Philip Greenspun’s Weblog

Eight of us arrive Monday at 6:00 am for surgery rotation orientation in a small conference room tucked away in the basement of the hospital. The surgery clerkship director introduces himself, and demonstrates suturing, hand ties, and laparotomy technique using a neat simulator device for 45 minutes.

He then leads a 45-minute discussion on postoperative care and complications. “Everyday the attending wants to hear the vitals, labs, and I/O [input/output].” The first two or three days after a surgery, the stressed body will hold onto water. Beginning Day 3 or 4, the body will begin to mobilize fluid. If you don’t see this happen, you should start to worry.” Does anyone know when is the highest risk for postoperative MI? [blank stares.] “It’s day 3 or 4 if the patient does not mobilize fluid. The fluid overload basically causes congestive heart failure.” We learn about the five most common causes of postoperative fever [5 W’s pneumonic]: Wind (pneumonia/atelectasis), Water (UTI), Wound (infection), Walking (DVT), and Wonder Drugs.

General Surgery at our hospital is organized into four different services: (1) elective, (2) emergency, (3) trauma, and (4) pediatric. The speciality services, for example, cardiothoracic, urology, otolaryngology, orthopedics and vascular are seperate teams. If a trauma alert comes in from, e.g., a car accident, the trauma service responds by meeting EMS and patient in the trauma bay. If someone comes into the ED for an appendicitis, emergency will go to the consult and determine if they need emergent surgery or if they can wait for an elective surgery later in the week. Each team has one attending, one chief resident (PGY4 or PGY 5, postgraduate year 4, i.e., 4 years into residency), one mid-level (PGY 3 or 4), an intern with 1-3 medical students. The interns started only a month before us so they are also learning the ropes.

For the next three weeks I am assigned to the elective general surgery service along with classmate Christian Charlie. His fame among classmates was assured during the first year mock breast exam when he exclaimed, “Is this what breasts feel like?!?” During anatomy lab, he asked, “Is this where the clitoris is located?” (He was engaged when these questions were asked, then married at the end of Year 1.)

Orientation wraps up around 7:20 am for us to meet our team for a few minutes before the first case of the day. I meet my Chief as she downs one of her favorite La Colombe coffee cans in the Surgeons’ Lounge. The PGY3, Quiet Quincy, and intern, Bumbling Brad, walk in shortly after me. Quincy is pretty open about his situation. He originally wanted to do orthopedic surgery, but did not get into a residency program. Having failed to match, he did two preliminary years in general surgery at two different institutions before finally getting a “categorical match” in general surgery (starting as a third year) at our institution. The intern couple matched with his girlfriend who is doing plastic surgery.

[I asked Brad about the couple match process. “It was terrible. We didn’t get any of our top choices for her to do plastics while I did general surgery. Two spots makes up a large percentage of a residency’s slots.” He didn’t have to be married to his match partner? “You can couple match with anyone. You don’t even have to match to the same institution. You can couple match as friends, as same sex.” He joked that if you really detest someone, you could couple match and rank hospitals at opposite sides of the country.]

Charlie and I are assigned by the Chief Resident to one of the two attendings operating today. The Chief joins one attending while the PGY3 and intern manage the floor of post-operative patients. The PGY3 may occasionally scrub in if the chief declines the case, if the attending requests him/her or if the PGY3 has been following the patient for a takeback (additional surgery following a complication). The intern never scrubs in. Brad explains: “They want you to be begging for the OR.” The intern, PGY3, and I head off to the floor to manage post-operative patients while the chief and Charlie head to the OR for the first case, a lap sig col (laparoscopic sigmoid colectomy).

Around 9:00 am, I head down for my first case, a melanoma (skin cancer) excision from the left thigh. I introduce myself to the patient in the pre-op with the chief. I then go through the “OR tunnel,” turning around once to grab a hairnet after a nurse yelled, “Where’s your hair coverage?”. I walk in and the four individuals in the room look up briefly as they continue their preparation. Fortunately, Quiet Quincy told me to always introduce myself when walking in: “Hi, I am a third-year medical student who will be scrubbing in.” The circulator nurse responds, “Get your gloves.” I don’t know where they keep the gloves… I look around and see the cabinet. The goal to pick up two layers of gloves and get them on without anything non-sterile touching the outside of a glove. The packaging of the gloves is considered contaminated. Only what’s inside the package is guaranteed to be sterile.

I grab “8.5 under, 8 over” gloves (two pair) and walk over to the sterile field. With my contaminated hands, I peel back the glove pack so that Loudmouth Lilly, the surgical technologist (surg tech, aka scrub tech) can grab the gloves without touching the outside contaminated plastic covering.  

Lilly enjoys poking fun at my surgical oncologist attending and, especially, medical students. She grins and asks, “So how many gowns will we need with you?” (Assuming that I will “break the field” and have to re-scrub.) I nervously smile, “Just in case, I’ll grab another one.”

The patient is rolled in by a nurse and the anesthesiologist begins propofol [Editor: Michael Jackson’s first choice] and the inhaled anesthesia. I ask the circulator nurse to help me place the “foley” (foley catheter, a plastic tube placed into the urethra to empty the bladder). We both grab another pair of sterile gloves, just for this procedure, so that she can guide me through it. There are subtle tricks to make it easier, for example, pulling the plunger out of the lube syringe so you can anchor the foley tip. This stabilizes the foley so it stays in the sterile field until you are ready to insert it into the urethra. “Make sure you grasp the shaft firmly, once you place your hand down, it needs to stay there because it is no longer sterile.” I advance it until I see the flash of urine, retract it a little bit and blow up the balloon to anchor it in the bladder.

Quincy and I then go to scrub in just as the attending arrives. He is a new attending in his 40s who completed a surgical oncology fellowship after completing a general surgery residency. I take the chlorhexidine sponge and scrub for 10 minutes. After I rinse off, I struggle for a few seconds to push the OR doors open (a practiced butt maneuver; everything below the elbows must remain sterile), upon which the circulator nurse opens them for me.

The surg tech hands me a towel to dry my dripping hands. Lilly then opens the gown as I spread my arms into it. “Keep you hands inside.” The circulator nurse ties the gown from behind. I struggle to dip into my gloves as the surg tech opens them up. My fingers are in the wrong glove holes, but this can’t be fixed with a non-gloved hand so I need to wait until the other hand is gloved to try to fix the situation. “These gloves are way too big. Get 7.5/7.5”. Once the circulator nurse hands the new gloves to the surg tech, we reglove again. The surg tech whispers, “You’ll get better.” My second glove dive goes much more smoothly. I start walking towards the OR table. Lilly: “Hey, your card!” Oops. I need to finish gowning by wrapping the belt around. I hand the tech a card attached to one end of the belt. She holds it while I spin around thereby wrapping the belt around me. I then yank the belt end, detaching it from the card, and tie it in front. The nurses hoard these little cards. Why? “We write notes down on them. It’s kind of a bragging right if you get a bunch of them.” I take my place next to the PGY3 on the patient’s right with the attending, surgical tech, and her Mayo stand (stand over patient with accessible instruments) on the opposite side.

The pimping starts immediately. What are the different types of melanoma? Easy. Sarcastic Samantha gave me her copy of Surgical Recall. I keep this book in my white coat and reviewed the section and also UpToDate before the case. He realizes this, and changes the subject to soft tissue tumors. What is a sarcoma? I respond: “A neoplasm derived from mesoderm.” What kind of animals are they classically found in? I’m stumped, and take a wild guess. “I’m going to guess dogs.” He scolds me: “You need to answer confidently. It’s okay to be wrong, but be confident. You know more than you think, and you must be confident with patients. I would rather you be confident and wrong than be right and timid. Now is the time to be wrong when you have attendings and residents to correct you… And by the way, dog is the right answer. We’ve learned most of what we know about sarcomas from studying them in dogs.”

[Editor: A peek into the often-in-error-but-never-in-doubt factory!]

The pimping continues as we sterilize and drape the patient’s left thigh and inguinal (groin) region. I am tasked with taping the scrotum up to prevent contamination. How large an incision do we want on this melanoma? I respond, “Margins are based on the depth of the lesion. His lesion is under 1 mm and not ulcerated, so we need 1 cm margins.” He respond, “Okay, that’s not answering the question. Quincy, how will you make your incision?” He turns his attention to Quincy but summarizes every step in a confirmation of my presence. Quincy uses a sterile ruler to draw a 1 cm margin around the 1 cm circular lesion. He then creates a 9:3 cm ellipse to get good closure.” The attending asks me: “Do you know why we drew this ellipse?” “Is it easier to close? I mean, to make it easier to close.” He responds, “Yes, but why?” I don’t have a good explanation. “You need to stop us if you do not understand something. I assume you know it if you say nothing.” He moves on to continue the case. The questions cease once he watches the PGY3 make the incision and inject “Local” (lidocaine with .25% epi mixture in a syringe). Once they removed the entire ellipse down to the rectus femoris fascia, the attending marks the superior and lateral margin of the specimen with a long and short suture that I get to cut with a suture scissors. I use Army/Navy retractors to retract the skin as they mobilize the skin around the thigh. The attending asks Quincy, “How would you close this?” The PGY3 responds, “I would do a deep dermal with 2-0 vicryl, then a running subcutaneous with 4-0 vicryl and dermabond.” “Okay do that.” He turns his attention to me while he watches Quincy’s shaking hands at work.

He asks me, “How do we determine what lymph nodes to remove?” I respond, “We injected contrast for the PET/CT scan, and we inject dye that flows down the lymph node [I’m not sure when we injected the dye, perhaps with the local?]. “Yes, you must do a sentinel lymph node for any melanoma that is not in situ. Clearly this had 1 mm depth so we know it spread beyond the basement

Students return for Year 3 of medical school. We’ve had a 2-4 week break depending on when we took our Step 1 exam. Most students, including me, are still waiting on their Step 1 scores. Lanky Luke surmises that we took a new test, which required aggregation of a few weeks of tests to normalize the scores to previous versions. Five classmates met up in Seattle for a road trip through San Francisco, San Diego, and the Grand Canyon. I visited family, and relaxed with Jane before she departed for boot camp. She returns next week.

“I am ready to learn some real skills,” exclaims Lanky Luke. “When friends and family ask about their various medical issues, I realize how little I know.” Hard Working Harold: “Give me a multiple choice question and I’ll answer the shit out of it. Send me into a patient room, and I’ll have no idea where to start.”

Orientation begins at 7:00 am with an introduction from the clerkship director, a practicing psychiatrist. “When I went to medical school, we used to call you clerks. You are no longer a student. You no longer shadow.” She lays out some basic principles for success:

1. “If you meet with me, it’s because you’re in trouble. I will be following your progress from afar. I hope I never see you in my office until you apply for residency.”
2. “The focus is no longer on you. This can be hard for young people. If someone does not smile back at you or yells an expletive because they just lost a patient on the OR table, do not take it personally.”
3. Become part of the team. “The team will function with or without you. Don’t get in the way. If there is a trauma that needs urgent resuscitation, this might not the best time to be asking questions or trying out new skills. You can impact patient care. Every block we get a report that a medical student discovered a complication. You will be able to know your patients at a much greater detail than residents or attendings because you have more time per patient.”
4. Duty hours. “Know your Duty Hours. It’s your responsibility to not violate them. You cannot work more than 80 hours per week, averaged over four weeks. It is extremely hard to violate this. I’ve had students in the past complain to me that they are being forced to work more than duty ours when they are getting of at 5:30 pm when they just had radiology rotation last week. Come on… Also, don’t complain on evaluations when you get out at 5:30 when they told you would get out at 5:00 pm. Things change. to get out to avoid this, I’ve stopped telling my students when I expect us.”
5. Be curious about everything. “Even if you are not interested in psychiatry, you need these skills for any specialty. We had a student deliver a baby on the psychiatry floor.”
6. “Check your email, not instagram. I make an effort to answer email until about 11:00 pm. That means if you believe it is necessary to send me an email at 10:30 pm and I respond, DON’T reply back in 5 days.”
7. Scrubs are not to pick up ladies. “Don’t steal scrubs. We watch. Scrubs Out must equal Scrubs In. An OR employee took a video that was sent to my desk showing a few medical students wearing their bloody scrubs at a local bar hitting on some women. I laugh when I get video of students walking out with scrubs on.” [Gigolo Giorgio: “How do they catch us? They must be surveillance cameras on the exits!”]
8. “Take evaluations seriously, especially learning environment violations [e.g., physical or mental harassment by attendings, inappropriate conduct towards students]. For God’s sake, read the question. I have so many examples of someone checking “Yes” and putting “N/A” on the learning environment violation. If you have a reportable offense write it, but spend enough time reading it to know what you are answering. It matters. The LCME scrutinizes our reported rate. They are like the Supreme Court.  Five people came from LCME a few years ago. They analyze every detail. For example, they ask how many residents we have here. They then asked to see every resident’s signature attesting they receive training about the learning environment. I know they cross referenced every one.”

Our next presentation is by the Dean of Student Diversity. Her new assistant, the Inclusion Coordinator, joins her and helps pull up her PowerPoint. Title slide: “In pursuit of cultural sensitivity and awareness.” 

She begins by explaining her own implicit biases and insensitivities. “I want everyone to go home and take Harvard’s implicit bias test. I learned a lot about myself. For example, I have an implicit bias that males are better leaders than females. I apparently have a bias that women are not as good at science. I didn’t even know that about myself.”

The talk concluded with a request that students share microaggressions that they had suffered personally. Fashionable Fiona shared that one of her relatives told her, “You should go to nursing school instead of medical school. It’s too hard. I was pleased to say, ‘I already got into medical school.'” [She got an award for her year 2 block exam performance.] Several women shared that patients mistake them for nurses instead of medical students. One student shared an experience in pediatrics when a nurse asked who the mother for the name of the child’s father. She replied that the kid has two mothers. The nurse replied, ‘But who is the dad? I need to fill this in on Epic.'” 

The Dean of Student Diversity concluded: “I hope everyone goes home and reflects about their own implicit biases. We each should strive to learn about a new community everyday. I will admit that I am ignorant about much of the transgender community. I am trying to learn about their language and customs. I don’t know much about them.”

The next day we begin with a presentation from a Department of Health official about vaccination. “As you begin your rotations, you are going to interact with patients that do not believe in vaccines. As a healthcare worker you need to know about the misconceptions that are out there.”

The biggest misconception is that vaccines cause Autism. She explained that this movement originated in Dr. Andrew Wakefield’s study that found eight children who got MMR around the same time autism symptoms presented. This caused havoc in the UK. MMR vaccine rates plummeted, yet Autism rates persisted. The UK now has 80 percent MMR rates, well below the 95 percent required for herd immunity. Measles is now endemic in the UK.

“We find that physicians are a key communicator in the community to get vaccine rates up. Most of the time, the parents will change their mind if you delve into their thought process. That takes time that most physicians unfortunately don’t have anymore.” 

Orientation concludes with a presentation on social media pitfalls and patient privacy. The Privacy Officer: “Long story short: don’t snapchat or instagram. Talk about patients in the resident lounge not on elevators.” [This advice was not heeded as Pinterest Penelope decided to snapchat a drug-screen result testing positive for benzos, cocaine, meth, heroin, and thc for a patient with the caption, “Must have been a crazy party.”

Friday afternoon, I volunteer at the free clinic associated with our university. I interview the patient first, and then present the findings to an M4. We then interview the patient together and give a final report to the attending, typically an internist, family medicine physician or emergency medicine physician. The first patient: 56-year-old female with a history of depression and type 2 diabetes presents for a diabetes check up. She has been doing fantastic, losing 50 in one year while keeping her A1Cs in the 6 percent range. However, last year, she has gained 40 pounds and her A1C this visit has jumped to 7.5. As I do a medication overview, she says she has been taking depakote (valproic acid), a mood stabilizer for bipolar disorder. Why? She explains she was prescribed it when she was brought to the ED while using heroin. She lied to the physician who took her symptoms as a manic episode. She has not seen the prescription physician since her ED visit. I ask, “Do you have a history of bipolar disorder?” She responds, “No.” She began the depakote around the time she began gaining weight. I speak with the M4 who recalls that depakote can cause a metabolic syndrome. We both go in an complete the exam. He quickly goes through a focused diabetes physical exam, complete with assessment of peripheral neuropathy and retinal exam. He fluidly asks questions focused on diabetes symptoms, e.g., polyuria, visual changes, numbness/tingling in the feet, shortness of breath. We propose our plan to the attending who decides to decrease her dose by half and have her follow up in a few weeks. Overall, I realize how out of practice I am with patient interview and physical exam skills. I recognize that I need to be able to do a diabetes exam, including retinal exam, peripheral neuropathy exam, like the back of my hand. It was exciting to see the M4 perform the exam with such fluidity. 

Statistics for the week… Study: 0 hours. Sleep: 8 hours/night; Fun: 1 night. Example fun: Jane and I attend our class’ July 4th BBQ on the weekend at a classmate’s house. We had an excessive amount of food and beer featuring ribs, burgers, chicken thighs, and local craft beer for a cost of $4 per person paid via Venmo. We eight, including me, who are starting on surgery on Monday are the butt of jokes. Mischievous Mary: “Throwing you to the wolves.” I talked with a refugee-status immigrant from Lebanon who attends the same church as a classmate. Straight-Shooter Sally overhears this and adds, “Oh, have you talked with Geezer George? His family is from Lebanon and he visits there regularly and is always talking about how great it is and encouraging us to come with him.”

The rest of the book: http://fifthchance.com/MedicalSchool2020

Our hero has graduated. Coronavirus is almost done (thanks to President Biden’s scientific rule, the virus began to decline weeks before he took office). It is time to resume publication of Medical School 2020, the book that explains what it is like to be a medical student in the U.S.

We previously published Year 1 and Year 2 (refresh your memory regarding these weekly diary entries on the book web site). So we’ll start with Year 3 tomorrow.