Categories
Clinical Opinion Public Health

It’s Time to Take Responsibility for our Unimmunized Patients

There is an old parable about a tree that falls onto an old dirt road in the forest. On the day the tree falls, the daughter of a rich king is passing through the forest in her carriage. The carriage runs over the tree, loses control, and crashes. A passing lumberjack sees the overturned carriage and carries the princess to safety. Her father, the king, throws a great celebration in honor of the lumberjack, and rewards the hero with riches.  In the next village, another tree falls on the road.  In this village, the lumberjack sees the fallen trunk and with great difficulty carries it off of the road.  The princess never crashes and she continues on her way, none the wiser.  A hero all the same, there is no celebration and no reward for this lumberjack.  This allegory wins no awards for its subtlety.  While life-saving and innovative treatments are often lauded by the general public, the praises of preventive measures often go unsung.

Vaccines are considered among the safest and most effective public health interventions. [1] There is no dispute among the scientific community, and repeated peer-reviewed studies have detailed the value of vaccines as preventive health measures. These studies collectively support the conclusion that the benefits of using vaccines to minimize illness outweigh the potential risks.  It is precisely because of the overwhelming success of immunizations that people have little or no personal experience with diseases like smallpox, or chickenpox, or polio.

Parental autonomy suggests that parents have the right to raise their children as they see fit.  As a result of this benign belief, however, more young parents believe that vaccination should be a choice. [2] To combat the anti-vaccination movement, health care providers have traditionally relied on their role as medical experts and discussed the scientific data, expecting patients to trust in evidence-based medicine. But the inability of overwhelming evidence to quell controversy and resolve debate has led to greater polarization—biased reasoning has made discussion counterproductive and has led to the intensification of beliefs for many of those opposed to vaccination.  As a result, there are groups of under-vaccinated children which increase the risk of an outbreak in the general population. [3]

There are patients who will continue to refuse to accept research and statistics, even when presented by a trusted family physician. These patients have fallen victim to misinformation and fear-mongering. Their concerns include side effects, immunization schedules, financial incentives, and “Big Pharma”, but more broadly represent suspicion of biomedical research and healthcare providers.  [1]

Physicians often suffer from the curse of knowledge—an inability to recall the lack of understanding that came before learning a new concept. This may play a role in the notoriously poor communication skills of doctors.  For example, watch a third year medical student discuss a clinical subject with a first year medical student and notice the difference in the use of clinical jargon.

Learning how to read a research paper, understanding how and why the study was performed, and recognizing the implications of its conclusions are skills taken for granted by those in the scientific community. These skills take years to learn, yet clinicians reference data and statistics to their patients indiscriminately.  If we want patients to trust us, we have to admit when what we are doing is not working, and be willing to change. For some patients, citing facts and figures is not an effective tactic.

It can be easy to vilify those opposed to vaccination, but new parents continue to be drawn to the movement every day. In a culture of blame, when there is an outbreak of an infectious disease, we instinctively search for someone to condemn and hold culpable. We would be better served by identifying what makes individuals skeptical and how we can change misconceptions and behaviors. The issue at hand involves trust.  Some patients will not trust what we have to say as providers. We have to consult the experts—we must refer them to their grandparents.

Grandparents can discuss the ominous nature of diseases that many of us, due to vaccination, are not frequently exposed to.  They can explain what it means to have a cousin under quarantine or a sibling living with the complications of an infectious disease.  They can express what it means to lose an infant child to a vaccine-preventable illness. Anti-vaccination parents have had the impact of their decisions mitigated due to many years of previous vaccination and herd immunity—a community’s general protection from disease because of a high proportion of immunity in its members.  It is time for us, as medical professionals, to admit that we must change our tactics.  Some patients may not understand the consequences of many of these infectious diseases, but I bet their grandparents do.

References:

  1. http://iom.nationalacademies.org/Reports/2013/The-Childhood-Immunization-Schedule-and-Safety/Report-Brief011613.aspx
  2. http://www.pewresearch.org/fact-tank/2015/02/02/young-adults-more-likely-to-say-vaccinating-kids-should-be-a-parental-choice/
  3. http://www.reuters.com/article/2015/08/27/us-usa-vaccine-exemptions-idUSKCN0QW2JY20150827
Featured image:
Clipart edited by Ilya Aylyarov
Categories
Clinical

Journey to the Center of the Lab

What is a stat laboratory? As far as most doctors are concerned, the stat lab is a mysterious place, located somewhere in the dungeon of the hospital, wherein a slew of unkempt “lab people” feverishly work to turn tubes of blood into useful numbers in the electronic medical system. While this view is not a complete misconception, I do think it would be constructive to provide a quick overview of how exactly these labs work, and how they fit into the overall healthcare picture.

There are two kinds of laboratories in the healthcare world: reference laboratories and stat laboratories. Reference laboratories perform high-volume, routine (non-time sensitive), specialized testing on samples sent from outpatient clinics and hospitals. These labs are generally located away from hospitals, in their own buildings, so they may have the extra space required to house highly specialized testing equipment and personnel. The downside to these labs is that the “turnaround time” for tests is slow (many hours to days), both because they are located offsite and because the specialized tests may take much longer to run. On the other hand, stat laboratories are smaller labs located on site in order to perform time sensitive (“stat”) tests. Although not very many highly specialized tests are available from these smaller labs, they provide all the basic testing necessary to support the emergency room and inpatient floors in a hospital, with turnaround times usually under an hour. Considering my work experience has been entirely at stat laboratories, I will focus on them in this article.

Stat labs have understandably become a staple in ERs and hospitals around the world because they quickly provide vital information about patients, allowing doctors to plan proper treatments in the short term. I mean, sure, you might be fairly certain that your patient has DIC, but wouldn’t it be nice to have a positive D-dimer to be sure?

First off, what is actually considered a laboratory, and how can you be sure the lab at your hospital isn’t churning out garbage? Well, according to the Centers for Medicare and Medicaid Services (the governing body for laboratories in the U.S.), the law requires:

“all facilities that perform even one test. . . on ‘materials derived from the human body for the purpose of providing information for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings’ to meet certain Federal requirements.”

I find it comforting that people (who are not me) dedicate their careers to quality control. Incorrect results lead to inappropriate treatment, which can have disastrous consequences on patient care. As such, each lab has its own quality control (QC) program in place, which includes running instrument calibrations/QC daily and monitoring the results over the short and long term. Much of the labor in the lab is dedicated to QC; in fact, depending on the test, the daily calibration and running of QC samples for one test can take the better part of an hour, and that’s if all the samples come into range as they are supposed to.

QC is the only way to be sure test results coming off the analyzer are accurate and precise. It is an unforgivable sin to release patient results when QC has failed, even when the other members of the healthcare team are adamant about getting the test results now. If QC has failed, all the results from that instrument are garbage until QC comes back in. Period.

Most stat laboratories are divided into roughly the following departments: hematology, urinalysis, chemistry, microbiology, blood bank, coagulation (PT/PTT), immunology, and specimen processing. In smaller labs, there are “float” lab techs who work in all of these departments. In larger labs, the techs are usually more specialized and stay in one department.

When, in this computerized day and age, an ER doctor puts an order for a blood test into the electronic medical system, the phlebotomist receives the draw order (if the nurse isn’t going to draw it). The draw order is usually a printed label, with the patient information, orders, and tube types listed on it. The tube type is very important; each colored tube contains specific additives tailored to certain tests (a CBC is run on a “purple top” tube with EDTA as the anticoagulant, etc.). Additionally, some tests require special handling (e.g. “on ice”) or can’t be opened until just before the test is run, as is the case for ionized Calcium.

The phlebotomist then goes to the ER, draws the blood, and transports it back to the lab. The specimen processor will then double-check to make sure all has been collected correctly, and mark in the system that the tubes have been received. At this point, the tubes diverge. The “red top” or “yellow top” tubes, which have no anticoagulant in them, must be set aside to be allowed to clot before being put into the centrifuge. The anticoagulated chemistry and coagulation tubes are thrown into the centrifuge and spun immediately to separate the RBCs, WBCs, and platelets from the plasma. The hematology tubes, which are also anticoagulated, are not spun, but put directly on the analyzer as whole blood.

After the proper tubes have been placed on the proper analyzers, most tests are automatically run and resulted. Exceptions to this include: a) chemistry results that are above the linear range of the instrument need to be diluted and re-run, b) blood slides that the hematology analyzer flags for tech review need to be looked at under the microscope, and c) the results that are critical values need to be called in. A critical value is the cutoff value at which the tech must call up to the patient’s nurse or doctor and report it. For example, the cutoff for a low potassium level may be <2.6 mEq/L at a particular lab, so if a potassium level of 2.4 comes off the machine, it cannot be resulted in the computer until the tech has verbally passed the information along to the direct caregiver. This is done because critical values are deemed dangerous enough that the doctor must know about it as soon as possible so as to treat it immediately.

After all the tests have been reported out, the tubes are taken off the analyzers and saved for a week in the refrigerator. This is necessary in case additional orders are added on later, or the patient dies and the medical examiner needs the blood, or to troubleshoot in the case of mislabeled specimens, etc.

And that’s the lab, at least the basics. Is it less mysterious now? I hope so.

 

Featured image:
The Chemistry Of Inversion by Raymond Bryson

Categories
Clinical Opinion

Does this make you uncomfortable?

Homo sapiens is one of the few species on earth that care if they’re seen having sex. The impala is unconcerned. The dingo roundly flaunts it. A masturbating chimpanzee will stare straight at you. To any creature other than you and I and 6 billion other privacy-needing H. sapiens, sex is like peeling a mango or scratching your ear. It’s just something you do sometimes.”
– Mary Roach, Bonk: The Curious Coupling of Science and Sex

Mary Roach is one of my all-time favorite writers because she delves into topics that make the average person squeamish. I’ll admit, as I read Bonk: The Curious Coupling of Science and Sex, I found myself peering over the top of the pages at the pool, carefully checking that no one realized I was reading about sex. After finishing this text I wondered, why was I trying to hide? Why is our society so confined (in comparison to, for example, Europe) when it comes to our sexual well-being?

Even though many medical students will boast that very little makes them uncomfortable (they get excited to dissect cadavers or watch an open heart surgery), it is clear from the literature reviews that a large number of medical students are not comfortable, nor prepared to take accurate sexual histories from their patients. A study published in the Journal of Sexual Medicine reported that, “The majority of medical students (75.2%) feels that taking a sexual history will be an important part of their future careers, yet only 57.6% feel adequately trained to do so. Furthermore, 68.8% feel that addressing and treating sexual concerns will be an important part of their future careers, and only 37.6% feel adequately trained to do so.”1

This data is pretty alarming seeing that many Americans, young and old, struggle with sexual disorders and diseases. In my opinion, there is one main reason that underlies these statistics – lack of education (don’t scold me for saying this, I know our training is already quite lengthy, but, hey, we are lifelong learners).

In the 2008 article “Medical school sexual health curriculum and training in the United States,” researchers reported that a whopping 44% of US medical schools lacked formal sexual health curricula.2 Although a few years have gone by, it is clear that this percentage is way too high. Similar results were reflected in a study done in Malaysia by Arrifin et al.; researchers reported that only half of research participants (final-year medical students) reported feeling comfortable taking a sexual history and only 46% felt that they had received adequate training to take the sexual history.3 This level of inadequate training reflects in the demeanor of medical students when they are asked to take a sexual history.

Although I can’t speak for medical students at other institutions, many of my classmates, including myself, have expressed a certain level of unease when asked to question patients about their sexual history. What is the proper way to ask a person about his or her sexual identity and orientation? How can I make patients comfortable enough to tell me about the rash they are panicking about, but too embarrassed to bring up casually in conversation? What if the patient identifies as a transgender individual, how am I supposed to know what his or her needs are from me as a health care provider?

All medical students should know it’s okay to struggle through these questions and mess up, possibly offending a patient (future patients please be kind to the students who are still learning!). These are all questions that I don’t have the answer to, but I want to learn more so I can give my patients what they need from me. These are essential questions for medical students to ask and explore, but more importantly these discussions really require an individual with years of experience and education to be present. Although many US medical schools may be working towards providing a more solid education on sexual health, it is urgent that this be done swiftly and accurately, because our patients are the ones who are suffering as a result of our inadequate training on this aspect of health.

To the medical school officials, please answer our desire to learn more about these topics. To medical students and other health care providers, don’t be afraid to bring up sexual health with your patients. Our minds and the overthinking we do are the only things that hold us back.

  1. Wittenberg A, Gerber J. Recommendations for improving sexual health curricula in medical schools: results from a two-arm study collecting data from patients and medical students. J Sex Med. 2009 Feb;6(2):362-8.
  2. Malhotra S, Khurshid A, Hendricks KA, Mann JR. Medical school sexual health curriculum and training in the United States. J Natl Med Assoc. 2008 Sep;100(9): 1097-106.
  3. Ariffin et al. BMC Res Notes (2015) 8:248

Featured image:
sex and love (because when love meets sex, bodies and souls become one and time, colours and place are on ecstasy…) by dim.gkatz

Categories
Clinical Reflection

Working Miracles With Gravity

Before medical school, I worked as an assistant at the clinic of a physical therapist. Half of the physical therapist’s business was bread-and-butter physical therapy, but the other half was vestibular rehabilitation. The therapist specialized in diagnosing and treating balance and dizziness disorders of the inner ear. And guess what? Most of his patients were there as a last resort, because the doctors and their drugs weren’t working. They had fallen through the cracks, and the tragedy is that the most common cause for their dizziness is easily treatable, in 5 minutes, with only a table and some body positioning.

Benign paroxysmal positional vertigo, or BPPV, is caused by rogue calcium carbonate otoliths. These otoliths escape from the utricle of the inner ear and make their way into the semicircular canals (usually the posterior semicircular canal). These otoliths cause aberrant movement of the fluid in the semicircular canals with changes in head position, confusing the brain, which is getting mixed signals about the body’s orientation in space from the right and left semicircular canals. Predictably, the brain’s confusion manifests as vertigo, which  defines as “an illusion of self or environmental motion.”

Patients with BPPV suffer from sudden dizzy spells triggered by changes in head position, usually lasting 15-20 seconds. Movements like looking up, rolling over in bed, or getting up out of bed in the morning set the world spinning, often with an accompanying nausea. As you can imagine, these patients do everything they can to minimize their head motion. They move in a characteristically rigid fashion, keeping their heads as still as possible in order to avoid repeat attacks. Clearly, this is an extremely unpleasant condition; one that is experienced at least once by 2.4% of the population. The good news, however, is that it is easily treatable, as long as it is recognized.

A certain amount of diagnostic finesse is required to rule out central nervous system problems, but once the proper neurological exams have been performed, BPPV should be high on the differential for patients with the symptoms described above. The test for BPPV is called the Dix-Hallpike Maneuver, in which the practitioner provokes a dizzy spell by changing the patient’s head position and observing the eyes for nystagmus.

Once a diagnosis has been made, treatment consists of The Epley Maneuver, which is nothing more than a simple series of head and body positions designed to use gravity to reposition the rogue otoliths into the utricle where they can no longer confuse the brain by moving semicircular canal fluid inappropriately. When the patients I saw were cured of their vertigo so quickly, with such a simple technique, they wasted no time in hailing the physical therapist I worked for as a miracle worker. They had been miserable for months, and that’s all it took to fix it?? In these situations, the patients were always ecstatic. I couldn’t help but smile.

As we go into rotations, residency, and practice, I hope we will be able to catch these patients before they fall through the cracks. My purpose in writing this article is to get the word out , because it is so easily treatable without the use of expensive, ineffectual, toxic medications. All we have to do is recognize it when we see it. As an added benefit, maybe someone will call you a miracle worker one day.

References
http://vestibular.org/understanding-vestibular-disorders/types-vestibular-disorders/benign-paroxysmal-positional-vertigo
Harrison’s Principles of Internal Medicine, 19th Edition, Chapter 28
http://www.neurology.org/content/70/22/2067.long

Featured Image:
Vertigo by Diana Mehrez

 

 

Categories
Clinical Reflection

Chronic Fatigue Syndrome

The year was 2011 and I was an undergraduate student at Weber State University in Ogden, Utah. I was on the premed track and looking for doctors to shadow and research to participate in. I was also working part time at a physical therapy clinic and one day I started a conversation with one of the patients. After hearing a little about my interests and career goals, she became enthusiastic about introducing me to her doctor who was conducting research on chronic fatigue syndrome.   I had never heard of the syndrome, but I was eager to take on any new medical experience and jumped at the opportunity. One week later I found myself at the clinic of Dr. Lucinda Bateman in Salt Lake City.

After meeting with Dr. Bateman and discussing chronic fatigue syndrome, I followed her throughout her day and sat in on several appointments. Because chronic fatigue syndrome is a relatively unknown condition, Dr. Bateman and her patients were strong advocates of educating as many people as possible about the condition, including me.

Many of the patients shared their stories with me. One woman I remember vividly: she was quite thin with short cropped hair and wore a smart business suit and trendy glasses. The immediate impression I had when I saw her was that she was someone who got things done. Her story was heartbreaking. I listened as she described her life before chronic fatigue syndrome and how she was a “go, go, go” person. She worked full time, ran long distance races, and was active in every sense of the word. Then, one day, she could not get out of bed. Her muscles ached intensely despite the fact that she had not exercised the day before. She was debilitated by an intense fatigue she could not overcome. These symptoms lasted for days before she scheduled an appointment with her primary care doctor. All the tests came back negative and she was prescribed bed rest, which did not resolve any of the fatigue or pain.

I could tell as she was recounting her story that she was trying not to become emotional. She was still experiencing the fatigue and recalling the activities she used to enjoy was difficult for her. I felt I could begin to understand some of what she was going through, because I could remember how cripplingly fatigued I had been when I had contracted infectious mononucleosis as a teenager.   I could not imagine having to deal with that kind of fatigue for months or years on end.

After shadowing Dr. Bateman, I went on to finish my undergraduate degree and was accepted into medical school. I heard nothing of chronic fatigue syndrome for years. In February, 2015 I was surprised to see that NPR had published an article on the syndrome. The article was written to cover a new report published by the Institute of Medicine. The report legitimizes chronic fatigue syndrome (known as myalgic encephalomyelitis in Europe), establishes  new diagnostic criteria  , encourages more research into pathophysiology and treatment, and recommends that the name of the disease be changed to Systemic Exertion Intolerance Disease (SEID).

According to the report, “between 836,000 and 2.5 million Americans suffer from myalgic encephalitis/chronic fatigue syndrome,” and the hallmark of the disease is “a substantial reduction or impairment in the ability to engage in pre-illness levels of occupational, educational, social, or personal activities, that persists for more than 6 months and is accompanied by fatigue, which is often profound, is of new or definite onset (not lifelong), is not the result of ongoing excessive exertion, and is not substantially alleviated by rest.”

As we go through medical school and enter practice, I think it is a good idea to be on the lookout for these patients. I highly recommend reading the report for educational purposes, especially since, according to the report, less than one-third of medical schools educate their students about chronic fatigue syndrome and fewer than half of medical texts mention it. The disease is poorly understood, but increased awareness and future research may help fill in our knowledge gaps and assist in finding effective treatments for those who suffer from chronic fatigue syndrome.

Read the NPR article: “Panel Says Chronic Fatigue Syndrome Is A Disease, And Renames It”

Read the Institute of Medicine report “Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness”

Featured Image:
cfs by Jem Yoshioka

Categories
Clinical Humour Lifestyle

A Guide to the Operating Room for Medical Students Or How I Learned to Stop Worrying and Love the Sterile Field

The summer between MS1 and MS2 I did a research project with an orthopedic surgeon at my school.  Part of the project had me observing in the operating room (OR) a few days a week, watching procedures and helping with any tasks that came up.  This experience was actually my first time being in an OR, and I was pretty nervous leading up to it.  I had heard horror stories about students breaking sterility, knocking over solution bottles, and generally making fools of themselves in front of important people.  While I tried my best not to do anything foolish or embarrassing, it was oftentimes very hard to avoid.  Slowly, I become more confident in the OR, and the blunders came further and further apart.  As a service to all the pre-meds and un-initiated med students, I now present a short list of important things to know before your first OR experience.

  1. Figure out the rules.  Surgeons love rules, and at times it seems as if they have a weird fascination with them.  If you don’t ask then the rules are never really explained to you, and you will be in big trouble when you break one.  Consequently, I think it’s prudent to ask someone what the rules are.  Considering your fear of talking to the surgeon, he or she isn’t the best option.  The resident or intern is probably too sleep-deprived and hopped-up on caffeine to notice you.  Your best bet is to ask one of the circulating nurses or other students who have been on the service for a while.  Believe me, it will save you a lot of trouble later on.
  2. Make sure you’re dressed appropriately.  Make sure everything you’re supposed to wear is on correctly.  Make a mental note of scrubs, cap, mask, and boots.  Aside from actually wearing the right attire, please make sure you are wearing it correctly.  You’re going to feel really stupid when someone points out that your cap is on crooked, or that you forgot to tie half of your mask.  You will also be the butt of many jokes over the next few days when you aren’t there.  In addition to knowing what to wear, it is also important to know what not to wear.  Don’t wear shoes that you actually like, unless you think it’s cool to have fecal matter on your $100 Sperry’s.  Also, leave the personal items and accessories at home.  While that puka shell necklace you made in 10th grade art class may be “totally rad, bro,” it is definitely a sterility hazard and you definitely shouldn’t bring it into the OR.  Also, if you’re still wearing puka shell necklaces in your mid-20s you should probably re-evaluate your life choices.
  3. Know where the sterile field is and how to avoid it.  This rule only applies if you’re not scrubbed in, and the decision of whether or not you get to scrub should have decided before you show up.  Anyway, just remember that the sterile field should be avoided like the plague.  Any blue towel or covering should send off warning signals in your head.  Don’t get close to it, don’t breathe on it, and don’t even really look at it if you don’t have to.  Don’t try to be cute either and inch your way as close as possible, because the scrub nurse will call you out and you will be embarrassed.
  4. Try to look interested even when you’re not.  After the 5th time seeing the same surgery, it’s only human nature to get a little disinterested.  There are only so many times you can be mystified by a hernia repair, and you’ve probably passed that threshold long ago.  It is imperative, however, that you look interested at all times.  Surgeons have an innate ability, almost like boredom-radar, to tell when you are dozing off or doing something else.  These situations usually end up in you getting pimped mercilessly in front of everyone.  To make matters worse, you don’t come off looking like a shining star when your response to the first question is “Huh?”  You can typically avoid these situations by employing certain maneuvers that indicate “interest.”  My go-to method was switching sides of the OR every 20 minutes to get a new “viewing-angle.”  Another tried and tested one is intently looking at the monitors or camera.  Find what method works for you, and stick to it.
  5. If you’re not scrubbed in, find yourself a role.  Surgeons dislike idle people.  There’s nothing worse you can do than to just stand in the same place in the OR doing nothing.  Find a job you can do, and be amazing at it.  Like to record information?  Write down the incision and closing times.  Like to clean?  Become the best darn disinfectant wipe user ever.  Like to retrieve things?  Be the person who looks up and prints all the obscure research papers the surgeon even tangentially mentions during the procedure.  Note:  If you choose the last one, be prepared for incessant pimping later.  Remember folks, nothing is without consequence, so choose your punishment wisely.
  6. Prepare yourself for the spectacle that is a patient waking-up post-op.  This is the part that you never hear about or even see on those dramatized TV shows about surgery.  A patient waking up from anesthesia is most definitely not pleasant.  Prepare yourselves for all sorts of near disasters.  Patients will try to pull out breathing tubes, or roll over onto joints that have just been operated on.  Some will even try to get out of the bed, as they don’t realize where they are for the first few minutes.  People will often kick out their arms and legs, and if they aren’t stabilized someone on the team is bound to get a black eye.  The best thing you can do is to be aware of the possibilities, and find out how the team handles such situations.
  7. Find a place to store food for post-op consumption.  We have finally reached the pinnacle, the crown jewel of my OR guide.  Don’t pay attention to the fact that this rule actually doesn’t correspond to anything taking place in the OR.  After spending countless hours in the OR, the first thing on your mind will be food.  No matter how mundane or exciting the procedure was, human need for nutritional sustenance will take over.  Make sure you have a safe storage spot for food, whether it is in the clinical workroom or in the students’ lounge.  Also, considering that everyone you will be working with (read: vultures) will also be voraciously hungry and will have no problem eating anything lying around, make sure you keep your food in a place only you can find it.  Invest in a locker and a lock if your facilities have them.  You’ll thank me for this advice later.  You’re welcome, by the way.

Featured image:
CPMC Surgery by Artur Bergman

Categories
Clinical General Opinion Reflection

One Size Does Not Fit All

I recall being fresh out of my first year of medical school and ecstatic to be spending my break not in a class room, but at an actual pediatric oncology unit. The night prior to my first day in clinic, I spent time reviewing immunology and looking ahead at the oncology lectures from the Clinical Medicine class I would take the next year in school. I wanted to be prepared in front of my new mentor.

The next morning, I hardly had time to impress my preceptor let alone introduce myself before we were running around. We stopped at the pathology lab. I gazed through the microscope, trying to remember what I had read the night before about identifying abnormal cells.

“I have a new patient that arrived today. She is very sick. We have to tell the family the definitive diagnosis. Come with me.”

We urgently walked up to the inpatient floor into one of the rooms. A beautiful young girl was sleeping in the bed. Her parents and grandma were diligently by her side. They froze and looked at the doctor. This was the final confirmation they had been waiting for. They held onto the hope that they had been sent to the oncology floor by mistake.

“We have confirmed that your child has a rare cancer.”

4729016997_bc4ec39867_bI watched as any sliver of hope vanished from their eyes. They would not wake up from this nightmare. The moment my mentor delivered the diagnosis, I could feel the world take a 180 eighty degree turn for this family. It was as if their world froze at that moment. How could this be? The child looked so peaceful, fast asleep while hospital monitors blinked around her. Just a week ago, they were running around to sports practices and dentist appointments and going through the everyday motions that we consider to make up a normal life. I’m not even sure that this family was breathing at this moment. The room became deafening silent as all the color drained from their faces. The doctor proceeded to talk about what would happen in the days to come. What did this mean for their child?

Just when the family (and I) didn’t think it could get worse, they were told about the side effects of the medications – the only option to treat their child’s condition. The doctor began with the common side effects like nausea, vomiting, hair loss. Next, cardiomyopathies. Neuropathy. Loss of reproductive function. This is when this family broke. Loss of reproductive function. I always thought the diagnosis would be the hardest thing to hear. For them, the breaking point was learning of the adverse effects of the very medications intended to save the child’s life. These medications are meant to represent hope, protection, and reassurance for a life beyond disease. The doctor paused again, giving this family time to just cry. Tissues went around.

“This is hard. Take your time. I am here for you throughout this entire journey.”

I watched the mother of this little girl look at her own mother. It was a look of despair, yearning for answers that wouldn’t come. Even if her child survives, bits of the future have already been stolen. We left the room after two hours to let the family have time to process.

Outside of the room, I tried to process what I had experienced. The information I read in my textbooks and PowerPoints did not prepare me for that interaction. I looked at my preceptor for guidance.

“This is real. This is hard. We will fight with them, though. We do everything in our power not only to treat the cancer, but to make sure that cancer does not define their life. This is what we do.”

Throughout the rest of my summer, I went on a roller coaster from new diagnoses to the “completion of chemo party”, from being declared cured after a 5-year visit with no evidence of disease to the tragic death of a child. I watched children balancing school with chemo. I watched teenagers struggle with fear and bravery while grasping at any chance to maintain their independence. I watched parents struggle to care for a sick child while still being present for the other children they left at home. The things I learned that summer could not have been taught in a classroom. With every family I met from all over the world, I witnessed raw and vibrant emotions: fear, determination, sadness, and never ending hope, even in the wake of death. It is this hope that I take with me. It is contagious. These are the emotions that makes us human.

At one point during the summer, I asked my mentor what the secret was to enduring such difficult clinical conditions. I had watched him interact with all of his patients each day. Every single one loved him. The mother of that little girl later told me how he was able to comfort them, cry with them, joke with them, and laugh with them with such ease. He was able to guide them through this journey, with the help of hospital resources, to give them a life within this new normal. In response, he said:

“There is no such thing as being the best doctor in the world. You have to be the best doctor in the world for the patient sitting in front of you. That is my first priority, more than my research or my teaching. Get to know you patients and their families. Learn from their stories. Keep fighting to improve. That is how you become the best.”

3377110664_c71de81ebc_zSo much of early medical education involves pouring over books and PowerPoints, trying to memorize as many details as possible. It is important to have that foundation of knowledge, but what I have come to realize is that there are rarely pure “textbook cases” because so much more goes into caring for a patient. One size does not fit all in medicine. This experience brought back the humanity of medicine. I witnessed how knowing and understanding patients enables a physician to be an advocate for their patients, a role I consider to be the most important of the many roles a physician takes. I can never come close to knowing exactly what these families are going through. I also can’t thank them enough for allowing me to be present during their most vulnerable moments, for taking time to talk with me for a brief period to get a glimpse of their journey. Ultimately, this experience was a reminder that the art of medicine can’t be discovered in textbooks. It is learned from our patients and the uniqueness that their individual journeys bring to each patient encounter.

 

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Lou Bueno
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Alice Popkorn

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Clinical General Lifestyle MSPress Announcements Narrative Opinion Reflection

“Preserving the Nobility of Medicine” Dr. Robert Alpern, 2014 Commencement Address of the Northwestern University Feinberg School of Medicine

Page 1 copyIn continuation of the Medical Commencement Archive, this Friday we are releasing a new commencement speech. Today’s commencement speech is titled Preserving the Nobility of Medicine. This commencement speech was given by Dr. Robert J. Alpern, a Northwestern University alumnus, to the students of the Northwestern University Feinberg School of Medicine. The esteemed Dr. Alpern is Ensign Professor of Medicine and Dean at Yale University School of Medicine. He also is President of the American Society of Nephrology, as well as a sitting Advisory Council Member of the National Institute of Diabetes and Digestive and Kidney Diseases.

Dr. Alpern took a moment for students to take a closer look at the value and weight of the two-lettered title: MD. He reflected upon the unique status given to physicians, and the reverence given to doctors from the community and from patients. Yet, at the same time the medical paradigm continues to evolve. Dr. Alpern astutely foresees a future where physicians must adapt to the growing roles in the medical team, changes in bureaucracy, and the changing expectations of patient’s for their treatment. Dr. Alpern also notes that these changes will influence the training and education of physicians. On top of our own desire to stifle the monsoon current of medical information during our education, there are legitimate concerns that the future medical student will receive but an abbreviated biochemistry course, or won’t need to take an MCAT, maybe even spend less time in medical school. Yet, Dr. Alpern urges one thing: to value the pursuit of scholarship. He reminds us that only with a strong foundation may a strong physician be built.

“We observe the patient and draw on our scientific understanding of how the body works and sometimes does not work, to develop a truth that we can implement as an action plan. We must know clinical guidelines and the most up-to-date treatment algorithms, but we must also be ready to identify clinical circumstances in which they do not apply.”

Dr. Alpern eloquently explains that, above all else, the pursuit of knowledge and scholarship is indeed the nobility of medicine. He reminds us to respect this pursuit in lieu of the changes we will see in our futures as physicians, such that “we do not return to the era of trade schools of medicine”. Dr. Alpern further mentions that, in addition to being a scholar, the physician must be compassionate, and that neither trait is mutually exclusive:

“I also want to make the point that an emphasis on science is not the antithesis of compassion, but it is rather the complement of compassion”.

At the end of his speech, Dr. Alpern concludes with this piece of wisdom:

“Do not be intimidated by the evolving healthcare system. Rather, as the next generation of physicians, you will define healthcare, and you must define it well.”

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“The Real Challenge: Balance” Dr. Richard D. Krugman, 2014 Commencement Address at the University of Colorado School of Medicine

Page 1This week, Dr. Richard D. Krugman’s 2014 commencement speech at the University of Colorado School of Medicine entitled, “The Real Challenge: Balance” debuts via the Medical Commencement Archive. This piece is my personal favorite within this year’s archive.

Dr. Krugman is a respected educator and leader in the medical field. Dr. Krugman received his bachelor’s degree from Princeton University, and earned his medical degree at New York University School of Medicine. He went on to complete his residency in Pediatrics at the University of Colorado School of Medicine. He currently serves as the Vice Chancellor for Health Affairs for the University of Colorado, Denver, where he oversees all five hospitals of the university in addition to providing support for deans and faculty. Among many esteemed positions, Dr. Krugman has served as a member of the Institute of Medicine and the board of University of Colorado Hospital. Dr. Krugman is internationally recognized as an authority on child abuse prevention.

Dr. Krugman begins his speech by discussing his desire to hold the title of spouse of the President of the United States.

“I have watched for years as each Presidential spouse came to the White House, starting with Jacqueline Kennedy, and each took as a cause some area of public policy that instantly got attention and, over the next four to eight years had billions of dollars appropriated toward resolving the issue.” He goes on to discuss his future endeavors.

With a humble nature, Dr. Krugman comments on the common nature of forgetting commencement speeches. He focuses his speech on what he believes will be the single most important piece of advice that the novel physicians ought to remember,

“it is probably easier to learn the facts and the technical skills you will need to practice medicine than it is to learn how to balance lives that are relentlessly crammed with the demands of your families and friends, your patients, your supervising residents and attending physicians, your students…”

Take some time to read Dr. Krugman’s recommendations for maintaining balance alongside a career in medicine.

Read Dr. Krugman’s 2014 Commencement Speech at the University of Colorado School of Medicine:  https://www.themspress.org/index.php/commencement/article/view/69

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Clinical General Innovation Lifestyle MSPress Announcements Reflection

“The Five C’s” Dr. Georgette A. Dent, 2014 Commencement Address at the University of North Carolina School of Medicine

Page 1This week, Dr. Georgette A. Dent, Associate Dean for Student Affairs at the University of North Carolina School of Medicine joins the list of spectacular commencement speeches in the Medical Commencement Archive.

Dr. Dent is an esteemed educator, writer, and innovator in the medical field. She received her Bachelor’s of Sciences from Duke University where she graduated magna cum laude. Dr. Dent went on to earn her M.D. from Duke University School of Medicine, where she also completed her residency in Anatomic and Clinical Pathology. Dr. Dent completed a fellowship in Hematopathology at the University of North Carolina School of Medicine, where she now serves and inspires students as the Associate Dean for Student Affairs. Among Dr. Dent’s many accomplishments, she has served as a member of the AAMC Electronic Residency Application System Advisory Committee, the Liaison Committee on Medical Education (LCME), and the American Society of Hematology Committee on Promoting Diversity.

“Going forward, when you have an “on” weekend, it will not mean you have a Monday exam, it will mean that you are on call.”

“The Five C’s”, provides a succinct and intimate view of the UNC SOM Class of 2014. Dr. Dent encourages her students to go forward as physicians while staying true to their caring natures, abilities to connect with others, competence, character, and engagement with cutting edge technology. Read Dr. Dent’s 2014 Commencement Speech at the University of North Carolina School of Medicine.