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? A 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?
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 roughly 150 spots, getting into McMaster’s Health Sci program is as competitive as getting into medical school.
This is a program where on average, more than 40% of their graduates will go on to pursue medicine. When the average Canadian medical school acceptance rate hovers around 10%, McMaster’s BHSc stands out.
In high school, I had really wanted to go to McMaster’s program. I tried my best to get high grades and spent lots of time writing my supplementary applications. It was the only program I knew I really wanted to get into. It was the hottest ticket, with it’s problem based learning and inquiry courses, I thought it would be a great fit for me.
Unfortunately when the acceptances rolled out later that year, I found out I had been rejected from their program. With a program that rejects applicants with average of 95+%, being rejected was the norm. [Medhopeful writes a very good post about the program here.] I was initially 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 for me in the long run. I was humbled by the experience. It taught me many lessons of life that were more important for me to mature.
Being rejected taught me humility, something I lacked before. I went to a high school with an enriched learning curriculum. I was went to classes with other “gifted” students who were to complete a more rigorous curriculum. I felt proud that our program was considered better than others.
I now know that if I had been accepted into Health Sci, I would have been too proud. I would have felt entitled or 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 are graduates, but I also know of many arrogant students who were in Health Sci who had that same sense of entitlement.
Instead, being in 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 was just happy to attend university. And I found out that many undergrad programs are just as rigorous and adequate for gaining an 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 all the programs that I truly 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 before many of my peers who went into Health Science too!). Along the way, I laid down a foundation of work ethic and study habits I would carry on to my future career.
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.
Clerkship Pearls – How to Get a Consultation
This is another post in the Clerkship Pearls series for medical students going through clerkship, and today I’ll be discussing
How to Effectively Get a Consultation for Your Patient
One of the scariest things to do as a clerk is to ask another consult service to help you with the care of your patient. A consultant, or consulting service, is usually another doctor or team that specializes in a certain area of medicine. When you ask for a consult, you are asking another doctor to aide in the care of your patient. Whether that’s getting a CT scan approved by the radiologist or asking a busy service such as ortho to come assess for surgery, making that phone call to get a consult isn’t always easy.
I remember a time when my staff in Internal Medicine thought there was an abscess that should be assessed. I was given the ask of finding a surgical service to come see the patient. I was turned down and harshly called out for inappropriate consults by both General Surgery and Plastic Surgery before someone finally agreed to come see the patient.
Sometimes it’s the consultant or their resident that’s rude. But there are a few things I have figured out you can do to make it more likely and easy for a consultant to see your patient.
1. Identify Yourself
When you make a phone call to a consulting service, identify yourself. “Hi, this is medaholic, clinical clerk year 4, from Internal Medicine and I have a patient that I would like you to provide your expertise on and to come and see.” The point is to make a connection with the person on the other end of the line so that you become a person asking them to help you, not just another “consult”
2. Clear Communication
There is a technique for health care communication called SBAR that you should become familiar with. The acronyms identify a method that you should follow to communicate effectively. SBAR stands for Situation, Background, Assessment and Recommendation.
Situation - encompasses identifying yourself and identifying your patient. Remember to include the patient’s full name, age, sex, health care number and location. If it’s an urgent call, make sure you let them know right away.
Background - Be brief. Tell the consultant why the patient is here and why you are requiring their consultation. List any information that is pertinent. Past medical history, relevant medications, investigations you have done and treatment.
Assessment – The assessment is always tricky for new learners, but let the consultants know what you think is going on. Explain to them why you think their services are needed.
Recommendation – If you want something explicitly, let them know. If you want their expertise and their opinion, state that’s what you want. Be clear on your expectations and make it possible for them to deliver.
3. Call before Noon or at a Convenient Time
Nobody likes getting a new consult to do just as they are planning to go home. Call as soon as you know you need a consultant’s help. If possible, call before lunch. Don’t call during lunch time unless it’s urgent.
Try to give them as much head’s up as possible so they can plan their day accordingly.
4. Leave Good Notes
Good documentation on your part makes a consultant’s life much easier. If you can provide them with as much information as possible, so they don’t have to start from scratch, you will facilitate patient care. Outline your reason for referral and possible expectations. Remember to leave your contact information so they can get in touch with you.
5. Do the Proper Workup
If you’re going to enlist the help of a consultant, you are expected to help them out too.
If you’re consulting orthopedics regarding a bone – take an xray of the bone. If you’re consulting nephrology – make sure you order urine tests. Likewise, if you’re consulting surgery, make sure you have the necessary bloodwork drawn such as PTT, INR, Cross & Type.
6. Follow up with the consultation
When you ask a consultant to come see your patient, you create an open loop, a task that is not closed or complete. Sometimes it can take a long time to get a consult, follow up on it until it gets completed and “closed.”
Similarly, it’s always a nice gesture to call them afterwards to see their recommendations and implement their plans accordingly.
7. Sign-off
If you no longer need the assistance of a consultant, contacting them and letting them know that they can sign off is a nice courtesy.
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