The times, they are a-changin': When scientific research isn’t enough

David-Edwards-bannerI recently marked my four-year anniversary of starting graduate school. When I reflect on the years that I’ve spent here, embedded in the practice of science like a mosquito in amber, I’m reminded of a line from that Bob Dylan song: “Then you better start swimmin’ / Or you’ll sink like a stone / For the times they are a-changin’.”

The times are a-changin’ indeed. The biggest thing I’ve learned from my experience here is that science is everything. Science offers us students—most of us overeager, street-dumb twenty-somethings—an unparalleled opportunity to peek behind the curtain of existence. Science allows us to dive deeply into truth-with-a-capital-T and retrieve information to help save the lives of those around us. It’s amazing…and it’s why I entered graduate school in the first place.

But science isn’t exclusively good. Science, the exhausting, elbow-greasy practice of it, is also a blackened altar onto which we sacrifice so much of our lives and our freedom. Science is a jealous god, one who hears the cries of its greatest worshippers and sometimes, more often than we’d like to admit, capriciously holds back its favor and love. We become a wandering people looking to the sky for manna and seeing only thunderclouds forming on the horizon.

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Learning begins at the end of your comfort zone

StudentSpeak is pleased to feature this excerpt from Caitlin Harrington Brown, MS4. Caitlin’s original post appeared on the web site for Women in Thoracic Surgery.

Caitlin Harrington Brown, member of the M.D. Class of 2017

Caitlin Harrington Brown, member of the M.D. Class of 2017

Surgeons are like professional athletes. They commit years to rigorous training, and spend hours preparing for a specific case, and then before they know it, it’s game day. All that pre-game prep is all well and good, but it’s what happens on game day that actually counts.  Every patient and case is different. Surgeons are prepared for the unknown in a very high stakes environment because they are trained to be problem solvers and be clutch in a crisis. They use their knowledge and their technical skill to fix complications, even if it’s the first time they’ve seen that particular problem. Their ability to operate when facing the unknown does not mean they are comfortable – it means they are competent and confident.

As medical students on a surgery rotation, we have been told that a large part of our attendings’ and residents’ analysis of us is their assessment of our decisiveness. We are seeing things for the very first time, and they are looking for us to apply our knowledge to an unknown situation and confidently make an educated choice.  When you first experienced this, it felt uncomfortable, right? Maybe it still does, and there is a reason for that! Making an educated guess feels like we are unprepared, probably because we spend the first two years being told exactly what to study for on an exam, and then suddenly find ourselves on clerkships where any question is fair game at any time. It’s hard to prepare for this, and if we don’t know the answer, it feels awful. But like with all things in surgery, there is a reason why our teachers put us in this position.

Continue reading on the Women in Thoracic Surgery site.

Pause here

Adalie-bannerWhen I got accepted to OHSU’s PA program, my husband and I made the decision to keep our home base in Bend and have me return from Portland every weekend. I have, to date, driven 349 hours in 51 round trips. The repetition of this endless loop sometimes gets frustrating [Why do slow drivers suddenly speed up at passing lanes?], but overall I like the weekly echo. My mind can wind down after a crazy week, and I have time to think slower, longer thoughts.

On the drive I pass by some small towns and many scattered remote homes. Seeing those, my thoughts pause on the topic of human migration. I am speaking of migration in its purest form, without influence from strife or other external factors. Moving for the sake of newness. Relocating for the sake of adventure. [Does victimless human migration even exist? Probably not, but let’s pretend.]

With this pureness in mind, what makes a person decide that a location is good enough to stop and make a home of? Like, imagine all you know of the land is that an ocean is due west, and you have just crossed an interminable desert to happen upon a lovely green dip by a river. Why pause there? Why not keep going and aim for something better? [Again, imagine you have a choice in where to stop. Again, imagine that there are no losers in this game; no displaced persons pushed out from your desire of a better life.]

The ability to stop on the journey and be ok with that land as your new home takes a calm sort of confidence. A complete ability to trust oneself. To know that you and your family can flourish here. That the horizon is fine being left alone for now. This isn’t a loud, showy confidence that needs an audience nodding approval at your decision, but arises from a core of self-assuredness.

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Just tell me a story…

Anthony-Lumbad bannerI think we can all relate in the fact that we each know people who seem more adept at storytelling. They build suspense, they hold the punch line until exactly the right moment, they kill it during wedding cocktail hours. They somehow captivate attention, an unofficial prerequisite to succeed in clinical year of PA school. At least, that’s what I’ve experienced. The challenge lies in convincing the most educated person in the room to listen to the least educated: that’s right, yours truly. It’s the inherent nature of being a student and especially evident in a teaching hospital with experts at the top of their field. On morning rounds, we interview our patients looking for salient characteristics of their disease. We work through OPQRST; when was the Onset, what Provokes it, what’s the Quality, et cetera, and present our patient’s case to the attending physician. But what seems to result from 15% eagerness and 85% absolute terror, our once organized information comes out seemingly garbled and out of context as the gaze from five white coats pierces through us. Sufficiently flustered, we smear historical details, lab values, and physical exam eponyms between the patients we are managing. We ask ourselves “how is this happening to me? I took such good notes…”

At times like these, I reflect on advice I received from an emergency physician early in my clinical training: “Just tell me a story, Anthony. Two people may have the same disease, but how they got here will always be different.” After this exchange, I quickly realized how inadequate “OPQRST” is with information gathering. Based simply on pertinent positives and negatives we try to place patients into discrete categories: cardiac vs pulmonary, sick vs not sick, admit vs discharge. But in this binary outlook, I believe we start to lose sight of who our patients really are. As we ask them to change out of their clothes and into hospital gowns, we unintentionally strip away their personality and quirks that make them unique human beings. Out of efficiency, we search for patients by medical record number instead of by name. We refer to them as bed 5 or exam room 1. We orally present a patient’s “case” to our teams as if we’re defending them in trial rather than addressing their health. No wonder it’s easy to mix up the details of their hospital admission. At this point, our patients are no more memorable than the bland textbook pages where we first read about them during our didactic training.

My point is this: put down your moleskine-bound notebook, the proverbial security blanket for health professional students everywhere and speak about your patients from your interactions rather than your notes.

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The White House reflections

Kakaday-BannerI have been lucky to somehow accomplish a number of milestones in my lifetime: graduate college, enter medical school, build a company, spearhead a premiere medical technology conference, pen a blog with over 10,000 followers and, now, in what seems like the largest stroke of luck, receive an invitation from The White House, under the direction of President Barack Obama’s Office of Science and Technology Policy (OSTP), to assist in the newly launched Precision Medicine Initiative.

Just recently, I traveled to Washington, D.C. to attend The White House OSTP and Stanford Medicine X joint workshop on “Engaging Patients as Partners in Research.” When I first received the invitation a month prior, embellished with the official logo of White House, I had to do a double-take and then verify the legitimacy of the sender. Indeed, everything checked out and I had been officially invited. Mom was the first to know.

After I received my official appointment badge, passed through security and entered the White House campus, a chill ran through me. I was entering arguably the most powerful building in the world, in which decisions are made that have effects and ripples everywhere. The gravity of my involvement was not lost on me. Determined to represent myself and OHSU’s innovative ethos well, I strode past doors that read “National Security Council” and “Office of the Vice President” with a resolve I hoped didn’t betray how giddy I was inside. Once all 50 or so guests assembled inside our conference room, the workshop kicked off.

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Thailand Experience – Culture of Wellness

Norma is part of cohort of nursing students traveling and studying in Thailand. Learn more about OHSU Global Southeast Asia.  Read about the recent trip to Thailand in this exchange

Norma-Bono-BannerClose your eyes…Now imagine yourself in a sauna and you’re profusely sweating. Your pores open, you breathe in, and it’s like breathing in nothing but steam. Now imagine you have stepped out of the sauna and have proceeded into the showers. Your body cools down, you towel off and you have now returned to your air conditioned room. You now feel refreshed, relaxed and energized all at the same time. You think to yourself, “Wow, I feel great!” – This has just described how I felt everyday while in Thailand. Yes, it was very hot and very imagehumid, however, it was a good feeling over all. What made it even better was remembering why I was there in the first place – for an amazing learning experience!

This opportunity offered a basic understanding of the current healthcare system in Thailand. We resided in Bangkok and visited outlying areas that surrounded the city. The visit and presentation at the Ministry of Public Health was a fundamental source of information, that allowed for greater insight into their healthcare system and infrastructure. The healthcare reform goals were shared with us, and one that stood out the most was the integration of Traditional Thai Medicine (TTM).

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Through the eyes of a “difficult” patient

Moss-BannerDuring shift change you get a hand-off on one of your patients, “a 68 year old Chinese man who was admitted again for fluid over load because he continues to be noncompliant with his medications and diet. His provider prescribed the meds to manage his heart failure related to his chronic unmanaged asthma. Adult protective services recently removed him from his home where he was living with his son, because it was pretty apparent his son was neglecting him. I mean you should read the case file, the guy’s bathroom was covered in feces from a broken toilet, his floor was caked in black mold. Watch out for the son, he keeps causing a scene every time you try to talk to the patient. And the patient wants to move back in with his son, but that is obviously not going to happen because this guy cannot take care of himself and it’s pretty clear his son is not going to take care of him. Get ready this family is difficult. I would stay outta there as much as you can.”*

I have had a hand-off like this, and I am sure you have too. One that makes you automatically develop an image of who you are about to care for, and often put them into a category of “this is what they are going to be like” before you even meet them. Often times the person who is sharing this with you is usually trying to help prepare you, while also decompressing from what was most likely an extremely long 12 hours. The problem here is when we are presented with a patient that is labeled difficult it allows us to detach from them before we even introduce ourselves. And when we detach from the beginning, we miss the opportunity to learn about their truths of how they got here, what they really need from us to leave better than when they arrived and most importantly eliminating our ability to provide truly compassionate care.

I wrote this guided imagery (with editing help from my dear friend Janell Senn) for a group project in response to an experience one of my classmates had with a client like the one in the above hand-off report as part of our presentation. I wanted the rest of my peers to reconnect to the part of them that makes it difficult to shut down and shut off, and for any of you that listen to this – I want that for you too. The next time you meet a person that makes you feel frustrated for the way they live or have a patient you want to call “difficult” or “non-compliant,” you might step back and examine your own compassion switch and be honest if you need to turn it back on.

(To play audio click your mouse on the empty space to the left side of the audio toolbar next to 00:00)

*hypothetical patient

Mortal responsibility

Pham-BannerIf you know anything about me, you probably know that I love to read. As a kid, I was what you could call a “half-tomboy/half-bookworm.” I could usually be found doing either one of two things: rolling around in the water or engulfing myself into whatever book I had my nose in that day.

Expectedly, as I began refining my intellectual pursuits, my personal reading choices concurrently evolved. As I got older, I nurtured a deeper interest in nonfiction, albeit my love for historical fiction, and eventually stumbled upon the world of medical nonfiction. Instantly I became enamored with the written works of Abraham Verghese, Atul Gawande and most recently, Paul Kalanithi. Each author’s prose is built upon his own personal experience, and the pages are filled with clinical stories and perspectives that are all so uniquely articulated. Their narratives allow readers into their minds, allowing us to observe their thoughts and to listen to their inner monologues; through their voices I learn what fuels them, what inspires them and why they practice medicine. Despite their narrative differences, perhaps what I appreciate most about these authors/physicians is their overall commitment to viscerally capturing the moral, ethical and practical hurdles that health practitioners inevitably face when dealing with life-threatening situations. What makes these individuals remarkable is their natural ability to articulate these situations with eloquence (and impeccable word choice), leaving me inspired to cultivate my own nursing practice with a similar sense of poise and relentless passion.

Up until very recently, these moral dilemmas I read about were hardly a reality; facing death was never something I contemplated seriously. I mean, I had always understood that death is inevitable– a rite of passage, so to speak. However, it was nonetheless hypothetical, a life event that would eventually happen some day, after I had lived a long, fruitful life of experience and contentment.

This changed very quickly several weeks ago. I was driving home after dinner with a friend, and a moped driver recklessly made an unprotected left turn across a line of traffic. Although I had the right of way going straight, neither of us saw the other, and I t-boned him. The moped driver instinctively jumped off of his moped to clear his leg from the collision with my bumper, instead somersaulting onto the hood of my car and falling violently onto my windshield.

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Not a fish

Thruston-BannerIt took a full minute of back scratching and hair stroking before she stirred.

“Hey, girlie,” I whispered as I leaned over the bed. “I’m going to work now. Can I have a big hug and a kiss?”

Without opening her eyes, she stretched her arms out, wrapped them around my neck and planted a kiss on my cheek.

“Are you going to go do surgery on people?” she asked, eyes still closed.

“Yep. Go back to sleep, kiddo. I love you.”

She rolled over and pulled the blanket up, and that was it. I lingered for a moment, expecting a screech of protest, but it never came. It was the first time since I’d started rotations almost 9 months ago that there was no demand for me to stay. At the very least I expected her to insist on being carried to the porch to wave goodbye to me as I left, but nope – she was out.

My rational brain knew I should be glad. Standing outside in the dark to wave goodbye to Mom at 5 a.m. every day wasn’t exactly best practice for a restful night’s sleep. The fact that she had stayed in bed was a sign that she was adjusting, normalizing, settling in. “All good things!” the voice of reason firmly reiterated, but in my gut I could already feel the cold grip of Mommy Guilt taking hold, and there really is no way to come back from that

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A lot like love

StudentSpeak is pleased to present a guest post by first-year M.D. student Alice Rear.

Rear-Alice“What do I do with my hands?” The question occurs to me as soon as I walk in the room. I thought I had considered every aspect of this encounter: how I would introduce myself, how much eye contact was appropriate, how I could express empathy without sounding insincere or patronizing. I never considered how my appendages would feel flopping by my sides or resting listless on my lap. Giving hand gestures a try makes me feel like a traffic director, and I immediately abandon the strategy. Taking a seat, I wonder if I should cross my legs on the low stool. I experiment crossing and uncrossing them, then cross them again. I uncomfortably commit to the crossed conformation, regretting it instantly. My questions, which felt fluid when rehearsed, are now awkward, jarring and disjointed. Realizing my speech has become incomprehensibly rapid, my face grows warm and flushed. I am certain my smile, expression and posture radiate my anxiety.

My first clinical skills exam feels uncannily like a first date gone wrong. In many ways this is an apt comparison as medical school inspires many of the same emotions as a romantic relationship. It can be as elating, disheartening and all encompassing as falling in love. Interactions as a training physician can be vulnerable in a way I did not anticipate, and in the same way I have learned about myself from loving another person, I have uncovered new aspects of myself while studying how to care for a patient.

Walking into an exam room, particularly during clinical skills tests, I often feel like I’m being evaluated not just as a student, but as a person as well. My empathy, vocabulary, skills and style are all open for critique and discussion. There have been instances where I have walked home feeling raw, questioning my ability to be a doctor and my place at OHSU. Interactions with the standardized patients have also been some of my most elating moments. Getting the correct diagnosis is great, but being told that the patient felt heard, safe and that they were comfortable with my clinical manner makes me feel real joy.

I had a similar moment during the medical specialty “speed dating” event held at the end of last term.

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Ever wondered what life is like as a student at OHSU? What does it take to become a researcher? Just how gross is gross anatomy? Welcome to the blog that answers these – and many other – questions. It’s students writing first-hand about their commitment to careers in science and health care. It’s honest about the challenges as well as the joys. It’s not always pretty. But it is our story. Thank you for sharing it with us. And please, let us know what you think.

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