Category Archives: Medical School

Penny-pinching surgery at a Tanzania hospital

“In Tanzania, the hospital was two hundred miles of sometimes one-lane dirt roads from Dar es Salaam, and flooding during the rainy season cut off supplies–such as medications and anesthetic gases–often for weeks at a time. There were thousands of surgery patients, but just five surgeons and four anesthesia staff. None of the anesthetists had a medical degree. The patients’ families supplied most of the blood for the blood bank, and when that wasn’t enough, staff members rolled up their sleeves. They conserved anesthetic supplies by administering mainly spinal anesthesia–injections of numbing medication directly into the spinal canal. They could do operations under spinal that I never conceived of. They saved and resterilized their surgical gloves, using them over and over until holes appeared. They even made their own surgical gauze, the nurses and anesthesia staff sitting around an old wooden table at teatime each afternoon cutting bolts of white cotton cloth to size for the next day’s cases.”

-from The Checklist Manifesto, by Atul Gawande

Advice from a chaplain

These notes are as much for my future self as for anyone else. Tonight I listened to a chaplain at my church talk about hospital visitation. He’s a brother, and I was glad to hear his wisdom. He was speaking mostly to people who would be visiting family or other church members, but I did ask him a few questions afterwards as well. Here’s what I remember.

  • To find out what people need, just ask: “Hi, I’m Ben. How can I serve you today?”
  • The most important thing is to be available and be flexible. It’s important just to go visit, and if all they need is a glass of water, bring them water. If they tell you to leave, then leave. If they want you to stay and talk, then stay and talk.
  • If a patient is unresponsive, talk to them. You can talk about the game on TV, items in their room–keep it light.
  • Be aware of what people need. Beyond just asking them what they need (first bullet point), you might ask open questions.
  • Be open to share your faith if they ask, but otherwise, just be there for them.
  • As a physician, it’s perhaps most important to be able to break bad news gracefully. Tell them the news succinctly. Express sincerely that you are sorry for their loss. Pause briefly in case they need something, and then get out of there.

Did King Jehoram have Crohn’s disease?

Maybe:

“And after all this the Lord struck him in his bowels with an incurable disease. In the course of time, at the end of two years, his bowels came out because of the disease, and he died in great agony.” -2 Chronicles 21:18-19

Crohn’s disease is known for causing fistulas between the bowels and other organs, including sometimes the skin. Off the top of my head, I can’t think of anything else that could cause his bowels to “come out”. The etiology must not have been infectious, or at least not transmissible, since the text singles out Jehoram himself as having the disease. He died at the age of 40, and so the time of onset of the disease was probably about right–it usually starts between the ages of 15-35. Since it wouldn’t have become so severe as to kill him immediately, it makes sense that he may not have died until age 40. Additionally, Jewish ancestry is a risk factor for Crohn’s disease. Anyone else have any other plausible ideas for King Jehoram’s differential diagnosis?

A peg in a secure place

For about the past six weeks, I’ve been studying for twelve hours each day. I know this because I’ve been timing myself. I keep a stopwatch on my desk. When I’m studying, I start it, and if I get up to get a snack or go to the bathroom, I stop it. It helps me stay motivated and keep account of my time.

I’ve been studying because I take step 1 of my licensing exam in three days. There are three parts of the exam, but the first is the most important, because residencies use the scores to sift which students they will and will not seriously consider hiring. I’ve rarely been this stressed in my life, and I’ve rarely ever worked this hard. Sometimes, the weight of studying seems crushing, as page after page accumulates, and half-remembered factoids keep me awake at night as I try to remember what I’ve forgotten.

There’s a beautiful and terrifying passage in Isaiah that describes ancient Judah in a much more dire situation than mine. The Assyrian empire is ravaging the world, and the tide-waters of the Assyrian army are lapping at the gates of Jerusalem. While Jerusalem is under seige, King Hezekiah sends Eliakim out of the city gates to negotiate. At this point, everything Judah trusted in has failed them. Egypt won’t rescue them. Their army is dwarfed by the Assyrians.

Eliakim and two others go out alone to meet the Assyrians, and Rabshakeh, apparently some kind of Assyrian commander, begins to mock and taunt. Rabshakeh promises that Jerusalem will fall, that Egypt won’t save them, that the Jews have no strategy, and that God Himself certainly won’t rescue Judah.

Eliakim must have been terrified. You can imagine him standing before the countless, clattering Assyrian army, trying to remember what he was supposed to say. Isaiah describes the moment colorfully–Eliakim is a peg in a wall, and all of Judah’s hope is hanging on his negotiating skills. At first, he is strong and secure, but as item after item is hung on the peg, the tension builds. Eliakim fails, and the peg with all the pots and pans that were hanging on it comes crashing to the ground:

“In that day I will call my servant Eliakim the son of Hilkiah… And I will place on his shoulder the key of the house of David. He shall open, and none shall shut; and he shall shut, and none shall open. And I will fasten him like a peg in a secure place, and he will become a throne of honor to his father’s house. And they will hang on him the whole honor of his father’s house, the offspring and issue, every small vessel, from the cups to all the flagons. In that day, declares the Lord of hosts, the peg that was fastened in a secure place will give way, and it will be cut down and fall, and the load that was on it will be cut off, for the Lord has spoken.”
-Isaiah 22:20-25

When Rabshakeh is done taunting, Eliakim doesn’t know what to say. Rather than negotiating, or boasting that God would save them, Eliakim asks Rabshakeh to please speak in Aramaic, rather than Hebrew, so that the soldiers on the walls of besieged Jerusalem will not be able to understand, probably hoping that the soldiers on the wall won’t become even more terrified (Isaiah 36:11). Predictably, Rabshakeh then begins shouting to the men on the wall in Hebrew, telling them that their God and their king can’t save them, and that they should either surrender or die (36:13-20).

Israel’s response? “But they were silent and answered him not a word.” (36:21).

Eliakim had failed. Like Israel, I often hang all my hopes on the amount of studying I do, and on my own ability to learn material. This is a mistake. At some point, I will fail. I’m not a secure peg. Studying is necessary, but only God can make me succeed–only God can make anyone succeed.

Hezekiah was crushed when Eliakim returned with the news. Now that Israel had nothing left to rely on, Hezekiah could only rely on God. He prayed, and the Lord answered. There was some kind of plague, or something more miraculous, and thousands of Assyrians died, so that they had to return home (Isaiah 37:36-37).

I am not a reliable peg, and nothing I study is a reliable peg. God has gotten me into medical school, and He’ll take me through it with just the right step 1 score, and just the right grades. All of my hopes and concerns should be hung on Him–anything else is bound to fail eventually.

“Therefore thus says the Lord concerning the king of Assyria: He shall not come into the city or shoot an arrow there or come before it with a shield or cast up a siege mound against it. By the way that he came, by the same he shall return, and he shall not come into this city, declares the Lord. For I will defend this city to save it, for my own sake and for the sake of my servant David.”
-Isaiah 37:33-35

People like people

There must have been at least ten of us all crowded into her room. She seemed very sick, and she probably would have rather kept sleeping. I felt bad waltzing in with my classmates to startle her, but our attending physician didn’t seem to care.

“How are you feeling today?” He said it cheerfully, as if he were seeing an old friend for the first time in awhile.

She whispered that she was feeling a bit better than yesterday. A few of us said hello, and she nodded slightly.

The doctor asked her to lean forward. She did so–painfully–and he moved her gown aside to expose her back. One by one, we placed our stethoscopes over her lungs and listened for a few moments while she breathed. By the time it was my turn, she seemed more alert.

“That’s a pretty shirt, sweetheart,” she said to one of my female classmates. The girl was a little surprised, but she smiled and thanked the old woman. Our attending physician then began explaining what we were hearing–I think he had a chest x-ray and some other data on the computer, but I wasn’t really paying attention. The woman had woken up a bit more, and she was now curiously looking around the room. She seemed relaxed.

“Okay?” said our physician.

My classmates nodded that they had understood whatever he just explained, but I was watching the old lady, who was now reaching across her table for a small plastic bag full of Dum-Dum Lollipops. She picked it up, and extended her the bag with a smile, the IV lines dangling from her forearm.

“Want some candy?”

We all smiled, and a few of us took a lollipop. As we walked out, the lady settled back into her bed, and she seemed more peaceful than she’d been before.

I’ve seen this often. Unless they’re very ill, people who are at first tired and sick often perk up when a troop of medical students walks into their room. I don’t think they’re startled; I think they just like company. People like people–strangely, it took me until college to realize this. So for the past few years I’ve been trying to talk to strangers and new people, because everyone seems to appreciate the attention. I’m not very good at it yet, but I’m getting there.

“The second is this: You shall love your neighbor as yourself. There is no other commandment greater than these.”

And the scribe said to him, “You are right, Teacher. You have truly said that he is one, and there is no other besides him. And to love him with all the heart and with all the understanding and with all the strength, and to love one’s neighbor as oneself, is much more than all whole burnt offerings and sacrifices.”

And when Jesus saw that he answered wisely, he said to him, “You are not far from the kingdom of God.”

Mark 12:31-34

[Just FYI, none of the patients I talk about are real–they’re composites of various patients and people I’ve met over the past four years or so.]

I enjoy tests because I’m prideful

Essentially, I enjoy tests because I love knowing things. C.S. Lewis would rebuke me for this. In his lecture, “Learning in War Time,” he stated that it’s dangerous to love the fact that we know something, rather than being intrinsically interested in the thing itself. To Lewis, loving the fact that we know something is the beginning of arrogance.

I’m inclined to agree with him. Still, I enjoy the gradual accumulation of knowledge culminating in a test. Pride is one of my vices. But I wish I’d been writing last year, and I wish I’d told you how frustrating my first year of school was. It was full of small facts without context. Only at the end of the year did I realize we had systematically surveyed all the intricacies of the human body. I may have forgotten 60% of what I learned, but the fact that I recall 40% means I know quite a lot.

But knowing something is morally dangerous. In whatever we do, we need to ensure our motives are pure. To be interested in science is to glorify God. To be interested in acquiring more knowledge is to glorify myself.

Perhaps this is one of the things that makes Christianity unique. The actions we take are important, but our intent is more important. God commands us to love him and to love people, but love is an emotion. God commands us to change our attitudes and our way of thinking. Once we do this, our actions will change. Enjoying the fact that I know something is arrogant. If I don’t recognize that, I may waste a lot of time trying to acquire knowledge so that I become greater. Instead, I should love science because nature displays God’s glory, and I should use the education he’s blessed me with to help others in any way I can.

“The Lord does not look at the things man looks at. Man looks at the outward appearance, but the Lord looks at the heart.”
1 Samuel 16:7 (NIV)

 

Me. A timid, white-coated kid with fake patients

No, no, I should use a deeper voice to sound more authoritative…

“Hello. My name is Ben, I’m a second year medical student. Today I’m going to ask you a few questions about your problem. I’ll also conduct a physical exam, and then I’ll consult with my attending physician. So, why did you come to see us today?”

Maybe that was a little too formal? And when should I ask the patient his name?

I was sitting in bumper-to-bumper traffic, practicing to myself. Today in school I had to see three “patients”. These patients are actors, and when the interaction is over with, the actors stop acting and offer us criticism on our communication skills. My number one criticism from all three patients?

Lack of confidence. An uncertain demeanor. A little timid.

Last year, when I did this same exercise, the patients said I performed swimmingly. The difference between one year ago and today is that for the past year, I’ve been constantly cramming knowledge into my head. Last year, I was full of self-confidence for one reason: no matter how much thinking I did, I just couldn’t think of any reason why I might be wrong. Now it’s entirely different. The more thinking I do, the more and more I doubt my initial impressions.

But patients don’t want a timid, uncertain doctor, and this kind of doctor won’t give patients the comfort they need when they’re ill. I may have an exquisite line of reasoning. I may be friendly, professional, and composed. But somehow, I need to convince the patient that I do, definitely, beyond any shadow of a doubt–know what I’m doing.

Of course, I won’t really know what I’m doing for another six years. Eventually, I’ll make accurate, lighting-fast diagnoses without even lifting a mental finger. Eventually, I’ll back up my confidence with competence. Until then, I guess I’ll just have to fake it.

Why I’m going into primary care medicine in an HPSA

On Tuesday, I found out that I have been accepted into the NHSC scholarship program. This means that the government will pay for the remainder of my medical school, and in return I’ll spend at least three years working as a physician in a federally designated under-served area. Of course my wife and I were ecstatic.

To have my schooling paid for is an extraordinary privilege, and as with all privileges, I wonder whether I deserve it. Only within the past few years have I been involved in community projects and service. I know many, many of my medical school friends who have done more meritorious and more service-oriented activities than me. The best I can say for myself is that I wrote my essays and my application as honestly as I could. If they chose me, it wasn’t because I made stuff up! I have a hunch I was chosen mostly because I’m from a high-need area, and I’d love to go back. Whatever the reason, I’m excited. I look at this not so much as a recognition of my merit (I don’t have much), but as a challenge to work hard, serve people in any way I can, and make certain I’m a “good investment.”

Anyway, I wanted to post something today, so here is a slightly-modified version of my application essay. I think it’s fitting for this post:

I was 17 when I first considered working as a physician in a medically under-served population. My friends and I had driven to central Idaho to go backpacking. When we were driving down a dirt road in the forest, a small fallen tree glanced off the side of the truck and lacerated my friend’s neck, throwing him to the floor of the truck. He was injured and we were scared, but it took us nine hours to get him to a medical facility. The first physician’s office we found was closed, with a sign on the door saying the physician came only once a week.

My initial idea to become a physician faded as I considered a career in physics, but I decided to become a doctor when I realized I wanted to work with people. It’s hard to describe why I’m interested in primary care medicine in particular. I’ve always been interested in pretty much everything—I’ve gone from physics to biochemistry to medicine–so the type of knowledge required in primary care is very appealing to me. I’d much rather learn a little about everything than a lot about a few things. I want to see a lot of different patients who have a lot of different problems. But I’m perhaps most excited because primary care physicians are needed, and I want to be needed in my career.

Over the past few years, I’ve become more interested in medically under-served populations. During one summer, I trained as an EMT-B near my home to gain some experience before applying to medical school. I remember one call on the ambulance where we spent two hours round trip to pick up a lady and take her to a city where she could get medical care.

Having grown up in a rural area, I’m interested in serving rural populations that need physicians, but I’ve also spent the last six years near the city. For about a year before I started medical school, I helped out at a free clinic for people without insurance. The clinic was about an hour away through traffic, so I only made it once or twice a month to volunteer, but I’ll always remember pushing the gigantic rolling files of paper medical records—a very physical reminder that even in urban areas, there are a lot of people without adequate medical care, whether because of language or economic barriers.

Cocaine

At first I thought he was alive.

His swollen, bloodshot eyes looked sad.

The photograph was taken at a strange angle, looking up toward the nose, so that a line of white powder could be seen plastered to the inside of his nostril. The point of the picture was to show all us students that the man had died while snorting cocaine, but the only thing I could think was, “I don’t understand this.”

Cocaine causes hypertension, lethal cardiac arrhythmias, heart attacks, seizures, renal failure. One picture our professor showed us was of a brain covered in thick, partly gelatinous blood. Normally the brain is clean and grayish-white post-mortem, but this person had died of massive intra-cranial bleeding caused by a cocaine-induced spike in blood pressure that ripped through one of his arteries.

The lecture was about chemical injury to the human body, but the fact that a chemical had damaged this man’s body seemed so far from the root of the problem as to be almost comical.

The world is broken.

Things are not right here, and this is not where we’re meant to be.

For med students, debt stifles idealism

Forget the youthful idealism you started med school with, real doctors need to look out for number one. This constituted about 50% of a talk I attended over lunch the other day. The speaker was talking about the need for doctors to be politically active not only out of concern for our patients, but also out of concern for ourselves. He was interesting, but I disliked the amount of time he spent talking about physician income, the cost of malpractice insurance, Medicare reimbursement, and money in general. It’s not that I think these things are unimportant–I think they’re terribly important–but these things aren’t why my classmates and I are in medical school.

Originally, when I decided to go to become a doctor, it was because I wanted to do missions work and help people in desperate need of medical aid. I’d still love to do this eventually, probably part-time or over a short term, but I haven’t yet taken enough steps toward missions work to be headed in that direction.

I am, however, headed in the direction of having a tremendous amount of debt–about $250,000. My wife routinely reminds me about what a huge sum of money this is. The loan repayment calculator at finaid.org estimates I’ll need a salary of at least $181,000 and ideally $345,000 to repay this loan. The more often I look at my loan statements and my financial aid “award,” the more pressure I feel to make a lot of money. How can I care for my wife if I don’t? How can we have a family?

If there’s anything that squashes the idealism of young medical students, it’s the need to acquire the realism of a working physician.

The 2009 AAMC Graduation Questionnaire found that the average education debt of medical graduates in 2009 was $156,456. The loan calculator suggests that a graduate with this amount of debt ideally should be making $216,000 to repay this loan. The OOH from the US Bureau of Labor Statistics states that primary care physicians have a median annual income of $186,044. (The median salary of “specialists” is $339,738. And we wonder why we have such a shortage of primary care physicians.)

My concern about debt increases with each semester, and if I bring it up among my friends, the main response I receive is that we should quickly do away with that topic and move on to something else. Likewise, I’ve found there’s no better way to ruin an evening with my wife than to bring up the subject of student loans. (Without a doubt, reducing tuition costs would encourage more students to enter primary care.)

It’s not that I didn’t look carefully at the numbers before I started. For one thing, the loan calculator above assumes that paying anything more than 20% of “discretionary income” for loans is “financial hardship.” I grew up in a lower-middle class family, and I’m pretty sure that if I’m making $150,000 a year then I can afford to pay a bit more into my loans. If I do choose to go into a specialty, I really shouldn’t have any problem at all.

That being said, I applied for an NHSC scholarship last spring. This is a government scholarship that pays for medical school if you agree to practice primary care in a medically under-served area for a certain amount of time. I’m currently waiting to hear whether I’ll receive an award this year. Since I prefer to go into primary care anyway, this would be a pretty sweet deal for me. I would likely make significantly less money than the average physician, but I would also have a very manageable amount of debt. While this isn’t the missions work I dreamed of in high school, it’s pretty close, and there are a lot of people in the US who are in desperate need of medical care.

NHSC is a wonderful government program, but it only solves a part of the student debt problem. If I’m awarded a scholarship, I can focus on caring for patients without worrying about loans, but my classmates will make their decisions with $200,000 weighing heavily on the scales.

And if I don’t receive the scholarship?

Well, I can only spend so much time calculating, talking to physicians, and looking up salary statistics. After I’ve done as much as I can, all I can do is trust the Lord to care for me.

Therefore I tell you, do not be anxious about your life, what you will eat or what you will drink, nor about your body, what you will put on. Is not life more than food, and the body more than clothing? Look at the birds of the air: they neither sow nor reap nor gather into barns, and yet your heavenly Father feeds them. Are you not of more value than they? And which of you by being anxious can add a single hour to his span of life? And why are you anxious about clothing? Consider the lilies of the field, how they grow: they neither toil nor spin, yet I tell you, even Solomon in all his glory was not arrayed like one of these. But if God so clothes the grass of the field, which today is alive and tomorrow is thrown into the oven, will he not much more clothe you, O you of little faith? Therefore do not be anxious, saying, ‘What shall we eat?’ or ‘What shall we drink?’ or ‘What shall we wear?’ For the Gentiles seek after all these things, and your heavenly Father knows that you need them all. But seek first the kingdom of God and his righteousness, and all these things will be added to you.

Therefore do not be anxious about tomorrow, for tomorrow will be anxious for itself. Sufficient for the day is its own trouble.”

-Matthew 6:25-34 (ESV)