Medical School

Medical School: “Obstetrics and Gynecology.” But Not Misogyny

Why Not Obstetrics? 

For an elective rotation in Obstetrics and Gynecology I signed up for a thirty-day stint at The Providence Lying-In Hospital. What better way to get exposure than to be in a place dedicated entirely to the biology of the human female and her reproductive system?

Sleeping quarters were provided in a building that also housed female nursing students on the floor above us.

Imagine fifty horny nursing students locked up in the same building as three or four male medical students as being almost as good as a seminary student getting to live in a nunnery. At first, I could not imagine what stupid logic went into that demographic, but as time went on I came to understand the point to be moot and irrelevant.

Things got off to a bad start, when on the first day I was assigned to an Obstetrical surgery case; a hysterectomy. The problem being that as no one had taken the time to teach us how to do a sterile scrub and don, the attending surgeon went berserk at our awkward fumbling. This delayed the case while exposing his own paranoia that the operative field would be contaminated. He threw us out of the operating suite.

That illustrates one glaring fault about medical training, especially in a nonacademic satellite facility: Not knowing how much the student does or does not know and usually assuming that he knows more than he actually does; without really asking first; or sometimes not seeming to really care. In this case, the seasoned nurses came to our rescue by kindly showed us how to scrub in and put on a surgical gown.

There is also another glaring deficiency in the tritely overused expression that in procedural medicine all you need to do is to: “See one, do one, then teach one.” I doubt that anyone would agree this axiom should apply to cardiac valve surgery.

Nor did it apply to the situation I found myself in when I had only assisted at several post delivery episiotomies, a procedure whereby the lacerated vagina and perineum is sewn back together after the baby rips it apart while coming through.

The vagina happens to be a very accommodating organ; as both birthing baby heads and “fisting “perverts have empirically discovered; but like everything in life there are always certain limits.

The OB Resident, having been completely exhausted by his duties, delivered a baby, then turned to me and announced as he took off his gloves:

  • Hey, I’m really tired. I’m going to bed. You sew her up.

This was the same resident who had previously taught me to carefully suture so as not to hook the bladder or the bowel and to pay extra special attention to the final purse string cinching by making sure that the vaginal opening at the perineum was nice and tight.

  • That’s what I call ‘the husband stitch’ and there are probably a lot of grateful men out there who don’t even know why their sexual satis-friction is all because of me.

Yes, unless the husband happens to be thirteen-inch-Long John Holmes and it won’t ever fit in there again. Or if so, maybe it just gets stuck.

So, there I was, expected on my own limited experience, to sew up a lacerated vagina as well as to correctly place the husband stitch and make this mother neo-virginal again. I had a serious crisis of confidence and whimpered softly to the vacating Resident:

  • Please come back. I’ll do anything for you. I’ll even send a copy of your personally autographed photo to all the happy husbands so you won’t have to live in un-adored anonymity anymore.

No such luck. Yet once again the senior nurses talked me through it, although to this day I have no clue as to where the stitches really went, or how tight the final cinching turned out.

I had nightmares for weeks about a crooked vagina, a loose vagina, an ultra-tight vagina or a nasty vaginal-rectal fistula which would be followed by having to deal with a vendetta from a very ungrateful husband; not to mention litigation.

To back up a bit, this OB rotation was organized into weekly segments that included:

  1. Prenatal clinic
  2. Postnatal clinic
  3. Routine check up clinic
  4. One of many potential routine problems clinic
  5. VD clinic
  6. Labor and Delivery
  7. Obstetrical night call

Also, no matter what weekly clinic we were assigned to, we had to be on standby call every third night for labor and delivery. So, although there are probably some perverts out there who might think that unlimited access to peering at female gonads could be fun, better think again.

This activity is cold, indifferently clinical and involves handling women who would rather be doing anything else than have a frigid slime covered speculum pushed up their crotches, or an equally slimy finger stuck up their rectum; and sometimes simultaneously. They do not like it and they do not like you for doing it.

Next, not everyone looks like a Playboy model, as well as the fact that one is required to examine ages that range from nine to ninety, including all builds, shapes, sizes or body types with levels of hygiene that range from the immaculate to the totally neglected.

There is nothing worse than examining a three-hundred-pound woman who does not believe in soap and water, or who may have a yet unidentified species of fungus growing within the folds of her breasts or her labia.

Then, although the “Routine Check Up” clinic was relatively innocuous, there was always the dread of discovering the unknown surprising disease entities lurking in the cracks at the “I Think I Have a Problem” clinic: Yeast, gonorrhea, herpes, chlamydia, syphilis, vaginitis, urethritis, cystitis, trichinosis, and chondyloma. It was a great day indeed if the symptoms were only related to a benign ovarian cyst.

Women of all ages, from all walks of life; from rich to poor; ugly to beautiful, anorectic to obese, hygienic to unbathed with a wide assortment of troubles; with the best part of it all sometimes having to tell the parent of a minor that her good little supposedly virginal daughter had recently been up to quite a bit less than good and wasn’t really virginal anymore. Or worse: knocked up.

Of course, this was the era before HIV and because condoms were not necessarily all the rage, VD and STDs were more a nuisance than a death sentence. But it was still at a time when teen-age sex was quite verboten or severely stigmatized; especially so in Providence, Rhode Island which being a suburb of Vatican City, had no nightlife at all and in 1972 had little to offer a date but a front seat six pack followed by a back seat boogey.

It all became a female genital blur. Pretty pussy, ugly pussy, hairy pussy, shaved pussy, clean pussy, dirty pussy, messy pussy, sweet pussy, sour pussy, pregnant pussy, laboring pussy, lacerated pussy; and then various combinations or permutations of adding to that: big lips, small lips, large clits, little clits, and crotch zits.

After the daily assembly line of “pussy galore” I would fall off to sleep at night with visions of pussy-plums dancing in my head.

Now top that off with taking care of women in every stage of pregnancy, finally culminating in the counter-joy of having to listen for hours on end to a large open labor ward housing a dozen or so women who all raise their voices in completely non-syncopated timing as they scream out the raucous chorus of the opera known as the: “The Throes of Parturition.”

And although a baby’s birth can never be timed for perfect convenience, some of the attending Obstetricians would add an alcohol drip to the usual regimen to time the delivery by more propitiously delaying its occurrence from the middle of the night toward a reasonable hour the next day.

This made the operatic chorus all the more interesting for the added feature of having a room full of inebriated laboring women and the interesting quirky things the booze did to their personalities. Some of them became quite psychotic and had to be restrained. It was atavistically primeval.

Then on to the delivery room, where although a rapturous joy for the parents, I found nothing joyful at all about the gush of pee, blood, baby, baby shit, mommy shit, amniotic fluid, placenta; and then secondarily the effect that gallons of all of these body fluids did to the only pair of shoes I owned.

It got so bad that I cancelled a weekend tryst with the woman I was dating at the time by making up some lame excuse, and then told her I would call her back in a few days.

She did not take it well, then made oblique references to the fact that I was probably cheating on her with some nurse or nursing student in Providence, while she was alone, lonely, and horny back in Boston. I could not at all get through to her that worse than that; I simply had no desire whatsoever to see her naked, much less do anything else with her body parts or any woman’s body parts for that matter. Like writer’s block, I had developed a serious case of libido block that could be best characterized as nothing more than a bad case of female genitalia burnout.

She said:

  • Sure. I’d believe that just as much as I’d believe you didn’t want me anymore because you and that stupid roommate of yours were gay. I knew that anyway. Goodbye and Good luck.

No chance of cheating anyway, as even the female nursing students had also evoked as much negative libidinous attraction as alien body snatchers that came out of vegetable pods. Add to that the fact that their recreational drug of choice at the time was Quaaludes (“Sopors”), which did not exactly make them a boat-load of fun at social gatherings. There is nothing like going to a party where everyone passes out, and truthfully speaking, date rape with a limp dish rag was not my cup of tea.

Yes, lets all get to the point where not only do we not know what we did, or who we did it with, but also do not remember if we even liked it. My preference for pussy was to have it alert, awake and even faking interest if necessary; but not semi-comatose and diffidently snoring.

Despite my girlfriend’s innuendos, it was not even a case of latent homosexuality because I knew I did not harbor the slightest hint of homosexual tendencies. I honestly and truly liked pussy! It was just a simple case of overexposure resulting in a negative feedback loop. Too much of what otherwise might have been a good thing, so to speak because it just wasn’t the Hugh Heffner presentation.

After the OB experience in Providence, I also knew that I would never look at sex and the human reproductive cycle in the same way; and that if I ever chose the OB-GYN discipline as my medical vocation, I would probably want to eventually go ahead and just have myself neutered.

 

 

 

Pussy Galore: No problem for Agent 007

 

Photo: clothing.cafepress.com

 

 

 

 

Medical School Third and Fourth Years: Clinical Rotations

Clinical Rotations

The third and fourth years of Medical School are entirely clinical involving monthly rotations through various subspecialties. The exposures focus on medicine and surgery, including certain required subjects as well as some leeway for choosing electives.

This is designed to expose the student, especially in the third year to a wide variety of basic elements, while forcing him/her in the fourth year to begin thinking about making a final decision on choosing an Internship. Although there are several choices, the critical choice boils down to whether someone wants to be a thinker or a cutter.

It also exposes the student to certain disciplines he will then automatically weed out potential future careers.

For example, when I had to spend thirty days on an in-patient psychiatric ward, I knew I would never be able to make a career out of the abstract qualitative issues associated with the mysteries of the scrambled brain. These were hard core cases, such a as incurable Schizophrenia and sometimes it was difficult to tell the inmates from the screwy attendants taking care of them. In this case, I chose to fly over the Cuckoo’s nest. 

On the Neurology Service, I knew that spending a career dealing with irreversible neurologic damage or chronic demyelinating diseases would make me suicidally depressed and that I would end up in the psychiatric ward anyway; without a real stroke, but equally incapacitated.

Hematology seemed too abstruse, and because it paired with Oncology was even more depressing than Neurology. I had a great deal of difficulty dealing with the depressing diagnosis of “cancer” knowing instinctively I would never be able to tell anyone they had it. The: “C” word. Or worse yet: the “Big C.” A bad one. Already spread everywhere. Metastatic and incurable.

Endocrinology seemed the most logical as it dealt with clearly defined human positive or negative feedback loops; but I found its scope too limiting. All glands. Not much fun. It would be like spending a lifetime adjusting a thermostat.

Pathology was a turn off after seeing only one autopsy. Bodies smell horrible because they have a sickeningly sweet odor when refrigerated. They also have a spooky color: Clay blue-grey.

Then when not cutting little specimens into pieces after extracting them from a corpse, the rest of it is spent squinting through a microscope to define well after it was too late to be of real assistance, what really happened to the person in question.

There is little satisfaction in telling the corpses’ doctor:

  • Hey, nice going. You were right about what he had but he died anyway.

Or

  • Hey, nice try but you royally fucked this one up. You had absolutely no clue whatsoever as to what it was that finally killed him.

Nephrology was too wrapped up in acid-base metabolism because I was never very good with ions and pHs. Beside that, if you look at the kidneys sideways, they curl up and die. This introduced the added negative feature of having to take care of dialysis patients; which for some reason offered no appeal. I think it was the machines, the constant smell of uremia, and the fact that all the patients are puffed up on enough steroids to make them look like pumpkins.

Pulmonary was boring. The lung. Oxygen: in. Carbon Dioxide: out. That’s what green plants do, only the opposite. Or maybe get a tumor or a blood clot. Maybe stiffen up. Mostly get infected or destroyed by chronic nicotine use.

Gastroenterology raised the exciting specter of spending a lifetime looking up peoples’ butt holes, and scoping other dirty orifices, or as necessary in Urology, if dealing with diseases of the penis, urethra, and bladder, offering the great opportunity to delve into some other equally enthralling orifices.

  • Yes. The bad news is that your prostate is larger than a grapefruit. But the good news is that it is still smaller than a watermelon. And the indifferent news is that none of that has anything at all to do with your erectile dysfunction.

Or

  • Oh, kidney stones. Take this little plastic cup home with you; filter every drop of your piss through a kitchen strainer, then save anything that looks remotely like a small meteorite, put it in the cup, and bring it back to me. That is, if the excruciating pain even allows you to get off the floor to go and pee in the first place.

Or

  • Sorry madam. But after six vaginal deliveries, bladder prolapse is an anticipated end game.

Pediatrics was out of the question simply because it broke my heart to see sick children; especially in the academic environment of seeing them referred for the worst childhood diseases; some of which were hopeless or incurable. There is nothing worse than having to deal with a child on chemotherapy or having handle those who suffer the world’s worst congenital deformities or inborn errors of metabolism.

Surgery was an extremely attractive option to the point I became enamored of going into plastic surgery. But after standing on my feet for long complicated general surgery or vascular cases and after seeing the gross disfigurations or severe burns that the plastic surgeons dealt with, I soon abandoned that plan.

Who knew at that time what lay ahead for the lucrative side of plastic surgery or that that soon a physician could make millions by adding or modifying lips, tits, cheeks, chins, noses and buns or by sucking out the unwanted fat pads and dough wads from the cadres of obese overeating Americans who were too lazy to want anything other than an instant cosmetic fix.

Then, there is the issue of being dissatisfied with your genetics. The only thing I ever really wanted to know about certain cosmetic repairs, is how much obligatory disclosure there might be on the part of the prospective spouse to tell his or her fiancé about whatever anatomical part was fixed before the prospective child was born with the same deficiency.

  • Honey. This baby has no chin. Are you sure it’s really mine?

Michael had a hand in talking me out of surgery because he said it was less than cerebral. He said if a monkey could be trained to be an astronaut, then given enough time any Simian could even learn to operate.

Being too smart to be a surgeon, he suggested I should stick with something in the domain of Internal Medicine.

Fate may have intervened, as when I became older my eyes got worse, I needed bifocals and developed a cervical disc related neuropathy that reduced my fine hand-finger coordination.

Nobody can put a lot of faith or trust in a surgeon who can’t see, feel, or properly tie and cut knots. Or worse, one who develops tremors.

Not wanting to be bogged down in generalities, and with diminishing choices, I gradually became enamored of Cardiology. The heart is not only complicated in that functioning primarily as a pump; it also has numerous other highly technical and interacting components to deal with: muscle function, chambers, pipes, valves, as well as an electrical system.It was a veritable gold mine for the intellect as well as having antiquity’s mystical aura as being the organ which is the repository of the soul. Most of the body’s other organs also think highly of the heart’s central importance, come to terms with having to depend upon it; and if possible avoid getting it too upset.

Later on in my career, however, I never ceased to marvel as to how many people could care less about their hearts or souls and more about what was in their wallets, or as equally superficial, who were especially fixated on how they looked.

Over the several decades after the great depression America became a society obsessed with youth and a quest for materialistic wealth.It was a quest that left a spiritual vacuum in the souls of many of the seekers and the perpetual impossible dream of turning back the clock on the natural aging process.

This obsession has progressively manifested itself in the worship of empty headed, uneducated teenaged Hollywood icons, their wastrel lifestyles and the materialistic trappings that goes with their territory or Hubris.

In this eternal quest for youth and prestige small fortunes are spent on plastic surgery, fraudulent cosmetic products, ineffective diet and weight loss plans, spas, automobiles, houses, clothes, and jewelry while at the same time having no attention paid to physical and/or spiritual health.

I have had patients who are driving Bentley or Mercedes Benz automobiles, then complain about the co-pay on an office visit dedicated to the ideal management of their cholesterol, or bitch about the cost of a diagnostic exercise test designed to see if their arteries are seriously plugged. Yet these are the same people who will think nothing of spending fourteen hundred dollars to tune up the carbureting heart of their fancy car.

One of the more extreme absurdities was the three-hundred-pound cigarette smoking diabetic who came in for a medical preoperative clearance to get his droopy eyelids cosmetically repaired. My diagnostic assessment was: What’s the point?

I have also seen people who have had breast implants, face lifts, nips, tucks, putty fills, hair transplants and wrinkles botoxed to oblivion, who also never once in their lives paid any attention to their blood lipids, only to then present to an emergency room in the throes of a massive heart attack.

In the Cardiology trade, we label this diagnosis: Drop Dead Gorgeous.

What a very different philosophy from that of the Native American who venerated: age over youth, the counsel, advice, and historical perspectives afforded by the village sage, as well as the desire to live in harmony with his environment; taking only what he needed while leaving the rest for someone else.

At a time when almost no one lived past forty, wrinkles were a sign of prestige. The old wizened shaman became a societal asset as well as a valuable cultural resource for helping the tribe to avoid potentially fatal pitfalls or for guiding young people to productively safe futures.

In our society, the tail of naïve youth wags the dog of lifetime experience as we discard our surfeit of wrinkled up old people like they were second hand clothes earmarked for the Goodwill Industry recycle bin.

 

 

Make be beautiful,

Make me thin,

Make me look like her or him.

Make me young,

Make me hot,

Make me something I am not.

 

 

   Photo source  www.impawards.com/1999/drop_dead_gorgeous.html

 

Medical School: Physical Diagnosis

Humility

The teaching system is structured in such a way that it eases a medical student into the process of doing a patient’s history and physical examination. The student then, although not expected to be brilliant in deducing diagnoses, is at least expected to begin to think about at least one diagnosis that can be isolated to a single major organ system.

We were first required to start with blindfolded examinations of each other; then write down what we felt to be significant findings, only then to suffer the double humiliation of the proctor not only pointing out everything we had missed, but also pointing out all our own personal physical flaws.

The first humiliation, for example, was that we all made gross assumptions that skipped important details.

For example, most of the medical students did not even first state the gender of the person. This was followed by our omissions of simple facts such as the fellow student we had just examined might be wearing glasses, had a beard, or wore earrings.

All of this underscored a basic tenet in medicine that one should never overlook the obvious and also that one should never assume anything.

When I began my first presentation of an examination of a fellow student, I was stopped after the first sentence.

  • So, first of all, was the person a male or a female? Even blindfolded you can tell if a person has breasts, or buttocks, or a penis or not.
  • Well, yes but….
  • Then why didn’t you first say that the person you were examining was a female? There are many important medical issues that depend entirely upon gender you know.
  • Uh, yes but…I didn’t think I should…I mean she’s a fellow student. Wouldn’t she object to being groped?
  • But nothing and grope nothing. This is an objective clinical exercise, not a course in sexual harassment. So just because you might be embarrassed about this means you can sit there and tell me that someday you might miss a breast cancer? The medical examination of the breast is entirely clinical and is not the equivalent of fondling. At least it had better not be.

When I told my mother about this experience she shrugged it off as being nothing that should bother me too much. She trivialized it as she reminded me that her near-sighted brother Bobby had also learned his physical anatomy by the Braille method, albeit at night in the back seat of a car, yet never once seemed to have any problems with gender identification.She said:

  • Forget the tits. That’s how your Uncle Bobby discovered that women have three holes.

The second humiliation came with the fact that all of us then had our own physical imperfections glaringly pointed out to us; dermal scars, a murmur, a curved spine, acne, a sloped shoulder, a missing pulse, an old fracture, crooked teeth, glasses, or braces; you name it. The worst part about it was that we were all only about 21 years old. By the time the proctor was through with me I thought I was should just cash it in and apply for the job of being a cadaver for the class of 1974.

It was the beginning of a lifetime dedicated to thinking morbidly of even the slightest personal ailment, a thought that unfortunately played back into my mother’s perverse tendency to always look for the worst in people.

Noticing all the things wrong with someone or painting worst-case scenarios for diagnostic outcomes does not make for an optimistic outlook on life. By the same token, it does also constantly remind one that life is indeed very short. This thinking can either work beneficially by making one always try to live in the moment or it can backfire by incubating a ridiculous urge to live life to extremes.

In my case, it did not take more than a few clinical deathbeds prompts to instill a desire do everything I wanted to do while I was still young.

I did, in fact, try too many risky things at least once and stupidly tried some of them twice; like scuba diving the 130-foot-deep Maracaibo reef in Cozumel with no real experience, scuba diving an ocean inlet on an outgoing tide, sailing and tipping over a Hobie Cat in a full October gale without a wet suit in 60-degree water, taking psychedelic drugs; smoking hashish, trying cocaine or more than once, when I became a House Office, attempting to screw every nurse in sight, without condoms. Damn the V.D. Full speed ahead and fire all the torpedoes.

The second phase of Physical Diagnosis comes in learning to logically format and to then scribe all the elements of a comprehensive approach to diagnosis; Age, Gender identification, Vocation (or not), Chief complaint, Past Significant Medical History, History of Present Illness, List of Medications, Social History, Family History, Surgical History, Allergies, Review of Systems, Physical Examination, Differential Diagnosis, Plan for Diagnostic Testing, and Therapy.

Then one must write a set of Orders to be carried out the actual implementation of the Diagnostic preposition and Care Plan.

At the end of this process I realized I had watched too many doctor shows on television because this was nothing at all like the relatively easy, carefree approach to medicine enjoyed by the likes of Dr. Kildare. It was also not even close to the equally irrelevant focus the actors had on each other, but not on their patients, in the complicated soap opera lives enjoyed by the likes of the cast on General Hospital.

These people spent all their time perusing sex when they weren’t screwing over all their other friends or relatives physically, emotionally or financially; but somehow never seemed to get down to the real business at hand: like taking vital signs and emptying bedpans.

  • Doctor. Your patient in Room 3 has a fever.
  • What was the exact temperature, nurse?
  • I don’t know doctor. But not as high as the hots I have for you.

Nothing at all like that, this new aspect of Medical School, being very difficult, was the first time I doubted my vocation. Unfortunately, it would only be the first of many self-doubting or soul-searching episodes as little did I know how bad things could ultimately be or how humiliating things were about to become.

First, when doing any clinical rotations, the student is expected to wear a shirt and tie, put on a short white jacket that designates the inferior rank of neophyte, as opposed to the long white coat that comes only when rising to the rank of an Attending Physician. One also then must carry around about twenty pounds of ancillary tools in a little black bag, or in the coat pockets of the white jacket, including a stethoscope, ophthalmoscope, reflex hammers, tuning forks, note pads, pens, calipers, EKG rulers and of course the Little Red Book.

I felt like a G.I. going off to battle or as uncomfortable as I was at any time I ever had to put on a tuxedo.

If I had ever thought a Cub Scout uniform was bad, having to dress like a cross between a Bus Boy and a Good Humor Man was nauseatingly stilted and made me feel as though I would be infinitely better off instead standing stiff legged still in front of a drill Sergeant. with a little round wooden dowel shoved up my rear end. Cinch tied like a wild bucking bronco under his first heavy saddle; and saddened by the reality of having to ditch my soft comfortable hippie togs for a suit that made me look like a fumigator, off I trudged to the hallowed halls of the hospital wards.

My first real test in clinical medicine was being rotated to a hospital to examine a patient with liver failure, after which I wrote up the findings per protocol and then presented the case to a proctor in front of a group of five other students.

I thought I had done a pretty good job. The proctor however, did not.

My paper was a monument to how much red ink can actually be held in a ballpoint cartridge and how close a graded paper can come to being a Jackson Pollock masterpiece. I had missed just about everything pertinent: spider angiomas, everted navel, ascitic fluid, liver size in centimeters, rhinophyma, etc.

Then to make matters worse, when I attempted a verbal defense in front of my fellow students, the proctor jumped down my throat like that drill Sergeant would have done anyway, as he proceeded to rip me a brand-new asshole.

If I ever did have that little plug up my butt, this was when it would have hit the ground with a hollow empty thud as my knees turned to jelly and sphincter tone suddenly failed.

He said:

  • Do you know who I am? Do you know who I am? You don’t even know who I am, do you? Well let me tell you, then. I am Dr. Frank Iber, and I am a full Professor of Medicine at Tufts University Medical School. So, when I speak or when I critique; you will remain silent and do nothing but listen and learn. Your examination of that patient was a disgraceful example of incompetence. As such, we shall now proceed to go back to show both you and your fellow students how superficially incompetent your evaluation really was. And when we are all done with that, you will take your paper back home, then you will re-write it, after which you will also memorize the section in DeGowan on all the signs of liver disease for a verbal quiz, which I will administer at my personal discretion.

And so, we did. And so, I did. And so, he did.

Bad enough I got the proctor with the bad temper and the inflated ego, but he also happened to be a national expert in Gastrointestinal Diseases who also wrote the textbook section on “The Liver.” I guess then this rotation was both the bait and the trap, eh?

It was stupid of me to have been mollified into assuming everyone was like the jocular, philosophical proctor who taught us all to be HIPPAYs. In retrospect, I guess that professor, with his pleasant affect and his all- forgiving non-offensive mentoring personality must have been a Psychiatrist.

To make matters worse, I really did not know who Dr. Iber was until I looked him up in the school directory, and thus learned a painful lesson about the mysterious hierarchies of the world of Medicine. Some people are, in fact, more important than others and obviously not ashamed to let you know it. Doing background research ahead of time, if nothing else, could have at least ensured me a few ingratiating brownie points.

I was hurt, humiliated, embarrassed, demoralized, angry, and ready to quit school. However, Michael propped up my badly bruised ego, having encouraged me by the reassurance that everyone goes through it, and that after the first time it can only get better.

It was just another game that had its own set of rules, with a peculiar set of standards that had to be learned; such as the correct timing for self effacing groveling or the tossing of dust on and over ones bowed, scraping head. Once you know the rules, it becomes infinitely easier to play the game.

I was not so sure, but then again, the alternative would have been meeting a real U.S. Army Drill Sergeant and having to trade in my Little Red Book for a Big Brown Duffle Bag along with a one-way ticket to Southeast Asia.

It did take a while, but I got over it and I did improve.

My roommate Michael said it was just like learning to drive. Scary at first, and you might hopefully have only a few minor accidents, or get a few tickets, but after you get the hang of it and learn to play the game, it’s just as easy as learning anything else.

But to me the length and breadth of medical knowledge seemed as insurmountable as a successful climb to the peak of Mount Everest; even with the added benefit of having some extra oxygen canisters on board.

Michael also helped with the proactive part of things by proceeding thereafter to point out the best clinical rotations to take in the third year of school as well as the pitfalls of each one, the peculiarities of the proctors, the nice ones, the mean-spirited ones along with all the important signs, symptoms, facts, or trick questions to anticipate as each one came along.

When you come to think of it, the scary thing is that in just over twenty-two months of clinical training, the Medical student goes from the floundering, blubbering naïve state I found myself under the hawkish scrutiny of Dr. Iber, to becoming an Intern in a hospital where he or she has the responsibility of making decisions that can mean the difference between life or death.

Because Internships begin in the summer, there is an insider’s facetious mantra in all the academic medical training programs that is unknown and secreted from the general public:             “Just don’t ever get sick in July”

The failsafe here is that the rigid pecking order ensures constant supervision at every level. The Attending supervises the Fellows and the Residents; then the Fellows and the Residents supervise the Interns.

But Interns will always at times find themselves in situations in which the decision to be made must be expeditious and solely his own responsibility. That is when the “Yell for help” becomes the credo of not only the real neophyte; but also of everyone else in the teaching hierarchy.

Then the more he is exposed to disease, dilemmas and disasters, the better trained the physician becomes as he slowly rises to the top of the medical food chain and finally gets to wear that long white coat: Full Attending Physician or Professor of Medicine.

One thing I came to learn for sure was that there is no shame in admitting “I just don’t know” because in Medicine when pride supersedes humility the unintended consequences might be permanent harm or even death. No one in medicine knows everything. But everyone does know something.

And just as is it at the highest levels of any professional performance, there is always someone who is better at something than anyone else is.

Even Tiger Woods could lose and eventually every icon becomes old, tarnished or simply out of date. Just ask Jack Nicklaus what he thinks about that.

At least I got the drift that when finally getting to the top of this academic world, I could still reserve the right to be somewhat nice or pleasant about it; and also learned that compassionate constructive criticism was probably a better way to teach a subordinate than abject self-promoting narcissism.

 

Ask and it shall be given unto you

Seek and you shall find

There is assurance of salvation

And blessings when you knock

(The Bible. Hebrews 11:6)

 

 

     Jesus:  http://www.carmelwagga.org.au

 

 

 

 

Medical School: Year Two

Clinical Exposure

Physical Diagnosis is a medical school course that overlaps the conclusion of basic sciences and is given at the end of the second year.

Students are required to buy the “Bible of Physical Signs” other wise aptly known as: Physical Diagnosis, a little red leather covered book by DeGowan and DeGowan, which they are then told to memorize and carry with them in their little black leather bags for the rest of their lives. Memorizing it is easier said than done. After all, it is a Bible and if the Bible itself is all you must memorize, then perhaps over a lifetime you might become successful at regurgitating it.

Just ask Billy Graham, or any other Bible toting evangelist. Pose a question. Receive a parable in return. No real thought required. Problem solved. Or problem only temporarily shelved:

  • Go in peace my son; I know that your life really sucks, but keep praying to God for eternal salvation. Things might seem to be bad right now, but ultimately, they can only get better.
  • But that’s the same thing my stockbroker told me when I lost all my money. Twice.
  • My son. Do not ever confuse the secular world of monetary greed with the promise of joyous everlasting life in the next world.

Unfortunately for physicians, we must memorize a few dozen Bibles, as the solutions to our problems can often be so obscure that even invoking the name of God does not always result in a comforting resolution.

  • After this terminally ill patient finally does rest in peace, we’ll say perpetual Novenas to the Gods of Malpractice that we never get sued.

There is a rigorous approach to the Physical Diagnosis course stressing the basic elements of abnormal physical findings that my instructor boiled down to what he thought would be a jocular contemporary mnemonic to assist us getting through it: HIPPAY; which stands for History, Inspection, Percussion, Palpation, And…. Yell for help!

He thought he was being funny. We thought he was being idiotically insulting. After all, we were the nuclear radiated mutant hippie class, were we not, so why keep rubbing it in?

Medicine is replete with mnemonics that are designed to prompt memory and remain useful cues if they are appropriately applied; but not like the singsong one traditionally used to teach children the alphabet. It took my mother quite some time to force my understanding that LMNOP (ele-mena-pee) does not stand for one single letter or a single-minded desire to evacuate the bladder.

This point illustrates that in learning anything, Rote is not necessarily equivalent to Right, unless logical thought processes use the Rote in the Right way.

For example, using MOST DAMP as the mnemonic cue used to treat the internal drowning of congestive heart failure has a rational application, if it is used with a certain clinical panache. If not overzealousness automatic use of all of these elements may sometimes do more harm than good. Sometimes you only need M&Ms to treat heart failure: a little Merck (Lasix) and a few drams of Morphine.

This was only one of the reasons God invented narcotics and why a leading research Cardiologist at the Columbia–Presbyterian Hospital orientation program gives his first-year Fellows a button to wear on their white coats that reads: Lasix kills. This teaching point being not to treat every patient with a cook-book recipe as opposed to an analytical thought process with subsequent careful medical titration.

P: for Phlebotomy did not even work out very well; when in the Middle Ages leaches were used to bleed patients half to death, having subsequently been abandoned as an ancillary therapy for heart failure.

  • Yes. Once we leach out all his malodorous phlegmons, your husband will hardly be able to speak, much less ever be able to stand up or possibly even walk again. But he will be better.
  • Thank you doctor. I’ve been trying to get him to shut up, sit still and stop chasing after my ass for the last thirty years. I’ll be sure to remember you in his Will.

Mnemonic learning is also helpful in medical training because the body of medical knowledge is so overwhelming. But this method eventually becomes abandoned as clinical experience adds a base of reality testing to rote learning.

Yelling for help is always sound advice for the same reason. One cannot possibly remember everything and so asking a colleague for a consultation or advice or personally consulting text and literature can often be vital. Unfortunately, some egocentric doctors seem to forget this tenet; or worse they sometimes forget that they forgot.

It was amazing as my career in medicine moved along, as to how many colleagues seem to have forgotten that the story a patient tells is about seventy-five percent of the diagnostic battle, the physical exam adds another fifteen percent; and with a good synthesis of both, a seasoned clinician can then direct a limited number of lab tests that should hopefully finish off the job.

That is unless the disease entity is so obscure as to baffle even the best minds, which is why we have places like the Mayo Clinic or other Meccas of academic excellence. When in real doubt: Punt.

It is also unfortunate that many physicians do not care to take the time to listen or do not know how to peel back the onion-skin of the patient’s story to get to the core of the problem. This is a skill that takes years of practice to develop and even more years of practice to ensure that it can be done in a short framework of time.

For the most part, physicians do not have the luxury of the infinite amount of time that Marcus Welby seemed to have when as week after week, not only did he have only one patient to attend, but also found himself purposefully inserting himself into that patient’s personal life and then becoming the family’s best friend.

Better than having a family dog, just go out and get your own personal M.D. and although in real life it simply does not go down like that, some of my patients still think nothing of having me entertain their queries while I am shopping for food or practicing putting.

  • Doctah, doctah. I know you’re relaxing on your day off, but do you think you can take just one tiny little minute to take one eensy little peek at my teensy little new skin rash?
  • Oy vey. As you know, I am not a Dermatologist. But if I were going to guess, it looks to me like it might be case of genital herpes. So, you can put your clothes back on now, then go ahead and pay for your groceries.

Shortcutting the non-essentials is also critical to saving time. For example, when seeing a patient and asking when the chest pain problem first started, one is not interested in retorts that catalogue every action the patient did from birth or tedious monotonous histories such as:

  • I woke up today at 5 a.m. I usually wake up at 4:50 a.m. I knew right then I was in for trouble. Then I had a bagel for breakfast. That’s not what I normally eat. Normally I eat granola and yogurt. Then my coffee pot broke and I need my coffee and my normal food so that I can have my normal bowel movement. If I don’t get my normal bowel movement I know my entire day will be off and I will just be logy and tired and miserable all afternoon or maybe even have to take a nap even though I really don’t want to. So, against my better judgment I gave in and had a Sanka. Then when I finally had my bowel movement, later than I usually like to have it, it wasn’t like the normal one. Usually it is short, fat, tubular, dark and brown, then breaks into pieces and sinks to the bottom of the bowl. This one was long, thin, light and yellowish; about 18 inches total, stayed all in one piece and floated. That was when I knew I was really going to be in for a bad day. So, then I had to get dressed when I normally don’t get dressed and….

Prattling on and on and having nothing to do with the fact that this person is being evaluated for the new onset of chest pain; it took me years of experience to learn how to re-direct a patient’s thought process and expedite getting quickly to the point without being undiplomatic or making the patient feel as though I was rushing them.

  • Why don’t you just think about what’s happening in your case as being bad constipation in your coronary arteries. Now tell me about your chest pain.

Unlike the legal system, in which time, like a running taxi meter is endless, where time also then equates to  money, and additionally where the truth can be hopelessly perverted, ignored or purposefully obfuscated, in Medicine time is of the essence, money is discounted and the truth is the vitally important element that can mean the difference between life or death. I came to believe that the universally appropriate gift for a Law School graduate should be a tie tack shaped as the Infinity Sign.

After all: Time is infinite. And legal time means infinite money.

 

(Reminds me a little bit of the 3-Cs (prior post: Cornflakes, Coffee, and Cunnilingus). Except that now everyone is getting fucked, but no one is getting laid)

As a countervailing issue, in the modern era of medicine there is often too much reliance on the shotgun approach to lab or procedural testing, while too little emphasis is placed on basic logical thinking. Accessibility and availability of advanced technology as well as excessive malpractice litigation has sent the cost of medical care through the roof.

With the fear of the Medical Malpractice legal vultures always circling overhead; on wisps of doubt, as well as the fact that it does not cost a physician anything to order a test, we are now living in the era of medical errors of commission. Lawyers have taught us that if one can think of a test to do, one should simply do it. Meanwhile as always viewing issues from the perspective of Monday morning quarterbacking and self-righteous hindsight they constantly feed off the carrion of imperfect outcomes.

When asked to see some patients in consultation, where the requesting physician has omitted many elements of basic training, including a good history and physical examination as well as a dearth of logic or common sense having been applied to a morass of useless information, I rely on an axiomatic statement taught me by an attending physician who supervised us during those first years of training in physical diagnosis:

  • Ladies and Gentlemen, when all else fails, why don’t we just begin by examining the patient?

However, there is a certain degree of psychic trauma that accompanies the beginning clinical training as the second-year medical student leaves basic book learning behind.

This is a Right of Passage in which rote memorization does not help unless facts can be synthesized, in which introverted, socially isolated intellects actually have to meet, touch and talk to real people disadvantaged by illness and where quantitative analysis breaks down at the level of qualitative evaluation.

It is a time when multiple choice test questions become replaced by a differential diagnosis and when a patient may face the additional problem of dealing with multiple concurrent illnesses. Guessing wrong on this test runs a gamut of far different potentially negative results than only receiving a poor numerical grade.

  • Oops, sorry, it was a really a heart attack and not just a bad case of indigestion.

It is a time when deductive reasoning reigns supreme; but also, when a naïve student begins to develop a personal inventory of logic that only comes with continued experience and clinical exposure. The patient becomes a book that has a limitless number of pages, but a book that also does not have an index or chapter headings.

Every patient becomes a new black box. The student then must logically deduce what is potentially wrong with a person who cannot necessarily explain it well and who may also be covered with dirt, crust, scales, rashes, odors or sometimes even with insects. One also must be able to do it expeditiously; without regard to race, color, creed, personality, sexual identity or personal bias, and preconceptions; not even withstanding the deeper layers of the physical exam than can include a rectal or vaginal probe, or both.

It is a time when the art and science of medicine is a blank palette in a student’s hand and is also a time where the cornerstone of the Hippocratic oath is placed in the foundation of the medical student’s career. But as  with any potential building, some cornerstones and some foundations turn out to be more solid than others.

Being shyly xenophobic to begin with and since I had never even wanted to speak to strangers; much less then even having to touch them, I struggled to overcome the barriers I needed to expeditiously become superficially intimate with perfect strangers in a short period of time.

Medical training requires the ability to become intimate while at the same time maintaining a certain professional barrier that should preclude becoming friends. Because once a doctor truly befriends his patient, he tends to lose the ability to think objectively and thus the serious potential pitfall to provide a disservice.

One of the great failures of medical training programs and a disservice to humanity in general is to guide or to allow the student, Intern, or Resident to enter medical disciplines that do not suit any or all of his individual talents, his personality, or his individual skill sets; as well as failing to inform some of these individuals that they should seek career choices in another discipline altogether.

  • Son. Surgery is not your forte. But you are good with a knife, so you might want to consider a career as a butcher.

It is very hard to do this after a student has come so far and for so very long. But similarly, the mustard of medicine is often very difficult to cut and not every student really gets truly seasoned by the time he graduates.

Some physicians I know who did make it all the way through, unfortunately should have never even been allowed to lay a hand or a scalpel on a cadaver; much less to later lay either of these two tools upon the body or flesh of a live human being.

 

 

Swedish Aphorism

Vhere iss Yorgay?

Yorgay is in da bootcher shop practicin’ to be a doctor.

Vhere den iss Svengay?

Svengay is in da medical school practicin’ to be a bootcher.

Und vhere might den be Ingrid?

Ingrid is in da haystack practicin’ to be  a nurse

(Swedish Aphorism/courtesy of Michael)

 

 

Medical School: Basic Sciences and other musings

Basic Sciences 

The first two years of medical school are devoted exclusively to academic classroom work and parses the time among a series of courses in basic life sciences, with emphasis on the biology, physiology and patho-physiology of the human being.

The reason for taking pre-med courses in college and the droll subjects of Organic Chemistry, Physical Chemistry, Physics, as well as the dreaded math courses of Algebra, Calculus and Statistics becomes crystal clear when the student is exposed to the basic science program in medical school.

One cannot go forward with life sciences, or even begin to theorize or philosophize about life without this critical background.

Slowly but surely the reason for studying molecules and equations begins to make sense at the next level of being able to understand Biochemistry, Microbiology, Pharmacology; then by blending in Gross Anatomy, Genetics, Embryology, Histology, and Epidemiology the student begins to apply his background to better understand how the body functions, but more importantly then how it fails to do so.

The agenda is a very difficult, highly concentrated discipline requiring tedious hours of homework.

But once it ultimately dawned on me that the “organic” in chemistry referred to the “life” in the organism, I was at least now able to apply molecular science to real life. There was finally a light shining at the end of the scholastic preparatory tunnel,

One of the most fascinating concepts for me was the explanation as to how life on earth shifted from anaerobic to aerobic metabolism at the single or primitive multi-cellular level.

The emergence of cyanobacteria, followed then by blue green algae and their subsequent ability to saturate the earth’s atmosphere with oxygen, facilitated the emergence of organisms that developed internal systems able to efficiently utilize oxygen as the basic fuel to drive energy production at the cellular level.

This was the change that caused the explosion of life as we have come to know it and allowed the planet to evolve life forms above the level of simple units of life such as yeast, fungi or anaerobic bacteria.

It changed the characteristics of the planet forever.

The difference lies simply in cellular efficiencies.

Anaerobic organisms have limited ability to utilize oxygen, being only a primitive life form that could succeed without relying on oxygen. They existed on earth far before more advanced forms of life.

Their energy production is paled by the energy production capabilities of the aerobic organism that can use oxygen to convert stored sugar, carbohydrate and fat at a rate 90% more efficient than that of the less efficient anaerobe.

This energy production takes place at the level of the intracellular organelle known as the mitochondria, a structure that some evolutionary scientists believe might at one time evolved from the symbiotic incorporation of a specialized oxygen utilizing bacteria into the larger structure of a less efficient parasitizing, or conversely, parasitized cell.

This energy production happens in a unique metabolic cellular pathway known as the Krebs cycle.

Regardless of how it happened, the result was the ability of life on earth to evolve into much more complex forms that allowed the emergence of the complex diversity of animal and plant life; including humans and the rest of life that surrounds us.

What many people fail to comprehend is the very fine line between any of earth’s organism’s success or failure and just how uniquely oxidative metabolism affects us all simply because by its very definition it is responsible for both our life as well as for our death.

The oxygen saturation of the earth’s atmosphere is 21%.

Most of the rest at 78% is Nitrogen, which is inert, and then 1% of the residual is argon, water vapor and small amounts of carbon dioxide, which itself is an end product of oxidative metabolism.

At oxygen levels of 7% all oxidative life on earth would cease to exist.

This explains why a Mount Everest climber requires an acclimatization period to increase his red blood cell counts; ergo his oxygen carrying capacity, as well as needing supplemental oxygen canisters to succeed at or near the peak.

The oxygen content of air at this height is so low, that if this climber were dropped out of a helicopter on the summit, he would immediately die of asphyxiation. The same thing would happen if cabin pressure in a Boeing 777 failed at 35,000 feet; not to mention the temperature of -60 Fahrenheit. Your last breath would be frozen to your porcelain face.

Paradoxically, too much oxygen is also harmful. At saturation levels higher than 50%; with chronic exposure to it, a person would die of oxygen toxicity because these higher levels would destroy his organs by literally burning them up like a match put to a piece of dry paper.

It is thus a pathetic fallacy that an NFL football player can improve his oxygen debt after a sudden sprint; or even his overall performance in general by sitting on the sidelines and getting a hit of pure O2.

In fact, if he breathed pure oxygen throughout the game he would not survive to the end of it, even though nevertheless the O2 sucking scene of the weekend warrior huffing and puffing on that sideline bench evokes sentiments of fantastic, fabulous macho bravado.

How about fixing this problem by just doing a few more wind sprints in practice instead?

One must realize of course that this is a chicken and egg phenomenon because life as we know it evolved in Earth’s atmosphere only because this atmosphere was already there. A different gas mix may have produced a different outcome, an altogether different panoply of life; or possibly no life at all.

It is also a fact that a significant part of the aging process is because of oxygen or free oxygen radicals causing a long slow process of tissue damage resulting in the subsequent accumulation of inert, harmful intracellular material; otherwise known as microscopic non-recyclable sludge.

This is exactly what happens when iron is exposed to air. It rusts.

It is this potential harm of oxidation that fuels the current hysterical concept behind the multi-billion-dollar business scams that focus on the fabulous but expensive anti-oxidant products that can supposedly keep a person young and beautiful forever.

Trust me. Do not waste money on these products of false hope. It is not a few hyped up, useless pharmaceuticals or topical emollients; but rather genetics, environment and a bit of good luck that really plays into how gracefully or not we all age as well as for how old we can ultimately live.

This is also why, when patients complain to me that they are not enjoying their Golden Years because they are slowly falling apart, or because their spouse has died; I marvel that they have been succored into buying the myth of the retirement propaganda campaign. It is a myth rooted in the unrealistic concept that a person will be able to do the same things he did at age 70 or 80 that he could do at age 30.

I suggest instead that the retirement years should be better termed the Iron Age. It would be wiser to spend ones’ time or money on recreational fun when young than to waste it later, on anti-aging products, face lifts or in the fruitless search for perpetual youth.

I have taken care of people who have smoked heavily well into their eighties yet miraculously avoided the serious end consequences of nicotine addiction. Conversely, I have cared for health conscious macrobiotic or vegan food junkies who have died in their forties of breast cancer or leukemia.

Although this is just a giant crap shoot with extremely uncertain odds, the general rule of thumb for longevity is to not smoke, drink modestly or not at all, maintain normal body weight, exercise regularly and hope you got a bevy of good genes at the time of your conception. Then bank a little bit on good luck, too; because anyone crossing a street can still be hit by a bus.

It is axiomatic that we are born to die and that try as you may, you can never beat the grim reaper.

My Italian grandmother had a slightly different and more simplistic take on it all. She used to say:

  • La vita è un figlio di una cagna; e la vecchiaia è una carcassa morta in attesa di un Tesoro.

(Life is a son of a bitch; and old age is a dead carcass waiting for a scavenger.)

krebbs-cycle

 

The Krebs Oxidative Cycle. Not only your best friend; but also, your worst enemy

Krebs Cycle © Graphic; From Sequim Science
http://homepage.mac.com/dtrappeChem.f/lab.B10.html