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SMS Unplugged

Health Policy, Medical Education, Patient Care, SMS Unplugged

The downside of a free lunch: Incentives and the medical student

The downside of a free lunch: Incentives and the medical student

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.

money on hook  smallDoctors are people, too, and they respond to incentives. That was the message we got from a recent health-policy class session that discussed various ways of paying doctors for their work, and how this can play a role in patient care. In an ideal world, physicians would be motivated only by what is best for their patients; however, the reality is that doctors, like all people, can be influenced by external factors such as money, autonomy, and time.

This got me thinking about the incentives that currently shape my life as a medical student. While we would all like to say that the choices we make are determined only by our own internal desire to maximize our learning and become the best future physicians possible, even the most idealistic student among us would have to admit that incentives, big and small, influence our decisions every single day.

On a day-to-day basis, incentives determine how we budget our time and focus our efforts. For example, given the huge demands on our time and our budgets, the promise of a free lunch provides a strong incentive for us to attend lunchtime seminars and panel discussions – even if the subject matter is not of immediate interest or relevance to us.

In class, because of the Pass/Fail grading system during our pre-clinical years, our external incentives are not our class grades, but instead the standardized board exam that will play an important role in our residency applications. Our collective ears perk up every time our professors say “This always shows up on the boards,” even if we are told that the particular information is rarely (if ever) applied in real-world clinical practice.

In the bigger picture, as we begin to explore various specialties and avenues for practicing medicine, it is impossible to ignore the reality that average salary, lifestyle, and autonomy vary hugely from one specialty to the next, and from one type of practice to another. Not feeling very passionate about private-practice urology? Does that change when you find out that urologists make about twice the annual salary of a family medicine doctor?

The reality is that our intrinsic motivations to make the world a better place by becoming the best possible physicians do not always align with the incentives that medical school, and the larger health-care system, provide. We are incentivized to spend time and effort on things that will not help us be better doctors, and in the long run we might even be incentivized to make decisions that will reduce the amount of good we can bring to the world. Is it the job of policymakers and medical educators to better align incentives to create the desired outcomes for our health-care system? Or do we, as future physicians, need to shoulder more responsibility to do the right thing, passing up the literal and figurative “free lunch” in the process?

Maybe there is an ideal middle ground for each of us – a place where the incentives align at least reasonably well with our own internal goals. In that case, one of our tasks as medical students for the next several years will be to find it.

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

Photo by Tax Credits

Infectious Disease, SMS Unplugged

The bacteria that nearly killed my grandmother

The bacteria that nearly killed my grandmother

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.

Staphylococcus aureauMagnification 20,000“Hefur þú lært um Staphylococcus aureus?” I almost don’t recognize the bacteria name because my grandmother pronounces it differently in Icelandic.

“Já–” I’m about to translate my microbiology flashcard for her when she interrupts, her hands busy kneading the cookie dough and her eyes on my little sister near the oven.

That’s the bacteria that almost killed her eleven years ago, she tells me. I can hear her words building up. This is a story that has been waiting to be told often enough to be reconciled.

They did not know what was wrong with her. They thought maybe cancer, maybe tuberculosis – and I almost interrupt her story to tell her about Pott disease. That’s when tuberculosis from the lungs goes through the blood to the vertebrae and causes back pain, fever, night sweats and weight loss. I memorized the flashcard a few weeks ago.

My little sister stops doing handstands in the middle of the kitchen and comes to stand next to my chair. Together we watch Grandma roll the cookie dough as she continues talking.

It took the doctors a whole long time to figure out what was wrong with her. In the meantime, she was in so much pain from her back that she had to be on high doses of morphine. Codeine.

She could hear them yelling at each other in the next room, my great uncle and the other doctor. The two internists had very different approaches. My great uncle wanted to identify what was going on before putting her up for surgery. The other doctor yelled at him that he was going to wait so long the woman would die.

My grandma stops her cookie cutting and sits across from me. She looks at me for a moment over her glasses and tells me how terrifying it is to know that your doctors don’t know what’s wrong with you.

My poor great uncle, I tell her – he was just trying to make sure that they didn’t make you worse by operating.

My grandma nods and describes how when they finally did agree to have her undergo surgery, my great uncle called the best surgeon in town and had him come back early from vacation to operate on her the next day. And good thing too, for when they did, they found that three of her vertebrae had been turned to dust.

With an infection like that, the surgeon said she was hours away from death.

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SMS Unplugged

Six thousand words to describe my decidedly non-medical winter break

Six thousand words to describe my decidedly non-medical winter break

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 winter break was all about me NOT being a medical student. For three blissful weeks, I didn’t have a copy of First Aid for the USMLE Step 1 anywhere near me, I didn’t log on to Coursework (Stanford’s online course system), and I barely checked my email. This is a snapshot, worth 6,000 words, of what happened instead.

Top left: I met up with a friend from high school and we baked bread from scratch! I’m not much of a baker, so the fact that this bread ended up being edible is a huge accomplishment. My younger brother ate pretty much half the loaf all by himself, which could only be a good sign.

Top middle: New Year’s Eve was spent playing a cutthroat game of Pictionary. Sadly, my team lost. But on the plus side, the game helped me stay up past my 10 PM bedtime to ring in the New Year!

Top right: Under my mom’s guidance, I managed to FINALLY learn how to make my own lattes – not that that has prevented me from spending $3 a day on coffee from the med café…

Bottom left: This picture, taken in front of Universal Studios in LA, will very likely be my only red carpet moment for a while.

Bottom middle: I got to spend an entire day with these two adorable twins. They’re entranced by a show called Peppa Pig. If you haven’t seen this show, I highly recommend you check it out on YouTube!

Bottom right: During my time in the LA area, I went with friends to not only Universal but also Downtown Disney, where we stopped by the LEGO store and created this masterpiece – and left it there for the next person to find and wonder who the heck I am.

Thus passed my winter break. And now, back to the grind – just 9 weeks till my classmates and I are done with our pre-clerkship years!

(Side note: I was struggling for a blog idea, when I remembered this entry, written by a fellow MIT alum – Elizabeth C. – back when we were both blogging for MIT admissions. All credit for this entry idea goes to her!)

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

Photos by Hamsika Chandrasekar

Health and Fitness, Patient Care, SMS Unplugged, Technology

“Nudges” in health: Lessons from a fitness tracker on how to motivate patients

“Nudges” in health: Lessons from a fitness tracker on how to motivate patients

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.

fitness trackerIt was 11:47 PM. That meant that I had 13 minutes to reach my pre-set goal of  “activity” that the fitness tracker on my wrist had been registering throughout the day. If I met the goal I would get a “trophy” on the accompanying app. I probably looked pretty funny bouncing around my living room doing a squat here and a sit-up there, punching a pretend opponent, and running in place. But I made it minutes before midnight. If I hadn’t – well, then I would have just blamed the piece of technology on my arm for not working.

The tracker was a gift from my cousin Steve. Steve is impressively fit; he runs marathons, tackles obstacle courses, and races road bikes. A few years back at Christmas dinner, Steve challenged me to a pull-up contest – I was super hyped and ready for it until, well, I lost. Every holiday season since then, I’ve spent the weeks prior to heading home logging extra push-ups, pull-ups, and bicep curls just in case a re-match comes up. Without knowing it, Steve inspired me to get active. Now, with blinking lights and status reminders, the fitness tracker he gave me does so more frequently, more annoyingly, but in a way, more enjoyably and effectively.

The fitness band on my wrist doesn’t tell me to go to the gym or go for a run. The periodic updates on how far I am from my pre-set goal, however, “nudge” me to get up during a commercial and do a set of push-ups, to get out for a walk, or to take the stairs. I’ve even turned to running in place or a set of body squats whenever I find myself yawning to make sure I get enough points.

In the past, I’ve been good about working out, even doing stretches of two-a-day gym trips. But this doesn’t last very long as I use the busy “medical school” schedule as an excuse. After getting the fitness tracker, it’s been a string of random, spontaneous, and unstructured “work outs” throughout the day. While I may not have achieved Mr. America status, I’ve felt good about meeting my daily goal and racking up “trophies.” It’s even become a bit of a game to see how high I can actually make my numbers go. I’m competing against myself. This may sound weird, but at least I know my opponent and understand what I’m up against, right?

Wearing the fitness band reminded me of the concept of nudges. Nudges, as discussed by Richard Thaler, PhD, and Cass Sunstein, JD, describe how a person can be steered toward making a particular decision without hard instruction. An individual encounters small pushes towards doing something that is desired of them, unaware that they’re being led in that direction. Commercial companies have mastered this in form of advertising, making us feel as if we “need” their product. This fitness band has me thinking that I’m playing a game; the soreness in my legs and looser fitting clothes would indicate that I’m working out.

My experience with the fitness tracker has reminded me of the importance in framing conversations with patients. We often resort to telling patients, “You should work out and eat healthy – if you don’t you’ll get this or that disease.” It’s easy to frame things in the negative and use scare tactics. But rather than give constant reminders of what they aren’t doing, conversations with patients should contain nudges of encouragement. Nudges such as aligning goals with patient priorities, setting check-in time-points, and incorporating social networks for accountability. If we could do for chronic-disease management what the fitness band tries to do for working out, our patients might have an easier time.

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 by Vernon Chan

Health Policy, SMS Unplugged

A student’s reflections on the American Medical Association

A student's reflections on the American Medical Association

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.

AMA picLast month, I had the opportunity to attend the American Medical Association’s interim meeting in Dallas, one of two annual conferences held by the organization. I went to the meeting to present at a research symposium, but I stuck around for a few extra days because I was curious about the inner workings of organized medicine. As someone interested in health-care systems and the delivery of medical care, I was aware of the AMA but wanted to learn more about its purpose and process. (Plus, I had heard they throw great conferences. They didn’t disappoint – among other things, I got to practice my lassoing skills).

To provide some background, the AMA is the oldest and largest physician organization in the United States and has historically played an important role in the development of American health-care policy. While membership has ticked upwards in recent years, the AMA has been struggling with a decades-long trend of declining involvement and fading physician interest.

There are a number of possible reasons for this decline. Some commentators cite an overarching shift in social norms, arguing that people today are simply less likely to join groups. Others attribute it to the changing needs of physicians. Physicians are now more likely to work for a hospital system rather than opening a private practice. Given that the AMA’s advocacy has traditionally focused on the interests of independent doctors, employed physicians may feel disengaged. Finally, the proliferation of local, state, and other national physician organizations have likely drawn members away from the AMA.

Such issues have brought up questions about the sustained relevance of the AMA. Going into the conference, I’ll admit I was somewhat skeptical about its continued impact. However, I came away feeling like participation in the AMA is highly worthwhile.

With reform underway and a health-care system in flux, it’s more important than ever for health-care providers to understand how policy approaches influence patient care. The AMA offers a forum that serves two major roles. First, it gives medical students and doctors a way to learn about issues in health care. Topics like payment reform, the implementation of new health-care technology, and organ-transplant restrictions don’t come up in medical school in any significant way, but they have a huge impact on what we can do for patients. Every medical specialty has its share of conferences to make sure providers stay up to date on the latest developments in that field. The AMA helps people stay informed about the big-picture issues.

Second, conferences like the one I attended allow students and doctors to not only learn, but also to develop and exchange their own ideas on how to address issues in health care. The policy sessions at the conference often featured lively debates. While some physicians feel like the AMA doesn’t represent their views (it certainly didn’t represent some of mine), the best way to change that is to participate in these debates rather than disengaging. The AMA remains the single most important physician voice in policy discussions. If individuals don’t contribute to that voice, policymakers will no longer take the physician perspective into account when making decisions on health care.

The AMA is by no means a perfect organization. Like any political group, it comes with quite a bit of bureaucracy and the self-importance was occasionally irritating. Regardless, it serves as one of the best ways for medical students and physicians to become aware of the issues that affect our profession, and come up with solutions.

Akhilesh Pathipati is a second-year medical student at Stanford. He is interested in issues in health-care delivery.

Photo courtesy of Akhilesh Pathipati

Medical Education, SMS Unplugged

When the white coat comes off: Is “medical student” a full-time profession?

When the white coat comes off: Is “medical student” a full-time profession?

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.

P1000878In our transition to medical school as first-year medical students, one significant part of our learning has been adopting the dress of the medical profession. Twice a week, in our first year Practice of Medicine course, we wear professional attire and don our white coats, the famous symbol of the medical profession. As we learn how to interview and interact with patients, the white coats encourage us to fully embrace our new professional roles as physicians in training.

At first, the strong symbolism of the white coat made me highly aware of the different roles and personas that we occupy as medical students. If the white coat symbolized my role as a professional, wearing a T-shirt and shorts to my developmental biology class symbolized something decidedly more student-like. In many ways, being able to take off the white coat and hang it up for the day was a convenient way to demarcate our different selves: our professional persona on the one hand, and our “normal” (and more familiar) role as students on the other.

Over time, however, I began to feel a shift in terms of what that my “normal” self was. As I spent more and more time practicing clinical skills that involved helping people to feel comfortable, respected, and cared for, it felt only natural to adopt these qualities in my daily life. After all, after devoting a great deal of effort doing the little things to help make the lives of our patients better, did it really make sense to stop putting in the same effort when interacting with the rest of the world, just because the white coat and badge came off? Is our role as physicians only to help the patients who are sitting in front of us, or should we be thinking about our impact on the well-being of everybody we interact with, from our faculty and staff to the person answering the customer service complaint line?

In some ways, this idea of adopting the professional persona full-time is a scary one. Work-life balance is one of the most discussed concerns among medical students, and many (if not all) of us have fears of our work dominating our lives and keeping us from important things in our lives such as family and friends. Because of this, I have a feeling that the separation that the symbolic white coat offers will become more and more important for us as our careers progress and we become more immersed in our work lives.

That being said, I also acknowledge that, as medical students, the professional persona can help us to consider our daily impact on the world around us, which just might influence the health and happiness of a few extra people each day. For now, then, I’m willing to admit that perhaps there is a little more value to taking our professional mindset home with us than I first realized.

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

Photo courtesy of Nathaniel Fleming

Emergency Medicine, Medical Education, Patient Care, SMS Unplugged

Role reversal: How I went from med student to ED patient in under two minutes

Role reversal: How I went from med student to ED patient in under two minutes

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.

emergency sign - smallAs part of the second-year clinical skills course, each member of my class is required to complete two 8-hour Emergency Department (ED) shifts. I had my first ED shift last week, and when I walked in, I introduced myself as a second-year medical student who needed to practice IV placements, EKGs, and any other procedures that happened to come my way. Three hours later, when I walked out of the ED, staff knew me not as a medical student, but as a recently discharged patient, grasping paperwork with my official diagnosis: “syncope and collapse.”

It was 30 minutes into my ED shift, while I was watching a pelvic exam (ironic, given my post a couple weeks ago), when I began to feel a little dizzy. I’ve fainted twice before – once in high school after getting my blood drawn, and once when watching a C-section at a clinic in India – so I recognized the signs: feeling a little hot, starting to see black dots, slightly swaying. I tried to fight off the sensation by breathing slowly, but I could tell it wasn’t working. At the earliest possible opportunity, I turned to the attending in the room, saying, “Is it okay if I leave? I’m feeling lightheaded.”

I barely waited to hear her response before I bolted out of the room and found the closest stool to sit on. Bad call. The stool had no back to it, and next thing I knew, I was on the ground. When I opened my eyes, there were at least five  nurses around me, one whom matter-of-factly said, “Honey, you just became a patient.” Another nurse quietly slipped my hospital badge off my jacket, returning two minutes later with a medical bracelet that she fastened around my wrist.

My memory of those early moments is a little shaky, but I do remember saying over and over again, “I’m so sorry, I’m so sorry.” I felt awful that I had come to the ED to learn from the patients, physicians, and staff – without being a burden – but had ended up being another patient for whom they had to provide care. The nurses and attendings immediately normalized the situation, telling me repeatedly that this is a common occurrence in the ED and that many of them had had this happen to them as well. Their assurances made me feel so much better.

The efficiency of the events that followed totally impressed me. The nurse helping me to the bed did the fastest history on me I’ve ever heard, all while hooking me up to a BP cuff and a pulse oximeter. Did I have allergies? (Nope.) Did I  have diabetes? (Nope.) When was the last time I ate? (That morning). Any other medical conditions that I’m being treated for? (Nope.) Any family history of cardiac conditions? (Nope.)

The attending who was with me when I initially felt lightheaded came in at that point and asked, “Has this happened to you before?” and when I told her about the C-section, joked, “ObGyn probably isn’t your favorite thing, huh?” She then laid out the plan for what would happen next: an EKG, a glucose stick, and a blood test, to check for cardiac abnormalities, low blood sugar, and anemia, respectively. Within 30 minutes, all three of these had been done, and I even got a bonus ultrasound thrown in by someone who was practicing recognizing cardiac pathology (not that I had any). Noticing my scrubs and med student badge, this person took the time to show me each ultrasound image, pointing out the various heart chambers, valves, and the location where my IVC entered my right atrium.

By 2 PM, my tests were all back, everything was normal, and I was able to laugh about the entire situation: Somehow, I had come into the ED hoping to practice blood draws and EKGs but came out having them done to me instead. Just another day in the life of a med student.

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

Photo by zoomar

 

Medicine and Society, SMS Unplugged

Why I screamed when my boyfriend hugged me

Why I screamed when my boyfriend hugged me

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.

black and white rocksI was checking my email when it happened. My boyfriend had texted me saying that he was late arriving to the airport. So I stood outside with my suitcase behind me and clicked to an email from my mother.

I didn’t notice until too late that someone had approached me, and I screamed when I saw a black man reach out to grab me from the corner of my eye. Before the sound reached my ears, I realized it was my boyfriend, excited to have surprised me. I unfroze my arms as quickly as possible and embraced him.

We never talked about it. In the car ride back to Stanford, where we were both seniors, we talked about our upcoming spring break. I wondered if he had noticed other people on the sidewalk turn to stare at us. I wondered if he would ever surprise me at the airport again.

Mostly though, I chewed on the newfound knowledge that I had prejudices. Would I have screamed if a white man had grabbed me? An Indian man? A Hispanic man? Probably. I knew girlfriends who had been assaulted by all of the above during our time in college.

Regardless though, the thought in my mind when I screamed was not fear of being assaulted, it was fear of a black man. And I’m so ashamed to put this to words. I am half white, half Hispanic and grew up with a family that values diversity. I have been blessed with friends of all different backgrounds. So if I, with a liberal, multicultural upbringing had a prejudiced reaction in a moment of stress, I shudder to imagine what lies dormant and unrecognized in other people’s minds.

The question is not whether we are prejudiced. We are. Every single one of us in some way or other categorizes people by how they look and assign a danger factor to them. It’s how we are biologically wired to survive in nature.

The question is what we are going to do about it. In the quiet of our own home when no one is watching, are we going to unpack our assumptions and examine how we can improve ourselves? Are we going to encourage each other to go out of our comfort zone, to open ourselves to ridicule for admitting that we are imperfect, to challenge ourselves to be better?

My boyfriend and I are no longer together. We are at separate medical schools and I know that one day, when we are doctors in our respective specialties, I may call him for advice on the health of a loved one. I know that I will trust him more than I trust many of my peers who happen to be white.

And it hurts me to know that sometimes, it won’t matter that he has a gentle soul. Sometimes, the world will see him as dangerous before even looking.

Ferguson has hit our nation, our people, hard because it lives in every home – black, white, yellow, red or brown. It’s not a controversy over hyper-reactive policemen or a history of slavery. It’s a slap in the face that every single one of us has to own up to our discriminatory thoughts and grow. Americans need to grow as people and as a people. We the people need to become a we, not an us and a them.

Natalia Birgisson is a second-year student at Stanford’s medical school. She is half Icelandic, half Venezuelan and grew up moving internationally before coming to Stanford for college. She is interested in neurosurgery, global health, and ethics. Natalia loves running and baking; when she’s lucky the two activities even out.

Photo by Chris_J

Medical Education, SMS Unplugged

My couple's match: Applying for medical residency as a duo

My couple's match: Applying for medical residency as a duo

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.

Moises and fianceIn my last post, I wrote about the pressure that comes with the scrutiny of residency applications and the interview process. Adding to this, many applicants apply alongside their significant other, making use of the “couple’s match” option. Let’s think about that: No longer do you have to stress for yourself, but now you worry for your partner too. And while your primary concern is for them to do well in the match for their own success, it’s hard to overlook the fact that their outcome directly impacts your own.

This spring I’ll be couple’s matching with my fiancé, also a Stanford medical student. We both recently took part in our first interviews, and I’m not sure whether I was more nervous for mine or for hers. While she was at hers I was wishing and hoping for the best; while I was at mine, I was thinking about how my interview reflected on her as well. The topic of applying as a couple has come up many times during medical school, and I expect I’ll be asked it during future interviews.

When I talk to other students who are in relationships with fellow med students, I typically hear two things. Some people say it’s ideal to have a partner outside of medicine, so as to have an escape in their personal life. Others believe that a real benefit of having a partner in the same profession is the understanding that comes with it. I’d say they’re both right. My fiancé and I had to deal with the normal challenges of growing as a couple, but we’ve had to do it in front of shared friends, professors, and clinical teams – which was less than ideal at times. Ultimately (and fortunately), though, these challenges have only contributed positively to our development as future physicians.

Also lucky for us, Stanford’s pass/fail grading scheme during pre-clinical years helped reduce tensions when studying together. In a productive learning manner, it didn’t matter who did better, simply that we were able to help each other pass. Step 1 challenged this a bit: The score mattered. I have to admit getting sucked back into a competitive persona more than I would have wanted – something that didn’t make life much fun for my fiancé at times. Still, those long days of reviewing First Aid and USMLE World were made more tolerable by having her by my side.

We didn’t plan it this way, but our clerkships never overlapped – and the benefit was that we could fill the other in on the quirks of each service. I sure appreciated the heads-up and tips on how to fit into the ob/gyn team. And it was nice to see us each develop our special interests – hers in pediatrics and me in emergency medicine. We’ve started turning to each other with respective questions, making the learning stick better.

The National Resident Matching Program has a different process for matching couples than they do for those going solo; it’s not just about her top choice or my top choice, it’s about the best choice for us as a couple. That could mean an option that places me at my fourth-choice program while she’s at her first, but that’s a win in my book.

As geared as we are in our type-A personalities for personal success, working next to my fiancé in medical school has taught me how to enjoy selfless happiness. I have two envelopes to open come Match Day: twice the pressure, but twice the fun.

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.

Previously: “It’s tough feeling like you’re always in a position to be judged” and other thoughts on medical school
Photo courtesy of Moises Gallegos

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

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