Tell me...

Note: Thanks to IHI Open School for asking me to guest write this entry on their blog.

As a first year medical student, I spend most of my time in lecture halls dimly lit by computer projectors learning the basic sciences of medicine. Once every week I get the chance to escape from the lecture halls and spend time in the clinic with patients through a yearlong course where we learn and practice different elements of the patient interview. This course is a welcome reminder of a core reason we are drawn to this profession. However, these experiences are not without challenges.

One of the first concepts we are introduced to is building rapport with a patient and getting to know them as people. Upon this foundation, we add layers of information regarding the patient’s current illness and medical history, social support and family history. Our preceptors also incorporate in these lessons introductions to how to discuss tough issues such as alcohol and drug use, sexual history, and domestic violence. For myself and many of my classmates, it has been difficult to become comfortable with assessing when these questions are appropriate and how to discuss them in a nonjudgmental manner. Even when the patient is actually one of our preceptors role-playing, these patients are strangers and establishing mutual trust is difficult.

Whether asking about possible domestic violence or gathering all the details of the present illness, an overarching challenge that I have encountered as an interviewer is to avoid jumping to conclusions based on a patient’s initial responses. Sometimes, the excitement of remembering a detail in class that might apply to the patient (“It’s the positive pleural pressure!”) inadvertently directs me to jump to specific, closed questions that may miss an important component of the patient’s health. I have to constantly remind myself to go back to the broad, open questions, and I imagine that this balance will be easier with more clinical knowledge and experience.

A challenge from a different perspective is a patient’s reluctance to reveal all the facts or not knowing what information is pertinent to his or her health. The issue is not as simple as the stereotype of patients who lie because they think it will please their physicians, and I did not begin to appreciate this complexity until the first time I was a patient since starting medical school.

My recent visit to the university clinic was for a routine annual physical. As my physician began to ask the same questions that I had been learning throughout the year, I had a feeling of being a detached observer of the interview. I thought to myself, “Well, this is how I would expect a patient to answer,” and then I realized that it was I who was the patient.

For a few questions, I experienced a split second of hesitation to wonder if what I was about to say would be an important detail or if it was just medical school-induced hypochondria. Small things like past tobacco use or an unusual mole. Feeling compelled to be a “model” patient, I did report this information to my physician. She smiled and told me that the occasional cigars in college did not constitute being a past smoker. However, my physician also examined my skin and referred me to a dermatologist. Reflecting on these minimal internal debates, I can only begin to understand what it would be like to be wary of discussing much more serious and personal issues with a physician.

I do not think addressing these issues of communication between patient and physician are as easy as reaffirming confidentiality of the interview. In my observations, the physician does set the stage by expressing empathy and trying to build a connection. I have been surprised that silence can be as effective in interviews as follow up questions. A purposeful pause following a patient response can lead to the patient reframing a more complete response and revealing a significant detail. Yet, I worry if there will be the ability to conduct full interviews as time becomes compressed through medical school and during residency. I hope that my classmates (and future colleagues) and I do not forget the skill of maintaining a full dialogue with our patients.

The Streets of Boston, updated

Here is an update from the personalized Google map of adventures and everyday life that I made in September. It highlights the places I got to document when Stanley came to town as part of a student exchange program in December as well as some communities I've been visiting through volunteer work. It has really been exciting to get to know the city more throughout the year, and I have had a great time showing visiting friends the city. Although I feel very comfortable and familiar with many areas of the city, there are still many parts of Boston yet to be explored.


View Michael's Boston in a larger map

Here's a link the Google map in case the map doesn't show.

Patriots' Day

Runners in Back Bay rounding the last turn of the course

Today was the observance of Patriots' Day in Massachusetts and Maine, commemorating the Battles of Concord and Lexington that started the American Revolution. In Boston, this means that the city is filled with tens of thousands of runners and spectators for the Boston Marathon, the Red Sox host the earliest major league baseball game of the year, and most schools and offices have a holiday.

For us, it meant we had an immunology exam scheduled for four hours Monday morning. I suppose one could spin it as our patriotic duty. We thankfully had the afternoon free, and a group of classmates and I grabbed our lunches and while eating, started walking towards the course. Fittingly, another classmate who saw us heading towards the marathon commented that we looked like a militia.

The marathon is 26.2 miles, and Boston's originates in its far western suburbs. Looking at the course map, I realized that my perception of distance in this city was completely off. The farthest subway line out west did not even go half the distance of the course, and the origin of the race in Hopkinton sounded like a world away from the Longwood Medical Area.

Our small spectator militia dispatched to mile 25 of the course, at the very last turn where the runners can first see the finish line. I can't even imagine how happy the runners were to see the archway and banners of the end and the throngs of spectators lining each side of the road.

The End

We stayed on the edge of the course for over two hours and caught a glimpse of our friends and classmates who ran the course (Congrats Matt, David, Nina, and Jon!). It was amazing how runners just kept going by the entire time. Some were pumping their fists and smiling when they rounded the corner, others were grimacing, and a few were limping. There were runners in packs with jerseys displaying their charitable causes, and even a couple people who were pushing their children in strollers and bicycle-like wheelchairs.

Many people, including some of our classmates, were bandits who ran the course without official registration. While we watched from the side, we saw a dad suddenly hoist his son over the fence so that he could join his mom for the last mile of the race. More than a couple runners were in outrageous costumes including trash cans painted to look like solo cups.

Our favorite pastime was to pick a runner who had marked or pinned his or her name to their jersey, and start wildly cheering them on. Usually, the cheers elicited a smile, a thumbs up, or a pick up in their pace; however, sometimes we got these looks of utter "Who are you, and why are you yelling my name?" I figure this is probably due to the pure exhaustion the runners were experiencing. Otherwise, why would they put wear their name in the first place, unless it was to identify their bodies in case they passed out?

When we decided to head back, the race was approaching 5 hours and still there was a steady stream of runners. While I had strong admiration of their determination and resilience, I was quite happy to be just a new Bostonian cheering on the sidelines that could go home to a warm bowl of soup.

Even the Apple store demonstrates the company's ability to be aesthetically pleasing
and useful (for viewing marathon runners that is)

Giving Thanks

Note: As a follow up to the last post, this is a letter that a couple of classmates and I wrote for a memorial service for our anatomy donors.

Dear family and loved ones,

We are writing on behalf of the Harvard Medical School and School of Dental Medicine Class of 2012 to express our sincere gratitude to the anatomical donors who selflessly donated their bodies and provided us with one of the most important experiences in our medical education.

In the past months, we have had the honor of learning from the first patient for whom we will have responsibility. We did not take this responsibility lightly, and both faculty and students constantly emphasized interpersonal cooperation, professionalism, and respect for the gift we received.

While this course was an emotionally difficult experience for many of us, we never lost sight of the privilege we were given. We came to think of these donors as our teachers who imparted to us some of the most fundamental and pragmatic lessons of medicine. Students and faculty alike believe that these essential lessons are best learned through laboratory experience, and we are thankful to our donors for giving us an education of the highest quality.

Nobody can summarize how we feel better than the student who wrote the following quote shortly after finishing the course:

“This has been an incredible experience, one that has changed me forever. It has been a continuous emotional thunderstorm with ups and downs, but mostly dominated by very powerful feelings. I cannot even express in words my gratitude for our donors. I cried and continue to cry sometimes when thinking about the amazing gift we received. This has been a tremendous privilege and I feel honored, humbled and at the same time overwhelmed by the opportunity that I was given. I am also incredibly frustrated with the fact that I do not know how to thank our donors; I wish I could do something to show them how much their gift meant. I think the only option I have is to become a good doctor, a much better doctor than I would have ever been without them. This has been the greatest gift anyone has given us, and will remain in our hearts and minds for the rest of our lives.”

It is in this spirit that we write to you.

Sincerely yours,

The Harvard Medical School Class of 2012, and
The Harvard School of Dental Medicine Class of 2012

Five Ways of Seeing

Note: in catching up with posting, here is one I started writing when anatomy finished in November.

It's hard to describe the process of gross dissection. We were split into groups of four to each cadaver and armed with four sets of tools, a dissection guide, and an anatomy atlas. No part of the body was unexplored.

Our Lady, of no religious affiliation, was old and thin. Her toenails were painted pink. She had graciously donated her body for us to learn the intricacies of our tissues and vessels. As morbid as the thought may be, she was our first patient, the first person whom we had responsibility over her care although it was far from treatment.

As the class progressed, we found ourselves almost protective of Our Lady--of all our classmates and instructors, we knew her best. No, of course she wasn't a smoker. No, she had no evidence of cardiac heart failure. We received no personal or medical history, and even with the help of a pathologist at the end of the course, we were unable to determine the cause of her death. Strangely, it left me with a feeling of lack of closure.

Working in a group was absolutely essential. We would read aloud instructions from the manual, we had to hold while another cut, and we continuously checked each other to see how comfortable we were both mentally (identifying all the different parts) and emotionally (not feeling nauseous from seeing all the parts).

The eight weeks of anatomy flew by as time does when I feel like I am constantly playing a game of catch up. The last lecture caught me almost by surprise. One of our course directors took the time to step back and recount all the knowledge we had encountered. She characterized the course as the "five ways of seeing." Her metaphor stuck with me as a reminder of how much we had learned and how much we still had to master.

The first, most central way was through gross laboratory. Three of the remaining four were introductions to technical fields intercalated with the dissection.

Histology was the skill and art of examining tissues through microscopes. What initially looked like a piece of modern art could be interpreted as lung or liver or another vital organ.

Radiology was a true practice of specificity; our lecturers would be able to identify body parts and make diagnosis from blurry black and white graphs.

Embryology traced the formation of these organs from a single fertilized egg.

These three ways of seeing the body were exercises in trying to extract arcane knowledge from figures, pictures, and specimens. While it was impossible to forget the significance of our gross dissection, it was maybe too easy to forget that in each CT scan we saw, each specimen we examined, represented a person.

This is an issue I think many of our courses have tried to address--the reduction of human life to a molecular pathway or an interesting radiograph finding. In anatomy, our course director framed it as the fifth way of seeing. It was personified by the few patients that visited our class sessions where they would be interviewed by a physician in front of a full lecture. Families with children who had been born with congenital defects and people that had experienced significant surgical repair came to share their experience and advice.

As constructed as these sessions felt, they were still a reminder of the patients that we will serve using our training in seeing.

The First Buds

From Boston

What a difference 4 months makes. While Boston has the terrible habit of lingering winters, the promise of spring is felt in the sun on a day like today and the small buds that are appearing on the trees around here. Even in class we are reminded that summer is not far from the horizon. We've started our last course for the first year, a combined block of Immunology, Microbiology, and Pathology. It begs the question, where has the time gone?

So in the spirit of spring cleaning, here is a recap of the last few months (with links to photos):

• December: Over the holidays, I saw both sides of my family visiting Las Vegas and Houston. As is always the case with my extended family, the predominant activity was going to restaurants and eating excellently.
• January: After the intensity of anatomy and genetics, January was a relative respite as we took a course in clinical epidemiology and grant proposal writing. This second class was a significant source of stress for many of us as we scrambled to make plans to do research or community service over the summer. Over MLK weekend, I visited a college friend who is a medical student at Dartmouth and had my first, very unsuccessful, experience with downhill skiing.
• February: Our most rigorous class of the year, physiology, was everything as advertised. We spent roughly a week on each human system (respiratory, cardiology, gastroenterology, nephrology, and endocrinology), and this was the first time since starting medical school that I truly felt thrown into the deep end of a pool with my arms tied behind my back. We also started our second semester course in medical ethics. Thankful for national holidays, I spent President's weekend in our nation's capital being patriotic with some SPHINX Buckeyes.
• March: The conclusion of physiology was gratifying because preparation for our final exam promoted working in groups to truly integrate the vast amount of material across human systems we had learned in the short six weeks. Directly following, I finally spent enough time visiting Columbus to feel settled at home, read leisurely, and visit friends.
  

As I recount this, I am chuckling a little bit at the pattern in each month consisting of and . There are experiences that have spanned this entire period including interviewing patients for our patient-doctor course, exploring my interest in the field of humanitarian relief, building friendships with classmates, catching up with friends who pass through Boston, having fun volunteering in the Boston area, and getting my only exercise through intramural volleyball.

While life is presently dominated by the day to day of preparing for class and assimilating medical knowledge and culture, thankfully, there are still times everyday when the tension breaks. Jokes are made, time is allowed to pass by, and the small things in life are appreciated. That is the promise of spring.