Sunday, October 13, 2013

Being a good medical student doesn’t mean you’ll be a good doctor, A Doctor's Story


     There is a saying that you enter medical school wanting to help people but exit it wanting to help yourself. It may be a cynical view, but a realistic one. The criteria to being a good medical student are far different from being a good doctor. Medical education may be breeding a legion of self-serving, grade-grubbing, SOAP-note spewing machines rather than the empathetic, compassionate and caring physicians of admission essays yore.  

  I was no different. My first two years of medical school, I was largely a disinterested student. I didn’t care for basic sciences, research or pathology. Like many others, my knowledge waxed and waned with the test schedule, and after Step 1, I entered my clinical years an acceptably successful medical student. Excellent medical student, terrible clinician Third year begins a reign of terror lead by the constant gauntlet of heavily-weighted rotation grades, standardized exams and the looming threat of residency applications and the Match, when, after 20 years of schooling, some pie-in-the-sky computer would tell me if I was good enough or not to be a doctor, and subsequently determine my life for the next three to seven years. 

 Grades were a priori to make myself the most competitive residency candidate possible. I studied and worked hard. Each patient became an opportunity for me to impress on notes, rapid-fire oral presentations and predict nuanced “pimp’ questions. I learned to charm patients just enough that they’d acknowledge my care to the attending during rounds. I interrogated my patients just enough to write the excellent notes I knew I’d be evaluated on. I learned about my patients by memorizing their daily lab values to proudly recite on rounds. Patients weren’t people with problems but stepping stones to rack up points with the attending. 

  Once rounds were over, patients became time-sucks from studying time, an exam worth 30% of every rotation grade. Real humans do not follow textbook presentations, but exams do; the warm body in front of me only detracted from my evaluation by cold scantron. By my attendings’ clinical comments, I was an excellent medical student, but I knew I was a terrible clinician, rehearsed only in the games of academia, not medicine. How I learned to stop worrying about the Match and love patient care My shift in paradigm came with a shift in career path. My worst fear as a fledgling surgeon was not matching for a residency spot. 

  My worst fear as a fledgling emergency physician was killing a patient. Suddenly playing doctor became very real, and in the middle of my OB/GYN rotation, I started to care not about textbook presentations but real-world ones. I didn’t care for OB/GYN and volunteered to cover the peripartum critical care unit, a similar environment to emergency medicine. My first day on the unit, I saw a patient roll in as I was in the middle of practice questions on the computer. I glanced up but returned to my test preparation, justifying my delay in evaluating the patient because the resident was still in surgery. Half an hour later, the resident came to evaluate the patient and I followed — the patient was obtunded, hypotensive and sitting in a growing pool of her own blood. It would not have taken a MD to realize that this patient required immediate medical attention, and I kicked myself for not evaluating her sooner. I may have been a pretend doctor, but it finally struck me that I was a pretend doctor on very real patients. 

  For the rest of my time in the unit, I made it a point to personally round every hour, on the hour, on every patient. I didn’t always write notes for these hourly rounds — getting credit was no longer important to me — patient care was. While they initially questioned my obsessive rounding, the residents quickly came to trust my dedication and leave me to my own in the unit, knowing I’d alert them if necessary. At my institution, hell hath no fury like an OB/GYN resident unnecessarily interrupted, so I spent my time reading on appropriate treatment courses for the different conditions I saw in the unit. 

  After I rounded, I’d give the resident a list of orders to put in, and the nurses began to treat me as the main provider in the unit. I got to be the first person to make critical medical decisions, responding to truly acute situations and drastically changing the course of a patient’s treatment. I pulled long hours and hardly studied in the traditional sense with prep books and practice questions, but I was constantly reading on my patients. That shelf exam and clinical evaluations were my best of the year. I had learned to stop worrying about the Match and love patient care. Not “just” a student After that revelation, I fought to earn more responsibility and trust on each rotation; I learned more, gained competence and became more satisfied in my chosen career in medicine. 

  During emergency medicine , the specialty that started it all for me, I learned more medicine in one month than I did in my entire third year. It was a pass/fail course with no motivation by grading, but I was terrified I would be the first person to evaluate a patient and not recognize a critical condition. That hemorrhaging patient from day one on the peripartum critical care unit still haunted me. People can decompensate quickly and unpredictably — at any moment, you may go from being “just” a student, to being the only medical provider in the room. At the end of that rotation, Step 2 breezed by with none of the misery I experienced with Step 1. Behind each question I’d see faces of patients with that exact presentation; behind each answer choice, I’d see the clinical consequence of making the wrong decision. 

  Finally, I understood what it mean to be both an excellent medical student, and (at my level of training) an excellent clinician. The academics of medicine often makes us forget the “59 yo AA M, PMH CHF dx 2010 (EF 20% by TTE 8/2013) p/w SOB x 2d” is a real person, with real vulnerabilities and real fears. We are not “just” students, but trainees and members of the medical profession. Grades and exams do not define us, but are simply checks on clinical competence. Trite as it may be, remember what you wrote about in your admissions essay — why you embarked on this journey in the first place. We came to medical school not to become excellent medical students, but to become excellent doctors. Always keep that in mind. Everything else, the grades, the Match, the exams, will fall in place. 

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Saturday, May 26, 2012


 Diabetes is detected by measuring the amount of glucose in the blood after an individual has fasted (abstained from food) for about eight hours. In some cases, physicians diagnose diabetes by administering an oral glucose tolerance test, which measures glucose levels before and after a specific amount of sugar has been ingested. 

 Once diabetes is diagnosed, treatment consists of controlling the amount of glucose in the blood and preventing complications. Depending on the type of diabetes, this can be accomplished through regular physical exercise, a carefully controlled diet, and medication. Individuals with Type 1 diabetes must receive insulin, often two to four times a day, to provide the body with the hormone it does not produce. Insulin cannot be taken orally, because it is destroyed in the digestive system. 

Consequently, insulin-dependent diabetics have historically injected the drug using a hypodermic needle or a beeper-sized pump connected to a needle inserted under the skin. In 2006 the United States Food and Drug Administration approved a form of insulin that can be inhaled and then is absorbed by blood in the lungs. The amount of insulin needed varies from person to person and may be influenced by factors such as a person’s level of physical activity, diet, and the presence of other health disorders. 

Typically, individuals with Type 1 diabetes use a meter several times a day to measure the level of glucose in a drop of their blood obtained by pricking a fingertip. They can then adjust the dosage of insulin, physical exercise, or food intake to maintain the blood sugar at a normal level. People with Type 1 diabetes must carefully control their diets by distributing meals and snacks throughout the day so as not to overwhelm the ability of the insulin supply to help cells absorb glucose. They also need to eat foods that contain complex sugars, which break down slowly and cause a slower rise in blood sugar levels. Although most persons with Type 1 diabetes strive to lower the amount of glucose in their blood, levels that are too low can also cause health problems. For example, if a person with Type 1 diabetes takes too much insulin, it can produce low blood sugar levels. This may result in hypoglycemia, a condition characterized by shakiness, confusion, and anxiety. 

A person who develops hypoglycemia can combat symptoms by ingesting glucose tablets or by consuming foods with high sugar content, such as fruit juices or hard candy. In order to control insulin levels, people with Type 1 diabetes must monitor their glucose levels several times a day. In 1983 a group of 1,441 Type 1 diabetics aged 13 to 39 began participating in the Diabetes Control and Complications Trial (DCCT), the largest scientific study of diabetes treatment ever undertaken. The DCCT studied the potential for reducing diabetes-related complications, such as nerve or kidney disease or eye disorders, by having patients closely monitor their blood sugar levels four to six times a day, maintaining the levels as close to normal as possible. The results of the study, reported in 1993, showed a 50 to 75 percent reduction of diabetic complications in people who aggressively monitored and controlled their glucose levels. Although the study was performed on people with Type 1 diabetes, researchers believe that close monitoring of blood sugar levels would also benefit people with Type 2 diabetes. For persons with Type 2 diabetes, treatment begins with diet control, exercise, and weight reduction, although over time this treatment may not be adequate. 

People with Type 2 diabetes typically work with nutritionists to formulate a diet plan that regulates blood sugar levels so that they do not rise too swiftly after a meal. A recommended meal is usually low in fat (30 percent or less of total calories), provides moderate protein (10 to 20 percent of total calories), and contains a variety of carbohydrates, such as beans, vegetables, and grains. Regular exercise helps body cells absorb glucose—even ten minutes of exercise a day can be effective. Diet control and exercise may also play a role in weight reduction, which appears to partially reverse the body’s inability to use insulin. For some people with Type 2 diabetes, diet, exercise, and weight reduction alone may work initially, but eventually this regimen does not help control high blood sugar levels. In these cases, oral medication may be prescribed. 

If oral medications are ineffective, a person with Type 2 diabetes may need insulin doses or a combination of oral medication and insulin. About 50 percent of individuals with Type 2 diabetes require oral medications, 40 percent require insulin or a combination of insulin and oral medications, and 10 percent use diet and exercise alone.

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Monday, September 5, 2011


Scientists have identified three ways that HIV infections spread: sexual intercourse with an infected person, contact with contaminated blood, and transmission from an infected mother to her child before or during birth or through breast-feeding

A. Sex with an Infected Person
HIV transmission occurs most commonly during intimate sexual contact with an infected person, including genital, anal, and oral sex. The virus is present in the infected person’s semen or vaginal fluids. During sexual intercourse, the virus gains access to the bloodstream of the uninfected person by passing through openings in the mucous membrane—the protective tissue layer that lines the mouth, vagina, and rectum—and through breaks in the skin of the penis. In the United States and Canada, HIV is most commonly transmitted during sex between men, but the incidence of HIV transmission between men and women has rapidly increased. In most other parts of the world, HIV is most commonly transmitted through heterosexual sex.
B. Contact with Infected Blood
Direct contact with HIV-infected blood occurs when people who use heroin or other injected drugs share hypodermic needles or syringes contaminated with infected blood. Sharing of contaminated needles among intravenous drug users has been a primary cause of HIV infection in parts of eastern Europe and central Asia.
Less frequently, HIV infection results when health professionals accidentally stick themselves with needles containing HIV-infected blood or expose an open cut to contaminated blood. Some cases of HIV transmission from transfusions of infected blood, blood components, and organ donations were reported in the 1980s. Since 1985 government regulations in the United States and Canada have required that all donated blood and body tissues be screened for the presence of HIV before being used in medical procedures. As a result of these regulations, HIV transmission caused by contaminated blood transfusion or organ donations is rare in North America. However, the problem continues to concern health officials in sub-Saharan Africa. 
C. Mother-to-Child Transmission
HIV can be transmitted from an infected mother to her baby while the baby is still in the woman’s uterus or, more commonly, during childbirth. The virus can also be transmitted through the mother’s breast milk during breast-feeding. Mother-to-child transmission accounts for 90 percent of all cases of AIDS in children. Mother-to-child transmission is particularly prevalent in Africa.
D. Misperceptions About HIV Transmission
The routes of HIV transmission are well documented by scientists, but health officials continually grapple with people’s unfounded fears concerning the potential for HIV transmission by other means. HIV differs from other infectious viruses in that it dies quickly if exposed to the environment. No evidence has linked HIV transmission to casual contact with an infected person, such as a handshake, hugging, or kissing, or even sharing dishes or bathroom facilities. Studies have been unable to identify HIV transmission from modes common to other infectious diseases, such as an insect bite or inhaling virus-infected droplets from an infected person’s sneeze or cough.

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