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a journalist becomes a doctor before your eyes

Category: Medical School: Year 3

Seeing the NYC street art scene

Joy (left) and me posing in front of one of the Bushwick Collective murals earlier this fall.

When my youngest sister Joy came to visit me earlier this fall, she had an offbeat itinerary. I previously wrote a post about our exploration of the Jim Henson Exhibition at the Museum of the Moving Image, which I highly recommend visiting. I also wanted to share some photos from another one of our excursions. Joy wanted to get in on the NYC public art scene so at her behest, we headed to the Bushwick Collective in Brooklyn. It’s an out-of-the way collection of vibrant street murals that run the gamut from political commentary to psychedelic-trippy. The art is all temporary, with pieces constantly being added or replaced. So the images I’m sharing here are a simply snapshot in time of the day we visited. It’s a quick cab/Uber or subway ride from Manhattan, and it’s definitely worth the trip.

Click on any of the thumbnails below to open up a slideshow with larger images.

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A message of solidarity and encouragement in times of struggle

Medical school is hard. Life is hard. However you identify yourself — student, employee, patient, mom, dad, child, sister, brother, grandma, grandpa, the list goes on — we all have to scramble, strive, scuffle, and struggle sometimes. Sometimes, it feels like most of the time.

That’s how I’ve felt lately. I’m guessing some of you have felt that way recently, too.

I was out walking on 2nd Avenue the other day, running a quick errand, when I saw a sandwich board sign in front of a fitness studio called Pure Barre that stopped me in my tracks. In New York City, with so much weirdness and activity all around, which you just come to accept as normal, it takes a lot to stop me on the sidewalk. But it was like this sign was talking directly to me. So I paused, and allowed myself to fall into the category of “annoying person stopping on the sidewalk taking a picture with their phone.” This wasn’t a stupid selfie though. This was important self-talk aimed at self-soothing and self-preservation.

So I took a picture of the sign, and walked to look at the other side. Lo and behold, it had a personal message for me too. So I snapped a photo of it as well.

I share these pictures here for multiple reasons. So many of my posts are uplifting and positive. That’s not me faking anything. But I want my readers to know that I’m human, and I tussle with human emotions, trials, and tribulations. I also want to let other people know — other people who may be struggling themselves — that they’re not alone. And last but not least, I want to offer a public message of encouragement to all of us, myself included.

So whether you’re grappling with a difficult boss, a difficult patient, a difficult family member, a difficult illness, or something else, know that you’re not alone. And hard as it is, for you and for me both, we will get through it, like we always do.

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.

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.

Only in medical school … (#1)

Medical school is a unique environment. It’s also an immersion experience. As such, over the last 2 years I’ve had all these moments where I’ve said/thought/done something that seemed natural, but upon reflecting I’ve realized that my words/thoughts/actions were a bizarre product of medical school. I had one of these moments yesterday, and decided I should start recording these experiences here, going forward. I think they speak to how much medicine seeps into you when you’re steeped in it all day, every day. I also think they’re rather humorous, but I’ll let my readers be the ultimate judge of that. Here’s what happened.

Medical school affects how I think about everyday, nonmedical things — including how to describe the direction I cut my sandwich.

I was making my lunch, a ham-and-cheese sandwich on sourdough bread. I’d had the same thing the day before. And the day before, I’d cut the sandwich in half diagonally, a little offset from the corners, the way we’d done it at the sandwich shop where I worked one summer in high school. Yesterday though, as I stared at my sandwich, I decided to shake things up. Since I live alone, I have a habit of talking to myself out loud sometimes, and said this to no one in particular other than me, quite definitively:

I think I’ll cut it midline today.

I started sawing at the sandwich, then stopped halfway through, realizing what I’d said. Three years ago, I would have said something quite different, probably that I’d cut it “in half in the center,” or “down the middle.” But now I clearly think anatomically, like an attending surgeon discussing with his resident where to make an abdominal surgical incision. That’s what 8 weeks of rotating through surgery will do to you, apparently.

I chuckled as I finished cutting the sandwich and wrapped in foil.

I hope this brings a smile to your face as well.

Working in the psych ED

As many of you know, I write a monthly column for the online magazine The American. Here is my latest piece, describing my reactions to working in the psychiatric emergency department. You can see the original piece here.

 

“Repairing the mind”

Bless you,” one of our lecturers told me when she heard I’d asked to spend part of my six-week psychiatry rotation in the psychiatric emergency department (ED). I understand all too well why the psych ED is a place many people might want to avoid. Many patients in this locked unit are acutely and severely ill. One patient might come in talking about hanging himself, another of how how voices are commanding her to kill people. An ambulance might bring in someone found found running down the street in undergarments. A handful of these patients can turn aggressive or violent, yelling and threatening to harm the physicians and other staff.

Most can usually be talked down but some require sedation via an intramuscular injection — and in a few cases physical restraints. Safe to say there are few dull moments.

Before I discuss my own response to the psych ED, I want to talk about a tension that generally speaking exists in medicine. I’ll use hypotheticals to illustrate my point. Imagine a doctor sees a hospitalized patient afflicted with a rare, potentially fatal disease.

“Wow, what an interesting case,” the doctor tells a colleague when the patient is out of earshot. The colleague replies, “No kidding, I’ve never seen a case of that before. Let me know what the outcome is.”

This fascination with a rare, possibly incurable disease might seem cold-blooded to a non-medical observer. What kind of person would say something like that? But medicine is all about compartments. Doctors have compassion for their patients. They care for them to the best of their ability — applying empathy and professionalism. At the same time, they’re possessed with intellectual curiosity about the underlying processes of diseases. Probing pathophysiologic principles is part of the scientific method they’re trained in.

Though compassion and curiosity coexist quite peacefully, all this might sound callous to a casual observer uninterested in these medical compartments.

My years as a medical student have taught me that patients and their families are sensitive to remarks made in passing. Medical curiosity can seem unfeeling. As a result, I’m careful as to when and how I express it.

That preface in mind, let me move on to the psych ED, an assignment I found both medically and professionally exciting. The unvarnished truth is that patients need the service and the service needs a staff. The psych ED is a high-impact place with plenty of patients ill enough to pose an immediate threat either to themselves or others, or both. For a doctor, it’s a high wire act whose reward comes in the form of helping prevent a suicide or bringing someone down from a dangerous manic episode. Plenty of patients admittedly don’t want to be in the unit. Some refuse medication and protest their hospitalization. But even in such precarious situations, you’re still providing patients with short-term safety.

The psych ED encouraged me to use both my journalistic and my medical training. Skepticism is essential in any kind of psychiatric work. Some patients will lie and behave manipulatively. They’ll do whatever they can to get out of the hospital, or remain inside. Others will try to lie their way out of medication, or into it. Part of the history-taking process includes gathering what’s called “collateral information,” which involves calling around — psychiatrists, therapists, social workers, and internists — to verify a patient’s details. With permission, we’re also allowed to get in touch with family and friends to get the fullest possible portrait of the person, assess his condition and safety, and create the best treatment plan. The number of phone calls and the tracking process can revive old investigative journalist training. You doggedly hunt down clues, refusing to back down when one lead dries up. Persistence comes in handy.

As a medical student, I’ve spent a significant amount of time with patients themselves. Once a patient is safe and secure, students are often tasked with conducting the initial psychiatric evaluation. They then present their findings, assessment, and a proposed plan to the resident and attending, afterwards writing up a note about the encounter.

This sense of teamwork, of contributing to hourly and daily goals, is uplifting. In other clinical environments, my work was duplicated — often in front of me. I’m a student. Obviously, some of my moves require double-checking for safety reasons. That’s normal. But the duplication often left me feeling redundant.

In the psych ED, when I called the patient’s psychiatrist, I wrote a note about the conversation and then presented my findings. If I missed key information, I called the doctor back. My work wasn’t repeated. I felt more trusted, more competent. Having spent a decade working in publishing, I’ve missed both the trust and the sense of competence.

There have been many challenges. The psychiatric patient interview differs from a standard medical evaluation. In the case of suicidal patients, for example, it’s essential to ask whether they have access to a gun at home. That’s not a typical question in other disciplines.

It’s a delightful combination — to feel both challenged and effective on a daily basis. Most important, I feel like I’m making a difference in someone’s life.

It’s the muppets! (and more)

I never thought I’d get a hug from Big Bird. Here I get hugged by Big Bird AND my sister at the same time. So amazing.

My youngest sister, Joy, is in town for the weekend. It’s her first time in New York City, and her main tourism priority was a little off the beaten path. Her #1 activity choice in the city was seeing The Jim Henson Exhibition at the Museum of the Moving Image. It’s something I’d wanted to see too, though not with quite so much fervor.

I’m so glad we went. The museum, which highlights and celebrates the evolution of cinema and television, was incredible. As was learning (and seeing!) all the muppets I’d grown up with. This was one of the most interactive museums I’ve been to, with stations that allow you to create your own frame-by-frame animations, add strange sound effects or music to well-known films like “Jurassic Park” and “The Terminator,” and dress up your own muppet.

To the latter, I added an additional educational layer. I’m on my neurology clerkship now. One of the issues neurologists frequently get called for is eye deviation. This can be due to a number of things, including failure of one or more cranial nerves to fire and signal the eye muscles to move. I created two different muppets, as you’ll see from the photos below. The one with the red hair has a cranial nerve VI palsy, because he’s trying to look right, and his right eye cannot move laterally (lateral gaze is mediated by cranial nerve VI, while medial gaze is mediated by cranial nerve III). In the picture where I’m smiling with my lovely platinum blond-haired muppet, she’s doing fine, looking down and in toward her nose. In the image where I’m frowning, she’s undergone some sort of trauma, and cranial nerve IV isn’t working, because her left eye can’t make this down and in movement, which is called “intorsion” (cranial nerve IV is the one most likely to be damaged in trauma because of its long course). I know, I’m a nerd.

But it’s not just the muppets. There’s so much more. Of course, you can’t have a museum dedicated to TV and movies without a section on sci-fi. I enjoyed seeing the paraphernalia from Star Trek (I grew up watching The Next Generation series) as well as Star Wars. Some of the Star Wars stuff was bizarre, including mugs featuring the mugs of Princess Leia and Luke Skywalker, a teapot with Luke riding a tauntaun, and a scotch tape dispenser with C-3PO.

As a writer, I also couldn’t help but take a picture next to the sign emphasizing the essential contribution of screenwriters. I especially like the quotation it includes from “Sunset Boulevard.”

Audiences don’t know somebody sits down and writes a picture. They think the actors make it up as they go along.

While that may not exactly be true, I do think the writing is often taken for granted because it takes place behind the scenes, rather than directly on the screen, like acting or special effects.

If you’re in the city and haven’t been to this museum, I highly recommend it. It’s a good time, a perfect mix of learning about the moving images that are such an integral part of our culture, of making and doing things, and of laughing. For me, it was especially wonderful to share this experience with my favorite youngest sister. Thanks, Joy.

Charting new creative territory

I’ve shared some of my origami crane notecard creations in another post. Over the last couple of weeks, I’ve expanded into new territory. One of my new directions even relates to science.

I have plenty of paper — rolls upon giant rolls, all stored under my bed. But I was getting bored. I needed something to spark my creativity. When I was flipping through a box of cardstock recently, I came across some calendar pages I’d collected while working in a research lab years ago. They had colorful microscopy images on them.

“Huh,” I thought. “I could use these.”

And I did. Here are the results of my science collection so far:

With these cards now complete, I’ve basically used what I have in terms of glossy magazine-type pictures. But a classmate has promised to get me more science/nature magazines from her parents, so I should be getting additional inspiration soon.

Against my better judgment, I also headed to my favorite paper website, Paper Mojo. They have an insanely huge collection of both solid and printed paper. Specifically, I wanted to peruse their collection of chiyogami (a type of Japanese printed paper) and marbled paper. As I was scrolling through the pages of paper patterns, I was reminded that for many of them, you can buy 5″ x 8″ sample pieces rather than a large sheet. I only needed small squares or circles for each card, so this was perfect — I could get many different patterns without spending too much money.

My chiyogami and marbled prints arrived Friday night. I dove into using them yesterday, with great delight.

Here are the cards I made using two of the marbled prints:

And the cards I made using four of the chiyogami prints:

I’ve still got more chiyogami and marbled patterns to play with, and the promise of magazines soon, too. Working with paper, mixing colors, matching prints and solids, is a wonderful study break. And when so much of my time at home is spent with my nose buried in a book, it feels good to hold something tangible that I’ve made with my own two hands.

Note: For each of the photo groupings, you can click on any of the pictures to open a slide show with larger images.

Once a copy editor, always a copy editor

Having worked as a professional copy editor, grammatical mistakes make my hair stand on end. Especially when they’re printed on signs in public places. I’ve never actually done anything about this, other than to internally cringe. Until this past week.

Below are photos I encountered on a handwritten notice advising that a drinking fountain was out of order. I immediately noticed the error in the message. I started to step away, but felt drawn to return. To fix what was wrong. I pulled a pen out of my pocket and quickly did just that. My handiwork is subtle, matching in ink color so as not to draw too much attention to itself. My goal was not to shame the writer, but simply to correct the mistake.

I’ve included before and after photos to illustrate my good grammatical deed.

Before / After:

I left the drinking fountain with a smile on my face, feeling I had done the right thing. Feeling I had done a necessary thing.

Ah, saving the world, one grammatical error at a time …