Notable Quotables: MH

"A lot of it is a process of elimination, but when you pick your specialty that better be a process of selection.  Pick something that really just turns your wheel. " 

- M.H. [General Surgeon]

Its dawning on me that I have about a year to figure out exactly what I want to do with the rest of my life. Sometimes people say things to you in passing that really stick with you so keep an eye out for more Notable Quotables, the initials just help to maintain anonymity but still allow me to mentally catalog who it was for future reference.

 Have any of your own from mentors, friends, family or famous folks?

The M3 Merry Go-Round

As an M1 and M2 everyone's ultimate goal is to finally wade their way out of the swamp of basic sciences and into the fairyland of clinical skills.  Now that I'm a majority of the way through my M3 year my understanding of its purpose has most certainly shifted. 

At the most basic level third year clerkships allows medical students a taste of all of the core rotations: Ob/Gyn, Surgery, Family Medicine, Internal Medicine, Psychiatry and Pediatrics.  Different schools have different time periods allotted to each but for the most part each of these lasts between 6 and 12 weeks.

There is a massive amount of variability associated with clerkships experiences based on many things.  The residents and attendings you work with and other members of your team have a tremendous impact on your experiences as does the actual hospital where you are working.  Some medical schools have their students rotate in house (at their own institution) for most of their rotations while others do a combination of in house and alternate sites.  This too significantly impacts a student's experience because the latter set up requires the student to consistently readjust to a new environment quite literally like a different hospital and likely a new electronic medical record and a variety of other infrastructural differences.  This is all layered atop the obvious difficulty in constantly being moved from one rotation to another. 

One of the biggest challenges for M3 years is being flexible and readjusting quickly to an ever changing environment.  The clerkship experience is built to show you a little bit of everything, something of an sampler platter of medicine and thus by the time you become comfortable and mildly adequate in your role you're whisked off to another place where you are once again a deer in the headlights.  

When I started out this year I thought the purpose of these clerkships was to see a wide array of medical practice and see what we liked.  Like walking through a restaurant kitchen and sampling a bit of what each chef is whipping together.  As I make my way through this process my understanding of it is starting to evolve and readjust.  

We aren't going to chose 90% of what we see, that is the nature of it.  We will choose one field of medicine and pursue that thus making a majority of our rotations useless.  But they infect will have taught us something even more valuable which is how to effectively communicate with our colleagues who will each pursue their own speciality choice. 

Communication is moving to the forefront of medicine, being able to communicate effectively with each other is the key to excellent patient care.  In 20 years when I'm an attending and have to call another physician for a patient for one thing or another, I hope I can hone my message in a way I know will make the most sense to that specialist.  This is the only time in my career I will so fluidly be able to move from one speciality to another and after just a few days come to be accepted as part of the team vs. a visitor. 

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. 

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.

(Re)learning How To Talk to People

 (as always any and all names have been altered/deleted to protect the privacy and anonymity of all parties involved)

By now the white coat has become kind of old hat.  I can’t believe I’m saying that because literally one year ago I regarded this addition to my wardrobe the crowning jewel—too often I now find it crumpled in a heap at the bottom of my bag .  Its interesting to me how quickly we readjust and more interestingly how quickly we regain the same level of dissatisfaction we were at before a “significant” life event.  

My whole life I feel like I’ve been counting down till med school and now I’m here and honestly I feel the same.  This is a matter of perspective and the dilemma of being unable to observe your life from the outside looking in really resonates here with me.  I can’t wait to be an attending but for now that seems like a lifetime away which was underscored by my realization of how incomplete my own clinical knowledge bank is and even further how immature my clinical judgment is.

I knocked on the patient’s door and  gently pushed the door open to enter the room with my best attempt at a friendly smile.  The patient was seated the armchair next to his bed in his washed out blue hospital gown and green socks with the grippy lines on the bottom.  He motioned me over and I took a seat perched on the edge of his hospital bed.

“Hi my name is _________ and I am at second year medical student at  ___________, and I was wondering if it would be okay if I ask you some questions about what brought you to the hospital?” I said with a little too much enthusiasm, even I caught myself off guard.

He responded “Sure, go ahead”

“Mr. _______? Is that correct?,” I continued

“Yes”

“And how would you prefer I address you?”

“Pete is fine”

“Okay Pete, thank you for allowing me to do this so lets get started”

For those of you who have been following me through this journey you will know how strongly I feel about asking that question (click here to see an old post regarding the same topic: Don't Call Me Bob).

 

From there I went through the CC (chief complaint) and HPI (history of present illness) and am finding OLDCARTS (onset, location, duration, character, aggravating factors, relieving factors, timing, severity) to be a very useful pneumonic in keeping the HPI in order.  It feels like something that will become more natural as my training progresses but for the time being I need a structure to follow so I don’t miss something.  A post of clarification of terms will be forthcoming.

We discussed the clinical course of Pete’s condition and his situation was not the most ideal for an M2 to be investigating because he had been admitted to the hospital due to some post-surgical complications, but we made it work.  I managed to wade my way through the remainder of the complete history punctuating that with a full ROS (review of systems) rapid fire in a way that probably made it impossible for me to glean any abnormalities even if they were present.  Quickly glancing through my notes I saw that I had collected all of the information I needed to do the complete write up that was required and turned to Pete and thanked him for his spending the time doing this with me.  Before I left I did something that I’m trying to make a habit of doing with all patients I see, I turned to him and said “Pete, if it wasn’t for patients like you none of us would ever learn anything or become better doctors.  Can you tell me what I can do, as a future physician, to make sure my patients know that I care? And can you tell me how I did?”

Although you have to use your judgment based on the patient’s conditions if they would be willing or able to engage in this discussion with you but I have found for the most part they are exceptionally receptive to this.  Shockingly to me I have learned the most about the patient’s medical conditions and personal lives in this follow up conversation.  This is after the “clinical encounter” is done.  It floors me to know that there is this huge untapped potential that is accessible to me that for some reason in my clinical persona suddenly become obfuscated. 

For now I foresee the largest challenge at this juncture of my training, and arguably indefinitely into my future, will be how to temper my personality effectively into my clinical persona.  Retaining a friendly demeanor and having interactions with patients that are based on trust and understanding while keeping site of the clinical goals, necessities and very real time constraints seems like a very difficult and delicate balance.  

Teachable Moments II: Low incidence ≠ Low Importance

One of the most interesting aspects of second year is the team based learning components that are usually led by a physician who is a specialist on the particular topic we are studying (ie dermatopathology is taught by dermatologists).  These sessions are interactive and allow us to exercise some applications of the knowledge we have learned.  I really appreciate the higher percentage of MDs associated with our curriculum now versus first year that is very PhD heavy.  This isn't a criticism but rather an observation but is to be expected with a first year focus on basic science while second year starts to diffuse a serious clinical background into our learning.

While working through a patient case regarding some highly rare disease we all were disgruntled at the professor for having chosen something that was so unlikely.  One classmate raised his hand and voiced this concern: what's the point of talking about something that is so rare.  The professor's response to this is something that really resonated with me he said

"just because a disease is rare does not mean that it is rare for that patient"

It really hit me what those words meant and why we learn all of the minutia that we do.  Someone somewhere has this and if that someone happens to wander into my office I want to have the ability to help--to identify, to diagnose, to treat--with humanity.  Thats what got me, it was a reminder of the humility and humanity that is so quickly drowned out in a sea of lab values and patient findings.

When you step outside the house and its raining your first thought probably isn't welllll the chances of precipitation were only 25% so the fact that i'm 100% sure its currently raining is bothering me less.  To always be cognizant of each and every patient as a person, however cheesy and obvious that sound, is a principle I will strive to uphold in my career.

I have to admit that I never expected to be sitting in a classroom being lectured at and having that shape my clinical perspective, but it has.  Bringing physicians to us in a learning capacity provides us a tremendous asset in bridging the gap between book learning and clinical experiences.  That being said I think the most lasting and impactful lessons I am learning are when someone who has been a doctor for 30 years passes on a pearl like this one.  All day people teach at me how to read an EKG, how to differentiate between crackles and rales or how best to use an ophthalmoscope (left, left, left <-- more on that later) but what I want is someone to remind us how to do this while maintaining poise, grace and ultimately respect for the people who we serve.  I want more professors to remind us that becoming doctors doesn't gives us superhuman status, that it doesn't automatically grant us some kind of authority but instead we are being entrusted with an amazing responsibility.

for even more naive optimism and borderline preachy rhetoric see this old post

Sometimes I Feel Like A Thankless Child

To those of you who are still in the midst of  pursuing a seemingly elusive goal of being in medical school I highly encourage you to take a few moments and jot down why you want it so badly.  Make a quick list of all the reasons why you want to be a doctor and how you will feel once you achieve that monumental goal.  For those of us in the thick of it, in medical school or beyond, try as hard as you possibly can to mentally rewind back to that point.  Remind yourself of the passion and burning desire that brought you to where you are, especially one the days where all you want to do throw in the towel and curl up and sleep.  The following is an anecdote that a woman shared at an informational meeting I decided to check out (a little because I was interested in the group and a whole lot because I wanted some free Thai food) early on in my first year and has haunted me, in the best way possible since.

***

It was a beautifully sunny day as everyone filed into the windowed room and took seats around a large, oblong table and scattered seats along the wall.  Students chit chatted about needing to get back to class and wondering when the main attraction, free thai food, would finally arrive.  Meanwhile quietly in one corner a young woman sat with her hands neatly folded in her lap with a white lab coat.  She didn't make conversation but smiled politely.

The meeting began after everyone was done scooping little heaps of pad thai into their plates and shuffled back to their seats around the table.  Some introductions of board members were made and the general idea of the student organization was described.  At the close of the meeting they asked for any questions or comments and after some expected questions the young woman in the corner raised her hand and said "could I please share a story with the group".

The club president smiled at her and replied "of course"

"I had always wanted to be a doctor, it was just something I never thought was possible for me.  I was married very young.  I spent most of my life in Africa and when I came to the United States I did not think that even going to medical school was an option for me.  I was always one of the brightest girls in my class and I even went to college but it all seemed so far away. By that time I was already a mother of two young children that made a very busy schedule for me.  Somehow I managed to secure admission into a program that allowed me to do some coursework and upon successful completion they would allow me to go to medical school.  I could not believe my eyes or ears and I worked hard, so hard to make sure I could do it.  My grades were all very good.  But then I started to notice that my youngest son was not speaking as he should be, he was not developing at a proper pace. The doctors said that he had autism.  He would need speech therapy and physical therapy.  Hours of individual attention was needed and my husband he worked.  He told he he could not do anything we needed the money, he had to go to work.  I was left with no choice and I had the acceptance letter in my hand and I declined my admission to medical school.  After all of that work, someone had to take care of my son.  I had to care for my child and I had to give up my dream for it.  I wish my husband had supported me more, so I could achieve my dream.  Even today when I walk on the sidewalk and I am walking in one direction and one of you, a medical student, is walking the opposite direction and passes by me in a white coat.  I stop and I turn around and I look at you walking away, I see my dream that I had walking away from me.  I am so happy for each of you and I am so sad for myself, that I did not find a way to make my dream"

The entire room sat in silence.

***

Sitting in that room with nothing on my mind besides needing to get back to class at the end of the lunch hour this woman's story really touched me.  I could feel tears welling up in my eyes.  This story just serves as a stark reminder that this is an opportunity that we were lucky to have been given.  It sucks sometimes.  Its really hard.  It makes you want to punch the wall.  But no matter why you did it, there was something that drove you.  If you can keep a piece of that with you, remember back to the time you would have traded anything to be where you are today, everything gets a whole lot easier.

Money, Money, Money, Money . . . MONEEYYY!

note: the title of this post was to belted out a la the apprentice theme song (if you need a little refresher click here)


There is no sense in denying the fact that one factor that often pulls people towards a career in medicine is the financial compensation.  For some reason it feels like a taboo topic, to admit out loud that the of course you have  passion for helping people and a strong desire to serve and it doesn't hurt that you're going to be making a fairly comfortable living.  Nobody gets upset at lawyers for being money grubbers (but then again, aren't we all just looking for an excuse to hate them) or accountants (although being such a personality less number-cruncher should have some kind of upside) for pursuing opportunities that pay the highest.  Its a very strange phenomenon that I think we somehow hold ourselves to a higher standard as well, when I consider my future I feel bad weighing the options because of how much pull salaries can have.

All that being said the more important point I wanted to bring up was that if you intention is to become very rich, very fast I implore you to explore other career options.  Although the compensation is likely in the 6 figure range even for those pursuing primary care positions the fact remains that compared to other career paths this one pays out far too slowly to be a viable option for those looking for quick monetary gains.  Let me explain a little bit of why I find this to be the case with a look at some numbers as well as some anecdotal experience.  Once again I have to emphasize this is how I have come to see the world, at the end of the day its my opinion and please take it as just that.

So lets look at a timeline of education and earning.  According to the AAMC the average age of matriculation to medical school for women is 24 and for men is 25 so lets put that at 24.5 years old (source).  Medical school across the board is always going to be four years and theses years have to be billed as negative income especially because as of this year all loan money is UNsubsidized which means every cent that you borrow will collect interest from the day you start to borrow it, this is a serious bummer for graduate students (source).  In any case if you bill each year at about 40,000 a year (this figure is debatable but just for argument's sake I picked a round number that comes close for many people) x four years according to the AMA the average medical student graduates with $157,944 because lets not forget the interest that will be accruing at about 7% which will be compounded at the end and you will be charged interest on the interest once you graduate (source).  So you finish medical school at 28.5 and finally start making money and residency is anywhere between 3 - 5 years during which according to the AAMC you will make an average of $48,4600 (increasing incrementally each year) (source)  So at this point you're between 31 - 33 and are about to plunge back in for some more training i.e. fellowship or you're out into the real work making some real monies.

If for example you decided to become an accountant at about 23 and start making $50,000 a year and lets say a very modest 3% raise per year, in the ten years your buddy was in medical school you've made about $570,000 assuming no bonuses or proper pay increases.

My point here was not to frighten you away from you dream of being a physician but rather to deter those who pursue this career path for reasons based in financial success.  Yes you are rewarded handsomely  eventually, but the road there is a long, long one.  If you don't do this because you absolutely love it you will without question be miserable.  Once you become a doctor paying back these loans is a matter of budgeting and financial savvy, nbd.  But the path there can be absolutely miserable.  I try to bring this back whenever I can but the best way to make it through medical school is to understand as a student (which you arguably will be for at least 7 years and longer when fellowship is considered, and don't even get me started on those MD/PhDs but most of them don't pay very much so thats a different story) your life doesn't end.

Medical education and training is a journey meant to run parallel to your life story, not completely take it over.  With that attitude you will be able to enjoy all of what your life experiences bring you instead of constantly looking to the end and making promises of what your life will be when you are finally a doctor.  I think what i'm trying to say is carpe diem (I refuse to say YOLO although it seems pretty appropriate here).

Oh yeah, with the average internist being offered $205,000 without bonuses and incentives x however may years you work for the rest of your life, I think at some point you will be able to recoup any and all  losses you have incurred.  Maybe you can even take your accountant friend out for lunch.

Teachable Moments I

**please note: names have been changed for reasons of privacy**

Finally, no more shadowing and awkwardly stumbling around while my overly dressed up self scrambled to follow a doctor from room to room, nope because I’m a medical student.  It was time for me to get assigned to my preceptor for the year!  If you’re as confused as I was about what that is let me explain: physician shadowing, except this time you get to wear a white coat and a stethoscope.

 As first year students we come equipped with a severe lack of any clinical knowledge juxtaposed with a strong desire to act cool in clinic.

 A memory I know that I will reference for a long time in the future, as a yardstick for measuring how I have connected with a patient and family is from a day that I spent in the hospital with my preceptor rounding on patients on the Family Medicine service.  The day was essentially over and he decided to go check up on a few patients before heading out for the day.  One of the last patients we saw was an older African American man who was recovering from a brain surgery after a severe stroke.  The following is my recollection of that encounter:

“Hi, I’m Michael Parker, I’m one of the physicians taking care of your loved one today”.  Can we stop right there? Have you ever heard a doctor introduce themselves as not doctor? I feel like by the time we complete all of our training we wear our title of doctor not as a badge of honor but rather a triumph.  Maybe it was unintentional, maybe not, but in knocking on the door and simply stating his own name he put himself at the level of the patient and his family.  It made him immediately accessible.  There were two women and one man visiting the patient and he was wavering in and out of consciousness.  He was not able to interact at all, at that point the doctor would probably not have much to do, right?

Dr. Parker took the time to introduce who I was to the family and ask if it would be okay if I stepped into the room, they were more than happy to allow that.  He then inquired about how the patient was recovering from surgery and the family related that they were unsure how he was doing because of the unstability of his consciousness.  

Here it comes, teaching moment for life.  Dr. Parke proceeded to relate to me how difficult it can be for a family when they are going through a recovery process from such a major surgery especially when the course of recovery can be so varied.  He addressed me but also engaged the family in the conversation and they could be heard expressing hushed agreements—“mmhmmm” and “that’s right”—and nodding along as Dr. Parker conversed with me.  He then turned back to the family who had been listening to him with rapt attention and asked them again if they had any other questions.  The woman sitting at the patient’s bedside echoed some of the sentiments that Dr. Parker had shared with me while the other family members nodded in agreement.

It was amazing for me to see how in such a creative way he was able to express the uncertainty of the situation for their loved one without robbing them of hope or giving a promise of too much.  By the time we were ready to leave the room the patient’s visitors were wishing me the best of luck in my career and relating that they had a niece who had similar aspirations.  Before we left Dr. Parker thanked the family for allowing us to speak with them and noted that someone would check in with them again shortly. 

The lesson I’ve learned from Dr. Parker is that we will have an urgent responsibility as physicians not only to treat patients but also to effectively interact with the environment around them. In that conversation there was nothing Dr. Parker did directly for the patient, but he reinforced the support system that will be vital to this patient’s recovery, something that is integral albeit indirectly to the patients health.  In that moment he transcended race, gender, age, ethnicity and socioeconomic status.

It is of great surprise to me to know that no matter how much we prepare and study it will only be with time and an active desire to improve that we will come close to delivering optimal care to our patients, I think I now have a greater understanding of why we practice medicine. 

Life Lessons on Public Transit

As future or current medical students something that we all likely envision is ourselves in our white coats.  Although I touched on this earlier there is a definite sense of accomplishment and pride that is associated with this simple garment.

I remember getting my white coat and gently running my fingers along the slightly raised letters that spelled out my name.  Its seriously awesome.  But a giant lesson I learned is that wearing a white coat is an exclusive privilege of a clinical setting.  No matter how cool you think you look wearing your white coat down the street and/or the bus or train, you aren't.

Nothing crystalizes some facts of life like seeing some reflection of yourself in another person and what follows are two stories that have helped shaped my understanding of white coating.

*     *     *

The rickety back and forth motion of the train made it hard not to look up occasionally and make sure the train was still on a track and nobody else was panicking.  The doors slid shut and out of the corner of my eye I caught a flash of white and looked up to see a full on white coat.  Additionally the student doctor was also from my own institution as evidenced by the patch on her coat.  In my head I rolled my eyes, really nobody wants to see that.  Nobody is sitting there thinking 'oh wow, she's a doctor' they're all wondering why the F you wore your work clothes onto the train.  It would be like if a chef walked onto the bus with his giant chef had still on, makes zero sense.  I went back to reading my book and at the next stop approached glanced up again and there wasn't a white coat to be found.  Initially there was confusion, but standing in the exact spot was just another urbanite getting from point A to point B.  As soon as she had hopped on the train she had removed the coat and stashed it away probably because she had to rush to catch the train and didn't have a chance to remove it before.  For some reason I just really appreciated that she had done that, maybe its just me but that really resonated with me.

*     *     *

Its rush hour, the bus is packed and at least twelve more people just got on.  I'm putting that out there because I was already on the edge of my seat (both literally and figuratively) so my toleration for irritation was far lower than usual.  In the hustle and bustle of all of this one guy sticks out, like a sore thumb.  Who would that be? The obnoxious medical student that is dressed in plain clothes and his white coat.  The best part is that the only people who ever do this are medical students and weirdo lab techs (I also have no idea why they do that either).  I'm still not sure if this is also slightly a part of my imagination or not but I felt like white coat guy was looking around with a stupid sneer on his face to see if people were looking at him and his white coat.  Whether or not he was I contend that wearing a white coat in public, in non-clinical or non-clinic related settings is attention seeking behavior.  You're essentially trying to make a spectacle of yourself.

*    *    *

Don't get me wrong here, if you want to be that guy, then go ahead.  By all means, wear your white coat down the street and all the way home in your heading thinking you look like BAMF when in reality everyone is whispering about how you look like a total a**hole OR not even noticing you.

Maybe some of you disagree but the verdict is: no white coats in public

I love the smell of formaldehyde in the morning . . .

Anatomy Lab.  The quintessential medical school class, right? I swear whenever I imagined what medical school was like the only thing I envisioned was anatomy lecture and being in cadaver lab.  I pictured myself meticulously taking notes, color coding them, filling pages and pages with drawings, diagrams and splashes of color.  My imagination took me through a journey in which an atlas served as my exact guide and I could go vessel by vessel, nerve by nerve along its course, at the end being satisfied by the specimen that I had so exactingly dissected.  I couldn’t wait to feel like a real medical student.

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9 months later: I absolutely have come to hate some aspects of anatomy.  I hate the endless hours (I’m not exaggerating) you spend pouring over a body cleaning out fascia.  I spent a year in anatomy lab and I still don’t think I know what the hell superficial fascia is.  You know what is the worst? When you spent 2 hours carefully scraping something clean then the professor comes over and rips through it like an old cobweb.  Then you want to cry.  You know what is even worse? When it’s your turn to teach your group and you have no effing idea what is going on because your cadaver refuses to cooperate.  By the time exam time rolls around the things you dissected at the beginning have started to look more like decaying old wood than any semblance of a body.  “Oh hey look, this is the cephalic vein! Oh sorry, IT’S A FRAGMENT OF MUSCLE, NBD”

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Rewind 8 months and 29 days (ie first day of lab). I walked into the anatomy lab locker room and was overwhelmed by the most bizarre smell I had ever encountered but shrugged it off and changed into my scrubs.  To this day I am still a little confused as to why we insist on wearing scrubs to lab, there is no rule that you can’t just wear an old pair of jammie jamz (pajamas) or some comfy sweat pants and t-shirt you never want to wear again.  For some reason I think we lump this all into our requisite wardrobial rite of passage which includes but is not limited to: scrubs, white coat, those funny shower caps for your shoes, respirators (face masks) and stethoscopes (I have no business owning one but you better believe it was one of the first things I bought. LITTMAN BABY!).  In any case I changed and feeling very important slid by ID card through the scanner outside the lab and let myself in feeling like a BAMF.

So my group and I congregate around our table and slowly lurched open the large metal hinged doors that cover the body and latched them as they swung under the table.  We hesitatingly unzipped the bag and uncovered our cadaver.  This was happening simultaneously all over the room and you know what I found to be the most shocking thing? Not the dead body in front of me or the numerous other strewn about the room but the fact that not a single one of us flinched.  This is one occasion (of a handful) when you come to realize that people who go to medical school aren’t normal. There is some kind of morbid curiosity that drives us.  But a random sample of 100 people in the same situation I can guarantee 70 – 80% of them are going to have some kind of adverse reaction ranging from mild to moderate to severe.  Med students are basically freaks of nature.

You BFF in anatomy lab

Something that you will come to have a love-hate relationship with over the course of your first year will likely be Grant’s Dissector (sometimes called Tank”s).  Essentially the only anatomy lab manual you ever need.  So here we all are standing around with our copy of Grant’s and they tell us to take out our dissection kits and start. 

That was it.

And with that I began my first year of anatomy.  Here’s a scalpel, here’s a lab manual, here’s a cadaver. GO!

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For all the complaining and late nights and stress and a perpetually impending sense of doom associated with it in retrospect I wish I could do anatomy all over again. Why after all the b****ing? Because anatomy really is everything I dreamed it was, but it wasn’t the romanticized notion I pictured.  It wasn’t easy.  It was frustrating.  Every artery and vein and nerve didn’t always magically appear when I looked for it, sometimes they downright didn’t exist.  Sometimes instead of an abdominal aortic bifurcation you find a giant aortic aneurysm, but that’s life, right? 

I can’t believe I took for granted that incredible gift that those donor’s gave to us.  As medical students we are given an opportunity to look where very few people do, inside ourselves.  Every single cadaver that you will dissect or see or study from was at some point someone’s someone.  A mom, a dad, a brother, a sister, a grandmother, an aunt, a friend, a neighbor.  The only piece of advice I would want to pass on is to encourage some time for self reflection and I guess this doesn’t apply only to medical students but especially so because we are afforded such a tremendous opportunity and sometimes we get so caught up in what we’re doing we forget that we’re in the middle of something so much bigger than ourselves.

Don’t get me wrong though, sometimes anatomy will make you want to punch yourself in the face (then your nociceptors and c-fibers will go bananas ;) )

Don't Call Me Bob

First history taking workshop ever.

I smoothed the creases from my clothes, made sure the hem of my pants wasn't tucked into my socks and straightened my shirt out.  Carefully taking it off the hanger and sliding it on, the pièce de résistance, my white coat.  I stood there feeling a little bit in awe of myself.  I had waited so long, it felt like my entire life for this moment to finally put on that coat in a serious capacity.  

It was the first clinical skills workshop of the year.  This was the first time I would put to use the tedious amount of instruction we had received in clinical skills plenary sessions about how to interact with a patient, what to ask, how to ask it, when to ask, how to diagnose, how to rule out one disease versus another.  I was pumped.  It was gonna be my first day of doctoring.

What I encountered could not have been further from what I had imagined.  We were all herded into a room where we proceeded to split into groups and each group was to interview two mock patients.  So here we are sitting in a large multi-purpose room in the college sitting around a "mock" patient (these were people who did suffer from the medical conditions they were describing to us but had been nice enough to subject themselves to the utter clueless-ness of M1s) who we were supposed to interview as if in a clinic setting.  There were six of us so we went around the circle (like it was a second grade sharing time) and each asked questions until we had exhausted our totally inadequate list of what information we needed to elicit from the patient. 

I went home from that experience feeling so much less like a doctor than I wanted, essentially nothing like a doctor.  That was when I realized how many eons away I was, we all were, from even being comfortable enough with ourselves in a conversation with a patient to be of any use clinically. 

One thing that struck me from that day, that I will never forget is something one of our patients shared with us.  He was an older gentleman who shared with us that for years and years he had harbored some slight resentment for his primary care physician because the young chipper doc had affectionately called him "Bob" from the very first visit.  The doctor didn't realize what a colossal misstep it had been not to ask the patient what he preferred to be called, although the patient had approached the situation with a 'grin and bear it' attitude and eventually came to like the physician there always remained that initial feeling of discontent.

It seems like such a small thing, just tell him not to call you Bob, but it isn't.  As physicians we often are in situations where the power is shifted tremendously on our side and away from the patient.  For that reason I believe it is of utmost importance to cultivate a relationship that gives the patient a loud enough voice even if the only thing they want to say is "Please, call me Robert"

A little introduction

First things first, right? Who the hell am I? Why am I writing a blog? I hope in this first post to address some questions and then delve into the nitty gritties of M1 (<-- if you don't know what that means then probably the rest of this blog will be uninteresting to you either that or you call it MS1 and now I'm judging you.

Who am I? I have just kicked off what I have been told by many is the last summer of my entire life because my first year of medical school has just ended, so to answer your question: medical student (and for the uppity follow up lurking in some of your minds: I attend an allopathic medical school in the United States in a large Urban city)

What is this blog about? This blog will help document what I have experienced in the last year which was my first year of medical school as well as into the future as I progress through the remainder of my medical education.  Although I in the future I hope to mix in some posts that are in real time as things occur--for the first year I jotted some journal entries down and hope that using the added benefit of hindsight will be able to present a more complete picture of what this year was.  That being said this is in no way meant to lump all medical school experiences into one, this is my own personal journey and I hope to share the things that I learned, my successes and failures, random thoughts I had etc.  

Why am I doing this? I wanted to consolidate all my thoughts about this year into a format I could refer back to, I want to be able to reflect back on my naivety as I progress through this and hopefully have a way of keeping myself connected to the youthful energy and passion that I brought with me in this process. 

What does the title of this blog mean? I wanted to have a title that encapsulated exactly how I felt about the academic path I have chosen.  Much like the literary character Godot and MD seems like such a highly elusive and esoteric concept to me.  Most of my life I thought that once I entered medical school I would feel different, that I would feel like a future doctor and right now I don't and thus I am waiting for MD both figuratively and literally. 

I want to thank you for sharing your time with me and I encourage each one of you to share your own stories, pointers, tips, questions and experiences as well.

Happy Reading