Monday, November 18, 2013

Rub a Dub Dub


What is a soap note? In theory they had instructed us in class a number of times. S: subjective, what the patient tells you. O: objective, labs, physical exam  and other pertinent clinical date. A&P: assessment and plan.  What are each of your patient's problems? And what exactly do you plan to do about them?

Sounds deceptively simple.

My last post was kind of a whine-a-thon and I can be honest about it.  But underneath that is a thread of true frustration that I felt.  It was horrifying to spend a month doing something and seeing myself stagnate, I was barely keeping my head above water.  The next month I spent on medicine was absolutely a 180 degree difference.

So much of this experience is dictated by the team that surrounds you: the interns, the senior residents and the attending.  Granted my senior resident ran a tight shift, we were on call almost every other day and the medical students never went home earlier than the rest of the team but I learned so much.  By the end of my 3rd week in a feedback session the attending candidly told me that my first week I was difficult to follow and all over the place. But she added, now had gained confidence and honed my presentation skills to a level close to that of the interns around me.

I'm so happy.  Not just because of the complimentary feedback but because I feel like I am part of the team and am working and improving my skills.  It is dawning on me that this is the only time in my career I will get a sampling of everything in the way I am now.  This is it, the only training I may ever get in internal medicine if I choose another route.

It is so easy in medical training to get away from the true type of student that I was, always striving to be the best, always trying to make a good impression and always, always working as hard as I could.  These last few weeks have been mentally and physically exhausting with most days 12+ hours but I felt the drive that brought me to medical school start kindling again.

Tuesday, October 29, 2013

Lost at Sea

NB: I didn't have a full understanding of what internal medicine meant until I started med school, as a brief primer for those as confused as I was: after medical school trainees pic a field in which to train further one of the biggest subsets of that is 'internal medicine' or 'medicine' as we often refer to it.  These are physicians trained in the art of caring for the general medical problems of adults, their counterparts who focus on children are known as pediatricians. 

I had been looking forward to the start of my internal medicine rotation, its the real bread and butter of medicine.  The core of what all other medical training I have in the future will be built is the solid foundation I obtain during this clerkship.  I started my first day expecting to feel confused and lost but did not anticipate that feeling dragging on for the better part of a month.  My biggest frustration was that I spent so much time seeking out opportunities to learn but never finding quite the instruction I was looking for.  Although we do receive a fair amount of instruction in the M1/M2 years about note writing, in all honesty none of it really stuck because I didn't have to use it.

My first call night I sat around twiddling my thumbs, half of me hoping I could get a patient and the other half crossing my fingers I wouldn't have to.  As call wound to a close I happily drove off into the night feeling relieved that I didn't have to put on a display of my own ineptitude in front of my residents.  The next morning when I had to quickly scan over the admission history & physical done by the overnight resident and "present" that patient to my attending I regretted not having been able to do the admission on my own.

My second call night I was happy to receive an admission in the middle of the afternoon, my senior resident called me and told me to head down to the emergency room where the intern was already seeing the patient.  This time I was prepared, I had created a template for myself to make sure to hit every point necessary HPI, past medical, past surgical, current medications, social and family.  I pushed my way through the widely swinging ER doors and spotted the medicine resident across the nurses station and quickly made my way over.

"Oh Mrs. Jones, this is my medical student _______ who will be working with me," the intern quickly said to the patient

"Hi, its very nice to meet you. Can you tell me a little about what brought you into the hospital today?" I responded, addressing the patient

"You know, I've already asked her all of those things so if you had anything else specific you wanted to ask you can go ahead. Or I guess you can listen to her heart" the intern quickly chimed in.

"Oh okay, Mrs.  Jones would you mind if I listened to your heart?" I responded.  I proceeded to listen to her heart and then threw my scope around my neck and followed the intern out of the ED.

"So you can go ahead and write your note and then we'll talk about it, okay?" he told me as we quickly walked down the hallway back to the secluded computer labs on an upper floor of the hospital.

"Yeah, sure.  I may need you to fill in some details that I'm missing if you don't mind," it was all I could manage as I tried to hide my severe disappointment at what had just transpired.

I wrote a note on this patient, well as much as I could have.  I pieced together the information my senior had given me over the phone, what the intern was telling me and what bits and pieces I picked up at the patient's bed side.  It was so far from ideal.  I was fuming with anger.  I didn't have most of the information I had wanted to ask and even if I did I wanted to hear it first hand.  I didn't know how to put together a note or at least not the assessment and plan which is the only part anyone ever reads.  I flipped through old records to find notes that looking thorough and tried to mimic their style.  I had no idea what I was doing.

The next morning I was expected to present this patient to the attending, which I did poorly considering I knew next to nothing about this lady.

In many ways I can take responsibility for what happened, I could have gone back and asked the questions again.  I could have waited till she hit the floors, I could have gone in the morning but the point here is the entire purpose of the exercise was lost because someone didn't bother letting the medical student know what was going on in a timely fashion.

I understand we're at the bottom of the totem pole and everyone gets put through the ringer during clerkships.  I'm a hard person to suck the optimism out of but I'd have to say I can feel it slowly starting to seep out of me.  Its really starting to dawn on me the life altering choice a career in medicine has been.  My clinical life is probably at the lowest intensity it will ever be in my life but I already feel exhausted and overwhelmed by it.

Part of me thinks this is just the learning curve slapping me in the face and once I make it over this little hump it'll be smoother sailing.  Another part of me is worried that I'm never going to get good at this.

Wednesday, August 28, 2013

Medical Jargon Demystified II: Pecking Order

Something that I have always found incredibly confusing until I became a part of this structure myself was the hierarchy of medical education. I thought it may be useful to just clarify who is who and how far along in their educational journey in a post.

  • Attending (This person is definitely a doctor, they are what we usually think of when we say doctor. Undergrad + Med School + Residency (depending on the field, fellowship))
  • Resident (All of these people are technically doctors, they have an MD or DO after their name)
    • PGY (INSERT #) (post graduate year) depending on how long their residency training program is this could be PGY 1 - 10)
    • PGY 1 (these guys are the interns, they are the lowest of the low in the MD totem pole.  They are first years that were medical students between 2 and 10 months ago and act fairly clueless for the better portion of the year)
  • Medical Student (These people are not doctors yet, they DO NOT have MD or DO after their name)
    • M4 (4th year student, operates at a similar level to a PGY1)
    • M3 (3rd year medical student, fairly clueless but depending on how far along in their 3rd year are closer in performance to an M4)
    • M2 (2nd year medical student.  Still in the didactic learning years with minimal clinical exposure, have net to no idea what they're doing)
    • M1 (1st year medical student.  In their first year of didactic learning, little to no clinical exposure, has absolutely no idea what is happening ever)

I hope that little snippet helps give a better understanding of what all these weird letters and titles really mean. 

Saturday, August 3, 2013

Medical Jargon Demystified I: Wait, I'm still an Undergrad?

I thought it was high time I wrote a post clarifying some of the terminology associated with medical school and generally about the timeline.  This may be quite obvious to many of you out there but I myself was a little bit confused by all of this jargon before I was thrown into the thick of it.

First lets take a look at the timeline from high school onwards down the path of physician-hood

  1. Complete high school (4 yrs)
  2. Complete bachelor's degree aka undergrad (3-4 years)
  3. Complete medical school (4 years) (complete, HA . . . oh don't we all wish it was that simple) there are some added nuances here of allopathic (MD) vs. osteopathic (DO) as well as foreign grads (including some MBBS) but that is a story for another day
  4. Complete a residency training program (3+)
  5. OPTIONAL: Complete a fellowship training Program (1+)
  6. Become a practicing physician aka be an attending (FOREVA+)
Disclaimer: this is really a barebones look at how this breaks down for some people sometimes.  All of these steps do have to be completed, in this order but not necessarily in one fell swoop straight out of high school.  Many people insert alternate careers between steps 2 and 3, some choose to travel the world, others peace out for a little bit DURING STEP 3 (not to be confused with the USMLE Step 3, but again, another day another story).  Some follow the "traditional" route outlines above while others still opt for guaranteed admissions programs that couple college + medical school into a 7 (sometimes 6) year program. 

The nomenclature that I found the most confusing was that medical school which in my mind is professional school maybe loosely referred to as graduate school is called undergraduate medical education.  I thought to myself, "are they serious? I just finished undergrad, this makes zero sense to me."  This all started to make sense when I began hearing people refer to residency training programs as graduate medical education.  

Moral of the story: in med school you're the bottom of the food chain, again. 

In any case at the completion of medical school although you may have your professional title of Doctor there is still some board exam/licensing examinations and residency training that needs to be completed before you are able to practice independently.  

I hope that this post was able to clarify some of the confusion associated with this process.  Keep an eye out for more posts aimed at simplying and clarifying this journey that often feels shrouded in mystery. 

If you have any specifics or other questions feel free to comment below or e-mail at

Tuesday, July 30, 2013

"You look 18, are you sure you're in medical school?"

My very first rotation is coming to a close.  I can't believe it.  Time for another strike out M1 M2 M3. 

Its hard keeping up with the blog but the truth is I really am meaning too.  There is a list of drafted posted with little tidbits and stories I didn't want to forget.  Between moving and rotations starting its been a rollercoaster.

Thanks for sticking it out.

Sunday, June 23, 2013

Sage Advice

When I was little and people asked me what I wanted to be when I grew up I said "a doctor".

It wasn't until I started medical school that I realized how non-specific of an answer I was actually giving people.  Doctor.  Internist (I didn't even totally understand what that meant until M1 year)? Pediatrician? Surgeon? Pathologist? Orthopod? Psychiatrist? Family doc? Not to mention advanced fellowship training . . . cardiologist? intensive care doc? allergist? neonatologist?

The list is literally endless.

I've always had an inkling about what I thought I wanted to do.  I wanted to be a pediatrician--or so I thought.  It then occurred to me that this was likely because for the first 18 years of my life, literally from birth to adulthood that was the only physician I had ever seen.  Naturally thats what I thought I wanted.

When I started medical school I thought it was imperative to keep an open mind, there are fields of medicine that exist out there that I have yet to even discover as potential careers.  As a medical student prior to clerkship years how can you possibly already know what you want? Granted there may be those few who since birth have known what their one true passion is, what about the rest of us?

I'm itching to start my clinical years and put the pre-clinical years and step 1 behind me and forage ahead into the world of medicine.

I had the opportunity to spend some time shadowing in the NICU (neonatal intensive care unit) and struck up conversation with one of the Neonatology fellows.  One of my favorite questions to ask of people above me in the totem pole is "When you were in my shoes, what was one thing you wish you had known?"  He gave me one of the best single lines of advice I think I have received in all of medical school thus far

"Don't look at the fellows or the residents, we are all exhausted.  Look at the attendings.  Could you see yourself doing what they do for the rest of your life? Do you like them?"

So simple and in some ways so incredibly obvious.  I hadn't really considered things from that perspective, the one that lumps medical students in with residents and fellows.  Really its just a extension of the education spectrum.  They're still in the grind, they've got their eyes on the same prize as us.  Being a real doctor.

Maybe though when I finally reach attending status I'll be able to look back and chuckle and realize its not all that different on the other side.  Until then I've got my eyes peeled.

Thursday, June 13, 2013

May The Odds Be Ever In Your Favor


REWIND: My alarm was blaring, it was 5:30, I needed to get up. I felt around my nightstand for my glasses and grappled to put them on my face. Todays the big day. I trudged my way to the bathroom and took a quick shower--a burst of hot water propelled me further into wakefulness.

As I got dressed my mind was racing. It was racing with all of the last minute things I forgot to look up. I quickly ran to my desk and flipped to the equation section of First Aid. Waves of panic washed over me in a rhythmic beat. Clearance. Loading Dose. Maintenance dose. Renal Plasma Flow. Glomerular filtration rate. Inulin. PAH. As I scribbled those down to look over on the ride to the testing center my mind came to a screeching halt and starting leading me down another corridor of confusion. P450 inducers? What were they? Phenytoin, Rifampin. P450 inhibitors? Grapefruit juice. There are more, where is my mnemonic? I raced to the page where I knew I had scribbled a helpful note in the corner. Glancing over the list a momentary sense of relief, I knew them.

Flipping through the pages of first aid at every turn I felt like I was sinking. Did I remember the material? I don't know. My roommate was somewhere in the background packing a lunch and calmly getting ready. I'm not that person. I can't stay calm in those last moments and hand the reigns over to fate, not just yet. I believe in cramming till the 11th hour. Some people say you know what you know. I whole heartedly disagree. How many times on an exam are you searching for just that one little tidbit? Sometimes I find that little tidbit floating in the ether of my mind because I happened to see it as I unceremoniously shoved my notes into my bag before entering the exam room.

The exam itself was quite a marathon but in all honesty I don't even know where the time went. Not to say that I was completely rushed and racing the clock, but it didn't feel quite as long as I was expecting. It was tiring and long and at certain points I felt downright bored.

I did what I could to prepare, based on what I had seen and heard. Uworld? FA? Goljan? Pathoma? Pharmcards? Microcards? CMMRS? Rapid review path? So many resources and so little time.

The step 1 was like no other exam I have ever taken, I don't even know how many questions I answered with 100% confidence. I hesitate to share my study plan until I receive my score.

I set my goals high at the start of all of this, I walked away from that exam hoping, begging and pleading the universe for a pass.  Walking out of that exam felt very much like the end of the road for some of my hopes and dreams but nobody walks out of that feeling like a million bucks.

Stepping out of my testing center and onto the busy sidewalk I was again struck by the realization that it was only my life that had been on pause for the last month.

I'm really hoping that somehow Effie Trinket's words ring true for me, but until then I'll be holding my breathe. (I apologize for the Hunger Games reference, but I had to, I can't say taking the step 1 is all that different than being thrown into the arena)

For now I'm shifting my focus to gearing up for clerkships.  Ready to hit PLAY again.

Tuesday, May 14, 2013

Into The Wild

Studying for the step 1 has to be the most daunting academic challenge I've ever had to overcome.

I'm finding that the stress of it has as much to do with the grueling hours spent and sheer quantity of material as it does the finality of the whole thing.

If I mess this up then I've essentially ruined any shot at being a successful doctor, a good doctor.  Thats how it feels.

Similar to any standardized test in the past I am confident that at some point in my life I will look back on it and chuckle--vaguely remembering my score +/- 20 points because thats how little it will matter.

That thing is starting to happen where I'm violently oscillating between having too much time and too little all in the matter of hours. (clearly one of the stages of studying for me, for more check out this prior post: Note To (Future) Self

Times like these are a testament to the resilience of the human body and brain or more accurately, plasticity.  A month ago--studying for finals--more than 4 hours of studying felt like too much.  Anything less than 12 hours feels sub-par right now.  Oddly there aren't enough hours in the day for what I've set out to accomplish, everyday I'm surprised by how much I intended to do that remains unchecked on my to do list.

There is something to be said for slipping outside for a few minutes and getting some fresh air and a reminder that the earth is still spinning, people are still living their everyday lives even though it feels like mine has come to a standstill.

Sunday, April 21, 2013

Thank you!

Elated to have been chosen as one of the Top 30 Healthcare Blogs of 2012 over at Top Masters in Healthcare

Also check out this feature over at The Goldberg Files: Frustration in Medical School.

Thanks everyone for the positive feedback and stay tuned for more of my ramblings that delve into the highs and lows of preping for step 1.

Saturday, April 20, 2013

Note To (Future) Self

As a student I often find myself wondering how a professor or an attending could have the expectations that they do for us.  I am particularly perturbed by this because I know for a fact that at one point they were in my very shoes.  How then could they have forgotten how it feels to be on the other side?  I am writing this post in hopes that my future self will stay connected to this, to remind myself as I trek through this journey where it all began:

The test is in 3 days, no big deal.  Study.  Flip through notes. Eat. Where did the day go? Dinner. Yawn. Two more days. Sleep.

Two days.  Geez.  I'm getting a little concerned that I'm going to know too much for this test.  Seriously, 48 hours to cover this material? Thats more than enough. TV break.  Review notes. Sleep

One day. Oh my god.  What happened? I had three days, now theres 24 hours.  If I sleep four hours that gives me 20 hours to review.  Theres about five sections.  Four hours per section.  That doesn't seem like enough.  I start frantically flipping through the pages of the text book realizing five minutes in that I have absorbed nothing.  I'm just flipping.  Where is the day going? Its already 1 pm.  I woke up at 7.  By now I should have finished reviewing half the material.  I start counting: 1 pm, 2 pm, 3 pm . . . . 11 pm, 12 am, 1 am.  Thats twelve hours.

Okay good. 12 hours, that should be enough.

Somehow its 8 pm.  I've managed to eat my way through a bag of candy and 3 cans of soda.  All of a sudden totally irrelevant, menail tasks became high priority.  I absolutely had to reorganize the bathroom drawer.  It was happening before I could stop and I had to finish.  Its okay, I've gone through most of the material.

There is an ebb and flow to the panic and serenity.  A little dance, my heart rate fluctuates between tachycardia and bradycardia.  One second its beating in my ears as I see the minutes of sleep slowly slipping away as the night grows closer and my pile of work remains the same.  Another I feel on top of the world, envisioning a 99%.  High pass for me.  Stress. Relax.

Finally I decide I need some sleep.  I'm not one of those people who can pull an all-nighter.  I need a little shut eye.  I drift off to sleep with a page of notes clutched in my fist.

The clanging of my cell phone awakens me from a non restorative sleep and I bound out of bed as the panic washes over me again.  Two hours.  Theres only two hours left.  Is any of this actually going to stick in my brain now? Should I just stop? No.  I know these little details I can't remember, if I can just come up with a way to remember them.  Some mneomonic: krazy kittens gurgling the night.  There is no way I'm going to remember all of this minutia, there is no way they're going to ask about that.

As I reach the exam room the stress reaches its zenith as I pick up bits and pieces of other peoples conversations.  Every so often I heard a tidbit that I don't know and a fresh wave of panic washes over my body.  Its too late now--I'll just have to guess if that comes up on the test.

"You may begin"

I hate that feeling.  The on where you remember where the answer is.  Its on the bottom right corner of the 3rd page, you highlighted it and scribbled a note next to it.  Thats all you know.

Thats the worst.  When you feel like you should have studied just a little bit more.  If you could have just pushed yourself a little bit harder.  Then you wouldn't be sitting here with an exam in front of you and absolutely having to guess on questions.

Somehow your body goes into exam mode, you just start churning out answers.  The test taking monster inside you takes over.  Process of elimination and educated guesses slowly dilutes down to sheer dumb luck and guessing.

The walk home from the exam is awful.  First you have to escape the group of students bickering about question #68.  How do they even remember? I don't want to know.  I jam my earbuds in my ears and high tail it out of there.

On my walk home I pull out my slightly crumpled study guide and race to the bottom of the 3rd page, where I highlighted and scribbled a note.  IL-10.  Thats what it was.  How could I not remember? There's something wrong with me.

What if somehow I literally answered every question wrong? Statistically pretty unlikely but even at 25% would be awful.  What if I fail? What am I going to do? I thought I studied, I thought I knew the material.

I hope they post grades soon.

3 days later . . . .pass. Phew.  Wasn't so bad was it?

Panic. Fear. Pressure. Self doubt. Confusion. Restlessness. Sheer exhaustion. Those are all a part of this temporary condition but the fact of the matter is to us, at that particular moment they are all too real.

I understand that some of this is a part of the package.  Medical school is a grueling undertaking I juts wish more attendings and professors could take a second to reflect on what it felt like to be where we were--just to ease the pain for us a little bit.

They say "be the change you wish to see".  Someone check in with me in 20 years and see how thats going.

Monday, April 15, 2013

Comic Relief I

Some of my classmates can't resist the urge to already be appending an MD to the end of their names--this is how I feel about it.

Have any burning questions about med school? About classes, life, professors, family, lectures? Anything at all feel free to post a comment or shoot an e-mail at

Thursday, April 11, 2013

Teachable Moments III: Harm Reduction

I happily trotted through the front door of the clinic and planted myself in front of the elevator waiting to go up.  Although many students complained that their preceptors didn't know their names or didn't acknowledge them my experience was completely the opposite.

Dr. Parker was fantastic.  Not only was I clinically useless but mostly incompetent but he never made me feel that way.  He was kind, he was warm and he had this way of being reassuring that not only gave you confidence in him but in yourself, just for under his guidance.

A long time patient of Dr. Parker's, we'll call her Maria, came into the office for the 3rd time to finally be given a clinical diagnosis of hypertension.  Her BP was off the charts (in retrospect probably it wasn't that off the charts because if it was it would have been malignant hypertension--see me dropping that M2 knowledge--and we would have called and ambulance to take her to the hospital).  The obvious answer here was to start her on some pharmacotherapy and then make sure we could assure some compliance to keep her within a healthy range.

Much to my surprised Dr. Parker turned to her and asked what she thought.

Maria responded, "You know doctor, I really don't want to take a pill.  I know its really high.  I see that, but that is just not something that I want to do.  What are my options?"

"Well if we can get you a little bit more active and check in for another BP reading and see if its declined maybe we can hold off on taking a medication," said Dr. Parker.

For the next ten minutes Maria shared that some ladies at work had been walking a few times around the block at lunch time and doing yoga after work two days a week.  Dr. Parker and her decided she would try to get on this regimen with them and if the next time she came in it was still elevated she would choose to take the medication.

In my head I was screaming.  She had high blood pressure! She needed to take medicine to bring that down otherwise . . . and that was when I figured it out.  Otherwise what? She had been walking around  with this pressure for a while another week or two wasn't going to kill her, but giving her the opportunity to make a lifestyle change could alter the course of her life, could save her.

Too many of us, medical students I mean, are the type of people that see a problem, synthesize a solution and implement it in rapid succession.  Slowing that down, breaking the solution down into incremental chunks is a challenge for me.  I had the opportunity to witness a harm reduction principle in motion, before my very eyes.  For those of you who aren't familiar with the term it is essentially the idea that when you're wresting with a very severe outcome from an adverse event, any small decrease in the adverse event is a great.  Allowing free needle exchanges for IV drug users in order to reduce the transmission of HIV and Hepatitis C by infected needles is a direct correlate of this public health principle.

Dr. Parker met her where she was.  She wasn't ready to take a medication but she was ready to discuss adding some physical activity to her life.  If that didn't work or she wasn't happy with that outcome he would be there to guide her down another path.

At the time I left the clinic that day I was still baffled as to why the so obvious solution was not implemented immediately--but after some reflection I realized that making the conscious choice to delay use of that solution exemplified far higher level thinking.