Thursday, November 29, 2007


Dude. Make it stop.

Just when I thought I was out of the woods, homework-wise, they drop the frickin' A-bomb of busywork on me.

I can sum up my misery in four words: Stupid, online, required cases.

Ugh. Apparently, many med schools around the country use them. You log on to a web site and are led through a web of lameness like a small blind child, and are occasionally forced to answer a multiple choice answer or (shudder) type a response in a box. The web site says that the cases should take about 40 min to complete; I've been taking 20-30min each, which is still 20-30min each of my life I will never get back. We are required to complete at least 5.


But that's not the worst of it. They set it up so that you are required to complete at least 5, but that just gets you a pass. To get a high pass or honors you have to complete more LOTS, LOTS more. And although it only accounts for 5% of your total grade (WHY do they insist on acting like your 3rd year grades are objective by assigning things percentages and numbers? It is a total lie. I may talk about this in a future post...) you just know that if you decide to slack and only do the minimum that you would miss a good grade by 2.5% and the you'd just die.

Anyway, the cases go something like this. You open the page and it has a picture of a scary person who as far as you know just broke out of prison. They say,

"Hello. My name is Dr. Doverschlogenmarchowitz. Today we'll be seeing little Timmy, a 4 year old who insists on traveling everywhere by hopping on one leg and has a history of explosive diarrhea. Why don't you go in and introduce yourself?"

Then you click on the next page button and it has a picture of Timmy, and it asks you some kind of question mildly related to the situation, like:

"Explosive diarrhea can stem from many causes, such as watching reality television. Which ONE of the following is the least medically accurate television program?
A. Grey's Anatomy
C. House
D. Diagnosis: Sexy!: The Search for the Hottest Doc in America"

Then you are forced to click on questions for the patient and read their answers and it goes on and on and oh my God it is horrible.

Anyway, I could mock them all night, but really I'd like to finish another one of these stinkbombs so I can go to sleep. By the way, in the interest of full disclosure, I would like to state that I know that at least one of my classmates, an otherwise totally sane human, has stated that he believes these cases are helpful. For this person I would like to suggest haldol. For Timmy, I suggest laying off America's Most Smartest Model.

Saturday, November 17, 2007

Student, evaluate thyself

First of all, WHEW.

I'm done with inpatient pediatrics. One more month left in this rotation, which is a week of newborn nursery and three weeks of outpatient clinics. But the tough stuff is the inpatient, with longer hours, call and weekends.

So, how was it? Well, I am totally beat, but I really like peds for a bunch of reasons I won't go into here. In fact my liking of it is such a majority that it is easier to say what I don't like about it, which is:
1. Crazy adolescent patients
2. Crazy parents
3. 1 and 2 (they often go together)
4. Extremely depressing patients, such as victims of child abuse (shaken baby syndrome being possibly the most depressing) and those with profound CP and mental retardation

Still, even with the above, I could see myself really enjoying pediatrics. Because the vast majority of time, even in bad situations 1-4, you still leave feeling like you managed to help, even in the smallest way.

But that is not what I would like to talk about today. Today I would like to discuss (with my keyboard and my three readers) the idea of self-evaluation.

Most rotations do this in some respect, but peds does it more formally than others I've had so far. At the half-way point they give you a long questionnaire which you fill out in what is supposed to be an intensely self-searching and honest manner, and then you go over it with one of the attendings.

Now, as an oftentimes exorbitantly introspective (and, okay, insecure) person, I found this process both redundant and depressing. Basically, it allowed me to write down all the shortcomings I have been acutely aware of since day one on the wards, while at the same time introducing new and disturbing facets of inadequacy which I may now ruminate over at my leisure. When I finished the forms, and was feeling even more disappointing than usual, I started questioning the utility of this form of review. The way I see it, there are Three Main Classes of Student, and self-evaluation fails each of them, albeit for different reasons:

-The Egotistical Jackass: This is the person who sees most everything as beneath them and their superior level of function. The self-evaluation fails here because the egotistical jackass will never consciously acknowledge that they have room for improvement; if they do it tends to be something inane like "I will try not to make the other students as jealous of my awesomeness." (You think I am lying, but there are definitely students like this out there. Sometimes they actually are pretty good, and sometimes not. Sometimes their ego is kind of endearing, and sometimes it makes you want to tie their vulnerable appendages to your car bumper and drive off.)
-The Oblivious and Often Inappropriate Nutbar: Again, it is surprising how many there are. Most of these people, in my opinion, simply lack introspective prowesses. They say and do ridiculous things and don't seem to understand why they are wildly inappropriate. Example: one of my fellow students, who is so strange and inappropriate that it would not surprise me in the least to learn that he is actually a humanoid robot shell operated by alien beings, actually started pimping us, our interns and our senior resident in the middle of rounds. By name. As in, "(Senior Resident's name), why don't you tell us some metabolic derangements you might see with this disease." It would have been even funnier if it wasn't so sad. Asking them to figure out how they can improve is like asking an cow to derive the equations of motion.
-The Paranoid, Insecure Self-Torturer: I think I fall into this category, and I think the result of self-evaluation for most of us is as I described above. The last thing we need is more stuff to beat ourselves up about.

I think the main goal of this self-evaluation stuff is to come up with an "action plan"; that is, a way to address the areas you think need to be improved. Again, in light of the Three Major Types of Student, I think this step is not useful. The egotistical jackass has not come up with anything reasonable to improve, so it's kind of a moot point there. The Oblivious and Often Inappropriate Nutbar... well, it's best not to delve deeper into their psyche. And the Paranoid, Insecure Self-Torturer formulates about 20 action plans for their perceived areas of weakness every single day on their way home, so to ask them to do it formally is to risk pushing them into Generalized Insecurity Paralysis (GIP) which I think we can all agree is counter-productive.

All that being said, my session was somewhat helpful for me. For instance, my attending moved several areas of self-perceived weakness into the "strengths" category, which was honestly a load off of my mind. Example: my knowledge base. I always feel behind my peers, so having an attending tell me that wasn't true was frankly a load off of my mind. She also did point out that some things I perceived as deficits in my presentations were actually not an issue, but that my lack of confidence was; and as I had not realized my insecurity was so apparent, that was a helpful observation.

So, med school bigwigs, on behalf of my other equally though differently dysfunctional classmates, just tell us what we are good at, and what we suck at, so we can go back to being in denial, or insane, or self-deprecating. Thank you, and I hope I've given you a plan for improvement.

Sunday, November 4, 2007

Like Being in the Ring with Mike Tyson

That is what it's like on the wards for a 3rd year medical student.

You step into the ring and KAPOW!!! You're reeling, you try to shake it off, but before you can JABJABJAB! BODY BLOW! You hit the canvas, they're counting, you stagger to your feet and KABLAM!! Lights out.

What I mean here is, it's tough on the wards for people like me, still trying to figure out what the hell is going on. As soon as you recover from one mistake, you make a complete ass of yourself in front of your team and possibly trip over an IV on your way out. One time I dropped something on a patient's leg, right where she had just had a skin graft. She cried. It was horrible.

Dumbass Moment 1: Presentations during rounds
I swear to God, it doesn't seem to matter what time I get to the hospital to prepare, how much reading I do about my patient, how carefully I write out what I need to say. I cannot seem to get through a single presentation without making some mistake. I wish I could say that I make a new and different mistake every time, but sadly, that is not the case. There is a set of mistakes that I make over and over and over again, forcing the attending to ask things like "So why is this patient here?" and "Are you sure their heart exam was normal? Because that child has a murmur you can hear from Mars." In addition, I'm generally spastic and strange throughout most of my presentations (see "Medical Tourette's" below). You are supposed to go in a very specific order, and sometimes I'll make it the whole way through the presentation, but then people are still looking at me, so I'll just kind of yell "LASIX 30mg PO BID" for no reason.
Yesterday I presented a new patient. I had a particularly bad day the day before, so I worked very hard to shake it off and make it my best presentation, and when I finished, I felt great... for about two seconds. Then a fellow pointed out that I had said "lungs clear to auscultation, except for some scattered wheezes". That's like saying "patient is doing well, except that he is dead". Last week I was actually given a very complex patient to follow, but after one horrible crash-and-burn presentation they switched me to a patient just saying overnight after a percutaneous cath. It was like "There, there. Give mommy the power tool. Here is a nice soft plastic block with rounded edges."

Dumbass Moment 2: Totally off-base answer to pimping question
This happens to me a lot. They'll ask something like, "What is something in your differential diagnosis for lower abdominal pain?" And I'll just blurt out "CHEST TOAD!" It's like I have Medical Tourette's. I say completely idiotic things, and I say them loudly. It's horrible.

Dumbass Moment 3: Flubbing the Interview/Exam in Front of a Patient
I have done this plenty, but my favorite example is actually something a fellow medical student said. He was interviewing a patient's mom about her daughter's vomiting, and he actually said, "Any pets? How about a beaver?"

These are just a few examples of classic Ward Dumbass Moments. There are many more. What makes is hard is that these are inevitably scattered throughout every single day, and you have to find a way to immediately recover from the humiliation and shame so that you can go back to making the next mistake. It's very exhausting. So far Mike hasn't gone for my ear, but I'm sure it's just a matter of time.