Tuesday, March 29, 2016

Humiliation of the Medical Trainee

In three short months I will be starting my residency. I will be Dr. Vieve, the lowly intern,with a batch of third- and fourth-year medical students to supervise every day. My job will include serving as their instructor while keeping up with the notorious, over-sized workload given to physicians in their first year of practice. I'll be evaluating my students' performance and making comments that shape the Dean's Letter they will use when applying to residency. Most importantly, I will have the opportunity to model what professional behavior can look like. They will inevitably hear me misspeak or say something that is incorrect. They will watch me be corrected by my seniors and attendings. And there will most definitely be times when I will need to correct them. Medical training is known for hazing--for instruction edged with humiliation. I hope to rise above it.

Dr. Pamela Wible is a family physician who has found herself in the unintended role of physician advocate. She speaks directly of the culture of humiliation in her recent TEDMED talk Why Doctors Kill Themselves. It is sobering to listen to, reminding me of the need to watch-out for my coworkers and students while also safe-guarding my own mental health. There is a stigma associated with depression, and it seems to be even worse for those whose are entrusted to care for other people's health. Unfortunately, there are systems in place that perpetuate that stigma and stand in the way of physicians seeking treatment for themselves.

My unpleasant experiences with difficult physicians has been limited. Part of that has to do with the good-hearted people I work with, and part of it has to do with having a well-formed identity prior to starting medical school. No doubt about it, med school is a beat down! I count it a blessing that I have  endured enough challenging experiences in my life that have taught me resiliency. Not all of my peers have yet mastered this. For many of them, it is the first time that they have been publicly challenged. Situations that have left me mildly embarrassed, have made others feel utterly humiliated.

Life is challenging enough without getting a little endemic humiliation handed to you.

My divorce was an "easy" one, but it still made me feel hurt beyond belief. I knew that I wanted it, but that didn't stop me from grieving the loss of the if-not-happily-at-least-not-sadly ever after I dreamed of. I knew that something would have to give, and I so desperately didn't want that something to be my sanity. I saw a psychiatrist and was treated with antidepressants for a few lonely months (and appropriately for a few more months after those lonely feelings disappeared). I'm so grateful to be on the other side of it and recognize that I weathered that storm more easily than others.

As I began the process of applying for a provisional medical license, I was shocked to discover that seeking treatment for my episode of depression could have required me to sign over my right to privacy. I was confused then I read the line on the application that asked "In the past 5 years have you been treated for schizophrenia, alcohol or other substance abuse, bipolar disorder, pedophilia, or major depression?" Which bureaucrat determined that these disorders were similar enough to be lumped together in one question?

I asked my residency coordinator what would happen if someone said yes. She just shrugged her shoulders. "Yeah, you probably should just send the state office your entire medical file." And then she added, "I don't really know. No one's ever been treated for mental health stuff." If that's true, then countless physicians are struggling with untreated depression in an effort to save face and preserve their privacy. Perhaps unknowingly, that question sends the message that getting help for depression is similar to seeking treatment for pedophilia. And placing your privacy before the review of Ms. Baker at the State Office Building is an insufferable humiliation.

What would the repercussions have been if my depression was more serious than adjustment disorder? After all, when I was in the midst of depression, it simply hurt, and I didn't find myself thinking, Gee, I'm so lucky that I have a 'legit' external cause to blame all this on and I bet the pain will end super-duper soon so as to qualify as acute. No. I was simply depressed. But the question didn't even ask if I was depressed or if I used alcohol or if I had schizophrenia. The question asked if I sought treatment.

It frightens me to think of how my decision might have been different if I had known that two years ago. Would I have had the courage to take care of myself? Would I have told myself that seeking help was "weak" and I needed to suck it up? I knew Medicine's reputation for putting trainees through public embarrassment. I never imagined that a physician's personal medical records could be put on the line.

Monday, November 2, 2015

Ten-Hut! (Or "The Order of It All and Why I'm Probably Going to Continue to Get into Trouble")

There are some folks who should never enter the military. Often, those are the same folks that need the discipline and structure the military provides. I am one of those people. Compared to most flowcharts, chain-of-command hierarchies never impressed me. Too linear! (Yawn.) But the well-oiled machine known as the American Health Care System relies on such hierarchies to ensure care is given in an orderly and predictable manner. I understand that. I even appreciate that. The structure and hierarchy that I've stepped into is both instructional and protective. For this, I am grateful.

Like all good hierarchies, each wrung in the ladder knows her place. I am keenly aware of mine. I am there to be stepped on when convenient. Fortunately, that's not a daily occurrence.

For those of you unfamiliar with the hospital hierarchy, let me elaborate. The attending physician sits at the pinnacle. When things go wrong, this person is the one who bears the brunt of all "official" action. Sure, attendings are know for being demanding, but it's her license on the line when an underling screws up, so that edginess is somewhat understandable.  Next in line is the senior resident, the person who paid the dues of being an over-worked lackey just one or two short years ago. The intern resident is lackey to both his senior resident and his attending. He's the one who has to carry the most pagers and document the majority of clinical interactions--a task which has proven to be far more time-consuming than I ever imagined. (Yes, they make us practice writing "notes" ad nauseum.) The intern is fresh out of medical school, newly anointed with the title of "doctor," and terrified of messing up. And then there's the medical students. We've passed Step 1, which means we've ingested volumes of medical knowledge. Of course, most of that knowledge seems to have disappeared once we regurgitated it during our licensing exam. And to remind us of how little knowledge we've seemed to digest in the learning process, residents love to ask us questions preceded by the statement "Step was more recent for you, so you should still know all these details."

Luckily for me, I'm blessed to have a few good interns who've got my back. The Family Medicine class ahead of mine has been there for our little group, offering support and encouragement throughout med school. I'm grateful to know that these are the people I will be lackey to next year!

After wrapping up my week in the medical intensive care unit (MICU), one of the Family Med interns checked in on me. (Pardon the typos.)

Earlier in the week, Dr. MICU had asked the senior resident if he remembered what Abraham Lincoln had said. (Hello? Abraham Lincoln said a bunch of stuff!) When the senior resident said, "No, sir," Dr. MICU shared a beautiful and inspiring quote which I seemed to have forgotten. As we walked out of the room, I leaned towards my senior resident and said, "I wouldn't have guessed that quote either. I thought he said, 'Gee, Mary! Do we have to go to the theater tonight? I've got a headache.'" Dr. MICU heard my not-adequately-whispered comment and shook his head. Yes, I have got to learn to shut up. 

At the end of my Internal Medicine rotation, one of the attendings wrote on my evaluation that I needed "a thicker face to handle criticism." That same physician ranked my performance as "honors." I'm fairly certain that it was Dr. MICU. 

Friday, August 7, 2015

Welcome to the Floor, a.k.a., Why Can't You Read My Mind, You Idiot!

The third year of medical school is when the rubber hits the road. The first two years of basic sciences are all about learning to recognize (1) what can go wrong and (2) how to fix it.* Third year is when you begin rounding on the hospital floors and commence the nonstop testing of that information. I knew that I would feel a bit on edge in anticipation of questioning from the resident physicians, but I hadn't planned on the constant confusion that comes from repeated failures at mental telepathy. Apparently, being a good clerk entails not only having solid clinical knowledge, but also a keen ability to read minds.

After a couple of weeks in, I felt like I was doing a fairly decent job of shrugging it off. Yes, it is challenging to work with a dozen different doctors in one week that have a different style of doing things, but it wasn't that hard to remind myself that these same folks had the challenge of working with two new students virtually every day.

Clinic Week
Day One: Resident A, "You did well by going in to see the patient. When the card is on the door, you know they are ready. Don't keep them waiting. Bring one of us the card when you are done."
Day Two: Resident B, "Why is the card not on the door?" Me, "I took it off when I went in to see the patient." Resident B, "Always leave it on the door."
Day Three: Resident C, "Why did you go in to see the patient without me? That's inappropriate."
Day Four: Resident D, "Yes, go ahead and start a clinic note while I'm seeing the next patient."
Day Five: Resident E, "Medical students are not supposed to write notes. You can for practice, but I won't read it. It's a waste of time."

I just accepted that fact that I would do something in the first 10 minutes of each shift that annoyed the physician I was assigned to. No big deal; adapt and move on.

During week four, I was fortunate enough to work with just one chief resident with two junior residents and four attending physicians. By late Tuesday, I was in a good rhythm. I had a sense of what I could do to be helpful to the chief and how to not irritate the attendings too much. I found myself looking forward to beginning my night rotation in labor and delivery. The other student and I would work with the same two residents the entire week. It seemed like life as a clerk would become monumentally more simple. But I was wrong.

L&D Week
Day One: Resident F, "I'm not going to tell you when I'm going into a room, so you should just follow me." I nodded, despite finding this statement a bit bewildering. There were over a dozen delivery rooms. Half of the patients during any given night were in the care of our team, the others were not. We also had triage rooms to manage. To improve patient comfort, the other student and I divided the caseload so that the patient wouldn't have to deal with unnecessary people involved in her care. Follow the resident everywhere, but not into the rooms of private patients, and not into the rooms of the patients the other student was working with. It seemed as though simply saying "triage two" or "room six" could make things run a little more smoothly, but this doctor was committed to not telling us where he was going.
Later: Resident F, "Where are you going?! Don't go see a patient in triage without pulling up and reviewing her chart."
Later: Resident F, "You don't need to follow me everywhere...I'm just getting coffee."
Later: Resident F, "I'm not going to warn you again. It's not my job to tell you who I'm going to see. You'll just need to follow me."

Day Two: Resident G, "Go into her room and check on her Pit." Me,"She is a private patient; is that ok?" Resident G, "Yes, of course."
Later: Resident F, "You're a midwife?" This question has plagued me since one of my friends casually mentioned it to the Department Chair during week two. Me, "Yes, sir."  F, "Oh."
Later: Resident F, "No, no...stay out; this patient is private."
Even later: Resident F, "Why are you keeping the patient in triage waiting?" Me, "I was looking at her chart for her dating ultrasound." Resident, "You don't need to do that--hurry and see her."

Day Three: Resident F, "Go get the ultrasound." I head back to triage and push the power button on the machine. Ten seconds later, F appears, "What is taking you so long?" Me, "I'm sorry. I was told to let it power down before unplugging." F shakes his head, "This is urgent." He pulls the plug, hurries down the hall, plugs it in by the patient's bed, and then begins a conversation about increasing her pitocin or maybe going into the OR for a cesarean. A bit later, he scans her and walks out of the room.
Later: F, "Where did her ultrasound say her placenta was?" Me, "I didn't look at that before seeing her in triage, but I can look that up." He rolls his eyes at me.

Day Four: While walking out of triage room 3, F tells me, "Go plug the ultrasound in so we can scan her." Fifteen minutes later he asks, "Where is the ultrasound?" "I plugged it in for the patient in triage 3." F then rolls his eyes at me, unplugs the machine and moves it into triage 1 with the patient we had seen an hour ago. Again, highlighting his unyielding commitment to not telling students where.

Day Five: Resident G, "Sorry. Sometimes things just work out that way and you don't get a delivery." This came after I reminded her that I still needed to do a delivery and this was my last night there. And then fortune smiled upon me. The clerkship director happened to be the attending on call that night. As we were leaving a patient's room, I swallowed hard and spoke up. "Dr. Clerkship Director, I haven't been able to do a delivery yet and my shift ends in an hour. I understand that these things are beyond anyone's control, but I just wanted to make sure that was ok since a delivery is a requirement." She looked appalled. Resident G tried to explain to the director that I really shouldn't go into the next one since she was the patient I was following last night and not tonight (yes, it was a very long pitocin induction). The director scoffed, "Of course we want you to do a delivery." I stayed past dismissal time and waited for it. I stood there, with F on my right-hand side and the director on my left, each whispering different and sometimes conflicting instructions to me. But after the baby's head emerged, I naturally stepped to my right to facilitate the delivery of the shoulders and serendipitously caused F to take a single step backwards. I was in that moment...that wonderful moment when a baby takes her first breath. The world just seems to stand still and all is right. It was a beautiful ending to one of my ugliest weeks as a med student.

*Any first-years out there? How I wish those two simple concepts were in front of my mind as a first-year! Keep reminding yourself that you need to know (1) what can go wrong and (2) how to fix it, and you will be ahead of the game in figuring out which information is your highest priority to learn.

POST-ROTATION UPDATE: Despite feeling like there were a healthy number of folks in the department hoping to see me fail, I honored this rotation. Elation!

Wednesday, July 29, 2015

The Results Are In: Step One

Prior to medical school, learning various factoids about human health and physiology was down-right fun. Being force-fed those factoids ad nauseum for two years was not. I've heard it been said that medical education is a bit like attempting to take a sip from a fire hydrant. "Oh...you've got a thirst for knowledge, do you?" Within seconds, you are gasping for air, regretting that you said "yes." And though I have not once regretted my decision to enter medical school, I have frequently wished I was somehow more prepared prior to its start. The truth is, nothing could have possibly prepared me for the non-stop, rapid integration of information, but a few little tweaks in my study habits could have made the past two years a little easier.

Part way through second year, I began using Anki. Anki is a free (on your laptop, but $25 for the mobile app) flashcard program, that does more than most out there. Anki uses an algorithm for spaced repetition to help you memorize far more than you think you can. There is a great little website by Piotr Wozniak, PhD, that talks about spaced repetition in learning theory if you are interested in reading more about why a program like Anki makes sense for the overwhelmed med student. I started my first year of medical school with a different (and pricey) flashcard program that was honestly too much for me to work through. My learning became a ton more active and more efficient as I began creating my own cards (from lecture PowerPoints) or editing pre-existing decks to meet my needs. If there was just one resource to begin with, using Anki to help you plow through class lectures would have to be it. Fortunately and unfortunately, there isn't just one source! The fortunate part is that there are many great tools that can help you master the material. The unfortunate part is that med school is so fast-paced that you will probably waste precious time trying to figure out what works best for you.

As I got closer to taking Step 1, I opted to use the Doctors in Training program to guide my study time. Like most teaching tools, bootlegged copies are floating around on the Interwebs. DIT has put in considerable effort to revamp and improve their program. The 2015 version was engaging and (no...really...I'm not lying...) enjoyable. It was like having good company in the midst of my misery. I relied heavily on Pathoma and SketchyMedical to fill in the blanks and reinforce what I was reviewing in First Aid. (P.S. Subscribe to Sketchy when you are in microbiology; the payoff is huge.)

So what did the six weeks prior to Step 1 look like? In short, hell. Some days were spent speeding through 16 DIT lectures, and others were spent feeling like I could barely keep my focus long enough to get through four. I attempted to follow a more predictable, constant study schedule, but that just didn't seem to agree with my life. My friends and I would set aside times to meet up and review practice tests together. It was an invaluable part of my learning process, but that also meant each test entailed taking an 8-hour "break" from my scheduled lectures: 4 hours of questions and 4 hours to discuss our rationale on those questions. Oh yeah...and then there were those other little things like taking care to an allergic reaction that my son had, and getting my daughter settled-in at her summer internship out of town, and all those other little mommy moments that are delightfully unpredictable. But I got through it, and if you are determined enough to land your butt in medical school when others tell you that it's a selfish thing to do, and you're capable of cramming your brains into oblivion before each and every freaking exam, then you can certainly do it too!

A few weeks ago, I found out that I passed that awful thing. Having Step 1 of the United States Medical Licensing Examination behind me is a glorious feeling. Yes, I still have the two-part Step 2 exam to take before I graduate next year and Step 3 awaiting me during my first year of residency, but knowing that I've conquered the beastly Step 1 gives me the confidence to know I can see this thing through to the end. Which really means I'll soon be seeing a new beginning.

Monday, July 6, 2015

Day 1 of Ob/Gyn Rotation

Cozying up to my copy of Case Files last night was like catching-up with a friend I haven't seen in a while. In anticipation of my obstetrics and gynecology rotation, I pulled out the book for bedtime reading. I've been so nervous about this second phase of my education (from lectures to clinic) that I thought the reading would be a way to busy my mind until sleep took over. That wasn't what happened.

The Case Files series of books, as you might guess, starts each chapter with a new case, asks what the next step of evaluation or treatment is, elaborates on the answer, and then ends with a short quiz. I found myself reading the first page, formulating a response, and turning the page to discover the answer. You know when you fly into town and see a friend that first night? Your plane was late. You're tired. You've got a full-day on your itinerary in the morning, but you and that friend get to talking. The banter is so free and easy. "Oh, my goodness! I bet you totally..." "Yes, I remember that!" And time passes so quickly.

I knew that I'd be thrilled to attend births again, but I had no idea how giddy I would be to flip through our orientation material today. We got our individual schedules for the eight-week rotation this morning. A friend leaned over and asked me what I'm starting with. "Reproductive endocrinology," I squealed in a not-quite whisper. My excitement surprised me.

I've been worried about doing OB as a med student. During my career as a midwife, I have met some wonderfully helpful OBs. That said, I've met many more who would like nothing more than to abolish midwifery. And that mistrust of midwives is inculcated early on in medical education. I've had standardized, board-written questions about Erb-Duchenne palsy caused by a midwife. With well over 90% of babies in this country delivered by physicians, there are undoubtedly more cases of this condition caused by the hands of a physician than a midwife. I've even had case presentations of a baby with a genetic defect who was born at home. Why add that detail? How does knowing the baby was born at home help me differentiate the signs and symptoms of Trisomy 13 from Trisomy 18? The whole premise of tacking on to the case "born at home" is the unstated assumption that all genetic defects are detected prenatally. It perpetuates the myth that interpreting an ultrasound is just as clear-cut as an X-ray of an open femoral fracture. It also implies that midwives never order lab work or ultrasounds for their patients, and they don't believe in risk-assessment and referral. I understand why obstetricians are wary of a profession whose training model is so very different from their own, especially when exam questions reiterate that a midwife-attended birth is the source of most obstetric nightmares. And, yes, I literally shook my head as I read the midwife-attended birth questions on my licensing exam. Of the 308 questions I was asked, I'd estimate that a dozen of them had to do with embryology, pregnancy, reproductive anatomy, and the neonate. There were only three questions that specifically mentioned "birth," and of those, two were a doctor needing to clean up after a midwife.

I'm certainly not without my biases. I love that family doctors have less than half the cesarean rate of obstetricians. I'm not a fan of elective inductions, and I think newborn nurseries need to stop handing out formula samples. (It pains me a little that my hospital isn't designated Baby-Friendly.) I long to be one of the few family physicians in this country that still practice obstetrics, and I appreciate that desire will limit the places that I can work. I also love the breadth of work family doctors do! Because I had a longitudinal family medicine rotation throughout my entire second year of medical school, I was able to see a woman prenatally and then visit with her again at her baby's six-month well-child visit. My favorite days in the family medicine clinic were the ones with a diabetes check-up followed by a joint injection...followed by a 18-month well-child check-up...followed by a new OB physical...followed by a geriatric patient. (Ah! The variety of it all!)

The ob/gyn clerkship and residency directors at my school have been fantastic. They are bright, approachable, and eager to teach us. I have no doubt that I will learn a phenomenal amount over the next two months, just as I did during my family med rotation. My education and training as a midwife focused exclusively on low-risk OB. I was taught how to monitor the normal course of the reproductive year and ensure a quick transfer of care as needed. I'm ready to park my own biases at the door and learn from a new perspective. And there is just so much to learn! When a friend asked me if I was going to study tonight, I just smiled. "There are only two rotations that I truly want to Honor. Family medicine, because that's where I want to go, and this one because....well....just because."

Sunday, July 5, 2015


If it seemed as though I disappeared from the face of the Earth for a while, that's because I did. I entered the deep, dark place known as "Step studying." Oh, sure, the name sounds innocuous enough, but for those of you who appreciate Star Wars references, it was much like heading into the Dagobah System. I spent six concerted weeks honing my medical knowledge surrounded by a gloomy cloud of dread. Pass or fail. Not happy with your passing score? Too bad; no retakes.

Most of my time was spent in my tiny back office, ever-so-slowly pedaling away on my recumbent bike while annotating First Aid with the  hints, reminders, and clarifications I gleaned from review lectures. Never in my life have I studied so concertedly and consistently. My kids were shocked. "No, guys, for real. This is the big one I've been talking about. Give me some time." They dealt with my sequestration well, knowing that the longest stretch of attention I could muster usually lasted less than two hours and then I would listen to their stories or resolve a conflict or watch a YouTube video with them. My 10-year-old wisely told me one morning, "Mom, you should study hard today, but not so hard that you get tired and grumpy. But you need to study enough so that you don't get all nervous and mean." I smiled and thanked him for the advice. He just shrugged his shoulders and added, "I don't really know what I'm talking about. I've never really studied before. Hope it helps." My wild and crazy life with my children is what has kept me sane these past two years.

Studying for the first "step" of three licensing exams was a bittersweet experience. I'd have an incredible ah-ha moment as to why the drug used to treat cystic fibrosis was also an antidote for Tylenol overdose (those magically pesky disulfide bonds!) followed by a sinking, panicky feeling that I would never remember exactly which cytokine spoke to which cell. Much of the time was spent refreshing my memory of minutiae that had long ago evaporated, but a fair amount of the time was also spent integrating concepts of disease processes and treatment regimens. If I said it was enjoyable, I'd be lying. But it was immensely beneficial and will undoubtedly make me a better physician.

I took comfort in knowing that I was never alone in my study-exile. An occasional group text saying, "Ugh...Can't brain...anymore" from a friend would result in one of us finding enough personal motivation to send a cliche meme to each other. Thank you, Shia LaBeouf, for making the most inspiring speech at just the right time for us to laugh our way out of our drug-mechanism-of-action-and-toxicity-induced stupors. I think at some point, all of these "Just do its!" found their way to my phone. As each of our test-days approached, the unicorns and rainbows and other "I believe in you" messages would appear. We'd remind each other that we've spent two years studying this stuff, and solving 308 cases in about a minute a piece was well-within the scope of possible. (Solving them correctly is still up for debate as our scores have not yet been released.)

Third year orientation has already happened, and I'm eager to report to my first day of my OB/gyn clerkship tomorrow morning. A couple of nights ago my 17-year-old daughter plopped down on my bed, grabbed one of my books, and began reading PreTest questions to me. I helped her pronounce words like "cephalohematoma" and then we'd break down its etymology. After about a dozen questions, we began talking about which colleges she will apply to this fall. It's so nice to know that Step happens, then life goes on. Right now, I'm simply loving mine.

Wednesday, April 22, 2015

Ending all the BS

Today was my last day of class. The first two-years of my medical education comprising the basic sciences (affectionately known as "BS") will end on Friday, when I take my last professor-written exam. From there on out, all my testing will be done through national board exams. Before starting medical school, there is no way I could have fathomed all that I would be capable of learning in 21 months. It's odd, really...simultaneously appreciating that I have learned so much while profoundly realizing that I know so little.

I've attempted a somewhat half-hearted review of all my previous classes while trying to wrap my head around this last bit of BS I need to learn. As the lecture schedule began to wind down over the last few weeks, I've ramped up the Step Prep just a bit. After all, my first licensing exam is less than 60 days away, and I am keenly aware of knowing so very, very little.

Here's how the next two weeks are shaping up:

  • Friday. Exam over block content
  • Tuesday. "Customized" shelf exam (somewhat of an oxymoron...the Block Director selects the content area and the National Board of Medical Examiners supplies the questions)
  • Thursday. State-wide physicians' conference. I serve on a committee and am expected to attend.
  • Monday. Pathology NBME shelf exam
  • Tuesday. Pharmacology NBME shelf exam
  • Friday. CBSE-2. A repeat of that "are you really ready" assessment required by my school
  • Entering into the study cave