Cardiac Examination

Did you know that when giving a cardiac exam, you are supposed to "First palpate for heaves, lifts, or thrills, using your fingerpads"? I didn't know this. But it does make me feel like my medical school band should be named: Heaves Lifts and the Thrills.

Bates' Guide to Physical Examination and History Taking. Tenth Edition. page 356.

The Effects of Stress on Blood Glucose

First test went poorly. How do I know this? I know this because my initial blood sugar prior to the onset of the test was 104 mg/dL. Five hours later, with only the consumption of a cookie with approximately 25g of carbohydrates, my blood sugar was 345 mg/dL. If my current corrective factors are 1 u insulin per 10 g carbohydrate and 1 u insulin for 25 mg/dL over a normal baseline of 125 mg/dL, my blood glucose was off by around 180 mg/dL. It was off because of stress. The stress was equivalent to 88 g of carbohydrates. 352 Calories. 5 shots of Tanqueray or a Quarter Pounder with cheese or two cups of Lucky Charms.

It went that bad.

Studying for Anatomy

Our first test is tomorrow.

I have a great sense of direction but I'm pretty terrible at solving spatial puzzles. For this reason, the following paragraph means nothing to me, although I'm pretty sure it's important:

The superior borders of the transversely elongated bodies of the cervical vertebrae are elevated posteriorly and especially laterally but are depressed anteriorly, resembling somewhat a sculpted seat. The inferior border of the body of the superiorly placed vertebra is reciprocally shaped. The adjacent cervical vertebrae articulate in a way that permits free flexion and extension and some lateral flexion but restricted rotation. The planar, nearly horizontal articular facets of the articular processes are also favorable for these movements. The elevated superolateral margin is the uncus of the body (uncinate process).
"Clincally Oriented Anatomy: Sixth Edition. Moore, Dalley, Agur. Lippincott Williams & Wilkins 2010; page 445."

The what now?

Subdural Hematoma

I think subdural hematoma was the first doctor phrase I learned. It has a nice rhythm to it. I think I was watching late night television with my parents, maybe a sister, when my dad got a call and then he conferenced with my mother about whether or not to go in. I don't know; apparently, most of your memories are completely constructed by the time your an adult.

Today I learned that the subdural space is a "potential" space that is not meant to be used. Except by hematomas. Which are bad and you don't want those.

Patient History

So last Friday, things got real. This is, of course, an overstatement, because as a first year medical student, the misnomer "real" simply implies that the activity is modeled after the "real" thing, "real" here being clinical rotation.

[A brief aside: There are a lot of extraneous words in medicine. To excel at most of these courses, you need to understand how the English language, and its romantic predecessor, work. You also need to know an astronomically huge number of words. During the briefing for anatomy we were told we'd learn 5,000-7,000 new terms just by cutting apart the human body--which I guarantee you is a finite object. Today I found myself looking up terms during our embryology lecture. I believe I have an intermediate grasp of vocabulary. But when I had to look up "occlude", I felt like an idiot. At least when I leave medical school, I won't feel embarrassed pursuing conversation with my peers, intellectuals who went on to pursue graduate studies in English, at cocktail parties: Oh yes, I feel like this 1999 Cabernet Sauvignon is occluding the citric taste of these gourmet Chipwiches. Closing aside: What is the exact definition of clinical rotation?]

The session I had on Friday was an introductory lesson on how to take down a complete patient history, including chief complaint. I was observed on a computer screen by my partner, taking brief notes, in another room. I was judged on several metrics, and I knew this as I sat across from someone and talked to them about their health. The whole thing was fake because the patient was standardized. There are actually professional patients. The pain they explain is not actually real. Their names and their lives are fictitious. But they are "technically" alive, and this is where it got tricky for me.

I love doctor-patient communication. I find communication fascinating. And it's important. Learning how to say the right thing is sometimes more important than knowing what the right thing is. I firmly believe I have a handle on the way doctors and patients should interact. I wrote a thesis on the topic, and I am convinced my final solution, crafted out on pages thirty-eight through forty-two, would work wonders for the field of primary care... if we lived in a theoretical world. Unfortunately, undergraduate institutions love idealizing things. Everything seems more "right" or "wrong", "effective" or "useless" when you're reading hundreds of papers and looking at statistics and analyzing everything from a safe distance.

Put me face to face with an actual human being, who is alive, and I no longer care that I am supposed to ask them about their lives or that I need to know the exact quality of their pain. I no longer know that perhaps the way I speak is too fast, too convoluted... nonsensical. I'm palpitating just thinking about it.

If the professional patient/actor had been a robot, with non-judgmental eyes, maybe I would have calmly proceeded to ask it a lot of seemingly irrelevant but pertinent questions. Maybe I would have done well. But I wanted to become a human doctor. Serves me right. I shook the entire time. I started sentences I was unsure how to finish. I never did get around to asking questions about family history. My notes are a jumbled mess.

I wonder in what situations meeting someone for the first time won't be nerve-racking. Will that time occur when I'm a full-fledged doctor and my status crushes fear? Or will it always be stressful trying to think with a first time patient why they feel as bad as they do.

My professional patient said I did a good job of sounding coherent and making eye contact, but I know that's not good enough. She said I needed to do a better job of setting up an agenda from the get go. I wonder what's the best way to do that?

So right now I am putting my theories on hold. The funny thing is, all this dread and apprehension was caused by a clinical setting that was highly controlled and entirely fake. The real world is waiting for me, not too far away. Real patients. Real problems. Real communication issues. Now that's terrifying. 

Clinical Medicine

I learned something today. This is very exciting. Up to this point, all material presented in lecture and in notes has been review or ignored by me.

Today I learned that "most fractures are identified by cortical interruption." Dr. Waxler informed the packed Rhoades auditorium of this today. He is a radiologist. I didn't think radiologist's would be funny. I was surprised. Good thing, too. Today was also the first day we had four straight hours of lecture.

Professionalism

I recently had a terrifying thought. I can no longer afford to be a "child." Sociologists have been talking about the prolonged period of childhood that young Americans are currently enjoying. Unfortunately for me, my mother, the perpetuating essence of childhood, works at the institution where I am attempting to become a "professional." Why should I worry about anything that may deal with being a professional when I can have my mom tell me what to do? What to wear? What to say? and whom to talk to?

This afternoon I had an exercise that thrust me into the position of mocking an actual doctor. A doctor. All my life, no matter how close I got to the field, I guess it never occurred to me that I'd ever actually become a physician. There was always a way out. A way to be less responsible. Jail time. Artistry. Hell, even suicide. But no. I am twenty-two years old and I am still alive. And I still want to help people discover health for themselves. I will talk more about my experience in the EEC lab, but for now I will just say, the entire practice slapped some sense into me. Dreadful sense.

I have an apartment now. I have a dishwasher. I still haven't put all my clothes, the few clothes I've brought with me, onto hangers. And as I laid in my living room, next to a basket holding my clothes, looking at a ceiling that belonged to me for the next two years, I realized I could no longer just put off "cleaning my room" for a later date, for the next Wednesday when my mother would walk in, arms akimbo, telling me that the cleaners were coming and if I wanted the crumbs and dirt vacuumed up off my floor, I better get at it.

The problem is, I don't know if I'm ready. I went back home tonight, to pick up some things... things to help me study. I have a giant Anatomy book now. The pictures are fantastic. And I have my dad's old chemistry set so I can build the twenty amino acid structures like so many lincoln logs or legos, stacked on top of each other. I am a child. I love learning. I always will. But am I ready to learn for the betterment of other people? Or am I still a selfish, small child?



I need to become a pediatrician. I need to work among my peers.

An Interesting Aside: I'm Diabetic

Today one of the lecturers for one of my classes decided to tell everyone an exciting "diabetes-related" finding. I no longer remember how it related to Embryology, but the point was something like this: EVEN DIABETICS WITH GOOD CONTROL OF THEIR SUGARS END UP SUFFERING THE COMPLICATIONS OF DIABETES IN THE LONG RUN. WHY? OH, WELL, BECAUSE THE INITIAL SPIKE IN BLOOD GLUCOSE CAUSES METHYLATION OF THE DNA WHICH LEADS TO COMPLICATIONS SUCH AS BLINDNESS, AMPUTATIONS, LOSS OF HEARING, LOWER QUALITY OF LIFE, ETCETERA. Why the hell did this professor feel like this was a necessary sidenote? I don't know. Maybe because he talks like someone raised firmly on the Mason-Dixon line and cutting to the point doesn't make a whole lot of FUCKING SENSE to those people. So yes. Elora Apantaku, the beautiful, kind of hilarious, kind of lovely ELORA APANTAKU, will be losing her long legs and her perceptive …






I started crying. No sense in continuing. Fuck.

America's Screwed

I am enrolled at Chicago Medical School. It's in glorious North Chicago which is twenty miles from the harrowing Wisconsin border. The first two years at CMS are spent embedded in the Rosalind Franklin University of Medicine and Science. But RFUMS is composed of four institutions besides CMS. Most famously, the Scholl College of Podiatric Medicine resides here, named after the man--the podiatrist and legend--who achieved commercial success with his shoe inserts.

During orientation last week, the dean for CMS stood in front of all the first years in all five programs and told us that this was an exciting time to be getting into medicine. Why? There's a shortage of doctors in America. I disagreed with his use of the word "exciting" when "important" seemed more accurate. But no matter how anyone chooses to describe the situation, it's still a problem. I've read about the issue extensively, and the number of doctors America will be missing in the next decade is startling. Even the most modest estimates claim that the American health system will be missing 91,000 doctors by 2025. As I sat in the middle of Rosalind Franklin University's largest auditorium, surrounded by one of the larger medical school classes in America--boasting almost two hundred students--it occurred to me: this country is screwed.

I tried to run the numbers through my head. There aren't thousands of medical schools in America. There are 159. If the average class size is fifty... that's about 3,000 new medical students per year. If they all practice for about forty years before retiring, then that's about 120,000... but then the population of America will probably keep increasing... and you have to figure that at least half of all physicians will specialize and then America's left with a dearth of primary care again so... Yea, America's screwed.

I don't know who decided to limit the number of medical students--yes, there's a cap on the number of students allowed into medical school each year. And I don't know who decided to make medical school so expensive--I put down $601 for text books this term, wait no... that only covered half of my course expenses. And I don't know why no one seems to be subsidizing primary care physicians even though American legislature has no problem subsidizing corn crops, a process that has negatively impacted the global food market, the obesity rates of Americans (who, as a result, will require even more physicians), and Iowa. But if I could meet the people who decided these arbitrary things, I'd punch them in the face.

I attempted to forget my bitter thoughts on this issue. The dean finished his talk; the entire auditorium erupted in curt applause that ended quickly. Then the dean of the podiatry college was introduced. She was funnier than our dean. But near the end of her time standing in front of anxious first years, she too echoed the first dean. Did you know? There's also a shortage of podiatrists in America.

So at least there's that.



Further Reading:

• The Decline of Primary Care

How Doctors Think

In anticipation for orientation, I've been reading How Doctors Think by Jerome Groopman, MD. It was interesting, and I was immediately compelled to finish the 200+ page book after he references and quotes Judith Hall and Debra Roter in the introduction. Hall and Roter are two researchers who have looked extensively at doctor-patient interaction and communication styles, and I referenced them a lot in my Rhetoric thesis that examined communication in health care. The book was eye opening in that it did a great job of informing the reader about which types of cognitive errors bias the way doctors treat their patients. Absolutely fascinating. I've always found that understanding logical fallacies allows you to deal with people and to make sense of complicated situations. To know that there are several logical fallacies that even well intentioned doctors make frequently is reason enough to write an entire book.


I have two concerns with Dr. Groopman, however. First, he seems to be praising all the doctors he talks about (with a few exceptions). I wonder if it would be more useful for people to know how bad doctors think more so than to understand how competent doctors deal with diagnoses, because sometimes you aren't given the liberty, although you should have it, to choose your clinician for yourself.

My second concern is more insidious and/or uppity. Paternalism. It's clear that Dr. Groopman is against it. He is quick to praise a few doctors who unbiasedly talk to their patients in order to make sure that their patients choose their treatment for themselves and aren't subjected to being helpless to control their own medical destiny. But Dr. Groopman has a severe pronoun problem. Even though he talks about two or three excellent female physicians, he always refers to doctors as hes. And I guess that wouldn't be unforgivable, because grammatically he can be used as a gender neutral pronoun, even though it no longer carries that meaning for most readers. No, what makes it unforgivable is that he often refers to hypothetical patients as shes. He even ends his book talking about this hypothetical patient, and how she is adding vigor to the clearly sexist clinic by being an expert communicator and able to understand her male physician's every thought.

Gross. When the movement began to minimize paternalism in the clinic beginning in the 1970s, paternalism was symbolized by the interactions women had with men in that time. Women don't make decisions. They let their husbands decide for them. Because men and doctors generally have an elevated standing in society compared to women and patients respectively, this visualization makes sense and should strengthen a progressive individual's will to end clinical paternalism at all costs.

Though the insight that Groopman has into clinical practice makes it easy to forgive him. Also, the fact that he's in his sixties or seventies and trained during a much more... sexist time, makes it a burden, but an acceptable one, to not get overly upset and just take value where there is some and ignore the rest.

Debra Roter and Judith Hall are two excellent female researchers. They have looked into the differences in communication styles between male and female physicians and are aware of the challenges facing women in health care. I wonder if they, after reading Groopman's book, noticed this slight rhetorical misdeed, or just conceded that there are some minor injustices you just have to accept.

The First Post

Orientation week begins in a few days, so it seems appropriate that I had my first clinical nightmare last night. This is not a metaphor. I actually had a nightmare that took place as I was making "rounds." Tellingly, one of the main characters in this dream was JD from Scrubs. So... that happened.

I begin as an M1 (somehow this translates to first year, but I have yet to know what it actually stands for) at Chicago Medical School (CMS) in less than two weeks. I'm fairly anxious. And I don't think watching Scrubs will help.