Sensitivity Nazis

Dissent Will Not Be Tolerated

You are about to run the guantlet of the vast subculture in medical education devoted to sensitivity training. Your personal views, the values instilled by your parents, or your religious beliefs are about to be dismissed as detrimental to your functioning as a physician. All of these must be replaced by the latest politically correct memes fresh from the minds of pseudo-educated hacks with way, way too much time on their hands since they achieved tenure.

This training will come at you in various guises. It will be easy, of course, as reflects the shoddy academic credentials of its proponents and if you are hard to intimidate it can be a lot of fun once you get over the the fact that large chunks of your medical education are being wasted on this kind of thing.

You will be taught certain things which are to be internalized as articles of faith.

First, patients are not responsible for anything they do. After all, they didn’t have the advantages that you had growing up with that silver spoon in your lily-white gated community so they cannot possibly be held to the same standards. Therefore you are not allowed either to expect or, more importantly, to encourage your patients to be responsible for their own actions.

If Mr. Jones refuses to buy his blood pressure medications spending the money instead on cigarettes and beer then this is your fault for not motivating him properly. If you could just use the right combination of psycho-babble you might have a breakthrough where the patient slaps his head and says, “But of course! I’m having intercranial bleeds because a systolic pressure of 240 is a tad higher than normal!”


Of all the techiniques used to shut down debate, the assertion that the advantages we enjoyed as children negates our authority is the most spurious. I will grant you that many of my poor, uneducated patients will never amount to much because of poor upbringing or worse education. On the other hand we’re not asking them to work like dogs to get into medical school, work hard for four years, and struggle through from between three to seven years of residency training. We’re just asking them to take a couple of friggin’ pills every day and maybe keep a couple of clinic appointments.

My residency program gets all tied up in knots over how to make our patients more compliant. In fact, the term “non-compliant” is frowned upon and is instead replaced by the less-judgemental “pre-compliant.” Their current holy grail is a system where we essentially follow the patients home and plead with them to take their medicine. I subscribe to a different point of view, something I like to call the “French Hooker Rule” which postualtes that no matter how beautiful, no matter how accomplished the young lady is, she can only give you what she can give you.

You come to the clinic. I spend twenty or thirty minutes with you at every visit setting up your medication regimine, your smoking cessation strategy, and your weight loss goals. I’ll refer you to the appropriate specialist if indicated and I will neither belittle nor patronize you but in the end I can only give you what I can give you. When you walk out of the door you are on your own with nothing but your desire for good health to make you well.

I will certainly not treat any adult as a helpless child. Underneath all of the happy happy, joy joy, kumbayah talk about patient autonomy and respect is the patronizing and often-times racist assumption that certain patients are incapable of making decisions.

The point is that most adults make decisions about their health based on many complex factors the least important of which sometimes is your input as their physician. We might call them bad decisions but some patients enjoy smoking and eating fatty food more than they enjoy dieting and taking their blood pressure medications. Once you lead your horse to water through education it is up to them to drink.

So suggest that personal responsibilty needs to be stressed and watch the fireworks fly.

Let us discuss being non-judgemental. We mustn’t judge. After all, who are we to say what is right and wrong, good or bad? We sure are non-judgemental except of course when we are confronted with people who smoke, drink, eat Big Macs, own guns, spank their kids, watch TV, or don’t want the schools handing out condoms to their fifth grader. In that case we develop a superior attitude that would warm the heart of self-righteous puritans everywhere.

I want those of you who are now worked up to a fine lather of indignation (being highly judgemental, I might add) to step back a minute and ask themselves where it is written that non-judgementalism is the highest virtue of a physician?

Nowhere, my friends. It is merely the residue of the 1960s and all of the psycho-babble that resulted from it now manifested through the establishment who came of age during that idiotic, self-indulgent time.

Naturally your patients will expect and deserve a high level of tolerance from you. This does not mean that you need to subordinate your morality to theirs. If you don’t want to refer a woman for an abortion or put a fifteen-year-old on the pill then don’t do it. Likewise if you think that asking patients about guns in the house is an intrusive bit of politically correct idiocy then don’t do that either.

I don’t belong to the AMA because they are anti-gun and very intolerant of the anti-abortion position. I guess some judgementalism is hunky dory.

Sensitivity is a religion and the sociologists with their fuzzy degree are its priesthood. You will, in the course of your training run up against these happy people who hold nebulous positions in the institutional hierarchy but teach nothing, treat no one, and don’t even administer anything remotely related to patient care. They have fancy titles and speak in a strange language full of phrases like “brainstorming” and “intergroup dynamics” which they bring to bear on fabricated problems which are of no concern to anybody with a real job.

Political correctness is an industry, my friends, which employes an army of bearacrats to try to put a happy, sanitized face on everything. Must be nice to have a job at the Office of Institutional Diversity or some such sinecure from which one may pretend to work at fictional problems for which no measurable results can ever be expected.

Sensitivity Nazis

Things You May or May Not Need: Part 2

The Two Week Rule

Eventually you will fill all of the pockets of your white coat with various pocket reference books, tools, and pens the wieght of which will suprise you. These things will accumulate on you like barnacles on a whale and you will be reluctant to scrape them off against the possibility that you might need one of the items and not have it.

A good rule of thumb is that if you have not used something in two weeks you probably don’t need it and it is safe to leave it home.

The advent of the PDA has gone a long way towards reducing the load carried by interns and medical students. The contents of Harrison’s Textbook of Medicine, which in print weighs ten pounds, fits easily onto a small corner of my PDA’s memory so you can see that with a decent PDA you can carry around a complete library of reference books.

Which you’ll never use, of course. The best applications for the PDA are the electronic equivalents of the pocket reference books. The best, in my opinion, is Eprocrates.

Epocrates is the “killer app” for medical handheld computing and does for PDA what the spreadsheet did for the personal computer and what porn did for the internet. The current version includes a drug reference handbook, a concise medical texbook, a catalogue of lab tests and their interpretation, a medical calculator, and a few more goodies. All of them are cross-referenced and formatted to be read easily on the typical PDA screen.

Epocrates got it’s start as a drug reference and in this it is superior to any other product on the market. You can search its database by drug class or name. It gives you dosages for adults and children, contraindications, mechanism of action, and even price.

Epocrates also has a rapid clinical reference database which I mentioned earlier. Let’s suppose you are treating a Sickle Cell patient. With a couple of taps you can pull up everything you really need to know about the condition including its pathophysiology, treatment, prognosis, and even what labs and studies to order on your patient. Now, to be honest the detail isn’t quite as good as a medicine textbook but it is surely good enough for rounds and will keep you safe in case you are pimped.

On a similar note the “Five Minute Clinical Consult” series is pretty good. They are written for practically every specialty and now that you can load them into your PDA you don’t have to carry around a huge book.

A “Sanford Guide to Anti-Microbial Therapy” is another one of those essential little books (which you can also get for the PDA). It is a good place to look when starting an antibiotic regimine on a patient, especially if you are considering “empiric” therapy, that is, before cultures and sensitivities come back from the lab.

Most medical centers also publish their own small infectious disease manual which lists characteristics of the microbes specific to the medical center.

The trend now is to tie wireless devices into the hospital database. At Duke this works pretty well and you can easily access lab results and other improtant rounding data on your PDA. Some schools are years away from this. Wireless connectivity is a nice plus but not essential and sometimes more trouble than it’s worth unless your school has implemented the technology to make it seamless for the user.

I despise mucking around with computers. All I want is to turn them on and use them,

Good PDAs can be pretty expensive. Many schools make their purchase manatory (along with a laptop computer) and this just adds to your student loan debt. If I could, I’d hold off getting one until third year because you will not need it for first and second year and any PDA you buy as a first year will be pushing obselecnce by the time you start third year. Either that or the prices will come down.

It should go without saying that you will need comfortable shoes. Whether you are in the OR or rounding on a medicine service, you will spend much of the day on your feet. Your dogs will be barking for not the least of which reason as that during first and second year you spent most of your day sitting down. Clogs are very fashionable for men and women and you will see the surgeons wearing them. I think they look kind of silly but then I prefer a more conservative look.

Whatever your preference in fashion, a pair of shoes that are comfortable, cool, and easy to slip on and off will make your long hours on the wards more enjoyable. If you can slip them on and off this will let you really rest your feet if you have a moment to sit down as well as making it easier for you to get moving when you are on call and are startled awake by your beeper.

Would it kill you to buy more than one white coat? Presumably you should change the oil on your coat every three or four thousand miles. Still, you will see medical students and residents rounding with white coats which are almost gray from use. I know it is just me being superficial and that many of the folks I see skulking around in greasy, off-brown white coats are ten times the physician I will ever be but that’s no excuse to look like an ass-bag.

Buy three. Wear one for a few days then wash the the stupid thing. Hit it with an iron too, if you are to cheap to buy the polyester blend.

Oh, and get your wife, girlfriend, or same-sex spousal equivalent (as we say at Duke) to sew a few extra pockets on the inside to carry your gear. A pocket with a velcro or button closure is nice for your PDA. Most scrubs don’t have very good pockets and the minute you break into a trot when the code pager goes off your PDA will slide right out onto the floor.

Trust me.

Things You May or May Not Need: Part 2

Things You May or May Not Need: Part 1

Save Your Money

As you can imagine, medical school is a fairly expensive undertaking. It will also consume huge quantities of your time. With this in mind I’d like to go over a few things that you do and do not need either because they are expensive or because they will complicate your life rather than simplify it.

Just my opinions, of course. Your mileage is going to vary considerably depending on your comfort level, your school, and your financial resources. I will endorse some products but I am not being paid to do so (not that I wouldn’t like to be, you understand). Please don’t post angry comments.

First and most important, you really don’t need textbooks. Good Lord. Why would you sacrifice huge quantities of your study time parsing closely packed text for the few important facts buried therein? Of course you need study materials but like everything in medical education, you want them to be “high yield.”

The typical Biochemistry textbook, for example, is an 8-pound 1200 page behemouth full of essentially useless trivia. Not only that but you could easily drop 150 bucks for it, barely open it, and then lug it around from residency to fellowship to your first job before you get the courage to throw it away.

The first thing you need to understand that in a lecture based-curriculum, the tests are based on the lectures. In other words, essentially all of the questions you will be asked on any test will come from either the material presented in the lectures or from the course syllabus (Oftentimes a packet of handouts and notes). Occasionally you will get a list of “required reading” from the approved textbook for the course but this is usually just wishful thinking on the part of the professor.

I suppose a professor could enforce the required reading by taking his questions from obscure details only to be found in the textbook. In two years of lecture, however, this never happened. Occasionally the professor would throw in a few trivia question from the textbook but, as medical school tests usually run into the hundreds of questions, the potential to miss a couple of questions is not much of an inducement to miss potentially forty or fifty questions through wasting time studying trivia.

The key is to have access to good notes. Notice I didn’t say “take good notes” because it is almost impossible to take notes during a medical school lecture. Unlike undergraduate education where the courses proceeded slowly, dwelling over the subject matter and allowing time to digest and annotate, medical school lectures are a study in information overload and there is just no time to take decent notes.

But don’t despair. Usually one of the first orders of business of your newly elected class officers will be to set up a note taking service. There are many variations of this service. Some classes divy up the lectures among the students who are each responsible for preparing the notes for the lectures they are assigned (usually by transcribing from a tape after the lecture) and then emailing them to the class.

Our class hired a professional note-taker who sat in on every lecture with her tape recorder and then emailed the finished product to the people who subscribed to the service. I never bought the notes because my school posted the lectures (Power-point presentations, mostly) on our class web site and I studied directly from these. I though the note-taking service was redundant as it usually just recapped the Powerpoint presentations.

So don’t sweat it. With a few exceptions, eschew the textbooks. Instead, judiciously acquire review books. High Yield and BRS are the most popular and they have them for every subject. You will probably pay 20 bucks for a good Biochem review book which will have only a small fraction of the information in it’s bloated cousin but since you will actually read it and only the relevant information is covered you are going to come out way ahead.

With all this being said, you probably need to get a good anatomic atlas. Netters is the gold standard and you cannot go wrong buying it. A photographic atlas is also pretty useful. I liked my Rohan’s Photographic Atlas and still use it. Avoid buying a big pathology or physiology book. First of all they have them in the library or on line and if you really need to read them you can find them their. Second the review books will cover the things you really need to know.

Remember. Medical school is all about time management. Use your time efficiently and effectively.

How about diagnostic equipment? What will you need and what can you avoid buying?

You will need a good stethoscope. Most people get the Littmann Cardio 3 or one of similar quality. Not only is auscultation of the heart an important diagnostic skill which should be an inducement for you to get a good quality stethoscope but your stethoscope is kind of de facto badge of authority. You will probably end up wearing it around your neck and your patients will recognize this as your license to stick your finger in their rectum pretty much at will.

In the old days a rolled up piece of paper sufficed as a stethoscope. There are still old-school cardiologists who insist that they can hear just as well with the el-cheapo Rite-Aide stethoscopes but for my part I like to be able to hear the heart and any technical advantage I can get I will take. I would unashamedly get one of those new electronic stethoscopes except I am a resident and can’t really justify the expense. By all means look on line for a good deal but don’t skimp here. You will probably use this thing every day for your entire medical school and residency career.

Otoscope? Opthalmoscope?

Save your money.

I know. I know. It is on the “required equipment list.” Maybe you can’t avoid buying them but buy the absolute cheapest models you can possibly find because you will probably only need them for standardized patient exercises where it doesn’t really matter if you see anything or not. The patients are pretending to be sick and you can pretend to look at their retinas and into their ears.

When you start seeing real patients in third and fourth year you will find that every clinic will have an otoscope and an opthalmoscope on the wall. You will never, ever bring yours to work with you for several reasons.

First, even if they are not lost or stolen if you bring them invariably somebody will want to borrow them and in a matter of days they will somehow wander away and become common property somewhere in the hospital. The only way to prevent this is to exercise constant vigilance which you will not have time to do. You may have paid 400 bucks for them but to a causual user they are just like a pen or other “freebie.”

Second, they are heavy and bulky and you will already invariably be carrying around a white coat “combat load” which would make a Marine wince.

Trust me. Nobody carries them around. If you must, look on line for the really, really small otoscopes which fit in your pocket like a pen. They run around 100 bucks and are all you will need for a pediatrics rotation.

Blood pressure cuff? Don’t make me laugh. I suppose you’re going to carry all of this stuff around in a little doctor’s bag. (Neurologists who need a lot of tools actually do carry around little bags.) Nurses usually take blood pressures and measure other vital signs. You may occasionally want to verify a blood pressure but the cuffs are on the wall in most clinic and hospital rooms.

Reflex hammer? Why not. You can use the bell of your stethoscope of course but a nice reflex hammer will only set you back a few bucks and it will fit in your pocket.

A penlight is indispensible for examining the eyes and for looking into the mouth and other body cavities. These also fit in your pocket and are cheap. Knock yourself out.

To Be Continued…

Things You May or May Not Need: Part 1

Talking Turkey

I’m Not in it for My Health

Folks, there is absolutely nothing wrong with wanting to make a good income at your chosen profession or with trying to get the best salary you possibly can on the basis of your skills. And I don’t really care if the door greeter at Wal-Mart thinks it’s unfair that a physician makes twenty times his salary.

Your typical Wal-Mart employee didn’t just spend the whole day changing dressings on the rotting feet of diabetic vascular surgery patients, nor does he get up at zero-dark thirty to write notes on patients to have ready for rounds at a time in the morning when most working people are hitting the snooze button.

The correct phrase is “investment in human capital.” By the time we finish our training we will have been at it for little or no pay for between seven and twelve years depending on specialty. If you don’t think there should be some salary distinction between that kind of commitment and a fast-food worker then, with respect, you place very little value on your time.

I don’t mean to bust down on regular working folks. Still, my neighbor comes home at five and generally sits out in his back yard drinking beer and listening to the radio except when he goes hunting or fishing. I sometimes say hello to him early in the morning as he backs his bass-boat into the street. He is a decent, stand-up guy but hunting, fishing, and a few “irregular pleasures” are the extent of his ambition and I’m not going to cry “crocadile tears” if, with luck, I make more in a month then he will make in a year.

On the same note, I don’t envy those people who either make or have more money then I could earn in fifty lifetimes. Their wealth has no effect on me in the same way that my salary has no effect on my neighbor.

The moral here is not to count other people’s chips. A hard lesson to internalize especially since it is so easy to be envious of others.

Talking Turkey

Scrubbing In: Part 2

All Dressed Up, Nowhere to Go

Are you essential to the running of the OR? Will your skills be of any value?

Of course not.

On the other hand, just because you don’t know your ass from a hole in the ground when it comes to surgery does not mean that the team does not want you there. On the contrary, because everyone likes to show off to an appreciative audience your attendings and residents will be happy to have you there even if they will occasionally poke fun at you.

You would have to be a hoary old misanthrope not to appreciate the opportunity to demonstrate what you do well to someone who has not seen essentially the same resection of the colon fifty times. There is a certain thrill in impressing the new guy and, believe me, you will be impressed.

While it is true that many surgeons have personalities that would make Ghengis Khan wince in shame, there is no denying that over the course of their training they learn amazing skills. Be appreciative but do so silently because, as I have said elsewhere on this blog, nobody likes a tool.

Don’t be a tool.

So there you are. Scrubbed in. Ready to go. At this time if no one has told you, you should ask your resident or attending where she wants you to stand. Usually you will stand to the right of the attending. The resident will stand across the patient from the attending. This is not written in stone as sometimes it might just be you and an upper level resident loosely superivised by an attending who may or may not think it necessary to scrub in.

Your job now is to keep you mouth shut, your eyes and ears open, and to above all not do anything stupid. Leave your ego at the door. Being silent and respectful neither makes you a suck-up nor a tool. Do not take any good natured ribbing personally. Hell, don’t take anything personally.

I have a friend who’s attending threw him out of the OR after cursing at him and then throwing a few (non-sharp) surgical tools at him. He had forgotten to take off his ring and the attending could see it under his glove.

In a situation like this, do you go to your school’s office of cultural sensitivity and file a complaint? Of course not. He’s a surgeon. His personality, failed marriage, and long hours are more than enough punishment. All you will do is establish a reputation as a cry-baby and somebody who can’t take the heat. At the very least my friend always remembered to take of his ring so we can probably file the whole incident under “learning experiences.”

I keep coming back to not being a tool. For your surgery rotation more than any other you wil have to grow a thick skin as this is the rotation which cares the least for your hopefully non-fragile ego.

If you are asked to hold something hold it. In fact, your primary job will very likely be to hold retraction which usually involves holding body cavities open. Either that or to hold up limbs during orthopaedic procedures. Not too much else, if even that, will be expected of you until you show a little bit of interest and a little bit of the ability not to crush important organs.

Sounds easy but occasionally you will hold retractors for what seems like and often is hours. Pick up a light book and hold it out at arms length. See how long you can do it. That’s what holding retraction can feel like.

No doubt your school will have a suture lab during the end of second year at which time you will learn the mysteries of both suturing and knot tying. Pay attention and practice on your own. It is unlikely that you will be asked, on your first day, to close an incision but you might be asked to tie a few knots and nothing says “loser” quite like not being able to tie a simple sugeon’s knot. If you can do it, on the other hand, don’t expect any accolades. It is a basic skill, after all.

You might also be asked to use the suction catheter to keep the surgical field clear of blood and fluid. Watch what the resident does and imitate him. Do not poke and prod randomly and when in doubt, ask.

Invariably as the hours creep by your legs will get tired, you will itch all over, and you will regret skipping breakfast. Or nature will call with increasing urgency. Tough luck. You will just have to gut it out.

A few pieces of random advice:

1. Don’t lock your knees.

2. Do not doze off and fall into the surgical field. It can happen. Some operations are long and boring especially if you are not actually doing anything but watching.

3. Eschew the extra cup of coffee in the morning.

4. Turn off you pager. Residents and attendings typically put theirs on the board in the OR so the circulating nurse can answer their pages but you are just not that important.

5. Study the relevant anatomy before the operation. Typically you will look at the OR posting sheet the night before to determine where you will be. At the very least have a copy of Netter’s in your locker so you can quickly brush up on the arteries supplying the colon or anything else you might be asked by way of pimping.

6. Be scrubbed in and ready to go before the attending. This is not always possible but you should do it if possible.

7. Try to relax. Remember, as a medical student you have no real responsibility. Whatever happens you will be done with the rotation in a matter of weeks. If you don’t like it, tough it out.

8. If you really don’t like it surgery more than any other rotation offers you abundant opportunities to “hide and slide.” There are a thousand reasons, some of them actually quite good, not to scrub in on cases. In the end nobody will really keep that close track of you and you are only depriving yourself.

With that being said I had a friend who knew that he wanted to do psychiatry and nothing else so he saw absolutely no reason to to get jiggy on his surgery rotation.

let your conscience be your guide.

Scrubbing In: Part 2

For God’s Sake, Don’t Be a Tool

Is This Person a Tool?

1. Asks questions during lecture, especially near the end when everybody else just wants to get a break.

Folks, lectures are mostly a passive affair more often than not delivered straight from the Power-point slides. This is why most lectures are sparesly attended. In the old days we relied on a note-taking service. Nowadays the professor usually posts his slides and notes on line making it virtually uneccessary to actually attend the lectures.

Still, many of us are old school and feel cheated if we don’t sit in a lecture hall most of the time. We certainly don’t want to hear you’re idiotic questions the answers to which you could easily look up on your own except you think you are scoring points with the professor.

2. Claims to never study.

Everybody studies in medical school. Sorry. In fact, many people are rudely awakened with failing grades on the first exams of first year when they try to apply their undergraduate studying paradigm (just cramming before tests) to medical school. You will soon see that the people at the top of the class are always in the library, the student lounge, Barnes and Nobles, or somewhere studying all the time.

3. Takes student government seriously.

There is nothing wrong with running for class office. It looks good on your resume, gives you as little bit more insight into medical school policies than you would otherwise have, and allows you to implement minor but none-the-less appreciated changes.

Our student government upgraded our school’s weight room which was great.

On the other hand you are not going to change anything big, at least not without a lot more support than you are going to get from your class who care less and less about school policy the closer they get to graduation.

When we were first years with an enternity of medical school ahead of us we could get all irate and self-righteous about some of the school’s policies with which we disagreed. By the middle of third year we didn’t care not the least of which because the policies now made much more sense.

And we laughed at the pretensions of the first years even though we knew we were just like them in our time.

4. Is an insufferable zealot.

Come on. Admit it. Many of you have never met a real conservative or anybody, for that matter, with religious, political, or a moral point of view that differed substantially from yours. No harm done. Although a majority of physicians are either conservatives or Republicans, academia is almost exclusivley liberal and Democratic.

Therefore it is not unsual to go through four years of undergrad and even four years of medical school living in something of a bubble. With this in mind don’t get all sullen and indignant with your collegues who have a different point of view than yours.

Here is a list of a few things which do not disqualify someone from being a physician: Serving in the military, supporting the troops and our current war, being pro-life, being against affirmative action, for the death penalty, voting Republican, being a devout and observant Christian, telling a few off-color, homophobic, misogynistic, or ethnic jokes here or there, being against socialized medicine and being for market capitalism.

Not to mention expecting to make a decent living as a doctor with only a marginal interest in serving the underserved.

Like being pro-choice or voting Democratic, all of these things are well within the mainstream of American culture and there is no need for you to act sanctimonious or have a hissy fit if some of our views differ from the liberal orthodoxy which is the de facto religion of academia. I have observed this on many occasions and marveled at the the sheer bad manners of anyone who will make contemptous remarks about religion or politics to a room full of strangers.

5. Is Hypersensitive.

Sometimes you are going to get criticised. Sometimes you are going to be the object of a little good-natured and usually well-deserved ribbing. Heck, sometimes you will be the target of cutting insults which are not good-natured.

This is medical school and residency. Grow a thick skin. Everyone is over-worked, tired most of the time, and pissed off at one thing or another. It just goes with the territory. People will not have time to spare your feelings or coddle your fragile ego. If you let every little slight get under your skin you will be desperately unhappy for the next seven to ten years depending on the specialty you choose.

Conversely, be unflappable and polite with everyone from the janitor to the chief of staff. Never get mad. Never insult anyone. Never show your frustration. Just smile and ask what you can do to solve the problem.

For God’s Sake, Don’t Be a Tool

Gallows Humor

Compassion Fascists

No matter what you think now or what you wrote on your AMCAS personal statement, as you mature you will find a great deal of humor in your patients, even some who are pretty sick. This is called “gallows humor” or “black comedy.” Some try to pass this off as a coping mechanism but I am more inclined to think that some situations are just funny, even if they do involve patients. It is hard, for example, not to find humor in a 500 pound pregnant woman delivering a baby about which she knows nothing and which she denies even as you hold up the infant to show to her with the cord still running to the placenta.

Yeah, yeah. I know. Eating disorder. Body dysmorphic syndrome leading to poor self-esteem. Socioeconomically disadvantaged. Blah blah blah.

I get it. But the situation like many you will encounter is just funny. You would be absolutely wrong to make fun of a patient or laugh at them but physicians are notorious for the funny stories they tell amongst themselves.

Now, some will become sanctimonious and insist that all human misfortune including mind-numbing stupidity is the result of fate, not personal choices, and that there but for the grace of God go we. Or the dreaded commandment against being “judgemental” will be invoked, as it often is, as an attempt to stifle the debate.

I have no doubt that if my program, which is very uptight and sanctimonious, heard me make a humerous or disrespectful remark about a patient I would be called in for discussions and made to explain my thoughtcrime. It has happened to a collegue of mine.

The point is that you have to be circumspect. There are some people around whom I would never make an off-color joke or insensitive remark because they are sensitivity Nazis whose zeal for politically correct conformity would put the most vigilant of puritans to shame. With my very few close friend we hardly do anything but make off-color jokes and insensitive remarks. (My wife always asks me what my compadres and I talked about to which the standard answer is, “We exchanged vulgarities.”)

I am a former United States Marine Infantryman. I am happily married and am the father of three. I have worked for my whole life. I respect the law, vote, attend church and am a pillar of the community upon whose back the whole edifice of our civilization is supported. (And I was raised in the bad old days before political correctness made us all so hyper-friggin sensitive.)

Yet, if I was overheard by the wrong people to make an insensitive remark on any of the politically protected subjects than at the very least I would be formally reprimanded and forced to undergo sensitivity indoctrination at the hands of the thought-police from the compassion beauracracy. I would actually probably be fired and my career destroyed such is the insipid age in which we live where what someone says is more important than what they do.

In other words, watch your back. Sensitivity is a religion. There are well-paid people at every academic institution whose job it is to enforce the articles of this faith, usually by creating problems where none really exist. The priesthood of this faith are the poorly educated beauracrats at places like the “Office for Instutional Diversity” who hold nebulous and important-sounding titles in the hierarchy of your institution but teach nothing, treat no one, and don’t even adminster anything remotely realted to patient care.

Gallows Humor

Scrubbing In: Part 1

Yes, the Scrub Nurse is Laughing at You

The dreaded day has arrived. You are on your first surgery rotation. After a brief orientation you are told to report to the operating room to “scrub in” for your first surgey.

Get ready to run the gauntlet. You have the potential, in the next few hours, to screw up pretty much everything. Either that or you will do everything right and blend into the woodwork which is about as much as you can hope for on your first day.

I just want to give you a few general guidelines about what to do as a medical student in the OR. By all means take what I say with a grain of salt because I am not a surgeon, local customs vary, and maybe your surgeons are caring, compassionate souls who will calmly take you by the hand and lead you gently into the world of surgery.

Or not.

The operating rooms are generally clustered in one part of the hospital. Street clothes and more importantly, street scrubs (the ones you wear to and from the hospital) are not permitted in this area. Even before you enter the OR itself you will need to change into clean OR scrubs, shoe protectors, and a hair covering of some kind.

Now, while it is true that the OR suites are not sterile, the idea is to minimize the introduction of environmental pathogens. When you are in the hallway outside the OR it is not generally necessary to wear a mask. On the other hand, everytime you go into the OR itself you must have a cap and a mask on at a minimum even if you are not scrubbed in.

In other words, if you are asked to help position the patient you can enter in just scrubs, shoe covers, a mask, and a cap. Likewise if you are just observing from outside the sterile field as you will often do.

You will notice also that the nurse or tech who is prepping the patient will not scrub in but will wear sterile gloves as he shaves, swabs, and otherwise prepares the patient.

But you are instructed to scrub in. What do you do?

Outside the OR you will find the scrub sink. Obtain a scrub pad, open it, and place it on the ledge over the sink. (Usually these pads are pre-loaded with hibi-cleanse or other surgical scrub soap.) Next put your mask on because once you scrub your hands you can’t touch anything that is not sterile and your mask, my friend, is a hotbed of bacteria and other nastiness.

Usually either goggles, glasses with side-shields, or a mask with a transparent face shield are required in the OR. These things will all fog up on you quickly if you don’t take certain steps. Most surgical masks can be fitted to your face by bending the nose guard. Still, I always found that either the face shield or my glasses would fog up no matter what I did. Consequently I started putting a two inch strip of tape across the bridge of my nose, taping the mask flat and sealing it to my nose.

Do whatever it takes. You may laugh but you might want to take a mask home and try this to see if you can get it right. I prefer goggles to the face shield so unless your residents tell you otherwise as long as you have a mask on and your eyes are shielded you can do whatever you want.

Put everything on right and make sure they are comfortable because once you start scrubbing in you can’t touch your face or anything on it for the duration of the operation…and I have been in some that lasted almost eight hours.

Unless it is emergency surgery (as you may do on a trauma surgery rotation) scrubbing your hands should take you at least five minutes. This is why their is a clock over the scrub sink. If your residents and attendings only scrub for two minutes that’s their perogative but you, my friend, need to do it right.

First take the pick out of the scrub package and clean under your nails. The water is usually turned on by a foot valve or other no-touch mechanism. You will not touch anything non-sterile from now on.

Next, carefully and methodically scrub your hands and arms up to the elbow. First use the brush side of the pad to scrub your fingernails. Then, systematically scrub every finger, the palm, and the back of each hand in turn. Scrub hard with the sponge side.

Oh wait. Did you take off your watch? How about your rings? Sorry. All rings and jewelry below the elbow must come off. Better to leave these things at home. I put my wedding ring on a loop attached to my ID badge. Do not leave anything on the scrub sink that you don’t want to walk away.

After scrubbing one rinses, starting at the hands and letting, as much as possible, the water run down your arms away from your hands. Just do what your residents do. Do not touch the sink, the faucet, or anything else for that matter. Keeping your hands away from your body enter the OR by opening the door with any part of your body but your hands.

I should also mention that before you scrub you need to let the circulating nurse know your glove size so the scrub nurse will have them for you once you enter the OR. Typically you will wear green indicator gloves under your outer gloves. The green indicator gloves provide an extra protective layer and also show you if your outer glove is torn.

Since your hands are still wet, the scrub nurse will hand you a sterile towel. Keep the towel away from your body. Start at the top of your arm and dry in one direction. Then reach under the sterile towel to the hanging end opposite from the side you used and switch hands to dry the other hand. Drop the towel somewhere, where depends on your OR’s procedures but don’t touch anything while you do it.

While gowning and gloving without assistance is a skill you need to learn, in the OR the scrub nurse will hold your gown up for you to put in your arms. Put them into the sleeves but do not extend anything more than the fingers past the cuff. Usually the circulating nurse will tie your gown for you in the back. Note that only the front of your gown, your arms, and hands are going to be considered sterile so a non-sterlile person can tie you up in the back.

At this time the scrub nurses will hold up your first glove oriented for you to put in your hand. Reach deep into the glove but don’t touch the floor for god’s sake. For your other hand the scrub nurse will hold the glove up for you but in this case you will reach under the cuff with your gloved hand and open it up for your other hand.

Sometimes your fingers will go in the wrong fingers of the glove. Don’t worry and do not reach over with your ungloved hand to adjust your glove. Even though you have scrubbed your hands, all you have done is knocked down the number of colonies. Your hand is non-sterile even after scrubbing and if you touch your gloved had with it you will be asked to scrub out and repeat the whole procedure.

Once you have both hands gloved you may, with perfect aplomb, adjust your gloves to your heart’s content as your gloved hands are both sterile.

Now here’s the tricky part. The front of your gown has a cardboard tab attached to the wrap-around ties. Grab one tie with one hand (pulling it free of the tab) and hand the red end of the tab with the other tie attached to it to the circulator (or anybody) being careful not to touch your gloved hand to the non-sterile person you hand it to. Spin once to wrap the closure around your gown, hold the two ends of the closure and let the circulator pull the tab off of the cord. Tie your gown with the cord.

There you go. You are now scrubbed in. Keep in mind that the scrub nurse, the circulator, and anybody else who loves to harrass medical students will be watching you intently to catch you in a mistake. Maybe you touched something non-sterile. I once, for example, reached up to adjust my goggles and had to “scrub out” and repeat the whole procedure from the top.

Don’t take it personally. While it is legitmate fun to pick on medical students, the insides of the human body provide an ideal culture medium for bacteria, spores, and viruses. Surgical infections are serious business and the best way to deal with them is not to let them happen.

A word about the sterile field. You will note that the patient will be completely draped in sterile coverings leaving only the operative site exposed. The operative site will have been scrubbed before the drapes went on. The sterile field extends to all sides of the operative site which are covered by a sterile drape. Your hands, your arms, and the front of your gown from slightly above waist level to about the clavicular line are part of the sterile field. Never drop your hands below your waist. It is acceptable to fold your arms if you are just going to be standing around. Never touch anything above your waist which in not part of the sterile field.

By all means rest your hands on the sterile field. That way you will not get into any trouble. You can play a game of soitare on the sterile field (if the cards are sterile natuarally) without comprimising sterility as long as you never touch anything outside the field.

The scrub nurse’s table is part of the sterile field and is covered in a sterile drapes upon which sterilized instruments are placed. These instruments are passed back and forth between the patient and the table but as long as they don’t leave the sterile field they are sterile.

Are you seeing a pattern here? Everything in the OR is structured to keep a small area of the room sterile. The point of entry is the scrub nurse who always takes her job seriously. She may be defferential to the attending but she is not afraid of residents, interns, and least of all medical students. Do what she says in regard to protecting sterility. If you are in doubt, politely ask her what you should do.

Next: Retracting 101.

Scrubbing In: Part 1

First Day on the Wards: Part 2

You Are Worthless and Weak

What is rounding?

At it’s most basic, rounding is the process of visiting hospitalized patients as part of a team. The team usually consists of an Attending Physician, a collection of upper level and junior residents and medical students.

The Attending Physician, or the “Attending” is the boss. He is usually a senior physician with academic and clinical credentials who is responsible for all of the patients on his service. At medical schools he is most likely a professor and you may also have seen him lecturing to you during first and second year.

The day-to-day running of the service is the responsibility of the upper level resident. On a medicine service this is usually a third year resident who is in his last year of training. He will discuss the patients with the attending who will will rely on his judgment and skill in all but the most unusual cases.

The lower level residents, such as interns who are in their first year of post-graduate medical training, are responsible for the nuts and bolts of patient care. They are assigned patients and follow them, managing the many details of their treatment. This includes both working up new patients (clarifying their history and developing a plan) as well as managing existing patients.
Basically the lower level residents manage a patient from admission to discharge.

Your job as a medical student is to learn, in your turn, the nuts and bolts of patient care as well as to increase your clinical knowledge. You do this by following patients of your own, usually under the direct supervision of the lower level residents.

Nobody is going to expect you, on the first day of third year, to pick up a new patient, formulate a well considered plan, and implement it resulting in a miraculous cure. Nor are you going to be, as you may see on various popular television dramas, at constant odds with your team as you try to fight the corrupt system to get your patient the care he deserves. This is not “Patch Adams.” No matter how smart you think you are on the first day of third year you are going to feel like the biggest idiot on earth and you will be thankful if the worst thing that ever happens to you is that you are ignored.

Additionally you will probably see more straight-up medical knowledge and clinical skill in one place, represented by your Attending and upper-level resident, than you ever knew existed.
Consequently the keys to third year are to keep your mouth shut and your eyes and ears open. You also need to be enthusiastic and willing to work hard without, it must be added, being a kiss-ass about it.

Don’t be a tool. That is, don’t be that guy who asks idiotic questions the answer to which he could look up himself except he likes to hear the sound of his own voice and really thinks the Attending doesn’t know he is a tool.

Silence is golden because invariably after being assigned a patient or patients you will be required to present them.

Typically you will walk down the hall and stop at a patient’s room. After a brief pause, the person following the patient is expected to begin a short, succinct narrative describing the patient’s history, what happened since the previous day, and the plan for the patient. This narrative includes many things but if you think about it the SOAP note described in the previous section is a good place to start. If you write a good note before rounds and understand what is going on with the patient presenting to the team should be a snap.

Naturally you should know any pertinent lab values and the meaning of either their normalcy or derangement. You should also know what consultants have advised, either by talking to them informally (a “curbside” consult) or the contents of their formal written recommendations.
Any studies or images ordered on the previous day also need to be reviewed. You should look at the films if possible ( this is getting easier because many hospitals have them on line) but at least read or listen to the dictated reports.

Rounds can be a lot of things. They can be grueling tests of your endurance as is typical on an internal medicine or medicine subspecialty service. You might, for example, spend an hour in front of a patients room listening to the Attending opine on the meaning and significance of a low serum potassium followed by a half-hour discussion of his differential diagnosis. A learning experience to be sure but quite tiring after the first five hours.

Get comfortable shoes.

There is such a thing as “speed rounds” which are typical of most busy surgery services. In this case the attending wants you to be succinct . Typically the discussion will focus on the presenting complaint only with an eye to cormorbidities only as they impact the progression of the surgical patient towards his usual state of health.

In other words, your goal is to diagnose his ischemic bowel, surgically repair the damage, and manage his recovery to whatever good or bad state of heath he was in before the operation. Surgeons have full time jobs in the operating room so while rounds are important, they are a necessary evil.

Occasionally you will have “sit down” rounds where the patients will be discussed around a table after which you will go as a team for “speed rounds.”

A note on rounding etiquette.

Do I need to state the obvious that you should be attentive to the attending and the chief resident? Pay attention and keep your mouth shut unless asked a question or unless you have something relevant to add to the discussion. Maybe even if it is a joke but you should carefully assess your Attendings disposition before you make a foray into humor.

Generally, as a medical student you will have very little of relevance to add to the discussion. Your attempts to demonstrate your limited knowledge will make you look like a tool so look interested, stand where you can be seen, and keep yer’ cake hole shut.

Since one purpose of rounds is for the Attending to confirm physical exam findings, you should accompany him into the patient’s room and stand ready to assist him in his physical exam. Not only is this expected but you will also pick up invaluable physical exam pointers which will serve you well in later years.

Keep notes. Often your resident or Attending will make what you think is an off-hand remark about a lab value she’d like to see. Meaning that she’d like it ordered so she can see it. Don’t hesitate to clarify the plan before you move to the next patient by confirming your impression of what is needed.

Of course you need to be punctual for rounds, even if they start at some ungodly early hour like they will for most surgery rotations. You also need to dress up, not down, on your first day unless explicitly told to do otherwise. Many Attendings are “old school” and expect a shirt and tie for rounds. If your Attending and residents are in scrubs then you can emulate them.

A word about “pimping.” During the course of rounds (and during surgery, clinic, and just about every other activity for that matter) your Attending or residents will ask you questions to test the limits of your medical knowledge. This practice, known as “pimping,” is traditional and a valuable part of the learning process. Invariably however you will be asked a question which you know you should know but don’t and will stand gaping like a fish making apologetic noises or inarticulate grunts.

Don’t sweat it. Nobody expects you know everything. More on pimping in the next section.

What are the keys to rounding as a third year?

Enthusiasm, punctuality, attention to detail, and a little bit of humility. You are not going to save the world and you are not, despite what anybody tells you, a vital part of the health care team.

First Day on the Wards: Part 2