4.28.2008

filling my time with less frequent blogging...


I heard that blogging can be hazardous to your health.

It's interesting, because blogging can be stressful and overwhelming...especially if you're expected to produce new material more often than you actually *have* new material. After blogging about a year (more-or-less consistently), I find I have ranted and fussed about most of the things that bother me most (but don't fret, I still have a few annoyances I'd love to expose...and new annoyances things are always "coming up"). I have shared my enthusiasm for my profession. I have documented the process, the thoughts, and the transition from medical student to attending. And I've talked about memorable (pseudo-)patients. Now, I don't feel as pressured to write all the time.

Additionally, it's takes quite a bit of time on the computer to post even one (legible/comprehensible) entry. To translate your thoughts to print...and make them comprehensible by most who'll read them...takes time (depending on the thought). And, I've seen hours "disappear" as I update my blog, surf the net, return email, etc...all while the kids are on their 8th episode of SpongBob SquarePants of the evening (just kidding...kinda).

As the days get longer...and the weather warmer...and the kids get bigger (i.e. more activities, more time needed to engage them, more friends over, etc)...I think I'll have to spend less time on the computer. When they were in bed by 8pm - and me not until 11pm...I had lots of time. But now the little guys aren't in bed until 10pm (it's actually still light outside until almost 9pm in the summer here). So, I have less time to waste spend on the computer.

Just thought I'd post this for those who may wonder 'what happened?'.

Just enjoying the sunshine...

4.03.2008

What was medical school like? Years III and IV

After completing years I and II, you have a small break. At our school, this break was only a few weeks....and it wasn't really a 'break' at all.
After completion of year II, it was required that we take (and pass) the USMLE Step I. This first part (of a three part series) tests your basic science skills. Basically, the things we learned in years I and II are being tested. Our school was pretty good about teaching to the test (somewhat), and boasted a high first time pass rate. But you see, that 'break' was spent cramming for this licensing exam.

This exam was very difficult. You know, one of those exams that you can't even discuss afterwards because there were just so many uncertainties. You have no idea how you did. On other exams we've taken, most of us had a feeling about it:
"I think I did okay...but number 10, you know, the question with the xray...I wasn't sure if they wanted this answer or that answer...etc.'" OR, "that exam was horrible...what?! you put C for number 4?? geesh, I musta missed that one too...etc" (like this). After this exam, it didn't happen.

When I took the exam it was 2 days long...all day (except an hour for lunch). After lunch on day two...I just started marking everything 'B'. I was so tired of testing.

After you take that exam, you begin your third year. By now it seems as if everyone knows what they wanna specialize in. And if you do, that's a good thing. The sooner you know, the better. No one told me that...and I wish they had. If you know you wanna be, say ophthalmology, you can engage in research, and start kissing ophtho ass early. You'll take the rotation as soon as possible...and as many ophtho rotations as necessary to get the letters you'll need to match.

Years III and IV consist of clinical rotations.
Our 3rd year rotation schedule was made for us (i.e. we didn't get to choose the order of rotations). Basic required rotations were surgery, internal medicine, psychiatry, OB/GYN, family medicine, orthopedic surgery, pediatrics, and neurology. Our 3rd year consisted of these rotations. Most were about 6 weeks. You had about 12 weeks (maybe it was 16 weeks) of vacation. You could take that as a block, in two 6 week blocks, or however you could manage it. You requested your vacation time...and the university filled in your 3rd year schedule around it.

Our 4th year (frequently referred to as a 'sub-internship') we did our own schedule. There was a second round of required internal medicine...and many of us didn't necessary get all of the 3rd year (required) rotations completed in 3rd year (maybe because of vacation request, or scheduling, etc). So, you had to finish up those. Many of the rotations (the 'interesting' rotations) required the student to have completed a prior 'basic' rotation. For instance, an NICU (neonatal ICU) rotation will no doubt require the student to have completed pediatrics (and possibly OB/GYN) prior to starting. During this year, students typically take rotations like radiology, anesthesiology, emergency medicine, ophthalmology, dermatology, and maybe some bizarre elective at a far away place (but these electives are hard to get approved, and most students opt for pre-approved, 'normal', nearby electives). Also, you get to choose which hospital you'd like to do some of the required rotations. University hospital, County hospital, Community hospital, etc. There are some rotations that are notoriously easy (meeting like twice in 6 weeks) for an easy pass, and a nice break. I (am not ashamed to say it) *maximized* these opportunities. ;o)

During the rotations there are weekly lectures that your school 'requires' you to attend. These are usually very welcomed "breaks" from floor work/scut. Every day the students would try to get out of evening rounds by announcing: "uhhh, we have lecture this afternoon..." The residents and attendings were made *very* aware of the requirement of students to attend lecture...and were powerless to say or do anything except let us go (but beware, they'd sometimes verify that we're actually at lecture). Additionally, there were morning rounds, grand rounds, attending rounds, sometimes evening rounds. Lots of time in 'meetings'...really makes for along day when there's lots of scut to do.

The lectures were by in large *very* useful. And, in retrospect, I'm very happy I attended most of them. Learning pediatrics while doing a peds rotation...really solidifies the information. At the end of the rotation, there was an exam (on the lecture material). Some schools use the shelf exam, thankfully ours didn't. We had exams written by our professors. Everyone passed...eventually. You could take the exam multiple times, until you passed. Every (required) rotation had an exam.

Also during this time we had to take an OSCE (like a fake/simulated patient encounter). Completely bullshit (even in retrospect), where they bring in actors to play patients, and you're graded on how well you "play doctor." I hated "playing doctor." And I hear that this bullshit OSCE is now apart of the USMLE?? Requiring poor (literally, poor) med student to cough up money to take this BS? (but I digress...)

As a 3rd year, your presence on the team is largely unnecessary (despite what they tell you, and regardless of the student's arrogant belief to the contrary). You slow down the intern/residents; and all of your orders (rightfully) have to be cosigned...hence they are useless. In clinics you're really annoying to the people actually 'working.' In-house on the floor, the patients think you're 'cute' and they always 'know someone, who knows someone, who 'gonna be a doctor.'' And instead of telling you their deepest concerns and intimate medical issues...they wanna talk about *you.*

In retrospect I realize that much of that...that inability to be taken seriously by patients was my fault. I was insecure, didn't really know what to ask. My history was unfocused. AND I actually sat there with them for hours getting largely irrelevant information...which made me their "friend" and not their "doctor." (which is okay since I *wasn't* a doctor...).

The various rotations differed from each other tremendously (and I'll discuss that on a different post). But, in general, to do well in the clinical years involved working smart - and the realization that you're really gonna have to make some time sacrifices during those rotations that involve the specialties you're actually interested in applying to...because they will haze you.

Let's just take internal medicine as an example:
To do well in internal medicine you should try an be apart of the team. That means not leaving too frequently to attend "lecture" or whatever. That means arriving before everyone else does, and leaving after they do. When you have patients assigned to you, realize that *you* are not managing the patient - the attending and residents are managing the patients, and you are doing what they tell you to do. Your role is to listen and learn. But more than that, having assigned patients means you're responsible for *information gathering* for those patients. As a 3rd year (and 4th year...and intern) YOU ARE AN INFORMATION GATHERER.

Some will tell you to 'know everything' about your assigned patients. Well, that advice didn't help me much because, on a practical level, that is not possible. Better advice would have been as follows:

You come early and get the lab values (know the trends), the radiographs/results, the medication list with the antibiotic day number, fluid intake/output/weight change, any overnight events on the nursing note or per the patient. You should know what the physical exam shows (new rash? pressure sore? crappy lung sounds?) You should know the vital signs, and if any fever spike overnight (and if so, what time). You should know if any orders had to be written on your patient, why, and if what was done helped. You should know their bed number (and if they were moved, the new bed number, and why they were moved). You should know their working differential diagnosis...and do some reading about the disease(s) and how to treat them, what complications to expect. You should have written the daily progress note (to be completed after you are told by your team what the assessment and plan are). And you should anticipate (or have the handbook) of possible questions the attending will ask...and know the answers so you'll look like a star.

Your school will let you know if overnight call is required. There needs to be a place for you to sleep, and something for you to do. The nurses may (or may not) be instructed to call you first. And if they don't, well...it's kinda no point for you to be there. Especially if your orders all have to be cosigned. The intern will have to take every call, and write every order anyway...

...but at some community hospitals I rotated thru, there were very nice call rooms for everyone...and the nurses *did* take student orders...and they *did* call the student first (usually these are 4th year rotations where you're working as a sub-intern). It's easier to stay on-top of your patient information gathering duties if the nurses call you when there's an issue. And you felt important. Also, typically OB requires overnight call for obvious reasons.

Exactly what do you do all day?
Well, you go in early (whatever time makes you the first person there). You go physically look at your assigned patient (usually you'll have 2 or 3). Make sure they are alive, breathing, and are still in the location they were yesterday. If they are awake, ask them how they feel. Be sure they know you were there (this is more important as an intern and beyond, sometimes patients will complain that 'their doctor never comes by and see them' not realizing that *you* are the doctor...and see them multiple times a day. You can't have patients spreading rumors like that about you). Put a stethoscope on their chest. Pull back the covers gently and make sure there's nothing obviously wrong. Do a focused exam - meaning, check the part of the body that's causing them to stay in the hospital. Note any changes.

Then you have your paper/index card for that patient. You write their room/bed number on top next to their name and medical record number. Then you grab their chart and flip thru it...looking for the information I described above. Look at the nursing notes...and read what they wrote overnight. Look at the vital signs sheet for the last 24 hours. Look at the order sheets and see if/when anything was ordered. Read the physician progress notes, and note anything significant. Be sure to look at the medication list. Check the labs, and remember to check for any positive blood/urine/sputum cultures. Know the medication allergies. Look and see if any of the consultants wrote any (new/old) recommendations. Then, write your note with all of this information incorporated SOAP note style (leaving the AP blank until after rounds). If your note is good, only the attending will have co-sign, and it'll count as an official note (i.e. the intern won't have to write a full note, and they'll be happy).

Do this for every one of your patients. And with any time left over, you go eat, and read a bit about the diseases your patients have (and what to make of any overnight changes).

If your hospital still has plastic xray films, you should find them, and gather them. Carry them around for the attending to look at. If you have a pacs (digital) system, log on (or have someone log on for you) and look at the films. Look for any radiologist reports...and look at the images yourself. You should be able to identify any significant changes between today's xray, and the one taken yesterday. Lungs more white? Kinked chest tube? Free air?

During rounds you present your patient the way the attending likes it. Be sure to at least mention (to someone other than another student), things that *you* think are important, but couldn't say on rounds. Remember, rounds isn't always about learning or information exchange...sometimes, with some attendings, it's about providing them a platform to flex. They may not appreciate someone like you making them 're-focus' on patient care.

Many teams will have short 'okay-this-is-the-*real*-deal' rounds after the attending leaves. Where the work is divided. Then everyone goes to morning report/rounds. Morning report is a lecture where an intern presents a case, and everyone does this mental masturbation exercise about the patient.

Then it's time to work. Most hospitals where residents exist aren't very efficient. The nurses don't do shit...and the students/residents do everyone else's job. This is what takes forever. This is the problem with resident education. This is why it seems as if the surgeons aren't as well trained with restrictions in place...eventhough they're in the hospital 88 hours a week. Are the surgical interns/residents so stupid that they cannot learn what they need to learn in the 88 hours/week, 5-7 years they're there training?? (I just love what the medstudent tells Bongi in the comments section of this post). Of course not!! They aren't doing all the necessary *doctor tasks* to properly train because they spend 90% of their time doing other people's work and miscellaneous non-physician/non-educational/irrelevant bullshit. Drawing labs. Finding lab results. Pushing patients to scans/xrays. Finding xrays. Massive clerical work. Trying to plead with hospital staff to do what they're supposed to be doing for the benefit of the patient (so they can get that study done, or that consult completed...so everyone can go home). Residents/interns play social worker, trying to discharge patients with no place to go. And during it all while being constantly interrupted by pagers. Some of the bullshit is unavoidable, but much of it can be changed if the higher-ups were really interested in change and patient safety...while maintaining the high quality of the doctors being produced.

But instead, they advocate for unrestricted resident hours...

Unwritten rules include:
it does you no good to make your fellow student, the intern, or resident look bad in front of the attending. If the intern is asked a question by the attending on rounds, and s/he doesn't know the answer...don't you jump in and blurt the answer. You say nothing...unless the attending directly asks "does anyone else know?" And still you wait a minute. I would advise that 'if your superiors don't know, then you don't know', period. If you are smart and actually *do* know, it will show in different settings - such as when you concisely present your patients to the attending with a focused differential, and the subsequent pimping session proves you know your shit; or when the attending asks you a question first and directly and you *modestly* give a correct answer. You do not get cool points from anyone being a smarty-pants know it all. And if one of your teammates doesn't know something about his/her patient, you can tell them discreetly, but never one up them on their own patient in front of the attending. And, please, *never* ask questions that you know the answer to. This annoys everyone!!

It's best to not talk negative about anyone. That can only come back and bite you in the ass.

On rounds you follow the pack. You stand if chairs are limited. You carry all the crap (the stethoscopes, the otoscope, tongue blades, whatever is commonly needed but not commonly easily obtained). You don't argue. If someone says you're wrong, you're wrong. Even if you're not wrong...just forget it. If you want honors, and a match into the specialty, you'll realize being 'right' doesn't matter.

Many times inappropriate comments were said (especially on surgery), and may put you in a difficult spot. Usually some sort of sexist jack-ass with a small dick blurts out some off the wall comment about women...but sometimes it's even more hateful than that. It was not unusual for surgical attendings to throw full-on (two year-old type) tantrums. Surgical instruments thrown across the OR because anesthesia had the table too low. Or verbally abusing everyone, just to see how many times he can make the resident cry.
What seemed to work well at our school - a group of students who agree that the person is out-of-line would go to our student affairs dean and complain because it's never just one episode of ignorant behavior, and many people can usually agree that the guy (it's usually a guy) is an ass. We'd express our concerns, and demand to be moved to another team, or another service, or another facility. Usually, if there was a (big) problem, you could be moved (as it should be being that you're paying up the ass for an education). And on more than a few occasions, students were not placed on certain teams, or with certain attendings with a reputation for being assholes. But realize that as an intern...the solution is not so simple.

Offer to do a presentation for the team. Bring in an interesting journal article (if you happen to find one), and educate the team about it. Have a happy disposition. Be reliable. If your intern relies on you, you cannot miss attending rounds...because they will not know the detail about the patient that you know because they were *relying* on you to know (and be there). (Even if you're sick, you need to come in for attending rounds...then ask to go home). And don't leave until all the work is done...or at least ask if there's something you can do to help out the 'slow-poke' before you leave. Usually the answer is "no", but if you acknowledge that they are still there, and offer the help...it will be noticed.

In order to graduate from our school the USMLE Step I must be taken and passed. USMLE Step II is taken during senior year. It does not have to be passed to graduate. There are strategies as to when to take Step II. Some do it early to make their application competitive. Others do it later, as not to tarnish an already acceptable application. It depends on the competitiveness of the specialty, and the competitiveness of the student. Also a consideration, if you did awesome on Step I...you may not want to take the chance that your Step II score will be lower, and some of your shine is lost.

USMLE Step II is easier (more practical information), than Step I. It was also 2 days long. Exam topics are those of the basic rotations - peds, IM, psych, etc. Some specialties consider the USMLE score to be the single most important part of the residency application.
***
Overall, in years III and IV you have much more control of your time. Only a few rotations are brutal, and only being so because of their long hours and the amount of scut (i.e. gathering information, and pushing the patient along in the hospital diagnostic/treatment process) required. Some rotations will be more stressful because you're trying to impress the staff. Usually, by mid 3rd year everyone is pretty sure what their interests are...and it's no secret to surgery residents that you're not into what they do. And they don't torture you as much.

You have time now to see a movie. The tests are easily passed with a day or two of studying. Even the USMLE has great prep material out there such that you don't have to study much more than a 150 page book and do well (enough). If you're a good team player, and do well on the exam, you'll honor at least a few (maybe even most) rotations. If you do very well, and people really like you, you may be inducted into the honor society, AOA. AOA on your CV looks very good to program directors of competitive residency programs. Also, you have time to engage in some research (not alot of time, but *some* time). And some students will take a year or two off after 2nd year to do research (or have babies, or travel, or get an MBA, etc). This will also look good on your CV (well, maybe not the 'have babies' part, but that can be disguised as 'research' if done correctly).

Many medical students decide to have children during 4th year. Some do away rotation in Costa Rica. Some take no vacation...and save it all to the end (this is what I did). This was fantastic since my last rotation ended in early February, and I had 'vacation/freetime' until I graduated in mid May!!

That was my last 'summer vacation.'
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p.s. so, now that you understand what medical school is (sorta) like...you'll appreciate the (hilarious) humor in these videos on my sidebar:
This one. This one. and this one. (you just have to see them all. After the first one plays there's an opportunity to watch the others...)
I'm LMAO just thinking about them!!