26 February 2007
Once you have decided that you are going to apply for something, you need to take a look at the criteria that will be used for evaluation of your application. For medical school, this means your undergraduate grade point average, your score on all sections of the Medical College Admissions Test, your extra curricular activities, your letters of recommendation and your personal statement. For residency, the players change to your grades in medical school and your scores on USMLE/COMLEX exams (Steps 1 & 2) and for fellowship, your evaluations during residency and scores on in-training exams.
You need to look carefully at what you bring to the application process. You cannot change your grades so if you are an undergraduate and reading this, you need to get the highest grades that you can possibly achieve. Do whatever it takes and make thorough mastery of your undergraduate subject matter (along with your pre-med coursework) your major priority. Contrary to popular belief, great letters of recommendation or wonderful extracurricular activities will not erase a poor undergraduate performance (nor will obtaining a graduate degree). You have one shot with your coursework so make the most of every opportunity to show your excellence.
As I have written elsewhere, you need to thoroughly prepare for and take the Medical College Admissions Test. This test should be taken after complete knowledge and preparation using the same manner of questioning as on the actual exam. Do not believe that you can take this exam once for practice and then once for "real". Nothing sounds an application "death-blow" like more than one mediocre MCAT attempts (or several attempts unreported). This is not an exam for "practice" but a measure of your suitablity for medical school. Whether you believe this test is valid or not, it's a stepping stone that is quite important.
Once you reach your sophomore year, you should have a good idea of where you stand in terms of preparation for medical school. If you have taken the pre-medical courses in sequence, you should be done at this point. You should start writing your personal statement too. The reason for this is that when you request a letter of recommendation from your pre-med science professors, you should include a copy of both your CV (curriculum vitae) and personal statement. These two documents allow your letter writer to get an idea of you and your outside of class achievements. You should also include a deadline and waiver of inspection of the letter. For most undergraduates, these letters should be sent to your pre-medical advisory committee/office where they will be stored in your folder. (If you have not made contact with this office, you need to do so as soon as you know that you want to attend medical school).
During your junior year, you should be solidifying your knowledge in your undergraduate major and preparing for completing your AMCAS/ACOMAS application. This usually involves obtaining unofficial transcripts from every institution that you have taken courses at since secondary school without exception. Even if you took a typing course at a local community college, you need to request and obtain a transcript because that course needs to be listed on your application.
Choose your medical schools in early fall of your junior year and make sure that you have taken 0r are scheduled to take the required coursework to make application. Some schools require courses like genetics, biochemistry or calculus in addition to the traditional pre-med courses. A consult of the MSAR (Medical School Admissions Requirements) should keep you informed on these additional requirements.
In terms of a choice of what major is best for you, choose the undergraduate major that interests you most. It is a huge chore to attempt "engineering" because you "heard" that it was more impressive to members of a medical school admissions committee. Nothing is more unimpressive than a mediocre undergraduate performance in a major that doesn't interest you. I often say to myself, if I had it to do over, and I knew that I would be going straight to medical school, I would have majored in American Studies, minored in Spanish and took my pre-med courses.
These thoughts are only fleeting because I attended college with the notion of preparing myself for a career in scientific research (not medicine). My undergraduate majors of Analytical Chemistry and Biology with minors in Physics and Math were my preparation for graduate school. I also loved and was quite passionate about those subjects. I enjoyed hours of working on problems in applied differential equations class and higher algebra/advanced calculus. If these courses are not for you, head into something that DOES excite you. After all, you are spending thousands in tuition dollars so you might as well get your money's worth.
I also cannot emphasize the importance of exploring the nature of your fellow human beings. College is a great time to gain exposure to a diversity of ethnicities and ideas. Immerse yourself in another culture by spending a semester or two abroad or studying the art, language and music of another culture. These experiences are easy to find on the campuses of universities and are a great source of stress-relief. There are literally millions of ideas out there to explore and enjoy even if the experience makes you a bit uncomfortable. Your life will be richer for the experience.
Application for residency closely parallels application for medical school except the deadlines are more unforgiving. In the allopathic system, the ERAS (electronic residency application service) deadlines have to be exceeded or you miss out on interview opportunities. You have to be thinking about your choice of residency shortly after you complete first year.
The reason why I give the end of first year as a deadline, is that you can use your summer between your first and second year as a means of exploring some of the specialties. Do not choose a specialty because you believe it will be prestigous or pay loads of money. Dermatology is often sought after as a prestigous and highly paying specialty but I would be a miserable dermatologist. I enjoy my colleagues who pursued this specialty but it was not for me. (See my posts on why I chose surgery).
Don't choose a specialty because you believe it will be in demand. Demand in terms of specialty comes in cycles and by the time you are applying for residency, the demand could be poor. I remember when I started medical school, the demand for anesthesiologists and anesthesia residency was pretty poor. Now, this specialty is fairly sought-after and in a couple of years, the field will be saturated. (Anesthesia is not a rapid turn-over specialty).
Choose a specialty because you love it and you can't imagine doing anything else. Sounds just like the reasons that you choose to apply to and attend medical school.
23 February 2007
As I see it, I can survey the X-Box 360 from my Sumo-Omni or just park it in front of my patio door (removing a couple of beagles) and enjoy the afternoon sun on a lazy Saturday. I am also expecting that I will spend a fair amount of time removing the beagles from the Sumo-Omni so that I can hang out in this thing. Likely, I will end up buying one for them and one for me. In short, I am about to spend $260 on a couple of beanbags but as I see it, a great investment in getting myself "back to the womb".
Why am I mentioning this? Because one of the greatest lessons that I have learned is that after spending days in the hospital, coming home and tossing myself into a Sumo-Omni with abandon is just my idea of heaven. Keeping some sanity in this profession is all about doing little "nice things" for yourself regularly. This is a $130 daily vacation complete with sunlight on the weekend. Who know? I might have to import this thing into the Chiefs Den for catching a nap between cases.
21 February 2007
I am a person of ideas and questions. I am always looking for a new "take" on a problem or some new aspect to an old problem. I was always curious about anything and everything that had to do with observations of the world. My Mum noticed as early on, when I was a toddler, that I could amuse myself by examining the world around me. I started out with anything that was placed in my hands and from there proceeded to catalog all of the plants in our gardens on the grounds of our farm.
She said that even before primary school, I would spend countless hours watching frog's eggs develop in the stream near the back of our house or I would sleep in the barn with my father when it was time for one of the mares to foal so that I could be awake for the birth. Our farm provided a living laboratory where I honed my powers of observation. In addition, the Encyclopedia Britannica, a gift from my father, provided a wealth of information at my fingertips that encouraged more observations.
One of my first "experiements" was the isolating Belladona, a cholinergic stimulator, from the May Apple Plants that grew wild in the fields. I ground up the plants and did the extraction following instructions from a scientist friend who lived nearby. He was totally surprised when I was able to obtain small amounts of atropine from the plants. He knew that I had succeeded when I appeared at his doorstep with dilated pupils at the age of seven. I guess I was on my way to being a chemist.
I was also intrigued when my Mum would kill and evicerate a chicken for dinner. It wasn't the meat that was of prime interest to me but the dissection of the heart and the identification of the structures in the heart. I dissected liver, made slides and examined the tissues with my small light microscope that had a mirror as a light source. I even used iodine as my primary stain for many tissues that I sectioned from the entrails of those chickens.
When I headed off to university, post secondary school at the age of 15, I didn't realize that by being as young as I was, that I was a bit different from my classmates who were all 18. To me, it was three years but to them, it was a generation. I spent most of my "downtime" hanging out with a couple of mates who were from New England. We listened to music and solved most of the world's problems from our limited perspectives. I also had a part-time job in the chemistry laboratory preparing experiments and making compounds. From atropine to nickel-complexed bioorganic substances. I had arrived.
I decided at the end of my freshman year, that I would be a research scientist. I was interested in analytical chemistry and getting to know all of the instruments in the lab. They were my friends and companions for most of the day. In the evenings, I would accompany my research advisor and his wife to the symphony (I was a great fan of Baroque music). I also played any wind instrument and wrote some short compositions. Even to this day, there is no genre of music that I do not enjoy. My music collection contains everything from classical to rap to country to jazz to new age to indie. I love to listen to everything.
When I was a junior, I had already decided that analytical biochemistry was going to be my career. The science of large biomolecules, especially proteins and their analysis, was of great interest. I had been analyzing some mushroom toxins (see, I really love those plants) and moved into working with snake venoms. These venoms were my first venture into the world of systemic pharmaceutical effects. I loved what I was working on.
I also worked in the lab of an analytical chemist who further nurtured my interests in just figuring out how things worked. He was a pioneer of computer modeling and was adept at making very complex mathematical descriptions and models of energy changes in the manner that compounds interacted with each other. I loved working with the graduate students and seeing how his ideas and theories developed. He also make me understand how mathematics was a great tool of the scientist.
My interest in medicine was awakened just before I began to study for my comprehensive exams in graduate school. My best friend in the graduate program was a Brazilian neurosurgeon who was working on his Ph.D in Biochemistry. We studied together and shared information often. In addition, we talked about medicine and the differences in practice between the United States and Brazil. Some of the best times were when he would bring his 8-year-old daughter to the lab so that she could hang out with us. She reminded me of myself at her age and what could be better than hanging around in the lab.
Right after comprehensives and defense in June, I knew that I was scheduled to take the MCAT that August. I had already filed my AMCAS application and had designated six schools (including the one where I was a graduate student). I also knew that I would be evaluated later because of the August MCAT but I didn't have a choice. It was in May that I even decided to apply to medical school so I had already missed the April MCAT. I would file everything that I could and then have my scores catch up with the rest of my application.
Well, the rest was done. I took the MCAT and the application was done. I was so busy working on my lectures for the next year, that I didn't really expect that I would get into medical school. After all, I was 45 year old but had tons of energy and an interest in everything. I recall reading one of my letters of recommendation and wondering if I was even suited for the practice of medicine. My letter writer, a cardiologist, wrote of my incredible insight into pathology and physiology of diseases. For me, these were just more things to study, explain and catalog, something that I had been doing all of my life.
My MCAT scores were released to my prospective medical schools that October. I had my first invitations to interview by the end of October and went on my first interview the first week in November. Most of the other folks who had come to interview thought I was faculty and were fairly surprised when I said that I was an applicant. One guy even laughed because he said that no medical school would "waste a seat" on someone that was as old as me. This comment was a source of humor throughout the entire process when I received the first of my six acceptances.
As I went through medical school, I noted few differences between myself and my younger colleagues. I was the third oldest person in my class. I was single so I would party with the single folks but I enjoyed the kids of my classmates because children are just neat. There are no sharp divisions between non-traditional and traditional medical students. We all have to master the same amount of material and just get the job done. Medical school is a great equalizer.
As I headed into residency, I still found little difference between myself and my younger colleagues. My gray hair (been gray since age 24 like Taylor Hicks) afforded me instant rapport with my patients but I was no more tired after a night on call than my younger colleagues. I slept little, answered every page, and always loved to operate through the night with one of my chief residents. As soon as I hit the OR, I was always wide awake and ready to work.
The long hours now make me appreciate little amenities like sitting in the hot tub or going for an early morning swim before getting to the hospital on weekends for that extra energy boost. I love the world of getting to the hospital before the sun comes up and seeing the progress of my patients. I also love reading and discovering new treatments and therapies.
If nothing else, my age allows me to appreciate this great platform from which I can observe the world. I just doing the same things that I did back when I cataloged all of those plants in our backyard.
19 February 2007
I have added a link to the Short Media Forum. This website is chocked full of cutting edge information about anything that has to do with computers, networks, information technology and software. If you are looking to upgrade or want the latest word from the pros on an operating system, you should check out Short Media first.
Short Media also has a team that is actively engaging in medical research. Team 93 is participating in the Stanford University Protein Folding Project where your home/office computer can work on elucidating optimal foldings and configurations for many new drugs and therapeutics useful for treating cancer and other diseases. To join Team 93, just go to the Short Media site www.short-media.com, then go to the Forums; join; scroll down to the "Neighborhood" section and you will find "Team Short Media". From there, you can read information about joining them and getting involved with this important research project. There is a thread http://www.short-media.com/forum/showthread.php?t=29803 that lists all of the information that you need.
The more folks joining this project the better for medical research. Team 93 also keeps milestones for their members so you can plot your progress.
18 February 2007
16 February 2007
You may want to consider location as your first priority. Medical school can be a very expensive undertaking but add in the cost of a few cross-country airline flights each year (you do want to come home for Christmas don't you?) and you can add significantly to your costs of attending. You may also want to look at the cost of living in some of the cities that have medical schools. Cities like Washington, DC, New York and San Francisco can be quite expensive to live in while other cities like Cleveland may have substantially cheaper housing.
Your first step in choosing a medical school is to look at your competitiveness as an applicant. The 2005 (last year that we have numbers) averge GPA and MCAT for medical school matriculants was 3.65 and 29. You can simply look at your numbers and figure if you are above average, average or below average in terms of matriculants across the country. You can also consult the MSAR (Medical School Application Requirements) and look at the averages for individual schools. Again, are you above their average, at their average or below their average.
The next thing to look at is curriculum types. Most schools have some variation of an integrated (systems-based) or classical curriculum. Some schools also have problem-based learning (PBL) integrated with a systems-based curriculum or classical curriculum. The classical curriculum requires a fair amount of self-integration of the material for USMLE (all steps intergrated). The intergrated and system-based curriculi require less self-integration but may pose problems if you are a slow starter and find that you missed key portions of an important system.
Depending on your learning style, you may find that PBL is not going to be a good "fit" for you. PBL demands strong individual initiative and proactivity in terms of getting the information that you need. If you are not a natural leader or work poorly in group situations, PBL is going to prove problematic. PBL is also fairly dependent on good faculty who thoroughly understand its concepts and implementation of those concepts. In short, some people become lost in the PBL process and find recovery difficult.
How about "ranking" of your medical schools? It is not so much the rank of your school but how well you perform there. The high performers at any medical school are going to go further than the low performers at a high ranked school. If you are uncomfortable or stressed (money, housing, study space) in the environment of your "high ranked" school, you are not going to perform well and thus, the ranking of your medical school is not going to help you very much in terms of your performance.
Your medical school environment should provide adequate access to study rooms and materials, adequate lectures and access to the faculty that presented those lectures, adequate access to the information that you need for doing well in your coursework and a safe environment for you to come, go and stay late for study. If your faculty are not available during office hours or there are no study rooms available either in the library or in the school itself, you are going to have a difficult time mastering the material that you need to become a good physician. Again, this has little to do with the "prestige" of your medical school and more to do with the quality and ethics of your faculty. Strong medical schools may not be highly ranked by US News & World Report and the best medical school for you as an individual may not be ranked #1 by the rest of the country. In the end, your individual performance will determine how well you do on licensure boards, in your coursework and how much control you have over your choice of residency.
12 February 2007
This examination, along with USMLE Step II Clinical Knowledge and USMLE Step III are given on computer in a Thomson-Prometric Testing Center. Once you are eligible for each step, you may register and schedule these exams on a day of your choice. USMLE Step II Clinical Knowledge tests a medical student's readiness for the supervised practice of medicine i.e. internship. Most medical students in the United States will take this exam at some time during their fourth year. Step III is usually taken after graduation from medical school with application for permanent medical license at the time of Step III. Some states have a seven-year rule in that you must take and pass all three USMLE steps within seven years of taking USMLE Step I so keep your dates and years in mind. Optimally, get Step III out of the way as soon as you can.
In addition to USMLE Step II Clincal Knowledge, there is a USMLE Step II Clinical Skills (USMLE Step II CS) that must be taken. This Clinical Skills exam has been required of all graduating medical students since 2005. This exam is also staken during fourth year as it usually involves some travel to a specified testing center, Atlanta, Chicago, Los Angeles, Philadelphia and Houston on a specified date and hotel accomodations unless you have friends in this city that will put you up.
Now, for the "nuts-and-bolts" of USMLE Step I: First of all, the test is intergrated which means that each question block has subject matter from your all of your pre-clinical courses. The questions may test a specific type of subject matter but there are intergrated questions throughout the test. This means that you probably should not study for this test in a "subject-specific" manner but rather intergrate the materials. For example, a virus might attach the heart muscle and cause a myocarditis that leads to biventricular heart-failure. This may be presented to you in a case-scenario but you have to know the physiological and pathological effects of heart-failure along with the effects of myocarditis. This is why memorizing individual questions or attempting to study before you are done with your coursework is counter-productive.
Another popular USMLE Step exam technique is to ask secondary learning questions. A scenario might go like this: "A , neat and well-dressed young man comes to the office of your psychiatric practice. He states, ' I don't know why I am here but I came anyway. My friends seem to think that I have a problem but I don't think or see that I have a problem. It's just that when I see something out of place, I feel compelled to put it back in its place. I like things neat and orderly." A likely diagnosis for this patient is: A. Schizophrenia B. Acrophobia C. Obsessive-Compulsive Personality Disorder D. Obsessive-Compulsive Disorder.
In order to answer this question, you have to know something about the characterictics of the disorders in the answer choices and be able to differentiate between them. You also need to READ every answer choice and make distinctions betweeen them especially the last two which, are the key to answering this question. Again, you just cannot memorize a bunch of facts and definitions without putting this information into the context of the disorder/pathology or entity that is presented in the case.
What about those expensive USMLE Prep Courses? What about using review books and memorzing them along with your course work? The problem with most of those expensive review courses is that they present the material by subject and the actual USMLE exams are intergrated. The problem with review books is that they are often superficial summaries of what you already have in your coursework. It is far better for you to organize and thoroughly master your coursework before you attempt a "review". You cannot "review" what you haven't thoroughly "learned" in the first place.
Most second-year medical students will take USMLE Step I the summer between second and third year. At my medical school, a passing grade was required on Step I before we could start our clinical rotations in September therefore USMLE Step I had to be taken before the third week in July so that the Dean had received our passing scores. Our coursework was completed at the end of April so that most people took Step I the second or third week of June.
Those of us (myself included) who had summer fellowships were required to take our exams before June and thus had to be more efficient. I took Step I the third week in May. Inevitably, those people who failed the exam, were among the later takers and thus were delayed in starting on the wards. If you took the exam early, you would have time to re-take and start one rotation into your third year but if you waited unti August and then failed, you would drop an entire year of medical school. Bottom line: Take that exam when you are thoroughly prepared and reviewed but don't wait too late.
How about USMLEWorld and Kaplan's Q-Bank? These are currently the best question resources available for students. They simulate the actual exam in terms of computer interface and can be used in both the "Test" and "Tutor" mode. The best way to use these resources is to work in 50-question blocks using "All Disciplines" rather than subject by subject. You can use the "Tutor" mode where you can review why the correct answers are correct and the wrong answers are wrong.
Beware of feeling confident that if you have a specific percentage correct on USMLEWorld or Q-Bank that you are guaranteed a pass or a specific score. Also beware of memorizing the quesitons because the questions on the actual exam are different from either of these resources. Both of these on-line question sources have many questions that are more difficult and more specific than USMLE Step I.
These sites are nicely utilized with a study group too. You should do your review and then do a couple of question blocks discussing the answers with each other. You would be surprised how having these types of discussions can enhance your retention and understanding of the material.
Also beware of "one-source" reviews out there. USMLE Step I is an exam that is scheduled for 8-hours over one day. There is no audio "high-yield" review tape or single resource that will give you everything that you need for this exam. You need to practice questions and reveiw systematically.
After you have completed your second year coursework:
- Figure out when you are likely to be taking the test. Second or third week of June is generally the most popular dates.
- Figure out how you are going to review: Systems-based or subject based.
- Gather your resources meaning review books, on-line question systems
- Set a study schedule and stick with it. Don't make the schedule so tight that you can't get everything accomplished. Be sure to put in some "down-time" so you can relax as you review.
- Use USMLEWorld or Q-Bank as measures of your progress and do not attempt to memorize these questions. For example, if you miss a question, use it again in under test conditons and see if you get it correct. If you miss it a third time, use one of your review books and review the subject matter of that test.
- Be wary of subject-based reviews as the actual tests are intergrated. If you do review by subject, be sure to question yourself in an intergrated manner.
- Try to have a study group where you can help each other and discuss the questions.
10 February 2007
Now why did I put the word "undergraduate" is all capital letters? For significance and emphasis. Your undergraduate GPA is the grade point average that is most significant. Obtaining and pursuing a graduate degree in order to attempt to "shore up" an uncompetitive GPA is not going to be helpful.
Now, back to the MCAT. This test will examine your ability to use the knowledge presented in the pre-med subjects (General Biology, General Chemistry, Organic Chemistry and General Physics) to solve problems. These "problems" as presented on the MCAT do not test your regurgitation of facts (in the manner that many undergraduate courses test) but require that you are able to do secondary thinking. You must apply your knowledge base to a problem.
Often students make a very grave mistake in thinking that obtaining an "A" in all of the pre-med courses ensures a competitive MCAT score. Because the testing manner of the MCAT is far different from the testing manner of most colleges, practice and preparation with the types of questions and the manner of questioning of the MCAT is required. Quite simply, the MCAT tests both your knowledge base and your test-taking skills base. The MCAT tests how you "think" and "evaluate" information as much as it tests your basic knowledge and fund of information. It is no surprise that the MCAT tests how you will evaluate information for the rest of your career in medicine.
Your preparation should include making sure that your knowledge base is adequate. This may be done with any means of good MCAT review books and commercial courses (expensive). The commercial MCAT-prep courses will provide their students with outlines of the subject matter that is tested on the MCAT. These courses also provide plenty of practice exams for making sure that their students are thoroughly with the MCAT testing procedures and manner of questioning.
A common mistake is for students to feel that they must "memorize" every test question presented in a book or course. By taking this approach, students wind up with major "burnout" by the actual test day. You simply cannot memorize every potential question that the MCAT can produce or offer.
Another common mistake is believing that there will be grammatically incorrect answers to questions that will be easy to spot. The MCAT is not constructed in this manner. Looking for patterns of answers will not be helpful in taking this exam. While you do need to be extremely skillful in your reading comprehension and observations, you still need a significant knowledge-base in order to to well.
Many students make the mistake of not actually reading the full question and all of the answer choices. They read the question, come to an answer choice that they think is correct and move on to the next question. There may be an answer further down the choices that is MORE correct and thus you need to read all of the possible solutions.
Another useful skill is being able to solve quantitative problems by using order of magnitude. Let's say, you are presented with a physical science question that requires knowledge of a formula. If you are familiar with units and the order of magnitude of the numbers that go into a formula, you won't need to do a complete calculation in order to choose the correct answer. In the case of more than half of the questions that I encounted on the physical sciences portion of my MCAT exam, I didn't need to do the complete calculation once I looked at the answer choices.
In terms of the Verbal Reasoning and Writing Sample portions of the test, you want to have plenty of practice with reading and writing. It never fails that good readers are also good writers. Practice with the editorial pages of your local newspaper. See if you can pick out the arguement and propose a counter arguement. What is the hypothesis and what evidence does the writer show in support of that hypothesis. What is the writer's conclusions and how does the writer tie all of his/her evidence that leads to a conclusion?
When you write your answers to the questions in the Writing Sample, the outline is Introduction where you present your thesis, evidence (next paragraph), evidence (next paragraph), counter thesis for arguement against and conclusion. You should write about 1 and 1/2 pages total on each of the subjects. You want your subjects and verbs to agree and you want your ideas as crisp and logical as possible. Again, spend some time in the Writing lab of your school where you can get critiques of your writing style.
Remember that you study for your coursework and review for the MCAT. If you have not completed your coursework, do not spend time away from your studies attempting to review material that you have not learned in the first place. Put your emphasis on thorough mastery of your Pre-Med courses while you are taking the class. When your class is complete, you can start your review if you wish. Allow plenty of time for review. This step cannot be rushed.
Your planning for taking the MCAT should be one take and that's it. DO NOT take the MCAT for "practice" and repeat for "actual grade". The MCAT is not a practice test. One test take when you are thoroughly prepared and you are done. An application killer is several mediocre MCAT test attempts (whether released or not) and a mediocre score in the end. This is a huge "red flag" on your application.
You also cannot talk yourself out of a good performance. "I hate standardized tests and I am no good at them" can be self-fulfilling. If you thoroughly prepare and are thoroughly familiar with the MCAT testing manner, you can do well on this test no matter what you have done in the past. Talk yourself "into" a good performance rather than talk yourself "out" of a good performance. Also, don't let the fact that the test is computerized unnerve you. The computerized test has the same knowledge requirements as the old paper exam and thus you still need the same knowledge base. If you have found this website, you have all of the computer skills that you need to take the computerized MCAT.
05 February 2007
When I was a pediatric respiratory therapist, my specialty was the respiratory care of the patients in the Pediatric Intensive Care Unit. I preferred pediatric respiratory patients because they were unlikely to continue smoking after spending days in the intensive care unit or hospital. I also liked the challenge of delivering medications by inhalation to children. I had to gain their trust and deliver their medications at the same time. Often this would take the form of having a pediatric post op patient blow feathers across a table or perform incentive spirometry and light up a clown's nose. I also enjoyed the artistry needed to mechanically ventilate children of various sizes and needs. Pediatric Critical care was a wondeful method of practicing respiratory therapy and seeing respiratory physiology in action on a daily basis.
One of my most memoriable patients was a child who had been born prematurely to a set of much older parents. BK was born at 24 weeks gestation (normal is 38-40 weeks) and had spent the first five months of their life in the neonatal intensive care unit. At the time (late 1980s) inhaled pulmonary surfactanct had not been available for administration into children born this early. As a result, BK, who had been on mechanical ventilation because of extreme lung immaturity, developed bronchopulmonary dysplasia.
Children with bronchopulmonary dysplasia (BPD), a result of ventilation with relatively high levels of positive pressure, developed changes in their lungs that closely resembled the changes seen in adult patients with emphysema as a result of smoking many years. These children were chronically susceptible to pneumonias and were often oxygen-dependent, and bronchospastic when they were weaned from positive pressure ventilation. With the advent of artificial pulmonary surfactanct, BPD, is far less common today than in the late 1980s.
BK had been weaned from mechanical ventilation but remained oxygen dependent. This child also had problems with growth and nutrition but had a spirit that was a thousand times larger than its tiny body. BK also had parents who loved every second of their child's existance, even the touch-and-go, up-and-down character of getting a small premature infant into the catch-up phase of life. They had spent countless hours of the first five month's of their child's life at the bedside in a neonatal intensive care as they saw the sheer determination of this child's will to live.
BK was discharged from the hospital at age 5 months. Going home meant going home with an oxygen tank, respiratory medications and an infant apnea monitor. It also meant careful attention to feedings and nutrition but BK's parents were joyful and happy to have their child home. BK also had two nurses that assisted Mom with daily care and feedings.
BK was home for three weeks before a viral upper respiratory infection called Respiratory Syncitial Virus or RSV caused increased work of breathing and a trip to the pediatrician's office. Later BK was admitted to my Pediatric Intensive Care Unit. Because of the highly infectious nature of RSV, BK was placed in an isolation room and placed back on mechanical ventilation with administration of a medication to treat the RSV infection.
When I first saw BK, I saw a tiny child with huge blue eyes that saw straight into my heart. This child never smiled but took in my every move from a vantage point in an isolette. At first, my care of BK consisted of delivery of the medication to treat the viral infection. Later, my care consisted of delivery of inhaled medications and extra oxygen within the isolette. At times, BK needed to have nebulation therapy every hour.
During our 15 minute treatment sessions, I would gently support BK's head and chat with the child through the isolette. Most six-month-olds will mirror your smile and heartily respond to your touch but not BK. Those huge blue eyes would blink and watch but no smile. For two weeks, I spent most of my shift taking care of BK in terms of the delivery of respiratory care. In those two weeks, I developed a great relationship with BKs mother and father who doted on their child at every turn.
After three weeks, BK was able to come out of the isolette for "love and hug" therapy by Mom. It was a wonder to see the great relationship between Mom, Dad and little BK. Still those huge blue eyes followed everything and everyone. If BK had any respiratory difficulties, I was close by and ready to administer what was needed. BK also gained some weight and seemed to be thriving.
One afternoon, we had difficulty keeping BK's oxygen saturation levels up. At this point, the "holding and hugging" sessions had to be sharpy curtailed. Finally, BK needed to go back on the pediatric ventilator for some positive pressure therapy. Still those huge blue eyes never betrayed the struggle that this tiny child was going though. BK's Mom brought in nursery rhymes that she had taped and music for the isolette to drown out the sound of the positive pressure.
After three days, little BKs continued to deteriorate and finally late one afternoon, BKs parents made the heartbreaking decision that their child would not be subjected to mechanical ventilaton again. At this point, we delivered almost continuous nebulization therapy which provided some decreased in BK's struggle to breath. Finally, we placed BK in Mom's and Dad's arms. At this point, those huge saucer blue eyes were peacefully closed and little BK breathed the last breath surrounded by family and extended family of the PICU who had grown to love this little warrior.
Five years later, when I dropped in to visit the pediatric critical care pulmonologist that I had worked with so closely when I was covering the pediatric intensive care unit, we took a tour of the new pediatric hosptial and the new units. By this time, I had left respiratory therapy had had just received my first acceptance to medical school. I had wanted to surprise my pediatric pulmonologist and he was just so proud of me. As we walked by the doors of the old pediatric intensive care unit, now housing offices, we both looked at the last room at the end of the hall and said, "BK's room" at the same time.
I learned so much in the six weeks that I knew BK and family. I don't know if BKs parents every realized how much their child had touched all of us and how we never forget the struggles of such a young child. BK did not see a first birthday but brought so much joy even though we never saw a smile.
To this day, my patients and their struggle keep me going in that 30th hour. My patients never "give up" and I never "give up" on my patients. This job is difficult but to have a chance to meet and experience patients like BK, every difficult task is work the effort.
03 February 2007
Pediatric surgery is the one surgical subspecialty that covers every surgical aspect of their population. Pediatric surgeons create fistulas for hemodialysis access in the pediatric population. A pediatric surgeon will ligate a patent ductus arteriosus (persist vessel between the pulmonary artery and aorta). A pediatric surgeon will perform hepatic resections and resections of choledochal cysts in addition to removing lung tumors and repairing chest wall abnormalities. Pediatric surgeons will also remove thyroglossal cysts and cystic hygromas (neck malformations). Pediatric surgeons will perform skin grafts, tracheotomies and transplants in infants and children. In short, pediatric surgeons perform procedures in children that would be performed by surgical subspecialists in adults.
A pediatric surgeon first completes five years of a General Surgical residency. Most complete two years of dedicated research in addition to the five years of residency making a total of seven years of training just to get to the pediatric surgical fellowship. In addition, the fellowship is two additional years making a total of 7-9 years of training beyond medical school to enter pediatric surgery.
Landing a pediatric surgical fellowship is no easy task either. There are presently about 23 fellowships nationally which means that applicants for pediatric surgical fellowship will apply to all fellowship programs and hope for enough interviews to be able to land a fellowship. Criteria for selection are scores on the American Board of Surgery In-Traning Examination (ABSITE) and a high level of performance in general surgical residency. The small number of fellowships nationwide in addition to the fairly large candidate population makes obtaining a pediatric surgical fellowship one of the most competitive if not the most competitive that any physician can obtain. In short, pediatric surgeons are the elite among all surgeons.
My pediatric surgery attendings fit the mold of pediatric surgeons completely. All four did fellowship in top programs in the United States and Canada. They all were extraordinary teachers and all had amazing surgical technique. It was a joy to stand across the table and see not a single wasted motion or miscue. They were equally gifted in teaching both the craft and the art of all aspects of surgery not to mention being some of the most professional folks to work with in the operating room. They treated the OR staff and the resident staff with great respect and made learning quite enjoyable. Here were four individuals who were the absolute best of the best among surgeons and they were just wonderful to learn from and work with and were the "least malignant" personalities I have ever met. Some of my best times in the OR were on the pediatric surgery service as both intern and chief resident.
On a typical day, after finishing up cases in the OR (around 4pm) I would receive sign-out from the folks who were not on call. I would be responsible for checking all post operative patients to make sure that they did not have problems urinating or had adequate pain control. I also carefully checked all vital signs and dressings to make sure that there were no problems that needed to be taken back to the OR. In addition, the attending surgeon that was on call with me would check in before he left for the day, just to make sure that the house was good for the night. If there was an impending admission, he would let me know when the patient would arrive.
I could generally grab a bit of dinner from the cafe and then head off to check the burn unit and emergency department. I would also check for any patient who might need pre-operative orders. Most surgical patients were either emergency admissions, who would go to surgery that night or AM admissions who were still at home. Many nights, trauma patients would be flown in by helicopter from neighboring counties and thus would have to be cared for by my service (me alone after 5pm). The best thing was that most children are not out after 10 pm so traumas after 10pm were rare in pediatric hospitals and more common in adult hospitals.
By midnight, I would be napping in the call room. My naps would be punctuated by calls and questions from the nursing staff. In general, few things needed my presence at bedside if I had done my post op checks thoroughly. Usually, questions would be renewals of orders or an extra pain medication dose. I usually covered my post operative patients with something for nausea with a call to me before it was administered.
Often a first-year pediatric resident and a couple of medical students would take call with me. It was my duty to be sure that this resident and the medical students got the best experience. If I received a routine call from the emergency department, I generally didn't awaken my staff unless there was something that was going to the OR that night. I preferred to perform my own history and physical exams but I always gave the students a chance to check and observe the incoming pathology.
Patients who had been burned would be sent directly to the Burn Triage area and would not stop in the Emergency Department. Usually the Burn Triage nurse would let me know if a patient was coming. I would check over the burns, write the necessary orders and the nurses would take care of the patients. Again, adequate pain management was usually the most important aspect of burn care along with very strict attention to wound care.
My most memorable case was placing a newborn on Extra Corporeal Membrane Oxygenation or ECMO. This patient had been born with a diaphragmatic hernia that allowed abdominal organs to form in the chest cavity causing the patient's lungs not to develop properly. When these children are born, ECMO allows the hypoplastic lung to grow and takes over oxygenation for the child. Two large bore vascular catheters are placed in a neck vein and artery. I jumped at the chance to participate in this procedure because ECMO is rarely used. It had been 2 years before that ECMO had been done at this hospital. The resident that was on call had no interest in the procedure but I was thrilled to do this. Later I participated in the definitive repair of the hernia with a good recovery from a potentially lethal congenital defect. It was awesome.
I also participated in a liver resection in an 8-month old with cancer. Again, I had a chance to participate in a fairly rare case with very interesting pathology. This patient also did well after a week-long stay in the Pediatric Intensive Care Unit. The power of regeneration in the liver is nothing short of remarkable. In a pediatric patient, the physiology of these cases are amazing. Liver anatomy is also very interesting as are the techniques used in liver surgery. My favorite surgical instrument is the Argon Bean Coagulator which is used to coagulate the raw edge of the resected liver. This is literally a plasma scalpel.
By 4am, I am usually up, showered and making my early AM rounds. I try to get my notes written so that work rounds are not rushed before we start AM cases. I am required to be out of the hospital by 12 noon on my post-call day but usually, I am done by 9am. I try to make sure that my patients are taken care so that the incoming call resident is not weighted down carrying my patient load and his. For me, it's all about planning. I usually give a very complete signout with anything that needs to be watched and what I would do if there is a problem. The on-call resident only has to look at my sheet to be able to jump in and do what may be needed.
Another interesting aspect of pediatric surgery is seeing the patients in clinic. In general, the attending who is on call is in office while I am on call at the hospital. This made getting over to clinic more difficult but I did get some clinic time. It is good to see the patient in clinic, do the work-up, perform the surgery and post-op care and then see the patient back in clinic. I love to see how my closures worked and the patient pain-free. Clinic was always interesting.
I thoroughly enjoyed my pediatric surgery rotation because the patients are great fun to take care of and because peds surgery pushes the limits of a surgeon's diagnostic capability. A surgical abdominal problem in a pediatric patient present far differently than in an adult patient. Even hernia repairs in pediatric patients are more fun than adults because the anatomy is seldom distorted.
I also always keep in mind two quotes: One from Alfred Blalock, the late chairman of surgery at Johns Hopkins. He said, "It's takes arrogance to cut open a human being." and the other from one of my pediatric surgical attendings who said, "You wouldn't hand the keys of your car to a total stranger, yet these parents hand over their child to you, the total stranger. You have been given a great trust."
02 February 2007
One of my best friends has struggled with passing her first board exam in medical school. She did well in her coursework but has not been able to get past Step I even at the time that I am writing this blog. She has missed a pass by less than five points on every attempt. Needless to say, she is struggling and even questioning whether medicine is in her future. (In order to become a licensed physician in the United States, three steps licensure boards must be passed).
Many may ask, "How can she do so well in her coursework and yet not be able to pass Step I?" "How good a physician would she make if she couldn't pass boards on the first try?" The answer to both of these questions is, "an excellent physician" because passing board exams, while necessary for licensure, does not measure one's ability to treat patients. There are many excellent physicians in practice today who struggled with Step I, Step II or Step III of liscensure boards.
On the other hand, there are far more poor physicians in the United States that sailed through board exams. The bottom line: You have to pass three steps of licensure boards in order to obtain an license to practice medicine. Passing all three of these steps may be a struggle but they must be passed. Whether it takes two or three tries on each step, once all three are passed, your license is issued and it's up to the individual to practice excellent medicine or not. The practice of excellent medicine has more to do with work ethic than board scores.
Another class mate of mine struggled with several courses in medical school. She is dyslexic and had difficulty with physiology and pathology. She too struggled with one step of her licensure board exams but prevailed. She has been discouraged at times but she is one of the best physicians that I have ever observed. She is certainly a far better physician that I who didn't struggle with passing board exams. Her patients love her care and flock to her office. It is very evident that she has a high level of medical knowledge and is gifted in her application of that knowledge. She just struggled with boards.
We had members of my class who repeated a year of medical school (first or second year). In every case, they excelled with they started their clinical years and are establishing practices at this point. It was in the struggle that most of them truly learned to appreciate the journey. They also learned that sometimes "things" happen in your life that are totally beyond your control. These "things" must be taken care of before you can move on with your studies. It's not the way you planned for your career to work out but it's the career that you have been handed and you make the best of it.
Often I listen to folks who anticipate attending medical school who just KNOW that they will be a neurosurgeon. Just the mention of neurosurgery causes them to sit up more straighter in their seat or breathe a bit deeper. These budding neurosurgeons discover a wonderful course called Neuroscience and their plans for neurosurgery take a hike. Sometimes they get past the neuroscience but hit surgery clerkship in their third year and discover that there is nothing about surgery or being in the operating room that interestes them. The whole mystique of the OR or the "prestige" of the specialty that drove their interest in medicine will leave and often leave them depressed or unhappy about their choice to study medicine in the first place.
On the other hand, my classmate who sat behind me first and second year, always knew that he wanted to be a neurosurgeon. I had the pleasure of doing a case with him when I was on my pediatric surgery rotation. He was the neurosurgery resident and I was the pediatric surgery resident. It was great. We have since worked together on Trauma service too. It's neat to see how our careers have developed respectively.
If you find that you are struggling with undergraduate or medical school, figure out a way to get some help. Your performance is not diminished by the fact that you ask for help or attend tutorials. I remember an MD-Ph.D candidate who was a pharmacist before he started medical school. He spent hours helping all of us with our pharmacology during medical school. He was awesome and a very gifted physician scientist. There are loads of us, myself included, that owe him a debt of gratitude for taking the time to point out the finer lines of pharmacology.
If you fail something or repeat a year of medical school, remember, that no patient is ever going to ask you how many years it took for you to get through medical school. If it takes you five years instead of four and you are a good physician, then every second of those five years was worth it. In the end, the job is all about taking the best care of your patients that you can. Sure, you are not on the schedule that you set for yourself but it's the endpoint that is really your goal. Pat yourself on the back for hanging in there and know that the experience with struggle and strife only makes you more resiliant.