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There's a lot to learn during medical school. As a society, we know a lot more about the human body, mechanisms of disease, and evidence-based medicine than we did 100 years ago. there are thousands of medications being prescribed with mechanisms of action and clearance, indications, adverse reactions, and drug interactions to memorize, and they each have several names. There's a lot to learn, and medical school has not become longer in the last 100 years.

I'm still learning, and once in a while, there's a lecture that makes something really click for me--a new way of looking at a problem or organizing it in my head. The last one for me was on health literacy, and I hope I never forget it.

Can you read the subject line of this post? My professor handed out a whole paragraph of instructions for us to read but the words written backwards. His point? That process is what it is like to read with marginal literacy skills. If reading is difficult for people, so much effort goes into individual letters and words that the meaning of the whole sentence or paragraph might get lost in the process. That was a pretty dramatic example for me, but how many of patients would this apply to? Here are some stats:

• 48% of Americans (53% of Bostonians) cannot consistently read a bus schedule or identify information from a bar graph


• 21% cannot enter information on a Social Security application


• Patients will low literacy are 4 times more likely to be non-compliant with Anti-HIV meds


• Low literacy patients are more likely to be hospitalized, to have poorer glycemic control, to have late stage prostate cancer at presentation.


• 68% of low literacy patients have never told their spouse about their reading problems

This lecture absolutely blew me away. In a busy office, we rely heavily on the written word. Primary care doctors do many things, but patient education is usually a large portion of the visit. Well, it should be, but often the office is busy. Instead, I just hand the patient a print out on their disease and the medication side effects and send them on their way. After being in the medical world for long, I forget that my patients might not know what "inflammation" or "contraception" mean. I thought I would never use medical jargon when talking to patients, but I catch myself doing it all the time.

What's the solution? Unfortunately, all the solutions require time, which is usually short. However, being aware of the problem is the first step. I set two goals for myself:

• Be aware of medical jargon use.


• Ask patients to repeat back instructions to me.

I made these changes to my education practices in ophthalmology clinic, and so far, I have caught some communication errors (e.g. one drop four times a day vs four drops once a day)!

trying to practice what i preach

as a future primary care doctor, i feel that i should try to follow the advice i dole out to patients, but these things are a lot easier to say than actually follow.

eat right. i have a particular interest in nutrition, so this one should be easy, right? WRONG!!! i love white rice, fried foods, red meat! i don't really understand the new food pyramid that's customizeable. i'm supposed to eat 2 cups of orange veggies and 3 cups of dried beans or peas a week? that doesn't sound very appealing to me. the only diet education that's worked at all for me is the new american plate concept--visualize the plate as 1/3 protein, 2/3 whole grains and veggies. my plate isn't there yet, but it's easy to visualize my goal.

exercise more. i went to the gym five times a week for my first two years of medical school, and i haven't been back since. how did that happen? i made the gym part of my schedule back then. after class, i would go to the gym with my study partner and then hit a coffee shop to study afterwards. if i wanted to be lazy, there was someone counting on me to be at the gym. since my schedule is much more erratic, the gym seems all but impossible for me. truthfully, i don't like the gym that much to begin with. so, i took a page out of the patient education materials i received during family medicine and started the 10,000 steps program. i bought a $10 pedometer and wore it around the hospital. it turned out that some days i was over 10,000 steps and some days i wasn't. what made the difference? strangely, it was all the things i've been trained to tell my patients--take the stairs, take more public transportation, or get off a bus stop early. if i did these things, i was consistently over 10,000 steps. i've been trying to add some pilates to that, but i was only able to do my 20-minute video three times a week for one week. that's right. i stuck with my new exercise program for one whole week, but i'll try again ... next week.

see my doctor annually. this one is definitely easier than it sounds. there was a two-year period during medical school when i didn't go to the doctor. why not? it felt like i didn't have enough time. plus, the wait for a regular appointment with my doctor is six weeks, and with the travel time to and from the office and the unpredictable amount of time in the waiting room, the doctor's appointment will take at least half my day. if i knew i had half a day free in six weeks, would i really want to spend it getting a pap smear? during my ob/gyn rotation, i did pap smears all day long on other women, and i finally worked up the courage to tell my attending i needed to take a morning off to get mine done. going to a doctor is a pain in the butt. why do i make time to go see my doctor? honestly, it's mostly because i don't want to be a hypocrite, but i'm never sorry that i took half a day to go.

Hallelujah! I saw the macula!

today is a day of celebration! why? i finally saw the macula today with my ophthalmoscope!

the direct ophthalmoscope exam (when your doctor looks in your eyes with a light and gets really close to your face) has been the bane of my existence for the last four years. the idea is that you can look through the pupil to see structures in the back of the eye, but it's like using a telescope to find a specific constellation in the night sky when you're too zoomed in. you can only see a small part of the "sky" in your circle of vision, and you have to figure out how to navigate towards your destination with only a vague idea of where you are. in the eye, you should see blood vessels be able to follow them towards the optic disc (where all the vessels converge). then, you say "look into the light" and the macula, a part of the retina that is mostly for central vision, comes into focus.



i spent hundreds of dollars on an ophthalmoscope my first year, and i have been looking and looking into people's eyes with it. however, the best i have seen are blood vessels before my hand shook or the patient moved. maybe i imagined some of the optic nerve a few times, but that's it. i was starting to think i would never get it, and it would be best just to sell the darn thing and refer all my patients to optometrists or ophthalmologists.

however, today was magic. i was on fire! i saw the optic disc, was able to see the sharp borders and estimate the cup to disc ratio. then i said "look into the light," and there it was! the macula!!! i was surprised (and lucky) i didn't drop my ophthalmoscope. i did do a little victory dance in the hall, though.

i feel like i just climbed mt. everest, and i can't wait to do it again!

on shadowing

i'm now in clinic for my last weeks of patient interaction of my medical student life. i'm definitely glad for any teaching i get because because i know i still have so much to learn. i just turned in my limited license application, and i'm starting to get scared about the responsibility that comes with signing "MD" after my name.

sometimes being a medical student is boring. depending on your team, you end up doing a good amount of observation and following people around. (sometimes i go on autopilot. i once followed a male intern into the bathroom by accident! i saw urinal, and i ran back the other way!) actually performing a history and physical myself is more exciting and usually more educational; however, i enjoy shadowing here and there because you have the opportunity to see how different physicians interact with their patients. you can observe their question-asking style and their rapport with patients. i'll often take their techniques on a test run to see how they work for me, and over time, i will hopefully develop my own style.

the other interesting part of observing is seeing how people change their personalities when it comes to dealing with patients. i have met some rather gruff old men who scared the living daylights out of me and the residents, but when we are at the bedside, i'll be amazed at the transformation. they're teddy bears! kindly grandfathers! i've also seen kind, nurturing mentors of mine snap and be dismissive towards a patient. is there a correlation between a person's normal personality and his or her professional one? i suppose anyone starting in a field has to shape their professional demeanor, and i'm beginning to wonder what mine will be. will i continue in my chatty, people-pleasing ways? or will i become authoritative? cynical? callous? i'm hoping the changes will be positive ones that will allow me to be efficient in the office without short changing my patients. we had a seminar in my second year about how medical training makes people lose their empathy. i've been trying to guard against it. let's hope it stays that way.