Day 137: Shadowing a cancer geneticist

Today’s inane image of the day:

Very late, I know… but this was from the [South] entrance of Beaumont that I’ve grown so used to walking through to get my caffeine fix at Starbucks.

A couple of weeks ago, I had the unique opportunity to shadow a cancer geneticist. Prior to meeting the program director (Dr. Dana Zakalik), I was completely unaware that cancer genetics was even a specialty option. But after coming in to give two fascinating lectures, I thought it would be interesting to see what a day in the clinic would be like.

The clinic team on the day I went in was composed of Dr. Zakalik and a few genetic counselors. Although the only cases I witnessed were patients concerned about breast/ovarian cancers [which make up the bulk of the patients that come in], the clinic also sees patients for hereditary colon cancer [e.g. Lynch syndrome, Familial Adenomatous Polyposis (FAP)]. The general procedure went something like this: a patient would come in for genetic testing [many times in the BRCA1/BRCA2 genes which are directly correlated with a significantly higher lifetime risk for breast/ovarian cancers], undergo a genetic counseling session, decided if a test is right for them, do the paperwork and the blood draw then return a couple of weeks later for the results and discussion with a genetic counselor and a physician. I’m really distilling this process down a lot, so please forgive me.

A couple of things really struck me about the experience: first, was how incredibly detailed the genetic counselor was during the preliminary session. She used a great analogy for what testing the BRCA1/BRCA2 genes means [I might be reproducing this slightly differently, but it’s the same idea] — basically, the genes are like an instruction book that every person has. Usually the book is spelled correctly and the genes can be transcribed/translated into their protein product. But in some cases, there is a misspelled word that leads to genes that don’t function properly. In the case of BRCA1/BRCA2, they are tumor supressor genes so a misspelling can lead to a higher likelihood of developing breast/ovarian cancers. Thus, the genetic test is like a spell check that lets you know if you have a misspelling.

Second, it really showed the importance of an accurate family history. Each patient is asked to provide information on first degree relatives and by the time the patient arrives for their counseling session, a pedigree is drawn up to show if there are any patterns. After seeing a few pedigrees, it became really apparent how much information can be gathered from the tool.

Third, it amazed me just how many people [it was a really busy day — there were so many patients to see!] yet how few people were aware of genetic testing. One patient was really disappointed that she hadn’t been referred by her physician to the clinic earlier on. Although not all hospitals are equipped with a cancer genetics clinic, awareness among physicians about these life-saving preventative measures could really make an impact in the long run.

Overall, I thought the experience was enlightening and really interesting. I was in the clinic for over four hours, but it felt like only an hour had passed. At this point, I’m really drawn to oncology but am still not sure where I want to go with it — although the shadowing experience piqued my interest in the specialty, I do still want a bit more of a patient relationship. I guess we’ll see what else is out there [after all, I do still have quite a bit of time to decide]!

More on physician shadowing

I was perusing the SDN forums as I like to sometimes do and found a gem of a post [DISCLAIMER: this was intended to primarily be a humorous post, but the checklist does really provide some good suggestions for things to try to look out for in a more well-rounded shadowing/volunteering experience]: Gnomes’ Guide to Shadowing.

Honestly, I’d suggest that if you could get a good number of these items during your shadowing or clinical volunteering experience, that you have a good basis to go into interviews with. I personally did a quick run-through of the checklist [where I actually included experiences from both shadowing physicians and while volunteering] and sadly ended up in the “Shadow more” category. Uh oh…

If you’ve already completed a successful application cycle, what category did you score in? Do you think this could be an accurate metric to gauge shadowing experience on?

Double header: ethics of physician shadowing & the waitlist limbo

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Today’s blog topics: ethics of [pre-medical student] physician shadowing and the waitlist limbo.

Ethics of [Pre-Medical Student] Physician Shadowing
Somehow an SDN thread on physician satisfaction with the profession led to a MEDLINE search for physician satisfaction, which then led to an article in JAMA that then resulted in stumbling upon a commentary entitled, “Shining a Light on Shadowing” by Elizabeth A. Kitsis, MD, MBE [where MBE is a Master in Business and Engineering, apparently].

Basically, the piece cited four concerns about shadowing [italics are quoted from the commentary]:

  1. a physician’s fiduciary obligation:How is a patient’s welfare served by having a college student present during an appointment with his or her physician?”
  2. privacy, confidentiality, HIPAA:In addition to their fiduciary obligations, physicians have other duties to their patients that are breached by college student shadowing, including maintaining privacy, maintaining confidentiality…
  3. patient consent/coercion:Physician shadowing by college students also may involved subtle coercion of the patient. To maintain his or her rapport with the physician, a patient may feel compelled to allow students into the examination room if his or her physician makes the request.
  4. student misrepresentation:It is possible that manipulation or deception may be used (unconsciously or consciously) to gain entry for a college student into a patient examination room… are college students simply introduced as ‘members of the team’ or generic ‘students,’ which may incorrectly lead patients to assume they are medical students?

While I understand the validity of these concerns, I find it incredulous that this could be posted in this day and age when physician shadowing [or something similar] is just about a must for entrance into medical schools. Not to say that the author isn’t aware of this [she does mention its importance in the application process]. Happily, there were a couple of responses from other practicing physicians that did a great job countering each of these concerns [though, sadly, Kitsis. rebukes them with the same “what if” scenarios…]

My personal rebuttal:

  1. a physician’s fiduciary obligation: I agree that this obligation may be in question when asked how the patient benefits from a college student’s presence, but I’d argue that a large proportion of students who shadow physicians end up pursuing medicine, and thus, the benefit may not be apparent for that single patient, but will be in the long run. For the most part, I believe that many pre-medical students who shadow physicians do not use the experience as a way to discover career paths, but as a confirmation of their choice.
  2. privacy, confidentiality, HIPAA: This is definitely a big one, but in all my shadowing experiences, I have always signed and agreed to the rules designated by HIPAA, making my presence similar to other healthcare professionals [though, admittedly, I believe that medical schools do delve into the issues that surround HIPAA, so I may revisit the topic later to discuss if I had any revelations after learning more that would make me see this issue differently]. Furthermore, we are all patients ourselves and should understand how important patient-doctor confidentiality is.
  3. patient consent/coercion: While I agree that a physician may subconsciously have a bit more weight in convincing a patient to allow a student to shadow, in today’s day and age, many people are a lot more vocal about their concerns. Admittedly, I do not have a good rebuttal to this one.
  4. student misrepresentation: In pretty much all of my shadowing experience I have had the physician introduce me vaguely as a “student” — while I understand that there is a fine line between what can be deemed ethical in this case, I do believe that this specific case does not necessarily cross it. The term is up for further dissection if the patient wishes [I have been asked what I am studying in school, so the possibility that I am not a medical student has crossed patients’ minds] and I feel that especially because the student is doing absolutely nothing except being a fly on the wall, there is no harm done. Though, I do believe that pre-medical students should be introduced as such in all cases.

My personal experience with shadowing has been extremely positive and helped confirm my almost-lifelong dream of becoming a physician. While I had been searching for shadowing opportunities earlier on, I did not secure an opportunity until right before I submitted my application. Although I was able to include my first shadowing experience in my AMCAS, I did not formally mention my additional experience anywhere [though, one of them did work its way into one of my secondary essays].

I shadowed a cardiac interventionalist, pediatrician and internal medicine physician. Although I cannot say I am particularly enamored with primary care, the opportunity to see primary care physicians in action made the  challenges I had read online, real. It truly is one thing to nod and agree with the patient load and frustrations that primary care physicians have to face, and it’s another to watch an infant’s mother refuse vaccinations or an obese patient refusing to change her diet despite being plagued with a variety of cardiovascular-related ailments. While the cardiac catheterization procedures were interesting, I cannot say that they really sparked my interest [I was just really cold in the OR and really happy that I had a lot of lead on to keep me somewhat insulated].

This all being said, I’d like to propose some “shadowing etiquette” tips:

  • Dress and act professionally — patient impressions are important, especially if you aren’t a doctor yet
  • Make sure you’ve signed a HIPAA statement and have discussed its meaning with the physician you are shadowing — might as well address this ethical issue
  • Ask the physician beforehand if you can be introduced as a pre-medical student to reduce ambiguity
  • Stay quiet while with the patient — while you may suspect that the patient has all the classic signs of strep throat, you aren’t a doctor… yet
Let me know if I missed anything, or if you have a physician shadowing experience that one of these issues arose during.
The Waitlist Limbo
As some of you may already know, I was waitlisted at 3 schools [OUWB, NYMC, MCW]. Keep in mind that my application was late in the cycle, so one of my interviews [MCW] was for a spot on the waitlist [more details on how this works later].
Unfortunately, the only school that outright accepted me [Wayne] did so in early May, so I was in waitlist limbo from March until May. Undoubtedly, the kid on 11 waitlists on SDN who has been on those lists since October had it a lot worse than I did… but 2 months of just waiting around trying to figure out a back-up plan for the fall was pretty traumatic. Especially since most of us pre-meds are neurotic and crazy… after sprinkling in the “unknown future” factor, it really magnifies the personality.
Honestly, I was not myself after I received word about my first two waitlist decisions. As some of you may already know or will soon know, after investing that much of yourself into this process, and realizing that there is a high chance that you will be unsuccessful the first time, it tends to be hard to find the energy to keep going. I know that had I been unsuccessful, I definitely would have needed to take a serious vacation before starting from square one.
This all being said, here are some important things to keep in mind while chilling in waitlist limbo:

  • A waitlist is not a rejection. I promise you, people get off the waitlist and make it to medical school. Many times, a waitlist could just be because you were late in the cycle and there are no seats left in the class [such as MCW].
  • Be proactive. Don’t be crazy and call the admissions office 3 times a day asking if there has been waitlist movement or if your application is with the committee or if you will be accepted. Do call and check in every once in a while [if the school permits — just ask if you are unsure] so that they become familiar with your name when it comes up.
  • May 15 is a very special day — but probably not for you. While this date is the deadline for multiple acceptances [people holding more than one must rescind all of their acceptances except one, but may remain on waitlists], chances are the admissions team needs to re-evaluate [especially if we’re talking about an unranked waitlist] or prepare for making acceptance calls. Not to say that no one gets off the list on that date, but a lot of people don’t hear anything until a day or more later. I received my OUWB call a couple of days following the deadline.
  • Update letters/letters of intent. I sent in one update letter to OUWB [and look where it got me!]. I do not suggest sending in anything “fluffy” — as in, don’t make an excuse to write them a letter [two more hours in a clinical setting probably won’t boost your application significantly…]. Send in meaningful updates — I personally had an international conference presentation submission accepted as well as received an award, so I made sure to include those in my letter. My letter was not a letter of intent. It is ridiculously important not to lie in these things — if you would not rescind your application from every other school once this school accepts you, then don’t say that they are your top choice. However, I did mention that OUWB was one of my top choices [which it was]. I do not believe that letters of intent make a huge difference, but sometimes they could tip the scales in your favor. 
If you have any questions about the above, let me know! I’d love to make this blog a relatively comprehensive resource.
Finally, some schools will do a couple waitlist-only interview days such as MCW. A good rule to follow with these is that if you do not yet have an acceptance, go for it since every interview gives you a better chance of getting in eventually. Since I did not yet hear any good news, I booked myself a plane ticket and hotel room and headed to MCW for their last waitlist-only interview day. The way that MCW’s waitlist-only interviews work is that you can receive two post-interview decisions: waitlist or rejection. Since their waitlist is tiered [and probably ranked… but they’ll at least release your tier] and they generally fill a quarter of their class from the waitlist, you have a good chance of being accepted. Furthermore, you can be placed higher than someone who interviewed earlier in the cycle [non-waitlist-interview], and thus end up in a better position. 
I really loved MCW when I visited and I saw myself going to the school — I believe that this was pretty apparent during my interview and felt like both the professor and student interviews went well. Apparently, my feeling was correct because when the tiers were released, I had been placed in the top one. I received the acceptance call in early June.
I’ll talk more about my decision to attend OUWB over my 2 other acceptances later!