Monday, April 14, 2014

GUEST POST: Remembering Patients: A Walk Down Memory Lane of Learning

Dr Jessica Lazerov (pictured here) writes:

As medical professionals, we must learn and retain an unthinkable amount of information.  Especially during the first 2 years of medical school, this truly is a task not to be taken lightly.  Traditionally (that’s code for “back when I was a student”) there has often been minimal to no context to all of the information we are required to know, and it is a grueling experience for most of us.  I still have flashbacks of studying the biochemical intricacies of the kidney, and don’t even get me started about the vast and confusing spinal column pathways…

But most of my learning was done with an eager mind and a real curiosity about the epic nature of the human body. Though sometimes I wonder if the experience I remember is somewhat different from what happened in actuality, much like mothers tend to forget the unforgiving details of childbirth.

Be that as it may, I managed to make it through the 3 steps of the medical board exams and my initial Pediatrics certification process smoothly.  Now 10 years older, I am studying for my recertification (aka “maintenance of certification”) exam in Pediatrics and I am faced with the daunting task of relearning many things that I have not thought about for almost 10 years. Yes, I have a decade of real-world experience under my belt, which counts for quite a bit in my day to day life as a general pediatrician, but I have learned a few basic lessons that will trump all other information when it comes to caring for patients:

(1)    Know what you know
(2)    Know what you don’t know
(3)    When you don’t know, know where to find it…quickly

Now sometimes you really do need to remember the details. A technique that has helped me remember the obscure, rare zebras in addition to the “not so rare” conditions is by remembering details about specific patients I have cared for. I still know the name of the 8 year old boy I got to know in residency with Wiscott-Aldrich Syndrome.  Picturing his face reminds me of many seemingly random facts about his illness and gives that information some context.  I remember that teenage girl with Henoch-Schonlein Purpura that I admitted as a 4th year medical student who was disappointed that she had to miss her prom, but what helps me recognize it again is that I also remember exactly how her illness presented. 

So my message for those going through training is to make sure that you get to know your patients and commit them to memory. Make sure that you remember what is typical and atypical about how your patients presented, what tests you ordered and why, and how you treated them. You may very well see an obscure question on one of your board exams that was intended to throw you for a loop and a memory of a specific patient will help you. But most importantly, you may see a patient in the ER, in the hospital, or in your clinic once you are an attending that will benefit from your memories and the connection you made to patients as you were learning.  This type of learning continues throughout your career and really does bring a softer, human side to this amazing journey known as “The Art of Medicine”.

ABOUT OUR GUEST POST CONTRIBUTOR: Jessica Lazerov received her MD from the University of Maryland where she also completed her Pediatrics Residency.  She is now an Assistant Professor of Pediatrics at The George Washington School of Medicine and works in the Southeast DC Children’s Health Centers.  She is interested in health care disparities and working with underserved populations in addition to understanding and treating childhood and adolescent obesity.  She enjoys traveling and spending time with her husband and two “spirited” children.  Read another post by Dr Lazerov here

Wednesday, April 2, 2014

Top 10 things I learned at a conference for medical student educators

Our annual conference of pediatric medical student education leaders (COMSEP) just concluded.  It was expertly hosted by PUPDOC, just north of us in Ottawa, Canada, where the weather is cold but the people are warm and friendly.  The theme of the meeting was appropriately, reaching your peak, leadership in medical education. Once again, I depart the conference feeling energized to educate and grateful for the opportunity. I learned (or was reminded of) a few things while I was there, such as:

  1. Like car companies, we build things, but our "things" are fine physicians who serve children.
  2. It's not just paediatrics that's spelled differently in Canada, but also oesophagus, which makes GERD become GORD.
  3. Change has become the new constant in medical education as well.
  4. And that Kaizen means change is good. 
  5. The pediatric residency program directors have called us medical student education directors the "huggers and dancers"
  6. Playfulness, i.e. celebrating the joys of teaching and learning is actually in the mission statement of the pediatric medical student educators' group(COMSEP).
  7. There are outstanding new faculty development videos/resources on the COMSEP site that can help us all become even better medical educators. (And these will help ensure that faculty never use a pain scale to evaluate students.)
  8. According to Dr Carol Berkowitz (former AAP President), it is time to retire when all the mean people where you work are gone.
  9. And also, per Dr Berkowitz, "It's not what you are, it's what you do... and you can do everything, but not all at once, so simply space it out."
  10. We clerkship directors are mostly academic coaches, sometimes firefighters, rarely police officers, and always teachers, while we are physicians serving patients and teaching others to do the same, every day.  And thankful for what we get to do.
Here were our tweets, and here's what I had learned at last year's meeting.  And I'm looking forward to more in the future. 

Before you go to your next conference please check out this post.

Tuesday, March 25, 2014

Does clerkship order matter? Planning your 3rd year schedule

No doubt that medical school schedules vary. Some begin "3rd year" during the "2nd year" and integrate the clinical experiences. Others start 2nd year with clinical rotations and also have a year of scholarly experience. And yet, many others (still) have the traditional 1910 "Flexnarian" 2+2 model of 2 preclinical years plus 2 clinical years. If you are presently immersed in basic science but are being asked to weigh in on your schedule for your clinical clerkships (or know someone who is), keep reading...

One intriguing study in JAMA in 2010;304 (11):1220-6 looked at clerkship order (the sequence of the clinical clerkships) exploring the notion that those completing the internal medicine clerkship might perform better on their subsequent clerkships than those who do not complete internal medicine first. Of note, this study was set at a single institution that had multiples campuses.

Their findings? Clerkship order mattered in some ways but not others. Specifically, first clerkship specialty was associated with subject exam scores, and to a lesser degree with overall clerkship grade. First clerkship specialty was not found to be associated with clinical grade or with USMLE Step 2 score. Students completing internal medicine first had higher mean overall clerkship grades than students who completed OB-GYN, psychiatry, or family medicine first.

The authors discuss "student lore" that the most desirable clerkship order starts with internal medicine. And, given that not everyone can do internal medicine first, they make some suggestions, including the incorporation of more "internal medicine-like" experiences early in the 3rd year. Of note, these experiences do tend to occur on pediatric clerkships as well, such as bedside learning, clinical decision making, continuity of care, exposure to a range of cultural and socioeconomic issues, and others.

Having heard the “word on the street” and hearing about this elegantly designed study from JAMA, there are still some other factors you might consider (to the extent that you have any choice or flexibility in your clinical clerkship sequence, even if what to go for in the lottery):
  • What field do you think you might want to go into? Though it is OKAY not to know!! Think about when during the year it might be good to be in that clerkship, for learning's sake, and to some extent with regard to how you will perform.Read on…
  • If you might want to go into pediatrics, for example, should you do that clerkship first, towards the middle of the year, or the end of the year? Let's ponder what might happen at the beginning of the year: you have tremendous energy, some nervousness, and you are also learning how to be a third year. In the middle of the year, you might still have some nervous energy, and use it for good. You will be somewhat more experienced, building your clinical reasoning skill set. And then towards the end of the year, some subset of students (though importantly, not all) lose energy. Some may feel they have already made their career choice and do not recognize the interdisciplinary nature of medicine and unfortunately miss out on some learning opportunities. But if you aren't going to lose that energy and can remain fully engaged in the learning and clinical care process at that point in the year, you will learn and could stand out, favorably so.
  • Perhaps not an option, but do you have any elective time in your 3rd year? If so, how will you make the best use of that time? Try out a subspecialty of interest? More exposure to your potential future field? Do something new? Get involved in a research project? A health policy or advocacy or medical education project? Travel for a global health experience? Some medical schools may not have any "built in" elective time in the 3rd year, but might still have options for carving out such time via creative rearranging/splitting/deferring. But if not an option at your school, please don't fret as there are plenty of experiences within the core clerkships, and of course, 4th year.
  • Even if you have little to no choice in arranging your schedule and even if you are completely undecided about your ultimate career path, remember that in any setting you can always learn one more thing and have one more experience that can potentially help some current or future patient or yours. That is, reflect and learn about people, about teamwork, about responsibility, about clinical decision making, about patient safety, about professionalism…and I could go on. Don't miss those everyday learning opportunities!

Monday, March 17, 2014

What will you be doing Monday of residency match week?

Competition for residency spots has heightened... There are more graduating medical students without a corresponding increase in residency programs and spots. More medical students graduating abroad seeking residency positions in the US. Fewer unfilled positions in the match.
In past years there had been a "dirty" scramble, without transparency, trust, time, integrity, rules, consistency, stewardship. Hence, the NRMP and AAMC scramble workgroup took on the task of cleaning up the problem, with SOAP.  Not SOAP of the Subjective, Objective, Assessment, and Plan variety, (nor Dove, Dial, or Tide), but rather the Supplemental Offer and Acceptance Program match week extravaganza.

On Match week Monday at noon eastern, both you (the applicant) and the programs will find out at the same time if they filled and if you matched. That is, unmatched applicants and unfilled programs will find out at the same time. Hopefully, you see a "Congratulations, you have matched" message. Go celebrate, responsibly!!! But you will need to patiently await more details to follow on Friday midday, at which point you can celebrate again.

If not, you may be a candidate for the Supplemental Offer and Acceptance Program. Applicants and programs in the SOAP must use ERAS to apply, with timed cycles of offers and acceptances, and a binding NRMP Match Participation agreement in place for match week SOAP offers.

If you find on Monday mid-March you are in need of SOAP, do contact your dean's office and your clerkship directors and advisers for guidance!

Read here from the AAMC for more details on SOAP.

And here for the NRMP Match FAQ and here for the NRMP on SOAP.

And here for the NRMP Match Week schedule 2014.

Friday, March 7, 2014

Springing ahead... when less is more!

Children everywhere (including in my household) will be waking their parents up approximately one hour earlier/later/differently than their parents had wanted them to this daylight savings Sunday morning. The upsides and downsides of springing ahead are numerous as a parent, pediatrician, medical educator, and child health advocate.

One less hour to sleep.
One less hour of screen time.
One less hour of being on call.

And one more hour of daylight to:
  1. exercise outside: walk, hop, skip, jump rope, run, and throw, bat, dribble, or kick a ball
  2. read out on a field, patch of grass, park bench 
  3. experience seasonal allergies
  4. plant some fruit, vegetables, or sunflowers
  5. teach, study, learn (and blog, update, tweet)
  6. get in a traffic accident - please be careful, stay alert!
  7. check your home smoke alarms and change the batteries
  8. hug your family members
  9. advocate for children locally
  10. advocate for children globally

Monday, February 24, 2014

Running and Reflecting

So much about which to learn, care, think, decide.  Ups and downs along the way.  Every day, and sometimes by night.  It was a medical student who prompted me to reflect.  She was doing a project on the ways students and health care providers use the arts to "connect to what they see, experience, and feel as they move through" their studies and careers, to keep life balance.

Though no artist, I run (and jog) and reflect.  And thus began the initial (foot) steps forming this essay, Running on the Road to Reflection, published this month in Academic Medicine, here.

I share my words in the medical literature (and here in the blogosphere) in the hope that it will resonate with anyone else out there along the journey.  And to my pleasant surprise, I was then asked to read my piece for AM Rounds, which you can hear, here.

The key is to run to, not away from, these opportunities to reflect.

Friday, February 14, 2014

Dear pediatrics, will you STILL be mine?

[photo credit: Terry Kind]
Even as you grow (height, hair, body parts), as you mature, as you develop your skills and try new things (potty seats, tricycles, body piercings, condoms), as you say new words, and as you need new medications, please know that you are still the reason I come to work every day renewed and refreshed.

In sickness and in health, for preventive care and sick visit, as a follow up from another provider or seeing you anew for the first time, I will stick with you for a lifetime, or at least until you are about 18-21 years old (at which point we can skillfully transition you to an adult-oriented provider) and may not need me anymore.

Can't believe another year has gone by. It is definitely time to re-read the love letters to pediatrics from our early days of this blog, please see: "Dear pediatrics, will you be mine?"

Still Your Valentine