How to Teach

In our orientation to becoming senior residents, we were talking about how to teach. It's common for a lot of residents to feel like teaching is a burden -- teaching less experienced residents and medical students is essentially an additional job and our primary job is pretty much all-consuming. Therefore, I wanted to share a couple of tricks, especially for new interns, about what I've learned about teaching in the last year (especially teaching medical students)

1. Probably the biggest point about teaching is that you DON'T need to be an expert to teach. Lots of interns still feel very inexperienced and diffident. It's normal to feel threatened by teaching. It's normal to feel scared about what will happen if a medical student asks you a question and you don't know how to answer. There's two prongs to addressing these fears:
A) As an intern, you have really learned a lot in the last year/year and a half of training that you have compared to a medical student. Think back to when you were a third year, just starting rotations. Everything was new. Even if you don't know a lot about a topic, what you have to say is valuable to a medical student
B) It's totally okay to be honest about your limitations. If a medical student asks me a question I don't know the answer to, I usually encourage them to look it up and let me know. Everyone learns by looking things up and that's a really healthy habit to get into. I don't think of it as me being an inferior teacher by resorting to having the med student look it up (or looking it up with them), I think of it as me teaching them how to learn.

2. Time. Time is the perennial enemy of the resident. The secret is that teaching doesn't need to take a lot of time -- if you're clever about it, you can even net time from teaching.
A) Make your limitations clear. If I don't have a lot of time to teach, I make it really clear how much time I do have by saying things like: "let's talk about asthma for five minutes" or "here's the five things that are really important to know about Kawasaki disease." This makes the discussion feel complete, rather than rushed. If there are questions I can't answer due to time, I treat that limitation the same way I treat my knowledge limitations -- encouraging the student to seek some answers on their own and regroup with me later.
B) Remember how much you learn by doing. People feel guilty making medical students do work. That's a really, really silly attitude. Most medical students realize that the currency in which they get paid is teaching and the currency with which they pay is by doing work. Even with that transaction aside, medical students are not just there to learn the academic side of medicine; they are there to learn the practical side of medicine. Have a ton of orders to write that's keeping you from teaching? Awesome! Medical students need to learn how to write orders. They also need to learn how to examine patients, talk to nurses, write prescriptions, call outside labs to check on results, call consults and the million other day to day things that make intern's lives hectic. I'll be honest -- it usually does take me more time to teach the medical student how to do these things than to do everything myself, but it doesn't take THAT much more time and I don't feel guilty for ignoring my student.

3. "But I don't know WHAT to teach!" or "I don't know HOW to teach!" It's unfortunate, but we're never really taught how to teach well. Not as medical students and not as residents. But it's not that different from anything else you teach yourself how to do: you learn it by doing it over and over, watching what mistakes you make and trying new things until you get it right. For me, a lot of how I learned to ad lib teach was by creating a couple short teaching talks that I could give and giving those over and over until I felt confident. I learned how the would go, solicited feedback on them from the med students and perfected them. If I'm stressed out or intimidated, I still go back to them. It works best if they're things that are common, so that they're likely to be relevant to one of your patients, likely to be something you know well and likely to be something the student will use again.
For peds, I think the newborn exam is perfect. It's fast, easy to teach, easy to teach while you're getting work done (like admitting a newborn), something all pediatric residents know well and something that's usually totally new to students.

4. Teaching repays you. Besides being fun, making you feel like you've contributed to the next generation of doctors and helping you recruit med student minions to help get your work done, I think the biggest benefit of teaching is how much you learn by doing it. Medical students ask questions I never would have thought of and by having them look it up for me (or looking it up with them), I've learned things I never would have on my own. But even more importantly, by spending my time thinking about how to boil down topics to a few essential points to make them quick and easy to teach, it really helps me remember things.

More Stuff I Learned

The emergency department (and life in general) has kept me really busy lately, but here's some stuff I learned recently:
1. Syphilis can be painful, despite medical school teaching that it isn't (luckily, I didn't learn this from personal experience!) Chancroid and lymphogranuloma venerum are the two leading differentials for painful genital ulcers, but both are unusual in the United States.
2. Appendicitis has a largely heritable component. Courtney asked me in conversation why some people get appendicitis and others don't. Lit review shows that about 50% of the variability is explained by genetic factors. Who knew?
3. Although MRSA is not a major player in causing otitis, it should be covered when treating mastoiditis


In other news, I found out that I'd been knitting in the round WRONG for the last 10 years. Apparently, you hold the needles close to you and the cables away from you!

How to talk to teens

I had a really frustrating experience in the ED the other day.

I needed a urine specimen from a teenager. Everything had been ordered and I was busy dealing with an actual emergency (it does happen sometimes!) when the nurse came up to me and told me that the patient was refusing to provide a urine specimen and she needed me to talk to the patient.

So I went in to the room and said "I heard you had some questions about the urine specimen. What questions can I answer for you?" The teenager refused to even make eye contact with me. The mother said "She doesn't want to pee in a cup."

"Okay..." I responded, a little confused for how the mom became the spokesperson for this decision. I addressed the teenager again "can you tell me why not?"

She shrugged, but neither her nor her mother proffered an answer. I was a little frustrated, but it also seemed like no one had tried the common sense response so far, so I decided to go for it. "I think that you probably think that it's gross to pee in a cup. To be honest, I know it's weird and it feels strange. Unfortunately, I need for you to do it so that I can make sure you're healthy, so not providing a urine specimen isn't a choice right now. The choices are that you can pee in a bed pan, you can pee directly into a cup or you can pee in a hat (a thing you place on the toilet to catch urine.) If you don't like any of those options, we can use a bladder catheter, which is a tube that we put into your bladder through your urethra. Those are the only choices I can offer you right now. Do you have any questions?"

She now made eye contact. I held my gaze steady. I was pretty willing to be the adult in this circumstance. She shook her head. "OK. Do you have a preference?" She shook her head again. "OK, I'll have the nurse come in and show you the hat and the bed pan and you can choose."

She peed in a bed pan.

The demographic in the emergency department is always a little different. A lot of times we have parents who just don't know how to tell kids that certain things aren't options. Certainly, not all parents are this way (and in the particular case that this is based on the parent was a great parent, who was just at the end of her rope for reasons that weren't relevant to the story.) I was pretty impressed by how easily I reached consensus on what was going to happen. Sometimes, it just takes firmness and explaining what is and is not up for discussion.

Quiet Call Day

Today's been really a quiet day. One of the things that I love about being on call in the NICU (OK, I just generically love the NICU) is that there's bedside nurses for all of the patients. If I want the nurse, I can just walk to the bedside and talk to her (there's about four male nurses in a cohort of several hundred NICU nurses and none of them are working today.) This is great for collaborating with the nurses on the plans, and also just creates a really nice work environment. I know most of their names (on my side of the NICU there's two residents, about 5 NPs and probably 75 plus nurses; I try to know all of their names, but it's hard.) They all know me. If I want something, I can go and talk to them face to face, without needing to call or page to find them. I walk around every 4 hours, or so, to check in and it goes quickly and I feel involved and in the loop and like a good doctor.

Most floors aren't like this -- most floors some nurses change at 7am and some at 11am and some at 3pm and some at 7pm and some at midnight and it's hard to know which nurse has whom and if you can't find the nurse, there's a million places where s/he might be. It's harder to be a team.

Since it was so quiet, I was chatting a lot with the nurses, mostly about them and their lives, but also about being on call and what it's like. The fact of the matter is that I like my life with call a lot more than any of the alternatives. I like that for a total of 28 hours, I'm really the doctor for these babies (I have a fellow and an attending, but they're mostly only involved when I call them.)

And there's an asceticism to taking call that can be very rewarding in an odd way. Expelled through the hospital doors in the morning, sleep-deprived, blinking in the bright sunlight, having been in artificial lighting for the last 28 hours, shockingly warm after 28 hours of frigid air-conditioning, you feel reborn into the world. Little pleasures like breezes and being able to eat whenever you feel like it feel poignant.

It's my last call for a month, before I go to the emergency department. I'm a quarter done with calls for the entire year (an advantage of being in genetics) and at the end of the year have nearly five months with no call...I think I might miss it a little.

Three things I've learned today this week
1. Congenital diaphragmatic hernias - are associated with pulmonary hypertension
2. The differential for congenital diaphragmatic hernia is eventration, where the diaphragm is weak, but not truly herniated
3. Hypokalemia can, in and of itself, cause an electrolyte-wasting tubulopathy

So one of my patients was just* diagnosed with cancer. The psychiatrist e-mailed me. The psychiatrist, because we'd thought that all of her symptoms were related to her (overwhelming) anxiety and rushed her out of the hospital.

(*N.B. this post was quarantined for several months, in addition to changing of several possible demographic features to ensure that there is no clear connection to any specific patient)

I had inherited the patient from the previous intern when I came on, which is always hard, because you don't really get your own first impression. My attending had felt really strongly about the psychiatric nature of her symptoms and about rushing her out of the hospital. I wasn't sure I agreed, but I didn't have a strong sense of the patient and my attending was very strong willed. On the second to last day of her admission, I talked on the phone with the psychiatrist and she had said to me: "you know, I'm still not convinced that all of her symptoms are psychiatric" and I'd replied "off the record, I'm not sure either."

But to be fair, the next words I'd said were: "but I am convinced that she has nothing physiologic that is rapidly progressive or threatening her well-being or will benefit from an inpatient admission." And that, even with the retrospectoscope, I completely stand behind. I'm not even convinced, even now, knowing that we're discussing a patient with a metastatic malignancy diagnosed one week later, that any of the symptoms for which she was admitted have anything to do with her cancer. (She got diagnosed after presenting with a totally new symptom a week after discharge)

You hear these horror stories of missed cancer diagnoses, by Horrible-Bad-Doctors and think "how could they not have known." And the answer, at least in this case is two-fold
1. Patients with high levels of anxiety and high levels of somatization bombard you with every complaint that they can think of and every possible diagnosis that they read in the internet and it's hard to see the forest for the trees. You think "well, I can't think of a diagnosis that contains all of those symptoms" and "all of the diagnoses that this patient has suggested don't fit" so you dismiss the entire package. And 99% of the time, that's the right response. But even hypochondriacs and patients who somaticize develop true organic illness, buried among the somatic complaints.
2. The goals of a hospital admission from the point of view of being a doctor are different than the goals of a hospital admission from the point of view of being a patient. As a doctor, a patient should be in the hospital only so long as necessary to establish a safe discharge (in which airway, breathing, circulation and hydration/nutrition can be accomplished.) It's my job in the hospital to make sure that the patient doesn't have anything rapidly progressing that would make them unsafe, but not my job to diagnose every symptom. Diagnosis is largely left to the outpatient realm.

It's still scary. I'm glad someone diagnosed it.

Three more things

This afternoon, after call, I went to a lecture by my department chair on the history of inborn errors of metabolism. He focused on how the discoveries leading up to the modern understanding of inherited genetic diseases revolutionized how humanity thinks of itself. Namely, the idea that inherited characteristics and even more specifically, the mind is governed by biochemical principles. It was a really inspirational, fascinating talk. Anyway, posting post-call, so without further ago: here's what I learned today

1. Neonates generally don't benefit from ventilator rates less than 10 (this only kind of counts -- I totally knew this, but didn't make use of my knowledge at 5:30 AM.)
2. People with PKU who are treated early average a normal IQ but often have subtle cognitive differences, especially decreased executive functioning.
3. Glycogen storage disease type I patients cannot ever mobilize glucose in response to glucagon, but type III patients can if they have been fasting for less than 2 hours.

Bonus: Apparently the phrase "Selling coals to Newcastle" is similar to "Preaching to the choir," because Newcastle exports a lot of coal. However, it's historically inaccurate because lots of people have profited by selling coal to Newcastle. Honestly, to me, it sounds like an Iron Dragon reference. (Selling dragons to Nordkassel?)

Three things I learned today

So I've been doing something new. Actually, it's not quite new - I did it at the very beginning of last year, too. But I've been trying to formally think about three things that I learned in any given day. Often, they're about medicine. Not just because the vast majority of my waking hours are spent physically in the hospital, but also because one of the huge advantages of where I live and where I work is that I have a half-hour walk each way, which is a fantastic time to reflect (and also where I get most of my reading done.)

However, I consolidate new information well by writing. I often write in my Little Black Notebook and over the years have amassed huge amounts of information in my Little Notebooks; however, my handwriting is little even proportional to the Little Notebooks and there's no search function on the Little notebooks, so I thought I would start trying to blog. It has the added bonus of being a form of microblogging that's based on something I already do, which tends to help me overcome my barrier to writing.

For those of you readers not interested in medical science, I'm going to tag these posts 3til to make avoidance easy (no promises that there won't be non-science contained in future posts.)

So without further ado, here are three things that I learned today:
1. Jaundice in newborns can be caused by UTIs. This is especially true of conjugated hyperbilirubinemia and jaundice that starts after 8 days of age.
2. Cori's disease (Type IIIa glycogen storage disease) can cause hypertrophic cardiomyopathy. In retrospect, I could have derived that information from what I already knew about glycogen storage diseases and cardiomyopathy, but I didn't, so there.
3. Many little known things about NEC:
a. usually in the TI or colon
b. not associated with the rate of feed advance OR with the timing of starting feeds
c. not associated with trophics (this is cheating as I totally knew this already and tried to show off on rounds by saying so, but I was "corrected," so I'm including the recorrection.)
d. IS associated with acid blockade

Hope

We went to talk to women who are living in the homeless shelter or transitional housing today. It was pretty interesting -- a lot of really articulate, dignified women. I had a lot of respect for some of them, especially two of the older women, one of whom had double digits of sobriety under her belt. I've learned from taking care of grandparents who have drug addictions just how hard getting sober and staying that way for so long can be.

One of the things that came up at the very end is the distrust that people develop in doctors because they're told that a loved one will die or has a very grim prognosis and then does well instead. I kind of automatically stepped into my script for patients with terminal prognoses. It's a script I built under the tutelage of an excellent palliative care doctor (seriously, the institution that housed my medical school is famous for many things, but it is not as famous as it deserves to be for the quality of its medical ethics and palliative medicine departments, both of which I was fortunate to spend some time with as a medical student.)

The script, supported by recent evidence in the pall med literature starts by emphasizing that it's important to have many different types of hope. I explain that based on the evidence in front of us, we think that (specific outcome) is the most likely and it's important to know that so that we can make plans based on the possibility of that outcome. It then acknowledges that parents hope that I'm making an error or hope for a miracle and that those hopes are reasonable and that I want parents to have those hopes. In a slightly antagonistic environment, like the one that developed today, I try to diffuse the tension by saying "my hope for your child is that 10 years from now you'll be telling everyone what a stupid doctor I was and how your child (survived, had a good cognitive outcome, etc.) despite what I said. I sincerely want nothing more for you."

And then I try to transition to saying "but, if (negative outcome) happens, I want you to have hopes for that, too, so that's why it's important to focus on (negative outcome) for a while." This conversation takes different turns depending on the negative outcome, but I try to guide people to realizing that they can both hope for a miracle AND hope that if their child passes away that they have a pain-free death or that if their child has cerebral palsy that they will continue to be able to care for the child at home.

It's counter-intuitive to give people permission to hope for miracles. It was initially really uncomfortable, because often my medical knowledge tells me that a miracle won't happen. I've learned to make my peace with that cognitive dissonance. I feel like parents feel like I'm on their team when I let them want a miracle.