Thursday, February 22, 2007

My First Time, IVs, and Less Than Bulletproof

Monday evening this week my lab was required to do our GTA teaching session. GTA stands for Gynecologic Teaching Associate, which is the title of the women who are paid to be teaching assistants for students learning how to do the breast and pelvic exam. The role of the GTA is not just to teach how to do the breast and pelvic exam, but to allow the students to learn the exam by performing it on them while they teach. Now, it's one thing to do a prostate exam (a requirement to fulfill before entering our third year, for whatever reason), but the awkwardness of inserting your first digit in a man's rectum pales in comparison to the awkwardness of performing your first pelvic exam. One thing's certain; you never forget your first time.

I was one of two guys in a group of four students, with two GTAs who work as nurses in the OB/Gyn department at Columbia Regional. The nurses gratefully understood the nervousness of performing a pelvic exam, especially for us guys who don't routinely have pelvic exams ourselves and are unfamiliar with the whole process. Their friendliness and openness made performing the exam far less awkward, and there was a lot of friendly chatter with no lack of humor surrounding the circumstances. The ability to laugh without fear helped ease tensions, and we talked openly about how not to say or phrase things during an actual exam. For instance, you never tell a patient that her anatomy "looks good"; instead, you would tell the patient that everything "looks normal". It may even be uncalled for to say vagina; instead you might say "bottom".


Starting an IV

Wednesday we have IV lab. One of the best things about this block is learning how to do procedures. Last week we did intubation on dummies with inflatable lungs. Once we got the hang of the procedure, we began competing for time. Amanda was hands down the fastest with a time of less than 15 seconds to getting a patent airway. I digress...

I've often paired up with James Alaly for lab activities, and so we did again on this occasion. He went first, attempting to insert the IV into my left hand. Unfortunately, with a little misguidance from the anesthesiology resident, he instead had a good inch and a half of 22 gauge cathether needle inserted between the knuckles of my first two fingers inside my hand underneath the vein he was trying to stick. Repeated efforts to hit the vein by retracting and readvancing, angling up and to either side, and starting all over only managed to dig around my flesh without hitting a vein. Don't worry, I was given anesthetic beforehand, and he eventually found the vein. I got my revenge when, after getting venous access on him, removed the needle and opened the catheter port without holding the vein closed, allowing him to start an open bleed all over the table.



"Only three other people know this; I may not be coming back after this year."

It was almost painful to hear a friend of mine mention this to me recently. Something that has become even more apparent to me, especially this late in the second year, is how much of a toll the stress of medical education places on each one of us. It's not so much that the stress isn't manageable, because it is. I think more than anything its that so many of us have not learned how to or understand how best to deal with the stress of our environment. After all, most of us are very driven, type A, highly successful individuals who are unfamiliar with being merely average. After being in the upper echelon of most undergraduate courses, it comes as a shock to find yourself working as hard as you can to at best make a mid to upper 70's test score. It also doesn't help that learning in medical school can be like drinking from an open fire hydrant (in fact, I rarely feel as though I've covered everything adequately before exams). Seeing scores like that triggers an almost fight-or-flight response in most medical students. Our instinct is, after all, that if we aren't at the top, near-perfect, we're not adequate. Compounding that drive to be flawless is the pressure to be a doctor who will never be stumped, who always knows the diagnosis, the correct treatment regimen, and never harms a patient. The hard truth of imperfection becomes an overwhelming burden many try to deny or simply cover up.

Maybe a part of this has been trained in us early on. Starting as early as childhood, kids who excel in the classroom are first identified as being "gifted". By high school this continues with our placement on the honor roll. Not that any of this is bad, but it definitely begins to create a behavioral reward thinking paradigm. In college we learn that in order to be doctors we need to excel in the classroom, be leaders of organizations, involved in the community, and so forth. We learn that in order to stand a chance of admission compared to the other many hundreds of applicants, we need to be better than almost 90% of all other applicants. For comparison, the University of Missouri - School of Medicine had 916 applicants for the 2006 entering class. 298 applicants were invited to interviews, and from that group 95 applicants matriculated, or only 10% of all applicants (see link for statistics on the class of 2009). Understanding this creates an intrinsic instinct to attempt to succeed at all costs, and then when we enter medical school and are faced with an even more difficult academic challenge, for which most of us will at best be average, we continue to push ourselves like a high performance machine needing to operate at high production without taking time to rest and do personal maintenance.

It's somewhat a rarity for anyone to ever admit what they scored on an exam beyond mentioning they received a passing grade. Maybe people are trying to hide behind that bulletproof shell of perfection, not admitting that they were merely average. Or maybe it's more of a "strongest shall survive" attitude. Whatever it is, it's a heavy facade to hold up without getting worn down, and the thicker your bulletproof cover is, the more and more distance you create between yourself and others. Pretty soon everyone is walking around and feeling as though they are strangers. You can see the strain in everyone's faces as they struggle to maintain that spark of early inspiration that drove them to want to care for people. Some people have lost most of it, and what remains is a jaded shell that's been sucked dry by the system.

I'm glad that a few cracks have shown up in my own cover. Without them, I may not have had the courage to simply let the facade fall and be seen as a struggling individual who needs others to help him along. I love learning medicine, and I just can't wait to be able to see real patients and put all of this pent up desire to help others to real and active use. I can't do it alone though, and I can't pretend that I can or I'm going to become so bitter, so depressed, so hopeless that I end up as just another drone in the system, where everyone is like a beaten dog out for themselves. Or, I'll continue to let the stress rise as I strain for a greater sense of perfection, until it reaches a breaking point and a simple mistake causes a total system meltdown. I've got to let people know that I'm not perfect, and that it's ok. I need to let others know I need them, just as much as they need me to tell them I'm there for them.

So a lot of other things have been going on with my friend outside of school as well, involving family, personal health, and other things. In fact, it isn't a consideration of not being able to pass tests, but rather a loss of interest in medicine. The stress has taken it's toll physically and emotionally. I'm glad I'm trusted with a secret, but I'm terribly sad to hear that medicine might not be what they want to do. Out of our entire class, they're easily one of the few I see as being a great doctor. Not because they are an excellent academic, but because they care for people in a way that just can't be taught, and seeing someone so instinctually compassionate leave is hard. More than that, it's going to be a little bit harder without such a good friend around for the next two years.