Monday afternoon found me wandering from building to building in the research park, clutching a bag containing a slip of pink paper and someone else’s urine sample in one hand and my car keys in the other.

Let me back up.

The summer between first and second year of medical school is really the last free summer of my academic life. This isn’t really too traumatic from my perspective, since I’ve already been a part of a workforce that doesn’t get a two-month vacation every year. Still, for many medical students, these eight weeks (ten for last year’s class, and how is that fair, I ask you) mark an important transition on the way to adulthood.

There are a lot of ways to spend this final summer. Some students go abroad to do research or learn a new language. Some put their feet up and embrace laziness for the last time in the foreseeable future. Other students, like myself, make a few extra bucks (or rather, earn back a pitiful fraction of our tuition) by helping out with research projects at the university.

I landed my gig by putting out a plea to the neurology department in general, and ended up working with a clinical researcher. In case you’re not familiar with the lingo, a clinical researcher is someone who is doing research with actual human patients, as opposed to bench research in a laboratory or chart reviews on a computer.

This was perfect for me, as I skipped out on a lot of bench lab skills by taking all my science courses in a single year. So for the summer, instead of having to learn how to pipet or stain slides or even look properly through a microscope (harder than you might imagine), I spent my days in professional dress and a white coat with a clipboard chasing down possible study subjects in a neurology clinic.

I actually helped with a couple of projects over the summer, but the one that counted as “my” project involved asking patients to fill out a long packet of surveys and collecting a urine sample. Simple enough, except for a few key points.

First of all, tracking down patients in a busy clinic is not an easy task for a wayward rising second year. No one quite knows where I fit into the usual hierarchy of things. On the one hand, I was attached to a particular attending, so my study had the weight of her position (and occasional presence) behind it. On the other hand, between the other attending physicians, the residents, the third year med students on rotation, the nurses and the general clinic staff, I rated somewhere below the janitor in terms of clout. (And let’s be honest, at least the janitor is directly useful on a day-to-day basis.) I spent a lot of time trying hard not to disrupt the goings on of the clinic, while somehow managing to get in everyone’s way.

I also ran into quite the snag when it came to paying for the urinalysis that was vital to our research. Even now I can’t explain exactly what was so complex about billing a six-dollar lab test to a readily available research fund, but suffice to say it involved my mentor making angry phone calls to administrators between patient visits, a brush with insurance fraud AND the possibility of several physicians not getting paid. For the record, none of that was my fault, but it was a stressful couple hours.

The urine samples also had to end up at the laboratory somehow. Usually this was a straightforward matter of leaving them in a cooler in the blood draw room, or calling for a pickup from a box in front of the building. Of course one day things didn’t go as planned and I found my samples sitting right where I left them after I returned from a nice, relaxing weekend. That was how I ended up wandering the parking lot of the research building, sample in one hand, keys in the other. “Just drop them off, directly,” my mentor told me. The glamorous life of the summer research student.

Ultimately my research involved a lot of waiting. Waiting for patients to show up for their appointments, waiting for them to finish filling out all of the surveys, waiting outside the bathroom for the tell-tale flush signaling a successfully obtained sample. I did a lot of reading. I chatted with the third year medical students doing their neurology rotations. I picked up tips from the occupational and physical therapists who came through. I learned a ton. But there is only so much expertise you can get through osmosis, and by the end of the summer I was ready to get back to the business of becoming a physician.

And our first unit now that we’ve returned? They changed things around a bit. Instead of starting with cardiology we’re jumping right into the urinary system.

From my notes:

Disease (objective): the organic pathology that afflicts the patient

Illness (subjective): the psychosocial experience and meaning of perceived illness

Taking a thorough patient history is one of the fundamentals of medicine we are being taught as future doctors. For reference, I mean sitting down with patients and interviewing them for a good 15 minutes to a half-hour in an attempt to elicit every facet of their illness and general lifestyle. A good history includes not only every conceivable detail of the progression of the current illness and past medical events, but also the history of any family illnesses and every social habit from alcohol use to religious affiliation to sexual habits. And then to top it off, a review of the body from head to toe, looking for anything out of the ordinary. Ideally all of this occurs before the doctor orders a single test  or begins any sort of physical examination.

The point of a thorough history is to take into account anything that might be relevant in treating the patient. We’ve had sample cases where the key to the whole diagnosis was asking a single, specific question, like whether they have travelled recently or what herbal supplements they might be taking. In other cases, the point has been to highlight socioeconomic factors that might affect treatment, like inability to pay for medication or an abusive relationship. Even when asking questions about the current illness, the most innocuous-seeming details, like when pain or fever is most acute, can hold vital clues.

As we practice which questions to ask, we are also learning how to ask them. We’ve had long discussions about how to phrase certain inquiries (how should you initiate questions about a patient’s sex life?) or how to react to difficult patients (angry, seductive, anxious.) We do some of this  through role playing in small groups or with standardized patients. We hear about some in general terms in large lectures. A few times, they’ve sent us up onto the wards to talk to real hospitalized patients.

It’s harder than it looks. You end up wearing a lot of different hats as you go through the interview. Part of you is frantically sorting through differential diagnoses, trying to make sure you don’t miss any question that might rule something in or out, while another part is trying to listen and react appropriately and empathetically. Meanwhile, you’re attempting to scribble down all the relevant details so that you can give a coherent and comprehensive presentation at the end. You’re also trying to incorporate the volumes of feedback you’ve received from previous attempts, words and phrases to avoid, and questions to remember.

Pictured: medical students practicing interviewing skills

We medical students are like newborn puppies, constantly tripping over ourselves, ending up in a cringeworthy heap. The first time I practiced a sex interview I turned confidently to the student sitting next to me and asked, “Do you have men with sex women or both?” Trying to elicit a family health history from a hospitalized patient, one of my partners jumped in with, “I would assume your parents are dead by now, right?” (Fortunately the subject of the interview and her children, who were still in the room, found this hilarious.)

In the real world, a full patient history is rarely taken by sitting down with a physician for a block of time. Most primary care doctors just plain don’t have enough time. . They usually gather information piecemeal through intake forms filled out by the patient, follow-up questions from the nurse, and whatever they can tease out in a visit. Also these days a lot of medical care is provided by specialists who may have a narrower view of the potential problem or who may be working off information gathered by a referring physician. Of course, there are other times when a full history just isn’t practical, like in emergent situations when stabilization is priority one.

I wanted to write a bit about taking a medical history because illness is complicated and often involves a great deal more than just the most obvious symptoms. Although explicitly the message is that any detail might be vital, the real lesson is that every detail is relevant. And I think it is important for both patients and doctors to realize that. I hope the fact that our medical education emphasizes this so much means good things for the next generation, my generation of physicians.

Since starting medical school, I have been harboring a not-so-secret resentment towards the simplicity of men’s professional clothing. Button-up shirt and a tie, slacks, dress shoes, white coat and you’re done. Sure, there are variations on a theme and I’m sure there are men out there who put a lot of thought and care into their outfits, but even if you’re just falling on the basics it’s hard to go too wrong.

I don’t know anything about this dude, but I already trust him to save my life or take all my money.

It’s not that I don’t like getting dressed up. We had med school prom last weekend (I know, right?) and picking out a dress and accessories was an enjoyable distraction from academics. But that’s the thing about women’s fashion: it’s fun because it’s complicated. There are choices to be made, and choices mean a certain level of success and failure. Great for a night out when you want to make an impression. A pain in the neck when you’re running on four hours of sleep with an exam hanging over your head.

Let’s start from the ground and work our way up. Flats or heels? And if you go for heels, how high is appropriate and comfortable to walk around in? When and where are open-toes, open heels or sandals acceptable? Socks? Stockings? Tights? Bare legs? Dress, skirt or pants? And how short a skirt is acceptable? How tight a skirt is acceptable? How loose and flowing a skirt is acceptable? How large a belt? Is your skirt see-through? Is your shirt see-through? If it is, as is the case with most women’s clothing, what sort of undershirt should you wear?  Is it too low cut? Should you wear any jewelry? How much make-up?

The answer to any of these questions varies drastically depending on the person you ask. If you get it wrong there can be serious consequences. I’ve already written about the trials of wearing the wrong shoes, but there can also be more subtle types of pitfalls. For example, studies show that wearing exactly the right amount of make-up will help a women be taken seriously in interviews, but too much or too little will leave a negative impression.

There is this fine line between being attractive, but not too attractive. There can be absolutely no sign that you are attempting to look sexy, but it can be equally damaging to be perceived as “mannish” or plain. There are few solid rules to follow; the fabric of a shirt or the shape of the woman wearing it can push either extreme. And because of the subjective nature of these judgements, you may never know when or how you transgressed.

Clothing stores and designers are not helping either. There is no clear delineation between the different tiers of professionalism and fun dress when you walk into a department store. Watch any television show and the going standard for professionals seems to be six-inch stilettos and a carefully calculated cleavage-to-neckline ratio that defies most Newtonian laws of physics.

At least the skirt covers her knees?

I don’t mean to imply that all of the women in our class are walking a razor’s edge every time we’re expected to look professional for a patient. Still, it does take time and energy and attention to detail that I don’t expect the guys in our class experience in the same way. It is also starting to get expensive, not only because women’s clothes tend to be pricy but also because each outfit is distinct enough that repeats are noticeable even to the less observant. I’m sure the boys all change up their clothes regularly, but I’m paying pretty close attention if I even spot a repeat tie pattern.

Of course much of this stems from larger, systemic issues regarding the treatment of women in the workplace and the double standards we set for professional behavior. I could go on for days. In the end, though, I wish we could dispense with the whole mess and just all wear scrubs to work every day. How can you go wrong?

Okay, fair enough.

Light warning: While this post does not contain any of the explicit descriptions of dissection featured in the last two entries, it does, to borrow a phrase from This American Life, acknowledge the existence of cadavers and the events of anatomy lab. Also, my perception of acceptable dinnertime conversation remains off center, so please take that into account as you read this entry.

There is a special kind of fear struck into the hearts of medical students at the mention of the anatomical practical exam. Although this frustrating ritual of medical education has decreased in importance in recent years, it is still an important rite of passage for medical students. I call it a rite of passage because I question its direct vital importance to the learning of anatomy, despite feeling that the actual dissection of cadavers has been immensely helpful in my medical education. To be honest, I think the practical exam exists mostly as a means of motivating us to devote the proper time and attention to studying the cadavers, rather than being an accurate means of testing our mastery of anatomy.

At our school, the exams are held on a designated Friday afternoon. The class is divided up into groups, and each group (ranging from 30 to 50 students depending on the number of questions/stations available) is assigned a time. We are to

Seriously though, who even owns a clipboard these days?

bring a clipboard and a writing tool. Those who wish can change into scrubs, but no safety gear is required.

We arrive in the hallway in front of the lab, drop off our backpacks in the locker room, and stand around nervously. Eventually the anatomy professor emerges and hands us all pieces of paper with 60 blank lines. She instructs us to write nothing other than our names on the papers, but as soon as we enter the lab we can scribble whatever notes we wish. Once everyone is ready we file into the lab through the women’s locker room.

One of the lab instructors likes to spice things up. As we enter the lab there are jock jams blaring from an old boom box, and he’s wearing a bright orange baseball cap backwards as he jumps up and down. The man is in his late 50s at least, with a bushy white beard and an awkward, soft-spoken manner, so the first time I saw this I burst into nervous laughter. The other lab instructors and fourth-year TAs are also standing around in their scrubs and white coats, smiling encouragingly at our obvious anxiety.

We each head to a station. There are a number of cadavers, several models, and a number of computer screens with X-rays or CT images. Each cadaver has two stations, one on each side. Each station has a pin, an arrow or a string tied around a structure, and there is an index card nearby with a question or an instruction. There are several orange chairs positioned around the room as rest stations.

One of the professors gives us our instructions. They are the same every time: “Look at the number for your station and circle it. Be sure to write your first answer on that line. Don’t write your first answer on line one unless you are at station one. Check which number you are on frequently. You will have one minute at each station and there are a certain number of rest stations. Stay in order. Do not skip stations. If you get lost ask for help. If you do not know what structure is indicated, ask an instructor. If you ask anything else the answer will be, ‘use your best judgement.’” He says this last part with a sympathetic smile because he knows this is the most frustrating answer in the universe and the only way for the teachers to get through this exam in one piece.

Then he offers the usual advice: “First get oriented: are you on the front or the back? Which way is the head? Then identify the indicated structure. Next, read the card at your station and write the appropriate answer on the blank that corresponds to that station. Answer only the question on the card. Not all of the cards say ‘identify.’”

There are about eight televisions, the big boxy ones on metal shelves hanging from the ceiling like in public school classrooms. The screens are blue with a number in the center. When the instructor says go, the number starts at 59 and counts down silently to zero like you’re on a game show. Whenever the number hits zero, the lab instructor yells some variety of “rotate!” or “move!”

The instruction to “get oriented” seems obvious, but the cadavers are well draped. Mostly this is to protect them from drying out, a major problem, it turns out, once you remove a person’s skin. There is also a fair amount of obscuring done for the sake of difficulty. You cannot see faces, genitalia, hands or feet unless that structure is specifically being pointed out. The cadavers are also largely sans skin, so all the usual orientation clues are missing.

We are not allowed to touch anything either, which is frustrating given than all of our studying has required us to find the structures by digging them out for ourselves. If I’m used to locating the musculocutanous nerve by finding its origin at the brachial plexus, I had better hope they have positioned the cadaver so you can see the brachial plexus when they pin that nerve. It’s also harder to distinguish structures like arteries and nerves when you can’t feel to see if they are hollow or move the drape back just a bit to see if you can see what branches it gives off. I end up twisting and contorting myself trying to peer into body cavities without blocking the light, my nose and hair getting dangerously close to formaldehyde-soaked fabric.

One minute, as it turns out, is precisely enough time to settle on an immediate answer and then second guess yourself. In some ways it reminds me of physics tests from postbac, where it was better not to even try to check your work if you managed to stumble upon an answer. Just keep moving and don’t look back.

Spelling doesn’t count on these exams, which is good because the words ophthalmic and infundibulum will never cease to send my brain and fingers into spams without a spell check. We are strictly forbidden from abbreviations, however, which I find intriguing given how pervasive abbreviated language is in medicine and our school curriculum. (In two labs

Look at that judgmental expression. As if he could spell pterygopalatine fossa off the top if his head.

of brain anatomy alone we’ve already learned about PICA, and AICA, SCA, PCA, MCA and ACA.) They will also, apparently, take off for lack of specificity; it is the styloid process of the ulna, not the styloid of the ulna. There are also no points for being technically correct either; the identity of one x-ray structure was the adductor tubercle, and the fact that the arrow was also pointing to the medial condyle of the femur did not mean that was an acceptable answer.

Once the exam is over, we turn in our tests, file out, and, usually, head off to study for the written exam. By the time our tests are graded and accessible, we are usually well past the point of real concern. As good or as bad as it feels to see where you ultimately fall on the curve, the skills being tested in anatomy practicals don’t seem to correlate to anything particularly useful in medicine. “When am I ever going to have to diagnose someone without asking any questions or touching them?” one of my friends pointed out.

I will say, in defense of the anatomy practical, that studying for something “hands on” is completely different from studying for a written test. I could have pored over dozens of textbooks and memorized every division of every artery and nerve and never have really understood how it all fits together as well as I did studying it within a body. Some of my esteemed colleagues may disagree with me on this point, but I would argue that, although the exam may not have realistically assessed my understanding of anatomy, it was a powerful motivating force. I doubt that I would have ever learned so much or so thoroughly had that impending exam not driven me back to lab so many afternoons.

Warning: This is another graphic dissection-related post and possibly contains some of the grossest descriptions yet. I also might ruin oranges, cottage cheese and s’mores for you forever. Read at your own risk.

Do you know what you get when you send out an email asking medical students if they would like to give up an afternoon to assist with an optional brain removal dissection? A lab full of medical students wielding bone saws and chisels.

Where do we cut? The top part, right?

(If you’re already rethinking your commitment to reading this post, the back button should be at the upper lefthand corner of your screen.)

We’ve started our unit on the central nervous system, which means I am in full neuro-nerd mode. (Another student called me that earlier today and I like the alliteration so well I decided to keep it.) We’re not actually doing a lot of cutting in our dissections for this unit, but the brains did need to be retrieved from their usual location. The idea was to use all of the brains from our cadavers along with a few supplemental brains* from surgical pathology so that we won’t have to alternate dissection groups like we have been doing with our cadavers.

Here is how to remove a brain:

First you have to remove the skin of the cranium. You do this by making an incision from between the eyes to the back of the head and from one ear to the other and then peeling back the flaps. This was a bit more intimate than I was expecting, given that we had covered the face of our cadaver on the first day of lab and had not uncovered it since. The rest of his body was devoid of skin except for the soles of his feet and the backs of his hands. In many ways our cadaver had ceased to feel like something that had once been a person. Uncovering his face and making that first incision between his eyes was different. I have a hard time attaching an emotion to it–I didn’t find it sad or gross or creepy–but I noticed it.

Peeling the skin off the bone of the scalp is like peeling an orange. It comes away with a good solid tug and makes that same soft unsticking sound The deep fascia underneath even looks like the white inner rind. Underneath, the top of the skull looks just like every skull you’ve ever seen, off-white and smooth. The temporalis muscle on each side (the thing that tightens up at your temple when you clench your teeth) is the only non-boney landmark. We reflected them back as well so that we would only be sawing through bone.

The striker saws have small, semi-circular blades. They cut through the bone pretty easily, but they are just unwieldy enough that it’s hard to judge how deep you’re going. The goal is not to saw through the entire bone, but rather a few millimeters deep and then to crack the rest of the way through with a chisel and hammer. Halfway through this process you have to flip your cadaver over to make a complete circle around the head. Then you flip it onto its back and saw across the top like a headband.

The bone saws kick up a lot of bone dust and the friction creates a bit of smoke. It smelled to me like burning marshmallows. (No, I wasn’t hungry during this dissection, I swear! I reasoned it out with another student later: marshmallows and bones are both made of gelatin, after all.)

Some of the cadaver brains weren’t properly embalmed, which brought a whole new meaning to the phrase “my brain is mush.” They were the consistency of cottage cheese and oozed out of the new opening in the skull. Even the anatomy professor was grossed out. Those brains were left in their respective cadavers with several layers of wrapping around them both.

Our brain was well-preserved. The skull cap made a ripping/popping noise as it came free: the sound of the dura mater (the tough, protective coating of the brain) pulling free of the bone. Then we sawed through the occipital bone at the back of the head so that the spinal cord could be severed.

Even then, there was a lot more to be disconnected: the roots of the dura mater, the vessels that carry blood into the brain, all of the cranial nerves (there are twelve pairs.) Then we were done, and the brain came free like it was never all that attached in the first place. What, all that work just for me?

Strange to think that the object I was cradling carefully in two hands (not-dropping a brain on the first day was pretty high on my to-do list) had held all of the thoughts, the memories, most of the personality of the person it once belonged to. It is dead now, fixed and quiet, but I wonder if someday we might be able to look at all of the connections that existed and see something of the thoughts that passed through it once. Or maybe we’ll discover that to be something completely unknowable, something greater than the sum of its parts. It sort of hurts my own brain to contemplate. In a good way.

Ze Brain

*Every time I say the phrase “supplemental brain” I want to make a joke about borrowing one for the next exam. I know, it’s terrible, but I just can’t resist.

Warning: This post concerns my experiences in cadaver dissection. At this point in my medical training, I can casually chat about what went on in lab over dinner and not think anything of it. You, on the other hand, may have slightly conventional standards, and might find it a bit graphic. Please take that under advisement before continuing. 

Ready? Let's go.

Ready? Let’s go.

 

It’s a relief learning you are not the only person who finds skinning and separating out muscles on a cadaver oddly satisfying. It’s not really something you can bring up in polite company, but when a group of med students are sitting around the lunch table waiting nervously for their first practical exam, these sorts of things come up.

We’ve just finished our third week of lab and our cadavers are now largely sans skin. Removing it is a time-consuming process; skin and the fat underlying it are rather firmly fixed to the fascia and muscle below. The technique involves making two incisions to create a corner flap of skin, carefully going deeper layer by layer until you can see the red of the muscle or the silvery stripes of tendons. Then you grasp your flap (careful to not grasp any of the muscle tissue along with it) and pull back hard, like you could peel it right off. Then you scrape gently at the wisps of fascia between the fat and the skin with your scalpel, slowly detaching them and peeling away the skin. The idea is not to go so deep at to cut through the muscle and also to remove enough of the fat and fascia that you can see the muscles and structures below.

When it is going well it is not unlike managing to pull the entire peel of an orange in one piece. Or finally getting the long red piece in Tetris you’ve been waiting for the whole game.

When it isn’t going well, you can’t tell muscle from fascia from tendon from fat and you kind of want to start throwing your tools around the room.

Separating the muscles is similar, although you usually don’t even need a scalpel. You run your fingers or a probe through the fascia surrounding the muscle groups, pulling it apart like spiderwebs.

Nerves and arteries are more frustrating. They are usually bound up in a lot of fascia, but delicate enough that you want to avoid ripping through with your hands or slicing through with the scalpel. They also often look enough like bits of fascia (especially the smaller nerves) that you might not even notice them at first.

Going to lab has utterly revolutionized our schedule as medical students. Instead of spending four hours in a classroom listening to an array of lectures, we spend three or four hours on our feet, actively working through a lab. In some ways it’s a break for our brains; the concentration required to decide if you’re in a muscle or still on the plane above it is completely different than that required to memorize innervations or artery bifurcations. Most of the lab is physical work with breaks to try to identify structures. The time flies by and there is absolutely no risk of falling asleep.

We’re also divided into two groups per cadaver. One day my group might dissect the abdomen, the next day the other group will examine our work and dissect the front of the thigh. Which means a whole day off, at least once a week. After the non-stop slog of Monday through Friday 8 a.m. to 12 p.m. classes in the fall, this is like a dream come true.

That isn’t to say anatomy is a walk in the park. Some things in medical school are difficult simply by virtue of the fact that they require decades of experience to really master. Reading x-rays for example, or recognizing histology slides. I can memorize the nerve innervation for every muscle in the lower extremity, but learning to distinguish artery from nerve at a glance is an art. Sometimes even the professors aren’t quite sure what they’re looking at. This is the part of medicine that takes the most practice and is the hardest to explain how to do. It is also the part of medicine that feels the most like being a doctor.

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Okay, so this isn’t a blood draw needle, but you get the idea.

I’m thinking of creating a version of the Who Said It game called “Medical Students or Burgeoning Serial Killers?” Here are some approximate quotes I’ve collected over the past several months.

  1. “I’ll just keep all of the blood vials in this basket here until I can figure out how to dispose of them.”
  2. “Skinning a human cadaver is harder than I expected.”
  3. “We should get some pig’s feet to practice on. It’s more like human flesh.”
  4. “He gets all the supplies by telling the clinic staff we’re planning to practice blood draws.”

Okay, since I don’t actually know any serial killers in training (I hope),  the game is pretty one-sided for now.

For a bit more context (lest you think perhaps a quick call to the FBI might be in order), this week marked our foray into cadaver dissection, and also the third so-called phlebotomy party.

The phlebotomy parties came about around Thanksgiving after a primary care conference where students were able to practice skills like suturing and blood draws. I wasn’t there, but from what I heard, many of the blood draws were not terribly successful.

I don’t know about my fellow students, but practical skills in medicine make me nervous. I know that I can memorize pages of information and answer multiple choice questions with reasonable accuracy, but none of that guarantees I will be any good at basic medical skills like lumbar punctures or taking blood pressures. The latter I can practice whenever, at least. Mostly of my family and friends have been subjected to me brandishing my stethoscope and sphygmomanometer. But the stuff involving needles? At best you might get to practice them on a dummy, which is really not going to prepare you for a terrified patient, angry at being used as a training tool.

Blood draws, at least, are fairly straightforward. So with a few donations from a local clinic, one of my small-group classmates with some phlebotomy training gathered together everything we might need and had six of us over for dinner and bloodletting. After all, if you’re going to mess up poking someone with a needle, it might as well be someone who is planning to stick you right back.

The first stick is, in a word, terrifying. There was this moment before I slid the needle in that I was thinking to myself, “I can’t do this. How could I ever think that I could do this?” Then bam, a minute later I was triumphantly holding a full vial of blood, my heart pounding in my chest and a general feeling of “Holy crap, I can’t believe I just did that.” Then I turned around and offered my own arm up for some first-time needle sticking.

Our first session was such a success that the host has had two more since. They are well-attended and it is a relief to watch everyone go through the same spectrum of emotions each time: terror, followed by determination, and then elation at their eventual success. We can do this! It’s for real.

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Uh…now what do we do with it?

A friend of mine pointed out that as physicians we probably won’t be taking a lot of blood. That is more the purview of nurses and techs, even if we will eventually learn the skill. Still, it is a relief just to know that I can handle the basics. For the first time I was able get past the literal barrier of the skin, into the parts of a living person that we generally never see. I don’t expect this will make me less terrified or apologetic when I finally do have to practice on a stranger for the first time. But at least now I don’t have to wonder if I am even capable.

And, even if it’s only the barest of comforts, at least I can say, “I’m new to this, but I’ve done it successfully a few times before.”

I have been waiting to write about cadaver lab since I started this blog. It is such a defining piece of medical education and is surrounded by so much history and mythology that it is hard to imagine where the reality lies. Cutting open dead bodies is the stuff of horror films or indelicate humor. The idea that one body will become my template for understanding how humans work inside is creepy and exciting all at once. I am already intensely curious about the body I will be working on. Will it be a male or a female? How did she die? What kind of life did he  have? What made her decide to donate her body to us?

The school takes cadaver lab very seriously. We have several classes designed to address the implications behind dissection. At the end of the unit there is a memorial service for all the cadavers. We are warned to treat them like patients.

Our first assignment with the cadavers will be to wash and shave them. We have very specific step-by-step instructions on how to go about this. They are curiously impersonal and somewhat vague. For example, if your cadaver is lying face down you are to turn it over onto its back. And yet I have no practical idea of how one would efficiently go about this. There are certainly enough of us to manage the weight, but the logistics of arms and heads and the immediacy of lifting a dead body for the first time seem perilous.

If necessary, we are to trim and then shave the hair on the head, armpits and pubic region of our cadaver. I am interested as to how a group of nine people decides who is responsible for shaving the genitals of its cadaver. Certainly we are all going to have to get extremely familiar with uncomfortable areas of the body, but I will confess I am a little intimidated. I can’t even figure out if the fact that our cadaver is dead makes it better or worse.

I am excited to start anatomy in the same way I get excited at the top of a roller coaster. Part of me is thinking, “At last the thing I have been waiting for,” while the other part is thinking, “Um…maybe this wasn’t such a great idea.” I expect that, also like with roller coasters, I will be glad I did it in the end.

It’s been a rough week, and I’m well past overdue for a solid update to this blog. Still, sometimes it is the little things that stand out in a day, so as a study break I would like to take you for a little behind-the-scenes look at how interpreter call lines work.

In the hospital setting, especially at a big, public hospital, there are often language barriers between doctor and patient. The best way to deal with something like this is to get a family member or friend to translate. The second best scenario is to enlist the help of someone on staff who speaks the language. Still, there will be times when an on-site interpreter cannot be found, and for those occasions many hospitals have hotlines hospital staff can call to gain access to an interpreter.

For our patient presentation this week, we had a doctor interview a gentleman who recounted for us his experience with an illness we had been studying in the past few weeks. He also spoke almost no English

If communicating to your patient through a third party via phone sounds awkward and cumbersome, that’s because it is. And if you happen to think presenting such an awkward and cumbersome activity to an auditorium of 150 medical students sounds like it might present some logistical problems, you would again be right.

The presentation was sent up with the doctor and the patient in the front of the auditorium. A microphone was positioned over a cell phone lying on the table in front of them. The cell phone was on speaker, and the microphone actually managed to pick up most of the call surprisingly well, given the technical difficulties we’ve had with sound during many of our lectures.

On a screen above their heads was a list of basic guidelines for using an interpreter hotline.

  1. Introduce yourself and your patient to the interpreter
  2. Write down the interpreter’s ID in the patient’s chart
  3. Speak directly to the patient and make eye contact
  4. Speak in short, direct sentences

The physician dialed and we listened to the phone ring. Then, like with any hotline, a recording answered.

“Thank you for calling the interpretation hotline. Please enter your ID number and PIN.”

(ID and PIN, I thought. I guess you wouldn’t want just anyone taking advantage. I could picture a lonely patient looking for the sound of a familiar language sneaking a call in the middle of the night.)

I believe a real person picked up then, but it was hard to tell the difference from the recording. “Please state the language you need translated,” she said.

The doctor leaned forward and spoke slowly into the phone and the mic at the same time. He requested the patient’s primary language and then added a backup in case they couldn’t find a translator for the first.

“Please hold while a translator is located,” said the woman on the other end. There was a click followed by the all-too-familiar strains of hold music drifting up through the mic. The class laughed.

The hold music played for a minute. There was another click and recording announced, “All translators are currently busy. Please hold for the next available translator.” Another little laugh passed through the crowd.

A few moments later the operator returned and told us an interpreter for the primary language was available. We were transferred over.

Through all of this, our patient sat…well…patiently, looking down at the phone. I wondered how much of this process he understood; certainly he must have been through it dozens of times. He seemed pretty calm, but I couldn’t help thinking how uncomfortable I would be, sitting in front of so many white-coated students, unable to understand most of what was being said around me.

The interpreter came onto the phone. She introduced herself and gave her ID. The doctor introduced himself and the patient. I waited for him to explain to her that she was on speaker in front of a classroom full of medical students, but he never told her the situation directly. Instead he dove right into the interview, asking the patient if he was nervous to be in front of us all and tell him that we were just kids and didn’t know anything. I wondered what the interpreter was picturing on her end of things. She gave no hint at being surprised or annoyed at being called upon for demonstration purposes.

I don’t know if it was the awkwardness of the set-up, or the convention of such translations, but the doctor was robotic throughout the interview. He spoke slowly and loudly in simple sentences, probably to make the translation as easy as possible, but there was no inflection or emotion in his voice. I found myself looking away when he would ask his question, embarrassed by his stiffness and unsure if the extent of his simplicity was entirely warranted.

The patient spoke in short affirmatives at first–we quickly learned the word for “yes”–as the doctor narrated his background. Eventually he began to answer real questions and fill in the pieces of his tale, the soft flow of his words melodic in contrast to the short, direct sentences of the physician.

Despite my interest, it was hard to sit through. The translation took a long time; even beyond having to wait through the interpretation and reply, there were times when seemingly short answers seemed to necessitate far more words in translation. There were times when I could hear the interpreter struggling to find the right words or phrase in both languages. Sometimes her translations hinted at a nuanced answer that simply couldn’t be conveyed adequately in the given situation.

On the other hand, we were able to find a translator who spoke a very specific language fairly quickly , and went from a complete language barrier to effective communication in a short period of time. Clumsy though it may feel, that is something of a miracle.

“The definition of insanity is doing the same thing over and over again and expecting a different result.”

You have probably heard that saying (or some version of it…I have a knack for butchering quotations) before. It usually applies to some part of a person’s life, although I’ve always felt that relationships were a particularly ripe arena for such behavior. We all have a friend, or are the sort ourselves, who fall for the same “type” over and over again and are continually bewildered when things don’t work out. Again. For exactly the same reason they didn’t work out the first ten times.

I’m realizing, as I dive into yet another unit of my education, that I have just such an insane relationship with medicine.

It goes like this:

I look ahead at the coming week, and inevitably I find something to get excited about. Perhaps we are going to be learning about cancer, or bacteria, or delve into pharmacology or the ethics of end-of-life care. It is medical school, so there is obviously going to be some medically related theme, and I, it turns out, am a sucker for wanting to know about medicine. (No big surprise there, otherwise there are a lot of questions you might be asking about how I ended up here in the first place.)

I get excited. And I make plans for how amazingly well I am going to study this subject and how intricately I am going to learn all of the details. And then the week begins.

The trouble is, medical school is hard. Just as surely as I will get excited about what we are to be learning, I will also hit a wall where I just don’t know that I can learn it all. Sometimes the concepts are complex. Often it is just the sheer amount of material piling up before me; lists of microbes and drugs and pathways that I swear are more numerous than neurons of the human brain. No matter how much I want to know the information or how interested I was the weekend before, no matter how convinced I was that this week was going to be different, I am overwhelmed and quite sure I will never learn it all.

Eventually the week comes to an end, often bringing with it some sort of assessment, and seemingly by the skin of my teeth and a bit of luck, I manage to do pretty okay. I curse myself because, well I’m perfectionist and even in a pass/fail system doing pretty okay makes me nervous. I tell myself that next time I am going to nail the material into my brain so hard I will carry it to the grave.

I look at the next week’s material. We’re learning about viruses.

I love viruses.

Seriously, how weird is this thing?
Source: Wikipedia