Boonshoft Blogs

Notes of a Medical Student
Communication Is Key
Jacqueline Collins, M.D. ’11
December 19, 2009

One of the most important things that they try to teach you in medical school, besides how to recognize and treat different diseases, is how to connect with your patient. The importance of this topic to quality health care is starting to be stressed more and more in medical schools across the country. I was recently told by one of my lecturers that most medical students are great communicators-until they get to medical school.

My first course was anatomy, and it was an absolute nightmare, not because it was difficult to learn how to study to the degree necessary (although it was), but because I was confronted with what seemed to be a whole new language. While cleaning out my apartment recently, I came across one of my first lab exams from anatomy. It reminded me that during those first few months, I could barely pronounce, let alone spell, the vast majority of my answers on that exam. Over the past two and a half years, however, something happened. This new language became my first language. No one ever tells you this is going to happen. It just sneaks up on you, and one day you look across the table at your mother or sister after venting about the details of metabolic disorders, and she is giving you a blank stare.

Now, two rotations into my clinical years, the doctor-patient relationship and the ability to communicate effectively with patients have become the struggle of my everyday life. How do I get my patients to understand what I am telling them and what it means for their current and future health? Working with so many physicians, I have seen a wide range of communication skills. I have been extremely impressed by some doctors' abilities in this realm, and at other moments, I have walked out of exam rooms with the distinct feeling that the patient didn't have any idea what the doctor had just said.

What I have learned is that in order to be a good doctor, one must, above all else, be a good teacher. I have met some brilliant people in my lifetime, but it takes more than just being smart to be a good teacher. Some of the best teachers I have ever had were the people who were able to take tough information and boil it down into small, easily digestible ideas.

The key to good medicine, then, is figuring out what it is that your patient understands, and what needs further explanation. This is rarely an easy task, and it requires medical students in their clinical years basically to develop a multiple-personality disorder. Among the hierarchy of physicians who evaluate our performance each day, we must be technical, precise, and formal, but in the exam room, we must transform ourselves into whatever we need to be for that particular patient.

My current rotation in pediatrics has given me a great venue in which to practice this skill. Three-year-olds probably cannot point to where their liver is, nor do they have any idea what the word "regurgitation" means. Words like "tummy" and "ouch," long gone from my vocabulary, have resurfaced. Along the same lines, not every adult understands what it means to say someone is "septic" or that they are "not tracking properly." I have to remember that up until two years ago, before tens of thousands of hours of studying, I wasn't really sure either.

I am lucky in that my school encourages its students to work on communication. Each patient is a new opportunity to learn and to teach, and I have no doubt that I am becoming a better physician as a result. What good are the skills and knowledge I have worked so hard to amass if I can't use them effectively? So, each day I work to find the right words, gestures and expressions, and with each patient I try to learn to be a good teacher and a better doctor.

Notes of a Medical Student
The First of Many New Beginnings
Jacqueline Collins, M.D. ’11
October 19, 2009

It's 4:30 in the morning, and already I've been up for half an hour, taken a shower and had my breakfast. Most people are still fast asleep, but as I have begun to learn these past few weeks, sleep is a luxury that those of us in medicine are rarely afforded.

Never having been one to roll out of bed before noon if I could avoid it, I've been surprised by my ability to awaken before sunrise and be functional. But then, I've also been waiting two years for this chance, to actually use what I have worked so hard to learn. Time seems to be moving very quickly all of a sudden. Boards are over, and I am in the middle of the first of my third-year clerkships. My days are full of new challenges, but in a lot of ways, they represent a refreshing change from the tedium of the past.

As it happens, I have chosen to begin my journey with the beginning of life. I will admit that I had more than a few misgivings about starting my obstetrics and gynecology rotation. I've always been a bit on the squeamish side, and the birthing process is known for being rather messy.

Luckily for me, the first birth I assisted in was as amazing an experience as one could hope to have in my situation. About two weeks ago, under the guidance of a midwife whose calm, efficient and confident demeanor I can only hope to achieve someday, I helped deliver a beautiful baby boy to a truly wonderful couple.

As first-time parents, this couple was thoroughly engaged in every step of the process and graciously allowed me to be a part of their life-changing experience. As expected, there were a few moments of panic, when I wondered if I was ready for all of this, if I would just be in the way, if I would be able to overcome my weak stomach.

The thing is, I didn't really get a chance to indulge in those moments of self-doubt. Unlike a multiple-choice test, with ample time to ruminate and second-guess, I now had a woman looking at me for reassurance, depending on me to take care of her and the baby she was about to bring into the world. A powerful feeling exists in the delivery room, when a wanted child is preparing to make its entrance. The love and excitement on the father's face as he looks at his wife, the words of wisdom from a mother about to become a grandmother, but more than anything, the sheer awesomeness of the woman in labor, her fierce determination.

I have to tell you that for me, there has been no greater experience than making that connection with my first mom-to-be, coaching her and encouraging her to find those last reserves of energy. I know that I will never forget this couple, the baby I helped to be born or the midwife who was such a wonderful teacher and who let me take such an active role.
The past few weeks have made it clear to me how much I still have to learn, but I look forward to the challenge and a year filled with many new experiences.

Notes of a Medical Student
What Do You Want to Be?
Jacqueline Collins, M.D. ’11
July 19, 2009

“What do you want to be when you grow up?” I heard a woman ask a little girl at the park a week or two ago. This was during my lunch break, midway through a long day of studying.

“Maybe a teacher, or maybe a doctor,” she said.

I chuckled to myself when I heard that. Apparently, no matter how hard I try, I can't get away from medicine for even an hour.

For whatever reason, adults seem to like asking children of all ages that question. I used to think very little of this commonplace interaction between the generations. But hearing it that day-after a month of studying nine or 10 hours a day, after two years of classes and mountains of debt, not to mention the whole process of getting into medical school in the first place-I wondered if that little girl might give a different answer if she had even the slightest idea what it really means to pursue a medical career.

Goodness knows I didn't at her age. When I was young, I told people I wanted to ride horses for a living, and during stressful moments recently I've wondered if that might have been a better option.

I wonder how many kids say they want to be doctors, especially in the first decade or so of life? More than a few, I would imagine, and far more than say, “I want to be a lawyer,” or “I want to be a CEO.” Perhaps this is because people of all ages and walks of life interact with doctors. For most of us, the doctor was there when we entered the world and will be there when we leave it, with a few visits in between to help us feel better when we are sick, stay healthy, or just check to see how we are doing. The white coat and stethoscope are part of a uniform even toddlers recognize. I guess it's natural for the profession of medicine to make a child's short list.

At this point, I am just starting what may be my last summer vacation for a long time. I'll have a break of a little less than four weeks before I will start rotations and begin to see patients and learn how to care for them. I am both excited and terrified by this thought. There is still so much more to learn, and I can't help but wonder how much my life is going to change.

Will I be able to work the long shifts, or will I fall asleep on my feet after being at the hospital longer than most people are even awake? Will I have any time left over to take care of my own needs? To spend time with the people I love? Will I ever be able to keep that white coat clean? More importantly, what will it be like to help a child come into the world, or to support a patient fighting cancer? How will it feel the first time I do something that helps to save someone's life? And how will I cope when I have to accept that no matter how hard I try or how much I learn, sometimes it is just someone's time to go?

For me, this break has been a time to catch my breath and think about all that lies ahead. As I watch friends struggle to find or hold onto jobs, as I reflect on the fact that at 27, I am still in school and taking out student loans, and as the future role of physicians continues to get cloudier, I often wonder if I made the right choice. Someday, when I ask children what they want to be when they grow up, if I hear the response, “I want to be a doctor,” how will I react? Will I feel pride and camaraderie, and smile as I tell them how rewarding it can be to help those in need? Will I warn them off and tell them that medicine “isn't what it used to be,” and that it's no longer worth the years of study and the immense burden of carrying the suffering of others home with you every day? Or will I look at them and remember that they are still only children who have many years to experience life before they need to make any such decisions?

I guess I can only wait and see.

Notes of a Medical Student
A Day at Children’s Medical Center
Jacqueline Collins, M.D. ’11
May 19, 2009

As the first member of my family to pursue a career in medicine, I hear opinions from everyone about which specialty I should choose. My grandmother and my sister, who has three young children, seem to think pediatrics is the natural choice. They say I've “always been good with children.” They are right: I was the preferred babysitter on my block. I was great at coming up with games and activities to keep whole groups of children occupied for hours. When it came time for my first pediatric encounter, I should have been excited. This was an area where I could really shine. Babysitting and pediatrics, however, are in completely different hemispheres in the world of children.

The truth is, the idea of having infants and children as my patients has always made me a little apprehensive. Medicine is not an exact science, and all of my instructors have stressed the importance of a good and detailed patient history to help me make an accurate diagnosis. Herein lies the first stumbling block; how does one take a patient history from a child? Depending on their age, kids either can't tell you what is wrong, are too afraid of you to try, or simply lack the vocabulary to describe it. And half of what they do happen to say will be muffled by their mother's sweater, into which they have buried their face. The young patient can be quite a challenge when it comes to the physical exam as well. Children have a special talent for making students, who may already be nervous, look like they have no idea what they are doing. Getting them to cooperate often becomes a bit of a game... usually with you as the loser.

Last Friday, I spent the better part of my day at the Children's Medical Center of Dayton working with some residents. I can't say the experience altered my opinion of the difficulty involved in pediatrics. One little boy we examined was more interested in the TV than in sticking out his tongue and saying "ah." He squirmed, pulled away, and pretended not to hear when asked how he was feeling. Usually, I walk away from a patient encounter and feel that for my level of training, I have been thorough. Not this time. With children, there is always that unsettling feeling that perhaps there is an icky sound at the bottom of a deep breath they are unwilling to take. The whole process is enough to make you want to throw up your hands and say, “Forget it.”

To do so, however, would be to ignore one of health care's most vulnerable populations. The residents I saw seemed relaxed and at ease with their patients. As if sensing my discomfort, one doctor turned to me, shrugged a little, smiled, and said, "Well, you just do the best you can." I thought about that as we saw other patients. After examining the little boy, we checked on a little girl, less than a year old, sleeping peacefully with a swollen abdomen while waiting for a liver transplant. Looking at her, I realized that pediatrics may be a challenge, but it is an important one.

Getting down to a child's level, trying to think creatively to get the information and cooperation you need, may be difficult, but patients who are hurting need you to “just do the best you can” to help. Pediatrics is such a challenge because pediatricians are more than physicians. They are a voice and an advocate for their patients. A little girl may not be able to stand up and say, “I hurt. I need help.” But her pediatrician can.

To be honest, I'm relatively certain pediatrics, as a specialty, is not in my future, though I have been proven wrong before. But I am grateful for days like this that really illustrate how great medicine can be. Pediatrics may not be my new career goal, but I certainly developed a heightened level of respect for physicians willing to take on such a challenge. I hate to think what health care would be like without them.

Hibernating in Summer
Jacqueline Collins, M.D. ’11
May 19, 2009

Welcome back, summer! The sun-filled days, the endless nights, the warmth, the fun, the outdoor sports and, most important, the reappearance of the human race that seemed to be hiding for all of those cold winter months. Suddenly, the streets are full of people again: families on bikes, runners getting back into shape. Yet, for me and the rest of my class, reverse hibernation is about to take place.

For students in their first two years of medical school, the thought of one day causes even the coolest character to break out in a sweat. For most, that day will come in early June, and for a very brave few, at the end of May. Regardless of the date, each one of us has a clock in our heads that counts down the days, hours, minutes, seconds… until we take the test that will dictate the rest of our lives: the United States Medical Licensing Examination (USMLE) Step 1.

This is the time of year when it becomes very easy to spot a medical student. We are the ones making the mad dash to the bookstore to buy the latest BRS (Board Review Series) book, the ones muttering under our breath like crazy people, fervently trying to remember the configuration of the brachial plexis that we learned centuries ago (in real time, about a year and a half). The most obvious sign, however, is our new life companion, the well-worn yellow-and-blue FIRST AID for the USMLE book, which we now must keep within a five-foot radius at all times, lest we go into a full-blown panic attack.

Most of our professors try very hard to do damage control. They work to keep us focused on the courses we still have to complete, to calm us down by telling us how well Wright State students have fared in the past. But medical students are hard to fool, and every last one of us knows that the score we get on this test will determine whether or not we actually get to graduate and be what we have been working to become for about 20 years. No wonder we look a bit unkempt and unhinged!

For two years now, we have crammed more information into our brains than should be scientifically possible. Now that test-prep mode is in full swing, I basically walk around all day mentally quizzing myself and trying to go through the knowledge I have amassed to organize it in some meaningful way. Unfortunately, that means I have also lost the ability to remember where I parked my car, where I left my keys or glasses, whether or not I turned off the stove and just about anything else that requires the slightest bit of awareness. I will admit to being a bit of a liability these days.

Yet, with the pressure of the big day looming, there is also a sense of the light at the end of the tunnel. If we do manage to get through it all without too many scrapes and scars, we will emerge on the other side and finally get to see real patients! That's right, in the midst of all the Step 1 chaos, there is also the knowledge that we are getting ready for the next step in our career: medical clerkships. Set to begin on August 3rd, clerkships represent a whole new way of life. No longer will medical school consist of me, alone, in the library with a whole bunch of books. What awaits is new, exciting and downright terrifying.

The next time I write this column, Step 1 will be over, and, if the fates allow, I will be preparing to start my clinical training and to see if I can put all this acquired knowledge to good use. I will also be facing a whole new set of challenges. How do I give a patient bad news? Will my clumsiness translate to poor surgical skills? So many questions left to be answered. It's almost distracting enough to make me forget about June 13th… Almost.

Building Connections, Changing Lives
Jacqueline Collins, M.D. ’11
March 19, 2009

This past weekend, my parents came to Dayton for a quick visit and to drop off some much-needed groceries, since medical school doesn't afford me the time or money to acquire my own food. To keep them occupied for a while, I gave them photos from my trips to India and San Francisco this summer.

When I took a break from tidying up, my mother showed me a handful of photos she had questions about. Mostly she commented on how crowded the hospital in India was, how tiny the babies, or just how generally "different" everything looked. Looking at the pictures, all I could think was that they were a poor substitute for actually being there. How do you connect with a human life through a photo? How do you convey to someone just how devastating a broken bone or treatable disease can be for patients confronting social stigma and inadequate supplies of medication, nurses and hospital beds?

When I was 17, I went with a group of doctors and aide workers to provide basic medical care to people who make their homes in the garbage dumps that dot the outskirts of Mexico City. This trip was difficult for me, as it was the first time I saw extreme poverty and need. Nothing in the United States comes close, not even in our poorest neighborhoods. It would have been easy to be overwhelmed by it all, and I was, but more than anything, I was also intrigued. Most of the medical care that takes place in these outreach settings is of the most rudimentary kind. There were no brain surgeries or heart transplants performed. Yet still, surrounded by dead rats and trash, I watched doctors change people's lives simply by treating their infections and easing their pain. I began to see that there is an art and a skill to medicine that can, despite some difficulty, overcome cultural or socioeconomic barriers. Although it would be years before I decided to pursue a career in medicine, on that trip I developed a new respect for doctors.

In the 10 years since that visit, I have been lucky enough to travel extensively throughout South and East Asia and have learned a great deal about some of the diseases and health issues that continue to plague our world. This summer, I returned to one of my favorite places: India. With tetanus, diphtheria, dengue fever and malaria still pressing concerns, India can provide quite an educational experience for any health care professional. Like every population, India also has its own prominent genetic diseases, such as Thalassemia. Although treatable, Thalassemia carries such a social stigma that children born with it are often allowed to die.

I will never forget the day we visited the Thalassemia clinic and met a little boy whose mother brought him from far away for treatment every month. It was his birthday, and the blood transfusion he needed would require him to spend most of the day on a bed with a needle in his arm. Seeing how unhappy he was, the other students and I used our break to run to a shop around the corner and buy him a cake. As we sang Happy Birthday and his mother helped him pass out pieces of cake for everyone, I saw him smile for the only time that day. In a life so devastated by a disease that in the U.S. is treated far more efficiently and without the stigma, a little bit of kindness can go a long way.

While infectious and genetic diseases often draw international students, less glamorous aspects of health care also desperately need attention. In the villages we visited in India, nothing affected residents' health more than a lack of clean water. Such a simple thing, and one we take for granted every time we go to the faucet. We often forget how much we have to be grateful for, and our responsibility as human beings to do what we can, where we can.

I often find it hard to explain to people why I keep going back. Besides my love of the colors, food and people of India, I also think about my first trip to Mexico, when I saw people from such diverse backgrounds connecting through medicine. I love that aspect of medicine, and I love the people I have met and the lives I have touched through my trips abroad. Like photos, my explanations may never fully convey my experiences and the effect they have had on me, but I know I will continue to reach out in this way, whenever I can, for the rest of my life.

Notes of a Medical Student
Reflecting on a Year of Focus Lost and Found
Jacqueline Collins, M.D. ’11
December 27, 2008

The summer after my first year of medical school went by in a blur: cardiology in San Francisco, global health in India, and a quick family visit. As usual, I tried to cram too much into too little time and found myself with just four days to reflect and distill my experiences before starting year two.

At the end of those four days, I found myself facing 100 pairs of expectant eyes — those of the new first-year students about to embark on the journey I had just completed. And they wanted something from me.

What they wanted were those precious gems, the secrets that helped me get through the first year of medical school. I'm sad to say I met their first few inquiries with a blank stare and stuttered response. Four days simply hadn't been enough time to really think things through.

As I write this, the incoming class is gearing up to begin anatomy, the first truly intensive course of their medical careers and, for most, their first time in the cadaver labs. Books and movies often present this course as a grueling and distasteful rite of passage in the medical world.

For me, anatomy seems long ago, lost in the multitude of new experiences the past year has presented. If I take a minute to look back, I can still recall the intensity of those first few weeks. The hours spent repeating all the bones, muscles, nerves, arteries, and veins. The agony of trying to remember which do what. The times I showed up after midnight hoping the lab would be less crowded and I could get some private time with the donors who had generously given their bodies so I might learn.

The sheer amount of material seemed overwhelming. My confidence began to waver, and free time became scarce. I remember doubting myself and wondering more than once if I was really cut out for this.

Then, around mid-year, I found my stride. Somewhere, in the mess of biochemistry and anatomy, I had lost touch with what brought me to medicine. The day I found an extra reserve, a little bit of strength left when I thought was totally spent, came when I did my first patient interview for Introduction to Clinical Medicine. I walked in ready to collect a patient history by firing through a list of standard questions I had memorized.

In the hour that followed, something truly wonderful happened. I became reacquainted with the idealism and empathy that had led me to medicine. I realized how much I cared about what this woman was going through, and how much I wanted to build a skill set to help me make her life, and other lives, better. I delved into a conversation with her that included few pre-planned questions but gathered all the information I needed to create a full patient history-and allowed me to get to know her as a person as well.

When I got up to leave, my patient stopped me and said, “What was your name dear? Jacqueline? Well, Jacqueline, I really enjoyed talking to you, and I think you are going to make a fine doctor someday.”

I left the hospital that day feeling recharged and ready for anything. For the first time in medical school, I felt like I was indeed learning to be a doctor. Days like that, the ones when I worked face to face with another human being in need of help-those were the secret. They were what got me through my first year.

Finally, I had an answer to give all those new students that I felt was honest, heartfelt, and worth its weight in gold: "No matter how caught up you get in medical school, don't ever forget that the reason you are here is to become a doctor.

Notes of a Medical Student
Finding Your Balance
Jacqueline Collins, M.D. ’11
October 19, 2008

“Medical school will test you. Not your intelligence, but your ability to adapt and grow.”

This is what a great friend and mentor told me just two years ago as we sat on her front porch enjoying one of the last warm days of the season. I don't think I understood what she was telling me at the time. Now I often wonder how she could have been so perceptive.

Most people will tell you medical school is hard. It is, but not in the way that I would have expected. Oh, yes, there are mountains of material to learn in blocks of time that always seem too short, and with each class I develop a new appreciation for the human brain's capacity. But we are medical students, and there is not a single one of us who doesn't know how to study.

What is it, then, that makes this life experience so challenging to navigate?

I think it can be summed up by a comment a friend of mine made when he saw me reading a book about South Asian History.

"How can you do that?" he said. "I would be scared to read something outside med school right now. I don't have room for anything else in my head!"

Unlike college, where most programs strive to create a well-rounded individual, medical school focuses entirely on the cause, diagnosis, and treatment of disease. Once, you could switch gears from studying calculus to completing an art project or writing a paper for a political science class. Now, everything that is not studying medicine you do while haunted, in the back or your mind, by the unending list of things you still don't know. Med school can't be left at the office. Relationships and hobbies go on the back burner, and major world events often don't even show up on your radar. When a friend asks, "What did you think of Palin in the debate?" you might distractedly reply, “What debate?”

The result is a day-to-day struggle to find balance. You start to think about where you can fit in a couple extra study hours. Should you really go to the gym? To that lecture on “Women in Shakespeare”? To church? Slowly, the events on your calendar become less and less diverse, until all that is left is one word at the top of each day: Study.

A few weeks into my first year, I called my mentor, full of frustration. She asked me one question: “Jackie, before you started medical school, why did you think you would be successful as a doctor?”

“Because I am good at relating to people. They trust me,” I said.

“How do you relate to people?”

“I don't know. I guess I talk to them.”

“What do you talk about? The latest drug to treat seizures, or the new home-testing kits for HIV?”

Right then, I saw what she wanted me to. I thought back to all my experiences with physicians and patients. I realized that the doctors I chose for my own health care were all ones I felt a connection to, based on a shared love of India or traveling, urban renewal, or even religious studies. All this time, I had failed to see that being a doctor is more than just being a pro at pathology. It's about creating relationships with patients. And that requires nurturing the part of a person that grows and develops outside of medical school.

All of us have had the experience of sitting in a white gown, uncomfortably exposed while a doctor talks AT us instead of to us. There is perhaps no more isolating feeling than dealing with a doctor with no empathy, with a poor bedside manner-a one-dimensional pseudo-person. But it's clear to me how doctors can become that way, how easy it can be for aspiring young physicians to get trapped into thinking the only thing that matters is their score on the next exam, and to let all the other great facets of their personalities slowly slip away. Part of the challenge of medical school is in not allowing that to happen to you.

I am lucky to have trusted friends and advisors outside the realm of medicine who help me maintain a healthy perspective, for the most part. With their help and my own commitment, I may turn out to be the kind of person and doctor I've always hoped to become.