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Frustration In Medical School

Surgeon-divining

From Med’Toons by S. Goldberg, Medmaster.

The huge amount of studying that medical school demands can at times be so frustrating as to make one question medicine as a career.  The following illuminating story is reproduced with permission from the interesting blog WaitingForMd.

“It was a beautiful sunny day as everyone filed into the windowed room and took seats around a large, oblong table and scattered seats along the wall.  Medical students chit chatted about needing to get back to class and wondered when the main attraction, free Thai food, would finally arrive.  Meanwhile quietly in one corner a young woman sat with her hands neatly folded in her lap with a white lab coat.  She didn’t make conversation but smiled politely.”

“The meeting began after everyone was done scooping little heaps of pad Thai into their plates and shuffled back to their seats around the table.  Some introductions of board members were made and the general idea of the student organization was described.  At the close of the meeting they asked for any questions or comments and after some expected questions the young woman in the corner raised her hand and said ‘could I please share a story with the group’.”

“The club president smiled at her and replied ‘of course’.”

“‘I had always wanted to be a doctor; it was just something I never thought was possible for me.  I was married very young.  I spent most of my life in Africa and when I came to the United States I did not think that even going to medical school was an option for me.  I was always one of the brightest girls in my class and I even went to college but it all seemed so far away. By that time I was already a mother of two young children, which made a very busy schedule for me.  Somehow I managed to secure admission into a program that allowed me to do some coursework, and upon successful completion they would allow me to go to medical school.  I could not believe my eyes or ears and I worked hard, so hard to make sure I could do it.  My grades were all very good.  But then I started to notice that my youngest son was not speaking as he should be; he was not developing at a proper pace. The doctors said that he had autism.  He would need speech therapy and physical therapy.  Hours of individual attention were needed but my husband worked.  He told me he could not do anything; we needed the money; he had to go to work.  I was left with no choice and I had the acceptance letter in my hand and I declined my admission to medical school.  After all of that work, someone had to take care of my son.  I had to care for my child and I had to give up my dream for it.  I wish my husband had supported me more, so I could achieve my dream.  Even today when I walk on the sidewalk and I am walking in one direction and one of you, a medical student, is walking the opposite direction and passes by me in a white coat, I stop and I turn around and I look at you walking away. I see my dream that I had walking away from me.  I am so happy for each of you and I am so sad for myself that I did not find a way to make my dream.’”

“The entire room sat in silence. Sitting in that room with nothing on my mind besides needing to get back to class at the end of the lunch hour, this woman’s story really touched me.  I could feel tears welling up in my eyes.  This story just serves as a stark reminder that this is an opportunity that we were lucky to have been given.  It sucks sometimes.  It’s really hard.  It makes you want to punch the wall.  But no matter why you did it, there was something that drove you.  If you can keep a piece of that with you and remember back to the time when you would have traded anything to be where you are today, everything gets a whole lot easier.”

On a personal note, I was at the bottom half of my class in medical school and there were many frustrating times.  I was a slow reader.  What I have learned is that under such circumstances, it helps to simply keep going.  In the end, it will work out. Small steps each day add up.  When it appears that you are hopelessly behind, you are not as far behind as you think.  And just like a hiker cuts through the obstacles of a dense forest underbrush, but eventually arrives at a clearing with a brilliant panoramic view, there will be a time when you no longer have the continual pressure to pass exams.

The Lowly Medical Student

Students feel they are Big Man On Campus (or BWOC) at the end of elementary school, high school and college.  Not so in medical school.  While on the wards in the 3rd and 4th years of medical school, the student status is still low, below  interns, residents, and attendings.  The student is not paid, and often lacks confidence, due to a paucity of knowledge and experience, and the attitude of certain higher ups toward medical students.

You should not feel this way, however.  One of the great fears patients have is that they will be lost in the hectic hospital atmosphere.  Medical student histories and physicals tend to be longer than those of attendings, and the patient often is quite grateful to receive the extra attention.  In fact, the student history and physical may reveal important information missed in the sometimes hasty workup of others higher up in the hierarchy.  For instance:

When I was a medical student, I saw a young woman in the E.R. who complained of abdominal pain.  She had multiple surgical scars on her abdomen from operations in which she said nothing was found.  She had been placed on phenobarbital as a relaxant.  One of the first things I asked her was whether or not she had porphyria, a condition that affects the liver and could cause severe abdominal pain.  Now, this is probably way at the bottom of the list of important questions to ask, because the condition is so rare (about 1-5 cases per 100,000 population).  However, I had just learned about it in class.  She told me that she didn’t know if she had it, but two of her brothers died of it.  I told the chief resident about this.  A crowd soon developed around the patient when the urine test showed the disease.  Of course, the chief resident took credit and I was confined to the sidelines unnoticed, with no accolades for making the suggestion.  A lowly medical student.  But I felt good, especially since phenobarbital exacerbates porphyria, and it would be beneficial to discontinue the drug.

Another time, I was awakened one cold morning in the Einstein College of Medicine dormitory by a woman’s cry  “The baby is coming!”  I looked outside the window and there was a young woman lying in the frost on the dormitory lawn, with an older woman (her mother) standing at her side.  They had lost their way to the hospital (it was the young woman’s first child).  I rushed downstairs.  The baby’s head was already out.  I delivered the baby on the lawn, and by that time other students arrived. With me holding the baby still attached by the umbilical cord and other students lifting the mother, we carried both into the  dormitory and put the mother on the lobby couch.  The baby was not breathing.  I remembered my OB rotation several months before, where we were told “Don’t rush to cut the umbilical cord,” because the baby is still receiving oxygenation from the mother.  I rushed into the cafeteria, got a straw, and sucked out the baby’s mouth.  By this time, a dorm resident, who for some unknown reason was storing all sorts of surgical instruments in his room, used them to cut and clamp the umbilical cord.  The baby was rushed to the hospital, doing well.  Later that afternoon, I visited the mother to find out how she was doing.  Her response:  “Oh, another student who said they delivered the baby.”

Sometimes it is better to remain unknown.  As a student, I once walked into the floor exam room, where I found a newly admitted elderly woman lying on the exam table with no pulse or respiration.  Not having time to inquire about her history, I immediately started mouth-to-mouth CPR and called a code.  The code team arrived, but to no avail; the patient had died.  The code chief then angrily remarked, “Who called this code!!? this is a DNR (a patient with orders ‘Do Not Resuscitate’)!!”  I didn’t volunteer that I was the one, so sometimes it is better to remain in the background.

As comedian Rodney Dangerfield used to say, “I don’t get no respect.”

Well, there is always self-respect.

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Do you have an interesting experience to relate?  Email us at mmbks@aol.com.  We may publish it in a future blog.

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How do you feel about using eBooks vs Print books?

Fatigue In Medical Education

When I was a student and intern, I wish I had the advice of Dr. John Preston in his two blog posts, Depression: Often Obvious, Sometimes Hidden, and Stress and Anxiety, particularly his comments about fatigue.

Once, as an intern (which for me was the most difficult year in my medical education), I was interviewing an elderly woman who was admitted about 2AM.  She was very slow to respond to questions and I actually fell asleep during the interview.  Perhaps it wasn’t that bad, because when I awoke, the patient was also asleep. But it shouldn’t have happened.

When I first began my internship, the chief resident told us that if there was any time during the year that we were just too overwhelmed and couldn’t see an admission that we should call him to arrange for someone else to handle it.  This happened to me once during the year.  It was about 3 or 4 AM and a new patient was admitted; I was just not functioning and needed a brief period of rest.  I called the chief resident, and he responded with a witch hunt against my incompetence.  Now, I realize that he must have had his own set of problems and didn’t want to be disturbed, but I continue to have bad memories of the time.

As a medical student, I remember overhearing an attending commenting to other students about what an idiot I was.  (I also remember him as a physician who was not especially kind to his patients either.)

Perhaps it was my sensitivity to the problems that even excellent students face in the course of medical education that influenced my decision to start MedMaster in 1979.  There is so much to know and so little time to learn it.  There is a battle between trying to study enough and also having enough sleep and personal time.  I have received many letters through the years from both students and instructors about the value of the small, clinically relevant book that provides understanding and rapid learning.  I hope these books continue to be of value.

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Do you have an interesting story to relate? Email us at mmbks@aol.com.  We may publish it in a future blog.

*****

How do you feel about using eBooks versus Print books?

Stress and Anxiety

"...and if the medication causes any headaches or hallucinations, please call me."

(by guest author John Preston, Psy.D)

Common symptoms of stress include:

  • Trembling; feeling shaky
  • Muscle tension
  • Nervousness; edginess
  • Sweating; cold hands and feet
  • Initial insomnia (difficulty falling asleep)

Symptoms associated with moderate to severe anxiety:

  • Shortness of breath
  • Tachycardia
  • Diarrhea ; frequent urination
  • Panicky feelings; fears of losing control

Symptoms associated with specific anxiety disorders:

  • Extremely intense, rapidly escalating anxiety generally lasting for 1-10 minutes (Panic disorder)
  • Recurring, significant worries about: maintaining order in ones environment (accompanied by checking behavior; e.g. checking and rechecking if doors are locked, oven is turned off, etc.); unrealistic fears of dirt, contamination  (accompanied by rituals, e.g. hand washing) (obsessive-compulsive disorder)
  • Recurring nightmares, intrusive memories, anxiety attacks, and times feeling numb (Post-traumatic stress disorder)

Note: these three anxiety disorders have very small rates of spontaneous remission. Without professional treatment they can last for years.

Symptoms that can significantly interfere with functioning at school or work

  • Impaired concentration and attention
  • Inability to maintain focus
  • Memory problems
  • Very low frustration tolerance
  • Irritability

The five symptoms listed above can severely interfere with functioning, and failure to succeed academically or occupationally can, in itself, become another source of increased anxiety.

Stress symptoms are often brought about by exposure to either very significant life events (e.g. the death of a loved one; being reprimanded or fired from a job).  But also such symptoms often arise not from specific, highly stressful experiences, but from the accumulation of many lower-level stressors (e.g. when people take on too much).

There are four factors that are at the root of many stress symptoms:

  • Loss of perspective which often leads to a perceived loss of control
  • Lack of adaptive outlets for reacting to the stressors
  • Sleep deprivation
  • The use/overuse of caffeine and/or alcohol, both of which can contribute significantly to stress symptoms.

These are causes, but also each point the way to effective stress management.

Stress management: First it is worth noting that when people are experiencing severe stress reactions it is very common for friends or loved ones to offer useless advice, such as “You just need to relax;” “Don’t take things so seriously;” “You are too sensitive.”  You better believe it, everyone who is experiencing severe stress has already done everything they can to turn the volume on stress symptoms. To have someone offer one of these platitudes never helps and often results in the person feeling misunderstood or angry.

Techniques that work: Read the rest of this entry

Depression: Often Obvious, Sometimes Hidden

"And how long have you been, in my opinion, evil?"

(by guest author John Preston, Psy.D)

A number of factors can contribute to depression. There are the usual suspects, e.g. loss of a loved one (due to death, separation, or divorce), assaults to one’s self-esteem (e.g. being fired, demoted, failing an exam, or being rejected in a romantic relationship), developing a serious illness. Additionally, a number of situations that contribute to depression  are commonly encountered among those in medical school, internship, or residency:

  • Prolonged exposure to significantly stressful situations.
  • The perception of powerlessness. For example, the belief that “no matter what I do, I still cannot stay on top of things.” Chronically feeling overwhelmed.
  • A lack of self-confidence. Developing doubts about one’s self.
  • Sleep deprivation: This is a very common but often overlooked cause of depression. This can be due to the choice to regularly sleep less (e.g. spending long hours into the night studying or being on call).  Also, a loss of restorative (slow wave) sleep can be caused by the overuse of caffeine or other stimulants and by chronic anxiety.  Prolonged stress or anxiety disorders result in high levels of stress hormones such as cortisol and norepinephrine.  These hormones significantly reduce the time spent in slow wave sleep. Stress often results in difficulty falling asleep (initial insomnia) and, in addition, the loss of restorative sleep. The daytime exhaustion that results is often combated with increased caffeine use.  Caffeine also interferes with the ability to enter slow wave sleep.
  • In attempting to overcome initial insomnia, people often turn to the use of alcohol and benzodiazepines, most of which also interfere with restorative sleep.  Fatigue and chronic loss of slow wave sleep contribute to cognitive problems (especially the ability to maintain attention and concentration).

Stress may lead to impaired sleep, daytime fatigue, excessive caffeine, alcohol or tranquilizers use, and symptoms of depression. Read the rest of this entry