3rd Year Struggles: How to Look Less Stupid than You Are

Dear rising MS3s,

Welcome to the big show - sorta.  Third year is this magical time where you are expected to know how to take care of real patients.  Rather than worrying about that, I am sure you are busy taking selfies with your white coat on and stethoscope around your neck while tweeting about how early you have to start getting up, #medschoolproblems.

This may come as a shock, but you are a clinical moron.  The sooner you accept that, the sooner we can move on to improving it.  I don’t care if you are coming off your 260 step 1 score, real patients don’t present with multiple choices.  All that score means is you are good at diagnosing and treating paragraphs of words, not people.  I am only saying this from experience.

When you start your first day on the wards you are going to realize you got pushed into the deep end of the pool, sans floaties.  Like someone truly drowning, you will be tempted to flail about, reaching out for anyone to save you.  Don’t.  No one has time to hold your hand, and you will quickly make people hate you if you constantly beg for advice/help/guidance, etc. 

Have no fear, I am going to give some tips to make the transition easier and help you look semi-competent.  Behold my list of life-saving resources for third year. 

1. Scut Sheets (http://www.medfools.com/downloads.php) - you will likely follow 1-5 patients while on the wards.  This sounds easy, but things move fast and you don’t want to be presenting old data on rounds.  Scut sheets allow you to organize your patient information in a way that is easily accessible and portable (iPads are great, but in my experience you can’t beat good old paper).  Further, the H&P sheets help to remind you of all of the things you need to examine/inquire about.  You don’t want to be the student who comes back to report on a patient with epigastric pain in whom you never examined the cardiopulmonary system.  Print a couple of each style to find one you like.

2. Stanford 25 (http://stanfordmedicine25.stanford.edu/index.html) - remember that time before step 1 studying, when you had to practice actually touching people?  That was called the physical exam, and you are expected to actually do that… on every patient… everyday.  Better refresh on it so you don’t look like a fool palpating the thyroid over the thyroid cartilage.  Go to the website, click “The 25″ button and see the 25 physical exam skills every student should know, along with detailed explanations.

3. MedCalc (http://medcalc.medserver.be)

Enough said.  Qx Calc is also worth downloading (http://www.qxmd.com/apps/calculate-by-qxmd).  

3. Journal Club (http://www.wikijournalclub.org/wiki/Main_Page) - I guarantee that during the year some jerk-off attending is going to ask you, “what is the best NOAC for atrial fibrillation?”  Obviously, like most, you will stutter because all you know to use in Afib is warfarin.  Then he or she will smile, knowing they have established their superiority, and tell you to look it up and do some sort of presentation.  Welcome to the best tool ever for such scenarios.  This wiki is run by a team of physicians who synthesize large trials into digestible snippets.  The app is well worth the money too. (The answer to the above question is apixaban, by the way, as determined by the ARISTOTLE trial; not that this scenario is based on a real event that occurred to me or anything). 

4. Smart Medicine (http://smartmedicine.acponline.org) - this app is amazing.  Seriously.  It is free to American College of Physician (ACP) members; and membership is free to students.  You should join just for this app.  This is much less cumbersome than UpToDate and will will make you shine when you present your assessment and plan (also, rumor is that DynaMed and ACP have teamed up to create an even more amazing tool that is coming out in August, also free to members).

5. Medscape (http://www.medscape.com) - this is an awesome resource that is free. Medscape is one of my go to apps for understanding disease pathophysiology.  Another feature, which most students don’t realize, is the articles on surgical procedures.  This is HUGE for your surgery clerkship.  You can read over the procedure, see relevant anatomy and know just enough to be one step ahead of this guy:

Plus you get updates on medical news, have access to practice questions, etc.  Get it, use it, love it.

6. Online Med Ed (https://onlinemeded.org) - aside from learning real medicine, third year is about preparation for the step 2 of the USMLE.  I advise finding a question bank and organized program to keep your studying on track throughout the year.  Enter God’s gift to med students.  This is one man and a mystical dry erase board that will make learning clinical medicine easier than cooking a Totino’s pizza.  And it is one of the few things cheaper than a Totino’s!   

So there you have it.  You now are better equipped for the coming onslaught of pimp questions.  My suffering is your gain.  Below I will list a few other apps I have used this year that were less important to my success.  Happy studying.

ASCVD Risk Estimator (http://tools.cardiosource.org/ASCVD-Risk-Estimator/) - I believe there is an app in the app store as well.

Anticoag Evaluator (http://www.acc.org/tools-and-practice-support/mobile-resources) - see the risk factors for coagulation

CDC vaccine schedules app (http://www.cdc.gov/vaccines/schedules/hcp/schedule-app.html)

Read by QxMD (https://www.readbyqxmd.com) - allows you to get medical articles directly to your phone using your institutional access.

Sensitivity and Specificity (http://lifeinthefastlane.com/techtool-thursday-055-sensitivity-and-specificity/) - link to the app and review 

Pap Guidelines (http://appcrawlr.com/ios/pap-guide) - a free version of the ASCCP app and a life saver while on Gyn. 

Side Effects May Include....

While attending medical school, you may experience:

1) Insomnia

2) Narcolepsy (exacerbated by professors who are only capable of reading slides in a monotone voice)

3) Caffeine-induced anxiety attacks

4) A drastic increase in your use of profanity (at least in your mental dialogue; may be exacerbated by pending exams)

5) Mental hangovers aka the emotional and intellectual inability to give approximately 0 f**ks the day following exams

6) Chronic single-ness (and an inability to find anyone worth dating whose idea of a relationship doesn’t involve hooking up on a first date)

7) The appearance of speaking in tongues, especially when around non-medical family and friends

8) Rarely, students have reported weird and sudden bouts of euphoria, typically following an aha! moment, a fulfilling clinical encounter with patients, or otherwise being reminded of why you put yourself through this utter torment in the first place

Medical school teaches you how to be 100% person. As a future doctor, you have to be intelligent - of course. You have to be truly devoted, strong, confident yet humble and ready to work harder than you could’ve imagined ‘till now. You have to be striving for perfection, because you can’t afford to be 99% right. You are either 100% right or 100% wrong.
—  My professor of Internal Medicine on ‘Introduction to Internal Medicine’. 

It’s up to you now. I’d like to share something with you.. You know that feeling when you need to study and you’re just not feeling it, but you think if you watch a movie or eat some chocolate or watch TV or YouTube or do anything else you’ll get that epic motivation and stay all night awake studying? That stupid thought “I’ll do it later”? Well let me tell you, when you get that feeling, DON’T run away from studying, because even when you finish procrastinating and doing things you like, that motivation will not come, you will feel the same and want to procrastinate more! So, when you are not feeling like studying, remember that you’ll not be feeling it even when you finish procrastinating, so forget that “I’ll do it later”, sit down and STUDY HARD! I know it is hard, I know exactly how you feel in that moment when you have to study but you reeeeally don’t want, but believe me, you will feel sooooo much better when you finish, and success actually will motivate you! Good luck and don’t give up! :)

The Blight of Third Year

My third year of medical school has been an exercise in restraint.  I am consistently disappointed by the terrible descriptors used to discuss patients.  Smelly, stupid, ignorant, etc., are all words I have heard used to define them.  This mostly comes from the residents and is often defended by the fact that they are working long hours in difficult conditions with little sleep.  But to me this is no excuse.   

It is no surprise then that students exposed to this behavior are destined to repeat it.  This has been called the “hidden curriculum” of medical school.  Far from the shining examples of patient care gone right is a world of loathing and dissatisfaction.  Doctors find themselves pulled away from family, bothered by seemingly meaningless problems, and thrust into a world where costs matter but cannot be contained. They then let loose their resentments in the only direction they can: at patients.   

Perhaps this is why the third year of medical school, the first clinical year, is where cynicism takes root (Hojat, Vergare, Maxwell, et al., 2009; Newton, Barber , Clardy, et al, 2008).  We have created a cycle of discontent.  Students flock to the wards, after years of cramming book knowledge, only to have their fantasies quickly quelled by those ahead of them.  Instead of learning the finer points of end of life care, I have found myself in surgeries that the surgeons jokingly called “autopsies,” since the patient might has well have been dead (and likely would be soon). Rather than being part of a teachable moment, I have seen patients given unnecessary antibiotics to satisfy their “complaining.”  And I have seen patients who, for cultural reasons, denied care and were called ignorant, missing the opportunity to explore a culture not our own.

Many have attempted to explain this slow erosion of compassion.  Reasons abound, from the introduction of electronic health records, which diminishes direct patient contact, to the push for evidence-based medicine, making algorithmic and science-oriented medicine predominate over individualized care. But as a third year student the causation is obvious – poor role modeling.

Imagine if the above scenarios had gone differently.  What if the residents had voiced concern over operating on a dying patient who was unlikely to get benefit from the intervention?  What if the attending listened?  That would have been a dramatically inspirational moment, one that would have greatly impacted me as a student.  A lot of money is being spent on learning how we can improve student empathy and patient-centeredness.  Perhaps the solution is a sizable bolus of compassion.

Third years are so impressionable as they flood the wards in their short white coats, scurrying after attendings like baby ducks after their mother.  They are easily influenced because they are searching for a way to fit in and impress.  We do not need another lecture or activity to guard students from the fate of bitterness. We need instructors to step up at each opportunity, to share teachable moments, and to perhaps ask themselves, “what would I want my doctor to do?”  One day it might be them, laying on the gurney, benefiting from those wonderful lessons in compassion.

Citations

Hojat M, Vergare MJ, Maxwell K, et al. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Acad Med. 2009;84(9):1182-91.

Newton BW, Barber L, Clardy J, Cleveland E, O'sullivan P. Is there hardening of the heart during medical school?. Acad Med. 2008;83(3):244-9.