My progression of clinical skills

January 30, 2009 at 11:24 am (Clinical rotations)



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Signs that my resident got an MD from a questionable university

January 24, 2009 at 7:40 pm (Clinical rotations)

1. When I said that the patient has massive angina, she told me that if I ever repeat that, she’ll bring me up on sexual harassment charges.

2. She signs her admission notes with hearts over each “i.”

3. She uses House, Scrubs, and Grey’s Anatomy for hints on treating patients.

4. She really does believe that patients tell the truth about drug habits and sexual history.

5. She just can’t deal with the stress of a PMR residency.

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A letter to the patient’s wife on the fourth floor

November 29, 2008 at 10:47 pm (Clinical rotations)

Dear Mrs. Canseco,

You and your husband have had a long, fulfilling life together. Ever since your marriage over 50 years ago, you have stood by his side through good and bad times. And when he was diagnosed with end-stage lung cancer this year, you were there ready to support him to his last breath. However, there comes a point when devotion gives way to fanaticism—and you cross that line a few weeks ago.

When your 75-year-old husband was admitted to the hospital two months ago in respiratory failure, the admitting physician was not being cruel when he inquired about Do Not Resuscitate status. He had nothing personally against you or your husband when he brought up the idea of seeking Hospice care.

You wouldn’t hear any of it. You demanded that your husband be placed in the intensive care unit and be given round-the-clock supervision by nurses and physicians. When I spend five minutes with your husband every morning pre-rounding, followed by another 30 minutes telling you that nothing has changed in the past 24 hours, stop accusing everyone on the staff of “not explaining what’s happening.” Your weekly family conferences where my attending and I sit down with you, your three children, your brother, and two of his kids are really getting to be a drain on our time. I just don’t know how many other ways I can tell you that after being in a coma and on a ventilator for the past two months, your husband really doesn’t have a shot in hell of living through this. You have refused pain medications, saying that we are, “Killing your husband.” You have declined a Hospice evaluation, stating that, “We are turning our backs on your husband.” When we brought in a pulmonologist to reevaluate the situation, only to have her agree with us, you accused her of, “Not knowing your husband.”

But expertise be damned. Your daughter, the massage therapist who has had extensive training in medicine, told you that she believes your husband will make it off the ventilator without any problems if we just wait a little longer.

You’ve treated our hospital like it’s a hotel, having moved in and spent 61 consecutive nights sleeping in your husband’s room. You have refused to leave the room under any circumstances, claiming that bad things would happen to your husband if you walked away. You have demanded that the hospital provide you with meals from the cafeteria three times a day. You have demanded that nurses be forever present in your husband’s room so that they can respond to your every beck and call. You have neglected that these hard-working nurses have four—sometimes five—extra patients who are also very sick and must be seen. I wish I could just put a white coat on a mannequin and place it in your room to try to give you some kind of solace. He could have an outstretched arm to hold your hand with an audio tape on continuous replay saying, “I am here for you.” Because in the end, that’s all that I can offer you at this point.

And then there’s the issue of the money. Don’t act like it doesn’t exist. The combined hospital bill from your stay so far is going to run well over $200,000. But you have never cared how these services are going to be paid. You proudly flaunt that you have no insurance and since you’re not an American citizen, you are ineligible from Medicare. Neither you nor your husband own any property. When it comes right down to it, we’re all really working for you for free.

You have shown us that you know more about the pathophysiology of a coma than any physician ever could. You have taught us that living on a ventilator is better than dying with dignity. You have pointed out that our nurses are incredibly mean and lazy for not dropping everything they’re doing in another patient’s room to come see your husband, whose condition has not changed in two months. Thank you for giving me the opportunity to learn by having your husband as a patient. Thank you for teaching me that everything my attendings tell me is wrong, that medical care is free, and that nurses don’t care about people in a hospital.

Half M.D.

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Who’s on first?

November 20, 2008 at 2:58 pm (Clinical rotations)

Sometimes I encounter patients who are so inept that I wonder how they can remember to breathe and feed themselves. I occasionally have people show up to the emergency department who give a history that closely resembles Abbott and Costello. The following is a real honest-to-God encounter I had recently.

Me: what brings you to the hospital today?
Her: I fell and hurt my arm.
Me: how did you fall?
Her: I slipped in a chair.
Me: did you fall on the floor?
Her: no, I was in the chair.
Me: did you fall into the chair?
Her: no, I was already sitting there.
Me: so let me get this straight: you were sitting in a chair and then fell into that same chair.
Her: exactly.
Me: and you hurt your arm?
Her: yes.
Me: where on your arm does it hurt?
Her: right here on the inside.
Me: how did you hurt the inside of your arm?
Her: I fell in the chair.
Me: did you hit something?
Her: I hit the chair.
Me: on a scale from 1 to 10, how bad is the pain right now?
Her: it’s a four.
Me: I see here that you have a previous history of arthritis. What is your pain level usually?
Her: it’s a four
Me: so let me get this straight, you’re in the same amount of pain right now that you are always in?
Her: yes.
Me: what’s different about today than any other day?
Her: I hurt.
Me: is this a new kind of hurt?
Her: yes.
Me: what’s different?
Her: I fell.
Me: I see. How about I just send you out on some ibuprofen?
Her: okay.

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The angry resident. You will meet this person

October 15, 2008 at 8:35 pm (Clinical rotations)

Just look at this census. Many of these patients have been here over 2 weeks. Good lord! This guy has been here for 34 days. Just what is his deal? What’s that? You say that these are burn patients? Well if they’re just going to lie in bed all day and drink Ensure, they can do it at home.

Why do these patients’ families want constant updates? Good God, cut the umbilical cord already! Your 40-year-old daughter can deal with her subarachnoid hemorrhage just fine. If there’s ever a real emergency, I’ll give you a call.

Don’t these patients have anywhere better to go? Just look at the waiting room in the emergency department. Half of them are here just because they want a turkey sandwich and a bus token. They’ve got no real health issues. Maybe if they would go out and get a job, they wouldn’t have to constantly exploit the system. Hey, I see that guy wearing a gold chain. He had better not tell me he doesn’t have insurance.

Why the hell hasn’t the orthopedics resident returned my page yet? I’ve called him twice in the past 10 minutes. The last time I had to get a hold of them, they use some excuse about being in the OR for a trauma case. Don’t give me your mass casualty nonsense. If a busload of schoolchildren just happens to flip over while driving down the highway, there are certainly plenty of other hospitals that people can go to. But there should always be at least one person to answer my page.

There goes the psychiatry resident talking to himself again.

What does this attending think he’s doing, cutting in front of me in the cafeteria line? I’ve got to be at clinic in 15 minutes. And although he supposed to be there, too, he certainly won’t be seeing as many patients as I will. I hope he chokes on his chocolate cake. That was the big slice meant for me.

Why is this med student following so closely behind me? I know it’s his first day as a third-year, but does he really have to be my shadow? I think I’m going to have to run in a zigzag pattern and then duck behind a corner to lose him. Stop asking if “there is anything that you can do” already! I’m not the one who writes your evaluation. But if I did, I would say that you’re creepy and you know nothing about medicine.

Oh look, the nurses on the fifth floor are calling me again. I wonder what they want this time. I wish they would just learn to read my handwriting already and stop asking me stuff like, “What do you mean here?” I mean, give the patient his pain medication and stop pestering me.

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The Half M.D.’s Life Raft for third year

July 3, 2008 at 12:17 am (Clinical rotations, Life Raft)

All across the country this week medical students are coming back from their Step I vacations, dusting off the collared shirts and neckties from the back of the closet, and putting on pristine white coats as they head onto the wards as new third years. I want to congratulate all of you M3’s on getting this far. If you’re like me, you’re probably totally lost at this point as far as what your responsibilities are on your clerkships. I’m creating a new series called The Life Raft where I will move step-by-step through each rotation to tell you about your responsibilities, etiquette, what books are useful, and some general tips that will make you shine.

Before accepting anyone’s advice you should look at his qualifications. So, I feel that a bit of self disclaimer is necessary. I went through eight clerkships this year and earned honors on several of them, including getting the highest grade in the class on one rotation. Out of the 30 or so evaluations that were filled out by residents and attendings, all but one of them were for honors. Consistently my biggest struggle has been with the Shelf exams. I won’t be giving out any advice on how best to prepare for the tests. Instead, my goal is to make you a star on the wards.

General etiquette
There are some rules you should observe regarding your interactions with your teammates and teachers. First, realize that you and the rest of the medical students make up a team. You are partners. And unless there are any glaring differences, you will all generally be looked upon with either the same high regard or disgust. Therefore, you should do whatever is necessary to make your teammates look really good. You should alert your teammates to any changes with their patients. An example is if you have to stay till eight o’clock because of a late surgery and discover that someone else’s patient suffered a code at seven, you should call your teammate to let him know what happened. He’ll need to be prepared when he pre-rounds next morning. He certainly doesn’t need to get caught off guard with any surprising information when he arrives to the hospital at 5:00 a.m. the next morning.

Second, give teammates credit when delivering presentations. Whenever an attending posed a question to the group and told us to look it up, I would present the information the next day and state that my partners and I all played a role in researching the topic. My teammates ended up paying back the favor and cited me to make me look good on rounds. What the attending sees is not a group of students who individually hunt for data; he’ll see a cohesive team where members teach each other and work well together. The end result is that everyone gets high marks. If you’ve ever heard of the prisoner’s dilemma, the same situation applies here.

In short, the prisoner’s dilemma states that the best result can be obtained by forgoing a large reward and helping yourself and your partners obtain smaller rewards. The reasoning behind this action is that if everyone is searching for the largest reward—e.g., “I want to get honors and no one else should”—teammates will begin stepping all over each other, will make each other look bad, and then no one gets a reward of any kind. I’ve had several attendings tell me at the end of the rotation, “Your team is so great. I’m going to give you all excellent evaluations. You’re much better than many of the other students I have seen around here.” In reality, I don’t consider us that much better at all. I think that we showed up on time, knew about our patients, and did our work for the day. The only difference is that my teammates felt the same way I did. I will say that I’ve been lucky in that regard. I’ve heard horror stories from my friends about lazy partners who make the whole team looked bad. Nothing is worse during third year than a dysfunctional team. I’m lucky enough to have been shielded from much of that.

The final piece of etiquette is that you should never say anything bad about other students, residents, or attendings. Even if you have the world’s dumbest intern—and your attending openly calls him that on rounds—you should never say the same thing. Remember what I said earlier about making your team look good? The same rule applies in a way that you treat the house staff.

You should also go so far as to never make fun of other specialties. While I admit to making a lot of disparaging remarks about different specialties on this website, you should realize that this is just an anonymous place for me to vent. I would never call a psychiatrist a fake doctor while I’m in the hospital. You just never know who you’re talking to. While you’re ragging on shrinks in front of your surgery attending, he might feel a little insulted if his wife happens to be a psychiatrist.

With that said, this concludes my introduction to The Life Raft. Hop on over to the downloads section and pick up a patient tracking sheet that you can use on rounds. Welcome to third year. You are now a Half M.D.

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The fake surgeons

June 8, 2008 at 12:03 pm (Clinical rotations)

A few months ago I wrote a post about psychiatrists’ being fake doctors.  I stated that their inability to manage diabetes and hypertension disqualifies them from using the term “physician.”  Today, I would like to extend that similar reasoning to the obstetrician/gynecologist: the ob/gyns are fake surgeons.

All throughout medical school ob/gyns promote their specialty by saying, “We practice both medicine and surgery.  We see patients from across the lifespan.  Praise us because of our vast repertoire of knowledge.”  Things simply don’t work like that.

One immediate example is the multitude of second-year and third-year residents who are unable to tie suture knots.  The ability to properly place sutures (“stitches,” as they’re called outside of medicine) is a skill that every doctor needs to acquire before graduating medical school.  Certainly, I would expect all surgeons to be able to tie knots and appropriately perform simple surgical techniques.  However, I have seen residents who time and time again must be re-taught methods of one-hand and two-hand knot tying.  During many of these operations once the attending leaves, the third-year medical student takes over and finishes closing the patient.  That perfect line on your belly from your C-section?  That was me.

I’ve seen simple surgery such as laparoscopic hysterectomies take many hours solely because the attending in charge does not know how to use the equipment.  If you’ve ever seen the bariatric surgeries on television, you’ve noticed that the surgeons hold one instrument in each hand to perform the operation.  They then control the movement of the instruments using only fine finger motions.  My own attendings are so inexperienced that they grasp the entire instrument with one hand to prop it up, and then use the other hand to manipulate its movement.  The result is a need for additional hands (additional surgeons), wasted effort leading to fatigue, and an almost doubling in the amount of time necessary to complete the operation.  In one particular case I was extremely annoyed when the attending tried to teach me anatomy by turning around the camera within the patient’s abdomen so that she could point out the liver and gallbladder.  Well holy shit, lady!  I would’ve never been able to figure out where the liver and gallbladder are.  Thank you for halting the operation, singling me out as a medical student, and then showing me such basic anatomy as far as where the liver and gallbladder are.  All of that time on my general surgery rotation I had imagined that those organs were within the legs.  Thanks for correcting my ignorance.

Due to the need for additional hands (more residents), these cases get so overcrowded that the students take no part.  When I did surgery, students typically held retractors and a conversation flowed with the attendings.  Now, I don’t touch anything, I can’t see anything, and on several occasions I have had to completely step away from the surgical field because of all of the bodies pressing around the patient.

Perhaps the most annoying comment is the one about treating patients from across the lifespan.  Given that they only see women who are of either childbearing age or postmenopausal, I would say that they have a very small subset of the population.  Further, their lack of medical knowledge is astounding.  For a specialty that promotes itself as performing both medicine and surgery, I would expect them to better able to manage hospitalized patients.  When asked on rounds how to work up a patient with tachycardia (a fast heartbeat), my resident replied, “Consult with internal medicine.”  His name was instantly added to the growing list of physicians that I would never let my family visit.

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Birthing: the miracle of life or “don’t drop it”?

May 26, 2008 at 1:14 pm (Clinical rotations)

Hospital nurses are the front line in any patient’s care. They provide his medications, they clean him, take him to the bathroom, feed him, and dutifully report the night’s events to the physician in charge. OB nurses will take this charge to the extreme. Their years of vast experience tell them that they shouldn’t let medical students or interns anywhere near a patient in labor. Despite my hospital’s policy that medical students should be involved in delivering all babies, the OB nurses will do all they can in their power to ensure that students are nowhere near the event.

For example, two sets of gowns and gloves are required for the delivery—one for the resident and one for the medical student. Medical students are supposed to be involved with every delivery in the hospital. The nurses know this, yet will passive aggressively prevent students from taking part. They will bring only one set of gown and gloves to the patient’s room, and when asked for another set by the resident, they will ignore this request and force the medical student to go on a hapless journey around the labor floor trying to find supplies. In my own case, by the time I got all the necessary equipment together and returned to the room, the patient had already delivered the baby.

The attendings are well aware of this problem. Despite multiple pleas from hospital administration, nurses continue to block medical students at every pass. This weekend was my last day on the labor and delivery rotation. Since I had not delivered a baby by myself yet, my attending told me that I would not be allowed to leave the hospital until I had caught at least one child.

My attending walked me to every nurse on the floor, introduced me, and said, “He’s going to deliver this patient’s baby tonight. Make sure that he has everything ready.” Expecting the nurses to once again have the room prepared for only the resident and not me, I preemptively went around and gathered all the necessary equipment and hid it in the patient’s room so that I would have everything laid out.

At 1:00 a.m., our patient decided to deliver. I threw on my equipment, got between her legs, and prepared to catch the baby as it made its way through the birth canal. The media portrays birthing as the miracle of life. An expectant mother has waited dutifully for nine months for the chance to see her baby breathe its first breath. In the movies, the baby always comes out perfectly clean and very beautiful. In reality, newborn babies look like aliens that are covered in fluid and shit and are very slippery.

The baby I caught came out in just one push. During the entire ordeal the father was holding his wife’s hand and telling her that everything was going smoothly. Meanwhile, I’m pulling out the baby and thinking to myself, oh shit! Oh shit! Oh shit! Don’t drop it! Don’t drop it! Don’t drop it!

I managed to hold on to this slippery creature, cut its cord, and handed it over to the pediatrician. After taking care of the placenta, my resident said, “Great, you finally delivered a baby. Now you can go home.” And just think, she’s going to be there for another six hours delivering more children.

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Misplaced fears

May 24, 2008 at 1:24 pm (Clinical rotations)

There are lots of things in the hospital to be afraid of: violent psychiatric patients who try to attack everyone who looks like their family, homeless patients who cough on you, OB nurses, and attendings who want to tell you about Jesus. Hospitals have a rightfully deserved reputation as a dangerous work environment. Despite all of these things to be afraid of, nothing will throw people into a fit greater than HIV.

Let’s be absolutely clear about the way that HIV is spread. Only a direct insertion of bodily fluids will cause this virus to gain entry. Examples include drug abusers’ sharing needles, unprotected sex, and blood transfusions. What will not cause a spread of the virus is the physical exam. Skin-on-skin contact such as listening to the heart and lungs cannot cause a transmission of HIV unless both the patient and the healthcare provider have open wounds. This concept is pretty easy to understand. Yet despite all of the research and education that goes into this disease, people-including health-care workers-are woefully ignorant about the subject in practice.

Earlier this week I had a nurse stop me during the middle of listening to a patient’s lungs and admonish me for not wearing proper protective equipment such as gloves. I just don’t understand where this fear comes from. Yes, I know that there is a stigma associated with AIDS, but I would expect at lease for a nurse to understand how difficult HIV is to transmit. Mentioning those three letters on one of the nursing floors in my hospital will instantly cause a panic. Staff will begin putting on gowns and masks as if they are expecting a chemical weapon attack. Despite all of the frenzy that a weakly communicable disease causes, many people still will not follow proper precautions in other instances. For example, if a patient has an MRSA infection-requiring contact isolation-many nurses and doctors will continue visiting the patient without wearing the proper gloves and gowns. These health-care providers will then gleefully move onto the next patient’s room and spread all manner of bacteria.

Because of the extremely high number of nosocomial infections in my hospital, management has created several protocols for handling infectious diseases. We have placed alcohol rubs inside of every patient’s room so that people can wash their hands before and after each patient encounter. And while I’m thankful for these devices, I think that we need to do more. First, let’s get rid of the white coat and necktie. Multiple studies over the past few years have indicated that white coats and ties easily transmit disease from patient to patient, so much so that England has banned white coats from clinical areas [1, 2]. Second, let’s force all health care providers to use alcohol swabs on their stethoscopes after every patient encounter [3]. I carry a pocket full of alcohol pads everywhere I go. After each patient, I clean my stethoscope similarly to how I wash my hands. If you’ve never cleaned your stethoscope before, give it a try. You’ll be very surprised by the amount of dirt that comes off in just one pass of the alcohol pad. And stay way from those silver-containing diaphragm covers. The advertisements claimed that by using silver ions, these devices can kill bacteria. In reality, however, these covers are a greater source of infection than regular dirty old stethoscopes [4].

So there we have it. Evidence shows that white coats, neckties, stethoscopes, and artificial nails are a source of infectious disease transmission [5]. My hospital requires medical students to wear white coats, wear neckties, carry stethoscopes with them at all times, and has no policy regarding artificial nails. And the result is that we do a pretty good job of infecting people with C. diff, MRSA, and Klebsiella. Maybe what we should be doing is telling everyone that all of our patients have HIV. That way, they’ll be sure to carefully protect themselves from any communicable diseases.

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Counting down the days

May 19, 2008 at 9:35 am (Clinical rotations)

Every morning I wake up, look at my alarm clock, and groan in agony as I have to go in one more day. Given that within the past week my resident has twice shown up late for rounds, I believe she is experiencing the same phenomenon. I keep telling myself that I have less than a month to go in third year. After that, I’m taking two months to study for both parts of STEP II, and then it’s off to do my externships. I won’t see the inside of my hospital again until October. I’m eagerly awaiting the beginning of fourth year. It’s all classes than I signed up for with a focus on my specialty. I pick some difficult courses as well as some real sleepers. After all the work I put in during third year, I’m looking forward to a break. By the time mid June rolls around, I will have gone 50 weeks continuously in the hospital with only two weeks off for winter break. That’s the longest I’ve gone without some kind of extended vacation—and it shows. I can tell from my writing on this website that my creativity has really gone on a decline. I’m working on some new material that I can unveil once rotations end. But until that last day arrives, I’ll keep counting down my time using my old friend, the Donut of Misery.

Donut of Misery

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