Everything I Learned in Medical School: Besides All the Book Stuff (5 page)

Chapter 10

Mistakes

People expect a lot from their doctors. They expect honesty and openness, they expect treatment, and they expect results. One thing no one expects is a mistake. After all, doctors don’t make mistakes, right? Well, like any other human being, doctors make lots of mistakes. Even the best doctors make mistakes. Allow me to demonstrate.

I take you once again to my ophthalmology rotation. For an entire week, my assignment was to work with one of the most well-known ophthalmologist in the state, and quite possibly, the country. Patients took trips from all over the nation just to see him for a 20 minute clinic visit. In the medicine world, he was a rock star. For an entire week, I saw him handle some of the most complex cases with confidence and ease. In the OR, he was like a machine, going through case after case of small, delicate eye surgery. Then one day, I learned he too was human. An African-American woman was having surgery on her eye muscles to correct her “lazy eye”. They initially sedated her, and then performed what is known as retrobulbar anesthesia. For this, a needle is inserted through the eyelid and behind the eye, where the anesthesia liquid is injected. This inactivates all of the nerves that run behind your eye, both the sensory nerves and the motor nerves. Since your sensory nerves are no longer functioning, you don’t feel any pain. You also can no longer see anything, since vision travels along special sensory nerves. The motor nerves control eye movement, so you can’t move your eyes either. In essence, that eye is useless for about eight hours after the injection.

In the OR, to ensure that the proper eye is operated on, the person’s face would have a big “X” drawn with a marker on the forehead over the correct eye. But on this day, the “X” had been partially obscured by the sterile drapes that covered the patient for the operation. The ophthalmologist grabbed the needle with the anesthesia, and carefully inserted it in her left eye. It was only after he finished that the anesthesiologist pointed to the “X” on the right side of her forehead. Everyone stopped, and the ophthalmologist stood there in disbelief. The small amount of his face that was visible behind the mask and surgical cap was turning redder by the second. He walked over to the patient’s chart, still in disbelief. But it was true, he had completely anesthetized the wrong eye.

I expected him to say something humble, taking responsibility for the mistake. Instead, he started mumbling about how the anesthesiologist usually sits on the side opposite the eye to be operated on, and how the anesthesiologist was on the wrong side, and that’s why he made the mistake. “Bullshit,” I thought to myself.

Was it truly a big deal? After all, he hadn’t started operating yet. That would have truly been tragic. But now, the other eye for this patient would have to be numbed up, and that would mean the patient would be totally blind for the rest of the day! That could be a problem. They needed permission to do this to the patient, and so the doctor left the OR in hopes that her mother or father were in the waiting room. Unfortunately, only an uncle had come with her, and he wasn’t allowed to give permission for this. So, the patient had to be woken up out of sedation and told of the mistake. She could then decide to come back another day, or agree to inject the other eye and be temporarily blind. So, the anesthesiologist started reversing the sedation, and we waited for her to become fully alert. When she was finally awake, the doctor broke the news to her.

“It appears we made a mistake, and you got the numbing medicine in the wrong eye.”

She responded with a very appropriate question, “Isn’t there a big ‘X’ over my right eye?”

Yup, there sure was, and the doctor had still injected the wrong eye. In the end, she agreed to proceed with the operation, even though it meant she’d need a close assistant all day to guide her around.

Unfortunately, the patient wasn’t the only blind one in the operating room that day. Mistakes happen. Everyone makes them. But you’ve got to see that you’ve made a mistake and learn from it, or else you’re likely to make the same one again.

Chapter 11

Big Pimping

Mention the word to anybody in medicine, and they’ll know exactly what it means. No, it has nothing to do with a cane, a sparkling sports coat, and the exploitation of women. The world of medicine has a completely different definition of pimping. It’s the process in which those that are higher in the medicine hierarchy ask their subordinates questions on various topics in medicine to test their knowledge. Most of the pimping is directed towards medical students. There are three main reasons that an attending or senior resident would pimp medical students. And here they are…

Reason 1: The True Teacher

The first reason is probably the best reason to pimp. Many attendings ask very reasonable questions simply to see what a student’s level of knowledge is, and if the student does not know the answer to a particular question, the attending uses this to delve into a brief teaching session. The truly attentive physician will preface his/her question with an “outie”. This “outie” is a phrase that prevents you from feeling stupid in case you don’t know the answer. Examples of outies include, “I really don’t expect you to know this, but…” or, “One thousand bonus points if you can tell me…” This is a great way of pimping.

Reason 2: The Showoff

I’m convinced that some physicians like to pimp just so they have a reason to show off their medical knowledge. They’ll ask very specific questions, such as, “What are the diagnostic criteria for endocarditis?” The question is usually very matter-of-fact, as if everyone should know the answer, and he simply wants you to share, since you of course know it as well. And when you don’t know the answer, the physician fakes a small bit of surprise, and then goes into a long-winded discussion on the topic, including the recent data on the subject. Not a fun way of pimping students, as they are usually too embarrassed that they didn’t know the answer to truly pay attention to the teaching session that follows.

Reason 3: Searching for the next Ms. Cleo

The worst of all the pimpers are the ones who ask the unanswerable questions. No matter how much you know, there is no way to answer their questions. Attendings are, in essence, asking you to read their minds. These are the questions like, “Tell me what four things you worry about in this patient,” when it is a patient who happens to have 20 medical problems. Sometimes, the question is often prefaced with, “This is a read-my-mind kind of question, but…”. If those words come out of your mouth, don’t ask the question! Don’t do it. It’s just silly. I’ve told myself that when I become an attending, my questions will all be for the sole purpose of teaching students in a comfortable environment. Although, just for fun, I will stand around one morning, with my bright-eyed and bushy-tailed students, who are expecting all this knowledge and intellectual questioning to come out of my mouth. Instead, I’ll just point to the one that looks the most nervous and say, “You! What am I thinking right now?”

Chapter 12

Reading Between the Lines

P=MD. It was an equation passed down to us by classes that came before. This simply meant that since our medical school was graded on an honors/pass/fail grading system, all we had to do was pass everything to earn our MD degree. And since it was surprisingly difficult to fail courses so long as you gave some effort, this made it seem like medical school would be a cakewalk. But in reality, things were not as simple as P=MD. Almost every member of our class wanted to pursue a specialty, and finding a residency spot can be quite the competitive process, so grades did matter.

Getting good grades in high school and college was never a problem for those in my class. They would not have made it into medical school without being able to perform on tests. Our basic science courses during our first year were like our college courses on speed. We covered insane amounts of material in short periods of time. But at the end of the day, it was still the same old, same old. Your grades were based on how easily you could memorize material and how compulsively you wanted to study.

But as we got closer to the real world, the way we were graded began to change. After our first year in the classroom, we entered the hospital and began working on the ward teams. The majority of your grade was based on the subjective evaluation by residents and attendings. Suddenly, scales such as “professionalism” and “ability to work with peers” determined your grade, something new to everyone. It was those that were socially adept that now found themselves a step ahead of the bookworms.

In such an environment, you always have to be careful of what you say. It becomes very important to come across as enthusiastic and interested in learning. This can sometimes be difficult, given the situation. Here are two examples:

Situation 1 – It’s time to go home. The typical medical student will stay in the hospital until the upper level resident tells them they should leave. Sometimes, the residents get so busy that they lose track of the time, and forget that the students are still around. But when it’s 6PM and you’ve done a whole lot of nothing all day, and you’re ready to go home, it’s a tough balance between hinting that you want to go home, and not sounding like you want to go home. After all, the perfect medical student would never want to leave early. Some of my classmates would just suck it up and wait around until getting permission to go home. The minority would leave without checking in with the resident. For me, it came down to expressing my enthusiasm, yet subtly reminding the resident that I was still around and had nothing to do. During my first year on the wards, I would usually say something like, “What else can I help you with?” It was an easy way to express enthusiasm while reminding the resident I had nothing to do. Worked every time.

Situation 2 – Scut work. Scut work is the kind of work that has to be done around the hospital that a well-trained monkey could do. Most residents are good about not giving medical students this type of work, since it’s bad form on their part. After all, students are paying to be there, and we’re supposed to be learning, not doing crap work. But sometimes, there is just too much going on, and there is nothing else for the students to do. So we bravely rise to the challenge of scut. But when we are asked to help with scut work, it is again important to come across as enthusiastic about the task, so as not to show our lack of interest. So, when the resident asks, “Hey (insert med student name here), could you run these x-rays down to the file room for me?”, the correct response is, “I’d be more than happy too.” Or, “Hey student, can you call this patient’s pharmacy and get his medication list?” “Sure, I’d love to do that.” Sometimes, the task calls for a slightly modified response. The resident may ask, “Hey student, can you go do a rectal exam on Mr. Jones in Room 12?” In this situation, the typical, “I’d be more than happy too” sounds a little creepy. The more moderate, “No problem, I’ll take care of it” usually suffices.

This all sounds a little silly, I know. After all, does it really matter exactly how you ask to leave, or respond to scut work? Well, in retrospect, it probably doesn’t matter much at all, so long as the resident knows you’re working hard. But as a student, you feel like you are constantly under the spotlight, and every move is being watched and noted. Even small things, like having a resident see you checking email during the day can make you feel as if you just lost a few points. For many students, this constant obsession with looking dedicated and seeking good evaluations is almost a pathologic disease. It is a very real phenomenon, and it seems to affect students across the board, although they often display the signs and symptoms differently. It’s almost a constant discomfort in one’s own skin. They promptly stand up to offer their seats to residents, they feel the constant compulsion to take notes when attendings are talking, and they nod in agreement with every comment. They apologize profusely if even a little late, they present patients for much too long and give too many details. It is this constant unease that distinguishes the medical students in every environment.

Maybe we hold ourselves to an unreasonable standard, which inevitably makes life that much harder on the wards. I eventually learned to relax, and just act like my normal self. It was this normal self that got along well with others. This normal self was the social achiever, and my grades reflected my ability to get along more than they did my academic prowess.

By the fourth year, students transform into more comfortable creatures, and our whole language changes. We no longer make residents read between the lines. The question changes from, “Is there anything else I can do,” to, “I’m gonna take off, unless there is something you need.” This change comes with time, and every medical student goes through some level of attitude change while on the wards. It’s exhausting to keep your guard up for two whole years. Eventually, you learn to relax a little, truly enjoy your time on the wards, and let the grades simply come as they may.

Chapter 13

Blood and Gore

I walked into the operating room, and found my way into a corner. For this surgery, I was to be only an observer. The operation was underway, and the patient’s abdomen had already been cut open. There was a small curtain that separated the lower half of the body from the upper, so I couldn’t see the patient’s face. There were large retractors that were hooked under the skin and pulled back, allowing for a better view of the inside of the body. The surgeon continued cutting, skillfully using a bovie (an object that looks like a pen that sends current through the tip, thereby burning shut the bleeding vessels it touches). The surgeons were all wearing full body protection, from the facemask all the way down to shoe covers. They were expecting this one to be messy.

A small incision was made deeper into the abdomen, which I couldn’t see. Fluid came gushing out, and spilled over the side of the body, along with blood and various particles of tissue. Had they made a mistake and hit the bladder or stomach? I couldn’t believe this patient was still alive. It seemed like she had already lost so much blood, and now something appeared to have exploded inside her. Just when I thought it couldn’t get any worse, two of the surgeons grabbed hold of something deep in the belly, and began pulling in opposite directions. They put their entire weight into it, leaning back while holding onto some part of the woman’s body. The tissue gave way, and the horrendous sounds of human tissue tearing could be heard above the din of the anesthesia machines. Surely this was the end for this patient. It seemed like they were killing her!

“Doing okay?” the doctor asked.

“I’m fine,” came a small voice from behind the curtain.

“Oh my god,” I thought to myself. “This patient is actually awake!”

The attending gave the nearby intern a nod, and the intern immediately fell forward onto the lower chest of the patient, bearing down with all her weight. This was no small intern either. This would surely be the final blow. And, as the intern bore down on this poor woman who continued to bleed profusely, the attending surgeon dug his entire hand into the open abdomen, felt around, and pulled out what appeared to be an alien life form covered in creamy goo and blood. The creature let out a piercing scream, announcing his arrival. The baby had been born.

I had no idea that a caesarian section would be so gruesome. I still can’t believe the human body can live through something that appears so traumatic. After making the initial small incision, the surgeons literally tear open the uterus. Amniotic fluid rushes out, which is the swimming pool that the fetus has called home for nine months. The pressure applied to the upper abdomen helps pop the fetus out of the uterus. All the while, the patient is usually awake throughout the procedure! Thanks to anesthesia, she feels no pain. They do hold up a drape to separate the patient’s head from the abdomen, so the mother (and father that may be present) cannot see the war zone. Good thing. The experience left me feeling truly fortunate to be a male, although I developed an undying respect for women and all they go through in life, including the miracle of childbirth.