UNDEADING

So you're driving down the road, and look ahead to see some idiot slowly crossing the road. My first response has always been utter exasperation and wonder- don't they know they're going to get hit?

This morning when I saw that, I had a revelation: Maybe they just don't care.

I never had this thought before medical school, and it still greatly bothers me when it goes through my head (so don't feel the need to call a shrink on me or anything). But long days, hazing, frequent ridicule and a (relatively) bleak near-future, and suddenly you have the occasional fleeting thought that you might NOT care if a car hits you when you cross the road. I don't think that thought even counts as passive suicidal ideation (again, that might be relative), especially If you're on certain rotations in medical school, like cardiothoracic surgery.

Life can be tough....

GREAT MINDS...without chairs

So, a while back I posted about chair hierarchy in the hospital. Someone else (who clearly has better artistic ability) had the same thought!!!

It's a bird! It's a plane! No...it's the correct diagnosis!

Excerpts taken from Dr. Bernard Lown's The Lost Art of Healing:

"[The physician] urged us, as beginning medical students, never to prescribe for a chief complaint unless we had come to know the patient well and figured out what was truly troubling the person. A physician committed to healing could not and should not focus exclusively on a chief complaint, or even a diseased organ. If one was to help those who were sick, the stressful aspects of life had to be exposed."

"Limiting history-taking to the chief complaint often initiates fruitless pursuit of irrelevant matters that are quite tangential to the main problems."

Unfortunately, this happens every day- time constraints result in doctors focusing on the one chief complaint, and the underlying problem is never addressed. Medications, "bandaids," often cause more harm than good, and these patients end up undergoing a battery of unnecessary treatment and tests.

A solid HPI is essential to establishing a correct diagnosis but is rarely conclusive, and should naturally lead to a detailed social history which provides context for the "chief complaint."  The easiest and fastest way to handle multiple complaints is to send someone to a specialist.  So the depressed patient who comes in for back pain, headaches and low energy gets referred to an orthopedic surgeon, neurologist and endocrinologist (or cardiologist!), when an extra 10 minutes gathering history (recent death of spouse, or lost job) would result in a logical, easily-managed diagnosis.  In fact, the 2 or 3 weeks of trialing an anti-depressant would likely be faster than making an appointment with a specialist, and clearly would be less stressful and much less expensive for the patient.

Clinicians get sucked into the idea that we have to explore every possible cause (again, thanks to lawsuits), but why are we still looking for zebras??  Modern technological advances have unfortunately created a safety net for poor history-taking and physical exams.  Just because we CAN find more zebras doesn't mean we SHOULD!

My advice to a patient (or potential patient), would be to tell your doctor EVERYTHING! (If your doctor won't listen, get a new doctor.)  Many people don't associate their chest pain with their family feud, or their headaches with caffeine withdrawal.  If your doctor doesn't know about your stress or your quitting coffee cold turkey, they might forget or not have time!  While I'm far from condoning "quick" histories, I think patients have to help out and pick up some of the slack, unfortunately.

Patients are their own best advocates, and it's tough to speak up sometimes. Clinicians have to do a better job of making them feel comfortable asking questions or questioning a medication, procedure or even a diagnosis (within reason).

A Wholesome Gallop

While straining to keep an interested look on my face while "listening" to a resident physician go through a consent for a procedure, I noticed that the patient was also not listening. Rather, she kept a suspicious eye on the nurse setting up for an IV, and finally put her hand on the nurse's arm and sassily told her that last time she was in the hospital, no one could get the IV and she was not going to allow someone to stick her five or six times again. Anyway, it really set up for a dismal outcome and it made me realize what an impact a patient can make on his or her own outcome.

As a paramedic I heard that 20 times a day- "I'm a hard stick, don't even try." Honestly, that made me really angry. During some of my "darker" days I took that as a challenge (I had a good track record, pun intended).

Now I realize how that sort of comment can be horrific- if you set the stage for failure, both in your head and the other person's, you'll probably fail. I know most of the "I'm a hard stick" patients are the frequent flyers and the purpose of the statement was anything but the denotation, but nonetheless....

So that was going to be the blog. But later that day in a lecture, a physician mentioned a story along the same lines and it really made an impact.

Long story short, a well-renowned cardiologist was treating a patient with bad heart failure, and made a point to have all the students and residents listen to this man's "wholesome gallop" (a heart sound usually only heard in heart failure).

No one thought this guy would last long, but within a few weeks this guy's heart function was completely back to normal! The cardiologist asked the patient what happened, and the patient told him that he was encouraged when the doctor told him he had a "wholesome gallop," because he reasoned that only a strong heart could still gallop.

The doctor clearly hasn't meant "strong" heart; in fact, he meant the opposite, but the patient's positive interpretation resulted in complete recovery!

According to the physician giving my lecture, the moral is that you should always find the good news. If they have a nonresectable cancer: "Good news! Your cancer doesn't need surgery! We can treat you with chemo and radiation!"

I've always held the opinion that words are a physician's most powerful and influential weapon. Unfortunately, on a daily basis, I hear them misused. To many, a doctor's words are the be-all, end-all, and sometimes assumptions are made on both the doctor's and patient's sides. Seemingly minute details in a conversation can change someone's view or even possibly outcome.

I think the toughest part of learning to be a doctor is how to use your words. The easy way out is to be enigmatic and vague- a commonly used tactic. Many healthcare providers, it seems, are comfortable with medicine but are unsure of how to talk ABOUT medicine with patients (somewhat justifiably so given all the litigious people out there). We need to better teach how to feel comfortable talking to patients by giving the whole picture. We need to tell people what we know, and what we don't know. Sometimes we don't like telling patients when we don't know the answer yet, and they interpret our silence as a deliberate omission (and patients therefore make assumptions about why information was withheld).

Deferring- "why don't we wait until the test results come back to discuss this-" can cause weeks of angst and worry. Granted, there are probably situations where this wouldn't be the best decision, but I think that talking to patients is comforting to them. Being in the dark is a thousand times more frightening than knowing (again, in most cases).

That same cardiologist whose "good news" cured his patient's heart failure wrote an amazing book which I started today: The Lost Art of Healing (Dr. Bernard Lown). A parting thought from Dr. Lown:

"As the patient is empowered, the doctor's curing power is enhanced."

Life of a med student..per parodies of popular music

Some of the best med student videos out there:


The Doctor's Out Tonight (Dynamite remix): ALL-TIME FAVORITE!

I wear a coat (I'm on a boat remix):

Somebody that I used to know remix (2nd half is best; pretty much about first aid)

I'm at a code (another I'm on a boat remix)...still pretty funny:

Residency Interview Advice

Interview offers are like new pleural effusions. 

You should never let the sun set on one.

Greatest. Quote. Ever.

Moral of the story: schedule your freakin interview the day you hear back!

How highlighters made me bitter for a second

For a second I wanted to be this girl, who I stood behind on an elevator in one of the clinic buildings near the hospital. I saw this girl in baby blue scrubs, and four perfectly-aligned highlighters.

If you know anything about me, you'd know that writing instruments are one of the few things in life I'm picky about. I am extremely particular about the experience of writing (if it isn't a nice pen, you won't write neatly). I once read that neat handwriting is a courtesy to the reader. (Of course, I am in NO way implying an opinion about physicians...)

Anyway, it had been a long day, and I was on my way out when I became fixated on these highlighters. All I could think was, "what does this girl do, that she only needs four pretty highlighters in her pocket?" And then, "since they're so neatly arranged, does that mean she doesn't actually use them?" (Ie, does she actually do anything.)

Clearly med school has warped my thought processes, seeing pretty highlighters and having such a visceral response. Overwhelmingly I was reminded of my own (short) white coat..a few shades off from the bright white when it was new (ok, a lot), jammed with pens (one of each color, a highlighter, permanent marker and penlight!), lip gloss, a few dollars, a radiation badge, a bunch of old patient lists covered in notes that I eventually want to organize and copy into my "little black book," reference charts, my phone and pager, a small bottle of ibuprofen, and probably a bunch of other random stuff.

I know that that moment was one of my "why am I doing this again" thoughts, which seem more frequent but fleeting, the closer I get to graduation.

I had this instantaneous yearning to have a normal, predictable job where all you need in your pockets are four highlighters. As quickly as that feeling came and went, the next brief thought was, "that seems like a horrible job; how boring and unrewarding would that be?"

Then I just felt guilty for having such a cruel thought, and then I remembered how really, really tired I was, and if I hadn't taken the picture I probably wouldn't have remembered it for this blog anyway.

Dominate Step 2 CK

As promised, I will include a few thoughts in reflection of my Step 2 CK (clinical knowledge) exam prep.  First of all, I scored very low on Step 1 (but passed), and that has cast a shadow over my career since.  Knowing that top tier residency programs were now out of reach, I realized I had to dominate Step 2 in order to have a fighting chance at a decent residency program.  My major concern was that I have always wanted to go into cardiology, and in order to get a cardiology fellowship, you need a great residency position (and therefore, great step scores).  So a low Step 2 score would have pretty much been the kiss of death on my cardiology dreams.

This story has a happy ending: I scored a 251 on Step 2!  (My fiance is so sick of me shouting this number out, even a month after the score came back.)  My dean's office adviser told me it was the biggest jump he'd ever seen between 1 and 2 (I'd rather have the honor of scoring the highest on both, but this will suffice).

I feel like I was not prepared for Step 1, and I'll have to explain that to residency programs.  But I keep telling myself: it's a lot easier explaining one bad test score than TWO bad test scores.  I can truly say that I had a bad day.  While I'm still out of the running for a lot of top tier schools (that I may have had a decent shot at, had I done as well on the first one), I still have high hopes for some fairly good programs.

So what happened?

What I did wrong while preparing for Step 1:

• The WAY I studied: the "test taking prep" center at my school singled me out for "help" before my first exam and did a one-on-one session; they concluded that I just didn't know how to do multiple choice questions and gave me a strategy (this method took about 3x as long).  Assuming that my weakness was rooted in the questions, not content, I essentially just did a massive amount of practice questions.
• WHAT I studied: I figured if I did 2000 practice questions (or all of UWorld) I'd hit every topic, so when I got a question wrong, I'd go through all the wrong answers to make sure I knew that content as well. 
• HOW LONG I studied: I took the test shortly after finishing 2nd year (less than a month) and didn't get many full days of studying in

What I did right while preparing for Step 2:

• Taking it seriously: this unfortunately translates into a financial issue; I researched test prep for about a day before hesitantly deciding to purchase Kaplan's online lecture series (yeah, over $2000 for 3 months).  Best. Decision. Ever.   
• WHAT I studied: I realized that the question banks test you on a microscopic fraction of the material, spot-checking your knowledge for massive gaps, and you have to know how to use your performance to study: don't study with the qbanks.  I'll go ahead and do a free endorsement for Kaplan: they concisely presented a massive amount of material making it a finite amount of material (I felt overwhelmed on Step 1, wondering how you could study everything; well, YOU CAN'T, but no one tells you what to study or what not to study- until Kaplan!).  The lectures were cumbersome but memorable (at times I was falling out of my chair laughing).  Best of all, I remembered it when doing questions.  
• The WAY I studied: after doing lectures, I used UW for its intended purpose: spot checks. I literally only did about 500 questions over the 4 weeks I intensively studied, because I was sure I knew the material.  The best part was seeing the questions in a whole different light: with Step 1 I felt overwhelmed with the question (I often didn't even know exactly what the question was asking), and narrowing down to 2-3 choices and guessing randomly. With Step 2, within the first few sentences of the stem I'd know the topic, what 3 questions they'd predictably ask, and often, the answer (yes, before even finishing the stem).  

Step 2 (and maybe Step 1...can't speak on that obviously) is an extremely predictable test.  The problem is no one tells you that, so you prepare for an unpredictable test (studying a little bit of everything, just in case). They really only ask a few types of questions, so you only need to understand those concepts from each topic (for example: what's the diagnosis/what's the best way to diagnose/what's the best treatment are really the only questions asked).  

But again, Kaplan broke things down to the basics and built up from there. They really focused on looking at things that were similar (ex: lung infections: bronchitis vs abscess vs pneumonia vs TB) and looked at the similarities and then the unique characteristics that the test would focus on:

Pt presents with fever and cough: think lung infection (any of the 4 diagnoses)

Keywords for diagnosis: "normal chest x-ray" (bronchitis); "bad teeth" and aspiration risk like seizure history (lung abscess). If they're going to ask a specific question about a specific diagnosis they have to "tell" you what the diagnosis is!

Diagnostic tests: universally a CXR initially; but based on diagnosis know that there are exceptions for definitive diagnosis, like a lung biopsy is most accurate for abscess 

Treatment: know which antibiotics treat which organisms (ie penicillin family for staph/strep) and then know which organisms are commonly causative (ie abscess=anaerobes so therefore clindamycin)

I didn't touch First Aid, but I hear it's a good resource (wouldn't rely on it solely though, unless you just want to pass).

Crush Step 2 (Brochert): excellent summary of high-yield topics. Not very thorough (you'd definitely pass just reading this, but would use it as a review during the last few days to make sure you got all of the important information down)

Step Up to Medicine: love this as a textbook, to look up pathophysiology you don't completely understand; wouldn't use as the primary study aid though (saw some people do that)

Kaplan's notecards: I got these last minute (Diagnostic tests, physical exam findings and a general one) to have something to carry around. I also do better with short, concise points; plus they have great pictures. I think it's a great supplement (although a bit expensive; I will probably try to sell mine later, but they're good for step 2 and 3).  Like Crush Step 2, makes sure you didn't miss any important high-yield topics.

NBME Practice Tests: again, pricey ($50 each I think). I did 2 of them "officially." Great for estimating your progress and score; I took one about a 2 weeks before the exam, and scored in the 220s, then did one a few days before the exam and scored 241. There are always rumors that some of the questions overlap with the actual exam (I didn't notice that, although some questions just have to be asked on every exam and those may be the ones referenced), but I think more than that it confirms whether you're ready for the exam.  They all seem to correlate fairly well with your actual score (look on message boards on the net for how each correlates- some overestimate/some underestimate, but by a predictable amount).

Anyway, hope this helps someone out there.  I really think that if you approach studying (even for step 1) by seeing it as a predictable test with a finite amount of information you'll dominate it.  You just have to be willing to go find a resource that will teach you what is important.