually touching me while we are speaking. Ultimately, the doctor had the best intentions -- he wanted to educate the patient and help her get control of her migraines, but the approach was not for me.

3) The ADD epidemic. It is well known that ADD and ADHD are over diagnosed in children in the United States. It is no joke to put your kid on medication for life not to mention the psychological impact of "you have a disease that makes it harder for your to succeed" on the child. One of our patients was a mom bringing in her young daughter for ADD evaluation. She kept going on and on about how her kid refused to focus and how whenever she found something difficult she just quit or how she puts the wrong answers because she gets impatient with working out the problem. This child may very well have ADD, but I didn't like the way the mom was talking about her own child with the girl right there in the room. It just felt like she was being attacked and being told that something was wrong with her. It bothered me.

Looking back over the last year of OPEX experiences, I have learned so much. I can take a history and do a physical with ease now. I can come up with a differential diagnosis and a treatment plan for patients. I've seen the application of lecture material in real live patients over, and over, and over again. It has been a great experience and I am so glad that it is part of Emory's curriculum.

The Power of Positive Thinking

This week we have been learning about movement disorders in our neurology module. We've had patient interview almost every day, which has been great. The patients we had with Huntington's Disease and Multiple Sclerosis particularly impressed me. What stood out about them was not their severe, lifespan-shortening disease, but rather their positive outlook on life. Seeing these patients struggle to walk and move and describe their cognitive decline is difficult. It makes me sad for them, and I think about the struggle they and their family must go through. Yet, both of them were happy.

The multiple sclerosis patient was jovial and joked around with us during the interview, making fun of his doctor from New Jersey with a few Jersey jokes. "Did you ever notice the Statue of Liberty is facing AWAY from New Jersey?" and "Did you know they charge a toll to go out of New Jersey to New York, but there is no toll to go in?" At the end, he simply stated "There are people worse off than me. There are people going to bed starving every night. I think I'm ok."

The Huntington's disease patient described the judgement she encountered at the National Huntington's conference about having a child, and she said "I have ENJOYED my life." ...even having Huntington's.

I have so much admiration for these patients. I don't know if I would be able to keep a positive outlook if faced with such an incredible challenge.

"17 Degrees Ain't Nothing"

I am part of the planning committee for Homelessness & Healthcare Week that is happening this week at Emory. Last night was our first event -- a documentary screening of "17 Degrees Ain't Nothing" followed by a discussion with the filmaker and formerly homeless individuals. The documentary is about a group of homeless individuals living in an abandoned warehouse in Atlanta.

There are so many misconceptions and stereotypes about homelessness, and when we asked the formerly homeless men what they wanted us to take from the discussion -- they said to approach every homeless individual with an open mind, without stereotyping them first.

There are so many different reasons why people become homeless. For example, when I asked Joe* how he had become homeless, he proceeded to tell the audience the incredibly moving story of his life leading to homelessness. Joe was a proud, productive entrepreneur. He had just launched his own business when he had a debilitating stroke. He unfortunately didn't have health insurance and his hospital bills cost him his life savings. At the time, Joe had been in a relationship with a women for 15 years. They had a son together. After Joe's stroke, his partner started becoming verbally and physically abusive. As his caregiver, she would neglect Joe. He couldn't go to the bathroom by himself, and she would just leave him. Joe struggled with this because he knew he was in a bad situation, but he didn't want to abandon his son. After several years of the abuse, Joe knew he couldn't live there anymore, and he decided to leave even if it meant becoming homeless. Joe didn't have anything and he didn't know anything about living on the streets -- there is no guidebook to being homeless. It can happen to anyone.

________________

Day 2

Today we had a lunch time discussion about mental illness in the homeless population. As an introduction to the issue of homelessness, the lecturer presented some video/audio clips of how homeless individuals are treated in our society. There was the video of the "bum hunter," a spoof of the crocodile hunter where a man would sneak up on homeless people, tie them down, and try and force them to fight each other. He was doing this to other HUMAN BEINGS. What has our society come to that people think this is ok? Another homeless man on NPR talked about how "Friday nights were the worst nights to be homeless" because drunk teenage boys would pee on him, beat him up, and treat him like trash.

It just really saddens me that people would treat other human beings as less than human. They might have made mistakes to end up homeless or maybe just landed in a really unfortunate situation like Joe, but they are still people who should be treated with compassion and respect.

*Name changed

Untold Stories of the ER

As M2s, we get to apply for an elective for the next few months. I am in "Thrills and Spills" -- where you get exposure to the ER and learn new techniques such as intubation, IV placement, and suturing. Exciting!

I started shadowing this week -- first Grady (Blue zone) then Emory Midtown. Two very different experiences.

I LOVED my time at Grady. I was working with the residents, seeing patients, high energy (while simultaneously laid back?). It was great. At midtown, I was placed in the "red pod" which is assigned to the more intermediate cases -- abdominal pain, dizziness, etc... I was also working with an attending, which created a different environment.

Among all the craziness, the thing that struck me most was patient relationships. Both at Grady and Midtown, there were specific couples that just struck a cord within me.

At Grady, an 65yo woman was rolled into the ER because she was in pain and extremely hypotensive. IVs needed to be started on her immediately. Her husband was with her, and he was SO worried. As the ER attending was rapidly firing questions at him about his wife's medical history, he tried to answer the best as he could all the while shooting concerned glances over to his wife moaning in pain on the ER bed. As she screamed while the IVs were being placed, he had to leave the room-- I think it was too much for him. You could just see how much he loved her and how much he just wanted everything to be ok. His wife had a history of MS which even further showed his dedication and love to serve as a constant caregiver to a patient with a chronic condition.

At midtown, a 60yo woman came in for dizziness. Looking up her chart beforehand, I read her history -- "hepatitis C, liver cirrhosis, coagulopathies, double leg amputation after car accident in the 70s, severe dystonia." -- this lady again was a chronically ill patient. As I walked into the room to ask her about her dizziness, her husband was sitting there was well. He helped to answer questions that she couldn't -- filling in the details of her medical history. She was easily agitated and severely debilitated by her dystonia-- not an easy patient to care for, but again, you could tell how much her husband loved her, patiently staying by her side as her loyal caretaker.

Seeing these patients just reminded me of how much I love Ben and how it would break my heart to see him sick or in any kind of pain -- really giving insight into the patient's family perspective.

Passing the Torch

Tonight I met my "little sib." Emory assigns each of the incoming medical students a "big sib" to act as a guide/mentor/friend/whatever you need to the M1. It's a pretty nice to have someone to share their wisdom about medical school life because it's a pretty big adjustment, and you are freaking out about what you're doing for about the first 6 months.

I remember meeting my big sib last year and getting a follow-up email from her full of valuable advice -- overwhelming at the time -- but great to refer back to throughout the year. It's such a strange feeling to now be the "big sib"-- the wiser, older med student who has been through it all and is now giving advice to the "new generation."

I remember how advanced in their knowledge base and confident the M2s seemed last year. Am I really that M2 now? Looking back, I have learned an INCREDIBLE amount in this last year -- more than just facts and disease algorithms -- I have started to feel a little bit more comfortable in the doctor role, I have adjusted to the level of information we have to shove in our heads, I have learned to balance school with Ben, family, friends, and other interests.

Hard to believe a full year has passed and I am that much closer to becoming a doctor.

Walking a Mile in Someone Else's Shoes

Today we pricked our fingers to find out our blood glucose levels. Then, we gave ourselves subcutaneous shots of saline (instead of insulin) to mimic what diabetic patients have to go through every day...multiple times a day.

The worse part is definitely pricking your finger. I now understand why patients don't want to do it that often. I had to prick my finger twice because I pulled the lancet away too quickly (because it hurt!). I think the automatic lancets are worse than just having a needle you can poke yourself with -- there is definitely an increased level of anxiety as you push that button. There is also anxiety as you wait for your readout. Will you be in normal range? I felt anxious about it and I don't even have diabetes (my fasting glucose was 84, so need to start worrying quite yet). The needle for the insulin shot, however, is so tiny that I barely felt it when injecting myself -- definitely not as bad as I expected. The nurse told us that even some of the really young kids can inject themselves by the time they leave the hospital after their training.

Just a small slice of what life is like as a diabetic...

Highs and Lows

There are days where I feel so confident in my abilities and my future in medicine -- bring on the next patient, let me place an IV, let's do that pap smear-- and then there are days where I think "Oh, crap! I'm going to be doctor soon, what am I doing? A pap what?"

So here are few of my highs and lows over the last few weeks:

High: Taking a sexual history, doing a pelvic exam, pap smear, and STD test on a young female in the free women's clinic at Open Door.

High: Seeing a super friendly 50 year old male at OPEX and being able to provide health maintenance counseling. He had been diagnosed with melanoma and had focused on treatment for the past 5 years. Now that his melanoma was under control, he wanted to know what else he should be doing for his health. Being able to give advice re: immunizations, colonoscopies, EKGs, physical exams, and prostate exams = totally within the realm of things I can do.

Low: Learning how to do pelvic exams with standardized patients. Awkward contrived setting. Unsure of role (am I doctor or student? Is this women patient or teacher?). Conflicting advice from teaching doctor and standardized patient. Being corrected before having the chance to correct myself. Just...overall yucky feeling of incompetence.

Low: First physical exam under supervision of OPEX preceptor. Patient -- 26yo male coming in for yearly physical. Here is the thing...whenever I see patients close to my age, my confidence skips town. I feel like 7 year old playing doctor . The ease of taking a history slips away, the physical exam becomes a series of steps you have to memorize instead of a natural compliment to the history. Now, I didn't do terrible. I asked the right questions, I heard the regular rate and rhythm of his heart, I saw the clear tympanic membranes. BUT, it was uncomfortable. I know it, he knew it, and my preceptor knew it.

High: Knowing my crap about diabetic patient management and diabetic ketoacidosis in small groups this week. Maybe I do actually know something...

From the First Cut to the Final Goodbye

A few weeks ago, the anatomy faculty hosted a memorial service to commemorate those who had donated their bodies to further our medical knowledge.

The ceremony opened with "Amazing Grace" being played on the bagpipes by one of the students (none other than my anatomy partner). As the notes bellowed through the chapel, we all sat reflecting on the time spent with these cadavers in the anatomy lab. I remembered how I felt sad and strange after the professor made the "first cut" into our cadaver, the first time turning our cadaver over and seeing his face, holding his hand for hours on end as I worked to find those small muscles, arteries, and nerves of the hand. I remembered how grateful and, strangely, proud I felt that our cadaver had such large, well-preserved muscles and (relatively) little fat. I remembered how somehow our cadaver had escaped being shaved before donation, and little hairs would end up all throughout our dissection. I remembered the awe of holding his heart in my hand, the fear of puncturing his intestines, and the satisfaction of finding that nerve/artery/vein/lymphatic vessel after hours of searching and meticulous dissection. I reflected on all the time I had spend with our cadaver and how much I had truly learned.

Other students read poetry, sang songs, gave spiritual reflections, and told stories. We lit a candle and laid down a flower for each cadaver, silently thanking them for providing us with such an enormous gift, their own bodies, so that we could learn from them and use that knowledge to become the best doctors we can be.

Bringing Medicine to Life

One part I really like about our curriculum is the frequent exposure to real, live patients.

For each module we have studied, we've had at least 1 patient who comes in and talks about their experience with a specific disease relating to what we are studying.

We started Endocrinology and Female Reproduction this week, and we've been lucky enough to have a patient every day.

Today's patient, Mr. X, came into the room, eager to tell his story. He starts to tell us how he suffered from high blood pressure for the past 4 years and how he had frequent episodes where he felt like he was in "the twilight zone" with a blood pressure measurement of 260/140 +. During these episodes, his whole body would tingle, his vision would go black, or color would be intensified. He described it as "If I was having an episode and came up on a red light, the whole room would have a red glow to it." He kept going back to his primary care physician, only to have his blood pressure medications changed or increased...without any significant impact except to "make me more irritable."

One part of his story really touched me when he was talking about being at his daughter's softball game, having an episode, and rushing to the doctor's office with his wife and daughter. "At one point, I guess I blacked out, and when I came to, the first thing I saw was my daughter crying. She is 21 and all, but she was just worried about her dad you know?" In that moment, I could completely understand being a daughter scared for your dad, and it just made the patient's story that much more touching.

Eventually, Mr. X was referred to the right doctor who picked up that he had a pheochromocytoma. He ended up having surgery and is doing very well after surgery. Going from 12 blood pressure medications a day to...TWO with a regular blood pressure of 120/80.

International Medicine

I returned from a medical trip to Haiti a little less than a week ago. I went through an organization called Project Medishare that aims to provide access to healthcare to the people of the rural, central plateau through local clinics and mobile clinics set up by international volunteers, like us.

I have been on a similar trip before to Costa Rica and Nicaragua, and both times I was struck by the EXTREME poverty around me. How much can sporadic primary care change the lives of people living under a faulty social structure? Although there may be a fairly constant stream of mobile clinics coming through somewhere close (and by close, I mean within 60 miles) to their vicinity, it's not like they have the same doctor who knows their history or even a different doctor that can look up their past medical history in a chart. Every time they see a new (most likely foreign) doctor, they have to start all over -- building a relationships, recounting their symptoms -- all through the barrier of non shared languages. Yes, translators help -- in fact, they are essential, but it's still not as good as being able to speak to and understand your patient.

It's an internal struggle doing international work -- am I really making a difference? Am I providing an essential service? Am I just doing this to make me feel better about myself? Am I doing more harm than good -- prescribing medicine without follow up, without knowing if the patients knows how or why they are taking their medication? I'm not the first person to face these struggles, there have been journal articles examining the effectiveness of international medical work, and even the different articles can't come to agreement-- are we doing something good or bad?

After my experience, I would say we aren't doing anything bad, and we are actually mostly doing good, AND occasionally, we're even doing something life changing. The medications we prescribe and give to our patients are mostly drugs most americans can get over the counter -- pain medication, antacids, multivitamins, etc... There is the occasional antibiotic, but honestly, antibiotic prescription abuse probably occurs more in the US than in Haiti. The doctors are very careful about prescribing anything that needs follow up --ex: anti hypertensives. And yes, it is hard to tell with a lot of the patients if they are actually sick or just describing the symptoms they know will get them the medication they need for when they really are sick and the american doctor isn't there. But when I think about it, so what if they are faking it? They are doing what they need to do in their circumstances. If I didn't have regular access to medicine, I'd probably do the same thing -- why not get some medications and get seen by a doctor while they are there? Also, I think having the doctor look at you and say "Your physical exam is normal" can provide a lot of psychological benefit.

The "life changing" patients -- the ones that have decompensated heart failure, glomerulonephritis, severe infection, early stage dementia, failure to thrive, or AIDS -- that maybe 1-3% we see, we can help them. We might not be able to be the hospitalist administering their care, but we can make sure they get that referral, that money, that transportation to get to a hospital and get taken care of.

And you know what? that 1-3% makes it completely worth it.

Patient Autonomy

When I was in clinic today, my preceptor (Dr. M) told me about a patient he saw last week. An 86 year old man came into the office with his son and daughter because of altered mental status. His children reported he has been getting progressively more confused and the patient could barely stay alert during the office visit. At one point, they had given him coffee to try and help him stay awake, and he felt asleep holding the coffee, ending up spilling it on himself.

Altered mental status in an older patient is never a good sign, so Dr. M discussed going to the emergency room with the family. The patient was insistent that he didn't want anything done to him and he certainly didn't want to go to the emergency room. Dr. M and the family compromised and decided to do blood work in the office that day and set up an appointment to get a CT scan the next morning (to rule out stroke, etc...)

The blood work came back the next morning with HUGELY elevated liver enzymes and some other minor elevated electrolytes. Dr. M immediately called the daughter to advise them once again to go the hospital. He even arranged for a hospitalist to admit them directly, so they wouldn't have to wait in the ER. The daughter said the previous night had not gone well, so she would discuss it with her brother and father. She later called Dr. M back that day to tell him her father had passed away, not wanting to go to the hospital.

This story bothered me. At the core of it, lies the issue of medical ethics. One of the four pillars of medical ethics is patient autonomy -- you can't make a patient do something they don't want to do, but as their doctor, you feel a certain level of responsibility for their well being. So what do you do? Can you force someone to go the ER? If someone has resigned themselves to death, but you know there is an easy way to save them, do you just let them die? I think it's one of the bigger lessons in medicine that I'll have to learn -- to accept that you can't control everything, sometimes it's the disease and other times it's the patient's will.

Becoming comfortable with the uncomfortable

Today we learned/performed the male GU exam. An important exam, no doubt, but an uncomfortable one for the patient as well as the doctor sometimes. The male GU exam involves examining the genitals, feeling for hernias, and doing a digital rectal exam to check the prostate.

It was a lot easier/less awkward than expected.

First of all, our standardized patient was fantastic. He was completely comfortable teaching us how to do a proper exam, and I think his comfort level put us all at ease. Any man that is willing to go through 8 consecutive prostate exams by first year medical students is someone who really cares about us learning for sure. It was really helpful to have instantaneous feedback regarding our exam technique (too much pressure, too little pressure, try a different angle, etc...)

Afterward, we had a "debriefing" session with the urologist where we discussed how to handle different patient reactions during the exam (he's had people get so nervous that they faint), which is also a really important aspect to think about.

I have to say, it is SO nice to have the first male GU exam out of the way-- probably one of the most awkward experiences is past.

P.S. Heading out to Haiti in 4 days -- so crazy!

Firsts

Today was...exciting.

I did my first pap smear.

I drew my first blood sample.

I did my first IV line (ok, so that one was on a simulation mannequin)


I volunteer at the low-income health clinic fairly regularly, but I never have the confidence/comfort level to volunteer to do any of the more procedural based activities (pap smears, blood draws, etc.). I don't really know what was different today, but I said yes whenever someone asked me if I wanted to try something new -- and it was awesome!