The Eyeball Test

These days, I walk around with pockets that are less bulging.

I traded the gauze, suture removal kits and medical tape for stickers and a doggie pen. I am proud to say that I walk around with stickers in my pockets, including Sponge Bob and an assortment of dog stickers. My favorite part of my job involves giving stickers to my younger patients.

I have moved from the world of surgery to pediatrics, two completely different worlds. I went from waking up before the sun had risen to waking up to the sun shining (I am currently working in the Urgent Care Clinic). I move away from focused abdominal exams to full head to toe exams, including looking into patient's ears and noses. It's a constant battle to get the otoscope into my younger kids, who cry and squirm. Even getting kids to open their mouth can sometimes feel like moving mountains. And yet, despite the challenges- it's such a pleasure to work with kids and families. When they smile, you feel a little less guilty about having to probe their ears.

In many ways, it's a stark contrast. I'm well-rested these days, catching up with friends and starting up my half-marathon training. The chief complaints have primarily been lots of upper respiratory symptoms and ruling out swine flu in kids having flu-like symptoms. In summary, lots of runny noses and coughing. Surprise surprise.

I do miss the intensity of surgery, the operating room and the complexity of the pre-operative and post-operative management. There is something remarkable about cutting someone open, visualizing the anatomy and defect, and fixing the problem with your hands (or instruments). I will miss the suturing for sure. There is no experience quite like it. A part of me will always be in love with surgery.

***
I do look forward to working with younger patients and developing an understanding of how to best approach common and not so common pediatric problems in the outpatient, urgent care and inpatient settings.

Although pediatrics and surgery are so different, there is one thing very similar to both fields--the eyeball test.

In pediatrics, you are oftentimes working with patients, who can not speak for themselves or give accurate histories. So, you rely on the caregiver to convey the history.

One pediatrician jokingly compared pediatrics to "veterinary medicine," since the patient is a poor historian for obvious reasons and you have to consult the owners (or the parents) for information.

As a result, you rely on your ability to "eyeball" the patient, which involves observing the patient and taking note of how they look, how they interact with others, and if they look sick. In doing so, you can answer some really important questions- "is this patient sick or not sick? Does this patient need immediate medical intervention?"

In surgery, you apply the same approach when evaluating a patient. You "eyeball" a patient to get a general sense of their disposition and health, which enables you (as a surgeon) to quickly decide if the patient is sick and if they need immediate surgery.

The eyeball test can also replace lack of knowledge; it's almost an instict or gut feeling. It got me through my surgery rotation and has been useful for me in my first days of pediatrics.

Excellent, the New Average

Sometimes we all need to remind ourselves about the light at the end of the dark cavernous tunnel that is the third year of medical student. It can get murky when you are constantly being watched and evaluated and when you learn about what to expect in the near future.

The fourth year has become uncovered and now we are learning about the residency applications and the MATCH.

The cycle starts all over again.

Our third year creeped up on us not so long ago, and now it's starting to feel like it is slowly coming to an end. We are over half-way through and the fourth year discussion has already begun. Over fifty per cent of our class will choose to extend their education by at least one year, during which time they may travel, perform research or work. I am still on the fence about whether I want to take an extra year to sort things out. Medical training already seems so long. And having gone straight to medical school from college, I am accustomed to moving forward non-stop. At the same time, I want to certainly keep my options open and am considering research fellowships or an advanced degree in either public health or education.

Amidst all the lectures about fourth year planning, the Step 2 exam, clinical performance standards and extending medical school by taking a year off- we are learning more about the process involved in applying for residency and the match. The process and timeline remains very unclear and represent a source of anxiety for many third years.

But one thing is for sure, the third year is all about labeling. Our clinical performance is packaged into a one word adjective. You can be any of the following- "Superior, outstanding, excellent, very good, or good." With over 53% of the UCSF class labeled as "excellent," excellent has become the new average. Seriously.

This culture of labels makes me wonder about the utility of such characterizations. First, the entire process is subjective and determined purely based on other's opinions of you. Second, medical students are unique individuals with very diverse backgrounds, opinions and perspectives, who really can't be characterized by a single number or adjective. But despite such issues, we continue to label each other.

To standardize the process, we are evaluated and given a numerical value that reflects a number of fabricated categories that are intended to measure our fund of knowledge, clinical reasoning and patient relationships. In many ways, the numbers marginalize us, and we may even see ourselves in light of the label we are given. The feedback that accompanies the number oftentimes does not always correlate and we wonder what we could have done differently, or if we should do anything differently. There is only so much any individual can change.

The system exhausts me. It's tiring to always think about what others think about you. A number of us (myself included) have decided to make the most of our third year by focusing on learning and taking care of our patients. And in the process, we hope the evaluation will reflect that. But as much we tiptoe around the inevitable evaluation conversations, there really is no way to avoid the unavoidable. It's on all our minds akin to the white elephant in the room. We all think about it and wonder about it. Some of us complain or try to rationalize the process. No matter what, we work hard and hope it all works out.

And last time I checked, there is nothing wrong with being excellent.

The End of Surgery

Friday was the last day of surgery. We ended on a somewhat anti-climactic note with the surgery shelf exam, a somewhat arbitrary measure of knowledge and clinical reasoning. I was experiencing flashbacks (nightmares) to preparing for the Step 1 exam, as I hopelessly reviewed esoteric details of diseases I had never encountered. It was certainly one of the least pleasant testing experiences I've had with 100 long questions in 2 hours- marathon test taking at it's worst. Sigh.

"If you finish you are ahead." I was told by another medical student.

As I studied for my shelf, the fellow on my service was preparing for his oral boards. Sadly, the tests just never end.

I left the exam feeling numb and bit flustered. Before I could start thinking about the test, I plugged myself into my headphones, tied my running shoes and set out for a long run. Actually, a really really long run- the longest run I've had thus far (14miles).

With the sun beating down on me, I just had the urge to keep going as I took in the sights of a city I had become estranged from while being on my surgery rotation. Moving one step forward, not looking back at all. This is definitely the year to run a half marathon.

Despite the challenges of surgery, I will definitely miss the rotation.

***

My last two weeks of surgery were spent on the kidney transplant unit. The best night of my rotation was on Monday, when I joined our team during an organ procurement. At 10:30 PM, we set out from San Francisco in a black van and made our way to a local bay area hospital, where we procured the liver and kidneys from a donor. The experience was surreal.

I felt disconnected at times-- not quite fully thinking about exactly what we were doing. But I also kept reminding myself how the organs we harvested could potentially save lives. No matter how I justified it, I could not forget the reality of what we were doing. We were removing organs out of a patient, who had been proclaimed brain dead. I got my best anatomy lesson that night. The heart continued to beat and the organs remained perfused, as we dissected away one organ at a time.

***

After my shelf and long run, I spent my golden weekend in the company of family and friends. My weekend was filled with quality time and food. I was able to recharge and refocus my energy.

I move now to Pediatrics, which starts next week.

Before moving ahead, all third year medical students will congregate in the classroom for a week of intersession, a series of lectures and small groups dedicated to ethics and clinical reasoning. Even after being lectured about how to resolve ethical dilemmas today, I feel more confused and uncertain about how to grapple key ethical topics, including allocation of scarce resources, end-of-life care decisions, euthanasia and patient autonomy. I hope this week will shed some light on these topics.

It's hard to believe that we are over 50% of the way through our third year of medical school. We reminded of this during one of our lectures, which focused on planning our fourth year of medical school. Already? I'm still just getting the gist of third year.

Shelf

About to take the surgery shelf exam.
And will then be done with the rotation.
Stay tuned...

Empty Crib

I will remember the empty crib. On my last day of my pediatric surgery rotation, we returned to round in the intensive care nursery. As we made our way to the west side, we walked to the crib and the baby was not present. Right away, we all knew what had happened-- the baby had died.

My fellow medical student and I had been following this infant's course during his hopsital day. Each day we reviewed his numbers, noting little signs of improvement. We would come by and examine him and speak with the mother. At one point, he was being maximally sustained on pressors and the maximum ventilation support. Despite all the interventions, the infant failed to improve, something we had expected from the start.
***

In the neonatal intensive care nursery, each infant receives the most specialized attention from a large team of healthcare providers, including physicians, nurses, social workers and students. Every conceivable piece of information is recorded on large elaborate flow sheets, everything from vital signs to infusions to amount of urine and stool to when the baby moves or sleeps. The life of an infant is chronicled by the hour. The fluids and output are meticulously measured. Medications and drips titrated exactly to the infant's weight. The amount of detail is nothing short of perfect.

And when the decision to withdraw all forms of life sustaining treatment is made- the flowsheet detail decreases, eventually disappearing. The infant is whisked away to a seperate room, where he can be with his family for the last few moments of his young life.

***


During my last week of pediatric surgery, I observed the spectrum of interventions to sustain life, from basic to complex procedures.

I watched as we sewed the ends of an esophagus for a baby that was born with esophageal atresia, where the esophagus ends in a blind pouch. The physician meticulously laid each suture to create an anastomosis between the blind bouch and the remaining esophagus, which was located more distally.

I watched how we managed acute renal failure in a baby with an obstrution secondary to a large cyst. I saw numerous inguinal hernia repairs and catheter placements.
I saw how we fix congenital diaphragmatic hernias, a defect in the diaphragm that develops when the diaphragmatic folds fail to fuse during development, which results in abdominal contents herniating into the thorax and preventing proper lung growth. Infants with this defect are born in respiratory distress and typically require ventilatory support prior to surgery.

We performed two repairs this week, on infants who had severely defected diaphragms. With the thorax open, the abdominal contents were carefully redirected into the abdomen and the diaphragm defect was patched and sutured close.

When I asked the neonatologist about the prognosis for infants with severe hernias, he told me the following-

"Fifty per cent of such infants will make it out of the hospital alive."

He was right. Only one of our infants survived.