Worst-Case Scenarios vs. Occam's Razor

If you are friends with me on Facebook, you know that for the last six weeks I have been on my third-year pediatrics rotation. One of the key points that they focus on for babies' appointments (but that was not tested at all on our SHELF exam, which was frustrating - that's a rant for another time) is developmental milestones. 

Around the age of 12-18 months, most kids reach a point where they start to learn at least one new word every day, and they become nervous or even outright frightened at strangers. Around the same time, they may develop night terrors (in their deepest stages of sleep, that they usually don't remember, and often frighten parents or babysitters more than the the toddlers).

Around preschool/elementary school age, as most of you do remember, children start getting nightmares. They can't always tell what is real and what is not, and it manifests in sad and terrifying (and very memorable) images that haunt their REM sleep until they learn to remember what is real, and keep the bad dreams at bay.

Nowadays, as I learn a new skill or diagnosis or other piece of knowledge every day, it's again what I don't know that terrifies me. In my first two years of medical school, we learned the physiology of the human body and the pathophysiology of the many diseases that can ravage it. That was our equivalent of night terrors - terrifying information that we did not always fully grasp, and much of which is hazy in our minds after we are tested on it. And while medical student syndrome runs rampant ("Oh God, I totally have the symptoms I'm studying!"), I'm sure it is much more frightening or annoying to our parents, significant others, and non-medical friends - the ones who have to deal with us telling them about the latest disgusting disease manifestation we saw, or comfort us when we freak out about tests and grades and our careers. The ones who, when they asked us about their own medical issues, got the WebMD-style complete differential on the worst things that could be happening to them ("oh, your stomach hurts? Well, it's probably just gas, but maybe you're bleeding internally or you have a tumor or an intestinal blockage or... tell me more about your pain!").

Now, in third year, we struggle not only to relearn all of that information and then some, but to apply it to patients, and to retain it beyond just the next test. Because now we are in the second half of our training, and what we do now, more than anything before this, is going to shape our future careers. So we have to prove our medical knowledge and skill, and that means facing our nightmares - all the incredibly complex diseases that preoccupy us at test time, but which are only rarely seen in the field. We have to be on our guard and watch for the signs carefully, without becoming alarmists who forget to rule out common things and ignore Occam's Razor (thus panicking patients and annoying attendings). 

What worst-case scenarios do you fear in your job? In your life? I'm not talking about stuff like death and safety that most people share - what are the ones specific to you? What do you think about and then have to stop and remind yourself that that is not the only scenario, or that there is an easier way?

Medicine Waxes Poetic (Yeah, Like That Never Happens To Me)

     Well, it's been a really long time since my last post, but this past school-year was pretty insane, so I guess I have an excuse. Friday was the official last day of classes of my second year of medical school. Which means now it's just a steady push to taking the USMLE Step 1 exam and reaching what has been the light at the end of our current academic tunnel - third year. Actually rotating on the hospital floors.
     It can't come fast enough, because sitting for hours in our dungeon classroom was starting to wear down our last nerve. But as I've posted here before, there are always bright moments, the ones that remind us why we med students put ourselves through this.
     Geriatrics (the practice of medicine as it relates to elderly people and their health) was not anyone's favorite course, and making the trip to a nursing home to meet with our patient once every couple of weeks could sometimes be seen as an inconvenience.
     Still, as the course finished, and we were required to reflect on our experience, some of us realized that we had definitely learned something or at least found something to shape our learning as doctors. (Of course, there were always a few patients who were temperamental, uncooperative, or who attempted to seduce the young medical students assigned to them...).
     Anyway, my partner and alphabet-buddy (our names are side-by-side on the class roster) Kellie thought we could best reflect on our patient in the form of prose poetry. It's no Whitman or Wilde or Kafka, but it definitely conveys the lessons we learned from a rather interesting elderly woman.

EM. A Reflection.

Ironic.

That was what our experience with EM was.

"Hi EM. We are medical students from UB, do you mind if we ask you some questions today?"

"Sure, I've got nothing else to do. Have you been here before? You look familiar".

"Yes, we've been coming every other week for a few months."

Ironic that we gained so much from getting to interact with the same patient for the whole semester when she struggled to remember who we were.

Ironic that we learned so much about her and her life and her personality, yet she could only remember our faces.

Ironic that our experience with her defined so many aspects of medicine that had before been abstractions.

Perseveration, dementia, activities of daily living - intangible before EM exemplified them.

Ironic that by now we may only be abstractions and faint memories to her.

Repetition.

"Now we are going to ask you about your level of independence, do you need assistance dressing yourself?"

"No. How old am I again?"

"You're ninety-one."

"Ninety-one! Oh, I don't believe you! I guess I am doing pretty well for my age"

"Yes you are. How about cooking, do you need cook for yourself?"

"No, they take care of all of my meals here."

"Good. Do you need assistance using the telephone?"

“No, but I have three sons and I call them every week.”

“That’s great!”

“How old am I?”

“You’re ninety-one”

“Really? Wow!”

EM has dementia and repeats herself often.

EM showed us that in medicine it’s important to practice repetition.

The same steps should be followed and the same questions should be asked, no matter what the situation is and who your patient is.

Misleading.

“EM, compared to other people your age, overall do feel like you are better or worse off than them?”

“I think I am doing pretty well for myself. I am pretty healthy. How old am I?”

“You’re ninety-one.”

“Really? I don’t believe you! I’m doing pretty well then aren’t I?”

“Yes you are. Do you feel like you have trouble with your memory?”

“Well, I am getting older, and everyone has trouble with their memory when they get older and I guess I am no different.”

“Ok, now we are just going to ask you a few questions to assess your mental status. Can you tell me today’s date?”

“No. Living in a place like this, you don’t need to know the date. Everyday is the same.”

A person with dementia can be very misleading.

The information EM gave us wasn’t always correct.

If what the patient is saying doesn’t seem right, you have to go look for the truth.

Familiarity.

“I am going to name three objects, can you repeat them back to me? Apple, penny, table.”

“Apple, penny, table.”

“Good, now remember those, because I will ask you them again. Can you spell the word world backwards for me?”

“D-L-R-O-W”

“Great, now can you tell me those three objects I had you remember?”

“No, but they weren’t really that important for me to remember, were they?”

“Well, no, I guess not. That’s ok.”

“How old am I?”

Familiarity allows you to learn so much more about a patient than their health.

Familiarity helps you realize that your patient is trying to cover up their disabilities with their personality.

Familiarity can mean expressing amusement at a patient’s joke.

Or the realization that the patient can’t confront their own illness.

Familiarity is knowing when EM’s illness is talking for her, and when she genuinely means what she says.

Gratitude.

“Well EM, this is our last time meeting with you. Thank you for spending the time to meet with us this semester.”

“Of course, I like helping young people learn. Did I tell you that I have three sons?”

It’s people like EM that are the real teachers in medicine.

The ones that make us realize that patients are more than just their conditions. More than just symptoms. More than just a diagnosis to be reached.

Symptoms and diagnoses can’t express approval or accept gratitude. But EM did, every time.

Fuel.

This experience has further fueled our excitement for our future careers and for the relationships we will build with our patients.

The irony of learning medicine, the repetition of our day-to-day, the search for what a patient actually means, the familiarity to find it.

All of these and more EM taught us, and fueled our desire to learn and do our best.

“You’ll both be great doctors some day.”

And she meant it.

Two Thank-Yous, An Apology, and a Lesson

Even the proudest experience can turn humbling.

Back in May I started this blog, just a week after undergoing the nostalgic and celebratory craziness that is college graduation. I've been meaning to write about my experiences from that weekend. Actually, one experience in particular that really left a mark on me...

Yup, that's broken glass.

And I wasn't sure what lesson to take from it. And more importantly, I didn't know how to put a humorous spin on it and create a good blog post about it. Special thanks to my good friend Chelsey for helping me talk my way into learning something.

There were a lot of things that helped define my college career. A great UB education, surrounded by awesome people in my major that pushed me to do well in our classes together, and a great circle of friends. But one of the most significant aspects of my time at UB was my leadership: Helping to lead the Residence Hall Association, interacting with other leaders there and with Mortar Board Honor Society, leading jazz band rhythm sections and more. And yes, maybe I worked too hard on leadership things, to the point where it detracted from my academics. Maybe I could have gotten better grades if I had devoted more brainpower to my studies, but looking back...I don't think I would have changed anything. I learned a lot, both in books and out of them, and I had amazing times with my friends. But I digress. A lot.

Anyway, in early March I was chillin' in the Center for Student Leadership and Community Engagement (which I was doing a lot during the year), when the director asked me if I'd received a letter from UB's most beloved "silver fox" (named by female friends of mine), the VP of Student Affairs Dennis Black. I replied that I had not, to which she responded "Okay, let me know when you do." And then she walked away. Leaving me very confused.

Eventually I was told that I was going to be recognized at the College of Arts & Sciences graduation ceremony with the VP Student Award for Senior Leadership. I felt honored. Dennis said some nice things about me, people cheered, and it was an amazing experience.
So I would like to thank the Department of Student Affairs for giving me that award. It was beautiful.

And I'm really, really sorry I dropped it. And shattered it. In the last ten minutes of the graduation ceremony.
It slipped!

And thank you again, Student Affairs, both for worrying that I would cut myself and taking away most of the shattered pieces, and for giving me a new award. One that is twice as thick as its predecessor.

So far this post has basically been an exercise in expressing arrogance, and for that I apologize. But I did learn something that I hope everyone bears in mind - a humorous lesson, but a lesson nonetheless. No matter how much we succeed, and no matter how amazing a leader can become...he/she can still do stupid things, have silly moments, and in general, make a fool of him-/herself. Those are the experiences that bring us back down to earth. We need those moments to keep us humble, and thereby keep us human.

That's why I keep those two pieces of glass - the only parts of the original award I have left. They remind me that I will always make mistakes, so while I can be proud of my accomplishments, I shouldn't let my successes go to my head. Gotta stay on my toes.

So what are your pieces of glass?