An Enthusiasm for Mentoring (Unknown to Mankind)

Hi folks, I guess it's been a while since my last post. My rotation at Wright-Patterson AFB in Ohio went really well. Some highlights:
  • Getting the residency application process going. Turned in the first part of my military application and had my first set of interviews.
  • Lots of good food options. Of course, there was the dining hall on base and the cafeteria at the medical center, but off base my favorites were The Pub, Thai 9, Dublin Pub, and the Fox & Hound. (Fox & Hound, especially, for their weekly Thursday military appreciation nights.)
  • Claudia coming to visit! Specifically watching Harry Potter 7.2 and Captain America together.

[Taking the first step to my psych residency!]

Now I'm at Lackland AFB in Texas for my second Air Force psychiatry away rotation. There was a recent didactic session for the interns on how to be good teachers and role models for med students, which reminded me of an article that my friend Gordon Chien forwarded to me a while ago about burnout in medical school: http://abnormalfacies.wordpress.com/2011/06/22/problems-with-clinical-mentorship/

Being at the bottom of the med school totem pole can definitely wear out lots of people. While we can't change the immense amount of material to learn, the seemingly endless studying for seemingly endless tests, and the unforgiving work hours, what we can change is how members of the medical team interact with each other. After reading that article, I began thinking of ways I plan to (hope to?) prevent burnout, not only for myself, but also for future med students.
  1. Don't forget where I came from as a medical student. Don't forget what it feels like to be a medical student.
  2. Take time to teach while doing hospital work, even if teaching doesn't come in the form of sit-down talks. Some of the most helpful teaching I've encountered came from residents explaining their trains of thought as they reviewed a chart or put in orders, i.e. explaining why they were doing what they were doing.
  3. Peace and love. Peace and love.
The intern lecture that I mentioned above had some more helpful suggestions:

[Traits of Effective Clinical Teachers]

[What's Expected of Residents]

[Create a Supportive Learning Environment]

[Create a Positive and Supportive Learning Environment]

[Supervise/Mentor Effectively]

[Teach Dynamically]

Even before these slides were shown, the interns came up with examples of good teaching on their own that were similar to the ones presented. It was encouraging to see that these future colleagues of mine seemed to have an innate sense of mentorship.

And I think that's what this all boils down to: an enthusiasm for mentoring others. Looking back, I can think of ways I set myself up for a role as a resident teacher:
  • Tutoring math for underclassmen when I was a senior in high school.
  • Being trombone section leader in the LSJUMB, helping "my frosh" navigate the Stanford Band culture.
  • Being president of my fraternity, trying to set a good example for how to lead others who looked up to me.
  • As a fourth-year medical student, passing down insight gathered over the course of medical school, specifically helping pre-meds in college with the application process and providing advice for med students interested in going into psych.
Of course, as a resident my priority will be patient care and also educating myself to become a top-notch physician, but these goals don't have to be mutually exclusive with teaching med students. In fact, I would like to think that keeping their education and livelihood in mind will help keep me grounded and augment my own experience. Makes me excited to think about my upcoming Medicine Sub-I at the VA and the M3s I will get to work with. Looking forward to it!

P.S. 20 points for anyone who recognizes where the inspiration for the title of this post comes from.

That Lovin' Feeling

Hi folks! After two weeks of studying, I took my USMLE Step 2 CK (carpooling with Brandon, Zoe, Steph to the test site), and then drove off on a roadtrip from Michigan to visit friends on the east coast. Highlights from the roadtrip:
  • Meeting up with my old college roommate and fraternity brother, Sunny, in Maryland.
  • Driving with Sunny to meet up with Jill, Matt Spitz, and Lori (friends from the LSJUMB) in New York City.
  • Driving with Sunny from NYC to Washington D.C. and eating at Comet Ping Pong pizzeria.

[Harold and Kumar hit up New York City]

[Comet Ping Pong: featured on the Food Network]

After returning to Ann Arbor for an evening, I promptly started driving to Wright-Patterson AFB in Dayton, Ohio on July 4 (God Bless America) for my first Air Force away rotation in psychiatry. This would be the first of my two Air Force psychiatry rotations, the next one being at Lackland AFB in San Antonio, Texas.

[My room for four weeks at the Air Force Inn at Wright-Patterson AFB]

[The Wright-Patterson Medical Center, literally right across the street from the Air Force Inn. Very convenient.]

[July 4 fireworks in Ohio]

[Surprise! A Bar Louie in Beavercreek, Ohio.]

But enough of pictures. I want to talk about a feeling. That feeling you get when you know something clicks or is right for you. You could compare it to falling in love with "the one," but I want to extend it beyond romance or relationships. My first few days here observing the Wright-Patterson psychiatry program have cemented my love for psychiatry.

On my first day, for example, I heard a resident recount a story of a patient who claimed to communicate with fairies, but also practiced Wicca (a nature-based religion), which raised the issue of whether she was being schizophrenic, delusional, or simply practicing her religion; I knew I would love psychiatry when I found myself wishing I could have been at that case presentation in person and learned how she was eventually managed. I took it as a good sign that I got fired up answering practice questions in my head during a lunch review session for the PRITE exam (the annual national test for psychiatry residents). I was also fascinated to see a patient demonstrate CBT techniques during a follow-up visit and was happy to see a psychiatrist convince a patient with refractory depression to seriously consider ECT. An introduction to psychodynamic counseling left me wanting to hear how residents negotiate a patient's Id, Ego, and Superego.

What's more, all of these experiences have happened during a hectic week when residents are in transition (new interns arriving and old residents moving up one year). As a result, I haven't had much direct patient contact yet unfortunately (mostly shadowing attendings so far), but if I'm getting this excited at this point in the game, I can only imagine what I have to look forward to next week when I hope to have patients of my own, and next month when I get to compare Lackland AFB to Wright-Patterson. It's gonna be great!

Carry On My Wayward Med Student

Finally, some time to catch my breath.

I was originally hoping to blog about my trip to Chicago for Step 2 CS right after I came back. Obviously that didn't happen. However, I can list some highlights:
  • Driving through clouds of white cottonwood fluff on the highway with green trees on either side of the road was surprisingly serene.
  • Arrived in Chicago on Sunday night, 6/5, and had dinner at Giordano's with Ari (fraternity brother from Stanford) and Dave (my cousin). Chicago stuffed pizza with ground beef and mushroom paired well with frosted mugs of Stella.
  • Later that same night, Ari and I went out to sing Live Band Karaoke with some of his friends.
  • Breakfast of yogurt/fruit parfait and coffee at Starbucks with a last minute review. Lunch from Chipotle.
  • Eight-hour long test. Had to remember the following keys to passing the test:
    1. Speak English. 
    2. Wear professional clothes. 
    3. Wash your hands before the physical exam. 
    4. Drape the patient. 
    5. Don't punch the patient in the face.
  • Breakfast at Orange Restaurant with Ari, Claudia, and Tina (more friends from Stanford), had a nice driving tour of the Chicago neighborhoods with Ari, lunch with Dave at Lao Sze Chuan in Chicago's Chinatown (pork kidney, Mongolian lamb, garlic spinach, minced beef = yum!)
  • Driving back through clouds of cottonwood again.

[Singing Ozzy's "Crazy Train" to a live band: easily the best part of taking Step 2 CS]

Ever since getting back from Step 2 CS, though, it has been an almost non-stop marathon of studying for Step 2 CK (the computer-based, multiple choice test portion of Step 2). My days have fallen into an unexpectedly consistent routine: waking up around 7 AM, studying all day with breaks for meals, and getting to sleep around 11 PM. When I look at all of these hoops that we med students have to jump through, it's tempting to ask sometimes, "What's the point?" I'm sure this question will be even more prominent when I'm a resident, working long hours in the hospital. Sure, there's the goal of becoming a doctor, of helping patients, of having a long/successful/fulfilling career/life. But I had a eye-opening experience recently that I think answered this question on a deeper level.

Between taking Step 2 CS and starting to study for Step 2 CK, I had a weekend when I flew back to California for the wedding of Kalena Masching and Sam Howles-Banerji. I had known Sam for four years at Stanford through the Stanford Band (he was the Tööbz sexion leader when I was the Bonz sexion leader; and no, those aren't typos, that's how we spell in the Stanford Band). I had known Kalena even longer, since middle school in fact, where we both played trombone. They are both very good friends, but the reason the wedding was especially meaningful for me was this story: although Kalena didn't go to Stanford, she stayed in Palo Alto after high school, and since I knew she played trombone I invited her to join the Stanford Band my freshman year, which was where she eventually met her now-husband. That unremarkable, casual invitation was an act of friendship that had incredibly life-changing implications (something that Kalena's parents very explicitly reminded me and thanked me for while I was at the wedding).

Going back to all the med school hoops, my point is this: oftentimes, despite our best efforts to extrapolate meaning, the most meaningful points seem to be the ones we never anticipated, stemming from actions to which we would never have given a second thought. If something as simple as asking a friend to join the Stanford Band could affect both her and her husband's lives so deeply, imagine how much we can help future patients if we put our minds to it. Yes, it can be difficult at times to see purpose in what we do, but we all have a part to play in this life, even if we don't know what it is. And those preciously rare moments when we are blessed with the opportunity to see what part we did play...though they be few and far between, those can be the moments that help push us onward in times of doubt, in times of struggle, in times of seemingly useless endeavor. Keep those moments close and use them to carry on.

[Congratulations, Sam and Kalena!]

Renewal

First month of M4 year: done.

Emergency Medicine was a wild rotation. It was a great way for me to hone my H&P skills to under 15 minutes (which will come in handy for my upcoming USMLE Step 2 CS exam), and it gave me the chance to see all sorts of medical conditions, from the acutely psychotic to the acutely traumatic (flexing both my mind and my suturing skills). For the most part, the rotation was a microcosm of my entire clinical education with one large exception: it was the first time I had seen a patient die.

Less than a week into the rotation, within the first ten minutes of my shift, our team was notified of an incoming patient: 21-year-old female with a history of heroin abuse presenting in cardiac arrest. She had been found down and unresponsive for an unknown period of time. The doctors, nurses, and techs were ready to receive the patient in the resuscitation bay when EMS came in, performing chest compressions and bag ventilating. It was not looking good. After the team quickly moved her from the stretcher to the bed I started continuing chest compressions, the only thing a med student is usually qualified to do in that situation. I remember thinking how terribly young this person was. She had an eyebrow and lip piercing, and a tattoo of a bird on her arm. Completely unresponsive. As is standard protocol in the ED, we used trauma scissors in order to cut off all clothing when she arrived to give us IV access. About halfway into the resuscitation attempt, the team laid a sheet over her lower body as the patient's mother came into the room to be at her daughter's side while chest compressions were still going on. Twenty minutes after the patient's arrival, with her heart only twitching on ultrasound despite medications and CPR, we informed the mother that we had to call it. She couldn't bear to look up from her daughter's hand. All we could do (all I could do) was move on for the rest of the shift.

In some ways, medical students are trained to handle emotionally-charged situations like this through simulated patients. Part of the Emergency Medicine rotation, for example, is completing a Standardized Patient Interaction on Breaking Bad News. I certainly appreciated the feedback I received from the volunteer who played the role of a wife whose husband had just passed away in the ER (make sure all relevant persons are present and accounted for, use the deceased patient's full name and address the relatives by name, offer family members the chance to see their loved one). I also was relieved that I could keep my emotions under control during that exercise, and was happy to hear that I apparently have a soothing voice and demeanor. However, I feel like these lessons are designed more for a physician-in-training's future patients than for the physician-in-training. The communication techniques and tips help doctors console patients, but how can doctors frame these experiences for themselves?

For me, taking part in my first code revealed the brokenness of the world in a way I had not known before. I will never know when, how, or why that 21-year-old woman became addicted to heroin. I will never know if our resuscitation efforts were futile from the beginning. What I am thankful for, though, is the chance to contrast the brokenness I experienced that day with a vision of what the world could be. Just a couple of days after that ER shift, Phi Rho friends and I took a trip to the movie theater, a rare treat for busy med students. We not only bonded as a group, but also bonded with a subletter from the UK, Mandeep.

At first glance, this simple display of friendship might seem insufficient to balance out the tragedy of a needless death. I guess my point is that we (med students, physicians, humans) shouldn't discount these happy moments as any less real or meaningful. Why do I have this conviction? Well, going to the movies that day, Laurel mentioned how she participated in an autopsy of a 20-something woman from St. Joe's who had died a couple of days ago. Sure enough, upon further questioning, I found out it was my patient. Taking that story full circle, the juxtaposition of brokenness and renewal, helped me realize that happy moments like the one I was experiencing at that time were still worthy goals to aim for, goals for us and for our patients. No matter what specialty my classmates and I choose, we can do our part to help renew others, even if the renewal is as simple as enjoying a trip to the movies with friends.

[Renewal (and sunshine) finally in Ann Arbor]

In other news, residency applications are starting to loom over the M4 class. I have my Dean's Letter appointment this coming Wednesday, which basically consists of going over comments from my clinical evaluations and reviewing a draft personal statement/CV. In writing my personal statement rough draft, all I could say was thank goodness for this blog. Turns out my online ruminations were helpful reminders of why I want to go into Psychiatry, and my path to committing to that specialty. This weekend I drive to Chicago for my USMLE Step 2 CS exam, then comes 3-4 weeks of vacation...to study for the Step 2 CK portion of the test.

Med school life, fo' sho'.

Final thoughts on the Honduras mission

Now that I've dipped my feet into the cool waters of M4 year, there has been enough time for me to reflect on the medical mission to Honduras.

One of the pleasant surprises of the trip was being able to utilize the Spanish that I had learned during high school. It was awesome to still be able to converse (albeit rather brokenly at times) after more than 7 years out of the classroom. The experience has reassured me that I might be able to (barely) get by in a Spanish-speaking country for an extended period of time, if the opportunity ever arose.

I was also amazed at the resourcefulness of Hospital Suizo. By necessity, team members were limited to one surgical mask, one hairnet, and one pair of shoe covers each day. The surgeons had to be extremely mindful of what instruments were needed in any given procedure; if possible, they would try to use equipment that was already on the field rather than open up new packages. And in clinic, we had to sterilize and reuse otoscope funnels instead of throwing them away after a single use. Outside of the OR, the people of La Ceiba have to get by with less as well. The church we visited on the Sunday before clinic started had to use a pay-as-you-go system in order to expand the building. Instead of paying everything up front and constructing the building straight through, the church pays to build one floor, raises more money, then builds the next floor, etc.

Finally, I treasured the relationships I developed on the trip. I met new friends and reconnected with old friends who had grown distant during M3 year. Most importantly, the trip has made me more comfortable about my relationship with God and about associating myself with Christianity. This isn't to say that there were thunderbolt revelations or anything on the trip. However, over the course of the past 6 months or so when I started exploring Christianity, there have been times when I've felt God's presence, and I have no doubt He steered me toward this mission trip to do good work. Since returning, I've also become more open to talking with others about my beliefs. Just the other day I had a genuinely civil discussion with a housemate about my journey to Christianity and why I believe what I believe. Recounting this entire spiritual journey would probably require an entirely new blog, not just a separate blog post. Needless to say though, I hope to continue the conversation with others and welcome dialogue.


In the end, the trip was an amazing success. This year was the single biggest year ever in terms of number of patients treated. The final numbers over the course of 5 days were as follows: 500 patients seen in clinic, 58 surgeries, and 16 in-office procedures.

It's now almost a week into M4 year and Emergency Medicine. During orientation and in the ER, I was definitely thankful that I had the chance to practice IVs while in Honduras.

[The true test of friendship: starting IVs on each other (left: me; right: Brandon Smith)]

[The aftermath of the IV workshop during Emergency Medicine orientation.]

[I offered to be a human pincushion for the day.]

My rotation at St. Joe's has been pretty good so far. Reasonable hours, enough time to enjoy pleasures outside of school (e.g. 2011 commencement, Biorhythms). Lots of things to look forward to in future blog posts!

La Ceiba mission: Day 8

A big travel day back home.

[Photo 1, 2: a last look outside the window of my hotel room.]

[Photo 3, 4: crates and luggage being packed.]

[Photo 5, 6: Alex and Paul...with the mountain of bags looming behind them.]

[Photo 7: a full bus.]

[Photo 8: checking in at the airport.]

[Photo 9: brunch at Wendy's in the San Pedro Sula airport, decked out for Mother's Day.]

[Photo 10: waiting to board our flight.]

[Photo 11: layover in Atlanta for dinner. Panda Express chow mein, Golden Treasure Shrimp, String Bean Chicken, and Black Pepper Chicken with a raspberry iced tea.]

[Photo 12: boarding our flight to Detroit. Almost home!]

[Photo 13: picking up our stuff at DTW...almost there...]

[Photo 14: ¡el fin! Home safe and sound!]

La Ceiba mission: Days 6 & 7

For yesterday's Devotional, we mixed it up a bit by having Alex lead some hymn singing (Come, Thou Fount; and In Christ Alone). In terms of the hospital, yesterday was my day in the pre-op area and my overnight call.

[Photo 1: the sign outside the hospital. In for a long day.]

Pre-op consisted of starting lots of IVs. In between patients, I had a chance to read C.S. Lewis's "The Screwtape Letters." My pre-op shift ended around 2 PM, at which point I was able to go back to the hotel for a bit before my overnight call. After a two-hour nap, email time, and dinner, it was time to return to the hospital.

For the most part, last night went pretty smoothly. There were some late surgeries, with the last patient arriving in recovery at around 9 PM. However, all the patients admitted to the hospital (turned out to be four in all) were fairly stable. The nurse who was on call with me, Michelle, was gracious enough to let me get a few hours of sleep while she monitored vital signs overnight.

[Photo 2, 3, 4: the hospital at night.]

[Photo 5: taking care of the last two patients to arrive in recovery.]

This morning, it was simply a matter of getting some quick vital signs before the surgeons arrived, eating the boxed breakfasts that our colleagues brought for us, and heading back to the hotel to have the rest of the day off.

[Photo 6: clinic starting to pick up in the morning.]

[Photo 7: standing outside the front of Hospital Suizo.]

It promised to be a busy day at the hospital. The original plan was to only have clinic and no surgeries because we'll be leaving tomorrow, but the group ended up scheduling in surgeries for today in order to accommodate all the patients that needed to be treated.

As for me, though, I went back to the room to nap before getting an all-American lunch at Pizza Hut.

[Photo 8: the movie that was playing at the Pizza Hut, featuring Jackie Chan!]

The rest of the day consisted of emails, other computer tasks, and gift-shopping. I had plenty of limpera (Honduran money) to bring back some genuine Honduran coffee, postcards, and keychains.

[Photo 9: before going gift-shopping, a special coconut cookie...with a bite taken out of it.]

[Photo 10: the souvenir shop, El Buen Amigo.]

[Photo 11: chilling in a hammock.]

Tonight was also the end-of-the-trip banquet. It was a night of good food, good company, toasts to all the folks who made the trip possible, and overall merriment.

[Photo 12: the med students at the hotel, before the dinner.]

[Photo 13: our banquet table.]

[Photo 14: Alex, me, and Josh.]

[Photo 15: Alex busting out the tunes.]

Tomorrow is a big travel day. See you all back in the States soon!

Whoops

Didn't mean to post an incomplete post about Day 5. The Internet has stopped working on my laptop. Will correct the mistake ASAP.

La Ceiba mission: Day 5

Today's morning run was probably the most humid this week. After returning to the hotel, showering, and coming down to breakfast, we found out why: there was a torrential downpour, the first time it has rained on this trip that repeat participants could remember.

[Photo 1: raindrops falling to the ground.]

Fortunately, the weather cleared up by the end of breakfast, and we were off to start the day.

And what a day it was! I started the day learning how to do a tonsillectomy, and then took out a tonsil all by myself. The surgeon I was working with, Dr. Fung, said he was impressed that it took me all of two minutes. He commented something along the lines of "Good hands for a future psychiatrist."

[Photo 2: the fruits of my labor. I think the tonsil I took out is the one at the top of the photo.]

Literally right after the tonsils were removed, we were informed that our OR needed to be used for a C-section! We turned over the room as quickly as possible. Members of our team were drafted to assist with anesthesia and with the surgery itself.

[Photo 3: crib, ready for the newborn.]

[Photo 4: Dr. Fung (left), first assist on the C-section with the Honduran Ob/Gyn.]

[Photo 5: ¡hola!]

[Photo 6: yes, turns out pediatricians do the same newborn exam in Honduras.]

[Photo 7: a coy smile from our youngest patient.]

[Photo 8: new Facebook photo. Count it.]

After that bit of excitement, I took part in a thyroid resection and septoplasty.

[Photo 9: a thyroid.]

Overall, it was quite a satisfying day. Tomorrow, I'll be in pre-op starting IVs, and then spending the night on call.