What Medical School Looks Like XV

When my senior resident dismissed me at 5 o'clock this evening (pleasant surprise!), I decided to take advantage of the lovely weather by unwinding at the park next to the hospital. After facebooking for a while, I lay back on the bench and completed my daily 10-question quiz while butterflies chased each other around me. Above is the view of the walking labyrinth, which is bordered by mint and butterfly bushes. A literal and spiritual breath of fresh air like this makes the surgery rotation bearable, despite having to get up at 4am, stand on my feet for hours, and rearrange meals.


Older

Newer

Children's Sermon: Pentecost as a Reversal of Babel

Unsurprisingly, one of the biggest challenges of writing children's sermons is figuring out how to translate Biblical texts for small children. After all, the Bible is a mishmash of genres (myth, poetry, political history, parable, hagiography) written for adults inhabiting historical and cultural contexts far removed from the 21st century. One favorite tactic is to use metaphors: "God is like..." or "The Kingdom is like..." Jesus employed metaphors all the time! But psychologists tell us that such abstract thinking doesn't develop until the teenage years. Another common tactic is simply to tell stories; the Older Testament and the Synoptic Gospels in particular lend themselves to this. However, what to do when a more complicated passage is the preaching text? How to teach our children better moral lessons for living? (Preferably ones bigger than "be nice" and "obey your parents," although I have fallen back on these at times.) I am also aware that the congregation is my audience as much as the kids who come to the front of the sanctuary.

Then there is the problem of props. I find that even five minutes of pure talk for a children's message is not riveting enough for most kids (especially the young ones who still come down the aisle for them). Having a prop of some kind at least catches their visual attention, and you hope that their mental attention follows! However, it is also entirely possible that they will become so engrossed in the prop that they do not hear what you're saying.

With these monthly conundrums in mind, I tackled the Scripture for Pentecost (Acts 2). Seeing it with fresh eyes and ears this year, I was struck by the list of "God-fearing Jews from every nation under heaven" who had gathered in Jerusalem for Shavu'ot (the Feast of Weeks, to celebrate both the first fruits and the giving of the Torah). Somewhere or other I had read that Pentecost can be seen as a reversal of the Tower of Babel myth in Genesis. Building a tower with blocks would give us something to do while talking about God's relationship to all nations, so I decided to run with it. Here, more or less, is the children's message I delivered this Pentecost Sunday.

~ * ~ * ~ * ~ * ~ * ~

Good morning! I'm so glad you came up front this morning, because I need your help with these blocks. Can you help me build a tower? Let's see how high we can make it!

Do you know the story of the Tower of Babel? It's a myth in the Older Testament of the Bible. Long, long ago, in a land far, far away, the people wanted to be closer to God. This was back when everyone spoke the same language. So they got together and decided to build a tower allll the way up to heaven. However, God knew this wouldn't work, so the Bible tells us that God "confused" their languages. They couldn't talk to each other anymore, so they had to give up on the tower.

However, the people and God still wanted to have a relationship with each other. So the Newer Testament of the Bible tells us that God sent Jesus. He lived, and taught, was crucified, died, and buried, and then he rose from the dead. After he was gone, the Holy Spirit came to inspire the disciples to share the Good News to people from all the different countries in the world. Even though they all still spoke different languages, now they could understand that God loves them and that they should work together to build the Kingdom of God on earth.

Thank you for your help today. You know the point wasn't to build a tower out of blocks, right? It was to build the Kingdom of God for everyone. Let's pray about it: Dear God, thank you for the Holy Spirit. Help us to build your Kingdom. In Jesus' name, AMEN.


We left the tower standing in the chancel for the rest of the service as a reminder to the congregation of Pentecost as a reversal of Babel.


Editor's Note: some of my other children's sermons are on the Transfiguration and Holy Week.

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.

Older

Newer

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.
Headshot.
Transcript.
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?

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.

Older

Newer

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.

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.