Abnormal Psych

This one goes to Shravan, who constantly asks me when I am updating this….

Over the last 6 months, I have found that there is one question related to medicine that I dread answering. In fact, I dread this question so much that I get antsy meeting new people. Inevitably, every conversation related to medical school and 4th year leads to the following: “What specialty are you thinking about going into?”

Ugh. What a terrible question to be asked when you don’t have a clear, defined answer. Whether or not it actually exists, there seems to be a stigma attached to not knowing what you want to do with your life at this stage in the game. Often times this question is followed up with statements like…”Shouldn’t you know by now?” or “It’s ok, it will come to you.” On one hand the whole process is comical. You apply to medical school with the intentions of being a physician. You get in or eventually get in and start learning about the nitty gritty of the body. After Step 1, you wipe you brain clean of that knowledge and start learning clinical medicine. At this point, for many people, you look back on your medical school application and realize that you had no clue what you were writing about when you were explaining why you wanted to be a doctor. In fact, much of the medical school experience was probably a strong departure from what we were expecting.

Despite my hatred for being asked about what I am doing with myself in the future, I have found that my favorite person to be with when I am asked that terrible question is a friend from high school, Wendy. She is always quick to interject that my lack of a decision means that psychiatry is still on the table and that I will potentially become her clinical collaborator when she is the PI (principal investigator AKA top dog) in a psych research lab.

After doing a psychiatry rotation, I can honestly say that psychiatry and I were not destined to spend more than 6 weeks together. (Sorry Wendy!)  That short time, however, was filled with many interesting people. I’d like to tell you about my favorite patient.

Mrs. B was a 64 year old, heavy-set African-American schizophrenic who was admitting to the inpatient unit because she was acutely psychotic. Simply, she was convinced that she could communicate with Jesus – they would communicate through what seemed like a sneeze. Although he wouldn’t give her commands, he did answer her yes or no questions. Should I go to church? No. Should I trust this man/woman? No. Should I take my medications? No. Should I pay my rent? No. Should I let my social worker, who is concerned about me, into my apartment? No. As you can guess, this series of decision-making landed Mrs. B in our psych ward.

Because of the laxity of our clerkship site, my 2 fellow medical students and I often saw our patients by ourselves, in rooms with closed doors. Meeting these people for the first time was always a daunting task – simply put, it was often difficult to assess whether someone’s “crazy” would come out in an aggressive and physical way. The first time I met Mrs. B, I was quite nervous. I knocked on her door and was greeted by a sweet lady, wearing shorts, a t-shirt and what can only be described as a strange head-dress. She closed the door after letting me in the room. I was immediately frightened (I believe this is described clinically as a “feeling of impending doom”).  However, all it took was one question before my fear was assuaged and I was able to delve into her rich personal history: “How are you doing today?”

Having met with her daily for a week and a half, I learned a great deal about Mrs. B. She quickly became the favorite part of my day. Growing up during the civil rights era, Mrs. B spent much of her youth living with her grandmother in the South, shielded from the harsh realities of Jim Crow laws and segregation. As a pre-teen she and her sister moved to Boston to live with their mother. At this point, she came face to face with the limitations that came with her skin color. The experience was quite shocking to her and left her feeling quite jilted.

The more I learned about Mrs. B, the more her illness seemed to make sense in the scope of her experiences. Her life was filled by her attempts to obtain a high education, her shock at the culture of the North in the 1950’s, and her extreme sense of faith. All of these contributed to her “delusion” that she was the chosen one, elected by Jesus to lead “her people” to a better life. Her faith in Jesus was so strong that it was almost admirable.

After a week in the ward, Mrs. B’s medications began kicking in and she became more receptive to completing normal tasks of daily living such as paying bills, going grocery shopping and attending appointments. Her strong sense of faith, however, remained. She and the big guy in the sky were still pals, communicating as they always had. Jesus was now telling her that seeing the doctor was a good thing and that she needed to take her medications. She was discharged from the ward a week and a half after I had met her.

For the duration of my psychiatry rotation, I often thought about Mrs. B. While we could all agree that she was a little off, it was impossible to ignore the fact that her rich “delusions” could in fact be true. Talking to Mrs. B made me realize that there was a fine line between prophecy and fantasy. Her faith combined with her conviction made it difficult to confidently dispute her beliefs. Let’s be honest, if many former prophets tried to pass of their beliefs in today’s world, their stories would be strikingly similar to our beloved Mrs. B.

Although my psychiatry rotation was full of interesting patients, it was hard to shake the feeling that maybe they weren’t completely crazy….

Today, I leave you with my friend Vivek who is an incredibly talented singer. Check out his website: www.vivekmusic.com


Day 3…

Yesterday’s Challenge: Upvas # 2 – completed

I realize I am throwing around the term Upvas without quite explaining what it is that I am doing. To keep this on the short side, Upvas is when you abstain from food. There are different types depending on whether you chose to drink water or not..and depending on what type of jain you are. I am doing Tivihar Upvas – meaning I do drink water..preferably boiled and cooled at room temp (this I will start doing today).

My plan was to keep the upvas going with day 3 today. Unfortunately, between my house and Children’s the best way to commute is by walking for about 25-30 mins. My walk home last night ended up being quite brutal. Although I woke up this morning feeling pretty good, I did feel a little weak. Even having eaten a little something this morning, the walk ended up being difficult.  New challenge: Fri/Sat/Sunday – Upvas. Hopefully the fact that I will not be walking to work turns out to be in my favor.

For me, a big part of Paryushan is taking the time to look back on the year and see what you could have done better – how you could minimize your attachments or live with less. There is an aspect of being selfless…which reminds me of a patient I had the privilege of meeting during my general surgery rotation…

After my first week on Trauma, general surgery clinic become a routine event. I’d show up, put my name on the white board and wait for the patients to start rolling in. After the first half hour, clinic normally became quite busy. The afternoons passed quickly as we saw patients and wrote notes. With the fast pace and the large volume of patients, I often walked into a room only knowing a name and vital signs. In this type of environment, each day was filled with a few surprises.

During my second week, midway through clinic, I walked up to a newly filled room and grabbed the sheet in the door. Mrs X, vital signs normal. I walked in to find a pregnant women sitting on the exam table with her husband and 4 year old girl. As I opened the chart, I started asking Mrs. X what brought her in to clinic. She explained that she was here for a dressing change and began rolling up her pant leg. Below the old faded denim, her skin seemed almost mummified. Her leg appeared warped to her thigh. Most of the skin had healed into darkened lesions but a few areas were open ulcers. As I flipped through her chart, I noticed that she had been seen routinely for months for an injury sustained after being hit by a bus.

After chatting with for a few minutes, it became clear that she had been seeing a wound care nurse in clinic. While we waited for the nurse to arrive, I got to know Mrs. X better. She had an extended stay in the hospital as a result of the accident. Her leg had improved over the last few months but she continued to have many problems including difficulty walking. She told me that if she wasn’t careful about the socks she was wearing or how she position her legs, her ulcer would become worse. Despite all the hardship associated with her injuries, Mrs. X was excited about the upcoming new addition to the family..

After the wound care nurse arrived, I presented Mrs. X to the attending. He patiently listened to my updates and asked me if I knew why she had sustained such tremendous injuries. I quickly replied that she had been hit by a bus. He corrected me and explained that she wasn’t just hit by a bus. Her 4 year-old daughter had run into the street. Mrs. X saw the bus coming, ran into the street to grab her daughter and throw her onto the sidewalk. She took on the bus to save her child. To this date, it is one of the most amazing stories I have ever heard.

I don’t have to say how selfless Mrs. X’s actions were. For 20 minutes in my Trauma rotation, I had gotten the chance to meet an incredible woman. In any rotation, it is easy to get bogged down by all the superfluous tasks that medical students are expected to perform. Every so often, you meet a patient who reminds you of why you picked medicine in the first place. Beyond medicine, Mrs. X’s story was simply inspiring.  Given that it is Paryushan, I felt this was fitting.

Normally I’d leave you with a video..but today, I’ll leave you with an excerpt (and link) from the Happy Days Blog which is part of the New York Times. Thanks to Shivna for the find…

“We want enjoyment, we want to avoid pain and discomfort. But it is impossible that things will always work out, impossible to avoid pain and discomfort. So to be happy, with a happiness that doesn’t blow away with every wind, we need to be able to make use of what happens to us — all of it — whether we find ourselves at the top of a mountain or at the bottom of the sea.”

Student doctor signing out.

I’m ok!

Forgive me, by the time you read this, this is one day late.

Today marks the first day of Paryushana and I am excited. Last year, Paryushana fell during my surgery rotation. Needless to say, I was a “bad jain” and did nothing special.  As strange as it may seem, this is actually my favorite time of year. There aren’t very many “holidays” where people come together quite like this. Its a time to reconnect with people you have lost touch with, a time to ask forgiveness from people you have hurt, a time to forgive people you have been hurt by, and most importantly, it’s a time to rediscover oneself. I consider the 8 days to be a challenge and I love challenges. Today’s challenge: Upvas.

I’ve decided I truly have the best friends. Last night the med school held an event at Umbria. The idea behind it was to mingle  with the different classes, but as those things turn out, you spend most of your time with people you already know. In my case, that was spending time with people I really don’t get to see that often. Last night I was reminded how awesome the people I know are and how much they do care.

Not to end things prematurely, I did have a patient story I wanted to attach to this post. Unfortunately my foodless brain is having tough time coming up with a great transition. I will save that story for another post – which I will make this week!

Instead I will leave you with my new favorite video…the first is real and the 2nd is a spoof…

Student Doctor signing out.

Blatant Honesty

I must apologize to those that actually read this, I have about 4 or 5 posts that I had started but seem unable to finish.  This weekend I made an attempt to finish at least one of them, but I realized that I wouldn’t be able to write while my mind was consumed with other things happening my life.  So, here is my attempt at blatant honesty…

The last few months have been full of  life changes. As some of you know, 3rd year was extremely draining for me. I’m sure that this is a sentiment shared by many of my classmates. I can’t explain what it was that got to me – whether it was the constant pressure to impress people or simply having to spend weeks doing something I didn’t enjoy, but for many months I didn’t feel like myself. My friend Jim and I often will Gchat each other and ask about how our “spirits” are. Well, for at least 3-4 months, my spirit was gone.

My spirit was one of the biggest reasons why I moved forward with taking the year off.  I can already say that this is one of the best decisions I have in a long time. My year off has officially started two and a half weeks ago when I took my Step 2 exam. For the first time in months, I feel like myself – like I have something to offer again. At the same time, it has been strange adjusting to having so much free time. I spent the last year on fast-forward, always busy with something to do, something to study, some exam to take. It has taken some time to get used to coming home with no exams looming. For the most part, I have been trying to find ways to counteract the boredom that sets in within an hour of coming home.

On a separate note, one of the reasons why I have been so MIA from the blogging world was the fact that I was taking my Step 2 CS and CK exams. For those that have no clue what the means, it is basically the 2nd part of the boards. Step 1 is probably the most difficult and is taken before rotations begin. Step 2 is taken before graduation or if you go to BU, before December 31 of 4th year.  I got my Step 2 score this week and I am really happy with it. It was also a little satisfying to know that I could rise above how the last few months have been.

Now, I’ll make a stab at finishing up those other posts. In the interim, I’ve been feeling this song. Enjoy:

Student doctor signing out.

Fake Patients…Terrible Actors

Over the last few weeks, I’ve been keeping busy traveling across the US. After a pit stop in Puerto Rico for Purvi’s Bachelorette Party, a weekend in Boston with Ronak, and adventures in the North End with Nina, I made my way to Los Angeles, California for the Step 2 CS exam.

For those that are still wondering what I was doing in LA, the CS exam is one part of the USMLE Step 2 Exam. It’s comprised of 12 encounters with patient actors, each 15 minutes long with an additional 10 minutes to write a progress note. With the patients, we take a focused history, physical exam and patient counseling. In real life, new patients with an acute problem generally need more than 15 minutes to be seen but this has to be standardized. This exam in only offered in 5 cities: Philly, Chicago, Atlanta, Houston and LA.

In my particular exam, I would say that somewhere between 25 and 50% of the examinees were foreign medical graduates. For them, the $1000 registration fee was topped of by an equally expensive plane ride to one of the 5 aforementioned sites.

Being in LA, I had high expectations for the patient actors that I would encounter. As I was told by Amit, 40,000 aspiring actors move into LA yearly…you figure some of them must try to make a quick buck acting as patients. Man, were the actors awful. Every patient encounter involves some sort of diffiicult questions…something like “Do you think I am dying?” or “Do you think I have cancer?” All I can say is I have never seen people less concerned about dying or having cancer

I am over-exaggerating a bit, I did have 1 or 2 patients who did a stand up job acting. Despite how great they were, the contrived nature of the encounter could not be avoided. In a regular day at the office, you rarely have to spend 15 minutes with 12 different patients and have to get a full past medical history, family history, social history, ect.  In terms of the encounter itself,  you walk into the room – you know that there is something going on, which is not always the case with real people. You also know that they have memorized pages of information related to their case…and they aren’t up-front with any of it which is unlike real people. You also know that you are being graded…which is unlike the real world. Like my friend Jim says, it’s  hard not to feel like you are fighting these people for information that you know they have.

While I understand the ultimate idea behind the exam. It seems a little silly to me that the thousands of medical students graduating from accredited American Medical Schools regulated by the LCME should each spend over $1000 to take an exam which proves that they are competent during a patient encounter. It seems like it should be the responsibility of the medical school to evaluate the competency of their own students. It’s hard to believe that an individual with poor clinical skills could make it through 3rd or 4th year without one or two red flags. BU employs its own version of this exam with 6 encounters with standardized patients trained at U Mass called the End of Third Year Assesment (EOTYA). Its is run the same way as the CS exam. In this assessment, there is a minimum needed to pass. To be honest, I found no difference between the EOTYA and the CS exam. Since the CS exam is Pass/Fail – there really seems to be no benefit to taking this standardized exam as part of the USMLE series vs getting the ok from one’s medical school.

With so much national concern over the number of people going into specialties, it’s a little funny that medical students are asked to add another $1000+ in loans to take an exam that barely requires half a day to study for.  At least, that is my opinion on the matter.

Vacation Time

At 3:24 PM on May 15, 2009, I officially finished my third year of medical school. Despite having completed an awful family medicine exam, my body was shaking with the excitement of one word: VACATION.

As some of you may know, I am taking a year off to work at Children’s Hospital in the Department of Cardiology.  So really May 15th marked my hiatus from medical school. Beyond doing benchwork, I hope to reclaim my life.  This year will be full of all of the things I miss doing like running, dancing, and hanging out with my classmates…who will soon be doctors.

One goal of this year is to actually update my blog with all the patient that have helped me grow this year (believe me – I have been keeping a list). But before I begin with what, I must pay my respects to the 18,000 people that became “Doctors” this weekend.  For some reason, I have been in graduation mode so I volunteered to usher for this year’s ceremony with my roommate.  The both of us pretty much spent the afternoon walking around and enjoying the snacks. Eventually we did help people find their seats.  After 20 minutes of work, we, like all of the friends and family in the audience got to enjoy the ceremony.

Besides cheering on friends being announced as Dr. So and So, the highlight of the ceremony was the graduation student speech.  Instead of a patient story, I leave you with a youtube video of the speech. Enjoy!

A Time For Reflection

Idealism          Listen to the pronunciation of idealism

1 a (1): the practice of forming ideals or living under their influence

In Family Medicine, we were asked to reflect on whether we have seen burn-out with 3rd year or idealism……here is my reflection:

It’s funny. In many of our clerkships, we are encouraged to reflect on our medical experiences thus far as a means of coping with exciting/disastrous/tragic/rewarding facets of medicine. While most of naturally cope using exercise, extracurricular activities, and leisure time as means of decompressing, we are always forced to reflect in one particular way – by writing. While many of our assignments illicit an eye-roll and a gasp of sorrow, this is a topic that I am glad to write about.

When I first received my white coat during medical school orientation, I was surprised at how mundane it seemed. It was plain – no patches, no embroidery, and no embellishments. The fabric seemed rough, like a burlap sac, and the pockets were too small. It almost seemed funny to me that this article of clothing was a cause for celebration. Did my parents really need to take time off from work to see me put on this $10 coat.

The day of the White Coat Ceremony came around and I was still a little skeptical. I must say, I was a little excited about the reception food and desserts but the concept behind the ceremony still seemed a little silly. It’s hard to believe that this would be one of the more memorable aspects of my medical career. For me, the defining moment of the event was the recitation of the Hippocratic Oath. Somehow that Oath transformed the plain jacket I was wearing into a symbol – an icon representing the responsibility and privilege of patient care.  It made me optimistic about myself and the journey I was embarking upon. It also made me optimistic about my fellow classmates making the same commitment. I carried that optimism through the first half of medical school.

Despite the stress and anxiety of Step One’s, I looked forward to my first day on Internal Medicine. The first month of the clerkship was great. I was learning an incredible amount of information and really connecting with my patients. While not all of my cases had happy endings, I was trying my best to ensure a high quality of patient care. Many of the people I worked with enjoyed my enthusiasm, but it was difficult and stressful to balance studying, friends and family. Initially, I found the simple act of providing care enough to get me out of bed every morning.

Sadly, that sentiment faded and the enthusiasm and idealism I started 3rd year with diminished. While many moments were incredible, they are overshadowed by the moments in which I realized that I was not actually a patient’s provider. The moments where I called a consult on a patient to somehow became the last person to hear their recommendations. The instances where my evaluations reflected my ability to search for journal articles rather than reflecting my attention to patient care. The moments where I pretending to be excited about another hernia repair, chest pain admission, Pap smear, and/or pediatric asthma case. The moments that seem to add up and leave me constantly fatigued.

Like Toxic Intern Syndrome, I do believe there is a Toxic Third-Year Syndrome. It started first with a quiet rebellion against spending extra time in a clinical setting. It continued with a disdain for SCUT work and call-schedules. With the stress of the impending shelf exams, Step 2 and the MATCH, patient care starts to slowly fall by the wayside. Soon one begins to wonder whether it’s worth staying an extra half-hour to check on patients or whether it’s better to give up, head home, and study.  Eventually, one begins to do the bare minimum because overachieving is rarely rewarded.

The sentiment that predominated during my 3rd year stemmed from a discord having a genuine interest in providing medical attention to patients and realizing that I was simply a student. Although I have experienced “burn-out,” it is not a result of my attitude toward patient care. Rather, it’s a manifestation of overwhelming desire to be Dr. Savla, not Student Dr. Savla.