The Daily Something: Working With Med Students

I love working with med students.

I remember very well what it is like to be a med student, and I cringe at all the horror stories I hear about how residents treat med students badly. Especially on L&D rotations. That is total crap. Med school is hard enough without someone taking out their frustrations and residency-related rage on some poor med student who is trying to learn, who we have a responsibility to teach, so they can go out and be a competent resident themselves soon. And hopefully not scare them out of a career choice just because we were an A-hole to them.

But I don’t love working with them because it’s my responsibility to. I actually enjoy the responsibility of teaching, of watching their knowledge expand before my very eyes, their brains soaking it all up like hungry, impressionable sponges. I love that they love that I make at least half an effort to teach, and include them as much as I can, if my evals from this year are any indication anyway. (They were awesome, literally, the biggest self-esteem boost I’ve had in my medical career to date, reversing at least some of the damage Intern Year has wreaked. Forget the diplomas, I may have those evals framed.) And fine, I love working with them because, frankly, I love having a buddy to hang out with in the trenches (so to speak). When we’re working all buddy-cop style, and I’m rambling on about how great OB/GYN is, I remember myself, and when I’m trying to make it fun for them, it always ends up being more fun for me too.

And also, of course, every time I work with them on L&D call it is invariably A Night Of Firsts. With the last med student, it was The First C-Section. I had them scrub in as third assist (this being The First for them, and all). It was a challenging repeat, the baby was (for lack of a better term) a Big Fella, and I got to be primary. So, I was too busy during the actual surgery to pay much attention to how the med student was faring (aside from the fact that they were right there with suture scissors and bladder blade at appropriate intervals, and didn’t appear to be faltering or swaying in any I’m-totally-going-to-pass-out-right-now sort of way).

Afterwards, when we left the OR to put in the post-op orders, I finally remembered my buddy and asked, “Oh yeah! Hey, So what did you think of your first C-section?!” To which my (completely reserved and apparently introverted up to this point) med student compadre replied, “What. Just. HAPPENED in there???!! OH MY GOD!!! There was just…like…stuff….coming out everywhere!!! And then, there was…like…a BABY!!! And it came out…and it was all, like……….”

(Best reenactment I could find of what med student compadre did at this point.)

I stopped, watching this graphic reenactment, and then I laughed. Really, really hard. For awhile.

I have done, or scrubbed on so many sections at this point, I forget what it what must look like to people who haven’t. There is a reason why it’s is my favorite surgery. Triple-bypass-multiple-transplant-sterotactic-robotic-Whipple’s got nothin’ on us. I mean, I’m always highly aware of this, but med students are Awesome for (graphically) reminding me of it.

I love working with med students.

(Not-So-Youthful) Enthusiasm

Today, is just, a great day.

It is a beautiful, uncharacteristically snow-free, somewhat Spring-y March day outside, I’ve officially got one less week before I’m done, I get to spend (another!) entire weekend off with one of my most dearly beloved best of buds, plus, I learned SO much this week!

SO much.

My excitement about all this learning of Useful Stuff (with all due sincerity) cannot be overstated.

Other Student on Rotation: “Um, yeah, I’ve never seen someone get this excited about RPhWorld. I applaud your, uh, enthusiasm.”

Me [madly, gleefully clicking links]: “Are you kidding me? This is so….I mean it’s just….so…..awesome!”

~ One of many, new-found knowledge Moments Of Joy courtesy of this week.

Sure, I have been tired out, adjusting to spending so much time just reading and studying after months of purely clinical experiences, but it has been so worth it. I have been tearing through ACOG Practice Bulletins and Cecil Textbook of Medicine and learning ridiculous amounts of clinically useful information.

For instance, did you know:

* That Primary Hyperparathyroidism is the most common cause of hypercalcemia and Glucocorticoids are an extremely effective treatment for hypercalcemia but only in conditions where hypervitaminosis D is the underlying cause?? Or that hypercalcemia can lead to depositions of calcium in soft tissues (including the cornea!) especially when there is concurrent hyperphosphatemia??

* Or that albuterol (in higher than usual doses) is a treatment for hyperkalemia? And calcium gluconate used to treat hyperkalemia is actually used to counteract effects of high levels of potassium on the myocardium??

* That standard of care is to discontinue antenatal chronic B/P medications within two days of finding out a patient is pregnant, then you should offer an alternative medication (usually methyldopa), then you need to discontinue methyldopa within two days of birth and resume the antenatal medication?? Unless its an ARB, ACE Inhibitor, diuretic, or amlodipine, which are all contraindicated with breastfeeding??

* That 70-85% of pregnant women have nausea and vomiting, and 35% of those women have clinically significant nausea and vomiting (leading to significant psychosocial morbidity), and one study found hyperemesis gravidarum is undertreated and has lead patients to terminate pregnancies??* That Vitamin B6 and doxylamine (Unisom) are first line treatments for nausea and vomiting in pregnancy, and that preconception supplementation with a multivitamin can potentially help patients avoid or diminish nausea and vomiting in pregnancy?? Not to mention, that if not treated with Vitamin B1 (Thiamine), pregnant women who have had significant nausea and vomiting for > 3 weeks are at risk for Wernicke’s encephalopathy with lasting neurological sequelae?? (I mean, what??)

* Don’t even get me started on everything I just learned about OB analgesia and anesthesia. Seriously.

Pretty much my life for the last week. So frigging awesome. Really.

Ah, unless you are watching me study. Which, apparently, is so frigging boring.

Oh! And, in addition to the usual clinical resource suspects (i.e. UptoDate), I have been discovering and plundering new, amazing, and (very importantly!) reliable provider and patient** resources. Such as:

RPhWorld.com – Ridiculous amounts of pharmacologic knowledge. And calculators. I had no idea so many helpful med/clinical calculators existed in the world (For the Maths impaired individual, this has to be on par with finding oil in your backyard. RPhWorld where have you been all of my medical life?) AND it is FREE. No. Joke.

ACOG.org – Chock-full of everything you ever wanted to know about OB/GYN and more. For providers and patients. (Note: Plus, as a student you can apply for membership for FREE. Pssst – ACOG membership looks really good on a CV if you are going into OB/GYN!)

Epocrates Online – This is a standard resource for clinicians, particularly in the form of smart phone apps, but I also discovered providers and patients can register online (again, for FREE) to access not only tons of information about medications, but also about common disease conditions. (Note for students: If you click on a disease and see the resources listed below, you can often click on a citation for a full text article – Bonus!)

Medscape – Another standard resource, but note it is also for providers and patients. Plus it is another (reliable) source of the latest news in medicine, full-text articles, and again, you can use it for FREE if you register.

This is just a taste of the clinically relevant bounty I’ve encountered this week. I could keep going (like, indefinitely), but it’s time to pack for a weekend of extreme fun (in which I continue suppression of all obsession related to The Impending Match. With loads of BFF QT. Yay!).

Such, a great day. I daresay if L&D picks up next week and I actually get in on a delivery or section in the midst of another week’s learn-a-thon, life, will be all Mary Poppins and sh*t.***

*According to ACOG and an NEJM article.

**Personally, I have been encountering quite a few patients lately who are getting medical information from TV commercials (“I’m not taking [Insert Medication Here]!! Have you heard all the side effects of that [Insert Medication Here] on the commercial??! Hell, my [Insert Body Part here, usually, Pecker] could fall off!!” Usually, I have seen the commercials, and can’t say I blame them.), Woman’s Weekly, or Dr. Google. I am all about providing patients with quality educational materials, and I think it is totally awesome when patients take the initiative to research medical conditions and treatments, so I love having actually accurate, and reliable, sources to refer them to.

***Practically Perfect In Every Way

Forgetting. And Remembering.

Despite all the napping and procrastination yesterday, I really hoped was totally confident I’d managed to do a decent job preparing for rounds this morning. This feverish hope utter confidence, combined with just coming off a rotation with, like, the Nicest Most Confidence-Buildingest Attending Ever had me feeling all……..

Nurse, MD: (Almost) Doctor. Bring it.

Then, rounds actually started. And I realized, after weeks of working solely with Dr. SuperNice, I had totally forgotten about pimping, and apparently, almost all of what I learned in the last three years of medical school.

There I was standing in the middle of the ward, surrounded by staring, erstwhile peers, and Dr. LessNiceAndMoreScary while I struggled desperately to retrieve some arcane rule about hypercapnia and something about 10’s. Some information I’d surely had down pat at some point, but had since carelessly tossed into an abandoned synapse like an empty can of Busch light or an unwanted puppy out of a car window onto the side of a dirt road while blissfully road-tripping my way through fourth year (not that I would ever do that, I mean litter, or throw a puppy, or not want a puppy).

I quickly devolved into…….

Oh my GOD. I am SO not ready to be a Doctor. Help. Me.

This was rewarded with “Even an obstetrician needs to know that.”

Ouch.

I hate being pimped. Actually, I hate not knowing the answer to Absolutely Everything, when I get pimped. I had forgotten how much.

Flash back to last year. Small group and I’m up. At the white board furiously scribbling. And the group leader, a deceptively Santa-resembling retired MD, pipes up to ask a question. I stop scribbling to hem and haw, standing in front of the class doing the med student’s version of the pee pee dance. I tentatively venture an answer, am completely wrong, and my shoulders slump in defeat.

“Yeesh,” says Dr. NotSaintNick, “if you’re that sensitive, I hope you’re not going into surgery.”

Righteous Indignation.

Who are you call...I am NOT sensitive....sniff.

Okay. Maybe I am a little sensitive. I’m working on it alright.

The point is, I remembered some very Important Things today.

1. There is lots of pimping in medical school. There is going to be even more in residency. Get used to it.
2. Just like crying in baseball, there is no place for sensitivity in medicine. (Wait, that doesn’t sound right.) Doctors are very sensitive towards patients, just not each other. (Wait, no, that’s not right either.) Medical students and residents can’t be sensitive. When they get pimped. They just need to buck up and learn and…..(Good grief….Ahem.) You will get pimped (a lot) in medical school and residency, don’t take it personally and try to learn something from it. (Aha!)
3. Even though you studied your brains out in medical school, you are not going to remember/know everything. Keep studying.
4. Do not get all over-confident as a practitioner. Fear (at least a little), and the persistent knowledge that you do not and will never know everything, is healthy. It will keep you on your toes, keep you studying, and constantly striving to check and double check, to make sure you are making the right decisions in regard to patient care.

Right after the pimping disaster I ran into one of my nurse buddies who was visiting a friend in the hospital. She is one of my favorite people ever. A sort of overly sensitive, perpetually naive, grandmotherly type, who makes me think of homemade chicken noodle soup, hot cocoa (with mini marshmallows), and cuddly knitted afghans. Patients ask for her by name, and without exception, love her. So do I. As soon as the other stuffy doctor-types were out of eyesight, she told me how proud she was of me and gave me a big hug.

I’d forgotten how awesome her hugs are.

Like warm sun shining on your face on a cold, snowy day.

My bruised ego balmed, I walked away, from a part of my (more sensitively acceptable) nursing past, towards the group of white coats huddling up around another chart, my future.

And now, I’m going to keep studying, and try to remember.

 

*Note: As an added bonus, today I also re-discovered Natalie Dee and her awesome comics, which I had completely forgotten about.

HOW could I have forgotten??? They are so awesome!!!!

Lessons from The Interview Trail…….

The main reason I’ve been a bad blogger lately is because I’ve been spending a lot of time on The Interview Trail. In the last month I’ve gone to five interviews (you do the maths, I been busy), and per usual, I had pretty much no idea what I was walking into. Thus, I have learned some important (I think) lessons in the process. Occasionally The Hard Way, per usual. In the continued spirit of cooperation and good Karma, I’d like to share a few of my hind sights, and hopefully save some other poor, unsuspecting med fools a modicum of angst. Feel free to partake or leave them as you will. Per usual.

Lesson #1: Planning. It’s all about Planning.

Planning for your fourth year rotations, residency application, Steps, and interviews takes a lot of time, foresight, and organizational skillz in order to have maximal experiences with minimal stresses. Which I know now. Oops. Seriously though, if you’re at all like me, i.e. not much of a secretary, you need to get cracking on this stuff for realsies halfway through third year.

 

1. Scheduling, Schmeduling….

* Make sure you schedule your testing periods for the Steps so you can take the tests in time for scores to reach residency programs. I would advise scheduling them as soon as you feel reasonably prepared, and getting them over with. The good news is they are not nearly as difficult as Step 1, and you will not need (nearly) as much prep time. Bite the bullet and get them out of the way because you are going to have a lot of other stuff to do later in fourth year.

* I think it’s also a good idea to schedule a rotation with a lot of downtime, or a week off at the beginning of fourth year to get your residency app done. Completing the app, filling out your CV, writing your Personal Statement(s), and gathering Letters of Recommendation can be time consuming. You are going to need four or five LORs, at least two from attendings in your specialty of choice, and one from your school’s Chair of the Department of your specialty of choice, as many programs will require it. From the Duh Department, try to get letters from people you have actually worked with, who will write glowing reviews of your performance in medical school and as a human being in general, or just, you know, nice stuff. And give them plenty of lead time to get letters done. Some Docs are champion procrastinators, be prepared to bribe and/or (nicely) nag if necessary. I’m just saying. Point being, sit down and hammer it out ASAP so you can get on with the good(er) stuff.

* You also need to schedule enough time off or flexible rotations in November, December, and January of your fourth year so you have enough time to make it to all the interviews you want. You are going to need a lot of time to  prep for interviews and travel, in addition to time for the actual interviews, which are usually two day affairs. These three months (especially November and December) are not the time to be stuck in rotations with strict attendance policies.

 

2. The Rest of Your Life. No pressure.

* Get busy figuring out what specialty you want to go into, how competitive you are, and what programs you like. Information about how competitive you are and the current residency programs in your specialty should be available online. Try Googling “How many programs should I rank in [enter specialty of choice here]” or “[Specialty of choice] residency programs.” Using this high-tech approach for OB/GYN, I found these very helpful sites:

General OB/GYN residency application guidelines

APGO OB/GYN residency directory

* Depending on how competitive you are, in order to give yourself the best chance of matching, you need to apply to an appropriate number of programs, plan on scheduling an adequate number of interviews, and if necessary, start setting up away rotations for fourth year at programs you are interested in. For example, I am applying in OB/GYN and with my board scores I needed to apply to about 20 programs, plan on about 8 interviews, and rank 7-8 programs. (Note: On the away rotations, I say if necessary, because they give you an edge if you are less competitive, you want a really competitive program, or you are set on a certain program.)

* After you start receiving interview offers you have to act quickly. Spots fill up fast (I’m talking 24 hours) and in my experience  many programs offer interviews on the same five or so days, so be prepared to prioritize and take interviews at the programs where you are most likely to actually want to do your residency.

 

3. Mo’ Money, Mo’ Problems.

* Lastly, the Step 2 tests, and interviews are freaking expensive. I am currently spending about $300 – 500 per interview. Your loans are probably (most likely) not going to cover all these expenses. Especially if you plan to continue eating, having a roof over your head, gas in your car and, you know, other piddly stuff like that. So plan accordingly. Start sucking up to the parents, taking out a(nother) credit card or a personal loan, donating plasma, getting a job (ha ha), etc. Do what you gotta do. Preferably, before the middle of interview season when you are faced with the prospect of living in your car and eating ramen noodles prepared ala radiator.

 

4. Last, and most important, Don’t Freak Out.

See this guy? You do not want to be this guy. I suggest you plan accordingly.

Take time to process peeps. More Lessons from The Interview Trail coming soon!