Learning to Take in Order to Give

So this is it. I’m officially a real fake doctor now! I have just completed my first clinical rotation. Thus far, I spend 99% of  my time thinking “where am I?” and “am I annoying my resident/intern/attending by being in the way?” and the answers are usually “lost” and “yes.”

I am on neurology and one of our first patients of the morning was a middle-aged woman who had recently been diagnosed with ALS (Amyotrophic lateral sclerosis) a few months prior. ALS is a degenerative neurologic disease that is characterized by progressive loss of motor function. Patients end up losing the ability to move, talk, eat and eventually breathe. This patient had already lost the ability to talk and eat on her own.

My fellow medical student and I went to see her after rounds so that we could get a better idea about what a neurologic exam would look like in someone with ALS. When we got there the patient was in obvious pain and her daughter told us that she wanted morphine. The patient (who communicates now by writing) pointed to her pad where she had written “Ouch. Pain. Help.” Being lowly peons, we don’t yet know how to find a band-aid much less put in an order for narcotics so we quickly left to find the resident (who assured us that the order was being processed by the pharmacy). Given her level of discomfort, there was no way we’d ask her to undergo another exam so I just asked if there was anything else I could do to help. She got out her pad and started writing something.

“How can I help you?” she wrote in painstaking capital letters.

Here was a woman who had just been given a devastating prognosis. She had already lost the ability to speak and her disease will continue to progress, causing her to lose all motor function and die within a few years (median survival is 3 years from onset of weakness). She had been poked and prodded by the medical team, the neurology team and she had just undergone a serious procedure. On top of this she was in serious pain. Yet still she wanted to know how she could help me.

 “I….well…” I didn’t know what to say to this amazing woman. Sometimes medical school stinks. Plain and simple. We don’t have much to contribute at this point in our careers except time and enthusiasm. Our only job is to learn, which makes it feel like an inherently selfish process sometimes. Indeed, I have spent most of this week feeling in the way. Her small act of kindness nearly unbalanced me.

“You are already helping us,” I told her. “We are medical students and this is our first week ever working in the hospital.” She broke into a huge smile.

“We are trying to learn as much as we can from our patients. For example, even though I’ve read about it, you are the first patient I have seen with ALS and I will always remember you because of that. I am going to go home and read as much as I can about it so that some day I can take care of patients myself.” She broke into a huge smile, touched my arm warmly and gave me a thumbs up.

Throughout my first year and a half of medical school I have been blown away by the generosity of those who contribute to medical education:

• My LEAPP patient (a patient who we followed throughout our first 1 ½ years here) whose family let us sit in on her appointments, ask them countless questions and literally invited us to their home.
• Our course director for dermatology who came to speak to my interest group, personally showed me patients during dermatology grand rounds and then spoke about career paths with me for an hour.
• My MS3 “big sister” assigned to me by the Elizabeth Blackwell society who gave me invaluable advice about surviving my pre-clinical years and gave me all the books I needed for my clinical years.
• The MS4 who brought me on board with her project, helped me understand clinical research and is trusting me with presenting our work at a conference this spring.
• Our lecturers and small groups leader-physicians who volunteer their time in order to instruct us on everything from psoriasis to palliative care.
• The resident I worked with in Botswana who taught me how to think clinically about a patient this summer and then this fall coached me through writing a case report that she could easily have written herself.
• The countless patients who spoke movingly and openly to our class about living with cancer, mental illness or rare genetic disorders.
• And now - starting with this patient - all the patients who allow us as medical students to participate in their care.

I know that this is a cheesy story. I know that it’s not possible or advisable to get emotionally wrapped up in every patient you care for. I know that this outpouring of “touchy-feeliness” would earn me an eyeroll from more “seasoned” medical professionals. But I don’t care. And I know that I will remember this incredible woman. I am going to carry her with me throughout my rotations. Because she reminded me that every patient gives me a gift. They give me the gift of sharing their story and helping me learn. I may wear a white coat but for now all I can do is take. Take in the knowledge that is being shared: by the patients and by the physicians, nurses and staff who are helping me learn. One day hopefully I will be able to give something: care for my patients and, if I’m lucky, the ability to teach someone else. But first I need to figure out where the heck I am.

Learning in Action

A few months ago I was in a CVS in center city when a man came charging through door, shouting “I need an AED!!”

The pharmacy employees looked back and forth at each other but no one made any actions. The man became angrily impatient, crying out “Come on, there’s a guy dying out there!!”

Before I had really processed what was going on I had set down my basket and my feet were carrying me out the door. I knew that administering CPR can become very tiring very quickly, and having just completed my Advanced Cardiac Life Support course I was as qualified as anyone to lend a hand.

Out on the street I immediately saw a group of people crowding over a man collapsed on the sidewalk. As I got closer I could tell CPR was underway but it wasn’t until I was standing directly over them that I felt a jolt of fear. Though in the past I had seen patients who were very sick and patients who were already deceased, somehow I had made it through three years of medical school without witnessing someone actively dying. The purple color of his skin was frightening.

He was receiving quality CPR from an incredibly fortuitous group of bystanders: A nurse at a local center city hospital and a soon-to-be internal medicine intern were trading off on chest compressions, while coincidentally one of my classmates, Mike Hoaglin, was keeping his airway open and performing pulse checks. I was impressed with how perfectly coordinated the nurse and (almost) intern’s handoffs were- the chest compressions were flawlessly continuous so that any positive pressure build-up in his circulation was not lost as they traded turns. Despite all this it was very clear that he was dying.

Just then the man who had burst into the CVS ran over to us. Out of breath, he managed to report that he had looked everywhere, and asked all the local restaurants and pharmacies, and he couldn’t find an AED. The ambulance had of course been called first thing, but we couldn’t yet hear sirens, and the purple tone of his skin was becoming a sickening gray.

Suddenly a picture flashed in my head of the wall in the mail room of my apartment building nearby. I knew where there was an AED! I jumped up and sprinted down the street, flew into my building, grabbed the AED off the wall, shouted something to the confused doormen, and returned to the scene.

As I crouched down again and opened the AED box I said, “I’ve never done this ‘for real’ before”. No one else had either. Luckily, it was exactly like it had been in ACLS training, and there were very, very simple instructions so that even if I hadn’t been to class I could have easily done it on my own.

With the power button pressed the box immediately spoke to us. ‘Analyzing rhythm, continue CPR’. It was reassuring to hear its automated voice providing instructions.

A few moments later, it spoke again:

“Shock advised. Stand clear”.

The shock sent a jolt through his entire body with enough force to raise his head and send it falling back down onto the concrete sidewalk with a thud. I winced but the AED was unperturbed.

“Continue CPR two minutes”.

Chest compressions were resumed, and before the two minutes had elapsed when it would have been time for another shock, if necessary, the ambulance came screeching down the street. As the paramedics loaded the man into the van Mike said he may have felt a faint pulse after the first shock. I wasn’t so sure.

I headed home knowing we had done our best, and wondering if I would ever find out how the man had fared…

The paramedics contacted Mike the day after to thank us for performing excellent bystander CPR, but they didn’t know the condition of the patient, so it was of little satisfaction.

However, a few weeks later, I received a letter in the mail. It was from the man. He had survived, and had asked his emergency room doctor for our contact information from the paramedics. The letter was three pages long and told me about his family, his job, and his hobbies. It talked about what it was like for him to wake up in the emergency room, and how he has memories of being ‘zapped’ and of people yelling at him to stay awake. It talked about his plans for the next few years and how he can’t believe his luck to still be alive. He also included a $100 check, which I didn’t cash, but plan to hold on to forever.

This story had the best possible outcome, and I really believe it was the AED that made the difference. Despite getting the highest quality CPR I think that early shock was crucial. So, I’m ending this blog post with a shameless plug:

This week Penn launches an amazing new phone application and they are kicking it off with a competition. Using your cell phone, you take a picture of each AED you see around the city. The grand prize for the most AEDs photographed is $10,000!!!!!! But even better, all the pictures you take will be used to create an application that will map the location of AEDs all over the city. Then the next time someone needs to find one, they won’t waste time checking pharmacies and restaurants that don’t have them- they can take out their phone and go directly to the nearest place. What a great idea!!

The Beginning is Near!

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. Just yesterday, I started "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 examples - 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 Year!

- Karthik

A Very Special Christmas

This year marks a particularly special holiday season for me. Not only have I finished the preclinical years of med school (and apparently the last full-time classroom work of my life!), but this is also my first Christmas as a mother. In addition to my role as a medical student, I am also married to another medical student and a mom to an adorable and chubby 8-month-old boy named Raymond.

As an undergrad, I was accustomed to juggling multiple responsibilities, having been a pre-med student at Duke while also a varsity pole vaulter and a lab researcher on the side. I would be constantly switching gears between the classroom, lab, track, in addition to a myriad of other extracurricular activities I had taken on.

This past year, the juggling act was a bit more hectic, to say the least. I gave birth in late April and powered through the rest of my first-year courses until the end of June. Penn's administration graciously allowed me to Skype in for small group sessions right after I delivered so that I could stay home with my newborn and keep up with school at the same time. In the fall, I came back to class in person again and fell into a nice routine - when I was at school, I tried to study at maximum efficiency so that when I went home, I could put schoolwork aside and be fully present for my family. Even with class and a four-hour roundtrip commute (more on that in a second), we managed to cook and have dinner together pretty much every night, as well as go to our fair share of happy hours at neighborhood establishments (baby-friendly, of course). The commute I mentioned is the 100-mile trek I do Monday through Friday between Baltimore and Philly on the Amtrak because my husband is at Hopkins, and we wanted to stay close to my in-laws in the DC area. Sometimes I love it (protected study time can be wonderful), and sometimes I hate it (is it really going to take over 2 hours to get home?!). But I'm happy that there's a way to make everything work. All in all, starting a family while in medical school has actually been really fun.

Right now, my husband, son and I are spending time with my parents in San Diego. We are enjoying the 70 degree weather and sunny, clear skies. Though we both love med school, it is really nice to have a break from lectures and studying and just hang out and relax. It is also really special for me to have more time with my baby boy. Usually I leave before he wakes up and once I'm home, we only have a few hours together before he goes to bed for the night, so it's really great just to be able to sit and play with him for hours and hours on end. He has grown so much this year, and it seems like's he's just getting cuter with each passing day (but I'm biased of course!).

Another reason I'm really relishing this break is that I know it's about to get truly crazy soon. My clinical rotations start in just a matter of days, and I'm starting on the surgery block. The hours are going to be substantially longer than what I've been used to for the past semester. And Ray will be getting older, becoming more interactive and wanting to play more. I have a feeling this whole juggling act is going to become even more complex. However, I am truly excited for the clinical rotations as well, and even with a husband and baby at home, I trust that somehow it will all work out. I'm looking forward to blogging more about my experiences as the year progresses, but for the time being, I'm going to enjoy my last few days of freedom!

Happy 10th Anniversary to the Botswana-UPenn Partnership!

As I mentioned in my first post, I spent this summer in Botswana working on a study looking at viral contributors to vulvar cancer. The head of the study is Dr. Carrie Kovarik, a Penn dermatologist and all-around superstar at life. I won’t blather on too much about my incredible summer (my other blog: hayleyinbotswana.blogspot.com has enough blathering to last a lifetime) but I will say that it was amazing and that it furthered my determination to make global health a part of my medical career.

Dr. Kovarik speaking about
telemedicine in Botswana

This year marks the 10th anniversary of the Botswana-UPenn partnership: a collaboration between the government of Botswana and the university that has allowed students like me to spend time learning about research and health care in a developing country. In order to celebrate the past 10 years, Penn hosted a Ten Year Anniversary Symposium.

Needless to say, I was incredibly excited for this week’s events. I attended a grand rounds on viral contributors to cervical cancer, a presentation on research in Botswana, a seminar on ICT4D (Information and Communication technologies for development... this is actually an ongoing seminar series) and also a general symposium. While it was cool to hear more about what is going on in Bots, I was even more excited to see some familiar faces: doctors and friends who had flown all the way from Botswana to attend the events!

I also got to attend a meeting about telementoring which is something that I am very interested in. My mentor, the aforementioned Dr. Kovarik, is head of telemedicine for Botswana. While I was in Botswana I got involved with some amazing projects that fall under this umbrella:

• There is a robotic microscope that we would load our dermatology tissue slides into and, via the internet, Dr. Kovarik could control its movements and read the slides from Philadelphia!



We celebrated Cynthia's first
trip to the US with some Philly
Cheesesteak!

• Many speciality services like dermatology, dentistry (and oral pathology in general) and radiology are using mobile phones to take pictures of lesions or X-rays and get expert opinions from all over the world.
• Smartphones are also starting to be used for telementoring: letting residents and doctors have access to medical “apps” that connect them to medical information and to each other.

I am currently helping with a study that deals with the last project and it was amazing to have the opportunity to meet with our Botswana-based constituents: Ryan Littman Quinn (photojournalist extrordinaire/Mobile Telemedicine Programs Manager in Botswana as well as a friend) and the newest member- Cynthia Antwi. The work that they are doing for telemedicine in Botswana is really exciting and I hope to be able to continue my involvement.

Given that we are currently in our renal block (fabled to be one of the hardest parts of the pre-clinical curriculum)... my brain is currently full of ions. I can’t tell you how refreshing it was to be able to stop thinking about potassium transporters and think about how to improve access to healthcare!

A Trip to Chi-town for Science!

Dr. Christos Coutifaris, me, Dr. Clarisa Gracia

This past week I traveled to Chicago for the Oncofertility consortium, an annual conference held at Northwestern to discuss advances in the field of fertility preservation for cancer patients. As mentioned in my previous post, I am currently taking a year out from medical school to conduct clinical research in infertility, my field of interest. Oncofertility is an area in which my mentor, Dr. Clarisa Gracia, specializes.

The field looks at cancer treatments like chemotherapy and radiation that are toxic to the reproductive organs. For a long time these effects have been a medical afterthought, as the focus on survival after cancer diagnosis took precedent over other health concerns. But as improved cancer therapies result in better prognoses, it is necessary to consider the side effects associated with treatment. Specifically it is important to think about fertility preservation before cancer treatment begins so that patients may have options down the road for building families. While relatively easy for men to accomplish via sperm banking, for the women that Dr. Gracia sees the options are significantly more challenging and invasive. If there is adequate time before a cancer treatment begins she will work with the patient to bank embryos or eggs. And if there is not time to undergo a stimulation cycle, she offers patients the option of a small surgical procedure in which a piece of tissue from the ovary is removed and stored so that it may be used in the future to obtain eggs. This technology is not yet fully developed, however, and it must be explained to the patient that the procedure does not guarantee that they will be able to have biological children- we hope that by the time they are finished with their cancer treatments the science will have advanced.

I could go on and on about this topic, and being at the conference this week has gotten me more fired up, as I heard directly from all of the people working tirelessly to address some of the concerns of this new field. Basic scientists spoke about the advances in preserving the tissue samples and maturing eggs from them, lawyers and patient advocates spoke about the difficulties financing these procedures for patients, ethicists spoke about important moral considerations as the field advances, and cancer patients spoke about how grateful they were that these options were available. All of the members of the consortium come together each year (and at teleconferences throughout the year) with the idea that if they wait to read each others' papers when published in medical journals then the pace of advancement in the field will suffer. Thus, there was an incredible spirit of open collaboration, group problem-solving, and the sharing of everything from lab techniques and tips to cohorts of clinical research data. As this was my first real academic conference I can't yet say if this level of openness is unique, but it made me proud and in awe of those working in my chosen field.

Now that I have returned from Chi town I'm looking forward to starting a new epidemiology and study design class, beginning journal club for the Doris Duke students, and also working as a student preceptor in Doctoring class. Doctoring is a class for all first year medical students that focuses on the doctor-patient relationship and helps prepare students for life on the wards by addressing topics like cultural awareness and communication skills. Importantly, it is also a place where students can talk openly about the challenges they're facing, both academically and personally, and discuss difficult issues that may arise throughout medical school. My job as an older student is just to listen and occasionally chime in when asked a question about how things work in the wards. My group is incredibly insightful and I was blown away by some of their comments last session. This week's topic is cultural competency and I am excited for the discussion on Thursday!

Hello From The Clerkships

Hello to everyone in the Perelman-verse:

My name is Sarah Ginsburg and I am a third year in the midst of my clinical rotations. Incredibly, I am almost 75% done with my clerkship year. As a quick primer on the curriculum here, pre-clinical classes run from the fall of first year to December of the second year. After that, the clerkship rotations run from January of second year (staring 4-6 months earlier than other medical schools) to December of third year. The remaining time before graduation (15+ months) is really want you want it to be - some combination of electives in the hospital, a research project (Scholarly Pursuit), residency applications/interviews, and whatever else you can think of. I'm quite excited to be nearing the "whatever I can think of" stage. It really is great to have the extra time for electives to aid in the process of figuring out what you want to be when you grow up.

2+ years of med school learning. With empty space
because there is so much more to go. And shelves
trying valiantly to hold up so much knowledge.
Metaphor, anyone?

I've been trying to think about the best way to describe "Life in the Clinics". The honest answer is that I really don't have an answer. Each week - each day even - is a different adventure. Your patients change, your team changes, your location changes. And even when all of those things stay the same for a few weeks, each day brings a new set of questions and challenges. You come into the hospital each day trying to find the best way to help your team, whether it be performing the initial history and physical on a new patient, calling a consult or tracking down old records. The clerkship year is about figuring out how to integrate yourself into the clinical team on the fly just as much as it is about learning the facts of medicine and developing rapport with patients. Each team has its own vibe and expectations for medical students. It is a whirlwind, exhausting, sometimes baffling, but ultimately incredible ride. Which is probably med school - and medicine - in a nutshell.

I will now sign off for the night after spending two paragraphs on clerkships without actually talking about the clerkships. Tomorrow, ridiculously adorable children await at my outpatient pediatrics site. As a student, I work one on one with a preceptor, first seeing patients on my own then presenting to the physician. We then formulate a plan (on a good day, the final plan hopefully resembles whatever I suggested in my initial presentation) and go see the family together. Which gives me double the opportunity to interact with said adorable children. After one week (with two more to go) my favorite age is 9-12 months.

More updates to come as the fall rolls along.
Sarah Ginsburg