Feedback

I received some of my course evaluations for teaching first year medical student small groups in February. One evaluation caught my eye: "I wish he would be my small group leader forever, and I hope someday I have to have surgery and Craig ends up putting me under, even though I would be too skillfully knocked out to actually get to hang out with him." That made my day. I loved my small groups. But they really ran smoothly because of the students - they were fantastic. The first year medical students were far smarter than we were three years ago, and they worked so incredibly hard. I really didn't do too much, and I get the credit for it. Thank you.

Puns

Friend: I'm getting a pedicure!
Me: Ah, like antibiotics for kids. I personally like amoxicillin.

Bedside Manners

The profound power and effect of bedside manners really struck me with one particular patient I saw last week. The family had gone through a stressful, harrowing surgery and the post-op course was rocky. There were a few medical problems that the surgeons asked consultants for advice on, and so the family encountered many new faces. Everyone acted in the patient's best interest, but in doing so, one practitioner encountered a situation that she thought was urgent. Because she was enacting a plan to care for this patient, she did not have time to build the best rapport. The following day when I met the patient and her family, they fixated on the poor care they received from this one practitioner. I spent a significant amount of time trying to smooth it over.

Bedside manners are a surprisingly fickle entity. From a distance, they seem to be obvious: respect your patients, listen, be kind, sympathize, form a partnership, explain what you're doing, be professional, modulate facial expressions and behaviors. But putting this into practice is not that simple. When you notice something that might be life threatening, you might gloss over the finer points of eliciting a patient's feelings. First impressions color everything; if you don't make a favorable initial rapport, then recovering is exceedingly difficult, even if your bedside manners are perfect. But I found that listening to the patient's concerns really helped me understand their perception of the problem and allowed me to earn some measure of trust with which to repair that therapeutic bond between the patient and her caregivers. It is extraordinarily difficult to have outstanding bedside manners all the time - rain or shine, sleep deprived or not - but we all must strive to maintain it as much of the time as we can.

Broadening my Perspectives

Much of my personal growth and transformation in these last four years of medical school has been learning to broaden my perspectives, do away with stereotypes, and avoid unwarranted judgments. When I started, I considered myself to be open minded and accepting of everyone and any lifestyle. But as I encountered people further and further from my way of life - pregnant teenagers, IV drug users, victims of gang violence who vowed to hurt those who put them in the hospital, parents accused of child abuse - I had to actively work to maintain this frame of mind. Even little things like HIV-infected patients who were happily married with 3 kids surprised me - and I don't know why; we're taught that anyone sexually active is at risk for the disease, so why should this situation bother me? Medical school has been a really enlightening experience. No matter how liberal, open, and accepting I thought I was before, I continually encountered situations that made me aware of how close-minded I could be. How can you not judge someone accused of domestic violence or who knowingly has HIV yet refuses to be treated or have safe sexual practices? This was a question I asked myself a lot. Because my professional role was to remain a patient advocate regardless of his moral nature, I found myself in quandaries at times. It's not easy to be tolerant of anyone and anything.

Revision: New York, New York

I just made some minor tweaks as a result of feedback from my writing group. Sorry, the blogs have been a little sparse lately, but I have a lot to write about in the coming weeks.
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New York, New York

"Now this is a city" I said among unfolding arms and boughs of snow, cradles of coffeehouses, pinnacles and triumphs and towers of glass, sprouting chimneys gracing ash, dodging into a bookstore, glasses fogged with the scent of morning roast, running my hands over the texture of words, easing open a virgin spine, and then out among cartwheeling staircases where black-bag edifices astound, into the smell of baking bread, the crumble of creme brulee, the crates of vegetables, the slit-snap of plastic restraints binding newspapers, the taste of urgency, the strangers encroaching upon our space in the rumbling mausoleum, the seismic concrete, the snowbanks piled wet with the cries of sledding, in search of warmth where escalators escalate as we weave through department stores, forests of mittens, crowded monuments, the lights descending, our eyes migrating in droves across this city of scarves whose breath in heaves awakens...

Last Day

Today was my last day of rotations as a medical student! I also felt like the only medical student in the hospital; all the third years were taking their end-of-rotation exams and nearly all the fourth years were on vacation (I had squandered my vacation earlier so I had to do a rotation all the way to the end). At noon conference today, I was the only student in the room. But I got the best feeling in the world today, turning in my pager knowing that it was the last day in the hospital as a medical student. I'm celebrating tonight.

Bronchoscopy

One of the cool procedures in the armamentarium of pulmonologists is bronchoscopy, the insertion of a thin scope or camera into the airway of a patient to inspect the lungs, do diagnostic maneuvers, and occasionally, treat airway problems. We have been doing several bronchoscopies a week using an instrument similar to the one shown above. Most modern bronchoscopes, however, are connected to a fiberoptic camera allowing projection of the image onto a computer screen (rather than staring into the device like a telescope). It has been very cool and educational for me to see the vocal cords and review the lung anatomy. I've also seen a wide range of findings, from the normal lung to mucus impaction to narrowing of the airways to bleeding lesions.

The other day, I got to play with the bronchoscope. I manipulated the camera through a model lung, learning how difficult it was to coax the device where I wanted it to go. But it was a lot of fun, similar to a video game, as I tried to inspect every segment and subsegment of the fake lung model. Eventually, the goal is to place a paperclip or object in one of the subsegments and, using the bronchoscope, determining where it is.

Image of an old-time flexible bronchoscopy is in the public domain, from Wikipedia.

Decision Making

One of the hardest things as a medical student is to commit to a plan. We are often asked to "put our money down" and decide on a diagnosis or a test or a treatment. Of course, this is an educational exercise; residents and attendings use this opportunity to discuss why our decision was correct or incorrect. But it feels scary, as if we were actually deciding on a course of action for a patient. As a student, we feel like we don't know enough, so we hedge. "Well," I say, "if we think she has a community acquired pneumonia, we'd start these antibiotics. But if it's just a flare of asthma, her inhaler will do." But that's simply skirting the question - the attending wants to know based on my clinical judgment whether the patient has an infection or not. This is the transition from a third year medical student or clerk, recording information, to becoming a doctor, interpreting that information and acting on it. This year, I've been trying much harder to take a clinical stance with each patient. I am often wrong, but then it becomes a learning opportunity. I've realized in the coming years as a resident, I will have to develop more independence in decision making. It's a scary step, but I think I am ready for it.

Poem: Elk

I always had trouble with nature poems, but here's an attempt. I may write about this beautiful weekend in a post later on.
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Elk

What do you know of elk?
I know nothing

so I set out in exploration,
coaxing the car over paved mountains
through San Francisco's towers and drab

past the panhandlers and the man
selling roses over the bridge.

The sun blooms in Marin
and the GPS satellites
surprise me with back roads,
with the splotch and run
of cows to the nearest stream
and horses whose noses touch the ground.
I slow so the vultures
can take one last bite of carrion
before embracing the wind and alighting.

Driving to the elk reserve at Point Reyes
I discover a shimmer of ocean to my left
in anticipation of a whale migration,
and I look for seagulls
when we find Bird Rock deserted.
At the end of the trail
on cliffs overlooking blues,
crags scatter with mussels;
it was lunchtime for us too

and as the flour of the baguette
paints our faces in a way
that makes sunscreen jealous,
bread and cheese and water
never tasted so intimate,
seasoned with the smell of ocean
and the roll and suction of the incoming tide.

After lunch, lost in a potpourri
of shoulder-length yellows, pinks, oranges,
we imagine ourselves stars of a movie
running home through fields of flowers.
Then lost again in the overgrowth of bushes
navigating the trail by a blush of dirt.

Imagine my surprise as I spot
their gaze, their odd cotton tails, the statuesque
pose that breaks into a leap across the lake,
and then two, and five, and fifteen
casting water and light into shapes and motes,
over ducks nonplussed by this procession.

They reach the top of the bluff before we do
silhouetted against a sky so bright I squint,
wreathed in poppies.

Eosinophilia III

This is the conclusion of the case from the last two posts.

The eosinophil, an example of which is shown above, is a bizarre cell in the minds of medical students. A fairly rare type of white blood cell, it fights parasites and causes us grief with allergies and asthma. The word "eosinophil" means acid-loving because granules within the cell appear bright red after staining with eosin.

Most of the time, when I see an increased number of these eosinophils, I brush it off as related to allergic rhinitis (hayfever) or asthma since those conditions are so common. But eosinophilia of 20% as seen in this patient is highly unusual and prompted me to review a differential diagnosis I had never considered. Medication side effects were certainly possible, and this patient was on many medications for his multi-organ failure, but it was difficult to tease out the temporal relationship of starting new meds and the eosinophilia. Classically, parasites are taught as the cause of eosinophils, but this patient didn't have a travel history consistent with helminth infections like Strongyloides, hookworm, or Toxocara. Nevertheless, sending stool for ova and parasites was be a reasonable step. Fungal infections too could cause eosinophilia, and given the patient's asthma, we wondered about allergic bronchopulmonary aspergillosis. Since he has been in central California, we considered coccidioidomycosis. Lastly, given his asthma and neurologic symptoms, we toyed with the idea of Churg-Strauss syndrome. Adrenal insufficiency was also considered, especially given his profound weakness.

In the end though, given his multi-organ involvement, hematology/oncology began to favor a hypereosinophilic syndrome or neoplastic disorder. The cardiologists felt strongly that the echocardiogram was diagnostic of Loeffler endocarditis and that is most commonly seen in a primary eosinophilic syndrome, eosinophilic leukemia, carcinoma, or lymphoma (though it is so rare that we have only case series). Furthermore, this disease presents in different stages; the first necrotic stage involves the patient's initial symptoms: fever, sweats, lymphadenopathy, weight loss, biventricular failure. The patient probably entered the second phase - called the thrombotic stage - when he presented to the outside hospital and had multiple strokes. Lastly, when he came to us, he had evidence of the third stage, a restrictive myopathy.

The patient underwent multiple bone marrow and lymph node biopsies, but they did not demonstrate any cancer or myeloproliferative disorders. The final diagnosis was primary hypereosinophilic syndrome with cardiac and neurologic involvement. The patient responded to steroids.

Image is shown under GNU Free Documentation License, from Wikipedia.

Eosinophilia II

This is a continuation of yesterday's case.

How do you go about approaching a bizarre case of constitutional symptoms, global weakness, eosinophilia, and multi-organ failure in a young man with only mild asthma? Of course, as the information comes in, we alight on different bits of data which take us down diverging pathways. As we realize the gravity of the situation, we begin to take a more shotgun approach, ordering any tests that might give us clarity of the situation. But unfortunately, such tests can often confound things.

Here, the outside hospital ordered a battery of tests, most of which came back negative. The following were normal: SPEP, anticardiolipin antibodies, treponema pallidum antibodies, B12, parvovirus B19, Sjogrens A and B, ANA, antithrombin III, lupus anticoagulant, HIV 1 and 2 antibodies, mycoplasma, ASO, Hep B panel (evidence of immunization, no infection), Hep C, Hep A, TSH. The following were abnormal: IgE elevated, RF elevated, ESR and CRP mildly elevated, protein C slightly low (protein S normal).

Of course a patient like this gets pan-consulted, running the risk of too many cooks in the kitchen. Specialized tests and procedures get thrown about and each specialist interprets the data slightly differently. As rheumatology, heme/onc, and neurology weighed in, we got more tests: negative myeloperoxidase, anti-proteinase 3, HTLV, and BCR/abl. A C3 was slightly low and C4 was normal.

The way I approached this case was figuring out cause and effect. As things began to unfold, we reasoned that the altered mental status was likely a result of the multiple embolic strokes; these emboli, it turns out, were coming from the heart. The liver failure was likely from congestive hepatopathy and the renal failure was likely from decreased perfusion due to cardiac injury. Thus, in our minds, the case whittled down to a bizarre eosinophilia with cardiac dysfunction.

Further imaging began to elucidate the picture. A CT chest showed four-chamber enlargement with sub-endocardial irregularity and low attenuation in the apices of both ventricles. Bulky lymphadenopathy and patchy peripheral ground glass opacity and consolidation were also seen. A transthoracic echocardiogram showed severe left ventricular hypertrophy, normal systolic function, and endocardial thickening with obliteration of the left apex. There was involvement of the posterior mitral valve leaflet with mitral regurgitation. All of these were suggestive of something I'd never heard of: Loeffler endocarditis, a restrictive cardiomyopathy associated with eosinophilia.

Eosinophilia I

N.B. Some details have been changed.

A 22 year old man with a past medical history of mild asthma is transferred from an outside hospital for diagnostic evaluation. He was in his usual state of health until several months prior when he began having episodic fevers, chills, night sweats, headache, and myalgias. He couldn't identify any triggers but symptoms were more severe on the weekends.

He then had acute onset of global profound symmetric weakness of all extremities which prompted him to go to the emergency department. His neurologic exam was non-focal. A chest X-ray showed cardiomegaly and interstitial infiltrates, troponins were elevated with a peak of 15, and a transthoracic echocardiogram showed an ejection fraction of 50% with a pericardial effusion. At this time, he was found to have eosinophilia of 20%. He began having encephalopathy, and MRI showed bilateral scattered lesions consistent with embolic strokes. A CT abdomen, chest, pelvis showed prominent mediastinal lymph nodes, anasarca, and hepatomegaly.

He was diagnosed with and treated for myocarditis, but over his hospital course, began having a transaminitis with AST 1500, ALT 1200 as well as acute renal failure (Cr 1.5). At this point, with multiple strokes, myocardial injury, acute liver failure, and acute renal failure, he was transferred to our hospital. His lungs were doing well, but pulmonology was consulted to assess the possibility of transbronchial lymph node biopsy.

To fill in the rest of the history, he has mild asthma requiring occasional (once/week) use of an inhaler. He has a positive family history for lymphoma and lupus in second-degree relatives. He works with cleaning solvents, hunts wild game, had recent contact with bats, and has two pet lizards. He smokes, but denies drugs and alcohol.

On exam, he was afebrile with blood pressures 90s-100s/40s-60s, HR 80s-90s, breathing 12-18, saturating 95-100% on 2L nasal cannula. He was ill-appearing but not in acute distress. His neck was supple, he had bilateral bibasilar crackles, a hyperdynamic precordium, a soft belly, no palpable lymphadenopathy, trace edema, and altered mental status with global weakness but no focal deficits.

Chemistries were grossly normal with an improving creatinine. A CBC showed WBC 12, Hgb 12, Plts 100. Eosinophils were 2.4. INR was 1.5. Troponins were trending down. BNP was 600. AST/ALT were 200/400. U/A showed large Hgb, 21-50 RBC, 5-10 WBC, 30 prot. EKG was NSR, prolonged QT.

Wow. This was the first patient I saw when I came onto service, and it was a true Moffitt medicine mystery. More tomorrow.

Radiology and Pathology

On this rotation, we have regular radiology and pathology rounds. We discuss films in detail with chest radiologists who've written the textbook. Despite taking radiology, this is still really hard for me, mostly because the pulmonologists look at fine nuances in each film and we consider strange diagnoses like hypersensitivity pneumonitis or lymphangiomyomatosis (which I hadn't heard of before this rotation).

More surprisingly for me though was learning of pulmonology's relationship to pathology. Every week, we review biopsy slides, mostly of transplant patients looking for rejection. Histology was always my greatest weakness as a first year med student (I can barely identify granulomas), and it amazes me how some of the seasoned clinicians can pick up on the finest details. Others, however, stare into the microscope and make comments like: "That slice of tissue looks like Yemen."

Both images of emphysema shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Power Outage

Today the power went out at the hospital. Quickly, the backup generators went into action, making sure critical machines like ventilators did not stop. Within an hour, power was restored. But this got me thinking of how crucial electricity is. Imagine being stuck in an elevator while transporting a critically ill patient. Or having the lights go out in the middle of surgery. Even mundane tasks like checking labs in the computer or text-paging physicians or writing notes come to a halt. Indeed, some teams awaiting critical labs had to call down to get an answer, not even sure if samples could be run during a blackout. Now that all our records are electronic, a simple blackout robs us of all our basic information. Luckily, the backup protocols were in place to assure that patient care was the foremost priority, but this reminded me of the importance of disaster readiness and preparation.

Image of crossed wires causing a short circuit is shown under Creative Commons Attribution Share-Alike License 2.5, from Wikipedia.

Clerk

In the old days, third year medical students were called clerks; hence the word clerkship for our rotations. Indeed, notes by third year medical students are the most thorough and complete. I remember arduously writing up 4 or 5 page admissions notes on medicine, a task that seemed impossible at the time and a feat that seems unimaginable now. Partly, this stems from our inexperience at understanding what is important and what is not; hence, we ask about and document everything, no matter how trivial. We also feel like writing perfect notes is one thing we can do as a medical student and worry that it is the only way we'll be evaluated. After all, we don't have clinical judgment or answers to all the patient's questions; all we can do is record things beautifully. And there is an educational component in writing the note; it reinforces the importance of the history and physical exam, the thought process in decision-making, and the interpretation of data.

But as we graduate past the third year of medical school, our notes become more sparse and focused. My notes as a sub-intern were worse than those by the fresh third year medical student on the team. This contraction comes out of necessity; as an intern next year, I may be writing 10 daily notes on my patients, and I simply cannot keep producing volumes of work. My attention has shifted from being a clerk and documenting unnecessarily to taking care of the patient and making sure orders get executed. As a fourth year, I may know what matters in a note and where to focus. But lastly, being on a consult service for much of the year has taught me the value of short notes. For most purposes, the concise, well-written, clear synopsis is superior to a rambling, overly thorough note. That is what I've been trying to work on in this rotation. That being said, when I get a new consult, I still take a look at the third year medical student note since, until I am an intern in a few months, I have the time and I really appreciate the hard work put into the four page life-stories of each patient.

Pulmonary Function Tests

One of the most fun things I got to do on this rotation was take my own pulmonary function tests (PFTs). PFTs are a battery of breathing tests commonly ordered to characterize asthma, chronic obstructive pulmonary disease, and other lung abnormalities. At its most complex form, the set-up is the one shown above. There is a "body box" which can be completely sealed so the machine can precisely measure changes in volume and pressure.

You put your mouth on the device shown above which can deliver various combinations of gases and measure pressures, flow, and volume of breathing. We went through basic spirometry as it is taught in medical school; I breathed normally, then inhaled to my maximum and exhaled as quickly and completely as I could. I then did a handful of other maneuvers from inhaling and exhaling as hard as I could against a closed valve (calculating maximum inspiratory and expiratory pressures) to breathing in large volumes as rapidly as I could (to test for diaphragm weakness). I also breathed in a whole bunch of different gases: carbon monoxide to calculate diffusing capacity, methane, and 100% oxygen as two separate methods of calculating total lung capacity. The data generated included graphs like this:

Overall, it was a great way to spend the afternoon. It was highly educational, both in reviewing basic lung physiology, formulas, and relationships, but also in interpreting data. Seeing my own graphs and numbers was far more fascinating and relevant than reading a textbook chapter. But moreover, I found it really important to learn what a patient experiences when we ask him to do pulmonary function tests. It wasn't as easy as I thought it would be, and I'm a healthy person. I can't imagine how hard it must be for someone with lung problems. I think it's educational, fun, and important for providers to undergo some of the tests their patients have to take, and this was a great experience for me to do so.

All three images are shown under GNU Free Documentation license, from Wikipedia.

Pulmonary Consult

My very last rotation of medical school is pulmonary consult at Moffitt-Long hospital. Oddly enough, it is the first time I've donned on the white coat and picked up my stethoscope in months. And although the hours are much busier than research and radiology, it is wonderful to be back in the hospital. I think now that intern year is looming, I am focusing on shoring up my inefficiencies during clinical care. Pulmonology will be useful for both medicine and anesthesia, and I'm starting to get back into the routine of ward medicine. My team is fantastic and there is a focus on daily education. In general, we get consulted on patients with the bread-and-butter exacerbations of asthma to patients with obscure diseases like Langerhans cell histiocytosis. I really enjoy the focus on lifestyle interventions; we spend a lot of time talking to patients about their smoking and drug habits. Even more than that, a lot of conferences have been about the benefits of exercise and weight loss on cardiopulmonary diseases. Pulmonologists are true internal medicine doctors focusing on the whole patient, their social situation, their lifestyle, but they also have such expertise in critical care, bronchoscopy, and rare disease entities.

Image is in the public domain, from Gray's Anatomy, from Wikipedia.

Match Day

What a bizarre affair. Every school does their match day differently, and perhaps this is one time when being on the west coast is better; we found out our results at 9am (it's synchronized across the country so east coast schools get results at noon and presumably, Hawaiians wake up early). In a Californian fashion, it was very low key; no big ceremony, no pomp and circumstance, no speeches, which is the way I like it. Many people didn't even show up, preferring to get an email or check online later in the day. But it was wonderful to see classmates who did come, and I spent much of the morning catching up. The tension was palpable and there was an atmosphere of anxiety. In a characteristically unceremonious manner, we picked up our envelopes and opened them at the same time, frantically searching the paper for the results. Most of my friends got their top few choices and I am very grateful for that. The rest of the day was spent in celebration; many of us went out to brunch on a fabulously beautiful, sunny, and truly Californian day. It was perfect and strange to have a day off on a Thursday, but we took the greatest advantage of it with our friends.

Poem: Easter

Easter

Blurred between nonbelief and velocity
I make my home on the farm of dreams;
my friends are the hopping sheep, the sweat-
shop chickens, the lolling cattle. We dare
to vault the moon, and propelled
by three hundred sixty four days of momentum
I carve a world, spluttering pastel and glitter.

Why believe in this magic but not the other?
A host of modern world conjurations
wash out the book, dilute miracles
we once held sacred. What is real
is what we make real, or otherwise.

Match Results

It was fascinating for me to see the results of this year's match list for the graduating class (composed about 50-50 of students who matriculated in the class of 2010 and 2009 since a large proportion of us take a year off to do research, pursue other degrees, have a family, or accomplish other things). 151 of us are going into residency next year. Here are some highlights:
-12 family medicine, 11 internal medicine (IM) primary care, 1 IM/preventative medicine combined, 1 pediatrics primary care, representing 16.5% going into definite primary care.
-30 internal medicine, 1 peds/IM combined, 11 peds, 11 ob/gyn, representing 35% who may go into primary care or subspecialize.
-4 neurosurgery! Wow!
-Along with neurosurgery, 6 surgery, 4 urology, 3 plastics, 6 orthopedics, 1 oral-maxillofacial representing 16% surgeons.
-For the "ROAD" to success, we have 5 radiology, 1 ophthalmology, 10 anesthesiology, 2 dermatology, and 2 PMNR (not in the mnemonic but probably should be) representing 13% of the class.
-The two most popular non-medicine specialties were emergency medicine (11% of the class) and surprisingly, psychiatry (9% of the class).
-A ridiculous 77% of us are staying in The Golden State. 30% of the class is staying at UCSF, 21% of us are staying in the Bay Area, and 21% are going down to southern California.
-The next most popular state was Washington, drawing 7% of us followed by Massachusetts (5%) and New York (4%).