Med School Advice

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As most people are working and studying from home right now, I wanted to share some concrete, implementable ways you can help yourself feel better. Though I believe productivity and quantity of work done (or lack thereof) doesn’t/shouldn’t translate into your self-worth and how you view yourself, when you get work done, you actually do feel better in your own body. 

By the way, it’s the first time I’m formatting a tips/guide post like this, so I apologize that I couldn’t be more concise.

I’ve spoken to a licensed professional counsellor as well as to some professionals who have been working from home for a long time, and some of the advice above is from them. I’m also sharing from my own experience as someone who used to be very productive and an (ex-)overachiever, and still attach a lot of my self-worth to grades and other tangible accomplishments. I hope these slides can help you. In case it’s hard to read, I’ve included it (reworded) in text form if you’d like to read more. 

Oh man. Just beware that I have some embarrassingly strong opinions on medical notes. I was (and still am) one obsessive motherfucker when it concerns patients under my care… probably, at times, at the expense of my mental health. So…

We’ll start with your general hospital H&P

As a medical student, however your attending wanted your note written was always the correct answer. That applies to a lesser degree during residency. You’ll generally figure out the people who have strong opinions because, without fail, they will tell you. In those situations, again, the correct answer is whatever your attending says is correct is correct. 

The biggest tip I can give is to develop a mental template for everything. I wrote every H&P during residency in a very specific format. It had a couple of advantages: (1) I never left something important out, and (2) it sped up my ability to churn out H&Ps. Now that template had slight variations depending on which service I was on because, as you probably already have realized, different things are important to different subspecialties. In the beginning, it may be near impossible to put together a mental template just because you’re still learning to differentiate the signal from the noise. Everyone is. I will say that my notes now, as an April first year fellow, are much better and more succinct than my notes were as a July first year fellow. That is perfectly ok to adapt things as you learn more and more. So my basic template for a hospital admission was this:

2. The doctors who do not dismiss the concerns, or instinct of a nurse, nursing student, or med student.

3. A doctor who isn’t afraid to admit when he/she is wrong; to the patient, the nurse or any student in their charge - and a beautiful sincerity in apology without blaming others for what they are responsible and accountable for.

4. A physician who respects students of all descriptions - med students, nursing students, PA students - perhaps likely remembering the beginning of their own journey. One that respects the inherent worth of all his/her colleagues from the housekeeper to the cafeteria worker.

5. A doctor who actually does their assessments, not just standing by the door, observing and charting inaccuracies.  Moreover, there is something memorable about the ones who not only anticipate quality of care, but the ones who take the time to listen intently to, and care for their patients.

6. A doctor who doesn’t embarrass, or make examples of a nurse, resident, or  med student during rounds when they answer a question incorrectly  - and actually takes the time to explain so there’s learning involved. (Not to mention respect of their knowledge and patience).

7. Physicians who understand that there’s sometimes a time to let go, despite any heroic measures, there’s insight of what would be best for the patient, over relentless  interventions.

8. A doctor who doesn’t come out of a patient’s room to ask a nurse/nursing assistant to put a nasal cannula on, fetch a glass of water, blanket or any basic items that a patient is also probably secretly wondering why they have to go get someone else to help me with something so simple; and while some of the more time consuming tasks are not expected - it’s always so very appreciated when one takes the time to assist a patient with positioning, or cleaning.

9.  Doctors who stand up for nurses to the Nursing Supervisors, or one who defends the nurses when a patient or family member is being disrespectful.

Wherever the art of medicine is loved, there is also a love of humanity. - Hippocrates

We all know we need to study, but that’s pretty obvious. This post is about the other side of medicine.The side that you can’t necessarily get from a book. There’s no ‘secret’ to becoming a good doctor, at least not one anyone hands out to you, but there are skills and ways of looking at things we can try as we go along.

Learn to observe other people, rather than judge them. This means take time to learn about lives far removed from your own. Watch documentaries, read their stories and try to engage with how other people may experience the world in a very different way than you do. This is important, because your patients are going to come from all walks of life, and it’s hard to serve people if you cannot see them as anything other than a body, or the other. I even think that reality TV has its place in this; yes, it is sensationalised and probably has a script that does not address nearly enough issues, but it still allows some people a voice that would otherwise never be heard.

Related to this; you are so lucky to live in an age where people can share their experiences freely over the internet. Your forebears could go their entire lives without meeting a patient with a particular condition. Whereas now there are support groups and information pages; places where people wish to openly share their experiences so that others understand what they face. Seek out the words of the marginalised and the sick. Read blogs by different marginalised groups, including people with illnesses and the disabled. Read, but do not comment. Or at least, do not comment as a clinician; they do not need or want your medical opinion, or your defense of medicine in general. If you must comment, do so as a sympathetic human towards another. You are not there to teach them, but to learn. Online, there is a need for both of us to carve out spaces to vent, but it is usually best if we do not intrude on each other. Give them the space to process and to heal.

Listen to people’s stories. As a med student, your job is to learn, but it’s also to listen to patients. You have no idea how much of a privilege it is for people to trust you with their deepest secrets. Letting them share their story is sometimes an important part of making people feel better; do not underestimate this power. In busier times you might be tempted to skip over the talky bits, but remember, if at all possible, your job should be to try to make people feel better, as well as make them better.

Read books. Pick up a Russian classic, or Dickens, or Shakespeare, or Aeschylus or Terry Pratchett or  Harry Potter, or whatever you enjoy, but take your time to explore the human condition as others have seen it. Perhaps even write your own. I think it’s interesting that med schools sometimes prefer you to have done all sciences for A level, when really I think I learned as many useful things in, say English class as I did in physics. This doesn’t just refer to books, by the way, but to the arts in general. See plays, enjoy musicals, mull over poetry, and let yourself wonder about human nature.

Take a life drawing class. Or just look up some artist drawing reference and have a go. You don’t have to be in front of a naked person if that’s too awkward, there are lots of perfectly artistic references online that aren’t inherently sexual. This isn’t just about drawing; it doesn’t even matter if the pictures that come out aren’t very realistic. The important thing here is to learn to observe the body as a collection of shapes and become familiar with its undulations. Our job relies a lot on observation, and for that we need familiarity. It’s also about seeing the body as more than a sexual form; nudity does not have to be either embarrassing or sexual. For many people, the only experience they have of other people’s nude bodies is through sexual contact, and there can be a lot of emotions or awkwardness attached to this, particularly for the younger or less experienced students. The more comfortable you are with the human body, the more comfortable your disrobed patients will feel when you examine them.

Play some video games. Play sports. Play an instrument. Draw. Pick up juggling. Knit. Do something you enjoy, but work on your manual dexterity and spacial awareness. It’s particularly useful if you want to be a surgeon, but it’s fun even if you don’t. Your job will be a very tactile one; we rely on our hands to examine, to carry out procedures and to operate. There’s nothing like the feeling of absolute precision you get when you nail a procedure, or do something just right. Also, hobbies are important.

Teach others. Part of our job is actually teaching the next generation of doctors, so the more comfortable you learn to be with imparting your knowledge, the better. This doesn’t have to be medical, and it doesn’t have to mean powerpoint slides or big talks. Sometimes it’s explaining a topic to your friend in a different way so that they can understand it better. Sometimes it’s taking a wannabe med student through the application process, or sharing your experiences. Teaching takes many forms.

Observe your seniors. Think about their actions, reflect on what they did well, and what you could learn from them; we can gain a lot of skills through observing our seniors in how they interact with patients, for example. Sometimes we also learn what not to do, and that’s also a really valuable lesson. There are doctors we wish we could one day be like, and doctors we vow we will never become. Remember both, as you go along.

Talk with your peers and reflect. We learn from experience; but we can also learn from each other. I’m not just talking about technical knowledge, though I approve of opportunistic learning wherever we may find it. I mean learn about their experiences. What worked, what didn’t, what you or they might do differently next time. The kinds of close friendships you form with friends or colleagues, in which you can truly share your worst fears and your biggest worries about your practice; these are the friendships to cherish.  Reflection doesn’t always need company; self-reflection is an important part of our training, and that starts here. You don’t have to write it down, you don’t have to tell anyone, if you don’t want. But reflecting on what you’ve done, how it went, and what you can learn from it is an important part of our growth. If you think you could have done better, don’t beat yourself up; formulate a strategy for doing better next time; these are habits we form through trying again and again.

Keep an eye on what’s happening in the medical world. And I don’t just mean things like ‘another statin has been invented that cuts stroke risk by 0.01% compared to current best treatments. I mean that you should take an interest in current events on a wider scale. How is politics affecting healthcare? How are marginalised groups affected? What’s happening with your contracts and working conditions? Are there any cases in the news (whether patients or doctors), and what is going on with them? How will they affect your practice? So many things that go on in the world could have a huge effect on your life as a practicing doctor, so don’t let them pass you by.

DRSABCD is a familiar acronym for those who have undertaken First Aid/Basic Life Support courses. Now DRSABCDE can used as a simple, yet comprehensive, approach to CXR interpretation.

Normal CXR 

D – Details: 

Patient name, age / DOB, sex

Type of film – PA or AP, erect or supine, correct L/R marker, inspiratory/expiratory series

Date and time of study

R – RIPE (assessing the image quality)

Rotation – medial clavicle ends equidistant from spinous process

Inspiration – 5-6 anterior ribs in MCL or 8-10 posterior ribs above diaphragm, poor inspiration?, hyperexpanded?

Picture – straight vs oblique, entire lung fields, scapulae outside lung fields, angulation (ie ’tilt’ in vertical plane)

Exposure (Penetration) – IV disc spaces, spinous processes to ~T4, L) hemidiaphragm visible through cardiac shadow.

S – Soft tissues and bones (it is common to leave it until the end)

Ribs, sternum, spine, clavicles – symmetry, fractures, dislocations, lytic lesions, density

Soft tissues – looking for symmetry, swelling, loss of tissue planes, subcutaneous air, masses

Breast shadows

Calcification – great vessels, carotids

A – Airway & mediastinum

Trachea – central or slightly to right lung as crosses aortic arch

Paratracheal/mediastinal masses or adenopathy

Carina & RMB/LMB

Mediastinal width <8cm on PA film

Aortic knob

Hilum – T6-7 IV disc level, left hilum is usually higher (2cm) and squarer than the V-shaped right hilum.

Check vessels, calcification.

B – Breathing

Lung fields

Pleura: reflections, thickenning

Vascularity – to ~2cm of pleural surface (~3cm in apices), vessels in bases > apices

Pneumothorax – don’t forget apices

Lung field outlines – abnormal opacity/lucency, atelectasis, collapse, consolidation, bullae

Horizontal fissure on Right Lung

Pulmonary infiltrates – interstitial vs alveolar pattern

Coin lesions

Cavitary lesions

C – Circulation

Heart position –⅔ to left, ⅓ to right

Heart size – measure cardiothoracic ratio on PA film (normal <0.5)

Heart borders – R) border is R) atrium, L) border is L) ventricle & atrium

Heart shape

Aortic stripe

D – Diaphragm

Hemidiaphragm levels – Right Lung higher than Left Lung (~2.5cm / 1 intercostal space)

Diaphragm shape/contour

Cardiophrenic and costophrenic angles – clear and sharp

Gastric bubble / colonic air

Subdiaphragmatic air (pneumoperitoneum)

E – Extras

CVP line, NG tube, PA catheters, ECG electrodes, etc