- One patient was a little too happy that I attempted to say hello to her in her own language. As I began to examine her with my gloved hands and stethoscope, I said "Hello" in her language. She suddenly lit up, grabbed both my hands with her own, said "Hello!!!" and proceeded to kiss my gloved hands. Sadly, I think this was actually more sanitary than had she kissed my bare hands.
- Constipated patients get used to people asking them about their bowel movements. However, a select few get a little too worked up about their situation. One patient was so happy that he finally had a BM, he very generously saved it for me to examine when I returned the next day. Thanks, buddy.
- Nurse: Doctor! The patient is in extreme pain! 10/10! I think we should really give him something for his pain
Doctor: I just went to see the patient, who I am covering for another doctor. He is sleeping soundly and snoring.
Nurse: Yes, but when he wakes up, he will be in extreme pain!
Doctor: ... - One time, a fellow intern admitted a patient, who soon after admission had a code blue. In this case, the code blue was because the patient had stopped breathing. This could happen to any patient, but it was funny to hear the intern remark "But he was satting 100% on room air when I left..."
- Patient's reason for admission: I ate a bad plum and then vomitted, but I feel better now
The hospital's reason for admission: rule out heart attack
... what? - In general, a quick assessment of mental status is to ask the patient their name, their location, and the date. If they know all three, they are "alert and oriented times 3". However, it's sad when I examine a patient and realize they are more alert and oriented than I am, especially about what day it is.
- Me: I spoke with Jennifer, the nurse
Unit clerk: Which Jennifer?
Me: Uhhh... the one I just spoke with?
Clerk: We have 4 nurses named Jennifer on this floor: Jennifer C, Jennifer T, Jennifer P and Jennifer J
Showing posts with label anecdote. Show all posts
Showing posts with label anecdote. Show all posts
Tuesday, July 28, 2009
7 Quick Stories From Medicine Wards
My first month of internship is coming to an end. I did a month of medicine wards. The hours are long, but it's been interesting. Here are a few quick tidbits from my month:
Friday, December 26, 2008
How To Scrub For Surgery
Scrubbing into an OR is part of any medical school education, but one that does not seem to be formally discussed much. A medical student's first time in an OR can be an intimidating experience for this reason. The OR has its own rules and culture, which may seem byzantine at first to the uninitiated. For me, the worst part was getting into the OR: specifically, how do I scrub for surgery?
Updated 2015-12-18
I've tried to address this previously in posts like:
Perhaps you might be wondering why I am so concerned about scrubbing for surgery. Well, hearing about my first time might explain. The experience was horrible. I was doing a 1 month rotation in Mexico City, Mexico between my first and second years of medical school. I had never been in an OR before, much less on a rotation of any kind. Even though I had watched people in scrub in several times before I ever had to, there were all sorts of subtleties that escaped my notice. When my time finally came, the attending simply said "Go scrub" in Spanish with no instructions. The washing wasn't too bad, but putting on the gown was a disaster. I did not understand what to put on first, what I could touch, how to turn. The nurses tried to help, but I was already stressed and my Spanish wasn't that good! The instructions yelled in Spanish just confused me more! Finally, after struggling for a few minutes, I managed to get scrubbed in, but you can imagine how little confidence the surgeon had in me after that performance. While my little mistakes are no match for those of a resident placing a central line for the first time (as described in 'Complications' by surgeon Atul Gawande), they still left an indelible impression on me. Entering an OR for a laparoscopic procedure (heh, or IR suite) is not so daunting these days, but I'll never forget my first time!
Thursday, March 06, 2008
The Soft Bigotry of Low Expectations of Patients
The 'soft bigotry' phrase was often used by President Bush in his campaigns with reference to education (it's not clear where the phrase originated). However, I think the phrase also applies to healthcare professionals and how they interact with their patients. The notion of discrimination in healthcare is not new. However, I was surprised to find myself carrying these biases in a recent patient encounter.
The patient was an elderly male from a minority group. At first glance, he seemed to be a nice enough gentleman, but perhaps from one of the lower social strata. I don't think I made any conscious judgments about the patient as my preceptor began describing various treatment options. My preceptor tried to explain the options to the patient in terms the patient could understand. However, I was surprised to hear the patient respond with the technical terms for the procedures (terms that, frankly, I did not know myself). My attending could not hide his surprise as well. He gave the man a puzzled look, to which the patient replied, "Last time, you gave me a booklet about my condition. I read it."
Well, duh. Why should we have expected any less?
At first, I'll admit that I just found this amusing and was glad that the patient was so invested in his own health (and, I still find this fact reassuring). However, my narcissistic side soon started to reflect on my own visceral response to this exchange. Why had I expected this patient to be any less interested in his own health than the most well-to-do appearing patient? I suppose to some degree we cannot help our prejudices, and should strive to mitigate them and certainly never act on them. I cannot tell what exactly led me to have low expectations of this patient (his race? his age? his speech patterns?); regardless, these low expectations surely would shade whatever treatment decisions I would make. Perhaps, were I the physician, I may subconsciously choose to be less aggressive with his treatment, or not describe the options as fully. I certainly hope that I treat all my patients the same, but such pre-formed expectations are hard to dislodge if one is not even aware of them.
So, how should we change these low expectations? Clearly, the long-term solution requires social change in terms of education, healthcare delivery, and cultural attitudes. But, for now, perhaps a more modest systemic solution is necessary. I believe that the low expectations I had were formed partially due to repeated interactions with patients and families who were unaware and ill-informed about their diagnoses. To change this, the healthcare system should adopt a uniform standard for informing patients about their diagnoses, especially for major/chronic illnesses like cancer or diabetes. There is already a precedent in place: all children's vaccinations require a Vaccine Information Sheet that explains what the vaccine does and the associated benefits and risks. Why not expand this system to all disease conditions? Perhaps there is some roadblock I am not aware of, but it seems like this would be within the realm of possibility. Such a standardized system would greatly shift the expectations doctors have regarding their patients. Of course, some patients will still be poorly informed, but at least there would be a basis for educating our patients. Perhaps, by educating the patients, we may broaden our own perspectives as well.
The patient was an elderly male from a minority group. At first glance, he seemed to be a nice enough gentleman, but perhaps from one of the lower social strata. I don't think I made any conscious judgments about the patient as my preceptor began describing various treatment options. My preceptor tried to explain the options to the patient in terms the patient could understand. However, I was surprised to hear the patient respond with the technical terms for the procedures (terms that, frankly, I did not know myself). My attending could not hide his surprise as well. He gave the man a puzzled look, to which the patient replied, "Last time, you gave me a booklet about my condition. I read it."
Well, duh. Why should we have expected any less?
At first, I'll admit that I just found this amusing and was glad that the patient was so invested in his own health (and, I still find this fact reassuring). However, my narcissistic side soon started to reflect on my own visceral response to this exchange. Why had I expected this patient to be any less interested in his own health than the most well-to-do appearing patient? I suppose to some degree we cannot help our prejudices, and should strive to mitigate them and certainly never act on them. I cannot tell what exactly led me to have low expectations of this patient (his race? his age? his speech patterns?); regardless, these low expectations surely would shade whatever treatment decisions I would make. Perhaps, were I the physician, I may subconsciously choose to be less aggressive with his treatment, or not describe the options as fully. I certainly hope that I treat all my patients the same, but such pre-formed expectations are hard to dislodge if one is not even aware of them.
So, how should we change these low expectations? Clearly, the long-term solution requires social change in terms of education, healthcare delivery, and cultural attitudes. But, for now, perhaps a more modest systemic solution is necessary. I believe that the low expectations I had were formed partially due to repeated interactions with patients and families who were unaware and ill-informed about their diagnoses. To change this, the healthcare system should adopt a uniform standard for informing patients about their diagnoses, especially for major/chronic illnesses like cancer or diabetes. There is already a precedent in place: all children's vaccinations require a Vaccine Information Sheet that explains what the vaccine does and the associated benefits and risks. Why not expand this system to all disease conditions? Perhaps there is some roadblock I am not aware of, but it seems like this would be within the realm of possibility. Such a standardized system would greatly shift the expectations doctors have regarding their patients. Of course, some patients will still be poorly informed, but at least there would be a basis for educating our patients. Perhaps, by educating the patients, we may broaden our own perspectives as well.
Thursday, January 24, 2008
Pimping On The Wards
Pimping on the wards is a common experience for most any medical student. I forget what I initially wanted to write this post about, but I was reminded of the contrived haphazard nature of pimping recently. My attending, who was well-intentioned I believe, was aware that I am taking USMLE Step 1 soon. At our previous meeting, he told me I should bring whatever book I was studying from as he wanted to glance at it (he's a foreign medical grad, I believe), so I obliged. After I had shadowed him, we went back to his office. I assumed he'd just ask me a few questions about how the day went and send me on my way. What I got instead was 30+ minutes of him flipping through First Aid for the USMLE Step 1 and asking me random questions while two other students looked on.
Thirty.
Straight.
Minutes.
Straight.
Minutes.
Now, luckily I've been studying for a while and had a pretty good familiarity with First Aid, so I got most of the q's right (or at least, made some reasonable sounding comment). And, sure, I need to review and study. But... man, I can't imagine what would have happened if he had tried to do that 4 weeks ago. This episode (among others) leads me to wonder the real motivations behind pimping. Sure, people say it's for educational purposes. I agree that when done in a systematic, relevant manner, pimping serves this purpose. However, someone flipping through a book asking random q's is not that. Heck, the attending even said at the end that the session was like Jeopardy, which was a fairly apt description. So, here are what I think the 5 real reasons are:
5. Showing off - Just because someone has 10+ more years of education more than you and more than enough accolades doesn't mean they don't want you to know how much they know.
4. Schadenfreude - Trust the Germans to have a word like Schadenfreude. Part of me can't help but believe that some attendings experience a bit of joy at our squirming.
3. Insecurity - To be honest, I haven't had this be the case at all, but as this post and this NYTimes article note, it can be one reason why attendings pimp in some cases.
2. Tradition - They got pimped, so they feel "obligated" to pass along the "fun." Thanks. No really, thank you sir, may I have another?
1. Because they can - 'Nuff said.
Hm, I guess I sound more bitter than I really am. For the most part, I haven't had that many bad experiences being pimped, but I guess I just fail to see the point most times and would rather enage in an open discussion and have someone ask questions in a non-"put me on the spot" way and then explain concepts vs. just firing q's at me. Anyone have their own outrageous attending pimping experiences? Let's hear 'em!
4. Schadenfreude - Trust the Germans to have a word like Schadenfreude. Part of me can't help but believe that some attendings experience a bit of joy at our squirming.
3. Insecurity - To be honest, I haven't had this be the case at all, but as this post and this NYTimes article note, it can be one reason why attendings pimp in some cases.
2. Tradition - They got pimped, so they feel "obligated" to pass along the "fun." Thanks. No really, thank you sir, may I have another?
1. Because they can - 'Nuff said.
Hm, I guess I sound more bitter than I really am. For the most part, I haven't had that many bad experiences being pimped, but I guess I just fail to see the point most times and would rather enage in an open discussion and have someone ask questions in a non-"put me on the spot" way and then explain concepts vs. just firing q's at me. Anyone have their own outrageous attending pimping experiences? Let's hear 'em!
Worried about being pimped on the wards? Check out:
Monday, October 22, 2007
Hospital Rounds: Inefficiency By Design
I should preface this post by noting that my experiences are shaded by working at a public hospital that does not yet have electronic medical records. I am not complaining about my workload in particular, but rather the structure in which everyone in the health care field operates in when 'rounding' on patients in the hospital.
A Typical Morning
On many services, mornings are scheduled around some kind of morning conference. For this example, I will assume that I am on internal medicine, Morning Report is at 8:30 AM, and I have three patients to see. The attending wants to round after Morning Report at 9:30. This all sounds reasonable enough, right? However, here is what really happens. The residents, reasonably enough, want to discuss the patients prior to attending rounds, so we have prerounds/work rounds, typically at 7:30 AM, before morning report. I allocate about 30 minutes per patient (15 minutes for looking up results from the previous night, 10 min to see the patient, and 5 min transit time), so this forces me to arrive at 6 AM to see my 3 patients prior to work rounds.
Now, if I were able to utilize that time fully to understand everything that had happened with my patient the previous night and discuss problems thoroughly with my team, that would be great. But no. Instead, I waste most of that 1.5 hours hunting down charts that are being shared by up to 10 individuals who are caring for the patient (nurses, respiratory techs, other techs, consult teams, etc). When I finally find the chart, I have to hunt all over the place for vitals, medications, etc, which may or may not be filed under the correct tabs. Then, I have to read notes other people have left, but there are two problems here. First, everyone is forced to regurgitate the same basic info about the patient, so you have to skim through all of it just to get to the relevant stuff. Second, HANDWRITING: some people just refuse to write legible notes, thereby defeating the purpose of leaving a note. In that 90 minutes, I sadly only get 30 minutes max to actually see how my patients are doing, let alone think and discuss the issues they have.
Why 'Rounds'?
Why do medical students round? There are many ways to teach and practice medicine. There is no inherent need to 'round' in order to care for patients. My history may be a little bit rough, but I believe the idea of rounding in American medical education can be attributed to Sir William Osler and the program he began at Johns Hopkins. Physicians had rounded prior to that, but my understanding was that Osler was the first to integrate medical students and education into this system. And, for decades, the system succeeded and many learned medicine at the bedside. And, I must admit, I learn a fair amount on rounds. However, it is ironic that while the buzz in medicine is all about 21st century technologies and practices, we are still stuck in a 19th century work flow pattern. Remember, when Osler rounded, there were no X-rays to interpret, no EKGs, no other fancy studies. Heck, they barely had blood pressure cuffs. Rounding was an appropriate way to pattern work for the 19th century hospital, but rounds are no match for the information overload that each patient now presents.
A Modest Proposal
Well, perhaps several mini-proposals. Rounds should change to keep up with the advances in medicine. First, there is no excuse for having paper charts in the year 2007. It just makes no sense when nearly all the data that goes into charts is generated by some piece of electronics. Second, why must I see my patient 3 times each morning, yet not really examine them because each time I am in a rush to get to the next set of rounds and/or conference? The med student pre-pre-rounds and pre-rounds should be combined. The obvious criticism is that the med student would not be as exposed to the data and would not be required to think on their own. This is easily avoided by simply ensuring that the residents allow the medical students to examine the patients first and to "lead" the rounds for their own patients. By doing so, the students will have more opportunities to ask questions and have their physical exams directly observed by their interns and residents who can help them do a better job. Lastly, and maybe this is just because I'm not a morning person, can't we just combine Morning Report with noon conference? The "break" at 8:30 seems nice, but all it is really doing is extending the day in a particularly inefficient way by breaking everyone's work flow. Anyway, that's my two cents.
A Typical Morning
On many services, mornings are scheduled around some kind of morning conference. For this example, I will assume that I am on internal medicine, Morning Report is at 8:30 AM, and I have three patients to see. The attending wants to round after Morning Report at 9:30. This all sounds reasonable enough, right? However, here is what really happens. The residents, reasonably enough, want to discuss the patients prior to attending rounds, so we have prerounds/work rounds, typically at 7:30 AM, before morning report. I allocate about 30 minutes per patient (15 minutes for looking up results from the previous night, 10 min to see the patient, and 5 min transit time), so this forces me to arrive at 6 AM to see my 3 patients prior to work rounds.
Now, if I were able to utilize that time fully to understand everything that had happened with my patient the previous night and discuss problems thoroughly with my team, that would be great. But no. Instead, I waste most of that 1.5 hours hunting down charts that are being shared by up to 10 individuals who are caring for the patient (nurses, respiratory techs, other techs, consult teams, etc). When I finally find the chart, I have to hunt all over the place for vitals, medications, etc, which may or may not be filed under the correct tabs. Then, I have to read notes other people have left, but there are two problems here. First, everyone is forced to regurgitate the same basic info about the patient, so you have to skim through all of it just to get to the relevant stuff. Second, HANDWRITING: some people just refuse to write legible notes, thereby defeating the purpose of leaving a note. In that 90 minutes, I sadly only get 30 minutes max to actually see how my patients are doing, let alone think and discuss the issues they have.
Why 'Rounds'?
Why do medical students round? There are many ways to teach and practice medicine. There is no inherent need to 'round' in order to care for patients. My history may be a little bit rough, but I believe the idea of rounding in American medical education can be attributed to Sir William Osler and the program he began at Johns Hopkins. Physicians had rounded prior to that, but my understanding was that Osler was the first to integrate medical students and education into this system. And, for decades, the system succeeded and many learned medicine at the bedside. And, I must admit, I learn a fair amount on rounds. However, it is ironic that while the buzz in medicine is all about 21st century technologies and practices, we are still stuck in a 19th century work flow pattern. Remember, when Osler rounded, there were no X-rays to interpret, no EKGs, no other fancy studies. Heck, they barely had blood pressure cuffs. Rounding was an appropriate way to pattern work for the 19th century hospital, but rounds are no match for the information overload that each patient now presents.
A Modest Proposal
Well, perhaps several mini-proposals. Rounds should change to keep up with the advances in medicine. First, there is no excuse for having paper charts in the year 2007. It just makes no sense when nearly all the data that goes into charts is generated by some piece of electronics. Second, why must I see my patient 3 times each morning, yet not really examine them because each time I am in a rush to get to the next set of rounds and/or conference? The med student pre-pre-rounds and pre-rounds should be combined. The obvious criticism is that the med student would not be as exposed to the data and would not be required to think on their own. This is easily avoided by simply ensuring that the residents allow the medical students to examine the patients first and to "lead" the rounds for their own patients. By doing so, the students will have more opportunities to ask questions and have their physical exams directly observed by their interns and residents who can help them do a better job. Lastly, and maybe this is just because I'm not a morning person, can't we just combine Morning Report with noon conference? The "break" at 8:30 seems nice, but all it is really doing is extending the day in a particularly inefficient way by breaking everyone's work flow. Anyway, that's my two cents.
Tuesday, June 12, 2007
A Funny Story During My Surgery Clerkship Rotation
Funny story I heard from a friend about a med student and the Chair of the Surgery Department here... we'll call him Dr. B
The student (let's call her Amy) is a 4th year med student rotating with Dr. B for a month on the general surgery service. Dr. B is known for being very touchy-feely with his patients and listening to their issues.. you know, the "softer" side of medicine. However, he's still a surgeon and definitely has a serious side.
The patient they are about to see on morning rounds has had many problems during her life. In addition to her surgery, she has many co-morbidities as well as stresses in her life. She has also been battling depression and weight issues. Today, her main concern is some kind of eye problem. Maybe a corneal abrasion or conjunctivitis, who knows. Dr. B and Amy proceed to talk to the patient and then perform a physical examination. Both carefully inspect the patient's eyes, conclude their visit, and quietly leave the room to discuss:
Dr. B: So, what did you think?
Amy: She has a lot going on...
Dr. B: I mean, what did you see in the patient's eyes?
Amy: Umm... sadness?
Dr. B: ...
Dr. B: What?! Go look in the patient's eyes again! What did you see IN the patient's eyes?!
Oh, Amy, sometimes you just can't win for trying =)
Rev 20200228
The student (let's call her Amy) is a 4th year med student rotating with Dr. B for a month on the general surgery service. Dr. B is known for being very touchy-feely with his patients and listening to their issues.. you know, the "softer" side of medicine. However, he's still a surgeon and definitely has a serious side.
The patient they are about to see on morning rounds has had many problems during her life. In addition to her surgery, she has many co-morbidities as well as stresses in her life. She has also been battling depression and weight issues. Today, her main concern is some kind of eye problem. Maybe a corneal abrasion or conjunctivitis, who knows. Dr. B and Amy proceed to talk to the patient and then perform a physical examination. Both carefully inspect the patient's eyes, conclude their visit, and quietly leave the room to discuss:
Dr. B: So, what did you think?
Amy: She has a lot going on...
Dr. B: I mean, what did you see in the patient's eyes?
Amy: Umm... sadness?
Dr. B: ...
Dr. B: What?! Go look in the patient's eyes again! What did you see IN the patient's eyes?!
Oh, Amy, sometimes you just can't win for trying =)
Friday, June 08, 2007
My Surgery Core Clerkship Experience
Surgery has been going pretty well. I only have 6 more days of general surgery! The time has really flown by. In the few weeks I've been here, I've seen several excisional breast biopsies, some laparoscopic Roux-en-Y gastric bypasses, some Port-A-Cath insertions/removals, a laparoscopic gastric banding procedure, and laparoscopic cholecystectomy. Not the broadest variety, I know, but it was good to see the same thing done several times to see the variety / scope of the technique. I also have gotten better at suturing up wounds and feel much more confident about my manual dexterity before starting surgery. It really is like tying knots on your shoelaces... slippery, bloody knots, but still.... same idea =) What I really should be doing is studying for the surgery shelf exam!
Updated 20200228
Some drink for thought: Does a "break the seal" phenomenon truly exist? I had never heard this phrase before, but OverMyMedBody has an interesting post about whether the first bathroom episode after drinking leads to subsequent ones.
Updated 20200228
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