Archive for the ‘The Medical Student Experience’ Category

Daisy Duck Moments

Thursday, August 25th, 2011

As is the case with life, we as humans occasionally do something so phenomenally thick-skulled that it defies all previously-held notions of the limits of human stupidity.  What is even worse, we are sometimes even convinced that we’re doing something really smart, even as the ship slowly sinks.  I now refer to these moments (thank God they’re few in number) as ‘daisy duck’ moments.  There’s a good reason for that, as I’m about to explain. The original ‘daisy duck’ moment happened a few months ago, not long after I arrived at St. Mary’s.  I was so embarrassed after it happened that I couldn’t bring myself to share it in a blog, although after months of hearty laughs and good-natured badgering from Dr. B, one of my preceptors, I have decided to face the music.

On the aforementioned day, I was preparing for an afternoon of office visits by scanning through the list of upcoming patients and getting to know their medical histories and chief concerns.  Near the end of the schedule I came across the chart for ‘Duck, Daisy’, a patient tucked into the 4:30-5:00 PM slot. ‘Hmm… Odd name,’ I thought as I opened her chart.  ‘Daisy Duck… don’t hear that one often.’

Well, apparently you do if ever watched cartoons on the Disney Channel, or have ever been to Disney World, or have not been living beneath a rock for the past, oh, 60 years or so.  It is fair to say that, in my defense, we did not have television growing up AND I was raised in a town of about 50 residents in the woods of Maine, so it wasn’t entirely my fault.  Still, I should have recognized the first red flag warning me that a moment of great stupidity were about to transpire.

I started to browse through Ms. Duck’s chart, which had a long list of medications, a number of notes from prior office visits, some med requests, and some phone notes.  ‘Hmm…I see she has had a cholecystectomy, an aortic aneurysm, a lump in her breast, some anxiety, Type I diabetes (ugh- bad string of luck, Ms. Duck!)   Yep, got some high cholesterol and afib in the picture too, past screening for prostate cancer… wait a minute. What’s THIS?! They screened her for prostate cancer? But… women don’t even HAVE a prostate gland!’ I couldn’t believe my eyes.  Right there on the screen was glaring evidence of gross medical error- a female patient had been screened for prostate cancer!  What was even more amazing was that such an obvious error had not only been missed from the outset but had actually made it all the way into the patient’s chart. How could this happen? My God, at least they didn’t try to give her a TURP!

When Dr. B walked into the office from his lunch break, I was nearly coming off my seat waiting to point out this glaring error that everyone had missed but that I, the lowly medical student, by dutifully reading the charts of all the patients before their visits, had picked up.  I excitedly recounted my findings, observing that it was really an amazing thing that nobody had noticed this yet (it’s awful that she has experienced so many medical problems too!) and what would be the best way to proceed? Should we apologize to the patient for drawing an unnecessary blood test? How could such a thing every make it past all of the doctors, nursing staff, and lab technicians (you’d think SOMEBODY would have picked it up)? What sort of system could be put into place to ensure that such a thing did not happen in the future?

Looking very concerned, Dr. B asked me who the patient was. ‘Ms. Duck. Daisy Duck.’ I excitedly blurted out. ‘Odd name, I know.’ There was a moment of shocked silence as he weighed the ramifications of this great mistake. Then, to my great surprise Dr. B did not pull up her chart, brows furrowed as he scanned back through her labs and past visits to figure out where the system tell apart.  Rather, he laughed until he almost cried.

In the mirthful aftermath (his mirth, my aftermath), I found out that ‘Daisy Duck’ is a dummy chart used to help new office staff learn the electronic medical record system by adding medications, uploading new diagnoses, and creating complete notes for the record.  In addition to being the ‘practice chart’, Ms. Duck is also used as a space-filler in the schedule when appointment slots remain open.  In retrospect, I picked up on a few small things that might have tipped me off:

1)      Daisy is referred to as a ‘she’ in the chart but is listed as a 42 year old male- apparently they got her sex wrong too.

2)      She gave consent for her providers to speak with Daffy Duck in case of emergencies.

3)      Half of the notes are empty.

4)      Daisy quit after smoking 2 packs per day since the age of 12- but her quit date is April, 2012.

5)      Elsewhere under ‘Medical Problems’ is listed, ‘DEAF AS A DOORKNOB.’ (That should have been a giveaway).

Alas, what might have been a shining moment in my budding medical career turned into, well, a ‘Daisy Duck’ moment.  It may have not been the stupidest moment in human history but man, it sure felt like it.  After a long and hearty laugh that lasted for a few days and returned every time Daisy popped back up in the schedule, Dr. B suggested that maybe this would make a good blog story.  For obvious reasons, I would have been content to let this one fade away but Dr. B was persistent.

It would be easy to end this by quoting some moral drivel about ‘the folly of pride’ or ‘losing the forest for the trees.’  Really though, I don’t think we need to dwell on it.  Let’s say we’ll all just forget about this one?

(This blog is dedicated to Dr. B.)

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Continuity of Care — The LIC Model in Action

Monday, August 1st, 2011

David Skavdahl. Medical Student

St. Mary’s is one of the 5 health systems in Maine which is taking part in the Longitudinal Integrated Curriculum (LIC) being pioneered by Maine Medical Center and Tufts University. The LIC is an alternative method of clinical learning during the 3rd year of medical school which encompasses the 6 major disciplines of medicine at the same time. In contrast to the LIC model is the traditional “block” structure which divides the disciplines into blocks throughout the 3rd year. In this model, a student stays on family medicine service or surgery service for an 8-10 week block of time. In the LIC model, we have exposure to each discipline every week for a 9 month period. The two major goals of this model are to develop a continuity of patient care which allows the medical student to see the disease process and give the patient continuity in their care. 

Over the past two months I have been able to see these goals put into action. The first example is of a woman who was diagnosed with breast cancer about the same time Bob and I arrived at St. Mary’s. She was a patient with my internal medicine preceptor and was subsequently referred to the surgeon who is also my preceptor. In this case I was able to follow her medical visits as well as assist in her surgery. Following surgery I participated in her necessary oncology care. Currently, I will participate in her medical visits until I leave in January. This all encompassing perspective allows me to see everything involved in the care of the patient and gives the patient someone who can be an advocate for his or her care. 

The 2nd example is a woman who I followed in the OB clinic. I participated in her prenatal care and was able to go to Maine Medical Center (MMC) with her for further testing and evaluation of the pregnancy. When she was evaluated at MMC, the OBs wanted to admit her and proceed with her planned C-section at MMC. It was disappointing that she could not deliver at St. Mary’s, but I was able to scrub into the C-section and participate in the delivery of her adorable twins at MMC. It was a wonderful experience as I was the only person the patient was familiar with. I was able to tell the OBs information about the patient that would have been difficult to obtain without a thorough chart review. 

I share these examples because they set the LIC model apart from the block model in a significant way. I would not have been able to participate in the full care of either of these patients if I was in the block structure. The LIC model gives us the flexibility to do this and I believe both the patient and the learner are better for it. We’ll see in 9 months, but judging from the first 3 I think it is going exceptionally well. I commend St Mary’s for taking part in such an innovative program.

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Tell Me a Story, Bob!

Monday, July 25th, 2011

Robert Bruce, Medical Student

Lots of people ask me what it’s like to be a medical student working in the hospital. I tell them it’s like being a monk, only without the time for sleeping. ‘No, no! Tell me about the cool stuff you get to do!’ Med students get this question a lot and now, after a few years in the biz, something has finally dawned on me… that question is really codespeak for ‘Tell me stuff I want to hear about!’ What I think is really cool and what my non-medical friends and family think is really cool doesn’t always match up.

For example, everybody wants stories about babies. As a medical student, you cannot tell enough baby stories. I’m beginning to think that I should always keep a stable of birthing anecdotes handy just in case someone asks, ‘So Bob, tell me about medical school!’ at a dinner party. There are even certain people to whom I’ll only tell baby stories- did the baby have hair, was the child a boy or a girl, was he/she cute, etc. Everybody goos and gahs and makes happy squealing noises and then conversation shifts to the Red Sox. Don’t get me wrong- there are few thrills greater than bringing a new life into the world, but that’s only a part of what we do.

The problem lies in the fact that what medical students think is really cool and the experiences that become the highlight of our month/week/year are often a bit ‘too real’ for people to hear about. Part of that is related to the process of desensitization- things that used to really flip my stomach often don’t have that effect any more. Vomit is still gross but now instead of grabbing my nose and fixating on how bad it smells, I’m grabbing my nose and leaning closer to see if it’s bilious, feculent, frankly bloody, or perhaps a sample of ‘coffee-ground’ emesis. When you know what you’re looking for and what it means it’s all fascinating stuff. For some strange reason, only my medical school friends get excited about vomit. Nobody else seems interested…

A great part of that perception gap between the medical and non-medical world is that your view of things changes when you begin to have a deeper academic understanding of what you’re seeing. For example, one thing I rarely speak about outside of my medical friends that probably had the greatest impact on my medical school career was dissecting cadavers during our Gross Anatomy course. It’s generally considered an uncomfortable topic for understandable reasons- dissection is a very personal confrontation with death. It was uncomfortable at first; however, in no time at all, the cold limb on the table became so much more than a picture of death with all of its morbid and fantastical emotional baggage in tow- it became a window into the intricate workings of the human body: skin over fat over fascia over muscle, nerve, tendon, lymph, ligament, vessel, and bone. It’s difficult to state the impact that had on me. I remain in awe of the gift of knowledge that was given to me by Miriam, the woman who gave her body after death so that a medical student she never met could pore over her anatomy like a textbook. It was the greatest learning experience of my life, so much so that I intend to donate my body when I die. THAT is cool stuff I get to do in medical school. That is also something I NEVER bring up at dinner parties.

On a lighter note, I forgot about the perception gap at a friend’s family gathering the other day when someone asked me what exciting things I had seen lately. I excitedly recounted how, for the first time in my life, I had reached into a patient’s chest and touched his beating heart. It was during an operation to remove part of a patient’s lung and, as I gently retract part of the upper lobe of the lung for the surgeon, my gloved hand came to rest against the very pump that delivers life to the body. That gooey, pulsating chunk of muscle along the back of my hand was the living, beating core of the patient. Not only that, but I was feeling and touching a part of the patient that he had never seen!

I thought that was the coolest thing in the world, but two girls who were present decided it was cool enough to make them not want to finish lunch. As my friend gave me the withering stink-eye from across the table, I countered with a quick baby story and beat a hasty retreat toward the fruit plate.

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Medical Issues and Social Concerns are Intertwined

Wednesday, June 29th, 2011

David Skavdahl. Medical Student

I have been paying attention to some of the recent events around the L-A area and have been deeply saddened by what has occurred over the past few weeks. Between murder-suicides and murder robberies one becomes starkly aware of the human condition. While it is fairly obvious to most health care professionals in Maine that domestic violence is one of the state’s not- so-secret dirty secrets, when these events occur they make most of us shudder. Fortunately, violent crime in rural Maine is not so great that we have become numb to it. A friend of mine works at two of the county hospitals in Brooklyn known notoriously for the amount of violent crime they see. Over time, health care workers begin to become numb to the violence as the violence is seen as part of the culture. Patients are not treated as human beings, but as objects. Then cynicism begins to set it: “Why should I fix this person’s stab wound when I know that they are going to get out of the hospital and attempt to take revenge on the person who stabbed them.” In this type of environment, where brawls will erupt in the ED and patients have been gunned down on a gurney as they were being wheeled into the hospital – it can be difficult to retain hope. Honestly, is an excellent vascular surgeon going to fix the root cause of the problem?

In rural Maine our violence is more subtle. It goes unheard and unspoken for much of the time. I believe this is why we have to be even more on guard – domestic violence impacts our patients more than we understand and it certainly impacts the relationships we have with our patients. Often this gets lost when we are taking care of patients. Recently I was helping take care of a patient who was refusing treatment. Initially, I was very frustrated because she was pregnant and her choices were affecting the health of her baby. She outright stated that she did not trust doctors (I was pretty sure this meant medical students were certainly not to be trusted). Eventually I was able to spend some time with the patient and she admitted to me that she had been abused and was extremely fearful of situations where she was not in control. I began to understand the patient’s perspective and had to examine myself for my own shortcomings of initially ignoring her anxiety. It is true that this patient had some serious problems, but that is no excuse for me to become frustrated and ignore these issues.

Currently, Maine is in poor economic condition. Our current unemployment rate is 7.7%. People are stressed out. The past 3 years of financial recession have taken their toll and problems of domestic violence are only exacerbated by these conditions. As health care professionals it is our duty to not only be aware of domestic violence, but to listen to our patients and make sure they know they have resources for help. Listening to our patients’ stories gives them a voice, and it reassures them that they are human beings. I am not so naïve to believe this will change the course of domestic violence in Maine, but I do know that it means a great deal to our patients. Fostering a culture that cares deeply about patients’ social needs is actively resisting the culture of cynicism that will set in if we are apathetic. This is not easy to do, it takes effort and it will exhaust you physically and emotionally, but it is the right thing to do. I will be the first to admit, that I am often lazy and will focus my attention on the medical problems of the patient and ignore their social concerns. Unfortunately, these two problems are closely intertwined and if I fail to address the social concerns I know that there is a much lower likelihood of successful medical treatment.

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Excitement or Challenges

Thursday, June 9th, 2011

David Skavdahl. Medical Student

Bob Bruce and I are now running headlong into week 5 of the program, but it feels like we have only been here since yesterday. Each day is met with some new excitement or challenge that keeps me, ahem, alert and oriented x 3. For me it is truly an exciting time of learning how medicine works, how to care for patients, and how to think through patients’ concerns in order to best serve their needs. Each night I leave the hospital, I consider it a deep joy to be given the privilege of participating in the care of patients at St. Mary’s. Whether it is the excitement of new life entering the world, or the grief and solemnity of life exiting this world, as medical students we are given the great privilege of witnessing, and even participating in these events. I must constantly ask for the humility to never take this privilege lightly. There are a couple of patient encounters this past week that made this clear.

Over the weekend, I was on the hospitalist service and we were evaluating a patient in the ICU. The team was doing everything possible to keep her condition from deteriorating however, her prognosis was poor. We made sure to find her husband and deliver this news. We then had the husband visit his wife in the ICU. He walked up to her bed, spoke her name and simply said “I love you.” It took three words and suddenly my perspective turned 180 degrees. I couldn’t help but think, what if that was my wife on her potential deathbed? What would I be doing or thinking? Medicine seemed so powerless in the face of death. I think the husband knew this and so he said what no one else could say. I can only imagine that behind those three words was a lifetime of service, sacrifice, forgiveness, repentance and caring that can only be understood by two people who have lived the majority of their lives together.

Earlier in the week, I was doing the history and physical exam on a patient who had been admitted. During the exam I noticed that she was incredibly anxious about an upcoming diagnostic test. After I finished the exam I asked her if she wanted someone to pray with her about her anxiety. Her eyes lit up and she grabbed my hand and asked me to pray for her. Of course, I was thinking a chaplain or priest was a much more appropriate person for the job, but told her that I would gladly pray for her. This was humbling to me – that a patient was willing to have 3rd year medical student pray with them, rather than consult the priest or chaplain. This patient barely knew me, I had only just taken her history and physical exam, and yet she trusted me to pray with her. I was able to observe her test later in the morning and she proceeded through the procedure quite well. The Holy Spirit, plus a little bit of Xanax, works every time.

It is these very human moments of medicine that often confuse me more than the pathophysiology of disease (though this still really confuses me). It is the interaction with patients that is the true joy and often, true challenge of medicine. Ultimately, I believe none of us would be in the health field if we did not find joy in this interaction. I know for myself that I can show up each day with excitement because there are patients who need to be served and through this service, patients teach me not only about medicine, but also what it means to be human.

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Life and Death

Friday, June 3rd, 2011

Robert Bruce, Medical Student

Life has been ROARING along since my last blog. Hard to believe I have only been here for 3 full weeks- feels like a year (that’s in a good way, mind you..). Dave and I have been averaging about 80 hours per week. That sounds like a lot, and we do get tired, but it’s funny how quickly our eyelids snap open when a new patient walks in the door. I’d need a short novel to tell you about everything I have seen and done. Instead, I’d like to share a few experiences that have been real eye openers.

For starters, I DELIVERED MY FIRST BABY LAST WEEKEND! Just to clarify, it wasn’t MY baby- it was a patient’s baby (I made a similar announcement on my Facebook page and had a lot of hearty congratulations from old friends who also wanted to know when I decided to get married and start having kids). While I have already observed numerous C sections and vaginal births with OB/GYNs at Women’s Health Associates, this was just the first time I was “in the driver’s seat” when a new life came into the world. It was both an exhilarating and a very humbling experience. The labor was progressing well and we knew the mom was only a few pushes away when the Doctor stepped back and motioned for me to take over. I wish I could tell you in a calm and confident tone how I monitored the progression of the labor while keeping a sharp and knowing eye on the fetal heart rate and tocometer tracings…. in reality, the sole thought running through my head was, “Just don’t drop the baby!” What can I say? It was my first delivery, I was terrified, and newborns are kinda slippery.

Happily, I did not drop the baby. The birth went off without a hitch (under the watchful eye of the doctor!) and mom and her new peanut have since left St. Mary’s happy and healthy. Baby delivery #1 will remain a happy highlight for the rest of my life.

There have been some less-than-happy but equally powerful moments in the past few weeks. Dealing with death and loss is certainly one of the more difficult experiences I will face in this profession. I was working the redeye shift in the ER with the hospitalist when a patient was admitted. It was clear from the exam and imaging that the prognosis was poor. For the first time, I found myself on-hand while a physician had ‘the talk’ with grieving family members clustered by the bedside. In such an emotionally-charged setting, the hospitalist delivered the news in a manner that was professional and honest while at the same time deeply respectful and supportive. When he spoke to the family he was as much a caring human being as he was the doctor. The family was deeply touched and, despite their grief, you could see their appreciation. I was deeply touched as well. I only hope that I can grow to equal that task and, when my time comes to deliver bad news, that I will do so with every bit of compassion that I witnessed in the ER that evening.

The last experience I want to share was when a patient asked me for a miracle.

As a newly-minted, third-year medical student, I make a point of asking patients to not call me “doctor.” I am a medical student, not a doctor, and won’t be until I complete many more years of training. Though lacking in the technical know-how, one area where I can contribute as a student is by taking the time to get to know the patient and listen to their worries and concerns. Busy physicians don’t always have the time to just sit and chat with their patients, and it is always amazing how many patients just want someone to sit and listen.

I met one such patient who arrived in the ER with her daughter. I helped by obtaining a thorough history and performing the physical exam. Afterward, the doctor left to order labs and imaging while I sat with the two in the exam room and just listened to them. Later, when the mother was admitted as an inpatient, I rounded on her daily in my free time and came to know her and her daughter better.

A short time later, the mother was brought to another department for an invasive procedure that, while necessary, was not without risk. The attending physician clearly explained all of this to the patient and her daughter and addressed their concerns and questions. To my great surprise, the patient’s daughter turned to me and said, “Doc, you gotta do me a favor. Pull out a miracle for my Mom on this one.” Before I could say a word in protest, she walked out.

I wasn’t performing the procedure and I’d been very clear that I’m still just a student, but she turned to me anyway. On the one hand, it is terrifying that someone would place so much hope and trust in a doctor that they would ask for a miracle. On the other hand, it is humbling to see the personal connection and impact that can formed with complete strangers, just by listening to them in a time when they are frightened and in pain.

Right now, I’m still just a student who often knows only a bit more about what’s going on than the patient. The two years of classes in Boston and the next 9 months at St. Mary’s will bring me closer to the day when I’m the one wearing the white coat and performing the procedure. That patient’s request made me realize what people often ask from their care providers- miracles. I only hope, in the next few years, to learn as much good medicine as I can so that I’ll be the best doctor I can be for my patients. That said, if during that process I stumble across the occasional miracle, I won’t turn it down.

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Dave Skavdahl’s, Medical Student, blogs about his experience at St. Mary’s

Tuesday, May 31st, 2011

David Skavdahl. Medical Student

May 26, 2011

I knew I matched at the right hospital on the first day when the VP of Mission Effectiveness explained that St. Mary’s Regional Medical Center was intentionally serving the poor and medically underserved.  During the past two weeks I have been impressed by the multiple ways that that mission is embodied by those who work at St. Mary’s. Let me give three examples.

First, the way in which I have seen the nurses care for patients at St. Mary’s continues to impress me. No matter how belligerent or non-compliant a patient may be, the nursing staff remains patient and compassionate and seeks to address the patient’s needs and concerns.

Secondly, the physicians embody the same principles. I was asking an attending physician about a complicated case that needed readmission for an infection. I was concerned about reimbursement for the physician in cases of readmission.  Her response was, “I don’t know how reimbursement will work, but I consider this part of good patient care so we are going to take care of the patient.” It was a true joy to hear that this physician felt like she had the freedom to do what was in the patient’s best interest and was not worried about the financial repercussion which might befall her.

Finally, I am impressed by the way in which the staff works together to ensure the best patient care. The teamwork I have seen at St. Mary’s is truly a model of how healthcare should be delivered compassionately and effectively. When we are willing to swallow our pride, admit our mistakes, and listen attentively to each member of the team, the patient will be healthier, remain in the hospital for shorter periods of time and be given the ability to lead joyful lives.

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About the Medical Student Authors

Wednesday, May 25th, 2011
 

Robert Bruce, Medical Student

 

Robert Bruce grew up in Caratunk, Maine and graduated from Dartmouth College with a degree in Genetics and Molecular Biology. He is currently pursuing a degree in medicine through the Tufts University School of Medicine-Maine Track Program on a U.S. Army medical scholarship. As a third year student, he looks forward to the wonderful opportunity to learn from patients and physicians at a Maine teaching hospital, St. Mary’s Regional Medical Center.

The skills I learn at St. Mary’s will help me to achieve my goal of someday providing top-level, compassionate care to small communities right here in my home state.” 

 

 

  

   

David Skavdahl, Medical Student

  

  

David Skavdahl grew up in rural Washington State and graduated from Seattle Pacific University with a combined degree in Biology and Philosophy.

He is currently furthering his studies at Tufts University Medical School. As a third year student, he is pleased to have the wonderful opportunity to learn from patients and physicians at a teaching hospital, St. Mary’s Regional Medical Center. 

“I am excited my learning activities have brought me to Maine. My wife works in Topsham and we are looking forward to calling the Pine Tree State our home for years to come. “

 

 

 

 

 

 

 

 

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Bob Bruce, Medical Student at St. Mary’s blogs about his and Dave Skavdahl’s first couple of weeks at St. Mary’s

Wednesday, May 25th, 2011

Robert Bruce, Medical Student

As the 3rd-year medical students from the Tufts-Maine Track program who will be working at St. Mary’s for the next 9 months, Dave Skavdahl and I have been charged with writing a weekly blog to give readers an idea of what day-to-day life is like for a student doctor. The original proposal was a daily blog but Dave and I conferred and decided a weekly update would be better. We weren’t too sure how upbeat we’d sound in a daily entry after a 12 hour shift in the Emergency Room or an on-call night with OB/GYN helping to deliver babies. I’m guessing that once a week will give you a less grumpy version of a day in the life! I’m taking the first entry and you’ll hear from Dave next week.

For this first blog, I’d like to tell you a little more about what we’re doing here and how our next 9 months in Lewiston will play out. In a broader sense, the program is designed to give us experience practicing medicine in more rural areas, where Maine is often most in need of doctors. This is great for me because I’m originally from Caratunk, up by the Kennebec River. I am also of the humble opinion that Maine is the finest state in this great nation of ours, so after two years of intensive coursework in Boston it’s a real treat for me to get back on friendly soil.

The 3rd-year program at St. Mary’s is an integrated model as opposed to the tradition training model. This means that, rather than breaking the year up into 6 week chunks of time devoted to each major specialty (i.e. Family Med, Internal Med, Surgery, OB/GYN, Psychiatry, and Pediatrics), we work in each of the specialties every week. In the 5 days since I have started, I have already been on hand for multiple C-sections, hernia surgeries, office visits with multiple doctors, psychiatric consults, and a *mammoth* shift in the Emergency room this past Saturday. Beyond the intensive clinical training, the great benefit of this program is that I will often work with the same patients in multiple settings and derive a much better understanding of what it is like to navigate the healthcare system.

I can say from the onset that, in terms of organizing my time, it has been a challenging week. Not only do we work long hours (we’re averaging about 12 hours per day, 6 days per week, plus homework when we get home) but that time is often spent going bouncing among departments and working with multiple doctors. Thus far, I’m really pleased and excited by the response I have received from my teachers. I’m looking forward to a lot of hard work and some great learning.

We’re here for 9 months so there will be plenty of stories to come.

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