Sunday, April 5, 2009

Freefalling


There is nothing like rappelling into ice cold murky water to wake you up out of a daze. It seems that ever since the Match, I've been in an excessively reflective mood - perhaps because a major life event, the culmination of eight years of education and a student existence, is coming to an end. Or, maybe, it is that I've begun the process of redefining myself as a professional.

I imagine that eventually there has to be a break from fourth year medical student persona to responsible physician. As is my nature, I decided to take it upon myself prematurely rather than sometime midway through intern year when you've appropriately acquired enough experience to redefine yourself through new skills, relationships, and patient responsibilities. For me, this took the shape of defriending people on facebook that were no longer central to my life (why should they be privy to my updates, if they would never pick up the phone and call?), booking a trip back home, and becoming a silent observer of the people around me. Perhaps, I thought, by reflecting on what I did and did not like about my friends I could realize what kind of self improvement I could practice. It turns out I just realized how different I was than a lot of the people I spend my time with. After the pretense of studying and "school stress" becomes passe, you learn quite a bit about other students in your class. Sometimes, it's not a very welcome discovery either.

Part of the thrill about moving to a new location and meeting a new set of friends lies in the intriguing possibility of redefining who you are. People no longer have preconceived notions and you can "become" the person you wish to be. Perhaps I would like to be a person that my cointerns can trust with their problems, will want to share a beer with in their freetime, and is outgoing, approachable, and fun. I'd like to hope that this is only an upgrade of my current state and not a new program alltogether.

Anyway, I went rappelling with a group of friends this weekend and it woke me up out of my stuporous state of reflection. We camped overnight near the entrance of the hiking trail at a site that required the ability to truly rough it. The bushes became bathrooms and the brush fuel for the fire. A couple of grilled chicken sausages and bottles of beer later it felt like the best idea ever. The weather was playing along too; it was just cold enough to want a sleeping bag and warm enough to enjoy the breeze. I went to sleep satisfied that I could enjoy the simple things in life and had made a good set of friends in four years time. I wanted to be sad to leave by graduation and I finally realized that despite the sometimes difficult times, I would be losing a lot of close friends in two months time.

In the middle of the night I felt something pressing against my soles and woke up. It turned out to be a prairie fox with huge pointy ears and a long tail looking curiously into my tent. I must have been in quite a daze because I simply pulled in my feet and continued sleeping. Sometimes it surprises me what I will sacrifice to get a good night of sleep. The next morning a close friend of mind no longer had a sandal. I wonder who made away with it?

We cleaned up camp and headed to the hiking trail where we met our three guides. At this point it hit me that maybe what we were doing wasn't quite as harmless as I had imagined. Why would 14 perfectly able young med students need this many guides to go rappelling? It turns out there is a lot of setup and spotting necessary to rappel safely and we could never have managed on our own even with the appropriate equipment. A couple of awkward warm up exercises later (don't ask me why we had to sprint back and forth in preparation of an 8 hour hike) we were finally set to leave. Part of me didn't want to believe it when they informed us that everything we had with us would get wet. Little did I know that we would be rappelling directly into pools of water and there was no way of evading full immersion.

The hike was beautiful. The mountains were bare of anything but the rare bush and yet the white polished surface of rock alongside the gulleys was quite a site to behold. There had been floods only two weeks before, so we were assured that the murky water was actually "fresher" than usual and we didn't need to worry. The first release of the safety rope and backward propulsion into the water was everything but easy. You're never quite ready to let the rope go knowing what awaits you below. The water was icy cold and it took a second to regain my breath and yet there was a sense of accomplishment on having enough courage to let go and make it to the embankment. The thrill of those final minutes of rappelling and being suspended in midair - many times without a secure foothold - was worth the shock of the cold water and downtime between descents. I could make a metaphor about the leap of faith when going into the specialty of Emergency Medicine, but I'm going to spare you the cliche.

By the end of the day, we were tired out, exhausted but happy. It was definitely a fun trip that made you proud at the end of the day that your nerves didn't get the better of you and you held your own. It's times like these that I'm so grateful to be evading a desk job for the rest of my life. Thank God for shift work and the many random day trips that will follow...

Wednesday, April 1, 2009

One step closer


Today, I spent a significant part of my day filling out paperwork for residency. I always thought third year electives would be the last wrangling with forms that I would have to do in medical school, but I was gravely mistaken. Not only do you need to submit a several paged detailed account of your health and vaccination history, but you also need to fill out paperwork for a limited medical license, a parking pass, a hospital ID, confidentiality agreements, etc.

This could have been an easy task, if it were not for the fact that our school secretary is neurotic and the least task-oriented person I know. It took me a good two hours to get a Dean signature and another hour to get my titer record. Then, I had to make an appointment to see the notary services at the embassy and call the school doctor to get my health forms signed. Wasn't I supposed to be at the beach sipping martinis post MATCH?

We're on day three of our medicine subinternship. I was dreading returning to the medicine wards after all the negative attitudes that resound about this particular rotation during interviews. I have to say it is not nearly as bad as I was anticipating and far more enjoyable than it was last year during our clinical clerkship. My ward specializes on infectious disease and the professor is somewhat of a regional TB expert, so if nothing else I will come out of these three weeks with a superb knowledge of how to work tuberculosis into virtually every differential. We covered some particulars of DKA management and insulin dosing today, which should come in handy during internship. Suddenly, I see everything in the light of how this will make me seem less clueless in residency and it is my hope that this new found motivation to learn will actually let the material sink in for longer.

Malcolm Gladwell's theory of 10,000 hours of practice leading to expertise most definitely applies to medicine as well (at least this is my excuse for not feeling nearly ready to be a practicing MD). Given that the average medical student spends forty hours per week either studying or in the hospital in the last two years of medical school and there are on average 30 days of vacation time, we should reach around 3500 hours of medical training by the end of medical school (40hours x 30days x 11 months). How many years should it take for us to be truly competent in medicine then? An additional 6500 hours. In internship, residents work an average of 60 hours per week as indicated on the aamc website for emergency medicine residency training. So, in internship we should accumulate another 2640 hours. This means that mid way through our PGY-3 year we should reach the 10,000 hours of clinical training in medicine. I'll let you know in January 2012, if I've reached that point.

Now to apply this to the 3 vs. 4 year emergency medicine debate...With this line of thinking it should make sense that a three year residency program would suffice for adequate training. BUT, if you really want to be an expert in your specialty, you should only start counting on the first day of your emergency medicine training, in which case you really need to be in a four year program to accumulate 10,000 hours of clinical training in residency. However, this exercise does not account for time spent in off rotations, the repetition of material, the ability of a resident to retain knowledge, and the varying patient load depending on the hospital where you are located.

On a completely different note, I listened to a great NPR podcast today on PTSD in Tibetan monks. I can't imagine a better past time when you're commuting than listening to Fresh Air podcasts. Terry Gross does a great job of conducting insightful, interesting interviews that keep even the most inpatient listener engaged. On 3/26 she interviewed Dr. Michael Grodin, who is the co-director of the Boston Center of Refugee Health and Human Rights. He talks about his experience treating monks that were tortured for resisting the Chinese. His efforts to lead them in meditation often failed because they would have flashbacks of their time in prison. He also talks about the challenges of drug compliance in this population and helping them create a meaningful existence in present day Boston.

Interestingly, he also works with Holocaust survivors that relive their terrible WWII experiences with the onset of dementia. He theorizes that the disinhibition of dementia is leading to flashbacks from this time. The smell of urine in the nursing home, for instance, is enough to revoke thoughts from the Nazi era concentration camps. I find it quite tragic that these people must relive such sad events in the last years of their lives. Dr. Grodin mentioned that one important therapeutic measure was to emphasize to the patient that they are not burdening the therapist by revealing this information. Many Holocaust survivors are worried that by relaying painful memories they are spreading the suffering to another generation.

It is a difficult role caretakers must play with post traumatic stress patients. You need to encourage the individual to vocalize their fears and at the same time protect them from reliving past traumatic events over and over again. Unfortunately, the prognosis is grim with 50% becoming chronic, especially when treatment for PTSD is delayed. Many times the hypervigilance that is seen in this condition is addressed with meditation (something that lead to the unexpected observation in Tibetan monks). Dr. Grodin describes a particularly helpful therapeutic approach of visualizing a lotus flower that floats down the river every time a disturbing thought comes up. He has had quite some success employing this strategy in addition to medication, psychotherapy, and other methods. Here is a link to the podcast, if you're interested.