Medicine From The Trenches

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

New Gross Anatomy

Many medical schools have gone from cadaver dissection to prosection to digital dissection in their Gross Anatomy labs. Certainly concerns of inhalation of formalin are removed with digital delivery but hands-on dissection of the human body is quite sacred and tremendously educational for a physician. I also understand that digital dissection is far cheaper than having cadavers for teaching purposes.

With digital dissection, many lose the ability to see the variations possible. When I was in Gross Anatomy Laboratory, it was wonderful when another group shared an anatomic variation or a great dissection with the rest of the class. We could see and touch it. It was the touch with the appreciation for anatomy in three dimensions that was a wonder. That three-dimensional anatomy and seeing structures within context probably crystallized my love and appreciation for the variations I see in surgery on a daily basis.

All human bodies are a wonder to observe, examine and treat. On any given day, each patient with their capacity to heal, is a marvel that can’t be made by man. My study of medicine after study of biochemistry, deepened my appreciation for all that the human body is capable of performing without exception. Dissection and observation with hours of hands-on work only served to deepen that appreciation.

We might argue that digital learning is powerful because the medical student can be in the anatomy lab at any time. Digital anatomy platforms like Anatomatage can move through the body layer by layer but just as something is lost with a text message instead of a phone call, looking but not touching the structures is a loss.

The best use of digital dissection is as an adjunct to dissection of the cadaver. During those hours in the Gross Anatomy lab so many years ago, I carried my Netter Atlas, my Grant Dissector (filled with notes) and my list of structures that I needed to find so that I could see and feel them in all of their dimension.  The experience was profound; deepened my appreciation for those physicians who had spent hours doing the same thing in the quest to learn medicine.

Today, education experts and designers look at teaching and delivery of curriculum as a profit-making entity. Many of these experts have never studied my discipline, practiced medicine/surgery or even taught in a classroom. My duties as a professor are to be leader and coach for my students. I give them the benefit of what my anatomy professors, surgery professors and mentors in medicine passed on to me. Education experts tend to discount experience, one of the essentials of medical practice, and attempt to replace with newer (read cheaper) substitutes.

Yes, digital delivery of curriculum is a great adjunct but it doesn’t replace hands-on experience especially in the Gross Anatomy Lab. Prosections are great but the process of discovery is lost when one does not find structures for oneself. Vivid memories of the dissection of the venous supply of the face remain in my memory today though I seldom perform surgery on the face.

I would hope that those who didn’t get a chance to perform cadaver dissection at least spend some time in the Pathology lab assisting/observing autopsies. The marvel of the human form will not be lost upon you taking the time to do this. Even today, unless you are near a forensic lab, you don’t see too many post-mortem exams taking place. If you have an opportunity to observe one, take advantage and watch. Every structure, normal or abnormal is miraculous.

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23 September, 2017 Posted by | academics, medical school | | 5 Comments

Continuing Medical Education

During the summer, I attempt to ramp up my efforts to complete as much continuing medical education as possible. During the academic year, it seems as if time gets away from me and I find myself busier and busier. Continuing medical education (CME) is a great way to refresh one’s knowledge of basic science while learning new information that will be of benefit to the patient’s in my practice.

I strive to keep work on my internal medicine knowledge as well as my surgical knowledge because my patients often have complex medical problems that send them to my care as a result of complications. While I have no problem consulting my family medicine and internal medicine colleagues for assistance in patient management, I need to be a vigilant as possible in the total care of the patient.

CME is far from being a chore for me because I love the learning process. It was the constant quest to learn how medicine and surgery works, that drew me to medical study in the first place. One becomes familiar with the volume of information in medical school but comfortable with the constant upgrading of one’s basic knowledge base in practice. I have found that every time I read even familiar information, I gain new insight and strategy for providing better care.

Certainly, one hates to be forced to do anything which is why the Maintenance of Certification (MOC) requirements became an expensive burden especially for newer physicians who are already struggling with heavy debt from medical school and pressure to build a practice. Most physicians are employees of large health care groups which adds to the pressure of practice building and maintenance. There are only 24 hours in a day; time becomes a precious commodity.

Finding a schedule that will allow one to keep up with journal reading, CME and MOC can become an added burden to already long hours and stressful work. Again, finding a balance becomes more and more important in order to have a lifestyle that can be enjoyed. Additionally, one does need precious “down-time” for mental sanity these days.

I don’t use my vacation time for CME or MOC as I need the vacation time for taking time away from academics and medicine. As I am older now, I appreciate my vacation time as valuable to my practice and teaching. There are few points for suffering in medicine on the part of physicians. This suffering can lead to “burn out” which isn’t good for anyone physically or mentally.

In closing, my recommendations are to find some manner of CME/MOC that works within and compliments one’s schedule. Take some time and try many methods of obtaining the hours that are needed for licensure. The worst stress comes with putting of CME until the last hours which like anything last-minute, becomes more stressful. Embrace the reinforcement of learning and find something that’s enjoyable, just like exercise, something that one can incorporate into one’s life on a regular basis.

28 July, 2017 Posted by | medical school, medicine, practice of medicine | | 6 Comments

Getting Into Routine

Since the nature of medicine (and life) is change, getting into the best routine to greet and excel in a changing environment is being in the best mental and physical condition possible. It’s very easy with study, long hours of duty and other demands, to gravitate towards anything that bring rest and relaxation/lack of stress. My challenge for those who are starting school, getting ready to start school, starting a new year of clinical duties or any changes; is to have a routine with good stress that allows for optimal performance within the context of changes and challenges.

For many in medicine, stress is the bane of our existence. We are stressed with long hours that often demand the good performance in early morning hours, as most of the population sleeps. We are stressed with keeping up with our academics and studies that mark our ever-changing profession. We are stressed with keeping a sound balance in life that will enable us to enjoy our personal lives in addition to our professional lives. This sound balance is as vital to having a great career and general well-being but finding that balance is not easy or quick.

As the summer has always been the time that I try to improve on my routines and make changes, I will invite you to consider making small changes that will help you deal with the mental and physical challenges to come as your careers change. These challenges need not derail your health and mental resilience but might enhance the enjoyment of your career at any stage.

Good Nutrition

When one is tired physically, mental acumen wanes and one becomes both mentally and physically exhausted. This mental and physical exhaustion can lead to choosing foods that are high in sugar or fat which might lead to a quick energy fix but weight gain in the long run. Trust me, carrying extra weight around doesn’t help with mental or physical exhaustion, often leading to more of both.

Eating a well-balanced diet that has more fresh fruits and vegetables with less fat and refined sugars helps keep your weight under control in addition to keeping you healthier. You can make small changes in terms of grabbing a piece of fresh fruit for a snack rather than relying on the high fat alternatives of the vending machine. Also cooking a week’s worth of healthier food that you pack rather than eating the burger and fries in the hospital/school cafe can help make small changes.

Small changes can lead to larger changes or that routine that becomes more comfortable for you. While I love an occasional burger and sharing fries/chips with my friend (the only way I indulge in these), I keep these occasions as special and not routine. Not only does eating a healthier diet help my immune system, my healthier diet helps me avoid long term chronic disease such as obesity, atherosclerosis and diabetes.

Regular exercise

Exercise tends to be one of those activities that suffers when one enters a demanding profession. It is easy post call, to come home, drop on the sofa and rest. This was my routine in medical school where I gained significant weight after being robustly active during my graduate school years. It took years of work to rid my body of the excess weight but once regular exercise became my routine, I found that I had more energy and more time rather less.

Today, I am a distance runner, using that time on the running trail to work out problems, meditate and simply enjoy myself. I have strength and energy for my work and for recreation. I also have a greater capacity for dealing with stress and the physical stress of a 10-mile run helps everything in my life. Running is quite solitary which appeals to me but anything that gets your heart rate up at least 30 minutes 5 times per week is better than nothing.

My workout time is as precious as my work time. I have mapped out running routes around my hospital, in my neighborhood and when I travel. I keep running gear in my locker (running shoes and shorts) so that I have no excuse not to move. I also try to get my workout done in the early morning before I start my day.

You don’t need to block hours of time for a bit of an aerobic challenge as you can run up a flight of stairs several times per day; park the auto further away and walk briskly to your workplace; take a brisk walk for 10 minutes as a time over lunch with a friend. Distance running isn’t for everyone but most of us can do something as simple as walking. Incorporate small changes which can become a habit that becomes part of your life.

Avoiding excuses (reasons)

As one becomes mentally stressed and physically exhausted, reasons for not adhering to healthy habits abound. For each of us, there will always be challenges that take us out of our routines. Take a moment to reflect on what reasons/excuses become commonplace and how you might meet or avoid them. For me, I looked at every hour of my day and examined where I could make small changes. Those small changes became my routines.

For example, I wanted to have more time for journal reading thus I looked for where I could set aside 30 minutes daily for my journals. I ended up finding at least an hour for my journal reading which became a welcome habit. I looked at where I could “sneak in” a workout even on my busiest day. I also left time for complete relaxation when I needed that too.

Staying in good physical condition is the best way to stay in good mental condition. As I look around me, those friends who are physically fit are the most mentally resilient too. In my life, my good physical condition has been a key to many successes in my career. As my physical capacity increased, with a combination of endurance and strength training, the greater my capacity to work and play with my pleasures coming from enjoyment of craft beer, good food and fellowship with friends and colleagues.

Final Thoughts

Take a moment and look for the following:

  • Where you might incorporate small changes that will increase your physical conditioning.
  • Where you might substitute better food choices in terms of avoiding high fat and high refined sugary foods for foods that are whole grain, fresh fruits and vegetables with leaner meats.
  • Where you might take time for small tasks that enhance your professional development.
  • Where you can find some time for pure recreation and enjoyment of life.

Make the changes today, that will help your life and enjoyment of life in the long run. It’s easier than you imagine as you don’t have to become a spartan or fitness nut. Your studies and your mental health with be much stronger which is the key to success in today’s world of medicine.

18 July, 2017 Posted by | academics, medical school, practice of medicine | | Leave a comment

Listening to Your Patients

At one point or another, we are required to interact and communicate with our patients. In general, when a patient presents to our care, we obtain a history although in today’s world of physician pressure to see as many patients as possible during a patient encounter, the check form history has become commonplace. Often, we scan that check form, history form before we are face to face with the patient. It has become my experience to scan that form but pay closest attention to the reason the patient has sought my care, i.e. the chief complaint.

Often the chief complaint may not be readily evident from that check list form but becomes more evident as you communicate directly with your patient or observe your patient when you enter the room or see them on the stretcher in the emergency department. This first impression, is quite useful in addition to listening to your patient’s voice, observing their demeanor, posture or simply observing their state of dress, interactions with others, such as family members who may be present. I try to use every second of my interaction in order to gain the most accurate assessment of their reason for being in my care.

Listening with your ears while observing with your eyes can be an important skill to hone as you see patients. When what you are hearing matches what you are observing, you naturally feel more confident in your ability to get to the root of the patient’s problem but don’t forget to challenge yourself to look at the encounter from as many directions as you can. Having a strong sense and comfort level with consideration of alternatives is a skill to hone.

As I have challenged myself to spend time with my colleagues in theater arts and acting, I have acquired some skills in patient observation. Additional, my theater colleagues and self-imposed exposure to stage and film productions has enabled me to appreciate good dialogue and words. Sure, my actor/director friends make fun of my fledgling efforts to understand their crafts, far more complicated that I imagined before watching them but my best friend, a professor of theater arts has increased my knowledge of how to observe human beings, most important, how to listen to my patients. I would encourage those who are undergraduates or applying to medical school, to take theater arts coursework as it will be very beneficial in your future patient encounters.

As physicians, we should return to our history-taking skills course and directions even if our medical school experience is quite remote. If we revisit our Physical Diagnosis course notes and directions from time to time, coupled with our experience with every patient encounter over the years, we get better in our listening skills. In short, anything that we practice, we tend to hone.

It’s no accident that patients tend to prefer older and more experienced physicians, often feeling apprehensive in the presence of younger physicians.  This apprehension can be addressed by the younger appearing physician/medical student by conveying a sense of interest in what the patient is saying. Listen to every word, reflect out loud on what your patient is saying and repeat your patient’s words to make sure that your are fully understanding what they are communicating.

Full understanding, good eye contact and conveyance of a sense of relaxed interest by you, the physician can greatly increase getting good information from your patient. By making sure you clarify anything on that history check form with what you observe and hear within the context of exploration of the chief complaint/reason for the encounter is also necessary.

It’s no accident that patients tend to associate better care with better communication and with physicians who have good listening skills. In today’s world of shorter patient encounters, it becomes our tasks as physicians to become something of actors in making sure that our patients feel comfortable enough to give us the information that we need to solve their problems.

We also have to develop our observational skills, visual and aural, that will allow us to make sure that we are as accurate as possible in treating our patients. For me, even as I have become one of those old gray-haired surgeons, to consistently and constantly improve my connection/communication skills. The more impaired or confusing patients in my care, the greater my satisfaction in getting their problems solved.

Yes, listening with my ears, observing with my eyes and in many cases, noting smells have all contributed to my connections and communications with my patients. For me, this is some of the most satisfying aspects of medicine. My warning is to not let being rushed to get through your patient volume, interfere with your ability to connect and communicate one by one. In the long run, you don’t save anytime if you are not getting the patient’s problems solved one on one.

13 July, 2017 Posted by | life in medicine, medical school, practice of medicine | | 1 Comment

An Addict With Alzheimer’s

This wonderful post is from a master clinician/neurologist who is a very gifted poet and author. This post is very timely. He has captured something that all of us will see in some of our patients. Remember this post and remember his words because they are very accurate for many these day. Enjoy and reflect!

The Wooded Path

He made himself known in the
bathroom of a halfway house
where by the bed he’d lost
his borrowed dime store glasses
with bottle thick lenses through
which his crooked world was framed
and missing the mark like something
he thought less than man or woman
he tottered downcast and blinded
toward the bed to wait for Mama’s
forehead kiss and trusted tucking
safe into the feathered shell of night.IMG_2399

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4 July, 2017 Posted by | medical school | Leave a comment

The Boobs Have It

When I read this wonderful post from a fellow physician blogger, I knew I had to reblog this. I felt exactly the same as my very gifted colleague during my surgical intern year on my Breast Surgery rotation. Yes, it’s been a long time since I have referred to breasts as “boobs” out of respect for the miracle that is the human body and all its parts. Enjoy this wisdom.

Behind the White Coat

Display in museum in New York City
Do you know how many breasts I have touched?

Thousands of them.

It is staggering when I reflect upon it.

So many breasts. So very many. All shapes and colors and sizes. Hairy. Not hairy. Moles and rashes and skin tags galore. Droopy. Perky. Somewhere in between.

During breast exams I have for years and years referred to the exam as the “boob check.” Whenever I made reference to my breasts of anyone else’s I nearly always called them boobs or boobies.

To be honest, I thought it was cute.

Touching another woman’s breasts makes me uncomfortable, maybe even a bit embarrassed. I feel the same when someone else is looking at or touching mine in a nonsexual, clinical sort of way. So I made fun of breasts and joked about the situation. It took some of the sting out of the situation to act goofy.

One of the many…

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21 June, 2017 Posted by | medical school | 1 Comment

Hospital Haiku

“hospital moonlight

cacophony of machines

teardrops cascading”

As we come to the end of National Physician’s Week and today, National Physician’s Day, I related this haiku from one of my most gifted and amazing friends. Some years back, he suffered a  critical and life-threatening illness that resulted in profound changes in his life with some time in the intensive care unit. This illness changed a man who is talented beyond belief, a brilliant creative genius and professor in ways that few of us can relate or even imagine. Still today, he’s affected by his illness and the events that surrounded it.

I share this haiku because it brings to mind, something that we as physicians must always remember about our patients. They place their health, their trust and many of the most intimate aspects of their lives in our hands. With our hands, we have to care for them; relate to them, in many ways hold them, and be mindful of the honor and privilege of having them place their lives in our care.

As such, we also have to be mindful that illness changes their reality and in many cases their lives profoundly especially when they are critically ill. We have to reach out and extend more comfort over the “cacophony of machines” that becomes the background of their intensive care and sometimes hospital care experience. We have to block that “cacophony” whenever and wherever we can.

I remember watching a tear roll down the side of the face of one of my ICU patients who appeared comatose. The nurses were bathing him and chatting with each other as they turned him. I saw the tear; asked them to speak with him over the ICU noise background. I asked them to play music in his room and I always held his hand when I entered the room to examine him. I am sure that my soul could feel his soul even though he didn’t ever speak to me. I never saw that tear again, after we began speaking and focusing on him, holding his hand, touching his face, and playing his favorite music even though he did not recover from his illness.

I seek to connect with my patients without exception as that is my honor as a physician/surgeon. I spent years learning the science and techniques of medicine and surgery but in these, the later years of my clinical practice, my focus is on the art of medical practice. Within that art is my chance to give some of my heart to those who have placed their trust in me (and my training). I strive to be more human and more comforting. To do less of the science and more of the art is great joy for me. My joy is in the connections; kind of strange for a surgeon.

On this National Doctor’s Day, I am honored to be a physician and grateful for all that this profession has given me. This profession has given me far more than I can give back but I will spend as much time as possible giving as much as I can to those who are in my care.

30 March, 2017 Posted by | medical school, medicine, practice of medicine | , , | 2 Comments

A touch of tenderness (Reblog)

Here’s is a great post to remind us that touch may be the best medicine out there for our patients. Don’t be afraid to touch your patients and connect with them. This is the true “magic” of medicine. Touch is needed more today than ever.

Sue Vincent's Daily Echo

The Cathedral by Rodin.

My son gleefully squeezed harder at the knotted muscle in my shoulder, with a ‘Now I’ve got you’ as I groaned in agony. We have established and agreed that he has a slightly sadistic tendency where I am concerned. It may have something to do with my knack of getting just the right spot on the painful muscles as we got his body working again. Day after painful day, for months on end. So now it is payback… and he appears to enjoy it. He still manages to lay the blame squarely on my aching shoulders, muttering something that sounds vaguely like ‘hereditary’.

He is a little more squeamish than I. His face screws up in horror as my wrist bones crunch back into place when he applies traction. It is, however, nice to regain freedom of movement occasionally. So I make him do it…

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25 March, 2017 Posted by | medical school | 3 Comments

Great Post from “Life of a Med Student”

“Beyond the H&P” A Guest post by Jessica Morgan It’s 4:00 pm on a Thursday: time to present at teaching attending rounds. I have prepared my presentation and know about the patient’s pathology, but I can never help myself from being incredibly anxious for these moments. I gather my papers and begin…

via Beyond the H&P — #Lifeofamedstudent

24 March, 2017 Posted by | medical school, residency | | Leave a comment

You Have Matched!

A hearty “Congratulations” to all who matched! This is the next step in your medical career no matter where you matched. On Friday, you will find out where you matched; some taking the news with tears and fears. Make no mistake, if you didn’t match, the future becomes more uncertain but certainly not bleak. As I have stated in other posts, those who didn’t match should be aware of the current S.O.A.P process and should be working on getting a training position for next year.

If you have matched, some things to work on as soon as you can:

  • As soon as you know where you will be training, get in contact with one or two of the senior residents to find out which textbook(s) is (are) the major reading material for your program. Purchase the book(s)(electronic or paper) and start reading.
  • Make a list of the sentinel journals for your specialty and start reviewing articles. You need to practice evidence-based medicine. Getting a head start on your journal reading helps to make journal reading a habit.
  • Start a physical conditioning program if you have been relatively sedentary during medical school. Aerobic exercise (30 minutes per day) can help reduce stress, help with stress and keep you healthy. Make physical exercise a habit along with journal reading. Even on your on-call days, you can walk/run the steps for a quick work out which will keep you more efficient in the long run. You will also sleep better if you are in good condition. Add some strength training too.
  • Find a place to live if you are moving. Don’t put this off because you need to be comfortably in your residence before orientation week in your new hospital. Your home should be simple, convenient for commuting to the hospital, restful and useful for your lifestyle. Though you won’t be spending tons of time at home, you need for your home to be your haven in your off hours. Make sure you have a washer and drying in your residence. You don’t want to be heading to a laundry room when you need to be sleeping.
  • Get your paperwork done for your training license as soon as you get information from your program. Some states have many tasks for you to complete before you can be licensed for training purposes. The sooner you get this done, the better.
  • Take a week or so off but do this long before you start your program. You need to have a bit of fun but using too much time in vacation before you start your PGY-1 year can be a problem too. Complete off time is great but not an escape.
  • When you get your residence, scout out several routes to the hospital so that you know how to get in even if there is a problem with weather, roads and other mishaps. Make sure your car or bicycle is in good repair with a good back-up plan.
  • Learn how to cook and take your meals into the hospital. Trust me, hospital food in most cases, is not great for keeping you healthy. I cooked on my days off, put a week’s worth of meals in the freezer and carried them in for my call days and nights. Good nutrition is key to good learning and training.
  • Learn a good organizational system for your ward work. I used an Excel program complete with dropdown menus for my sign-outs; still use this system. Learn to make check-off sheets to stay on top of your patients and their needs (lab tests, radiographic studies).
  • If you can, arrive a couple of days early to get familiar with your hospital’s physical layout, systems for dictation and record-keeping. Do a recon mission that will save you time in the long run.

Finally, this is a great time of learning and professional development. Having some organization is key to keeping your head in the right place. Enjoy the experience so that you can take advantage of every minute of residency with a positive attitude. Don’t underestimate the value of a smile on your face because you are learning the tools that will make you a good physician.

14 March, 2017 Posted by | medical school, organization, residency | | 5 Comments