Category Archives: clinical experiences

The Color of Courage

In the small town Emergency Department where I do my clinical hours, we see a lot of hurting people.

By definition, an emergency room is the go-to place for patients with lacerations, who just had a fender-bender on the icy streets and need an x-ray to make sure there’s no serious injury, or the endless stream of parents of kids with earaches and croupy coughs.

But there’s also the tougher cases. Not medically tough. But
emotionally tough.

The addicts hoping that their story this time will result in a prescription for narcotics. The person with mental health issues that we really don’t have a solution for. The homeless person who just really wishes they could get a warm shower and a safe place to sleep for a single night, but doesn’t have anything physically wrong to justify an admission.

Sometimes, its those emotionally tough cases where I learn the most. About the sort of doctor I choose to be. About how to listen with compassion. And even how to get along with medical professionals who have a very different view of respect than I do.

I’ll call him Sam. We were handed a thick stack of paperwork that showed all the different times Sam had been in area Emergency Departments in the last while. Four times in just the last month.

Sam is a heroin addict. And people like Sam seem to spark some of the most unprofessional attitudes I ever see in the field of medicine.

Sam was in pain. Sam thought he had a deep muscle abscess in his left shoulder, because it felt as awful as his right shoulder had felt recently when he’d required surgery to drain a seriously infected abscess caused by shooting drugs deep into  his muscles.

I watched as my mentor listened intensely, respectfully, while Sam explained where he hurt.  I watched him order tests, then go back and have a conversation with Sam about the results (thankfully not yet showing a deep infection).

Then I was amazed as Sam said, “So doc, can you prescribe xxx for me? I really want to kick. I really want to get clean. I’ve done it before, I know I relapsed, but I really want to do it right this time. Can you help me?”

And without a hint of judgment or condescension, my mentor immediately replied, “Yes, I can do that for you.”

Sure, Sam might not make it. He may change his mind ten minutes after he walks out of our Emergency Department. But for that moment, Sam was heard, he was treated with respect owed to every human being, and he was given hope.

And that’s just one of many reasons I love medicine, and is a picture of the sort of doctor I hope to be.

If you’re hurting, reach out. Some of us care. Deeply. And are willing to act.

If someone reaches out to you when they are hurting, hear them. Listen intently. And always offer hope.

 

A Chapter Book

Tonight I had the chance to spend several hours in one of my favorite places – the Emergency Department of my local hospital.

A dislocated kneecap (its a temporary thing and will be fine in time, go easy).

Putting staples in the back of a 9-year-old boy’s head (brave little kid, very nervous father, my first time holding the “staple gun” – funny how I always pictured a great big stapler and this thing is actually so small!)

Woman brought in by police officers who found her digging in the neighbor’s flower beds looking for her “stuff” (a little too much meth and a week without her psych meds, she’ll be fine after ‘catching up’ the meds and sleeping it off with a few warm blankets provided by a nurse who I’m convinced is one of the best nurses on the planet).

Then there was a man I’ll call Jack.

I was sitting beside my mentor while he caught up on charting when I heard the ER Director holler, “Is Student Doctor J still here?” 

“Come with me, I want you to feel this.”

I entered a room where an older gentleman sat in a chair wearing that oh-so-flattering hospital gown.

After quick introductions, the Director said, “Here, feel right here. Jack fell about 8 feet off a ladder. Tell me what you feel.”

I pulled aside Jack’s gown and immediately saw deep bruises where his back had hit something on the way down, and I felt him wince as my hand gently probed his right side. My fingers almost immediately found the “rice crispies” feel of subcutaneous emphysema – air trapped under the skin where it most definitely didn’t belong.

The Director towered over me, and with eyes dancing (he knows how much I love to learn / feel / experience new doctor-type things) asked, “Do you feel it? Tell me what it means.”

Yes, I feel it. There’s air under the skin. Perhaps a broken rib punctured his lung when Jack fell. We need to check the x-ray for fractures and the CT for a collapsed lung and be prepared to put in a chest tube if necessary.

Jack took in the information, asked a few questions, then a few more.

“I understand,” he said. “I just need to know what to expect. I’m so grateful my lung isn’t collapsed right now, and if it happens later I understand when to come back in. Now let me tell you why I’m not going to worry…”

And there followed a full 15 minutes of what I can only call masterful storytelling. Understand, 15 minutes is a long time in an ER. When I began to feel impatient, I’d remind myself, stay present! This is as much a part of doctoring as stapling a kid’s head wound or calling the Crisis Line for an overdose. 

Jack talked about spending his life in film – he was well past 80 after all, and had a rich history as a communications professor and a successful film director and loved stories. He talked of being married to his first wife for 52 years and watching her die of a rare cancer that followed the facial nerves. As he reached out to gently touch his second wife’s hand, he described the amazing experience of them finding each other after each losing a spouse, yet discovering a way to fully embrace their next chapter of living.chapter

Chapter.

Chapter books.

Jack said, “Everyone’s life is a chapter book. Not everyone knows how to let a chapter be read and finished so they can move on to the next. But the book, the story, is so much more than just one chapter!”

At 80+ years old, Jack looks and acts much younger than men twenty years his junior. His ribs and his lung will heal. His wife will gently support his recovery. And his ‘chapter book’ story will continue to inspire med students like me.

Thank you Jack.

 

Life and Death and and an Open Heart

About 24 hours ago the nation was rocked with news of the worst mass shooting in recent history, when a gunman opened fire on the Pulse nightclub in Orlando. Families didn’t know if their loved ones had survived the horror, and grief and rage and political posturing was rampant.

On the same day, I learned that a dear friend’s father passed away, quietly taking his last breath as he held his wife’s hand.

As a healthcare provider, I am confronted daily with life and death. Serving in a hospital setting means I get to see people at their worst, masks gone. Last night, I was struck by the wide divergence in how providers approach crisis and death. While news outlets scramble for the latest juicy morsel to boost their ratings, I get up close and personal with death.

Report from Provider A:

Ohhh you’re gonna love this one. He’s a frequent flyer, Done so many drugs I swear he’s got oatmeal for brains. I’m tough though – he knows better than to ask me for anything for withdrawals because he probably doesn’t want to hear the lecture any more. One of these days they’re going to pick him up dead. When you go in there, be ready for the stench – I swear he never takes a shower! Go on, go see him. We’re taking bets on which body part he’s going to say is in pain to try to get some narcotics. This is your brain on drugs hahaha…

Report from Provider B:

Shhhhh he’s finally sleeping. This patient is just 43 and had neck surgery a couple of days ago, then had a seizure during recovery and aspirated. Now he’s battling pneumonia and might not make it. Sometimes he’s oriented, most times he isn’t. He’ll get quite agitated but responds well to firm touch and gentle conversation. We’re medicating as much as we can to reduce his discomfort and anxiety without depressing respiration. We’ll be trying for a second IV site soon and will need your help with that – he doesn’t have many good veins.

What? Oh yes, his right side is affected from an old stroke. We think it was from excessive IV drug use. But he is such a resilient man – we’re hoping he pulls through. I’m so glad you’re here to help care for him.

So here’s a question for you. If you were the PARENT, which report would you hope was given about your son or daughter?

In the last week, I have held in my arms a woman dying of lung cancer (after smoking for 40+ years, she quit, but it was too late), a young adult who tried to kill herself by drinking antifreeze (it was touch-and-go, but she was discharged… determined to try again), and a man permanently disabled due to years of drug use. In each case, I watched providers struggle with how to handle the knowledge that each crisis was preventable, was a direct result of poor “lifestyle choices”, and that their care was pretty much useless in the long term.

Yet, I remain committed to hope. To joy. To gentle compassion. Even when – perhaps especially when – its the patient’s “fault” that they’re in a medical crisis.

I’m not naive. I’ve worked in some capacity in health care for a very long time. I’ve watched providers become jaded and angry. I’ve been witness to crass jokes as some attempt to use dark humor to guard their hearts.

Yet still, I remain committed to hope. To joy. To gentle compassion.

If you’re a provider, angry at the futility of your service, frustrated by a system that seems to use you up and ask for more, I invite you to explore the beauty of an open heart. Will it hurt more? Absolutely! But way back when you first decided to enter the field of health care, you CARED.

Find that.

Find the gentleness in your heart to reach out. Again. Even when you are certain it won’t make a difference.

Because even those who created their own crisis deserve compassionate care. And your heart will be better for feeling the pain, holding the dying, turning away from the jokes and anger and political posturing, and simply serving.

With an open heart.

Epic ER Firsts

This week has been epic in so many little ways. For starters, last weekend I spent about 20 hours training a group of folks (one of my income-generating ‘jobs’ that helps pay tuition). Then I moved – that major downsizing  wise move that will make focus on studying simpler but left me with aching muscles I forgot I had. Add in a few other life things and I’ve had a week of major sleep-deprivation.

Yet I just arrived home from my second ER shift of the week, feeling completely energized and just downright happy.

A couple of “firsts” merit mention.

Tuesday was a crazy-busy night in the ER. Was it a full moon or something? A woman with sky-high blood sugar who didn’t know she was diabetic. Drug addicts and anxiety attacks. A man who had been run over by a car (really!) and a probable stroke.

Then there was the young woman who thought she was pregnant, and complained of symptoms of a vaginal infection.

As I took up my usual stance in the corner, the nurse looked at me, looked at my mentor, and said, “How about the med student does the pelvic exam? You’ve gotta start somewhere right?”

I nearly hugged her. Then nearly had my own panic moment.

But its funny how years of being on the receiving end made it simple, especially with my mentor walking me through. There’s something magical and awe-inspiring to me about the human body, and about women’s bodies in particular. One human being growing inside of another – wow! I’ll never tire of this experience.

Fast forward to today. Another crazy-busy night in the ER with a steady stream of broken bones, chest pain, tummy bugs, and babies and elderly folks with health issues. It was nearly end of shift and my mentor was headed to the back to work on charting when Dr. U stopped me. “How are your suturing skills?”

Oh geez. Without even thinking I said, “I’ve never done it”.

And with his typical cheeky grin, he answered, “No time like the present!”

I was even more nervous as we walked into the exam room and Dr. U explained to the patient I’d be stitching him up. This young man had a few pretty deep gashes on his right hand from holding a glass when it broke, and was obviously quite uncomfortable.

Dr. U placed the first stitch and talked through each step, then handed the needle to me.

Eeek!

And, it was so much easier than I imagined it would be. Maybe because I’ve spent so many years hand sewing. Maybe because I paid such close attention to how Dr. U worked.

Stitches neatly placed, a fist-bump with Dr. U, and a super helpful diagram from my mentor Dr. J showing me how to determine the width and depth of needed stitches, and I’m hooked.

I will never tire of the variety, moments of intensity, even the mundane and downright annoying parts of working an ER. But this week, I catalog two more “firsts” that help solidify my dedication to becoming an emergency physician. I will never tire of doing “emergency” pelvic exams, placing stitches, cleaning wounds and splinting broken bones. I’ll also never tire of reassuring new moms and dads that their baby’s diaper rash is typical and easily treated, and calming the elderly patient who’s afraid of needed treatment and forgets my explanation before its complete.

Now, to sleep, and dream of growing up to be an emergency medicine doc one day. Tomorrow is a heavy study day, and I’m looking forward to it.

Its a Blue Baby!

Squeezed between intense study sessions, the very best part of my medical education continues to be the clinical hours spent learning and doing in the Emergency Department. Its not the adrenaline thing, although some folks insist that’s why I love ER. But what I truly embrace about it is the unpredictability, the chance to see something new constantly.

Last night was no different.

We were a little busy. Soon after my shift began, both docs suggested I go do an exam in Room Two where there was a baby brought in for “possible bruising”.

My heart beat faster – after all, its not often they send me in alone first and tell me to practice doing a full exam. At the same time, I was a little worried. Without even seeing the patient, my mind immediately skipped to possible abuse issues, playing through scenarios in my head and wondering why the docs chose this particular patient for me.

Determined to practice compassion while doing a thorough exam, I knocked on the door and introduced myself.

Hi, I’m Student Doctor J, I’ll be doing an exam and then my supervisor will need to come see you as well. So tell me what brings you in tonight…

Baby was dressed in just a diaper as dad tried to explain to me how he had been born with a little mark on his back, but it continued to spread. Now the marks covered baby’s back and went across both shoulders. Not a rash, not the sort of bruises I’d ever seen before. But marks that were kinda bluish. I continued to examine baby hoping I wasn’t missing something, and more convinced as I went along that this really wasn’t bruises and we didn’t need to be concerned about abuse.

I’d never seen anything like it.

Thorough exam complete on an otherwise healthy baby boy, and after learning that dad really wanted some simple blood test to tell him what this was and if his child would be okay, I went back to report what I knew.

Which wasn’t much. Often, when I see something for the first time, I feel completely tongue-tied trying to explain it and last night was no different. Then my attending and I got to do a little research to figure out what this was as he didn’t immediately know either (which perversely made me feel a little better).

Aha! Now I know what congenital dermal melanocytosis looks like! More prevalent among those from Asian (this baby) and African American decent, its an issue where melanocytes are trapped in the lower part of the dermal layer during embryonic development. Its harmless, and most often completely resolves by 3-5 years. And even if the marks remain throughout life, there’s no report of any adverse affect. Parents can be understandably worried when they see those funny looking blue marks, but clinicians need to be aware of the condition in order to avoid concerns about abuse.

Last night, between the inevitable colds and chest pain and panic attacks, I learned about a new condition that I’ll now always remember. And that little bit of researching and reassuring reminded me once again why I positively love medicine in general, and the ER in particular.

Now back to the books; its a Review day, and I’m getting an early start with the endless q-bank questions about glycogen storage diseases, pharm basics, and opportunistic infections. And I’m finding the joy in Review that comes from realizing I actually do remember details of what I first learned many months ago!

Pessimism

I consider myself pretty dang tough. Over the last couple of decades, I’ve honed skills of determination, introspection, and time management. I’ve learned which goals are super important to me and what I’m willing to do to achieve them. And I’ve told myself for years that I’m not swayed much by circumstance especially when it comes to issues that are important to me.

Then last night happened.

Working at the hospital as a medical student gives me the almost indescribably wonderful advantage of learning all about emergency medical care, with few of the stresses I’ll experience as a 3rd or 4th year during rotations. Since I’m a first year student, I get teased often when my typical answer is “I don’t know”, and my mentor and other docs seem to enjoy the prospect of having me as their captive audience to teach. I’ve been exposed to several different styles of practicing emergency medicine, and many different doctor personalities.

Last night was an eye-opening experience. As the typical non-emergent patients began their journey through our Emergency Department, I found myself surrounded by frustrated physicians. Maybe it was just an ‘off-day’ for them. Maybe last night was the end of a long week of shifts. Maybe this patient was the 47th who had come in with nebulous pain complaints and no definable injury or illness. Maybe frustrations over endless bureaucratic paperwork and pointless busywork were spilling over onto the patients who didn’t know where else to go.

I don’t know why. And bottom line it doesn’t matter. All I know is that as the evening wore on, I found myself joining in with eye-rolls and jokes about the intelligence levels of those allowed to procreate. I felt a growing internal battle over my drive to always deliver compassionate care, and a sarcastic almost jaded attitude toward those asking for that care. And I watched as I laughed at the jokes, added a few of my own, and mentally excused times when caregivers ignored requests or talked over a patient trying to find a way to express themselves.

And today, thinking about last night makes me uncomfortable. Not that there were jokes and sarcasm – lord knows there needs to be an element of humor in medical care to help balance out all the seriousness. But what bothers me in hindsight is how quickly I allowed myself to be drawn in to an attitude of jaded pessimism.

That’s not me.

Not only am I not a “follower”, but I have some bottom-line standards that I hold myself to. Always before I’ve been able to simply observe when I saw behavior that nudged close to the invisible line, reminding myself that I could learn from each encounter even if the person I was observing was practicing medicine differently than I would choose to.

So now… now, I get to raise the bar. For myself. I get to remind myself that I can be swayed by those around me, even against my own internal standards, if I’m not careful.

From my life experience I know that only so long as I remain conscious of potential pitfalls can I guard against waking up one day only to discover that I’ve become one of “those” docs who seems to genuinely dislike their job.

I’m grateful for the lesson this early in my medical school journey.

I Don’t Know

Working the ER last night, I had one of those realizations. You know the kind – that moment that rocks you back on your heals and makes the breath catch in your throat. The moment when you realize that some of your basic assumptions about medicine are simply false.

I can’t begin to tell you the times I’ve said I don’t know over the last few months. Working alongside my clinical mentor gives me the opportunity to observe diseases and treatments that I haven’t studied yet, and frequently my mentor will ask simple questions that I just don’t know the answer to.

Take last night for instance.

A patient came in complaining of “just feeling ‘off'”. She was tachycardic (124), had elevated blood pressure (181/110), and her face was flushed. Afebrile, no diaphoresis, no nausea, no chest pain or difficulty breathing. In fact, her physical exam was completely unremarkable. This patient exercised regularly, drank no caffeine at all, and pretty much thought she was healthy. After blood work we still had no better idea of why… cardiac enzymes were normal, d-dimer normal, TSH levels normal, nothing helpful on the EKG… Still, after two hours in a quiet darkened room, her symptoms remained precisely as they presented initially. Metoprolol magically lowered her heart rate and blood pressure back within normal ranges, and my mentor and I went to see how she was doing.

And then I had that moment.

Dr. J looked at me from the other side of the patient’s bed and asked, What are we worried about?

MI, blood clots, PE or other pulmonary issue, perhaps metabolic disorders….. my voice trailed off as I realized I simply didn’t know anything beyond that, and I looked forward to hearing his explanation to the patient. Possible causes of her symptoms. Treatment options. A concrete plan going forward.

But what happened was much different than what I was expecting.

We just don’t know what caused your symptoms. Three months ago you were here with similar presentation, and at that time the doc who saw you thought it might be that you were drinking too much caffeine. But you’re saying you cut caffeine completely out of your diet so it can’t be that. All your tests came back normal so we’ve ruled out the life-threatening issues, which is a good thing. We’ll provide you with a prescription of a beta blocker to help prevent your heart rate and blood pressure from spiking, then get you in to see a cardiologist asap.  

Whoa. So me not knowing wasn’t only about my clinical inexperience or being in an early stage of my education…. Even my mentor didn’t know.

Que huge shift in my thinking.

Medicine isn’t necessarily about absolutes. Even highly educated and experienced physicians will often not know what’s causing a particular set of symptoms.

And that’s okay.

I write that’s okay as if it is. I’m surprised at how uncomfortable those two words make me. I want medicine to be an exact science – enter in symptoms, spit out a diagnosis and concrete treatment plan. But that’s not reality.

And in those times of not knowing, I’m learning how vital it is to treat the patient with compassion and competence. Regardless of the storm of discomfort aroused by that I don’t know conclusion, our task as physicians is to provide as much reassurance as possible to the person actually experiencing whatever it is that has us baffled.

I’m well aware that it is impossible for me to ever know everything about everything in the medical realm. But moments like I had last night hugely motivate me to learn more, know more, understand more, minimize as much as possible the times I must say, I don’t know. And with that, its back to the books for me, oh so grateful that this upcoming block of lectures covers cardiac issues and I’ll gain a little more knowledge to help minimize those I don’t know moments.

 

Bored

I’ve been bored. This week after New Year’s was filled with fun stuff like lunch with family, catching up on laundry, playing with my pups and previewing next week’s classes powerpoints. But by yesterday afternoon I was painfully bored.

So I sent off a quick text message to my clinical mentor: Are you working this evening? 

Thirty minutes later I had changed into scrubs and was in my local emergency department examining a patient with extreme edema, an exacerbation of CHF.

This woman with such a sad smile looked up at the ceiling as I asked her how she was feeling.

I’m very tired you know. My doctor suggested I come in to the ER tonight, maybe just so I could get one night of real sleep. Please please don’t send me back there tonight.

Her responses to my questions were spoken barely above a whisper, with long pauses. My heart hurt a little as I asked her, “Why do you not want to go back to the facility tonight?”

Very long pause.

Its not that they don’t provide good care…

An even longer pause. I held her hand gently and simply waited.

Well, actually, yes it IS that they don’t provide good care. Its just – I guess its just that I don’t have anyone who cares at all.

After a consult with her Cardiologist and the Hospitalist, we finally got approval to admit her for the night. She would get at least one night of good sleep. And tomorrow, she’ll meet with the hospital social worker to see if maybe there is a different living situation that would provide her the level of care that she needs.

It was a crazy whirlwind of patients last night. But that patient I examined when I first got there has stayed with me. Modern medicine can’t fix her heart failure. As time marches on she will get progressively worse, and at some point her heart will simply give out. In the meantime, I hope that her interaction with me, a student doctor, gave her at least a brief moment of assurance that yes, there is indeed someone who cares.

 

Hands On Patients

In the few days between right now and Block Two’s final exams, I took a few hours last night to work once again in the Emergency Department of our local hospital. And once again got to experience a few “firsts”.

A handsome young man was brought in having overdosed on Benadryl. Part of my mind flashed to my own young-adult son, and I ached for his parents trying to cope with this image of their son that I’m quite certain they wished had never happened. At the same time, one of the ER docs I hadn’t worked directly with before said, “Glove up and come help” as it took a whole team of folks to hold the patient secure while IVs and a catheter were placed. Then a rapid fire conversation (well, her asking questions, me saying “I don’t know” a lot) that ended in her grabbing a mobile computer, logging me into the system, and saying, “Research the difference between sympathomimetic toxidrome and anticholinergic toxidrome. You have five minutes to come find me”.

Breathless and excited to have answered questions in less than the five minutes allotted, I was looking for my mentor when Dr. M grabbed me once again. “Come help me with a lumbar puncture.”

I felt obligated to mention, “You do remember I’m a first year right?”

Dr. M: “I don’t care. I’m treating you like a 3rd year. By the time you really are a third year, you’re going to know exactly what you’re doing. Make sure you’re keeping a list for your portfolio – its important because believe me, you’ll forget your first lumbar after you do a dozen more.”

Fast stop at the desk surrounded by textbooks in a back corner of the ER, Dr. M grabbed a thick text titled “Emergency Medicine” and flipped to the section on spinal taps: “I know its a lot, read this section on technique. Read fast. You have five minutes to come find me in room 3. What size sterile gloves do you wear?”

I have rarely so blessed my gift for speed reading as at that moment. Six pages scanned, at least the basics retained, I found Dr. M in room 3 and quickly gloved up. Patient placement. Family seated (don’t want to have to worry about family members passing out while doing a procedure).

I truly figured I would just watch this time. After all, I am a first year student. I wasn’t quite prepared for Dr. M to say, “Okay, show me how you determine the puncture placement.” Scanning in my mind’s eye through those six pages I had speed-read just five minutes before, I found the iliac crest, felt for the space between L3-L4, and silently blessed this young patient who was making it so easy. (I nearly giggled as Dr. M marked the spot using a sharpie, and flashed on all the times I had told my then-teenage son to stop writing on himself hehe!) Then I swabbed the area with Betadine in exactly the way shown in that text I’d read and was just a teeny bit gratified to hear, “Well done” from Dr. M.

The rest – injection of local anesthetic and the actual collection of CSF – that part I just observed. After all, I really am just a first year student. But mentally I recited the layers the needle passed through, “saw” the little ‘give’ as the needle first passed through the ligamentum flavum, and a second little ‘give’ as it passed through the dura.

As crystal clear CSF dripped slowly into the collecting tube, the patient said softly, “I don’t feel so well” and the nurse standing in front of her gently supported her head as she quietly fainted (and I remembered Dr. M telling me to always make sure I have a nurse with me when doing a lumbar puncture – now I have a first-hand view of precisely why).

With the spinal tap complete, the lesson was only half done. Results came swiftly, and I then was asked to explain the significance of no gram stain, low protein, no white blood cells, one single red blood cell, glucose within normal limits, and a clinical picture that pointed to probable multiple sclerosis – What’s the next test? 

I discovered that while Dr. M is super tough and pushes me hard, she also has great patience with my floundering to put words to what I do know and what I don’t. And super cool icing on this cake was finally finding my mentor and him suggesting, “Okay, now that you’ve done it, explain it all to me as if I’ve never done a spinal. You teaching me will solidify it in your brain for the next time.” As I explained the lumbar puncture technique, this particular patient, what the test results meant, and what was next, I found the words coming a little more easily.

Now its Sunday morning. Writing out last night’s adventures I get the butterflies now that I didn’t have time for then. And I am overwhelmingly grateful for every single speck of the amazing experiences I am privileged to have.

Now, to flowcharts, flashcards, and whiteboards. Block final exams for immuno, micro, and pharm are in just five days. Funny how much more motivated I feel about endlessly reviewing bacteria and viruses having done a little real-life work last night.

My First REAL Patient

Sometimes I just sit very still and let the wonder of this whole process roll over me. After all, I worked toward THIS for nine years.

I guess I kind of figured I’d spend the first two years cramming information into my brain, then the second two years learning how to actually use all that info in practice. My experience has been very different than that, and that more than anything is what daily blows me away.

As I’ve written about previously, a big part of my medical school experience is spending 20 hours a month with my mentor from the very beginning of year one – a practicing physician who has agreed to let me follow him while he sees patients. Theoretically, this is considered “an observership”, one tiny step up from the shadowing I did as an undergrad. However, it very quickly turned into much more.

This past Tuesday, I arrived at a small university health clinic and almost immediately my mentor and I were moving from room to room, addressing headaches and plantar warts and completing study-abroad papers. My ‘job’ was to complete the EMR note, and I’m getting better at listening to my mentor rattle off the diagnosis and medication / dosage without having to say, “could you repeat that please?” Thirteen patients seen in a little over two hours.

And then it happened.

As we were with the last patient, freezing a particularly recalcitrant plantar wart on the foot of a determined soccer player, the nurse stuck her head in. “Any possible chance you could see one more patient? He just walked in and looks really miserable…” 

And the doc looked at the nurse, smiled, and said, “My student can see him.”

I cannot begin to describe my moment of panic. I’m a first year student. That means I say “I don’t know” a whole lot. I follow, look over my mentor’s shoulder, ask questions. I’m partway through learning long lists of bacteria and viruses.

I’m sure my panic was written all over my face as my mentor reassured me, “I’ll double check once you’re done – just think, you are going to be SO PREPARED by the time you hit clinicals! Here, use my stethoscope…”

And just like that I found myself knocking on the next exam room and reaching out to shake the hand of a miserable-looking young man who didn’t care in the slightest when I introduced myself: “My name is R, I’m a medical student. How can I help you today?”

I pulled up the EMR record, glanced at vitals the nurse had entered, then started right in. The patient was complaining of a sore throat for the last four days. No fever, no nausea or vomiting, no headache. Just the sore throat.

I tried to remember the ‘right’ order of things. Check the eyes, ears, nose. Look in the throat (yikes that looks really painful!), check sinus pressure, feel for swollen lymph nodes, listen to heart and lung sounds (so nervous I truly couldn’t hear a thing omg I’m messing this up so bad!), then have a brief conversation with the patient.

I’m a student so Dr. J will come in to confirm. But at this point it looks like you’ve got viral pharyngitis, basically a sore throat. Since its a virus, it won’t respond to antibiotics, but I know its super uncomfortable. You’ll want to drink plenty of fluids, get lots of rest, treat the discomfort with over-the-counter meds like Ibuprofen and maybe a throat numbing spray like Chloraseptic. Do you have any questions?

(I’m secretly praying he doesn’t. Don’t ask me anything! I promise I don’t know anything!!) But he asks how long before he feels better, and I reassure him that his body should fight off the infection in another 3-5 days. If he starts feeling a lot worse, or develops a fever or other symptoms, please come back to the clinic.

My visit with this patient took less time than it just took me to write about it, although at the time it felt like I was taking way too long. Then back to my mentor to report what I knew. Try to remember those TV shows I used to watch (back when I had time for TV),  students reporting on a patient to their Attending. Run through the patient’s complaint, my exam, try to describe the throat (it doesn’t look like the strep or mono sore throats we’ve been seeing – more like areas of ulceration or something) and then the doc is peering in my patient’s throat, glancing at my SOAP note, then leaning back against the counter while he confirms everything I just told my patient.

And now I know what a coxsackie virus throat infection looks like.

Once the patient is gone, my mentor looks at me. “Two things”, he said.

First, get your own stethoscope.

Second, make peace with the fact that most often (both now and for your entire career), you’ll feel like you’re operating more from life experience than from your med school information. Trust what you know. You’re really good at this.

I could have hugged him. But I didn’t… enough to know I’m on the right path. This is a “first” I’ll remember … for the rest of my life.