IU School of Medicine IUSM Office of Admissions

Patrick Titzer

Third Year Medical Student

Patrick Titzer
About Me IUSM Campus:
Terre Haute
Evansville, IN
PreMed Majors:
BS, Liberal Arts, University of Southern Indiana, 1991
Bachelor of Fine Arts, Indiana State University, 1991
Master of Fine Arts, Notre Dame, 1994
Little known fact about me:
I can forge a 2" diameter solid bar of steel down to nearly a needle point with my gas forge, power-hammer, and anvils.

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Man Who Stares at Coats

Life as a second-year medical student


Filed under: Uncategorized — Patrick Titzer on January 12, 2013 @ 6:27 am

I may have scrubbed this post a bit too much; please excuse all the ‘they’ and ‘their’ I use to refer to an individual:

My recent rotation in Internal Medicine was a good one; the doctor, a cardiologist, and I discussed anecdotal experiences of patients which didn’t match literature descriptions. We had a patient, an educated individual, who spoke of their 2 most recent annual influenza shots. They were currently recovering from a serious infection requiring hospitalization and sequela aftermath, which is why they were in the office. They voiced the opinion that their illness, flu followed by pneumonia, immediately followed the shot this year, and they had a similar, but not as intensive, illness in the same manner last year. Coincidentally, the doctor and I had just discussed the shots, which are mandatory in some facilities. The doctor did not get the shot because of what he felt was a reaction he had to the shot-possibly to some preservative in the shot he thought. In another coincidence that day, a retired nurse related to us how 200 nurses in the IU Health system had just resigned over the requirement that they take the shot to continue in their jobs-something I had not heard about at the time. My own reaction to the patient, and I discussed it later with the doctor, was that patients should acknowledge their own anecdotal, personal experiences and consider them when making healthcare decisions. In some cases, there is a bit of hysteria fueling a boycott of a shot, as with the autism fear fueling boycotts of immunizations. But that doesn’t mean that a patient’s view isn’t valid. We discussed the importance of listening to, and hearing, what patients are saying to you. This particular patient was critical of their PCP because that doctor was dismissive of his claims of illness, citing coincidence, not causality to explain the patients fears and suspicions. But that doctor just lost the confidence of his patient, I could see. The doctor I was rotating with discussed the fine balance between education and patient beliefs. Myself, when I was discussing the patient’s conversation with the PCP, almost tried to dismiss his fears as well, but something held me back from an outright dismissal. Instead, I listened to the patient and without encouraging his current belief, I acknowledged it’s validity and then left it on the table. As I later discussed with the doctor I was rounding with; respecting the patient’s self-awareness and fears, and acknowledging that there are instances when we can’t say with certainty the patient is wrong, and thus can’t, or shouldn’t, dismiss them out of hand, sometimes trumps spouting the letter of the medical literature to them. Maintaining mutual respect will inform future interaction with that patient. They will be more likely to share important aspects or thoughts on their health, rather than staying silent out of fear you will dismiss them.

Pink Floyd in a Nursing Home…had to happen, sooner or later.

Filed under: Uncategorized — Patrick Titzer on December 12, 2012 @ 11:01 pm

I just sat down a minute ago to write, after telling my lovely, devoted wife-whom I‘ve promised repeatedly to write a blog on, extolling her innumerable virtues-about a neat experience I just had with one of my attending’s as we rounded at a nursing home. I get it that young students might think that such activity is to be avoided; as a younger man, one of my greatest regrets is not visiting my Grandparents more often when they were in the nursing home. Youth simply doesn’t often mix well with…not-youth. And nursing homes aren’t designed to be welcoming for young people; they can be a bewildering array of sights, sounds and spaces that assault the senses of those unprepared.

But I’ve always enjoyed the stories my elders tell, the history they carry in their bones. The population of what we used to call the elderly is growing rapidly, though now that I am closer to them in years, they don’t seem so elderly-just older-to me.

On my second visit to the home, the nurses know me a little bit, I know the residents a little bit, and they at times remember me-more often than not, to my surprise. Tonight I met a patient I hadn’t seen last week, when many were already tucked into bed. She had a problem, and the doctor asked me to take care of one aspect of it. While I waited for the nurse to return with the supplies we needed, I took a moment to sit myself at her eye level. At first she didn’t make eye contact, but when she realized I was there talking to her, her pretty blue eyes widened, and she managed a charming, crooked smile. It had nothing to do with me, of course; she was just happy for the interaction from someone new, I suspect.

Carolers were roaming the halls earlier, so I asked if she had joined them in singing. She said in a tremulous voice that she went down to listen, but usually sings with the other residents when they get together for an activity. I asked her what her favorite song was, thinking of the carols sung earlier, and she said firmly “The Vault”, followed by “Pink Floyd”, and I jumped to thinking she meant to say “The Wall”, their 1979 album. She and I talked for a few minutes more, I mentioned the Canadian band Rush, and she lit up again. Our conversation lasted the time it took for the nurse to travel to the supply closet and return, but it was a neat moment for me, one of many this evening.

As I mentioned I just shared this small moment with my wife, and out of curiosity I looked up “Pink Floyd” and “vault”. Turns out they released a collection of their work titled “Pink Floyd, Tracks from the Vaults” in 2009. Turns out the residents are hipper than I am. Don’t say it…

Too much tech talk for you?

Filed under: Uncategorized — Patrick Titzer on December 1, 2012 @ 2:59 pm

I started my Internal Medicine rotation with two days of orientation in Indy this past week. It was the end of the Thanksgiving weekend, over which I spent time with Karen, my wife, her family, and part of my family. Sunday I celebrated one last meal in TH before heading over to Park Place apartments, a facility that seems to cater to a variety of students from IU. Walls are thin, and my heavy meal seemed determined to defy digestion, so I woke several times in the night with the sensation of a boulder just below my diaphragm, and listened to my neighbor hacking up a lung as they say, in his room. I don’t think either of us had a pleasant overnight.

IM is an intimidating rotation; it seems to be when we are really challenged to make the progression to dissecting signs and symptoms gathered in our still largely rote exams. Technically, we can pass as simple reporters, an aspect of RIME, which is the model of progressive growth as physicians we make in our time in med school. RIME stands for Reporter, Interpreter, Manager, Educator; this progression is often subtle. It can, and often does, happen in fits and starts. We may fall back as simple reporters when the case becomes complex, or we see a collection of signs and symptoms new to us. But our training is designed to allow us to gather that information, process it, put a working diagnosis out there to explore with focused questions and testing , and manage our subsequent diagnosis.

I am used to the isolated, solitary environment of my sculpture studio to experiment; failing, redirecting and finally succeeding. My clients never had to see that often-ugly process. But hernia surgery is not a good area to let students run amok in isolation, therefore we have been closely supervised until now. So this week, when my preceptor gave me breathing room to see the patients, gather their stories and filter them with the results of current and past labs and test results and impressions, and formulate opinions I expressed in part in my first H&P (History and Physical), I was more than happy to dig in.

I’ll review my first effort later today in a phone conversation with Dr. Vu, the statewide clerkship director, but already I’ve found myself analyzing the information I discover as I become more familiar with the EMR (electronic medical records) to reform my diagnosis. Among other data, I can access drug lists from prior admissions, and since pharmacology is still one of my weakest areas (in spite of Dr. Z’s best, unceasing efforts) I’ve indulged the time to look up the drugs and categorize them along the patient’s various comorbidities; diabetes, hypertension, etc. With this exercise, I can start considering “adverse reactions” and “drug interactions” and contextualize these somewhat broad nets into what I’m seeing in the patients before me.

In my review, for example, I found a subtle difference in the conditions seen in two admissions for a patient. In one the Pt had persistent high blood pressure with variable, but persistent tachycardia. A few months later, the blood pressure recorded was still high, but the heart rate was persistently normal. One thing to consider in this situation is magnesium levels, which if low, can cause vasoconstriction, which might explain the high BP without increased HR. But-and this shows one of the frustrating shortcomings of being a novice-how low is low enough to cause a problem- can you still have a “normal” Mg level, but because of some unique aspect of the Pt’s physiology develop such a problem? Her Mg was actually at the bottom end of our reference ranges, but I have to consider, is that still low enough to cause the problem we were seeing?
Of course, the problem might also stem from the narrowness of effect of her medications, with HR well controlled, but BP lacking control; now, Ca+ channel blockers, like amlodipine make sense, but then so do certain B-blockers, like labetolol. We think we want to induce vasodilation without inducing an increase in HR, so then we have to think; which of the two drugs is better? If the pt has mentioned some symptoms of angina, amlodipine might win, as amlodipine has some effect on angina; if angina is not a problem, then cost, or other points come forward as deciding factors. And we always should monitor the subsequent results of our tweaking, in case we need to switch again, based on side effects or lack of efficacy.

Thirty minutes or less!

Filed under: Uncategorized — Patrick Titzer on August 27, 2012 @ 7:16 pm

So about thirty minutes ago I was a different person. I had never helped deliver a baby before thirty minutes ago. 15 minutes before that I was driving my wife to her job, where I study while she works. Then I felt my phone ringing, and knew I was going to hear some good news.


We had witnessed the rupture of the membrane, the so-called “water breaking” about 4 hours earlier, but two hours later the mother was still only at 3cm. That is not much room to try to get a baby through, unless the baby is made of play-doh. This baby was not made of playdoh.
So we waited, and our good mentor Doctor Nour, used to such things, did his normal thing normally. We three students; Jackie, my cohort-in-rotation, and our new pal Corianne, a PA student in ISU’s new PA program, fretted over whether we should sit in the office, camp outside the patient’s room, or go home. Complicating this was that Corianne lives 50 minutes away, and Jackie, about 20-30 minutes. We finally settled on going home about 4:30, and as I mentioned, I was heading back downtown with Karen when the phone rang.


I delivered Karen to her job, and toed the speed line to get to the hospital. I made it in, just a few moments ahead of Jackie, and raced to change into scrubs before dashing to the room. The family outside were all smiles, and I was suddenly afraid I had missed it. A laugh from inside dropped my hopes a bit further; then a family member took pity and said she could hear her still pushing seconds before, and didn’t think she had delivered. I gently opened the door, careful to enter this new stage of life for this family kind enough to allow a student to enter and learn.


I was prompted to don a gown and gloves-at which point I cursed my hands for being size 8. The nurse pulled a sterile “large” from a cubbard, and I worked my way in. Standing next to the good doctor, I kept feinting forward looking for the signal to step in. Push! He cried; keep going! Patrick get over here! I reached forward to squeeze posteriorly and touched the rather wrinkled and hairy head just crowning as mom grunted, heaved, puffed. As baby head presented, doc worked the first shoulder out then brought the baby up as curds and whey streamed along. Suction! I kept having to remind myself to squeeze the ball BEFORE trying to suction (and did so MOST of the time) the mouth, then nose, and baby was crying.

The cord is oddly beautiful and much like a delicate fluted column of blue and porcelain white, red and pink. Doctor clamped the cord twice closely together, and the new father, tears of joy moments before, reaches forward with scissors and more than a little giddyness. Camera! shouts mom. An aunt or cousin produces a small pink digital panasonic, and the birthing rhythm continues unabated. Baby is shown to mom and handed to nurse as doctor applies steady traction to the remaining cord. A steady gentle massage of the pelvis coaxes the placenta to separate, and I follow the cord up inside to feel the bloom as it comes free. Like a second baby, it crowns, and I step up with the basin to catch it as it falls of its own weight. We flip it over, as now it is inside out, inspect to confirm it was a nice complete separation, and doc challenges me to dissect to separate amnion from chorion. I am able to find an edge where the two membranes are apparent but somewhat irregularly separated, and we all laugh with the relief of a successful delivery. I am cognizant of the privilege bestowed upon us, and congratulate the father before thanking and congratulating the mother again. I can now say I’ve delivered my first bouncing baby placenta!

ps.  it is not-technically-called a ‘bloom.’

Some moments count more than others.

Filed under: Uncategorized — Patrick Titzer on July 21, 2012 @ 5:16 pm

HIPPA is a a veil we must work with constantly; check what you say, to whom, all the time. As students, we decompress at times by relating to each other some amazing procedure or intense experience; ideally, legally, sans all identifying details about the patient. So you edit and revise and become more circumspect in your comments.

To wit:
The blood welled up as soon as the last port was removed. Suddenly, the routine outpatient procedure was life-threatening. Blood pressure crashes as systemic intravascular volume pours out and the anesthesiologist works feverishly to stabilize vital signs as the surgeon scrambles to secure the ruptured varices (an abnormally enlarged vessel often due to some pathologic process like liver hypertension).

The average person probably imagines a grossly bloody field, but more often the 1st assistant has captured the major flow as it exits and the crimson liquid collects brightly in a clear canister (or two, or three, or more) mounted on the suction equipment at the foot of the table. Those involved work with determination, never letting on that the stakes have risen dramatically.

As the only student in the room, I have a moment of clarity, when I truly realize how high the stakes are, and I am focused on intense observation, acting as a spare hand if needed, but most importantly NOT slowing or disrupting the process of life-saving. The urge to be a shrinking violet presents itself briefly, but is instantly kicked back in it’s place. You open every pore in your mind and body and try to anticipate, to see everything, to be an extension of some life saving action, even if that means putting your finger over a port that is simply annoying, not really life-threatening with its whistle.

And then the moment passes, the vessel has been ligated, the volume is going slowly back up, and with it, the BP. The racing heart beep slows gradually, and you start to count just how many people are now in the room, working in symphony to that one all-important purpose.

You might fool yourself into thinking that you were an important part of saving that patient’s life, but in reality, he did the heavy lifting as he introduced you to medicine in a way no didactic lecture ever will.

So you eat a protein bar and a banana, drink some water and rest your feet. And then on to the next procedure…


Filed under: Uncategorized — Patrick Titzer on July 4, 2012 @ 3:58 pm

We begin the 3rd year of medical school shortly after we end the second. For me, even with taking one exam a week early, I only had 4 weeks to study for Step 1, the big comprehensive, integrative exam after the first two years of basic science. The first week, was toughest, as I was uncertain how I did in one of my classes. What happened then is I flailed back and forth between sitting with my books because I know I need to, and doing something sort of related to studying, because I can’t focus really until I know for certain this massive exam is going to happen, because I have this fear, however irrational, that second year is going to happen again instead. I might have even convinced myself that another year with the material will really SOLIDIFY my understanding. But then the report comes back, and I discovered I don’t have the luxury of another year at that level, AND I now have only 3 weeks until that big exam.
Which flew by sort of, in a surrealistic slow motion/repeated image of me reading and doing questions sort of way. Karen was good in that if I seemed to be wandering off topic, she would recruit me into some manual labor thing in the yard. Focus restored.
I took my Step 1 exam in Evansville on June 1st, and stayed over to spend some r&r time with my parents. We had dinner that evening and they could tell I was a little keyed up after the 7-hour exam that determines how much choice you have in how the rest of your life plays out.
Dad asked if I wanted to go for a cruise in the coupe, and I jumped at the chance. He drove and we headed out to Mt. Vernon, kinda looking for a cruise-in that was supposed to be happening somewhere. I think we drove around for 45 minutes or so, just shooting the bull, craning our necks to see the stop lights and trying to catch a glimpse of another hot rod that looked like it knew where it was going. The evening was pleasant, and the sunset over the rolling transparent hills of southern Indiana was spectacular. Thanks Dad and Mom, you knew exactly what I needed.

Cut ahead, after a furious week of honey-do projects on our property in Terre Haute, and I am on the main campus with my colleagues, going through 4 very busy days of orientation and technique practice. Hey, I can tie my own suture! Sort of. And that week was my “summer” in its entirety. Don’t misunderstand-I am excited to be at this point, and I will have plenty of time to relax here and there, in small doses. Cut ahead to Friday of that week, and we are back in Terre Haute, going through orientation at Regional Hospital on the south side of town, and Union Hospital on the near-north side. Two days later and I am in the surgery intake area of Union at 8 am, meeting Jamie, who gives us a quick bit of info and some scrubs, and suddenly, we are on our first rotation. The “we” is of course myself and Jackie, my rotation partner.
Suddenly! We are in our first rotation. Anesthesia. Dr. Levine, the clerkship director greets us and we begin following him like toilet paper on your shoe. He turns and we turn, he pauses, we fall over ourselves stopping. The experience is like the first time you jumped into a cold river from ten feet above and touched the bottom. You are almost holding your breath; your senses are bombarded with too much information, and SUDDENLY you are doing something you’ve never even considered doing before. Until you remember that training session from last week, and you get half the motions right before the experts step in so the patient can begin breathing again. Take your time, remember to breath, remember what you are doing and sweep the tongue aside before elevating it and visualizing the vocal cords. Now GENTLY slide the tube through the cords. What? You didn’t see it go into the cords?? OK let’s just check end-tidal C02. Can you see the chest rising? Listen for breathing sounds with your stethoscope. Looks like you are in.
As the days of our first rotation pass, I became a little less shell-shocked and better able to attend to the details, to study myself as I intubate or execute some other procedure, realize that Jackie is MUCH better at setting a peripheral IV than I am. Over our 8 days, we met most of the other Anesthesiologists that worked with Dr. Levine, and then worked with many of them ourselves. We observed amazing surgeries, saw beating hearts in open chests. We took every opportunity to DO, suddenly, after two years of being and observing and listening. By the end I could, under close supervision, ape my way from a pitiful pre-surgery interview with the patient through a more confident preparation of the epi and neosynephrine syringes that are there JUST IN CASE. I could in the correct order, PUSH the appropriate drugs into the IV (that Jackie likely set ) to induce the state most conducive to intubation. I could bag-mask ventilate them to ensure they had a good saturation level before performing the sweep and lift and insert. I knew where to look, what to be aware of, what needed to be at what level before turning on the Sevo and flipping the switch from manual to automatic ventilation. I was trained to be careful, and triple check the drugs being administered, and constantly listen for bells, and rhythms and wave-forms and numbers.
When I was in college the first time so many years ago, I enjoyed reading about things like the concept of Zen. What I remember is that it cannot really be described, or taught so much. It is a state of being. If you achieve this state, you are an instrument that is in seamless communication with the world around you. I should mention I learned this, in part, by reading a book called “The Tao of Pooh”, which used Winnie the Pooh as a metaphor for this elevated concept. Good beach reading, by the way.
And bringing it back around, this concept reminds me in some way of the art of anesthesia, at least it is how I experienced it. Watching the numbers going up and down, watching reaction to stimuli, and knowing when to give a little anti-cholinergic, and when not to. There are no precise algorythms to follow here, so much as a learned intuitiveness. You have to see your patient in total, see how they react to the gas, the intravenous drugs, the surgery, and adjust your technique as appropriate.
And suddenly we were done. 6:45 am on Thursday, June 28th, we took our final exam, and a few minutes later, began training for Advanced Cardiac Life Support (ACLS) for two days. Done with that, we all leapt into the weekend, which was suddenly done, and we found ourselves in Indy, doing a 5-patient OSCE on Monday. I’ll explain what that is next time around.
Today, it is the 4th of July, and I want to thank all those who have served and who are serving. My rotation partner, Jackie, is a Navy doctor in training, so she is included. We began our Surgery sub-specialty rotations on Tuesday, me in ENT, and Jackie in I forget what. Some surgery thing, ‘sposed to be good for you. (You won’t get that reference unless you are my age, methinks, and liked Life cereal).
Happy 4th. Please forgive any typos right now, I want to get to the pool.

A tale of two citations.

Filed under: Uncategorized — Patrick Titzer on April 5, 2012 @ 6:14 pm

I actually wrote this last semester; some of the references are to events long past.  The gist remains relevant:

Today I left pharm class a bit early to make the drive to Clinton, Indiana, where I was scheduled to give a short presentation to a group of senior citizens at the Clinton Senior Center.

My presentation was part of a series titled “Dine with  Doc” which I think I mentioned at some point in the spring or winter blog entries last year.  Created by a local individual, it provides access to doctors in an informal setting for educational presentations followed by q & a.  Our campus of IUSM had agreed to work with the organizer to provide volunteer speakers from among the medical students, and MSII Tyler Fromm has been the student contact.  I had originally discussed with Tyler the possibility of speaking this past June, but a miscommunication lead to my presenting today.

I thought a good topic would be the positive effects of exercise and activity as people age, with the meat of my information based on articles I had recently read;

http://www.sono.org.br/pdf/2007 Cassilhas Med Sci Sports Exerc.pdf

These two articles had inspired the topic, so I was looking forward to meeting the group and sharing some information that might give them an approach to the usual loss of muscle and cognitive function we associate with aging.

The drive up takes about 25 minutes through almost immediately rural Indiana, and the day itself was bright and sunny.  A hint of the coming fall color was playing around the edges of the tree canopies, so I thoroughly enjoyed the journey.  The Senior Center is a compact structure with ample parking in an almost park-like setting, and finding it was simple enough.  I was greeted warmly as soon as I entered, and after a brief introduction that certainly flattered my ego, I launched into the material.  I had not had time-I thought-to commit to memory my speaking points, so I apologized for reading directly off the page.  Of course, I hate to just read things, so almost immediately I began ad libbing the material, referring to the written word only now and again, just enough to catch my breath and get a chuckle from the group as they saw me realize I had covered the topic.

My familiarity with the material stemmed primarily, I realized only after (when I was debriefing with my wife), from the fact that I had been ‘preaching’ it to my parents for the last few years, and the recent articles only reinforced my beliefs.  Not very science, but it’ll work in a pinch.

The gist of my presentation, was that exercise CAN build lean muscle mass in the elderly, and improve general health conditions both physical and mental, and actively challenging your brain stimulates measurable neurogenesis in the brain structures associated with spacial relationships as well as emotion and reward and memory. I feel strongly this message is not communicated enough to the senior members of our society in a way that they can use practicably.  So part of my spiel was to encourage creative problem solving and teamwork. So that if you can’t afford a gym membership, then get together with friends and do something that is physically challenging and maybe even fun, and try working out  in pairs so that you can help each other.  Look for ways to get the resistance training that seems so important.  I recalled the antique irons my grandma Brack had on the floor in her kitchen-they only weighed about 5 to 10 lbs each, but they would certainly serve in the stead of a dumbbell for someone on a budget.  One basic concept I explained was that if you only did your normal routine everyday, you would effectively see a slow progressive loss of strength and energy as you went on aging.  It is imperative that some time is devoted to activity that goes beyond normal routine, to challenge the body and mind.

My presentation was followed by a number of questions and several of the audience members spoke up about their own experiences which seemed to reinforce my basic message.  I especially enjoyed the story from the woman who trained herself to put on full-length hose without using her hands.  What a trooper.

We had our annual visit from the Indy Deans yesterday, and made good use of the opportunity to discuss various programs.   I think everyone would agree that education in general, and medical education in particular, is in a state of flux as we all wrestle with new technologies, new budgetary realities, new philosophies about what should be taught, etc.  As Dr. King explained last year in Biochem, for example;  when he began 20 some years ago, they were focused on teaching the chemistry “mechanisms” which have little if anything to do with clinical medicine.  For him it was an unnecessary waste of time when there are so many other more relevant aspects of biochem to learn.  Of course, even back then you could probably ask a practicing physician how much they used those mechanisms, and they would have laughed and said they couldn’t even recall what they looked like; but that is just what you had to go through to become a doctor.

We would all like to think that the days of teaching things because they had always been taught, rather than because they were relevant are long behind us.  Most professors will acknowledge that 1/2 of what we are learning today will likely be disproved in 10 years (perhaps hyperbole).  Medicine is a moving target, and even when you are given an answer, your first responsibility as a student is to understand why it is right or wrong based on the best information available.  Our tests in fact are for the most part based on the concept of “what, of the following possible answers, is more correct”. Our ICM II class faced this recently when we completed a 50q take-home exam on the gastro-intestinal system (GI).

Using a variety of sources it quickly became evident that in medicine today ‘more correct’ is relative to the source of info.  What we usually settled on as we completed our work in various groups, was that the best answer was the one someone argued most reasonably, or conversely,with the most energy, when the lack of a definitive answer was apparent.

But when it comes time to be scored, the best answer is the one provided by the source, and though it has not been an issue on this particular exam, at times any attempt to discuss the logic or correctness of a question isn’t met with resounding encouragement, but rather is perceived as an attempt to ‘claw back’ points.

Perhaps my perspective is off because I am so “old”, but in my mind, I am in a partnership with the faculty.  One where the right answer isn’t always the one provided as standard issue.  We have a responsibility to challenge the faculty to teach us, especially when the process is in a state of flux, where ‘right’ answers aren’t so obvious, and at times changes to curriculum need to be suggested or encouraged.

In a recent online test we took, we were told up front in the test explanation that even expert clinicians will only agree on diagnosis or treatment 80% of the time.  But our testing methods emphasize without fail “most correct”.   Of course you have to have some metric for assessing progress with material, so ‘settled’ answers have become the norm.  I think one thing that is forgotten at times, though, is that even on the USMLE tests, some of the questions are experimental, supplied to see how students interpret them, to see if a majority will consistently arrive at the same conclusion, given the same features of a situation.  In other words, is it a good question?  In the average classroom, this also occurs, and professors are at liberty to ‘give back’ points if they see a particular new question stem is not working.  But not everyone uses this evaluation process, and given that most medical school professors don’t have degrees specifically  in “education”, it is inevitable that occasionally bad questions creep into the tests.  Which brings me back to the point, that as partners in this educational process, we have an obligation to bring up such issues, so that those who follow behind us will benefit from our experience as guinea pigs.  But this only works if both sides recognize the role each has to play.  And I think that is why the Deans visited with us yesterday, to survey our opinions about the state of medical education on our IUSM campus and place our responses in the context of the statewide system.  From the sound of things, much work is being done to ensure that IUSM remains one of the top programs in the world.   I like the sound of that, even if the reality is a little bit messier.

Sunday! Sunday! Sunday! Health Fair in TH

Filed under: Uncategorized — Patrick Titzer on January 27, 2012 @ 10:14 pm

We’ve had a fun few recent weeks in Terre Haute as planning for our annual Community Health Fair has neared its logical endpoint.  This Sunday, we host nearly 80 different organizations and businesses at the Hulman Center from 1 to 4 pm in Downtown Terre Haute.  The event is free and open to everyone, and offers opportunities not only for free screenings, but conversations with health professionals about whatever is on your mind.


Out front of the Hulman Center, The Indiana Blood Center will be waiting for blood donors, eager to replace blood that is constantly being used up in medical procedures around the state.  The organization has a website where you can see what times are available, and even register in advance, so you know when you get there, the wait will be minimal.  I am going at 1pm myself;  please join me for a little blood letting!  Walk-ins welcome.

Make an Appointment – DonorPoint  


Online scheduling for appointments to donate blood.


New this year is an area where the first-year medical students, led by Christian, the class representative,  can practice taking vitals;  admit it, you’ve always wanted to be a guinea pig.   This won’t hurt a bit…


Another always-popular area is the Kid’s Corner; run by Bernie and Kyle this year with a slew of other medical students, ready and waiting to entertain your children while you check out the displays and ask questions.


There will most certainly be free refreshments, and many medical students just waiting to point you in the right direction.


Naturally, these things don’t plan themselves, and as event Co-Chair, alongside the hard-working Naina, it has been impressive for me to see my classmates each shine in their various roles.  Rough patches were navigated, as in any big project, and it turns out I am a bit of an autocratic, but nobody’s perfect.


Behind the scenes, alongside Naina and me, Anna orchestrated the vendor participation, a job that we hope will be divided between four people next year…yes…four.  Overseeing our accounts, Lauren and Teela worked hard to keep us all from spending too much while keeping an eye out for donors, and Evan combed the community looking to provide door prizes and bag-stuffers.


It is always a privilege to acknowledge those who none see do their work, and in that vein I want to recognize that the continuity and flow of the event was assured by Mary Beth and Kristy, who we all owe a debt of gratitude to, as well as our faithful sponsors in the community.  And please visit the website I mention to see the full list.


Getting back to impressive; watch this video of one of the television spots (WTWO)our very own Dan and Ryan did-one of several ‘media’ spots they put together as the promotions co-chairs.  I think Dan has a new friend…




They also appeared on one of the other networks (WTHI) in town, but I have no video upload to check out.  Please note how the local media really partnered with us to get out the word.  The  Terre Haute Trib-Star ran a nice article too:

Terre Haute Community Health Fair coming up » Valley Life » News From Terre Haute, Indianatribstar.comTERRE HAUTE — Leaders in health in the Wabash Valley will gather to educate residents about their health and how they can improve it during the Terre Haute Community Health Fair from 1 to 4 p.m. Jan. 29. Medical students organized the first health fair in 2005 as a service project that allowed th…


For more info, check out our website (I apologize for the links, you may have to cut-n-paste to get them to work):




A week or two ago, the Rural Track students met on a Tuesday morning for lunch with Kelly, the 3rd and 4th year coordinator, to pick our rotation.  We have 12 slots, and luckily, we all kind of fell into working relationships before the meeting, so the choosing went smoothly.


I should probably explain what a rotation is, though if you are reading this, you likely know.  A rotation is a period a medical student spends in a medical specialty, learning that specialty alongside the doctors, and studying all the time to prepare for a pass/fail exam taken on the last day of said rotation.


With the Rural Track, as of last year, we now spend all four years of medical school (2 years basic sciences in a traditional lecture format, 2 years of clinical rotations with didactics) in Terre Haute and most, if not all rotations can be done locally.  Terre Haute was the first of the IUSM campuses to do this, though I suspect some day they may all offer it as an option, as the need for physicians grows with the population.


Returning to our main storyline; we began that Tuesday meeting by mapping out the various important life events.  It turned out our cohort has three weddings coming up in the next year.   These are important to note and schedule vacation slots around, as delivering someone else’s baby on your wedding night-because you are on your pediatrics rotation and on-call-might fall under the heading of  ‘you’re kidding me’.  So planning is necessary.  Once those blushing brides/groom were neatly fitted into schedules that worked, the rest of us fell into place rapidly.  And the yogurt and bagels were great too.


My first rotation this summer is Anesthesia.  I am excited to begin there, in spite of having no experience to go on, because I think it will be great to jump in and get the gases flowing.  Or something like that.


The conventional wisdom is to begin with something you aren’t interested in then finish with what you are, so as to be as experienced as possible and make a good impression where it most matters.  We’ll see how that goes, as I am interested in family practice, but without any real experience with many of the specialties, I am going in eyes wide open, and will work to find out what the best fit is.


I am paired with Jackie, who at times admonishes me to be a little less wordy.  An interesting concept I do admit, but I’m still not sure how to implement it.   Seriously; Jackie and I get along well, and I respect her no-nonsense attitude, which I suspect will serve her well in the Navy.  In fact I fully expect to become a man of few words because of her……maybe someday.  It is on my list of goals somewhere.  Which I have around nearby…maybe.

Speaking of no-nonsense;  Jackie and Sara-both blushing brides-are also the Health Fair on-site coordinators, so if you come, please take note of how well run the thing is.  I am thinking wedding day dry-run.  That is, if the wedding offered hearing tests and information on STDs.


And of course, that thread leads me back to mention that we will be giving away door prizes in drawings for those who take a few seconds to fill out our event questionnaire.  The free event I mentioned in the first few paragraphs…you remember.

This has been a public service announcement.




Creationism…as a law…in Indiana?

Filed under: Uncategorized — Patrick Titzer on January 26, 2012 @ 3:45 pm

I subscribe to an interesting science education website and today I received an update regarding a current bill that just left committee:


I am at the moment embarrassed to be a Hoosier. I am further embarrassed because Indiana State Senator Dennis Kruse, the author and sponsor of the bill, according to one online source, is an alumnus of IU as well.

Now, obviously, this bill can’t become law. OK, it could, but then we as hoosiers would be admitting our senate is run by a bunch of rubes. After this last year of attack on public education, it astounds me how our elected officials can sit in their wood-paneled committee rooms and think about….how the world came to be?


We stand diminished in the world’s eyes because we have allowed our education systems to slowly wither on the vine under the guise of  reform.  I shiver when I think about the conversations apparently going on in Indianapolis.  “Hey!  I know how to improve our graduation rate, and improve the economy;  let’s make those darn, recalcitrant teachers who keep arguing with us teach my personal religious belief as a science.”


Even religious leaders were against this Senate buffoonery.


So how does this even begin to be a reflection on my life here in med school?  It goes to show just what we will be up against as physicians.   Creationism is great to teach if you happen to teach Sunday school, but in a field based increasingly on what science tells us about our world, what does it say if the ‘new’ science has nothing to do with the scientific method?

Can we now prescribe folk tonics and elixirs because, according to Senator Kruse, science doesn’t really need to be all that sciencey?  Perhaps phrenology can make a comeback and we can diagnose people based on the science-ish technique of skull-bump reading.  For $2 more, I’ll read your fortune!


Medicine is the field where most people really see science at work in their lives.  Granted, it may seem at times like voodoo, but the basis for treatment better be founded on good science, or someone’s malpractice insurance might go up.  And a fundamental role we have as medical professionals is as educators.  Can any of you, with a straight face, explain how the influenza virus changes over time necessitating the latest vaccines be used in order to offer protection against the current strains…using creationist science as your guide?


Would someone please take these misguided politicians aside in a quiet corner, and explain to them how such legislation damages the state?





SOC-it to me!

Filed under: New experiences — Patrick Titzer on January 15, 2012 @ 9:37 am

Over the winter holiday break, Jackie, a fellow MS2 on the Terre Haute campus, suggested that students from the Terre Haute campus sign up en mass to volunteer at the IUSM Student Outreach Center.




The SOC is a very unique, student-run wellness center where the uninsured or otherwise financially challenged can come to receive evaluation and potentially treatment, medications as available, or referral for whatever might be bothering them.


Not only do students from the med school participate, but students in pharmacology, social work and law do as well, and Dr. Frick volunteers as the final word on each patient (and educational resource for the students).
I liked Jackie’s idea, but had some trepidation about what to expect when we actually arrived.

On a frigid bright morning-yesterday, January 14th, 2012, in fact-I drove Jackie and Tyler to join Anna and Derek at the Center at 9:30am. With light Saturday morning traffic on I-70, we had a rambling conversation on the way over and the day felt like it was off to a good start.


We didn’t know exactly where to go in, but as soon as we did enter, we were greeted with a warm environment of fellow students and potential patients. I was surprised to find one of the student board members was non-other than Charles Goodwin, a fellow blogger, and remarkable MD/PhD student (gratuitous compliment, but he was great to work with).


See his blog here:




We were quickly oriented to the format of the day, after a few minutes of social interaction and kidding with the students (who ranged from a single, remarkably capable first-year, through several MS3s and MS4s), and when 10am rolled around I was lucky enough to be the second student to be handed a chart and triage my first patient.
The independance was exhilarating, and I found myself for the first time feeling like, hey, I am responsible for this patient’s well-being; I better get this right.


I can’t think of a better way to instill clarity into the soup of learning med school can become.
My initial role, however, wasn’t a brain transplant. I took vitals by trying to juggle a clipboard on my lap and fish my BP cuff from various scrub pockets and assemble it.  My first patient was great; from his chart, I could tell this was his first visit, yet he dealt with my various contortions and apologies for ineptness with dignified patience and good humor.
I should mention that while dressing that morning, I made the wise decision, after consultation with my wife, to wear long underwear under my crisp blue scrubs. I am so happy for that.


The Center is a wonderful example of what I would guess is early 20th century parochial school architecture, designed for maximal use of natural light and most likely steam heat via a boiler, though I suspect that system had been updated to modern forced-air heating.


In an era before modern insulation, the thermal mass of the bricks was expected to suffice in maintaining a reasonably stable temperature, which means that when people arrive in the morning and turn the thermostat up, it can take awhile for the room air to adjust, and even though the windows were modern updates with good seals, the heat loss through the glass further delayed that warming feeling we all needed-especially the patients, who I repeatedly apologized to when palpating their abdomen or searching for a pulse with my icy cold fingers.

(After all that blah blah, I could have just said it was 11 degrees outside and a bit chilly inside, so my hands were both cold and a little clumsy.  I dropped things, repeatedly, and my pen didn’t work so well, which began this particular narrative.)

Back to me trying to record my patient vitals and chief complaint before corralling a 3rd or 4th year student for further evaluation; my apparently chilled pen is recording a sad, patchy script that even a pharmacist couldn’t likely read (Ever helpful, one of my patients, later in the day, explained how they sometimes would use a lighter to warm up the pen).


Thank goodness for pharmacy students, who always have extra pens, and allowed me to borrow one, knowing they might never see it again  (it later fell apart on the floor and I had to hold my thumb over the back end to continue using it because one part disappeared under a cabinet-I don’t know what I did to it).
It seemed that everyone involved in this ‘doctor incubator’ understood the uncertainty that can occur, and it was set up so that you understood you were never alone in any decision.

You are free to perform a focused H&P (history and physical) if you are comfortable doing so, but you are also encouraged to grab a 3rd or 4th year student after the initial brief vitals/chief complaint interview and proceed with someone with more experience guiding the process.


At every point we were gently cheered on to take the initiative and practice our art, to evaluate, consult, consider differentials and drug interactions in a way that really can’t be done in a typical classroom because there is no sense of the immediacy of your actions.


A human being in need is a compelling motivator to learn, and in some way the experience paralleled that scene in Forrest Gump when Forrest is clanking along with his leg braces, chased by the bullies, and the plaintive call of “run, Forrest, run!” pushes him to break free of the braces and discover his ability not only to run, but make running one of his defining strengths.  I gained some confidence yesterday is what I think I am trying to say.
My classmates are going to laugh at this, but I play my cards close to the chest sometimes.


By this I mean I prefer to listen to both patient and those further along in their education before I comment. At times this means I don’t say much-a revelation that will cause some  snorting in the peanut gallery.


At the Center yesterday, I found myself actually involved in the conversation, presenting part of the patient case to Dr. Frick, discussing drug interactions, side effects, etc. with the 4th years I grabbed for consult.  Discussing what was best for the patient because it finally mattered-wasn’t a theoretical construct with a “model patient”, with a single, expected “best answer”.


What we decided, upon approval by the Doctor, was what would happen. So we needed to get it right.

Aside from Christmas with my wife and family, yesterday was the best day I’ve had in the last six months.


If you are a medical student, especially if you are interested in patient-centered care and interaction, and you have not yet volunteered for the SOC, then you are simply missing out.


Search for IUSM SOC, and just do it. Especially you first years, or anyone who is struggling with where they are in school. It can be a reality check-in with with the fact that you have actually learned something while here in school, if you are feeling uncertain.  And it is great practice for your future practice.




Thank you Jackie for suggesting it, and thank you Charles and the whole crew at SOC. See you in February! (I mean you guys at SOC, not you guys reading this blog).


Normally that would be a simple way to finish a blog-it seemed final when I wrote it, at least.


But there is an after-story of sorts.  Anna recommended we try a mexican restaurant, El Sol de tala ( http://elsoldetala.com/ ), on Washington, a few blocks from the Center, where she had been going with her family for years.  The restaurant had recently expanded into the newly renovated posterior portion of the building they’ve occupied for years, and when we dropped in, we were greeted, by the two managers on duty, with a broad,warm welcome and much verve.


We hadn’t eaten while at the clinic so it was a great way to wind down, and I have no problem giving them a shameless plug for the great atmosphere and great variety on the menu.  I was disappointed they didn’t have the Mahi-mahi the day we were there (in the interest of full disclosure though, until I saw it on the menu, I had no idea it was something to be find in a mexican restaurant).  But then I never claimed to be that sophisticated.


The End, part II.

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