Rotation in Palliative Care

This month, I decided to do a rotation in palliative care and already I'm wondering what on earth I've gotten myself into. The training is very valuable, but the process can be heart breaking. The Palliative Care Team that I am working with is extremely compassionate toward end of life care. I am learning all kinds of techniques for speaking with families and providing comfort measures. It is important to me that I learn these skills so I can give comfort and support to my own patients some day. If I had my preference, my patients would just live forever.

My first patient on the first day of the rotation was a patient who is my age. This patient is suffering from advanced lymphoma which is complicated by an intracranial bleed. They have been married for about as long as Matt and I have been married. I couldn't help but think about my husband when I was speaking to the patient’s family. It was difficult for me to look at the family without thinking of how tragic it would be to lose my own spouse. I had trouble keeping the tears back and it took every ounce of professionalism I could muster to hold it together. It's so difficult when patients remind you of your own loved ones, but I find that more often than not I begin making these associations.

The patient had been on comfort care measures only, but a new oncologist on the service had some hope for a palliative treatment that might improve the patient's neurological status. It would involve weekly intrathecal chemotherapy. The oncology team had good intentions. They were invested in saving the life of the patient. We are all trained from the beginning of medical school that the goal is to save lives. Death equals failure, but is ultimately unavoidable. Now the family is torn between keeping their loved one comfortable and doing everything medically possible to extend their life. There is no right decision.

According to family members, this patient is a fighter and has expressed his wishes to fight the disease until his death. Following this logic, should we do everything medically possible? Where is the endpoint? At what point do we cross the line of "do no harm" while using heroic measures to save the patients? Is the Palliative care team correct in their philosophy of comfort care measures or are the oncologist’s efforts more appropriate? I'm not sure any of us have the answer. It's a judgment call.

After reflecting on this case, I think the important thing for this patient was to keep the patient comfortable while doing everything possible to treat his cancer so the family can be at peace with the efforts to help their loved one. It is important that we don’t force our own beliefs on those that trust us in the end. The death process is very individual. The patient's wishes should be at the forefront of our thoughts when we are making treatment decisions. My own opinion is shaped and formed by my experience with the death of my father. He was also a “fighter” and wanted to treat his multiple myeloma until the very end. He taught me that some people value quantity of time over the medical profession’s judgement of quality of life and this must be considered if we want our patients to face their death with dignity and peace. I still have a lot to learn when it comes to ethics in medicine and I encourage people to respond with their own advice and opinions on this topic.

Taking the Boards

Recently, I had the opportunity to sit for Step 2 CK. Most of you probably know this already, but every medical student has to take (and pass) these "board" examinations. there is a lot of pressure. For four weeks, I have been studying for this exam. When I asked students who took the test last year about their study methods, it seemed the only universal recommendation from those who had gone before me was to use the USMLE World questions. After that, the answers varied. Some recommended Kaplan while others recommended "First Aid for Step 2" (by Le and Bhushan). I chose to work through USMLE World questions supplemented with "Crush Step 2" (by Brochert). Reading Crush gave me a nice break each day from the monotony of the vignettes associated with the question bank. I studied for at least eight hours per day (including weekends) to prepare.

Everyone will tell you that Step 2 is easier to prepare for than Step 1. I think my own experience coincided with this for the most part. The old adage is "Take two months to study for Step 1, take two weeks to study for Step 2, and take a #2 pencil to Step 3". This is an exaggeration of course, but I did feel more confident on Step 2 than I did on Step 1. I think the most helpful study tool was the USMLE World questions. I will pass that piece of advice down to students in the class behind me. The more questions you can do the better. I used the tutor mode so that I could take notes on questions I missed or important points within the answer explanations. Then I referred back to my notes each evening as a wrap up to the day. This won't be the best style for everyone, but it simply gives an example of what I did to work through multitude of questions.

I always take my favorite treats with me for these marathon tests. My test day lunch bag included a PBJ sandwich with raspberry preserves (yum!), an assortment of chocolates, and enough diet coke to last a week! It's critical to have a small little delicious energy source ready between questions blocks. My best medical school friend always takes a Dove chocolate bar to her boards. Just anticipate that you will be tired and worn out from question after question that day. Be ready to give your mood a lift with a little indulgence!

That's not all. Next I will be traveling to Chicago for the Step 2 CS exam. To help prepare us for this test, my school has set up a mock exam with feedback. I have spent the last two months on Family Medicine rotations which I hope will help me with my exam skills. Additionally, I am using "First Aid for Step 2 CS" to read up on the best way to write my notes and develop my differentials on that day.

I was able to schedule my exam on a Friday so Matt will be joining me and we will be spending a little vacation weekend in Chicago! It will be the fun weekend we both need after I've been studying for boards for the past several weeks.

Call can be hard but you learn a lot!

During my Sub-I rotation, I had two evenings of overnight call that opened my eyes to the demands of being a Family Medicine resident physician.  The first call night took place while I was working on the pediatric floor, and the second during my week on the medicine floor.   Up until this point, I had no idea how different two separate nights of call could be.  On both days I reported in the morning for a regular work day.  Around 5:00 pm, the day shift residents checked out to the night float and they went home. On the pediatric floor, the night float resident and I had plenty of time to get to know each other before the night got busy. We became friends at once!  We had dinner in the cafeteria and as we got to know each other we began to find all of the things we coincidentally had in common.  About 10 pm, we headed to our respective sleep rooms, to wait for our pagers to summon us.  I was able to get a few hours of sleep before our first admission came in.  The resident asked me to go to the Emergency Department to meet the patient and to take a history and do a quick physical.  The patient was a pretty straight forward cystic fibrosis exacerbation case.  I got to practice writing my admission orders and calculating pediatric doses for medication.  After our patient was tucked in, we both headed back to our rooms and laid down for the rest of the night.

My medicine call was entirely different.  I reported for a normal work day and met the night float resident around 5:00 pm.  We didn't have a whole lot of time to get to know each other before the phone was ringing with several new admissions.  We went to work immediately, separating once we arrived to the ED to begin working up two different patients at once.  At the same time, my night float resident was getting pages with questions about patients that were in the hospital.  Most of our night carried on at a similar tempo.  We were able to break away for a late dinner around 10:00 and my resident took that opportunity to teach me a few concepts.  At 3:00 am, our night had slowed down enough for a quick nap before the 5:00 am day crew came.  Instead of letting me go to sleep, my resident decided to give me a quick primer on acid-base analysis.  At first, I groaned to myself but actually, it was the best acid-base lecture that I've had!  It was so busy that it would have been easy to use that as an excuse to not do any teaching. I thought it was kind of him to take a few minutes of his sleep time to teach me something.  I went to sleep at 4:00 am and emerged from the call room at 4:50 am.  As soon as I stepped into the conference area, the resident was asking me to recite Winter's formula!  I faltered from lack of sleep, but needless to say, I will never forget it again after that experience!  I stayed for rounding and morning report which tallied my shift to 28 hours in length. Right at the limit! These long days will definitely take some getting used to.  Intern year will be a challenge!