doc w/ Pen

journalist + medical student + artist

Tag: clerkships

My window to the world

I didn’t get much natural light while I was on my medicine rotation, so I made a point to look out the picture windows near the unit where I worked. It’s a lovely view.

This morning at 9 a.m., my class has an orientation meeting to our four-month research block. When I exit the door of my apartment building around 8:45 or so, I hope to see something I’ve had very little of on my medicine clerkship: sunshine. (The forecast today calls for clouds, but that’s ok — there are other sunshine-y days ahead.) For the last several weeks while on medicine, when I’d leave my apartment in the morning, it was dark. When I left the hospital in the evening, it was dark again.

It’s disorienting. Without daylight, you lose track of time. It happens to everyone in the hospital. I remember seeing a patient in the ED late one morning. She asked me what time it was. I told her it was 11:30. She looked surprised, and told me she thought it was later than that. I quickly realized she thought it was 11:30 p.m., not 11:30 a.m. Granted, she was rather confused to begin with, but the lack of windows in the ED (and the lack of a clock) only made matters worse. I honestly told her that being in the hospital, I sometimes lost track of time too.

I was fortunate enough, though, to get regular glimpses of the outside world that grounded my circadian rhythm. To get from the elevators to the ward where I worked, I had to pass a series of gigantic picture windows. Look straight out, and you got a lovely view of the East River, and one of the bridges in the distance. Turn slightly to the right, and you got a lovely view of the New York City skyline. Every morning on my way in, and several times throughout the day, I would take a moment to look out those windows. To chronicle the various views — of sunrise, snow, and sparkling city lights — I started taking pictures through the windows with my phone. Here are my favorites, broken up into two groups, the skyline view and the East River view.

Click on any of the images to open a larger, slideshow view. Oh, and pardon the glare — you know, those harsh hospital lights.

 

Skyline view:

 

East River view:

My post-medicine to-do list

While on my internal medicine rotation, I’ve done lots of steps and stairs, as my iPhone attests. But when the clerkship ends, I need to get back into a regular gym routine.

As I write this, I’m almost done with my internal medicine clerkship. Just 12 hours to go. Wednesday was my last day in the hospital. Thursday I crammed for my exams. Today I plow through a 110-question multiple choice test, and a 2-hour EKG-reading test.

It’s been an exhilarating, and exhausting, eight weeks. I’ve taken more ownership of my patients than in any other clerkship. I’ve gotten to know them better, and been more intimately involved in their care. All of that has been immensely rewarding. I’ve truly felt like part of the team, like I’m contributing in a meaningful way. It has also been devastating, for example when a patient took an unexpected turn for the worse, a turn from which they were not expected to recover.

The work schedule has been intense too. Monday through Friday were generally 12-hour days, counting both in-hospital time and time I spent chart-reviewing my patients at home in the morning. Saturday, we generally were let go a couple of hours early. Sunday was my day off. But not really. It was really my day to catch up on studying. Because when I got home Monday through Saturday, it was hard to bring myself to do more than 10 (maybe 20) practice questions before my mind shut down. Forget trying to read or memorize anything. So Sunday was my day to study. Doing “life stuff” got put on the back burner. “Survival” was my mantra.

It’s been too long since I’ve visited the Tiffany windows at The Met.

That means that this coming weekend, I have a lot of catching up to do. It won’t all happen in a day. Thankfully, next up is my four-month research block. This will be plenty of work too, but won’t involve the same crazy schedule. So here are some items on my to-do list, in no particular order:

Spend time at places other than the hospital and my apartment. I’m looking forward to seeing the sun (other than through a window), and visiting some of my favorite NYC haunts (like The Met), as well as exploring some new ones (like the 9/11 Memorial).

Spend time with my friends and family. I’ve done very little of that recently, given my lack of time and energy post-work. It’s time to catch up, both in person with those who live in New York, and on the phone with those who live elsewhere. (You know who you are!)

For too long, my vacuum has sat abandoned in my closet.

Clean my apartment. I especially need to vacuum. Now that I have long hair, fallen strands have a tendency to collect in little clumps along my baseboards. Scooping up the biggest ones with my hands is really not cutting it.

Do laundry. I mean ALL of my clothes, and in actual washing machines, not just emergency items in my bathroom sink.

Do my dishes. Regularly. The other morning, I had to use a fork to stir the sugar and half and half into my coffee. Not ideal.

Eat better. I need to get back to cooking regularly, rather than slapping together a ham sandwich for dinner, or picking up unhealthy take-out. (E.g., no more orange chicken from Panda Express, which is directly on my way home from the hospital.)

Exercise. While working in the hospital, I run around a lot, from floor to floor, so get in quite a few steps and stairs. But I need to get back to a regular gym routine, and back to doing my mat Pilates.

Meditate. This is something I’ve wanted to try for years. Medical school is stressful, and I know residency will be too. I think meditation could help with that. Ironically, all the stress lately has prevented me from trying something that might reduce my stress. So as I head into a less stressful block of time, I want to establish the habit so it hopefully sticks when I really need it next. A friend of mine recommended a couple of apps to try, including the Headspace app pictured at left, so that seems like a good place to start.

On a side note about stress, I’ve had multiple residents tell me that they much prefer the stresses of residency to those of third year. In residency your day off is actually a day off; you don’t have to study. You’re also not worried about constantly being evaluated by everyone around you, which is one of the major pressures of these clinical rotations (and something I plan to write a separate post about). A classmate said that one resident told her: “My worst day as an intern was still better than my best day as a third-year medical student.” I’m not sure everyone feels the same, but at least some of the stresses of medical school (studying for exams in the evenings and on your day off; having to always be “on” since you’re always being evaluated) will dissipate. And, I’m sure, be replaced with other ones.

Be creative. Using my hands to make things is such a rewarding outlet for me. I simply haven’t had the time or energy for it lately. I’ve missed it.

One of my new favorite songs, Snake River Conspiracy’s cover of The Cure’s “Lovesong.”

Write. I have a long list of essay ideas that I simply haven’t had time or energy to tackle. Several of them relate to things that have happened during my medicine clerkship. I look forward to sharing those experiences with all of you in the coming days and weeks, as I process all that’s happened lately.

Find new music. Over winter break, my youngest sister, Joy, convinced me to join Spotify. I’ve managed (barely) to keep up with the “Discover Weekly” playlist that Spotify sends me every Sunday night, saving the songs I like to a new playlist I aptly call “New discoveries to explore!” I’d like to delve into that list (which currently has 119 songs on it) and to investigate some of those artists and their albums more fully.

Watch TV. I don’t normally do much of this to begin with, but I haven’t even turned on my set in weeks. It would be really nice to relax on my couch in front of a good movie or TV show episode without feeling guilty.

My purchases at City Hops. Several of the beers are local, brewed here in NY state — pretty cool.

Learn about beer. And drink it, of course. For the longest time, I thought beer was simply gross. The closest I got was Mike’s Hard Lemonade. I stuck to wine, or my favorite, gin & tonic. Then I dated someone for a little while who enjoyed beer, so I would try what he bought. Turns out it wasn’t so bad, though still not my choice of adult beverage. Then my sister started bringing craft beers to family gatherings, and not only did I tolerate them, I actually liked them. It was a revelation. I’m particularly partial to IPAs, of all things. But the selection at the grocery store down the street is atrocious, and a six-pack costs about $5 more than it should. There’s a place called City Hops on 2nd Avenue not far from me. I’ve walked by it dozens of times, and often thought about going it. Yesterday I took a study break and did just that, and about $40 later, was the proud owner of seven different craft IPAs. I’m definitely drinking one tonight night to celebrate making it through medicine intact.

Pamper my plants. Many months ago, I bought some lovely houseplants from Home Depot, and some lovely plant stands online. The idea was to infuse a little bit of “green” in my environment as I live amid the concrete jungle. Unfortunately, I dramatically overestimated the amount of natural light that would be cast onto the corners where I put these plant stands. My poor plants became bedraggled over time. Luckily, they quickly perked up when I put them on my kitchen windowsill. But I can’t really enjoy them there. So I want to buy and install some grow lights, so I can put my plants back on their stands, where I can see them better, and enjoy them more.

My plants are fine on my windowsill, but once I get some grow lights I can put them on my plant stands (which are in places that don’t get much natural light, but are where I can see my greenery better).

The home page for FREIDA, the American Medical Association’s online gateway to exploring residency programs … *gulp*

Think more about my future. Before I know it, September will roll around, and I’ll be submitting my residency application. That means I need to figure out where I’m applying. And THAT means I need to do some leg work (well, more like “finger work” as I explore residency programs on the Internet). This is a little terrifying, as you might imagine. It’s also thrilling.

Clearly, I have a lot to catch up on. But it’s good stuff, fun stuff, stuff that’s rewarding in a different way than patient care.

Now, in anticipation of this upcoming reprieve, I wonder where my TV remote has gotten to …

Running the mental gantlet

This essay was first published in the online magazine The American. You can see the original version here.

 

Learning about a patient is like digging into a demanding novel: plot and characters need fleshing out.

Running the mental gantlet

Some people compare starting a new clinical rotation in medical school – something you do every six or eight weeks for an entire year – to starting a new job. A job you’ve never done, and one you feel wholly unprepared for. I liken the experience to being dropped into the middle of a novel. Dialogue explodes around you. But the speech lacks context and you struggle to make any sense of the words. Characters fall in love, have sex, shoot each other, but you can’t always tell the good guys and bad guys apart. For heaven’s sake, you don’t even know where you are. Russia? Iowa? The moon?

That’s how I felt when I started my inpatient psychiatry rotation on a summer Monday last year. I arrived promptly on the unit at 8:20 a.m. as I’d been instructed. I knew the names of the attending, resident, and medical student I would be working with, but not their appearance or where I was expected to meet them. I sheepishly hung out with a kind, chatty nurse until the 8:30 a.m. team meeting – a meeting I had no idea I was supposed to attend until the friendly nurse told me. A dozen or so of us entered a room and sat or stood around a big table to discuss general issues – safety concerns, upcoming discharges, new admissions, staff absences, special activities.

After this combined meeting, we had another meeting just with my team to discuss more specific updates on our own patients. Since I was new, those present introduced themselves. Overwhelmed by it all, I promptly forgot most of their names and their roles.

I got slight comfort in telling myself I’d pick up the details after everything settled down.

I noticed that the woman running the meeting had two binders. One bore the name of my attending psychiatrist, the other the name of a different attending. Not all the patients were covered by my team, which made me wonder where exactly they wanted my focus.

As the meeting progressed, with notes and updates on specific patients, I noticed that my medical school colleague, who was sitting next to me, occasionally scribbled a few notes. “Should I be taking notes?” I wondered.

I didn’t want to be perceived as not paying attention, but I had no idea who these patients were, which ones (if any) were my responsibility, and which updates mattered.

One of these updates might consist of something like this: “On Saturday, Jane Doe took her medications. She spent most of the day with her family. She expressed her needs appropriately. She slept well.”

That sounds bland, but perhaps this was the first day Ms. Doe had agreed to take her medications. Perhaps sleeping well was a major improvement for her. I just didn’t know.

With patient names and behaviors swirling in my head, I did my best to keep the confusion at bay, reminding myself that this was my first day, my first hour. I couldn’t be expected to keep things straight. Not yet.

Then the team resident, my classmate, and I talked individually with patients in one of the unit’s small, private meeting rooms. The resident immediately launched into questions. Sleep? Appetite? Mood? Hallucinations or delusions? Medication side effects? Thoughts of hurting yourself or others?

Between patients, my classmate tried to give me a brief synopsis of the next patient: diagnosis, treatment plan.

With only that to go on, I struggled to make sense of the encounters. The journalist in me cried out for each patient’s fuller story. Understanding the past would help me understand their present, and their prognosis.

As the patients answered the resident’s questions, in my own mind the replies only provoked more questions. One patient made a vague reference to a brutal childhood trauma. Another hinted at magical powers. How could I not want to know more?

Making matters even more complicated I had little understanding of what my supervisors (the psychiatry resident and attending) expected of me for the next four weeks. The medical student told me what he’d been doing – interviewing two of our five patients one-on-one daily, and writing a progress note on each. But more concrete information was hard to find.

I finally went to the source, asking the resident what her expectations were. She told me to do essentially what my classmate was doing — pick a patient or two, spend some extra time with them, and write my own notes. I had figured as much, but now it was official.

I selected my patients and dug into their medical records, combing through the notes in each person’s electronic chart. I was back to reading the novel, starting at the beginning and working my way forward. I began with each patient’s presentation to the psychiatric emergency department. That gave me a sense of how they were when they first came to the hospital compared to how they were now. I then moved to the initial evaluation note from the psychiatric unit (where I was now working). These two comprehensive notes helped me understand each patient’s present psychiatric illness, as well as past psychiatric history, medical history, family situation, and other life factors. I also read what are called “collateral” notes. These are conversations between a medical practitioner (often a medical student) and someone else in the patient’s life — a spouse, friend, psychiatrist, therapist, or caseworker, for example. They provide an outsider perspective on how the patient’s current condition compares to their norm. Last, I read daily progress notes, finishing with the one written that morning. These brief and focused progress notes told the story of the patient’s day-by-day existence on the inpatient psychiatric unit. How they were eating, sleeping, behaving, and overall living while in the hospital. These daily updates clued me into whether someone’s delusions or insomnia had improved, for example, or whether they were tolerating an increased dose of a medication.

At the end of that first day, I was still in the middle of the novel, on page 200 or so. But I’d gone back and at least skimmed the first 199 pages. And with that background, I was now ready to move on to the next chapter: the next day.

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.

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.

Four weeks of trauma surgery: lessons learned

Friday marked the last day of my four-week rotation on the trauma surgery service. As expected, it was an exhausting four weeks. But it was also incredibly exhilarating and educational. And it was filled with many profound moments that will stick with me forever.

This, in large part, was due to working with such a phenomenal team: An attending who taught me that if a trauma surgeon can take 10 minutes to sit down and talk with a patient, every physician should have time to do so; who inspired me to learn and ask questions; and who made me excited to go to work every day — even when that meant waking up at 3:30 a.m. A chief resident who carefully followed a patient’s blood tests after I got splashed in the face during a case, and personally kept me updated. A senior resident who was willing to put a nasogastric (NG) tube down my nose and throat because I wanted to know what our patients with small bowel obstructions were going through. (I’ll be writing more on that soon.) Interns who clearly wanted these four weeks to be an educational experience — and proved it by inviting us medical students to practice starting IVs on them. A fellow medical student, one I barely knew going into the rotation, who quickly became a confidant.

These are just a few examples of how my team helped make the oft-feared surgery rotation such a meaningful experience.

In medicine, you learn from your team. You also learn from your patients. Working on the trauma service for four weeks, I am now acutely aware of how a person’s life can be permanently changed — or even snuffed out — in the blink of an eye. I helped care for patients whose legs were now useless after a car crash, a gun shot wound, or even a freak fall from standing. “Pedestrian struck” was another too-common reason for admission to our service. Usually, the result was a laceration or some broken bones — things that were painful, but that would heal, with time. But sometimes the trauma of being hit by a car results in a brain bleed. Sometimes these resolve. But sometimes, they result in irreversible brain damage, or death. All because you were walking on the sidewalk, or crossing the street, at the wrong place and the wrong time. This hits especially close to home when the patient is close to my age, or reminds me of someone I know. This could happen to me. It could happen to any of the people I love. As could appendicitis, cholecystitis, or a small bowel obstruction — three other very common complaints I’ve seen on this service.

So as I interact with patients and their family members, I attempt to do two things. I first try to put myself in their shoes, as best as I can. This helps me understand (and if needed, forgive) any angry outbursts or other nastiness. It’s not personal. Second, I do my best to treat the patient, and the patient’s family, like they were my own family. I would want a doctor, nurse, or medical student to treat my parents, sisters, or friends that way. One of the trauma attendings modeled this behavior so well. When patients and their families thank him for his kindness, he tells them outright that his goal is to treat people like his own family. I’ve taken to doing the same.

These are not lessons I necessarily expected to learn on my surgery rotation. But they are important lessons that will remain with me, whatever I do in medicine.

Don’t get me wrong — I learned about surgery on my surgery rotation too — suturing, knot-tying, and so on. But I could learn those things from any surgery attendings or residents. My team helped teach me so much more.

Surgery, day #1: attitude adjustment

We weren’t wearing the appropriate maroon scrubs when we went to the OR to practice how to scrub in for surgeries. So we had to don the infamous blue “bunny suit.” These disposable, zip-up onesies are only stocked in XL, so most of us looked completely ludicrous. I felt it was important to capture the ridiculosity of the moment. My friend, who had kept her iPhone handy, was kind enough to oblige.

Around the country, the medical school surgery rotation has a reputation for being one of the toughest and most grueling. The hours are long, the breaks are few, and the expectations are high.

So it was with more than a little trepidation that I approached the first day of my surgery clerkship yesterday. But after yesterday, I find myself with a changed attitude. The hours won’t be any shorter, but our day of orientation got me excited about what I’ll be seeing and learning over the next 8 weeks.

Our orientation included the obligatory lecture sessions about clerkship logistics, leadership, grading, safety, all that. But after those things were out of the way, we got to do stuff. Fun stuff.

Our orientation was held in Weill Cornell’s Skills Acquisition and Innovation Laboratory (SAIL for short). It’s a suite of rooms in the hospital designed to help surgeons, surgical residents, and medical students practice their surgical skills. And while as medical students, we obviously won’t be performing the operations, we will be assisting in some ways. Depending on the trust earned with our residents and attendings, we may be asked to do things such as insert the foley catheter (for urine), retract, hold the camera during laparoscopy, suture, and tie knots. Retracting is pretty self-explanatory, but everything else requires some knowledge.

So yesterday, we practiced. We used actual foley catheter kits (the same kind that we will see in the operating room) on both male and female mannequins. Urine passage is obviously pretty different depending on the gender, and getting a tube up there is also a little different. While inserting the foley, we worked to maintain sterile technique to reduce the risk of infection. There were also workshops on knot tying (so many knots to learn!) and suturing (so many ways to suture!). The most high-tech workshop was for laparoscopy, also known as minimally invasive surgery. That’s where they make tiny incisions and insert a camera and other instruments rather than open up the abdomen (or other part of the body) with a long incision. There were several stations to practice our hand-eye coordination. It was a lot like playing a video game. At each station, you looked up at a screen (same as you’d do during a laparoscopic procedure) while holding the camera and/or instruments with your hands. Then you had to manipulate objects with your instruments, passing tiny blocks from one hand to the other, dropping beans into a tiny hole, or untangling rope (to simulate loops of bowel), for example. These stations actually replicate an exam that surgical residents have to pass in order to graduate. After doing a few stations, I have a new respect for this kind of surgery. I did notice improvement after a few go-rounds though, so I see how these practice stations are a huge help to surgeons.

Late afternoon, we headed to the OR for a brief tutorial on scrubbing, gowning, and gloving. Since I completed my ob/gyn rotation, I’d already learned these skills, though it was a good refresher.

At the end of the day, I’d recalibrated my attitude. And I’d formulated my goals for the clerkship. I want to perform well, of course — that goes without saying. That overarching goal encompasses lots of little goals, including studying for the shelf exam, reading up on patients, being a helpful student, working hard on my patient presentations, and so on. But I also want to leave surgery with a better grasp on some of these surgical skills, particularly suturing and knot tying. We were told yesterday that it takes (literally) thousands of hours to really learn how to suture and tie knots. I don’t have thousands of hours to practice. But I also don’t need to perfect my skills to the level of a surgeon. I do, however, want to feel more comfortable doing those things, because they’re useful across the practice of medicine. So I talked at length with the doctor who runs SAIL, which is open 24/7 for us to come in and practice. I’ve now got some sutures, gloves, and other paraphernalia at home to practice with. And he told me to come back in a week or so to show him my progress. He’ll help me if I’m struggling with anything or if I’m doing something incorrectly — both of which are very likely. I know that this kind of hands-on tutoring is invaluable when learning a new skill. I’m so grateful for the help.

Along with being a writer and medical student, I’m also an artist and former pianist. I love using my hands, and know the importance of building muscle memory. So I see this as a fun (and practical) challenge.

I love a good challenge. I’m in medical school, after all.

Primary care doctors: masters of flexibility

One week into my primary care clerkship, and I have developed an incredible new respect and appreciation for this group of doctors.

First, a little about the clerkship itself. At many schools, this would be a family medicine clerkship. (Family physicians being doctors who treat the whole family, from babies to kids to teens to adults, including pregnant women.) But Cornell does not have a family medicine department, so for this clerkship we spend time at various ambulatory care sites. Being at five different clinical locations throughout the week was disorienting at first, but I do think it will give me a good sense of various ambulatory settings. I’m in Brooklyn with an internist on Monday, and on the Upper East Side the rest of the week for dermatology, ob/gyn clinic, more internal medicine, and the emergency department.

So what’s so incredible about primary care doctors? Plenty, but what I want to focus on right now is how adaptable they are. In primary care, when a patient comes in for an appointment, you might know what her ongoing medical problems are — diabetes, hypertension, etc. — but you don’t know why she’s here today. You need to be prepared for anything, quite literally. You manage acute and chronic complaints in all systems: heart, lungs, stomach, liver, brain, muscles, bones, and so on. And when you do a physical exam, you don’t just listen to her heart, lungs, and belly. If indicated, you might do a focused musculoskeletal exam for back pain, or a neurologic exam if she has trouble with balance.

I’ve seen this flexibility as a patient, of course, when visiting my own primary care doctor. It seems so natural. But it’s different being on the other side of that doctor-patient relationship. There’s so much information to filter through during the patient interview, so many potential physical exam maneuvers, so many diagnostic possibilities to consider. In some ways, this is intimidating for me as a medical student. It’s all so new, and I have so much yet to learn. But it’s also incredibly rewarding to help solve these clinical puzzles — and to help these patients.

The one thing I can do as a medical student: listen

Show me a medical student who only triples my work and I will kiss his feet.

This is one of the “laws” from the satirical novel The House of God, by Samuel Shem. Now that I’m a medical student, I can see the truth in what that fictional medical resident said. It does take extra time to involve the medical student. And the scope of what I can do as a student is very limited. Of course, being included is the only way I’m going to learn — it’s the only way any doctor has ever learned. But when there’s so much to be done, I know there are moments of frustration for the nurses, residents, and attendings.

What I’ve discovered in the last few weeks, though, is that there is one job I can always do: listen. I’m in a unique position to do this. Most of the time the doctors and nurses simply don’t have time to sit there with a patient for very long. They have other patients to attend to, other more pressing tasks.

As I saw during my time rotating through ob/gyn, patients are often scared or upset. Just being present in the moment, hearing a woman’s concerns and holding her hand, makes a huge difference. Two encounters where this happened stand out in my mind.

One woman had presented to labor and delivery after falling. Trauma in pregnancy can induce labor or potentially cause a placental abruption (where the placenta prematurely separates from the uterus, resulting in painful, dangerous bleeding). She didn’t have any worrisome signs or symptoms, but was there for monitoring. I was the one to initially take her history, and noticed right away how anxious she was. Women who come in to triage, which is the emergency department for pregnant women, are all put on electronic fetal monitoring. She kept asking me how her baby was doing. After taking her history, I left to present the case to the resident. We returned together to see the patient. A little while later, my gut told me I should go back to check on the patient. She was still frightened. My reassurances that the baby was doing fine didn’t seem to help. So I went for the distraction technique. I asked whether she had a name picked out, whether she had a nursery ready. Almost immediately, the woman’s demeanor changed. For a few minutes at least, rather than concentrating on the angst of the moment, she focused on how excited she was to welcome this baby into the world in a few short weeks. Clearly wanting to share her excitement, she urged me to feel the baby kicking against her bare belly. It was obvious that a deep love for this unborn child was driving this woman’s fear. My heart went out to her. I know I didn’t take away the anxiety. But for the time I was there, I think she felt understood, cared for, and listened to. I believe that made some sort of difference — if only temporarily.

While on labor and delivery, I was also involved in many births. Some went smoothly, others less so. One woman in particular had a rough labor. This was during one of my night shifts. She’d been in the hospital for hours and hours, accompanied by her very supportive husband. She was exhausted. Her labor was not progressing well. I had been in the room for about two hours, helping her push. When the attending physician came into the room and recommended a C-section, the woman was devastated. The husband and I listened to her frustration. He held her hand, and I put my palm on her shoulder. The next morning, after the surgery, I ran into the husband as I left the unit. I was headed home after my 14-hour overnight shift for much-needed sleep. I walked up to congratulate him on the birth of his child. He dodged my outstretched hand and engulfed me in a hug. He thanked me for being there for his wife. He told me I had a marvelous bedside manner, and that I would make an excellent doctor. Suddenly every moment of my brutal night shift was worth it: I had really helped these people in their time of need. I walked the few blocks home exhausted, but on an emotional high.

Spending time with patients like these, listening to their life stories, jokes, or concerns, may not lessen anyone else’s work load. But I think it does help the patients. And that’s what I’m here for.