Some of the characters on my rotation:

Dr. WonderSurgeon: speediest hands in the OR. Super quick and precise. Watching her hands was like watching ballet on FF even the scrub nurse had trouble keeping up. Mild pimper, the kind that if you don’t answer fast enough she answers for you.

Resident Ice: PGY3. She’s the only resident on this community hospital. So she’s super busy all the time. She says very few words and speaks in short sentences to us, but I think she’s warming up to us. She comes off as Icey but she is really sweet. I actually love the way she talks to patients. In the OR, she’s looking out for you, but outside not really.

Intern: IMG who applied and matched into Radiology but with a surgery prelim year, which is not his jam. In case you dont know, radiology is one of those that you apply to residency and intern year separately. He is super cool, lets you know the favorite pimp questions of the surgeon who’s gonna pimp you, takes you on ginger ale runs, and sends you secret funny telepathic messages during surgeries.

Dr. RetiredSurgeon: She is a surgeon who early in her attendingship got into some sort of horse accident that unfortunately made her stay away from the OR. She currently manages all the patients on the floor and is in charge of the PAs, but you can tell she misses it. She is rough and loves teaching.

How To Be A Good Med Student In The Clinical Years

A doctor once told me that the best instrument we have is medicine is the retrospectoscope.  Basically he was saying that often it is easier to make sense of things when looking back from the vantage point of the future.  This is true of life too.  After being an intern for two months I suddenly understand what things make for a strong med students, and what things do not.  Unfortunately, I feel like I lacked many of the qualities that would have made me a helpful med student.  Though I cannot rectify my own mistakes, perhaps I can pass my advice on to future generations of third and fourth year medical students.  I now present, how to be a good clinical med student:

  1. Show up.  This seems obvious.  When you are there to work, then be there to work.  It is so frustrating when medical students are mysteriously absent all the time (only to be found later in the cafe or cafeteria) or when they are there but totally disinterested in what is going on.  I understand that sometimes as a medical student things get slow - like when the interns are putting in orders and notes or when there is a slow call day.  But at least bring something to read.  Don’t play Pokemon Go.  Don’t spend all day on Uworld.  Make an effort to learn real clinical medicine.
  2. Take initiative to learn.  When I was a third year I would wander the hospital to find learning opportunities.  I made friends with the telemetry nurses and they started a folder of good tele strips to give me each day.  I would go to other teams and see if their patients had good exam findings.  I found the cardiology fellows and asked if they had good patients with murmurs.  There is so much learning that can happen if you are willing to experience it.  Now, referring back to number 1, make sure you always let your residents know where you are.  Personally, I would be ecstatic if my students went to hunt down murmurs rather than playing Pokemon Go. 
  3. Read your patient’s chart.  This can be very helpful and will make you look like a star.  Residents are busy taking admissions and sometimes don’t have the time to hunt down records that are three and four years old.  You can stand out by doing that  Look at a patient’s past hospital notes or their specialty clinic notes.  For example, you might be able to alert the resident that an old echocardiogram demonstrated a below normal ejection fraction, which in turn might change how much fluid the patient is given.  Or perhaps you found that during a hospitalization in the past the patient became delirious and needed a one-to-one sitter.  Find ways to add information in a helpful, non-prescriptive, non-judgmental way.  I guarantee your reviews will benefit.
  4. Read about your patient’s condition.  Even if you just browse Medscape, UpToDate, or some other curated source, make sure you understand the basics of your patient’s primary diagnosis.  If they are there for heart failure, read over the basics of treatment.  If they have autoimmune hepatitis look up some info on diagnosis and prognosis.  These things will get noticed, especially when you ask intelligent questions on rounds.  Do not be like a med student I had who, when asked, reported for 4 straight days that he had not read about his patient’s disease.  He instead responded he was too busy with Uworld so he would get a good shelf score.
  5. See your patients.  I literally had students who, on rounds, tried to present without actually having seen the patient in the morning.  This is a huge no-no.  Get to work early enough to see your patients, review their labs, and their overnight events.  
  6. Practice your presentations.  Even if it is on your own or with other medical students, spend time working on your presentation skills.  Heck, even ask the residents to watch you.  I would be happy to do that for any of my students.  Unfortunately, none have taken me up on that offer and instead bumble through their presentation each day making the same mistakes.  By the end of medical school you need to be able to make a good presentation. 
  7. Spend time working on note writing.  Compare your notes to your residents’, your attendings’, and the specialists’.  Everyone has a different style.  Look at lots of notes to determine a style for yourself.  
  8. Forget all the step 1 stuff you learned.  I find many students perseverate on the terrible stereotypes and patterns they see on step 1.  Not all black people with cough have sarcoidosis.  Not every patient with acute kidney injury needs urine eosinophils.  These are good associations, but realize that step 1 has little overlap with real clinical medicine.  Take those associations with a grain of salt. 
  9. Don’t just look for zebras.  I cannot tell you how many times students opt not to follow a patient because the case “doesn’t seem that interesting.”  The majority of medicine is made up of mundane and common diseases such as heart failure, pneumonia, COPD, cirrhosis, etc.  It is pretty rare to get the exciting cases, like disseminated histoplasmosis or a crazy paraneoplastic syndrome.  A lot of learning can happen on cases that are “bread and butter” medicine.  Make sure you follow those cases too. 
  10. Be gentle to your interns/residents.  The transition from 4th year to being a doctor is swift and brutal.  It is easy to criticize when you aren’t the one taking 5 admits.  Find ways to help your intern/resident, because in return they will help you.  I learned this lesson the hard way my 4th year, when I unintentionally threw an intern under the bus while trying to look smart.  Afterwards she took me aside and reminded me that she controlled much of my fate while I was a student under her.  I learned my lesson and we went on to become very good friends.

The clinical years of medical school are daunting.  You constantly feel like a tap dancing monkey, trying to impress people you barely have time to get to know.  But personally, I am not looking for someone who knows everything about everything.  That’s why you are in school.  The best thing you can get out of third and fourth year is how to do a good history and physical, how to write good notes, and how to triage patients.  The best students are interested, willing to learn, and know their patients well.  If you keep that in mind, the clinical years are much simpler.  I promise, if you follow your patients you will learn much more than just doing qbank questions.   

Best of luck on your clinical rotations.  Don’t make things too complicated.  At the end of the day have fun, treat your patients right, and keep an open mind.  The learning will happen whether you recognize it or not.

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!

Keep reading

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?

“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.