med-student

Scapula


Before I say anything, look at this:

There’s the scapula with the humerus (bone of the arm) attached to it… what does it look like? 

Come on, I’m sure all of you saw this. I’ll be damned if you can’t swing around your scapula as a battle axe. 

Anyways, coming back to the scapula, I think we can all appreciate the reason why the scapula is called the shoulder blade. Because we can swing our scapula to victory it resembles the blade of an axe when put onto our own humerus. 

Now that we’ve gotten that very important information (and gif) out of the way, let’s dive into the scapula. 

But I have to warn the mobile readers, it may be better to use your mobile browser over your Tumblr app, because there are a lot of pictures here that the app will not display. Sorry about that guys! 

Positional Anatomy

Where is the scapula? Given that we know it is the shoulder blade, we know it s somewhere near the shoulder joint. 

The scapula, a triangular, flat bone, lies on the posterolateral aspect of the thorax, overlying the 2nd to 7th ribs. 

Notice where the scapula overlies in the diagram above - right over the 2nd to 7th vertebrae. 

We’ve seen how the scapula looks from the back; what about the front?

So the scapula is located in the posterolateral aspect of the thorax, but notice it is still able to articulate with the humerus. 

The answer lies in its superior view:

Notice how the scapula is angled: it is obliquely angled so that the main body is still on the posterolateral aspect, but its most lateral end is located lateral to the thorax, where it can articulate with the humerus. 

Structure of the Scapula

The scapula is a triangular, flat bone, as already mentioned above. We can figure out what surfaces, borders and angles it has simply by examining a triangle. Let’s try it:

Keep reading

Hospital transparency is a tricky subject. 

It’s fantastic for keeping hospitals honest, providing them incentive to improve, and allowing patients a venue for considered decision making.

For many hospitals, however, transparency has the potential to destroy bottom-lines. Strengths and weaknesses vary between hospitals, but being able to attract patients, through marketing campaigns (that depict stellar physicians or the latest technology, for example) or simple geographical convenience, is what keeps hospitals profitable and afloat, among other things. 

For decades, hospitals have enjoyed a product shielded from scrutiny by an inherent trust between physicians and the public, and the knowledge that medicine is much too complex for a layman’s analysis. In the age of the internet and open communications, that shield, however, is eroding and data is prying it open. 

St. Mary’s, the hospital central to this article, predictably attempted to counter transparency on its failed pediatric cardiology surgery service. They calculated that the risk of creating a new program (and thus growing as an organization) was worth the cost of public trust and lives - an admittedly high stakes gamble. 

It didn’t pay off to heartbreaking effect.

And therein lies the rub. If we look at medicine in general as a product, it’s one of the only products in the world with little to no margin for error. Customers expect medicine to work every time. To advance and innovate medicine from an organizational perspective, however, it takes risks that uncomfortably widen the margin - experimental techniques, drug trials, new surgery suite configurations, new EHRs, the list goes on. In St. Mary’s case, they trusted a pediatric surgeon from Stanford, a world renown school, to carry that innovation through and it seems he failed to deliver. 

So what’s the solution?

Well, it sure isn’t lying to patients, disregarding failsafes, and ignoring peers, as St. Mary’s seemed to do. Let this be a case study of a triple threat of failure - corroded public trust, shoddy self-improvement, and failed innovation all, possibly, in the name of the bottom line.

Side Effects May Include....

While attending medical school, you may experience:

1) Insomnia

2) Narcolepsy (exacerbated by professors who are only capable of reading slides in a monotone voice)

3) Caffeine-induced anxiety attacks

4) A drastic increase in your use of profanity (at least in your mental dialogue; may be exacerbated by pending exams)

5) Mental hangovers aka the emotional and intellectual inability to give approximately 0 f**ks the day following exams

6) Chronic single-ness (and an inability to find anyone worth dating whose idea of a relationship doesn’t involve hooking up on a first date)

7) The appearance of speaking in tongues, especially when around non-medical family and friends

8) Rarely, students have reported weird and sudden bouts of euphoria, typically following an aha! moment, a fulfilling clinical encounter with patients, or otherwise being reminded of why you put yourself through this utter torment in the first place

Medical school teaches you how to be 100% person. As a future doctor, you have to be intelligent - of course. You have to be truly devoted, strong, confident yet humble and ready to work harder than you could’ve imagined ‘till now. You have to be striving for perfection, because you can’t afford to be 99% right. You are either 100% right or 100% wrong.
—  My professor of Internal Medicine on ‘Introduction to Internal Medicine’. 
The Blight of Third Year

My third year of medical school has been an exercise in restraint.  I am consistently disappointed by the terrible descriptors used to discuss patients.  Smelly, stupid, ignorant, etc., are all words I have heard used to define them.  This mostly comes from the residents and is often defended by the fact that they are working long hours in difficult conditions with little sleep.  But to me this is no excuse.   

It is no surprise then that students exposed to this behavior are destined to repeat it.  This has been called the “hidden curriculum” of medical school.  Far from the shining examples of patient care gone right is a world of loathing and dissatisfaction.  Doctors find themselves pulled away from family, bothered by seemingly meaningless problems, and thrust into a world where costs matter but cannot be contained. They then let loose their resentments in the only direction they can: at patients.   

Perhaps this is why the third year of medical school, the first clinical year, is where cynicism takes root (Hojat, Vergare, Maxwell, et al., 2009; Newton, Barber , Clardy, et al, 2008).  We have created a cycle of discontent.  Students flock to the wards, after years of cramming book knowledge, only to have their fantasies quickly quelled by those ahead of them.  Instead of learning the finer points of end of life care, I have found myself in surgeries that the surgeons jokingly called “autopsies,” since the patient might has well have been dead (and likely would be soon). Rather than being part of a teachable moment, I have seen patients given unnecessary antibiotics to satisfy their “complaining.”  And I have seen patients who, for cultural reasons, denied care and were called ignorant, missing the opportunity to explore a culture not our own.

Many have attempted to explain this slow erosion of compassion.  Reasons abound, from the introduction of electronic health records, which diminishes direct patient contact, to the push for evidence-based medicine, making algorithmic and science-oriented medicine predominate over individualized care. But as a third year student the causation is obvious – poor role modeling.

Imagine if the above scenarios had gone differently.  What if the residents had voiced concern over operating on a dying patient who was unlikely to get benefit from the intervention?  What if the attending listened?  That would have been a dramatically inspirational moment, one that would have greatly impacted me as a student.  A lot of money is being spent on learning how we can improve student empathy and patient-centeredness.  Perhaps the solution is a sizable bolus of compassion.

Third years are so impressionable as they flood the wards in their short white coats, scurrying after attendings like baby ducks after their mother.  They are easily influenced because they are searching for a way to fit in and impress.  We do not need another lecture or activity to guard students from the fate of bitterness. We need instructors to step up at each opportunity, to share teachable moments, and to perhaps ask themselves, “what would I want my doctor to do?”  One day it might be them, laying on the gurney, benefiting from those wonderful lessons in compassion.

Citations

Hojat M, Vergare MJ, Maxwell K, et al. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Acad Med. 2009;84(9):1182-91.

Newton BW, Barber L, Clardy J, Cleveland E, O'sullivan P. Is there hardening of the heart during medical school?. Acad Med. 2008;83(3):244-9.