100 Things You Learn Third Year of Medical School

So every year I’ve been writing these lists of 100 things you learn in each year of medical school (Found here). I am incredibly excited this year to bring you my list of 100 Things You Learn in your Third Year of Medical School.

This list contains advice about how to function on the floor, how to study, and how to handle your work-life imbalance. Click through to find such advice as:
• Whatever size scrubs you wear will be the least common size to find. Take as many pairs as you can find and stockpile them.
• EVERY procedure in OB requires shoe covers. Better to not need them than to have forgotten them
• Night shifts only come in two flavors: Insanely busy or so quiet you can not keep your eyes open.
• The best residents will notice when you’re sitting around doing nothing and will send you home—the worst residents will forget you’re even there.
• Falling asleep at 9pm is nothing to be ashamed of—in fact be proud of it.
• Get comfortable with being uncomfortable.

Best of luck all you new MS3s!

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Advice to incoming MS3s

Third year is officially over for me, which is BONKERS. Some quick words of wisdom:

  • Start using UWorld with every rotation. I know, you thought you were free. You were wrong.
  • Have at least 2 white coats and wash with bleach once a week, don’t be nasty. 
  • An ipad mini fits in most white coat pockets. You will have lots of snippets of time- 15 minutes here, 20 minutes there- to study. 
  • Always ask if there is anything you can do to help the team before you sit and study.
  • Your scheduled leaving time is not concrete. Especially on wards. Don’t hang your hat on ‘4pm’ if that is when your syllabus says you are supposed to leave. It’s more like ‘around 4pm’. 
  • However the residents are busy and will often forget to dismiss you when you’ve served your usefulness for the day. Find the right words that include asking if there is anything else that you can do to help the team, and if not asking if you can go home to study for the shelf. YOU ALWAYS HAVE TO STUDY FOR THE SHELF. 
  • Find out on day 1 and with every new team what is expected of you. This will lead to less heartbreak later (ex: team 1 told me that xyz was ok. When team 2 came at the start of the month I asked about xyz and that was NOT kosher with this team and we never recovered. True life story).
  • Schedule internal medicine or family medicine last, so the broad shelf review can double as Step 2 review. 
  • Schedule surgery rotation when the weather is gross. At least you won’t be missing anything when you’re inside from 5am-5pm or later. 
  • Avoid rotating on inpatient peds during January if you can. It’s the busiest and worst month for peds wards. 
  • You will get either a nasty upper respiratory infection or a hideous gastrointestinal bug on peds. It happens to everyone. 
  • Emma Holliday Ramahi has SUPER CLUTCH lectures/powerpoints for internal medicine, surgery, peds, and psych. If you know her stuff cold you will be a-ok on the shelf exams. 
  • Pestana Surgery Review is also great for the shelf and being pimped.
  • Surgeons are always late. You are late if you are on time. Always be early on surgery unless you were scrubbed in a case. 
  • There is no good guide to study for the neuro shelf, but I used Blueprints and Casefiles and UWorld and I passed. 
  • For family medicine, join AAFP and register for their qbank (it takes a week or so to verify your account so do it early in the rotation). 
  • For ob-gyn the best qbank was APGO. Free for students and I felt the comprehensive quizzes prepared me for the shelf. 
  • Blueprints and Case Files were what I used for shelf exams and I passed all of them, but everyone has different resources so just use what you like. 
  • ALWAYS HAVE SNACKS YOU CAN NEVER HAVE TOO MANY SNACKS ON YOU AT ONE TIME SAVE A LIFE.
  • Have multiple pens. A pen is a precious resource in the hospital.
  • If you can, cut back on your caffeine intake before third year, because you’ll need it to do something for you this year. 
  • It is definitely possible to get at least 7 hours of sleep on non-call nights, but you have to cut pretty much everything else out. 
  • Take one day a week off from shelf studying for the love of tacos. 
  • Basic food prep ahead of time is massively helpful. 
  • Good luck going to the doctor or dentist (unless it’s an acute thing) tho, it’s kind of garbage. 
  • Do yourself a favor and put your full rotation schedule, rotation lectures and locations and random quizzes/assignment due dates in your organizer of choice the first day of the rotation. 
  • Forgive the interns, their lives are pretty shitty and that will be you in 24 or less months. 
  • Stick up for your fellow med students. 
  • You have more time than anyone on your service. Spend time with the patients. See if the nurses will show you how to draw labs. 
  • Sometimes you will be stuck with scut work. Scut work sucks but it usually is something that helps the residents and you always want to help the residents.

AND Here is my Basics for Wards series, hopefully it will be helpful to you.

Good luck!

A med student’s take on dissecting multiple choice questions.

On today’s episode of Step 2 procrastination, I thought I’d share how I tackle multiple choice questions. This is the strategy I’ve developed over the past year for Uworld, shelf exams and board exams (and MC exams in general). Most are things I found helpful that I’ve passed along to underclassmen and I figured I’d share them with you. Feel free to add your own tricks! 

Surviving a Day in the OR/OT

Of all rotations surgery is quite a foreign environment for fresh clinical year students. It can take the full rotation (or even a few afterwards) to get adjusted. It’s like scuba diving for the first time - it’s just a whole new world. 

Rule of thumb - no touching anything when you’re inside, and just get directions from the teams on where to stand and even place your hands. 

Let’s say tomorrow you’re ready to start a day in OR (operating room) or OT (operating theatre) = same things, just different lingo depending on where you are in the world. 

Day before 
(That’s right, you have to prepare the day before)

1. Find the theatre list

- if someone hasn’t pointed out where this is, just ask. Ask your team which rooms or theatres they usually operate in. Usually, teams use the same rooms, as they’ll have optimal set ups and equipment etc. After you find the list (by the name of your attending/consultant), find out what cases you’ll be observing or assisting in for the next morning or day. Write down the procedures and patient URNs or hospital identification numbers. 

2. Pre-Read as you would for class!

Read up on the surgeries if you have time (very cursorily, you don’t need to know the precise techniques as a student). If the patient charts are available (sometimes they are, sometimes they aren’t) then look up those too quickly and see what their indications were for surgery. 

Review the anatomy involved in the surgery. Approach it by layers - follow the pathway of the scalpel. What fascia, muscles etc. will the surgeon come in contact with. What are the nearby structures they’ll try hard to avoid - particularly blood vessels and nerves. What organs are they operating on, and what is their blood supply and drainage. What are some post-op concerns specific to the regions or conditions they’re treating. 

[From iFunny]

Of all the clinicians, surgeons as group especially believe in active learning. They love asking students questions, particularly about anatomy. Occasionally you’ll come across the surgeon who asks few questions or explains everything to you. However, many believe that students must be able to show some interest by doing some work ahead of time, and they check this by testing/quizzing you.

If tight on time, at least get a copy of the theatre list the night before or look at the list before you enter the OT/OR in the morning, then cram in your readings between cases/surgeries.

3. Organize a teeny note pad, pocket sized (that can fit in a scrub pocket) with last minute cheat notes. or, if you can, have pocket sized book with you. If there’s down time (i.e. you’re simply observing), you may have a few minutes to study here and there. otherwise..it’ll be boring when you’re standing in the back with nothing to do, not much to see.

Day of:


[From Nursingcrib]

1. Show up early - get ready (flee from rounds the minute your senior resident/registrar or consultant/attending does). At the OR/OT: introduce yourself to the scrub/scout nurse. Ensure the surgeon knows you’re there too. Ask if you scrub in. (always introduce yourself! at the beginning of a day). For security reasons/patient privacy, usually they need to know who is everyone is in the OR/OT.

2. If the patient’s in the anaesthetic room or getting prepped - see if you can chat to the patient and get a history (after you get consent and the anaesthetic team doesn’t mind). Possibly - do a really quick exam if they have a pathology or good signs (after surgery - they won’t anymore).

Read up on their charts if you weren’t able to the night before. Do some last minute reading, brush up on anatomy or the surgical procedure if you didn’t have a chance the night before. Most important - know why the patient is having surgery.

3. If required, help set up the patient in theatre. This could involve helping the team move them to the bed. Or placing the IDC (indwelling catheter). 

4. Scrub in when you see the surgical team disappear to scrub in (won’t go into scrub technique here). Make sure you’re ready to remain scrubbed in for the full length of the surgery, and you know how long the surgery will be (a Whipple’s could be hours). How much you do varies - sometimes you don’t get to do much but watch and hold a retractor (like a giant spoon or handle to hold back the patient’s fat or tissue so the surgeons can see inside the patient), or it could be suctioning (plastic tube thing that sucks up blood or sterile water they may put in) or actually assisting - i.e. cutting the surgeon’s sutures/stitchings. 

[From Quick Meme]

Or if not scrubbing in, find an appropriate place to stand (dumb as that sounds) - always be arm’s length or 30 cm away from the patient and table at all times. Or the nurses will eat you for breakfast. never get close to the scrub nurse when she’s scrubbed and surrounded by sterile equipment.  Make sure you can see the area being operated on.

5. The surgical team - depending on their teaching style (or interest in teaching) - they will ask about anatomy, the surgical approach (in one or two lines, no details, e.g. a cholecystectomy = removing the gall bladder), about the their patient and why they’re having the surgery (e.g. they have cholecystitis) and how the diagnosis was made (elements from the history, exam and any investigations). 

Afterwards:

1. Review teaching points from the cases of the day. Review any post-op things to be aware of, in case they ask on rounds the next day. Review any items the surgeons tell you to look up (they don’t forget) and anything you got wrong (they may ask to check that you followed up on your reading). 

Rinse and repeat. 


N. B. 

It’s a very general overview. Old school surgeons will want their students to know the patient case, anatomy and general aspects of the surgery that every/any student should be familiar with. Of course, not all surgeons are old school. However - just in case, always start out with a similar formula that would keep an old school surgeon happy. You never know when you will run into one, and you don’t want to start off on their bad side. 

Old school = simply means they have expectations or are strict. Almost military-like in a sense. Nothing bad - actually, it can be great. You’ll find you learn the most with these types. Most have no malacious intent, and the more they ask you questions, the more it means they care that you’re learning and they appreciate that you want to learn.

You’ll also run into surgeons who are less interested in teaching or are just too plain tired to. So they may not have any expectations on students to prepare ahead of time or interact very much at all :S

whatever happens

[From Redbubble]

If I’m missing anything..
Lemme know

8

- One more minute and you both would’ve been dead. Neither of you won. Your plan was a half-baked disaster, and if it was not for that fire we would all be pushing up daisies.

The 4 sentence surgery presentation

1st sentence: Name, age, post op day X from Y procedure, for reason Z.

2nd sentence: Relevant 24 hour events. 

3rd sentence: Vital signs (”hemodynamically stable” if you don’t want to list everything), physical exam (tailored to specialty), significant lab values (and the trend direction, up or down). This may not be one sentence but you need to make it fit in the time of one sentence, especially if the senior/attending is losing interest fast.

4th sentence: The plan. Why are they still in the hospital and what do you want to do to move them towards going home?

How to Survive the OR

(from someone who did it for two months with minimal yelling, puking, and fainting)

The OR is a very unique experience, and even if you 100% do not want to go into a surgical field it’s kind of a once in a lifetime thing and pretty freaking cool. I personally found the order and rhythm of OR days to be somewhat soothing (I’m weird and really get off on routine). That being said I was extremely nervous going into it and was terrified I was going to fuck up and/or die. So here are some tips I’ve compiled to hopefully make your OR experience enjoyable or, at the very least, tolerable.  

BEFORE

-GET COMPRESSION SOCKS/COMFORTABLE SHOES. Do not be me. Do not wait until a week of awful leg pain to decide to order compression socks. They were a complete game changer, especially since I’ve been very bullheaded about not buying Danskos so I was just wearing tennis shoes. You will be standing for 2-3 hours at a time if you’re lucky, 6+ hours if you’re not. And this will be repeated for about 10-12 hours a day. Also investing in massages is a great idea. The massage I got at the end of my first month of surgery was the best decision I’ve ever made. I almost cried when she worked on my quads because it hurt so good. 

-EAT, EAT, EAT. I’m not a big breakfast eater but I made sure to at least get a couple of protein bars in me before the day started. This will greatly decrease your chances of passing out, like my rotation partner did a few times. The resident actually told us to not work out in the morning because that will also get your system revved up and not help the situation if you’re already prone to fainting (not sure how legit this is because there’s no fucking way I was working out at 4am anyways). When it comes to water, keep hydrated but don’t down a liter before you go into the OR, or if you do make time for a bathroom break. And keep snacks on you that you can quickly scarf down between cases because who knows if you are going to be able to get a real lunch. 

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“Is the baby ok?”

They ask, hope in their eyes, dreams in their hearts. They can see the ultrasound screen, but it just looks like TV static. You know though. If there was a baby in there, they would have seen it by now- a giant alien head with tiny arm and leg nubbins, and a little fluttering fuzzy spot in the middle with a reassuring whoosh whoosh whoosh whoosh heartbeat.

The lines on the pregnancy test, once so solid and strong, fade away as the patient’s beta-hCG levels fall. The hope drains out of their eyes, and their dreams are flushed down the toilet or suctioned in the OR, a mixture of blood and coagulated tissue. Products of conception is what tests call it. My baby is what they called it.

The worst were the REI (reproductive endocrinology and infertility) clinic miscarriages. These patients had notations in their chart like “G8P0″ (gravida/pregnant 8 times, para/gave birth 0 times) and they were supposed to be 12 weeks- almost to the safety of the second trimester- but they woke up that morning covered in blood and knew it had happened again. These patients wailed.

To be fair, some days on REI were good days: we got to tell patients who had been trying for 10 years that they were having twins, all the babies were growing like they should, the lines on all the pregnancy tests were solid and strong, dreams blossomed and happy tears wet cheeks. Some days were ok- twin A is alive and growing but twin B is gone and is slowly being reabsorbed, we can fix your hormone imbalance and that should enable you to ovulate, your cervix is just shaped different but we can help the sperm get in the uterus.

Did you know that there is statistically only a 25-30% chance of conceiving every time a person with female reproductive organs ovulates? People get pregnant all the time. People miscarry all the time. It’s just part of it, the cycle of life and death, all in one person.

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LadyKayMD: An Open Letter to the Second Year Medical Students I Spoke to Today

Today I had the chance to sit on a panel for second year medical students talking about what it was that had drawn me to my chosen specialty (surgery) and how I knew it was the right fit for me. 

This open letter is the result of that panel. 

Just a few of my thoughts for you second (and third) year medical students who are trying to answer big question of “what kind of doctor do you want to be when you grow up?” 

No fear

“You really don’t have to be afraid to touch the babies. Like, not that long ago, a bunch of them were squeezed out a vagina, so your physical exam is not the worst thing that has ever happened to them, ok? Just don’t drop them and you will be fine.”
- peds orientation