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Education, Stanford Medicine Unplugged

Ten surprising things that Stanford med students do

Ten surprising things that Stanford med students do

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category.

Megan Deakins-RocheMy family keeps asking me why I want to write novels. After all, I’m in medical school. Isn’t that enough? No, I tell them. That’s just it. That’s why I have to write. I haven’t even started my clinical rotations, yet I’ve already seen some patients at their most vulnerable moments. I have seen myself and my classmates struggle to balance impossible expectations and inspiring dreams with the reality of our very human limitations. And so I argue back, what’s wrong with me letting my brain imagine a world in which I get to choose the outcomes? What’s wrong with letting myself create villains I like and protagonists who surprise me?

That is my way to process medicine, my way of being myself in a career path that is highly defined by my superiors. And I’m lucky to be surrounded by classmates who have their own unique, thrilling ways of living their individuality while in medical school. Stanford attracts some of the most creative, productive students in the world, and I’d like to share a small glimpse of the incredible people who inspire me with what they do outside of their careers.

Here, then, are ten of my fellow medical students and their surprising hobbies:

gourmet salad

  1. Sarah Cheng has her own gourmet food blog. The first year of medical school, she made coffee Oreo cupcakes for my birthday, and I nearly died.
  2. James Pan is a photography enthusiast. One of his photos is my profile pic. #instagood
  3. Brian Hsueh is a ballroom dancer who competed in the national USA Dance circuit for the first four years of his MD/PhD. He trained three days a week and teaches introductory classes.
  4. Cesar Lopez and (former Scope contributor) Jennifer DeCoste-Lopez came to Stanford’s medical school already married. I met them when I was an undergrad and was inspired by how grounded they were. I met them again on my interview day and they were having a baby as third year students, a testament to their ability to balance life in medical school.
  5. Megan Deakins-Roche is on the U.S. Mountain Running Team. She and her husband are sponsored by Nike and are a part of the Nike Trail Elite team.
  6. Justin Norden is a professional Ultimate Frisbee player. He’s a member of the San Jose Spiders and was a part of the team that won the 2015 championship.
  7. Austin Cook is a national champion in Judo. He now trains for fun… so I wouldn’t recommend taking a shot at him in a bar Friday night.
  8. Sheun Aleuko is a certified yoga instructor. It’s not trivial to meditate away stress… but if anything can help, it’s yoga.
  9. Ben Robison is a violinist, composer and producer who has performed around the world. He was won international prizes and has collaborated with luminaries such as David Finckel, Ani Kavafian and Luciano Pavarotti.
  10. Steven Sloan grows brains in a petri dish. He is an MD/PhD student in the neurosciences. During one of our recent conversations, he excused himself to go check on the neurons that were self-assembling into mini-brains. Just a side project, yo.

Natalia Birgisson is between her second and third year of medical school. She is half Icelandic, half Venezuelan and grew up moving internationally before coming to Stanford for college. 

Photo of Megan Deakins-Roche courtesy of Deakins-Roche; photo at lower left courtesy of Sarah Cheng

Education, Stanford Medicine Unplugged, Surgery

Ten percent more: Skirting the line between life and death in surgery

Ten percent more: Skirting the line between life and death in surgery

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

surgeryI was in the middle of my surgery rotation and was scrubbed in on a gastrectomy. A gastrectomy is a procedure to remove a patient’s stomach; in this case because of a stomach cancer. It’s a major operation that requires the manipulation of delicate structures but it offers an excellent outcome for many patients.

My job during the gastrectomy was to be a retractor – a classic medical student role. Retraction is a simple mechanical job that involves pushing skin, muscle, and other tissue out of the way in order to help the surgeons visualize the field in which they are working. More specifically, the attending surgeon handed me a metal plate and told me to use it to push down hard on the intestines so that we could get a good view of the stomach and associated blood vessels in the area. I was positioned behind the resident, who would be the one taking advantage of that view.

I pushed down with my left hand as the attending and resident went about clipping vessels and clearing tissue. Suddenly, the field of view filled up with blood. Some bleeding is to be expected during any surgery, particularly one like this. But this was more than expected.

The attending immediately started calling out orders. He told the resident to find the source of bleeding so that we could ligate it or clip it off. He asked the anesthesiologist to get blood ready in case we needed a transfusion. And then he turned to me and said, “Akhilesh, I need you to push down 10 percent harder. If we lose the field of view here, we might not find it again.”

I pushed down harder, and the search for the source of bleeding continued. The attending told us not to panic (when the attending says “Don’t panic,” that’s how you know there’s a reason to panic). He turned his attention back to me.

“Akhi, I need 10 percent more pressure.” And then: “20 percent more.”

I was getting tired.

“I know you’re getting tired bro, but give me 10 percent more.”

Finally, after a great deal of suctioning, searching, and approximately 130 percent more pressure, we found the source and stopped the bleeding. Everyone paused for a second to breathe a sigh of relief, and then it was back to the procedure.

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Education, Events, Stanford News

Hangout with Stanford’s Internal Medicine Residency program on Jan. 28

Hangout with Stanford’s Internal Medicine Residency program on Jan. 28

Have you ever wondered what it’s like to be an internal medicine resident at Stanford? Now’s your chance to learn more.

This Thursday, Stanford’s Internal Medicine Residency program will host a Google+ Hangout. Tune in at 1 PM Pacific to hear from program leadership and current residents as they share their experiences and answer questions about life at Stanford. Ron Witteles, MD,  program director and an associate professor of medicine, will moderate the one-hour discussion, which will touch on a variety of topics, including mentorship programs and research opportunities.

You can join the conversation here.

Education, Patient Care, Technology, Videos

Physician-writer Abraham Verghese on ritual, technology and medical training

Physician-writer Abraham Verghese on ritual, technology and medical training

stethoscope-448614_1280Listening to Abraham Verghese, MD, is always a treat, so I quickly clicked on a recently published Q&A featuring Verghese in conversation with Steven Stack, MD, president of the American Medical Association.

Of particular interest were comments on changes in the training of medical students. Here’s Verghese:

There have been some striking changes. For one thing, the model that you probably trained under and certainly I trained under — an intense focus on the patient and the bedside and rounds going from bed to bed — I think it’s been sort of kidnapped in a sense by the workstation.

One of the great disappointments students have when they come on the wards is… in the first two years they’re learning physical diagnosis, and they’re so excited to learn how to read the body as a text. And they arrive on the wards, and their moment of awakening, almost disillusionment, is to find that the currency on the wards does not revolve around the patient. It revolves much more around the computer. For many of them, it’s a moment of crisis. I think it actually leads many of them away from primary care, which is not a good trend.

Verghese also weighs in on the importance of touch and how a physical exam is a ritual akin to baptism or graduation. Two videos round out the post, where Verghese and Stack (the youngest AMA president since 1854!) discuss the excessive use of tests and Verghese’s motivation to begin writing books.

Previously: Abraham Verghese: “It’s a great time for physician leaders to embrace design thinking”, Abraham Verghese: “There is no panacea for an investment of time at the bedside with students and Physician-author Abraham Verghese encourages journalists to tell the powerful stories of medicine
Photo by HolgersFotografie

 

Education, Medicine and Society, Stanford Medicine Unplugged

The real reason why med students only talk about school

The real reason why med students only talk about school

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

SOM sceneOn a recent Friday, I went out with a handful of classmates for some food to celebrate the end of a particularly long and tiring week of school. Interestingly, although we had spent hours each day shuttling between lecture halls, the hospital, and clinical exam rooms, the conversation kept drifting back to one, very familiar topic: school. We talked about everything we had endured that week, compared notes on our different experiences, and looked ahead to our future plans. This isn’t a new phenomenon, by any means; in fact, almost all of our off-campus gatherings are intruded by talk of school, to the extent that it only stops when somebody finally says, “Can we not talk about school for a few minutes?”

So, why is it that med students seem to only be able to talk about school when they get together after class? Contrary to popular belief, it’s actually not because we’re so busy that we don’t have time to have a life outside of school. My classmates are athletes, musicians, entrepreneurs, husbands, and mothers – there is plenty to talk about in the world that’s not medicine! Similarly, I don’t think it’s because we’re such science nerds that we just love to talk about medicine and science all the time. Most of us need a break from that every once in a while.

What I’ve discovered over time is that we talk about school so much because the process of debriefing with our peers helps us to stay healthy as students. When we’re in class, patient sessions, or the hospital, we’re (rightfully) expected to maintain a certain professional demeanor; this can prevent us from expressing our emotions and understanding the experiences of our peers in the present. Looking around the table during an emotionally charged and difficult encounter with a patient struggling with mental illness, I see only faces of peers that appear calm and composed. Only by talking about it afterwards, in private, does it become clear that several of us are undergoing strong feelings – of sadness, nervousness, discomfort. It’s incredibly easy in med school to think that you’re the only person in the room feeling a certain way, until you find out later that every person in the room was feeling the same way.

What we’ve learned from these exercises is that nobody knows better than your immediate peers what you’re going through as a med student. Faculty and mentors have been through it themselves but are many years removed from the process and may have had very different experiences. Family and close friends know you better than anybody but often have difficulty relating to the more unique aspects of medical school. This means that there is no substitute to having peers that you can rely on.

Finally, I think it’s critical to highlight the point that being able to debrief openly and honestly couldn’t be more important in a profession like medicine, where the high stress makes rates of mental-health problems particularly high. Unfortunately, physicians seem to have a long tradition of sweeping emotional challenges and mental-health issues under the rug, in fear that they’ll be judged and ostracized by their patients and colleagues. We owe it to ourselves and our patients to try to change that culture, and I’m hopeful that our tendency to keep an open conversation with peers will help to keep all of us healthy.

Nathaniel Fleming is a second-year medical student and a native Oregonian. His interests include health policy and clinical research. 

Photo by Norbert von der Groeben

Education, Patient Care, Stanford Medicine Unplugged

As long as I have these hands

As long as I have these hands

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

clasped-hands-541849_1920

In neurology clinic, I was asked to see a young man with epilepsy — a seizure disorder — due to cerebral palsy from birth. It was one of my first clinical encounters of my first rotation of medical school, the tenuous transition from knowledge-absorber to translator and caretaker. I walked in to find a patient who was wheelchair-bound and largely non-verbal, and who interacted with the world by tracking gaze and moving his arms. He held a toy in one hand that he rotated constantly; the other lay limp on the side of the chair.

I read in the medical record that he attended a day program where he enjoyed watching other children play ball and liked giving high-fives. So instead of launching immediately into an interview of his parents for recent medical symptoms, I asked my patient for a high-five.

At first he didn’t respond, his body like stone. The father patted him on the chest several times, hard, signaling to his son to make the movement while asking him in Spanish to do so. I winced at the vigor of each tap. But soon the young man responded. He put out his hand towards mine, his eyes locked on me, and we high-fived, softly and repeatedly. When I move my hand higher, or to the side, he followed excitedly, and he did not want to stop high-fiving me until the visit ended. “He likes you,” the father said, his fiercely protective expression softening a bit.

When my portion of the interview was over, the supervising neurologist entered the room. After ensuring that the patient’s seizures were under good control, the doctor asked if the family wanted to consider an injection that would help reduce the young man’s oral secretions.

“Won’t that give him a dry mouth?” asked the father. “I don’t want him to suffer. I don’t want his mouth to be dry.” There was so much history to his mistrust; when the doctors had previously offered a surgery to help improve his son’s ability to walk, the son had ended up in this wheelchair. The mother shook her head before the words even left the doctor’s mouth, her red lips pursed. She looked at me imploringly, as if I would understand.  “No, no, no,” she said, holding up her arms to me. “As long as I have these hands, I can clean his drool.” Then, to the doctor, “I don’t mind.”

The doctor inquired again, suggesting that the oral secretions might be minimized by this injection and that it wouldn’t be permanent. “As long as I have these hands,” the mother said again, and I could read the depths of her care by the way she held her hands in the air, emphatically, hands that had mothered a son for many more years than she could have ever anticipated, but hands that had done so patiently, willingly, with no hesitation. Her hands will wipe his drool, no matter how much drips out of the corner of his mouth. She does not mind.

Now that I have completed most of my medical school rotations, I find myself returning to the phrase as long as I have these hands.

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Dermatology, Education

The ups and downs in my path to dermatology

The ups and downs in my path to dermatology

country-road-809921_1920I went into medical school determined to be an ophthalmologist. A close family friend of mine is a great ophthalmologist and loves his job, which I found inspiring. A part of me also felt pressured to choose a field early on, because I worried that I couldn’t get into a competitive one unless I started doing research, volunteering, getting to know the faculty, etc. In retrospect, this is silly, because exploring different fields to find out what you like is probably the most important thing you can do as a medical student. But I thought I knew, and so I threw myself into my research on mouse retinas and time at the free eye clinic. I enjoyed working with my amazing mentor and PI, but fast forward to the end of third year, after I did two months of ophtho rotations, I realized that I didn’t love the clinical work.

Major uh-oh, as I was three months away from residency applications.

I did some quick and frantic soul searching and reached out to several mentors. One of my early mentors from undergrad suggested that I try a dermatology rotation. Crazy, I thought to myself at the time. I had been interested in dermatology as a first-year medical student, but after hearing about the insanely high board scores, the intense type-A pre-derm students who were at the top of their medical school classes, and the crazy number of publications you needed to get in, I was completely scared away from the field. My mentor told me to try anyways, and I listened.

At the end of my third year, I switched into a four-week dermatology rotation. I think I was actually half hoping that I wouldn’t fall in love with the field, so that I didn’t have to go through the grueling application process. But I completely fell head over heels.

Dermatology combined what I loved about internal medicine (the actual thinking about the medicine!) with super interesting visual diagnoses. I loved the mix of procedures and clinic, the continuity of care I got with patients, and the huge overlap between dermatology and other fields like rheumatology, cancer biology, immunology, etc. In short, I liked it more than any other clerkship I had done and I could really see myself in this field. So I decided to go for it.

It was two months before residency applications were due, and I didn’t know the faculty well and I had very little to show in terms of dermatology research. My board scores were nowhere near the quoted average needed to be a “successful applicant.” I emailed all the faculty to see if anyone had a short-term research project, and  I ended up working on and presenting a case report of graft vs. host disease with an amazing young attending named Bernice Kwong, MD, in the Stanford dermatology department. I also did a special rotation with Toby Maurer, MD, the chief of dermatology at SF General Hospital who is the leader in global health dermatology (another huge interest of mine).

Fast forward to that November. Everyone in my class had gotten interview invitations, but my inbox stayed quiet. Then… the floodgates opened, and not in a good way. I had applied to around 85 dermatology programs, and every day I got rejection after rejection after rejection. I remember getting twelve rejections in a day once, and then, the cherry on top, I got rejected from one of my top programs. I had just gotten off the Muni (public bus in San Francisco) and it was pouring rain, and I just stood there on the street holding my umbrella and broke into tears. I had never felt so insecure, so unsure of myself and my accomplishments, and I felt like I had no future in medicine.

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Education, Stanford Medicine Unplugged

Teaching in medical school: Establishing quality standards

Teaching in medical school: Establishing quality standards

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

doctors and students talkingHaving just had three weeks off for winter break, I’ve spent some time thinking about my medical school experience. And in reflecting on my first several months of rotations, I realized that my most salient memories are not based on complex medical issues or patient interactions (although I have had one or two memorable encounters). Instead, they’re largely shaped by the interns, residents, and attendings whom I’ve worked with.

This is perhaps not an interesting revelation. Of course the people who we work with influence our experience. However, the implications of this statement are often overlooked in medicine.

Standardization is a hallmark of American medical education. While every school has distinctive curricular features, all of them cover the same core content and require similar clerkships. We use standardized patients to learn clinical skills, use textbooks that teach the same pathophysiology of disease and use the same set of resources to study for Step 1 of the U.S. Medical Licensing Examination. Medical students have many shared experiences.

The goal of such standardization is to ensure that all students achieve a threshold level of knowledge and skill that will allow us to be competent doctors. But amidst all the efforts to standardize curricula, information and experiences are ultimately conveyed by teachers. And maintaining high teaching standards is often de-prioritized, especially on rotations.

Every resident and attending takes a different approach to students. Some encourage us to be active and take on as much responsibility as possible. Others prefer students to have a more passive role. One resident carved out time to walk me through interesting medical cases nearly every day. Another told me that she didn’t have time for my questions.

As a result, two medical students might have vastly different experiences even if they are on the same rotation at the same institution at the same time.

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Education, In the News, Medical Schools, Research, Stanford News

Medical schools get an “F” at grading graduates, study suggests

Medical schools get an "F" at grading graduates, study suggests

witteles word cloud imagePerformance evaluations, an important piece of the medical residency application packet, are often incomprehensible, sometimes useless and, at worse, misleading and unfair, according to a recent Stanford study published in Academic Medicine.

The study, which examined performance evaluations — commonly referred to as the “Dean’s letter” — from 131 medical schools across the nation, found that about half don’t follow recommended guidelines set by the Association of American Medical Colleges in 2002.

“This has real consequences as it leaves residency programs in the dark about how well an applicant performed,” says Ronald Witteles, MD, senior author of the study and director of the internal medical residency program at Stanford. “Some of the examples are actually rather humorous, such as one school having 33 percent of its students in the ‘top quartile’ and only 8 percent in the ‘bottom quartile.’ ”

AAMC guidelines recommend that medical schools include “easily interpretable comparative data on core clerkship performance and overall academic performance,” the study states.

To quantify whether the 117 medical schools in the study achieved this goal, researchers examined the grading and ranking systems used, if any. Among the results, they found that 14 of the schools didn’t use any ranking systems at all. Among the 83 medical schools that did assign key words to rank students, there was “tremendous variability” in the terms used — a total of 72 — making it extremely difficult to compare students across institutions.

Adding to the confusion, those 83 medical schools used 27 different words and phrases to describe the “top tier” students such as: exemplary, superior, distinguished, outstanding, exceptional, most outstanding, recommended highly, recommended with distinction, extraordinary and enthusiastically recommended. The meanings of the words varied from institution to institution, Witteles says, and were often difficult to interpret.

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Education, Stanford Medicine Unplugged

The limits of textbook knowledge

The limits of textbook knowledge

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

open-163975_1280We are in the midst of an epidemic. It now causes more than 40,000 deaths and about 2.5 million emergency room visits in the United States annually, nearly double the number in 2001. It is the leading cause of non-natural death in the U.S. – even greater than motor vehicle accidents. Do you know what it is?

If your mind naturally jumped to gun violence, you would certainly be forgiven, given the recent spate of horrific events and the large volume of media attention they’ve received. However, the actual answer is (unfortunately) much more insidious: accidental drug overdose, the new leading cause of injury death of Americans. To make matters worse, of the nearly 44,000 deaths attributed to drug overdose in 2013, a shocking 52 percent of these were caused by prescription drugs – in other words, drugs that are theoretically being monitored and controlled by our healthcare system.

To me, the prescription-drug overdose epidemic forces me to consider one of the major challenges of the pre-clinical years of medical school: the fact that the textbook knowledge that we’ve learned about numerous diseases over our first two years can only take us so far in the real world.

For example, we learned all about the measles virus this year; we can recite who is most at risk, how it is transmitted, all of the signs and symptoms that it causes and how it is vaccine-preventable. But do you know how many deaths it caused in the United States in 2013? Zero. (In fact, thanks to the success of the MMR vaccine, most physicians in the U.S. have never even seen a single case of measles in their careers.)

This is not to minimize the severity of measles or to say that we shouldn’t be learning about it in medical school. What it does suggest is that it is far easier for us, as pre-clinical medical students, to learn what we call “illness scripts” – textbook presentations of diseases or conditions, many of which we are unlikely to ever see in our lives – than it is to gain an understanding of the complex, messy personal interplay involved in taking care of patients in the real world.

The problem with the prescription-drug abuse epidemic is that it lies somewhere at an ill-defined intersection of medicine, public policy, law and community health.

Unlike measles, it is a complex problem with no straightforward solution. With measles, I’m as confident as a second-year medical student can be. But with the drug epidemic, I can readily admit that it goes well beyond the scope of my knowledge. But should it? As medical students, we’re going to be putting our names on those prescriptions soon enough – prescriptions that cause 44 deaths per day in this country. We hear often that there are some things that can only be learned from experience. Now that our “textbook” knowledge is expanding during our second year of school, sometimes it feels as though that real world experience just can’t come soon enough!

Nathaniel Fleming is a second-year medical student and a native Oregonian. His interests include health policy and clinical research. 

Photo by PublicDomainPictures

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