A very special Christmas

Merry Christmas and an early Happy New Year to everyone!

I'm a firm believer the world won't end in 2012, but I guess we'll find out soon enough.

This is not a regular Christmas for me. The end of this year symbolizes a small (but important) transformation in my life. Starting January 3rd, I'll be "working" in the hospital for my clinical rotations. Gone (mostly) are the lecture halls and didactics that have been my home for more than a decade. Now, I start my on-the-job training.


I've mentioned this a couple of times before - the clinics are something I've looked forward to for a long time, something I've worked towards for many years. But it also creates a lot of anxiety. I feel woefully inadequate to take care of patients. But people reassure me that the training I've received so far is much more comprehensive than I realize. That I am more prepared than i realize. That small consolation goes a long way.

Then again, I guess this kind of anxiety is a good thing. A little bit of stress does improve performance... but more importantly, it harkens back to an important lesson from my differential diagnosis class - don't assume you know everything about the current situation. This is the cornerstone for a good differential diagnosis: you always keep your mind open to other possibilities, and you force yourself to think of counter example - what else could it be?

By walking into clinics assuming I know less than I do, I'll force myself to keep my eyes and ears open. It forces me to be on my toes just a bit more. At a personal level, this means I'm hungrier to learn more. But the more important (and bigger) effect it'll have will be for my patients: I'll be taking second, third and even fourth looks over their plans, histories, results... the works! I'm hoping this second guessing will make me a better student now, and (eventually) a better doctor.


So here's to the end of a beginning and the start of a new phase in my education. On the job training isn't something new to me - I worked in the corporate world for 5 years before coming to medical school. But this is a very different animal. Sappy as it sounds: lives are on the line.

There will be many more "ends of beginnings" to come, I have no doubt of that. But I believe recognizing and respecting milestones (like this one, even though it's a small one) is crucial to the learning process.

This is a bit tangential (and if this is your first time reading my blog, you'll realize that I almost always have tangents in each post), but times like this remind me of what it takes to be a good doctor. For some reason, whenever I think of that, I'm taken back to a scene from Scrubs (one of my favorite shows).

This is one of the most powerful scenes from the show and it has stuck with me for many, many years. A great doctor is someone who is very invested in his patients... but knows the importance of staying objective. Walking the line and keeping tragedies from debilitating your work is not the easiest thing to do, but I believe it is an important lesson to learn. Here's hoping I learn it.

Enjoy the New Years! And if the world does end in 2012 - I'm going to be very sad because I'm JUST starting the really fun stuff...

- Karthik

Let's recap

So what have I been up to since my last real post... It's interesting for me to look at this list and realize just how much happens in a med student's life in the span of a few months. This is in stark contrast to what I was accomplishing in my corporate life. I was definitely doing some awesome/fun things in my last life, but it was on a very different scale. I guess this is how I know I'm in the right place now?

1. Summer:

Over the summer I worked with inner city high school kids. I was teaching "watered down" medical science. But the main goal was to convince them to go to college. It was such a fun gig... I only worked 4 days a week (half time too!) and I got to teach! It was sweet!  The best part about the whole thing? This is how my students see me:

(the future surgeon part might be a bit of a stretch...)

2. My second year started! Each part of it sooo deserves it's own numbered bullet... As a side note - Penn Med is special - we start our clinics half way through our second year. So, starting Jan 3rd, 2012, I'll be in clinics! It seemed really close last year... and boy, it's a lot closer now!

3. Cardiology

This is one of our "tough 3" courses at Penn (the others are Brain & Behaviour, which we finished in January, and Renal - which comes right after cardiology).

And boy was it tough! For being a dumb pump, the heart is one complicated machine. Heart issues are also the #1 killer in America (and maybe the world, but I'm not sure about that statistic). It's difficult to describe, but a large part of my class absolutely loved cardiology (including me). As complicated as it is, if you really understand how the physiology works.... there's actually logic behind everything! (This is rare in medicine). Of course there are some things you just have to accept / memorize - but overall, it was so well run. There's a good chance this one course has pushed cardiology (mainly catheterization and electrophysiology) to the "top 5" things in medicine I'm considering.

4. Dermatolology

Putting dermatology between Cardio and Renal was the (second) greatest idea they had at Penn. This was a much needed break. The weird thing is, Derm is one of the hardest residencies to get into because it is so competitive; yet our class on Dermatology is only 1 week long and is pretty straightforward (the mean on the exam is a 100). They just hit us with the most salient points and keep things very simple (which is nice once in a while)

5. Renal

Ouch. I want to go back to thinking about the kidney as a black box that makes pee. I'm thorougly impressed by the amount of things a kidney does. It was pretty painful trying to learn all the things the kidney does (and the different ways the kidney does it), but at the same time - I'm so happy I've got not one, but two kidneys.

(btw, this is the third of the 3 hard courses at Penn).


5.5: Fall break!! This is the best idea they've had at Penn Med. They gave us a couple of days off after Renal. What did me (and 6 others) decide to do?

We went to the Bahamas.

Yup.

It was pretty epic! Definitely needed that.

6. Pulmonology

This is our last honors/pass/fail class before we head to clinics (we've got a microbiology review class and a class on differential diagnosis before January, but those are pass/fail). It's supposed to be easier than what we've been going through so far... I really hope it's true. For some reason, I'm just so burnt out after cardio and renal. It's also that I'm ready to hit clinics. I'm having a very difficult time motivating myself to study. If this continues, the Pulm exam will not end well for me. Here's hoping I can concentrate over thanksgiving break. If not, I'll definitely be screwed 2 weeks from Monday.

7. Clinics - wth!?

On the one hand, I can't wait, but on the other hand... I'm mortified. I've learned a lot int he last year and a half, but I've got so much left to learn. And now it's time to learn while doing. Which is kind of scary. (Who am I kidding, it's madness, but it seemed to have worked for everyone else who's gone ahead of me...)

I've always been a big fan of the quote "courage is not the absence of fear, but rather the judgement that something else is more important than fear". This is the best picture I could find to describe it (and double points because it's a harry potter reference)

But in reality... this is a more accurate picture of how I feel:

Signing off. Hoping to make another post around Turkey time.

Yowza

Ok, so I feel pretty bad that I haven't posted since June. Not only has a lot happened, I don't really have any good excuse for not posting since June. Med school's definitely ramped up a bit in my second year, but yes - I'm still alive.

I'll get out a real post over the weekend, but for now, here's something I've been thinking about for a while - and maybe I'll elaborate on it in a later post:

We always say the sum is greater than its parts, but I'm not sure that's always a good thing. Let's take humans. If an individual cell gets infected, it'll release a bunch of Interferons. This is a signal to its neighbours to say "hey, I'm infected with something - look out!". It'll also tell our immune system to wake up and kick some butt. At the same time, the infected cell slowly destroys itself - the ultimate sacrifice. This self destruction means it is no longer a factory for the infecting organism. It destroys itself to protect its neighbours.

Then there are humans.

We are built from these parts. We (the sum) are supposed to be greater than our parts (these cells). I don't think humans are nearly as selfless as these tiny little cells. We bicker, struggle for power, and hurt each other. How far we've fallen.

/facepalm

3 for 1 deal

So it's been 3 Sundays since my last post.

Whoops!  But I have good excuses!  The first Sunday was the Sunday before our double-header-exam: Endocrinology & Reproduction.  The Sunday after that was during the memorial day weekend.  This last Sunday?  Well, that was just me being lazy.

But to make up for it - I've put up three posts (including this one).  I've been working on the two bulky ones - here and here - for a while now.  Hope you like them.  I think my next two will be on time and responsibility.

My limiting reagent (heh, heh) a little while ago used to be lack of topics.  I didn't have anything deep to talk about.  I'm not sure I have deep stuff to blog about now, but I do have something to blog about.  These days it's the lack of time (yay medical school).

In other news:

I think people are starting to read my blog now.  I mean like, real people.

I apologize if you expect to find some deep / serious commentary on this blog.  I doubt you'll find that here.  But I'll try to make it entertaining (mainly by including pretty pictures)!

If you do a google search for Penn Med and scroll down a bit... this blog is now listed on the first page.  My reaction to this is: "what... why!?"  I know they say any publicity is good publicity, but I'm not sure publicity is what I'm going for with this blog.

If you want to see something really funny - google image search Penn Med.  My group was trying to find some Penn Med related images for a presentation.. and... well, we couldn't stop laughing at the results.

As a bonus scroll all the way to the bottom of the image search results.  You won't be disappointed - it's pretty hilarious.

Edit/Update: this info is not correct. When I google search, it tailors search results for me so my blog shows up on pg 1.  But this isn't true for the general population! So my blog does not show up on google yet - this is a good thing!  But the google images part seems correct though.

Ok, bed time.  I am very, very behind on sleep.

[1/2] Finding someone (or something) to blame.

When things don't go well, we often look for someone (or something) to blame.  You could say it's almost human to do so.  But that doesn't mean it's the right thing to do, nor does it excuse the finger pointing.

As with most things I blog about, I started thinking about finger pointing and blaming people when I made the mistake of finger pointing and blaming people.

We were in our endocrinology block and our lecturer was pointing out the strong correlation between obesity and type 2 diabetes. Absentmindedly (not an excuse), I remarked "hmm, well it's the patient's fault isn't it?  We suggest lifestyle changes and nutrition changes when we catch them in the prediabetic stage, but they don't do anything about it, and end up with full blown [type 2] diabetes".  

Harking back to an older post, this is when having good friends who will call you out is very important.  One of my close friends got on my case for having such a "blame the patient mentality" (which I don't, but I still deserved to be called out for my comment), and I got to thinking about the "blame the patient" mentality.  

I guess two things need to be clarified:

1. Blaming is just plain silly:
It doesn't do anything about the situation.  It just makes people feel bad and it causes resentment.  All of which are barriers to improvement - which is what we should all be struggling towards.

2. Blaming implies judgement.

No one is ever in a position to judge anyone else.  

2 (addendum): As doctors, our job isn't to judge: it's to heal and maybe even prevent.

But all of those have to be separated from the concept of a root cause.  You always need to search for the root cause.  But it has to be done without blame.

It's analogous to working very hard on something, but being detached from the outcome (as the buddhists and hindus say).  It isn't easy to do, since the work itself (eg. studying for an exam) tends to attach you to the outcome because the outcome tents to be a big driving force (eg. doing well and getting an A).  It is very easy to forget you are working hard because you want to, or because that's what the task deserves.  In the case of medical school exams - it's the idea that some patient in the future may need you to know that tiny detail that could change everything about his diagnosis and/or treatment.

It's similar in root cause analyses.  You work hard to find the root case, and when you get to the "end", it's very easy to try and blame the cause on something.  But it's almost always better to focus on how to deal with the cause.  Dealing with the cause doesn't mean you blame the cause.  In this situation, there's a tiny detail that might make it easier to not blame - to not get attached to the outcome.  The reason you started looking for and analyzing the root cause is to help a patient.

Blaming the patient does not help the patient.

Here's an example: obesity is highly correlated with T2db (type 2 diabetes).  One of the major reasons we have an obesity epidemic is because of the amount of junk food that's (cheaply) available coupled with low physical activity.  Blaming people doesn't do much.  But pointing out that it is something that can be controlled by each and every American is important - we need to empower people to do something about it.  But we have to do it without blaming them.

It is very important to tell our patients that controlling T2DB progression is in their hands.  Weight and exercise will prevent / prolong the onset of T2DB damage.  Contrast that to something like Huntington's disease: the patient has little to nothing they can do to halt it's progress.  So we need to present them with the information, urge them to follow it, but not blame.

I guess my point is it's a very thin line between falling into blaming the patient for something and pointing out these points to improve the patient's life.

I guess it's the difference between

"You have t2db because you are fat.  It's your fault, and you should change how you live"

and

"Your t2db is probably caused by your obesity.  I can give you some medications for this, but the best way to control and reverse this disease is by lifestyle changes.  But to do that, I'll need your help and your commitment to these changes. I am here to help you through this, so let's talk about what we can do to get you to a healthier lifestyle."

Not judging?  Check
Actually trying to help the patient? Check.

[2/2] Finding someone (or something) to blame.

In my other post, I talked about blame and finger pointing and why they are bad ideas on a philosophical level.  But does that mean fingers shouldn't be pointed?  Am I saying that people who make mistakes should get off without any repercussions?  No.  But I think it needs to be done in a productive way - I like to focus more on the end goal.

As doctors - you need to be hyper-aware of your mistakes.  The best way to describe it is "For everyone to whom much is given, of him shall much be required." -- Luke 12:48.  (Before people get confused, no I'm not Christian).  The "popular" way to interpret this is "to those whom much is given, much is expected".

Much is given to doctors: in many cases it is people's lives.  Thus (understandably) much is expected.  The only way doctors can hope to live up to these expectation is by being very aware of any mistakes that happen, realizing the root cause, fixing it, and making sure it doesn't happen again.  This is very important in the medical field because the question of mistakes happening is not an 'if', but a "when'.  I am not an idealist, so I understand that the steps I mentioned aren't always possible in every case.  For that to be possible, we'd need to understand how everything works... and we are far from that.  Medicine is called an art for a reason.

But this doesn't mean you don't try.

You don't point fingers at the doctor.  You talk to them - about what happened and about how to prevent it in the future.  As part of this process, the doctor has to own his/her mistake.  It's the only way they can improve.

As a side note - here's a good article about why mistakes are a very important part of the learning process. The only issue is that in medicine, mistakes are usually very, very costly.

Bottom line: the doctor, nurse, any healthcare worker (really anyone) who "points" at the doctor to blame him/her should do it in the spirit of trying to improve healthcare.  Not in the spirit of trying to find incompetence.  I'd like to think that most healthcare workers are pretty competent.  Or maybe that's just my naivety?

As patients - (this will be from the perspective of a healthcare worker more so than as a patient) as much as doctors try to help patients with health issues, at the end of the day it is up to the patient to meet us half way (usually it's more like 75% of the way).  Doctors cannot help patients who don't want to help themselves.

So ask yourself what you are trying to accomplish.  Blaming the patient is bad for quite a few reasons (the focus of my other post).  In my view, the main reason it's bad is because it doesn't encourage them to fix the situation.  If your job is to help people (and if you missed that in the job description, let me clarify: that is your job), healthcare workers need to find a better way.

Step 1 of that better way is to have an open and honest conversation about repercussions.  "I'm concerned about your LDL levels and triglycerides being so high because it really increases your chances of having major heart problems.  And there's a good chances they'll occur earlier rather than later in life".

Step 2 is working with the patient to figure out how they can fix the issue.  I'd love to have a one-size-fits-all approach to patients.  Take the issue of healthy nutrition / lifestyle for example: if we could just hand them a card that says "do xyz and abc, and you'll do great!" - that really would be great.  Problem is: it won't work for everyone.  As time consuming as it is, we have to work with patients - ask them how their lifestyle / diet is right now and what they would be willing to change (which usually means what causes the least inconvenience).  No one is going to massively change their lives.  This is especially true for preventative measures - few healthy people will take warnings seriously because... well.. they think they are healthy now so they'll be fine forever!

Bottom line: don't blame.
(1) Tell them you are concerned and what the consequences are
(2) ask them what their current situation is
(3) suggest (or refer to someone who can suggest) changes that wouldn't perturb their current situation too much.

Repeat as necessary.

These are just my opinions - a doe eyed first year med student.  I'm sure people have more advise on the matter (especially the more seasoned veterans - aka real doctors) - and if you do, leave a comment or two!

Remembering

This Wednesday, Penn hosted the Humanity Gifts Registry's annual Celebration of Remembrance ceremony.

This is a ceremony "for the individuals who have provided their bodies for one final service to their fellowmen - the contribution to Medical Education and Research".  Anatomy isn't something you can learn from a textbook or a professor.  I mentioned this in my blog post after our last anatomy class too.  My class (and other medical school classes from around the city) was happy we had the chance to show the family of these brave donors how much we appreciated our donor's selflessness.

I was lucky enough to be one of the eulogizers during the ceremony.  I was also the first eulogizer (no pressure!) Fortunately, I had an awesome set of friends who helped me craft a great eulogy - thanks Asmi, Jon, Anna, Paul and Eric!  I couldn't have done with without you guys.  I can't think of a better way to express my gratitude to our donors than the speech, so here it is:

In my culture, we have an old Sanskrit adage: “Matha, Pitha, Guru, Dheivum.”  Translated, it means “Mother, Father, Teacher, God.”  Like any saying that has deep religious and spiritual roots, the literal meaning of this phrase has been argued for a very long time.  To me, it emphasizes the importance of teachers in our lives: like our mothers who teach us to play nicely with our siblings; our fathers who teach us never to start a fight; or our friends who teach us to love and share with one another. In the classroom, we may learn from a professor, or from scripture.  We also learn from our classmates, like a friend who reminds you that the hip bone’s connected to the leg bone might not be the most accurate way to describe a leg joint. We all have many teachers, and they all share common traits: they shape and form us; they guide our conscience and learning; and they ensure that we stay true to our values. In short, they help us grow: intellectually; professionally; and personally. At the core, these are all examples of paying it forward: by educating us, they show us how to make a positive impact on the world.  Maybe this ripple effect on the student’s life, as well as all other people with whom the student comes into contact, is why my culture associates teachers with divinity. 

To say that each of the donors that we honor today is a teacher is an understatement.  In my medical school alone, each donor has, in one way or another, helped instruct 168 students. I don't think I'll ever have another class as amazing as Anatomy.  I'm extremely humbled and touched that people have donated their bodies to science so we can train to become the best doctors we can be.  I would like to take a moment to thank the people and their families who make Anatomy possible.  Thank you all, so very much.  Be assured that our class (and medical school classes around the world) has learned an immense amount from our donors, lessons we could not have learned any other way.  Know that our ability to improve or save lives in the future stems from the willingness and commitment of these selfless people, and their families, to our continued education.

What I didn’t realize then was how our donors stay with us long after our Anatomy class.  Even in our classes now – where we are learning about renal artery blockages, vericoceles, or cerebral vasculature with the circle of Willis, I stop and think back to my anatomy lab and recall what the relevant structure looks like.  The anatomy experience allows me to visualize the pathological process that is happening and how it fits into a patient’s illness and treatment.  This exercise cannot be effectively learned from a professor’s lecture, a classmate’s explanation, or a textbook; it would be impossible without the contribution from our donors. Every patient we meet teaches us something. We consider our donors to be our first patients: their impact on us will, without a doubt, stay with us for life.

At the same time, I do not know who these donors were in life.  But you do.  They were fathers and mothers, brothers and sisters, sons and daughters.  They were friends.  As Pericles said many millennia ago: “What you leave behind is not what is engraved in stone monuments, but what is woven into the lives of others.”   I am sure every one of these donors had an impact on your lives.  But only a select few can make a substantive impact even after they’ve left this world.  We will soon read aloud the names of each donor, and every single person on that list is part of that select few.  Their nobility will not be forgotten, and their selflessness will continue to be greatly appreciated by us, and by our future patients.

Thank you.