med-student

Nobody ‘has it coming.' 

 "As a resident, my highest ideal was not saving lives - everyone dies eventually - but guiding a patient or family to an understanding of death or illness.“ 

Paul Kalanithi, an inspirational neurosurgeon who was diagnosed with terminal lung cancer. I was truly moved after reading this memorable book but profoundly sad, one of the most powerful books I have ever read.

Ascites Fables: The Tortoise and The Hare

The slow build of fluid in the abdominal cavity is called ascites.

When the fluid is drained and the cells are examined in the microscope, they can give you a clue as to what is causing the fluid accumulation. 

A common causes of ascites is cirrhosis of the liver - when the liver becomes scarred due to diseases like hepatitis or chronic alcoholism. 

Don’t be quick to make that diagnosis. Using tenacity, ingenuity and histology you can read that these cells tell a different story that points to the presence of a malignant tumor in the abdominal cavity as a cause of the fluid build up. The cells are clustered together and have a high nuclear to cytoplasmic ratio, their nuclei are enlarged and there are spaces (vacuoles) in some the cytoplasm of some of the cells - characteristics of malignancy.

i♡histo

This famed fable of Aesop was kindly illustrated by some cells in a sample fo peritoneal fluid viewed in the microscope of @ali.rahbari.md (via Insta)

You can find love in the strangest of places

Clockwise, top left to center:

1. In a pancreas

2. In a Pap smear

3. In a thyroid follicle

4. In an anal canal 

5. In a lymph node

6. In a parotid gland

7. In a colonic crypt

8. In a bronchiole

9. In a lung carcinoma

i♡histo

Histology from the microscopes of i♡histo (2, 3, 4, 6), tamucvmclassof2019 (1), Chiara Ambrogio (8), bsymbol (7), simgeerbil (5) and João Boto (9)

You may not become the best doctor in the world, or this country, this state or city. Hell, you may not even be the best doctor on your street, at your hospital or clinic, or the best doctor on a hospital floor or in a room at a given time.
But when a patient comes to you, scared the headaches, the chest pains, whatever they’ve been having for months might be something worse, at that moment, YOU are their best chance for survival. You are that patient’s best hope, and proving yourself worthy of that responsibility is the only title you should ever care about winning.
—  A practicing physician for 40 years, and one who still hasn’t lost sight of what truly matters in this profession: the patients.
The Truth Behind Stereotypes

While preparing for my next patient I read in her previous note that she “..is a Vietnamese immigrant who works at a nail salon.”  I stifled a laugh as I recalled Dat Phan’s comedy bit on the Vietnamese taking over the U.S. one foot at a time.  I mentally scolded myself as I tried to dismiss my racist stereotype.  Yet, you cannot deny that this is one stereotype that frequently plays true. 

She smiled as I entered the room, remaining patient as I fumbled with the pronunciation of her name.  After exchanging pleasantries we discussed her reasons for coming in: a lingering cold and a skin lesion.  I noted that she had missed multiple appointments prior to this, failing to get follow up labs from over a year ago.  She blamed this on her busy schedule, caring for two children and working full-time.  For providers the chronically busy patient can seem as frustrating as the chronically sick patient.

Next we proceeded into her exam.  The stigmata for bacterial infection were conspicuously absent.  I described my findings to her, watching her mood deflate slightly when I explained that antibiotics would not help.  I continued to work my way down her body in a systematic exam, explaining as I went.  As I came to her hands I winced.  The skin was thickened, dried, and cracked.  My hands began to hurt in sympathy.

“Tell me about your hands,” I said.

She responded in deeply accented English that her hands became like this after working with the nail chemicals all day. 

“And do you like this job?” I asked.

“I hate it,” she responded.  I continued to inquire why, if she hated her job and it hurt her skin in such a terrible way, she did not seek other employment. 

“In my country I was a nurse.  But here I would have to start schooling over.  It would take twice as long because I would first have to take English classes.” She continued to explain that when coming over, many Vietnamese people worked in nail salons because that is where other Vietnamese people worked.  In other words, it was one of the few places they could get a foot in the door as untrained workers who barely spoke discernible English.  Suddenly the Dat Phan comedy bit seemed a lot less funny.

“Why come to the U.S.?”  I asked.  “If you were a nurse in Vietnam, why immigrate to a place with few job opportunities.”

Her answer?  She makes more here as a nail technician than a nurse in Vietnam, meaning she can send money to her family at home.  And being here gives her two teenage children a better opportunity for employment as they grow up.  In short, this woman gave up a job she enjoyed, to work in conditions she hates, in order for her family to have opportunities she never could.

Long after I wrote her note and sent her on her way, my Vietnamese patient lingered in my mind.  Interestingly, the more I thought the more I realized she did fit into a stereotype, although I had placed her in the wrong one.  Perhaps it is partially true to think that many Vietnamese immigrants are nail technicians.  But I think the better way to look at immigrants, in all flavors, is with the lens of selfless hope they often bring with them, rather than the employment circumstances they often find themselves in.  She, like the most tremendous among us, gave up her life goals in order to propel her family into a new socioeconomic class.  That to me doesn’t fit the image the media promotes for immigrants, but rather the image I think of when I see working class mothers struggling for their family’s sake.  And I think that stereotype, an example of the best that people have to offer, is a stereotype I can live with. 

You Can.

In less than two months I will graduate.  It is a surreal experience.  Just the other day I corrected a patient who referred to me as doctor, and it struck me that soon I won’t have to do that.  Somehow I made it.  And if I can, you can.

Medical school is a crucible; one I almost never made it to.  Eight years ago I was working a job I hated in order to fund my outrageous partying habit.  Through a series of life events I found myself facing a crossroad, asking “what am I was going to do that will make some difference in the world?”  It was then that I found medicine.  

No one thought I was serious when I said I would quit my job and go back to school.  I wasn’t even sure of my sincerity.  But I did it.  Soon the late nights at the bar were replaced by late nights in the library.  Alcohol was replaced with coffee and energy drinks.  I practically moved into a local coffee shop.   

During undergrad there were times I struggled.  One particular day, while stressed out and on the verge of giving up, an advisor told me I might want to reconsider med school if I could not handle the stress of undergrad.  A year later, I was criticized for accepting admission to my state school because I “wasn’t aiming high enough.”  And when I inquired about getting an MPH in medical school I was told by multiple sources that I would not be able to handle two degrees in 4 years (most programs require you take a year off, which I did not want to do).

This May, after 4 years of medical school, I will graduate with my MD and my MPH.  I have multiple journal publications.  I have held positions on national committees in organized medicine.  That’s not bad for a guy who “wasn’t aiming high enough.” 

I am not a role model for anyone nor am I here to speak of my successes; I am just a guy that survived the experience.  At every step of my journey there have been people who have tried to temper my goals with their doses of “reality.”  Each time, those predictions have proven to be false.  I want to share with you, the med students and pre-med students who read my blog, that you are the master of your future.  I am proof that you can make it when everyone around you suggests you can’t.

Your life is just that, your life.  You cannot let anyone or anything else dictate where it is headed.  Maybe you had a rough past.  Maybe your parents say you can’t make it.  Maybe your scores don’t seem high enough.  But what ever you want to do, you can do it.  The world abounds with stories of individuals overcoming odds.     

My point is this: I, an ordinary and unexceptional person, made it to, and through, medical school.  I promise you, if I can do it then almost anyone can.  Talent only gets you so far.  If you have the drive, the passion, and the work ethic then you can do whatever you set your mind to.  No matter who says you can’t, you can.

how to be an awesome med student (and your intern’s best friend)

Medical students are a precious commodity in the intern world. A good medical student makes it a lot easier to get through the day and get all the jobs done. But it’s a fine line between being a clingy medical student and a helpful medical student, and one that’s difficult to work out. So, this is my wish list for all my future medical students – do this and I’ll be indebted to you for life.

  • Ask for our number and give us yours. I’m always happy to be texted by a keen medical student who wants to put in lines and take blood and clerk patients. If you let me know you’re free, I’ll let you know how you can help.  Just don’t page me. Interns are perpetually one page away from a nervous breakdown.
  • Please carry files on ward rounds. I know that you’re not a human bookshelf, but there are a lot of files and I only have two hands. Any help here is greatly appreciated, and extra points if you volunteer to write notes. It lets me give my hand and my pen a break!
  • Learn to love the list. The patient list is the most important thing an intern has, and we need our medical students to value this. Whether it’s writing down jobs on the list, helping us type it up, or keeping track of the registrar’s list (he or she will inevitably misplace it), your contribution is noted and appreciated.
  • Ask questions. Interns are fresh out of medical school and know a lot of things. Most of the time, we’re happy to answer (and it makes us feel like we might actually be semi-competent doctors!). Just pick your moment – over coffee is good. During a code blue is not so good.
  • Volunteer to do practical things. An IVC resite can take half an hour. If you volunteer to put a new drip in (or even put an IDC in!), we will be forever grateful. I’m even happy to supervise whilst you do it – it gives me a moment to sort through my pages and even delete a few).
  • Remember that you’re going to be an intern soon – and internship means paperwork. The more you can help us with our paperwork, the better prepared you will be for your internship, and the more likely we are to pay you in coffee.
  • If the interns are busy, ask us for patients to clerk. I love it when medical students show an interest in my patients and in learning – do this, and I will always listen to you present your findings. It’s a good skill to learn, and it shows that you’re keen to be a part of the team.

I know this sounds demanding, but spending time on the wards with your intern not only prepares you to be a junior doctor, it gives you a lot of hands-on experience that you can’t get from your physiology textbook. And the more time you spend on the wards, the greater your chances of being rewarded with coffee.

Hope to see you on the wards soon!

How To Be A Good Med Student In The Clinical Years

A doctor once told me that the best instrument we have is medicine is the retrospectoscope.  Basically he was saying that often it is easier to make sense of things when looking back from the vantage point of the future.  This is true of life too.  After being an intern for two months I suddenly understand what things make for a strong med students, and what things do not.  Unfortunately, I feel like I lacked many of the qualities that would have made me a helpful med student.  Though I cannot rectify my own mistakes, perhaps I can pass my advice on to future generations of third and fourth year medical students.  I now present, how to be a good clinical med student:

  1. Show up.  This seems obvious.  When you are there to work, then be there to work.  It is so frustrating when medical students are mysteriously absent all the time (only to be found later in the cafe or cafeteria) or when they are there but totally disinterested in what is going on.  I understand that sometimes as a medical student things get slow - like when the interns are putting in orders and notes or when there is a slow call day.  But at least bring something to read.  Don’t play Pokemon Go.  Don’t spend all day on Uworld.  Make an effort to learn real clinical medicine.
  2. Take initiative to learn.  When I was a third year I would wander the hospital to find learning opportunities.  I made friends with the telemetry nurses and they started a folder of good tele strips to give me each day.  I would go to other teams and see if their patients had good exam findings.  I found the cardiology fellows and asked if they had good patients with murmurs.  There is so much learning that can happen if you are willing to experience it.  Now, referring back to number 1, make sure you always let your residents know where you are.  Personally, I would be ecstatic if my students went to hunt down murmurs rather than playing Pokemon Go. 
  3. Read your patient’s chart.  This can be very helpful and will make you look like a star.  Residents are busy taking admissions and sometimes don’t have the time to hunt down records that are three and four years old.  You can stand out by doing that  Look at a patient’s past hospital notes or their specialty clinic notes.  For example, you might be able to alert the resident that an old echocardiogram demonstrated a below normal ejection fraction, which in turn might change how much fluid the patient is given.  Or perhaps you found that during a hospitalization in the past the patient became delirious and needed a one-to-one sitter.  Find ways to add information in a helpful, non-prescriptive, non-judgmental way.  I guarantee your reviews will benefit.
  4. Read about your patient’s condition.  Even if you just browse Medscape, UpToDate, or some other curated source, make sure you understand the basics of your patient’s primary diagnosis.  If they are there for heart failure, read over the basics of treatment.  If they have autoimmune hepatitis look up some info on diagnosis and prognosis.  These things will get noticed, especially when you ask intelligent questions on rounds.  Do not be like a med student I had who, when asked, reported for 4 straight days that he had not read about his patient’s disease.  He instead responded he was too busy with Uworld so he would get a good shelf score.
  5. See your patients.  I literally had students who, on rounds, tried to present without actually having seen the patient in the morning.  This is a huge no-no.  Get to work early enough to see your patients, review their labs, and their overnight events.  
  6. Practice your presentations.  Even if it is on your own or with other medical students, spend time working on your presentation skills.  Heck, even ask the residents to watch you.  I would be happy to do that for any of my students.  Unfortunately, none have taken me up on that offer and instead bumble through their presentation each day making the same mistakes.  By the end of medical school you need to be able to make a good presentation. 
  7. Spend time working on note writing.  Compare your notes to your residents’, your attendings’, and the specialists’.  Everyone has a different style.  Look at lots of notes to determine a style for yourself.  
  8. Forget all the step 1 stuff you learned.  I find many students perseverate on the terrible stereotypes and patterns they see on step 1.  Not all black people with cough have sarcoidosis.  Not every patient with acute kidney injury needs urine eosinophils.  These are good associations, but realize that step 1 has little overlap with real clinical medicine.  Take those associations with a grain of salt. 
  9. Don’t just look for zebras.  I cannot tell you how many times students opt not to follow a patient because the case “doesn’t seem that interesting.”  The majority of medicine is made up of mundane and common diseases such as heart failure, pneumonia, COPD, cirrhosis, etc.  It is pretty rare to get the exciting cases, like disseminated histoplasmosis or a crazy paraneoplastic syndrome.  A lot of learning can happen on cases that are “bread and butter” medicine.  Make sure you follow those cases too. 
  10. Be gentle to your interns/residents.  The transition from 4th year to being a doctor is swift and brutal.  It is easy to criticize when you aren’t the one taking 5 admits.  Find ways to help your intern/resident, because in return they will help you.  I learned this lesson the hard way my 4th year, when I unintentionally threw an intern under the bus while trying to look smart.  Afterwards she took me aside and reminded me that she controlled much of my fate while I was a student under her.  I learned my lesson and we went on to become very good friends.

The clinical years of medical school are daunting.  You constantly feel like a tap dancing monkey, trying to impress people you barely have time to get to know.  But personally, I am not looking for someone who knows everything about everything.  That’s why you are in school.  The best thing you can get out of third and fourth year is how to do a good history and physical, how to write good notes, and how to triage patients.  The best students are interested, willing to learn, and know their patients well.  If you keep that in mind, the clinical years are much simpler.  I promise, if you follow your patients you will learn much more than just doing qbank questions.   

Best of luck on your clinical rotations.  Don’t make things too complicated.  At the end of the day have fun, treat your patients right, and keep an open mind.  The learning will happen whether you recognize it or not.