Everything I Learned in Medical School: Besides All the Book Stuff (10 page)

Chapter 24

The First Patient

During our very first year of medical school, we would participate in what was known as the Practice Course for half a day each week. This was a class in which we would learn the art of medicine, such as how to interview patients, ways to build rapport, etc. As part of the course, during the end of our first year, we were set up with a doctor to follow around clinic a half day each week to see medicine in action. It was entertaining to just sit back, listen and watch how they did business. Then, about one month into this clinical experience, after a morning of seeing patients together, the doctor turned to me, handed me a chart, and said,

“Why don’t you go see this patient?”

“On my own you mean?” I asked nervously.

“Yes, this one is all yours.”

My heart began racing. I had to walk into a room on my own and try to help this patient. The chart said it was a teenager who had a fever and cold symptoms for two days. What should I ask her? What should we do for her? Would she ask me questions? What would I say? All these thoughts raced through my head as I knocked lightly on the door and walked in. Inside sat the teenage girl and her mother. The girl was on the examining table, and she was crying. Apparently, she felt miserable. After trying to comfort her, I made attempts to ask questions, but the girl continued to sob and ignored me. The mother was of little help, and made a few weak attempts to convince her daughter to listen to my questions. After a few minutes of fumbling around with random questions, I realized I was not getting anywhere. I was scared to even try examining her for fear the crying would worsen, so I just left the room.

Outside I found the attending physician, and explained the situation, conveying the information I had gotten during my short interview, which was minimal at best. He gave a slight understanding smile, and we went in together to finish up the visit.

Looking back on this visit, it’s amazing how far a student comes during the course of medical school. Near the end of my four years, knocking on patient doors and walking in to get their stories came naturally, and there was no hesitation. No matter what awaited me behind the door, there was a sense of comfort with the amount of knowledge I had, and knowing that by the end of the visit, I would have some sense of what was causing the problem, and that if the patient had questions, I would at least be able to give some educated answers.

No matter what makes us nervous in life, it’s feeling prepared that gets us through it. Whether it be preparing for a large presentation, or studying for a board exam, the more you know, the less nervous you become. Hopefully, dealing with patients will continue to get easier and easier through residency and beyond.

Chapter 25

The Bad News

When a patient comes into the hospital, something in the body has gone wrong. If all goes well, the patient will make a full recovery, and they will go home no worse for the wear. But this is often not the case, and in the worst case scenarios, the patient will not make it out of the hospital alive. When the inevitable becomes clear to doctors, the next step is conveying this to the patient. Giving a patient bad news is one of the most difficult parts of medicine. The way a doctor delivers the news often distinguishes the good doctors from the great ones.

The first time I had to witness this conversation, it was difficult. We were in the VA Hospital, short for Veteran’s Affairs. The hospital was right across the street from the main hospital, and cared for those that had served in the armed forces for our country. It was one of the benefits they received for their service. This was where I met a man in his mid 60’s that had been diagnosed with liver failure secondary to chronic hepatitis B infection. He had gotten the infection through a blood transfusion he received when he was younger after being shot during a bar fight. When your liver starts failing, blood flowing through it can often slow down, and blood starts backing up in all the veins that drain into the liver. Additionally, your liver makes protein that floats in your blood and helps keep fluid in your vessels. So, in liver failure, fluid starts leaking out of your engorged veins and pools up in places like your abdomen. His belly was huge, and he came in because he was having difficulty breathing with all the fluid that had built up, and needed some removed. This was done by placing a needle into his belly and draining the excess fluid. We removed close to two liters, and although he still had a great deal of fluid left, pulling more than this at once could have been dangerous for his health. The body is not used to having such large amounts of fluid added or removed at once. Later in his stay, we decided to do some imaging studies of his liver to assess for cancer, sometimes a result of chronic hepatitis infection. The results of our CT scan shocked us. This man had a clot going all the way from his liver, through the vein that connects to his heart, and down into the inside of his heart, where it was flapping around with each heart beat. This was bad news for him. Any minute the large clot could break off and go straight into his lungs, leading to a quick death. Sadly, there was not much we could do for him. When we went to tell him the news, he was obviously distraught, but not all that surprised.

“Well, can’t I get a liver transplant or something?” he asked, trying desperately to look for a possible solution to his condition.

“Unfortunately, at this point, you would not be a candidate for a liver transplant,” the resident told him matter-of-factly, but still with a touch of sympathy.

The patient nodded, almost to himself, and sat back in his bed. I couldn’t make eye contact with him, I felt so bad. What must it feel like to hear that your life will soon be coming to an end. Everything you knew, everything you worked for, everyone around you would soon be gone. It was hard to imagine. We left to give him some time to think and come up with questions.

I came back later to speak with him some more. Like many VA patients, he did not have any family with him. He didn’t quite understand what was happening, and asked me if I could explain what the situation was. So, taking out a pen and paper, I began drawing a diagram of the liver and heart, explaining where this clot was, and how large it was. He attempted to follow along for a while, but then eventually told me not to worry about it. He had resigned himself to his fate, and must have decided he didn’t need to know the details. As I was leaving, he looked at me and thanked me for my help. I looked back and thanked him for all he had done for us. After all, he had risked his life in the Vietnam War fighting on behalf of this country. He appreciated the acknowledgement.

“I don’t often hear that, thanks,” he said.

It was always so ironic to me that a man who had survived one of the bloodiest wars of all time was now on his death bed because he got shot in a bar fight. It seemed cruel and unfair. Yet even though he was nearing the end of his life, he appreciated the care he was receiving, and part of it was likely because of the way he was told of his fate – with compassion, sympathy, and a listening ear. He knew we cared about him, and in a sense, that was all he needed. He needed to know that all had been done for him.

In the end, I learned that giving bad news doesn’t necessarily have to be a negative experience for the doctor or patient. The important thing is that when you tell them, you give them a glimpse of how you are feeling as well. Patients know when you care, and they come to accept bad news much easier if they know you’re with them through their struggle.

Chapter 26

Those Three Little Words

The very last rotation of second year was internal medicine.  It is perhaps the most mentally challenging of all the core rotations.  Here, they take care of pretty much any adult health problem that does not involve surgery.  Pneumonia, heart failure, kidney disease, pacreatitis...they see it all.  Of the two months dedicated to this rotation, my entire second month was spent across the street from Duke at the VA Hospital.  This was a government-run hospital, and the building was a huge brick eye sore.  The colossal building was staffed by residents and attendings from Duke.  This worked out well, since the hospital benefited from having a constant pool of workers from right across the street, and Duke had another facility in which to train residents and employ physicians.  It also worked out well for physicians who were well past retirement age but still wanted to work.  You see, Duke had a policy by which anyone aged 75 had to automatically retire, without exception.  This avoided the awkward task of having to kick out those that would become a liability rather than an asset in their old age, as often happens when physicians age and can’t keep up with the latest advances in medicine.  However, the VA had no such policy.  And as you can imagine, there are some doctors that are still as sharp as tacks, even at 75, and after a lifetime of building their medical knowledge, have no desire to stop working and take up shuffleboard. Dr. Steele was one of those doctors.

Dr. Steele (whose name I’ve changed, more to protect myself than him) was a veteran himself. It was obvious he was high ranking in his service, because he ran a tight ship. There was no give to him. He was a medium height and build, with hair that had completely grayed, and a face that did not have a trace of softness. His expression was always stern, and his words succinct and pointed. And when he talked, you listened. He would walk into the room in the morning and not have to say a word, as the room would get quiet and everyone would begin taking seats to start rounding. He ran things a bit different, as each morning we would sit and talk about every patient as a group, then walk around and see everyone. He would approach patients with a style that left no doubt who was in charge. He would matter-of-factly state his intention to examine the patient. If they attempted to talk, he would stop them, and inform them they could talk after he was done with his exam. It was clear he was the product of an age of medicine in which the hierarchy was even more defined and the doctor was always right.

As one can probably imagine, presenting patients to this man was no picnic. It was a constant test of fortitude. Every patient we presented would trigger countless, pointed questions to test our knowledge of both medicine and our patients. It was not a friendly manner in which he went about asking those questions, but one instead that made you feel as if you were in the spotlight in front of an audience, being asked to recite lines you hadn’t time to memorize. And if the answer was incorrect, he would stop you mid-sentence with a, “No, that is wrong,” and with no show of sympathy, would go into a long discussion of the answer. This would be followed by yet another, more difficult question. And since you didn’t know the answer to the first one, this next answer would no doubt be incorrect as well. It was an uncomfortable exchange. Although he did attempt to teach, he did not fit “the teacher” description of pimping as we discussed before, because I don’t think teaching was his only motive. He wanted to break us.

Sadly, with one resident on our team, he succeeded. This resident was in the family medicine residency, and they rotate through a variety of specialties during their training, one of which is internal medicine. Whether it’s fair or not, different residency programs get different amounts of respect based on how competitive of a field it is. Family medicine is considered by many to be the least competitive field to get into, and therefore, people in this field are incorrectly labeled as less intelligent than those in other fields. However, this particular resident was not up to par, and Dr. Steele could sense this weakness. Like a deer lost from her herd, the resident would timidly begin her presentation, and Dr. Steele would eye her down, slowly approach while she was not looking, and pounce! I dreaded the moment each morning when she would have to present, because I knew questions were coming, and I knew she would not be able to answer them. Dr. Steele would add insult to injury by often showing a look of surprise when she did not know the answer. The added tension of him being an old Caucasian male and her being a young African American female led me to feel even more uncomfortable as this same routine played out day after day. What’s worse is that the resident was truly making an effort, but even when she would get some questions correct, Dr. Steele would simply ask harder questions. Halfway through the rotation, I noticed that the other residents were putting in orders on her patients. Dr. Steele had taken away her privileges to put in orders, stating he was worried about patient safety. This was something I had never seen done to a resident. To a doctor-in-training, such a loss is soul crushing. She left the rotation early, stating she had other obligations. The real reason she left was clear; he had broken her.

By now you understand the person we were up against. So, was I trembling in my boots every morning when it was my turn to present? Would I be his next victim? Did I stay awake at night, fearing my next embarrassing encounter with him? No. Why? Because in my corner I had those three little words. These three little words would disarm him of his ability to intimidate and embarrass. I would use them over and over again.

I take you back one year to the very start of my second year of medical school, when we started rotations. The art of pimping was new to me. Having to answer questions from people smarter than you in front of everyone on the team was uncomfortable. Students handle these questions in a variety of ways, just as physicians “pimp” us in different ways. Allow me to introduce you to some of the more common styles of responding to being pimped:

1. The Rambler – this student will answer each question with a verbal diarrhea of sorts, saying everything he knows about the topic in a muffled voice in hopes that the attending will hear one or two key words and declare his answer correct.

Attending: “Tell me about triple therapy for reflux.”

Student: “Sure, reflux is something we see quite frequently in our adult population of patients. The treatments are quite varied, and triple therapy is one option amongst many. Ramble, ramble, ramble, antacids, ramble, ramble, infection, ramble, ramble.”

Attending: “That’s right, we use triple therapy for H. pylori infections.”

Student: (to himself) Whew, that was close.

2. The Egotist – Comparatively, smarter than his fellow students. Takes on each question with an air of unfaltering confidence, with the misperception that acting as if he knows something will convince people that he actually knows something. He argues with anyone that tries to correct him, even the attending. Even when he’s wrong, you almost want to believe he is right, just because of the confidence. These people go on to become surgeons.

Attending: “This patient just had his second seizure in the setting of a fever, what would you do next?”

Student: “He needs a CT scan and a lumbar puncture.”

Attending: “Well, he’s three years old, and his neurologic exam is normal. He looks great right now, so there is no need for either.”

Student: “But you don’t want to miss a big tumor or something.”

Attending: “With a normal exam, that’s not likely.”

Student: “Well this could be the start of a meningitis.”

Attending: “He would not look so well on exam. Besides, the guidelines say he doesn’t need it.”

Student: “You can’t always go by guidelines. What if this kid dies?”

Attending: “Let’s move on.”

Student: (to himself) Everyone’s an idiot, except me.

3. The Nervous Deflector – each question is met by a nervous shuffle through papers, a few “um’s” and “uh’s”, and an attempt to scan the floor in hopes that the answer is magically written on the tiles. This student finishes by nervously glancing at someone else in the group, thereby deflecting the question to this new person with a visual “tag, you’re it.” The attending turns towards this new person, and the Nervous Deflector is off the hook. Get a few of these in your group, and the question bounces from person to person through glance after glance, until the attending finally gives up and answers his own question. These students go on to become pathologists, who stare at specimens on slides all day and avoid human contact.

4. The Tangentialist – If the answer is not known, the student will simply state something she does know that somehow relates to the topic.

Attending: “What antibiotic would you use in this patient?”

Student: “Well, the rate of resistant bacteria is becoming a big problem in the community.”

Attending: “That’s true. In this case, I’d probably go with vancomycin.”

Student: “Yeah, that’s what I was thinking.”

5. The Name-Dropping Data Collector – This student remembers a variety of recent studies, recalls the name of the physician that wrote the studies, and uses them when the moment is right. These people go into internal medicine.

Attending: “What organism do you think is causing this patient’s pneumonia?”

Student: “Well, the internal medicine chairman, Dr. Holmes, recently put out a study that says the rate of strep pneumonia infections are highest for this county.”

Attending: (trying not to refute his own chairman) “Uh, yeh, that’s right.”

6. The Generalist – Uses a sequence of progressively more and more general statements without ever really answering the question. They make no definitive statements. These students become radiologists.

Attending: “What is the first line drug for hypertension?”

Student: “Well, I don’t think our hospital has a set algorithm for that.”

Attending: “Actually, we do.”

Student: “Right, but what I’m saying is that there is no good data on this question.”

Attending: “Actually, there is.”

Student: “Well, every patient is different.”

7. The Combinator – Combines the various strategies into one big attempt to save face.

Attending: “What do you think led to this new mutation in our patient’s DNA?”

Student: “Well, Watson and Crick first described the structure of DNA.”

Attending: “True, but that’s not the question.”

Student: “Dr. Holmes told us in a lecture that…”

Attending: (cutting the student off) “I don’t want to know what Dr. Holmes thinks, I’m asking you.”

Student: (Nervously glances at fellow student, who nervously glances back at him)

Attending: “Well?”

Student: “Uh, ramble, ramble, ramble, smoking, ramble.”

Attending: “What did you say?”

Student: “Well, every patient is different.”

As I began on the wards, I had no good strategy. I tried my hand as the Tangentialist, the Generalist, and even took a stab as the Egotist. But I never really felt comfortable. I knew I needed something else, a fail-safe resource I could rely on to avoid the nervousness, the pressure. Ideally, something I could program into a handheld device that would have all the answers. But sadly, there was no such thing. But one day near the beginning of second year, I had an epiphany. Something that was so simple, I couldn’t believe more people didn’t use it. All I needed were those three little words. So the next day, I decided to try it.

I could feel myself already less stressed as rounds began. A few questions were lobbed my way, but I knew the answer. Finally, the attending threw me a question that was tough, giving me a chance to use my weapon. I looked him straight in the eye, and without the slightest bit of hesitation, I let it out,

“I don’t know.”

And just as quick as I said it, the attending simply began teaching about the topic, educating us all. No nervous rambling, no glances at my fellow students for help, just those three words and I was out of the spotlight.

But wait you say, aren’t you losing points because you are admitting you don’t know? Well, I’m convinced that a confident “I don’t know” makes you look much smarter than nervously stumbling over the answer. In time, I would tweak my “I don’t know” so that I said it not only confidently, but with a tone that made me sound almost a bit surprised that I didn’t know the answer, thereby giving off the impression that I knew everything else except the answer to that particular question. Of course, for this strategy to work, you do have to correctly answer some questions, or risk people catching on.

I eventually learned that not knowing isn’t the end of the world. No one is expected to know everything, especially medical students. After all, if I already knew everything I wouldn’t be paying $50,000 a year to be in school. It’s a lesson I’m glad I learned early, because it came in handy, both in school and out. This ability, however, goes beyond just avoiding nervousness while being pimped, as we’ll talk about later.

So back to Dr. Steele. His questions would come at me fast and furious, and some I could answer. But for those I couldn’t, he would not get the pleasure of seeing me sweat and fumble. I simply threw the ball back in his court with those three little words. With each day, I felt more and more comfortable. At one point, I was even smiling while confidently saying, “I didn’t know”, and could have sworn I caught him smiling back. But only for a second, and just as quickly as it appeared, it was gone, and he began teaching. I had broken him.