doc w/ pen

a journalist becomes a doctor before your eyes

Month: November, 2017

Thankgsiving thoughts, circa 1993 and now

Growing up, our Thanksgiving dinner “meal ticket” was writing down what we were grateful for that year in a notebook that my mom put together. While we’re not so formal about this process anymore, we do still count our blessings together at this time of year, though it may be over the phone or via text, since we’re spread across the country now. My mom was flipping through our old Thanksgiving notebook yesterday, and when we talked on the phone this morning, she said she just had to read my entry from 1993 to me.

1993 … that was 24 years ago. I was 12. My sisters were 10 and 4. My family lived in Tucson, Arizona. It was a different time, before most people had heard of the Internet, before widespread use of cell phones, before 9/11. So much has changed since then. But in some important ways, nothing has changed. The top two items I discussed in my 1993 gratitude essay (typed, with near-perfect grammar and punctuation; the budding writer in me already making an entrance) would top my list today too. Here is an excerpt from that essay:

I am definitely thankful for my parents. I am very lucky to have parents that are always there for me, no matter what. If I had a problem or something was wrong, I could talk to them about it. I know my dad thinks I’m special because he takes me out to breakfast and we talk about anything from sports to the Bible. He also plays things like football and basketball with me. I know my mom thinks I’m special, because she does a lot of things like do my hair, make my lunch, and talk and pray with me at night. They also help me with my homework. When I first started at Cross [my middle school], there was a lot I didn’t understand in some of my classes. But my parents helped me, and now I do!

Another thing that I am thankful for are my sisters, Sarah (10), and Joy (4). I’m thankful for them because they love me very much. Some of the ways that they show this are when I’m sick, they’ll always ask if I’m feeling better. They’ll also get things like drinks for me. When I’m bored, they ask to play some kind of game with me. Even though sometimes they’re annoying, I can also babysit them, and earn spending money. During the summer, when everyone was asleep, Sarah would come to my room and we would talk for an hour about lots of things. When I’m sad or disappointed about anything, Joy will come up to me and give me a kiss and hug. Both of them mean a lot to me, and I don’t know what I’d do without them.

That last sentence says it all — I don’t know what I’d do without you, Mom, Dad, Sarah, and Joy. I love you all dearly. I’m so grateful for you, and the integral part each of you has played in my life. The only thing I’m not thankful for is that I didn’t get to spend this Thanksgiving holiday with you. But I’ll be home for Christmas, and we’ll all be together then. I’m counting down the days.

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The order: An important first

As many of you know, I write a monthly column for the online magazine The American. Here is my latest piece, describing an important first of my medical career. You can read the original article here.

 

“The order”

I placed my first medication order yesterday. Nothing exotic. It was a one-time dose of the drug Labetalol for a patient, my patient, whose blood pressures had been elevated. As I typed in my password to sign the order, I took a deep breath.

“By signing this,” I thought to myself, “I’m telling people that I think my patient needs this exact medication at this exact dose at this exact time.”

Suddenly, caring for this patient was no longer abstract or hypothetical. It was as real as the prescription I was about to issue. I wasn’t just writing out my daily plan for her care in my morning progress note. I was putting it into action.

As a medical student, any orders I place require a physician cosigner, either my resident or attending. The safety net exists for obvious reasons. Still, learning how to issue orders for my patients — whether it’s for laboratory tests or medications or fluids — and then doing so is part of assuming greater clinical responsibility. It’s also part of progressing from student to doctor.

But from a logistical perspective, just entering these orders is far from easy. Take the blood pressure medication. It is normally dosed twice a day, morning and night. It was about 1 p.m. at the time. If we ordered it twice a day to begin immediately, the patient would get it at 1 p.m. and 1 a.m. — not ideal if you’re the patient. You’d have to be awakened in the middle of the night to take a pill.

So I placed a one-time order for the medication to be given by the nurse immediately. I then placed another order for the same medication, same dose, this time twice a day, but starting that night. Going forward, the patient would be getting her pill at 9 a.m. and 9 p.m.

Making small things happen in the electronic medical record system is another thing entirely. It requires selecting or unselecting many checkboxes and highlighting the appropriate fields in various drop-down menus. I’m sure once you do it repeatedly it becomes second nature. But as a medication order novice, I needed someone to show me around the system. Thankfully, my kind resident took the time to walk me through the process step by step. Attention is paramount. If you don’t click (or unclick) one of the required boxes, you get an error message that reroutes you back to the order screen to fix your mistake. And if you don’t click (or unclick) some other box that’s important for your particular instructions but not technically required for the order to go through, your order may inadvertently tell the nurse to do something else altogether.

The “how” of these orders is the easy part. It’s the “what” and the “why” that require the real thinking. Why is the patient’s blood pressure elevated? Does she need a medication? If so, which one? At what dose and frequency? How long will you assess her blood pressure levels to determine if this medication is effective before either increasing its dose or adding another drug? And this is only her blood pressure. We haven’t gotten started on her antibiotic regimen.

It’s an iterative process that goes on throughout any given day. Sometimes you’re doing the investigating. Sometimes it comes in response to changes in vital signs or laboratory results (or urine output or an MRI). This means you’re monitoring all these details — vital signs, lab tests, urine output, and imaging, among others — over the course of a day to see if you need to change your handling of the patient.

To a third-year medical student just introduced to the world of inpatient internal medicine, it’s dizzying. But it’s also deeply exciting for obvious reasons. The more clinical responsibility I assume, the more I learn, and the more tangible the “live” practice of medicine becomes. And the more I am prepared for the time when I’ll be the one signing the orders on my own.

Much-needed encouragement

I’ve finished the first two weeks of my internal medicine clerkship, with six to go. On this clerkship, more than any other, it’s easy to feel clueless, since medicine deals in the entire body — every single organ system. As a medical student, I get asked questions many times every day to probe my knowledge and get me thinking about this field that is both fascinating and overwhelming. It feels like my most frequent answer is “I don’t know.” But I was recently reminded that while I have much to learn, I’ve come a lot farther than I realize.

About a week ago, a second-year medical student shadowed me during my morning pre-rounds routine. Together, we reviewed the charts of my patients, looking at their vital signs, labs, imaging, urine output, and other notable events that had occurred since I left the previous day. I’ve become pretty familiar with the electronic medical record (EMR) system now, but every action I took — selecting the correct tab to show the vital signs for example, or figuring out when the last dose of a medication was given — required a tutorial.

I showed him how to use templates in the EMR that automatically pull data like vital signs and lab results from the patient’s chart directly into your note. I started to show him how to write my daily “SOAP” note using one of these templates. And he asked, “Can you go over what a SOAP note is, exactly?” I was glad to, of course. (For those of you who are curious, here is what SOAP stands for. S = Subjective information from your patient about how they are feeling, such as pain. O = Objective data such as vital signs from the chart. A = Assessment of the patient’s condition. P = Plan for the day in terms of treatment, diagnostic studies, etc.)

Without thinking about it, I then described one of my patients as “being on PD.” I saw the look of confusion in his face, and realized I took for granted knowing that “PD” stands for “peritoneal dialysis.” So the next time I came to some medical abbreviation, I made sure to clarify its meaning.

There were lots of things I explained about treating patients too. Like how we put most patients on a bowel regimen in the hospital to make sure they have regular bowel movements. Or that when a person who has diabetes is hospitalized, we take them off their oral diabetes medications and put them on sliding scale insulin because they’re likely not eating the same way as they do at home.

We also saw my patients together, and I showed him how to do a brief, focused physical exam targeting potential findings related to each patient’s condition, and also assessing basic things like heart and lung function.

Having second-year students shadow us third-year students is a new part of the curriculum. It’s aimed at helping the second-years transition more smoothly into starting their own clerkships, which they will do in January or February. I hope all my explanations were helpful to my shadow. I know they would have helped me when I was a second-year student. As I was talking with him, I thought back nearly 9 months to mid-February when I started my first clerkship, OB-GYN, to when I knew none of these things either. To when I didn’t know how to write a SOAP note, or how to find things in the electronic medical record, or how to do a focused physical exam. I realized that I’ve come a long way in the last 9 months, much farther than I give myself credit for.

This encouragement couldn’t have come at a better time. Medicine is still overwhelming. But a little less so. And I have a newfound confidence in my ability to make significant strides in the remaining six weeks.