clinical skill

Basics for the Wards: History and Physical (H&P)

For me at least, writing notes on patients was one of the hardest things to get the hang of once I started my clinical rotations.

When you first encounter a patient, you want to do a history and physical. This will be the most in-depth note you write. Most services have a template for use, especially if your site uses an EMR. Ideally, you will will ask the patient about literally everything when you’re doing an H&P and it will be a masterpiece of thorough-ness and answer any and all questions that could ever pop up. However, sometimes/most of the time depending on what service you are on, you have to do a focused H&P, which is what I’ve been doing a lot of lately. The format is generally the same, but some places/attendings have a preference for the order of presentation so be aware of that!

Whenever you talk to a patient, be sure to use the appropriate language without being condescending- I’ve had patients ask me what ‘nausea’ means. In med school you get accustomed to using fancy doctor words and then once you’re unleashed on the populace you have to remember how to talk to normal people. It’s harder than it sounds- I once was in a class where we had to try and explain an ectopic pregnancy to a standardized patient (aka actor) who was portraying a person with a 9th grade education level and it was incredibly frustrating.

Last, make sure you are looking at the patient and actively listening. Saying, “Mhmmm,” and “Ok,” will show to them that you are paying attention. Don’t get so wrapped up in what you think is happening based on pattern recognition that has been beaten into your brain that you ignore what the patient is trying to tell you. Oftentimes the diagnosis is in the history, and it’s your job to find it.

So! Here goes-

History of presenting illness (HPI): “What brings you in today?”

First and foremost, this is why they are at the hospital/doctor’s office! And this is where you can quote the patient- ex: “My back hurts,” or “Some guy shot me in the leg.” Then, get the details- like a reporter, answer who/what/when/where/why/how.

If pain is involved, it is important to know as much about it as possible. A common mnemonic is OPQTRST:
- Onset- when did it start, what was the patient doing when it started, was it sudden or gradual.
- Provocation/Palliation- what makes it better and what makes it worse.
- Quality- Ask the patient to describe the pain. Sometimes they won’t know how to describe it, in which case a good question is “Is it sharp or dull?” Other quality words include burning, tearing, throbbing, constant, intermittent.
- Region/Radiation- where is the pain, I usually ask them to point with one finger where it hurts worst and then use their hand to indicate the area that hurts. The ask if the the pain moves or has moved since it started (ex: appendicitis classically starts off as a dull diffuse abdominal pain and then progresses to the right lower quadrant as the inflammation gets worse).
- Severity: how bad does it hurt. This is a notoriously tricky and nuanced question. Be suspicious if a patient is asleep when you come in the room, or smiling and laughing but tells you their pain is 10/10.  Conversely, some people will downplay their pain (I had an old farmer who was in an accident that broke most of his ribs, his O2 saturation was in the crapper because it hurt too much for him to take deep breaths and he would not tell me how bad it hurt). If a woman has given birth, I ask her how bad is it compared to labor pain. For everyone else, I use one my old neurology attending’s scales: 'If 1 is no pain and a 10 is a hyena is ripping your arm off, how bad does it hurt on that scale’.
- Time - How long has it hurt, has this ever happened before, and if it has changed since it started or since the last time it happened.

Past Medical History (PMH): “Do you have any medical conditions?”

This is where I say, “Ok, now that we’ve talked about what brought you in today, I’m going to ask you some questions about your background.” Sometimes they say they have no medical problems, but their chart says they have diabetes and heptatitis or take Keppra. Then I have to ask leading questions like, “Do you have any problems with your blood sugar/blood pressure/cholesterol/insert organ system here.” Be sure to use the layman’s term for medical conditions: hypertension is high blood pressure, hyperlipidemia is high cholesterol. If they have a medical condition, ask how long they have had it. Sometimes patients will say “A long time,” or “I don’t know,” in which case I try to make a joke and say, “Well you know us scientists always want numbers, so can you guess how many years/months it’s been?” Usually they laugh and tell me a number.

Medications: “What medicines do you take?”

If possible, get the number of pills (ex: two water pills in the morning) and if you are really lucky, the dose. Prescribed and over the counter medicines fall in this area! Be sure to ask about vitamins and supplements. It doesn’t always have to be a medicine they take every day.

Past Surgical History (PSH): “Have you ever had surgery in your whole life?”

Like past medical history, this is pretty straighforward. Tonsillectomy counts! If possible get how old they were when the surgery took place, or what stage of life (ex: hernia repaired as an infant, appendectomy in high school) if they can’t remember exactly how old they were at the time.

Allergies: “Are you allergic to anything?”

People think they are allergic to something if they ate it/touched it and got a bump or a cough that one time. Spoiler: probably not an actual medical allergy. So, when you ask people if they are allergic to something, find out what happened when they were exposed to it. If they say “My throat swelled shut,” or “I got giant hives,” odds are it’s a real allergy. Be sure to include both environmental and medication allergies.

Social history (SH): “Tell me about yourself.”

Patients are people too. They put their pants on one leg at a time just like you. Getting some background information on your patients is really important. Good things to include are:
- Vices - tobacco (what, how much, how long, have you thought about quitting), alcohol (what, how much, when, CAGE questionnaire if indicated), illicit drugs (I always say, “Now, I don’t care what you do and I won’t tell anyone, but if you do anything I need to know about it so that I can give you the best health care possible.”), sex (with who recently, protection)
- Living situation- where do they live, and with whom. If a patient is homeless or lives alone, this is good information to have for post discharge planning.
- School/Work- how far did they go in school, and what do they do for a living. If anything, this is helpful for directing your interactions and post discharge planning. In most cases, I’m going to talk and plan differently for a homeless patient with a 5th grade education vs a factory worker with a GED vs a teacher with a masters degree.

Family History (FH): “What medical conditions does your family members have?”

The big ones to ask about (especially in the South) are diabetes, hypertension, hyperlipidemia, asthma/COPD, and cancer. Ask if their parents and siblings are alive, and if not when they died and of what cause.

Vital signs/lab work

Not so much for when you are talking to patients, but when you are writing your note be sure to include their vitals (blood pressure, heart rate, respiratory rate, O2 sats, temperature) and any labwork (CBC, CMP, LFTs, etc).

Review of systems (ROS): “I’m going to ask you a bunch of yes or no questions, now.”

Most H&P templates have literally 150 things for every organ system on the ROS, and if you can go through all that, swell. For a focused H&P, you usually won’t have time. Now, it’s important to be clear that you are asking about recent/current symptoms, not 'have you ever had’ symptoms, because otherwise you will be there all day- most people have, at some point in their life, had nose bleeds and sore throats and diarrhea. You are concerned about the present illness.

I usually start with the head and work my way down:
- Head: headache, vision changes, loss of balance
- Neck: difficulty swallowing
- Lungs: shortness of breath, cough
- Heart: chest pain, racing heart
- Abdomen: nausea/vomiting, belly pain, diarrhea, constipation
- Genitourinary: problems peeing, any weird stuff with vagina/penis
- Extremities: able to move all limbs, get around
- Skin: any rashes/bumps/moles

Physical exam

I know we are all trained to do a very thorough physical exam that takes an hour. Sadly, that is just not practical in most cases. It’s important to know all the physical exam steps so you can tailor your exam to presenting problem. For example, if the patient is having horrible abdominal pain, it’s likely not as crucial to check all 12 cranial nerves.

Everyone is taught the order of the physical exam a little different. I also like to do this head to toe because it helps me not miss things. Figure out what works best for you and do it every time.

Assessment/Plan

This is for your H&P note. Now, every attending will like notes to be a certain way, find out before you start writing them. Someday you’ll be able to write your notes however you want, but for now you are subject to the whims of whatever doctor is supervising you. Start your assessment with a summary of everything above, mostly why the patient is there, and the relevant details from the history, vitals/labs, review of systems, and physical exam. (ex: 29 year old gentleman with a 4 day history of vomiting and watery diarrhea who recently went camping in Mexico. He is febrile and tachycardic but denies headache and chest pain, he has dry mucous membranes, and diffuse abdominal tenderness to deep palpation). Then go into your plan. Sometimes it is helpful to list your plan out by problem (ex: dehydration- IV fluids, vomiting - IV zofran, etc), but some attendings don’t like that.

Living the Nightlife: Tips for surviving night shifts.


I’m not talking about clinical skills; if you’ve gotten this far, you can do it. My tips about the techicalities of night shifts can be found in my Tips for New Junior Doctors post. Nope, it’s just hard to get used to night shifts at all. I’ve spent quite a bit of time chatting to various colleagues, and gathered a few things that seem to work for me, so this is a lost of suggestions which might help for those struggling to ease into the world of working nights. Not mandatory, by any means. I don’t really feel it’s a complete list, but I do feel like putting it out into the aether. If you have any tips, feel free to add to the list :)

In the lead-up to nights:

  • Sort out your life admin. On-calls don’t leave much time for other things.
  • Try to go to bed a bit later than normal. This is easier if you have a weekend or a day off before you start.
  • Let yourself sleep in late in the leadup to nights. The aim is to shift your body clock closer to when you will be on nights, so that you will feel less of a shock when everything flips.
  • Tell your friends and family you will be on nights. Anyone likely to text/call/whatsapp you during the day. Not to brag or whinge, but so they know that they shouldn’t disturb you, or sulk if you don’t answer!
  • Schedule any deliveries for the days before your nights, or only for times you know you don’t plan to sleep on your nights block. There is nothing worse than being woken up by a ring at the door halfway through your sleep. If you wake up it is harder to snooze off again.
  • Plan your ‘packed lunch’. Yup, 12 hour shifts are long, you WILL be hungry. Your doctors’ mess may not be well-stocked. The hot food and vending machines at your hospital may also be broken; always plan in advance; I spent my first night shift snacking on huge piles of shortbread because the machines were broken and there was nothing else in the Mess. Never again.

On the day:

  • Get as much sleep as humanly possible.
  • It may be easier to sleep in until late, then get up and go about your day before your evening shift sets in.
  • Or, some people prefer to get up at a relatively normal time, and take a nap in the afternoon preceding the night shift. There is no right answer.
  • Eat a good ‘breakfast’ before your shift starts. I usually eat ‘dinner’ in the morning (before bed), then ‘breakfast’ when I wake up (before work) then halfway through the shift when it is less busy (2-4am) I have ‘lunch’.
  • I feel it helps to set out the day pretty similarly to normal days, because it feels less jarring. Trying to eat at reasonably regular intervals also helps avoid that hypoglycaemic feeling of despair and not being able to cope. And the hangry rage.
  • I also pack snacks because long days are exhausting.
  • Don’t forget plenty of loose sheets of paper and your clip board, request forms etc.

The shift itself:

  • You will get a pile of jobs as soon as you start. The aim is usually to band to gether as a team to clear them as soon as possible.
  • Make sure that the person who handed over those jobs gave you all the right infromation.
  • Make two jobs lists: urgent jobs, and the ones that you ‘can do if you find a spare moment’
  • If you are lucky, it will become more peaceful around 2-3am.
  • If you are moderately busy, you will catch a breather around 4-5am as people stop wandering around or going to A+E.
  • You need to eat. If it hasn’t petered out by 2-3am, talk to your counterparts to plan breaks and cover each other.
  • You don’t need to have no jobs or patients on the list to eat or got to the toilet. If there are no urgent ward jobs, you can eat quickly.
  • If the patients waiting to be seen on the acute take have been triaged as low risk, are clinically stable, and have not been waiting long, having a cup of tea and a quick sandwich is not harmful. They will be monitored by your nurse colleagues. Just let your senior know so they can crack on with seeing patients.
  • You cannot look after patients to your best ability if you are exhausted, hungry, dehydrated or bursting to go to the toilet.
  • You never know when 30 people will turn up to A&E at once, or when 5 patients will fall on the wards in rapid succession. Take it easy when you can.
  • If it’s not bad on your take, help your ward equivalent.
  • If it’s not bad on the wards, check the A+E list for referrals and help your colleague clear patients.
  • Update the list whenever you have time.
  • If you don’t have time to eat but are feeling completely exhausted, a hot drink or some juice, or even a cup of water can work absolute miracles.
  • caffeine in reasonable moderation is your friend.

After the shift:

  • Do not drink caffeinated drinks after your shift.
  • …Unless you have a long drive ahead and need it for your safety.
  • Don’t drive long distances after night shifts. If possible, d not drive or cycle at all: you will be hugely exhausted and sleepy so are at particular risk of accidents.
  • Eat your ‘dinner’ when you get home, not long before ‘bedtime’. The postprandial effect may even help you drift off more easily.
  • No matter how awake you feel, go to bed, just as if it was night time.
  • Don’t get out of bed, even if you don’t feel sleepy.
  • If you wake up, don’t sweat it. It may be harder to get to sleep, but you can keep trying. Just stay in bed, don’t play on your phone or computer and you are much more likely to drift off.
  • Read about good sleep hygeine.
  • Don’t play on your phone; that will only kee you up.
  • Blackour curtains or a sleep mask are an absolute must.
  • Close your windows.
  • Put a note on your bedroom door/fridge/etc to let your flatmates know that you are working nights.
  • Explain to them that being noisy is the equivalent of you banging pots and pans around in the middle of the night for them.
  • Silence your whatsapp/text/ringtone. Everything that is not your alarm clock should be switched off.
  • Give yourself a good 7-8 hours of sleep. I always try to sleep more hours on nights than I do normally, by being stricter with myself. It actually means I barely feel sleepy on nights at all!
  • When you wake up, leave a good amount of time to eat and get to work.
  • Night shifts are 12=13 hours long usually. Even with sleep accounted for, if you don’t live too far away from work you still get a couple of hours to eat/watch TV/catch up with someone close/chill. Try to de-stress in that time.

After nights:

  • You get days off! YAY
  • But getting your body clock back to normal will be brutal.
  • Personally, I recommend not sleeping through the day that follows your last night shift, if you can. This will leave you more sleepy when it is night time, and hopefully make it easier for you to go back to normal sleeping patterns.
  • If you must nap during the day, keep it short and set an alarm so that you don’t end up sleeping the entire day and lying awake all night.
  • Despite your best efforts, you’ll probably find that you feel more sleepy during the next few days, and find it harder to sleep at night. That’s common, and your body will eventually settle back.
  • Practise sleep hygeine as best as you can, to settle into a normal pattern quickeer.

Hello, it’s #optomstudies here again with another Weekly Study Tip on university life! This will be a multi-part series that hopefully will give a unique insight, since I can go on and on about university, and I love giving advice and helping others :)


PART 6: SOCIAL LIFE

Keep close with your high school best friends. A lot of people from my high school came to my university, and they’ve done different things in this regard. I know some people who completely cut off contact with everyone from high school. Then there are others who stuck to the same group of friends, and then others still who became closer to high school classmates that they previously had little contact with. 

My advice is to choose to keep your closest friends, because making friends that close in university can be difficult. 

What if you cut off everyone and hang with uni friends, only to fail a subject and have to make a whole new group? This is a very real occurrence; many of the friends I was quite close to have left, and it’s just difficult to keep in touch as much as if we were in the same classes. I think out of a cohort with 110 ish people, we’re down to 56, and even then only about 2/3rds of us were from the original cohort that started together in 2013. 

Uni is great for meeting a variety of people. These might be people that you don’t get along with, people you find standoffish, people who you are forced to work with for the sake of an assignment, people who you think just act stupid/selfish/snappish or on the other hand, they might be people who become great friends that you continue to keep in touch with. It reflects the wider world, so keep an open mind and try and learn about different perspectives. I found that first year was really good for reading cues about people and figuring out little things from small subtle gestures.

You can’t get along with everyone. I kinda knew this before uni, but at the same time when I’m dealing with people it’s hard to keep it in mind. There are just people who you can hang out with for ages, and yet you still don’t get along, not because of any lack of effort on your part. If you don’t get along with someone and you’re not forced to, then just hang with others. I think that’s one of the main benefits of uni; you aren’t sort of forced to hang out just in those lunch groups anymore. 

Try to make friends with people outside of your degree. I just think that knowing and talking with someone outside of your degree interests makes you a more well-rounded person and you can often pick up things about a topic that you wouldn’t otherwise know. Likewise, join a club for socialising and meeting people with the same interests! So that you can fangirl over the same things :D

Don’t be the tool that cosplays a pauper. That omgsh-free-food-guys attitude is absolutely ridiculous because unlike American college students that almost always have to live away from home and pay for their tuition, most Australian students live with their parents. They also aren’t living paycheck to paycheck, so I don’t understand why people have to scramble for free food in a bizarre cult-like fashion. There’s even a free food facebook page for our university where anyone that doesn’t post about free food gets hurled abuse.

Maybe don’t talk about university homework too often? I know it’s tempting especially as most people reading this are probably studyblr owners, but now that I personally try not to talk about uni, I find that people start talking about uni to me. It can get exhausting after a while. Likewise, don’t be that person who omgsh-slept-only-4-hrs-last-night-and-hasn’t-even-started-that-assignment-due-tmrw-gosh-i’m-soooooooo-tired. Is that like a humblebrag or something? What’s up with half the student population competing for who handles uni life the worst? It gets old pretty fast. 

Going to annual cruises, parties, formals: go once in first year and once in your last year. Once for the experience, and then in the last year for the meaningful memories and celebrations. No need to put up with vomit and drunkards unless necessary. Plus, the events are usually held during mid sem break, which is when you want to catch up with your studies and your old high school friends for example. 

Uni is great for networking and learning professionalism much needed for future career relationships. There are a lot of resources, not to mention careers support, and some of the lecturers you talk to, or the seniors above you could be your future coworkers or bosses. Try to make a good impression on everyone you meet :) 

Find someone who likes to study/practise as much as you do! As an optometry student, I also need to keep my clinical skills up to scratch so I like to practice whenever I can… except the thing is that I almost always can’t find a partner. It’s so impossible because no one can be bothered going to practice when I do, and they all practice right near exam period which is when you have to start fighting to the death waking up at 5:30am for a practice bay! 


MY WEEKLY STUDY TIPS

WHAT I WISH I’D KNOWN BEFORE UNIVERSITY STUDY TIPS SERIES

SEE ALSO

The Integrity of Medical School

I’ve been in medical school for a little over a semester and I have become very disillusioned with medical school as an institution. I’m glad I’m in medical school and I know how lucky I am to be in medical school, however, I’m struggling with the ethics of medical school as an institution.

It took me six years to get into medical school. In that time I got a bachelor’s degree, a graduate degree, I worked full-time and volunteered nearly 20 hours a week. I took the MCAT and went on interviews and paid for my applications. In that time, I also probably spent well over 30 thousand dollars trying to get into medical school, not including the student loans I had to take out to pay for my pre-med and graduate classes. The cost of my applications, alone, was 5 thousand dollars. And that was the second time I applied. The cost of my interviews were also easily 5 thousand dollars as well. 

When I got into medical school I was excited to become a doctor. I was proud of myself and felt vindicated that all of my hard work paid off. I was ready to start learning how to be a doctor. My first semester was absolutely miserable. The morale of my class was extremely low. We go to a school that heavily emphasizes wellness but a slew of new changes based on feedback from students ahead of us created a schedule that was unsustainable and didn’t leave time for any self-care practice or wellness at all. The idea of wellness became a running inside joke in our class where people would proudly state that they participated in self-care by taking a shower for the first time in two days or by sleeping in past 7am on a Saturday.

But we got through that first semester, propelled by second year students telling us that it would be all downhill after that and that once we started organ systems second semester, we’d be so much happier and have so much time to take care of ourselves and study (because our schedule was so jam-packed that it left very little time to study and our attendance in class is required). We had third year medical students telling us how they would rather repeat their entire third year of medical school and all the crazy rotations that go with it than repeat their first semester. And so we took all of our finals and set off for winter break looking forward to next semester.

Our second semester started a little over three weeks ago. News that we lost six of our classmates spread through the class. They chose to leave or weren’t allowed to come back by the administration. It was an elephant in the room that none of us can talk about because of privacy rules. Still, morale is higher when we start up our organs systems classes.

And that is when I realized what a money scam medical school is. I am required to go to class if I want my class rank to be high not because our classes actually teach us information but because your grade is connected to your attendance, so poor attendance = a poor grade = a lower class rank. I sit in class for up to 9 hours a day and have clinicians read powerpoint slides word-for-word to me, none of which are interesting or helpful to my actual learning and all of which I could have read to myself at home. I am told by our academic administrators to buy resources like First Aid to study for Step 1, they bought us a Q bank but we have to pay for everything else. $900 later, I have subscriptions to Pathoma, RX, Sketchy, and Firecracker. I wanted to buy a set of clinical case books recommended to us but the price on Amazon was $653. By the time I take Step 1 I will have taken out 150 THOUSAND dollars in student loans ON TOP OF the student loans I already have from two bachelor degrees and a master’s degree. 

I will need to pay the fees for the Step exams on my own. I am expected to join various professional societies and pay their yearly fees because it will make my residency application look better even though joining those professional societies has no impact on what kind of physician I will be, how much I care about others, or my Step 1 score. And, of course, those professional societies are so generous and give you a discount because you’re a medical student, so instead of paying $500 you’re asked to only pay $150. But isn’t it worth it to add some fake prestige to your residency application by saying you went to the AMA conference one year? The AMA that endorsed Tom Price for HHS secretary? The AMA that endorsed someone who wants to remove the ACA and condemn 43,000 additional people to death due to lack of insurance every year. Sign me the fuck up, right?

I am disgusted with the cost of medical school. I knew it would be expensive but I feel it is unethical to ask students to spend so much money applying to medical school and taking the MCAT and then asking them to pay EVEN MORE. Especially when there was so much hand-wringing from the AAMC and NBME about how to make medical school more affordable and how to increase the diversity among students and increase the number of first generation physicians (since studies show that children of doctors tend to be worse doctors than their first generation peers). I have an idea:

Get rid of the first two years of medical school. Make Step 1 the admissions exam for students. Get rid of application fees and the MCAT altogether. Start students up in January, give them a ten week course in gross anatomy, followed by a two week intensive clinical skills course and a first aid/CPR certification, and start them up on wards in April, a full 2 to 3 months earlier than most schools. This gives students 5 to 6 months to explore specialties after their required rotations instead of 2 to 3 which aren’t even really used for students to explore since those are the rotations they need to do in order to get the letters of rec they need for their residency applications (may be the lack of time to explore specialty options is why 60-90% of physicians hate their fucking jobs). 

And then, of course, you have to spend thousands of dollars on your residency applications and travel for interviews, which are not factored in to your student loan awards. 

This will never happen, though, because the AAMC makes billions of dollars in application fees, MCAT fees, and official test prep materials. The NBME makes billions of dollars off the backs of students paying for their exams and the LCME makes just as much. None of the organizations that could change the system have the incentive to do so because they are too busy milking medical students for all the money they have.

I know it sounds like I’m too money focused. The truth is, I’m not. I gave up hope of ever paying off my student loans years ago. I will never pay them back and I didn’t want to be a doctor because of the salary. My disillusionment with medical school as an institution is due to the ethics of it all. When I was applying to medical school there was a huge push to improve medical class diversity and encourage more minority and lower class students to apply. You can get fee waivers and financial assistance to cover the cost of your MCAT fees. But that doesn’t go far enough. Those application fee waivers don’t make booking flights for interviews any cheaper, they don’t lower the cost of having to rent a car or buy a suit for an interview. 

How can we expect students living in poverty to drop 5 grand on interview costs just to get in to medical school? How can we expect students living in underserved communities to afford the cost of Step 2 and the price of travel to and from the 6 locations in the country you can take it? Underserved communities NEED students who understand what living in those communities is like to go back and be their doctors. And, yes, there are scholarships and small-scale help, but I’m arguing that the entire system, right now, is designed to keep students who can’t afford to pay for medical school admittance out. Is a student whose family is on food stamps really going to have $150 to pay for the MCAT? No. 

I look around at the people in my class, which to my school’s credit is exceedingly diverse in race and religious background, however almost everyone in my class comes from a family that was middle class or above. Half of my classmates have parents who can afford to pay for their tuition and living expenses. I am part of the other class that has to take out loans. But when I was applying to medical school and there was a mix up with my teaching assistant stipend that lead to it being delayed, my dad was able to loan me the $2500 I needed to submit my AMCAS application on time. If I had not had a full-time job as a graduate student, though, I would not have been able to afford the cost of interviewing, and a third of the interviews I went on were local. 

In class, we are asked to think about treatment plans for patients and discuss them with each other. The girl sitting next to me says she thinks this ethics class is a waste of our time. The patient is an overweight child who we need to counsel, she lives in a run down part of a large city. We work together on her treatment plan and my partner comes up with a list of groceries to buy. I point out that the patient in question is a minor and likely not in charge of her food and that the education needs to be directed towards the parent and the patient. I also point out that due to the income level of the area they live in, the patient’s mother is likely relying on food stamps. I go over the grocery list and not a single thing is realistic. I point out that food stamps cannot be used to buy milk. My partner is shocked, her eyes widen; when I tell her how food stamps in my state can’t be used to buy rice, her entire world is turned upside down. I voice this in class when we are invited to share. A male classmate who is openly gay and voted for Trump comes up to me and asks me to explain why food stamps can’t be used to buy milk. I do and he doesn’t know what to say.

I look at my classmates who do not understand what poverty looks like in reality and I think about the people I know in rural towns who blew their entire savings trying to get into medical school only to be told when they didn’t get in that they needed to go take the MCAT again because the 29 they got wasn’t good enough, they needed a 30. The people suggesting this to my friend recommend taking an MCAT course not realizing the closest one would be two hours away and that the nearly 3 grand the course costs makes that impossible, not to mention the cost of taking the test again. It doesn’t matter, though, because she wouldn’t be able to afford all of the resources for Step 1 let alone the cost of THAT exam once she got into medical school. She works as a CNA in a nursing home.

How can we put such a financial burden on students applying to medical school? How can we ask medical students to pay so much money for residency applications, licensing exams, and tuition? How can we do that and then ask them to enter a profession that requires them to get permission from insurance providers and hospital administrators to order a damn chest CT? How can we ask them to pay so much money and then ignore the fact that there aren’t enough residency spots available for all of them to train in? How can we ask pre-med and medical students to pay so much money when the health care system is in shambles and the only people making money are hospital CEOs and insurance companies? How can we expect medical students to pay back their massive student loans in a system like that? Why are institutions like the AAMC so comfortable setting so many medical students up for failure?

Because my school emphasizes wellness, we have mandatory wellness classes we have to attend. Because, in medical school, giving students time to practice self-care isn’t as important as requiring them to attend a four hour class telling them they need to practice self-care and get lots of sleep, all while requiring them to be at school by 8am and making us sit in class until 5pm, giving us five hours of the day to study before we do it all again. And, of course, in those five hours of study time we also need to fit in time to exercise, feed ourselves, and maybe speak with our loved ones for five minutes to make sure they are still alive. Because self-care!

I wouldn’t say I’m jaded about medical school this early on but I am questioning why this system is in place. Why pay for two years of medical school when everyone just uses First Aid and Step resources to get a good score? I think medicine, as an institution, is really stuck in this idea of “well, I had to do it so you do, too” which I think is a really dangerous way of thinking. I think if medical students have extremely high rates of depression and anxiety (myself included, however mine was with me long before medical school) and it just gets worse through residency and becoming an attending there’s something wrong with the system. And if something isn’t working, why shouldn’t it be fixed? “Because I went through it and you should, too” isn’t a good enough answer for me. It’s also not accurate, right? The doctors who are saying that bullshit excuse went to medical school in a different time, where they could actually make decisions about patient care without having to call an insurance company for permission first. They went through medical school when it was actually affordable. They went through medical school when the idea of a woman being a doctor was either not allowed, unheard of, or looked down on, because who would take care of their kids at home while they went through residency if their wife was in medical school? 

So, yeah, they went through medical school and worked all of these hours and paid for medical school but the context was different, so I still want to know why such an archaic system that is already financially unattainable for people we NEED to be doctors and is quickly becoming financially unattainable for anyone who doesn’t have a trust fund is allowed to exist. I want to know why a 60-90% dissatisfaction rate is considered acceptable among physicians without any examination of the system that makes them into physicians.

21 Skills of Social Work Interns When Interviewing a Client/Patient:
  1. Introduction of self and purpose of interview
  2. comfort with asking questions
  3. Genuine warmth without awkwardness
  4. Shift between structure and flexibility according to feedback.
  5. conscious use of reflection, interpretation
  6. direction and focusing of interview
  7. staying with emotion
  8. permitting silence
  9. use of confrontation when necessary
  10. lack of false reassurance
  11. considers sharing life experience when appropriate
  12. moves away from advice-giving to exploring alternatives
  13. moves from “do for” client to exploring client’s ability to do for self
  14. moves from planning for client to joint contracting.
  15. recognizes when something went wrong, and has ideas why it happened
  16. ability to assess interview, understand significance of themes
  17. ability to explore history
  18. ability to make prognosis, after reflection and then during interview
  19. awareness of transference and countertransference
  20. understanding the role of a social worker is not necessarily to make client happy
  21. ability to end interview in structured, purposeful manner
Insight and Perception
  • Me: Do you have any other medical conditions or health issues?
  • Patient: No, I am really healthy. No other medical issues.
  • Me: Do you take any medications, either prescription or over the counter?
  • Patient: Yes, I take Ventolin and Metformin. Oh! And vitamins.
  • Me: ...Do you know why are you taking them?
  • Patient: I have asthma and diabetes.

I’m watching the last episodes of 13 Reasons Why and….wow…this counselor…0 clinical skills.  Like I get it  It’s clearly part of the story line.  But I hope that this does not turn people off to talking to a therapist or counselor about depression, sexual assault, suicidal ideation, etc. 

Those conversations with real counselors do not go like that.  At all.  At least they shouldn’t.  Ever.  

Sorry for the absence

Currently agonizing over my fellowship app…because my last letter writer has still not submitted his letter of rec, despite my daily pestering. Meanwhile, my friend who is also applying with incomplete letters has gotten three interview invitations. None to places I want to go but like…I would like interview invites!

I’m also really conflicted about rheum. I suck at it, it’s constant clinic, the attending is facetious. But I feel like I’m learning a lot and doing a better job with my clinic skills. I’m just tired of it, I guess. 

Oh, and I got pulled for MICU right when I thought I was in the clear to go to my friend’s wedding. 

Just gotta ride this wave. 

5 Common Misconceptions About Vet School

Lately, when I’ve been discussing school with pre-vets, family, or friends, I’ve received some interesting insight into what people think vet school is like. So what are some of the common misconceptions that I heard of? Well…

1) If you love vet med, you’re going to love everything about vet school. Unfortunately, this one is something a lot of us believed before matriculating into vet school, to the point that when we realized we disliked some parts of it, we questioned whether this was the career for us. For all of those pre-vetties out there, let me be the first to tell you that there might be parts about vet school that you don’t like, whether it be the constant exams, overwhelming stress, or the sinking feeling that you think you just aren’t good enough for this. You even might actually dread going to school sometimes. And you know what? This is OKAY. Because you are not going through 4 years of torture to become a vet student, you are becoming a vet, so it’s okay to hate the middle man sometimes. I promise that you can still dislike vet school at times but still enjoy being a veterinarian.  

2) You get to play with puppies and kittens all day. Ha, if only! While we do have lots of club wetlabs and get some “clinical skills” sort of classes where we learn how to do physical exams, draw blood, etc, the first 2-3 years of vet school is sitting in a lecture hall for 8-10 hours a day cramming as much knowledge as we can down our throats. Sometimes the only interaction with animals we get are with dead ones.

3) The hardest part about vet school is getting in. This one is dependent on the person, so I won’t say this isn’t true for some people, but this is a bit of a blanket statement that is false for a lot of people, though I do admit I certainly would not want to apply again either. Once you get in, it’s not a guarantee like this statement would suggest. People who did well through undergrad can not only struggle, but they can actually fail out. Or they can do okay grades-wise but fall victim to crippling depression and have to take a year or two off. As much as I am eternally grateful where I am, the academic rigor, combined with the mental and financial sacrifice that I make every day, makes surviving vet school much harder than getting in, personally.

4) Vet school is only for 2 years or online. Most people are shocked when they find out that it takes 4 years to get your DVM (after 4 years of undergrad!). I, for one, am happy about the length, because I don’t think I will be ready to treat anything after 4 years, let alone 2 years! So yes, vet school is 4 years, and yes, I promise I’m going to be a real doctor practicing real medicine, even though I’m not treating humans. 

5) Once you graduate, you will know everything there is about being a vet. I’m not close to graduated yet, but I know this one is completely false. When I graduate, while I’m sure I’ll be on my way to becoming a competent veterinarian,  I’ll probably know about an inch out of a mile’s worth of knowledge. When I take my oath in a few years, I will pledge my life to continuing education to further advance the medicine that I will be practicing to provide the best quality care for my patients that I possibly can. Learning doesn’t stop once I cross that stage. 

OSCE Tips

In the UK OSCEs, Objective Structured Clinical Examinations, are exams where you are in a circuit and at each station you are instructed to perform a clinical task such as an examination of a patient, or taking a history.

  1. Practice! Practice makes perfect. Make sure you time yourself doing all the procedures. With practice you will become so slick at doing these clinical skills!
  2. Books such as Essential examination are amazing little guides to OSCEs
  3. Stay calm, OSCEs are the only exam in medical school, where you can know what is coming up and what the answer is. 
  4. YouTube videos are also great - I use GeekyMedics
  5. Be professional during the exam, it always helps make a good impression on the examiner. This includes how you dress! I dress how I would for clinical placement for OSCEs
  6. Be super nice to everyone
  7. Every station is brand new, don’t let your performance in one station affect the others
  8. Don’t worry if the examiner seems to be really blunt with you, they’ve probably been told to be, don’t let it phase you!
  9. Read the instructions! 
  10. Always wash your hands, explain the procedure, gain consent, confirm patient details! These are easy marks!

anonymous asked:

Hi I'm a student nurse and I'm going in to my last year where we have 2 normal placements and then our signoff. Was just wondering if you could give me some advice on where I should think about going for my last two official placements, one is meant to be critical care and the other can be anywhere. I want to experience as much as I can, I don't want an 'easy' work load, I want to be able to get as many clinical skills as I can from these last placements so I can think about where I want to work

Dear Anon,

If you’re looking for clinical skills, then I suggest any ICU unit and also an emergency department. As a student, I gained the majority of my hands-on, clinical skills in the ICU and ED.

Originally posted by twenty1copilots

Here are just some of the experiences I gained while in the ICU as a student:

  • hanging critical drips (gtts)
  • learning the starting doses and max doses for those drips
  • how to drop NG and OG tubes
  • how to assist with central line and arterial line placements
  • how to manage those central and arterial lines
  • how to care for various stages of pressure ulcers, particularly stages III and IV
  • how to care for post amputation patients
  • how to start and manage peripheral IVs
  • how to insert Foley catheters

In the ED, I gained experience in the following:

  • how to start a shit-ton of IVs
  • how to draw a shit-ton of labs
  • how to do a shit-ton of focused assessments

Looking back on my med-surg and step-down unit experiences, I did not gain nearly as many hands-on, clinical skills as I did in the ICU and ED. 

Of course, a lot depends on what type of nurse you want to be? Do you want to do med-surg? Then you probably don’t have to worry too much about bedside CVC or A-line placements as those patients will likely be in the ICU. 

Personally, I think having the skills gained through ICU and ED experiences will only make you a better nurse. Those skills certainly won’t hurt you if you decide to work med-surg or PCU.

I hope my answer to your question helps! Thank you for taking the time to ask! Good luck in your last year of nursing school - you totally got this!

Originally posted by ihiphop

Sincerely,
Mursenary Gary

anonymous asked:

Could you explain to me the medicine education system in the US? And what do you think about the system in Europe? I study in central Europe and I'm just curious:) Have a nice day!

I don’t know much about the system in Europe other than it sounds a little scary to a person graduating from high school who isn’t totally sure what they want to do yet.  

Here’s the US System:

Year 1

Years 2-3

  • Continue with pre-med and major classes.
  • Consider taking MCAT in the middle or end of 3rd year and apply to med school early decision (also link below).

Year 4

  • Finish premed classes and take the MCAT
  • Apply to Med school
  • Interview for med schools
  • Get in to med school.
  • Graduate from college with Bachelor’s degree 

Year 5

  • Start Med school. For the next 2 years you will be doing all the “book learning” part of medicine, learning anatomy, physiology, biochemistry, pathology, histology, and all the other -ologies.
  • Note that there may be anywhere between 0 and 25 years between graduating from college and starting med school. They don’t have to be continuous, and often aren’t. 

Year 6

  • Continue book learnin’. Take the USMLE Step 1 Exam (or COMLEX 1 for DOs) at the end of second year of med school.

Year 7

  • Start clerkship training in hospitals. You go through the standard required rotations of Internal Medicine, Family Medicine, Surgery, OB/GYN, Pediatrics, and Psychiatry (+/- Neurology, ER, Geriatrics, ICU, Rural/Community Medicine)

Year 8

  • Take mostly elective rotations
  • Figure out what kind of doctor you want to be
  • Take USMLE Step 2 CS and CK (Clinical Skills and Clinical Knowledge) or COMLEX 2 early in 4th year.
  • Apply to ERAS (Electronic Residency Application Service) in the early fall and send applications to all residency programs in specialties you are interested in
  • Interview during the fall and winter
  • Everyone finds out where they matched for residency on Match Day in March
  • Graduate with your MD or DO degree

Year 9

  • Start residency as an “intern”. You may do your intern year in the same place where you complete residency, and you may not. Some people take a transitional year (explained here). 
  • If you didn’t match into residency in year 8, you try again this year. You cannot work as a doctor this year even though you have your degree. 
  • Take USMLE Step 3 or COMLEX 3 at some point in residency and become eligible for a permanent medical license in your state.

Year 10 (+ 1-5 years)

  • Finish the remaining years of residency and learn your specialty. 
  • Number of years in residency varies by specialty. 
  • Apply for jobs or optional fellowship training.
  • Take board exams in your specialty at the end of residency or just after graduation to be a Board Certified Whatever Kind Of Doctor You Are.

Optional More Years

  • Opt to apply to a fellowship and learn subspecialty training. 

Work as an Attending physician

Additional Resources:

AAMC Timeline for Admission/Acceptance to Med School

AAMC The Road to Becoming A Doctor

Med School Admission Requirements

Financial Aid Fact Sheets

Early Decision Program

A Nursing Student's Guide to Privacy

1. Never reveal your grades. If they’re good, people will judge you. If they’re bad, people will judge you.

2. Avoid telling people your GPA. if it’s 4.0 people assume you’re book smart, lacking clinical skills - and if it’s low, people assume your intellect is based solely on grades, and not on the intellect you have clinically.

3. There’s a general curiosity in nursing about where you went to Nursing School; other nurses etc - be proud of graduating from ANY nursing school. It doesn’t matter if it’s elite, or a community college: we all passed the same NCLEX, (or Licensing exams external to USA) , we all have have the same letters, RN after our name.

4. Be mindful of whom you share your goals, and your nursing aspirations with. Not everyone is supportive. Guard disclosure of your dreams, and your vision; know the difference between those who are hungry for information - and those who will keep your trust, and stand with you through it all.

5. Often during clinicals, students cluster together to watch others perform skills. It’s ok to want privacy if you’re nervous. It’s embarrassing when the instructor asks if it’s ok to do it with others watching, in front of everyone - so of course you feel obligated to say yes. Tell your instructor about it on the side, before everyone gathers around.

6. Follow your instincts with people; competitive people generally reveal themselves one way or another.

7. If you’re doing well, and a good, methodical note taker - people will ask for copies of your notes. Be vigilant of whom you share them with: notes are often passed down through semesters.

8. If you have a good mentorship relationship with one of your professors, be mindful who you share this information with - not everyone is kind or understanding of these important connections.

9. During simulations, it’s ok if you don’t do all the skills expected of you while the cameras are rolling. While these cameras are in place for evaluation of how a student can refine their skills - It can also be intimidating. How you operate as a nurse isn’t necessarily reflected by how you do in a hour long simulation where you can’t stop to ask questions, bounce ideas off a more experienced person, or go look for support, supplies or have a tinted room of people watching.


10. Keep the amount of NCLEX questions you had to answer to yourself. Regardless of whether you answered 75 or 265, it won’t help determine how others will do when they’re asking. You can be just as intelligent at 75 or 265, or anywhere in between.

10.5. If you graduate with honors, guess what, you still don’t owe anyone an explanation of what your grades are, your intellect, or your clinical skills - wear your tassels well, and ignore the naysayers.

Things I learned during my first year of medical school

I cannot believe I’ve finished my first year of medical school already! Wow! 

Warning: long Parks and Rec gif-filled post ahead (90% of these are cheesy but I am pizza levels of cheesy when I’m reflecting):

Originally posted by gifsboom

1. Do your thing

The first semester of med school was a weird time of looking and seeing what other people were doing to study and wondering if I needed to do that too. 

I wondered, should I get a bunch of colored highlighters? Make a million flashcards? Am I behind because I haven’t studied that lecture yet? Should I stream instead of go to class because that’s what other people are doing?

Originally posted by yourreactiongifs

My advice? Try new things out but once you figure out what works for you, don’t be afraid to stick to it. Some people found out that they study best in groups. I found out I study best by myself. I don’t like highlighting but I do like writing down things I need to know in a spiral so I can review/remember them better. I also like doing as many practice questions as I can get my hands on. I like going to class and taking notes on my computer. 

I didn’t know any of that until I got here. And that’s okay. But don’t stress about what other people are doing - you’ll find what works for you. 

2. Don’t try to study 24/7 

Seriously. Don’t. It’s not worth it. You’ll burn out and realize you could have been more relaxed and focused if you took a break. I try to take a couple minutes of break every hour and a bigger break every few hours whenever I’m studying. I also try to take at least one day off per weekend and do something fun (even if it’s small). I also know I study best during the day so I usually take the evenings off as well unless it’s like crunch time. 

Originally posted by rachgrub

3. Investing in dress clothes is a good idea

Inevitably, you’ll forget that you have yet another clinical skills class that requires white coat attire (aka business casual) and only remember last minute, without time to do laundry. It’s way less stressful if you have a few possible outfits. Even easier? If you wear dresses, get some nice professional dresses. Nothing better than only picking a single thing out of your closet to wear! Also, along with that, make sure you have dress shoes that fit and are comfortable. I learned that I need to break in new flats sometimes before I wear them or I will get really bad blisters. 

Originally posted by impeterperez

4. Laughter is the best medicine

As cliche as it sounds, I could not have gotten through this year without laughing. Laughing with new friends, laughing at ridiculous situations, laughing at silly gifs posted in our med school’s FB group specifically created for that purpose (it’s the best, highly recommend. Our class has 3 facebook groups - one for class announcements/club things, one for study materials, and one for laughing. The silly one was started by an MS2 (now MS3 I suppose!)). Laughing is seriously therapeutic for stress. Also some of my classmates just happen to be hysterically funny. Also A+ to tumblr for keeping me giggling. Also, Broad City (put it on your list of shows to watch!) 

Originally posted by iamjustbeth

5. The days are long but the weeks/months are short

I still cannot believe it is May and I’m already done. I’m grateful that I’ve been able to reflect on my experiences on my tumblr so I can remember them (because sometimes it feels like my memories are getting squeezed out to make room for new knowledge). Journaling here allowed me to process this year in a way that I wouldn’t have otherwise. I would highly recommend it to anyone about to start school (of any kind!). 

Originally posted by transitionneededplease

6. Make new friends but keep the old

Yes, I am quoting a Girl Scouts song. Because it’s true. I am so very thankful for the technology that has allowed me to (try to) keep up with my college friends. Life is busy for all of us but it’s always nice to chat with old friends (and hang out, location permitting!) Also my med school class is filled with the most amazing people and it’s been so fun getting to know them :) I love my girls so much, they truly are my ride or dies. Med school is quite a bonding experience.

Originally posted by leslieandannforever

7. You’ll do things you never imagined you could

For me, that was anatomy and clinical skills. I was a bit nervous about dissecting and the whole experience but I was pleasantly surprised. It was not as weird as I thought it would be. In clinical skills, I was terrifyingly nervous about standardized patients and being filmed and getting feedback and learning how to do all the exams. We all got through it and now I feel much more comfortable. There are still hard days (like a couple of weeks ago) but I am not as nervous. I also learned how to do the male GU exam and it wasn’t as bad as I thought it was going to be. 

Originally posted by island-delver-go

 I also can’t believe that I went from knowing nothing to taking a history and doing a physical on a real patient all by myself AND presenting them to my preceptor. I still have a ton to learn and say stupid stuff sometimes but it feels like I’m on the right track. 

Originally posted by welcometoyouredoom

8. While sometimes first year feels like this:

Originally posted by iheart3j5

Originally posted by yourreactiongifs

Originally posted by adultum


Originally posted by superkevinthellama


Originally posted by superkevinthellama

You’ll have moments where you feel like


Originally posted by madpupper

And one last bonus lesson:

Originally posted by penguins-ruletheworld

Can that be the medblr motto? Also shoutout to medblr for being such an amazing and supportive community. Could not have gotten through this year without y’all!!!! 

Congratulations to all the other first years who are finishing up school or already done :) And welcome medblr class of 2020!!! So excited for y’all. 

Advice to Premeds: Questions, Questions, Questions (for interview day)

So I have an interview with UAB med school. What sort of questions should I have to ask them? What sort of questions should I be prepared to answer? -lifersway

Congrats on your interview! 

Here and here are lists of practice interview questions I’ve compiled to help you think about your answers. 

As for questions you should ask them:

  • How is the curriculum structured? How much time is lecture vs. PBL/group learning vs. lab time?
  • How much clinical exposure do students get in the pre-clinical (1st and 2nd) years?
  • What are the average Step scores/pass rate for the school?
  • Are the clinical rotations all in the same hospital, in multiple hospitals in the same town, or scattered all over? Is there an option for rural or urban rotations?
  • What research opportunities are available to med students?
  • What volunteer opportunities are available during the school year?
  • What is the school’s success rate in matching people in to the specialty you are interested in? Or what is their match rate in general (vs. number of students that have to scramble)? 
  • Where do most students live? Is housing affordable in the area?
  • How much free time do students have, and what do they do with it (this is a great question if you have a student interviewer)? Do the students hang out outside of school?
  • How are most students there financing school? Are there scholarship options?
  • What makes this school unique? What do they have that others don’t?
  • How do the students relate to faculty? Are they friendly? How available are faculty members for questions or tutorials?
  • Are there MD/MPH or MD/PhD options? How does that curriculum work?
  • How are clinical skills taught? 
  • Are there counseling programs available for medical students? What resources are available to help students struggling with burnout or depression?
  • What clubs or student organizations are available? Are there opportunities to be involved with organizations on the national level?
  • How much vacation time is available? How do most students spend their vacations?

And of course, before you go to your interview, research the school online. Find out what makes that school unique and ask about those programs and resources as well.