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:
- “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.”
- “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.”
- 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.”
- 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.”
- 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.”
- “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.”
- 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!”]
- “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
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