medical school

http://i43.tinypic.com/1ot0uw.png

i know this is poor form, but the patient from last month's NEJM interactive case was pretty hot

way to make me feel weird guys

Well, tbh it IS weird!

And gross.

yeah ok my bad

Yeah, nagl.

The NEJM thing is weird, wonder if they've had any feedback on that. The number of times a doctor will examine a patient who's stripped completely is zero. Most physical exam stuff is done on top of, around or under clothes/gowns. Proper draping to protect privacy is crucial and is something you get examined on in clinical skills training. The more intimate parts of the exam (breast exam, rectal exam, genital exam of either sex) should only be done when indicated. On the few occasions when I need to do that kind of exam on a female patient, I always offer to have someone else in the room as an observer (out of the line of sight), the patient's family/friend or else a nurse or other female. I guess they're trying in this online case to give you the big picture of the exam, to make you decide which parts will give you relevant clinical information, but there's no good reason I can see why the patient wouldn't be gowned.

Before the hosp would discharge me last Dec, they said someone had to do a full-body check to make sure they hadn't missed any injuries. Keep in mind I could barely raise my head/sit up, much less walk around the room. The young dude doctor who was going to do the exam told me to stand in the middle of the room and strip. I told him to get out and send back a doctor who was also a woman.

The woman just looked down the back of my gown and at my arms and legs and signed off. I swear.

yeah that's weird---the only time i've seen fully nude patients is in anatomical illustrations (as above), in the ED (when looking for injuries on an obtunded/unconscious/etc patient), or when they're getting prepped for surgery. and even in the case of the latter two, it's usually very brief---they get covered and draped (or put into a gown) pretty quickly ime. the nudity is a necessary part of the clinical transition, but it's incidental.

as plasmon said, the whole point of a hospital gown is that it makes selective examination fairly easy.

this is old but is doing the rounds (ha) again

http://jseliger.wordpress.com/2012/10/20/why-you-should-become-a-nurse-or-physicians-assistant-instead-of-a-doctor-the-underrated-perils-of-medical-school/

had to stop reading after like the 5000th word but that was mostly nonsense

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(so this was the wrong thread to check while woken up for a page in the middle of a night on call...)

This seems very much to have been written by someone in his 20s, single and without kids, who's never had a real job. Notable to me that he talks to no one actually practicing medicine independently (not as a resident) who calls their career choice "a huge mistake".

Point by point:

1. Money

Doctors make more than he says, because more than half of them are specialists. Lots of them make lots more than $160K per year. Residents don't work for free, they make about as much as a starting level RN, most starting at age 25-26.

"Most doctors earnings probably fail to outstrip nurses’ earnings until well after the age of 40." Well, maybe in primary care and/or for late starters, but otherwise no. And even if true, if you don't think that making double to quintuple the money you would've made otherwise in your 40s (and every decade of your career thereafter) isn't going to matter to you, you're probably still young, don't have kids and can't imagine what it would be like to be that old. "To some extent, you’re trading happiness, security, dignity, and your sex life in your 20s, and possibly early 30s, for a financial opportunity that might not pay off until your 50s." Or maybe your mid 30s to early 40s, and then constantly thereafter. But if your sex life in your 20s is your main life goal, you're right, better stay out of medicine.

2. Lifestyle, respect

LOL at blaming relationship failures on the "bullying culture" of medical school. It's obvious he's only talked to medical students, poor dears. Most doctors aren't any nicer than anyone else -- they can and will get themselves into more than enough misery in life without blaming medical school for it.

For lifestyle, residents do suffer, especially in the early years. Med students have lots of free time until they get to the clinical years. Doctors in independent practice have control over their schedules, can give themselves holidays (though the overhead doesn't change when you close up clinic for a couple of weeks). That flexibility is limited for the docs who work on salary for a hospital or university, but those jobs usually have quite limited hours for call exposure etc. The best comparison for a doctor in independent practice is a small business owner -- if you're running a restaurant or a contracting business you're not going to want to take much time off by choice, because that's how you build your business and your income. It's not entirely a bad thing, you're working for yourself.

He misplaces the difference in roles between doctors and nurses as something to do with social status. What's that supposed to be -- how impressed someone will be a party when they hear what your job is? The point where the roles become important is at work, not in social situations (since his sources have never worked and spend lots of time in social situations, they miss this point too). Obviously nurses are professionals in their own right and have their own autonomy (and PA's practice semi-independently). But in many or most medical settings, the doctors give instructions that the nurses carry out, and the nurses report information that the doctors are responsible for interpreting and acting upon. It's not just about social status, it's about being able to say "go and do this and this and this, then call me back and let me know what happened" vs having someone tell you that instead. Doctors probably have too much authority, and are fairly criticized as being arrogant, but it's still the case that the job carries with it much more managerial responsibility. If you like that kind of thing, you won't find nearly as much of it in most RN jobs.

"Medicine is, in effect, at least a ten-year commitment: four of medical school, at least three of residency, and at least another three to pay off med school loans. At which point a smiling twenty-two-year-old graduate will be a glum thirty-two-year-old doctor who doesn’t entirely get how she got to be a doctor anyway, and might tell her earlier self the things that earlier self didn’t know." Oh no, a glum 32 year old who's paid off student debts already, looking forward to making $150K a year in a well respected career with job security that offers a fair amount of flexibility and control, at the cost of feeling older and wiser than 10 years ago! What a disaster for that 32 year old.

3. Residency programs as a cartel

Total bullshit. The match is mutual: no resident is matched to a program they don't list as one they're willing to work in, and no program is matched a resident they didn't list as someone they're willing to hire. On the face of it, that's fair.

Lots of residency programs are poor. They sometimes go unmatched, that's the market feedback. Many residents are unhappy in their residency programs; in my experience, a solid half of that is a problem with their expectations. Every residency is a job, and every job has its problems. Many residents have never had a real job before and have no baseline to compare with. Again, it seems the writer has never talked to anyone who's finished residency or who deals with resident education from the other side.

This paragraph would be scary if it wasn't so silly: "The education at many residency programs is tenuous at best. One friend, for example, is in a program that requires residents to attend “conference,” where they are supposed to learn. But “conference” usually degenerates into someone nattering and most of the residents reading or checking their phones. Conference is mandatory, regardless of its utility. Residents aren’t 10 year olds, yet they’re treated as such." The person "nattering" is probably trying to teach these young doctors something useful. The residents checking their phones instead of paying attention are being paid to be there, that's why it's mandatory, and yet are failing to be professional and to take seriously the opportunity to learn. Continuing professional development is a part of every single profession these days (nurses too) -- to think that that's "being treated like a 10 year old" shows a lack of understanding of how the world actually works.

4. Helping people, doing what you want to do, and being happy

Nowhere does he recognize that spending half a lifetime doing a challenging job as a doctor might be in itself interesting or worthwhile. He seems to think the main goal of most doctors is "helping people", but that's a running joke in medicine, it's what you say in your med school interview. "Helping people" is part of being a doctor, but there's also lots of "figuring things out" and "being in charge" and "doing cool tricks" and "knowing what's what". Medicine is hardly the best way to help people (and neither is nursing). If your main goal is being nice to people and helping them do what they want, I'd suggest social work.

Everything he says about happiness research is bullshit, because happiness research is bullshit. People will say all sorts of self-serving things. For instance, as he points out, most medical students are resistant to thinking that they've made a huge mistake, even when it's pointed out to them by this guy who clearly doesn't know what he's talking about. Meanwhile, many people who thought about going to med school but then opted not to for whatever reason like to tell themselves that those grapes on the top branches are probably sour anyway.

i think i am interested in neuropsychiatry?

Yay. I'm reviewing a book on the neuropsychiatry of headache, that's a huge part of what I do all day.

have headaches?

so what can you tell me about neuropsych fellowships, Plasmon?

tell us about the first couple months of residency, gbx

and by couple i mean one

it's busy but not too bad (yet)

I've got the weekend off, so that's nice

Don't know much about fellowships, sorry. Decided fairly early on I wasn't going to move the family and delay going into practice.

took a kaplan practice MCAT this morning, no studying yet = 30. very pleased. signed up for a kaplan course, actual MCAT will be next spring

Nice! Must be a relief.

well it's just the practice one! it was definitely reassuring though to have it affirmed that my foundation is pretty strong, studying for the next 6 months or so can only help. and the kaplan lady said not many people break 30 on their first legit in-person practice one. supposedly they're pretty valid predictors of the actual test, but who knows, of course kaplan would say that. most people i've talked to seem to agree though

felt like i did awful on physical sciences (i...haven't taken basic chemistry since i was 17), but my scores were even, 10/10/10

Strong work, good prognostic indicator.

I taught physics, verbal reasoning and writing for Kaplan. Main thing is to be able to get double digits on verbal reasoning on your own accord. The rest of it is teachable but I had no luck bringing my students' VR scores up more than a point or two.

thanks!

the verbal was by far the easiest, yeah, i actually "didn't answer" two of the questions by mistake (by some brain fart i clicked on the answers themselves instead of the bubble next to them, which placed a strikethrough line through the answer instead of actually selecting the answer. both of them would have been right). no reason verbal should be less than a 12.

physical chem is going to be the place i need to improve the most -- i was able to deduce my way through some things but all of this anode/cathode half-cell whatever stuff is buried somewhere in the back of my brain along with whatever dumb stuff was thinking about in high school

yeah that's a great baseline, kev

my verbal reasoning score did most of the heavy lifting on my MCAT, bigtime. when i took practice tests i'd finish that section super early, and get like 11 on it. once i actually slowed down, and didn't make silly mistakes, i was able to get 13-14s

This discussion made me thing "oh thank god I never have to do standardized tests anymore" and then "oh wait I have two levels of borads to pass for LICSW and more for geriatric cert oh fuck"

however I do not believe I will have to remember any pchem for them

I totally thought I was going to lean heavily on my VR score but noticed that the more practicing I did, the lower my score on the practice tests would run (from like 12-13 down to 10 at one point), which I interpreted as a sign of overthinking (when I start obsessing about the test I tend to think it is all an elaborate trap, whereas sticking to my gut would normally be OK). I backed off a little but ended up doing a little worse than I had hoped. However, I got pretty lucky on the Biology part (which had been my highest-variance section, ranging anywhere from 10 to 13) on the actual MCAT, and that balanced me out.

http://www.medscape.com/viewarticle/815241_1

didn't know where else to post this but man alive is this guy the coolest person in the world or what

med nerd lolz...

https://www.youtube.com/watch?v=aEi_4Cyx4Uw

^^ A+ Medical Variety Night number

OK this is not a medical school question, but this seems to be where the physicians and physicians-to-be of ILX hang out (would like to hear from other health care professionals, but I don't know where the ILX nurses, therapists, etc. hang out).

With any luck I will be doing my first social work internship in the ICU at a hospital of a university named for the USofA's first pres. What is the ICU like? What will I be doing there? How should I prepare (for my interview and also for the internship if I get it)? Other thoughts?

Thanking u.

Oh this is a mixed med/surg ICU if that makes a difference.

will you have to round? pray that the answer is "no," because there is a special circle of hell that is just ICU rounds

The ICU I worked in was a mix of people just passing through immediately after major surgery (heart, organ transplant) and the super-sick/actively dying. I would brush up on end-of-life stuff.

End-of-life stuff and geriatrics will likely be my professional focus, so sounds like ICU is the right place for me to be for training. Thanks, Kate! Would love to hear more about your experiences.

Gbx, my guess is that I will round at least a little for the experience, if not as regular practice for ICU social workers. Don't really know, though. Please tell me about this special circle of hell, which I assume means more than just having to wake up at an ungodly hour. Also, are medical staff assholes to SWers as general practice or not really?

Gonna have some lols the first time a 23 year old med student talks down to me :)

ICU rounds are only hellish because they take. for. ever. like, non-stop rounding from 7am into the early afternoon. and, you know, ICU pts are complex and attention to detail is crucial, my god they are interminable.

ime, medical staff are very appreciative of SW, simply because they magically make things happen that, like, really really need to happen in order for all that medical stuff to stick. this is particularly true (doubly, triply) in my world (the psych ward)

any attending that caught wind of a med student or resident talking down to a social worker would probably have their guts for garters, imo

ime ICU rounds have been very multidisciplinary - you should probably be prepared to round a bit. kate is right that a lot of your time will be spent dealing with end-of-life stuff, particularly if your hospital protocol calls for social work involvement in family meetings (and it should). these are situations that are tremendously interesting to read about and learn about, but can be very frustrating/difficult/emotionally draining IRL, so be prepared for some ugly. so few people have advance directives. you've probably gotten into hospital social work because you're interested in helping people through some of the most emotionally and financially stressful periods of their lives -- the thing about working in the ICU is much of the time that'll mean dealing more with families than the patients themselves, since often they're intubated or otherwise unable to communicate. but i think social work has an extremely important role in ICU care -- the clinicians understandably are under a lot of stress due to the fragile conditions of their patients, and too often there's a poor understanding of what the goals of care are/poor communication about what exactly is being done/etc. good, compassionate doctors take the time to sit down with families and have the difficult conversations, and thats the kind of doctor i want to be, but their time is not limitless. this is where you are needed. NB this is what my impression of social work is from a clinical perspective so maybe you will do totally different stuff idk

gbx what do you dislike about ICU rounding in particular?

that they take all day!

hahahaha so true. i sort of love rounds though

oh btw i did not see that xpost duh

Thanks much kk and gbx, that is helpful info!

Re: advance directives--this is a passion of mine. My folks are all set with theirs (I am their medical proxy), but I am on spouse's case to get his parents (who are in their 80s) to do planning. Of course, I have not documented my own wishes or gotten spouse to get his down on paper. . . guess that should be a New Year's resolution.

also "guts for garters" is my new favorite expression!

ICU rounds are usually multidisciplinary for clinical staff -- medical, nursing, pharmacy, RT -- but I'd be shocked if you'd be expected to sit there for hours while everyone reviews the blood gases, chest X-rays and electrolytes.

Most inpatient wards have discharge planning rounds roughly once a week, in which social work plays a big role in helping with family issues, making arrangements for placement in a care facility, etc. Discharge planning would be less important in ICU, as patients are usually transferred to the ward before plans are made for what to do at the end of the hospital stay.

I'd imagine your main role will be in helping families with end of life issues. The doctors should be the ones explaining the diagnosis, prognosis and treatment options, but the support and care from social work is very important in that situation (for one thing, as gbx says, you have more time to spend with them, and you'll probably be more caring/compassionate than most of the medical staff). You'll likely be asked to sit in in any meetings the medical staff have with families about possibly withdrawing care, etc.

Another thing that might be part of your work there is dealing with insurance insurance. Lots of patients have disability insurance to pay for time away from work, cover mortgage payments, etc. In the US, there'll also be the challenge of paying for the medical services in the first place. In Canada, social workers help families with all of those practical financial matters, and I'd expect that will come up for you even dealing with patients in ICU.

I wasn't sure if insurance issues would fall to the social work department or to other departments within the hospital (billing or what have you); I have, however, developed a knack/patience/persistence for dealing with bureaucracy (lol government contract work), so I can definitely handle that stuff.

How often are ICU pts in need of direct social work care? My limited experience with ICU pts has been with folks who are medically fragile but still able to communicate, participate in decision-making, etc. If ya'll had to put a % on it, what % of ICU pt directly engage with social work services?

Depends on the hospital. Some ICUs cover post-op, post-stroke, post-MI, sepsis and other situations where the patient won't be tubed and may be able to communicate and discuss things with you. In the hospital I work in, those patients are almost all managed in separate step down observation units, and ICU is reserved almost exclusively for intubated patients.

Generally speaking, hospital social work is mostly dealing with families, not the patients themselves. Even stable ward patients are often too sick (delirious etc) and/or neurologically impaired (stroke, dementia, etc) to get as much out of your services as their family members will.

am about 2/3 through gawande's "better" and imo this is the strongest of his 3 books. the section on physician involvement in state executions is both characteristically thoughtful and uncharacteristically forthright. would highly recommend

haaaaaaate PS

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