Valuable principles for my upcoming clinical year

I've heard that on the words, nurses can be your best friend, and your worst enemy.

I have also heard that the more careful attendings, when asked to write a reference letter for you, ask your residents, nurses and other hospital staff about their experiences with you when the attending wasn't around... and you should therefore always act as though your attending is right beside you. Rumors can travel fast in hospitals, especially small ones.

This week I experienced a situation that reinforced both of these points quite well.

I was job shadowing an anaesthesiologist in the OR, and our second-last case of the day was the cutest ten-year-old girl, who charmed the socks off every single person she smiled at. She was such a sweetheart that everyone was disappointed when we had to put her under for her tonsillectomy.

Later on, when we were bringing our last patient into the recovery room, the nurse there came right up to me and took a good look at my ID badge. She then turned to the doctor who was supervising me, and told him, "You should know that your medical student Vitum is outstanding. He came in and checked on that little girl with the tonsillectomy to see if she was awake yet, and I was so impressed with him."

That would probably have really impressed my supervising doctor, had he not known the truth. But he did, and I couldn't take the credit and explained to the nurse: "Thanks, but I was just doing what I was told... the anaesthesiologist asked me to check on the patient!"

While I still believe that sometimes the things you do that go unnoticed are the most rewarding, the reality of medical school is you need those writing your evaluations and reference letters to be able to put down something tangible and positive if you want to to get where you want to go.

So maybe this is a third good principle for me to take with me to the wards in third year: it's sometimes the little things, just as much as the brilliant life-saving interventions, that will impress your supervisors...and more importantly, your patients.

Let me know if you have any more nuggets I should keep in mind next year on the wards!

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The day the ER nurses ganged up on me

I swear I was being good. Really, I was! Honest!

But still, they hunted me down and cornered me, like an angry, bloodthirsty pack of shewolves avenging the death of their young. Or something like that.

Tonight, during a ER shadowing shift, I was sitting unsuspectingly at a computer (I don't know how else to sit), looking up the difference between ringworm lesions and lyme disease target lesions. You know, minding my own business. I thought I heard some nurses off in the distance saying something like "student" or "medical student"... but I brushed it off and ignored it. I went back to my googling.

And then it happened.

I felt a massive shadow coming up behind me.

I turned around... in time to see half the ER nursing staff approaching me in a pack akin (great word) to a pack of shewolves (yes that word is worth the repeated reference).

I hadn't done anything wrong (other than written a certain blog post several weeks ago which shall remain unnamed here) but I figured I was screwed.

I felt like those folks must feel when the infamous Sumdude - a.k.a. 'some dude' - jumps them without warning, rhyme, or reason. By the way, for those who don't know, Sumdud is an emergency medicine phenom (another great word) documented by paramedics, respiratory therapists, nurses, and doctors alike.

Anyways, they surrounded me, towering over me - only because I was sitting down - and shone a light in my face. And thus they began their brainwashing session.

"Be nice to nurses!" they said. "Nurses know best." The skinny one in the back of the herd adjusted the giant, whirling spiral which I can only assume was meant to hypnotize me into oblivion. "And nurses love coffee - bring your nurses coffee."

I shifted uncomfortably. Their tactics were working. I was feeling their efforts to convince me were working. I nodded my agreement in an attempt to signal to them that the giant stainless steel probe they were holding just inches from my face wouldn't be necessary.

Okay, I was wrong about the light, the whirling spiral, and the probe. But a group of nurses did corral me today, and did tell me to be kind to nurses. They were mostly joking, but obviously there is a certain level of seriousness to their comments - I'd be dumb to assume that these nurses haven't been cruelly treated by a doctor at one time or another - though the doctors I was working with today were outstanding.

Fortunately I was able to explain to them the same thing I said in that other, previously mentioned but unnamed post, that I've been told all this already by my nursing friends and my nurse mother.

I wish this story had a more dramatic ending, but that was it, really; my comments seemed to appease them. The rabid pack broke apart, most of the nurses wandering off into the meds room, still laughing about their indoctrination method, and sharing stories of nursing back in the days when nurses used to stand up when doctors entered the room and mustard poultices and turpentine were common treatment methods, and I went back to my Tinea corporis and Borrelia burgdorferi.

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Geez, what a dumb nurse.

Make sure you read this post to the end before you make any quick judgments!

I was in the emergency department this week shadowing a doctor, and I was surprised when an older nurse came up to the doctor and said,

"I don't usually have trouble putting in catheters, but I have no idea why putting one in this guy is so difficult. Could you help us out?"

When I looked over at the patient she was pointing at, I gasped. How the heck could the nurse be that stupid?

I had to interrupt. Looking her right in those dim-witted beady little eyes, I said, "Excuse me, but are you trying to be funny?"

The patient was a 67-year-old male who had come in with a chief complaint of "I can't pee because my prostate is flaring up again."

No kidding you're going to have a hard time putting a catheter in, and what do you mean you don't know why?! The guy's got BPH (Benign Prostatic Hyperplasia). When the prostate has swelled up to the size of an softball, seeing as how the urethra runs right through it, of course it's going to pinch that urethra right shut. Especially when the internal zone of the prostate is the part that increases in size due to BPH.

I mean, come on - how could the nurse be that stupid?! I'm a flippin' first-year medical student and I know this basic stuff; she's been on the wards for decades and you're telling me you're clueless? Haven't you seen how big an enlarged prostate can get on gross pathology?

Okay, I'll stop this little anecdote right here and tell the truth - this didn't actually happen. I've never called anyone "dumb" and meant it, and don't intend to start now.

But it might have, had I not read what Kim at Emergiblog wrote after seeing BodyWorlds 3. (yeah I'm bringing up Kim again! can you tell I've found a new blog I love?) Don't forget, this is being written by a nurse of 28 years:

"I’m sure my mouth was open through the entire exhibit. There was so much I did not know or had forgotten over the years. I knew what was there, it was the proportions that astounded me.

• The only thing standing between us and paralysis is a thin cord of nerves about 1/2 inch wide - the spinal cord. It seemed very fragile when viewed in a display of the nervous system, from brain to periphery.
  
  
• The kidneys are so tiny - and now I understand in three dimensions where they lie in the body. I know why a 3 mm kidney stone causes so much agony as it travels down a ureter with a diameter of 1 mm. The spleen was smaller than I thought it was!
  
  
• The uterus, which looms so large in my imagination, is extremely small. All those period cramps come from that tiny sac? Holy cow! The ovaries? Smaller than walnuts - my daughter’s dermoid cysts were larger than the ovaries they inhabited!
  
  
• Sciatica? Well, that explains it!
  
  
• I not only know about COPD, I saw COPD!
  
  
• Cardiac tamponade? I see how it compresses the heart!
  
  
• Smoking? Take a look at the two lungs that look solid black. You’ll never smoke again.
  
  
• I saw why I can’t pass a catheter through an enlarged prostate."

End quote.

I'll be honest with you, and you'll see where that fable I told might have come from. After reading that list, my first thoughts were:

"Are you kidding me? You didn't know the spinal cord was 1/2" thick? You didn't know that smoking turns your lungs black?? I wouldn't have been surprised by ANYTHING on that list, and I'm just finished my first year! She's been a nurse for 28 years and STILL doesn't know all that stuff?!"

I suddenly looked up from my computer screen and felt a rush of shame come over me. I realized that if I had said that out loud, it would have no doubt come across as a jackass thing to say. The next thing in a rant like that could reasonably have been something like, "Geez, she is SUCH an idiot!"

How could I have thought something so rude? Me, of all people! After all my posts on interdisciplinarity and treating nurses with respect, after saying that I love and will always respect nurses because some of my good friends and my mom are nurses, and after pumping that same nurse who wrote that just this week, after having the purest and most idealistic of intentions, here I am pretty much bashing nurses already!

Then, I remembered something.

"That's right! I always knew that the nurses I went to undergrad with never really got the chance to work on cadavers and take pathology like I did."

And that's what I had been missing. Until now, I had never made the connection that unless you have taken pathology, or held a human kidney in your hand, it's actually pretty hard to visualize what an enlarged prostate looks like, or how thin the spinal cord is, or how small the kidneys actually are.

If I hadn't made that realization here, today, perhaps the little scenario I made up at the start of this post actually could have happened in a couple years when I'm on the wards.

I'm no better or smarter than Kim is. In fact, put me in a hospital or in front of a board exam right now and I bet you anything that Kim would answer more questions correctly and save more patient's lives than I would, after all those years of clinical experience under her belt. But already, after one year of classes, I was thinking thoughts that if spoken, could easily be interpereted as superiority, or simply being a jackass.

Yes, some doctors are assholes to nurses just because they think they can get away with it, because they have their own issues to deal with, because they're just assholes, or maybe because since orders have always been called "orders" they think it's okay to actually "order" other health professionals around. And after being through a year of medical school, I can almost sympathize with a doctor who stands up for him or herself and comes across as being a jerk, because after being through those first-year finals -- the most intense, trying time of my life -- I have a lot more confidence in myself, and quite frankly, after four years of this, I won't take crap from anybody.

But perhaps some of the barriers between professions aren't for any of those reasons. Perhaps some doctors come across as being jerks even if they try hard not to. Perhaps sometimes it's just because of simple misunderstandings.

Not because of a superiority complex, not because somebody thinks they're better than someone else, but because they just never took the time to stop and think about how differently we have been trained, and how our professions are designed to look at the same problem from different directions. And that's where the strength, the untapped gold mine of interdisciplinarity, comes from.

Yeah, I'm still fresh and new and idealistic, perhaps, but hopefully I can keep stopping myself whenever I think ignorant thoughts like that, and hopefully I'll continue to challenge myself to treat everyone with the respect they deserve. After all my good intentions of being kind to nurses, and then seeing my initial reaction to Kim's comments, clearly good intentions aren't all that it takes.

Thanks, Kim, for letting me pick on you without so much as asking, and I hope that this hasn't discouraged you from writing out your true feelings in the future, even though it it might make you vulnerable to ignorance people like me. I really do admire your writing.

---

Ever since Kim was kind enough to post this at Change of Shift (Grand Rounds of the Nursing blogworld, from my interpretation) I've noticed a lot of readers who have come from there. Those who want to read more about the difference between how doctors and nurses approach patients might want to take a look at the evil resident's take on this issue.

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Step Towards Interdisciplinarity: Blogging?

"[Until I read blogs written by physicians], I had no idea what it was like to be a physician."

Who would probably NOT say something like this:

a) A blogger who is a pre-med student 2 years away from medical school
b) A blogger who has been a nurse for 28 years
c) A blogger who is a patient that has suffered from a chronic condition for 3 years
d) A blogger who is an average, healthy 32-year-old female.

.
.
.
.
.
.

Did you choose B? I sure would have.

So you can imagine my shock when I read that quote on the high-quality Emergiblog, authored by a nurse of 28 years. Of all the people in this world beside doctors themselves, wouldn't you assume that nurses would the ones who understand doctors the best??

Sure, everyone knows that there is a varying level of disconnect between the two professions, but for being someone who has worked alongside doctors for nearly three decades you'd think she would understand what doctors are like.

It's great to see, then, that maybe blogging could be a tool for breaking down the walls between health care professions.

Unlike perhaps many medical students and doctors, I've got a soft spot for respiratory therapists, nurses, hospital security guards, and naturopaths, all because I've gotten to know some personally both before and after they entered their professions. Once you realize they're people too, people that you respect, you're much more inclined to respect their profession and look more closely for what they have to offer. Reading what they have to say, on blogs for instance, can help you towards that realization.

If reading blogs written by people in different health care professions helps us understand them more, then why couldn't that be one more step towards truly working together as a team.

PS - I think it's impressive that she would write that reading doctor's blogs has helped her "appreciate" physicians more than ever, especially considering how much crap nurses generally take from some doctors. Nice to see someone who has been in the profession that long who can still write things that are not bitter & jaded, when it's almost certain that over the years she has had to deal with more than a few doctors who haven't appreciated her as much as they should.

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What doctors REALLY think... and preliminary thoughts on interdisciplinary health

"Research is a real problem. Doctors just make up the data. They don’t report negative side effects, no question about it."

Someone at New York magazine had a brilliant idea a few weeks ago.

"If I ask a bunch of doctors a bunch of questions," they pondered, "but promise them anonymity, just think all the great dirt I'll be able to print! They'll be so straightforward and honest, I'll be one of the few people on earth to know what doctors really think."

Someone at New York magazine seems to have forgotten about the medical blogosphere.

Every day, countless doctors rant anonymously about the dirt that goes on in hospitals. They just happen to do so in the form of blogging.

But someone at New York Magazine ended up doing the interview, writing the article, and hey, it got published. How Comrade found this article in the New York magazine online four full days ahead of print, I'll never know, but thank him, since you'll probably find it quite interesting.

Selected highights, my smartass comments in italics:

• Why you have to wait so long in a doctor's waiting room.
  It's because you are not the doctor's only patient.

• Doctors make up research data.
  Did you know that 86% of statistics you hear are made up on the spot?

• The way we train doctors now is worse than it used to be, because the residents who do surgery on patients are now allowed to do surgeries after they have had time to sleep.
  Yeah, you'll have trouble convincing me of that one. Say it with me: "Old-Boy's-Club."

• Patients have to wait for 45 minutes after they press the call button, not because nurses are standing around chatting, but because there's a nursing shortage.
  Hmm, so it's not just in Canada, eh?

• Doctors think that "By virtue of our training and knowledge, we can get away with... treating patients like shit."
  Strange, it took me only one year's worth of med school finals to get that feeling. At this point, I call it self-respect. Three more years of this and you'll probably call it me being an asshole.

• A doctor admitted to dropping a baby once.
  You think that's a big deal? Read the next one.

• Doctors feel powerful when they've killed somebody.
  I told you you need to read this article. Here's the link again.

After reading that article, I'm surprised that even at my early stage in the game, a lot of it I could have told you. A good chunk of it is, in fact, common sense. Think about it. Doctors like seeing patients that don't yell at them. Surprise. You have to wait in the waiting room for a long time because, well, doctors are seeing other patients. Surprise again.

But there's one thing that I'm surprised they didn't mention. It's...wait a minute, what? you want my opinion?

Sorry, but apparently in training for making a living by, well, mostly giving my professional opinion, it's been made abundantly clear that I am not to provide medical opinions of any sort. Not even to a friend who asks about their cold. Or growth. Or whatever.

Of course, I'll give you my opinion anyways. That's what this blog is all about. But here, I'm protected by my fancy disclaimer at the bottom of this page. Yeah, it probably provides little more protection than did those fancy flying-squirrel-like jumpsuits that early would-be aviators donned before jumping to their deaths, but at least it's something.

So here's what I think. I'm surprised the article didn't ask any of the doctors their take on the "interdisciplinary health team" that everybody is talking about.

I was talking about this interdisciplinary health thing with a nurse friend of mine the other day. I was going with that old joke that I find so funny (that no nurses see any humour in at all), telling her, "I can't wait until I've graduated med school so I can boss around nurses." (That is NOT how I will approach nurses on the wards...trust me, I know better.) But after we got back on speaking terms, we got into this talk about interdisciplinary health care - a concept that is very interesting, considering how little of it I've heard in my med school curriculum.

Medicine these days is supposed to involve all "health professionals" on an "equal playing field" - doctors, nurse practicioners, nurses, licenced professional nurses slash registered practical nurses (depending on your geographical location), respiratory therapists, physiotherapists, occupational therapists, chiropractors, naturopaths, quack cure-all syrup salesmen... (uh, in no, particular order...I swear...), all working together in perfect harmony like oompa-loompas churning out everlasting gobstoppers. If that's the case, though, and if it's the new wave, how come I haven't been taught that yet in medical school?

But that's another story for another day - I have a rant on that waiting in the wings...to be continued.

Click here to read the continuation of this post.

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Learn from someone else's mistake #2: The Day my Sense of Humour Died

I told my last med school joke today.

So much for my mark for "Professionalism" for this block of case-based learning.

We were given a case and on one sheet, the information provided said that "vital signs were normal." Then, on the next sheet, the respiratory rate and heart rate were elevated. One person in our group said, "I thought we were told that the vitals were normal!"

My fateful response: "Don't trust nurses."

Ha, ha. I though it was funny. Most of the people laughed, too, and realized that I WAS JOKING, and that comment is NOT exemplary of what I feel about nurses.

Please let me provide context (perhaps my first mistake; I made my comment in the first session with a new group, so they probably didn't realize that I try really hard to respect everybody and every profession and every member of the health care team).

• I know from personal experience, and I strongly believe that nurses are an important and valuable part of the health care team and play hugely significant and essential roles. Without them, hospitals wouldn't function.
• I know that nurses can be a doctor/med student's worst enemy or best friend
• I have several good friends who are currently nursing students, or just became nurses. Heck, I read nursing blogs, I dated a nurse once, I have friends whose moms are nurses, and my mom's a nurse, too.
• I wouldn't wish anything bad upon a nurse and plan to treat them with the respect and admiration they deserve.
• my only exception: when there is incompetence or danger to a patient, then I have no tolerance (but this goes for anyone working in a hospital)

Anyways...the tutor asked me to repeat what I had said. I told him I was joking, and he went on a rant about how his wife is a nurse, how nurses are important part of a team, how what I said wasn't funny, and on and on and on. When he finished talking and I had turned red enough and sunk deep enough into my chair, I blubbered out an apology.

Serves me right - when we were laying out ground rules for this case-based learning block, I offered, "Be willing to give and accept constructive criticism." I didn't expect to have to accept some so soon. The funnier part was that, according to our case, it wasn't a nurse who presented the vitals - it was a paramedic.

Figures. Don't trust param.... i mean, nevermind! ONLY KIDDING! man, I really haven't learned my lesson. (Oh dear, do I have to make it clear that I love paramedics now, too?! okay here goes: that's what I originally wanted to do with my life, and a former paramedic in my class drove me to school today :) )

The tutor did say he was sorry for singling me out and later apologized again, and I had a chance to try to redeem myself and say what I really feel about nurses and that my flippant comment wasn't what I really believe. Good thing it was in a small-group session with only 8 other people.

I definitely am much more aware that I need to be careful with my jokes, because usually they don't emphasize the amount of respect I usually have. Also because this isn't the first time I could've been more tactful. Maybe it was my enjoyment of other blogs where med humour abounds that led me to say things like that...regardless of where it came from, from now on I'll keep it to the written word.

Wish me well in beating down my sense of humour. Class clown, signing out.

**Postscript (10/24/06)**
Our tutor has lightened up a bit; I think perhaps he feels bad for reaming me out. I've noticed a distinct - almost forced - effort on his part to laugh at all the (very sterile and non-offensive) jokes I've made since then.

**Post-Postscript (07/24/07)**
Since I've linked to this post I read it again. Fortunately I've learned from this (and I know better now, thanks Captain Constructive Criticism below who called me an ass). In my review for the block my tutor made mention that I shouldn't be too careful lest I lose my 'endearing' sense of humour.

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