Rural Hospitals

I recently did a surgery rotation at an outlying hospital. It was labeled a "rural" hospital, but in reality it is only a 30-minute drive from where I live. It was a great experience. Without residents, I actually felt that I was a useful member of the team and in the OR actually got to do more than hold something that I can't see. The hospital only had something like 30 beds and I expected that any patient requiring more than a minimally complicated procedure would make the 30-minute hop to the giant academic center nearby. To my surprise lots of patients there would rather have their complicated multi-organ bowel surgery at the small 30-bed hospital (with only 4 ICU beds). Their main reasoning was that they felt comfortable in a place with familiar faces, where they knew the staff as friends or families of friends, something that they preferred over a giant maze of a hospital where you're known as a diagnosis or a room number. Also, I quickly figured out that the quality of care was the same (if not better, in some respects) than the giant academic center. True, you couldn't get a transplant or brain surgery, but for most procedures that general surgeons (or orthopedic surgeons) do, they're just as good. What's more is that things happen amazingly fast at this small hospital. There were several patients that came in with suspicious breast lumps and within a week had a partial mastectomy with pathology results in and an oncology appointment made. Scheduling several procedures across four different specialties is pretty much not possible in a large hospital. So, even though there's a lot of "outside hospital" bashing in academic centers, for the most part, they're just as good.

4th year and radiology

So, I've decided to go into radiology and am starting the last year (#8 - can't believe I've spent nearly a decade here) with a radiology clerkship. Since I last took radiology before 3rd year actually started, now that I've actually experienced a lot of what medicine has to offer, sitting behind a resident or attending while they look at images actually isn't that bad. In a previous post I complained about how med students don't get the most exciting experience in radiology, but I've learned on this rotation, that you actually can. The best way to enjoy radiology is to do it yourself. With 3rd year behind me, I can actually make a reasonable attempt at reading some images. So the advice that I've been given (which works pretty well for me) is to find a free computer in the reading rooms and look through the new studies on your own and try to come up with a diagnosis. Then when the resident or attending go over them, you'll get much more out of their discussion. Amazing how in a few weeks those images that I could make little sense of actually start being somewhat meaningful (I'm looking at you ultrasound).

Seven alternatives to evidence-based medicine

Two more days of 3rd year left... can't wait.

This article is a pretty funny (but in my experience true) description of how some doctors justify their treatment plans. My favorite:

Eloquence based medicine---The year round suntan, carnation in the button hole, silk tie, Armani suit, and tongue should all be equally smooth. Sartorial elegance and verbal eloquence are powerful substitutes for evidence.

4th year will be sweet

Just about done scheduling 4th year and it looks like it'll be nice. Right now I actually have 22 weeks off! Of course some it will be taken up by taking the boards and interviewing for residencies, as well as research (and maybe I'll add a few more rotations later on), but it sure will be less hectic than 3rd year has been. What I'm really excited about is the end of working for grades, good evaluations, exams, busy work, etc... I will finally (with few exceptions) be able to spend 100% of my time in the hospital on learning what I am interested in. I kind of wish all of med school was like that.

Burnt out

It's official, I'm totally burnt out with 3rd year of med school. The primary care rotation is pretty relaxed, but I just can't get myself to study much or do any of the mind-numbing busy work that we are assigned. I'm glad I don't have something more intense like internal medicine or surgery scheduled now. Luckily, it looks like I'll have a pretty chill 4th year (though I'm not looking forward to taking Step 2 of the boards) and I'm looking forward to the adventure of applying for residencies.

Out of the psych ward

Just got done with psychiatry. I had a great time. I was in a general adult ward where most patients were voluntary. The staff was great and the patients were very interesting. What was really cool was that in their short stay of 3 to 5 days, most patients actually got better... not something I thought would happen quickly. What was even cooler was that there were no residents, so I was actually a useful part of the team and my patients were my patients. I got to interview them first, I got to write their admission notes, I got to do their discharges. This is probably the closest I've felt to a doctor.

Just for fun, here's something amusing that happened during the rotation:

Attending (while talking to a crack addict that didn't want to stop): You need to stop smoking rock and get addicted to something else. Like this (shows a picture of his cat). You can start getting high off of this.
...
Me (later): Dr. X do you watch South Park?
Attending: Yes
Me: Do you remember the episode where they get high off of cat urine?
Attending: It's called cheesing.
...
Attending (later, to patient): You should probably ignore what I said earlier about getting high off your cat. It's called cheesing and it's bad.

Psychobabble

I just started psychiatry this week and so far, it's been pretty good. I feel pretty comfortable talking to the patients I've had so far (although, they really haven't been out there, so I've got plenty of more chances to feel uncomfortable). Although I'm glad that we don't see much of it in medicine these days, in the 3 short days that I've been on psych, I've been exposed to the psychoanalytic model (Freudian stuff) more than I'd like (including part of our formal lectures). As a scientist who believes in theories based on objective experiments, I find it incredibly hard to believe the ideas in the psychoanalytic model. I mean, it's hard to believe that there are actually trained physicians (though decreasing in numbers) that actually believe stories about things like the "oral phase," the "id versus the ego," or the un(sub or whatever)conscious. It all really sounds like the quack cult psychology books (like The Secret) that Oprah and other daytime talkshow hosts promote. I know that the mind is difficult to understand and we essentially know nothing about where psychiatric disorders come from, but do we really need to make up colorful stories about some sort of hidden internal struggle in the brain? Some ideas may be useful in developing a treatment strategy, but still using outdated ideas and teaching untestable stories seems a little backwards to me.

Jenny McCarthy as my pediatrician?

As I expected, in pediatrics I'd run into some anti-vaccine parents. They were beyond convincing (and perhaps not coincidentally, many of them were chiropractors). However, the other day we saw a patient bring her child for her two-month check-up, when the first shots are given. The mom brought up her concern about vaccines causing autism. The pediatrician said that there isn't any evidence that it's the case. Grandma then walked into the room and said, "oh yeah, I heard that the original study that showed a connection between vaccines and autism was a fraud." (yay! word is going around). The pediatrician then said, "Whenever you hear things like that you should ask yourself, if my child had an ear infection, would I ask Jenny McCarthy for advice or would I go to my pediatrician?" The mom and grandma laughed and said, "pediatrician." The baby got her vaccines and the story had a happy ending... but as I was leaving the room I thought, even though it sounds like a silly question, a lot of parents wouldn't think it's such a funny question. There are plenty of people who would be happy to take the advice of celebrities (and quacks) on their kids' health (not just vaccines) over their pediatrician's.

4 Stages of a 3rd year med school rotation

1. Confusion: You don't know when to be where. You don't know what you're supposed to do, what you're allowed to do, and what you can't touch. You don't know the right terms for anything. You don't know who to talk to. You don't know where the patients are. You don't know when to leave.

2. Productivity: You got the logistics down. You've gotten to know how the system works. You're actually being useful to the team. You're actually learning from your patients. You know when to go home without asking.

3. Burn out: You're getting tired of the routine. You're getting tired of the busy work. You're less excited about the day. There are less learning opportunities during the day. You look forward to going home.

4. Numbness: Your mind is elsewhere and your goal is to just get through the day. Unless something really exciting happens, you're not gaining much from the rotation. You find ways to get out early.

This is kind of a tongue-in-cheek thing, but for some rotations it's definitely true.

Radiology as a med student: Not always fun

Radiology is great and is still on top of my list for what I want to be when I grow up. However, as a med student, it can be pretty boring. Last week I spent some time in the neuroradiology department. My two favorite fields, neuro and radiology, combined. Yet, my 2 1/2 days with them were pretty dull. The problem is that to enjoy radiology, you have to look at and interpret images on your own. Shadowing a radiologist doesn't really make much sense. Basically, you end up looking over someone's shoulder as they quickly scroll through scans and talk to themselves (into their dictation programs). There is very little opportunity to figure things out for yourself. Luckily, during neurology and my other rotations, I've gotten plenty of chances to go through images on my own. So, this post isn't about how I stopped wanting to be a radiologist. I'm just venting about my disappointment about the neurorad week.

Peds neuro: Can it tear me away from radiology?

On my neurology rotation I was assigned to pediatric neurology, and that random assignment might have changed my career plans. I loved it almost immediately. The patient population seems great. The diseases are often very challenging. And each patient is completely different. Granted for a lot of patients there is no treatment. Although, figuring out the mystery of why something is wrong with someone's child does a lot for both the parents and the child. For those kids for whom a difference can be made, the difference is dramatic. It could change a potentially severely disabled child to a normal, healthy child. Also, adding the normal changes that a child goes through as they get older along with the neurological problems they face is an added factor that makes the field interesting. Finally, the research opportunity is limitless. There is a lot that is not known about the conditions that these kids can suffer from. For many of them there is no treatment available. Also, their disorders shed light onto my field of interest, how the brain works and how the brain's plasticity can be used to overcome their deficits.

Will I go into it? Not sure yet. Radiology is still winning, but peds neuro is a quick second. The training in peds neuro is a little strange (for most people, 2 years of peds, 1 year of adult neuro and 2 years of peds neuro - you have to go through two different matches). Also, I'm not completely sure if I really like the pediatric population... we'll see, my peds rotation is next. Stay tuned.

Reflections on OBGYN

Just finished the last day of the rotation. I was pleasantly surprised. I thought that I would find absolutely no interest in it, but really, it wasn't what I expected. It is a field that encompasses a wide range of patient populations and covers almost every other branch of medicine. My favorite part was OB. First, from a purely scientific point of view, what happens to human physiology during pregnancy is simply amazing. When looking at an obstetric patient, you might as well forget normal physiology and normal lab values that you learned in internal medicine (for example, the white blood cell count, which is normally below 10,000, with a really bad infection being 20,000, can go up to 30,000 during normal labor). Then there is labor and delivery. It's something that is nice most of the time, but every once in a while it gets very scary and very sad. It's the one time that people are hospitalized for something that is completely normal and the expected outcome is not to make them better, but to make sure nothing goes wrong. Delivering babies is pretty fun, but watching the emotions of the people in the room affected me more. There are some interesting social dynamics in the delivery rooms also (like the patient who wasn't sure who the father was and was waiting until she saw the skin color of the baby before giving her a last name or the woman at 43 1/2 weeks gestation who refuses any medical intervention). Overall, each patient is completely different and OBGYN is a branch of medicine that combines the solving-a-mystery aspect of internal medicine with the get-in-there-and-fix-it aspect of surgery. No, I don't want to go into it, but I definitely had a lot of fun in the last 6 weeks.

8 more hours to go

I'm on night duty on labor and delivery this week. This is my second night, and although it is cool (I've gotten to deliver a couple of babies), it is pretty damn tiring. I'm actually pretty good at staying up at strange hours and can handle being on call overnight every once in a while, but working nights day after day is not easy to get used to. I'm a med student and don't have nearly as much running around as the residents do. How do they do it? It just seems really dangerous to have overworked and sleep deprived people dealing with emergencies. I guess they get used to it (or learn to sleep during the day better than I can). 5 hours down, about 8 1/2 to go.

An unreasonably natural labor

Being in OB and expecting a child makes me see many sides of being pregnant and labor. I see pregnancy and childbirth as a natural process and think that there are some physicians who "medicalize" it too much (C-section rates are higher than the should be, people are induced more than they should be, etc.). So, I see the why people would want "natural" childbirth, with no medical interventions (like pain control). But, the extent to which some people take it is completely, in my opinion, unreasonable.

Case in point is a woman who recently delivered at our hospital (she was not my patient, so this is second hand). Things went relatively smoothly and, except for receiving a small perineal tear, she was able to successfully go through labor without any medical interventions. The baby was born relatively quickly and was completely fine. The woman just needed the tear sutured and was otherwise fine. When the resident explained that she will numb up the region around the tear with some local anesthetic before suturing, the woman became angry and was adamant she wanted a natural birth without any "chemicals."

Kind of ridiculous. But, childbirth is a highly emotional time and whenever people are dealing with emotional events, they tend to stop thinking rationally.

From one end to another

That's what my Pathology attending said when I said I was doing my OB/GYN rotation next. I suppose he meant from one end of life to another (it could have also been from one end of the body to another, since I focused on Neuropathology). I started OB this week. We switch teams every week or so. Right now I'm alternating between an infertility clinic and an OB clinic. I haven't seen enough to comment on (although some of the infertility treatments are pretty clever), but it is nice to be expecting our own baby while on this rotation. It not only motivates me to study a bit more, but it definitely helps relate to what the patients are going through (since I've seen Mrs. mxh go through a lot of the same already). It's also a bit reassuring, since it has made me realize that a lot of the fears and problems that we've had so far are very universal.

Done Surgerizing

As you could probably tell from the frequency of posts in the last 2 months, surgery was not the most leisurely of clinical rotations. But it wasn't too bad. Maybe it is just our school (or just my experience), but the hype over how much work it is and how much pimping is involved is a bit overblown. Yes, it sucks getting up at 4:30 am everyday, but once your there (and awake) most of it isn't "difficult." I rarely got pimped (in fact there was only one time where I may have felt uncomfortable), I was rarely given any scut work and (this may have been a fluke because of some national conferences) I actually had time to read. Still, I quickly decided (after about 4 days) that it's not what I want to do with my life. What I loved about medicine was the opportunity to get a complete mystery and solve it with clues from your history, exam and labs. In surgery (for the most part) that is already done for you. It's a much more get in there and fix the problem kind of job. Don't get me wrong though... most of the surgeries were really cool. There are a lot of clever approaches to fixing otherwise very disabling problems (like making a bladder out of intestines). And there's nothing like cutting apart someone, hacking at bones, chopping up intestines and seeing the person functioning pretty much as normal a few days later. Here are some quick goods and bads:

Goods:
1. Most of the procedures are awesome - something not too many people get to be (somewhat) actively involved in.
2. There actually is thinking involved - surgeons have a lot of thinking on their feet to do when something unexpected happens intraoperatively. It's not just for jocks.
3. Results - for the majority of patients, the surgeries actually work! It's amazing to see the overnight transformation in patients.

Bads:
1. Hours suck - When med students are violating national hour-limit laws, I don't want to know what the residents are doing.
2. Not much to do for the student - unlike medicine where you can follow labs, actively discuss your patient, in surgery the most you get to do is throw a few stitches, hold retractors and get to open your mouth once every half an hour or so. There is a lot of standing around not doing anything, which sucks when you have to get up so early.

Advice:
1. Ask questions, very few people are enough of an asshole to call your question stupid (you'll figure out who those people are and avoid them).
2. Try to do as much as possible, ask (if you actually think you can handle it) if you could do it. This isn't a rotation to be quiet and timid on. You'll have a pretty boring experience if you don't try to actively get involved in whatever the team is doing.
3. Don't kiss ass. This goes for most rotations, but students interested in surgery tend to be the worst. Everyone ends up hating the person (including, I presume, the attending).
4. Don't fret over studying for pimping. Study what is important for your exam, but don't spend hours reading about details of an operation that you'll never think about again. The reputation of pimping is overrated... it is not what you should be worried about.
5. Always have something to read in your pocket. That way you'll read what you need for the day in your downtime, giving you more time to eat and sleep when you get home.
6. Don't volunteer for scut work just because you think it will give you a better grade. It won't and it'll be a complete waste of your time.
7. Have fun. You may never get to experience being in the OR again, so try to make the most of it. This is especially important to remember towards the end, when you're completely burnt out.

Despite the fact that it wasn't too bad... I gotta say, woohoo!! My two (supposedly) most difficult rotations of medical school are behind me. Now I get a relative vacation with 2 weeks of pathology before starting OB/GYN, something I have no interest in, but at least having a baby on the way will somewhat have me caring.


And remember, Jesus is with you... though he'll definitely get yelled at by the scrub nurses

Surgery

In medicine, you barely have enough time for TV. In surgery, you barely have enough time to eat and sleep. Not for me.


Although taking this monster out of someone's neck is pretty cool

The end of internal medicine

Well, at least the end of it for me (for now). Wednesday was my last day of the internal medicine rotation and the last two days were the end-of-rotation exams. The rotation itself was actually pretty fun. There was some waiting around not doing anything and there were times when I felt pretty useless. But, overall, I learned a lot, saw a lot of interesting cases (and a lot of not so interesting cases), got to feel like I was the part of a team taking care of people, and got a chance to get to know some interesting people.
Do I want to go into internal medicine? It's hard to say since I only got to experience what life is like for hospitalists. I only saw the specialists tangentially. I wouldn't want to be a hospitalist (things are too hectic and once you see something interesting, you call a specialist). However, from what I saw on the wards, infectious disease and rheumatology appealed to me the most. There is a lot of detective work in both of them and a diagnosis could quickly lead to an effective treatment (Interestingly, these were the two fields that I felt I was the worst at when it came to exam questions). Radiology is still at the top of my list, but going through a more patient-based rotation does make me consider other options. We'll see as the year goes by.

Some advice...
- enjoy your time, at least with my experience, there really wasn't any pimping. There's no reason to feel stressed.
- don't let your first few days' experience set your mood for the rotation. Every time you have a change there is some awkwardness and confusion. It will also take a few days for your team to get warmed up to you. You'll find your place soon.
- don't feel like you have to stay on the wards forever. If someone tells you to leave, leave... it's not a test. You've got a lot of studying to do, and everyone on your team understands that. If nothing is going on, ask if there's anything you can help with, the answer will be "no", and you could leave.
- Spend extra time with your patients. You've got the luxury to actually spend time with your patients. If they're up for it, spend some extra time with them. The more you know about your patient, the better resource you are for the team (plus, the patient will trust you more than the rest of the team, if they've made a connection with you).
- If your school allows it, try to get some experience in a different hospital. It'll give you a better idea of what's constant and what's variable in internal medicine.
- prepare to feel defeated if you're taking the SHELF (nationally standardized) exam. Holy crap the SHELF exam sucks ass. None of my studying prepared me for that test. Even knowing what the exam was like, I don't think I could have effectively studied for it. It is not a good assessment of how much you've learned on the wards. I've never came out of an exam seriously thinking that there's a possibility I could fail until now. Luckily, everyone else in my class felt the same. And from people who have taken it in the past, the results end up being better than you expect.

Now I get a whole weekend off before Surgery starts on Monday. I start with ENT, then have Orthopedic surgery, followed by a month of general surgery.



Old song, but it's been stuck in my head ever since I saw a patient with Wenckebach heart block last month

I take (some of) it back

So a week into my rotation in a more rural setting, I'm feeling a bit better. Last time I complained about several things, the most worrying of which was a lack of effort in teaching by the residents and attendings. I don't think I was being completely fair, since comparing a large academic hospital with a smaller rural hospital is not appropriate. The residents and attendings don't see too many medical students, so it makes sense for them to not know where we fit in the scheme of things. It took a few days, but things are going more smoothly now. Although I don't feel nearly as productive as I did at my home hospital, I also don't feel like the burden that I did for the first few days. Also, I know it's difficult for them, but they've gotten better at thinking about what would be beneficial for a med student to see or do. Hopefully the next three weeks will continue moving in the right direction.


P.S. paper charts still suck

P.P.S. everyone really is a Republican, but the blatant anti-healthcare reform postings have been removed.

More rural internal medicine

I am now in a different part of the state, in a relatively small town at a hospital catering to small town communities spread over this region of the state. I'm not exactly happy with the differences in how things are run from the major academic institution that I'm used to, but I'm hopeful about what I'll gain here. Here are some differences:

1. Less specialists - there are still consults, but (so far) the consult team seems less like they run the show than they do at my academic institution. Patients with an MI are seen by cardiology, but are not necessarily taken care of by a cardiology-specific primary team. This is good news for me because I will likely get exposure to a wider variety of patients than I did back at home.

2. Slower pace - my service caps at 6!!! That is considered a light day back at home. Also, you can only take patients on your call day!! As a result everything else goes at a slower pace. I thought it would be a good thing to have more time to think about, discuss and care for each patients, but really, I think the result here is that people just work slower. On the bright side, I get out earlier.

3. Teaching - I can't say much about this since I've only been with my team for a day, but people seem less enthusiastic about teaching here. I'm pretty proactive with asking about what's going on with each patient, but it seems like I've had to ask several times to get an answer. When coming up with a plan, the resident and intern usually quickly talk about it (quietly) with each other, leaving me out and forcing me to ask more questions than should be necessary (the lack of electronic charting makes it even worse). Finally, the answers to my questions are usually very short. For example, when I ask "Should we be concerned for a pulmonary embolism?" they say "No it's not a PE" versus at home where they actually explained what argues against it. I feel a lot more like a burden here than a part of the team. Maybe it was just today (or just the specific people I've been working with), so hopefully I'll feel better about it when I get more familiar with how things are run in the next few days.

4. Paper charts - I don't care what people say about electronic charting, but paper charts just plain suck. We live in the 21st century and shouldn't have to hunt around through dozens of pages of poorly written and half-torn sheets of paper to find what we're looking for.

5. Everyone's a Republican - I expect this in more rural parts of the state, but everyone (nurses, attendings, and patients) leans pretty far to the right. I just can't respect a physician who actively watches Fox News in the break room (actually, I fear for their intelligence) and I'm really concerned about the fact that propaganda against health care reform is posted all over the nursing station. It's not fun to work in a politicized environment, especially in such a hierarchical system as a hospital.

Hopefully my opinion of this half of my internal medicine rotation changes in the next few days, but if it doesn't, at least I'll appreciate going back home (even if it is for surgery).