Becoming the patient – It’s not easy, folks

Anup ShahBy Anup Shah, MS4

In June of 2013, I came down with the strangest illness. The events leading up to my visit to the hospital are almost as laughable as how bad I was at being a patient. But I want to share with you all the whole story because I now realize two things:

1. How much we take our patients for granted when we ask them to do the simplest tasks

2. How much we put them through when we are still learning to do basic medical procedures (especially drawing blood!)

One Sunday morning while studying at Panera Bread, I started to get the hiccups. I tried holding my breath and drinking cold water to no avail. The hiccups were minimal so I decided to ignore them and go on with my meal.

As I took a swig of iced tea, I hiccuped at the same time and aspirated some tea. That’s when the coughing fits began. I couldn’t stop coughing for the next hour. I decided to go home and take a nap and two hours later I woke up feeling feverish with convulsing hiccups.

That night, the hiccups worsened and I intermittently drank a liter of diet coke throughout the night and took Motrin and Tylenol to keep the hiccups and fever at bay.

It didn’t work. I was up at 4 a.m. and left for my clinic at 7:30. I was miserable all day. The hiccups were so bad that I thought my insides were going to collapse on themselves.

In the afternoon, I saw a patient who had a history of schizophrenia and bipolar disorder. My hiccups were so bad that the second half of our encounter was him giving me medical advice about my hiccups and he told me I should go to the hospital. I was still reluctant. On my way out the door, I made the executive decision to go to the Urgent Care Center because I was still feeling feverish.

I (somehow) drove myself to the Urgent Care Center in Baytown since both of my parents are medical professionals down there and I’d be able to avoid long wait times.

They took my temperature. 103.5. I couldn’t believe it! I next went to the ER where they drew my blood and established IV access. The nurse stuck me with the needle FOUR TIMES before she finally found a vein and said to me, “sorry, I’m at the very end of my shift.”

As annoyed as I was, I couldn’t be upset with her because I knew I would do this to a patient a few months later on my medicine rotation (update: I did…6 times). This was followed up with IV fluids, breathing treatment, a chest X-ray, and IV antibiotics.

Once I’d had fluids for a couple of hours, I felt the need to use the restroom. Again, this was not an easy task with an IV. I’m so used to just popping up, using the restroom and then resuming my normal activity, that when I had to drag the IV pole with the backside of my gown open for everyone to see, it felt like the longest bathroom visit of my life. NOW I feel terrible for leaving the room and not helping my patients use the restroom.

Now every time a patient asks to use the restroom, instead of leaving the room, I always ask if I can help them. If they say no (which I probably would have too), that’s okay. At least my conscience is clear.

Ultimately, the ER doctor told me that I was probably in the early stages of aspiration pneumonia and that the hiccups were because the aspirated fluid had gone into my right lower lobe and was irritating my diaphragm. I was given Baclofen (a muscle relaxant) and some oral antibiotics.

Not something you see every day, but I’ll tell you the biggest positive I got out of this: on my medicine rotation, we had a patient who had intractable hiccups and I suggested we use Baclofen (what was given to me) and the attending agreed. Definitely made me feel like my visit to the hospital was worth it. Maybe.

Healthy Diet: How Doctors Eat Their Words

Paras Mehta, MS4By Paras Mehta, MS4

Throughout medical school, I have seen physicians preach to their patients about the importance of a healthy diet. Physicians constantly tell patients that diet is the single most effective way to keep their heart healthy, lose weight, and prevent end organ damage from chronic diseases such as diabetes and hypertension. While a few patients heed this advice and change their lifestyle, the majority do not. Convincing patients to eat healthier becomes the most frustrating part of many clinic visits or hospital admissions.

While physicians emphasize healthy eating to their patients, many of them seem to ignore this advice themselves. Based on my observations, I would estimate that less than one-fourth of physicians regularly bring their lunch from home. The rest either obtain their meals from the hospital cafeteria or chain restaurant nearby. While there are healthy options such as Subway and Salata in the medical center, the longest lines I have seen are at McDonald’s, Chick-Fil-A, and Chipotle. And while some hospital cafeterias do have healthy options, the majority of purchases seem to include some combination of french fries, chips, desserts, and/or fountain drinks.

Here are a few solutions I believe can help physicians serve as better examples to their patients:

  1. Ban fast food from hospitals. McDonald’s has no business being located in the same zip code as a cath lab.
  2. Make healthy choices less expensive and make unhealthy choices more expensive. If a 300 calorie salad costs the same as an 800 calorie burger, most starving physicians will choose the burger. If a yogurt parfait is twice the price of an ice cream sandwich, most people will choose the ice cream.
  3. Ban pizza from conferences and lectures. Pizza is by far the most common free unhealthy meal provided, and almost anything else is a healthier alternative.

What kind of example are we setting for patients if we don’t adhere to a healthy diet ourselves? How can we expect our patients to change, if we, the supposed experts in the field, do not follow our own advice and stay healthy ourselves? And while none of us likely have the time or energy to cook meals every day, we can circumvent this by cooking in bulk 1 or 2 days a week. Just as an example, I usually cook a large batch of whole wheat pasta with vegetables/sauce/spices of my choosing once a week. I’ll take this pasta, along with greek yogurt and a fruit, for lunch every day; this takes less than 5 minutes to put together. Thus, with a little bit of planning and a few extra minutes in the kitchen, we are all capable of maintaining a healthier diet and serving as better examples for our patients.

Worth the Wait

Julia McGuinness, MS3By Julia McGuinness, MS4

Editor’s Note: All names have been changed and all patient identifiers have been removed from this story.

I will not lie. I was never so exhausted in my life as I was on Surgery. Waking up before 4 a.m. every day for my rotation on Kidney and Liver Transplant drove my body into a state of constant physical depletion. Sometimes my sleep deficit resulted in psychological exhaustion and apathy. I spent much of my time chasing lab results, almost no time with patient contact and I did not have frequent opportunities to go into the O.R. Some bitterness, even disillusionment, crept into my heart and mind. I was ready to be done.”

On the Friday afternoon after my first week on Transplant, I finally got my chance to scrub into a pediatric kidney transplant. The recipient was a teenage boy with obstructive uropathy who had already received a kidney several years before from his father and was now receiving another kidney from his aunt after his renal function had steadily declined. I was excited; I would be able to see modern medicine at work instead of spending my day in the team room. I arrived early at the O.R., gave my gloves and gown to the scrub nurse, and then waited for the surgery to start. And waited. And waited. The surgery, originally scheduled for 1 p.m., did not start until almost 5 p.m. My prior enthusiasm began to wane as I became restless. I imagined standing for hours, retracting, without getting a good view of the kidney. I just wanted to go home and sleep.

The first three hours of the surgery were spent standing and craning my neck, as I had predicted. I admittedly looked at the clock too frequently. Then, something changed. My view opened up, and I finally got a good look at the donor kidney. Shiny and grey from ischemia, it looked like a very large bean. Then, the surgeon unclamped its blood supply. Slowly but surely, a beautiful pink color diffused through the kidney until the organ was a resplendent red. I stared in awe.

The best moment had not yet arrived, though; soon after the kidney was transformed, a stream of clear urine spurted out of the donor ureter. I was transfixed by the perfect little arcs of fluid that emerged with each beat of that boy’s heart. All of the nephrology and urology I had learned in Basic Sciences was before me, not in the form of two-dimensional, cluttered diagrams of the nephron but instead manifest in the seemingly simple form of pale yellow liquid. The fellow asked, “Can you see this?” All I could do was nod my head in response; I was made speechless by the beauty and resilience of the human body. There was a communal pause to acknowledge the moment, and the transplant surgeon held up the ureter as the anesthesiologist captured a gleaming arc with his iPhone. Work still had to be done, though, and I soon lost my view again. Yet I was no longer apathetic. I had finally seen the miracle of human physiology with my own eyes.  I have no plans to pursue a career in surgery, as my talents and interests still lie elsewhere, but I will be forever grateful for the opportunity to bear witness to the marvelous beauty of the body.

Responsibility to Translate

Julia WangBy Julia Wang, MS 1

Translating literature from one language to another is often an art that requires devotion and integrity of both the author and the translator. It involves heated discussions about communication and the implicit versus explicit meaning of words.

As I continue to follow medical blogs and health related news online, I became interested in another type of translation. The translation of basic science papers to plain, everyday English.

A few skilled ‘translators’ I admire are regular contributors to The New Yorker and the Well blog of New York Times. Atul Gawande, for example, is the author of multiple best seller books and a regular contributor to The New Yorker. He often compiles clinical studies and translates them into engaging and thought-provoking articles.

While trying to keep up with the literature in our own fields of interest, we know more than anyone else how difficult it is to digest the basic science and clinical papers on PubMed.

The correct way to interpret experimental and observational data is not exactly intuitive. The titles of the papers most likely do not mean exactly as they say. The results and conclusions drawn often come with multiple significant caveats and troublesome assumptions that make interpretation difficult.

Being literate in these nuances of medical advances can’t be taken for granted and should be utilized to help others understand what it means when news articles or commercials try to grab your attention by stating things like “oranges will cure multiple sclerosis.”

As medical scientists in training, we have a few additional reasons why we should write for the public’s eye. Since the progress of the medical field is enormously imprecise and fast paced, frequent updates are important. The knowledge pool is so large that not every physician can keep up, let alone the general public.

Dr. David Eagleman, a neuroscientist at Baylor College of Medicine, wrote an inspiring article on the involvement of public writing. He makes great arguments for the benefits of writing for the public about science and he embodies this idea by writing the most interesting books about the secrets of the brain.

Inevitably, we will travel through gray areas where we wonder if we are truly qualified to decide how to communicate important information to the public. Nevertheless, I feel a responsibility to carefully examine research conclusions and translate this information and its implications accurately to the general public.

 

Navigating the financial trenches of medical school

Rachel SolnickBy Rachel Solnick, MS3

As a medical student (aka: professional at spending money that’s not mine), I’m very used to saving money as a daily exercise in the delayed gratification that is the only path into becoming a doctor. Despite the joys of hunting down finds at thrift stores and the randomness of GroupOn dates, having no money while hanging out with old college buddies with actual incomes can get pretty old.

But I have a secret to share with you, fellow med student – the one real economic perk of being a professional student. And yes, you can enjoy in the here and now. By just doing something you already have to do, but doing it smartly, can rack in massive amounts rewards.

What am I talking about? Credit card rewards (re: free money, flights, swag) from paying your tuition.

Every September and January, I devise my plan of attack for which credit cards I should use for tuition. Now of course this is going to be very dependent on your personal credit FICO score. The FICO is basically a measure of how “reliable” you are as a consumer and thus how likely you are to qualify for certain credit cards and how high your line of credit will be. (By the way, you should aim for a FICO in the 700s and you can receive a credit report for free annually.)

Often, if you have a good score and pay your credit cards on time, you should be able to apply for some very lucrative “welcome bonus” offers from new cards by searching financial blogs or seeking details on credit card company websites. A good example would be 40,000 reward points bonus for spending $2,000 in the first three months of account opening. Without a welcome bonus, it would take about $20,000 of spending to earn that level of points. With the more robust reward plans, these can be transferred to airline reward points, or you could get a credit card straight from the airline themselves. Presto change tuition equals free interview trail flights!

But wait you say, don’t these cards have fees? Yes, often the best reward cards are associated with annual fees, however, these fees are very commonly waived during the first year. After a year, you can decide if you like the card enough to continue to use it and pay the fee.

Which brings me to my next point, and lesser known strategy: If you have had a credit card for a long time, even if you haven’t used it in a while, you may be eligible for “retention offers.” This only works if you are actually okay with cancelling your card, because that is your bargaining chip.

Call the credit card company, ask to speak with the retention office and tell them that you are considering cancelling your account, but were wondering if there were any current offers that might convince you of the utility of the card. Examples of these offers (depending on how long you’ve had the card, how much you’ve used it) might be 10,000 reward points if you spend $3,000 in the next 6 months. (Just be sure to wait the 48 hours until the offer is applied to your account). But brace yourself, because this route may require a lot of waiting on hold to speak to the right person. Also, if it doesn’t work the first time, don’t despair! It’s definitely worth a second shot because different times, departments and locations may result in different offers.

For instance, on this last tuition, I was able to combine a retention offer with a welcome bonus, to get enough reward points to completely purchase a GoPro Hero3 action camera, no strings attached! And maybe next tuition payment, I’ll get some airline points to go on an adventure worthy of an action camera.

Fear not, fellow professional student, you may be functionally poor, but you can make your tuition hurt less with sweet little (and big) rewards if you are strategic with how you pay.

Where space exploration and medicine meet

Andrew Holt
Andrew Holt

By Andrew Holt, MS3

Astronauts are modern explorers. After conquering most of our own planet, we are starting to expand our reach. This comes with a new set of challenges in spaceflight – longer travel times, higher doses of radiation, and a myriad of risks associated with long-term zero gravity.

Enter space medicine.

As a space medicine physician, your patients are not sick. In fact, they’re far from it. We’re talking about the peak of human performance, both physiologically and mentally. The Mercury 7, our first class of astronauts, were equal parts genius and crazy. They were highly respected military test pilots recruited to fly cutting-edge technology, frequently utilizing their extensive engineering knowledge. They literally learned how to fly rockets… on the job. Each early spaceflight success was immediately followed by new, loftier goals at a ridiculous pace – only eight years passed between the first human spaceflight and the lunar landing!

This is the unique challenge of providing medical care to astronauts – they are incredibly healthy and intelligent patients who are thrust into an unforgiving, hostile, and largely unknown environment. The space medicine physician must coordinate detailed care that incorporates every medical specialty. The care is comprehensive, covering astronauts during training, pre-flight evaluation, in-flight monitoring, and post-flight recovery. Most of the physicians are well equipped with backgrounds in emergency medicine, engineering, medical research, and military training. But these aren’t prerequisites – any physician can find a niche in the field.

As we move forward, turning our attention to Mars, the role of space medicine doctors is evolving as well. With prospects of multi-year missions and colonization, they will need to be part of the crew. There are already physician-astronauts. In fact, several are on staff at Baylor College of Medicine (if you get to work with one of them, ask them about it – they love to share stories and pictures).

So what is Space Medicine?

It’s caring for the healthiest patients in the most demanding situations. It’s the direct integration of science and medicine. It’s a chance to go into space.

As a Baylor College of Medicine student, one of the most exciting things about space medicine is… it’s in your own backyard. Houston, with the world’s largest medical center and NASA’s Johnson Space Center, is uniquely situated to be a world leader in space medicine. With NASA, the NSBRI, and the BCM Center for Space Medicine all nearby, students have unique opportunities to work with leaders in the field and do research at top-level facilities. Take advantage of it!

Roof of the Mouth

Anup ShahBy Anup Shah, MS3

In clinics, many times you can be left feeling like an idiot. One of those times was on the second day of my outpatient pediatrics rotation. My attending asked me to go examine a young boy who came in with a sore throat. I very cleverly got him to open his mouth and looked at the back of his throat, tongue and tonsils and reported that I thought everything looked normal. Tonsils weren’t inflamed, no erythema (or redness).

As always happens, the attending came in to do his own exam. When you start clinics, this process is nerve wracking because you always feel like you left out something obvious.

And I had. My attending hadn’t looked in the boy’s mouth more than three seconds before he looked up and told me to come look at the roof of the mouth. It was a vivid and deep red, and I wondered how the heck I could have missed such an obvious finding.

Fast-forward a month and I’m rotating on my Pediatric ER rotation. We get a new patient who hadn’t been examined up to this point. He was an 18-month old boy whose parents said had a fever at home and was fussier than usual. I took one look and knew something was different about him. His eyes were more widely spaced than normal. I looked in his mouth with my penlight. Before I stepped back, I knew to be more thorough this time around. There it was. A gaping hole at the roof of his mouth, medically known as a cleft palate. I asked the parents about any genetic conditions and they mentioned that the boy had a genetic disorder called Wolf-Hirschhorn syndrome. I reported this to my resident and we were able to get the appropriate parties involved.

Several months after that, I was on my ER rotation – one of the last rotations I had left. At this point I was far more adept at performing a focused physical exam than when I was on pediatrics. A 40-year old man came in with some shortness of breath and severe nausea, weakness and fatigue. A few more questions and I learned that he was gay and had had unprotected sex with a partner for 10 years before breaking up over a year ago.

With this information, the unfortunate thought of HIV crossed my mind and I knew to examine his mouth thoroughly as part of the exam. Everything seemed clear except for, sure enough, the roof of his mouth which showed a grayish-white plaque. I tried to scrape the lesion with a tongue depressor (knowing that this was how I’d differentiate oral candidiasis from leukoplakia). I took this information to my intern and told him he should do an HIV screen before we present to the attending. It came back positive, and my intern ended up looking like a rock star.

Practicing medicine isn’t about memorizing book facts. It’s about utilizing those teachings to develop instincts. There is no way that – had the 40-year old man with HIV been one of my first patients at the start of clinical rotations – I would have thought to check his mouth so thoroughly, let alone even take a sexual history or scrape the roof of his mouth and run an HIV screen. But I guess that’s why they call it “practicing” medicine.