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Friday, February 6, 2009

The First Clinical Experiences

Towards the middle/beginning of the end of Med II, medical students are supposed to go on these so called 'Shadowing' sessions with the practitioners of health care; their mentors, superiors, attending physicians, whatever you want to call them. This is some kind of apprenticeship for more clarity... Needless to say, almost all medical students are tired of sitting in class and sitting for exam after exam after exam every week by that time of the curriculum (Med II is the last predominantly didactic year in the med curriculum). So these eagerly awaited sessions are the very first opportunities we get to see actual patients, and understand and witness how, and sometimes whether, what we learn in the classroom is brought to fruition in the real world.
I thought I'd share my experience with my first few 'encounters'...

Med Students and General Trends

So these sessions are generally very rewarding for med students. Well at least they should be. After all, these are the first few times we are exposed to the workings of the health care system and get a chance to experience a touch of what it feels like to be a "Doctor". Remembering the day of our absolute first PD (Physical Diagnosis) rotation, it was a day like no other! Everyone was dressed to impress, the ties, the suits, and the button down shirts -why? we have a formal dress code in our Medical Center (MC) - made it feel more like going to a wedding reception than to class! Right then and there the impressions began to rush into my mind as the personalities, values and norms became more and more public in our prided med students. I can't help but smile as I type this, because I'm remembering my thought process as I saw and analyzed the reactions and moods among the students (myself and my own included, see below). A select few couldn't care less, and it was just another day at the office for them; " hell with the dress code I'm wearing my sneakers today!". To others it meant a slight bit more, as I could tell from the tidiness with which their ties were tied, how neatly their shirts were tucked under their pants; nothing too excessive here, just a different mood you don't see everyday. Still others made a complete, full-fledged rite of passage of the matter and there was a billboard above their heads, piloned to their shoulders, that said "M.D." That stayed on long after the rotation was concluded. The billboard, naturally, came with the awfully unusual and unexpectedly excessive and outright creepy fake friendliness they greeted other, more 'normal' people as well as their colleagues with, not to mention their glue-on, fake, arrogantly proud, or maybe proudly arrogant ear to ear smiles that lasted for hours on end... Some found it would be cute to dangle their stethoscopes around their collars, even among those who were on the dermatology or ophthalmology rotations. Of course, these same students also thought it would be even cuter to keep their lab coats on after they left the hospital, and to flaunt their newly found glory and self-satisfaction and self-approval at the university's main gate and around the better part of the whole campus. Id tags and stethoscopes dangling from lab coat and shirt collars, respectively-and here you err into the nature and discussion of pride, status and meaning of the white apron and stethoscope, the social impressions, the implications and how fake and stupid they may be, but I digress...

My Personal Experience; and a Bit of Introspection to Go...

That morning, I woke up a bit earlier than usual. I can't deny the excitement, the expectations that I had on a day that was a bit more... important?... no... perhaps I should say, a bit different than other days. I put on my new shirt, my new tie, with the pants that I wore to my uncle's wedding some year or two ago. Here's a dead giveaway; my tie was very tidily tied, after all "A well tied tie is the first serious step in life" according to Oscar Wilde! So I left home in a mood that felt brand new. A mood that just seemed to put everything else that was going on at that time on hold. The stressors, the studying, the few nearly failed exams and the financial troubles; everything that had been restlessly gnawing at my brain since even before the day I started med school, was simply swept aside as the new order of the day was to discover what this excitement was all about. Also on my mind was what it would be like to see the inner workings of our MC, to see patients and cases from that new perspective! I can't remember ever starting a day like that before. After a serene 6:00 AM drive to university, a one-hour session of caffeine-kick starting to my system, and an Immunology lecture from 8:00 to 9:00, it was finally time to go to the Ophthalmology department at the AUB MC!

Here, I would have loved to say that the session was a fantastic, life altering experience because not only would that have been wonderful for me to write about, and for you to read, but it would also have been a perfect culmination to everything I've said before. But sadly it would be a lie. The fact is that it was a 35-minute session of show and tell. The ophthalmologist in charge of our group just sat there and force-fed us a review of the anatomy and histology of the eye... and then showed us around saying "oh this machine does this, that one does that..." and a bit of "I know so much more than you do!"... such a disappointment, especially when we got to see the other groups coming right out of Cardiology, ENT (Ear Nose Throat), etc... with their stories and now-even-wider fake smiles! The stuff that I do wanna write about, however, came in subsequent rotations so let's skip to those!
There are two patient encounters that really stuck with me. Two patients that made me realize how thirsty for knowledge we medical students are. Let me start from the end and say that as we got out of the respective rotations in ENT and Dermatology, we were blown away. Blown away, yes, but why? Because in the words of the human embodiment of high-end refinement that is the medical student and future Healer, "it was so cool. it was so interesting, a great case to start off with!" It is here, and after long thought, that I felt something was off and I lost a bit more faith in the medical community... Why? one would ask what the big deal was... I mean I've been rambling about how these experiences are what we've been looking forward to for years and years, why is is such a problem that they turned out 'cool and interesting'? Let me put things into perspective:

Case 1: the very cool case in ENT
A 5 month old baby girl referred to the OPD because she had intranasal obstruction and externally visible swelling over the upper part of the nose. After clear fluid started dripping from her nostrils, an MRI was requested and revealed an invasive mass that had worked its way up through the cribriform plate and into her brain, which explained the Cerebro-Spinal Fluid (CSF) drainage.

Case 2: the very interesting case in Dermatology
A 25 year old man (M.S.) that had a Bone Marrow Transplant (BMT) came to the OPD accompanied by his mother with a generalized exfoliative rash. One of the first signs of Graft Versus Host Disease (GVHD). In his own words: "I had a BMT exactly 120 days ago and this rash has developed lately [...] I'm worried about GVHD and we need to take biopsies[...]".

The implications of these problems/complications that the patients encountered are devastating. Really I don't think I have to explain to the lay person that a tumor reaching and invading the brain is bad. On the other hand GVHD is a complication of immune competent cell transplantation (Bone Marrow and sometimes blood transfusions) in which the grafted/transplanted cells mount an immune response against host tissue, often resulting in multiple organ failure and death. And to see M.S. and how he was handling something he knew so much about was a sobering experience to say the least. He started talking about his condition and throwing the acronyms around, telling the doctor which meds he was on by active ingredient and mode of action! It took me a few minutes to reach back into my rusty and dusty immunology memory and figure out what the hell he was talking about! I was afraid to make an ass of myself if the doctor asked me a question! Skinny M.S. looked tired, and when he undressed to show his rash, the scars scattered on his spent body told the tale of the time he spent on the operating tables. The dermatologist added two more as he biopsied his skin in two places. "I'll call you in a few days and let you know what turns up!" he said to MS. I left the clinic and never heard about MS again.
And there we were, a few hours later, with our "cool" and "interesting" and ooh my case was more interesting and bloody than yours, about life threatening and life altering complications that destroyed lives of patients and their families. That's right, I finally know what a GVHD rash and patient look like, and how a tumor can work its indiscriminate murderous magic! But it's the meagerness of our reactions to these catastrophes, and just how insipid and trivial we made them seem, that gets to me...

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