Music of the heart

Last year, during one of our "preclinical clinical experiences," I presented a patient who happened to have an interesting heart murmur.  I was excited because heart murmurs can range from being very difficult to hear to being palpable with your hands.  Since this murmur was a normal variant and rather unnoticeable to anyone doing a quick head-to-toe (and therefore undocumented on the patient's history), the precepting physician double-checked my finding.

Sure enough, the doctor agreed.  It was more of a good teaching point than an interesting clinical finding, but nonetheless, it was a shining moment.  I had pointed it out to my fellow medical student earlier (heart murmurs I can do, but neurologic exams are another story, so this is not meant to sound immodest).  She asked the physician how to logically approach listening for murmurs, a question many of us have.

The physician started off by asking me if I had played an instrument.  I played flute for 10 years (competitively, to a ridiculous extent).  Normally, this is a topic I avoid, having heard enough American Pie jokes for a lifetime. The other student had not.

He described heart sounds as being like an orchestra; there's not just one melody.  There are many melodies and harmonies superimposed, creating a piece of music.  To a medical student, listening to the heart sounds like  a non-musician listening to music: you get the overall effect.  If one instrument is grossly out of tune, or grossly out of rhythm, it's obvious that something isn't right.

Listening to this could be daunting!

The trick to listening to heart sounds is to break it down.  Can you pick out the trombone playing the counter-melody?  Can you hear the tympani, the clarinet, the french horn?  You have to start with the core of the sound- for the heart, the "lub dub," the baseline in music. Then you can listen for other murmurs, clicks or snaps.  So much can be gained by knowing when in the cardiac cycle the extra sound occurs.  How can you describe it if you haven't even identified the basic parts?

Aha! Early systolic decrescendo murmur with a mid-systolic click. Ok, it's an unlikely pair.

Listening to the heart is just like listening to music; it takes a skilled ear, but it can be learned.  

medical school in pictures

for anyone interested in some pictures of daily life in medical school, enjoy!

First and second year in the classroom, but no one really listens!

Well ok, the people in the center rows listen (but notice no one's taking notes!)

You NEVER stop studying, even when you brush your teeth

Sometimes you spend the whole day in the lab (by choice of course)

Some days you dress in pink and host health fairs

Some days all you do is study and play on your iphone

"Light" Reading for Med Students

The problem in med school is that there are so many interesting topics that there's just no way to be exposed to them all, and once you graduate you'll NEVER have time to catch up.  And the fact that no one seems to have a "must read" list for med students and residents!!

The Emperor of All Maladies: A Biography of Cancer

Ok, this is actually a history of medicine with a focus on cancer.  I'm only about a hundred pages in, but I absolutely LOVE how the author weaves personal anecdotes of patient experiences and historical references seamlessly among the facts.  Also addressed- ethics, development of modern treatment, effects on patients' lives...

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Cutting for Stone

By far, my favorite book on this list, and one of my all-time favorites.  I couldn't do it justice, so here's a critique:


Lauded for his sensitive memoir (My Own Country) about his time as a doctor in eastern Tennessee at the onset of the AIDS epidemic in the 80s, Verghese turns his formidable talents to fiction, mining his own life and experiences in a magnificent, sweeping novel that moves from India to Ethiopia to an inner-city hospital in New York City over decades and generations. Sister Mary Joseph Praise, a devout young nun, leaves the south Indian state of Kerala in 1947 for a missionary post in Yemen. During the arduous sea voyage, she saves the life of an English doctor bound for Ethiopia, Thomas Stone, who becomes a key player in her destiny when they meet up again at Missing Hospital in Addis Ababa. Seven years later, Sister Praise dies birthing twin boys: Shiva and Marion, the latter narrating his own and his brothers long, dramatic, biblical story set against the backdrop of political turmoil in Ethiopia, the life of the hospital compound in which they grow up and the love story of their adopted parents, both doctors at Missing. The boys become doctors as well and Vergheses weaving of the practice of medicine into the narrative is fascinating even as the story bobs and weaves with the power and coincidences of the best 19th-century novel.

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The Checklist Manifesto

While the author (a physician) wrote this with the focus of medicine, it's applicable to many other fields as well- business, law, government.  The author explains that while we have more knowledge and technology at our fingertips than ever before, flaws still exist in medicine (or business or law or you name it) because of imperfect execution and delivery.

For example, we know that heart attack patients need to have an intervention within a short period of time, but only about half make the time cutoff, because of all the little things in between or not recognizing the fact that the patient is having the heart attack to begin with despite our capability to do so. 

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Placebo Effects: Understanding the mechanisms in health and disease

I just started this a few minutes ago, which prompted me to post this blog entry.  I think the idea of placebo in medicine is incredibly important and not only underutilized but unrecognized or misused.  We often consider placebo effects to be psychosomatic or for weak-minded people, but actual molecular changes can occur, especially regarding pain modulation!  I think this is a fascinating topic, not addressed in medical school, that can revolutionize how a doctor practices medicine.  I don't think we should withhold medicine, but rather augment treatment with evidence-proven techniques like encouragement, empathy and awareness.

This book is written by a physician and geared toward physicians, unlike many of the other books which are more for patients and lay people.

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The Heart Speaks: A cardiologist reveals the secret language of healing

So I haven't started this one yet, but highly recommend it by what I've heard so far.  So here's a professional review.

With groundbreaking new research, Dr. Guarneri skillfully blends the science and drama of the heart's unfolding. She reveals the heart as a multilayered, complex organ and explores the new science that indicates the heart acts as a powerhouse of its own, possessing intelligence, memory, and decision-making abilities that are separate from the mind.

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 Heart Matters: A memoir of a female heart surgeon

Having spent six weeks on cardiothoracic surgery, this one hits close to home.  There's not enough money in the world that would make me want to be a surgeon, but as a female looking to join a male-dominated field, this is a great motivator.  In fact, the first chapter provided me with an epiphany for my residency application (sorry, not sharing that for awhile!).  It's a humerus and occasionally-serious look at the struggles she faced in her journey to becoming a surgeon.

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White Coat: Becoming a doctor at Harvard Medical School

I read this over the summer after my 2nd year, and I wish I'd found it earlier.  It's a few years old, but many of the emotions and reflections eerily parallel to my own (leading me to believe that this is a good representation of what med school is like).  In fact, I made my boyfriend read it at the beginning of our relationship so he knew what I was going through and how it would affect him.  It basically starts at the beginning of the author's journey and chronicles the trivial and the not-so-trivial experiences, from anatomy lab to clinical rotations to life outside of the classroom (what little there is).

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The House of God

An oldie but goodie!  The author's emotions transcend time, and are 100% applicable to being an intern today. You also need to be familiar with the laws of the House of God as they are occasionally referenced to in the clinical setting and you're expected to understand the joke.

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The Spirit Catches You and You Fall Down

A look inside the Hmong culture (mostly medicine) and how it clashes (and occasionally meshes with) "modern" medicine; a bit frustrating to read (I made it halfway through) but enlightening nonetheless- provides insight into cultural influence on how disease is understood, the role of family, decision-making, etc.  This has greatly impacted my understanding and appreciation (and patience) for other cultures with less trust in our system.

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Better: A surgeon's notes on performance

Not my favorite, but a worthwhile read.  Critic review: A surgeon at the Brigham and Women's Hospital in Boston and an assistant professor at the Harvard School of Public Health, Dr. Atul Gawande succeeds in putting a human face on controversial topics like malpractice and global disparities in medical care, while taking an unflinching look at his own failings as a doctor. Critics appreciated his candor, his sly sense of humor, and his skill in examining difficult issues from many perspectives. He conveys his message—that doctors are only human and therefore must always be diligent and resourceful in fulfilling their duties—in clear, confident prose. Most critics' only complaint was that half of the essays are reprints of earlier articles. Gawande's arguments, by turns inspiring and unsettling, may cause you to see your own doctor in a whole new light.

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My Stroke of Insight

A ridiculously easy read (written with the layperson in mind), by a neuroanatomist who details her experience of having a stroke from a scientist's point of view.  I've recommended this book to family members, coworkers and patients- it's a great way for health care professionals to gain insight into what stroke patients are experiencing, and for stroke patients to understand what is happening to the brain.  Symptom by symptom the author reflects on the anatomy, physiology and pathophysiology of strokes (while remarkably remaining in denial about the fact that she needed help). Pretty fascinating!

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 The Lost Art of Healing: Practicing Compassion in Medicine

Written by Dr. Bernard Lown, who developed the defibrillator, this is one of my all-time favorites.  It should be a must-read for all physicians and physicians-in-training. Using patients' stories, he reflects on the importance of empathy and compassion, and shares insight about how seemingly-trivial words can change someone's life. My favorite is when he has his students and residents listen to the "gallop" of a patient with severe heart failure, who miraculously recovered, later crediting Dr. Lown for giving him the encouragement, because a heart that could still gallop must be strong!

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On the shelf, to be read:

The Sublime Engine: A biography of the human heart

Amazon description: In this lyrical history of our most essential organ, a critically-acclaimed novelist and a leading cardiologist--who happen to be brothers--draw upon history, science, religion, popular culture, and literature to illuminate all of the heart's physical and figurative chambers. Divided into four sections: ‘The Ancient Heart,’ ‘The Renaissance Heart,’ ‘The Modern Heart’ and ‘The Future Heart,’ each section will focus on a major epoch in our understanding of the heart and the hidden history of cardiology. Erudite, witty, and enthralling, The Sublime Engine will make the heart come alive for readers.

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 Intern Blues: The timeless classic about the making of a doctor

Amazon description: While supervising a small group of interns at a major New York medical center, Dr. Robert Marion asked three of them to keep a careful diary over the course of a year. Andy, Mark, and Amy vividly describe their real-life lessons in treating very sick children; confronting child abuse and the awful human impact of the AIDS epidemic; skirting the indifference of the hospital bureaucracy; and overcoming their own fears, insecurities, and constant fatigue. Their stories are harrowing and often funny; their personal triumph is unforgettable.

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Other books on Medscape's must-read list:

My Own Country (Abraham Verghese)
Love in the Time of Cholera (Gabriel Garcia Marquez)
The Immortal Life of Henrietta Lacks (Rebecca Skloot)
Arrowsmith (Sinclair Lewis)
Complications: A surgeon's Notes on an Imperfect Science (Atul Gawande)

Don't wanna go home

So I was on call today and I was with the residents having a relaxing late lunch- as we only have one patient and haven't had any new admissions- and they mentioned that once I did this one task that I could go home. Normally any mention of the word "home" causes a huge rush of endorphins and racing thoughts of how I can finish my assignments as quickly as possible. But today my unconscious first thought was "I DON'T WANT TO GO HOME!" (mental silence.) I realized instantly how ridiculous that sounded as soon as I thought it. I'm perpetually exhausted, my apartment is a mess, and I have two dogs at home who can't hold their bladders for 12 hours.  I obviously had a split second of mental insanity. However, reflecting over the past hour (it's still bothering me), I cant help but be incredibly grateful for an amazing group of residents for these 3 weeks who have actually made me feel like I've done a good job and haven't been a complete waste of their time.  So now it's much later and I got my horrible wish to stay because we got a new patient.  But I got to hear a male resident sing Justin Bieber songs and that was the icing on today's cake.

Pimpin ain't easy

I feel like now that this blog has kind of transformed into a med student blog (ok, well actually has, overnight), I have to comment on pimping.

Pimping is basically what attending physicians do to students in order to "teach."  There are many different styles, and everyone has their own opinion, but here's mine.

There are essentially three types of doctors: those who don't pimp at all, those who pimp but really want you to learn (nice-pimping), and those who pimp because they can/hate students/have identity issues/hate people in general/hate their job (angry-pimping). I thought I'd prefer the non-pimpers, but you honestly don't learn anything on those rotations.  I still feel like a complete idiot during constructive (nice) pimping, but I definitely remember that stuff.

You can pretty much predict what kind of pimping to expect by the service.  Psychiatrists and family medicine docs tend to be more nurturing and point interesting things out (which I appreciate immensely, but promptly forget).  This, however, is good to have every few months to allow neuronal healing.  Surgeons tend to be on the other side of that spectrum.

As a med student, you also get really used to answering "I don't know."  The first few times are painful, as most of us are type A perfectionists, but after a few times it becomes second nature.  So, really the difference between being nice-pimped and angry-pimped is how embarrassed and humiliated you feel when you say "I don't know."

The worst kind of pimping is when it's not even related to medicine, like when that CT surgeon pimped me for 7 hours during a surgery about what band sang each song on his iPod (I got one right, total).  That's by far the biggest ego deflation, as you don't feel worthy enough to even get angry-pimped.

So thank your lucky stars when you get nice-pimped, or even angry-pimped.  At least they're acknowledging your role as a student.

Addendum 1/9/2012:

Troponinitis (Law 10 of The House of God)

If you've ever met me, you know that my calling my neuroticism regarding cardiology "pathologic" would be a huge understatement.

Well, after two and a half years, I'm finally on a cardiology rotation.  Not medicine, not find-the-heart-patient-in-OBGYN, not a summer research program where I got to hang out on cards rounds- I've finally made it to the bona fide third year selective of INPATIENT CARDIOLOGY!

Needless to say, I've been looking forward to this for a very, very long time.  But boy, I was in for a big surprise.

I've seen like 30 patients this week on the cardiology service.  And NONE of them were in the hospital for HEART problems!!!  So far I've seen gastroenteritis, cholecystitis, personality disorders, immune disorders, poisonings, you name it.  And they all have some sort of cardiac problem, but that's not their immediate problem.

So really, this is just a glorified internal medicine rotation.  But I started thinking...I've got three years of medicine before cardiology fellowship!  AND three years of cardiology fellowship with patients just like these!  Then who knows after that.  So really, this has just been a bit of an eye-opener about what the rest of my life is going to be like.

I don't love cardiology any less, but I'm 5 days "less naive" about my career choice.

One of the most useful lessons I've learned this week (well, saw put into practice) was jokingly referred to today as troponinitis.  The layman's description is best describe by one of the laws of The House of God which is one of the best books ever written about being a resident (the details are a bit outdated but the concepts are timeless):

IF YOU DON’T TAKE A TEMPERATURE, YOU CAN’T FIND A FEVER.

From a patient's perspective, this sounds terrible.  But clinically, it's an essential part of medicine.  If you do an MRI on every patient, you'll find something in every patient.  As cliche as it is, it's so important because you may be worsening an outcome by finding something (what if the patient dies in the OR, but otherwise would have lived another 5 happy, relatively healthy years?).

So troponinitis is fairly specific to cardiology- troponins are a marker of muscle death, which is part of the diagnosis during a heart attack.  It's easy to jump the gun and order the test on every patient on the cardiology service- these patients have a higher risk, so why run the chance of missing a heart attack, right?

Wrong.  For explanation's sake, the cutoff of normal is less than 0.06 (hospital-specific, for you picky people).  People having heart attacks typically have levels over 5, and sometimes much higher.  But what happens when you get a number just above normal, but isn't really suggestive of a heart attack??  Today my patient's was 0.07.  She was obviously not having a heart attack.

Then the problem shifts from "how to save the patient" to "how to save the hospital."  As horrible as it is, a lot of medicine these days is focused on how to prevent malpractice suits.  (This is another soapbox of mine which I would NEVER blog about.  But I honestly wonder how morbidity and mortality rates would change if there were no lawyers.)  The appropriate thing is to do a full, expensive, time-consuming, potentially-damaging workup on a patient who doesn't need it.

So this is a good example of how medicine is more of an art than it is a science, and what clinical years of med school and residency are about, rather than the details of physiology and things like that.

PS. "Troponinitis" is medical jargon, not an actual term (although many doctors would understand the reference), in case that wasn't clear.  It's basically a complaint that the levels came back elevated even though heart attack is EXTREMELY unlikely, leaving a clinical predicament.