23 December 2007

What to do if you do not get accepted into medical school

Let’s say that you have submitted your application and it’s late in the year. You have received no invitations for interview and since it’s now April, your chances of getting invited for interview and gaining acceptance are getting slimmer and slimmer. What are you going to do now? Since the day that you entered undergraduate studies, you have contemplated the study of medicine but at this point, it’s looking like you are not going to be a member of the upcoming year’s starting medical classes. What are you going to do?

Your current application
The first thing that you need to do is pull out a copy of your current application and take a long and objective look at it. Was your personal statement well-written and an accurate reflection of your goals in medicine? Did you illustrate strong extracurricular activities that showed your interest in your fellow humans? Was your undergraduate GPA competitive within the context of the schools that you applied to? Were your scores on the Medical College Admissions Test competitive within the context of the schools that you applied to?

What can you do about improving your application?
If you contemplate reapplying for next year, the first thing that you have to do is upgrade any and all things that were a liability for you in the current year. This might mean taking a course or re-taking the MCAT and making sure that your score is significantly higher. This means reworking your entire application including revamping your personal statement. If your application didn’t work for this year, it’s not likely that it is going to work for you next year. The major reason that people do not get into medical school is overestimation of their competitiveness within the context of the pool of applicants to the schools that they applied to.

The applicant pool
Every year since I have been working with medical school admissions, two things have been generally true. The undergraduate GPAs/MCAT scores of the applicant pool have been increasing and the number of application to my two schools have been increasing. We attribute the increase in the number of applicants to the generally poor economy and we attribute the increase in academic scores to both grade inflation (at some colleges ) and an increasing number of folks who use test prep companies for the MCAT. We are well versed in the undergraduate schools that practice grade inflation and we look very carefully at the patterns in the MCAT scores. Larger applicant pool and higher uGPA/MCAT scores mean that we are using much of the entire application to make our decisions as to whom we will invite for interview.

The URM myth
Both of my medical schools have about 1% URM representation in any given class. It is entirely a myth that being an Underrepresented Minority in Medicine is an automatic entry into medical school no matter what is on your application. We just don’t “hand out” seats in our freshman medical class for having a certain ethnicity. One of the prime forces for us is making sure that every student who is admitted will successfully get through four years of a very tough curriculum. The material to be mastered knows no color or ethnicity. In the past, with our admissions formula, we have been pretty fortunate in that our graduation rate in four or five years is greater than 99%. In general, those people who graduate in five rather than four years have some extenuating circumstances that have prevented them for continuing with their class not because they were not well-qualified in the first place.

Feelings that you are somehow inferior
This turns out to be a huge factor in whether or not a re-applicant will be successful on the second try. There are far more applicants than seats in medical school period. If you don’t get in, it is generally because you were not a good “fit” for the year in which you applied or you made some poor decisions in terms of the schools that you applied to again you were not a good “fit”. You can reassess you situation, change the things on your application that you can change and reapply stronger. There is very little difference in a student who is accepted and a student who is not accepted in any given year. You would be quite surprised to learn how close many “rejected” students actually came to an acceptance. Those folks who are wait-listed were definite acceptances but were a bit further down the list in terms of being offered a seat. They are definitly “alternates” but we just felt more strongly about the people who were offered admission.

Graduate school
In general, if you are NOT interested in graduate school, don’t undertake a graduate degree to enhance your application. If you have developed a passionate interest in Public Health or Business and you can complete your degree in one year or so, then obtain an MPH or an MBA but don’t look to these degrees to make you more competitive for medical school if your uGPA/MCAT was low.

If you elect to enter a Special Masters such as the Special Masters in Physiology (offered at many colleges/university), you can definitely enhance your chances of admission if you perform well in this type of a program. In addition, you will have some graduate training that can be used if you don’t enter medical school. These Special Masters generally have you taking the same coursework as medical students and can show that you are capable of handling a tough medical school curriculum. These programs are ideal for candidates who are just a bit below average (3.2-3.5) uGPA range or those who had a great deal of difficulty with the MCAT but higher uGPAs.

Retaking the MCAT
If you scored below that magic “30″ or had a severly lopsided score say 13 in PS, 12 in BS and a 5 in VR, then retaking that exam with solid preparation and remediation in your lower scoring areas might be a good idea. One of the things to consider is that you must shore up your deficiencs and be sure that you have done something major before you re-take this exam. Nothing can tank your application faster than several mediocre MCAT scores. While some schools will take your higher scores at each re-take and use a composite, most schools (includng mine) do NOT do this. If you retake, make sure that you are going to score higher period. Also remember that most people do not accomplish a higher score so you definitely need to do something different in terms of prep in order not to wind up with a lower score.

It is definitely true that the earlier you apply, the better your chances. Meet and exceed every deadline and in the case of reapplication, be early period. You can’t procrastinate on this one. As soon as you have decided to reapply, start getting your materials together for an early submission of your application. Most of the time, the difference between waitlist and acceptance is the timing of the application. Resolve that you are going to be proactive about getting your application done and that you are going to upgrade everything that you can upgrade within the time frame that you have between application cycles (this is not an infinite amount of time)

Reapplication time is also a good time to explore other career opportunities outside medicine especially if you are well below the averages for accepted students. One has to be realistic about their chances of acceptance if you are sitting on a uGPA of 2.9 or an MCAT score of less than 28. Sure some students in the past have gotten into some schools with those scores but most applicants with these numbers are automatically “screened out” of may medical schools. The other thing is that everyone is NOT going to become a physician no matter how great the desire. There are just too many applicants for seats.

Also do not make the mistake of thinking that you will become a Physician Assistant or enter Nursing as a substitute for medicine. While these are great careers, they are not the “same” as medicine. These careers can be extremely rewarding and satisfying but enter these careers because you have decided that they are a good “fit” for you and that you will enjoy them. Getting into Physician Assistant school is quite competitive and not a stepping stone into medicine. It is far likely that if you were not competitive for medical school, you are not going to be competitive for PA school.

Above all, if medicine is your dream, you will do whatever it takes to accomplish it but you need to be sure that you are upgrading your application with each reapp and that you are being realistic in terms of you competitiveness. Just reapplying does not increase your chances of acceptance in itself. Most people who reapply do something significant to upgrade their application. Make sure that if you elect to reapply, you do the upgrade.

14 December 2007

A Memorable Patient

I have been thinking about some of my more memorable patients these days. I especially remember one of my younger surgical patients from when I was a junior resident. I was on the Colo-Rectal surgical service, which was one of the more interesting rotations that you can have a resident. Colo-rectal surgeons handle just that, diseases of the colon and rectum that have to be treated surgically. One of the nice things about the service is that the colo-rectal attendings were among the most personable and knowledgeable of my junior years. They loved to teach and they loved to have us involved in their cases at every step.

One day, a gentleman presented to clinic for the final scheduling of his upcoming surgery. He was a young man (less than age 40) with a very low rectal tumor that we knew was cancerous. His presentation had been rectal bleeding and when his primary care physician found the tumor (it was palpable on digital rectal exam), he immediately referred the gentleman to our clinic for workup and surgery. At this point, the workup was complete: CT Scan, blood work and chest film. We reviewed everything and the patient was scheduled for AM admission, given pre-op orders and sent home to report back to the hospital two days later.

Two days later, we greeted the patient and his wonderful wife in the holding area. They had followed the prep instructions to the letter and he was cleared by anesthesia for the case that we would be doing. We had planned an abdominoperineal resection which involves wide excision of the rectum to include the lateral attachments and pelvic attachements and the creation of a colostomy. In the performance of this procedure, abdomen is opened and examined to see the extent of spread of the disease if any. Since we had a CT Scan that was two weeks old, that showed no evidence of spread of disease to other organs, we were confident that we would be able to remove the tumor, fashion a colostomy and get this patient on to recovery.

To have a colostomy at such a young age is life changing but to die of rectal cancer would be a tragedy and thus the patient was eager to get the surgery over with and get on with chemo and his recovery. He had been very eager to learn about colostomy care and life with this procedure. We open the abdomen and to our shock, the cancer had spread to his liver. As I moved my hand over the liver, the extent of the numerous tumors was quite evident. We all scanned the CT to see if we had missed something but we had not and neither had radiology. The tumor did not show on the CT Scan.

At this point, I helped my chief resident close the abdomen while our attending went to deliver the devastating news to this patient's wife. The cancer was unresectable and the patient had little chance of living more than a few months with the extensive liver involvement. The next day, we ordered another CT Scan and sure enough, there were multiple tumors throughout the liver in addition to the tumor in the rectum which really hadn't changed much in size.

The next two days, I rounded on this patient and wrote notes. I made sure that his pain was under control and I met many of his relatives who were just wonderful and very grateful for everything that we had done for the patient. I felt horrible because we all wanted to do more but there wasn't anything more that could be done from a surgical standpoint. On post op day 3, the patient was ready for discharge from the hospital. He was scheduled to see a wonderful oncologist and the possibility of enrollment in an experimental protocol was there but still, it was difficult to see this situation.

A week later, the patient came back to clinic for removal of his surgical clips. His incision was well healed and he joked about the small shave prep that had been performed. His lovely wife said that every day she had with her husband was a gift because he had been badly injured in an accident three years earlier and given little chance of survival but he did. She said that she was so happy to take him home and that he was a well-loved man.

I heard that this patient died peacefully at home six months after the surgery. His wife sent us an obit notice and wanted us to see that she had directed all donations go to the American Cancer Society. She thanked us again for the great care and the time that she had with her husband. Those words stung then and they still sting as I think of that lovely family from time to time.

It is always patients like this patient that remind me to give my best always. We don't know if we will be the last physician or the physician that will make an impact on our patients. This patient gave me so much by just putting his trust in our team. I see him often when I have to deliver bad news to a family or to a patient and I hope that he is at peace. His wife said that his death was peaceful and that his 10-year-old child was with him as was his mother and father. I can only hope that all of my patients can leave behind their disease in peace when the time comes. I am certain that the oncologist made sure that he was pain free as much as possible.

It's this time of year when I think of some of my more memorable patients. The ones who show me how to live by being a great example with their lives. I am a very fortunate physician.

22 November 2007


Thanksgiving actually starts the major holiday season around most undergraduate, medical schools and residency programs. As an undergraduate, you realize that the fall semester is heading for a close as there is very little time left before semester finals. As a medical student, Thanksgiving means a welcome respite from the intensity of coursework and as a resident, you know that you are going to get at least one day off from working the wards.

In residency, you quickly learn that either you are working the actual holiday or you are off. Everyone can't be off and your administrative chief makes sure that holiday time is equally distributed among the staff. Sure, you want to be there to sit down with your family but it just isn't possible for everyone to have every holiday off as people get sick on every day and at any time during those days. Sometimes you will not be able to go home for a holiday visit to be with your family.

I never particularly minded working on a holiday as long as I had one day to sleep in late. My idea of the perfect holiday is sleeping until 7am; getting up and drinking my coffee in front of the telly as I watch CNN. I know this sounds boring but residency taught me to appreciate the days where I can just do nothing (or a few things and at a very slow pace). I now appreciate going to places like Cancun or Key West where I can lie on the beach and appreciate the sunrise or the sunset. Before residency, my idea of a vacation was to head down to Belize and spend a week diving with friends or spending a week playing tennis. Now, just lying around or clubbing in a new city are my ideas of great ways to spend time off.

My other favorite vacation activity is to catch up on my reading or get ahead in terms of reading. As a physician, I make sure that I read at least 30 minutes each day and one hour on the weekends. I always have a journal with me to read as I am waiting or on those call nights when I just can't fall asleep. I have a monthly check list of journals that I definitely read such as Nature Medicine and New England Journal of Medicine (in addition to my specialty journals). Like exercise, if you make journal reading a habit, it become part of your life. I make notes on articles that I will use in my teaching or articles that I want to incorporate into my practice.

As a medical student, I made sure that I read every review article in New England Journal of Medicine and every case report. My faculty advisor encouraged this practice on our first meeting as we became acquainted during orientation week. It became as much a part of my life as brushing my teeth each morning. I also found that I acquired the "language" of medicine more quickly as I kept up with my reading. No matter how much studying I was doing, my journal reading was a welcome change of pace from the daily grind of mastery of coursework.

As an undergraduate and graduate student, I read journals regularly. This was a means to become a participant in departmental meetings and discussions. As an undergraduate, we had regular journal discussions in our laboratory research meeting. As a graduate student, I was expected to lead those journal club discussions. In short, as a pre-med student, you need to make sure that you learn to read and critique scientific literature. If you anticipate a career in medicine, you have to be able to evaluate journal articles and keep up with the literature of your practice. This is not something that you learn to do overnight but a skill that is developed with practice.

Once you become a medical student, gone are the days that you can just sit passively and regurgitate information given in course lectures. You will be expected to question information and make sure that information that you give out to patients will be accurate and up to date. Most of the information that finds it way into textbooks is already dated by the time the textbook is published. Those of us who write book chapters scan scientific literature regularly and include updates but there is a time-lag between the completion of a book chapter and the publishing of a text. It is up to you, to make sure that you are caught in that time-lag as a practicing physician.

Holidays spent in the hospital are usually break-neck busy (the time passes rapidly) or very slow. If I was having a slow day, I took the time to read, rest and socialize with the staff that was working. This is just my way of spreading some "good will" around the place. In short, someone has to work and I generally didn't mind working a holiday. My family wasn't going to vaporize if I missed Thanksgiving or Christmas dinner and I saved the calories so that I could splurge on New Year's Day. This was always my personal preference and my colleagues continue to appreciate this.

Part of being a member of a health care team is realizing that the world does not center around you. There will be times that you will miss family gatherings to take care of your patients. If this is something that you can't do without getting a bad attitude, then medicine is not for you. There will be times when you "draw the short straw" and have to work on an important holiday. Sure, it's not your preference but grumbling all day and whining all day will not help your attitude or your situation. Make the best of it and get your work done. For me, I never forget that it is a privilege to take care of people who need my help. I can certainly acknowledge that the situation is not my preference but that's the end for me. I set about the task of going merrily about my job and spreading some good will. After all, I chose this profession and I knew going in, that there would be holidays that I would be in the hospital the entire day. It is part of the life that I happily chose and I alway remind myself on Thanksgiving to be thankful that I have been allowed to practice medicine every day not just on non-holidays.

31 October 2007

Selecting Medical School Applicants for Interview

Many medical schools are in the “thick” of the process of screening applicants and selecting those applicants that they wish to invite for interview. This process generally falls along the lines of first, making sure that the applicant meets the minimum requirements for said medical school in terms of undergraduate grade point average (undergraduate GPA) and scores on the Medical College Admissions Test (MCAT). While most medical schools will review the entire application, in terms of figuring out how to get 8,000 -10,000 applications pared down to a workable number for closer scrutiny, we screen by undergraduate GPA and MCAT scores. There just is not a better way to make the preliminary cut than these two factors.

In the case of those who do not make the preliminary cut, we generally send these applications for a secondary screen by administrative staff who are looking for criteria that we have flagged so that many of those cut by the undergraduate GPA /MCAT screen might make it back into the secondary screen if our administrative staff keys in on something in the personal statement, coursework or letters of recommendation that we should discuss in the admissions committee.

Those applications who DO make the preliminary screen are divided among the admissions committee members who read every work on the application and decide if we want to invite the applicant for interview. In short, do we want to meet this applicant? Would they be a good fit for our medical school? Do they show promise of being able to get through our very demanding curriculum? Do we want to know more about this applicant? In short, we invite applicants that we strongly feel will make good physicians based on the material that is present in their AMCAS applications.

That being said, as applicants are filling out those AMCAS applications, they need to be sure that the information in the AMCAS is as accurate as possible and as clear as possible. Many people have been rejected for interview based on a poorly written personal statement. These rejected applicant may have had the GPA/MCAT score but neglecting to write a strong personal statement is like heading out on a long automobile trip and draining the oil out of your engine. You are just not going to get very far even if your engine appeared to be in great shape. You need to have a well-written and coherent personal statement.

On the other hand, a great personal statement/letters of recommendation will not make up for very poor academics. If your academics are poor, take the time to get them as high as possible keeping in mind that the average undergraduate GPA for medical school matriculants is 3.6/4 and the average MCAT score is 30 with no single score less than 8. Some schools may have considerable variation around their means but my medical school does not.

Are schools “forgiving” of a poor undergraduate start but a very strong finish? To a certain extent this is true but there are academic “holes” that can be too deep to climb out of without years of “damage control”. In short, if medicine is your goal, work diligently and consistently at a high level. Don’t count of anything being “forgiven” and keep in mind that no allopathic medical school in this country is searching for applicants. We have far more applications than we need.

We try to make sure that every application is screened at least twice before sending out that dreaded rejection letter. This is a monumental task that seems to take longer and longer each year. Again, keep in mind that one of my medical schools received more than 10,000 applications for 110 spots in the entering freshman class last year. This year, we have already broken last years numbers. There are just too many good applicants out there.

As I read through the applications, I always look at how many hours of coursework an applicant has taken in any given year as well as the grades earned. In addition, I look at the content of those hours. If a student took three laboratory courses in one year and managed to earn a 4.0 GPA versus a student who took one lab course along with general education requirements and barely managed a 3.0, I tend to look more favorably on the first student. We also make allowances for things like full-time employment versus full-time student.

We look at the age of academic work. A student may have earned high grades 10 years ago but without recent academic work or a recent MCAT score, we generally will not offer admission. Many things change over the course of ten years including the ability to jump into a very demanding academic challenge. In most cases, we ask for some recent coursework in addition to MCAT scores not more than three years old.

In terms of multiple MCAT attempts, we tend not to accept students who have more than three attempts. If a student retakes, we expect the score to go up. If not, that is usually a signal that the student wasn’t prepared on any of the attempts. To keep taking that exam and scoring mediocre scores is generally a very bad idea. If your first score is not what you wanted, do a thorough analysis of your performance and correct your deficiencies. To just keep taking that test without doing additional preparation or changing your method of preparation, is not using sound judgment no matter what your undergraduate GPA.

Graduate school GPA does not overcome a poor undergraduate GPA. As a graduate student, you are expected to maintain a minimum GPA and you are expected to do well. While earning a graduate degree can enhance your application, there are huge differences between graduate school and medical school. In the case of special masters programs that are specifically designed for pre-medical students who need application enhancement, you need to do very well in these programs. Just taking the coursework will not work, you have to take the coursework and make yourself “stand out” from the rest of your classmates in these programs. It goes without saying that we scrutinize the performance of special masters students very carefully and take into consideration strongly, your letters of recommendation from your SM professors.

I have written the above so that those folks who are in the process of contemplating application to medical school might definitely understand how important it is to have a complete and strong entire application. You are considered within the context of how competitive you are with the rest of our applicant pool and how competitive you are with the national applicant pool. We are given AMCAS data as it becomes available and we adjust our standards according to the data that we receive. For the past five years, undergraduate GPAs and MCAT scores have been increasing. We don’t expect that this trend will reverse.

The number of applicants had increased slightly this year. We don’t’ know if this is a national trend or just a trend for our school. In general, many people look at medicine as a very lucrative career and seek out admission to medical school for this reason especially when the national economy is not as strong as in previous years.

30 September 2007

Some Perspectives from Teaching students

I have been teaching some Physical Diagnosis skills over the past semester and I have learned many things. First, I learned that I was taught by some extremely skilled preceptors back when I took this course in medical school. My preceptors' sole objective was for me and my classmates to become excellent diagnosticians and observers. The better we looked, the better they looked and to this end, they taught us well. In short, I have great examples to emulate and I strive every day to live up to those examples.

It is no accident that when one attempts to teach something, one becomes stronger and more secure in their own personal knowledge. I distinctly remember when I was learning how to appreciate heart sounds. It seemed like I would never get the "hang" of figuring out if a murmur was systolic or diastolic. Now, years later, heart murmurs are as familiar as my favorite songs. This came with loads of practice in addition to integrating what I hear with what I know about heart pathology. This integration is one of the great joys of medicine. Every piece of experience can be added to one's knowledge base in some manner.

Every time I hear a murmur, I appreciate more and more. My uncle, a cardiologist always expounded about "auralizing" a heart sound. His lectures coupled with my harmony and ear training in music has come in quite handy. I distinctly remember back in my music courses, I learned to recognize a chord pattern by sound and experience. Listening to a heart murmur is no different. As I move my stethoscope from place to place, subtle differences in the first and second heart sounds are evident. The shape of the patient's chest also plays a role in what one hears too. Auscultation is truly an art that takes both experience and excellent training.

I play loads of recordings over and over for my students accentuating every heart sound and correlating each sound with the physiology of what is going on the the chest. By listening over and over, they gain experience. My own experience began when I would lie in bed at night listening to my own normal heart sounds. Next, I listened to the chest of one of my classmates who had mitral valve prolapse. She has a very thin body habitus and had the classical heart sounds of this very common condition. Again, more experience for me.

No good professor ever compromises their teaching methods to "torment" students. We do joke about making our students miserable but I can tell you from experience that recently, one of my students was able to see the vessels in my retina and nothing made me prouder. I was proud of her because she was determined to learn to use her opthalmoscope properly and she kept practicing until she could. I especially do not want any of my students to feel "tormented" by learning the techniques of physical diagnosis because these skills will stay with each student for the rest of their career.

I once heard the chairman of a department of internal medicine speak about how many medical students have an "under-appreciation" for the skills of physical diagnosis. I kept thinking how much I love walking into a room; taking a patient history; performing a physical examination and putting everything together into a solid clinical plan that is useful for getting to the root of the patient's problem. My feelings about physical diagnosis is far from an under-appreciation but more of a reverence for a fine art just like a reverence for find song.

I have been busy this weekend working on exam questions for my student. Since Physical Diagnosis is mostly a practical type of course, I am striving to make my questions test the practical aspects of performing the physical exam. Until you have been charged with the task of exam question writing, you cannot appreciate how difficult this task can become. My questions don't come from exactly what I give in lecture but from reading and actual performance of the the skills of examination of each system covered. The questions are not designed to "trick" students but to make sure that they know how to perform each task.

Physical Diagnosis requires that every aspect of a patient is examined. The demeanor, the speech, the gait and other general aspects of a patient's behavior and actions are all important clues to what underlying pathology may be present. A person who has a perforated peptic ulcer has a distinct demeanor and position on a stretcher/bed in the emergency department versus a patient who is passing a renal calculus (stone). One quickly learns to do a very quick assessment of the entire general appearance of any patient.

A very critical aspect to writing the report of a history and physical exam is making sure that your notes and evaluation are as accurate as possible. I have learned to record my findings and impressions such that any clinician picking up the patient record ten years from now can understand and appreciate what I observed at the time and why I treated the patient in the manner that I did. In short, a trained clinician should be able to follow my clinical thinking. This doesn't mean that I have every answer at the moment but it does mean that I followed a logical plan to arrive at a correct diagnosis and that I developed a coherent treatment plan.

Finally, a note about writing in a medical record. It may look wonderful to have a fancy signature and penmanship but I print everything as my cursive writing is not always clear. My signature is distinct but under that signature is my name, title and pager number in clear block letters. I pay very close attention to every letter when I write a prescription and dosage. I don't use too many abbreviations and Latin pharmacy phrases. I simply write four times daily instead of QID or I write out nothing by mouth instead of NPO. By doing this, it simply saves phone calls later in the evening. I am as pressed for time as anyone but some things save a bit of time if you take the time to do them correctly in the first place.

28 September 2007

Getting Through the Semester

By now, many students have had their first block of exams in medical school. Some people have done very well and some people have "breathed a sigh of relief" that they passed and some people have not passed one or or more of their exams. To fail an exam at this stage can be a huge personal blow but your actions after discovering that you have not passed (I am going to avoid the word "failure" here) are critical to figuring out what you need to do to get "above the yellow line". Sure you NEED to do a bit or mourning in terms of the loss of those wonderful feelings that infused during orientation week but don't let the mourning phase go on longer than a couple of minutes. Replace mourning with a very objective strategical look at what might have gone wrong and how you are going to fix the situation.

There is something in medical school that will throw every person. It may be that first round of exams, that USMLE score or a patient contact that just did go well. The important thing is that out of every experience, good or bad, you learn something about yourself and what you are capable of achieving. It is out of experience that you will learn to treat your future patients so let your experience become your teacher and move forward from here. Not passing an exam just doesn't feel good and can play with your "head" in terms of how your look at your future. My point here is that nothing except that round of exams is over at this point. You mourn a bit and then you push forward because (and I am not wrong on this), the material for the next round of exams is already upon you.

As soon as you know that anything has not gone well for you academically, ask for help. Your first action should be reviewing the test and trying to figure out where you went wrong. Do you need to rely on more detail? Did you move too fast and not answer the question that was asked? Did you neglect to read every answer choice with a more correct answer further down? Did you not fully understand the material? Were you distracted by something outside of school such as a relationship or illness and not put in enough time studying? In short, try to figure out what went wrong and take steps to make sure that you don't repeat your mistakes.

In some medical schools, class attendance is not mandatory. If this is the case, and you ran out of study time, try figuring out if there is one day a week that you can stay home and study the material using note service/lecture tapes or vids/textbook and syllabus reading. Many students do not attend class and find that home (or away from school study) works best for them. This may work for you but be careful if you have too many distractions at home or find that not attending class puts you behind. (Getting behind in medical school is deadly.)

If your work is not detailed enough, figure out which classes do not require the detail and which ones DO require more detailed study. In short, give each course what it demands. Many schools have integrated courses that definitely demand loads of detailed work coupled with "professional-type" courses like Practice of Medicine that are more performance-based. Try to look at your coursework from this perspective and see if you can give your integrated course a bit more time and your performance course a bit less time.

Another problem is that in many first year courses, the load of information can seem overwhelming. Resist the urge to dwell on what seems overwhelming and nibble away a chunk at a time. I always remember that scene in the movie "Shawshank Redemption" where the protagonist chips away at the prison wall over the course of 17 years with a small rock hammer. Eventually, he gets through the wall and escapes. Extreme but I think you get my drift in terms of divide your work into manageable chunks and stay on course. Keep moving forward because you can only affect what is happening now and use that to impact the future. Weekends are your friend because you can breathe a bit, relax a bit and catch up if you have fallen a bit behind your class. In the middle of the week, go to where the class is and use the weekend to "catch up".

I really discourage students from recopying notes as a means of study. When you have volumes of material and information, you can become more of an excellent clerk in terms of producing a beautiful set of notes that you have not mastered. Organizing your material is good (can be done with a highlighter or in the margins of your notebook) but total recopying of every word may be too time consuming and not as beneficial as when you were an undergraduate student with less volume. You may need to review the material and then constantly question yourself or recite the material back to yourself rather than a complete recopy. If you can recopy your work in an efficient manner while learning and your grades are good, then recopying is working for you and don't change your strategy.

Another problem that can interfere with some freshman medical students is feeling that they "need" to study for boards. You don't need to take time away from your coursework mastery to do board study at this point in your career. If you absolutely feel that you NEED to do some board study, then do it during the summer between your first and second year but the best preparation for boards is to thoroughly master your coursework and then study for boards at the end of your second year. You cannot "review" what you have not "learned" in the first place. Don't take valuable coursework study time to do board study. Board review books are most useful because they summarize material but most medical school courses require the details and not summaries. Beware of the "I am going to use a review book to summarize" method of study because it might work against you in terms of you not getting enough of the details to pass your course. The other extreme is to attempt to memorize the textbook which is most likely too much detail. In short, strike a happy medium that will work for you.

Don't be afraid (0r ashamed) to consult your instructor or your dean if you are struggling. Not to reach out for help (especially because of the amount of money that you are paying for your school tuition) is not wise. It really looks great to a residency program director to see comments from your dean or professor that state that you were able to overcome a deficiency and excel. These types of comments indicate excellent problem-solving skills which are highly prized in a physician.

Finally, tune out the boasting of your classmates who say that they "didn't study" and "aced" their exams. They are lying period. You have to do what you NEED to do for yourself. Congratulate them for being so "brilliant" and don't waste a second of your precious time worrying that you are somehow deficient because you studied like a demon and didn't do so well. There is nothing wrong with you that correcting your study strategy will not solve. Just don't add "questioning your worth" to your list of things to overcome. It isn't necessary and it won't get the job done.

Statistics (and odds) state that if you were accepted to medical school, you will get through the four years successfully. Some people make the adjustment to the rigors of medical school academics faster than others but trust yourself enough to know that you will get the job done. There is very little difference in intellect between the person who graduates first in their medical school class and last in their medical school class. Residency program directors know this which is why the person who graduates last in their class is still called "Doctor". Run your own race and get what you need.

31 August 2007

Physical Diagnosis (You get to play with your toys!)

Most medical students take a Physical Diagnosis class during their second year. This course teaches history taking and the skills necessary for performing a complete physical examination. Back in my second year of medical school, I found this course a bit intimidating in terms of what the syllabus outlined for us to accomplish in a few short weeks. Little did I realize that I had most of the tools that I needed to do well in this class, namely, an insatiable curiosity, a good ear, two good hands and total interest in my patients.

The first lecturer emphasized that we would get 90% of what we needed to make a diagnosis from a good patient history. “Good” was the operative word here because as one sits and reads the “how-to” of taking a medical history, it seems that there is an abundance of information that we must obtain in the patient interview while writing a couple of notes here and there. How would I remember every detail? What happens if I forget something important? What if the patient lies to me? How am I going to figure out what a comatose patient needs? Those were just a few of my concerns in addition to looking at my opthalmoscope and trying to figure out how I would ever get the “hang” of making this forbidding tool useful in my practice.

One day of the week, we would spend the afternoon in the hospital with our preceptors. My upperclassmen friends looked at the name on my paper and said that I had “hit the jackpot” with my preceptor assignment. My preceptor was a master diagnostician and an excellent teacher too. He was an endocrinologist who specialized in metabolic syndrome, a disorder that runs largely unchecked in most medically under-served populations because of poor diet and lack of physical activity. I was excited to get my practical knowledge underway with my new preceptor. My preceptor had two medical students assigned to his service at the same time. It turned out later that the other student rotating with me was my rotation partner for all of third year so we were great friends and become even closer.

We met our preceptor in his office and he led us to one of the medicine floors in the hospital. He had made a short list of his patients who were willing to have us use them for our history-taking practice. I entered the room of a middle-aged gentleman who was hospitalized for jaundice. I quickly went thorough my script of questioning this very soft spoken man who lay quietly in bed. I came to find out that he was a physician who had been diagnosed with a biliary disorder that would kill him without a liver transplant in the next two weeks. He was kind and patient as I asked all of those questions about family history, social history, medications and the like. He asked me to stop by later that evening and read my historical write-up back to him. When I stopped by, he helped me organize the information and provided invaluable assistance in thinking about how to question patients. We chatted off and on for a week, until he received the word that he was being transferred for his liver transplant. I saw him three weeks later when he was ready to leave the hospital with a new liver, a new life and such joy!

I practiced with my stethoscope on my own chest. It became very satisfying to lie in bed at night and listen to my own heart sounds. I listened to each sound appreciating the tones and timing. I also listened to my breath sounds, over the trachea, over the bronchi and over the lung parenchyma. I practiced listening to each heart valve and learned to appreciate the subtle differences between the sounds a the pulmonic site versus the sounds at the mitral site. I appreciated the split in my second heart sound with my respiratory cycle. If I could appreciate the subtleties of my own chest, I would be able to pick out abnormalities on my patients.

That pesky opthalmoscope was the biggest hurdle that I had to cross. The first thing that I did was learn to operate the light and aperture. Since I have no visual defects, I always start with the diopter setting on 0. I also quickly learned the utility of performing this examination in a dim room as bright light makes the patient’s pupils quite constricted. A dilated pupil is easier to examine. The other useful piece of information is to start with the opthalmoscope light dim so that you don’t blind the patient while you are attempting to examine the retina. At first, I could just pick out the “red reflex”. Soon, I found a vessel and later, I learned to focus sharply on those vessels and follow them to the optic disks. In short, there is a learning curve that is most quickly overcome if you force yourself to examine the retinas of every patient that comes into your office. If you don’t practice, you won’t learn to do an adequate examination. I would wager that most physicians out in practice today, other than the ophthalmologists and neurologists, do not perform an adequate retinal exam.

When it came to learning the rectal, pelvic and breast exams, we were taught by professional “patients”. These people knew the exams and used their own bodies to teach medical students. On the pelvic exam demonstrations, one of the demonstrators indicated that she was in the middle of her menstrual cycle. One of the male students in my group, left the room and never returned. I never found out how or if he learned to perform a pelvic examination but those demonstrators were excellent. They allowed us to practice and pointed out landmarks and hints that were invaluable. I found myself thinking about the type of person who is willing to become a professional demonstrator of breast, pelvic and rectal exams. While the job pays well, I would have to cross it off of my list of things to do if I needed loads of money quickly.

The neurological examination is the most fun to perform and write up. I found myself collecting an odd assortment of instruments to test sensations of hot and cold (I used capped test tubes filled with tap water); vibration (tuning fork), smell (alcohol pads, nail polish remover pads); color sensation (photos); light touch (feathers of various colors) and sharp versus dull (paper clip). I had a small bell and a small stuffed kitten as objects for my patients to name. I also collected a tape measure for lesions and an assortment of cotton swabs and tongue blades for cranial nerve testing.

I learned to perform my history while I was performing my physical examination. I would start with the head and ask about problems with headache, earache and vision. I would examine the eyes and nose while asking about sinus problems. I went from head to toe asking questions as I moved along. I always save invasive exams like pelvic and rectal for the end of the exam. While the patient is getting dressed, I would jot down my pertinent positive findings and spend the rest of the time chatting with the patient and explaining my findings. At this point, my preceptor would usually join me and we would discuss the treatment plans for the patient together.

The most important thing that I learned in this class was the value of communicating with your patient. I probably learned more from my patients than they learned from me. I learned to listen to their words and put their words and my physical findings into a cogent clinical plan for treatment. I also learned the importance of just getting to my patient’s fears, concerns, likes and dislikes. When a physician touches a patient, there is a relationship of trust that is begun. Your patient trusts that you will use everything that you have learned in biochemistry, anatomy, pathology, pharmacology and physiology to figure out what you can do to get them healthy and keep them healthy. There is a puzzle and the pieces must be fit together for the good of the patient.

I also came to appreciate the sanctity of the apprentice-mentor relationship that I had developed with my preceptor. In no other profession is that relationship so important than the attending physician/medical student. My preceptor was indeed a master and I was a very willing student. He led me through the maze of various patient encounters and kept me coming back for more. It was truly magical in many ways.

Finally, I mastered that opthalmoscope during the last week of my Physical Diagnosis class. I was quite comfortable with my exam and I appreciate the art of being able to make a diagnosis. While this class seemed to be quite intimidating at first, it became one the the sentinel courses in my medical school experience. After five plus years of practice and thousands of patients later, I wonder if my preceptor knows how many thousands of patients he has touched through all of his students.

12 August 2007

Surgical Clerkship 101 (Part 3)

This is the last in my series about surgical clerkship. In this essay, I thought I would address some of the things that can go wrong and present some strategies to fix them or do “damage control”.

Misunderstandings or Miscommunication - Communication in medicine - any specialty- is a key component. Learning to listen carefully to your patients, your colleagues and your teachers is of paramount importance. Sometimes anxiety or time prevents you from actually “hearing” the message. This happens to everyone and especially to people who are trying to juggle several tasks at the same time. If you make a mistake, own up to it, apologize and move on. Don’t internalize and don’t personalize anything on any clinical rotation. It is very easy to miscommunicate when you are under pressure and in unfamiliar territory. When you find that you have misunderstood something or that someone has misunderstood you, acknowledge the mistake and keep moving forward. Forgive yourself, forgive others and move on as misunderstandings/mis-communications are part of being human.

Not telling the Truth - This goes along with miscommunication and mistakes. Don’t lie about anything. If you didn’t check something, acknowledge your mistake and let it go. Make a note to yourself not to repeat the mistake and leave it at that. Many times, especially when you are tired, you will forget something. Again, make notes to yourself if you forget something or did not do something but don’t lie about anything that you did or did not accomplish. Your ”word” in medicine is golden and your career, your patients’ lives and you colleagues trust all depend on your word and its truthfulness.

Grave errors - I remember an incident when I was an intern. A fourth-year medical student was attempting to re-wire a central line and made a fatal error that caused the death of a patient. In the defense of the fourth-year student, he/she was not supervised and wasn’t familiar with central line rewiring. In defense of the resident on whose service this student was rotating, he/she did not know that the student had not performed the procedure unsupervised. In this case, the student and resident was reprimanded but both owned up to this grave error.

The worst problem is that this student will carry this incident for the rest of his/her life.
In short, never ever perform a task or procedure unsupervised unless you are sure of what you are doing. In any procedure, especially the invasive ones, you should be able to explain the procedure to the person who is supervising you along with any complications that can arise and how you will handle them. When you are learning procedures, learn them from preparation, performance, complications and management of complications. The learning curve for things like central lines is usually 10 supervised before you do the procedure unsupervised.

Personality Conflicts - There will be people on your team (nursing personnel, fellow students, interns, attending physicians) that you will not get along with. In my opinion, personality conflicts have no role in medicine as they are counterproductive to good patient care. When I have encountered a personality conflict, I will defer my feelings as long as the care of my patient is not compromised. In short, my business and my job is to be able to work with each member of the team as professionally as possible for the benefit of the patient. As I have said in other essays, the clock ticks and you will not be around this person for the rest of your life. Be sure that you don’t burn any bridges behind you.

Another rule of mine is that I never discuss my colleagues with anyone except the person that I am having the conflict with. I don’t have time for gossip and I never allow negative comments about my colleagues from nursing or other people. One of my jobs as I have moved through residency has been to evaluate others. In these evaluations, I have readily admitted when I have a personality conflict and tried not to allow this to interfere with my evaluation. If I place something negative on an evaluation, I always cite the reason and what I believe the person can do to improve the situation. I also do not place negative information on an evaluation unless I have warned the person and asked them to correct the behavior which is the object of an evaluation in the first place. In short, check your ego at the door when it comes to patient care.

Time Management - There are 24-hours in a day and you do need rest at some point. Don’t try to ignore your body’s signals when you are tired. Manage your time so that you get some rest (it’s never going to be enough) and take care of your physical needs (eating, hydration). When you start a new rotation, you won’t be as efficient as when you end the rotation because you don’t know the procedures. Pay close attention to your interns and residents and ask for help. Never be too proud or too afraid to admit when you are overwhelmed. Also, avoid drugs to “keep you going” as these often bring on personality changes that can cause problems.

Most chief residents and interns will allow you to rest when there is nothing of educational value going on. If you are told to leave (go home), do what you are told to do. Don’t hang around the hospital but leave. If you are not tired, go to the library and study or go home and study but don’t hang around. You won’t get too many opportunities to “leave early” on most surgery rotations. If something is going on that you want to observe, ask your intern or resident before you go off and observe. Don’t ever leave one service to “hang out” with another without permission from your intern/resident and the agreement of the intern/resident of the service that you are “hanging out” with.

Helping Your Fellow Students - If your are efficient at getting your work done, help your fellow students if they need it. Your fellow students are your colleagues and sometimes they just need a hand at some small chore. If you are able to lend this hand, do so. Share information with your fellow students if you have something that is useful to the team. Your fellow students are not your competition at this point. Try to do what you can for the good of everyone. If someone has an emergency, offer to switch their call (let your chief resident know) and do so if you can. You never know when you might need the favor returned.

If one of your fellow students mistakenly keeps trying to manage your patients, show off to the residents and attendings, speak to this person about their behavior. If they continue in this aggressive behavior, let the intern/resident know what is going on. I can tell you from experience that quite often, the chief resident is aware of what is happening and will deal with the problem.

Your job on any clerkship is to learn as much as you can. If someone, fellow student or resident, is interfering with this process, the clerkship manager/dean should be made aware of the situation. Ask for a meeting and come prepared with examples of how your education is being compromised. Offer solutions to the problem too. As I said above, personality conflicts have no role in medicine but nothing should interfere with your learning. Make sure that you outline that problem and depersonalize it before you present it. Most of the time, learning interference problems can be solved by good and honest communication as opposed to “running to the clerkship manager/dean”. Reserve going outside the team for things that you cannot solve within the team.

Beware of the fellow student who is “going into surgery” and feels the need to scrub any cases that he/she deems interesting. Do the cases that are assigned to you and don’t let your fellow students take your cases. If this is happening on a regular basis, that is, you have scrubbed 15 hernias and nothing else while your colleagues are getting all of the interesting cases, check with your chief resident. On the other hand, if you are just scrubbing the “easier cases” so that your inpatient list is short, your grade may suffer. Don’t be afraid to tackle a complex patient and a complex case. You will be surprised at how much you can learn by digging in and taking on the assignment.

Attitude - I have said that attitude is everything in clinical medicine. Approach each rotation with the attitude that you will master what you need. You don’t have to “love” everything that you are doing but you do need to be able to give your patients your best work regardless of whether or not you love the rotation or anticipate entering the specialty.
Ask for feedback early and often. No one was born knowing how to perform on a rotation. A five-minute “how am I doing conference” with your intern and resident is not a bad idea early in the rotation. Listen to what they have to say and make notes of what you need to improve. Practice your skills and add to them. Keep a running list of procedures that you have done complete with the names of patients, date of procedure and supervising physician.

Problems in the OR - Don’t get into a ”pissing match” with any of the Operating Room personnel. If a scrub person tells you that you are contaminated, step away from the field and take care of it with a “thanks for pointing this out” attitude. I can tell you from personal experience that some OR personnel will try to ”get to you” because you are male, female, human, and other characteristics. Let this stuff go as long as they are not interfering with your knowledge. As an assigned medical student, you have a role in every case that you scrub. You are not to be ”pushed out of the way” by anyone. If this happens, discuss it with your attending or chief resident after the case but don’t get into a shoving match during a case. This rotation is part of your medical school education and you are paying good money for this experience. Don’t allow anyone to compromise your learning experience.

If you feel “faint” in the OR, step back from the table. You can just say, “I need step back” and everyone knows what is happening. The circulator will usually stick a stool under your before you fall. It also goes without saying that you should never go into a case with a full bladder or an empty stomach. Keep some kind of a snack in your coat pocket and keep hydrated too. If you are feeling ill, don’t scrub especially if you have a fever. Explain the situation to your resident/attending and don’t scrub the case. If you are “sick” for every case, your grade may suffer but on at least one occasion, students DO get sick and should not be in the OR.

Remember that too much caffeine will make your hands shake. I have found from experience that caffeine doesn’t alleviate fatigue and doesn’t make you more alert if you are exhausted. Things that help me fight fatigue are rest, hydration, good physical conditioning and fresh air. A cup or two of coffee/tea is not going to hurt you but downing cases of cola or pots of coffee/tea will not help you and may compromise your health, not to mention the diuretic effect of caffeine. Use this drug with caution and avoid overuse.

Grades - You should know ahead of time, how your grade is going to be calculated for any rotation. Be sure that you are not neglecting the projects and performance objectives of your rotation. Go back and look at your clerkship objectives weekly to be sure that you are accomplishing what you need to accomplish. If you have been assigned to a Cardiothoracic team, be sure that you are not neglecting your reading when it comes to hepatobiliary conditions. Your shelf exam is going to cover all aspects of general surgery, trauma, critical care, orthopedics and cardiothoracic surgery. Be sure that you neglect nothing.

Be sure that you continue to hone your diagnostic skills. Even if you are going into primary care, you need to be thoroughly familiar with the diagnosis and treatment of the acute abdomen. In short, you need to be totally familiar with the instances where you need to “consult” surgery. Every case of abdominal pain does not require a surgical consult and you will quickly lose the respect of your surgical colleagues if you consult them before you have done a complete work-up. Be sure that you know why and what you need from any consultant and are not using them to do your work.

Physical Limitations - If you have physical limitations that do not permit you to scrub the longer cases, the let you chief resident know ahead of time. If you have a chronic condition such as diabetes, multiple sclerosis, cerebral palsy or other physical limitations, these should have been discussed with your clerkship preceptors and the residents should have been made aware of your condition. These should not be done in front of the rest of the team but you should make sure that the people who need to be aware of your condition are aware.

This is especially true if you are pregnant and are having complications. If you become pregnant during your surgical rotation, be sure that your preceptors knows what is happening and is made aware of any problems that encounter. Again, this rotation should not place you (or your/your unborn child’s health) in jeopardy. I have had medical students who were physically challenged who contributed more to the success of my surgical team than some students who didn’t have these limitations. In these cases, I didn’t run the stairs with the team or make that person scrub the ten-hour cases without a break. In the end, it all evens out.

Remember that your chief resident and attending physician preceptor are not your enemies. You need to have a good working relationship with them and good communication with them. You also need to be proactive about your learning by keeping up with your reading and adding to your skills whenever possible. General Surgery often moves very quickly and decisions must be made with incomplete data gathering. If you don’t understand how a decision was reached, ask the resident to go through this with you.

Have the attitude that you are going to be a valued team player because you are. You are not the “scut person” and you are not on a team to be the “butt of jokes” by your residents or fellow students. Pitch in and refuse to be alienated by things like occasional “locker room humor”. Don’t personalize anything and learn from your mistakes.

11 August 2007

Surgical Clerkship 101 (Part 2)

This is the second of a three-part series to help you get the most out of your third-year surgical clerkship. Since this is one of the most important required clerkships, I thought I would spend some time on this one. The subject matter of this essay will be scrubbing and assisting in the OR along with handling some of the “pimp” questions that frequently come during the cases.

Your first tour at the scrub sink need not be intimidating as long as you keep a couple of things in mind. First, you need to be dressed properly. By proper dress, I mean clean hospital scrubs with no T-shirt sleeves below the level of the scrub sleeve. You need to have your hair completely covered (no bangs sticking out ladies) by scrub cap or “shower-type” cap. These caps should be clean and ideally, disposable. You need to have eye protection that covers all around. The goggle-type glasses are the best but you can pick up the disposable “Angel Frames” which are better than nothing at all. Blood spatters in the eyes are no laughing matter and you need to be protected. After your eye protection is in place, you must don a mask that completely covers your mouth and nose. If you have a beard or large bushy mustache, you can wear one of the hooded type devices that serve as both cap and mask. Finally, you need to don shoe covers that completely cover your shoes including the laces. Blood and other fluids often drip down onto your shoes. If you have shoes without laces, so much the better. I have shoes that I do not wear outside the OR that I cover with two pairs of shoe covers. When I am done with the case, I dispose of the outer cover and keep the inner cover for the recovery room.

You need to put on your hat and shoe covers before you enter the operating suite. These are usually at the door or near the door of the locker room and within easy reach. You need to be sure that your scrubs are clean before you leave the locker area (no blood or coffee). At the scrub sink, you need to don your mask and eye shields. Make sure that your mask is under the rim of your eye shield and tight. If moisture gets through, your eye shields will fog during the case and you won’t be able to see. Place a small piece of tape if you can’t crimp the mask for a custom fit. (Some people will tie a face shield-type mask upside down on their forehead to prevent fogging. This works well and you don’t need the eye shields if you do this. Another advantage of the upside-down face shield is that the rolled up mask part acts like a wick if you sweat or are doing a peds case in a very warm room.

Before you begin to scrub, go into the operating suite, introduce yourself to both the circulator and scrubbed personnel and write your name on the board and your level (MS-III). Also, if you are wearing a pager, place this on the desk with a pen/small note pad clipped to it. You can’t answer your pages when you are scrubbed in a case. Obtain your gloves and gown and place them on the table where the circulator can open them and hand off to the scrubbed assistant. Be sure to obtain both pairs because you want to be double gloved. Be sure you have chosen the correct size (have one of the nurses/techs size you if you don’t know). I wear size 7.5 gloves (big hands) I place my 8 undergloves next to my skin and put size 7.5 on top. Gloves that are too tight will be miserable on a long case. Gloves that are too loose do not permit good tactile skills such as suturing.

Once your mask, hat and eye protection are in place, you should be standing in front of the scrub sink. There are two types of soap solutions available (the waterless and water requiring). If you use the waterless scrub, make sure that you have done at least one water-based scrub before you use this material. On vascular cases, I never use the waterless scrub alone and usually do a full scrub between cases. If a graft gets infected, the patient usually dies from that infection. I take no chances and always err on the side of caution. If you are allergic to iodine (and I am allergic to iodine) don’t use the povidine solution for scrubbing. You should have gone through a “scrub class” before you actually scrub but the short version is here.

Take the nail cleaner and scrub brush from its packet. Turn on the water with your foot (may be automatic) and wet your hands and arms starting with the hands and going up to the elbows. Be careful not to touch the faucet. Use the nail cleaner to clean under each nail and dispose of it. Scrub each surface of each finger with plenty of soap and the brush. Divide your arms into four quadrants and clean them using 25 strokes for each finger surface, the nails of each hand, the surface up to the elbow. Once you have scrubbed an area, don’t re scrub. Toss the brush into the trash can and rinse starting with the hands and letting the water drip at the elbows. Keep your hands up at all times. If you accidentally touch the faucet, start over with the scrub.

You will drip water but hold your hands up and open the door of the operating room with your rear end. The scrubbed person will give you a sterile towel. Allow them to drape this towel over your wet hands. Grasp the towel at one end with one hand and dry from hand up to elbow. Take the other end and do the same. Drop the towel across the laundry hamper or where you are told to drop it. You hands should be dry and continuously held up. The scrub person will hand you a gown or drape a gown over your shoulders (stand still and close enough) pulling up the sleeves. The circulator will tie the gown. The scrubbed assistant will place your under glove on your right hand (left first at Mayo) and then you use your index and long finger to stretch the second glove so that you can place it on your second hand. This is repeated for you outer glove.
You then “spin” and tie the outside ties of your gown.

At this point, if you are not doing anything, cross your arms and stand out of the way. The resident and attending surgeon will be draping the patient and will tell you where to stand and what to do. Keep your arms folded and once you are in place, keep your hands “in the case” meaning let them rest on the OR table in complete view of the scrubbed assistant. When the surgeon gives you a retractor, hold it as instructed and try not to move. Keep your mind on the case, step by step (you should review the procedure before entering the OR). The surgeon may ask you to do a couple of ties or throw some sutures. Be sure that you are totally familiar with whatever you are asked to do. If it’s your first time, speak up and someone will talk you through. Try to close the skin at the end of the case. At this point, you and the resident can share this duty and it’s a good time to learn.

If you are driving camera on an laparoscopic case, try to keep the instruments in the center of the visual field. Believe it or not, you have the most important job on the case. Good camera drivers usually get excellent evaluations from the residents and attendings so learn this important skill. In the event of an emergency and you lose gas pressure, remove the camera as quickly as possible. The light on the end of the camera can cause a very serious burn so you need to be sure that you don’t touch any tissue with the light and that you remove the camera efficiently if told to do so. Keep your eyes in the case and listen to instructions. If you make a mistake, correct it but don’t take anything personally. When a case isn’t going well, surgeons can get frustrated. It isn’t personal and don’t let it throw you.

At the end of the case, help the anesthesiologist, resident and technician move the patient to the stretcher and push the stretcher to the recovery room. Again, just do what you are told if you don’t know. Step up and volunteer your assistance if needed. Watch tubes and IV lines on transfer and remember that the anesthesiologist directs the move because he/she is in charge of the airway. Be sure to thank the OR scrub staff when you leave the OR for the recovery room. It’s just common courtesy. Once in the recovery room, be ready to write the ”Brief Op Note”. You can get all of the components from the anesthesiologist and the OR nurse. At the beginning of your rotation memorize the components of the Brief Op Note and be efficient at getting this note written. Again, ask to do this and ask the resident to help you if you can’t find something. Don’t leave this note incomplete. When I am dictating the case, I will use this note in my dictations so listen to the resident’s dictation (I dictate my cases in the RR at the end of each case) if nothing else.

Every patient that you assist on that is coming to your service will be your patient. If you have seen the case, you know what the incision looked like at the close of the case and you know what went on during the case. Keep these things in mind as you follow your patient. Be sure to read the anesthesia notes on your patient and ask questions if you don’t understand something. These notes can be invaluable in terms of fluid management of your patient post-op.
Answering those “pimp” questions. Most questions asked during a case will be directly related to the pathology of the patient or the anatomy of the region that involves the pathology. Be sure that you have reviewed these things before scrubbing the case. It’s a good idea to review the anatomy of the biliary system, the GI system and the chest before you start your rotation. Be sure to read and review common emergency cases such as appendicitis, acute abdomen and vascular anatomy. After that, read about the types of patients that you will be seeing on your service. Finally, cover trauma (unless you are on trauma service). Again, the Lawrence text is great for reading and total mastery of this book can take you a long way toward doing well on your shelf exam.

You also need to be sure that you skills are adequate. Practice with a knot-tying board until you can tie a secure two-handed knot without thinking about it. Be sure to bone up on your fluid and electrolyte information as pimp questions will frequently come for this subject matter. Stick close to your resident and don’t whine. If you are tired, your intern and resident is more tired. There will be times where you are just exhausted. The first thing you should grab is a bottle of water (dehydration makes exhaustion worse). Stay away from loads of caffeine and sugar and learn to “cat-nap”. Be upbeat and remember that no matter how bad the rotation, the clock is ticking and it will be over soon. For most people, this is their only brush with surgery and the most important thing to take away from the rotation is a solid knowledge of when to consult a surgeon. Next essay, when things go wrong and how to do “damage control”.

10 August 2007

Surgical Clerkship 101 (Part 1)

I thought I would take this opportunity to spend some time listing some helpful hints to moving through your surgical clerkship seamlessly. Surgery is one the the third-year “required” clerkships during medical school. It doesn’t matter if you are interested in surgery or not, you still need to master this important portion of your medical school training. Many student look at surgery as something to be dreaded but this approach will not serve you well in surgery (or any class or clerkship). It is most useful to go into this clerkship with an open mind and a willingness to learn and master what you need from this required clerkship to become an excellent physician.

As a third-year surgical student, you will be required to keep honing and using your Physical Diagnosis skills. Your acumen with the abdominal history and physical exam will be sharpened. In addition, you can pick up some valuable procedures and skills that will serve you well on any rotation regardless of specialty such as scrubbing and interaction with a sterile field, central venous access, suturing and simple skin closure. As a third-year surgical student, you ARE part of the team and you can either “carry your weight” or “drop the ball” but 95% of what you get out of this and any clinical rotation will be directly related to your attitude. In short, open your mind (and your ears) so that you get the most for your experience and money.

Surgical patients may present at any time of the day and from various sources such as the clinic, the emergency department or from your preceptor’s private office. In general, you will be assigned to a team (trauma, general surgical, surgical specialty) where you can expect patients from the above sources. You will be expected to take overnight “call” along with the interns and residents since many surgical patients will present in the middle of the night with emergencies. Your surgical clerkship is a very nice opportunity to interact with the “late-shift” personnel in various departments such as radiology, lab and nursing so that you can learn who to see when you need to get something done or when you need information.

The intern (PGY-1) is your first point person. Try to learn the scope of their role on the surgical team and how you can assist this person. The intern will usually be the busiest person but remember, that regardless of specialty, in two years, you will be in their position. Watch how the intern performs their job and learn how to function as an intern. During your fourth year “acting” internships or (AIs), you will want to have mastered time management and multi-tasking. It is great to have a good relationship with your intern and learn as much as possible and become as helpful as possible.

Being helpful does not mean that you become the person to “go fetch” coffee, radiographs and laundry but it does mean that you know more about your assigned patients than anyone on the team. You will pick up three to four patients on each rotation (more if you are efficient) that you will follow through their hospital course. It is your responsibility to follow-up on all orders, consults, labs and studies on your patient. The intern on your service will be covering every patient on the service so the more closely you can work with your intern the better. This means reading in your surgical text about your patients’ pathology and the surgical treatment of that pathology. This means reviewing and following up on every order, medication, dressing change and complication.

Typically, you will enter the hospital early in the morning to pre-round. In some cases, pre-rounding means heading over to a computer to gather any laboratory work, checking in with the overnight (post-call team) and reading any nurses notes/checking with the nurses who have been on duty overnight. Armed with this information, you should quickly check the previous 24 hours of vitals, intake and output. Finally (if this is allowed), you should do a quick (no more than 5-10-minute) focused physical exam on your patient. Armed with this information you can prepare your AM presentation which should make up the bulk of your AM progress note. If you encounter any problems, discuss these with your intern and be prepared to present this patient to the AM rounding team.

On AM rounds, the chief (or most senior resident) will listen to your report presentation. If you are not ready, the intern will present the patient but you should step up and have your presentation ready. Other good things to do will be to be at the bedside with things like extra bandages, scissors and tape if needed for your patient. I learned very early, how to “peek” under a dressing without removing it. In general, dressings may be removed at 48 hours but never remove a dressing unless you have cleared it with your intern. You can peek and examine the wound to figure out if it is intact. Also, be sure to note any dressing drainage (dry or fresh) and note if nursing has been reinforcing the dressing overnight (or since surgery). If you are on the vascular service, one of your tasks will be to “take down” your patient’s dressing so that the team may examine the wounds on rounds. You may be asked to replace the dressing (great skill to learn) by your resident. Get help from the intern (or nursing) if you have difficulty or questions with this.

If you have read about your patients’ pathology and surgical treatment, you should know (or learn) what complications to look for and how to monitor your patient. For example, you should know what to do if your patient develops a post-op fever at 8 hours, 24 hours, 36 hours or 72 hours. You should have a differential of things to check and monitor. You should know what to do if your patient has an extreme amount of pain that is unrelieved by their current analgesic regimen. You should know how to monitor electrolytes and when to replace them. You should keep your intern informed of the results of all consultants and any studies that have been ordered. In short, you micromanage the patient and you keep on top of things.

Another wonderful experience of your surgical clerkship is assisting in the operating room. I am going to devote an entire essay to this very important task. You will be performing tasks such as retracting tissue, driving camera (on laparoscopic cases) and closing skin. Do not underestimate the importance of these duties and do not underestimate the importance of thoroughly mastering the surgical anatomy of the cases that you scrub. Here again, is a great opportunity for you to show what you know and hone what you learned in Gross Anatomy and physiology. During many of your cases, you are going to be questioned by the senior resident/attending surgeon about the anatomy, physiology or procedure on which you are assisting. I will give you some tips to make you shine and guide you through this process.
Textbooks for your surgical clerkship: The big “three” texts for General Surgery are Greenfield’s, Sabiston’s and Schwartz. You need not purchase these texts (even if you are going into surgery) as they are readily available in your library (medical school or hospital) for research and consultation for presentations and projects. My favorite clerkship text is the Lawrence text for both General Surgery and the text for the Surgical Specialties. This book (or one like it) should constitute the bulk of your reading on this clerkship. In addition, you may want to invest in a smaller “pocket-type” book such as Surgical Recall that you can keep in your pocket for downtime during cases. Other good books in addition to your main clerkship text (Lawrence or something else) are NMS Surgery and NMS Surgery Casebook which contain excellent and compact information.

With Lawrence, NMS and the NMS Casebook, I cut the bindings off [FedEx/Kinko’s] and placed these in binders. I could then take pages with me and keep up with my reading between cases. The pages were held together by a ring and would fit in my jacket pocket or back pocket of my scrubs. I always had something to read with me be it Surgical Recall or my pages. This was the easiest way to keep reading and prepare for your surgical shelf exam. Surgical Recall was great for pointing out the surgical anatomy, surgical instrumentation and other answers to “pimp” questions for a particular procedure or pathology.

In my next essay, I will review scrubbing and assisting in the OR. In addition, I will comment on being a great third-year on call and keeping yourself “in the game” when you are exhausted and ready to “give up”. In my last essay on the Surgical Clerkship, I will point out some strategies for when things go wrong and how to prevent getting into situations where things can go wrong.

05 August 2007

Gross Anatomy (Revisited)

Since a large number of people are entering medical school, at this point, I thought I would re-post an earlier essay that I had written about Studying Gross Anatomy as it gives some pointers for getting off to strong start in this important class.
Gross Anatomy can set the "tone" for the rest of your medical school courses even though the rest (with the exception of Neuroanatomy) will be quite different in terms of approach and management. GA is a great course to master and hone your study skills because it requires observations and making conclusions based on those observations. GA is also a course that builds upon previous knowledges and skills learned. The first couple of lectures will set the tone for the rest of the course.
My experience with GA was great and I made some lasting friendships over the cadaver tank. Enjoy!
Mastering Gross Anatomy
I thought I would write a short essay about my experience with Gross Anatomy class when I was in medical school. This class can cause some angst and turmoil for some freshman medical students because it generally requires the greatest adjustment in terms of study skills and habits.First of all, Gross Anatomy does not require any great feats of intellectual insight. The material to be mastered takes diligent and systematic study. In short, there is NO substitute for just grinding through the process and taking the time to organize the material for study. At my school, Gross Anatomy also included Embryology which, made Gross Anatomy (GA) far easier to organize in my opinion.During orientation, we were given a huge syllabus complete with objectives, lecture schedule and lab schedule arranged by topic. We were also given an exam schedule which allowed us to know exactly how much material each exam would cover and when the exams would be given. The breakdown was along the lines of Exam 1 - Extremities and Back Muscles, Exam 2- Thorax, Abdomen and Pelvis, Exam 3 - Head and Neck. This division made sense because dissection and study of the Back Muscles and Extremities requires far less manual precision than dissection of Head and Neck Structures. By the time we reached study of Head and Neck, we were old "pros" at dissection and finding structures.My best tools for study of Back Muscles and Extremities were my embryology book and one of the skeletons. Our anatomy department had loads of bones and skeletons everywhere in the gross lab. My first approach was to sit down with the syllabus and look over what would be covered in lab and lecture. My next approach was to skim the material in the syllabus looking carefully at the objectives. This usually took less than 15 minutes tops and I was on to the reading making notes in the margins of the text that corresponded to material that was mentioned in the objectives.My GA textbook was Moore's Clinical Anatomy for Medical students. I had the binding removed from this book so that I could place the reading pages in a three ring binder. I always had something readily available for reading. My next step was to photocopy or scan the Netter plates that corresponded to the lecture that we would be covering. I would note with a pink highlighter, any structures that were mentioned in the syllabus. That was my prep for each lecture. After hearing the lecture, I would study my notes (or the noteservice notes) and do the same prep for the next lecture.In prep for lab, I would take out my dissector and make a check sheet of every structure that were expected to observe in lab. I would organize them according to superficial, deep, nerve supply and blood supply. When it came to the muscles, I would list every origin and insertion and action on a sheet with a check list. Before I began dissection, I would visualize them on a skeleton and visualize the actions. I learned the nerve and blood supply at this point too. For example, let's say that I was looking at the muscles of the back. My first task was to organize them into extrinsic back muscles (associated with the movement of limbs) and intrinsic back muscles (associated with movement of the spine). I would then organize them into superficial and deep layers.My coverage of the anatomy of the back would have started with organizing the anatomy into surface anatomy (my fiance was a willing model for this stuff), bony anatomy (learning all of the vertebral bones), spinal cord anatomy and then the back muscles. Associated with all of these lectures were embryology lectures on development of the muscles, bones and nerves. But back to the my organization scheme. The embryology lectures took place before dissection so that we had that background before moving into the lab.Let's say that today's lecture included the muscles of the back. I would have my Netter plates (with annotations) and my key words from the objectives in my folder for that lecture (the material that I had prepared the evening before). I would listen to the lecture taking notes as I needed them and adding notes to my plates or on paper. We would then head off to the lab where I would look at the skeleton and trace out every origin (medial attachement) and insertion (lateral attachement) for each of the back muscles. Lets look at the Latissimus dorsi for a specific example. The medial attachement is the spinous processes of the six most inferior thoracic vertebrae and the lumbar vertebrae, inferiorly: the iliac crest and the thoracolumbar fascia and the inferior 3 to 4 ribs. This muscle inserts on the floor of the intertubercular groove of the humerus. By locating the origins and insertions of a muscle, I would be able to picture the action of that muscle as it contracts. In the case of the latissimus dorsi, I knew for sure that this muscle was not an intrinsic back muscle but functioned primarily on the humerus (an arm bone).I would also learn the blood and nerve supply as I studied the skeleton. The nerve supply is the Thoracodorsal nerve which can be found heading through the axilla and to this muscle. One of my instructors like to say that the extrinsic back muscles "crawled out onto the back and took their blood and nerve supply with them". This statement easily explains why the thoracodorsal artery is a distal branch of the axillary artery and that I could trace the small branches on the anterior surface of the latissimus dorsi muscle back to the distal part of the axillary artery which is a continuation of the subclavian artery. The nerve system is the same as the thoracodorsal nerve is a branch off the posterior cord of the bracheal plexus which travels to the LD muscle that is located on the posterior, inferior portion of the superfical back. In short, by organizing the material before heading into the dissection lab, I knew where to look for nerves and vessels; the actions of the muscle and bony landmarks all at the same time.My GA class also required that we study radiographs, CTs and MRIs in addition to our dissection. I studied the available materials along with my dissections. When I came to the dissection lab, I had a checklist of all of the materials that I wanted to review and master. I can tell you that I was in the dissection lab at least 10 hours per week outside of the dissection lab times. On the weekends, I would review the week's materials which usually took three or so hours. This study was done with my study group. I also looked at every cadaver in the lab weekly in addition to my own. We kept a running list of excellent dissections (more likely to be tested) at different tanks. We always asked permission before entering another group"s tank.Another thing my study group did was ask one of the instructors (usually the course director) to spend 30 minutes quizzing us a week before the lab practical. He was totally willing to work with a five-student group. We asked him to be picky and brutal. Usually these sessions made us go back and work a bit more on our identification of structures. Our instructor was very good about telling us how to identify structures on a lab practical. He always liked to show us great landmarks.The most important aspect of GA study (any course study) in medical school, is not to get behind. If you miss something (illness) you need to go immediately to where the class in and catch up on the weekend. Some students get behind and attempt to catch up and never get there. Again, catch up on weekends (they don't lecture on Saturdays and Sundays). Also, don't underestimate how much your classmates can be great resources for you. I never found a classmate who wasn't willing to review structures with me in the lab. The biggest gunner gets an extra boost by helping classmates who are struggling. Everytime I reviewed something, I learned it that much better.Some caveats: You cannot organize the material for your classmates. Each person has to find their own system and each person has to learn the material for themselves. Working with a study group helps to reinforce the material but each person is responsible for their own learning. Don't even try to work with a group until you have done a thorough mastery of the material for yourself. If you are isolated, you lose out on the great reinforcement so don't isolate yourself. If you have a family and other outside obligations, schedule some study group time even if it is minimal. Medicine is not a solo activity and you will have to rely on your colleagues when you are in practice. Medical school is good practice for learning to work as a group.Well, the above is the essence of my system for GA and embrylogy. I can tell you that I spent plenty of time in the Gross lab and working on GA. It was interesting and it helped me appreciate my classmates even more. We all worked together and we all learned together. GA is not a course that you can sit down, memorize and master in a vacuum. You need feedback and your instructors/classmates are great resources. While there is much to learn and master, it's not all rote memorization. My classmates that were great rote memorizers did fine on the tests but crashed on USMLE Step I in most cases. The understanders and intergrator (like me) did equally well on the exams and on USMLE Step I. It takes both.I would also say that GA is not a course to be feared but a course to be mastered. A full 75% of my class failed the first GA lecture exam but only about 2 people failed the course itself. In most schools, you are not penalized for getting off to a slow start as long as you figure out what you need to do to get your information mastered. For me, GA was daily study, preparation and mastery. I also forged a great relationship with the GA instruction staff (I was the class rep for this course) so that we all could do our best. The instructors were not there to "fail" us but to help us master this neat course. In the end, it worked out fine.

31 July 2007

Study Skills Part IV

On the first day of your class, you will be issued a syllabus that outlines the professor’s grading policy, what will be expected of your in the class and a lecture/test schedule. Once you have that document in your hands, you can begin to set up your schedule for the rest of the semester. Ideally, you may want to purchase a very large desk blotter but the calender in MS Outlook (or something like it) will do just fine. On that calender, you want to place the date and time of every lecture, the topic, and the required reading. You also want to place the dates of your exams and note the dates of 3 weeks to exam, 2 weeks to exam and 1 week to exam. Any papers that are required should be treated like exams with 3 weeks to paper due, 2 weeks to paper due, 1 week to paper due.

If you are taking a lab course, you need to add the dates and times of your various lab sessions to your calender along with the topics of each lab. If you list your labs by subject matter of each experiment, you can relate these to your lecture material for better integration of the course subject matter. If your course has a recitation section, be sure to list this too as you do not want to skip any recitation sections. These sections can be invaluable when it comes to test preparation time.

Once you have set your master schedule for the semester, fill in your schedule for the week. This means filling in how much time it takes for you to get to school, the times of your classes and labs, your study time - remember one hour of study for each hour of lecture and 45 minutes of study for each hour of lab-your meal times, your work out times and your bedtime. If you are using a computer-based program for your daily schedule, print out your next day’s schedule when you are studying the night before. Look at it and be sure that you have organized and prepared for the classes that are on this schedule.

Class preparation means look at the subject matter of the upcoming lecture. Review the assigned readings - pay close attention to any bold words, headings and topics-review the syllabus and do any assigned problems. If you have difficulty with any of the problems, put notes or checks where you had difficulty so that you can walk into your professor’s office during office hours and get your questions answered. Don’t wait until after the lecture to work pre-assigned problems. Most of the time, anything that you had difficulty with, can be answered in class. If you wait until after class, you will be behind. Attempt assigned problems before your lecture.

Listen to your lecture and take notes only on the things that you know are not in the syllabus or text book. (See my previous study skills posts for how I would cut my textbooks). Take notes on things that help you to understand the important points of the lecture or clarify concepts that you previously did not understand. As I have outlined in other study skills posts, I would take notes on the left side of my notebook only using the right 2/3rds of the page. The left 1/3 of the page would be left blank so that I could write in summaries of the notes or definitions of terms that were important. On the right pages of my notebook, I would recopy notes that were taken in a hurry so that they were legible. I would also place notes and information from my text book.

Most of the time, I took lecture notes on my laptop computer or on looseleaf notebook paper. I discovered the utility of using notebooks that were designed for law students (summary paper) and then resorted to making my own version of these summary pages. I would print out my notes and clip them into a looseleaf notebook so that I could highlight them or make notes to myself as I studied. I would review the previous lecture, study the current lecture and preview the upcoming lecture doing the text readings.

As I stated under Organic Chemistry, I never walked into any lab unprepared. My lab prep consisted of knowing the purpose of the experiment; how long each step would take; what data needed to be obtained and what conclusions/observations I would be expected to make. I kept a sticky note in my lab manual or notebook with the steps of the experiment briefly outlined so that I could refer to my note. This make any lab write-ups pretty easy to finish. If there were pre-lab exercises, these were done before I attended lab. I would also consult my textbook if the material covered in lab didn’t correspond with the lecture (most of the time the lab material was a bit ahead of the lecture).

For courses like English and Math, I made sure that I had a solid reading schedule that kept me ahead of the class. Again, I would have problems worked before coming to class. In English, I would make sure that I had thoroughly covered the readings taking notes as to tone, argument and subject matter as I moved along. Again, sticky notes were good for making extra notes in my reading books. I could past them in and add them to my professor’s notes after the lecture.
Soon after each lecture, I would quickly review the lectured material filling in any words that I had left out or drawing arrows to link materials. I would make any quick notes of things that needed to be clarified during office hours. In terms of Math and English, I would have circles around any problems that I had attempted but was not able to complete before class so that I could get my questions/problems taken care of. If these were not taken care of in the lecture, they would be taken care of during office hours.

My professors got to know me pretty well because I would attend office hours even if I was sure that I had mastered the material. It doesn’t hurt to have a “tune-up” and a “knowledge-check” even if you are sure that you are understanding everything. Sometimes these “tune-up” sessions would give me valuable insight as to what to emphasize for the exams and what to place less emphasis on. I figured that if I was paying thousands in tuition for each course, I was going to get every bit of instruction out of the course that was available. It also gave the professor a chance to get to know me which was good when I requested a letter of recommendation for graduate/medical school. I always received high praise for my business-like attitude and organization of my coursework.

Spending so much time preparing and previewing for each class made studying and review for each exam practically effortless. By the time the exam rolled around, I had been over each lecture a minimum of three times. I reviewed the previous weeks lectures on the weekend. By staying ahead of the professor and the class, I always had plenty of time to integrate the materials for every class. My attitude toward university coursework (honed by loads of experience in secondary school) was that my “job” was to master this material. I needed to thoroughly master my coursework because it was background for my graduate studies and I wanted the best undergraduate education that my university offered.

Don’t get the idea that I spent every waking hour in front of a book. I used my university time to attend lectures and seminars on any subject matter that was of interest to me. I went to lectures on the Holocaust, aerospace engineering, mathematical theories, social theories, political science in addition to departmental seminars in biology, chemistry and physics. I obtained a departmental seminar listing during the first week of class and added these to my schedule. Even if you do not completely understand everything in a seminar, you can pick up valuable experience and broaden your knowledge base for free. These seminars are also a great opportunity to get to meet the faculty and learn their research interests.

As a medical student, I tried to attend grand rounds in Surgery, Medicine and Pathology as much as my schedule would permit. These grand rounds became invaluable for USMLE (all steps) as the speakers always presented both the basic and clinical science of their discipline. It was my interest in every aspect of medicine that lead me into academics and today, continues to allow me to keep up with basic science as well as clinical science.

As a student of science and medicine, you have to be quite proactive and a bit of a self-learner when it comes to the mastery of your craft. If you take the time to start keeping up with the literature and attending seminars/grand rounds while you are an undergraduate, you can carry those skills into graduate/medical school. You cannot afford to be a passive learner relying on the professor’s lectures for your entire education. I totally attribute my performance on the Medical College Admissions Test (MCAT), United States Medical Licensing Exam (USMLE) and my specialty board/in-training exams to my attendance at all of those seminars and grand rounds. By listening to the “cutting-edge” leaders in various subjects, you learn to analyze information and you learn to present information logically. These skills are free and the seminars are often free and easy to take advantage of.

Finally, approach your studies as you job. If you are working and attending class, you need to be organized but you need to do both well. I always recommend that students who work, need to take less hours. It is not useful to load up on semester hours only to do poorly or mediocre in the coursework. Take less hours in the first place, do well, and if you find that you have free time, use that time to attend seminars/grand rounds. If you are a full-time student with no employment, use some of your free time for seminars and experiences that widen your educational experience. You only get once chance at your university experience and you need to be sure that you are getting the most out of every class for you money. Make your studies of prime importance and be proactive about getting your needs met.