Working in a hospital with so many highly-educated patients that seem to know more about their diseases than we do, I think we probably run a greater risk of making assumptions about our patients’ education, intelligence, and vocabulary.

Many times I’ve noticed doctors, even when trying to explain things in “English” (as opposed to medical-ese), start using terms like “distal” and “proximal,” and patients start to get a look of confusion on their faces. I try my best to stick around and explain things better to the patient, but many times I don’t even think we realize we’re doing it. Even words like duodenum and common bile duct I would imagine could be very confusing. I assume that most patients have heard of the liver, the intestines, the stomach, and the pancreas, but don’t have a clue how they’re connected, where they are, or what they do. This has nothing to do with their intelligence or ability; they’ve just never felt the need or had the interest to learn. Many were probably never taught about them.

I’ve been thinking about carrying around some pictures of the abdomen to show them to patients and explain their problems and the surgical procedures to correct them. It’d probably go a long way to making them feel a little bit more in control of their care and their bodies.

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One of the things we’re taught in our ethics classes is that we, the medical staff, don’t get to decide what treatment a patient gets. The patient does. We can recommend until we’re blue in the face, and suggest as strongly as possible, but ultimately, it comes down to the patient’s choice. It shouldn’t be any other way, but sometimes it can frustrate both staff and patients, and patient care gets nowhere.

Before you get to this blue-in-the-face step, however, I’ve learned it’s important to make sure everyone’s on the same page, and everyone’s communicating on the same level. If a doctor understands a disease process differently from the way a patient does, each party may interpret the other’s actions, behaviors, or treatment suggestions as hostile, insulting, or punitive.

Take for example, Mr. Gouda . (Not his real name, but I’ve been craving cheese lately.) Mr. Gouda presented with all the classic–I mean, classic –signs of a small bowel obstruction. (A small bowel obstruction is when the small intestine gets blocked, either because it’s twisted, crimped, or squeezed from something outside of the intestinal tube. It’s usually caused by scar tissue from prior surgery or hernias.) He was throwing up, not pooping, not passing gas, and had lost his appetite.

The treatment for a small bowel obstruction is, for the first few days, watching and waiting (later it can be surgery). Give the patient some IV fluids to re-hydrate them (they’ve been throwing up and not eating), and also give the patient an NG tube–a tube that goes down your nose and into your stomach, which sucks out air and fluid that’s built up in the intestines. The only problem is this: having an NG tube placed is incredibly uncomfortable. Probably the most uncomfortable thing we do while people are fully conscious. We stick a tube up your nose, pass it down your esophagus as you gag, telling you to “Swallow, swallow” until it’s down in your stomach.

In the ER, they had tried to place Mr. G’s NG tube without any success. He hated it so much that he was willing to keep throwing up as opposed to having another tube placed. Please note that this was not normal vomit. This was feculent vomit. Translation: partially digested food, starting to look (and smell) more like poop than food. He was more willing to throw up poop than have the discomfort of another NG tube. That’s, uh, pretty severe in my book.

So we go down to talk to Mr. G, who absolutely refuses the NG tube. He says “Just put me out and do it!” We tell him that we can’t–if you’re unconscious and gagging, you can vomit and have it go into your lungs (this is called aspiration) and you get a really, really severe pneumonia and can die. Next, he asks us why we can’t just give him “some medicine to dissolve the blockage,” and I start to realize we’re not on the same page. This, my friends, is the key. That same visit, the team kept arguing with him, both sides got frustrated, and we gave up for the night.

Mr. G had thought, totally understandibly, that this “small bowel obstruction” was a blockage in his intestines. Something like a clogged drain. You pour down the Drano, dissolve the gunk, and voila, clean drain. There’s even a medical correlate: if you have a blocked heart blood vessel, you can insert some medicine inside the vessel to break up the clot.

My colleague and I went back to Mr. G the next day and explained that the blockage was external–like a kinked garden hose, or a clamp over a tube–and everything instantly changed. I get the feeling that he thought we wanted to do the NG tube just as punishment for being a “difficult” patient, but he finally understood that we couldn’t have him drink some substance–the obstruction was outside his intestines. Once he understood that, he was totally willing to try the NG tube. Our chief placed the tube, much easier than the ER resident, and two days later Mr. G was out of the hospital, with a referral from us for a primary care physician.

It’s always important to make sure everyone’s on the same page. We all have different definitions of words, especially in the medical field.

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Last week I started to have patient dreams. They normally fill some sort of supportive role–rarely are they the main characters–but they’re generally lacking their disease or IV poles. I’d like to interpret this as “seeing the patient as the person, not the diagnosis,” but I’m not totally convinced.

At first this kind of freaked me out: I was diving too far down the rabbit hole, or obsessing too much, but I’ve come to the realization that I generally have dreams involving the people I spend time with or think about. And since I spend a pretty sizeable amount of time at a patient’s bedside, talking to them, and then talking about them to my team, it’s no wonder they’ve invaded my dreams.

I’m also feeling really attached to my patients, and I wonder both if this will fade with time, and if they feel the same way. On my service a couple of patients were “mine;” I saw them each morning and afternoon, and reported about them to the rest of my team on rounds. I’d start to get to know them, their personalities, and little tidbits about their personal lives, and I looked forward to greeting them each morning, watching them progress from very serious surgeries to almost full recovery. When one patient in particular was discharged from the hospital on a day I was off, I was a little offended. “What, he didn’t even say goodbye?” I thought to myself, and then had to remember that I was probably not at the top of his list of importance; he’d been in the hospital 12 days and couldn’t wait to leave.

I guess it requires me to add another type of relationship to my list now: patients. You expect certain things from different types of relationships: brothers are different than parents are different than friends are different than co-workers are different than significant others are different from teachers. I guess I was still applying the “friend” mentality to my patients, and expecting them to say goodbye when they left.

The patient relationship is a fine line, and is sometimes two things at once. On one hand, you want to be objective: the scientific, square medical doctor that provides advice and data without emotion or attachment to get in the way of the best treatment. But if you remain in that camp, you miss out on the reason you became a doctor: because you truly care about people, want to help them, want to do what’s best for them. Just like you do for your loved ones.

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I get the feeling that surgeons like control (now now, don’t get testy; takes one to know one). “Management” sounds much better than “control,” so I guess that’s why they use the former, but I was really blown away by how much of surgery is patient, uh, management . And it’s my favorite part of the surgical rotation so far. I expected to just be in the operating room for 12 hours a day (sometimes it’s close to that), and wash my hands of patients once they’re stable in the recovery room, but the surgeon takes a patient from pre-op and diagnosis all the way to recovery and discharge from the hospital.

One of the neatest parts of surgery, says my attending (and I agree), is the fact that in surgery, you get to make a diagnosis, and then see if you were right. You see a patient acting a certain way, with a certain set of signs and symptoms, and you make an educated guess that their gall bladder is inflamed. So you open them up, go in, and see if your pre-operative diagnosis matches your post-op diagnosis.

The other great thing about surgery is that there’s really a limited number of things you’re really worried about. As opposed to internal medicine, where you’re trying to manage 20,000 chronic diseases with 30,000 medications to treat them, surgeons seem to care about, in order that I’m thinking of them: infection, farting, pooping, blood clots, fluids/dehyrdation, peeing, nutrition, vital signs, and walking around. If you’ve ever had an inpatient surgery, you have been asked these questions. Over, and over, and over, and over, and over again, by the medical student, the intern, the resident, the chief resident, the nurse, and the attending. We cheer if you pass wind, we applaud when you eat all of your meal, and we scold when you lay in bed all day.

This is not to say that a patient’s other medical problems are unimportant or ignored; many times a disease can affect something on the above list: diabetes can complicate nutrition, medications can complicate bowel movements, and so on. I think if surgeons had the time, they’d try to help manage a patient’s mental health status, or their heart disease, or their kidney failure, but sometimes the daylight’s wasting and there’s 10 other patients that require your management, too.

The cutting itself is pretty fun too-when you’re allowed to do anything. The medical student’s role is usually reserved for observing, being pimped (asked questions rapid-fire by a resident or attending), suctioning, retracting and, if you’re lucky, suturing incisions closed at the end. During the first week, you’re no help anyway: your sense of awe at the human body leads to an inevitable puddle of drool that collects at the bottom of your mask. I remember the first time I saw laparoscopic surgery (where they use a camera to look in the abdomen), and I was Simply. Blown. Away.

Next when I was invited to stick my hand in an open patient and feel a liver, a spasming colon, the aorta, and then the beating heart, it was almost too sci-fi to be real. This is a person. MY HAND IS INSIDE A PERSON! I’M INSIDE A PERSON AND THEIR HEART IS HITTING MY HAND! Does their heart have any idea this is going on? This whole surgery thing? That it has a HAND next to it?

And then the seriousness of it all comes down at you like an anvil from 100 feet above. The fragility of life is taken to a whole new level when something starts bleeding during your first surgery, even a little bit, and you think to yourself, “Holy shit. This guy could die. Right now. On this table.” It’s even stranger when you take care of the patient after their surgery, and you think to yourself, “My hand was inside you.”

I’m going to stop all this “hand inside you” crap now because I’m starting to feel a rectal exam joke coming on.

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And so our fateful hero returns (that’s me, if you were unaware), after an exhaustion-induced hiatus, secondary to starting clerkships. Specifically, the surgical clerkship. I’ll start with my thoughts about clerkships in general, and then maybe dive into the life of a surgeon (or surgical clinical student).

Quick background: medical students do two years of classroom work (known as pre-clinical), then take a really freaking hard 8-hour test (known as “The Boards” or “Step One”). Then we spend our next two years working in the hospital in different specialties, seeing which ones we like, which we don’t, and trying to get exposure to that which is actually medicine.

So it’s the Sunday night before I’m about to begin, and I’m just nervous as hell. I know that the next day is going to be only orientation, with no actual patient interaction or anything, but my eager/anxious pit in my stomach has been swelling all night. Monday is very orientation-ish, with nothing too boring, and nothing too exciting. We talk about expectations, learn how to scrub into surgery, how to get into sterile gowns, get a basic idea of how clerkships and clinics work, have a couple lectures on surgery, and a workshop on suturing and tying knots. More on that whole business later. I iron all my shirts, have the better half show me which ties go with which shirts, and try to go to bed early.

Tuesday is the first official day. I’ve reviewed how to talk to a patient (called “taking a history”) and examining a patient (called “examining a patient”). I’ve read suggestions from classmates and previous students, and I’ve excitedly received my first page to learn what time to report to my team. Tuesday arrives, I wake up early (“early” still means about 6am, ha!), shower, get dressed, and drive over to my hospital where I’ll spend the next month.

I meet my team, which consists of a chief resident, two interns, and myself. Lots of personal attention, but lots of responsibility. I’m starting to already realize everything in medicine (and life?) is a trade-off. More attention, more responsibility. Give a drug for this problem, it causes that one. Perform this procedure for a disease with risk amount X, and hope that it’s less than the new risks you’ve made from the surgery.

You’re really, I mean really , just thrown in there. You finish second year taking your boards, and you think you’ve got medicine down pat. You know what every drug does and what it treats, you know how every disease process works. And then you get into clinics, and you’re immediately humbled. You know nothing. There are new acronyms, strange new drug names, new locations, new computer systems, and new people. But to everyone else, it’s totally normal. You’re already playing catch-up.

You don’t want to seem like an idiot, but you’re also excited and inquizative. But you don’t want to be annoying, either. Your team isn’t just your team, it’s also people that are evaluating you, and trying to feel you out to see what kind of a team member you’re going to be. So you ask questions about things you’ve never ever heard of, and take notes to try to look up the rest later. You learn to mutter questions quietly and secretly to nurses and your interns, who will probably help you out (and aren’t really evaluating you as critically): they just finished medical school 3 weeks ago, so it’s easiest for them to remember where you’re at.

I quickly realized that real medicine is very different from ideal medicine. You’re supposed to give everyone a full check-up, look in their eyes, ears, and nose, and feel for their thyroid, but who has time for that? And different specialties want different things. Surgeons are obsessed with infections, fluids, nutrition, pooping, and farting. The obsession with the latter two is still novel to me. A patient told me he had a “tremendous fart,” and I was disappointed when no one else on my team even smirked at the description.

Feeling stupid makes you learn quickly, which is one reason I’m usually not too distraught when I get an answer wrong: I know it’ll be locked into my head from that point on. At the same time, “don’t get sick in July” is just way too true. Your doctors won’t be as quick to get a diagnosis, and your sutures won’t be as straight. Everyone’s supervised by multiple people, but July is usually especially hectic. You get a flood of new medical students, newly-graduated doctors, new residents, and new official attendings. Everyone’s trying to figure everything out, and it can be difficult.

The feeling has faded now, but I was so surprised at how very entitled I felt after my first week in the hospital. I was working 12-14 hour days, 80-90% on my feet, and I really felt like I should be getting some sort of special treatment because of it. That I should be rewarded or recognized for it. I wanted to go to the mall in my scrubs with my operating room hat hair so everyone would see that I’m a hard-working medical student. It was cognitivie dissonance at its finest: I’m paying $50k a year to work my ass off, so I figure there must be something I’m getting out of it right now. It was such a strong feeling that it really took some conscious effort to remind myself that I chose this path (and thank you, blog, for reminding me).

I’m incredibly exhausted, but incredibly happy. I’ve really started to get the hang of this whole clerkships thing (so far, at least), and it’s been a really amazing experience to see many of our patients go from the ICU to the wards to being discharged. I’m going to miss seeing them so frequently. And to you, the patient that we lost two weeks ago, and to your family, who allowed me to be part of the discussion about you: you’re one I will never forget. Thank you for your friendly smiles and waves each morning, and for trusting me into a most private part of your life. That physicians have the privelege and honor to be part of patients’ lives is a most amazing and sacred part of the practice.

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This was the line I heard yesterday over the intercom 30 minutes into my flight from Minneapolis to New York, and it scared the crap out of me. I’m always freaked out that I’m going to be in a situation where I will have the most medical knowledge of anyone around, and I’ll have to use it. Luckily there were like 4 doctors on the plane; an elderly woman passed out at the back of the plane, I think from dehydration and heat (the plane was sitting on the runway for awhile, really stuffy). She was laying down in the aisle by the bathrooms.

When they made the announcement, I got this look of sheer terror on my face, hoping desperately there’d be someone else. And then my imagination started to run with it:

Me: Well, I’ve had two years of med school, but I’ve never actually treated anyone!
Flight Attendant: You’ve got to be kiddding! How can you be halfway done with medical school and you’ve never taken care of anyone?
Me: I don’t know, that’s how it works, you do your first two years preclinical, and then you take boards, and then…
FA: Okay, shut up already and help this lady!
Me: Okay, uh, get her some oxygen, and uh, water! And… stuff.
FA: We’re screwed.

The lady was sitting up and fine by the end of the flight; I hope she’s okay.

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Why isn’t “Health Care for All” sexy?

We’ve got hundreds of thousands of people wearing those Lance Armstrong armbands , and tens of thousands I’m sure wearing those knock-offs, and I started wondering, “Why isn’t there one for the uninsured?”

If people can get behind supporting cancer victims, or donating money to Jerry’s kids, or walking for breast cancer, or basket-weaving to fight Prader-Willi’s, why not the uninsured? And where’s the celebrity spokesman? I started to think that it must just be that celebrities have insurance, and therefore don’t have any experience with being uninsured, but that’s completely untrue; almost all of them started out uninsured trying to make it big in LA or New York, I bet. Have they forgotten so quickly?

If people can so easily get behind some awful disease with no cure in sight (HIV, any number of rare genetic disorders, most cancers), why isn’t there more support for something that most other industrialized countries *have* been able to cure? (I’m using ‘cure’ liberally here, don’t get in a commenting tizzy.)

Is it that people think the uninsured don’t deserve insurance, or that it’s their fault they don’t have it? (There’s plenty of people that way about HIV, but it’s still supported.)

Or is it maybe that it’s easier to support something that we don’t entirely understand and know how to fix? That it’s something still beyond our grasp, beyond our means, that is dropped on unlucky individuals? There’s plenty of diseases out there that *are* 100% preventable; why aren’t we knocking those down quickly? (I’m thinking lead poisoning as an example.)

Maybe it’s that those diseases primarily affect the disenfranchised, impoverished, and the minorities? You don’t see a whole lot of funding out there for sarcoidosis, primarily affecting black people, or liver cancer, which is huge in Asia because of hepatitis.

So line right up celebrities and PR firms. Let’s make pre-existing conditions and 18,000 deaths a year the sexiest thing since testicular cancer.

On a side note: studying for the boards brings an insanely huge number of interesting ideas into one’s mind. My head is like an 8 year-old desperately trying to stall from having to go to bed. Boards studying is right up there with showering as far as number and quality of ideas go. I’m starting to think the great inventors and thinkers of all-time either a) took a lot of showers or b) studied for Step One for their entire lives.

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I have seen the future of medical school training, and it is extremely cool . And extremely expensive.

We went to the Palo Alto VA Hospital’s patient simulator today, and met our patients: two almost-creepily real medical mannequins (one cost $180,000, the other, about a quarter of that). As our professor said, “they can do just about everything but live.” The experience was to give us exposure to how to manage an acutely ill patient, and it was one of the coolest experiences in medical school. The mannequins have pulses (femoral, radial, and carotid), heart beats, breath sounds, and bowel sounds. They breathe in and out (and their chests rise), they can get IVs, chest tubes, cardioversion shocking with paddles, central lines, foley catheters, and just about anything else you can think of. They even have oxygen sensors in their noses: if you give them O ₂ , their saturation increases. And their pupils dilate and constrict. They even talk. (Well, okay, they talk through a speaker in their mouths, and the voice is from the control room person running the simulation, but it’s still a little eerie.)

We had several different scenarios, the first with the preceptor to just get acquainted to the simulator system: how to give IVs, how to call the code team (you actually dial a number on a real phone, and it links back to the control room), how to get monitors started (ask for them outloud and they magically appear on the monitor screen), and how to ask God things. Unfortunately, the mannequins don’t sweat or react fully just yet , so you sometimes have to say things like, “God, does Mr. Ford have full intact sensation in his face?” (To which God replies from a speaker in the ceiling, “Yes he does.”) The control room can also change any parameters they want on the mannequin in real-time: if you give the patient epinephrine, his heart rate will go up along with his blood pressure. If you shock a patient, they can put the patient back in normal sinus rhythm.

We split into two groups, and I got to watch the first group from a monitoring room next door. We all flipped out when our classmates kept missing some key information, and the patient eventually crashed for quite awhile (luckily God performed a miracle). But we knew it was much easier to watch than to actually perform. When it was our turn, I was a little eager but nervous.

We had a couple ideas initially from the patient’s history and basic presentation, so we started testing hypotheses. The patient kept getting worse, and his oxygen levels kept dropping, so we started to bag him (put a mask on him and force oxygen into his lungs), and then we decided we needed to intubate. As intubating has become my latest procedure of enjoyment (intubating is feeding a tube into a person’s airway while pushing down on their tongue to get the airway and vocal cords into view), I grabbed the laryngoscope and prepared to try it. This was the coolest part: the patient was technically still conscious, so the preceptor told us he was fighting us, and it was making it hard to intubate him. It truly was: when I first tried to stick the scope in his mouth, it seemed 100 times harder than it had ever been on any of the other mannequins-his tongue was totally in the way. We decided to sedate the patient, and magically, when I opened his mouth again, the tongue was down and out of the way. I wish my classmates could have seen it; it was the coolest surprise to me.

A really great experience, and further pushed me toward Emergency Medicine (or maybe anesthesia?); apparently there was an anesthesia resident watching us who commented that I’d make a good colleague.

These simulators are only going to get better, cheaper, and smarter, and I can totally see them entering the medical school curricula in the next 10 years (Stanford’s new med school building will have a simulator room all of its own, and has recently named a new Associate Dean for Medical Simulation ) – the same Dr. Gaba who runs the VA simulator. The simulators mean less experimenting on patients, and more practice before the real thing, which will hopefully lead to better outcomes and fewer medical mistakes, especially for newbies like myself.

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I’ve managed to completely forget that medicine is about people.

I came to realize this over the past couple weeks, especially at a ceremony to remember those that donated their bodies for the anatomy course. The first-years were reading poems, talking about their experiences in anatomy, and I found it all very drab and boring. And then I realized that I was finding it drab and boring, and realized that these were people. Mothers, fathers, brothers, sisters. Friends, co-workers.

And about a month ago, while we were studying analgesics (pain relievers), our pharmacology professor reminded us that one of our roles as physicians was to relieve human suffering. “Suffering?” I thought. “Oh. Yeah. These diseases cause suffering . I almost forgot.”

In medical school you want so bad to learn that you dive right in, without looking where you’re going. At first, you get confused by terms like “dyspnea” and “syncope.” You learn the language. Then you go deeper. You learn the organs, the body, and how it can go wrong. You learn about infections, and pathology, and disease. You learn buzzwords, associate diseases with stereotypes, all in hopes that when someone says “night sweats, weight loss, and hemoptysis,” you can be the first one to shout out “tuberculosis!” and ramble off the drugs of choice and their side effects.

And while you’re in the library memorizing diseases associated with symptoms or organs, or at a cafe going over tropical infections and how you get them, you gather this big list of words in your head. You try to organize these words and tuck them away, so you can recall them later. All the while, you haven’t seen a single patient with this disease, or that infection. You know how to describe a certain type of rash, or how it’s supposed to look, based on a Google Image search , but you’ve never seen one in person.

I completely understand how physicians can view patients as only their diseases; there’s enough to know about any one disease that it’s just less mind-exhausting to try to reduce someone down to a few lines or bullet points. But then you think about someone you know with a disease, and it sickens you that anyone would ever reduce them down to a list of symptoms or a pathophysiology. They’re too good for that, they’re too three-dimensional. Too funny when they’re drunk, or too insanely brilliant, or even too annoying to just be a disease.

We had a written clinical case today that discussed a woman with “multiple spontaneous abortions,” and I instantly thought, “ antiphospholipid antibodies! ” and figured I was done with the case. I successfully matched the buzzword to the disease.

But then I read the words again: a woman with multiple spontaneous abortions . How absolutely dreadful, emotionally awful, and mentally scarring.

I’m at a stage in my medical training where my goal is just to get the diagnosis right, but that’s nowhere near my goal as a doctor. If you don’t see the patient as a person, we might as well just replace physicians with computer programs-they can probably make diagnoses faster than doctors. Click here for your diagnosis.

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It was a dark and stormy night.

So I’m walking to Borders with fellow anatomy TA Ronnie, we’re just leaving the parking garage, and an elderly woman carrying an umbrella mis-steps and crashes to the ground. She doesn’t even get a chance to FOOSH it (fall on out-stretched hand). It’s like it’s out of a bad medical student training video or something. She kind of lands on her side, or so I think, and we hustle over to see if she’s okay; I instantly think broken hip.

She’s partially picked herself up, and she’s about to stand up, and I notice a little blood on her hand. I say, “Oh, you know what, you’re bleeding a bit, just sit down, let me grab some Kleenex from my car.” That is, until I see that the blood isn’t coming from her hand. Oh no, that blood is just some of the fresh red that’s gushing from her left temple. My eyes kind of do a zoom-out / once-over look at her, and there’s blood all over her coat, down her shirt, on the ground. I give my phone to Ronnie and tell him to call the paramedics, and run into California Pizza Kitchen to get some napkins or something.

My heart’s pumping. I grab the napkins, come back out, and she’s pressing some tissues onto her head, and the bleeding’s pretty much stopped. We wait for the paramedics, and I joke with her that she lucked out, falling right in front of two medical students. She rips back with “First-years or second-years?” and I get the feeling that she’s still with it. This Is Good. The paramedics arrive, check her neck and examine the laceration on her head, and the hematoma (big blood clot/bump under the skin) is bigger than a golf ball. I couldn’t believe how quickly the thing grew.

We eventually go off on our way; it feels kind of weird to just leave, but she’s in better hands with the paramedics anyway (let’s just be honest here). Ronnie and I start discussing all the possible complications-I’m focused on the hip, then he starts wondering about an epidural versus subdural hematoma. I just couldn’t help but think about how thin and delicate elderly people’s skin is, and how easily it can tear and rupture.

It was an exciting moment, and I of course use it as Clear Evidence from God Almighty that I should go into Emergency Medicine (my latest specialty of the month). Then again, after almost 2 years of medical training, I don’t know that my knowledge really helped me all that much; “apply pressure to wound” is kind of common sense by the time you get your second nosebleed in life.

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