Archive

Monthly Archives: July 2012

The third year of medical school is a pivotal experience in the lives of training physicians. In some ways, it is one of the most difficult years in training, besides intern year. In this series, I will share lessons I learned as a third year medical student and my experiences teaching third years.

In the first installment of this series, I discussed the common pitfalls encountered by third year medical students. This time, I will discuss the qualities of students that make them shine and prompt their attendings and residents to say, “Wow, she is a great student.”

While many medical schools now have common parameters on student evaluation forms asking residents and attendings to grade knowledge, examination skills, critical thinking skills, cultural competency, systems awareness, and professionalism, the bulk of a student’s performance that distinguishes her from her peers centers on qualities that are not specifically queried in these evaluations. These are typically strengths of character that underscore every aspect of the student’s behavior. While this is by no means a comprehensive list, I describe some of these virtues here:

1. Consistency.

The training of physicians emulates the principles of future practice, and one of these principles is that physicians are required to perform to the highest achievable quality of care (and other roles, such as teaching and research) every day. Accordingly, students who maintain a steady and improving performance curve during the course of their clerkships are the ones who succeed. Much of the notion of reliability centers on a consistent manifestation of behaviors and attitudes. For example, the reliability of a consultant depends on his routine demonstration of politeness, enthusiasm, and thoughtfulness in evaluating cases and offering advice. The more the consultant strays from this path by angrily berating consulting physicians for an excess work load and by offering unhelpful suggestions, the more this consultant is viewed by his peers as unreliable.

Similarly, the best students are consistent in their behaviors and attitudes towards all people they work with: the patients and their families, nurses, therapists and technicians, residents, attendings, fellow students, etc. Students who only pander to their senior residents and attendings are flaky kiss-ups, while students who treat all with respect, kindness, and collegiality are viewed as solid.

2. Enthusiasm.

The practice of medicine can be tiring and grueling. Nonetheless, teaching is often a source of joy that cultivates energy for many physicians. Accordingly, students who demonstrate and foster enthusiasm for learning are more likely to be engaged by their residents and attendings in minute-by-minute teaching and guidance throughout the working day rather than just during scheduled teaching sessions. Similarly, students who are enthusiastic about patient care rekindle this desire within tired resident physicians, prompting those residents to perform better in order to serve as good role models and guides to the students and their patients.

The most enthusiastic students might also sometimes share enthusiasm in a meaningful, nonintrusive and noncompetitive way with their peers (fellow students), encouraging all towards improvement of knowledge and practice. A genuinely enthusiastic student can truly galvanize a team towards functioning as a better unit, engaging in more teaching, and delivering better care.

3. Passion

While enthusiasm is a must, passion for the professional field of the clerkship (e.g. the training chosen by the residents and attendings) is not required for students. For example, I do not expect students on the Neurology clerkship to all want to become Neurologists. While an expression of genuine interest is always a pleasant occurrence, this does not set up this student in my mind as a better performer or as one that I should treat more kindly or with more attention. Inevitably, I do end up interacting with students who do have interest in this field slightly more because of the desire to ask questions and seek advice about residency, but this does not reflect on performance.

However, passion for something is an important quality that all physicians should have but many do not display, at least not openly. Whether it is a passion for public health or improving education or delivering better patient care or restructuring health policies, the expression of passion by students almost always works in their favor. People want to work with others who care about something, because passion is an energizing force.

4. Integrity

Moral behavior is usually the principle tenet underlying the concept of integrity for physicians-in-training. In particular, honesty is an essential trait. While it is acceptable for patients (particularly with neurologic, psychiatric, or systemic symptoms) to confabulate, it is NEVER acceptable for a student to outright lie or even slightly bend the truth. I have utmost respect for the students who say “I don’t know,” “I didn’t ask that question,” or “I didn’t examine that” when asked about history or examination details by an intimidating attending physician or senior resident. By corollary, I immediately lose faith in the integrity of students who fudge the truth, and I can no longer trust anything he says or does. Integrity can seem to be a very difficult quality to cultivate, but in reality, only the strength of a student’s commitment can keep him honest.

5. Compassion

Most physicians engaged in patient care derive some satisfaction and expression of purpose from patient care, and in particular, the giving of compassion to those who are sick. Particularly in a system which constantly conspires to keep physicians and patients at a distance (separated by time, excess documentation, and threat of litigation), the demonstration of compassion by a young trainee shines like a beacon that inspires hope. In particular, since each aging generation predicts destruction for the next, it is encouraging to see a commitment to the primary virtue (compassion) that fuels the practice of medicine, even when the health care delivery system itself does not readily support this virtue and often works against it. Seeing compassion in a student reminds the rest of us why we came into Medicine in the first place. For some attendings and residents, having that reminder each year with new students helps us cultivate and maintain our own commitments to this virtue.

6. Confidence

While overconfidence and lack of confidence can both discolor student’s performance, displaying a healthy degree of confidence is a positive asset for students on their clerkships. In particular, when faced with a question to which he does not know the answer (a frequent occurence on the wards given the nature of “what am I thinking?” questions often asked by residents and attendings), a student should feel comfortable stating that he does not know the answer but still have the confidence to try and reason through: “I do not know for sure, but I think that this could be caused by (etc., etc.).”

Most people do not know from where confidence should arise: often the assumption is that confidence comes with knowing everything, but this is a losing game for students because inevitably someone (an attending or resident) will know more. Rather, confidence should arise from a student’s commitment to fundamental principles of Medicine and to performance as a physician according to those principles: “I am confident that although I do not yet have all the knowledge or skills I need to perform this task, I will continue to constantly improve and learn. I am confident that I will always provide care for patients with as much compassion and integrity as I would want for myself or my own family.”

7. Groundedness

Much of the third year of medical school on an intellectual level is based in theory and discussion: third years spend a large portion of their time in attending rounds, tutorials, and conferences. However, the faster students transition to the reality of delivering actual patient care, the better they will be suited for their imminent roles as interns and residents. Accordingly, students who delve more actively and deeply into the nitty-gritty of patient care tend to find rewards in the form of gratitude from patients as well as from residents (who appreciate the care given that they otherwise would have to deliver and the identification of issues that might not have yet been addressed or discovered). Residents and attendings want to see progression of students as they emerge from their coccoons of the preclinical years to becoming full-fledged clinicians who are capable and pragmatic.

8. Hardiness

While clerkship policies vary from one medical school to the next, there in theory are no work hour restrictions for medical students (while there are strict restrictions for residents). An amazing amount of respect and gratitude goes to students who jump into the trenches with their interns and residents to actively engage in patient care, work long hours, and see tasks through to their completion (rather than wait for the updates the next day, a task which requires more time from the residents in the morning when they are otherwise busy preparing for the work day). By corollary, there is a strong cultural stigma against asking the question “Is there anything I can help you with? (two seconds later) Can I leave?” The general wisdom among medical students that is handed down by residents and attendings is that the more one helps out with patient care and getting work done, the more likely one will be given opportunities to learn as the residents will have more time to teach. This, of course, is a probability game: the teaching will not always happen, and not all residents are interested in teaching and not all are effective teachers. Nonetheless, demonstrating hardiness and resilience is an admirable trait: just like in battle, there are people you want to have by your side, and being one of those people gives one considerable value and respect in the eyes of others.

9. Camaraderie

Finally, at this time, medical care is rarily delivered solo, and within the hospital setting it is always delivered by teams. Accordingly, it is essential for physicians-in-training to cultivate camaraderie among their fellow trainees, with residents and attendings, and with other staff members who help to deliver care to the patients. Recruiting patients and their families into this “team” is also one of the most effective strategies for delivering long-lasting positive effects on individual health outcomes. The students who do this best support their fellow classmates (by sharing their learning and serving as leaders among the students), support their residents (by helping them out with patient care tasks, including performing initial evaluations, scut work without calling it or thinking of it as scut), support other staff (by treating nurses and others with respect and as equal partners in this enterprise), and supporting their patients (by becoming the primary liaison with patients and their families, fielding questions and offering capable answers when appropriate and seeking assistance when needed). Team players are valued in medicine, while most self-imagined virtuosos (or prima donnas) are almost all failures due to paralyzing personality traits (e.g. succumbing to the pitfalls mentioned in the previous post and not embodying the virtues described here). As such, anything one does to foster camaraderie on the wards will earn respect and admiration.

Fellow residents and attendings, what qualities do you value in students? What characteristics or behaviors help distinguish students as the strongest performers and the most likely to become excellent physicians? Please send in your comments and thoughts.

[ Introduction and Background ]

Previously, I discussed the merits and problems of my first keyboard case for the iPad, the ClamCase. While it still remains one of the best options available, a few factors have prompted me to search for an alternative case.

Just as a reminder, I am a Neurology resident at a training program at a large academic hospital that has three Neurology primary services and three consult services as well as a smorgasbord of general and subspecialty clinics. This hospital has a browser-based online medical record and order entry system that makes it very easy to use an iOS or Android device (or a laptop) to perform digital tasks to contribute to the medical care of patients. For the second year in a row, the program is issuing iPads to its incoming junior residents. Our program, in particular, generates massive amounts of admission, consultation, and progress notes (which include “accept notes” for all junior residents assuming the care of new patients, even if another admission note is available, and “chief accept notes” for chief residents in a similar position). Accordingly, having a method of performing actual word processing on the iPad is an attractive objective.

In the setting of my wife (also a Neurology resident) researching cases for her new iPad which her residency program is issuing to her for a similar purpose, I have sought out alternatives to the ClamCase. In particular, my desire was to find a solution that matched these criteria:

1. Battery Life – Perhaps the most important factor is that the keyboard case should have a very long and stable battery life. In my line of work, I can’t afford to sit down and plug in when I might have to respond to a Code at any given moment.

2. Weight – The ClamCase essentially doubles the weight of the iPad and adds considerable heft to the standard Neurology bag. I would prefer a lighter case if possible.

3. Comfortable Keys – Many of the iPad keyboard cases have relatively poor quality keys or oddly arranged keys that provide an unsatisfying experience that ultimately slows down the typing process, and hence, reduces productivity.

4. Protection – I would want a case that offers sufficient front face and rear encasing protection for the iPad. Sadly, I previously dropped an iPad in the line of duty (running to the Emergency Room to respond to an emergent consultation for a life-threatening traumatic head bleed). At the time, I was using the standard Apple “Smart Cover” which offered no front screen protection, particularly when it slipped out of my hand and landed glass-side first on the tiled floor!

[ Hypothesis ]

There must be a keyboard cases that provides a suitable balance between battery life, light weight, keyboard layout, and protection.

[ Results and Discussion ]

After viewing and trying out several cases in a local store including the Zaggfolio, Targus Versavue, and Logitech Solar Folio, I have recently settled on the Logitech Ultrathin Keyboard cover. The Zaggfolio and Versavue keyboards lacked a good typing feel (lack of spring in the keys). The Solar Folio is a nice option, but it lacks any backup method of charging besides the six hours of natural or incandescent lighting required to charge the keyboard battery. Nonetheless, I also had a lot of reservations about the Ultrathin Keyboard cover initially including the following:

1. It offers almost NO protection. – This is not actually a “case.” It is essentially a svelte version of the Apple Smart Cover with a built-in “chiclet” keyboard. It connects to the iPad with a magnetic hinge, providing a cover for the glass screen when closed but otherwise not contributing any protective benefit, particularly to the rear of the case. It additionally will do nothing to protect the glass screen when opened.

2. It cannot be flipped 360 degrees. – Unlike the ClamCase, the cover has to be detached in order for one to use the iPad comfortably. In other words, the cover cannot be flipped across the rear encasing of the iPad: the hinge will not allow for that much rotation. Fortunately, the cover is extremely easy to detach, but this is somewhat disappointing feature of the design.

3. It has few viewing angles. – Unlike the nearly 360 degrees of viewing angles offered by the ClamCase, this cover only allows for a single viewing angle which is approximately 60 degrees from the table. It is a relatively steep angle that makes typing on one’s lap potentially awkward when sitting upright.

4. It was not clear whether or not other protective encasings would be compatible with this device. – Some user reviews described being able to encase the iPad in a plastic shield whereas others vehemently denied this possibility.

5. Several users described not being able to type on their laps with this keyboard. – Since the keyboard is very light, some users expressed concern about the possibility of the top-heavy iPad toppling over their knees and onto the floor when trying to type on their laps.

Nonetheless, I decided to take the plunge and attempt to fit a Belkin Snapshield onto the iPad 2 and then see if this would be compataible with the Logitech Ultrathin Keyboard cover. Fortunately, this gambit paid off, and the finally result can be seen in these pictures.

This keyboard cover does have several key advantages:

1. It is very light. – Carrying my iPad and this keyboard in my bag feels almost weightless compared to the past several months when I was carrying the ClamCase.

2. The keyboard has a good feel. – While the keys do not have the laptop-style feel of the ClamCase keyboard, there is a slight separation between the keys that offers a good degree of spring. The feel is superior to most other keyboards incorporated into keyboard folio cases that I tried.

3. It is attractive and streamlined. – When attached to the iPad, it maintains a slim profile, approaching that of the MacBook Air.

4. It is compatible with the Belkin SnapShield. – At the very least, the iPad 2 with an iPad 2 SnapShield and the Logitech Ultrathin keyboard are compatible together (which has been corroborated by at least one other user). This may not be the case for the third generation iPad and associated SnapShield as the dimensions are slightly different. Having the SnapShield offers rear encasing protection for the iPad, attenuating the lack of protective qualities of this keyboard cover.

5. The cost is less than the ClamCase. – The Logitech keyboard is $100 while the SnapShield was an additional $30, making it slightly cheaper than the ClamCase.

[ Conclusions ]

Time will tell whether or not this combination of keyboard and case will be sufficient for the demands of the hospital, but at this time it offers a lightweight and attractive alternative to the ClamCase. Thus far, I have been using it for three days, including during noon conferences and lectures and during my continuity clinic for my clinic notes. My hope is that the battery is longer lasting and more stable than that of the ClamCase, and that the light weight does not come at too much cost with regards to reduced protective qualities.

Previously, I discussed the merits of the ClamCase, an innovative and useful keyboard case for the Apple iPad. Of all of the higher end and pricier keyboard cases, it definitively remains one of the best options available for the production of written content on the iPad. During the past seven months, I have written numerous admission, consult, and progress notes every day I have worked in the hospital, and I have additionally written weblog posts and numerous e-mails. I often had a hospital computer open to an electronic patient record while having the iPad open to a new word processing file which would allow me to type notes and read simultaneously. Unlike a laptop, the iPad with a keyboard case allows for instantaneous access for quick tasks at the bedside and while rounding (such as typing in an order in tablet form with one hand holding the device and the other hand tapping the screen and typing) while also allowing for comfortable word processing and reading. The combination of the ClamCase and iPad 2 essentially replaced my old laptop (a previous generation of MacBook of the black plastic variety) except for the occasional Photoshop task or for iTunes file synchronization and backup.

However, there are a few important disadvantages of the ClamCase which may or may not be generalizable across the product line. First and foremost, the battery life of the device is variable. Initially, I did not have to charge the keyboard for days at a time, but about five months into its lifespan I discovered that it was losing its charge during the course of a day’s work. After some weeks of experimentation, I have not found consistent behavior of the battery in response to overnight charging and roughly comparable usage each day, leaving me with some degree of anxiety as to whether or not it will keep its charge during a particularly busy day of consults and admissions. I suspect that this is the result of me not treating the battery correctly, but most people do not maintain good battery charging practices which makes me wonder how often customers have difficulty with the battery for this keyboard case.

There are a few other additional small and surmountable issues. The case is heavy: the weight of the device essentially doubles the weight of the iPad. The four protective pads on the keyboard side of the case which elevate the keys off table surfaces when flipped into a video viewing mode quickly lost their adhesive and tore off easily. The keyboard additionally has very nice laptop-style keys, but some do become slightly sticky with time, sometimes causing the keyboard to produce a string of repetitive letters which sometimes would require exiting from an app to interrupt. Over time, this has become a more frequent occurrence. Lastly, on a purely cosmetic level, my white version of the keyboard case very easily stained on the bottom surface within a week of ownership.

In summary, the ClamCase has been an incredible boon to my productivity on the hospital wards, but after seven months my particular device has aged and is starting to run into difficulties. Some user reviews have commented on issues with maintaining the battery’s charge and not being able to trust the green/amber indicator light. If I had assurance that the battery issues has been fixed, I would certainly purchase another ClamCase, but in the mean time, I have started to look into alternative options.

The third year of medical school is a pivotal experience in the lives of training physicians. In some ways, it is one of the most difficult years in training, besides intern year. In this series, I will share lessons I learned as a third year medical student and my experiences teaching third years.

The third year of medical school is the most confusing and disorienting year in the process of training to become a physician. While the first year of residency (intern year) has traditionally been the most exhausting and demanding (emotionally and physically), this year continues to lessen in intensity as the field attends further to the tolls and dangers of sleep-deprived trainees. However, the third year of medical school, if anything, is increasing in difficulty. While the responsibility and activities of interns is centered on patient care activities, the purpose of the third year clerkship is variable and highly dependent on the fickle expectations of residents, attendings, clerkship directors, and medical school curriculum designers. These expectations are unfortunately frequently in conflict with one another and include the following activities:

1. Learning the science of medical management (e.g. pathophysiology, clinical presentations, differential diagnosis, treatment, prevention, etc.) – through lectures, reading, teaching on rounds, the workup of individual patients, and tutorials

2. Learning the art of medicine (e.g. developing relationships with patients and their families, interacting with other physicians and hospital staff)

3. Learning “roundsmanship” and team work (e.g. operating as a member of a physician team)

4. Assisting with patient care (e.g. reevaluating patients, scheduling followup appointments, calling primary care physicians, calling subspecialty consultations, performing minor scut work)

5. Presenting to and teaching the physician team (e.g. learning about a subject and giving a short presentation on attending rounds)

6. Learning a broader standardized curriculum designed by the medical school that encompasses topics that might otherwise be missed between individual rotations (available in some medical schools)

7. Learning how to manage a continuity clinic (available in some medical schools)

Unfortunately, these expectations are often not explicit, or students do not know which expectations to prioritize. Accordingly, it is easy for a reasonably intelligent student with good intentions to fail during this important stage of training due to lack of flexibility, poor insight, and a lack of assertiveness. To guard against this, I offer a brief review of the most common pitfalls that third year students face:

1. Not being present.

The most common and devastating mistake that third year medical students make is to become invisible. In many schools, the clerkship final examination (the Shelf exam) may account for as much as 30% of the final grade. Having spent every year of schooling prior to this learning from books and taking tests on paper, it feels most natural and most safe for medical students to dive into the review books and Up-to-Date in order to desperately try to learn the vast amount of information that they might encounter on their clinical rotations. However, they may fail to account for the remaining 70% of their clerkship grade for which the majority derives from the evaluations written by residents and attendings that work with the students. They also fail to realize that most residents and attendings actually like working with medical students or at least feel some degree of responsibility for their education. This mistake typically manifests as the student venturing out of sight of the residents in order to read a review book in a quiet space. (At the very least, if a clinical service is quiet, the student should ask her residents if it is okay to find a place to read so that the residents know where she is and what she is doing.) Out of sight, out of mind. Once the student removes herself from the vicinity of the residents or attendings, she is no longer is available for the minute-by-minute pearls of wisdom, the observation of how patient care is coordinated and carried out, and the opportunities to engage actively in patient care as new issues and crises arise. Also, the tendency for residents is to write positive evaluations for their students, and being present provides more material to write about while being absent leaves the resident with little to say in favor of the student.

This pitfall is becoming more difficult to avoid as many medical schools redesign their curriculums in such manner that they are spending more time in the classrooms and away from the patient wards and their teams. The most common complaint of residents and attendings is that these new curricular changes result in the students never being around. Accordingly, third year students have to be very careful to cultivate expectations and let their residents and attendings know where they are or where they will be at all times.

2. Being late.

One of the crucial aspects of ensuring one’s attendance is to be on time to all regularly scheduled meetings. This usually isn’t a problem for most students, but again, students who spend more time away from their residents are more likely to be left behind when work rounds, attending rounds, or teaching sessions are shifted from their usual times.

3. Failing to learn something taught with emphasis.

In general, most residents like students and want to see them succeed. Furthermore, on a more self-serving level, students that perform well reflect positively on their residents (as teachers and role models). Residents will use different strategies to help their students perform well in the eyes of their attendings. The most obvious manifestation of this is a resident rehearsing a verbal presentation with a student for attending rounds. The resident will often point out key details for the student to highlight or describe a particular way in which the important information should be conveyed. Unfortunately, some students do not pay enough attention to these explicit rehearsal or teaching sessions. I have too often seen clear evidence of disappointment and disapproval on the faces of senior residents when a student fails to convey important historical details or examination findings or when he botches the presentation structure. While it is not always reasonable for a student to be able to remember everything advised by his residents or to be able to perfectly recite a script handed down by his resident, it would behoove him to be extremely attentive when a resident sits down with him to prepare for a performance. Similarly, when a new skill or concept is taught with emphasis, this becomes a marker for improvement for the student; failure to internalize this new lesson accordingly is detrimental to his subsequent evaluation by that teacher.

4. Being too proud.

Third year medical students are smart: they have clearly achieved excellence in order to make it to this stage, and their proximity to their recent preclinical coursework and Step examinations provides them with a wealth of book knowledge. However, most third year students have minimal amounts of clinical experience and little awareness or knowledge of how medicine is actually delivered. While most third year medical students are aware of this fact and accept it with humility, a select few have difficulty accepting the advice, moulding, and criticism that inevitably comes from residents and attendings. Everyone has room to improve, but not everyone is willing to change. These students unfortunately develop a shell that blocks out criticism and advice, discounting criticism as the product of a resident or attending that “had it out for me.” Unfortunately, these future physicians are also the future recipients of law suits and disciplinary action. Given that most residents and attendings are saddled with excess responsibility, it takes a lot of activation energy to produce constructive criticism, so advice or criticism given is rarely fictitious.

5. Lacking confidence.

While some students fail due to pride and overconfidence, most students trend in the opposite direction: they feel like imposters in a new and alien environment. Bombarded by questions from their residents and attendings, the habitual answer of the overwhelmed is “I don’t know” as it would seem to be the easiest and quickest way of cutting short the torture of feeling helpless and unknowledgeable. Students cope with this in many different ways (some more maturely than others), but typically the best recommendation given to them by residents and attendings is to commit to an answer or decision and yet still remain flexible to learning and changing.

6. Sandbagging or upstaging a fellow student.

At my medical school, showing off and upstaging fellow students or residents was called “sandbagging,” as though one were physically dropping a sandbag from offstage onto an unsuspecting colleague. The most common form of this is when a student answers a question directed at another student. In the stressful environment created by the wards, students all too often feel pressure to perform and look smart in front of their residents and attendings, and this can breed distasteful manifestations of competitiveness. This tendency is unfortunately fostered by some residents and attendings when they don’t direct their questions at individuals. Nonetheless, trying to look good at the expense of others inevitably reflects very poorly on one’s character as few people would want this type of person as a colleague.

7. Being unkind or cruel.

Lastly, students sometimes too easily pick up on the bad habits of residents and attendings. In particular, residents and attendings will occasionally remark unfavorably, joke, or complain about other people (who may be obstructing or causing detriment to patient care) in a private setting when students are present. However, residents and attendings have gained experience and training in tempering their feelings in such manner that it does not affect their interactions with these other parties; these expressions behind closed doors are, in some ways, safety release valves. Many students, however, have not learned or developed these skills and balancing measures. Students then may sometimes actly rudely or unkindly to others as they “side” with their residents and attendings. However, this type of behavior is never acceptable at any level of training or practice and should be guarded against at all times. One of the most important tasks for all physicians is to bridge gaps in understanding with patients, families, and other staff members (e.g. nurses, technicians, therapists) in order to lead and direct the best care possible, and the avenues by which this may occur are obliterated once rudeness and meanness color the interaction.

Fellow residents, what mistakes have you seen students make? What advice would you give to them to avoid common pitfalls as third year medical students? What measures should they take to succeed in becoming excellent physicians?

Follow

Get every new post delivered to your Inbox.

%d bloggers like this: