When Med Students Pretend to Know

Hugh: So, Doc tells me to go ahead and do the vag exam. I'm hoping he'll, you know, teach me how to do it. So I get gloves on...wait for Doc to come and help me out. I pretend to spend ages looking for lube hoping Doc will join me, the nurse gets annoyed and asks if I am going to do exam or not. I put on confidence face hoping that it hides fear face and tell her uh yeah! as I realize doc is actually now scrubbing up and has no intention of teaching me.

So I put a finger in and think Shit! what am i supposed to be feeling for? I kind of move my finger around and try to figure out the noteworthy anatomy and all I can think of is the vagina is so spacious! I can't feel a damn thing! Then I think if only I could put TWO fingers in, then maybe I could feel something...but I don't want to look greedy so I just keep to the one. How are you supposed to feel anything in there? How are you supposed to actually do a vag exam??

Me: [Initially unable to speak due to fit of laughter and piece of chicken lodged in my throat] Dude, first of all, never put the words 'spacious' and 'vagina' together in a sentence ever again. Second, two fingers isn't 'greedy' it is proper technique. Third, there is a reason it is called a bimanual exam.

That was an excerpt from recent dinner conversation with MD student currently on obs/gyn rotation. In fairness, Hugh is actually a very smart, personable, and responsible medical student. And yes, he had consented the patient to perform a vaginal exam under anesthetic prior to her procedure. It is probably good that she was asleep.

I am sure the nurses thought he was a complete idiot while they watched him flounder. But this whole story illustrates one of the pet peeves I have about medical culture. Medical students are students which means they are allowed to not know the right dose of clopidogrel the first time they see a heart attack. They are allowed to not know how to do a bimanual exam the first time they are faced with a real person and not a doll during a 1st year clinical skills lab. But yet the culture of medicine makes you think that you should know everything at all times and if you admit to not knowing, you are admitting to being a sub-standard medical student / future doctor / human. So as I nurse I witnessed loads of medical students pretending to know how to do something and not asking for help or not admitting they hadn't a clue.

It is scary that even as students we are afraid to admit we don't know, admit when we need help, or admit we're in over our heads.  What happens when we grow up to become real doctors?

*Shudder*

I know there is a fine line between looking incompetent and looking like someone who might have a clue, and clearly everyone would rather be in the latter category. But I can honestly say that in the past when I've admitted that I didn't know something in similar situations the person is usually happy to explain or demonstrate (passive-aggressive bullies, aside). In fact, afterwards (again, passive-aggressive bullies aside) the teacher generally trusts you more because they've seen that you're willing to admit your shortcomings, i.e. that you are safe.

I fear that many more botched vaginal exams will occur before medicine accepts learning and ignorance as part of medical education. In the meantime, confidence face?

I Simply Could Not Help Myself

When Nerds Bake or My Version of a Rorschach

Or Rawscone test, if you will...

Question:

When you see this photo of dough about to go in the oven what is the first thing that comes to mind?

a) mmm....scones
b) cardiac axis
c) the apocalypse
d) pink bunnies


Results:

If you answered 'a' you are a normal, high functioning person in society.
If you answered 'b' you are either in medical school or residency.
If you answered 'c' you ought to seek professional help from someone who has completed 'b'.
If you answered 'd' you are probably taking pills given to you by someone who has completed 'b' or someone who sells things in back alleys.  

Racing: The Irish Way

 

A few weeks back I convinced my brotha-from-anotha-motha, Ryan, to run this 10 mile race. So he signed up. 

I balked. He trash-talked. I registered. I regretted.

It was actually pretty fun.

The drive there was an adventure, at one point the GPS (who I've named Dunce Cap or D.C for short) even got lost, telling us to turn left but mapping us to the right and then getting all hissy when I went left. I really want to throw that thing in the majestic river Shannon most days.  Though the road (pictured above) was scary and narrow, the directions were typically Irish ('after a long bend in the road take a left and follow that road') we somehow found the place. I had a moment of anxiety the night before when I realised that doing a race in the middle of February is actually a really bad idea. You see, it is too soon for there to be any resolutionists (as I like to call them). No one decides on Jan 1st to do a race 6 weeks later. Most would think it is not enough time to train for a medium distance run. And this race, in particular, is known as the 'most challenging 10 mile race in the country'. I'm not sure about this claim as it is possible that it is the only 10 mile race in the country. So, the folks running an ass-buster in Feb are likely going to be really in shape, doing it as a fun day out as they prepare for their next big race somewhere else. 

Oh I so called it. As we pulled up we could see a blur of lyrca stretching and light-jogging up the first hill.  Formidable specimens, they were. I could see the outline of their vastus mediali  from the parking lot (which, by the way, was a farmers driveway, complete with fowl and swingsets, pictured above).

This is what happens when you set a camera timer and try to look tough.

The weather was outstanding. It was indeed a challenging race with loads of hills. But both Ryan and I were happy with our times (Ryan had hoped to do it in 1:30 despite the elevation and he finished in 1:19)! I was hoping to finish under 2 hours since I haven't really been distance running since....oh....2008! But I managed to pull a 1:32 out which isn't exactly olympic qualifying time, but it got the job done. And I was pleased. And apparently haggard.

Hello, beauty.

After the race I drove home, grabbed some food, water, bathing suit, and towel, and headed to the icy Atlantic nearby. My car thermometer read 7 degrees yet somehow I managed to strip off my many layers and plunge in. I am a firm believer in the ice bath. It had to be done and I figured a sunset dip in the ocean would be better than the view from my bathtub.

Turns out, I was right. Shortly after my dip the clouds rolled into this amazing formation that nearly took my mind off the fact that every cell in my body was shivering. I sat in my car, cranked the heat on (sorry environment, it had to be done for a few minutes) and ate my picnic supper. I made a mental note regarding what a lovely date I'd taken myself on, and deciding that yes indeed I would go out with myself again. Once the beach was dark I drove to the gym and vegged out in the sauna and decided that life was pretty much all I ever hoped it'd be. Oh Ireland, I really (heart) you sometimes.

FIRST CUT!!

Dear Diary,

Today I had the chance to make my first scalpel to skin incision. M.C was very nonchalant about the whole thing. I had set up the tray as per usual (thanks to years of nursing and having to set up many a tray for minor ops) and then he just casually said to me, "okay, so work away there...get a blade for yourself..."

Yeah, I tried to play it cool but I am fairly sure that the eyes-popping-out-of-my-head-with-questioning-stare gave it all away.

He smirked and pretended to have something to do away from the patient while I went about (excitedly) excising my first skin tag.

This was followed by a sebaceous cyst excision and another skin tag removal (of a patient I had seen 1 month ago and booked for the procedure). She said she hadn't felt a thing, and that I was worth every penny that he was paying me. HA! I shall never let M.C live that one down.

I was pleased to learn that I have a steady hand and do indeed get a rather large kick out of cutting people (in the socially acceptable cutting to cure sort of way). I am sure that such a milestone is something you never forget. Course I am happy that this happened in one of my favorite little hospitals, on Valentine's day nonetheless.

Today was a good day.

Sincerely,

ABB

Surgical Field Trip

Headed for the hills today for a surgical assist field trip. M.C took me with him to the wild and wooly west coast for an operating theater day in one of the remote hospitals.

I have Monday's off (from GP) but was more than happy to spring out of bed at 0545h, knowing that I'd have the chance to be first assist and 'camera woman' for all the cases today.

And indeed, it was well worth it. Worked a lot on my sub-cue suturing skills and scope handling. Lots of neck craning and nervous sweat. So. Much. Fun.

I really cannot pretend to be aloof about this whole surgery thing. Pretty soon I'll stop sheepishly mumbling and toeing the floor when people ask me what I want to be when I grow up. Not today, but pretty soon.

You Know You Live in Ireland When...

Driving home from the race today we hit a bit of a traffic jam.

Eventually they decided to let us pass...

Never a dull moment behind the wheel in this country!

Abort! Abort Mission!

My old roommate, Scott, and I used to have this secret hand gesture that we'd use at parties, called "the tap". If one of us was embroiled in a conversation that was giving us a rash we'd lightly tap on the underside of a table, beer can, ashtray, anything we could find. In our perfect, imaginary world you were actually tapping a small, invisible button that would do one of two things: either open a slide chute below that you could escape through, or activate a team of ninjas that would break through the windows, tumbling in, swinging on black rope.

The ninjas would surround you and then whisk you out of the room in a flurry of ninja-like moves. Either way you were freed from the shackles of painful small talk, irritating diatribes, drunken blathering, whathaveyou.

The other day I found myself reflexively tap...tap...tapping to no avail. The conversation went like this with a young fellow medical student...

Med Student: Why on earth would you go into medicine if you were a nurse? I mean, you already had a career, and a paycheck?

Me: Well, just because you are getting paid to do something doesn't mean you should keep doing that thing forever, right? Other things are required to feel fulfilled and happy in your career and life.  I was--

MS [cuts me off]: I mean I had no burning desire to do medicine, I just picked it based on a process of elimination, seemed like it'd be alright. But if I'd been a nurse already I'd never bother going into medicine!

This is the part where I had a flashback to all the money, blood, sweat, tears, and time that it took me to get into medical school. Then a quick roll call of some of the Canadians in my class who could say the same. Followed by all the people I know who are still trying to get into medicine.

Me: Er...[not really sure where to start]

MS: Did you do it because you could make more money as a doctor?

Me: It's really not a money thing [tap]...if I was doing something for money I wouldn't start by going $300 000 dollars in debt [tap]

MS: But you'll make tons of money once you're a doctor so it isn't really a big deal.

Me: tap....tap.....TAP.......TAPPPPPPPPPPPPPPPPP! Scott / Ninja's where are you when I need you??????

Slippery Slope

So I've just accepted my first handful of samples from a drug rep.

I shamelessly asked for them (to take myself) and he obliged.

Is this the start of a long and amoral love affair with pharmaceutical reps?

Perhaps.

(For the record, it was vitamin D and also for the record I think the stuff should be mega-dosed into the water table. Just sayin'.)

The Heart of Inspiration

Below is the combination of several pieces that I've written about my granddad and the story of his lectures which were given to me this past summer. I wanted to post this version, which I recently submitted for a school project. I think that (finally) this tells the whole story in the way that I wanted. Apologies to my frequent readers who are probably tired of hearing me harp on about all of this. 

I thought the timing was interesting, as this is another week where I've needed some major inspiration to keep my head up. 

--

My Beginning

I remember the exact moment that I decided to become a doctor. I was seven years old and standing in the front pew at my granddad’s funeral. I had been listening, really listening, to what the mourners in that packed church had to say. Granddad was a doctor. The eulogists spoke of his wisdom, generosity, and kindness. I heard references to his medical innovation, his skill as a physician, and his dedication to patients. Throughout the speeches there were murmurs and nodding of heads, dabbing of eyes. I was mesmerized by the sea of stricken faces behind me, feeling the powerful impact his life had had on all of these people. I saw very clearly a glimpse of what a meaningful life looked like, the legacy that was left behind. I knew I wanted to leave a similar mark on the world and I remember determining, in my seven-year-old mind, that like my grandfather, I would be a doctor.

Long Before That

My granddad, Russ Taylor, fought in WWII. For his service as a navigator in the Royal Canadian Air Force, he was granted free tuition in the university and program of his choice.  As a fifteen-year-old Russ had heard Norman Bethune, famous humanitarian and champion of universal medicine, speak at his high school.  From that time on Russ had wanted to study medicine. But the Taylors were a farm family with six children so Russ had attended normal school to become a teacher. And as well, in a part-time job his hand had been deformed in a printing press.  He never imagined that because of the war his dream would be realized.

For his post-war training Russ chose biochemistry and medicine at McGill and went on to become, first, a legendary rural family doctor and eventually a polio expert. He was on the team of physicians who brought the first iron lung to Canada. In his forties Russ studied internal medicine and then specialized in cardiology.  After further training at McGill he returned to set up the first Cardiac Care Unit (CCU) in Alberta.

Even after being diagnosed with cancer Russ Taylor continued to work in cardiology, still visiting his long-surviving polio patients.  In his last months he wrote an account of the polio epidemic for the university and he was working on a cardiology textbook when he died. The cardiac ICU at the University of Alberta hospital is named the Russell F. Taylor ward in his honor.

It almost feels wrong to extol the virtues and accomplishments of this truly humble man who was never comfortable with praise. Because I was a child when he died most of my knowledge of him is second-hand. I have only a handful of my own memories… watching  him play the piano, sitting with my head on his chest listening to his mechanical heart valve (consequence of childhood rheumatic fever), sharing scrambled eggs with him in the morning before he left for ward rounds.  I also remember clearly that he was one of the few adults who spoke and listened to me with genuine interest and delight… with respect for my personhood.

 All of my life I've been steeped in stories of his astounding medical career, his profound love of medicine, his intelligence, insatiable curiosity, and his interest in the world around him. Each of these stories is locked in my memory coupled with the sadness that I was never able to know him as a health care practitioner, myself. Sad that I could never hear his opinions on certain procedures, ethical dilemmas, learn what he loved about medicine, or find out what frustrated him. Ultimately, I feel cheated that I never was able to have him as a mentor. Others have often described him to me as the 'greatest teacher and mentor' and yet I never had the opportunity to learn from him.

My Granddad’s Voice

In the spring of 2011 my mother woke up one night thinking about a couple who been good friends of my Granddad’s, Dora and Richard Lam.  Dora had arrived in Canada as a young Chinese woman, to study at the Southern Alberta Institute of Technology in Calgary. After finishing her secretarial program she became my Granddad's medical secretary. Over time she and her husband, Richard, developed a close friendship with Granddad.  At that time Richard was a masters student trying to gain entry into medical school.

Knowing how much I valued learning more about my grandfather’s life, my mother set about trying to find the Lams in the hope I could someday meet them.  And I did meet them.

It was the week before my writing of the USMLE. I was feeling guilty for taking a day off from cramming for the exam, but at the same time I was looking forward with delight to meeting them and gleaning a few more details to add to the mental portrait I have of Granddad.  It makes me feel somehow closer to him when I hear about him from people whose lives he touched.

According to Richard, it was my Granddad's letter of reference that got him into medical school. His interviewer commented on the weight that a recommendation from Dr. Russ Taylor carried. Dora claims my Granddad was very much like a father to her, and that she would never have become a "damn good lawyer" if it hadn't been for his continuous support and encouragement. When people with tears welling up in their eyes tell you things, you simply have to believe that they are telling the truth.

At one point during our lunch, Dora pulled out a small bag that she had brought in with her.  She told me it was something that she'd kept for the past 30 years, through three residential moves…something she wanted me to have. Even before she pulled out the contents I felt my pulse quicken. "This is going to be a treasure," I thought. It didn't matter what it was...whether it was going to be an old pager, or a chart he had signed, a fountain pen...anything. I couldn't wait to see what the gift was.

Dora handed me a collection of audio tapes. All the hours of my Granddad's cardiology lectures to 3^rd year medical students.

She had been the one who typed up the manuscripts for him, and she had kept the old reel-to-reel tapes in a box in her basement. "These are his lectures on cardiology and his notes for the cardiology textbook that he was working on. I could never bring myself to throw them away. And now I know why,” she told me.

I was overcome with emotion.

All my life, all my adult life I have wished that I could hear my granddad speak to me about medicine.  And now that would happen. I couldn't contain myself. The tears poured down my cheeks. There in the trendy restaurant with a handful of photographs on the table and an empty coffee cup to stare into, I could not wrap my head around it. There in the final week of a very challenging year, studying for a terrifying exam, feeling completely over my head, second guessing myself at every turn…at that moment my Granddad's actual voice was given to me.

It was the boost I needed. Granddad speaking to me across the years, reaching me through people whom he loved. Talking with the Lams about their careers and about Dr. Taylor’s vocation for medicine gave me an immeasurable dose of determination and renewed my understanding of why I chose this path. It was not only because he was great physician, but because I could see how his example and his legacy continues to move and inspire others to meet challenges and make contributions.

I have finally been able to listen to my grandfather’s voice, the sound of which I had forgotten. I hear him talk about his passion, about something that inspired awe in him…Medicine.   

CBC

The radio show, White Coat, Black Art is a national program hosted by Dr. Brian Goldman, which airs on the Canadian Broadcast Corporation (CBC) twice weekly. Dr. Goldman is an emergency physician and best-selling author, and one of my medical heroes. I was thrilled when he contacted me last summer and asked me to appear on the show, for a piece they were doing on nurse and physician communication styles. When his producer asked me if I’d like to contribute again to the show I knew what I wanted to do. I wanted to bring the story of these tapes to life and create a radio piece with excerpts from the lectures.

When the show entitled Inspiration aired on Christmas Eve, it was very well received. A former RN who had worked with Dr. Taylor heard the show and emailed the host to say how much she had enjoyed being a colleague of Russ Taylor’s for years on the CCU. It was also a delight for our family to hear him over the radio waves after all these years… the sound of his voice rousing memories.

My Granddad loved listening to CBC, often sitting in his car in front of the house to hear the end of a program before coming in from a house call, or in later years retreating to his study to listen to a program on his old radio. It was a strange and wonderful gift exchanged between us…these tapes with his voice and my voice responding to them through the radio show. But the lasting gift was to me from him…a reminder of who set me on this path, why I chose it, and how I’ll carry on. Rededicated to my childhood ambition of twenty-five years ago… I will be a doctor.

Why You Don't Want to be an IMG*

Here is a little taste of how you are treated by Canadian universities--below is a timeline of correspondences that started last August when I was offered an elective (by the head of the department) for four weeks this summer. 

Anytime I'd email the hospital staff I'd get prompt, professional replies. When I'd email a question to the university in charge of overseeing this elective every reply started like this (I am the one who put things in bold):

The &*& Visiting Elective Office will not accept any email registrations until after February 1st, 2012 for April 2012 onwards.  I will not be keeping  a copy of this email so please email again on or after Feb 1, 2012 to officially register for this elective. 

(This in reply to a question regarding police record checks--i.e. do I need one from Ireland or from Canada or from both?)

Visiting student applications for the clerkship year April 09, 2012 – February 28, 2013 can only be considered after February 1, 2012. (There are no visiting electives between Feb 27 - April 08, 2012.) Please get in touch with me again at that time and I will provide you with department contact information. Thank you for your understanding.

  

That was a little annoying. But I rolled with it.

When the hospital coordinator emailed my offer and dates to the university a few days before Feb 1st the reply came to me:

 I will not be keeping  a copy of this email so please email again on or after Feb 1, 2012 with the department confirmation (email below from *&* is fine) to officially register for this elective.

So that was a little frustrating. But I just chalked it up to normal university proceedings and waited for the magical day that I could send my offer of elective email....again. 

Feb 1st rolls around. I send in my offer letter. Hear nothing for two days and then get...

Visiting student applications for the clerkship year April 09, 2012 – February 28, 2013 could only be considered after February 1, 2012. Once the mandatory rotation schedules for the next class had been distributed to the departments. As such applications for visiting electives opened Feb 1, 2012.

Thank you for your message requesting elective time at the University of &*&.  Unfortunately, with the increase in the number of our own students we are no longer in a position to accommodate all of the requests we get from visiting students. On Jan 30, 2012 UMEC has just passed a motion that is effective immediately that at the present time we accept applications (medical students) from LCME accredited international medical schools. With the increase in the number of U of &*& and Canadian medical students, it is felt that we can no longer accommodate students other than those from LCME Accredited schools. LCME Accredited schools are only in Canada and the US. Please go to the LCME website for a list of LCME accredited medical schools - http://www.lcme.org/directry.htm

Therefore your elective has been cancelled.  

Repeat.

I would suggest that you try one of the larger medical schools in Eastern Canada to see if they would be able to assist you.

 

I suspect s/he is referring to those Eastern Canadian schools which rejected my applications in the FALL because all the electives were already full there. Thanks, tips, for the help! 

And thanks for the apology for pulling the rug out this late in the game. Oh wait, there was no apology. 

Here are some simple equations for the uninitiated: IMG + electives in Canada = possible shot at Canadian residency

IMG + no Canadian electives = Would You Like Fries With That? + MD + $300 000 Debt. 

It does not make me feel all warm and fuzzy inside when I think about how hard I am trying to get back to a country that doesn't want me. 

Oh, Canada. 


---

*International Medical Graduate

Life One Liner

(I know this is supposed to be a medically related blog but lately it is more like a this is what I am eating and doing in my free time blog. Apologies. The heart-wrenching and hilarious moments of my emergency nursing days are long gone and I am starting to feel like a broken record of worn-out anecdotes. Also, I'm working like a fiend to finish up my research project and special study module as I hope to do an elective in March. I want to be able to leave the country knowing all my little scholastic ducks are in a row and life is organized. A very non-ABB behavior pattern. Usually when I leave the country there is a dizzying storm of clothes, textbooks, toothbrushes, running shoes, papers, granola bars, open luggage, garbage bags, and USB cables around me for 2-3 days...and then *POOF* I disappear. I swear this time, that shall not be. As a result I fear Asystole is not getting the attention it deserves. Hence, blogger guilt. It's like mommy guilt without the cereal in the hair and spit-up on the shoulder.)

Dr. Joe is on annual leave this week so I sat in with one of the other GP's in the practice, I thought I should branch out in his absence. Everyone here is lovely, though I must admit that I miss Dr. Joe's Prairie Home Companion version of social histories. During one of the consults the patient was talking about the age ranges of her four children, aged 6 - 13.  I thought she summarized things so brilliantly, "Ah sure, in my house there is everything from Santa Claus to maxi-pads". What a perfect slice of life. That is one of the things I miss about bedside nursing, the little glimpses into people's lives, scenes I could collect in a shift.

It got me thinking, what would my one-liner of life be right now?

It's all...tupperware and textbooks?

...Band-aids and backpacks?


...practice tests and data tables?


...scones and stethoscopes?


...residency worries and vitamin D supplements?


...bad skype connections and emotional eating? 


Dunno. All of the above I suppose. What is your one-liner these days?