"Rounds"

Have I mentioned before that I'm not fond of patient rounds?

Some rotations I've been on consist of half your time in "rounds," a quarter of your time in "sign-out," and the rest split between conferences and patient care. (I know, rounds and sign-out technically are patient care, but they hardly feel personal to me...)

It's no wonder residency programs have to keep their residents over night every fourth night. When else would work get done?

By the way, "rounds" is when a team of students residents and an attending physician walk around on the ward updating each other on patient status. "Sign-out" is when one team tells the next all of the details from the patients' care that day.

If...

If I didn't have sensitive hands...
If I were 5 years younger...
If I wasn't married...
If I could be content doing one thing at a time...
If I could put up with the hierarchy just a little longer...

I would totally pursue a career in cardiac or vascular surgery. In its favor is:

The 'get in there and fix it' mentality,
The meticulous microsurgery,
The dependence on bioengineered technologies,
The adrenaline of cutting open the aorta (on purpose), and
Working on a team.

I suppose I can find those things and a lot more elsewhere. Well except for the cutting open the aorta part...

Diagnose This!

You're a student on rotation at an academic medical center's walk-in clinic. A new patient presents with a one week history of pruritic 1-2 mm diameter vesicles and evidence of excoriation on the extensor surface of both hands that is most prominent between the metacarpophalangeal joint and the dorsal crease of the wrist. There are also some lesions at the proximal nail fold and distal phalanges. The interphalangeal skin and finger webbing is largely spared, except for the area surrounding the left 4th digit. There is no palmar rash. Upon closer inspection, the lesions have a diverse morphology, ranging from non-erythemetic fluid-filled indurated vesicles to bright red papules with a 3 mm diameter border to small salmon colored macules with crusted centers. A thorough skin inspection yields no other rashes. Complete physical exam is unremarkable except for dark circles under his eyes. The skin finding is shown below.

Further questioning reveals that this patient has developed irregular sleep habits over the past several months and has several other new stressors in his life, including physical relocation, new responsibilities at work, looming deadlines, personal grief, and a perception that his future depends on every daily task. He does report several adaptive behaviors to help manage this stress, including creative outlets that use all ten fingers... The rash has been refractory to cortisone and triamcinolone, and Actifed helps a little bit with the itching. He seems resigned to this condition, stating that his position will change in about a month.

After consulting your attending, you recommend which of the following therapies:
A) Bed Rest
B) Solar Therapy (Specifically In Zihuatanejo)
C) Desoximetasone Baths
D) Cutting Back On The Alcohol

Oh, I almost forgot: What's your diagnosis doctor?

Hit the Wall

These days, there's a new one around every corner. Just when you get the hang of something, bam, there's another one to climb. Studying, scheduling classes, seeing patients, sleeping. There's always a new challenge. If you have any tips on that last one, I am accepting suggestions.

Student Work Hours

If you don't want to read another complaint from another medical student, stop reading now.

You've probably heard somewhere along the line that medical residents are limited to 80 hours a week and no more than 30 hour shifts.

Medical students often have the privelege of working more than that. Remember that we are not covered by any work hours restriction.

I am in the 3rd week of my inpatient medicine clerkship. Here is my 'required' schedule:

Monday 6:30 AM to Tuesday 1:15 PM = 30.75 hrs
Wednesday 6:30 AM to 6:00 PM = 11.75 hrs
Thursday 6:30 AM to Friday 1:15 PM = 30.75 hrs
Saturday 6:30 AM to Noon = 5.5 hrs

What am I complaining about? Our total hours adds up to 78.75 - plenty of room before the 80 hour limit, right? Subtract out the 3 or 4 hours I get when I am on overnight, and that puts me at 71.5 hours. What am I complaining about?

If I want to have my patient progress notes written in time for rounds, I need to check up on my patients in the morning. Sometimes I'll get in at 6:00 to see a patient so that I'm ready to present my three patients at rounds.

What I don't like is that I need to study, too. That will have to wait. In the end, I'm lucky to be in medical school.

Surviving Overnight Call

There are probably numerous anecdotal reports out there about how to survive a post-call afternoon. I am too delirious to do the work of finding and/or categorizing them right now. Anyone have any tips?

For those outside of medicine, post-call is the afternoon after you were up most of the night caring for hospital patients. My two previous rotations only required me to stay at the hospital until midnight. Inpatient medicine is another story. I am at the hospital for 30 hour shifts twice a week.

While I am in the hospital, I'm pretty sure my cognition is around my baseline. I cannot however say that I am used to being post-call yet.

The first time I pushed through the afternoon with caffeine, went to bed early and woke up groggy at 3 AM. The next experiment involved cutting the caffeine at 10 AM (I am on until 1:00), taking a brief nap when I got home, exercising somewhere in there and then going to bed at a normal hour. In those cases, I got 4-5 hours in the hospital sleep room. Last night, I only got 2-3 hours. I promptly crashed for 3 hours when I got home, completed a rather lame attempt at a workout and now am still awake...

I have tried to eat my regular 3 balanced meals, but when you are up for strange hours, I think another meal or snack needs to be thrown into the mix. We must also consider the regularity and balance offered by hospital cafeteria cuisine.

Anyone out there have any tips? You should know that I have a celebrated history (as an undergraduate) of conducting all-nighters without much difficulty or consequence. I haven't decided if my difficulty these days is that I'm 1) out of practice or 2) old.

Evidence Based Obstetrics

One of the great things about blogs is how a post about one topic can quickly morph into a good discussion about another. I bet early meetings of Ben Franklin's Junto (or later the American Philosophical Society) were similar to what happens when a good discussion gets hijacked by a barely related intriguing idea.

Anyway, Drugmonkey posted an informative update about the current presidential candidates' positions on science. If there is one topic that has been wrongly overlooked by candidates this election season, it is a proper airing of their perceptions about science and health research funding, the role that science should play in public policy decisions and how science education can be improved. Head over to this DM post for a digest of Science magazine's handling of the candidates' positions on science. Within the comments thread, is a sub-discussion about the lack of scientific evidence for the choices obstetricians make during delivery. The specific question that I argue has no scientific answer to is: Do fetal cardiac decelerations necessitate Caesarian section? I admit: the left turn was kind-of my fault,but my appeal to you, dear reader, is to find your way to this thread and chime in about the role of evidence in Western obstetrical care. (Read about the candidates' views, too!)

I have a love-hate relationship with the current emphasis on 'evidence based medicine.' It is certainly indicated, even needed in many cases. Enough of the studies are poorly designed or in conflict of interest, that it is hard to change a policy because some perspective made it through peer review. I suppose I would advocate a slow transition to evidence-based practice. Meta-analysis means more to me as a mode for medical decision making.

But bringing this full circle, what does it say about the role of science in society that one of the areas of life that is perceived of as being influenced the most by science (medicine), is actually not very scientific? If science cannot be practically applied to medicine, or more specifically birth, can it really be applied to policy decisions? It's not like there's any shortage of research material.

Impersonating an MD

Here's an important quiz for you:

Which of the women below is a doctor? Which is a medical student?

Try not to pay attention to the body language in making your decision... If you're stumped, consult this introductory review.

Sometimes I wonder how much of medicine is just show. Good luck not being stopped by a nurse between the stairwell and the patient's room if your wearing just a shirt and tie. (Actually, I prefer an evidence based wardrobe: tie free and proud.) The appearance of physicianship causes people to hold doors for you, gives you wide berth in the cafeteria, and leads toward more held elevators than I care to list. I almost feel bad making those passengers wait for me as I turn in to the stairwell.

Get to the point, Robey!

Today I left the key to my hospital locker at home. This forced me to make a temporary wardrobe change. Not many med students serve at this hospital, and few of the staff are as large as me. There is a rack of clean guest coats in the residents' locker room; I was lucky to snag one labeled 2XLT. So until the program assistant was able to lend me an extra key, I wore the mantle of a resident. Not only did this coat fit better, it looked good. (Please apply your best girlfriend language to that last phrase.) If you think medical students' white coats look funny down to the hips, consider what it would look like down to the belt. Yes, it is that bad.

Anyway, by 8:00, the administrator had returned so I was able to slip back into my short white cloak of vulnerability. I'll just have to savor my 2 hours of power.

Here's what I will not savor:

• Wearing white coats on the bus. Talk about a power trip. Come on people, get over it already. Yes you are a doctor. You are also one of us. (Speaking as a non-doctor.)
• Wearing coats in the cafeteria. Who knows what other substances rhyming with cafeteria are on that coat. It's worse than Mr. Yuk - It's Dr. Yuk.
• Brown sleeve cuffs and clear signs of dirt. How does the jingle go? A-L-L: the stain lifter!
• White coats at noon conference. At least take the jacket off while you munch on your sandwich.
  
• Doctors coming out of bathrooms with white coats on. Gross!

Those who know me, feel free to call me out on any of these should you note hypocracy...

Graded?

I don't know how it works at your medical school, but here at the University of Washington, eons pass before the clinical clerkship evaluations make it back to the student. It's been only a few weeks since I moved on from pediatrics to family medicine, but my current roommate - he finished his first clerkship in mid August - still has not heard about his marks. This is a good reason to ask for feedback real time during the rotation.

What gives, UWSOM???

"Didactics"

I'm willing to bet that many medical students in their third year think that they should be provided with classroom-style teaching as part of their clerkship education process. Medical $chool is, after all, really expensive. One might think that an education that keeps you in debt for many years should have a good amount of structured teaching. Many still think it is important to pull you away from hospital learning to sit in a class with four to fifteen other students to view some Powerpoint slides about the differential diagnosis of pediatric cough or the role of sleep apnea in pulmonary medicine. (My clerkship director thinks this, for example.) Five years ago, I may have agreed with the need for structured lectures.

These days, I much prefer learning in small groups in the care provider room, in patients' rooms, in the halls of the clinic, or even over dinner when on call. The thing about the medical training system, is that MOST people are in the process of learning and teaching. There is an adage in medicine called, "See one, Do one, Teach one," and while this may not be appropriate for some complex procedures, everyone should be in this mode. The residents teach each other and the medical students; students absorb experience from nurses and other providers; everyone learns from attending physicians. That's how teaching hospitals work. And don't just rely on others to teach you! If you are light on heart malformations, ask for some teaching from a cardiology fellow or the sub-intern on the cardiology team! Look up a paper, and present the tetrology of Fallot to your team. Chances are good that several others could use a brush up on that.

I know that the medical school wants to standardize its education so that everyone sees the same thing, or that some people just learn better in the classroom. I am pretty sure that the practice of medicine does not have didactics very often. If you cannot learn on your own or on the fly with and from your colleagues, good luck keeping up. I wish I didn't have to waste a good chunk of my days commuting to the lectures and figuring out ways to keep interested in them.

I mean no disrespect to the lecturers at my medical school, and specifically in my clerkship. It is clear that the administrators pay close attention to students' feedback - the lecturers are hardly ever boring, speakers generally use A/V aides appropriately and they often engage the students - I just think that time is better spent in clinic. We sat in the same chairs for almost 2 years absorbing info in classrooms. I wonder if these 5-10 hours of classroom learning are just a way to wean medical students from the structure of a classroom.

I'd rather go cold turkey.

Standing Around

I don't like how when we round as a team, I get lost in the details of the 20 patients or so that are on our board. I realize that this is the most efficient use of everybody's time, and that as a medical student it is my job to figure out the system so that I can make it work when I get to that point, but right now, I don't like the frustration, confusion and lower leg fatigue entailed in supporting the system.

Patty Cake

I like that I can play patty cake with my patient, and not have anyone think I'm crazy. More specifically, I can help Olivia the bear play patty-cake with my patient.