Okay, one more Blink-related post (see previous post for introduction to this text). Gladwell seeks to examine the role of snap judgments in the setting of difficult police encounters. He explains that “in interviews with police officers who have been involved with shootings, these same details appear again and again: extreme visual clarity, tunnel vision, diminished sound, and the sense that time is slowing down. This is how the human body reacts to extreme stress, and it makes sense. Our mind, faced with a life-threatening situation, drastically limits the range and amount of information that we have to deal with” (224). However, one can only hope this is how we react to extreme stress. “Dave Grossman, a former army lieutenant colonel and the author of On Killing, argues that the optimal state of ‘arousal’– the range in which stress improves performance — is when our heart rate is between 115 and 145 beats per minute…’after 145’ Grossman says, ‘bad things begin to happen. Complex motor skills start to break down. Doing something with one hand and not the other becomes very difficult…at 175, we begin to see an absolute breakdown of cognitive processing…’.” (225). The absolute breakdown of cognitive processing, what could be more petrifying? As a future ER physician the ability to remain composed, to filter unnecessary outside noise, to perceive with visual clarity and achieve “the optimum state of arousal” is essential to success. It is essential to saving lives. I began to evaluate my own personal abilities in this arena. I have been told by friends and family that they admire my ability to stay calm and focused when the energy of a situation is heightened. But what situations have I truly experienced in which these skills have been properly tested, especially clinically? Shockingly they don’t leave medical students in charge of life-threatening situations too often. Yet, I wondered if I’d had a taste of optimal arousal at 115 – 145 beats per minute during a challenging situation. I guess you could say I’ve had a small glimpse.

It was my third rotation of third year. On our first day of our elective anesthesia rotation my friend and I met with the clerkship director who told us “this rotation is whatever you make it, no one would notice if you weren’t here.” As a fourth year student those were be the greatest opening comments one could ask for, but as third year students my friend and I were hoping for more guidance. This was our first lesson in truly becoming self-directed learners as we shamelessly harassed the anesthesiologists and CRNAs to let us intubate and be involved in interesting cases. Receiving even a molecule of attention was the most difficult part of the rotation — with the exception of the days we chose to practice IV placement with our favorite pre-op nurse, who was wonderful. Each day I would remind my friend that we essentially pay $200 per day for medical school, and I wasn’t going to leave until it was a “$200 day.” For weeks I honed my procedural skills, focusing on beginning to feel competent intubating in a controlled setting. It was my last day of the rotation and I had worked up the chutzpah to ask to do the airway for a case being run by a particularly…intimidating anesthesiologist. I walked in the operating room to find the following cast: a CRNA who had yelled at my friend, the intimidating anesthesiologist (she was migrating from room to room so I didn’t expect her to be there), a notoriously medical-student-unfriendly surgeon with his arms crossed, one of my other colleagues on her surgery rotation, and what seemed like an excessive amount of technicians and nurses. Heart rate climbing — at least 100 beats per minute. “You only get one shot, I don’t have time for this,” remarked the surgeon. Now I was probably around 130 beats per minute. I steadied myself behind the patient’s head with my hand gently upon the non-rebreather mask. I preoxygenated, the anesthetic and paralytic were administered, head-tilt-chin-lift, carefully I scissored open the patient’s mouth and place the blade inside. The patient was stable but I was on the surgeon’s clock and the anesthesiologist’s responsibility. I had placed the blade too deep and I knew it. “I don’t see the chords just yet,” I stated calmly. I could feel the tension build as the CRNA and anesthesiologists hovered behind me. “I’m just too deep, I think I know how to adjust”, I said, seemingly ignoring the surgeon’s “you get one shot” declaration. Extreme visual clarity, tunnel vision, diminished sound, and the sense that time is slowing down. To some degree, I felt this — the whole room was watching, but my world was entirely centered on the intricate anatomy of the patient’s airway. I readjusted the blade up, visualized the chords and slid the endotracheal tube into position. The CRNA listened for breath sounds as I watched watched the CO2 waveform on the monitor and the end tidal CO2 detector change color. “Alright good,” the anesthesiologist remarked as she relinquished a fraction of a compliment with a palpable reluctance. I left the operating room, and met my friend as I was grabbing my bag. “You’re heading out? I guess it was a $200 day?” “It was.”  

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Source:

Gladwell, Malcolm. Blink:The Power of Thinking Without Thinking. New York, NY: Back Bay Books/Little Brown and Company, 2005. Print.

How do you know you’re a nerd? When you essentially end up writing a book report during your free time on a snow day.

I intend to saturate the second half of my fourth year of medical school with an abundance of enriching experiences: travel, new hobbies, old friends, reflections, libations, celebrations, etc. Oh, and of course more writing! I’m currently working my way through my reading list, and I recently finished Malcolm Gladwell’s Blink: The Power of Thinking Without Thinking, which has been on my list…forever (it was published in 2005). For those unfamiliar, this novel tackles the challenging subject of good and bad decision making, and the art of making snap judgments. It is a thrilling ride of endless examples exposing the consequences of “conscious deliberation [versus] instinctive judgment” (269). Ten pages into the book Gladwell describes the Iowa gambling task, which involves participants turning over cards from four decks (two blue and two red): each card either loses or wins the player money, and the goal is obviously to maximize profit. The red cards are essentially a “minefield” with high rewards and high losses, while the blue cards offer a steady payout. The scientists at the University of Iowa discovered it takes roughly eighty cards for the participants to confidently state they understood the pattern — “we have some experiences. We think them through. We develop a theory. And then finally we put two and two together. That’s the way learning works” (9). Participants additionally stated that after fifty cards they had a hunch regarding the pattern; the Iowa scientists explored this idea by hooking each participant up to a machine that evaluated physiological parameters consistent with the stress response. Turns out, the participants began generating stress responses after only ten cards, and then began to change their behavior accordingly. Gladwell inquires ”what does the Iowa experiment tell us? That in those moments, our brain uses two very different strategies to make sense of the situation. The first is the one we are most familiar with. It’s the conscious strategy. We think about what we’ve learned, and eventually come up with answer. This strategy is logical and definitive. But it takes us eighty cards to get there. It’s slow, and it need a lot of information. There’s a second strategy, though. It operates a lot more quickly. It starts to kick in after ten cards, and it’s really smart, because it picks up the problem with the red decks almost immediately. It has the drawback, however, that it operates –at least at first–entirely below the surface of the consciousness” (10). Wow, could these concepts be any more imperative to my future career as an Emergency Medicine physician, I asked myself? Learning to make decisions in the blink of an eye? Of course, the utility of Gladwell’s concepts in the ER setting is by no means a novel idea, in later chapters he focuses extensively on Cook County Hospital’s development of the Goldman algorithm for evaluation of acute chest pain. But needless to say, I was eager to learn more about his theories.  

As I continued to read and reflect I realized how familiar I am with some of what Gladwell is essentially describing — the concept of intuition . For as long as I can remember by mother has always said “trust your intuition” or “what does your intuition tell you?” Even before I could probably spell intuition. I continued to examine the role this has played in my life — had my intuition, my gut feeling, my ability to “thin-slice” (which Gladwell refers to as “the ability of our unconscious to find patterns in situations and behavior based on very narrow slices of experience”) ever truly failed me? I then began ruminating over instances when the utilization of intuition, thin-slicing and snap judgments had intersected with my career. In considering my EM rotations over the summer I recalled moments, patients or interactions with faculty where I ignored my gut feeling.  As an educated individual this is where I know I should provide specific examples, but my intuition  informs me that these details should remain nestled in my noggin. The point is, why did my reliance on these subconscious decision making skills not always translate to my experience as a medical student? Not to worry, Gladwell had an answer.

While Gladwell fills his novel with an abundance of examples illustrating the capabilities of the human instinct, he certainly does a fair job of acknowledging that “our unconscious is a powerful force. But it’s fallible, it’s not the case that our internal computer always shines through, instantly decoding the ‘truth’ of a situation. It can be thrown off, distracted, and disabled. Our instinctive reactions often have to compete with all kinds of other interests and emotions and sentiments (15).” This struck a chord. Distracted and disabled were accurate descriptions of the state of my instincts recently, and as an individual keen on perpetual self-reflection (oftentimes to my own detriment) I had been searching for clarity in hopes of achieving any degree of self-improvement. It became clear to me that I let the emotions and sentiments of my fourth year overpower my developed ability to decode the “truth of the situation,” a skill that I was certain to be a strength in my personal life. Gladwell opens Blink with a powerful example of the experience of Getty curators in their controversial pursuit to identify the authenticity of Greek sculpture — many experts were recruited to evaluate the statue, and within seconds sensed varieties of “intuitive repulsion” which informed them the statue was fake. However, the curators at the Getty spent fourteen months convinced the statue was real, somewhat do to compelling data, but mostly “because the Getty desperately wanted the statue to be real. It was a young museum, eager to build a world-class collection, the kouros was such an extraordinary find that its experts were blinded to their instincts (14)” I think this is something to be aware of — we all are all acquainted with situations in which we let our desire for an outcome or achievement cloud our intuition as we become fraught with over-thinking that is charged by emotional undercurrents. Instead of embracing my instincts in a display of confidence, I had recently become withdrawn under the burden of over-calculation. After advancing towards these conclusions I then asked myself, I feel confident using snap judgments in many areas of life, but was it appropriate for me to have these skills in the infancy of my medical training?      

Gladwell points out to readers that “it is striking, for instance, how many different professions and disciplines have a word to describe the particular gift of reading deeply into the narrowest slivers of experience. In basketball, the player who can take in and comprehend all that is happening around him or her is said to have ‘court sense.’ In the military, brilliant generals are said to possess ‘coup d’oeil’ – which, translated from the French, means ‘power of the glance:’ the ability to immediately see and make sense of the battlefield (44).” In the ER I was constantly being exposed to outstanding physicians with incredible clinical gestalt, medicine’s own “coup d’oeil,” if you will. And these outstanding physicians expected me to show them how my clinical gestalt was developing, essentially what kind of court sense does this student have? Initially I struggled with this, not because I wasn’t confident or had a lack of medical knowledge, but rather because I recognized and respected how humbling medicine, especially Emergency Medicine, is and I had to reconcile the relationship between confidence and humility regarding by own instincts. These were my first lessons as a future ER doctor. Learning to stand at the following intersection: both having confidence in “the ability of our unconscious to find patterns in situations and behavior based on very narrow slices of experience” and acknowledging Gladwells final conclusions: “It’s the kind of wisdom that someone acquires after a lifetime of learning and watching and doing. It’s judgment. And what Blink is — what all the stories and studies and arguments add up to — is an attempt to understand this magical and mysterious thing called judgment (260). You’ll never learn to trust your intuition if you don’t practice developing that trust within yourself and recognize the complex relationships and influences that affect our instincts. All I can ask for in moving ahead is to cultivate excellent judgment, which I finally feel to be less overwhelmingly “magical and mysterious,” but rather beautiful and powerful.  These reflections have allowed me to make a conscious effort to trust my intuition, acknowledge it and how it might be overshadowed or manipulated…and most importantly have confidence in my developing coup d’oeil. So far, it’s going pretty well. 

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Source:

Gladwell, Malcolm. Blink:The Power of Thinking Without Thinking. New York, NY: Back Bay Books/Little Brown and Company, 2005. Print.

Scanning through endless records prior to seeing my new patient I came across one of my favorite phrases: “patient is a pleasant 92 year old man.”  When patients are described as “pleasant,” it usually means they enjoy your company and have a lot to say. Admittedly, I also have a soft spot for elderly patients. I suppose this stems from my belief that we as a society need to do a better job of respecting our elders. It also stems from the enjoyment of hearing an elderly person say exactly what is on their mind; witnessing someone unapologetically express their truest self becomes the purest form of comedy, and incites the deepest form of envy. Needless to say, I am consistently very eager to talk elderly patients.

I entered this particular nonagenarian’s room quietly as it was evident he was curled up in his bed asleep. I gently patted his shoulder and spoke his name, first softly and then progressively louder. Once I had reached a substantial volume he finally woke up and yelled “wwhaaaa?” I pulled up a chair next to him and asked if we could talk. I won’t tell you about his medical history, firstly for the purpose of protecting his privacy, and secondly because we didn’t discuss it much. His dementia rendered him a poor historian regarding his medical conditions, but what he chose to focus on was his diagnosis in relation to when his wife had passed away four months prior. He recounted how they had met fifty years ago, tripping on his words as they caught in his throat in between spells of openly weeping. Initially I was uncomfortable, not because of his swift outpouring of emotions, but rather the juxtaposition of his despair and the comedy of the content of his stories. “My wife, she didn’t want any children. So, instead we had two pet pigs! But one winter we had to eat them” he recalled, barely able to articulate this tale without his dentures becoming completely displaced. “Oh!” I responded, repressing a laugh and trying my best to be respectful. We chatted for twenty more minutes as he wrestled with the painful sentiment that his mortality was directly coupled with his wife’s death. “I just want to be with her,” he repeated over and over.

On the surface the concept of an individual’s longevity being connected to an independent (or arguably interdependent) entity is nothing new. So many of us have heard stories of one person passing away shortly after his or her significant other does. The idea that our patient’s longevity might be directly influenced by forces external to the immediate medical treatments is a consideration that I feel is often overlooked. What can we, the medical team, do to address these additional influencing factors? Do we forget, when breaching the uncomfortable topic of mortality, to ask patients not only if they would want to be resuscitated, but also about the factors that keep them fighting to live each day? My patient was 92 years old and the conversation of his code status was, for him, not centered around his age or diagnosis, but rather the fact that he didn’t see a point in fighting for a life without his wife. The presumption that an individual’s longevity is linked to a separate person (or ability) is something my family deals with regularly. My grandmother is 93 years old and suffers from Alzheimer’s Disease. Each time we visit she constantly reminds us how thankful she is that her little Schnauzer is there to keep her company. This dog, unfortunately, has diabetes and related complications which has rendered her rather ill. My grandmother has the resources to provide care for her beloved little companion and my father, as her POA, respects that she chooses to make her dog’s healthy a priority. It is the opinion of many family members that my grandmother’s longevity is directly linked with her little buddy. While superficially this may appear simple, the reality is far more complicated. How do we make sure to address factors that are important to our patients and their longevity? What happens if they don’t have the resources available to help them nurture and experience the things in life that are most important to them? Do we often, as providers, overlook these personal aspects of our patient’s will to thrive? When having this difficult discussions in my future career I aim delve beyond inquiring whether a patient would want a machine to help them breathe, and always remember to ask further questions about their support system, their goals, and if there is anything we can do to help (even if I am in a rush). Sometimes a Schnauzer’s special diabetes-friendly kibble is much more important than we realize.    

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 This ended up being a fun version of my personal statement for my residency application. It started as an exercise to get ideas flowing, and then turned into a entertaining piece! 

This is a 26 year-old female with a past history of Emergency Department volunteering, Emergency Medical Technician experience, and Emergency Department scribing who presents with the need to find the appropriate residency. Symptoms began three years ago in the Emergency Department while working as scribe; patient began experiencing the unusual side effect of enjoyment while charting, likely secondary to environmental factors which included exemplary physician role models and unparalleled feelings of working with a highly effective team. Patient was prescribed “open mindedness” during medical school, but symptoms of Emergency Medicine enjoyment persisted as evidenced by a strong interest in trauma during surgery rotation, a love for the acute cases in cardiology and neurology, an intense desire to work towards identifying and treating sick children during pediatrics, and an unforeseen comfortability with psychiatric patients. Patient also noted to engage in activities such as being a member of the Honor Board and Sports and Fitness Club that likely intensified the need for a career focused on quality leadership as the foundation for success. Patient reports palpitations upon witnessing the incomparable teamwork in Emergency Medicine, noting this to be the only remedy when battling the opera of chaos that frequently characterizes the department. Review of systems is negative for fear of hard work, fear of the undifferentiated patient, or fear of bodily fluids.

Past medical history includes adrenaline addiction with associated surfing injuries, marathon-running-induced stress fractures, and a transient episode of intense facial pain secondary to skydiving. Family history is negative for other healthcare workers, but positive for persistent support. Social history is notable for a strong commitment to community and diversity as indicated by involvement with the local healthcare clinic; patient reports sudden onset motivation to treat the underserved and underinsured community after moving to North Philadelphia and receiving a considerable dose of insight into the social determinants of health. She is now dedicated to making a meaningful impact on these communities with her willingness to serve anyone that walks through the door. Patient denies cigarette use, but in regards to enthusiasm for treating patients of all ages, races, and varieties of illness, she “smokes” the competition.

Based on this history, it suggests that this patient’s chief complaint is associated with a variety symptoms. She wishes to treat high acuity patients, she understands the necessity of leadership and teamwork, and she aims to help anyone in the community she serves regardless of socioeconomic or insurance status. Given these findings, my differential diagnosis includes Emergency Medicine vs. Emergency Medicine vs. Emergency Medicine.

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I usually approach each post with the purpose of outlining an idea, lesson, observation or reflection. This particular post is merely for the purpose of remembering an experience that was profound in its own right.

Sweat began to seep through my scrubs as my body rejected the prison of lead that we are encouraged to wear for protection in the trauma bay. I had just removed my disposable gown when we got word that a second trauma was coming in: Level A, male in his 40’s, found down at the side of the highway next to a bicycle, unhelmeted, waxing and waning level of consciousness, 5 minutes out. I swiftly put on a fresh gown and assumed my position at the foot of the bed, trauma shears in hand. Our patient rolled in, offering only occasional answers to our questions; he told us his head hurt. It was decided that he should be intubated and quickly rolled over to CT scan. I stood in the room adjacent to the scanner with the trauma attending, it was the third level A trauma of the night and he had yet to be impressed. “Oh. Damn. Look at this,” our attending commented as he viewed the frontoparietal skull fracture that extended the length of the patient’s cranium. This particularly nasty head injury had, most importantly, resulted in bilateral subdural hematomas and bilateral subarachnoid hemorrhages, in addition to the skull fracture. For those readers less familiar with this terminology, there was a lot of blood, in a lot of places, compressing this patient’s brain. Bad news. Our patient was admitted to the SICU were I would have the opportunity to continue assisting in his care. It was 3 weeks into my SICU rotation, and I was enjoying the continuity of seeing patients in the trauma bay and then following them in the unit. What I wasn’t ready for was the degree to which I would see this case through.

From an educational perspective this case was a tremendous and challenging learning experience. The principles behind managing an individual with a traumatic brain injury can be summarized as follows: the cranium is a fixed, closed space which allows little room for bleeding and/or swelling. Primarily, the goal is to do all we can both medically and surgically to prevent pressures in the skull from getting too high; if this occurs, the brain can herniate through the base of the skull, resulting in death. We also aim to make sure the brain has adequate blood supply, despite the compressive forces. The concept is to use medical interventions to achieve specific parameters that function to minimize the metabolic activity of the brain…essentially the brain needs a tremendous amount of rest. Now, back to our patient.

The night that this patient arrived I happened to be on a 24 hour shift, and I observed him as he struggled through his first night. We were doing all that we were supposed to. He was in a quiet, dark room with the head of the bed elevated. His neurological status was being evaluated every hour. He was heavily sedated, his pain was controlled, he was given hyperosmolar therapy, kept normothermic, and had the appropriate blood pressures and ventilator settings. Despite this, his neurologic exam began to decline and another CT scan indicated that the bleeding had worsened. The neurosurgery team placed a device to monitor his intracranial pressures and then another device that could both monitor ICP and remove the excess fluid in his head. At this point the chances of a meaningful recovery after this degree of insult to the brain was minimal. In parallel to challenging medical aspects of this case, we were having a difficult time tracking down any family members. Eventually, one of our phenomenal caseworkers was able to make contact with the family; once as the bedside, their reaction to the situation was complicated. The family explained that this patient was an intellect, an accomplished historian on track to becoming a professor at a very prestigious university. It was revealed that sometime in his late 20’s he was diagnosed with schizophrenia. Instead of seeking treatment, he self-medicated with alcohol for years, and would ride his bicycle while intoxicated. Essentially, they saw this accident as…‘a long time coming.’ They also explained that the he greatly prided himself on his intellect; this was the aspect of himself around which he assigned the most value. His family explained that he would not want to live when the most important part of himself had suffered such tremendous injury. After some careful consideration, the family met with Gift of Life and consented for organ donation.

“This is a unique opportunity, Amy. You should definitely go.”  Me? Go?? To the organ procurement??? I was nervous. But I nodded vigorously and conveyed my enthusiasm to the team. I walked back into the patient’s room, physically navigating the forest of IV poles, while emotionally navigating this delicate moment with the patient’s family. I explained that I would be going down to the operating room with them. They were very kind. We waited for the transplant surgeon to arrive from another hospital while struggling to properly oxygenate our patient. Like a brass instrument with faulty pipes, I can still hear the sounds produced with every squeeze of the bag as we forced air into lungs drowning in fluid. We arrived in the operating room, which was a sea of unfamiliar faces. I introduced myself to the transplant surgeon who explained the events that were to follow: “First he’ll be sterilely prepped as we would for any surgery. All the instruments will be set up, he’ll be hooked up to the monitor, etc. Then, we will place a large drape over the body and another drape over the instruments. His head, of course, will be exposed. We will then invite the family in to stay their goodbyes. He will be extubated and disconnected from the ventilator. I expect death to come quickly for this man, but typically patients must die within an hour in order for organs to be procured. Once there are no signs of life, time of death will be called, the family will exit, the drapes will be removed, and we will get to work. For all of that you must stay out here with me. You either can be on the side where you withdraw care or on the organ procurement side, but not both. We don’t want there to be any conflict of interest. Any questions?” Conflict of interest? I thought to myself, realizing the surgeon probably wasn’t aware that I had spent the last week with this patient. I think we are beyond that now. I didn’t say anything.

Time of death was called within ten minutes. The surgeon and I entered the room and the first (and only) incision was made extending from the sternum to the suprapubic region. After sawing through the sternum, he cut through the superior vena cava and the descending aorta in order to place a catheter that would drain the blood. There was so much blood. Freezing cold saline was running through the patient’s veins as we battled against time for preservation. In these moments the experience became scientific and emotionless. It was the best anatomy lesson I had ever received. I was no longer the medical student squished against the foot of the bed during surgery, I was clamping the aorta, dissecting lymph nodes, and holding the heavy, fluid engorged lungs that only an hour prior we were trying so tirelessly to oxygenate. With a sense of abandonment born from the understanding that he was already deceased, I soaked up every opportunity for experience and knowledge. The kidneys were carefully removed by the surgeon and placed in ice water. At this point you may be thinking that the title of this piece is rather…insensitive or inhuman, which is fair. But with his face covered, and organs carefully resting in multiple places around the operating room, there was a powerful disconnect between body and human. The surgeon gave me the opportunity to close the body, I took my time to at least make the incision appear decent. We removed the sterile drapes and I viewed this patient as a whole; lying there, naked, with the pale yellow hue of an exsanguinated individual. I have seen people die, but this was different. This is what death actually looked like, and this I will never forget. 

I ripped off my gown, removed my face mask, and thanked the surgeon and Gift of Life team. As I made my way back to the ICU I took a moment to reflect and acknowledge the privileged position I am in; the position that allows me to care for patients and their families as they make difficult and selfless decisions to both preserve the integrity of their love ones, and make efforts to benefits others in the process. I allowed myself to reflect on and acknowledge the incredible trauma and ICU teams that work tirelessly everyday to save lives, as well as those who dedicate themselves to the exceptionally important job of helping those with mental illness.

Once I arrived in the ICU I printed out a new patient list and caught up with the team. It was only 8:00 pm and I was on my last 24 hour shift of my ICU rotation. I regrouped, ready to help those sick patients on our service. As I chugged a bottle of iced tea to replenish the fluid lost while sweating through each stitch in the OR, the trauma pager went off. Level A trauma. ETA 5 minutes. And off we went.  

**Some of the information has been changed to protect this patient’s privacy.

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“No, but we literally cannot win,” my roommate lamented as we sat, still scrub-clad, sunken into the living room couch as I traced my name through the condensation on the bottle of bud-light lime I was holding. Another exhausting week of medical school complete, my colleagues and I always seem to circle back to the same topic of discussion. Prior to beginning my clinical years of medical school I had always anticipated grasping real-life pathophysiology while attempting  to develop clinical gestalt would the most daunting challenge of these years. Don’t get me wrong, these tasks are incredibly demanding, but what I had not expected was the challenge of constant adaptation. In addition to navigating the intersection between science and human experience, we are tasked with navigating the intersection between our comfort zone and our everyday reality. I cannot imagine what it would be like to go to the same workplace everyday, with the same colleagues, and the same expectations. Medical curriculum has this cruel way of allowing you just enough time to feel comfortable (whether in an office, a specialty, or with a specific provider) and then snatching that feeling of certainty away with the expectation that you are ready to thrive as you are unceremoniously plopped into the next new environment. We are constantly being watched, criticized, and evaluated. This, at times, is arguably the most exhausting part of medical school. Given the nature of the curriculum it oftentimes feels impossible to impress those you are working with because everyone has different expectations,  there is different information you are expected to convey, and different roles you are to play within the healthcare team; we relentlessly work to please, to improve, and to adapt. With this said, I take comfort in two ideas: natural to the process of constant change and adaptation is the exposure to many unique experiences, and with pieces of these experiences I have the opportunity to mold myself into the physician that I aim to become. Additionally, the ability to be resilient and enter each new situation with some semblance of confidence is a quality that can be transferred to all aspects of life.

During my surgery rotation I learned to adapt to being frequently reprimanded, putting that aside, and continuing to do the job. I learned that when given minimal information or instruction, always ask questions because this will be in the best interest of the patient. During neurology I learned to take a good history because, more often than not, the patient is giving you the answer. In cardiology I learned background is everything, look at records and always paint a picture of the patient in order to understand them at present time. In psychiatry, I learned to adapt to having little guidance and the importance of making the most of a rotation as a self-motivated learner. During Family Medicine I learned how to adapt to a new office environment, and quickly develop relationships with the staff who are helping me care for patients. In Emergency Medicine, I’ve learned take ownership of my patients as I make the transition from student to doctor.

What I have realized is that from these experiences of being forced outside of my comfort zone, I have grown resilient and confident in other aspects of my life. I have learned to communicate better, I have learned the value of just picking up the phone to ask questions, I have learned to be aggressive with what I want to accomplish, and I have learned to be more compassionate and understanding. This has been a beautiful byproduct of what seems like an everyday struggle. My goal is to reflect upon these sentiments in the future when I am working with medical students. I aim to acknowledge the difficulty of constant adaptation and feelings of unmet expectations, conveying the message that this process ultimately makes us better both professionally and personally.

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I had just finished my 8-week rotations. And with arguably misaligned priorities, I welcomed my psychiatry rotation because it was notably less time consuming than others. Prior to beginning this rotation I hadn’t put much thought into what I wanted to get out of the experience, it was just sort of…there. This isn’t to say that I did not have an initial sense of respect for the field. My best friend in medical school plans to be a forensic psychiatrist and her passion for the field is infectious. I have, by osmosis, obtained a surprising knowledge base of serial killers, true crime, and everything in between….but I digress. What I did not foresee was that the six weeks I would spend on psychiatry would give rise to some of the most fulfilling clinical experiences that I have had thus far.  

For the first two weeks of my psychiatry rotation I was on the consults service. For those not familiar with what exactly that entails, it is essentially the service that tends to the psychiatric needs of anyone on a medical floor of the hospital who is being treated for a primary medical illness. I was most nervous about this service, and my discomfort stemmed from my inexperience with how to evaluate psychiatric patients. I knew what questions to ask about chest pain, but hallucinations? Delusions? A completely different animal. I assumed that patients would not be open to discussing their psychiatric history or current battle with psychiatric illness. I have never been so wrong. Somehow, after initially entering the room and explaining that you are working with psychiatry, patients are more than willing to discuss the most personal aspects of their history. For me, this had never been the case when working on a medical service. Bringing up alcohol or drug use had previously begged a follow-up “what does that have to do with anything?” What I came to understand while on consults was that, in fact, it has to do with everything. I had previously never appreciated the impact mental illness and substance abuse had on the overall health of the patient. Consults came in every age, race, size and gender. They came with the heart attacks, the diabetes, and the broken legs. Psychiatrists have the privileged position of  being allowed into the darkest part of patient’s lives, to view patients through a lens often inaccessible to other specialties. Perhaps treating an individual’s depression would allow them to get out of bed long enough to exercise, cook healthy food or follow-up regularly with their PCP.  

My next stop was the Older Adult Behavioral Health Unit. The soundtrack of this previously unexplored wing of the hospital was essentially the same each day: a little old lady in a chair by the nurse’s station yelling “help” over and over for no reason, someone violently protesting being assisted in the shower, another person yelling “get out of my room!” to the psychotic wanderer. I found it ironically charming. Everyday I would follow the same patients and talk to them about how they felt they were doing, “what did you learn in group sessions yesterday?,” “how do you feel about your medication adjustment?” “Any thoughts of hurting yourself or others?” “Who do you think is stealing your money?” I developed a special relationship with each one of my patients and upon discharge a few of them thanked me for helping them. Let me repeat that. I, a third year medical student whose only skill is taking up space, actually was being thanked for really helping someone. And, I got a hug! It occurred to me that although I could not make the final decisions related to patient care, nor could I place orders or write for medications, I could talk…and more importantly I could listen. I knew these patients well and was actually contributing to the treatment team. I had the privilege of being on the journey with them as they gained insight into their conditions. It was remarkably unique and unexpectedly rewarding.

My last stop was the Adult Behavioral Unit. These patients are younger and tend to have more energy, as well as more recent diagnoses of psychotic disorders. I did a lot of patient intakes; these are essentially hour-long conversations about every aspect of these newly admitted patient’s lives. Through the course of the interview you start on the surface — lists of previous admissions to the psychiatric unit, lists of drugs they have abused, lists of attempts at suicide. You read prior notes about patients getting violent in the ED, notes describing behavior unparalleled in bizarreness, but I always tried to access the nucleus of the patient in attempts to understand what they really needed from us. If you spend enough time, you can find the human in most people. These were people that, on paper, I should have been scared of…but I welcomed the challenge of looking beyond that.

Thus far I have made psychiatry sound like glorified therapy, which it most certainly is not. So, let’s talk about medication. Many non-medical folks naively believe that people with psychiatric illness may be over-medicated, and that we should be “trying to get to the foundation of the problem instead of covering it up with drugs.” These are patients that are ill, have detrimental chemical imbalances, structural changes to their brain, and voices telling them to harm themselves or other people. Most don’t need a long leather couch and a tissue box, or to be incarcerated; rather, these patients need us to employ our current understanding of these disease processes in order to help them become functioning members of society who are not a danger to themselves, or others. For many these illnesses will be a lifelong struggle, but we do the best we can. My experience in the Adult Behavioral Health Unit allowed me to see the effects of these medications — I saw people who were, for lack of a more descriptive cluster of words, out of their damn minds. I saw people who were so depressed they physically could not move. I saw people who had so many racing thoughts they simply could not function. I also saw all of these people get better. After a few days, weeks, or even months of medication adjustment I was able to go from being randomly yelled at in the hallway to hearing my patients play guitar, or tell me about their kids. It was, in many ways, remarkable.

Last year I told my friend that I believe she is attracted to the field of psychiatry because she finds most people annoying or obnoxious — bare with me here. In medicine you encounter a lot of unsavory people who treat you terribly because they just…aren’t great people. But, in the psychiatric population, there is usually a reason for someone to yell obscenities or show aggression, essentially pathology behind being a jerk. I think there is a twisted sense of comfort in this. Comfort in accepting that mental illness is, and should be treated like any other medical condition; and that hopefully psychosis or depression can be alleviated in the way we alleviate physical pain. I am deeply grateful for everything I learned on this rotation, particularly as someone who plans to work in Emergency Medicine. Patients are often at the peak of their struggle with psychiatric illness when they enter the emergency room and I firmly believe a little empathy will go a long way. When I encounter a frustrating psychiatric case in the middle of the night in the ED I will always think of the patients that let me into their lives, and the lessons they provided me. This is the least I can do in helping to make progress towards appropriately addressing mental health in this country.

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I remember sitting nervously in a seminar filled with other pre-medical students hoping to receive the faintest sliver of direction regarding how to tackle the formidable task of the personal statement portion of my application. The first words spoken by any instructor, at any seminar, inevitably fell heavily on most students – “you can’t just say that you want to help people and you like science.” Well duh, I thought to myself. This was immediately followed by the realization that I needed to get creative, and quickly. But that is another conversation. If you ask me today, or at anytime in the past, the reason I wanted to become a physician is because I want to help people and I like science. If you ask any adviser why one needs to go beyond this idea for their personal statement, it is simply because the notion is nearly universal among physicians, and thus lacks individuality. What I have come to conclude is that while this fundamental paradigm is nearly universal, for each individual it does play a unique role in what motivates the rigorous learning required to become a physician.

During the didactic years of medical school, we are so far removed from the actual “helping people” portion of the equation that is becomes very difficult to see the big picture. This is when, for better or worse, additional elements come into play. Another staggering commonality among future physicians is their undeniable competitive nature. There are varying degrees of competitiveness, but it would be ludicrous to deny that we aren’t all extremely competitive. Educators are acutely aware that during the didactic years we are far from actually understanding how to execute what we have learned in order to be effective clinicians, and it becomes frustrating to stay motivated to learn; despite this, we need to learn a lot, and in short order. Capitalizing on competition ensures continuous consumption of information in order to succeed. Exams, class rankings, grades…any measurement to afford us some semblance of success and advancement. It sucks, but it’s effective. In my discussions with classmates I have found that some students choose to look at material and relate it back to the notion that it can be used as a tool to help their patients in the future. They assign value to the material in a different way, it becomes constantly personal. I, myself, would find this terribly exhausting and this was something I had previously felt guilty about. I like science and I want to help people, but these have always remained separate entities.

My personal motivation for learning during the didactic years was, in all honestly, driven by fascination and the simple pursuit of knowledge. I seek a degree of mastery in a subject that both intrigues me and is of massive importance. I have always approached the acquisition of knowledge as a humbling endeavor, and choose to focus on mastering fundamentals before utilizing what I have learned. I waited until I had my degree in human biology until I felt comfortable doing research, simply because I needed to learn how to think before I could even consider making any contribution to science. In my recent reflections I have realized that my subconscious choice to keep science and “helping people” separate was not because I was a terrible future doctor who didn’t constantly consider patient care, but rather because I value the sanctity of medicine as the interplay of science and the human condition. The ability to navigate this delicate balance is granted to those who take the time to invest in the pursuit of knowledge at its most fundamental level. For me, learning material didn’t need to be assigned any more value than it inherently had.

I am just now getting my first glimpse of how lifetime learning and pursuit of medical knowledge is actually translated into making a difference in people’s lives; it’s beautiful, powerful and extremely humbling. While I stand by my motivations to learn during the pre-clinical years, I have abandoned what were my reasons for learning at the beginning of my clinicals. After my first rotation I reflected upon what motivated both myself (and other students) to continue to pursue medical knowledge now that we were out of the classroom. What I experienced was self-serving, ego-driven, and not in the business of helping people. We were all scrambling to essentially avoid humiliation, collecting data not for patient care, but rather to prevent looking clueless during rounds or while being pimped. For me, I felt just as removed as when I was sitting in a classroom the previous year. I made a conscious decision to make my learning patient-centered and whatever embarrassment I felt during rounds, or while being pimpled, was all part of the process. Constantly I now ask myself, what knowledge can I use to help this person? I wish I could say that this immediately fused my previously separate ideas of liking science and wanting to help people, but it has been a slow process…and it should be. The notion that I am finally beginning to see the intersection between the knowledge base I am building, and making a difference in the lives of patients has been extraordinarily motivating. If am I this excited when I see these small advancements in my abilities, I cannot wait for the future. I guess now when people ask me ‘why become a doctor’? I am recently finally able to say, “I like using science to help people”.  Because I a finally am….using science, that is. Sorry pre-med advisers, but this is a big deal.

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Intermittently, third-year-students at my school are required to attend academic sessions in which students and faculty join together with the intention of generating discussions surrounding relevant topics in medicine (professionalism, social determinants of health, etc). This week we were asked to consider the role of medical students within the hierarchy of the medical team, and how this hierarchy influences patient care and our individual education. The hierarchy, if utilized appropriately, can function as a platform on which students can identify what their goals should be during each step of medical training. Simultaneously, developing the understanding of the role of medical students, interns, residents and attendings allows students to define what their current role should be in the healthcare team, which can often be of great benefit to the patient. When the topic of the hierarchical arrangement of the medical team is being discussed there is inevitably an uglier component that must be addressed: how common do medical students feel abused, discouraged and fearful of those higher in the chain of command? The 1996 JAMA publication ‘Medical student abuse during third year clerkships’ certainly reinforced the notion that students frequently experience abuse in a wide range of categories spanning from verbal, physical, sexual and academic. These staggering results call into question where the line between benefit and detriment is drawn in relation to the function of the medical student in the hierarchy of the healthcare team.   

Clinical education does not come with an instruction manual. For many, this grim and intimidating realization must be met with some sort of guidance on how to establish a platform on which to build the understanding of what is expected during each level of training. The hierarchy of the medical team has allowed me the opportunity to investigate the role of each level of provider (student, intern, resident, attending) so I can better understand what I should accomplish through each level of education. Working as a student on the healthcare team grants a unique opportunity to select mentors, decide who you want to emulate, and how to set appropriate goals and competencies. The efforts to understand the dynamics of the team hierarchy additionally affords students the opportunity to decide how we, as students, can make a difference in patient care. Medical students have the particular advantage of having time to accomplish specific tasks that others may not have time for. I can recall a specific example of a cerebral palsy patient who was in the ICU after being re-admitted to manage a wound infection; he had a significant seizure after being admitted and the history surrounding previous seizures was unclear. While the attending physician was managing a long list of other consults, my colleague and I spent a marked amount of time tracking down his history, discussing the patient with his nursing home staff and after being put on hold and transferred numerous times, we finally felt we had enough information to actually help this patient. Taking the time to do this is a luxury that only medical students have, and the recognition of that allowed us to feel like we have a role on the healthcare team.

The negative associations with the idea of medical team hierarchy can, on the surface, seem petty. Many could argue that students, who mostly have been in school for their entire lives, are finally being exposed to the real world experience of a hierarchy in any job. The commonality of the experience of being forced to work with (or under the supervision of) individuals you do not care for is almost comical. Yet, there are elements of medical education that makes this extraordinarily different from the typical pangs of hierarchical woes. We are paying, not getting paid. We are being evaluated not for the sake of maintaining a certain salary/position but rather receiving feedback that should shape our futures as physicals, and grades that will determine what that future will look like. The stakes are objectively much, much higher. With that being said, one would hope that the hierarchical system would be used appropriately and advantageously, yet the topic of abuse of medical students continues to be researched, studied and discussed as a serious issue. In my experience I have had a handful of unsavory interactions but would not proclaim feelings of abuse in the traditional categories as outlined in the JAMA article, rather I would want to acknowledge “abuse” in the form of neglect. There must be a line drawn between promoting self-directed learning and blatantly not fulfilling a duty to train the next generation of physicians. This is one of the bigger issues that I have seen students face. I am still aiming to learn how we can foster encouragement to teach students, to nurture the next generation of physicians, and to encourage mentorship that will inspire us to be the interns, residents and attendings that will utilize the medical hierarchy to help students establish goals for both their education and their role in helping to better the care of our patients.  I hope this is the future of medicine. 

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It has been a regrettably long time since my initial post. While my last reflections seem like a lifetime ago, I am still resonating with a similar topic. The ideas of initiation, hazing, and cyclical feelings of inadequacy have again reared their ugly head as I am a few months into my third year. The transition from the pre-clinical to clinical years is a notoriously difficult time in medical education, yet the challenges were not what I had anticipated.

As a “premed” I spent many hours volunteering in the Emergency Department, I knew the hospital inside and out, had the rooms clean before the nurses were aware the patient was discharged, was intimately familiar with the contents of every cart in the ED, and felt completely comfortable generating casual conversations with patients. If you needed any flavor of Jell-o I could find it. If you needed a specimen run to the lab, I had already done it. This was my job as a volunteer, I knew what I was supposed to do, and I did it well. The year before I began medical school I worked as an Emergency Department scribe. As the right hand to the physician I could listen to a history and generate a patient chart in 5 minutes, I was organized on their behalf, I anticipated needs,  I tracked study results. Most importantly, I felt I was part of the patient care team. This was my job as a scribe, I knew what I was supposed to do, and I did it well.

Fast forward to the present day, after two years of medical education and a half day of orientation, my colleagues and I prayed we would swim as we were unceremoniously hurled into the deep end of clinical education. In my head I begged to be asked a question about the pathogenesis of disease, something to show for the grueling past few years. Instead I felt relentlessly inadequate for not knowing basic ways in which I could be part of the patient care team; I didn’t know where the wound cart was, I didn’t know what was in it, I didn’t know the hospital. This was my job as a medical student, I didn’t know what I was supposed to do, and I wasn’t doing it well. Throughout the course of those first few weeks I constantly would flash back to my premed days, having moments where I would give anything to feel as confident as I did as a volunteer or a scribe. After an arduous application process, a cross country move, and two years of sacrifice for my medical education, there I was wishing to be half as competent as I was as a premed? There are few moments in my life where I have had a realization so utterly devastating. What did I have to show for my years of hard work? But, with every perceived struggle in life, I searched for the bigger picture, the everything happens for a reason. 

In my last post I described Gross Anatomy as a process of hazing. It served a purpose to introduce enthusiastic first years to the complexities of the field of medicine, to instill the idea that the journey ahead would be extraordinarily rigorous, and to ensure that students would walk out of their last day of cadaver lab with a sense of humility and eagerness to learn. We were at the top of our classes in college, we were recently gifted with a bright new white coat, yet it was imperative that we begin this new experience grounded and humble.  After two years of book work students face what seems like a mountain of an obstacle, USMLE Step 1. This exam is the culmination of years of work, focus, and dedication and pushes students beyond limits they had previously held insurmountable. We are released from other side of this exam as  kings and queens of the multiple choice question, master study marathoners, professional learners. Perhaps this was the time for the unwelcomed reality check. The abrupt dive into clinical years was a painful reminder that we have so much to learn. It has been a reminder that our transition into becoming physicians must be a culmination of everything we have invested so far. For me, I must be that premed volunteer finding anyway to help the patient care team from Jell-o to friendly conversation with patients. I must be that scribe who knows the study results as soon as they are available. I must recall the knowledge I have accumulated over the past two years in order to understand disease and treat patients. I must continue to stay humble, hungry and helpful.  In May of 2018 I hope to be a ‘pro’ medical student, feeling on top of the world as I rush around the hospital I am so intimately familiar with, fulfilling the role that I will have come to better understand. And, in July of 2018,  I know that will all come crashing down. There a few individuals in a hospital more terrified than a new intern, and so repeats this processes of endless initiation. The cyclical rise and fall in confidence and adequacy serves to remind us of the bigger picture. As we transition through our career and gain new responsibility, it must not be taken lightly. Every stage in training serves a purpose as a reminder that there is no field more humbling than medicine. Feeling inadequate is part of the job, doing something about it part of the odyssey. 

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