Tidying Up

I think a little blog dusting/reorganizing was in order.  New updated title, reshuffled the layout and added some gadgets. 

Thanks for reading.

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. 

Surgery: 4 AM Wake Up Calls, The List and other Assorted Drudgery Pt. I

Im sorry. I really want to keep up with this blog, I have so many things I want to say but sometimes it just falls off my list of things to do.

The past few months I have been dealing with some significant family health concerns coupled with my surgery rotation I've had little to no time for anything extra.

But the show must go on! Just as with everything else on this blog these are my personal thoughts and opinions--not meant to offend but merely to inform and present one naive young person's perspective.

***

Surgery.  Those of you who are not in medical school probably don't know but the moment this rotation comes up in conversation it strikes fear into the heard of 98% of us.  There is that bizarre little group of people who are giddy with excitement and actually electively choose to spend the rest of their lives doing this.

To be honest before I started this rotation I thought it was what I wanted.  I love working with my hands.  I've always been a tinkerer and I thought surgery would be the perfect way to merge my personal passion and strengths with my career.

I was wrong.  Lets first discuss how awful the hours are.  For the last 8 weeks I've been waking up at 4 am everyday, barring the one day a week we get off.  I arrived at the hospital between 4:45 and 5 and am expected to see my patients and have my notes completed before 6 when the team will round with the senior resident.

That wouldn't be all that horrible except for another menial task that is assigned to students: The List. What is the list you may be asking yourselves?  Let me tell you.  It is a print out of the list of patients the team is responsible for that day it includes the name and age of the patient in a grid like format.  You would think with the electronic medical records (EMR) that we use (the hospital I was at had the cadillac of EMRs, EPIC) there would be the option to say right click all the things you wanted for the patients and have them come out in list format. WRONG.  Every morning myself and the other two students on our team would by hand have to fill in for every patient in the 1 cm row like space the following information: reason for admission, overnight events, vitals [temperature, heart rate, respiratory rate, blood pressure], total intake, total output, urine output by shift, medications, diet status ([NPO (if they can't eat anything], clear liquid diet, full liquid diet, pureed diet, heart healthy, general, etc).  That is completely absurd.  It would take between 30 and 40 minutes every morning to make this list and to be honestly most of the time nobody even used it.

After pre-rounds with the residents were completed we were expected to split up the surgeries on the board for that day and scrub into those and keep an eye out for when attending rounds would happen.  Thats another disaster.  As students nobody really ever remembers us and attending rounds occurred on a pretty haphazard basis so we had to rely on our interns to let us know when and where they were happening.  This led to one too many occasions where we would run into one of our team members somewhere only to have them let us know that rounds had just finished.

Frustratingly enough there was a second list we were asked to make during the day too.  Sometime between pre rounds finishing at 7 am and attending rounds occurring whenever the attending decided to show up we were expected to record the labs values for every patient.  This entailed printing out another blank list and filling it with hemoglobin, hematocrit, platelets, WBC, sodium, potassium, Cl, bicarb, BUN, creatinine, glucose, calcium, phosphorous, magnesium and any other assorted values that were recorded such as PTT, PT, INR, CEA, etc.  The worst is when we would scramble to finish the labs only to find out we missed rounds.

Although there was a lot of busy work involved with it being in the OR was quite a unique experience. The excitement of holding the camera during laproscopic procedures did start to wear off but I can definitely appreciate the fact that surgical interventions are kind of mind boggling.  More on the woes of scrubbing in and accidentally touching your face and other comedic moments during my surgical clerkship.

Rub a Dub Dub

SOAP NOTES.

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.

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.

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. 

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 WaitingForMD15@gmail.com