Boonshoft Blogs

Notes of a Medical Student
Tell Me What You See
Avash Kalra, M.D. ’12
September 19, 2011

I held the photo in my hands and squinted. Like an X-ray, it was black and white.

But instead of analyzing lung fields or the cardiac silhouette, I found myself looking at a photo of a young man at a rodeo, riding a bucking horse and appearing to thoroughly enjoy the attention from a capacity crowd.

Depicting a scene that was part sport, part theater, the photo itself seemed to be at least a half-century old.

"You're probably wondering why I handed you this picture," said Dr. M., the physician at the Veterans Affairs (VA) Medical Center who meets with medical students such as myself every morning.

"Tell me what you see."

Feeling uncomfortable, I looked at the photo closely, searching desperately for clues, signs of illness that the man (or the horse) might have. Perhaps, I began to wonder, I was missing something obvious.

So, logically, I counted the man's arms and legs. Start with the basics.

Both legs were present, as were his arms and hands-one used to grasp the horse's reins, and the other raised in the air, either to maintain his balance or to tip his cowboy hat to acknowledge the adoring crowd.

Really, I thought, he seemed to be having a grand old time...

On more traditional mornings, Dr. M. shows my classmates and me radiology images of patients, challenging us to find something abnormal-a small fracture on an X-ray, perhaps, or a hidden tumor on a CT scan.

It's all part of what is informally known in medical education as "pimping"—a version of the Socratic method of teaching—designed to put residents and medical students on the spot, always in front of our peers and sometimes even in front of our own patients.

Its purpose is less to make the medical students feel inadequate and more to make us learn and remember something useful.

More importantly, it's to demand that we always strive to know everything about our patients, from their liver enzyme levels to their current living situation, from their vital signs to their personal histories.

At the VA Medical Center, the personal histories come from patients who include former soldiers, Air Force pilots, Naval officers and the like. Some fought decades ago in World War II, while others more recently, in Vietnam or Afghanistan.

My first patient at the VA, a former soldier, was suffering from Hepatitis C. After seeing him every morning for several days, he was ready to be discharged from the hospital.

"My family is coming to see me later today," he said during our morning chat. "I would like it if you could stop by and tell them about my condition."

Indeed, that afternoon I met the patient's family, including his parents, and was grateful to get a glimpse into the patient's life beyond the hospital walls, an impression of what his life might have been like years ago, growing up in Dayton and hoping to nobly serve the country.

He had a kind and caring family, and though he was sick now, it was clear that the past was filled with better days...

I continued to gaze at the ragged photo in my hand, unable to find anything wrong with the mysterious man on the horse.

"He looks healthy, doesn't he?" asked Dr. M. at last.

I nodded. And mercifully, the answer was revealed.

"This is a gentleman who was here in the hospital recently and was very ill," said Dr. M. "I wanted to show this to you as a reminder that these patients at the VA weren't always old and sick."

I looked up, as did the other medical students—realizing that, although we had been duped to some degree, we had become so trained to look for disease that we had missed recognizing something far more important: good health.

Indeed, by the time we see patients, they usually are sick. Many times, they're elderly as well. But knowing everything about them means seeing more than a snapshot-knowing where they have come from, what their lives were like before meeting us in the hospital.

Hopefully, if we do that, we can take better care of them-and perhaps more importantly, help them feel young again, too.

Notes of a Medical Student
Do You Want to Know a Secret?
Avash Kalra, M.D. ’12
April 19, 2011

As evidenced by the unwelcome layer of frost on the windshield, winter is approaching. And as I drive to the hospital, passing churches that stand like European castles on the still-empty streets, this morning is certainly colder, darker than yesterday.

Unfortunately, the sun won't rise for at least another hour, maybe two. Instead, I notice the constellation of Orion looming above the hospital, the moon presumably somewhere nearby, obscured for now by clouds.

It's Monday, which means last night's episode of AMC's Mad Men is on my mind. Of particular note were the haunting closing credits, which rolled solemnly to an instrumental rendition of the Beatles' song "Do You Want to Know a Secret?" The question implies two qualities at once: the great responsibility of knowing a secret and the profound sense of trust conveyed by sharing one.

I soon arrive on the mental health inpatient unit, where I am spending my six-week psychiatry rotation. Here I often find myself in the privileged position of being entrusted with other people's secrets-deeply personal information that patients choose to share with my colleagues and me.

This trust, of course, lies at the heart of our daily interactions. Within minutes of meeting a patient, we ask questions about substance use, sexual history, and bodily functions-not typical small talk.

But the power of trust allows patients to answer those questions, despite the fact that we are often complete strangers.

Particularly in psychiatry, patients share horrific secrets-about childhood sexual abuse, or multiple attempts to commit suicide-secrets about their past that, in many cases, not even their closest family members know.

And they certainly don't preface these stories by asking, "Do you want to know a secret?"

Nor should they.

After all, a crucial aspect of treating mental illness, at least from my observations, is providing a safe environment that encourages patients to confide in their physicians. In doing so, the treatment team can better understand the precipitating factors that led to the patient's arrival at the hospital, as well as predisposing factors from the patient's past, and perpetuating factors of the patient's current life.

Mental illness carries with it a stigma-even today, when diseases such as depression, schizophrenia, and bipolar disorder have been shown to be biologically, neuro-chemically, and even genetically influenced.

But the science behind mental illness means little when a physician stands in a room to interact with a patient. At that time, the emphasis is on the art of being empathetic-understanding a patient's emotional pain as a genuine experience that is qualitatively different from physical pain.

This Monday morning, as I stand in my patient's dimly lit room, just minutes before the sun finally rises outside, she tells me about the suicide attempt that landed her in the hospital, the stressors in her life, her children, and her own childhood, which included being severely bullied in school.

"Is your daughter the same age now as you were when you were bullied?" I ask.

"No," responds my patient. "But she's the same age I was when I was molested."

She says this so bluntly that it catches me off guard.

I look up, and she has a familiar, distant stare that I have seen often during the last six weeks, most notably in patients with depression. But she has told me this secret for a reason, and it hangs in the air, like so many secrets spoken by patients who have sat in this room before her.

"I appreciate you telling me that," I say, and I mean it. "I can tell these memories are really difficult for you."

Similar interactions fill the remainder of the morning, and each time, I feel that being empathetic, even in a small way, is the least I can do.

Other times, it's the most I can do.

At the end of the day, I walk back to my car not with a heavy burden of knowing other people's dark secrets, but with a feeling of appreciation for their willingness to share them.

I drive home along streets much busier than they were so many hours ago. The frost will return tonight and will bring another cold morning tomorrow.

But do you want to know a secret?

With a little warmth, I know the frost always thaws. And I look forward to doing it all again.

Notes of a Medical Student
Can I Go Home?
Avash Kalra, M.D. ’12
March 19, 2011

For the last two weeks, I have chosen to visit this hospital room, this patient, first.

I enter, and the calming sense of early morning quiet is quickly broken by the ongoing sounds of a breathing machine—a device that allows my 25-year-old patient with Down syndrome, “John,” to sleep through the night.

Beside him, as always, lies his mother, who has slept on a makeshift bed by her son’s side for 14 consecutive nights.

As always, I begin my morning routine in this room, and I do so with a combined sense of hope and dread—hoping that John will be well enough to go home, but dreading that I wilI have to tell him, again, that he’s “not quite ready yet.”

Standing in almost complete darkness, I look at John and squint at the oxygen settings of his breathing machine.

Two weeks ago, he was admitted to the hospital with right-sided heart failure, a condition that had developed secondary to heart complications related to Down syndrome. He is also diagnosed with obstructive sleep apnea—a condition that, in John’s case, increases pressures in the vessels that transmit blood from his heart to his lungs.

Now, he requires supplemental oxygen to breathe, 24 hours a day.

But he looks better, healthier, than when I first met him. He struggles much less in his effort to take deep breaths, or to sit up in his bed. His legs are no longer swollen with fluid backing up from his heart.

He seems calm.

I take a deep breath myself, and apologetically, I wake them.

“I’m sorry,” I say—always my first words to them in the morning. “I’d like to see how John is doing today.”

“It’s okay,” says his mother. “I think he’s doing better.”

John wakes up as well, and as he has done so for so many mornings, he smiles underneath his breathing mask and extends his hand.

“Good morning,” he says, earnestly clasping his other hand over our handshake. “Can I go home yet?”

“I hope so,” I reply cautiously, knowing that for days on end, our collective hope has merely translated into another night’s sleep in this room for John and his mother.

Still, they have remained—above all else—patient, understanding the notion that extra days in the hospital now may save them the grief of an unwanted return trip in the future.

For most of us, breathing is a subconscious process, driven by a coordinated effort between the brainstem, the lungs, and the chemical composition of our blood. It is a process we undoubtedly take for granted.

Our goal for John, of course, is for him to breathe without struggling to do so. If we reach that goal, we can help John reach his own goals—one of which he mentions to me every morning.

“I’d really like to go home so I can see my dog,” he says, his voice often cracking and his eyes welling up as he describes his dog to me, each day as if for the first time.

“I know,” I reply. “Let’s see if we can make that happen.”

After morning rounds—during which I discuss John’s progress with the rest of his medical team —I return to John’s room. He is sitting up in bed, his exhausted mother still by his side.

I realize that, for two weeks, I have spent more time with John and his mother than with my own family and closest friends.

And for the first time, my sense of dread upon walking into the room gives way to anticipation.

I tell them the good news—that, although John will require oxygen at home, he is stable enough to leave. Tonight, they can at last sleep in their own beds.

John, perhaps appropriately, says nothing in return. He simply smiles and sighs—out of relief, I’m sure, and with the thought of seeing his dog again.

It is, without question, the deepest breath I have seen him take in two weeks.

The next morning, purely out of habit, I visit John’s hospital room first, almost walking in and expecting to see him lying in the dark, with his mother next to him.

Now, the room is unoccupied. The window shades are up, and there is no sound of a breathing machine.

I simply stand in the doorway—still unsure why I have chosen to visit this room first every day, but aware that perhaps part of the reason is for this moment, when I know that John is breathing okay.

And I don’t have to wake him up to ask.

Notes of a Medical Student
Let’s Play It by Ear
Avash Kalra, M.D. ’12
January 19, 2011

In Greek, stéthos means “chest” and skopé means “examine.” And from the Mediterranean to the far side of the Atlantic, from its invention in 1816 to modern times, the stethoscope has become perhaps the most recognizable symbol of the medical profession in the world.

Simply walk into a hospital, and you'll see physicians and medical students with their stethoscopes tucked into a pocket of their white coats-amidst sheets of papers, penlights and reflex hammers.
Often, we wear them around our necks like gaudy pieces of jewelry. In our defense, it's a comfortable location, and besides, that's what the doctors on television do.

When we use it, the stethoscope transmits sounds from inside the body. It's a simple but impressive instrument that somewhat magically allows us to hear a malfunctioning heart valve or detect the presence of a defect in the heart wall.

It lets us take a journey through the skin and chest wall, into the patient's lungs, and it can warn us about the possibility of narrow blood vessels, among other things.

But the stethoscope isn't what we use to actually listen to the other human being in the room. We rely most of all on our ears, which we use-by training, yes, but by human nature most of all-every moment we are with a patient.

One could, in fact, argue with ease that our ears are the most important diagnostic tool we have at our disposal-more useful and more meaningful than X-rays, blood tests and blood pressure cuffs.
After all, with our ears, we listen to our patients' stories, long before we put on the stethoscope to listen to their hearts.

Recalling William Osler's frequently quoted observation-"The good physician treats the disease; the great physician treats the patient who has the disease"-the difference between "good" and "great" may simply depend on our willingness and ability to use those two appendages on the sides of our heads.

With them, we learn not only the history of the patient's present illness, but we provide the patient with an outlet to share any deep concerns, worries, and feelings. Just like the rest of us, patients need an opportunity to share their stories-medical or otherwise-and that's why, in my experience, the patient does most of the talking.

Soon after beginning my third-year clinical rotations this August, I met a patient who came to the office with a sore throat. But the visit focused very little on the sore throat and very much on the mounting stress in her life-from losing her job to caring full-time for a family member recently diagnosed with Stage 4 cancer.

There are many more solutions for a short-term sore throat than for long-term stress. There's no question about that. But at least she was able to tell me her story, and all I needed to use for those 20 minutes were the great "medical devices" that all humans have, and that are used by physicians all around the world for listening to patients.

Ultimately, as I walked out of the room, the patient — her throat probably still sore but her mind, I hope, more at ease-offered one last sentence for me.

“Thank you so much, for listening.”

My stethoscope, of course, had never left its comfortable location, securely draped around my neck.

Notes of a Medical Student
Three Letters Change Everything
Avash Kalra, M.D. ’12
December 19, 2010

It was an unseasonably warm Tuesday afternoon in early December. Outside, the temperature had climbed to over 50 degrees. Inside, meanwhile, 100 second-year medical students filled an auditorium to listen to a physician's lecture-a routine occurrence, typically not worth mentioning.

Except, we discovered, this particular physician doesn't practice medicine anymore. He's now a patient instead.

Why? CTG.

CTG. A mere three letters. This column alone contains more than 1,000 times as many. Our genetic code-the personalized Rosetta Stone within each of us-contains letters too. Over three billion of them. And in one seemingly inconspicuous spot, on one tiny chromosome, a repetition of gene bases represented by the letters CTG results in a disease called myotonic dystrophy. While the disease is not necessarily terminal, it is incurable and degenerative.

In this case, the disease's mid-life onset and progression-with muscle wasting, an inability to relax muscles, vision problems, and even difficulty eating-led our guest, Dr. M, to halt his medical career long before he ever would have planned.

All because of three letters.

Certainly, at one point or another, all physicians experience the medical profession from the perspective of a patient. But most of us won't have to face a cruel genetic disease that can take away our ability to practice medicine. That's what had happened to our guest, though, and every student in the room-myself included-listened intently. Perhaps we were particularly captivated on that warm December day because not long ago, the patient in front of us had sat exactly where we did.

Dr. M told us he had learned the exact number of CTG repetitions in his DNA that had caused his ailment, and he described his pure relief when he found out that his son had not inherited the disease. After all, he had a 50 percent chance of doing so, and anything can happen when you flip a coin.

We can only wonder if Dr. M dwells much on the past, thinking of the years he spent training and the relatively brief time he was able to care for patients. F. Scott Fitzgerald's famous final line of The Great Gatsby-"So we beat on, boats against the current, borne back ceaselessly into the past"-describes that feeling, when we look to the past because our hope for the future has been compromised.

Still, the quote seems to insist that we move on, that we keep rowing, and whether our boat is with or against the current might be irrelevant, especially for a patient. And that may be the most memorable lesson from that afternoon-even though the physician's medical career had ended, he had gained a perspective that allowed him to continue being a doctor in the truest sense of the word.

"Doctor," after all, means "teacher" in Latin.

I can assure you, Dr. M had our full attention that afternoon. And he taught. At times, his story was inspirational. But he also described his devastation and bitter disappointment with brutal honesty.

By a rough estimate, my classmates and I may care for a combined 20 million patients over the next 50 years. That's 20 million mini-lessons within the ongoing education that defines this profession. Sometimes we will teach those lessons, and perhaps more often, we will learn-from other physicians and, most powerfully, from patients as well.

This time, we were able to learn from both at once. It was just one of many upcoming lessons, but I suspect it may prove to be one of the more memorable. Because of Dr. M's connection to us, of course, and his ability to show us two perspectives at once, his willingness to sit in front of 100 pairs of curious eyes, and his memorable sense of humor, which showed us his belief in always fighting against the current.

So, it turned out we weren't only lucky because it was a rare warm day in December.

Thanks to our guest, we were fortunate, most of all, to be inside.

Notes of a Medical Student
Left Breathless
Avash Kalra, M.D. ’12
September 19, 2010

“Mr. Aster” hopped up onto the exam table, the familiar sterile paper crinkling underneath him like crispy autumn leaves. From that modest amount of activity, he was completely out of breath. A few minutes later, following a monologue of Shakespearean proportions, our patient wasn't the one left breathless.

I was.

The scene: Dayton's free clinic, Reach Out of Montgomery County, located downtown in the shadows of Miami Valley Hospital.

The cast: Mr. Aster on one side of the room, Dr. S (his physician du jour) on the other, and me, intentionally blending into the background-a wide-eyed, wide-eared and ultimately wide-mouthed medical student who just watched, learned and took mental notes-to-self.

Dr. S, whom I was shadowing that evening, noticed Mr. Aster's shortness of breath as well.

"You couldn't move from the chair to the exam table without gasping for air," she said bluntly, in a tone made of equal parts concern and displeasure.

Mr. Aster looked down at his feet, which were swollen at the ankles, as if he had not heard her. He was embarrassed.

But she continued, this time more sternly: "In all likelihood, you'll be dead in 15 years."

Now Mr. Aster looked up, his lips parting to shape a defensive response. I looked up as well. That was harsh, I thought.

But it was nothing compared to the lecture that followed, one that would have made Napoleon proud, with our no-nonsense physician performing what I later recognized to be one of the most compassionate acts possible, given her position. Mr. Aster, as you may have diagnosed by now, had every risk factor for heart disease imaginable — stunningly high blood pressure, obesity, a heavy smoking history, diabetes, and the list goes on.

He was 35 years old, but his heart had aged well beyond.

In all likelihood, at a free clinic, a physician will see any particular patient once, and never again. For all Dr. S knew, she had only 20 minutes to genuinely change Mr. Aster's future.

No pressure.

Certainly, Dr. S prescribed medications. She suggested some followup referrals. But Mr. Aster's situation called for something more. This was a simple moment about getting through to the patient, to treat the disease not only by fixing its symptoms, but also by addressing its causes.

Without a doubt, one of the elegant aspects of the medical profession is that moments like this happen in doctor's offices all over the world every day, multiple times a day. A physician might treat high blood pressure, or warn a patient about heart disease risk factors, hundreds or thousands of times in his or her career. But that's not the way we as medical students, as physicians, think. After all, it might be the patient's first time with chest pain.

With that mindset, we build the foundation to do special things. An otologist recently told me that a tear comes to his eye every time he sees a child hear for the first time. Another physician, an ophthalmologist, told me that there is no better feeling for him than restoring someone's sense of sight. Medicine, we realize, is simply the sum of these moments, with a physician's lifetime devoted to creating them for others.

As Dr. S made her impassioned plea to Mr. Aster on that night at the Reach Out clinic, I stood in the corner, stunned at how forthright and candid she was. And she had to be. I remember watching our patient look up, first to me and then to her, and finally, something seemed to click inside. You could see it as he exhaled, nodding to himself.

"You're right," he would later say, just before walking out the door. "No one's ever said any of that to me before."

That was the last I saw of Mr. Aster. Of course, we can't know what happened to him. But we do know that Dr. S gave it her best shot, completely involved in that moment with him as if there were nowhere else she'd rather be. As for me, I realized that sometimes, the best thing we can do for a patient is simply give them the opportunity to take control.

I continued shadowing Dr. S that evening, seeing patient after patient, and that's the way it goes. I was a first-year medical student at the time, beginning to learn what it truly means to be a doctor. You may be left breathless, but you have to catch your breath and do it all again, never complaining, because it's not about you; it's about the patient. You knock on the door, meet the next one, and no matter what, you look them in the eye and say, "Hello. I'm your doctor."

"And I'm going to take care of you today."

Notes of a Medical Student
Frequently Asked Questions
Avash Kalra, M.D. ’12
July 19, 2010

For me and my classmates, the first two years of medical school are, as they say, in the books.

And if you've ever wondered how exactly it's possible, during a mere 30-minute nap, to dream about a scenario that seems to last much longer than a half hour — well, that's essentially how the last two years felt.

Certainly, this recently completed first half of medical school was a time defined mostly by questions— long ones, short ones, right ones, wrong ones, multiple-choice ones and open-ended ones.
Hard ones, easy ones, pointed ones, questionable ones and even overturned ones.

There were the questions that were asked of us ("What's the treatment for Crohn's disease?", those that we asked ourselves ("Which field of medicine is starting to interest me?") and, of course, those that we asked of each other ("I'm serious — does anybody know the treatment for Crohn's disease?").

There were also the probing questions we learned to ask patients who have chest pain, who feel dizzy, or who are fatigued. With these questions, we narrowed down diagnosis possibilities.

Indeed, we began to learn to ask the right questions of patients, presumably so that as our clinical rotations begin, we'll be ready at the right time. Most, if not all, of those questions are really just variations of the basic inquiries we posed once as toddlers-what, where, when, and how?

And we often ask those questions in an attempt to answer one far more profound: Why?

Occasionally, the answer to a question comes in the form of another question. Why become an oncologist if it means treating terminally ill cancer patients? Well, why not?

Without question (no pun intended), we were also faced with unanswerable questions. And questions with multiple answers. These often involved ethical scenarios, real or imagined, and the complex problems were actually the questions within the questions.

Many more of those are still to come, I'm sure.

Finally, sometimes our best answers have been mere educated guesses, the only possible response to questions that don't immediately turn on the answer light bulb.

The never-ending questions are no doubt part of the framework of the medical and scientific culture. Without them, we might not have discovered penicillin (or at least not as early as its accidental detection in 1928) or developed a surgical treatment for babies suffering from the Tetralogy of Fallot heart condition.

The questions — and in particular, the drive to answer them — keep medicine moving forward.

Still, as if we didn't have enough experience with questions, we all spent weeks doing practice ones-as a class, we attempted well over 300,000 of them, all in preparation for the 322 featured on the United States Medical Licensing Examination (USMLE) Step 1 Exam — a little test that usually goes simply by its nickname: The Boards. Think "The Shot" by Michael Jordan or "The Drive" by John Elway-this test is just as legendary.

The exam included the final set of questions we answered in our first biennium, before waking from that 30-minute nap that somehow included our first two years of medical school.

Now, as of press time, as a newly minted third-year class, we are less than 30 days from beginning our clinical rotations. Of course, the time for questions will probably never end.

Nor should it.

But we're out of the classroom and will soon be into the hospitals. And I get the feeling that we're going to start getting some answers.