Friday, November 7, 2014

A breath of air in med school

I've hit the point in med school where I have managed to have a few days off and relax.  4th year is really great, but the days that I have been working were not too bad as compared to when I was just starting my rotations. 

I am really fortunate to have been interviewing for residency and I have had all great experiences so far, even though I do feel a little nervous the night before the flight when I'm packing.  It's just natural, I guess.

Anyway, I feel like I can finally breathe and relax, especially after Step 2, working so hard to get all my recommendation letters in, and working on demanding rotations.  I'm fortunate I am happy with my scores and evals and grades and can relax.  I think medical training is a lot like swimming underwater: pretty competitive and you're constantly working hard and placing all kinds of demands on yourself and it is all pretty intense until you get a break and can surface for air, as short as the break might be.

Cherish every single minute of free time you have, when you can breathe in the crisp autumn air and not have a worry or concern in your mind. 

Med school is a place where you unfortunately have to keep making sacrifices until your good score comes back.  The hard work pays off, but try your best not to burn out in the process.

I'll be writing more and more, likely when I'm waiting for a flight or this or that, but I haven't forgotten about you guys.

Thank you for reading my blog and let me know if you have any questions

Wednesday, October 8, 2014

Step 2!! aghh!@@

I finally have some time and energy to write about Step 2.  It was kind of a beast at first, then got better for me as I worked my way through the exam.  I'm just not about 8 hour exams, you guys.

Step 2 actually makes me think of the ABSITE the surgery residents take: 95% clinical, with a few questions here and there about pathophysiology and mechanisms.  I thought it'd be all clinical, but there's still that pathophysiology/physiology aspect.

Honestly, the best way to study for Step 2 is to do timed UWorld Step 2 questions, timed blocks so you learn the pace and get to cover as much as you can.

The First Aid Step 2 book is really basic and doesn't delve into everything you need to know, so I
would supplement it with UWorld.

As for how important Step 2 is for matching, I honestly think it depends on what your programs/specialty think.  Some people say "well, it's more of a clinical test, and you're a clinical learner, so we don't weigh it as much"  or some people might say "If you did great on Step 1, Step 2 isn't a big deal."

Then I hear about how different programs use Step 2 to rank you.  It's crazy and I can't provide enough insight yet, but hopefully I will match and be able to better inform you.

Good luck and study hard, everyone

Tuesday, October 7, 2014

starting on the residency interview trail/NRMP outcomes

All my hard work has been paying off.  My first interview is soon and I've been so fortunate to have been offered so many interviews already.

I've never been so excited in medical school, and it's a great feeling that all the physical harm I've done to my body being a medical student (48+ hour days with little to no food/water/bathroom breaks) is amounting to something.

If everything goes without a hitch, I'll match into my specialty since the NRMP charting outcomes for my specialty indicate I have a pretty good chance with my Step score and number of interviews.

I just have to interview well and and rank wisely.

Here are the NRMP match outcomes:

if you're going to see a physician assistant or a nurse practitioner

You should change your mind if there's no attending physician at that place.  I'm not here to stir up fear, but in this past week there's been a missed diagnosis of cancer, overly liberal administration of antibiotics (including the less-than-optimal kind and for way too long), wrong dosing, and minimal following of guidelines at best.

There's a lot of ego around here, especially with the NPs who talk down to the residents and medical students, when the NP then gets criticized for not having a thorough enough history and physical exam, as well as a "very superficial" assessment and plan.

I feel like an NP is more of a "physician extender" than a physician replacement, same goes for PAs. Doctors go to medical school to study from Cecil's, develop a strong foundation in physiology, pathophysiology, pharmacology, side-effects, nuances in the physical exam, and then they go onto do residency and maybe fellowship where they're in charge of using their minds to take care of the sickest patients.  Not to mention they have to take the USMLE Step 1, 2, 3 and take board certifications in their specialty.

I feel like the NPs are at the level of a third year medical student, and the PAs more along the knowledge and skill level of a 4th year medical student.  Their physical exams and histories are all done with checklists (so a high school kid could do it), and there's little to no thought about a differential diagnosis.

I haven't had an NP or PA been able to tell me what the latest guidelines are on management of  X or Y, and I never hear them explain why they're recommending a certain dose, why they chose that antibiotic, and why they chose to treat for that amount of time.  It's just "because that's how it is," or "why don't you google it?"

I'm sure there are great NPs/PAs out there, and I would really like to work with them.  This environment is just too much for me, really.  Too much for me because it's all "voodoo medicine," where people don't prescribe this or that because of one isolated incident, or because they heard a scary legend at a party.

Evidence-based practice is what needs to be going on here, no "oh I heard this can cause Stevens-Johnson syndrome" or "I've just seen this work better."

Just to add, there doesn't need to be just an attending physician there, but someone who is really good and thorough and passionate about patient outcomes.

Nurses are trained to do, doctors are trained to think.

If a nurse wants a million letters after his/her name and wants to practice medicine, they should go to medical school.

I feel bad for all the patients who have been the victim of medical mistakes because of mid levels. I'm not saying midlevels are the worst or that doctors are perfect (because many make many mistakes), but I just can't trust someone to take care of me if they haven't gone through medical school and residency.

Thursday, October 2, 2014

how do you even get out of scut work?

Being a medical student often means you're "just the extra person around," depending on the service you're on.

I've been on a lot of services where my H&P actually mattered and I got feedback on my differential diagnosis, and I've been on a lot of services where team members just make up random tasks for me to do, like fax this form, or find this tongue depressor 2 floors up, or basically perform nursing duties.

I used to be fine with it.  I used to be all about the team spirit, but now I just feel like I'm paying so much money to get moved around the hospital like a pawn on a chessboard.  I feel like people find it "too hard" to teach and find it much easier to just make you an extra pair of hands without a mind when I could actually be doing a history and physical on an ill patient, or getting a short teaching session.

How much does it cost to drop a few bits of clinical knowledge on your medical student as you walk down the hallway instead of forgetting they're there?

Medical school is a place for education, or am I dementing?  

I've worked with residents and fellows and even attendings who will go do a menial task instead of sending me out to do it because it has no educational value.  I've worked with team members who have sat me at a desk to answer calls and take messages and page this person and that service for hours at a time.

I don't know how it is at your medical school, but it would be great if there was some kind of a more reactive spirit and the time of medical students was valued.  Because guess what, there's only so much time in medical school to train and learn, and then you hit intern year where your knowledge and your skills are put to the test every minute of the day and you can't afford to make mistakes.

Being designated the snacks/coffee person just because I'm a med student really wears on me now.  I miss being on services where I was the "student doctor" who was actually educated and had their clinical acumen made a little sharper.

I've been on services where team members stand up for me when someone makes me run an errand or stand around there silently holding someone's personal belongings while they look for something in their white coat.  I've been on services where I'm just forgotten about.

I hope a lot of people read this entry and can come a little closer to understanding/remembering what it's like to be a med student.  We're eager to learn, every minute of our time needs to be spent learning so we can become great doctors who nail the diagnosis, save the hospital money by ordering the right tests, and know how to catch subtle physical exam findings.

Everyone in medicine is told to be compassionate with their patients.  No one is taught to be compassionate to learners, and there's hardly any spirit of teaching unless there's some really dedicated, passionate team member.

Pretty often, I feel like I'm missing out.  As self-propelled and assertive I am about my education, it's hard when a service is so busy that there's no time for teaching, or these senior team members just have little excitement for teaching.  There's so much I could learn from these people with tons of experience, but it's out of the question all too often.

If you're going to send us out to do a task, at least pay us in knowledge or procedures.  We're not paid to be in the hospital, we're paying to be there.  Thanks.

super important residency topic

So we're all going to be interviewing.  One of the most important things besides how you'll fit into a program and their residents is how involved and supportive the program director is.  I heard some stories lately about residents getting fired, so I wanted to write a bit on this.

You know you can get fired during residency, right?  Everyone will tell you residency is a stressful time and there's the constant fear of screwing up and hurting/killing a patient.  Just because you're a resident doesn't mean you're under some kind of special protection.  You can get fired and also sued as a resident.

So you need to find a program that teaches you a lot, makes you a great clinician, and has faculty that will train you with supervision and have your back.

One of my biggest anxieties about residency is how everything I do will count, in one way or another. As a med student, it's fine if I give an incorrect answer, but I'm pretty sure every order I write as a resident is going to be scrutinized whether or not it leads to a mistake.

A lot of older physicians will tell you stories about their mistakes and how they got burned pretty badly.  You see the effects of those events still weighing on them heavily, especially in how they obsess about a creatinine level or whether all drug allergies have been reviewed three times.

Find a program where residents are respected, mentored, and the faculty is passionate about teaching and patient safety.

I'm going to try to relax now

Wednesday, October 1, 2014

recommended med school electives

I really recommend a CCU elective and/or one ICU rotation.  You'd be surprised at how comfortable you can get with STEMIs and managing complex medical problems.  

I spent a month seeing heart attacks and cardiac ischemia everyday, and you get really good really fast at the management, inpatient care, and the type of preventive care you start in the hospital.  It's a great way to learn when to hold/start heparin, who to cath, etc.  I was lucky to work with some really great cardiology fellows and attendings who taught me how to read complex EKGs, a critical skill in medicine and surgery.

The ICU will be scary for anyone starting it, but you learn how to think in terms of systems.  Divide and conquer, really.  The ICU is a great place to learn about ventilator settings, and it will really hammer home how important it is to use the minimum amount of vascular access for the shortest amount of time possible due to the likelihood of IV site infections and sepsis.  It's also a great place to learn about the nutrition of critically ill patients, management of pressors, and getting "comfortable" with life-threatening arrhythmias and asystole.  Be assertive and learn as much as you can in the ICU, because soon it'll be you running a code, maybe even on your first day as a doctor.