This Perspective article about the effect of the clinical clerkships on the professional development of medical students was written from the alternating perspectives of a teacher and long-time clinician, Katharine Treadway, and a third-year medical student, Neal Chatterjee, who is now an intern in internal medicine.
It ain’t pretty
Chatterjee: At the end of the year, we were asked to reflect, in writing, on our first year in the hospital. What eventually filled my computer screen had nothing to do with vital signs or chest pain.
I began to write, “I have seen a 24-hour-old child die. I saw that same child at 12 hours and had the audacity to tell her parents that she was beautiful and healthy. Apparently, at the sight of his child — blue, limp, quiet — her father vomited on the spot. I say `apparently’ because I was at home, sleeping under my own covers, when she coded.
“I have seen entirely too many people naked. I have seen 350 pounds of flesh, dead: dried red blood streaked across nude adipose, gauze, and useless EKG paper strips. I have met someone for the second time and seen them anesthetized, splayed, and filleted across an OR table within 10 minutes.
“I have seen, in the corner of my vision, an anesthesiologist present his middle finger to an anesthetized patient who was `taking too long to wake up.’ I have said nothing about that incident. I have delivered a baby. Alone. I have sawed off a man’s leg and dropped it into a metal bucket. I have seen three patients die from cancer in one night. I have seen and never want to see again a medical code in a CT scanner. He was 7 years old. It was elective surgery.”
Treadway on how powerful the clerkship experience is for med students: First, students are entering a foreign world where they face difficult, often overwhelming experiences. Second, the rules governing the responses to these experiences are unclear. It is not obvious to students that the beliefs and ideas with which they entered school still apply, so they take their cues from the behaviors they observe. Furthermore, since responses to these events are rarely discussed, students often erroneously ascribe a detachment and lack of caring to house staff and senior physicians. Third, these experiences have frequently gone unacknowledged and unexplored.
For the past few years, I have been a mentor to medical students during their clerkship year. As they have their first experiences with patients dying, they don’t know how they should respond, whether it’s OK to be upset. One student told me about his confusion when a patient he’d admitted to the hospital died and no one on his team even remarked on the death. It made him feel he wasn’t supposed to care. When, days later, his intern mentioned how bad she felt about losing the patient, he was relieved — it made him feel he was normal. His story revealed how vulnerable medical students are to the influence of behavior that contradicts their belief systems
Videos from the March 16 conference. Part one includes:
Opening and Welcome
David A. Mindell PhD ’96, Chair, MIT150 Steering Committee and Dibner Professor of the History of Engineering and Manufacturing and of Aeronautics and Astronautics, MIT
Susan Hockfield, President, MIT
Tyler Jacks, Director, David H. Koch Institute for Integrative Cancer Research and David H. Koch Professor, MIT
Session 1: Reflections on Major Milestones in Cancer Research and Technology Development
Session Chair: Nancy H. Hopkins, Amgen, Inc. Professor of Biology, MIT
Phillip A. Sharp, Institute Professor, MIT
Jacqueline A. Lees, Associate Director, David H. Koch Institute for Integrative Cancer Research and Professor of Biology, MIT
Robert S. Langer, Institute Professor and Professor of Chemical Engineering and Biological Engineering, MIT
Group discussion including Michael Goldberg
Don’t get enough of virtual Dr. Kevin — the NH doc billed as “social media’s leading physician voice”? See him in person in Boston this Friday. Sponsored by Racepoint, a Boston PR company which is — take a deep breath –“… defining the new model of communications through an unrivalled understanding of the evolution of traditional and social media.”
Harnessing the Power of Social Media in Healthcare Communications — Interactive Panel Event in Boston
Date: Friday, April 1, 2011
Time: 7:30 – 9:30 am
Location: Joseph B. Martin Conference Center at Harvard Medical School – Room 217
77 Avenue Louis Pasteur, Boston, MA 02115
In today’s digital age, the health of a business can be measured by its ability to effectively connect with and engage its target audience online. Did you know:
- 900+ hospitals are using social networking tools
- 1 in 4 doctors plan to purchase a tablet for their practice in 2011 because of ease of use and mobility
- 72% of physicians carry smartphones; 95% use the devices to download medical data
- 72% of patients search for medical info online before or after doctor visits
It seems the raw milk debate has bubbled up with the local foods movement. Some people think unpasteurized milk is healthy. Most states ban it for fear of dangerous bacteria. David Gumpert, who has chronicled the push for unpastuerized milk, reports on a Maine town that wants to be exempt from state and federal regarding food production.
Citing America’s Declaration of Independence and the Maine Constitution, the ordinance proposed that “Sedgwick citizens possess the right to produce, process, sell, purchase, and consume local foods of their choosing.” These would include raw milk and other dairy products, and locally slaughtered meats, among other items.
It wasn’t just a declaration of preference. The proposed warrant added, “It shall be unlawful for any law or regulation adopted by the state or federal government to interfere with the rights recognized by this Ordinance.” In other words, no state licensing requirements prohibiting certain farms from selling dairy products or producing their own chickens for sale to other citizens in the town.
What about potential legal liability and state or federal inspections? It’s all up to the seller and buyer to negotiate. “Patrons purchasing food for home consumption may enter into private agreements with those producers or processors of local foods to waive any liability for the consumption of that food. Producers or processors of local foods shall be exempt from licensure and inspection requirements for that food as long as those agreements are in effect.”
Gumpert talked about the issue on WBUR’s Here & Now this past summer.
Quietly – since the accepted medical and public health wisdom is that raw milk is a dangerous source of bacteria, including listeria, salmonella, and E. coli – hundreds of consumers around Boston have made the same decision (to buy raw milk). A total of 24 Massachusetts dairies now have permits to sell raw milk, double the number two years ago.
Lots of organizations give out journalism awards, but these count. The Association of Health Care Journalists this year honors amazing reporting on organ trafficking, end-of-life care, dying hospitals and elder abuse. The list of winners is inspirational.
Kay Lazar’s 2010 Body of Work; The Boston GlobeLazar’s entry included stories about:
- Antipsychotic medications given to patients in nursing homes and the risks for patients that have dementia
- The impact of earlier coverage of this issue: state regulators and industry leaders formed a task force and launched an educational campaign to reduce the inappropriate use of the medications.
- An unintended consequence of Massachusetts’ pioneering health care reform law
- The widespread practice of no-bid contracts in the Massachusetts Medicaid procurement system and the $400,000-plus salaries of officials involved in the contracting process.
See the stories on the Web:
- Nursing home drug use puts many at risk
- Short-term customers boosting health costs
- Feeling him slipping away
- Medicaid contracts with UMass Medical School unit scrutinized
- Mass. aims to cut drug overuse for dementia
Kay Lazar of the Boston Globe, for the range and depth of her health policy coverage, and its measurable impact. Her reporting on no-bid contracts for Medicaid and on “gamers” who exploited a loophole in Massachusetts’ universal health coverage law exposed costly problems and drew responses from state regulators and lawmakers. Her reporting on excessive use of antipsychotic drugs in state nursing homes prompted regulatory review and new training. Her news feature story about a storeowner with early-onset Alzheimer illustrated the impact of a devastating disease and the genetic testing quandary facing family members.
WGBH also brought home a first prize to radio reporting.
First Place: Rationing Health: Who Lives? Who Decides?; David Baron, Patrick Cox, Sheri Fink, WGBH-Boston
In 2010, PRI’s The World reported from South Africa, Great Britain, Zambia and India to examine how other governments manage the costs of delivering health services to the public. Each country, with its unique economic and cultural environment, provided an opportunity to spotlight different approaches to the challenge of rationing scarce health care resources: explicit rationing by committee, rationing by cost effectiveness, unintentional rationing, and innovation to avoid rationing altogether. The series, the result of a more than half-year reporting and editing effort, was presented along with a website and opportunities for interaction via Twitter and online discussions. See the story on the web.
The terrific series addressed one of the hottest 2010 election topics in a different and fascinating way by looking at the realities faced in other parts of the world.
I was hooked by the first characters – doctors deciding who will get life-saving dialysis in South Africa.
It was clever to not start with the obvious – the much demonized British system – but smart not to wait beyond part 2 to address this country as well. Parts 3 & 4 were also very intriguing and the analysis in the final part was a nice way to button up the series without belaboring the points already made in the previous episodes. Great job.
Jack P. Shonkoff of Harvard’s Center on the Developing Child at Harvard University gets a mention in this week’s New Yorker story “The Poverty Clinic.” The story profiles a San Franciso doctor who is trying to address the childhood neglect, abuse and trauma that trigger health problems later in life.
Shonkoff is noted as a leader in this area, having edited the 2000 “From Neighborhoods to Neurons” study out of the National Academy of Sciences, which “presents the evidence about “brain wiring” and how kids learn to speak, think, and regulate their behavior. It examines the effect of the climate-family, child care, community-within which the child grows.”
Here’s a link to a panel held last year to follow up on the study. For more, the center is hosting an upcoming talk on the topic which is open to the public.
Thomas Boyce, M.D. “A Biology of Misfortune: How Stratification, Sensitivity, and Stress Diminish Child Health and Development” April 12, 2011 4:00-6:00 p.m. , Kresge G2, Harvard School of Public Health,,677 Huntington Avenue
This event free and open to all University students, faculty, and the general public.
ABSTRACT: Social class differences in early childhood adversity are among the most important and least understood determinants of human health and development. This lecture will propose the following three hypotheses: (1) maladaptive outcomes of social stratification in early childhood anticipate, parallel, and amplify the effects of inequality in adult societies; (2) these effects operate through central and peripheral neurobiologic and epigenomic circuits that are responsive to stress and adversity; and (3) extensive variation in stress responsivity reveals a subgroup of children with exaggerated sensitivity to both aversive and nurturing social conditions. The disproportionate prevalence of health and developmental problems among children with elevated sensitivity to context suggests a “biology of misfortune” that involves inter-related cycles of subordination, affliction, and adversity that have important implications for public health.
W. Thomas Boyce, M.D., is the Sunny Hill Health Centre/BC Leadership Chair in Child Development at the University of British Columbia, Vancouver, Canada, and a professor in the College for Interdisciplinary Studies and Faculty of Medicine. He is also co-director of the Experience-Based Brain and Biological Development Program of the Canadian Institute for Advanced Research and a member of the American Pediatric Society. A social epidemiologist and developmental-behavioral pediatrician, his research addresses the interplay among neurobiological, genetic, and psychosocial processes that leads to socioeconomically partitioned differences in childhood morbidities. He is also a member of the National Scientific Council on the Developing Child. His research has demonstrated how psychological stress and neurobiological reactivity to aversive social contexts operate conjointly to increase risks of physical and mental health disorders in childhood. His work seeks a new synthesis between biomedical and social epidemiologic understanding of human pathogenesis, with particular attention to its population health implications. Dr. Boyce earned his M.D. from the Baylor College of Medicine, completed his pediatrics residency at the University of California, San Francisco, and was a Robert Wood Johnson Foundation Clinical Scholar at the University of North Carolina, Chapel Hill
Finally, I’m not one of those Red Sox fans who fumes at the thought of the Yankees. I’m from Jersey, so I’m related to a few Yankee fans. Which is good, because this week’s Health Wonk Review is loaded with good links but studded with pictures of players from the evil ex-empire. All we have to say is: Go Sox!
Enjoy St. Patricks Day but don’t be a fecking eedjet. The Globe offer tips on how to drink without wrecking your health, ruining your diet or killing your friends.
Our favorite drinking delusion from the list: “Thinking you can’t get drunk at a sporting event.” Dedicated the people who usually sit behind me at Red Sox games. More here.
CBS News also has a story on how to take it easy and still celebrate. They also offer a list of the “drunkest” states, based on a CDC study of binge drinking. We’re No. 11. Two other New England states make the list. Connecticut is No. 6 and Rhode Island is No. 8.