Perspective

“There is no more difficult art to acquire than the art of observation, and for some men it is quite as difficult to record an observation in brief and plain language.” – Sir William Osler, MD, CM

With the first year of medical school under my belt, I’ve received the expected types of questions from family and friends: “Are you happy where you are?”, “Did you like it?”, “Was it what you expected?”, and “Will you take a look at this?” The answer to all of the above being “yes”, “yes”, “yes”, and “please see an actual medical professional.” My favorite question, however, is “what was your favorite class?”

The Art of Observation

It is often said that medicine is both an art and a science, a statement that took on a deeper significance during my selective, the Art of Observation. This course offered a chance to explore the oft-overlooked humanities component of our medical education by focusing on the critical appraisal of artistic work and examining the collaborative and intertwined history of both art and medicine.

Our first exercise was to do something most medical students are reluctant to do: tell everyone why he or she has the right answer in front of the doctor. After being shown different paintings of various scenes, we were asked to interpret what was shown to us – the time of day, period of history, mood of the scene, etc. We were then asked why we thought what we thought, forced to defend our hypotheses with visual evidence in the work – shadows cast by the sun, the fashion of the dresses worn, the expressions on people’s faces, so on and so forth. Further still, we were asked to objectively examine what led us to our conclusions based on fact alone. We supposed that the scene was taking place in the morning because of sunlight breaking through a window. But what else is sunlight other than a decrease in the value of colors over a certain area? Is a window not four rectangles circumscribed by a larger rectangle? And do we know it is made of glass because colors and shapes can be seen within the rectangle that are different from the colors and shapes outside the rectangle?

Our second exercise focused on visuospatial assessments and interpretation of 3D images. Chop a sphere in half and what do you get? A circle of course. And a cube? Obviously, a square. What about a cone? Depending on the angle of the bisecting plane a circle, ellipse, and triangle could be the right answer. Maybe I should have paid more attention in geometry and calculus. You utilize these skills to interpret an MRI or mentally reconstruct a 3D image (or even physically reconstruct a 3D image) based on 2D data. It’s also an important skill in understanding the 2D limitations of tests like radiography. This exercise was followed-up with a charcoal drawing studio session with a nude model and more painting analyses in the gallery. During this class, we practiced bringing our observations and interpretations to life. After being told to draw and erase a few times and meditating on the idea that nothing is permanent, I put together a piece of work that I’m actually very proud of (as a beginner of course).Processed with VSCOcam with b5 preset

Medicine, like art, requires us to sift through sand to find gold. A skill learned in this course, such as tolerance for ambiguity, is important because the right answer is rarely ever as obvious as we would like it to be. Often times, we are forced to with sort through mountains of ambiguous information in search of patterns that lead us to the correct diagnosis or treatment. One might even say that tolerance for ambiguity allows us to appreciate and validate different perspectives, a skill that is useful when consulting your colleagues or trying to have a conversation with a patient about his or her fears or goals. It is useful for us to tolerate ambiguity and uncertainty as a step in the learning process, instead of perceiving it as a threat or an obstacle. Other skills learned in this course, such as spatial awareness, might even be useful for assessing facial expressions and body language in your patients and colleagues, a necessary facet of emotional intelligence.

Another challenge, as Sir Osler stated, is “record[ing] an observation in brief and plain language.” Trying to explain a disease process to a layperson is like trying to explain to someone what their reflection is if they’ve never seen a mirror before. It’s an exercise that one can easily write off as trivial because we know what a mirror is from previous experience. But when you’re explaining to a patient why you think a their proximal muscle weakness is polymyositis versus a limb girdle muscular dystrophy for example, your own previous experience is going to mean little to them if you can’t explain why using simple terms to parse difficult concepts into digestible information.

This course really was my favorite class, but it was something that I didn’t fully appreciate until we finished our musculoskeletal-dermatology-rheumatology block.  “Having a patient walk can tell you a lot about what’s wrong with them”, “a rash isn’t just a rash”, and “we don’t really know what’s going on here” are a few of the important points I picked up. A few weeks ago, I spent a Saturday at the MoMA, excited that I knew why Paul Klee’s painting style differed from one painting to another (it was systemic sclerosis, of course). Do me a favor the next time you’re at a museum: tilt your head or crouch down on the floor. There could be a whole world in front of you that you never even knew existed, if you only look a little harder.

I’m going to close this post with a little interactive session. Below are a few images that were used during my course, each of which depicts a certain medical condition or inconsistency (highlight under the picture to reveal the answer or discussion – best viewed on desktop). Make an observation, defend your hypothesis with evidence in the painting, and have fun.

– TS℞

The Anatomy Lesson of Dr. Nicolaes Tulp, Rembrandtthe_anatomy_lesson

  • The proportions of the body are off. The head is off-center to the right and looks propped up or devoid of a neck. It also looks a little larger than what would be expected for the body. The right arm is shorter than the left and does not reach past his hip. These inconsistencies may be due to multiple iterations of the painting using various cadavers with varying proportions. Click for article.

Rubens and the Graces, Rubens55mythol

  • One of the Graces might have arthritis. The leftmost figure displays a Boutonnière deformity on the fingers of her right hand (the distal interphalangeal joints are flexed while the proximal interphalangeal joints are extended).

The Ugly Duchess, Massys1024px-quentin_matsys_-_a_grotesque_old_woman

  • The Duchess may have had Paget’s disease, a disorder of bone deposition in which unchecked osteoclast activity leads to accelerated and disorganized deposition of lamellar bone.

The Death of Procris (A Satyr mourning over a Nymph), di Cosimopiero-di-cosimo-a-satyr-mourning-over-a-nymph-ce1

  • The adducted, medially rotated, extended arm and pronated forearm would lead me to believe that the nymph developed a condition called Erb’s palsy/waiter’s tip due to a lesion of her C5-C6 nerve roots (which makes sense given the location of her injury – the cricoid cartilage). One might also look at lacerations on her forearm and posit that they were sustained while defending herself against the satyr (who are known in mythology for their voracious sexual appetites). I don’t know, I’m not a forensic pathologist.

 

 

Chrysalis

“All is flux and nothing stays still.” – Heraclitus, 500BC

This blog post has been waiting a long time to be written. Since my last post in November, this idea existed only as a text document silently blinking in the corner of my laptop, a mess of jumbled ideas and half-thoughts impeded by my Block 4 burnout. Little by little, I’ve been adding to it, hoping for the day that I could finally muster up the inspiration to add form and substance to my ideas. Well, today is that day. And like all good ideas, it comes right before a busy week of a TBL, administrative meetings, presentations, and the start of the Infectious Diseases block.

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The theme of this entry is transformation. Quite paradoxically, transformation has been the one constant that I’ve noticed over the past few weeks (my existential rambling will be explained shortly). To put everything into context, our past month was spent on a course called LifeStages, which explores the transformation one goes through from birth through death, and emphasizes the psychological, economic, and sociocultural determinants of health along the way. Although it was explained to many of us as “Winter Break Part 2,” I appreciate that it distilled much of what clinicians amass over years of experience. Thus, it was an opportunity to reflect on the journeys that we all go through, and the transformation that occurs along the way.

It’s funny how different I feel, even within the span of a few months. While I obviously have much, much, MUCH longer to go, I made sure I spent this winter looking back on the things I was able to accomplish. My first post on this blog was an early, but very real concern that I would not hit my stride. At that point, I had my doubts about making friends or succeeding in a new environment. Now, I’m finding my place in school leadership, forging new partnerships between my school and community organizations, and inching closer toward the doctor I’ve always dreamed of becoming. This month my clinic team and I were able to graduate our patient to a different program. From the first day I met her as a med student who knew absolutely nothing about patient care, we have gone on a journey together. The last time I saw her, she looked different. She smiled in a way that I can tell she hadn’t in a long time. As a team, we helped her get health insurance after she left her job due to chronic disability and anxiety, as well as tackle her newly diagnosed depression and loss of autonomy. Eventually, she came to realize that it was ok to ask for help, and that we were there so she didn’t have to go through something like this alone.

Although I thoroughly enjoy my time in clinic as a grounding experience that anchors me in the present, my other favorite aspect about being at a new school is our ability to mold our environment as we move forward; I describe it to students visiting on interview days as a “medical school startup.” We broke ground in this city for a reason; there is a purpose to everything that we do. We are constantly reminded that our mission is to transform and empower a community, and if we don’t do that, we have failed. I realize now that we are not only being groomed to effect positive change in this city, but to transform the dialogue of medicine and society at large. This past Wednesday, an ad-hoc panel comprised of myself and a few of my classmates had our second meeting with senior leadership staff regarding bias in medicine and medical education. I don’t know how often this occurs at other schools, but I am still taken aback by how our dean, vice dean, and other leaders actively engaged with us about how to best address issues of race, gender, sexual orientation, and overall respect within our institution. Our requests included additions to educational material to reflect our community and the challenges our patients must overcome, as well as standards that ensured mutual respect between both faculty and fellow students. While we are nowhere near resolving the issues that this community and our nation at large still struggle with, I honestly believe that I am at the right place. I am meant to be at this school surrounded by people I have the privilege of calling my classmates and friends.

Without divulging too much personal information, all I can say is that my classmates are amazing. To end LifeStages, we had a final “Meet the Students” segment. Throughout the course, we had various “Meet the Professors/Patients” workshops integrated into our curriculum, mostly there to shed light on how patients and their families deal with medical disabilities. However, this session was an opportunity for some students to speak in front of the class and faculty to share their life experiences. Mental illness, poverty, domestic violence and child abuse, drug addiction, you name it. And still, the theme was transformation: fighters became artists, users became creators, lambs became lions. There was a sanctity that came over the room when people spoke. At times it felt so raw and uncomfortable, invasive even, that sitting just three feet away from the podium made me feel like I was intruding on a private moment. In an hour and a half, the mood went back and forth between the austerity of a funeral and the ebullience of a wedding, yet somehow it all made sense with the rhythm of the event. What I took away from that afternoon was more important that anything I could learn from a book. In a way, listening to someone tell you a story like that can change you too. I don’t think that I can look at a friend, a patient, or any other person for that matter without thinking about the transformations they’ve gone through. Or perhaps, the transformation they are undergoing right now. You just never know who’s gone through hell and back.

To those who wish to pursue medicine: I don’t have much experience yet, but I can honestly say that I’m living my dream. What I do know is that you should stay focused, be compassionate, have empathy, advocate for your patients, and embrace transformation. In the end, those qualities are all that you really have to offer and the only ones that actually matter. And that is something that will never change.

Thanks for stopping by.

– TS℞

 

 

 

White Coat Woes

“Hi, I’m student doctor James, nice to meet you. What brings you in today?”

I never really intended on blogging, but after starting a maybe-kinda-sorta-project on Instagram a few months ago, I decided to chronicle my adventures in medical school. I have no intentions of being famous from this, I just want to share my story (but with the way my student loans are looking, that actually wouldn’t be so bad). Though I initially intended my IG account to be a superficial collection of lifestyle posts, OOTDs, and awesome food, it soon became apparent that I needed to do more. While I believe my IG account will continue to stay as it is, I hope to use this to share more detail: thrift store hauls, style tips for the sartorially inclined, an awesome meal I’ve had, advice and fears about medical school for premeds and fellow medical students. I also hope you all can share with me, even if I only have 5 followers. So, let me start off with my first few months of medical school.

Like many of you premeds and med students out there, this is a goal that I’ve worked toward for the majority of my academic life. It’s interesting being back at square one, especially after being so laser-focused on getting into med school for over 10 years. It’s humbling (yet funny), going from knowing nothing to still knowing nothing, but about different stuff. I’m adjusting well both academically and socially, but to be honest, I’m still uncomfortable in my white coat. I just don’t feel like I’ve earned it yet.

Before my white coat ceremony I thought it was nice that my school waited until after our first exam to don us with the symbol of our profession (although if I had to change one thing, maybe it wouldn’t have been directly after our exam that morning). In contrast to some of my peers at other schools, I thought “yeah, I’ve earned the right to wear this.” I was right, kind of.

Since then, I’ve demonstrated proficiency on two exams in genetics, biochemistry, physiology and most undergraduate science majors combined and condensed into two months. I’ve had simulated office encounters on standardized patients and had the opportunity to become part of the healthcare team in our student-run free clinic. I’ve rotated through different departments in the hospital (OR, IM, Peds, OB/GYN, ICU, ED) and contributed my knowledge as a healthcare professional in laboratory medicine. And yet, I’m still unsure. Our professors tell us all the time how different our school is, how special our class is, how they wish they had received same the immersive, integrative training when they were in school. I try not to take this experience for granted, I’m in a special place after all. But, and I think this is the first time I’m admitting this, I’m actually terrified.

It’s amazing how quickly the nagging monsters of self-doubt come back to haunt you after you thought you’ve laid them to rest, especially when you’re caring for a real, live person. I just want to do good by them, by all of them. The ones I’ve seen and have yet to see. I just want to be a good doctor. I see the M3s and M4s walking into patient rooms, talking to them with confidence and assuredness, impressing the attendings and residents with their knowledge. Maybe I’m being too hard on myself, we’re only a few months into school after all. We’ll all get there soon, call me impatient.

WELL. Hopefully that wasn’t too much of a downer. I hope to keep this blog relatively light, but I don’t want to be afraid to tackle real issues if they come up. Thanks for reading, everyone.

Come back soon for your refill,

– TS℞

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