Adam Lamble

At the beginning of my 4th year I get to take my second licensing exam. This exam, known as Step 2, has two parts. The first part is a knowledge based multiple choice test taken on a computer, similar to Step 1. The second half is a clinical skills exam. For this part, I have to fly to Chicago, Houston, Atlanta, LA, or Philadelphia. There, I will go to some specialized testing center to interview 12 different fake patients and write 12 different progress notes about the encounters. The pass rate for this part of the exam is high and therefore there have always been hyperbolic rumors that this half of Step 2 is really just an English proficiency exam.

To prepare us for this test of our clinical skills, the first three years of med school have been littered with similar encounters our school has developed to mirror the exam. I introduced you to one of these encounters in my previous post. The encounters have ranged from someone presenting to the ER complaining of chest pain all the way to having to fend off a flirtatious patient’s advances while conducting an interview (this skill, believe it or not, hasn’t been much of a necessary asset lately, seeing as how I’m at the VA right now working with a bunch of old guys).

We receive feedback from these paid actors ($15-25 an hour) and they also videotape each encounter. We’re supposed to review the videos and reflect on things we did well and things we did poorly. Unfortunately for me, the way the cameras are positioned I just get a birds eye view of the interview and the only thing I really find myself reflecting on is how much hair I’ve lost since med school started.

I knew the diagnosis wasn’t going to be good, but it wasn’t until I begrudgingly read the words Multiple Myeloma on his chart did I realize how grim it was. I sighed to myself, realizing how difficult it was going to be telling my patient that he had cancer.

“Mr. Smith, may I come in?” I calmly asked after knocking on the door. This wasn’t the first time I had seen Mr. Smith. A week earlier I had met him for the first time when he came to me complaining of some innocent back pain.

After I deceivingly asked him how he was feeling and we exchanged pleasantries, I continued, “I know we’ve met before but I would like to reintroduce myself. My name is Adam and I’m a medical student.” Even before the words left my mouth I was wondering how a team could justify sending a medical student in to break this kind of news to a patient. I could only imagine what was going through his mind.

“As you know, we had you come back in today because we wanted to discuss your lab results. We were concerned by the cause of your back pain and that’s why we ran these tests.” After a brief pause, I swallowed and continued, “The results weren’t what we were hoping for.”

“You’ve been diagnosed with a cancer called Multiple Myeloma.” He slowly raised his hand to his eyes as he began to cry. I couldn’t remember the last time I had seen a grown man cry.

As I let the silence do my talking, my mind began to wander. Why hadn’t he brought any family members with him? Then I began to imagine all of the traitorous antibodies coursing through his body, recruiting his cells to betray the bones in his back.

I chose not to go into details about his disease because for one, I didn’t know them all, but more importantly, the information would fall on deaf ears due to the emotional levity of the news. Instead, the conversation continued with me clumsily stressing that he wasn’t alone and that this wasn’t the end. I tried to explain that there are treatments available and that my team and I will be with him every step of the way. Then I awkwardly excused myself, not exactly sure how to end the conversation.

As I stepped out of his room I saw that some of my classmates had already finished breaking similar news. I waited in the hall patiently, reflecting and relieved that the first time I had to tell someone they had cancer, they were an actor instead of a patient. My thoughts were then interrupted by “Mr. Smith” who invited me back into the exam room to discuss the encounter.

A lot of people assume since I’m entering the health care field I’m up to date on health care news. Nothing could be further from the truth. Med school has done a pretty good job wringing out any awareness I once had of the outside world. Just the other day someone asked me what I thought about “Balloon Boy” and I thought they were talking about that old John Travolta movie.

On the other hand my current rotation, Pediatrics, has provided an exception to this rule. On some days, every other patient I see has H1N1, and if the Swap-Bot message boards are any type of barometer for the popularity of current events, then the Swine Flu is pretty hot right now.

Other than the kids with actual Swine Flu, there are two types of mothers on opposite ends of the spectrum that I have been repeatedly running into in clinic. Mother #1 is uncontrollably afraid of H1N1 and wants her child to be tested and started on Tamiflu as soon as possible because they have a runny nose. Mother #2 refuses for her children to be vaccinated, citing “research” she has done on the internet in regards to the vaccine’s adverse effects.

While most of the blame for this hysteria and confusion should fall on the media, it’s not all their fault. Hospitals were forced to over respond to H1N1 in the beginning since it was such an unknown variable. For example, I had a classmate who’s first rotation was pediatrics and he was started on Tamiflu and quarantined for five days just because he was exposed to a kid that might of had H1N1. Today, on the other hand, I saw four kids with assumed H1N1, one of which sneezed in my eyes. I made sure to wash my hands before seeing my next patient.

So, for mom #1. Get your kids vaccinated and even if they do get the flu, unless they have some sort of underlying respiratory disease, they’re gonna be just fine. As for mom #2, the H1N1 vaccine is just as safe as the seasonal vaccine and experts claim that H1N1 vaccination is literally, a thousand fold safer than getting the infection.

At the same time, those of you that do feel yourself coming down with flu-like-symptoms, it wouldn’t hurt to run to the pharmacy and pick up some oinkment. Man, that one kills with my younger patients.

I take after one of my parents more so than the other when it comes to verbal recall. At times, I find myself using multiple words to describe something when one would suffice. Or as I like to call it, “taking the scenic route”. Unfortunately, this isn’t the easiest weakness to mask when it comes to medical school.

In medicine, there are multiple names for everything. Every symptom, disease, procedure, etc. has at least a Latin and/or Greek derivation, a layman’s term, and sometimes an eponym assigned to it. For example, a runny nose is rhinorrhea, grinding of one’s teeth is bruxism, and as one of my classmates found out while presenting to an attending physician, a “butt crack” is technically referred to as a “gluteal cleft.” While this system is universal and in the end, probably makes things more efficient, right now it’s kind of like learning a new language.

I was writing a progress note on a patient the other day. She presented with stomach pain and had told me this pain was relieved when she would pass gas. When recording this information in my note, I went through a short period of writer’s block. I was pretty confident the word “fart” wasn’t in the medical dictionary but for the life of me, couldn’t come up with the correct terminology. I considered taking the easy way out by simply putting the patient’s remarks in quotations, but then, as it often does, the word “flatulence” came to my mind.

A similar patient presented with a pain in her side that was worse when she would bend over. She attributed this discomfort to irritation from her bra, but was also concerned about more sinister etiologies. When recording this in my note, I couldn’t decide if bra was an appropriate word for a medical document or not. I tried replacing it with the word “brassiere”, but then I was concerned the doctors might think my mom was writing the note. I finally had to settle on the uncomfortable sentence, “Patient believes pain was due to irritation from the underwire of her underwear.”

I know I’m not the only student that struggles with wording and I wonder if the attending physicians that review our notes get a kick out of them. Sometimes I imagine they pick out the most ridiculous student notes and make a slide show out of them to play at their Christmas parties. The only reason I’m guessing that they do this is because when I’m an attending physician, I know I will.

One of the more important personal skills I’ve refined since being in medical school is being efficient with time. Like so many people, I have found there just aren’t enough hours in the day to accomplish everything I need to do.

In undergrad, there was no sense of urgency in getting things accomplished. For instance, if I wanted to make a peanut butter and jelly sandwich but didn’t have any bread, I’d go to the store and buy some. If I got back to my house and realized I was out of peanut butter, I’d go back to the store. If, when I got back and found my milk was expired and I didn’t have anything else to drink I’d… well, in undergrad I’d probably have drank the spoiled milk, but I think you get the picture.

High level multi-tasking is basically a survival technique that you have to develop to make it through medical school. I learned early on that my undergrad, laissez-faire attitude wasn’t going to cut it, and that I’d have to adapt. At first it began with things that most normal people do anyway, like listening to a lecture at the gym, saving any shows I wanted to see until the evening when I could eat dinner while watching, or scheduling workouts for the morning so I only had to take one shower each day.

Quickly though, this mentality has gotten out of hand. I still eat while watching a TV show, but now I have to workout my knee or stretch during commercial breaks. I can no longer sit still while on the phone. I have to be in transit in my car, running some errands, or at the very least, cleaning my apartment while talking. Also, now that I have a smart phone, I refuse to read or reply to e-mails unless I’m sitting down to use the restroom (think about that next time you read an e-mail from me). Finally, I still drive back to my parents house to do laundry and there have been times I’ve seriously contemplated reversing my underwear to buy myself another week. Listen, no one ever said efficiency had to smell good.

It’s like my multi-tasking has become self-aware and has begun perpetuating itself. It’s only a matter of time before I can no longer justify eating dinner without talking on the phone while sitting on the toilet and cutting my toenails. I know it’s been awhile but, yes, I do realize this is the second post in a row I have discussed and ended with bowel movements.