Medicine From The Trenches

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

Why I teach…

Introduction

I have been teaching (involved in academia) in some form since 1994 which means that I have “been around the block a few times”. Teaching has been my way of “paying it forward” since I was in graduate school in the 1990s. I use the term “paying it forward” because I was fortunate enough to have outstanding professors at every juncture of my education. Medical school just added patients to the list of persons that I teach which continues to make my practice interesting and fun. I use the word “fun” to describe teaching but it’s not lost on me that my teaching is a way to show how my teachers affected the way that I learned science and medicine which I attempt to pass along to my students and patients.

The first  influential professor

The first professor who had a profound influence on me was my undergraduate physics professor. A “renaissance”  man in every sense of that word, my physics professor would start the class off by playing a few minutes of a Beethoven symphony whereupon he would ask us to identify the work. I was usually the only person to do this as I had spent more than some quality time study the compositions of Beethoven, Chopin and Mozart in my harmony and ear training courses that I had taken when I studied music. My professor marveled at how I could “guess” the identity of the piece with little more than three or four bars. For me, Beethoven, Chopin and Mozart were so distinctive in their styles that my task was simple. If he wanted to “stump” me, J.S. Bach would do the job.

In addition to music, this professor was a prolific writer, photographer and collector of thousands of ideas. My favorite idea was when he spoke of walking though Einstein’s office at Princeton and breathing much of the same air as the famous physicist. My professor also had the gift of being able to explain extremely complex ideas and theorems in a language that added this knowledge to our fledgling knowledge bases. As he filled multiple chalk boards with derivations of quantum theory and mechanics, I learned how to approach a body of knowledge, immerse myself and convey my thoughts and findings within the language of those complex theorems. In short, my professor showed me how to look at the world from the standpoint of mathematics and precision. After one semester of university physics for scientists and engineers, I was transformed.

My mentor in analytical chemistry

My next influential professor was an analytical chemist from Hungary. His influence on me was teaching me to love electrochemistry from the standpoint of chemical analysis. Like my physics professor, my chemistry professor was able to teach the utilization of any and all “tools” in the craft of studying a body of work. My chemistry mentor taught me how to prepare a PowerPoint lecture of a complex subject for different audiences.  He always said that one needed to be able to explain their research, no matter how complex, to other scientists, to scientists in other disciplines, to potential investors and to the lay public. His great lessons have proven invaluable to me over the year of graduate school, medical school and practice. He has a thriving research group that is putting out some amazing experiments because of his ability to bring out the strengths of each member of his team and his ability to get everyone to work toward a common goal. His lessons were great. Like my physics professor, my chemistry mentor was a man of ideas.

My biochemistry/physiology mentor

My mentor in biochemistry was actually a physiologist and a woman. She had a fine analytical mind but was very vulnerable in many areas. My greatest lesson from her was to be able to see collaborative possibilities in a multitude of situations. She had thousands of ideas every day which was refreshing to be around. When she needed to focus on one path, she was unshakable but she always saw the larger implications of everyone’s work and contributions which never went unrecognized.  She admired my quest for knowledge and I admired her ability to cut to the “bottom-line” of any situation, scientific or political. Under her tutelage, I became exposed to the politics of academia and came to understand how to get what I needed to present my best to my students. From my studies with her and under her, I learned how to integrate basic science with clinical medicine. One cannot separate science from medicine as science drives medicine which is its practical application. I also came to realize that since she had been one of Sir Hans Krebs’ graduate students, I was by association, a student of Sir Hans Krebs. Yes, I know the citric acid cycle inside, outside and backwards. One of my favorite tasks in graduate school was to substitute nitrogen for carbon and rework the “Krebs” cycle. (Hint: follow the electrons because it’s oxidation and reduction that “fuels” life on earth).

My first clinical mentor

My first clinical mentor was another renaissance man whose broad interests and talents make him a character. He was a specialist in Internal Medicine who was fond of referring to surgeons as “Philistines” (Orthophilistines, Neurophilistines and others) in the sense that Philistines are ill-mannered and generally crude. Some of his favorite statements were, “Internists practice classical medicine while the Philistines practice common medicine”. To his delight and astonishment, I ended up choosing to enter the practice of “common” medicine and become one of the “Philistines”  for which he always teased me when I encountered him.

The greatest thing about my clinical mentor was that he always gave his patients 100% of his attention and ability. He was a voracious reader and writer who encouraged me to begin reading the New England Journal of Medicine from the day I received my acceptance letter for medical school. He said that I probably wouldn’t understand much of the journal but have a daily habit of spending at least 30 minutes reading a journal would be of great utility to sound practice and education. He suggested that I read the Case Reports from Mass General first thing in every issue and then turn my attention to the Original Articles. To this day, this is the manner in which I approach the New England Journal of Medicine ( I have added about 30 additional journals each week). Again, I see the utility of putting the basic science with the clinical science which cannot be separated.  I am a profound believer that medical students should make it a habit of reading Mayo Clinic Proceedings, Nature Medicine and The New England Journal of Medicine from day one.

My surgical mentor

My surgical mentor is a laparoscopic surgeon who was trained a Duke University. When I met him, I realized that he had the same approach as the rest of my mentors which meant that he is a man of broad interests and abilities. He is an avid distance runner for whom I suspect his running keeps his agile and always active mind on course. He is another mentor who is able to put a strong team together where everyone’s strengths are highlighted. From my surgical mentor, I learned to never give up on any patient for any reason. When that 30th hours is creeping up and one is fighting sleep and a wandering mind, my mentor taught me to find a “kernel of focus” and build upon it. He also taught me the utility of rounding alone late at night when one can see the patient with renewed perspective. His late night teachings were some of the best (yes, he was up at 4am too). He taught me to rely on my training and thinking rather than emotion though I suspect that his emotions are far deeper than he shows on the outside. Under his direction, I became fearless to a certain degree and confident in my skills as a surgeon. The most outstanding characteristic of my surgical mentor is that he loves to teach and thrives on the excellent training of those who are under his direction.

Common thread

The common characteristics of my mentors over the years is that they are people of diverse ideas and interests. Every year at the start of a new year, I strive to get back to the characteristic that I most admire in my mentors. At each year’s end, I take stock of what I have learned and appreciate in this journey of medical practice. I know that I am fortunate to have had an opportunity to have been taught by many outstanding professors who have left their profound influence. I also know that there are those who I hear “whispering” in my ear on a daily basis. No matter where you are in your training in medicine, you should stop and take a minute to thank the people who have taken the time to teach you something. It’s good to remember that not all lessons are learned in the classroom and that it’s a privilege to have a mind that allows one to learn from a good professor.

31 December, 2011 Posted by | academics, medical school, medicine, surgery | | 4 Comments

Taking Stock of the First Semester

For most people in school, it’s the end of your first semester of something. That “something” might be your first year semester of medical school, college, clinicals or even the first half of your first year of residency. With the end- of -year holidays brings a time of reflection and adjustments for most people. My first thoughts are to tell anyone who is doing a first semester “post-mortem” to make sure that you don’t forget that you actually were able to survive your “first”. The next thing to do is to figure out what might need to be tweaked, removed or started. For most folks, no major changes are needed but don’t be surprised at how a small adjustment in one area can reap huge benefits in others. It turns out that life just works in that way.

There are some things that I have been telling my patients to institute for the last two weeks of 2011. I don’t call these “New Year’s Resolutions” because they can become habits for the new year rather that something that will be forgotten by the second week of January. These are:

  • Perform at least 10-minutes of exercise of some type per day.
  • Give up meat for three dinner meals each week
  • Don’t patronize any restaurant with a “drive thru” window (Sorry Dunkin Donuts!).
  • Don’t add salt (NaCl) to any food before tasting it
  • Try a new vegetable each week (most stores have a great selection).

Taking each one of my goals

I know that every study out in the news media states that one needs at least 30-minutes of exercise 5 to 6 times each week but I know that if one strives for 10-minutes, they will increase to 20 minutes and get to 30 pretty quickly. I am a person of small increments of change working better than one large increment that does not work. Like your studies, exercise can be divided into small manageable bits that can be checked off and mastered. A 40-page paper is written one letter and one page at a time. Daily systemic practice of one small change can lead to larger and better results as that practice becomes a welcome habit.

I also encourage my patients to allow their 10-minute exercise break to be a time when they don’t multi-task. This means that this break should be a true break from cell phones, tablet computers (well maybe the I-pod/MP-3 player) were the mind can be refreshed and renewed. Couple that with getting one’s heart rate up and you have a true “mini-vacation” that decreases stress and makes the rest of your day more efficient. If you want more of a challenge, go up flights of stairs on your 10-minute break. Your brain and joints will be grateful for the movement.

In getting to know vegetables/fruits again, one can develop a relationship with color, texture and anti-oxidants. While I know that fast-foods are wonderful time savers, those heavy fat meals are terrible for keeping alert later in the day. If one does the burger/fries routine for lunch, the rest of the afternoon is spent trying to overcome “food-coma” so that you can get through the day. If you do the burger/fries routine for dinner, one finds that “food coma” can make your studying particularly inefficient. Try making a nice light dinner/lunch of rice noodles and grape tomatoes which can be appealing for the eye and add some “zip” to your taste sensations. One can also have a bag of cut and uncut vegetables, carrots, bell peppers (red and green), carrots and those lovely grape tomatoes in your backpack so that you can snack on something that won’t put you into nap time during your study time. One can also invest in great spice mixtures, curry powders and chilis for waking up taste buds and mental clarity.

If I have one vice, it’s a hot, fresh cup of Dunkin Donuts  (DD )coffee. I just have to stop by the shop, get out of the car and walk in to get my steaming cup. I can drink this coffee black and enjoy its rich aroma and flavor. For me, DD coffee is less harsh than Starbucks (though I will drink Starbucks when I can’t get DD) and is a nice break during my day. In the late afternoon, I often reward myself with a nice hot cup of coffee or tea (Twinings Earl Grey) rather than something fatty or sweet. I try not to drink anything with caffeine after 5pm if I anticipate getting into bed at my usual time. Since I get up around 3AM most days, I find that I need to be in bed before 11PM most night for sleeping. If I am on call, all bets are off and I enjoy my coffee/tea at any hour. When my favorite Dunkin Donuts shop put in a drive thru window, I had to change shops because I don’t want to break the drive-thru habit.

Finally, the NaCl habit is one that most of my patients need to skip. The American diet has increased the love of that salt taste in most people in this country. Since most of my patients have more than a passing experience with hypertension and diabetes, I do encourage them (and my students) to tread lightly where sodium is concerned. This is why most “fast foods” are not good diet choices. Couple the high sodium content with the high fat content and one has a potentially troublesome combination. Do keep in mind that it takes some time to get used to eating foods without salt and to lose that love of salt. For me, it was difficult to get used to eating baked potatoes with no added salt but now I use pepper and happily enjoy munching on the potato (with skin) with nothing other than pepper added to this vegetable.

Taking Stock

Be willing to forgive yourself for doing things that were counterproductive to a strong performance in your academics or in any area of your life. Everyone, even the person who has the highest grades in class, would like to perform better and more efficiently. Efficiency comes with experience and with adaptability. If you can make some shifts and learn from things that didn’t work well for you, then your efficiency and performance will increase. Remember that every day is another chance to do better than the day before. One test, one semester or even one year do not define a lifetime. One can just decide to change your thinking about any subject or taking one step ahead rather than remaining stagnant. No one’s past defines them but the past does allow one to have thousands of experiences to draw from and to learn from.  As you move into the new year, look at one or two small things that you might like to try to do differently and try a to change them one day and one small experience at a time.

16 December, 2011 Posted by | academics, first-year, organization, study skills, success in medical school | , , | 7 Comments

What do I have to know in medical school?

Introduction

If you are asking the question,”What do I have to know in medical school?” then you have already started at a disadvantage. Medical school is not about “what” you “have” to know as much as it is about application of a body of knowledge to problem-solving. Sure, you can sit down and attempt to memorize a bunch of lecture notes so that you can repeat them verbatim but that isn’t going to get you past USMLE (any of the steps) or through residency. Medical school provides a foundation of knowledge that you can build upon. The more solid your undergraduate preparation, the easier you can add to your knowledge foundation that will enable you to treat patients.

Many medical students get into the “whine” about why they have to know so much detailed information when vast information resources are available at the “whisk” of a finger. In truth, the internet is as much of a blessing as it is a curse. No amount of information at your fingertips is going to be very useful unless you know how to evaluate that information and how to apply that information to clinical problems. While many undergraduate institutions are adept at getting students into a mode of being able to “memorize and regurgitate”, they fall far short in terms of providing a solid foundation in research and problem-solving. While there is no lack of information, learning what information to utilize and how to utilize the information that you learn is the biggest hurdle for most pre-clinical medical students. In short, all of the things that are on the internet are not useful or helpful when it comes to patient care.

Becoming an efficient learner in preclinical medicine

Many students start out with the idea that they are going to go home every night and re-copy their notes in order to memorize them for the upcoming exams. They quickly find that this strategy is neither useful nor efficient. The notes are generally an outline of what needs to be mastered in detail with the details largely coming in the form of the information that is stated in class between the bullet points on a lecture outline. Simply recopying notes will largely get one to the point of being a good “clerk” but generally doesn’t provide much of a basis for the depth of understanding that is needed for knowledge base mastery. In short, the Powerpoint lecture notes and the review books are just not enough by themselves for a thorough understanding. One just cannot “memorize the bold heading” and expect to be ready for board exams or course exams for that matter.

What is “efficiency” in learning pre-clinical medicine?

Efficiency is largely making the most of your attention span plus making sure that you synthesize and incorporate new knowledge within the context of the knowledge that you came into to school with. Many students who didn’t major in the sciences will lament that they just don’t have the background that their fellow students would have in subject A or subject B but an efficient learner will not only have the background regardless of major but will be able to add to that base with ease. In short, everyone who takes the pre-med coursework, has the background knowledge base to do well and be efficient in medical school.

If a person majored in biology as pre-med, the upper division biology courses required General Biology as a pre-requisite the same as Gross Anatomy and Biochemistry only require General Biology and General Chemistry as pre-requisites -note that I didn’t mention anything about Organic Chemistry as Biochemistry is far more related to General Chemistry than Organic Chemistry. If a first-year medical student didn’t major in science, they are at no more of a disadvantage as long as they know how to add to their pre-med base and build upon that base. In short, it’s a good idea to stop “talking” or “thinking” ones self out of a strong performance because of perceived perception that upper division science courses give an advantage. In short, the upper division science courses are only advantageous to folks who anticipate graduate school in that  subject matter.

In one wants to become an efficient learner, the subject matter is fairly irrelevant but the study techniques are quite relevant. One has to have an approach to new information that is devoid of emotional reaction, self-deprecation and a willingness to adapt to whatever comes next. Adaptability is a very useful characteristic for learning new material and thankfully, your brain is “wired” to adapt to new situations if you allow it to do the job without emotional checking. One has to have the confidence to dive into what needs to be learned, master what needs to be learned and to readjust if their first attempt at mastery falls short.

Confidence, the best learning tool

When I speak of confidence, I don’t mean that one boasts or constantly “pats their own back” but I mean that one has to have the ability to move past and learn from those myriad of small mistakes that will come with adjusting to any type of professional school. Some folks mistakenly believe that once they achieve a “high” board score or a good grade on a course exam, that they are in the upper echelons of medicine and can’t make any mistakes. Being able to bounce back and learn how NOT to do something is a valuable as knowing HOW to do something.  In every aspect of medicine, it’s the experience that will trump anything read in a book or in lecture notes but with experience should come making mistakes and making adjustments from those mistakes. In surgery, for example, skills are honed from practice and more practice but experience with practice is the best teacher and the best method of learning.

Learning in isolation

I hear over and over from medical students that they are just “not group studiers”. In medicine, one has to learn to interact, learn from and teach other members of the healthcare team. Nothing in medicine is done in isolation which means that the sooner one gets used to working with a variety of others both friends and colleagues, the better they become as physicians. I always remind the residents who are rotating with me on my service that it was a physician assistant who taught me the skill of closing the chest. This PA had spent years doing chest closures and knew how to teach in a manner that was great for a resident who was in the learning stages. My thoracic surgery attending was brilliant and guided me in many ways but that cardiothoracic PA taught me how to handle sternal wire efficiently and safely in the step-by-step manner that a junior resident needs to be taught. In short, the best physicians learn to appreciate knowledge from any good resource and learn to appreciate anyone on the team who is dedicated to the perfection of their craft. This holds most importantly for pre-clinical medical students as well as residents who are further along in their learning. Work with anyone at anytime who is willing to share their knowledge with you or who needs the benefit of your counsel. The ability to work with others and learn from them  will pay back in the years to come.  One cannot afford isolation in any part of medicine.

Getting along with others

While most of your learning is your responsibility, you have to be able to work with potentially any number of diverse people on a health care team. I vividly remember overhearing one of my fellow medical students  who was from India talk about a resident who was from Kenya. This medical student joked about how he “had it made” because the attending on the service was from India and the resident’s opinion wouldn’t really “count” in his grade for the rotation. Well, that medical student was pretty surprised to find out that his “honors” didn’t materialize because he just wasn’t receptive to learning from a resident whose ethnicity was different. He appealed his grade to the attending and to the dean of education but it stood because he wasn’t ready to work professionally with another person who had earned the right to be a resident and who attempted to teach. In short, professionalism means that one has to be able to work with a broad range of people and treat a broad range of people with respect.  The first mistake that many medical students will make on a rotation of any sort, is believing that they can’t learn from anyone except the attending physician who is in charge of the service or that they can treat anyone associated with patient care in a manner that is disrespectful.  I will often question nursing assistants, environmental service workers and nursing staff about the manner that students and residents treat them on a day-to-day basis. In short, everything on a clinical or in pre-clinical coursework always “counts”.  It’s just as easy to treat everyone  with respect (becomes a habit after a while) and not have to worry about offending  (or impressing) anyone.

So what DO you have to know in medical school?

You have to KNOW:

  • How to be an efficient and self-directed master of course materials.
  • How to work within a very diverse population of patients and healthcare workers.
  • How to make adjustments after trying something that didn’t work as well as you thought.
  • How to recognize that every experience is a learning opportunity and be open to the learning.

13 December, 2011 Posted by | academics, difficulty in medical school, medical school | | 4 Comments