“Look at every path closely and deliberately, then ask ourselves this crucial question: Does this path have a heart? If it does, then the path is good. If it doesn't, it is of no use.” ~Carlos Castaneda

Sunday, April 27, 2008

Not everyone will like you - part 2

“For my part I know nothing with any certainty, but the sight of the stars makes me dream.”
~Vincent van Gogh

I posted last year about a good patient experience. It was a story about a patient that actually liked me. I titled it "Not everyone will like you." Some people criticized the title as false advertisement. I received some comments that stated I was basically tooting my own horn. For those that know me, they know that is not the case. For most of us in clinical practice, we hear more of the bad than good and occasionally someone will actually like you. My personal opinion is that we should not practice so that people will like you, because not everyone will; you should treat people like human beings. It is not a popularity contest. So for all of those who were a fan of that one, here is another.

It is Sunday. As usually, I am completing some work, signing forms, writing letters, etc.. In my pile of work, I came across a hand written letter from one of my patients. I will share it with you.

Dr. Someonect,

Although you may not remember me, I wanted to thank you for the tremendous impact you've had on me this year. At the beginning of my Junior year, I was feeling overwhelmed by stress - I didn't have any of my best friends in my classes, I had just been rejected by a girl I'd been trying to charm for two years, and to top it off, I fractured my ankle in three places. I'd been in surgery before and broke a finger too, so at first it just seemed like a nuisance (I was the fastest cripple on two crutches at XXX school, which has a surprisingly large number of cripples), but then there came the worries that I might limp for the rest of my life - something about my growth plates, I still don't really understand it.

But when I met you and was told you'd be performing the operation, I had total confidence that I'd be back to my old ways in no time. I was especially impressed by your knowledge of Hendrix, RATM, Megadeth, and all the other guitar greats (I'm starting my lessons with my friend - I think he's the next Steve Vai) Just to see that a doctor could be that awesome yet so talented really inspired me. I'm not really sure what career path I'll take in life, but I've definitely added "awesome surgeon" to the list. The entire staff at XXX really made an impression me; I've never met a friendlier staff that seemed genuinely concerned with their patients, and I know that without their help I'd still be lurching around my house on home-school watching Seinfeld re-runs. You're the best doctor I've ever had.

My Patient

*P.S. - My step dad's getting getting his summer Mohawk next weekend.
That letter made my weekend. So I thought I would share it. It was nice.

“If your actions inspire others to dream more, learn more, do more and become more, you are a leader.”
~John Quincy Adam

Thursday, April 24, 2008

Stepping to the plate ....

“Nobody can go back and start a new beginning, but anyone can start today and make a new ending.”
~Maria Robin

It is Spring. It is the time for flowers, yard work, and baseball. I was watching the Cardinals the other day, and I got a great idea. Wouldn't it be awesome if surgeons came into the OR like a player stepping up to the plate to bat?

(Down with the Sickness playing in the background)


"Coming into room 9, we have Somonect. This year he is operating very well with an infection rate of less than 0.01%. He has only thrown 2 instruments this year with no personnel injuries. His surgery times are steadily improving, only gone over his operative time twice in the last 30 case. Today, his is handicapped by a first year orthopaedic resident, a new scrub tech, and a circulator that "doesn't usually do orthopaedics." In these situations, he averages 15 minutes over his scheduled time, no thrown instruments, and 4 curse words."

How would you step to the plate?

“Don’t ask what the world needs. Ask what makes you come alive, and go do it. Because what the world needs is people who have come alive.”
~Howard Thurman

Saturday, April 19, 2008

Brain mouth filter ...

“A lot of truth is said in jest.”

Socratic questioning has been at the heart of clinical medical education many years. Traditionally, the educator asks a question so that the original question is responded to as though it were an answer. The central technique of Socratic questioning is known as elenchus, meaning a cross-examination for the purpose of refutation. In medical school, this technique of education is more commonly referred to as pimping. This style of teaching is seen as a way of the educator showing his/her greater knowledge of a subject. Depending on how and where it is enacted, pimping is perceived as a unique kind of questioning practice with a wide range of intentions from knowledge checking to humiliation. Some educators use elenchus for knowledge checking; others educators pimp. The students perspective of this style is the same regardless of the intended purpose.

The earliest use of the term pimping dates back to 1628 in a statement made by Harvey in London. Harvey, feeling his students lacked enthusiasm for learning the circulation of the blood, stated: "They know nothing of Natural Philosophy, these pin-heads. Drunkards, sloths, their bellies filled with Mead and Ale. O that I might see them pimped." In Heidelberg (1889) a series of questions titled "Pumpfrage" or "pimp questions" were recorded by Koch for use on his rounds. And the first American reference to this was by Flexner in 1916. He wrote about his visit to Johns Hopkins: "Rounded with Osler today. Riddles house officers with questions. Like a Gatling gun. Welch says students call it 'pimping.' Delightful."

Now, if we look truly at the Socratic questioning, its purpose is not politically motivated. It is for the purpose of educating and to improve the students understanding of a subject through questioning. On the other hand pimping can be more politically motivated. Many times pimping is used as a way for an attending to show his/her knowledge. Knowledge is power. Pimping sets the hierarchy.

In the art of pimping, questions should come in rapid succession and be somewhat unanswerable. Questioning can be grouped into approximately 6 categories:
  1. Arcane points of history - facts not taught in medical school that have no relevance to medical practice.
  2. Teleology and metaphysics - questions that lie outside the realm of conventional scientific inquiry. Most often found in the National Enquirer and addressed by medieval philosophers.
  3. Exceedingly broad questions - for example, what is the differential for a fever of unknown origin. These questions are best asked at the end of conference. Regardless of how many good points the student makes, s/he will always be criticized on the points missed.
  4. Eponyms - questions like, what is the Hoffa fracture? These are usually dated terms that should be struck from memory.
  5. Technical points of basic science research - enough said. These technical points, although showing academic prowess, have no clinical relevance.
  6. The Devil's Advocate (my personal favorite) - with this technique, the educator takes the opposing view. This challenges the learner to understand the strengths and weaknesses of both views. For learners, defending against this takes experience, skill, and understanding. Novice learners are easily swayed away from their correct thought process down the wrong path.
For a master pimp, these are important categories to understand. Their utilization, while at a nursing station or in front of many naive on lookers, can gain the questioner many power points. It is like flexing your muscle in the gym mirror in front of the elliptical machines.

While understanding the ways of pimping tactics is interesting, it is more important for the student to understand the classic defense strategies to stymie the master pimp. When using these tactics, the student must be careful not to anger the questioner making the situation worse. If done improperly or if the technique is not properly disguised, it will quickly be countered with quickly countered. There are several classic techniques: the stall, the dodge and the bluff.
  • The stall - this is commonly used in x-ray conferences. The student typically looks at the study squinting, and bring their face so close their nose almost touches it. Then the study characteristics are described. "This is an AP, Sunrise, Notch, and lateral in a skeletally mature patient dated January 5, 2007." The next step is to describe what is not present. It is important interject pauses, face holding, and pointing, as diverting gestures. The hope with this technique is that the questioner will fatigue and ask someone else.
  • The dodge - this is a way of avoiding the question and wasting time. The most common ways this is applied are by answering the question with a question and/or answering a different question.
  • The Bluff - (3 classes)
    1. Hand gesturing - this is making reference to hot topics in medicine without supplying either substance, detail, or explanation.
    2. Feigned erudition - answering as if you have an intimate understanding of the literature and a cautiousness born of experience. For example, "To my knowledge, that has not been addressed in a randomized prospective controlled study." These statements are usually made after clearing the throat, standing professorially, and while holding something, coffee cup, glasses, etc.
    3. Higher authority - this is done by referencing someone higher up in the hierarchy or another institution. Using a senior attending as a reference is common. "In my discussion with Dr. x, he stated ...." It is also common to mention another institution where the student may have trained. "At Duke we .... "
Now, once the offensive questioning tactic is put into play and the student's defense is chosen, where do the errors occur. Probably the most common error for the inexperienced student is the misuse of defensive tactics. When a student shows his/her hand early, it allows the educator to see their lack of understanding of the subject and is like blood in the water for some educators. These are easy pickings for malignant educators. Just as problematic as improper use of a defensive tacts is not having good control of the "Brain Mouth Filter." Although knowledge is power, welding a little knowledge without an understanding will get a novice in deeper than s/he can handle. Once a novice learner gains some experience and knowledge, they begin to overstep their understanding and bring up other topics and controversies without being asked. Students that has a running dialog of his/her thoughts, it opens them to more questioning.When this is done, one of 2 things can happen: the student can get an endless onslaught of questioning there by saving all others from questioning or the team will share in the beating. The learner must develop ways of diverting questioning and putting a closure to the questions. Filtering their thoughts prior to speaking is a must.

In the end, the pimping phenomenon is a game. The educator is the game master controlling the many of the parameters of play. With time, a learner will develop both a knowledge base and thought process. They develop there own styles of processing and answering "pimp" questions. Hopefully at end game, education occurs.

“Sometimes questions are more important than answers.”
~Nancy Willard

Saturday, April 5, 2008

Putting a comment on blast ...

“Life is best enjoyed when time periods are evenly divided between labor, sleep, and recreation...all people should spend one-third of their time in recreation which is rebuilding, voluntary activity, never idleness.”
~Brigham Young

I received this comment from p3/4md. It is a bit of a rant, but speaks directly to many of my frustrations with some of the medical students that I encounter.
'I know he's only eleven months, but we think he might be a genius.'

Being a third year med student, almost done with my core clerkships, I'd like to comment on this from our perspective, and then, from my perspective.

First: Medical students are quick learners to do what is most efficient. We always have our eye on the end game. In college, it was medical school, in medical school, it is residency.

Let's just forget about the first two years of medical school in this talk, because quite frankly, in my opinion, it has little to do with how the students will act, clinically.
These statements are true. Like many things we do, it is about end game. What I try to stress to my residents is that they are not training to be residents. End game is becoming a physician. in our case an orthopaedic surgeon. Practice like it.
Residency is based primarily on your step I/II scores and your grades, most probably, your clinical grades.

In our Surgery clerkship for instance, our grade is basically derived 50% from shelf exam score, and 50% by your ward attending/resident.

We as med students know that if we show up on time, and blend in with our peers, we're going to get 80-85% for our clerkship grade. If our resident/attending likes us, and we're actually halfway competant and helpful, we'll get a grade of 85%-90%. If we're lucky, and the attending is nice, we'll get a grade in the 90's.

If we bust our behinds, work hard, and become advocates for our patients, we're still going to ride that luck factor to get a grade above 90% (which is honors.) I've had attendings/residents praise me, say they've learned more from me than they thought they taught me, and still give me an 87.5. Tell me, what do you expect of me to do well? I've had residents and attendings put down "the best medical student I have ever had" etc. etc. in the their comments, and still give me a 95%, why not a 100%? If I performed above expectations, and was the best you have ever seen, doesn't that logically warrant a grade of 100%?

Granted, I know no one is perfect, and some can be more stringent than others, but seriously, give me a break. I've had (in college and other areas,) people say "I don't believe in giving 100's, no one is perfect." Well, by that same logic, if no one is perfect, and 100% can never be achieved, why have the score there to begin with??? In that case, should it not be assumed that 100% is "just less than perfect" ??

Anyway, enough with that rant :) The point is, in order to do really well in our clerkships, the effort required can be overwhelming. The extra effort required to get into the 90's for our grade is tremendous, and many times, regardless of how well you perform, there's still a significant chance that you won't get an exceptional grade.

We all know this. We've all been there. We know that attending "He's a jerk.. it's not worth it".

In the face of studying for a shelf exam or the myriad of ungraded pass/fail papers that you have us write, I am intelligent, I can balance my time.

Why do I do this? Well, I know that if I do well on the shelf, the 5-10% of the clinical grade that may be impossible to receive, will be easily superceded. Enough said.

So why should I bust my hump.. when I can study more, and make up for it on exam, and then some.
I think this is what really frustrates me. It is one of the reasons that I posted previously about grade inflation. When I look at a resident and a student, I don't look at hours spent in the hospital or the kiss @$$ stuff. Most of us can see through the false smiles. What I look for is someone who is worried about doing the next right thing for both patient and team.
Consider the following (and this isn't me being arrogant or whatever.. this is just how it is):

Unfortunately (or fortunately, depending on how you look at it) my parents instilled a good work ethic in this young doctor. I care.. I really do. I work hard, examining patients, talking to them, building rapport, etc. I showed up 30 minutes before everyone else to preround on my patients, even though no one would ever hear my morning report. Yes, I can hear murmurs that residents can't pick up. Yes, I can put in IV's faster/more efficiently than my interns. Yes, when a patient is desat'ing, I have the ABG kit in my hand, and am feeling for a radial pulse before my resident says "we need an ABG." Yes, I've out diagnosed my resident and my attending. Yes, I paid attention, I read alot, and I understood. If i'm thrown in an ICU/SICU, I can navigate my way around, manage patients, and be confident. No, I know I'm not an attending, I know my limitations, but I also know that they're far beyond that of my peers.

Do I think that's because I am smarter, or better than my peers? No. It's because I know I worked harder to know this. And I damn well have the right to be proud of it. :)

Why did I learn this stuff? Because I think that doctors should graduate and know how to save people's lives. To be useful, and not just know a bunch of facts.

So I bust my hump, etc. And I am proud of myself..But then, I look at a peer of mine:

She shows up late, and does the bare minimum. It's a big month if she actually talks/puts her hands on a patient. She's "going into optho... why should she care?" She leaves early.. and studies while the attending is speaking.

No attending/resident is going to bad mouth her.. they're all too nice. They'll say something benign in her evaluation, and give her a grade of ~85. Then, she'll do well on the shelf.. and get honors.

Her transcript says honors
My transcript says honors.

To the residency world,.. we are equal.

I know more, I worked significantly harder.. but in the end, what difference did it make for the "end game?"

Yes, ideally, we all should be looking for the benefit for the patient.. and should learn to be the best that we can be.. Well, I say fiddle sticks to that.

The most important patient in this scenario is yourself. Who is going to sacrifice in a selfless way before themselves. Yes, there are a few.. but that is certainly not the majority.

So we are in a constant battle. And the grade is king, it truly is.
Although grade is king, you should always do what is right. End game is being a physician.
So, after a year of dealing with this junk.. yes, I now sometimes I find myself debating if I should put that extra effort in. I do it anyway, because I think it is the right thing to do. I feel obligated. I know I am not well accompanied in this thinking.

Most of us learn to just "get by".. and this is evident by the strength of the interns. Most of the interns I've encountered are babbling fools. Why? Because they "just got by" in medical school. It creates a vicious cycle. It sets the stage for residency.

In the wake of the recent match.. I feel bad for the folks who have to decide on these candidates. They all have honors.. they all did well. How do they judge work ethic and good clinical skills? It's almost impossible.

*sigh* what is ahead in the future..

p3/4md, I love this comment because I can feel your frustration with the system and the abuses of the system by your peers. The hardest thing for a residency selection committee to do is find people who have good work ethic and clinical skill. It is one of the reasons so many programs take people who rotated with them. Hang in there young padawan.

“The self-confidence of the warrior is not the self-confidence of the average man. The average man seeks certainty in the eyes of the onlooker and calls that self-confidence. The warrior seeks impeccability in his own eyes and calls that humbleness. The average man is hooked to his fellow men, while the warrior is hooked only to infinity.”
~Carlos Castaneda

Thursday, April 3, 2008

Regardless of how many times I do it 20 miles is still a long frickin run ...

"The range of what we think and do is limited by what we fail to notice. And because we fail to notice that we fail to notice, there is little we can do to change until we notice how failing to notice shapes our thoughts and deeds."
~R. D. Laing

About 5 years ago, I started running. On a dare, I ran a 1/2 marathon. I needed to be challenged. For someone who had never been a runner, the 13.1 mile distance seemed like an unsurmountable distance. After the race, I realized that it wasn't as difficult as I had expected. It didn't require a lot of training. Like many amateur runners, I quickly made the leap from 1/2 marathon to marathon. I read the books and got training plans. I talked to marathoners. The truth is that the marathon is not just running a 1/2 marathon twice. Most will tell you it is much more; the marathon begins after the 20th mile.

Marathon training can be painful. In the beginning, it's fun. Most of the runs are rather short. The average training plan is about 3-4 months. If you run regularly, the first few weeks are just a continuation of what you have been doing previously. The challenges come when the middle distance run is greater than 8 miles and your long run is greater that 16 miles. Training runs that use to be 30-60 minutes become 1 1/2 - 2 1/2 hrs. Injuries begin to pile up. Your body aches. You ask yourself on a number of occasions the question, why? For me the answer is, because it is there. It is a challenge. I will defeat the 26.1 mile monster. The training is a necessary evil. The long runs of 18-22 miles on a Sunday must be done to prepare me for the marathon day. If I don't prepare, I won't be ready and I will fail.

In one of the early posts, I wrote about how I felt residents and medical students today are soft. Maybe that was a little harsh; they are more like the new, the proud, and the privileged. Some who read this thought I was speaking to the hot button issue of the 80 hour work week. My opinions don't have anything to do with the hours spent in the hospital. It has nothing to do with them wanting to have a life, i.e. not being in the hospital all the time. It has more to do with how they view their chosen career. When you are training, you can't do it part time. Medicine is not a DELL computer where you choose only your favorite components. You can't come into a specialty without having at least a basic knowledge. These basic components become the building blocks for future learning and professional growth.

When I look at my residents and the young medical students, there is an inherent lack of drive to learn their craft. It is no longer a priority. Like many of my generation, Gen X, and even more so in the Mellinial generation, there is a undercurrent of entitlement. It is their right to be taught this information and to do these procedures. They are not here for so called "scut." Heaven forbid we talk about patient care and continuity of care. We are in the era of teams and patient hand offs. No one is responsible for a patient. Patients are handed from one person to another like a hot potato. The residents are well rested but who is actually responsible for the patient. Who is taking ownership? Ah yes, it is the attending's responsibility. So, now if I am going to do everything, why should I teach? And if the attendings and mid level providers are going to be doing a majority of the patient care, are we training 1/2 a physician? Are we training physicians who can pass a test but can't treat a patient?

Regardless of the rules and regulations placed on training, patients still expect you to be a physician. When a patient asks you a question, you can't answer "I missed that lecture because I was over hours." No matter how low the hour restrictions go, physicians in training will still need to gain the experience. They must put in the time to train.

Medicine is mountain, regardless of your specialty. The amount of information that you need to understand is increasing. In todays medicine, the number of known diseases, medications, diagnostic testing, and procedures, are probably double of what they were 20 years ago. The business end of medicine is more complicated. Medical practices have adjusted because of medical legal issues. The style of medicine practiced is affected by both private insurance and CMS. There are regulating agencies, like JCAHO, that make suggestions hospitals have to follow. Then there is the possibility of P4P. You must be a physician, business man, politician, and lawyer. To say we teach them all well would be the understatement of the century.

Like the marathon, medicine requires endurance training. It can be fun, but for the most part it is painful. For clinical medicine, you simply have to get the clinical experience. Book learning helps but experience solidifies the information and places the written word into perspective. Regardless of how smart you are, you still have to put in time outside of the hospital to read. The reading must be not only on clinical and basic science, but also on the business, and health policy, ect. You must train yourself to prepare for the end game, you medical career and practice. Everyday is a school day and contrary to popular belief, your learning and educating does not end at 80 hours; just like my run doesn't stop at 20 miles.

“Never mistake knowledge for wisdom. One helps you make a living; the other helps you make a life.”
~Sandra Carey