StudentSpeak is pleased to present this guest post by Larissa Guran, MPH, MS2. Instituting “Affective Time Outs” originally appeared on the blog, Wing of Zock.
This year, Oregon Health & Science University rolled out a new medical school curriculum for incoming first year students. YOUR MD is an innovative program, with a completely new schedule and focus; it is replacing the current curriculum, which is retiring after it serves my classmates and me. This is an exciting time to be a student at OHSU, but one of the drawbacks of this transition year is the disconnect between first- and second-year students. Our school has a strong tradition of previous classes supporting and guiding new medical students through the overwhelming experience of the first year. From our Big/Little Sib program to the Sage Books of wisdom and advice passed down to the next class, we’ve worked hard as a class to stay connected to and supportive of the new students. One way we have done it is through an elective called “Leadership, Education, and Structural Competency.”
Through this class, a group of MS2s including myself are learning about structural competency and how to lead discussions, write lesson plans, and build collaborative learning experiences. After months of training and practice, we are leading several small-group sessions to discuss structural competency. This emerging concept in medical education builds medical student skills in dealing with patients’ social determinants of health. Social determinants (like socioeconomic status, built environment, education, and social support) are often considered a “can of worms” by many medical students. In this class, we learned that contextualizing care relative to these social determinants can significantly improve patient outcomes.
When people learn that I am both a medical student and a single mom, there are a few questions they tend to ask. These include:
“Are you insane?”
“Do you have a live-in nanny?”
“How do you manage to do all that while maintaining such a gorgeous complexion and impressive personal physique?”
“Is your family nearby?”
“How do you study with a toddler around?”
The first four questions are easy enough to answer: 1) Yes, 2) HAHA, 3) …okay maybe I made that one up… 4) No. The fifth one can be a challenge, however, and not only because I’m usually cry-laughing too hard to respond.
So, for everyone who’s curious, I am now prepared to reveal the big secret behind how I study with a 2-year-old around — I don’t.
I’m sure there are children in the world who are content to be plopped in front of the television for an hour or two while mom makes path flashcards in the next room. There are probably also children for whom crayons and a cardboard box means a solid 30-90 minutes of independent play, as well as children who can be let loose in the backyard to entertain themselves while mom reads her neuroanatomy textbook on the patio.
My daughter is not one of those children.
Apologies for not blogging in a considerably long time (Even my parents have since stopped bookmarking this page. Sorry, Mom and Dad.). As delayed recompense, I thought I would include an excerpt from a small introductory speech I delivered earlier this week.
I was asked to speak about my research for five minutes to a general audience (Five minutes is nothing. Even the most socially uncomfortable scientist can bloviate about their research for hours on end.).
Instead of presenting my audience with an overwrought description of my work, I wanted to leave them with one compelling idea. Nobody except for me (and maybe my non-page-bookmarking parents, and maybe maybe my thesis committee) really cares about my research—on a deeply mechanistic level, anyway.
But they are interested in cancer. For that brief introduction, I have a responsibility to tell the audience something that they would remember, something that hopefully would change the way they thought about the disease. Grandiose, I know, but some famous person once said something about shooting for the moon and landing on the stars, and the answer is yes.
I’m writing this introduction because I want to show how important it is to consider your audience. Recently, I was fortunate enough to participate in a student lunch with a very prominent immunologist. I asked her about how she communicates her science, and she revealed that, regardless of her audience, she tailors every presentation she gives to be suitable for a group of smart high schoolers.
That was shocking to me. “Wouldn’t you run the risk of unnecessarily explaining things to people familiar with your field?” I asked. “Maybe,” she admitted, but it’s worth the fifteen seconds to explain something unnecessary in order to gain an hour of your presentation being understood by everyone.
One of the big draws to OHSU for me was the preceptorship program. I was a medical scribe for 2 years previous to medical school, and I love clinical medicine. You meet all kinds of wonderful and interesting people, and although science is somewhat predictable, people are highly variable. So, I was super excited to start my preceptorship and get some patient contact.
My preceptor is a pediatric neurosurgeon. I was initially disappointed, as she does mostly surgeries on the day I have available to work with her, and I was looking forward to talking with patients. That said, I had no previous exposure to the OR, and neurosurgery was well outside my comfort zone, so I knew I would learn a lot. On my first day, I watched brain surgery. Who else gets to do that? I had to reach deep to remember brain anatomy, but fortunately one of her residents was able and willing to explain what I was seeing as she was operating. Our patient was already intubated and anesthetized by the time I arrived, but I got a good look at the multiple layers covering the brain, and the soft, squishy tumor occluding the flow of CSF between brain and spinal cord. When I accompanied her to see our patient’s parents after the surgery, they discussed a few presenting symptoms, including personality changes and cognitive impairment, which helped me to get a fuller view of this patient.
The brain is necessary for our continued survival in both a physical and a more esoteric sense, which is unique among all the organs. That gray matter houses who we were, who we are today, and who we will be tomorrow. As I thought about it later, the exposed brain during surgery not only pulsed with blood and electricity, but also our patient’s life force. My doctor handled the brain gently but confidently, making incremental and patient progress until all visible traces of the tumor were removed. I fervently hope that her work saved our patient’s mind and body both, and gave him/her a future that they would otherwise not have had.
Medical specialties can be loosely divided into more physical and more mental disciplines. Surgeons use their hands to treat, while internists use their minds. I enjoy the puzzle, connecting patient symptoms to physical findings in order to arrive at a diagnosis. I also enjoy learning about individuals and thinking about how to connect a treatment plan to an individual’s goals. Medicine should not be about curing the disease, it should be about helping patients to live their life in the fullest and healthiest possible way.
Mr. S. is a 30-year-old gay male with a 9-year history of depression, a TBI in 2011 from a bike accident, and a recent 7-month history of graduate school presenting today with concerns about his future. He appears otherwise healthy, height-weight proportionate, though slightly tired looking. He reports a lack of energy and thoughts of self-doubt. He denies any suicidal ideation, panic attacks, and insomnia. Upon physical exam, relevant heart sounds show no signs of compassion fatigue but a positive hypertrophic empathy for his patients and peers. Lab results reveal frustration levels are stable and within normal range, but motivational biomarkers are low.
Have you ever written your own SOAP note? What if they looked like the one above, taking into account all the factors that affect our lives? SOAP, by the way, stands for Subjective, Objective, Assessment, and Plan. It is a tool we use in medicine to document clinical interactions with our patients. I need to remember to explain these abbreviations because prior to medicine, I spoke a different acronymic language that could drive people crazy to an obnoxious degree. But I digress…
Let me get to the main point of this article. PA/medical/dental/graduate students are not superhuman people. They are human people doing super things.
Medical school is intense, and I am not just talking about the science. People invite their doctors into their lives in very intimate ways, and illness makes us vulnerable in a way few other things can. I am in constant awe and gratitude to the patients I have met so far who have shared their stories with me in order to teach me how to be a better provider.
This past fall, I started taking an elective that explored patient and physician experiences with a life-threatening illness. As part of this class, I was paired with a patient-teacher who has advanced illness. We talked about POLST forms, both good and bad health care encounters, the importance of empathy in medicine and life and how impending death affects spouses, family, friends and the rest of a patient’s community.
Everyone dies in the end, but some of us have better deaths than others. You have terminal cancer? We can irradiate your brain metastases, give you chemotherapy which will slow the disease down and throw clinical trials at you. We might buy you an extra month of life, but you’ll feel like walking death for the next 3 months. Perhaps most importantly, instead of talking about pain control and giving you time to say goodbye to your friends and family, we fill your days with medical appointments and leave your family with mountains of medical bills. It is possible to hope for a miracle while preparing for the end, but physicians are not well trained to have those dual conversations. Death is not a topic for polite conversation in this culture. No one wants to confront their own mortality, and the death of a patient feels like failure. The more tragic failure is failing to help our patients and their families prepare emotionally for the end of life. Physicians have a better idea than most of how a particular person will die based on their illness, and so it is our responsibility to help guide and educate our patients. We all deserve the opportunity to say goodbye on our terms, and make whatever choices we can to ensure we die in a way we choose.
Whenever I hear instructors say that every student needs to know about osteoporosis, lumbar back pain, hip fractures and other highly prevalent complaints because it affects all specialties, I think that we need to have more conversations about caring for those with advanced illness in our curriculum. As the saying goes, the only certain things in life are death and taxes. I wish that every medical student had the opportunity to talk to a patient nearing the end of his/her life about death, and think critically about how we prepare to die and how physicians can help their patients in this process.
I said goodbye to my patient-teacher recently, and yes, there were tears. Some experiences change you forever, and this is definitely one.
StudentSpeak is pleased to offer this guest post from Randi Powell. Randi graduated from SOU with a degree in Cultural Anthropology and International Studies in 2011. Her passion for working with marginalized populations grew from spending several years living and traveling abroad in Haiti, the Dominican Republic, Ecuador and Sierra Leone. She is a proud student in the OHSU Nursing Class of 2015 and member of Nursing Students Without Borders.
Volunteering to work with marginalized populations has shaped my view of health care into a more holistic approach. After working alongside underserved populations, I am more aware of the barriers to obtaining healthcare and the obstacles to living a healthy lifestyle. Conducting community outreach has illuminated the fact that a person’s health is closely tied with their employment status, level of education, access to shelter and transportation and availability of healthy food. Having shelter and a warm jacket are just as important to a person’s health as diet and exercise.
Nursing Students Without Borders (NSWB) is a student run organization that offers nursing students the chance to support underserved communities, both locally and globally. The organization provides students opportunities to alleviate health disparities in their own community while also expanding their global perspective of health care.
I remember taking my entrance essay exam for nursing school and laughing at the question about the strength of my support system. Why is that important for getting into nursing school? It wasn’t like I was an addict who needed a support group. I was the one who was going to be doing the assignments and taking the tests. I am a strong and independent woman. People go off to college all of the time where they do not have any family and are successful. I answered the question vaguely saying I was married and had family living in the area and left it at that. I had no idea how relevant that question would be in my journey through nursing school.
“Life happens”… it struck me as odd that my instructors kept saying that. Unfortunately I did not understand what they meant until “life” happened to me.
A few weeks ago, I wrote a post about deciding whether or not to wear my white coat at a protest about recent events in Ferguson, MO, and Staten Island, examples of the more widespread problem of violence against communities of color in this country. As I’ve considered these events and their implications, I find I have a bit more to say.
On International Human Rights Day (December 10th), 20-30 OHSU students lay down in the atrium of the CLSB for four minutes, representing the four hours that the teenaged, unarmed Michael Brown lay on the pavement after being shot by a police officer. Unlike Michael Brown, we were not alone. Students from over 70 medical schools participated in this symbolic gesture and the hash tag #whitecoats4blacklives was trending on Facebook by the end of the day (you will not find OHSU’s name on the list of schools participating, as students were instructed to cover the logo on our white coats and not to affiliate ourselves with the university*). I participated in this gesture with tears in my eyes and hope in my heart. Just a week before, I wondered about the validity of wearing my white coat to a public protest – why was I OK with participating in a national movement that prominently featured this symbol?
I realized that I consider structural violence a public health issue. Put more simply, I think that when young black men unnecessarily are killed, this is a public health issue, just like preventable deaths from suicides and car accidents are public health issues. I also consider it a human rights issue.
I understand that there is often disagreement about what constitutes a public health or human rights issue.