Medicine From The Trenches

Experiences from undergradute, graduate school, medical school, residency and beyond.

Empowering Women

Today, I participated in a cable television show that centered around Women’s Studies and the Empowerment of Women. I had been asked to speak with this group about influences in my life and my decision to attend medical school. I was asked to speak about how my family has influenced me and my achievements.

I entered a television studio/classroom that was filled with women from their 20s into their 60s. There was one gentleman present too as men can find much to learn by taking a Women’s Studies course. At the end of my talk, he asked very probing questions. I had the good fortune to take a Men’s Studies course as an undergraduate which to this day, as a female in a male-dominated specialty, has proved more than useful. I gained great insight and understanding about what it means to be a male in today’s society.

I spoke to the class about the influences of my parents, most notably my mother, who had definite ideas about the education of her children. She simply wanted the best and instilled a love of learning in all of us at a very early age. My father loved to read, write and hold forth political discussions with the family at the evening meal. These discussions were some of my richest childhood memories and the launching ground for my career. My father didn’t care which side of an argument we took, as long as we could defend our argument with logic.

My uncle, a cardiologist, always challenged us to seek new “truths”. He loved research and loved scientific discussion of any manner. He plays classical piano and speaks several languages. In addition, he is a painter and fiction-writer. He inherited the gift of communication that runs throughout my family. At age 70, he decided to study karate with a Kem-Po master.

I spoke of my aunt, who after being disabled with multiple sclerosis, went on to board certification in two specialties, pediatrics and neurology. She practiced medicine full-time until one year before her death at age 72. She loved her patients and they loved her in return. I would accompany her to national meetings and courses as her note taker. It was wonderful to discuss neurology cases and reap the benefits of her keen diagnostic talents.

I spoke of my cousin who at age 58, who is a practicing pediatric neurosurgeon, decided that she wanted to attend law school. He father has been an attorney and she loved the fine logic of his many arguments and discussion. She graduated from law school and practices both law and neurosurgery. She loved her law studies and loves her patients even more. She was the first person to show me the fine points of doing a lumbar puncture. I carry that technique with me today.

The main points that I wanted my audience to realize that that if they have a goal, it becomes real as soon as they imagine it. There are millions of resources available in this country today for achieving your dreams. If you knock on enough doors, one of them will open and you WILL get what you want. You keep your eyes on your goal and you alter your strategy to achieve your goal as this makes life in the United States better than any other country on earth. If you want to achieve here, you can.

The only person whose thoughts about your goals and dreams that matters is you. What you think about your life and your dream will become the truth for you. Alter your thinking and you alter your life. My father always said “If something is not working, fix it”. “If you can’t fix it, then get rid of it”. This was his way of telling me to figure out what I need to do to always do my best and to run my own race.

My mother always said that it takes just as much time to do a task poorly as it does to do a task well. “You might as well have done it the right way and saved time”, she would always remind us. In your studies, in your work, and in your dreams, give yourself the best effort. You may not find perfection but you can look back with pride in your work.

In sharp contrast to the young women that I spoke with the past weekend, the older women were empowered. In turn, they empowered me. To touch one life, to inspire one person, is a great feeling. Yes, I love my work in medicine and surgery but I love meeting the wonderful people that this job has placed before me even more.

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30 April, 2007 Posted by | Women's studies, Young women in science | 5 Comments

Young Women in Science

A couple of days ago, I was a panelist participant in a forum called “Young Women In Science”. High school women (ages 14-17) were invited to attend the half day event where geologists, engineers, a surgeon (me), dentists, biologists, chemists and other women who have scientific careers could tell these young women about their careers and career possibilities. They could also participate in workshops where they could isolate DNA or study the physics of a soap bubble.

I took along some of my trauma photos along with some photos from medical school. I took a photo of our classroom, of bunches of us standing around during lunch and of some residency shots where I am operating or in the trauma bay. The students were just enthralled by some of the things that we showed them. They asked great questions about lifestyle, getting good grades and how difficult it was to be a surgeon.

One very astute 14-year-old noted that I must really like what I do because the hours are so long. She said that couldn’t imagine spending that much time at work each day. I told her that I love what I do so much that it isn’t like being at “work” for those amount of hours. It’s really fun most of the time.

A couple of the students expressed an interest in working with me in the research lab during the summer to gain some experience. I had to pinch myself and remind myself that these were high school students and not undergraduate students. They were thoughtful and eager to experience everything that was out there. There were a few who were not happy about getting up early and spending Saturday morning at a university instead of the shopping mall but for the most part, they seemed to enjoy meeting all of the women who gave of their time so generously.

My thoughts returned to when I was in secondary school. I had such broad interests and checked out everything, scientific or not, that I could experience. My school sent us to plays, to symphony concerts, to scientific exhibits, embassies and to botanical gardens. I took advantage of every speaker and every opportunity to listen, learn and experience new things. I am so thankful that my parents made sure that my school provided these opportunities for the students.

It’s was very satisfying to meet all of the young women and talk about something that I love, surgery. I was taken back to my days of mastery of calculus, chemistry, Greek, Latin and French. To be come educated was the goal of each of the 24 women in my secondary school graduating class. In then end, our minds absorbed every bit of education that was thrown in our direction. It was a great time. We didn’t have proms, football games or cheer leading but we had far more.

29 April, 2007 Posted by | Young women in science | 1 Comment

Keeping up with your undergraduate coursework

If you have “taken the plunge” and decided that you want to pursue medical school, no doubt, you are taking or have taken some science courses. Most pre-medical students will start with General Biology or General Chemistry as General Chemistry is a prerequisite for Organic Chemistry. General Biology is one of the ultimate “survey” courses. A good General Biology course should contain a thorough introduction to the upper-division courses in the major while providing enough depth to cover the subject matter on the Medical College Admissions Test (MCAT). The bottom line is that General Biology can introduce hundreds of terms and concepts that are the basis for your major (if you decide on Biology).

Your General Biology course should have a very strong laboratory component. These labs should be designed to demonstrate and emphasize the terms and concepts that you studied in the lecture portion of your course. In general, these labs should occupy about 3 hours one time per week in order for you to make the most of your experiences here. My General Biology course was my only study of botany and I totally enjoyed the afternoon field trips that we were able to take. One of our instructors walked us around campus and explained just about every tree, shrub and flower in the springtime. It was a wonderful experience.

My method of mastering General Biology lecture was to scan the syllabus and figure out how much reading I needed to accomplish before each lecture. I would make a list of terms that needed to be remembered and put this list next to my notes. I would also take notes on one half of a notebook sheet leaving the other half of the paper for summary or notes from my text. By the time I had finished my text reading before a lecture, I would have a sheet of paper with a list of topics and terms that I would listen for during the lecture.

As I said before, I would take notes on the right half of a piece of 8 X 10 inch narrow-ruled looseleaf notebook paper. The left half would be for summary so that I could cover the right half and quiz myself on the concepts. I might also jot down a note or two from the text if there was something that was particularly helpful to the understanding of the lecture.

I would study my lecture as soon as I could. Usually this would be the afternoon after morning lecture. I would study a week’s worth of lecture material every weekend paying close attention to how one lecture was related to the next lecture. In terms of the laboratory, I never went to lab unprepared. I would preview the lab; have a list of the procedures that we would be doing and then look at the questions that needed to be answered for the write-up. Since every lab required a written report, I was able to do half of my report before I actually performed the lab experiments or dissection.

I tackled General Chemistry in much the same manner as General Biology except for solving problems. I always made sure that I completely understood the concept that each problem involved. I kept a running list of formulas that needed to be mastered or memorized. When I had a spare moment, I could pull out my index card of formulas and do some memorization. Again, I would keep at least one lecture ahead of the rest of my class.

An ability to use algebra as a tool is essential for General Chemistry. If your math is weak, definitely shore up your deficiencies before you tackle General Chemistry. There are several short books around with titles like “Math for General Science” or “Math For General Chemistry”. Check out these books and do some math practice if your skills are rusty. If you were required to take College Algebra, make sure that you complete it before you take General Chemistry. You can substitute some General educational requirements and take your Chemistry after you have completed your College Algebra course. General Chemistry can be quite “unforgiving” if you math is rusty or not up to level. The same is true of General Physics.

Your grades in your premedical courses are vitally important for entrance into medical school. Make sure that you thoroughly master this coursework (for the MCAT) and that you keep the highest GPA possible. Doing GPA “damage-control” is very difficult. If you get off to a slow start, figure out your problems and get your grades up as soon as possible. One low grade will not “tank” your application but repeated courses with multiple “Cs” will.

Keep up! Shore up! and Stay Up!

25 April, 2007 Posted by | medical school admissions, pre-med courses | 1 Comment

Going Premed…

(The above photo is me in front of a poster as a graduate student)
At some point in your life, you have made a conscious decision to pursue medicine as a career. For me, that decision came after spending a couple of years doing research with and attending grand rounds with a very high-output cardiologist. At the time, I was far older than many of the professors in most medical schools yet alone the students but I was intrigued by the science and craft of medicine. My cardiologist mentor encouraged me to apply to medical school (after a bachelors degree in chemistry&biology + graduate study in biochemistry) as I definitely had more than mastered the pre-med coursework and had a strong interest in the direct application of my then research (ischemia/reperfusion effects on cell-cell communication).

For most medical students, the decision to pursue medical school comes in high school (or early undergraduate). They sign up for the pre-med classes: one year of general biology with lab; one year of general chemistry with lab; one year of organic chemistry with lab and one year of general physics with lab. In addition, most universities require humanities in addition to science in order to receive a degree. Biology is by far, the most popular major for most pre-med students but definitely not a necessity. Any major (from music to American studies) is a good major for pre-med as long as you are interested in the subject matter and as long as you thoroughly master the pre-med sciences.

For most pre-medical students, freshman year is occupied with General Biology, General Chemistry, English, History, math and a foreign language. Sophomore year is occupied with Organic Chemistry, General Physics and other general education requirements. Sometime during the sophomore year, a major is declared and so forth. The important things to consider are getting your general education requirements out of the way and doing exceptionally well in your coursework.

I was very fortunate to have attended a very strong secondary school. When I entered university, I had already taken Differential and Integral Calculus. My math course freshman year was Differential Equations. I had decided to pursue a double major in Biology with Math as a minor since I was interested in the subject matter. My interests in Biology were along the lines of organismal biology (comparative anatomy, parasitology, histology, cell physiology, biochemistry) and my math interests were very strong. I ended up taking Differential Equations, Applied Differential Equations, Advanced Calculus and Higher Algebra in addition to seminar. The bottom line was that I was passionately interested in this coursework because I was interested in being an excellent scientist and researcher.

At the time, I had no interest in medical school but a huge interest in the subject matter of science. This interest coupled with my study skills, enabled me to thoroughly master the subject matter of my coursework. I cared less about my grades and more about making sure that I knew everything that had been presented in these classes. It was during my freshman and sophomore years that I began to hone my study methods that would later serve me well in both graduate and medical school.

In organic chemistry, my performance in this class was not about getting an “A” but about making sure that I learned the theory and craft of organic chemistry. I made sure that I knew as much about the chemistry of carbon-containing compounds as possible in addition to the basics that I needed to devise synthetic themes. Organic chemistry started with an overview of types of bonding that carbon would participate in along with the introduction of families of compounds. Each family had their own synthetic reactions which intertwined to give more and more synthetic possibilities. My favorite means of devising a synthetic scheme was to take the final compound and work backward to the starting material. I was especially adept at anything that contained an alcohol (-OH) group.

In terms of organic chemistry and other coursework, I did not learn in isolation. All of my coursework was interrelated and contained valuable tools for my future work as a researcher. I never considered any course in isolation. General Chemistry contained principles that were useful in Organic. My math courses were quite useful in Physics for understanding how these principles were studied and developed. For some reason, I always saw the big picture.

Later on, as I moved from pre-clinical to clinical medical student, I could see how my ability to apply the principals of Organic Chemistry to the development of synthetic themes was just practice for applying the principles of my pre-clinical sciences to clinical problems. If I am treating a patient with Peripheral Arterial Occlusive Disease, I have to understand the science of how atherosclerosis is a complex disease process that involves inflammation (chronic) and epidemiology (risk factors). Nothing in medicine is studied in isolation. The nature of the pathological changes that I see in the arterial wall directly affect the physiology of the vessel and the progression of the disease. Organic Chemistry was my launch pad in the sense that it was a course that honed my ability to apply the concepts that I was learning to problem solving from many angles.

When I obtained my second bachelors in Analytic Chemistry (I was passionately interested in this subject matter), I found the ultimate outlet for my interest in problem-solving. My coursework for this degree consisted of Quantitative Analysis, Qualitative Analysis, Advanced Inorganic Chemistry (graduate course), Advanced Analytical Chemistry (grad course in electro-chemistry and mass spectrometry), Advanced Organic Chemistry and Synthesis, Instrumentation, Advanced Spectroscopy (grad course) and one year of Physical Chemistry. In addition, I took an undergraduate research course, Atomic Physics, Nuclear Physics and Analytical Biochemistry. When I began my chemistry degree, I had already taken the freshman and sophomore coursework (transferred in from my first university). I was in heaven in the chemistry lab and in class with graduate students.

Armed with a second bachelor’s degree, I applied for graduate school in Biochemistry and was accepted with full departmental funding. I was assigned to a research lab and began the work that would lead to my graduate degree in Biochemistry and Molecular Biology. My mentor was a cardiologist whose research interests were ischemia/reperfusion and low magnesium states. He was the ultimate mentor in that he was a fierce collaborator and Renaissance man. He had two research labs that contained a powerful group of basic scientists with broad research interests. I was fortunate to become associated with this principle investigator who encouraged me to master and study everything that was of interest to me. These broad interests later led to my application to medical school.

Your premed coursework is not torture (shouldn’t be anyway) but an opportunity for you to lean and master some fascinating studies. It is also where you set your groundwork for medical school. Your pre-med coursework is where you hone your study skills that will enable you to master large amounts of material in a short period of time. Undergraduate pre-med coursework moves at a very slow pace compared to medical school and thus you have an opportunity to build a solid knowledge base that you can apply (especially on the MCAT).

The whole study of medicine involves development of a solid knowledge base and application of that knowledge base to the treatment of your patients. There are few shortcuts to mastery of the materials that you will need for your day to day practice. If you think of your mastery of your pre-med coursework as the training ground for mastery of the study skills that will enable you to obtain your knowledge base, you will be well on you way to becoming an excellent physician. Medicine is the ultimate problem-solving profession which, makes medicine ultimately quite interesting.

23 April, 2007 Posted by | medical school admission, pre-med courses | 3 Comments

What is it that we do in medicine?

There are mornings after a night of weekend call, that I find myself thinking about what I actually “do” when it comes to the practice of medicine. My first encounter with a patient on a call night is usually in the Emergency Department after one of the interns or Emergency Room physicians has asked for a surgical evaluation. Many times, especially if the patient presents in a complicated manner, the Emergency Room resident or attending will call me directly and bypass the junior resident. This is not because the junior resident is incapable of making an evaluation, but largely to save time.

When I get one of these calls, I usually beep the junior resident and we see the patient together with the junior resident taking the lead. It the junior is in the middle of something else, I will start the evaluation and fill them in when they break free of what is demanding their attention at the time. In general, I have no problem “picking up the slack” when a patient needs to be seen earlier rather than later. I also try to pull a medical student or two if there is something of an educational note (definitely in these cases) that I believe will contribute to their learning.

I generally will introduce myself to the patient and begin to ask questions. Last night, I found myself face to face with a gentleman who had a cold right leg. “Mr J, how long has your leg been like this?”. “I don’t know doc, I think since this morning. It started turning color about four hours ago”. “Doc, I don’t want to lose my leg.” He began to plead with me not to “cut off” his leg. At this point, I begin to set in motion a series of orders to get anticoagulation underway for this gentleman. I also phone my vascular surgery attending who is heading in to the hospital. The interventional radiology fellow has the angio suite ready to go in case we need his services but a thorough examination of this gentleman spoke OR to me rather than angio. I quickly thought about my surgical approach and how I would do the embolectomy (removal of a blood clot) from a branch of the femoral artery by common femoral artery approach.

I reassure Mr J, that we are going to do everything possible to attempt to get some blood flow to his leg. I also explain the procedures and strategy which he accepts and understands. I am careful to explain that we have a very short window of time which may have already passed since he does not know how long his leg has been without blood flow. In cases like these, we treat aggressively unless we are sure that the time span is too long to be successful in the prevention of irreversible injury. Since nerves are the most susceptible to ischemic injury, level of pain is a fairly good indicator of injury. This gentleman had a fair amount of pain but not an overwhelming amount of pain.

As the patient was being prepped and anesthetized, I spoke with his wife who had now arrived and was in the surgical waiting room with the couple’s son. She was certain that this problem had occurred no more than three hours ago (more encouraging for me) and that they had taken the time to speak with their primary care physician who encouraged them to call EMS and get to the hospital as soon as possible. I made a mental note to notify the primary care physician as soon as we were done with this case.

Back in the OR, my attending and I scrubbed and examined our operating field. I had asked the surgical technicians to “prep” the entire extremity as minimally, we would remove the clot but we might need to do more. The angio fellow stood by as we would assess our blood flow by intra-operative angiography. I made my incision and carefully threaded a Fogarty catheter into the vessel. I inflated the balloon and withdrew removing several large clumps of clot at the same time. Upon removal of the clot, there was a rush of fresh arterial blood which we promptly controlled. I continued to pass the catheter down both the superficial and profunda femoral arteries until we obtained a strong pulse at both the dorsalis pedis and posterior tibial areas. I also had good backbleeding too.

We shot a quick angiogram which showed both vessels to be open and I closed the arterotomy in the common femoral artery and closed the small incision that I had made to gain access to the artery. The patient would continue to receive heparin anticoagulant therapy and we would watch for signs of re-ischemia and reperfusion injury. The patient was transferred to the vascular intensive care unit.

I spoke with his wife and spoke with the patient’s primary care physician. We would closely monitor this gentleman for signs of reperfusion injury. He might need additional angiographic studies once this immediate threat to limb had passed. I left him early this morning in the hands of the vascular service as I rounded on my patients and headed home. I have called the unit a couple of times and the patient’s pulses are strong. It looks like this gentleman will go home with two legs.

What do we do? I performed an intervention that restored blood flow to a gentleman’s leg. In the back of my mind, I remembered this man pleading with me to save his leg. I was also very careful to explain that even with the surgery, he might lose this leg at a later date. The fact that we were able to restore blood flow is a great sign that all will go well. In this gentleman’s case, the loss of blood flow to his leg was sudden but because of his age (early 70s) he is likely to have some degree of atherosclerotic vessel disease that may need further intervention.

You see a patient in the emergency room and in many cases, you become a significant part of their lives. Your evaluation skills, your procedural skills and your experience immediately kick in and you do what you have been trained to do. The process is almost gradual and you do not realize that it is even happening. That process comes with seeing hundreds of patients and learning the best course of therapy for their problems. The process comes from hours of reading about the pathology of your patient and why you would choose a particular intervention.

I have a very strong interest in vascular surgery. To me, it is a wonderful branch of surgery with many elegant procedures and cases. I also love the patient population that is likely to come in contact with a vascular surgery (middle-aged to elderly gentleman with atherosclerotic vessel disease). These patient generally have multiple medical problems including hypertension, diabetes and some degree of lung disease (former smokers).

When a patient squeezes your hand, looks you in the eye and asks you to save a foot or leg, you know that you are going to do everything possible to do just that. Most of my best vascular cases have taken place in the Veteran’s Hospital where vascular disease abounds. There just isn’t a better population of patients that need the best care than veterans. This is what I “do” in medicine.

22 April, 2007 Posted by | medicine, vascular surgery | 3 Comments

Burnout

I was answering a question from a student on that dealt with “burnout”. It’s that sensation that you can’t see “the end in sight” and that dealing with your high stress is taking a major toll on both your mental and physical health. Many students find themselves in the middle of a depression that seems to add to the stress. Depression is one of the first ways the mind attempts to handle high stress. This cycle becomes a circle of perpetual positive gain unless you find a way to break the cycle.

I certainly remember days when I felt as if I had 36 hours of work to cram into 24 hours. When this happens, I remind myself that I need to stop, get some organization and eliminate some of the small “stuff”. By small stuff, I mean things that are “low yield” in terms of contribution to the major tasks at hand.

There are things and actions that MUST be done daily. Eating, sleeping, showering and taking care of other physical needs come to mind in terms of the “MUST BE DONE” category. If you are employed, you can add work/study and its necessary tasks. There are things that are optional but necessary like physical exercise that make the other tasks go well but if skipped, are not the end of the world. Then there are the “small stuff” like cleaning out your closet, sink, bedroom etc, that are great to do if you have time but can be postponed to vacation/downtime with few consequences.

One of the biggest problems with the “small stuff” is that it becomes the thing that you find yourself doing with the “major stuff” becomes overwhelming. This can greatly add to your stress level but you are looking for relief and anything that IS relief is a temporarly welcome.

Other actions that can greatly add to your stress is that little “inner voice” that keeps telling you that you “should be ” doing something or “should be better” at work/study. The problem with that little voice is that it gets louder and louder the more stress that you find yourself under. As that project/exam nears, that “little voice” becomes a “constant shout”. This is another sign that you need to change something and break the cycle.

The first thing to do is organize your tasks. What do you HAVE to get done? What is the time frame? How much have you actually accomplished towards your major task? You can list your tasks on a sheet of paper and rate them as A, B, C in terms of importance. Your A tasks HAVE to be done; B tasks are good to do and C tasks carry little penalty of not done.

Take each A task and figure out how long it will take you accomplish each one. Your study schedule can be arranged around your class schedule and thus you want to have time to preview, listen to lecture, quick review, study and preview… Get your A tasks taken care of first and be sure to put in some “break time”. It is not efficient to pencil-in “Study Biochemistry 5 hours” because you will be saturated with Biochemistry after 1 hour (for me it was 50 minutes and I AM a Biochemist!). After one hour, take a ten-minute break, get some water, stretch, walk around, get some fresh air and then come back to your desk refreshed.

Check off your subjects as you get them done. This psychologically gives you a boost because you have a sense of accomplishment. Don’t beat yourself because you can’t look out the window and recite every enzyme of the Citric Acid Cycle complete with affinity constants. Your goal is to understand your studies well enough to apply them. For example: Sorbitol is an alcohol sugar that is produed by enzymatic/chemical reduction of an aldehyde group on a monosaccharide. It provides sweetness but does not increse blood levels of glucose or insulin. This makes sorbital a good sweetner for diabetics. The concepts are alcohol sugar, elevation of insulin/glucose in a diabetic and reduction of an aldose. In addition, since it contains more -OH groups than other monosaccharides, too much sorbitol can produce diarrhea too. Stop, try to link your lectures and keep the concepts in mind as you study. How does this fit into the big picture? Instead of rote memorization that puts information into your short term memory, go for understanding of concepts that links your short term memory with your long term memory.

Finally, do at least 30 minutes of physical exercise. Do something that you like and vary your routine. Take a brisk walk or walk up two flights of stairs and come down one. Do three 10-minute intervals of physical exertion if you can’t find 30 minutes in one block. Lean against the wall and stretch/breathe and laugh. This gets rid of stress and helps to keep you calm and focused. Use your 30-minute exercise period to let your mind go anywhere. Don’t try to study during this time, let this be your cheap “play time”. Remember “recess” when you were a child in elementary school. You didn’t combine “recess” with study back then. Don’t combine your exercise with study either for at least 30 minutes. After that, you put on your earphones and listen to drill/study tapes but do at least 30 minutes free of school work.

Keep your life organized as much as possible. Know how much underwear you have and get your laundry done before you run out. Lay out tomorrow’s clothes the night before so you have them ready in case you get rushed or oversleep. Pack a light lunch the night before (you can make a PB & J on your study break) instead of loading up on heavy and high fat foods that drag you down and decrease your alertness in the afternoon. Fold your laundry and stretch at the same time.

Finally, get yourself a mantra that you can repeat to yourself over and over when you find that you are starting to hear that “should be ” inner voice. You know, the only thing that you “should be” is yourself. Forgive yourself (this means that you give yourself permission to move on) if you make (a mistake or mistakes) and keep moving forward. Just because you did something wrong yesterday is not a good reason to do the same wrong thing today. Change your behavior now and change your thinking now. By doing this, you world will change and you won’t know who “Burnout” is.

10 April, 2007 Posted by | organization, stress reduction | 2 Comments