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Medical Education

Medical Education, SMS Unplugged, Women's Health

Learning the pelvic exam with Project Prepare

Learning the pelvic exam with Project Prepare

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

This past Friday, half my class crowded into a small room in the basement of the Li Ka Shing Center. When we walked in, we saw our names written on the board, under one of the following headings: “Male Pelvic Exam,” “Female Pelvic Exam,” and “Female Breast Exam.”

It felt like a safe space to make mistakes, ask questions, and fumble a little bit – without feeling like I was in over my head

For many of us, this was our first session of Project Prepare – a 3-session, 8-hour course designed to teach medical students how to provide supportive care for patients in the area of sexual health. (The history of the program is included in this article.) The teachers in Project Prepare take the dual role of patient and educator, using their own bodies to help students learn how to perform pelvic and breast exams.

This was my first day of the course, and I was scheduled to do the female pelvic exam session with a patient-educator whom I’ll call Stacie. I had heard from other classmates who had already done this session that it was “intense” and that it took some time to emotionally recover afterwards. I’d heard from others that it was “incredible;” one classmate even said it made her to want to be a Project Prepare patient-educator herself. The many mixed messages rolled together in my mind and distilled into a single overwhelming sense of anxiety.

But Stacie made everything so easy. She didn’t beat around the bush about how awkward or uncomfortable the experience could be. The first thing she asked us was, “What have you heard about Project Prepare?” and when I said I’d heard it was “intense,” she responded, “Why do you think that is?” In doing so, she set the tone for the rest of the afternoon: gentle, filled with open-ended questions and non-judgmental responses.

Over the next three hours, Stacie guided a fellow classmate and me through the exam techniques and word choice that accompany the 5-part female pelvic exam. She pointed out nuances that would never have otherwise crossed my mind, like how saying “that’s perfect” and “great” are fine in other parts of a medical interview or exam but painfully awkward and even inappropriate in the context of a pelvic exam.

After the session, I looked up Project Prepare, curious as to how many medical schools invite the team to their campuses. I was surprised to see that only Stanford, Touro University College of Osteopathic Medicine (both in CA and NV), Kaiser, and UCSF are on Project Prepare’s list of clientele. Though I still have two sessions left, it is so clear to me that Project Prepare is a unique, effective way of teaching students the pelvic and breast exams. As a medical student, the idea of doing these delicate exams for the first time on a real patient (one who is not simultaneously a trained educator) is terrifying. I had this experience last year, at Stanford’s Arbor Free Clinic, where I performed my first pap smear, with the guidance of an attending physician. I recall how scared I felt that I might hurt my patient and somehow “mess up.” In contrast, my experience with Project Prepare felt like a safe space to make mistakes, ask questions, and fumble a little bit – without feeling like I was in over my head.

This week, I have two more sessions with the Project Prepare teaching team, and this time, my feelings leading up to the sessions are colored with excitement rather than anxiety. To the Project Prepare patient-educators: Thank you so much for sharing your time, your knowledge, and most of all, your bodies, with us, as we take this journey from classroom to clinic. Our medical school experience feels more complete because of you.

Hamsika Chandrasekar is a second-year student at Stanford’s medical school. She has an interest in medical education and pediatrics.

Previously: Reality Check: When it stopped feeling like just another day in medical school

Medical Education, Patient Care, SMS Unplugged

Dreaming vs. doing: How my definition of compassion changed during medical school

Dreaming vs. doing: How my definition of compassion changed during medical school

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

dreamingI woke up gasping for breath. My patients had died, and I was dying with them. Gradually, my mind unclouded and I realized that it had been a dream, but that realization didn’t soothe my worries. I lay in bed wide awake, anxious. I was picturing the woman who couldn’t speak due to a stroke, who squeezed my hand and raised her eyebrows urgently, asking me for something I couldn’t identify. Then I was remembering the very sick elderly man whose wife brought homemade soup to the hospital every day, and who always had a warm smile and a flurry of gratitude in Mandarin for anyone who entered his room. Their faces swam through my mind for a long time before I returned to sleep.

I was in the midst of my first clinical rotation. After two years focusing on the basic science of medicine, finally caring for actual patients was exhilarating and all-consuming. Even after long days in the hospital obsessing over what else I could do for my patients, I would talk about my clinical experiences on the phone with my mom, on runs with my friends, and over dinner with my husband. I lived and breathed my new role so completely that in my dreams, my patients’ deaths were synonymous with my own.

Now, two years later, I still love my days spent caring for patients in the hospital and clinic, but I don’t dream about my patients anymore. I rarely talk about my work over dinner. This wasn’t a purposeful change, and sometimes I wonder if it means I care less than I once did. I worry that I am Exhibit A for the predictable erosion of empathy that we’re all told to expect by the time we graduate from medical school.

In my more self-forgiving moments, I tell myself this change in how I experience patient care means that I’m learning to compartmentalize my experiences to survive the many emotionally demanding years ahead of me in the medical profession. Based on what I hear in the periodic group reflection sessions that we have in medical school, many students, as well as senior physicians,  agree that this kind of compartmentalizing is the key to avoiding burnout. After all, being completely present for the patient sitting in the room with me means learning to put aside other concerns – including thoughts about my other patients. The same goes for my ability to be present in the rest of my life as a wife, mother, or friend. However, in spite of all this, there is still a part of me that wonders if my growing ability to mentally put my patients’ problems aside will translate into a decline in empathy and passion for my work. After all, I didn’t come to medical school just to survive it – I came to medical school because I believed caring for patients was my calling. What does it say about me that I can so easily leave that passion at the door of the hospital?

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Medical Education, SMS Unplugged, Surgery

Rituals of the body – honoring the loss of bodily wholeness in medicine

Rituals of the body - honoring the loss of bodily wholeness in medicine

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

footWatching my first below-the-knee amputation on my surgery rotation, I felt a curious mix of revulsion and detachment. The woman on the operating table had a gangrenous infection that had spread across her foot. Her long history of smoking and her delay in seeking medical care meant that she had stiff, black toes by the time a surgeon first saw her. The only treatment was amputation.

In the operating room, the patient was draped such that only the leg was visible and exposed. The first incision was easy, a semicircle around the calf, and then the surgeons dissected down further until they hit bone. A bone saw sliced its way through the tibia, while the slimmer fibula was taken apart in chunks with a bone cutter. The skin and muscle were cut in a flap; the flaps were brought around over the bone and sewn together to create the stump.

The amputated leg sat on the scrub nurse’s table, next to a tray of retractors. The foot was balanced upright. The skin was smooth until the edge, where it gave way to jagged edges of flesh, remnants of blood vessels, and two cross-sections of bone. I felt unsettled with the amputated portion of the leg so close to me, a graphic reminder of what was lost.

What was it that troubled me? Maybe it had been the ordinariness of the moment when the body was divided up, its fibers severed with precision and focus, but no surprise, no significance. This patient would wake up some hours later, still groggy from the haze of anesthesia. Though she had signed a consent form, though this surgery had saved her, I wondered how she would she feel when she looked down at her leg.

Even in the absence of phantom pains or other sensory reminders of the missing part, dealing with an amputation is hard. It breaks the taken-for-grantedness of the body. It forces people to move through the world in new ways. These experiences made me think, can we imagine any ritual to mark a loss of bodily integrity? A pause to appreciate the work the body has done, and to prepare ourselves for its new form?

I witnessed many bodily transformations on my surgery rotation, as we do in medicine every day. But in our increasingly technical engagement with patients, do we forget the many social and cultural meanings of the body and its parts? Like why a patient may ask for his rib back after it is excised from his chest well to relieve obstruction, or why grieving parents of a stillborn child may want to bury the baby with her placenta? Perhaps a ritual could help physicians recover the awe and the empathy toward bodies we care for, and further connect to how our patients make sense of these changes.

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Medical Education, SMS Unplugged

“It’s tough feeling like you’re always in a position to be judged” and other thoughts on medical school

"It’s tough feeling like you're always in a position to be judged" and other thoughts on medical school

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

One of the hardest parts about medical school for me has been the constant pursuit of approval. Having a pass/fail system during pre-clinical years helped ease things some, but there remains a personal desire to prove myself. In front of attendings, all I can focus on is performing my physical exam just right, presenting in the perfect manner, and nailing the assessment and plan. Unfortunately, my strong desire to look good in my evaluators’ eyes has led to missing learning opportunities at times. For example, I often passed up offers to do a procedure I really wanted to do, for fear that I would look bad if I messed up.

It’s tough feeling like you’re always in a position to be judged.

As I find myself in the middle of residency applications, I realize that this feeling of scrutiny has been elevated to a whole new level. And from this point, I’ll be judged on what is already done and how I’ve been evaluated on my rotations over the last few years. I can’t do anything more to change the “me” that those who review my application see. Part of the process is an interview, but it seems as if the interview has been taking place since I began medical school.

I’m extremely grateful for the training and preparation that Stanford has provided me, and I’m confident in my application – but the uncertainty is real. And the way I see it, my success with residency applications isn’t just reflective of me: I want to make my family and the Stanford faculty and mentors who have supported me along the journey proud.

As stressful as this process and the worry about judgment are, though, I’ve been trying to re-focus myself and “check my privilege.” To even be in the position of applying and interviewing for residency is huge. I’m months away from being able to put MD behind my name. As much as I could complain about how hard medical school has been, I’ve been blessed with a wonderful opportunity to be in a position to care for people when they most need it. And, in fact, of all the evaluations that we’re required to seek during a rotation, the ones I value most are from patients and their families.

For me, medicine comes easiest when my patients and their health outcomes are front and center in my mind -  not whether I stand out to my team or answer a tough question correctly. And so with my future patients in mind, it’s time to suit up (tie-clip and all). The work’s been done.

Moises Gallegos is a fourth-year medical student. He’ll be going into emergency medicine, and he’s interested in public-health topics such as health education, health promotion and global health.

Photo in featured-entry box by Yuya Tamai

Medical Education, Medicine and Literature

The book that made me go to medical school – and other good reads

The book that made me go to medical school - and other good reads

books - 560

Editor’s note: Over the last several months, numerous young Scope readers have inquired about which books they should be reading to prepare for a potential future in medicine. We asked medical student (and SMS-Unplugged contributor) Natalia Birgisson to offer some suggestions.

“In my business, you can lose big, but sometimes you win big, too.” So begins page 87 of the book that made me go to medical school. It was the summer after my freshman year of college and I was volunteering in an outpatient pediatric ward. In the span of a week, I had seen two babies die. A newborn died of complications from seizures right in front of me, and a two week old baby died of malnutrition as we watched him wither away in an incubator.

I couldn’t stand the feeling of being a part of a system that was cumbersome and ineffective, I couldn’t stand my heart breaking, and I wanted to want to be anything other than a doctor. I lay in bed the next day and looked around my rented tropical room for distraction. On the night table was a book left by the last guest, The Soul of Medicine: Tales from the Bedside by Sherwin Nuland, MD, and what I found in his collection of stories was solace, companionship, and hope. It is a compilation of stories, each chapter written by a doctor in a different specialty discussing his or her most memorable patient. If you’re interested in medicine, the reality of it, then I suggest taking Nuland up on his offer to glimpse the mark that medicine leaves on a doctor’s soul. I keep it next to my couch in case a lost friend ever happens upon it the way I did.

Mountains Beyond Mountains by Tracy Kidder was the next book that strongly influenced me. A detailed glimpse into the life story and accomplishments of Paul Farmer, MD, PhD, who not only serves as a role model for anyone interested in global health, but who has changed the world for the better in a tangible way. What I remember from this book is a short scene in which we learn that, at least during the time the journalist was shadowing him, Farmer saw his daughter only once a month. They say that part of a teenager’s angst is realizing that her parents are not perfect and being angry at them for their flaws. Well, Dr. Farmer, I’m still angry with you for missing out on your daughter’s childhood the way my dad did. And for the rest of my life, when I think about changing the world by saving peoples lives, it will be with the caveat of improving on the model that he lived by. Because to me, there’s no point in helping strangers if I’m hurting the ones I love.

Blue Collar, Blue Scrubs and Hot Lights, Cold Steel by Michael J. Collins, MD, were two medical memoirs that resonated strongly with me. I read these the summer that I was writing my medical school applications. Somehow, the application process has a way of making everyone feel incompetent or mediocre at best. And here was a guy who decided to take post-bachelor classes as a construction worker, carpool to medical school, and marry the love of his life before starting residency at the Mayo Clinic. Almost every page of his books had me laughing or crying as I rooted for him.

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Medical Education, SMS Unplugged

Why “looking dumb” in medical school isn’t such a bad thing

Why “looking dumb” in medical school isn’t such a bad thing

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

hands in air - longerIf I had to choose one theme that has stood out in the first weeks of medical school, it would be this: questions, questions, and more questions. In the first class on our first day of medical school, our professor set the tone by laying down the requirement that we ask a minimum of ten questions before the lecture was over. Based on my experience in large undergraduate lectures, where questions were as rare as rain in Palo Alto, I naively thought this would be a challenge for us. To my surprise, we met the challenge and probably asked at least twenty questions in that first class alone.

This first day set the tone for the rest of our time together so far, and my class has quickly gained a reputation among the faculty for the volume of questions that we ask. It’s a common occurrence for a lecturer to be moving along smoothly, only to look up and see four or five hands in the air, of people waiting patiently to ask for clarifications, pose hypothetical situations, or simply admit that the last lecture slide was way too confusing. More than one class session has been derailed and run out of time because of our frequent interruptions. One of our professors memorably poked fun at us by hinting – not very subtly – that our class had no problem with “looking dumb” in front of our peers.

Given the amount of important information and interesting ideas that I’ve learned through my classmates’ questions, I’ve quickly come to feel that learning how to ask questions is an important part of my early medical training. However, this can be a difficult thing. By asking a question in public, you’re more or less admitting to everybody in the room that you didn’t know the answer; that you needed help from somebody else to get the information. Only certain learning environments – namely, with a close group of non-judgmental peers and willing professors – are conducive to this.

With that in mind, what will happen with our class as we move through our medical training? I’m hopeful that our willingness to ask questions will continue, along with the receptiveness of our teachers and mentors. As first-year medical students, we’re not expected to have a vast medical knowledge yet, so admitting “I don’t know” is relatively easy. But what will happen in a few years, when we reach the clinics and are expected to be able to put the knowledge from our first two years to use? Or more importantly, what will happen when we are fully trained physicians, and our patients expect us to have all the answers? When we don’t have the answers, will we be as willing to ask for help as we are now? As a patient, I would certainly hope that my physician would be willing to ask the right questions when needed. Because of this, I think our class can and should aspire to keeping the flood of questions coming.

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

Image by Kaz

Events, History, Medical Education, Medical Schools, Stanford News

A trip down memory lane: Stories from the early days of the School of Medicine

A trip down memory lane: Stories from the early days of the School of Medicine

When Philip Pizzo, MD, came to interview for the position of dean of Stanford’s medical school in 2000 he stayed in a nearby hotel. Taking a cab each day to campus for interviews, Pizzo would ask the driver to take him to the School of Medicine. Not one driver knew where to go, recounted Drew Bourn, PhD, while leading a recent architectural tour of the School of Medicine.

At the time the dean’s office was buried in a courtyard of the Stone Building and hidden from street view. But now the medical school has a face, the stately Li Ka Shing Center for Learning and Knowledge, which will soon have a twin to the east. Within a decade or so, a new, matching building will replace the research building currently beside it.

This was just one of the many stories Bourn shared about the first medical school on the West Coast, which has its roots in Illinois, where physician Elias Samuel Cooper, MD, diced up cadavers of executed criminals to teach surgery.

The Gold Rush brought him west, and soon the Cooper Medical College sprouted up in San Francisco, before aligning with Stanford and moving south to the Farm in the 1950s.

Its first building was the current hospital, known as the Stone Building not for its construction material, but for its architect, Edward Durrell Stone, a famous midcentury architect who designed Radio City Music Hall, among many other national and international works.

Lest I steal all of Bourn’s best bits — including how Stone met an Italian fashion writer on a plane, and before landing convinced her to marry him — I’ll leave it to you to enjoy the experience on your own. Local readers: Bourn offers tours regularly — the next is Nov. 12 at 2 PM — free and open to all. All who want to spend an enjoyable hour learning, that is.

For more fun photos, check out the Stanford History Medical Center’s Flickr collection.

Previously: Stanford building houses one of the world’s largest medical simulation facilities, Stanford’s Clark Center, home to Bio-X, turns 10 and A new era in education at Stanford’s Medical School
Photos from Stanford History Medical Center


Emergency Medicine, Events, Imaging, Medical Education, Stanford News

Ultrasound has its day – and evangelists galore

Ultrasound has its day -  and evangelists galore

ULTRAfestUltrasound isn’t just for babies anymore.

“We use it for everything from head to toe and skin and organs,” emergency medicine instructor Laleh Gharahbaghian, MD, recently told writer Sara Wykes for an Inside Stanford Medicine story. “It’s become an essential tool at  the bedside we apply to immediately rule out — or rule in — medical conditions.”

That’s why Gharahbaghian and her colleagues are hosting ULTRAfest, a full day of ultrasound instruction open to all medical students on Oct. 18. Last year, more than 300 students from across the western United States attended.

Ultrasound uses sound waves that are too high pitched for our ears to detect. The waves bounce off material in the body, providing a glimpse inside.

ULTRAfest2What’s so great about ‘Sound (as Gharahbaghian calls it on her Twitter page)? It’s relatively cheap — new scanners start at $90,000 — non-invasive and portable. Ultrasound has also moved beyond mere diagnostics. For example, Stanford radiologist Pejman Ghanouni, MD, PhD, uses ultrasound to treat uterine fibroids.

Although the technology isn’t new, researchers are finding new uses for ultrasound. As detailed in that Inside Stanford Medicine piece:

More recently, the use of ultrasound has crossed into another part of the anatomy long thought to be immune to its imaging prowess: the lungs. In the air-filled environment of the lungs, the sound waves that are the basis of ultrasound have nothing to ping against. However, in lungs where disease has produced fluids, ultrasound has proven more accurate than a chest X-ray and faster than CT scan to diagnose common lung conditions, including pulmonary edema, pneumonia and pleural effusions.

Other doctors and medical students, including U-fest volunteer William White aren’t shy about touting ultrasound’s benefits: “I just fell in love with the technology, picking up a probe and looking into the body in real time.”

Previously: New technology enabling men to make more confident decisions about prostate cancer treatment, Listening to the stethoscope’s vitals, Plane crash creates unexpected learning environment for medical students 
Photos by Teresa Roman-Micek

Medical Education, SMS Unplugged

Escaping the medical school bubble

Escaping the medical school bubble

Hamsika at Castle Rock

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

A few months ago, I read the following quote: “Don’t live the same year 75 times and call it a life.” For some reason, this quote got to me. This year is my 18th consecutive year as a student, and there are too many days that seem the same, where I’m caught in the tasks and obligations of school and extracurriculars and forget to take time out of the day just for myself.

Fortunately, I’m surrounded by classmates who are very much aware of the bubble but also skilled at disconnecting from the med school busyness. A couple weeks ago, I took a leaf out of their book, woke up at 5:30 AM, and joined four of my fellow classmates for a hiking trip at Castle Rock State Park.

Castle Rock is about a 45-minute drive from Stanford and filled with beautiful redwoods, moss-covered trees, and stunning views. Much of the group had to be back on campus at 1 PM for meetings and such (can’t escape the bubble forever!) so we chose to do a ~6-mile hike, giving us time to pause along the way whenever we felt like it.

There were moments when all of us were quiet, relishing the moist, woody smell of the forest and appreciating the absolute silence that surrounded us. Of course, most of the time, we were chatting it up. Despite the fact that all of us are together almost every day, taking the same classes and working together on group presentations that accompany our coursework, it felt like we hadn’t really talked in ages! During our three-hour hike, we bonded over so many different topics – where we wanted to live when we graduated from medical school, things we’ve struggled with this past year, our families, and so much more.

This isn’t the first time I’ve had a chance to escape into the wilderness with classmates. Last year, med school kicked off with a pre-orientation camping/backpacking trip called SWEAT (Stanford Wilderness Experience Active (Orientation) Trip). SWEAT was a 4-day, 3-night adventure, and, like this hike, was an incredible bonding experience – one that even included a few bear sightings.

The point of this entry is to 1) make it seem like I have a life outside of med school (Kidding! Kind of…), and 2) emphasize how important it is to take the time to do things you love and enjoy. One of the things I struggled the most with – both when I went to college and when I came to med school – was figuring out how I could incorporate the things I’ve always loved doing – dance, drawing, reading, etc. – into a life filled with classes, deadlines, and meetings. While the classes will soon come to an end, the deadlines and meetings and obligations certainly won’t. And that’s when I’ll make a conscious effort to traipse off to a dance class, a bookstore, or a hiking spot like Castle Rock.

Hamsika Chandrasekar is a second-year student at Stanford’s medical school. She has an interest in medical education and pediatrics.

Photo courtesy of Hamsika Chandrasekar

Medical Education, Medicine and Society, Neuroscience, Science, Stanford News

Studying science at Stanford is a dream come true for one California man

Studying science at Stanford is a dream come true for one California man

new grad students

Tawaun Lucas grew up in Compton, East LA, a city with a reputation – whether deserved or not – for producing gangsters, not neuroscientists. It’s a reputation Lucas just ignored.

A high-school athlete who dreamed of playing  in the NFL or going to the Olympics, the 22-year-old instead joined this year’s entering class of neuroscience graduate students at Stanford with a new set of aspirations.

Dreams change, Lucas explained me when I interviewed him for a story I wrote about the 135 new bioscience graduate students starting the fall semester at Stanford. As I describe in the story:

Lucas only changed his aspirations from sports to science after being sidelined by injuries his sophomore year at California State University-Northridge, where he was on a scholarship as a track athlete. But starting Stanford’s neurosciences PhD program is a dream come true, he said. “Stanford was always my first choice,” he said. “I applied to 12 schools.” When he got the acceptance call from Stanford, he said he nearly dropped the phone. “I almost teared up and cried,” he said. “It was surreal. I can’t even describe the experience.”

Lucas’s mother worked as a bus driver for the Long Beach school district. His dad was a maintenance worker. No one in his family went to college, and he wasn’t a particularly good student in high school, so the path to studying neuroscience at Stanford was an unexpected one. But programs for underrepresented minorities in the sciences helped him along the way, as did his own fascination with human behavior and the study of the brain:

His interest in science didn’t develop until his undergraduate years. He was living at home at the time with his parents, working as a bank teller while attending Cal State Northridge.  He began to turn his energies to academics when athletics was no longer an option. “Once I figured out what I wanted to do, I became focused,” he said. He chose to study psychology because the environment he grew up in had sparked his curiosity about human behavior. “I grew up in an urban area around some pretty crazy people who made some pretty weird decisions,” he said. “I began to wonder why do people, say, raised in Compton or Watts, for example, make different choices than someone raised in, say, Manhattan Beach? Is it socioeconomic? Psychological? Is there a genetic element?

Anthony Ricci, PhD, a professor of otolaryngology and member of the Stanford Neurosciences Institute, who played a role in encouraging Lucas to apply to Stanford and is part of an institution-wide effort to encourage diversity in the sciences, emphasized just how important diversity is to future advances in science:

“A person’s background is really important to how they think about a problem,” Ricci said. “If everyone were white, middle-class, Harvard-trained, they might think too much alike. Science needs people who think differently.”

Previously: First-year science graduate students enter brave new world and No imposters here: Stanford grad students reassured as they begin school
Photo by Norbert von der Groeben

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