Yearly Archives: 2011

The Life Changing Benefits of Reading

I’ve always been a bit of a bookworm. However, the benefits of reading didn’t really hit me until university. I went to a relatively average university. Although I enjoyed the new experience of college, I often found my courses intellectually dead. Classes I thought I would like ended up being dull. Tutorials were taught by TA’s who were less than enthused to teach. Classmates often wanted to get by with their assignments and tests than to really learn something.

Early on, I decided I would not let my schooling be the determinate of my education. Instead, I set out to learn from the best minds in the worlds, and made it a goal to read good books. I decided to read 52 books over the course of a year, one for each week. Although I fell short of that goal, I ended up reading a total of 42 books that year, many of which introduced me to new ideas and changed my world views. I still try to average a dozen or so books a year.

For instance, reading Richard Dawkin’s The Selfish Gene inspired and taught me more about evolution than any of my biology classes. My classes in physics became way more interesting after reading Richard Feynman’s adventures on learning and being inquisitive. For psychology, I “enrolled” myself in a Harvard course on Happiness. Due to my premed scheduling, I was unable to take any economics courses, but through extracurricular reading, I’ve gained at least a basic understanding of how market forces work.

Reading good books changed the way I thought about the world more than my university courses did. Well written books are often the results of years of research and experiences. They are much richer in content and thought out than blog posts or news articles. If you haven’t gotten into the habit of reading outside of the classroom, I would recommend you start right away!

I have created a books section on this website with a list of  books that I have personally read and recommend. I’ll be sure to add to the list and write reviews whenever possible. Although medical school can be quite busy and there is a lot of medical reading that needs to be done, I still try to find time for leisure reading.

With the holidays coming up, try to find time during your break to read something outside of academics. It might just be the best thing you could do for your education.

 

How We Should Die

A quote from a beautiful piece that has been going around the web by Ken Murray titledHow Doctors Die

It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

Many times in the last year I have seen patients suffer from inappropriate medical decisions. Metastatic cancer patients who receieve aggressive treatment despite of the physical, emotional and financial costs associated with it. A 94 year old post stroke brain dead patient being kept alive in the ICU by a ventilator and triple-pressor support because the family did not want to withdraw care. Dieing can be a messy thing.

In undergrad, I read a book titled How We Die by Sherwin Nuland, a physician practising at Yale, that challenged many of my pre-med notions of death. Particularly, it helped me understand how little mastery we have over our mortality and that death is a natural process of life.  People are always eager to tell you how we should live but few broach the topic of how we should die.

One of the tasks we do as a medical student whenever we admit a patient is to determine their code status. We ask questions that people are unfamiliar with. What should our medical team do if anything was to happen to you. If your heart stopped beating, do you want us to perform CPR? If your lungs stopped breathing, would you want a tube passed through your throat to help you breathe? Discussing code status is an often misunderstood topic. Many patients and families find it difficult to approach the subject.  Does this mean the medical team is giving up? Does it mean the patient won’t receive any help if anything was to happen? What the patient and their families often fail to understand is the difference between quantity and quality of life. Many times in the course of a disease, our medical interventions cross over from benefiting the patient to harming them.

During my Internal Medicine rotation, an attending taught me to be specific with my do not resuscitate orders. Explain what each aspect of their code status meant and clarify each point. No CPR, No ICU, No Intubation, No Heroic Measures.

Death is a terrifying event for patients and their families. I know my views on it have changed this last year after repeatedly seeing death firsthand. What I’ve learned is that we shouldn’t be afraid to talk about death. As health care workers, we spend most of our time talking about possible treatment options, even when there is none left. We don’t spend enough time explaining realistic outcomes to patients and discussing what their final wishes will be. Are we continuing treatment for the benefit of the patient or are we causing suffering to spare the emotions of those that are living. Becoming a doctor is more than just learning about how to save lives. In the process, you learn to respect human life and the complexities associated with it, and you begin to understand the possibilities and limitations of our art.

A Minimalist Life

A month ago, I came upon a collection of articles that challenged my ideas about time management. Being in medical school, there’ s often an endless list of activities to do – clinical duties, studying, research, volunteering, student groups. You get comfortable juggling multiple tasks, ambitious to do more. You begin to believe that doing more is better. These posts helped me reevaluate some of my priorities. I highly recommend reading them.

focus: a simplicity manifesto in the age of distraction – by Leo Babauta of zenhabits

Best New Year’s Resolution? A ‘Stop Doing’ List – by Jim Collins

Better – by Merlin Mann (author of InboxZero)

I am now in my fourth and final year of medical school. Perhaps with some hindsight, I now see how distracting medical school really was at times. The clubs we were involved in, the group study sessions, the meaningless emails, the trivial tasks. You regret some of the priorities you sacrificed, your health, your hobbies, your friends and family.

From here on out, I am choosing to make my daily life simpler. I want to take on less tasks in hopes that I can do my important tasks better. I have unsubscribed from medical blogs that I don’t really enjoy reading, and spent a bit more time reading around the patients I see. I spend less time in my inbox and more time with friends. On this blog, I am focusing less on advertising and revenues and more on writing and reflection. I am slowly minimizing my distractions so I can focus on things that do matter.

Are there things in your life you can simplify? What’s distracting you from doing your best work?

Post CaRMS Application Tips

And I’m back! I’ve been busy completing my applications for the Canadian Resident Matching Service (CaRMS)

Having survived the CaRMS 2011 Application Submission Deadline, I was going to share some of the lessons I’ve learned from this stressful experience. Overall, I think I did most things well but could have done many things better. Thankfully, you only apply for residency once… (hopefully). Here are some of the lessons I learned.

1. It’s Ok to Highlight Your Best Traits! – It definitely felt strange having to sell yourself. It was like applying to medical school all over again, but this time with more on the line. List all your accomplishments, talk about strengths mentioned in your clerkship evaluations, describe all the activities you did. You want to put your best foot forward, not shoot yourself in the foot. Don’t be afraid to brag and boast as much as you can, but do it discretely.

2. Start Planning Early – It’s never too early to start planning. First and second year medical school is a great time to start thinking about residency. Know which specialties you want to apply to and which cities you could live in. Keep track of all your leadership, volunteer and research activities. Update your CV annually. It was able to complete the activities section quickly because I had carefully recorded all my activities and interests in the years before.

3. Be Organized– When the Applicant Web Station (AWS) went live and all the program descriptions were up, I spent an hour creating a master excel sheet to help me stay on top of things. I listed all the programs I was going to apply to along with their descriptions, requirements, essay questions, number of references needed and personal comments.

I also created a checklist of things to be done, a tracking sheet for my references and a timeline of the whole application process. This streamlined my application and enabled me to concentrate on the task at hand, without worrying about what to do next.

4. Get the Best References Possible – Ask all your preceptors you did a rotation with to write you a strong reference letter. That way, when it comes time to apply you’ll have more referees to choose from than required. Ask months in advance. Send your referees packages with your CV, evaluations and clear instructions.

A good reference letter is one that highlights your strengths, is written by someone who knows you well and from someone who has some influence. Don’t be afraid to ask for a reference letter from someone you didn’t spend a lot of time with, often times you only need a day or two to impress someone. Also, ask all your referees to complete their letters online. It’ll save you money and a lot of stress wondering if your letter has arrived at the CaRMS office yet.

5. Take a Professional Photo – Good lighting makes a big difference. You are applying to a professional job, look the part! Plus you can use this photo for the next twenty years or so… at least that’s what all my residents and preceptors seem to have done.

6. Milestones are there for a Reason – Milestones are suggested dates of when parts of the application should be completed. They are there to remind you to not leave everything to the last minute. In general, they mark out a good timeline to follow. If you keep up with them, you’ll be pretty stress free.

7. Don’t CRaMS! – Unfortunately, milestones are only “suggestions” and I found myself cramming a lot of writing in the final week of the CaRMS application. Suffice to say, it was a stressful final week.

8. Get Some Rest – Coupled with the fact that I was still on clinical rotations, I ended up sleeping less than 5 hours (sometimes 3-4hrs) a night during that last week. If you can, I suggest taking a week, either the final week or a week or two before, off to get your CaRMS application done. Also, don’t stay up writing when you can barely keep your eyes open. I’ll guarantee you will write better and grammatically correct sentences after a good night of sleep.

9. Get a Second (Non-medical) Opinion – Ask your friends and family to look over your application. Does this letter represent who you are? Does it sound like the person they know? Try to avoid getting too many classmates and other applicants to look over your stuff. They will have their own skewed view of the CaRMS process and may not offer you the best advice.

10. Don’t Go Looking at Other People’s Applications – The more applications you look at that aren’t yours, the harder it will be to be yourself. You’ll be influenced by what they are saying in their letters or how they have formatted their application. Focus on your own application and your true self will come through.

Just ten simple tips to make the whole CaRMS application process a bit smoother. Actually the whole process was pretty straightforward minus the personal letters. Speaking with residents, they say it’s a lot better for the R-3 match because all your previous documents are saved in the CaRMS systems. Plus most fellowship and +1 years only requires a one-page letter and you apply to fewer schools. Oh how I don’t look forward to CaRMS round 2.

CaRMS Roadblock

Sorry, no new posts for a while until I finish my CaRMS applications. The Residency Match process is pretty much the only stressor in your final year of medical school. Now back to those personal letters… it’s sort of like applying to medical school all over again… but with different worries.

The Patient’s Family

Looking through my old drafts, I found a post written when I was starting medical school that was never published. (Written September 28th, 2008) I’m glad to see I still agree with the feelings and thoughts I had then. Published now three years later as I am about to graduate from medical school. Unedited for authenticity. 

Every week in medical school, we have a class that focuses on how to be a good doctor. In this class we discuss how to take a history, what your posture should be like and how to empathize with patients. At this point in our education, our class generally finds the material confusing, considering we know nothing about anatomy and disease. How does listening to their concerns about their daily function going to help us heal them? How does talking to their family have anything to do with treating a disease? It all seem cryptic until, you’re on the other side.

My Grandpa was hospitalized a few days ago. He had just finished his Sunday afternoon lunch when he started having a shortness of breath. With each breath, there was an increasing pain in his chest. An hour later, he couldn’t breathe. When he was brought in to the hospital, the doctors discovered his right lung had collapsed due to a tension pneumothorax. My Grandpa is 86 years old and has had declining health in the past year. The doctors put in a 22 French chest tube into my Grandpa’s chest and moved him to the ICU. The last time I had been in a hospital was when I saw my Grandma lose her fight to cancer.

As medical students, we sometimes get desensitized from what it means to be sick and how it affects a family. We learn about all sorts of strange diseases in our lectures and labs and we spend enormous amounts of time studying them. After many hours in the library, we understand their pathology, biochemical reactions and common treatments, but we often forget how sickness impacts a patient’s life and their family members.

Even though I am a medical student who understands the science and complications behind my Grandpa’s collapsed lung, I was weak when I heard the bad news. I was overwhelmed with fear and worries. I asked about my Grandpa’s condition and if he would get better. I Google’d his condition and looked for answers. I hung on to every word from the doctor’s mouth. I was just as helpless as any other person.

It is from these experiences – when you become the patient and their family member – that the value of our patient-care classes become meaningful. I want a doctor who is competent AND can explain to things to me clearly and patiently. I want a doctor who will listen to our concerns and will work with us according to our values. Who will take the time to go over everything and ask if there are any other questions. A doctor who not only treats the disease but also heals the patient and their families.

I hope this feeling of uneasiness and nervousness stays with me throughout my journey through medicine. I want to remember how serious sickness can be and how it can cause family members to fly in from all around the world to unite with a loved one. I don’t want to forget how much of an impact illness can have on a family and how scary losing someone can be. I don’t know how my Grandpa will be. He is old and has lived a full life, but I want him to stay… if even for just a bit longer. I still want to talk to him and have dinner with him while listening to his crazy stories. If he passes away, I know my family and my aunts and uncles and cousins will grow more distant.

I don’t want to forget my Grandpa and Grandma. I don’t want to forget what it’s like to be a patient or to be dealing with a sickness in a loved one.

Poor MD – What Every Medical Student and Resident Should Know About Finances

Today I want to do a quick review of an PoorMD‘s eBook  titled First Aid for Personal Finance: What Every Medical Student and Resident Should Know

The best thing about this book is it only costs $0.99 and hopefully the small price you pay will pay for itself in with the knowledge in the book. Note, you can only buy the book in electronic format at this time (You’ll need either a Kindle or the kindle app on your computer or smartphone)

The book is divided into 10 sections + 1 bonus section. The first few parts are pretty general knowledge about how to keep your debt low in medical school, how to save on school textbooks and what types of scholarships/funding is available for medical students. Where the book really shines is when it talks about residency and how to save some money while doing your interviews, how to help pay for moving costs and how to start a family during medschool/residency. There are also sections on more technical financial advice including insurance, retirement savings and tax planning.

Dr. Chang offers practical tips as well as his personal philosophy when it comes to finances. In a profession where “money talk” is so common, First Aid Personal Finance is a quick and easy read with implementable strategies. It’ll take you about an hour to read the book from cover to cover.

Overall, it was a buck well spent and I hope the ideas and advice I found will help me manage my finances better during residency. Get your copy of First Aid for Personal Finance: What Every Medical Student and Resident Should Know at Amazon

Dr. James Chang is currently a radiology resident and his blog PoorMD.com currently features his medical webcomics.

 

An Anesthesiologist’s Dilemma

Conversation between me and a friend applying to Anesthesiology, while discussing our upcoming CaRMS applications.

Me:    “So you’re not going to miss talking to patients at all?”

Him:    “Not at all, I get to do as much talking as I want pre and post-op”

Me:    “You’re not going to miss having your own patients?”

Him:    “I get patients for each case, I don’t have to worry after they leave the OR”

Me:    “I guess the physiology is pretty cool and the drugs you use are pretty neat”

Him:    “Yeah, plus you learn how to manage really sick patients and do lots of procedures”

Me:    “Is there anything you’re going to miss at all?”

Him:    “Hmmm… I guess I won’t get to wear dress clothes to work anymore… that sucks… I have such nice clothes”

Thanks for checking out my blog to all the visitors from this week’s Grand Rounds at Health Business Blog. Always a good courtesy to send back some link karma.

Can the Physical Exam Help Decrease Health Care Costs?

If physicians and doctors in training were trained better in the physical exam, could that translate into health care dollars saved?

I’ve written about the Physical Exam and how it’s often at odds against newer technologies in medicine. In today’s world, where labwork, xrays and CT scans are so readily available, many say the physical exam is dead and just a relic of tradition.

Case Review: This thought was provoked by a patient I saw in the emergency department recently. A 76 year old lady presented with a distended abdomen that had been growing the last 5 days. On history, she also developed shortness of breath on exertion, orthopnea, PND, all classic signs for congestive heart failure. Looking through her records, she had been admitted previously for an episode of CHF two years ago secondary to ischemic heart disease. On physical examination she had an audible S3 heart sound, distended JVP and leg edema. Chest Xray showed bilateral pleural effusions and vascular redistribution typical of CHF. This was a lady who’s classic findings were pointing to to a diagnosis of exacerbation of her CHF.

Question: for this patient, should we order a BNP?BNP is a good marker that is highly sensitive for CHF. It costs about $25 to run. [www.ccjm.org/content/70/4/333.full.pdf]

I had recently been trying to go through the JAMA Rational Clinical Exam  Series and had just finished  “Does This Dyspneic Patient in the Emergency Department Have Congestive Heart Failure?” According to the article, in a patient with clear history and physical suggestive of CHF, doing a BNP was not recommended as it would not change management.

I didnt’ want to order a BNP as I knew it would come back positive anyway, but in the age of “defensive medicine” the ER doc ordered a BNP, along with a complete panel of bloodwork that was probably unnecessary. The results came back as expected with an elevated BNP of 680 and the rest of the labwork unremarkable.

Futuredocsblog, an internist from the University of Chicago, writes about certain things doctors could do to help reduce health care costs. Listening to the patient, doing a proper physical exam, thinking about indications for a test and knowing the costs of the tests that are ordered.

As doctors, we are entrusted to be good stewards of the finite resources available. Perhaps I’m just young and naive, and all it takes is one lawsuit to change my opinion. But right now, I believe good history taking and physical exams can help reduce the number of unnecessary tests and therapeutics.

What do you think? Is the physical exam dead? Can a good history and physical exam hold up against the available labwork and technology of today?

Update (Mar 2013) – an excellent journal article on the Utility of the Clinical Examination at JAMA Network

 

Why Being Rejected from McMaster Health Sciences is Good for You

If you’re never heard of McMaster University’s Bachelor of Health Sciences Program, you should know it is one of the “elite” undergraduate programs in Canada. With an applicant pool of over 2000 students for 150 spots, getting into McMaster’s Health Sci program is as competitive as getting into medical school.

This is a program where more than 40% of their graduates go on to pursue medicine. When the average Canadian medical school acceptance rate is around 10%, McMaster’s BHSc stands out.

During high school, it was my goal to be accepted into Mac Health Sci. I did my best to get high grades and spent a lot of time on the supplementary application. It was the program I wanted to get into, with it’s problem based learning and inquiry courses, I thought ii would be a great fit for me.

Unfortunately when the acceptances rolled out, I found out I had been rejected. Being rejected is the norm, applicants with 95+% grades often get rejected. [Medhopeful writes a very good post about it here.] I was devastated and felt like I had failed. I ended up choosing to do a life science program at another university.

You Learn More from Your Failures than Your Successes

In hindsight, being rejected from McMaster’s Health Science (and several other programs) turned out to be one of the best things to happen to me. I was humbled by the experience. I learned many hard lessons that helped me mature.

Being rejected taught me humility, something I lacked before. I went to a high school with an enriched learning curriculum. I was labeled a “gifted” students who was suppose to do better than others.

I now know that if I had been accepted into Health Sci, I would have been too proud. I would have been entitled or felt superior to my peers just because I had gotten into the most selective program in the country. I have nothing against the program, I know lots of friends who have graduated from it. But I also know of other health sci students who have that sense of entitlement.

Instead, I attended a university with a large science program. I got to interact with lots of classmates from all types of background. I met many exceptionally bright peers in Biology 101 and General Chemistry. I was lab partners with students who struggeld in high school and were just happy to attend university. And I found that many undergrad programs are just as rigorous and adequate for your education.

It Doesn’t Matter Where You Go for Your Education, It’s What You Do There that Matters

I entered my university degree with a chip on my shoulder. I had been rejected from the programs that I wanted to be in. I decided that I wouldn’t let my failures dictate my future successes.

I was motivated to be the best student I could be. I wanted to prove to myself that I wasn’t going to let an institution define who I am. In the process, I learned to value hard work and persistence. I didn’t take my education for granted, instead I set out to improve myself.

In the end, I achieved my goal of gaining an acceptance into medical school and ironically before many of my peers who were in health sci. Along the way, I created a foundation of study habits that I still use today.

Medical schools don’t care about where you did your undergrad degree, they care about what you did there.

Looking back, being rejected from Health Science helped me mature as a person. You learn more from your struggles than your successes. Let me know if you have had similar stories, would love to hear them.