Thursday, April 30, 2015

What Medical School Looks Like XIV

Medical school has sometimes reminded me of advanced preschool: these are pages I copied out of an embryology textbook as a first-year medical student. I found them while cleaning out my study last week.


Sunday, April 26, 2015

A Pound of Flesh

Shylock: Most learnèd judge, a sentence! Come prepare!

Portia: Tarry a little, there is something else.
This bond doth give thee here no jot of blood;
The words expressly are "a pound of flesh."

~ The Merchant of Venice, Act 4, Scene 1, Lines 304–307

Medical students frequently visit other medical schools in the summer or fall of their third year to learn things not offered at their home institutions; to audition for residency programs; to obtain a letter of recommendation to get into residency somewhere else; or sometimes just to live closer to home. Most schools have a designated application process that opens in the spring semester and uses a centralized website that disseminates information to applicants and submits information to programs. However, the website seems to be the only thing they have in common. Each has developed its own set of requirements, the most lamented of which is a different immunization form for each institution. But that is only the beginning. I looked into just 5-6 programs, which together required some combination of the following items:

Letter of intent from applicant.
List of clinical courses completed.
Curriculum vitae.
Letter of recommendation from a physician.
Letter of good standing from dean.
Board scores.
Request for accommodations.
History & Physical exam by student health center. Make sure you schedule the first appointment of the day so the doctor can be half an hour late and make you late for your own clinical responsibilities.
Annual influenza vaccine.
MMR x 2, or at least two measles shots, and/or MMR titer.
Tetanus, Diphtheria, Pertussis vaccine x 5 (original series).
Tdap booster in the last 10 years.
Chicken pox, varicella vaccine x 2, and/or varicella titer.
Meningitis vaccine.
TB skin test. If you fail that, a $30 blood test or a chest xray (the radiation is free!).
Hepatitis B vaccine x 3 and/or Hepatitis B Surface Antigen and/or Quantitative Hepatitis B Surface Antibody titer. If you send us a Qualitative HepBsAb titer so help us we will black list you for the next decade. Good luck getting into residency.
HIPAA certificate.
Basic Life Support (BLS) certificate attesting to the fact that you can perform CPR on a dummy.
Advanced Cardiovascular Life Support (ACLS) certificate attesting to the fact that you can perform CPR on a very expensive talking dummy.
Criminal background check ($35-75).
10-drug urine test ($40).
Fitting for a TB mask (cost: $95). In case a kid who shows up for a sports physical also has a case of active tuberculosis.
Blood-borne pathogen insurance policy.
Proof of universal precautions training.
Proof of tuition payment.
Proof of health insurance.
Proof of malpractice insurance coverage to $1,000,000.
A pound of flesh. Applications that arrive with even a jot of blood will be disqualified.
Processing fee to pay for the staff to check all the documentation we require you to complete before we deign to decide whether to let you associate with our medical students or patients.

It boggles my mind that this is the status quo. Third-year medical students are already busy with clinical duties 5-6 days per week as well as studying for the next subject exam (in 4-12 weeks) and the next set of board exams (summer/fall). We are supposed to be researching residencies and preparing our CVs, personal statements, and letters of recommendation. And some of us have teaching or research responsibilities in addition to personal lives and sleep needs. What kind of sheeple are we training up that medical students have not yet banded together to declare that enough is enough?

While students fear for their professional futures if they do not get a competitive away rotation to receive a strong letter of recommendation that will help them secure their desired residency, the medical schools and hospitals are territorial, jealous, and suspicious. At the very least I would like to see a single immunization form that only has to be filled out and countersigned once. At most there should be a single application process. We are all already matriculated students at LCME-accredited medical schools. Why do our institutions trust each other so little that we must spend time and money proving we are vaccinated, insured, and neither criminals nor drug-abusers?

Friday, April 24, 2015

What Medical School Looks Like XIII

Sometimes medical school looks like about five reams of paper heaped on the floor of your study. I went looking for the official printout of my Step 1 score from five years ago, and in the process I was inspired to recycle handouts, rewritten notes, study guides, and other detritus from the first two years of medical school. I estimated this is ~2/3 of what I accumulated then; some was recycled in the past, and the rest will assuredly go the same way when I graduate in a year. I found the score, by the way--and it is five points higher than what I had remembered it as.


Wednesday, April 22, 2015

Women in Medicine

A couple of female medical and graduate students and I recently (re)establish a branch of the American Medical Women's Association at my medical school. AMWA's goals are to support women in medicine and to improve women's health. This semester our chapter hosted a potluck for the local women's shelter and staffed a table at the National Organization of Women's Sex Out Loud event on campus. I made a poster and prepared trivia questions about women's health; participants won a piece of candy for answering a question (they didn't have to be correct). Want to play along? Answers are below!

1. What is the #1 cause of death among women?

2. What is the most deadly kind of cancer in Hispanic women? In non-Hispanic women?

3. About how many women die from pregnancy-related causes every year?

4. Do sexually active teenagers need a pelvic exam or Pap smear before getting birth control?

5. Hashimoto’s Disease is common among women. What part of the body does it affect?

6. What is the average age of menopause in the United States?

KE (M3), MW, KT, CD (M1s). Photo credit: CD.

1. The #1 cause of death among women is heart disease.

2. The most deadly kind of cancer in Hispanic women is breast cancer? In non-Hispanic women it's lung cancer.

3. About 700 women died from pregnancy-related causes in the year for which we have data (2011). Most of that was due to cardiovascular complications like congestive heart failure and blood clots; eclampsia and sepsis also contributed.

4. No, sexually active teenagers do NOT need a pelvic exam or Pap smear before getting birth control. Teens only need genital exams if they are symptomatic; otherwise everyone with a cervix should get their first Pap smear at 21.

5. Hashimoto’s Disease is common among women; it is a form of autoimmune thyroid disease.

6. The average age of menopause in the United States is 51.

Friday, April 17, 2015

Blue-Ribbon Medicine

Over the course of my third year in medical school, I have become proficient in a number of genres of medical writing: the long History and Physical (H&P), the short SOAP note (subjective data, objective data, assessment, plan), and verbal report. This past month I learned a new one: the clinical vignette. It's a five-minute power-point presentation that uses a case study to teach something new, interesting, or important to other medical practitioners.

Every year the medical school holds a day-long research symposium with research talks, posters, and clinical vignettes. I had an interesting case while on pediatrics and decided to write it up. The key to preparing a good vignette is paring down the amount of data to the bare minimum, given the 5-minute time limit. Above all, I tried to put as few words/lines per slide as possible. After talking with one of the chief residents, I also devised a nifty table for dividing the evidence into pertinent positives and negatives. (Putting together the slides was the subject of What Medical School Looks Like XI.)

Dear Husband was a great sport and let me practice on him a couple times, even though he didn't really understand what I was talking about. At the end, he pronounced me "multi-lingual" in English, German, and "medical."

The symposium is a competition, and I was the last speaker of the day. I thought the talk went well but not perfectly. However, it was good enough to beat out several residents and a couple of enthusiastic first-year medical students for the blue ribbon for Best Clinical Vignette. (Apparently, there's a check in mail!) For the curious, I've included the abstract below.

"Breaking the Rule of Twos"
The most common congenital malformation of the gastrointestinal tract, Meckel's Diverticulum is a remnant of the omphalomesenteric duct. The rule of twos says that a Meckel's Diverticulum is ~2 inches in length, has 2 types of heterotopic mucosa, occurs less than 2 feet from the ileocecal valve, is found in 2% of the population, and presents with painless GI bleeding by 2 years of age with a 2:1 male-to-female ratio. However, it can be found in older patients.

A 14-year-old boy with asthma and viral pharyngitis the previous week presented to the ED with an 8-hour history of multiple episodes of non-bloody, non-bilious watery diarrhea, multiple (near) syncopal episodes, and a fall in the bathroom with closed head trauma. Some crampy periumbilical pain had resolved, but in the ED he had one bloody stool. He denied nausea, vomiting, fever, rash, sick contacts, and recent travel. Past surgical history was notable for circumcision and unilateral cryptorchidism status post orchidopexy. Family medical history was notable for maternal Irritable Bowel Syndrome and possible Rheumatoid Arthritis. Although EMS reported a SBP in the 70s, by the time he was seen in the ED, his vitals were essentially stable. On physical exam the patient appeared pale and fatigued with a capillary refill of 2-3 seconds. Abdominal exam was positive only for lower abdominal tenderness to palpation. CBC found a hemoglobin of 10.3 g/dL. Upon consultation with Pediatric Gastroenterology, a technetium 99 scan was performed. It revealed a Meckel's Diverticulum with active gastric mucosa. One unit of packed red blood cells was administered for anemia. General surgery was consulted, and the diverticulum was excised laparascopically with elective appendectomy. After 1 week in the hospital, the patient was discharged to home with Norco PRN for pain.

This case demonstrates an unusual presentation for Meckel's Diverticulum: in an adolescent with mild abdominal pain, a single episode of melena, and syncope secondary to volume loss and severe anemia. Most individuals with a Meckel's Diverticulum are asymptomatic, but the 25% with atopic gastric mucosa can present with painless GI bleeding, (repeat) intussusception, or with a false case of "appendicitis." Heightened clinical suspicion led to diagnosis via Meckel scan, which has a sensitively of 85%, specificity of 95%, and accuracy of 90%. Treatment is surgical excision.

TL;DR This kid had an extra piece of intestine from where his belly button formed that didn't cause him any problems for years until it started making stomach acid that ate into his gut and made him poop blood. A team of doctors figured it out and cured him with surgery.

Wednesday, April 15, 2015

What Medical School Looks Like XII

Sometimes medical school looks like second-year medical students wearing plastic leis and blowing bubbles. Red clown noses and Chinese finger traps might also have been involved.

We were learning about healthy ways to handle stress and appropriate ways to use humor in medicine.

These students had just had their psychiatry final exam the day before, and they were understandably nervous about both their grades and catching up with studying everything else. In addition, most are counting down the weeks until their first board exam (Step 1) and feel overwhelmed.

I shared what I had learned about avoiding burnout as a third-year medical student: I only work six days a week, five if I can. As a graduate student without a lab or office on campus--and being too cheap to pay for food to work in a cafe--I wrote my dissertation at home. I felt as if I were "always" working. But I easily gave into distractions, so really I was always "working."

Now that I am doing clinical rotations, I work five to six days per week in the office or hospital. There is some but not much down time, so I feel more productive during the day. I try to study at least two hours in the evening. On weekends, I do household chores and work on side projects, like presentations. I told the second-years, "I cannot be a medical student seven days a week. I don't want to be a medical student 24/7. For my sanity, I need to be not-a-student on the weekends so that I look forward to resuming clinical duties on Monday morning." In other words, I have discovered the necessity of a Sabbath, thereby saving me from burnout. And I still pass all my tests.

However, with the next set of board exams just months away (Step 2), let's see how much of my own advice I take!


Friday, April 10, 2015

What Medical School Looks Like XI

Sometimes medical school looks like eating a make-shift dinner of cheese & crackers, carrot sticks, and trail mix while editing a clinical vignette Power Point presentation on the travel bus after a day of inter-professional simulation/training at the sister medical school in a city 2 hours away.

This presentation later won first prize for a clinical vignette at the research symposium!


Monday, April 6, 2015

What Medical School Looks Like X

Sometimes medical school looks like a computer game. Tonight the surgery students played Operation* with a da Vinci robot. One of my colleagues was so dexterous that I told her I would let her take out my prostate with the machine (!).

It consists of a console (bottom) complete with 3D/HD viewer, articulated hand controls, and a number of foot pedals. The system controls a separate robot that looks like a surgical octopus, with multiple arms for holding the camera and various grabbing, clipping, and burning tools. The surgeon and techs have to clean and prep the patient with “ports” to insert the instruments through small incisions in the skin first, but then the surgeon literally sits in a corner and operates from there.

The student also got to try three different computer training simulations: one picking up jacks and putting them in little cups; another taking rings off pegs, transferring them between instruments, and placing them on another peg; and an “endometriosis” simulation that required us to position two tools and a camera with our hands while working the camera and two different cautery tools with our feet. These were challenging but fun, since the only stakes were bragging rights. In reality, surgeons have to score at least 75% on 18 of these simulations before they can get robotic operating privileges at this hospital. I scored about 83%, 68%, and 90%. Another student had three passing grades, and we joked that he was well on his way to getting his privileges. (Funnily enough, he’s going to be an orthopedist. But bone surgeons are more often associated with hammers and saws than the delicate kind of operations for which robotic surgeries are often used, like removing a prostate or a uterus.)

The instructor asked that we post no photos publicly, so this one is from the official Da Vinci website. If you are at all curious, click on the link to see a couple short videos demonstrating the system. There's even one showing a surgeon from Japan folding an origami crane the size of a penny!

The <em>da Vinci</em> System surgeon console
* The game Operation was invented in 1964 by a University of Illinois design student, who in a cruel twist of fate found himself uninsured and in needed of dental surgery last year. I think the doc's edition must be an original one, as there's no "brain freeze" ice cream cone in his head. The set was complete with the Doctor and Specialist cards and their corny--and money-grubbing--rhymes.

"Water on the Knee"
Pump the water--fill the pail. Take your money, so you can set sail. $1000.

Patient has overloaded "Bread Basket." Remove a slice, the fee is nice. $1000.


Sunday, April 5, 2015

Children's Sermon: Holy Week & Emotions

As I explained in an earlier post, this year for Lent, instead of reading the week's scripture from the lectern, the RuacH creative worship committee has commissioned unique "Ignatian Contemplations" to be read in a combination of drama and prayer. The idea is to help congregants place themselves in the Biblical stories. Each one ended, "Look inside yourself, the onlooker, and consider what your emotions might have been. ... Whatever you are feeling, share it with God in prayer this week, and be open to hear God’s words as they come back to you."

I was assigned the Children's Sermon for Palm Sunday and wanted to continue on this theme of emotions. After all, we tell the kids they should be happy on Palm Sunday to recreate a parade for an absent Jesus--and then on Easter Sunday they're "happy" because they're hepped up on enough sugar that they don't notice the uncomfortable clothes they're wearing. I wanted to explore the variety of emotions aroused by the Holy Week events that happen in between these two "happy" holidays.

So I spent an inordinate amount of time, while eating lunch in a coffee shop, looking for simple, black and white drawings of Jesus teaching in the temple or washing the disciples' feet. I quickly discovered that Protestant sites offered many variations on the theme of "happy, smiling Jesus," but I had to go to Catholic websites to find images of the more disturbing parts of the Passion/Stages of the Cross, such as a frontal view of Jesus on the cross. There are hundreds of images of the open tomb, but far fewer showing Jesus' burial or the closed tomb. There are also some disturbingly cartoonish ones.

Because of the multitude of images--I eventually settled on 6 pictures for 6 days in Holy Week--I decided to affix them to a larger sheet of paper for ease of display and clean up. For someone with a smaller group of children or more time--such as a whole Sunday School (half)hour, this sermon could be easily adapted into a whole lesson. See below for more details.

~ * ~ * ~ * ~
Children's Sermon Text:

[Because there was some chaos in the transition between the children singing and starting the children's sermon, I went ahead and unrolled the paper scroll.]

Good morning! I am so happy to see all of you here today. So wait...why is today special? What are you celebrating? [It's Palm Sunday!]

Oh right! That's a pretty special day. And can you remind me, what is next Sunday? [Easter!]

Yes, Easter is another exciting day. Okay. But what happens in between? [Blank looks.] I'll give you a hint, it's right here at the top. [Holy Week!]

Yes, Holy Week. Here you can see Jesus riding a donkey into Jerusalem. The people around him a waving palm branches. How do you think they were feeling? [Happy, excited, emotional.] Yes, it was a very emotional time for them!

In this picture Jesus is turning over the money changers' tables and driving the animal sellers out of the Temple. How do you think he was feeling? [Angry, upset, frustrated.]

Then Jesus washed the feet of his disciples. This is Peter. See the question mark over his head? [I added the question mark in marker after printing, because of course everyone looks so *&#$^ happy in the picture.]  How do you think he was feeling? [Happy, confused.] That's right: when Jesus offered to wash his disciples' feet, Peter said, "Wash all of me!" But Jesus said, "No, just your feet will be enough."

Look: soldiers came to arrest Jesus in the Garden of Gethsemane. How do you think the disciples felt? [Scared, angry.]

Then Jesus was crucified. What do you think that made them feel? [Sad, crying, disappointed.]

After Jesus died, they buried him. How do you think they felt then? [Sad, lonely, forgotten. During the service one kid piped up, "happy!" and I reminded him that the people who knew Jesus didn't know that Easter was coming yet--an excellent teaching point.]

You see, just because we're Christian doesn't mean we only have to be happy all the time. The stories in the Bible show us a wide range of emotions, as you can see from the events during Holy Week between Palm Sunday and Easter. It's okay to feel those things. You can always pray about them.

~ * ~ * ~ * ~

Suggestions for a Sunday School lesson: space the pictures out side by side so that you can reveal one at a time. Describe the stories for them in more detail than I did above. Particularly for younger children, have them practice imitating the various emotions. Older children might like to each have a different color marker to write on the paper the emotion the scene evokes for them.

Easter Sunday ending: review the events/emotions from Holy Week. Then unroll the scroll to find the happy ending: an angel telling the women that the tomb is empty! (For more dramatic effect, leave more space between the two than I did here.)

Editor's Note: Some of my other children's sermons have addressed the Transfiguration and Pentecost/the Tower of Babel.