Saturday, March 12, 2011

ADCOM Q&A (coping with stress)

There is no doubt that medicine is a stressful career. You literally have people's lives in your hand. So it's understandable that admissions committees would want to know how someone handles stress, because that is a predictor of how they will handle it in the future, as a physician.

So, if asked: How do you handle stress?

Here is how I respond:

How I cope with stress depends on the time constraints of the situation and the type of stress. If it is "acute" stress (a short-term issue that must be acted on quickly), I handle it differently than if it is "chronic" stress (a long-term issue that must be dealt with over an extended period of time).

For acute stress, such as having a lab report, an exam, and a quiz all on the same day, what I do is first allow myself a moment to acknowledge that I feel stress. I think that is very important, not to deny that feeling. Because all that does is bury the feeling and give it more power over you. But I do not wallow in that feeling, or I would become paralyzed. Instead, I quickly move on to a plan of action, which empowers me. I prioritize what I have to do and then set about to doing it.

I find that this strategy not only works for when I feel stress, but it helps prevent stress. On my Google homepage, for example, I keep a running to-do list, organized by "low," "medium," and "high" priority. This keeps me on task, getting done the most important things first.

Chronic stress is different. You cannot necessarily act immediately and make it go away. An example from my current situation is that my husband, Geoff, got laid off from his job about three weeks ago. No amount of my prioritizing will find him a job. But no amount of my stressing will find him a job, either. So what I have to do is alleviate the feeling of stress that this situation causes so that I can continue to focus on what I need to do, namely, my school work. The way I do this is through several means of positive self-expression.

First, I talk. With my husband, with my family, with my friends. I tell them what I think, feel, fear, and hope. Expressing these things helps me feel a release, and also often helps me find remedies for the problem.

Second, I write. In writing, I find I can sometimes access a deeper level of thoughts and feelings because I have more time to consider my words. But it is still a method of sharing, of expressing, of releasing. And I find great relief in it.

Third, I create. Through color, shape, form, and texture, I express what is going on in my heart and head, whether it is frustration, anxiety, or anger. And often, the deeper I feel something, the more interesting my art is, because the more emotional inspiration there is behind it.

Fourth, I play. Music, that is. This is actually something that I used to do all the time and have gotten away from. But am trying to rekindle it now. I have played the piano since I was about 8 years old (I took lessons for 9 years). I have an extensive repertoire of songs that I can play, based on my mood. But I also find it rewarding to channel the nervous energy of stress into learning something new. I have recently gotten back into ragtime music (after being a childhood fan). And I just ordered Scott Joplin's complete rags for piano on today. So I will have plenty of material to keep me busy, and to help me de-stress.

I believe that having several coping mechanisms in your "toolbox" for dealing with stress is extremely important, because we all know that life is full of stressors. That is unavoidable. But I believe it can be overcome, and I believe the above-mentioned methods help me do that.

Friday, March 11, 2011

ADCOM Q&A (leader vs. follower)

I started a series several months ago in which I began answering some potential medical school interview questions. I haven't written any posts on this in some time, but plan to pick that thread up this semester, beginning here.

Are you a leader or a follower? Why? 

This seems to be a common question in many medical school interview samplings that I have looked at. It would seem that the obvious answer to this question is "leader," but I believe this question can really be looked at in a more nuanced way. And regardless, it's the "why" that is the important part.

When you go to a restaurant, one where the hostess has to seat you, you wait in the foyer until your table is ready. Then you follow the hostess, usually single file, into the restaurant. Ever since I was a little kid, I have always led that family parade. This alone, of course, does not make me a leader. But it hinted to me early on that I liked to be out in front, in charge of things. Leading the pack.

As I got older and went off to school, I often found myself as the group leader on school projects and group discussions. In part because I was willing to work hard, in part because I was organized and good at keeping people from getting distracted. I was focused on the task at hand. But more than that, I was confident in these abilities. To be a leader, you have to first believe in yourself and what you are capable of doing.

As an adult though, especially in the professional realm, I realized that it wasn't always my job to be the leader. In fact, sometimes it was my job to follow someone else. Like my boss. She (or he) was the one with more expertise, and I had something to learn in those situations. 

That said, I believe there is some stratification in the leadership process. I followed my boss, yes, because she was the one in charge of the whole office; but I lead the interns because I was the internship coordinator and was in charge of their learning environment and assignments. So clearly, it's important to be able to do both, and to recognize your role in a particular situation.

If you enjoy leadership, though, and are good at it, I believe you will seek it out and find the opportunity to exercise those muscles in some way, no matter what your level on the hierarchical ladder. When I got my job as a textbook editor, for example, I started out at the very bottom as an assistant editor. But after about a year, I had earned the confidence of my superiors, who entrusted me with more responsibility. I took those responsibilities and asked for even more, because I felt I could contribute, I was capable, and I would enjoy the challenge. I ended up in charge of one section of our textbook review, though I of course reported to my editor. So really, being a leader and a follower can be intertwined.

Why am I a leader? I believe I have indirectly answered that question: I have self-confidence, I am organized, I am focused, I enjoy the challenge of leading people and projects. But I think there is a related quality that must be teased out of the "leadership" role, and that is teaching. When done well, leadership is very much about teaching others, about helping them to excel and improve, not just about making yourself look good. And I find great joy and fulfillment in that part of the leadership process. 

When I was a textbook editor, I spent a great deal of time with one of my co-workers, who was unfamiliar with many of the computer "basics" I take for granted ("save as," cutting and pasting, finding where you saved something, and so on). I spent hours of my own time coaching her on those skills, and could only smile as I watched her improve over the weeks. (She is now a dear friend.) I consider that a part of leadership, and see it as integral to what I do in the future.

So I am a leader when it is appropriate, a follower when that is appropriate, and whenever I can be, a teacher.

Hospital Life: From Anesthesiology to Zebras

I belong in the hospital.

Not because I'm deathly ill (thank goodness), but because I want to work there someday.

I'm on spring break this week, and had the opportunity to shadow two physicians: an ICU director (a pulmonologist, Dr. Saunders*) and an anesthesiologist (Dr. Matthews*). Not only am I fascinated and intrigued with what they do, but (call me crazy here) I really like the hospital environment. Of course, the ICU and the OR are very different places, but I enjoyed things about them both. In this blog post, I will describe some of what I observed and learned in both the ICU and the OR, and why I find these places so interesting and compelling. I will also attempt to impart some of the passion and compassion I witnessed both of these days.

Day 1: ICU. 

I began my day at a local community hospital ICU by going on rounds. For those of you who have never gone on rounds, it's quite an overwhelming experience. Total information overload. Dr. Saunders, the hospitalist, pharmacist, cadre of interns, and I circled the ICU, stopping in front of each room, going over each patient's current status. Which, for patients in the ICU, is pretty detailed: recent labs, overnight events, medications, lines, and so on. The interns were in charge of relaying all of this information and then answering questions about what it all meant. What did it mean that Mr. Smith's potassium level was low? What did it mean that Mrs. Jones's renal function had worsened? And more importantly, what would you do about it?

Acronyms flew like geese on a fall day, but I quickly caught on to what at least a few of them meant. "SBT" -- spontaneous breathing trial -- is a particularly important one in the ICU for patients who are on a ventilator. SBTs are a good predictor of whether a patient will be able to breathe on their own, off the vent. And getting the patient off a ventilator as soon as possible is key, because the longer someone is on a ventilator, the more likely they will stay on one.

I was incredibly impressed with the hospitalist, who really took the reins of rounds. He had an amazing memory for both the big picture of a patient's prognosis (are they ready to come off the ventilator any time soon) and for the minute details (what their most recent ABG -- arterial blood gas -- showed). He also integrated teaching so seamlessly into the process, coaching and correcting, but not criticizing, the interns.

Toward the end of rounds, we looked at all of the patients' chest X-rays. First of all, it's not like it is on TV. (OK, OK, nothing is like it is on TV, I know. But bear with me.) On TV, when you see an X-ray of someone's broken bone, it's so obvious. There will be a huge gap there. Or if someone has a tumor, there will be a bright, white, grapefruit-size mass sitting in the midst of a black background. Again, obvious. But with these real-life chest X-rays, it was a mystery to me how the physicians could tell anything from them. They would point to a splotchy, whitish area and say it was pneumonia. And I'd think, "OK, I get it." Then on the next one, I'd think I saw a similar splotchy area, and then the hospitalist would say, "This X-ray looks great!" The way they had trained their eyes to see such detail was just incredible.

This is what I really gleaned from those two hours of rounds: There are two levels of understanding when it comes to a patient's condition and prognosis. And they need to be integrated. You need an understanding of both the minute details, and the big picture, as well as how those details contribute to the big picture. This requires a great deal of synthesis of clinical information and basic science. (Yes, all that basic science you learn does have a place!) The interns struggled with this, understandably; they are fledgling physicians. But for the hospitalist, I could tell this had become second nature to him. That was just amazing to watch.

One thing about working in the ICU is that while some patients get better, some of them don't. But with current advances in medicine, they can linger for weeks, months, even years. So at some point, it's up to the family whether to let the patient go or prolong their life artificially. I sat in on one of those family discussions. It was Dr. Saunders, an intern, a nurse, the patient's daughter, and me, all piled into a tiny office. Dr. Saunders began the meeting by asking the patient's daughter what her understanding was of her mother's condition. As he explained to me later, that gave him a sense of where she was both emotionally and cognitively with the situation. Then he presented some additional facts about the patient's condition and prognosis. Before he even had a chance to give a recommendation, though, the daughter said, "I think I know what needs to be done. I don't want her to suffer anymore." Dr. Saunders agreed, and encouraged her to talk with the rest of her family about the decision. It was a sobering reminder about the nature of life, and of death.

Dr. Saunders told me afterward that this meeting was one of the easier ones -- people aren't often receptive to the idea of letting go of a loved one. Even if, from a physician's standpoint, it is the best thing for the patient.

Later, I got to see something of a "zebra." (That's doctor-speak for a rare condition.) Dr. Saunders and I headed to the ER to do a pulmonary consult on a woman who came in with severe chest pain and shortness of breath. The diagnosis? Catamenial pneumothorax of the left lung. A pneumothorax is a collapsed lung. A catamenial pneumothorax is a collapsed lung associated with a woman's menstrual period, and with endometrial "implants" on the lung or pleura. No one seems to know exactly how or why this happens. But it had happened multiple times to this woman. The physicians decided to treat her with a chest tube and later VATS (video-assisted thoracic surgery) procedure. Which sounds really scary but is actually minimally invasive and allows the surgeon to repair the problem.

We also saw more patients, had another family meeting with the relatives of a man who had had a stroke (this one over the phone), and somehow managed to squeeze in lunch at the infamous hospital cafeteria (the food was actually pretty good!). Never a dull moment. And every moment something different. That's one thing I really liked -- the variety of the day, what we saw and what we (well, technically he) did.

Day 2: OR. 

The OR is a place where what seems like magic happens. The surgeon cuts a person open. The surgeon removes things, implants things, repairs things. The surgeon sews the person shut. But all of that is made possible because the person is unconscious, kept unaware of the trauma their body is undergoing. Making that happen is the anesthesiologist's job.

Dr. Matthews, the physician I was shadowing, got pulled last-minute into some administrative duties (he is the department chair of anesthesiology at the hospital where he works). So I spent part of the day with two certified nurse anesthetists, who perform anesthesia under the supervision of a physician. Between Dr. Matthews and the nurse anesthetists, I now have a better picture of how complex anesthesia is, and how fascinating.

At first glance, anesthesia might look easy. You stick a tube down a person's throat, pump them full of drug cocktails, and let a machine regulate their breathing. But there's a reason they make you go to medical school to be in charge of this stuff. It involves the subjects of biology, chemistry, physiology, and pharmacology (to name just a few). It involves understanding all aspects of a patient's history and how that history interacts with the situation at hand. It involves rapid decision-making, sometimes in crisis situations. It also involves patience, compassion, overall good bedside manner, and a sense of teamwork. (Oh, and it helps if you don't faint at the sight of blood.)

I observed two surgeries that day: a tummy tuck and an arthroscopic shoulder surgery. And I watched two nurse anesthetists at work. One thing I noticed -- which they corroborated -- was that they each had their own "style" of working, and of relating to the surgeon, surgical tech, and other nurses. They both explained to me that there are different ways of accomplishing similar things (such as pain relief, for example), and that different practitioners prefer different methods. One of them told me, for example, that he prefers to avoid using certain intravenous muscle relaxants because they require you to use another drug called a "reversal" to reverse the muscle relaxant effect at the end. He said that in his experience, patients who received those drugs seemed to experience more nausea after awakening.

Something else that really stuck out to me was that at one point during the shoulder surgery, the patient's blood pressure became a little low. Not dangerously so, but lower than the nurse anesthetist wanted to see it. He had two different drugs he could use to remedy the situation -- one would raise both blood pressure and heart rate, and the other would raise blood pressure while decreasing heart rate. The problem was, we didn't really want to mess with her heart rate at all, so what to do? He chose the second drug, based in part on the woman's age and medical history, and how the drug would affect her based on that history. Lo and behold, a few minutes later, her pressure was back up, and her heart rate had only decreased a couple of beats per minute. It was incredible.

As with working in the ICU, life in the OR is anything but boring. Every patient is different, and requires something a little different from the anesthesiologist. Keeps you on your toes. And I like that.

*Names have been changed.

An Adage A Day ...

"A picture is worth a thousand words," if you believe the common adage. Depending on the situation (and on the picture), that can be true. In the context of medicine, for example, you need pictures of human anatomy -- not just words describing human anatomy -- to learn about the body.

That said, another adage takes a different view: "The pen is mightier than the sword." This speaks to the potential power of words over forceful actions, especially in diplomatic situations. (I could probably make a really bad surgical analogy here if I tried, but I'm not going to.)

In sum, pictures, actions, and words all have their respective places.

As a writer, I believe in the power of words, not only on their own, but also to shape our actions and our mental pictures of the world surrounding us. And when it comes to words, people have had plenty to say on the subject of medicine. In many cases though, what makes someone's words memorable has less to do with what they say than with how they say it.

With that introduction, I would like to share some particularly memorable medical adages that I have collected. All of them come from a 27-page editorial that was published in 1928 (yes, you read that right) in The Bulletin of the New York Academy of Medicine. You can access the whole article online here.

Popular Chinese sayings

The unlucky doctor treats the beginning of an illness; the fortunate doctor the end.

It is easy to get a thousand prescriptions, but hard to get one single remedy.

Before thirty, men seek disease; after thirty, diseases seek men.

Chinese literary aphorisms

Men worry over the great number of diseases; doctors worry over the small number of remedies.
- Pien Chiao

When you treat a disease, first treat the mind.
- Chen Jen

To avoid sickness, eat less; to prolong life, worry less.
- Chu Hui Weng

Quotations from the Hippocratic Canon

The highest duty of medicine is to get the patient well; of several effective remedies, choose the least sensational.

Physicians are many in title but few in reality.

Where the physician can do no good, let him do no harm.

To do nothing is sometimes a good remedy.

Science begets knowledge, opinion ignorance.

(Greek physician and first anatomist; 335 - 280 BC)

To lose one's health renders science null, art inglorious, strength effortless, wealth useless and eloquence powerless.

Medicines are nothing in themselves, if not properly used, but the very hands of the gods, if employed with reason and prudence.

He who can discriminate between the possible and the impossible is the wisest physician.

Aulus Cornelius Celsus 
(Roman encyclopedist; c. 25 BC - c. 50)

The art of healing has no more solid base than experience.

The art of medicine has almost no constant rule.

We should not impute the faults of the physician to his art.

Better an untried remedy than none at all.

For major ills, major remedies.

Thomas Syndenham
(British physician recognized as founder of epidemiology; 1624 - 1689)

The art of medicine is to be properly learned only from its practice and exercise.

A man is as old as his arteries.

Jean-Martin Charcot
(Pioneering French neurologist; 1825 - 1893)

Disease is from of old and nothing about it has changed. It is we who change, as we learn to recognize what was formerly imperceptible.

Abraham Jacobi
(German-born physician, opened the first children's clinic in the U.S.; 1830 - 1919)

Treat the man who is sick and not a Greek name.

Nature does not kill and does not heal. If there were consciousness in Nature, she would feel indifferent about what she is, viz., mere evolution.

Sir Thomas Clifford Allbut
(British physician and inventor of the clinical thermometer; 1836 - 1925)

The name of a disease is not, as it is continually regarded, a thing.

William Osler
(Canadian physician and one of the founding professors at Johns Hopkins; 1849 - 1919)

From Hippocrates to Hunter, the treatment of disease was one long traffic in hypotheses.

Common sense in medical matters is rare and is usually in inverse ratio to the degree of education.

Thursday, March 10, 2011

Medical Humor: Hospital Chart Bloopers

One day many years ago I was talking with my dad about his job as a family practice physician.

"Do you know what my most important tool is?" he asked.

I thought for a minute. "Your stethoscope?" It seemed a logical answer.

"No, my pen," he responded.

Insurance paperwork to fill out, prescriptions to write, and probably most of all, the infamous charting. Everything you do and observe as a physician is supposed to go in a patient's chart. As I have seen at the free clinic where I work, this can take quite a while and be a very detail-oriented task, especially if there are multiple issues going on with the patient.

Here I present some examples of medical charting gone wrong, courtesy of an e-mail from my mom. I hope to post more humorous pieces like this in the future, because as the saying goes, "Laughter is the best medicine." Enjoy!

Hospital Chart Bloopers

1. The patient refused autopsy.

2. The patient has no previous history of suicides.

3. Patient has left white blood cells at another hospital.

4. Note: patient here -- recovering from forehead cut. Patient became very angry when given an enema by mistake.

5. Patient has chest pain if she lies on her left side for over a year.

6. On the second day the knee was better, and on the third day it disappeared.

7. The patient is tearful and crying constantly. She also appears to be depressed.

8. The patient has been depressed since she began seeing me in 1993.

9. Discharge status: Alive but without permission.

10. Healthy appearing decrepit 69-year old male, mentally alert but forgetful.

11. Patient had waffles for breakfast and anorexia for lunch.

12. She is numb from her toes down.

13. While in ER, she was examined, x-rated and sent home.

14. The skin was moist and dry.

15. Occasional, constant infrequent headaches.

16. Patient was alert and unresponsive.

17. Rectal examination revealed a normal size thyroid.

18. She stated that she had been constipated for most of her life, until she got a divorce.

19. I saw your patient today, who is still under our car for physical therapy.

20. Examination of genitalia reveals that he is circus sized.

21. The lab test indicated abnormal lover function.

22. Skin: somewhat pale but present.

23. Patient has two teenage children, but no other abnormalities.