Taking stock of year three: Advice for rising third-years

"The transition from classroom learning to the the clinical years will be the most difficult transition of your careers."

So said one lecturer preparing my class for clinical rotations, one year ago. This sentiment has been echoed by numerous other doctors over the past year. The transition from classroom to clinic represents a fundamental shift in the way that learning takes place, not to mention the additional considerations of teamwork and professionalism. Other major transitions in the medical career (e.g. graduating medical school and becoming an intern, or finishing residency and becoming an attending physician) represent increased responsibility, which is arguably more easy to deal with than a fundamental shift in the way one thinks.

Because of this, I decided that now would be an ideal time to step back, think about all that I have learned over the past year, and pass some of those lessons on to those who will follow me. Keep in mind that that what follows are my own opinions drawn from my own experiences. Other people will have different opinions, and I don't pretend to have all the answers.

1. Attitude. This can be said about anything in life, but I think it's especially true during third-year: A good attitude goes a long way. You are transitioning from learning in a classroom setting to learning in a clinical setting. You will have to figure out how to function well as part of the healthcare team. The reality is that there are many factors outside of your control that will cause you to be a burden on the team. This is more true at the beginning of third year than at the end. Try to minimize your burden on the team, and the best way to do that is to have a good attitude.

• Be happy; if you're not happy, don't show it.
• Be easy and fun to work with, even if you don't like your resident or attending.
• Be excited to learn, even when you're exhausted.
• Take the initiative when caring for patients.
• Take as much responsibility as your resident is willing to give you, even if you feel it's a stretch. If a question starts out with "Do you want to..." then the answer is always "Yes."

2. Perspective. Approach every clerkship as if that will be your specialty for the rest of your career. This may sound silly, or impossible, if you know 100% that you do not want to go into that specialty. But I found that this helped me to maintain a good attitude when I very well could have done otherwise. It's a lot easier to work hard if you feel that what you're doing is important. For that matter, if you absolutely hate a clerkship, remember that it will be over in just a few weeks; just push through it.

3. Study. Treat all of third-year as one long study period for Step 2 Clinical Knowledge. In my opinion, every shelf exam that I took was harder than Step 1. For each shelf exam, start studying early and study frequently, a little bit every day. My general approach to studying:

• Learn from patients. Your patients are your best teachers. Read about your patient's disease on UpToDate: review its pathophysiology, learn different ways that it presents clinically, know its diagnostic criteria and how to treat it. Do a pubmed literature search, if there are any questions related to your patient that can be answered by evidence-based medicine. Then bring back to the team what you find. Information sticks way better when you associate it with one of your patients.
• Pre-Test. This is a specialty-specific series that offers about 500 questions meant to prepare for shelf exams. I only used the surgery, psychiatry, pediatrics, and Ob/Gyn versions. They are all available as real books or as apps on iTunes. I borrowed the book versions of pre-test for psychiatry and pediatrics but decided to splurge for the $30 iTunes apps for surgery and Ob/Gyn. I'm glad I did, too, because there is a lot of waiting around during those two clerkships, so I would just crank out 5-10 questions whenever I had some time to burn. I finished all 500 questions before each respective test. It's important to note that these questions aren't nearly at the level of difficulty as questions on the real exam. In retrospect, I think pre-test would have been helpful for my family medicine departmental exam. I would stay away from pre-test for Internal Medicine, though, because there's MKSAP, a question bank published by the American College of Physicians. 
• Step 2 CK question bank. I bought a year-long subscription to Kaplan's Step 2 CK question bank at the beginning of my surgery clerkship and immediately wished that I had gotten it earlier in third year. I'm told that, like Step 1, Kaplan's Step 2 questions are a little harder than what is on the real test. They worked well for me as a shelf exam study aide. Throughout the clerkship, up until the last week, I did just 5-10 questions every other day or so. Then during the last week I did timed full blocks of 44 questions until I ran out of questions, of course reviewing explanations for every question. If I had extra time, I re-answered questions that I got wrong.
• Specialty-specific textbook. Most clerkships recommended specific text books. The family medicine departmental exam was drawn heavily from Essentials of Family Medicine, which unfortunately is an awful textbook (poorly written, poorly edited, too much emphasis on arcane statistics rather than big picture). The Internal medicine text is Internal Medicine Essentials for Clerkship Students 2 versus Step-Up to Medicine. I chose the first option because it is published by the ACP and is linked to the MKSAP question bank, which I also bought. The surgery departmental exam was drawn heavily from Essentials of General Surgery, which is actually a very well-written book, albeit heavy on text. Ob/Gyn recommended Beckman's Obstetrics and Gynecology, which provided a decent start to studying for the shelf exam. The rest of my clerkships did not recommend any specific textbook.
• Case Files. This is a specialty-specific series that offers case studies as a means of learning the materials. A patient's case is presented, then questions such as the most likely diagnosis or the diagnostic tests to establish the diagnosis or the means of treatment are asked. A short discussion then expands on those learning points. Each chapter is accompanied by a few softball questions that I found relatively useless. The major utility of Case Files, in my opinion, was talking over the cases with classmates. I only used Case Files for neurology and psychiatry, clerkships without a recommended textbook.

4. Practice. Your jobs as a third-year medical student are to learn how to take a good history, do a good physical exam, and present your findings both in notes and oral presentations. This is all easier said than done. If you're on your first clerkship and you think you're good, you're most likely overestimating yourself. Remember that there is always room for improvement. Don't worry if you're slow and clumsy at first; your residents and attendings expect that at the beginning of your third year, but they also expect steady improvement as you move through the year.

• Be methodical about how you collect your patient's history. The conventional order is 1) chief complaint, 2) past medical history, 3) past surgical history, 4) medications, 5) allergies, 6) family history, 7) social history. This will quickly be burned into your mind so deeply that it becomes the way you talk about patients in normal conversation. If it helps, create a template for you to fill in as you're interviewing your patient.
• Sit down when you're talking with patients, even if it means excusing yourself to get a chair or stool. It sets the patient at ease and gives them the impression that you're spending way more time with them than you actually do.
• Figure out how to end patient interviews without being rude or awkward. This is especially important because you'll often be pressed for time.
• Try to do a full physical examination, even if it means coming back to see the patient later when you have more time. Obviously this is not always practical, especially in the clinic where an entire patient visit is only 15-20 minutes. But the more normal exam findings you see, the easier it becomes to recognize an abnormal finding.
• Be proactive about seeing abnormal exam findings, even if it's not on one of your patients.
• Look to the fourth-year medical student notes as good examples to follow. The attendings and residents typically write more abbreviated and utilitarian notes that are not as useful for learning how to write a good note.
• Run your assessment and plan by the intern or resident before presenting a patient on rounds, if possible. This is an opportunity to see if he/she agrees with your plan or wants to change anything, and it helps make you look better in front of your attending.
• Find someone who you can present to as practice, if oral presentations make you nervous. This can be a friend or family member or a significant other. I was fortunate enough to have a resident who taught me how to present, but given how busy residents are, I think this is more the exception than the rule.
• When presenting, fall back on the methodical approach in which you took the patient's history. This will also save you if you're having a nervous brain-freeze. As you progress, you'll figure out how to pick out pertinent positives and negatives that tell the patient's story and guide the listener to your assessment.
• Don't forget to present the patient's vital signs!!! Some attendings want to hear each individual vital sign, but most of the time you can summarize it conversationally: "Patient is afebrile, normotensive, normal heart and respiratory rate, and satting well on room air." Or, more succinctly, "Vital signs stable and within normal limits."

5. Relax. No, seriously, relax. This isn't necessarily the most easy thing for me to do, but over the past year I learned how important it is for me to take full advantage of time off, even if that time is just a post-call day. Spend time with family and friends outside of the medical field, or at the very least try not to talk about medicine-related topics when you're hanging out with medical school friends. Think about what hobbies or activities recharge your batteries, and be proactive about scheduling time to do those. Be aggressive about protecting your relaxation time. Otherwise, you will burn out.

Code C: Emergent Cesarean Section

"Code C, room 8 to OR 3! Code C, room 8 to OR 3!"

The Labor & Deliver control room burst into activity with the overhead announcement. A quick glance at my resident, whose head nod told me to go for it, and I rushed back to OR 3 just in time to catch the patient being transported down the hall.

She smiled at me as she wheeled by. In the middle of a labor gone awry, surrounded by nurses and doctors moving and talking much faster than usual, lying in her inclined hospital bed, breaking speed limits as she flew down the hallway on her way to the operating room where she was about to undergo an emergent Cesarean section - this woman met my eyes and smiled at me. It wasn't a frightened smile or a nervous smile; she actually appeared serene, an emotion that didn't belong in this moment.

The patient was already on the operating table by the time I entered OR 3, nurses buzzing about the room as if their hive were being attacked. I stood near the patient's head, mesmerized by the serenity of her smile that was now hidden behind a face mask and then a few moments later faded with her consciousness. I moved down to the foot of the bed, out of the way but with a good view of the operating field, then stood frozen lest I get stung.

The anesthesiologist was preparing for a rapid-sequence intubation. The scrub nurse was already dressed in her sterile gown, governing her table of sterile instruments. Two Ob/Gyn doctors were already dressed in their sterile gowns and posted on either side of the operating table, one looking at the anesthesiologist expectantly and the other posed like a runner in the starting blocks, her scalpel blade millimeters from the patient's pregnant belly.

"Tell us when you have her airway!" said the first Ob/Gyn in a commanding voice that couldn't be ignored.

"Do you have her airway?" ...

"Do you have her airway?" ...

"Got it!"

Cut, a curved incision. "Cut again!" Yellow fat and gushes of blood. Scalpel down. The two doctors took a firm grip at either side of the incision and pulled with all the weight of their bodies to open the incision. Sound of ripping flesh. Underlying muscle. More blood. "Cut again!" More ripping flesh. More blood. Then the uterus appeared, large, holding a baby whose life was in danger. "Cut again!" Amniotic fluid washed away the blood. Hand inside the uterus. Some pushing, some pulling, then Baby. "Knot in the cord!" Clamp it, cut it, then Baby was whisked away to the care of NICU nurses.

No more than 30 seconds passed from first incision until Baby's birth.

With Baby out, the doctors turned their attention to controlling Mom's bleeding. I stood there planted in my out-of-the-way spot at the foot of the operating table, even as the flurry of activity around me dissipated, dumbstruck by the sheer speed and exquisite coordination of the emergent C-section I had just witnessed.

Mom recovered beautifully, and Baby was entirely healthy.

Oral presentations: The urge to keep talking

I have made amazing progress in terms of my oral presentations since the beginning of third year. I started out having literally no idea how to properly present a patient. A stellar resident taught me the basics during my Hospitalized Adult Care clerkship, and along the way other residents and attendings interested in teaching have helped to fine-tune my presentation.

Today, I was presenting to my attending an obstetric patient who was in for a regular check-up. The attending remained quiet as I went through all the pertinent subjective information about my patient's pregnancy, described the fetal heart rate and height, and gave her my assessment and plan for this patient.

I was about to talk about the patient's breastfeeding and post-partum birth control plans when my attending said, "Stop!" It's not uncommon for attendings to interrupt oral presentations of medical students. So I stopped, wondering what she was going to say. "Your presentation was perfect. You covered everything I wanted to hear, and you said it succinctly. I know your assessment and plan. You don't need to say anything else. Stop talking!"

The lesson: Part of a good oral presentation is knowing when I've said enough. I should be confident that I have covered all the pertinent details and act on that confidence by ending my presentation. For a third-year medical student who is just now starting to feel comfortable giving oral presentations, this is a valuable lesson to learn.

Nights on Labor & Delivery

This past week I worked the night shift on Labor & Delivery, from 6pm to 8am. Flip-flopping my schedule like that was disorienting to say the least. While I didn't break down and start a coffee habit, I did eat a fair amount of dark chocolate to keep me alert. In fact, I noticed that eating any food throughout the night helped me stay awake.

When there were things to do, when babies were being born, staying awake was not an issue. Rather, I had difficulty with those long stretches of early-morning quiet. I tried to use the time to study, at first, but my brain wouldn't cooperate. Preparing my progress notes during those quiet hours saved some time in the morning and didn't require too much brain power. If nothing really was happening, and my resident was feeling nice, she would send me to the call room so I could take a 1-2 hour "nap" before rounding on patients at 5am.

Generally, after a night shift, I'd get home at 9am, eat a bowl of cereal, and manage to sleep 3-4 hours in the late-morning and early afternoon. Except one day last week, I had to schedule a bunch of meetings on campus, which meant that I didn't get home until 2pm and was essentially running on no sleep for 2 days straight. I felt miserable.

Looking back, it's a wonder how I functioned at all. A week of nights on Labor & Delivery is as much a medical school hazing ritual as anything. It was definitely the most physically demanding week of medical school I have experienced yet.

I caught my first baby!

Early this morning while I was rounding on my patients, a nurse sitting behind me answered the phone. "Yeah, he's right here." I turned around, expecting the call was to tell me that one of my patients was about to deliver. "You're wanted in room 9, stat!" The nurse smirked as if she knew she were reading lines straight from a medical drama TV show. I dropped what I was doing and flew down the deserted corridor, overloaded white coat pockets flap-flap-flapping against my body.

The room was already prepared for delivery when I arrived. The bed was raised, the patient's legs up in footrests, my resident in sterile gown and gloves standing between the patient's legs, and the table of instruments and a nurse behind her. Standing room only crowd of family. A quick glance showed me that the baby's head hadn't yet crowned. "Gown and gloves!" my resident shouted at me. I gowned up quickly and stood beside my resident between the patient's legs.

"That's it, give me a good push, you're doing great!" I took cues from my resident. She was standing beside me the whole time, coaching me through each step with hand signals and a quiet but firm voice, ready to take over if necessary. After having watched so many deliveries over the past several days, the motions came surprisingly naturally.

The head crowned just a few minutes later. I held the baby's head in my left hand and followed him as he turned his head to the left. Unwrap a loop of umbilical cord from around his neck. Gentle downward pressure to deliver his top shoulder. Then with a gush of amniotic fluid and blood, he entered this world. With my right hand I supported his back and swung his body over so that I was cradling him in my left arm. Suction, suction, first breath, then a loud cry.

Remarkable. Miraculous. The whole process would seem magical if I weren't so familiar with the biology.

I clamped the umbilical cord and gave Dad scissors for the honor of cutting the cord. Then I presented Baby to Mom. She held him close on her chest, smiling down on him with tears in her eyes and that singular glowing expression of a new mother.

I could have lost myself in the emotions of that moment, but my job wasn't done yet. I collected cord blood, delivered the placenta, massaged the uterus, and inspected the vagina for tears. Under my resident's supervision, I repaired a mild tear with a single stitch. Then we cleaned up.

Dad asked my resident and me to pose for a picture with Mom and Baby. We gave our congratulations all around, I thanked Mom for inviting me to be a part of her delivery, then we left the family to celebrate.

How I decided on a combined medicine/psychiatry residency

The third-year medical student has three jobs: 1) To learn how to take a good history and do a good physical exam; 2) To learn how to present patients, both written and orally; and 3) To figure out what field of medicine to specialize in. I found this last job to be the most difficult.

Pre-med and the pre-clinical years

To provide some context, I came into medical school having worked for four years researching the neurobiology of eating disorders. I very much enjoyed and valued my pre-med experience in psychiatry, but I also wanted to keep an open mind when it came to other possible specialties and career paths. This translated into me looking practically everywhere except at psychiatry.

During the first two years, when I was just in the classroom and didn't yet have any practical clinical experience, I investigated various specialties: emergency medicine, neurology, neuroradiology, interventional radiology, surgery.

The third year

Over this past year, as I've gained clinical experience in various fields, I have tried to be purposeful and methodical about how I evaluate each specialty as a possible career. This process of elimination is pretty typical for third-year medical students. I had all but ruled out many possible specialties before third year, but I also tried to keep an open mind. I liked most of my clinical rotations and seriously thought about careers in those specialties.

• I was very interested in emergency medicine, ever since my first year, but eventually nixed it because I want to have continuity of care and to treat the whole patient rather than one acute problem at a time.
• I seriously considered surgery but reluctantly decided against it because of lifestyle issues.
• I got excited about anesthesiology but vetoed it because I want more significant patient interaction.
• I loved pediatric neurology and only recently crossed it off the list because I decided that I don't like general pediatrics enough to do the training. Also, even though I figured out that I could probably handle the sad stories and poor outcomes, I decided that it's just not what I want.

Then there were my internal medicine and psychiatry clerkships. I loved them both.

Internal Medicine

Last Summer, on a warm evening after a long day at the hospital, I was lying underneath a tree in the park talking on the phone with my sister. She asked me how I was liking internal medicine, and my immediate response was that I love the puzzle. I have a patient with a given set of symptoms and a unique history, and based on both of those, I have to decide on what labs and studies to order to figure out what is causing that particular constellation of symptoms and how to treat it. I told my sister that the inpatient setting gives me more time to sit down and really talk with my patients, as well as to thoroughly think through the differential diagnosis. I like internal medicine because it involves both thinking and doing.

Looking back, my most memorable and favorite medicine patients all had psychiatric comorbidities. After awhile, my medicine residents were giving me the "difficult" psychiatric patients because they knew that I was drawn to those patients.

Psychiatry

Then there was my psychiatry clerkship. I looked forward to it with excitement but also some trepidation. What if I liked it? Could I really become a psychiatrist? I worried about that because there truly is a distinction between the practice of medicine and the practice of psychiatry.

It turned out that I did very much like psychiatry. I found that reading for psychiatry was easy because I was so interested in the subject matter... I spent much longer talking with my patients than I needed to... I wrote much longer notes than I should have because I had so much to say and was so fascinated by my patients... I jumped into psychotherapy with some of my patients even though that's way beyond the scope of a third-year medical student....

Discovering med/psych

Liking psychiatry so much posed a problem because I held a mental block against it. Much of that mental block likely came from my desire to practice medicine, not solely treat mental illness. About midway through my psychiatry clerkship, responding to what I recognized as ambiguous reservations against psychiatry, I started researching various psychiatry fellowships. That's when I "discovered" combined medicine and psychiatry residency training programs.

I hadn't even known that such programs existed. Thinking back to my internal medicine clerkship and how much I enjoyed it, I immediately started daydreaming about what I could do with training in both internal medicine and psychiatry. I stayed up way too late that night researching med/psych programs.


The more I thought about med/psych as a training path, the more excited I got. I could continue my work in anorexia and bulimia or focus on binge eating and obesity. I could do geriatrics. I could do palliative care. I could do international and refugee medicine. So many possibilities! I'm the type of person who likes to keep my options open. Med/psych training could give me the best of both worlds; I could have my cake and eat it too!

I realized, though, that I was getting all excited about med/psych with a very limited amount of information, only what was available on the various program websites and the Association of Medicine and Psychiatry website. I needed more information, better information.

Talking with med/psych program directors

A few of the med/psych programs stood out to me, both because of the quality of the integrated curriculum and the general feel of the institutional culture. The directors of these programs wrote open letters describing med/psych, promoting their respective program, and inviting those interested in med/psych to contact them with any questions. Recognizing that contacting these program directors could potentially be self-defeating, I decided that it was worth the risk because I needed to talk with someone - multiple people - in the med/psych world.

I e-mailed three program directors and actually talked on the phone with two of them. I was blown away by how open and friendly and helpful they were, that they would set aside time from their lives to talk with me about med/psych. They answered my myriad questions, settling two major concerns about pursuing both medicine and psychiatry.

• Concern #1: You'd just end up choosing one or the other eventually, so why waste time training for both? Response: We actively encourage our graduates to establish a practice that incorporates both medicine and psychiatry, and most of them do find a niche for themselves. Even if your practice ends up being predominantly medicine or predominantly psychiatry, you will draw upon your training in the other and be a better doctor for it. I doubt that you'll ever regret your training. Both program directors said essentially the same thing in different ways, and I agree with them.
• Concern #2: A combined program would leave you less well trained in both medicine and psychiatry than if you completed a pure residency in one or the other. Response: Our pass rate is 100% for both the medicine and psychiatry boards. Our graduates report feeling very well prepared for both boards and for the responsibilities of being an attending physician. That speaks for itself.

Talking with current med/psych residents

I asked those program directors to put me in touch with current med/psych residents. Being in the middle of this stressful decision-making process, I wanted to talk with someone whose memories of that process are more fresh in the mind. How did you discover med/psych? Did you seriously consider other specialties, or medicine alone, or psychiatry alone? Why did you end up deciding on med/psych? Did you know what you wanted to do with med/psych before residency? I felt that these questions needed to be addressed now as opposed to during an externship or on the interview trail.

One resident answered that he decided on med/psych simply because he wanted to treat the whole patient, not just a set of symptoms. This struck a chord with me. I thought back to my medicine rotation and remembered how frustrated I felt when the psychiatry consult service swooped in to evaluate patients with psychiatric concerns: I wanted to be a part of that aspect of my patient's care. I also thought back to my psychiatry rotation and my frustrations when the smallest medical issue was outsourced to internal medicine. I want to treat the whole patient, too.

Enthusiasm flowed freely from every resident I talked with. Everyone was happy. Everyone was 100% satisfied with their career choice. Everyone would do it over again the same way in a heartbeat. And talking with each successive resident, that enthusiasm rubbed off on me. The vague intuitive sense of rightness I originally felt when I discovered med/psych crystallized into certainty that a combined medicine and psychiatry training is perfect for me.

Trying on med/psych for size

I can't count how many times I've been asked, "What are you going into?" or "Do you know yet what you're specializing in?" It's especially bad toward the end of third-year and even worse when I start a new rotation. So pediatrics and OB/Gyn have offered me numerous opportunities to see how med/psych fits. Rather than hedging, I started answering decisively, "I am going to do a combined medicine and psychiatry residency program."

Reactions have been interesting, ranging from "Oh, what a waste of talent," to probing my reasons for choosing a less traditional training path, to "Wow, that's awesome!" The negative reactions didn't get me down, and the positive ones only stoked my excitement for med/psych further. These self-observations are incredibly helpful in making the final leap to a decision that without overstatement will profoundly shape the rest of my life.

So I've taken that leap. I will apply to combined medicine/psychiatry residency programs.

From clinic to the operating room

A new patient was referred to the gynecology clinic from an outside community clinic that serves a low-income population. She was at the end of her rope dealing with symptoms from a condition that she allowed to progress for so long because she couldn't afford to fix it.

I was working with the chief resident, who is essentially almost a "real" doctor; even she was taken aback. "I'm going to go talk with the supervising doctor, and we'll see what we can do for you." The attending was equally impressed with the patient's history and physical exam and scheduled her for surgery the very next day.

My resident invited me to watch the surgery. "It'll give you a chance to follow a patient from start to finish." Thank you so much! This kind of continuity, as a medical student, is not the norm. I had to play hookie from afternoon clinic (with the chief's permission) in order to see my patient's surgery.

During the first two weeks of this clerkship, I saw many surgeries on women whom I had never met and never examined. The only history I knew of them is what I read in their chart and what the resident told me beforehand. Occasionally, I'd have a few minutes to chat with these patients immediately before surgery. But the whole experience felt disjointed.

That's why I'm incredibly grateful to have experienced the kind of continuity of care, from clinic to surgery, that the residents and attendings enjoy. The attending even stepped back allowing my resident to operate and leaving me to first-assist! And she invited me to accompany her to talk with the patient's family afterward! The experience felt complete.

I think more effort should be made to give medical students this kind of patient continuity. In terms of teaching and learning, I personally find that such continuity is especially effective: I will never forget this patient.

Urogynecology and gynecologic oncology

I finished my week of urogynecology and gynecologic oncology (UroGyn/GynOnc) having seen a lot of pelvic organ prolapse and transvaginal taping for stress incontinence. But I didn't see much pathology. In fact I didn't see any. No ovarian cancer, no uterine or endometrial cancer, no cervical cancer, no endometriosis. I'm disappointed, but that's the luck of the draw.

Up next: A week of gynecology clinic, then on to obstetrics (a.k.a. "baby-catching").

Anesthesiology reunion

Returning to St. Joe's for OB/Gyn has been fun because I'm seeing a bunch of people who I worked with several months ago during my surgery clerkship. One of those people is an anesthesiologist who got me so excited about anesthesiology that I seriously considered it as a possible career.

He happened to be the anesthesiologist working one of my gynecology cases, recently. We exchanged pleasantries, caught up a bit, then he asked, "So, are you going to intubate this patient for me?" This caught the attention of my resident who practically shouted, "What? You never let me intubate anyone!" My anesthesiologist friend replied, "Yeah, but I've worked with him before, and I trust him."

This was all just playful banter. My resident wasn't really upset, but the pressure was on: I hadn't intubated anyone for more than 3 months! I had a little bit of difficulty visualizing the cords, but I got them finally and successfully intubated the patient on the first try.

OB/Gyn site and schedule

I had such a good time on my surgery rotation at Exempla St. Joe's that I decided to do my OB/Gyn rotation here, too. Since the site assignments for the OB/Gyn rotation are given on a first-come-first-serve basis, I got lucky with getting my first choice. ESJ is a very popular site among medical students because it has a reputation of very nice attendings and residents. So far, its reputation has borne out to be true.

The six-week OB/Gyn block is divided into weeks on different services. My schedule:

• Week 1: Benign gynecology. Lots of surgeries. Get in early enough to pre-round on 1-3 patients and have my notes written and shared with the resident by 6:45 am. Usually leave by 5:00-6:00 pm.
• Week 2: Gynecologic oncology and urogynecology. Similar to benign gynecology but with sicker patients.
• Week 3: Gynecology clinic. Show up for educational rounds at 7:00 am and leave after the last patient, around 4:30-5:00 pm. Have to wear professional clothes, not scrubs.
• Week 4: Labor and delivery nights. Shift work from 5:00 pm to 8:30 am, starting Sunday night.
• Week 5: Obstetrics clinic. Essentially the same schedule as gynecology clinic.
• Week 6: Labor and delivery days. Not sure about this schedule, yet.

I definitely wasn't expecting that I would have most of my weekends free. I'll have to come in on the Sunday evening of my L&D nights week, and the residents may ask me to round on patients over the weekend if my patients happen to provide a particularly good learning opportunity.

Overall, I think OB/Gyn will be a good experience.

The week of hysterectomies

I saw several hysterectomies this week on the gynecology service, each a different flavor. A resident pointed me in the direction of a wonderful resource, the Atlas of Pelvic Surgery, which describes specific surgeries step-by-step with accompanying pictures. Reviewing each procedure ahead of time helped me better understand what was happening in the operating room.


One hysterectomy was a total vaginal hysterectomy, which delivers the uterus through the vagina. This patient had a prolapsed uterus, which basically means that the tissues holding the uterus in place were failing causing the uterus to sink down lower into the pelvis and out the vagina.


Another was a total abdominal hysterectomy, a procedure that removes the uterus through an incision in the lower abdomen. The abdominal approach was chosen, versus a transvaginal approach, because the uterus was burdened by several fibroids, one of them the size of a softball. Attempting to deliver such a large uterus through the vagina wouldn't have been smart.

The most interesting hysterectomy I saw was a laparoscopy assisted vaginal hysterectomy that was converted to an open procedure because of uncontrolled bleeding from the uterine arteries, which were difficult to clamp laparoscopically because of abnormal anatomy.

This turned into a true emergency. The gynecological surgeon never lost his calm, but he also started moving much more quickly than surgeons usually move. Less than 30 seconds after he called out "We're converting to open!" he and the resident made an incision across the lower abdomen and were literally tearing apart the subcutaneous tissue to gain access to the abdominal cavity. The bleeding was stopped, and the rest of the surgery went without further complications.

The attending asked me afterward, "What's the first thing you do in a Code situation?" My answer: check for airway, breathing, and circulation. Not entirely incorrect, but his answer was much more to the point: Take your own pulse.

Seeing three different surgical approaches toward the same end goal, removal of the uterus, was very helpful in terms of understanding the female pelvic anatomy. I also have a higher appreciation for how anatomic variability, both normal and abnormal, determines the course a surgery.

OB/Gyn orientation

The OB/Gyn clerkship orientation included some very practical instruction. What I found to be most useful out of the two-day orientation was a refresher course on how to do the breast and pelvic exams. We all learned these sensitive exams for the first time at the end of our second year with formal instruction from standardized patient-actors who taught the exams using their own bodies. But that was almost a year ago. Over the course of my third-year, I've had the multiple opportunities to perform breast and pelvic exams, but they were few and far between, not enough to keep those clinical skills sharp. Apparently, including this refresher session during orientation is a relatively new development and was done in response to student feedback. I'm grateful! I'm especially grateful after talking to some medical student friends at other institutions who were never taught how to perform a pelvic exam before seeing a real gynecological patient.


We also had a session with a medical mannequin in active labor. In my humble opinion, this is a much better way of preparing medical students for L&D than just throwing them in the deep end with a real patient in labor. Although this mannequin is capable of simulating labor and delivery to striking detail, the purpose of this session was really just to familiarize us with the basic steps of the birthing process. As happy as I am that I got this simulation experience, I have a feeling that it will be absolutely nothing like the real deal.

OB/Gyn prejudices

A friend recently asked me, "Are you looking forward to or dreading your OB/Gyn rotation?" I don't think either term adequately describes how I feel about this clerkship.

OB/Gyn is the one specialty that I pretty much knew 100% I didn't want to go into even before third year. But, I recognize that my OB/Gyn experience will be very educational and an opportunity that I likely won't have during the rest of my career. So I am definitely looking forward to the experience of OB/Gyn, especially the OB part that involves delivering babies. That being said, I'm also looking forward to being done with the clerkship.

Do I dread OB/Gyn? I have to admit that there are certain aspects of OB/Gyn that are slightly anxiety-provoking. I've heard disconcerting stories about some OB/Gyn residents and attendings. I'm wondering how I'll actually be received by patients, as a male medical student. I'll also be straightforward and say that I'm not looking forward to doing pelvic exam after pelvic exam for the next six weeks. But, like everything else in medical school, it's something that I just do, putting in my best effort and with a good attitude, even if I don't want to make a career out of OB/Gyn.

It'll be interesting to see how my opinions of OB/Gyn at the end of the clerkship compare to my prejudices of it now.

Pushing back against the war on vaccines

It was bound to happen eventually on my pediatrics rotation: coming across parents who for one reason or another refuse to vaccinate their children.

The most recent anti-vaccination movement stems from a 1998 Lancet article that ostensibly showed a link between the measles, mumps and rubella (MMR) vaccine and a so-called "bowel-brain syndrome" that involves non-specific bowel inflammation and a regressive type of autism. Vaccination opponents seized upon this article as legitimization of their views while the medical community collectively gasped.

Much has been written about the methodological and ethical problems with the study; a lot of time and energy was invested into reproducing or disproving the results of this study. Ultimately, though, it was an investigative journalist who showed that the author of MMR-autism study had allegedly cooked the data for financial gain (How the case against the MMR vaccine was fixed, British Medical Journal, 5 JAN 2011). This led to a formal investigation, public censure of the primary author, and the paper's retraction more than a decade after its publication.

But not before the damage was done. The authors of this paper used a respected and authoritative medical journal as a platform to spread what appear to be lies, the result of which was millions of parents questioning whether they should give their children the MMR vaccine - or any vaccine - for fear that it will cause autism. Many parents who had the misfortune of learning that their child has autism, desperately searching for reason, have stumbled upon the falsehoods spread by this article that seemingly explain the unexplainable.

Vaccinating children: Keeping the dialogue open

This is a dilemma faced by pediatricians worldwide, dealing with parents who are skeptical of vaccines or who flat-out refuse to vaccinate their children.

One such parent stood out over the course of my pediatrics rotation. She is the mother of an autistic child who hadn't received any vaccinations since 18 months and was coming in for a well-child visit. My preceptor warned me that this child's immunizations were not up to date and that the mother would likely continue to refuse all vaccinations. "What's your approach to such a parent?" I asked because some pediatricians (including one provider who I worked with previously) just have the parent sign a form without any discussion. "I always keep the patient in my practice, and I try to keep the dialogue open," she replied.

So, when it came time to talk about immunizations, I jumped right in:

"It seems that he's not up to date on his immunizations. Which shots do you want him to get today?"

Mom replied: "I don't want him to get any shots."

Feigned surprise: "Why not?"

"I just don't. He doesn't need them."

"Why do you think he doesn't need immunizations?"

"He just doesn't. He's not going to get sick."

My preceptor interjected: "Do you think there's a link between vaccinations and your son's autism? The only scientific publication that suggested a link was--"

"No, I don't believe that."

I sat back and thought for a few moments, perhaps slightly theatrically. "Tell me, what's your understanding of the diseases that these vaccinations protect against?" This question seemed to catch Mom off guard. The door was cracked slightly open, so I took the opportunity to educate Mom about hepatitis A and measles and mumps and rubella and chicken pox....

Oops, tactical error. Mom jumped on the chicken pox: "See, why does my son have to get a shot for chicken pox? I had it when I was a kid, and I did just fine!"

My preceptor rescued me: "Before we started vaccinating against chicken pox, a few hundred kids died from it every year. Percentage-wise, that might not sound like a lot, but if it's your kid who doesn't come home from the hospital because of chicken pox, then those chances are 100% for you. Did you have any complications from your chicken pox?"

"Yes, I was hospitalized for two days."

Then my preceptor closed the deal: "Well, it would be a horrible shame if your boy had to go through something like that if he didn't need to."

In the end, Mom agreed to vaccinate her boy against hepatitis A, influenza, and chicken pox, all that same day. She also agreed to vaccinate him against measles, mumps, and rubella, only if we could give those as separate shots.

Done!

I felt a real sense of accomplishment. Partially because of me, this little boy would now be protected against several serious diseases.

My opinion: Why every child should be vaccinated

Vaccines in general arguably represent the single most important development in medicine, ever. Some people may counter that antibiotics are a more significant advancement, and I'll give them that it would be a good debate.

But think for a moment: What would the world be like today if no vaccine had ever been developed? Just for starters, the world would still be ravaged by smallpox, a disease that few people can truly appreciate how devastating it really was. To put this in perspective, the Wikipedia page refers to smallpox in the past tense, citing its eradication in 1979! Then there's polio, which is so very close to also being referred to in the past tense thanks to a coordinated worldwide campaign to eradicate polio. Warehouses full of people living inside iron lungs are a nightmare of the past; we will never again have a President of the United States confined to a wheelchair because of polio.

Measles (one of the M's in MMR) is a great example of a horrific disease that practically disappeared because of population-wide vaccination but has recently made a resurgence, partly owing to the people who were never vaccinated against it. Measles is an incredibly infectious disease, which means that it's very easy to spread from one person to another. That in turn means that eradicating it will be that much more difficult, especially if there are significant pockets of the population who are susceptible to it. Recently, PBS reported on a mini-outbreak of 13 measles cases after the 2012 Super Bowl; all 13 cases had opted out of the MMR vaccine. In developed countries, one person will die of measles for every 1000 people who get the disease; mortality jumps to 5-10% for measles infections in developing countries (PLoS Med. 2007 January; 4(1): e24). Those are odds I wouldn't want to play around with.

The logic is simple: If you're vaccinated against Disease X, then you will not get Disease X. Given that the consequences of getting many of these preventable diseases include permanent disability, or worse, death, it's hard for me to understand why loving parents would would choose to not vaccinate their child.

A special mentor

The second half of my pediatrics clerkship was much better than the first half. This was partially thanks to working in a practice that focuses on special needs children, an interesting twist to what otherwise would have been three weeks of garden variety ear infections, upper respiratory infections, and stomach aches. But I mainly attribute the quality of my outpatient pediatrics experience to my preceptor. She's a role model for the kind of physician I hope to become, even if I won't be going into pediatrics.

She makes a real difference in her patients' lives; they travel surprising distances just to see her. She is a passionate advocate for her patients' physical and mental health in the context of an often hostile health care system. She is an excellent clinician, able to identify the rarest diseases with simple observations accumulated over her decades-long career. And in her spare time, she has traveled throughout the world participating in medical aid missions. She loves what she does and gains true satisfaction from her work.

I wish I could have spent more time with her.

Playing with zebras

There's a saying in medicine: "If you hear hoofbeats behind you, don't turn around and expect to see a zebra." Thus, the term "zebra" in the context of medicine refers to a very rare and unlikely diagnosis.

It just so happens that I am spending the last couple weeks of my pediatrics rotation working at a private practice that specializes in zebras. My preceptor is a pediatrician who provides health maintenance for children with "special needs." In the short time that I have been working at this private practice, I have seen a wide range of diagnoses; no child has been "normal":

• Non-accidental trauma, child abuse, and in utero exposure to alcohol and drugs. These are children with nauseating histories who otherwise would have been lost in this world if they had not been taken in by incredible adoptive parents who love these kids as their own.
• Attention deficit hyperactivity disorder, learning disorders, and developmental delay
• Autism spectrum disorder. These patients take the prize for most exasperated parents.
• Down syndrome. At various ages and levels of severity.
• Fragile X syndrome. I was struck by the variability of presentation. Aggressive behavior was the biggest concern.
• Williams syndrome. Truly a cocktail party personality.
• Prader-Willi syndrome
• Cri du chat syndrome. The child I saw was too old to have the characteristic cry.
• VACTERL syndrome

I can't overstate how helpful, in terms of my medical education, it has been to see in the flesh these patients with rare genetic disorders: to take in the gestalt of their presentation, to interact and play with them, to listen to their parents' experiences raising these children with special needs.

More personally, I am amazed, inspired, and humbled by the depth of love lavished on these children. Regular parenting is a full-time job, but caring for and raising special-needs children demands an enormous amount of fortitude that I cannot fully comprehend.

Sick

It was bound to happen on my pediatrics rotation: I'm sick. What else would I expect from exposure to coughing and sneezing and drooling and runny noses for 12 hours per day over the last 3 weeks? Kids are germ-machines.

I wore a mask when seeing almost all of my patients, always with the sick ones, and I washed my hands like someone with obsessive-compulsive disorder. This past week while on inpatient service, I also wore a gown and latex gloves while seeing all of my patients - required precautions. Apparently, all of that wasn't enough.

Abdominal pain in a child

Of all kids coming to the emergency department complaining of abdominal pain, plain old constipation is to blame 70% of the time. Just such a kid came into the ED, but it turned out to be much more interesting than constipation.

Talking to Mom, I found out that the girl had been having stomach pains intermittently for over a year, that she could be fine one minute but doubled up in pain the next. These episodes came in clusters, were not associated with school, and were separated by months with the last episode happening several weeks ago. She was indeed previously worked up extensively for her abdominal pain ruling out things like appendicitis, pancreatitis, and celiac disease. In fact, an abdominal x-ray a few weeks ago even ruled out constipation.


The little girl last had a bowel movement earlier in the day, and Mom noted it to be soft without excessive straining required to defecate. She also had two bowel movements the previous day. None of this was pointing toward constipation as the cause of this girl's abdominal pain.

My patient was difficult to talk to. She would hardly look at me. Even when I asked her simple questions like "What's your favorite color?" she would look over to Mom, who professed that her daughter was normally very talkative. Mom was also difficult to talk to: she couldn't get words out of her mouth fast enough, she went off on tangents before eventually answering my questions, and she spent a lot of time unloading all her worries about what might be causing her daughter's abdominal pain.

Within a few minutes of entering the room, and without even touching my patient on exam, I was already pretty confident about my diagnosis. This could be delicate and require some tact.

"Are there any significant psychiatric problems in the family?"

Jackpot. Mom described symptoms in herself highly suggestive of no less than three psychiatric diagnoses, all of them undiagnosed and untreated. She also said that the kid's father is on medications for two psychiatric disorders. Further delving into the social history revealed significant turmoil at home, including an absent father and other significant stressors.

After a thorough exam, I explained to Mom that I ruled out the scary stuff that could be causing her kid's tummy pain. I said that the clinical picture doesn't really fit a physical cause and that I thought it was more likely that her daughter's stress or anxiety might be behind her symptoms.

Brace for impact....

But to my surprise, Mom accepted what I had to say: "You know, that makes so much sense. No one has ever suggested that before!" Encouraged, I then explained to her that it is very common for children to convert emotional or psychological stress into physical symptoms and that this is called conversion disorder.

In hindsight, this child in fact didn't have conversion disorder because the diagnostic criteria for conversion disorder require another non-pain neurologic symptom, which this girl did not have. She probably met diagnostic criteria for chronic pain disorder with psychological factors, the treatment of which is psychotherapy and antidepressants.

I explained to Mom that it is really important that her daughter receive prompt treatment for this problem to decrease the chances of her developing other psychiatric problems such as an anxiety disorder. For what it's worth, she said she would follow up with her daughter's primary care physician for a referral to a child psychiatrist. I really hope that actually happens.

Pediatric emergency medicine

For the past two weeks, I've been doing shift work in the Children's emergency department at St. Joe's. I only had to do seven 12-hour shifts over these two weeks, and the rest of the time I had off. While I definitely very much appreciate all the free time it has given me, I have also learned that I like more regularity in my schedule. What's worse is that these shifts are 11a-11p, which has shifted my internal clock back several hours. Returning to a normal routine will be a bit painful.

Most of the patients presented with fever, ear aches, runny nose, cough, vomiting, diarrhea, or a combination of the above. It is flu season, after all. This got to be routine, boring. I also saw a few kids with minor broken bones. There were a few other truly interesting cases, which I'll write about later.

But all in all, I have come to the conclusion that I definitively do not like general pediatrics. Good to know. How does this affect my level of interest in pediatric neurology, a course of training that requires two years of general pediatrics? I still have to figure that out.

Endless ear exams

My least favorite part of the physical exam is looking in ears. It's especially difficult in kids because their ear canals are small and crooked, and of course kids tend to squirm and scream when you try to stick something in their ear. Go figure. But a good ear exam is absolutely essential in pediatrics. That's why I made a point to hammer away at the ear exam until I got the hang of it.


Tough going, at first. Too often I would look in a kid's ears and just see a ball of wax, or the sides of the ear canals but no tympanic membrane. When ear pain wasn't a chief complaint and I wasn't concerned about an ear infection, I just nodded my head reassuringly and continued with my exam. This falls under the category of "Fake it until you make it" - first to avoid alarming parents that they are entrusting the care of their child to such an amateur, and second to protect my own ego. But I would return to my attending, tail between my legs, and sheepishly report "Tympanic membrane not visualized" in the physical exam section of my oral presentation.

The attendings are for the most part understanding that a third year medical student isn't going to do a first-rate ear exam. In fact, they seem to expect it. One attending said, "I don't even expect pediatric interns to give a good ear exam. You have to look at thousands of ears to get good at it." Fair enough. Being that we're in the middle of flu season, I've gotten a good jump-start on those thousands.

I think I'm already getting better. I'm probably visualizing about two-thirds of all the ears I look in, at this point, up from around 0-5%. If there's wax, I remove it and try again. If the kid is squirming, I coach the parent on how to hold the kid down. If the kid is screaming, I ignore it. I'm such a meanie.

But being a heartless sadist has paid off. Today a kid came in tugging at her right ear. I looked in the left ear first, then the right, and thought I saw infection in both. The left ear actually looked much worse with erythema in the canal, no light reflex, and yellowish fluid behind the tympanic membrane obscuring the bony landmarks. I described these details to my attending, aware that they were at odds with the patient's history. After doing her own exam, she said five words that every medical student loves to hear from their attending: "I agree with your findings."