From one of my patients the summer:
"You don't get to decide how and when it [death] happens, but you DO decide how you live."
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MS2 has started, and I admit, I'm writing this blog post to escape reviewing the microbiology algorithm tree and the unpronounceable drug lists sitting beside me. Procrastination at its finest...
The proverbial "last summer ever" has come and gone. Sigh...it went so quickly!
My medical school's faculty and students pride themselves in many things, but especially its research prowess. Pretty much everything in our biochemistry syllabus was discovered here...and the faculty certainly don't let you forget it! Since November perhaps, students were emailing and frantically filing paperwork to join a laboratory over the summer. And it's understandable, I suppose; many competitive residency programs look for (or even expect) research commitments in medical school, and first authorship on a paper if you can wing it. Despite immense pressure from both students and faculty to work in the lab, given my college research experiences in oncology, I took the "bold move" to stay clear of the research world.
It's funny actually...I came into medical school thinking that I was going to continue my cancer research in some capacity. I became one of the head research assistants in my laboratory, and I thoroughly enjoyed my work, its implications, and its impact on medicine. But, I remember the long incubation times, the pipetting errors, the triplicate replications, the groveling to please esteemed faculty and Nobel Laureates, the lack of human contact...while I truly loved my work, it was quiet, lonely, and stressful. Little did I realize how much time I would spend turning the pages of my syllabi, pruning each page for perhaps one more fact before test time. Furthermore, the lack of patient interaction combined with an onslaught of basic sciences material taught in MS1 frustrated me immensely. So many nights I spent angrily declaring, "Why is any of this shit important?"
In college, I was an EMT; the night shifts I worked provided me with invaluable patient contact and bedside experience which motivated me to continue my dreams of becoming a physician. I crave this patient contact. It's odd to say that medical school itself has DEPRIVED me of the time to significantly provide assistance on a healthcare team. And so, it became clear my days in active research were a thing of the past.
For those who may not know, I struggled to stay afloat during my first year, and I am not ashamed (anymore) to admit my trials. Between the massive adjustment to a new and fast-paced style of lecture and some personal issues, I found first year to be one of the most trying academic years of my life. Studying for classes conjures the famous candy assembly line scene in "I Love Lucy" with a seemingly endless supply of knowledge and limited means and time to process it all. Difficulty with studying had never been an issue for me, and I was very perturbed with this problem. Furthermore, the clinical and beside significance of the first year curriculum are lost in the dense minutia and alphabet soup nomenclature, and so it became difficult for me to engage with the material. I found myself asking, "Why does any of this even matter" or "Huh, my ID badge said 'Medical Student' not 'Graduate Student'" more times than is comfortable to remember.
And, quite frankly, I felt defeated, worthless, unworthy, and incompetent after every examination.
I also did not really feel as if I "fit in" at my institution. The student body and faculty insult and degrade primary care fields at any given opportunity, which further isolated me from my academic community as I am a proud budding geriatrician interested in pursuing primary care. And although it is said to be a common feeling in first year, I felt like an impostor. For many weeks, I woke up and was convinced the admissions committee made an error in accepting me. My white coat was an ironic costume supposed to confer a sense of authority and respect, but instead provided feelings of shame and fraud.
Throughout the months of March through May, as summer approached and the deadlines for summer research were long gone in the rearview mirror, I could not help but feel as if I made a grave mistake. It certainly didn't help that students conversed about their laboratory placements with one another, assuming each student was in a lab until interrogated otherwise. Then - the awkward silence when I said I wasn't in a lab. And then the inevitable, "wait, really? Sooooo, what ARE you doing, then?" -- said in the most perjorative of connotations.
This summer, through the General Internal Medical Summer Preceptorship Program and the Texas Statewide Family Medicine Preceptorship Program, I was blessed with two month-long preceptorships in primary care. Preceptorships - an odd concept something between a shadowing experience and an MS3 rotation. You conduct the history and physicals, you construct a SOAP (subjective, objective, assessment, and plan) note, and you present to the attending or precepting physician. You have some autonomy with going into patient rooms and collecting patient information in a history and physical examination, but there are limited expectations. The student cannot draw any labs or formally become certified in techniques, but you learn informally how to do them. Basically it's preparation for MS3 with no strings attached...no grades on the line...all the patient contact you could ever want...developing strong history taking skills and differential diagnoses for a wide array of presentations.
In many ways, it's the perfect introduction to MS2. And despite failing the expectation to pipette for hours on end, or conduct and meticulously analyze patient survey results for the sake of some odd translational study, I was pretty excited to become reacquainted with patients...after all, that's why I went to medical school.
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I began my summer with my IM preceptorship with a well-known endocrinologist in the area. I didn't exactly expect to study endocrinology this summer (hoping for someone more like a general internist), but I figured I'd make the best of it. Plus, diabetes is everywhere, so .... yeah, I guess I could get behind the endo bandwagon. Within the first few days, it became obvious that my skill set was...in progress. Actually, I don't think that's a fair assessment. It's not that I didn't have the tools, but more so my preceptor wanted different tools. The hours and hours (and hours) I spent memorizing CYP pathways for endocrine physiology ... well, let's just say, despite my best efforts, I took quite a few hits when I got "pimped" (when med students are quizzed by their attendings with a splash of hazing thrown in the mix). But, my preceptor was more concerned with my development in taking a history and physical, developing rapport with patients, and thinking critically in making differential diagnoses, assessments, and plans. And once I became more comfortable with the clinic, the crazy CYP pathways became...relevant. The complicated interplay between hormones became...relevant. Suddenly, I had a reason to learn all this stuff, and it worked! I still can reflect on patients, their charts, their lab values, their interviews, and their treatment plans with an unexpected level of clarity. I noticed I began to learn....truly learn this material and not just cram it in the night before an exam. By the end of June, I began to rattle off dozens of drug therapies, differentials...I felt like a student doctor for the first time!!! (And, I overcame my initial fear of presenting to an attending!)
Interestingly, I found my most useful tools were skills virtually untouched in MS1: using my skills from EMS training- EKG lead placement, vital signs, etc- and making patients feel welcomed and comfortable in a safe space. As the preceptorship progressed, I learned how to propose my disagreements with procedures and medical decisions when appropriate, and many times, my thoughts directly impacted patient health. While such advocacy may seem routine, it is easy to feel worthless in the physician hierarchy as the lowly medical student at the bottom of the totem pole. But, learning to speak up made a world of difference for quite a few of the patients I saw this summer - be it fixing chart errors or EKG leads.
As I learned from my work in EMS and continued to see in this preceptorship, sometimes all that's needed for patient advocacy is a hand on a shoulder and talking with patients. When everything is going awry, when the doctor and the patient's children are disagreeing about grandma's treatment, when medicine isn't so clear-cut and simple...remembering the patient's feelings at that moment can make a world of difference, even if it's just getting the patient a glass of water and calmly explaining what is going on. I am happy to see that my experiences in EMS carry on in the career of a physician as well.
An adage often repeated in first (and second) year is that a good H&P (history and physical examination) is the most important skill in diagnosis. And certainly, this mantra held true. A solid H&P, in combination with getting to really take time to relate to your patient, allowed for meaningful strides toward better health...and some really amazing conversations (especially with regards to a detailed social history)! Unfortunately, our MS1 curriculum doesn't lend itself to really engaging in the patient-provider relationship and skill sets beyond a very superficial level, which is a bit depressing. Perhaps, these things are just not that teachable but are instead practiced and experienced. At any rate, I am thankful to have had such an experience!
Perhaps my most used skill was working on my conversations with patients who either prefer to speak or only speak Spanish. More than anything else, I enjoyed the ability to speak Spanish...especially being WAY out of practice in taking another foreign language in college. However, I was impressed that even the tiny bit I knew went a long way. I have always wished to be considered bilingual, but now I am inspired to actively pursue and practice my Spanish.
Three tips I learned from my experiences in bilingual dialogue:
1) ALWAYS ask the bilingual patient if s/he would prefer to speak in English or Spanish. The language barrier is a barrier most certainly, but it's not a broken bridge. In my short experience, I found that most times when a bilingual patient preferred to interview in Spanish, I could collect a more thorough history than if I pushed to interview only in English. I know I'm not alone when I say that non-native Spanish speakers read, write, and understand Spanish better than they can speak it...speaking seems to come later in the comprehension of a foreign language. Such sentiments are mutual, however -- asking a patient to speak his/her non-native language is also difficult at times, and s/he may neglect to tell providers pertinent information simply because of inability to bridge the language gap. In such way, asking a patient to discuss dietary habits, medication regimens, or feelings of malaise in Spanish and listening to the response is much more fruitful than forcing English-only dialogue.
Plus, you learn new words and practice on speaking Spanish.
Just as important, patients DO appreciate the ability to express themselves fully and articulately in a comfortable language - and thus you can build great rapport.
2) You will mess up. GET OVER IT AND TRY AGAIN ANYWAY! It can be difficult to balance your desire to present yourself as a knowledgeable healthcare professional and the struggle to understand your patients entirely when confronted with a language gap. Patients may use slang to which you haven't been exposed, or use a phrase that doesn't translate literally due to idiomatic connotation. And YOU are going to drop the ball too. The number of times I misused colloquialisms, botched prepositions/transitions (...but seriously, I don't know if I will ever get por/para correct), used phrases from a different dialect of Spanish which my patient didn't understand, or just simply blanked mid-sentence....was embarrassing. I would be very deceitful if I didn't say that, for whatever reason, misspeaking in a non-native language to a native speaker seems so devastating. It's so flustering!
But let me ask you the following: if you are an native English-speaker, think of all the times you misspeak in your native tongue, forgot what you were going to say mid-thought, or lost a word that was on the tip of your tongue. Or, perhaps you are stumped by a new word or phrase is used in conversation that you've never seen or heard. Or, you mispronounce something arcane. What do you do?
You pause, correct yourself, and move on.
It's not that big of a deal to misspeak: in native or non-native languages. Misspeaks happen. It's going to happen. You aren't expanding your knowledge of a foreign language if you don't make errors. Perhaps, like me, you learned a language like Spanish from several people from all over the world and can't keep straight which words belong with which dialect. (I did that embarrassingly with "sweet potato," having learned it as la batata when el camote is probably better understood in my particular community. Apparently, la batata is slang in one of patient's dialect of Spanish for something COMPLETELY different/slightly offensive out of context -- yikes! The patient had NO idea what I was saying until I embarrassingly and stupidly replied to her in Spanish, "Umm, it's the orange potato??") The patient got a chuckle out of my accident, I clarified my comment, and we moved on.
One note: just as you would do in your native tongue, it is important to recognize errors, apologize, and try to correct yourself, just as you would in your native tongue. And, from my experience, patients are very forgiving (and might help you out a bit when you just can't seem to figure out the right phrase).
3) You are probably better than you think you are. Simply the fact one has taken an interest in narrowing the language gap in undertaking a second language is fantastic and helps to further allow a cross-cultural and embracing environment, especially in medicine. You'd be surprised out much you can get around certain technical or complex terminology with a more rudimentary vocabulary. Also, even in a situation in which a common native language is understood, a healthcare provider has to be careful to avoid higher medical vocabulary with patients (use high blood pressure instead of hypertension, e.g.) to avoid miscommunication. So, why wouldn't that carry over into a non-native language situation? Sure, you may not (ever) speak at an extremely educated level in a foreign language. But, conversationally, the ability to describe uncertain words and phrases carries great weight, and might even be perhaps appropriate. Practice makes perfect -- well, great improvements anyway! (More often than not, my Spanish-speaking patients would ask if I were from a Spanish-speaking country, or if I were Hispanic/Latino, which I will take as a grand compliment!)
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With a rigorous but amazing IM preceptorship completed, a new adventure in family medicine awaited in July. I was particularly excited to work with an osteopathic physician and learn about techniques otherwise unseen in the MD curriculum including osteopathic manipulation for pain relief. And boy, did I see a lot of it! Patients would drop by for a 30min session and walk about feeling better by leaps and bounds, be it improved mobility or reduced pain. Since part of my desire to enter medicine stems from relieving patient suffering, I am definitely interested in learning how to do osteopathic manipulation myself, or at least offering such services in my future practice.
My mentor also prides herself in women's health and preventative medicine. With her guidance and patient approval, I became knowledgeable in an aspect of medicine to which, as a man, I cannot physically relate. Even though the majority of women understandably opted to not have a male in the room for pap smears and pelvic exams, to the women who allowed me to shadow and even perform parts of the Well Women Exam, I truly thank you for making me a better physician. I left my FM practice with a better understanding of women's health, procedures, tricks of the trade for less stressful examinations for the patient, and coverage options. To my male student physician colleagues, I hope you can find the time to shadow or partake in a women's health clinic of some sort as there is so much we need to see and learn to better serve the medical needs of women.
As with my IM preceptorship, I found my interest in languages helped once again. I had one patient come in who, at first, seemed to have difficulty speaking. After awhile, it became clear that the patient is deaf and she was using ASL with spoken language to communicate. With the physician, the scribe, and me all in the tiny exam room, the patient seemed flustered trying to answer questions and lip-reading everyone's replies. She was trying to explain why she didn't get a particular procedure done as requested from last visit. She tried to make a comment about her insurance coverage, but couldn't think of the spoken word and just made a sign. I happened to recognize the word: "shit." With my very limited knowledge of ASL, I attempted to sign with her, and suddenly, her face brightened, and we held a brief signed conversation. She thanked me for my communication and told me it meant so much that I was trying; she elaborated that so few physicians attempt to relate to the Deaf community in ASL. Definitely one of the most impactful moments in my young career in the making.
So many stories to tell: the time I caught a previously missed murmur, the right-beating nystagmus I saw which lead to a correct cancer diagnosis, the comforting of a patient literally vomiting from unimaginable pain from a spinal cord injury and arthritis...but, in the end, what I found most intriguing about my time in FM was how I communicated with patients. I felt more at ease with patients, more colloquial, more ... relatable. I found myself using slang, alternative phrases, breaking away from the "doctor speak" we are so accustomed to embrace as medical students. Rapport was instantaneous and genuine. I felt more like a patient and community health advocate than ever before in my ability to instantly provide patient advice and support. That realization made my time in the FM clinic unforgettable and exciting!
And my knowledge of healthcare coverage, ways to circumvent the system to help better provide for patients, and the ways physicians can stay on top of insurance pushback in both of my preceptorships ... truly priceless.
To any MS1 reader interested in gaining clinical experience between their first and second year summer, I HIGHLY recommend precepting. My summer may not have been the traditional/recommended "last summer" plans, and my decision to enter IM or FM is still in the works, but I have started second year with (1) heightened passion for and commitment to geriatrics, (2) a greater understanding of FM and IM careers, (3) new and improved skill sets, (4) confidence in my abilities as a student physician and patient advocate, and (5) a positive outlook moving forward with my medical education. For these things, I don't regret leaving the surveys and pipetters behind!
