Good and Not-So-Good Role Models

We all come across two types of people in life – those we wish to emulate, and those who, for whatever reason, we don’t. This notion applies equally to the clinical training environment. I’ve seen my superiors (namely residents and attendings) exhibit an incredible amount of medical/technical knowledge while maintaining an air of humility about their accomplishments.

Unfortunately, some prefer treating their colleagues, coworkers, and even patients in a manner which, to be politically correct, I internally question. As a student, it’s important to see both sides, differentiate good from bad, and align myself with those who promote traits I deem to be advantageous to my career.

Find Yourself In Each Rotation

I can’t even begin to count how many times my classmates and I have griped about our schedules, teams, and even patients. Someone who wants to do primary care will find surgeons obnoxious. Someone who wants to do surgery will find internal medicine too slow. The list of stereotypes and frustration goes on infinitely.

Early on, I adopted a different outlook regarding unfavorable situations – suck it up, be grateful, and find something about the rotation that you do like and can relate to; let that be the beacon upon which you judge the rotation.

Coming to med school, I had no intention of pursuing internal medicine or psychiatry, but both rotations have shown me just how much I enjoy interacting with patients. Driving in each morning, I look forward to what new personality disorder I might come across, how I’ll manage the next patient with withdrawal, how my long-term-care patients are doing and what new life stories in the military I’ll learn about. Maybe it’s fulfilling my “need to be needed”, but I’ve found a great deal of pleasure in actually interacting with patients, regardless of whatever the hours are or clinical tasks may be.

Scut Work

The term “scut work” is routinely thrown around by med students and junior residents to denote unrewarding, tedious, and often times trivial tasks assigned by our superiors. However, this is a very subjective term indeed and an individual’s interpretation of what actually constitutes scut work is directly related to team dynamics.

In general, an efficient team is a happy team… and a team which usually goes home earlier. If you’re the lowest on the totem pole (read: “medical student”) and there’s no learning opportunity at the present moment nor anything that needs to be followed up on patients, you should do whatever you can to facilitate the needs of your team. Make that run to McDonald’s for the team, get those prescriptions from across the hospital, carry those blood samples to the lab to facilitate processing, or if it’s a reasonable hour and your duties are otherwise done, ask if you can be dismissed.

The team and patients always come first – “scut work” is what you make of it.

Your Best Is Not Good Enough

I think I’m prepared for the procedure. I’ve done all the practice questions for the exam. Yet when the moment comes for me to shine, the attending/resident/shelf exam asks the one question I don’t know. I can identify all the surrounding anatomy except what the surgeon is pointing at. I know virtually everything about biliary disease except what the question is asking. Compound this sentiment multiple times through every rotation, and you’ve got a highly motivated student who has little to show for it.

With my USMLE Step 1 scheduled for March 15th, I’ve got less than 80 days to essentially make or break my career. I have to focus on my Family Medicine rotation in January, but after that, I’ll be studying more efficiently and intensely than ever. I’m motivated. I have a vision. There are no more excuses.

And I will succeed.

Thanks to everyone for their thoughtful comments, emails, and Twitter messages over the last year. I hope 2012 will provide me with more opportunities to share my experiences!

My emphatic response followed without hesitation – “no way!” I’ve written about this several times through the months, but the further I get into medical school, the more appreciative I am for this opportunity to help people in a way that very few can.

When I think about it, I’ve lost touch with a lot of my classmates and friends outside of med school. Fortunately, this void has been quickly filled by anticipation for the patient encounters I’ll have on the wards. What new conditions will I see? What life stories will these people share with me? How can I become a better student-doctor today? Learn a new fact. Nail that diagnosis. Be a better teammate. All things considered, the day-to-day responsibilities can burn people out, but it’s all about finding what inspires you, being grateful for having a medical school spot when countless others could not, and framing your day in the context of your future career.

I’m now sitting on my bed reading over the surgery section of Boards & Wards for my shelf exam in three weeks. I feel utterly unprepared. I know this is going to be a long week. Yet there’s that part of me that knows by tomorrow afternoon when I’m in clinic with the wonderful residents and my amazing teammates, I’ll forget about all these pressures (for better or worse) and make more precious connections with my patients.

Oh my gosh, the hours are so long. My attending yelled at me! I have to work a full 12 hour shift! And God forbid, back-to-back 12 hour shifts… including a weekend day?! Why am I here?

I’m getting pretty tired of how melodramatic some medical students can be about our responsibilities. Try to consider what residents go through! And what the doctors who trained “back in the day” of scant hour limitations went through. Many of us have 100+ hour weeks to look forward to later in our training… how many med students can genuinely say they have already experienced that?

If there’s one thing working hand-in-hand with residents has taught me, it’s that our schedules are nothing compared to what we have in store for us in the future. When we have actual liability for patient’s lives. When there are very few people left above us to catch our mistakes. When the only thing which dictates when we can leave the hospital is our patient load.

For now, our lives are easy in comparison! Sure, upcoming exams may create a sense of heightened stress, but in the day-to-day scheme of things, we are privileged individuals who have been given this opportunity to do things few others can claim with very little liability. Our patients confide their private lives in us. We are taught by some of the most brilliant individuals in their respective fields. We get to completely dissect another human being. And sure, we pay tuition for it, but these opportunities really are priceless. At this point, we’re supposed to be sponges – ask the questions, make the mistakes, and learn everything about anything we can.

So please, before whining about how “tough” the life of a medical student is. Or trying to garner respect from your non-med friends. Or acting like you’re doing this because you have to. Remember that a.) there are countless others who would humbly take your position and b.) it’s only going to get worse from here. Suck it up, work the extra hours while you still have someone supervising/critiquing your work, and embrace this relatively cozy training process.

You only get out what you put in… and I intend to learn with my $6 malpractice insurance for as long as I can.

I’d like to be very straightforward – most med students who utilize social media are amenable to suggestions and thankful whenever our colleagues, professors, mentors, or even the general public questions our postings. As a group of aspiring physicians, we share the same intention – to educate others while in turn educating ourselves – but we find ourselves challenging accords of professionalism from time to time.

“A 47 y/o Caucasian male with MRN # 123-456-789 presents with the only documented case of Condition X known to mankind” is obviously going overboard and a prototypic HIPAA violation.

But what if I write about seeing a patient with hypertension in clinic today? Given how prevalent hypertension is, would that constitute “identifiable information?” If hypertension were replaced with something less common ( take priapism, for example), am I more likely to offend someone? Where do we draw the line?

Extremely conservative individuals would argue that students shouldn’t write anything on public domains. Facebook, Twitter, personal blogs, and the like should be terminated at the risk of sacrificing one’s professionalism or image. My view is precisely the opposite. By stifling our adoption of social media into medicine, we’re inevitably working against the grain of where society is heading.

Over the last decade, social media has become a cornerstone for business, advertising, communication and it continues to permeate other fields. We need to embrace social media and utilize it to exercise our creativity, but at the same time, it’s important that we are each other’s whistle-blowers. If you’re a physician. Or a dental student. Or a nurse, PA, or tech. Even if you’re outside of healthcare – it doesn’t hurt to contact the writer (myself included) directly, voice your concern, and help mold our virtues of professionalism.

It’s remarkable how often as a healthcare professional, “one mistake” is all it takes – a slip of the hand in the operating room, an improperly dosed medication, and in this case, a single blog post or Tweet which can be inappropriately extrapolated to represent one’s entire career. I say we continue using social media as a learning opportunity to impart our knowledge and enthusiasm in a way that is both professional and efficacious, but it can only be done with appropriate guidance along the way.

Patients motivate me.

Coming into med school with a naïve pre-med mentality, I sought guidance: professors and other mentors who could get me on the right track, friends who would support me and maintain my sanity, and most importantly, sources of inspiration which would keep me motivated. Once clinics started in January, patients filled this void I had during the basic sciences, and I’m continually drawn to the idea of helping a complete stranger in a way that no one else can… fulfilling my “need to be needed”, if you will.

It doesn’t matter if you consider medicine a right or privilege, a lucrative business or a selfless service, refined or corrupt — when I’m at that patient’s bedside armed with medical knowledge, resources, and the sanctity of the doctor-patient relationship, everything else becomes irrelevant. I find myself frozen in time listening… synthesizing… formulating a diagnosis… thinking of how to best help the patient. People are always talking about the delayed gratification physicians in training must learn to accept, but these daily patient encounters are in themselves very rewarding. Extrapolate that over the career of a physician, and that’s a lot of joy.

Many times on my commute to the Texas Medical Center, I wonder what interesting disease presentations and life stories I’ll encounter on the wards that day. I’ll also make up weird scenarios to keep my differential wide, constantly challenging myself to draw connections between disease processes whenever possible. As a medical student, my job is to soak up whatever clinical information I can and explore the career paths which most interest me. In the process, I’ve learned that putting a patient’s face to a condition makes it timeless. Flipping through textbook pages becomes routine and cumbersome, but actually seeing a case of, for example, Stevens-Johnson syndrome… and seeing how it affects the patient, his/her family, how to work-up the case and treat it… *sighs*, this is how medicine was meant to be taught – making patients the cornerstone of education.

“Continuity of care” is a phrase routinely thrown around in fields like family medicine. It refers to the ongoing relationship between a patient and physician towards improved medical care. Before med school, imagined myself as a surgeon who would operate on patients once, and then… well, that’s it. Maybe a follow-up but nothing beyond that. Now I foresee myself as an otolaryngologist who follows his patient’s chronic sinusitis for years, or a neurosurgeon who removes a child’s posterior fossa tumor and sees her blossom into a successful young adult decades later. Maybe it’s the future parent in me, but I feel the most rewarding thing I’ll see as a physician is not the successful operation, but the patient achieving his or her full potential because of the operation giving them a second chance at a healthy life.

During my Internal Medicine and Psychiatry rotations, I encountered an incredibly vast array of patients, but there’s one thing all of them had in common – they each taught me something. Something about the military… about being a grandparent… about what it’s like to be homeless… about being abused… what life was like as a physician… and so forth. They shared secrets, joked about their spouses, and praised me for taking time to explain disease processes, describe how certain medications work, and just talk to them as a fellow human being. I indescribably loved the privilege of their interaction and trust in me as a student doctor.

…and this was just six months of clinics. I wonder what I’ll see in the coming decades as I finish med school, go onwards to residency, and ultimately start practicing. My MS3 year will be the most challenging year of my life to date (lots of rotations and Step I), but I’m looking to remain motivated by putting patients at the forefront.

Thanks to everyone for their kind e-mails, comments, and words of encouragement throughout the past year!

This isn’t to downplay any of the other rotations. Psychiatry has their own history-taking. Pediatrics requires a keen knowledge of developmental milestones. Surgery has a unique skill set, etc. It’s just that IM gives you such a great overview of medicine as a whole that you’re forced to address all aspects of a patient from here on out. For example, if a patient comes in with a three-vessel occlusion and is deemed a candidate for a coronary artery bypass graft (CABG) procedure, how will this affect his diabetes? What kind of measures will be taken for rehab? What nutrition guidelines should he follow? How does his end stage renal disease complicate the post-op recovery? What medications should he be taking for prophylaxis against infections? I’m sure these issues are addressed very well by surgeons and the like, but it’s nice to see the process unfold first hand on IM.

With a week left on the GI consult service at St. Luke’s, I’m preparing to be thrown back into the “primary team member” role at the VA hospital next month. I’ve also been very productive over the weekend trying to get as much studying in before spending all of March doing practice questions for the shelf exam on the 25th. All in all, I’m looking forward to finishing this week strong and ultimately applying my “comprehensive internist approach to cases” (hah) to all my patients in the future.

While learning Latin roots may help one better comprehend certain words in classical logic, human anatomy, and the English language, its utility in medicine (especially in the Texas Medical Center) comes no where close to Spanish.

With the booming Hispanic population, it’s so much more rewarding to know what a Spanish-speaking patient is saying without having to use a translator. At the same time, as a patient, I’m sure it’s comforting to know that one’s history is being given directly to the physician rather than through a mediator.

Many years have passed since I last took a Spanish course, but I remember enough to be conversational and am getting more attuned to using the language in everyday history taking. Most of my patients have been surprised and very appreciative for my attempts at using Spanish to communicate. A lot of the time, hand gestures will bail me out too.

So in short, if you’re looking to take on a new language to help with your future medical career, aprenda español! (learn Spanish!)

I learned how to learn.

Endocrine notes

The astronomical rate at which we’re advancing our knowledge of human biology forces physicians to be life long learners.

Over the last 18 months, I’ve tried a wide variety of studying techniques hoping that at least one would “stick.” Flashcards for pharmacology. Reading the textbook for immunology. Reading the syllabi for other courses. Studying strictly the PowerPoints during block 1. Rewriting PowerPoints onto as few sheets of paper as possible for courses like endocrinology and neurology. I’ve studied at school, at coffee shops, at my desk at home, at the gym, while playing Counter-Strike Source, on my bed, in the lecture hall all night before an exam, in the bathroom (…like I’m the only one who does that ) and realized one truth – for me, nothing beats just sitting down and reading the PowerPoint lectures. Rewriting notes and making flashcards take up time I could use for simply reading the material. Being away from home makes me want to talk to friends. My productivity and retention quickly approach 0.

You have no idea how efficient you are until it’s the weekend before a pair of exams, you’re streaming lectures and reading PowerPoints for the first time, and it seems relatively easy. This happened to me during the very last block of basic sciences. All my studying got pushed way back because of BCM’s 12 Days event, but I still did really well on the exams. At this point, it was more about understanding what was “high yield” material rather than trying to memorize all of it. Hmmm… I won’t be pressing my luck in the future. Nevertheless, it’s self-evident that I “learned how to learn” effectively by focusing on the primary material and accurately assessing what topics are important.

Desk before exams

I learned that high school drama never dies.

Having come from a small undergrad, I grew accustomed to an environment with minimal drama compared to the gossip-ridden halls of high school. “Did you hear so-and-so is going out with the new guy?!” “Oh – my – gosh, what is she wearing?!” People talking behind each other’s backs. People being too dependent on others. One would think that at this point in our lives, we would begin to represent the professionalism and maturity associated with being young physicians. It’s time to put the well-being of our patients at the forefront and drop the irrelevant sentimentality in our lives.

I learned about humanity.

Beach house in Gulf Shores

To this day, I cannot watch a dissection without considering the life and circumstances of the patient on the table, be it a living human or frozen cadaver. This sense of respect was instilled early in my training by a certain histology professor and continues to serve me as a measure of humanity amidst the hardcore science and technology of medicine. My basic science education has empowered me to explore the true wonder that is the human body, but learning about diabetes, seizures, and infections from a PowerPoint is very different from what I’ll be doing for the rest of my life – actually treating people. This implies not only treating each person symptomatically, but addressing their concerns from the past, predispositions about the future, and everything in between. Hippocrates, the father of medicine, is credited with saying: “Wherever the art of medicine is loved, there also is a love of humanity.” And indeed it is.

I learned about balance.

End of Basic Science Ball

Though exams, preceptorships, and other medical-school-related-activities frame the majority of my life, my time spent outside of BCM has kept me sane. It’s amazing what kind of friendships you can establish in medical school in spite of the aforementioned drama. People who take the initiative to be there for you, to bail you out of a tough situation, to check up on you from time to time… and the list goes on and on. *Sighs* I can only hope that I’ve provided at least something in return for the privilege of their friendships.

Balance is something which always came easy to me. Whenever I tried to venture into the realm of the closet gunner studying eight hours a day, I quickly reverted back to my recreational activities. I have to constantly alternate from one activity to the next in order to keep myself from falling into boredom. I really admire those who can stay at school all day and productively study, but I’m just not one of them. Could I have studied more over the last eighteen months? Of course. Did I experience long bouts of boredom or burnout at any point during the school year? Not that I can remember. It’s all about balance.

I learned about myself… again.

Class of 2014's White Coat Ceremony

Aside from learning that I’m lazy and have warm hands, I learned that I’m not liked by everyone, but more importantly, that I don’t care anymore. Spending most of my life as a people-pleaser has done no good, and now my obligations are to the patients I’ll see on the wards as well as my clinical team. This is easily the single greatest change I’ve gone through in med school… for better or worse. The unwavering notion that I am in medical school on behalf of my patients, not myself has been the cornerstone of my mentality in approaching medical school since the very beginning, and readjusting my scope on life has only solidified this feeling.

The basic sciences taught me how to learn – academically, socially, and from my mistakes. These valuable lessons will undoubtedly carry over to my clinical rotations and hopefully serve as a reminder of how far I’ve come and what a privilege I have to be training in the Texas Medical Center. It’s one I take seriously and with great humility.

I am ready.

I learned about medicine.

This is medical school, after all. In the first six months, I probed human anatomy by studying my cadaver – an unfathomable vault of medical knowledge and consequently my “best teacher” (as the Baylor Med profs like to say). My donor’s body provided me with examples of structure-function evolution teetering along biological perfection each and every lab. From the squishy, air-filled sacs of the lungs to the muscle-tendon-bone connections responsible for our incredible range of motion, human gross anatomy was easily my favorite course in the first four blocks and a rare privilege I will never forget. (link to my anatomy posts)

We covered the enzyme-regulated reactions of metabolism and the mechanisms which drive our body towards homeostasis in a constantly changing environment. We covered cardio, respiratory, renal, GI, endocrine, and reproductive anatomy, physiology, histology… just about every “-ology” known to the biological sciences. We explored the incredible expanse of the nervous system, appreciated how different bacteria, viruses, protists, fungi, and parasites invade the body and precipitate disease, thanked evolution for the wonderful immunological response we’ve developed to combat the aforementioned infectious agents, and picked up a bit of pharmacology along the way.

Is medical school really like “trying to drink out of a fire hose?” Eh, sort of. But it’s always humbling to think that by the time I graduate, medical knowledge will have doubled. Medicine, therefore, can never be entirely “mastered”, but as healers trained in both learning and compassion, it’s a lifelong goal to keep up with the latest knowledge and treatments.

I learned about camaraderie.

Having come from a relatively small college, Baylor Med was my first experience with a class of more than thirty people. Way more. While I enjoyed the small-scale setting of undergrad, having ~180 incredibly intelligent, diverse classmates with an identical goal fosters a level of camaraderie unlike any other. Whose notes do I use for the upcoming exam? Do I play basketball this week with one group or go out to dinner with another group? Or both? On top of this, these are the same people who go out of their way to follow up on why you’ve been missing lecture, why you skipped that party, if you need any lab handouts, help moving, or offer to let you crash at their place rather than having to drive home after a late night of studying. I’ve learned that there are two constants in at Baylor Med – the feeling of belonging to a family and lots of opportunities for free food. And I’m not entirely sure about the latter.

I learned about patients.

To this day, I remember the first, middle, and last name of the first patient I encountered in my ob/gyn preceptorship. Her chief complaint, her appearance, her husband’s recent surgery, her grandchildren’s life goals, and most importantly, her advice going forward as a medical student are as plain to me today as they were nearly a year ago. It’s this intangible “human factor” which defines, in my opinion, the most rewarding part of being a physician and why I chose this profession over research/IT.

The first time I had my preceptorship at the Veterans Affairs (VA) Hospital, I made the mistake of putting on my white coat in the parking lot (so I could stuff my notepad, stethoscope, etc. in its pockets). Before I even got to the door of the hospital, I was stopped on three different occasions by VA-goers asking if I knew where the bus stop was and if I knew which floor so-and-so worked on. Each of these individuals had an identical greeting – “Doctor, do you know…?” In my infinite ignorance, I didn’t know the answer to any of their questions, but the fact that they even considered me a potential source of information was uplifting. “Doctor”… wow, that title is only three years away.

I learned about the human condition.

In block 4, I wrote about my experience in a clinical ethics round at the trauma center. Two and a half months later, the snapshot of that patient is a humbling reminder of what we fight to prevent. Is it ethical to pull the plug to salvage hospital resources given the patient’s terminal condition? Does the daughter have the right to keep her mom alive? What really is “dead” according to the state of Texas? It just baffles me… ten minutes away from the very lecture hall where I learned about ethical guidelines, doctors and patients alike are having to make difficult decisions on a daily basis.

As MS1s, we also touched on a number of “bad things” that can happen to the human body during development, age-related degeneration, and results of infection. It’s amazing how precious a healthy life really is. The fact that you’re reading this is a testament to a series of mechanisms being executed in a precise order during your development. Your immune system is constantly battling off foreign particles to keep you healthy. Your entire body is synchronized in a very narrow window of pH values, electrolyte concentrations, temperatures, etc. to ensure your survival. And all of this without you even thinking about it. Truly remarkable!

But disaster strikes when, for example, a normally healthy cell goes rogue and becomes cancerous. This is where death becomes a reality. Patients die… all the time. Sometimes when they come to the hospital, they’re already terminal and show few or no symptoms. How have I coped with the fact that, as a physician, I will fail from time to time? It’s because of a well known medical philosophy which I previously blogged about – “to cure sometimes, to relieve often, to comfort always.”

I learned about myself.

I learned that I’m lazy and have warm hands. Brevity is indeed the soul of wit. Nah, in reality, it’s hard to really gauge how I’ve changed since August 2009, but that’s the beauty of keeping a blog. I can go back anytime and appreciate how I’ve reacted to the medical environment over the last year.

In spite of the rigors, tribulations, successes, failures, friendships, and questionable situations I’ve been confronted with over the last year, there’s one inexorable truth – I’m really, really enjoying medical school. With clinicals starting in January, here’s hoping I finish the basic sciences on a strong note while trying to remain humble, helpful, and happy.

Remember what got you here.

It’s a piece of advice I was given myself in the first week at Baylor Med, and in retrospect, it’s the main reason I’m still smiling today. The med school environment plunges you into an arena of incredible minds. Your upperclassmen colleagues will serve as great mentors. Your curriculum and professors will empower you to digest the wealth of information that is human biology. But no one can teach you how to be happy.

Fortunately, you intuitively know how to be happy. What do you enjoy doing in your free time? What interests outside of medicine do you pursue regularly? Maybe reading fiction or playing an instrument? Obviously some things (like traveling out of the country) may be infeasible given the curriculum, but everyone has an array of interests consisting of at least one hobby which can be carried through the duration of medical school.

Take me for example. I enjoy following the public market. I love assembling computers, creating algorithms, and streamlining efficiency. I like watching and playing basketball. I play “one-too-many” video games on a daily basis. In the face of all these “distractions”, how do I manage to keep up with my studies? Well, because they’re not distractions to begin with. They’re a vital part to keeping me motivated and happy.

Many are quick to say that incoming students should budget their time appropriately by setting side ‘x’ hours for studying and ‘y’ hours for leisure each day. I really don’t think people are designed to work that way, and the medical school curriculum requires a much more dynamic allocation of time. Some topics you’ll grasp the first time through while others you may find more challenging. Whatever the case, if you feel like doing something else, DO IT (within reason)! It’s about remembering what got you this far in life and realizing that it will also get you through medical school.

By the way, I’m not responsible if you fail. I would just feel really, really bad.